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(/'"' thldiln fii I'iij. ,;/..',,'.) «J'i I AN AMERICAN TH XT- BOOK OF OBSTETRICS FOR PRACTITIONHRS AND STUDHNTS BY James C. Camiron. M.I).. HnwAun P. Davis, M.l). RoBi-.KT L Dickinson, M.D.. Chari.hs Warkington Haki.i;. M.D., Jamis H. HrHKRiDOh. M.D., Hf.nry J. (lARRiGiKs, M.D.. Barton Cookk Hirst, M.D. Charms Ji-wktt. M.D.. Howard A. Kki.i.y. M.D. Richard C. Norris. M.D.. Chaincf.y D. Pai.mfr, M.D. THi:opH!i.rs Parvin. M.D.. Gkorgi-: A. Pii-rsoi.. M.D. Hdwari) Rkynoios M.D., Hi-nry Schwarz. M.D. Richard C. Norris. M.D.. Hditor. ROBKRT 1..^ i^lCKINSON. M.D.^AlCT HdITOR. 117/7/ X/ulRLV U(}(i COLORI'.n AM) KUUATA. V\f :i.'i (p. 4;{|. Th(> laliolliiiB on the cut of "axis of liriiii " shouUI lio •'pliiii«- 11 liriiii." , Kl^' 3.'i (p. 48). Ill the legend, for "luultiimrai" read "nullipaia'." Fii;. 209 (i>. 3,S.")). In the legend, the (one-eixth natural size) should be (fetus JiiciJixth natural sizf). riir. 211 (|>. 3>SS). In the lesond, for "axis of inlet" read "plane of inlet." FiS. 2(!r» (p. 4."»(!). Thi> fi«uiea A and H should lie leverst^d to a«ii'c with the k'l'ud. J PI. ISMp. IGG). The legend should read as follows: 1. The nor-^ravid womb lud the «ame at eight months, with varying heights of the fundus marked in pek.s. 2. Position of the chiM and the utoni'< in a ease of pendulous abdomen. PHILADELPHIA : W. B. SAUNDERS 92s WALNUT STREHT ^1^^-A.^ :^ s^. MDCCCXCV BiBLlOTwrp, ,r FROXTisriKrE. M Mr^iiil x'ciiiiii -.Imw ill;; tlif icliii i.iii oi tlir vi-ii rii in ilicii' iiui'iiml |Mi.sitiiiiis ' liii'Uiiisiiii), (/!//■ ililnilf I'll I'iij. ,'.'. ji. !,;.] h AN AMERICAN THXT-BOOK OF OBSTETRICS FOR PRACTITIONERS AND STUDENTS James C. Camiron. M.I).. Hdwakd P. Davis, M.D. RoBHKT L. Dickinson. M.D.. Chari.ks Wakrington Hari.k. M.D., Jami-s H. Htheridgi:, M.D., Henry J. (lARRiGiKs, M.D.. Barton Cooke Hirst, M.D. Charles Jewett, M.D.. Howard A. Kelly, M.D. Richako C. Norris. M.D.. Chaincey D. Palmer, M.D. Theophilis Parvin, M.D., George A. Piersol. M.D. Edward Reynolds. M.[)., Henry Schwarz, M.D. Richard C.^ Norris. M.D.. Editor" Robert I..' Dickinson. M.D.^Aia Editor. 11777/ Xr.ARLY 000 COLORED AND //AU'.fOXIi //JJ'STRAThhVS. t PHILADELPHIA : W. B. SAUNDERS 92=5 WALNUT STREET MDCCC.XCV ^S^^^-A-^ fy C>:^^ > \ t^ BiBLlOTWrpi ,r <'<'l'Ylil(,IlT, ls;i,'), KY W. II. S.\ (• N I) K US. WrSTCOTt t, THOMSON ILtCIHOTVMCHb HH.LAU* PRFSS Of W B SAUHUIHS PHIL«D«. PREFACE. .\l>VAXCKs in the science and art t)f ohstotrica liave kept jKice with the advances wliieh liave characterized all hr.mches of medicine and snrjjjerv. Althoufjh nur stand- ard text-l)(M)ks of ol)stetrics have r students and a guide for practiti<»ners ; for this pur|M»se the authors selected are those possessing experience as teachers of (»bstetrics in sevend of the leading iuedi<'al schools and hospitals of America. Tiie especial design in ])repariug this volume was to make clear those departments of obstetrics that are at once so important and usually so (»bscure to the medical student. Therefore the ol)stetric emergencies, the mechanics of normal and al)normal labor, and the various manipidations recpiired in obstetric surgery are all described in great detail, the text being elucidated with mnuerous illustrations and diagrams whicii will mate- rially assist the student to grasp the complex problems of o|R'rative obstet- rics. The diseases of the fetus and of the new-born infant are given sepa- rate secti<»ns of the volume, this subject being discussed more frdly than is usual in obstetrical works in the Kuglish language. An cft'ort has been made t(» render attractive the sections upon Anat(»my and Knd)ryology. While the various authors were each assigned special themes for discus^-' sion, nevertheli'ss an attempt has been made so to correlate the subject- matter as to preserve throughout the text a logical sccpu'iice not always found in composite publications. The writing of the subjects assigned to Or. Charles Waniugton Karle was only fairly begun when his untimely and widely-lamented death (M-curred. The Kditors were gratified to secure for the revision and completion of Dr, KarK''s manuscript one of his asso- ciates, Dr. M. J. Mcrgler. The table of C'(»ntents indicates the authorship of each section — a feature which doubtless will give sjitisfaetion. One of the just claims of this text-book to originality is that an attempt has been may the treatment of patients in the latero-prone posture. Kach ixirrowed cu^raviuf; has been (-redited t<» its sourci' in all cases where it eoidd he tr.iced. When alterations have not heen extensive these cuts are designated, respectively, as " redrawn from " or " lutNliticd from " the original. When such corrections and additions have heen inadi' as to eonstitut*' practically a new drawing, the origin of the cut is nirely in«licated. Where there may seem to he strong resemltlant'c to older work, without credit, it will he found that new pliotogr.iphs or sketches are the hasis of the new illustration. The htM'ntwcd cuts have all lu-en redniwu, excepting those rcpHKhiced from the i»ld copper-plates of Hunter and Smcllie — a stand- ard of artistic excellence set for us hy the most fam<»us engravers of Kngland. France, which has furnished our specialty with its stock-cuts for decades, gives the "American 'I'cxt-Hook" many suggestions through the work of Faniheuf and \'arnier. To (Jermany ohstetrics owes much gratitude for that aceuriicy in t(»pogr:iphical anatomy which had its rise in the heautifully pic- tured sections of Bniun, Schroi'der, Waldeyer, and Zweifel ; while we thank Scotland, through the atlases of Mart, IJarhour, and Wehster, for the know- ledge of the structure of the pelvic Hoor. Some of the finest pathological specimens illustrated in this text-hook were photogniphed at the Army Medical Museum at Washington, 1). ('., through the painstaking ccairtesy of Dr. I). S. Lamh, while Dr. Farcpdiar Fer- guson gave access to the New York Hospital Cahinet, and Professors Piersol and Hirst each hrought forward some of their most striking preparations. We are indehted to the staff of artists, Messrs. Max Colin, W. A. ('. Pape, H. ('. Lehmann, F. V. Baker, A. W. Doggett, F. Deck, W. H. Richard- son, and others, hy whose skill and years of patient labor art ha.s been placed at the servi<'e of scientitic illustnitiim. Only through an iniprecedentcd liberality on the ])art of the jHiblisher of a medical text-book has it been possible thus to re-illustrate an entire depart- ment of medicine. To Mr. W. H. Saunders, for his imremitting courtesy, patience, and generosity, we tender our thanks. The Kditors desire to acknov.ledge their indebtedness to Mr. John Vansant for valuable assist- ance in coiKhicting the mechanical (h'tails (tf the work and for the prej)- aration of the Index. The j)laii of this text-book, the exposition of only the latest ideas in pathology, the es|H'cial care that directions for treatment shall be particular an. DAVIS, M.JJ., IVoCsscr .,(• ()l,s,etri..s, JeHe.^,.,, M^II^H r I "^ "'''"'r''''''" ''"'-^^ <''i"iiMl f'l.ysic.i,n, Cl.il.l.vn-.s l>o,.art^K..u^I„^vard li" pul^ 'tl ' "^ ""'''""'' ^■'''"'"^' UOIJEIITL. DICKIXSOX, M. 1,., ]{ - '"^ "- ^-^ •" '-' ^-^i^o' i • • •fAMKS If. KTIIElili)(;i.;:viD^ Professor of (iviii.i..il..<»»r .... i /»i . . . 'HCAfJO, III. «>l<«.st to S,. Jo,.p„-s Hospital, Chiea^a ^^'•'^•^■"»n "„s,„tal ; ronsuI,i,.j, ,iyne- IIKXRYJ. (iAURKUKS, IVI. I)., IVofessor of ()|,sjt.t,.i,.s ■„ ,|„. V„„. v i t. ^"''^^^' ^'<>RK. M-^s nosp.,a. a„.. ,0 „.. ispe„s^ ' '^ '^:':J'^ ^ '>^-"'"*^'^' «' «t. HARTOX COOK,.: HIRST. M. ,>., I'rofessor of ()bsfp(ri,Hi r' • • I*"I',AI)Kl.i>itrA. y "- r.vin.Mn Charity and to iJ Preior 2 IT:"' ''"'"""■"'^' < »>>stotrieian ""**P""I. i-U: '" "^^-"'"n K^'feat; (Jyncc-oloffist t.. the Howar.l ("HAltLEs JKWETT, M. I). I'rofeKsor of ( >l,st..tr'io. a,„I PoHi^.r,- r , , ^HOOKLYN, N. Y. '" Kings County Hospital, vU: '"""^"'""ff < ■.vnec-olog.st to Htislnvick Hospital and HOWARD A. KKLLY, M D * "oceascital; ( iiiir>iil(iiiK OltNti-triciaii anil < iyiu-coloKirit to tin- Soii|lieast«>m I>is|i('nr4an- uiiil IIos|iital lor Woiiicii and ( liililrcn ; < iyiifcoloKiNt to llii* MotluNliHt K|iisco|ial lloHpiial; Follow of tlu' Aiiii'rinui t iyiu'foio>;[jca! SiH-ii-ty, vXv. CHAUNt'KY 1). 1»ALMKH, M. I)., 'im ixnati, Ohio. I'rofi-ssor of Ol>sli'lri(N, of Mcdiral anil Sur^fical I )is«'ast's of Wonii'ii, and of Clinical ( iyni'«'olo>?y in tlu- Mi-dical ('olU'>;«' of Ohio; Olistetrician and ( >yni'colo>{ist to tin- Cin- cinnati Hospital; Con.xuliiiiK (iynecMilogist to the tiernian I'roteHtant ami I'reHhyterian Hospitals in Cincinnati, etc. TIIEOPIlILrS I'AUVIN, M. 1)., IMiii-adkmmiia. rrofrnMorof Olwti'tricM and of l>i.seiiMi>M of Women andChildri'ii, Ji'tlerson Medical Col- lege ; Kx-1'resiilent of the Indiana State Medical Society, of the Association of Ameri- can Medical Jonrnalists, of the American Meilical Ass in Hoston I.yin>j-iii Hospital ; Assistant in ( Jynecolojry, liostoii City Hospital; Fellow of the Amer- ican ( iynecoloj;ical Society, the Ohstetric Society of lioMon, etc. HENRY SCHWARZ, M D., St. Lot is, M«). Professor of ( iynecology in the St. Tenuis Medical Collejie (Medical I>eparttncnl of Washington I'niversity) ; Consnitint; ( iynccolojjist to the Female Hospital ; (iynecologist to the Kvan^elical liiitheran Hospital, etc. i i- * mwil CONTENTS. f: I. THE GENERATJVK OKCiANS. I. Amitoiny of the I'c'lvis(l>ioi>i()|) "^* II. Anatomy of the I .Maternal Organisms induced by Pregnancv (I'lersol and Palmer*) . h ^^ly^y lli» II. Diagnosis op Pregnancy 150 1. Symptoms and Signs of Pregnaney (Palmer) j.-.n 2. Duration of Pregnancy (Palmer and Piersol) . . m .'J. Prolongation of Pregnancy (Palmer) ... ,-q* 1 /o m. Hygiene and Management op Pregnancy (Palmer) . . . i,so IV. Pathology op Pregnancy . INa 1. Diseases of the Several Systems (Davis) jg- 2. General Disorders of Pregnancy (Davis) ifHj 3. Acute Infectioni dur.ng l»regnancy (Davis) 9.'}^ 4. Accidents and SurgicalOperations during Pregnancy (Davis). ^48 5. Diseases of the Ovum (Etheridge) .~r., G. Abortion («"theridg(>) . . "'' " ' 2.(9 7. Extra-uterine Pregnancy (Kelly) ^-i 8. Disea.ses of the Fetus in Utero (lOarle and I^Ierglerf) . . . . . . 295 * "General ChanRes" (,,p. ir,3-ir,9) contributed by Dr. Palmer t The manuscripts of Dr. Earle were revised and completed by Dr. M. J. Mergler. 11 ^■w* mm m^mm ■mp tm 12 CONTENTS. III. LABOR. PAOB I. Physiology op Labor 318 1. Phenoiuemi of Normal Labor (Dickinson) 321 2. Clinical Course of Labor (Di<'kinson) 383 n. Conduct of Normal Labor 341 L Antisepsis (Jewett) 341 2. ]\[anagenient of Normal I^abor (Jewett) 349 Obstetrical Examination 340 1. Diagnosis of Fetal Presentation and Position 3r)0 2. External Measurement of the Pelvis SHS 3. AiK'stlu'sia 3()2 Examination iluring Labor 3(5r) Management of the First Stage 3(57 Management of the Second Stage 3(18 Management of the Third Stage 37() in. Mechanism of Labor 384 1. Ciassitication of Jiabor (Reynolds) 3SG 2. The Fetus (Reynolds) ■^*'l 3. Diagnosis, Freciuency, and Prognosis of the Several Varieties of Labor (Reynolds) -^'^^ 1. Vkktkx Pkkskxt-.tioxs (Reynolds) -117 A. Mechanism of the First Stage of Labor *i-3 li. Mechanism of the Second Stage of Labor . . -130 C, Mechanism and Management of the Third Stage of Labor . 440 1). Mechanism and Management of Posterior Positions of Vertex Presentations '"*- 2. FAfK PuKsKxrATioNs (Reynolds) "l^^ :Mechanism and >ranagement "^''^ 3. Huow Pkkskntation's (Reynolds) ■!*'<» INIechanisiTi an 1 Management ■**'♦* 4. Pkia'K- Pkkskntatioxs (Reynolds) "l^O Mechanism and Management *'" 5. FooTT>iX(i Pkkskntatioxs (Reynolds) ''^^ ]Mechanism and Management ^^"^ C. Thaxsvkksk Pukskntatioxs (Reynolds) "^^^ INIechanism and Management ^'^ 7. Pu(H-Al'SKl) EXTUKMITIKS (Reynolds) 492 PAGE 318 321 333 . 341 . 349 . 349 . 3r.o . 3r).s . 3()2 . 365 . 30)7 . 3(18 . 37() . 384 . 386 . 401 )f . 407 . 417 . 423 . 430 •. 440 if . 442 . 458 . 4()0 . 4G6 . 400 . 470 . 470 . 4S7 . 487 487 , 488 , 492 CO^^TENTS. 13 IV. Dystocia . . . page 1. ANOMALU>. ,N THK FoKCKS OF LaROH (W^v.t) 1 DeHeient Power of the Uterine Muscle; Inertia Uteri (ili.t) ""Peril's" """"""^"^ 5. ^tage.„e,U of Labor Obstructed by the Conunonest l-^orn.; f Contracted Pe,vi,s: a Hin.p.e Flat, a Rachitic Flat, and n fwer.erally-coMtractetl Pelvis (Hirst) «. Obstruction to Labor on the Part of the .S<,ftMaternal Struc-' tures ,n the Parturient Canal (Hirst) 7. Obstruction to Labor on the Part of the Fetus (Hirst)' " 2. Dystocia lie to AccinKXTH and Diskasks I. Accidents to the Umbilical Cord (Parvin) ^. dystocia due to Hemorrhage (Parvin and Sclnv. ■^. Dystocia due to Diseases of the Mother ^>nrv^n^ 493 493 493 497 498 510 543 . 54() . 501 • . . 573 • . . 573 irz*) .... 581 Mother (Parvin) (jo;} IV. THE PUERPERIUM. I. Physiology op the Puerperium (Jewett) n. Diagnosis op the Puerperal State (Jewett) m. Management op the Puerperium (Jewett) . IV. Pathology op the Puerperium t'l I. IXUUn.>. TO T„K (JKX.TAL OUCAXH KOLLOWIXf;" LaHOK ^'^ (hchwarzand Norrisf) ^^aisok II. I>IH>:ASKs or T„K SKX.'AL Okgav.S ''"" 1. Puer|)eral Infection ((Jarrigues) ... ^'^^ 2. Subinvolution (Norris) .... ^'^"^ 3. Hf'"">rrhages in the Puerperium (Norris) 4. Anon.alies of the Nipples and Hrea.sts (Norris) .). I>Jseases of the Nipples (Norris) .... 0. I>i«^«isesof the Hrea.sts (Norris). ..... 7. Arrest of Lactation (Norris) H. Anomalies in the Milk-secretion (Norris) . . . . . . " ' ' 7,;^ III. Diskasrs of THK NOX-HKXUAI. OWJAX.S ... 649 65() /34 7;J8 745 747 751 707 1. F.'ver due to ("auses other than Puerperal Infection (Norris) -*. Intercurrent Diseases (Norris) u^orri.s) . 3. Diseases of the Urinary Organs (Norris) 4. I>I«t"a>41— Methods, 942— Indications for the Operation, 942— Contra-indications to Version, 943— Dan- gei-s of Version, 943. 1. External N'ersion 944 2. Bipolar Version 94(5 3. Internal Version 951 in. Celiotomy for Sepsis in the Child-bearing Period (Hirst) 968 Index 977 * "Sympliysiotomy" (pp. 905-917) contributed by Dr. Jewett. PACK 807 813 813 823 826 835 851 859 861 867 AN AMERICAN TEXT-BOOK 941 944 94() 951 OF OBSTETPvIGS MM ANATOMY (»F TIIK I'KLVIS. I'l-AIK 1 'I'hi' nliitliili lii'twccii .lie inl\ is mill llir inlvic (irKMiis iiiiil I lie siiifiu'r ciC tlic licidy : v. iirmiiniitnry of tlio -iici'iiin ; s, -.ymiiliysis iMiliis ; i', I'll in I lis ol' llir iilcrus ; o. tlic nv.-iiy iiiiliriiciil liy tlif I'lilluiiiiiu t\il)o; tlio lint' il' till' I'Siills lllllsck' lllilii'Mti'il : 11, till' Irrllllll. Il ANATOMY OF TIIK I'KLVIS. Plate 2. '->t' segments wliieh in early life are distinct and unitC'l by intervening cartilane. The pieces comprising the innominate bone — the Hiuin, the puhh, and the hch'uuii — earliest unite, although the imi(Hi of the several portions of the acetabulum is not complete until from the eighteenth to tiic twentieth year. The sacral and the coccygeal segments fuse still later, tho.se of the coccyx re- Fiii. 1.— Ki'imiK' pelvis (tino-tliini natural size). niaining movable until middle life, while the attachment of this bone with the .sacrum occurs late in life. Diwing the usual period of ehildbearing, therefore, the segments composing the posterior boundary of the pelvis arc ununited, and, in the lower or coccygeal jiart of the wall, are capable of yielding to the demands of parturition for increased antero-posterior or conjugate iK'lvic diameters. The pelvis viewed in its entiretv presents an inverted truncated cone (Fig. 1), 2 * 17 II 'I 18 AMJJJi/CA.y TKXT-JiOOK OF OUSTKTIilCS. sli^^litly coniprcssod trinn heforc backward, mIioso base is dinrtt'd upward and forward, and whose sniallor end looks downward and l)ac'kward. Tlio sacrum and the coccvx occupy a median j)osition beliind, an< ; the portion lying above this j)lane, included within the widely expanded iliac bones, the verte- bral column, and the abdominal pai'ietes, constitutes the falne pc/vin and be- longs to the abdominal cavity, to the contents of which it affords support and protection. The true or /csnrr pr/ris is a short curved canal whose superior xtriilf, or inlet, is marked l)y the brim, a bony ring defined by the anterior border of the ])romontory of the sacrum behind, the ilio-pectineal lines laterally, and the j)osterior margin of the pubis in front. The plane of the inferior strait, or outlet, jtasses through the tij) of the coccyx, the tubera ischii, and the lower border of the symphysis pubis. In addition to the foregoing planes marking the upper and lower boundaries of the true pelvis, two others, corresponding with its widest and most contracted pai'ts, are recognized with advantage. The j)lane of (jreatest pelric expanxion extends from the union between the second and third sacral vertebrie behind to the middle of the symphysis pubis in front, its lateral boun'w spino of the ite side, are usually iioted. The HR'asiirciuciits of tho jilaiif of i/initfut 0|)|)0S orin in <>uro is iKMUg To-pos- (iin the nlor of crs (o| linos; tmoo of lotor. or lasuring Itho ob- ;'tion of 'PI r.r]>(i)i.sioH incliido an antoro-postorior dianiotor of 12.7-> coiitimotors (o^ inches) and a ti'ansvei*8e diameter of 12.0 eentinietors (o inches). Tho jilmtr of hint (liinenxintix possesses an aiitoro-posterior diameter of 11 tvnt i motors (4iJ inches), as measured between the end of tho sacrum and the ?'ummit of tho ]»ubi(! arch, and a transverse diameter of 11 contimeters (4^ inches), taken between tho inner siu'faoe of tho ischial l)ones near their posterior border; the distance separating tho spinie ischii is about 10.") centimeters (4J- inches). Tho infrrior xfroif, or anatomical outlet, of the |M'lvis, although loss regular in outline than tho inlet, jutssossos a geiuM'al ovate form, the smaller end of tho Hgure being -|M)storic»r (liaiiu'terfi of tlie superior, the iiifi-rior, and tiie interinediate plaiu's above dt'serilMMl. The pelvic cavity is enclosed Ity the smooth snrfac«'s prescnteil i)y the surrounding l)ony parts; its anterior wall, foruiiKl by the symphysis and the bodies of tiie pid)ic bones, is convex and shorter tliaii the posterior, measuring but little more than 4 centimeters (about \\ inches) in depth ; its {wsterior wall, inchuling the con- cave anterior surfaces of the sacrum and the coccyx, is much longer, cxtoinl- iiig ll.o centimeters (abitut A\ inches) from the sacral pronumtory to the end of tiie coccyx. The lateral walls correspond with the broad (piadrilateral .sur- faces of the ischial biKlies, and present an intermediate depth of 9 centimeters (3^ inches). The j)onl(lon of the pelvis, evidently, must vary with the changes in the j)osture of the body. In the erect attitude the plane of the inlet of the true pelvis is well elevated, forming with the horizontal an angle of about 55° (5U° to G0°), the inclination being generally somewhat greater in the female; the plane of the outlet coincides more closely with the horizontal, subtendinj^ with the latter an angle of about 11° (Pi. 3, Fig. 1). In the erect position the planes of the perpendiculars let fall from the anterior superior iliac spines and from the symphysis pubis coincide ; the base of the sacrum lies about 9 centi- meters (3i inches) above the upper border of the symphysis, the tip of the coc- cyx at the same time being about 2 centimeters (-J inch) above the summit of the subpubic arch. The (ixin of the pcfric inlet is directed forward and upward, toward the umbilicus; if pndongetl downward, it strikes the tip of the coccyx. The axis of the outlet, naturally downward and a little backward, will meet the promontory if extendtKl upward. The plane of the symphysis forms un angle of from 90° to 100° with that of the pelvic brinj. The importance of obtaining definite information concerning the dimensions of the pelvis, but, at the same time, the impossibility of determining many of the foregoing measurements on the living subject, has led to the substitution of external, readily accessible measurements which bear a direct and constant relation to the internal diameters. The most useful of these external meas- urements include — the distance between the anterior superior iliac spines, 26 centimeters; the distance between the iliac crests, 29 centimeters ; the dis- tance between the greater trochanters, 31 centimeters ; the distance between the spinous process of the last lumbar vertebra and the upper margin of the jiubic sym|!liysis, or external covjuf/dte, 20J centimeters ; the distance between the posterior sui)erior spinous ]>rocess and the anterior superior spinous jM'ocess of the opjiosite iliac bone, (»r the ohlhiue diameter, 22 centimeters; the distance between the ischial tuberosities, 11 centimeters. These external diameters, which are readilv obtained bv means of direct measurements bv the pelvimeter, bear sufficiently constant relation to the internal diameters to make them of much ])ractical importance. As j)ointed out by Klein, however, the antero-posterior diameter is subject to considerable normal variation. The aver- age thickness of the bony walls at the ])oints of measurement being known, the subtraction of this amount from the ascertained external diameter evidently J k\ ANATOMY ()!• IIIK I'Kl.N IS. I'LATK ». itiition instant iiieas- dis- ?t\voon lot" the jtweeii [)inotis lietcrs ; :tornal DV the make 'f, the aver- [n, the flently I I i I pelvis, shiiw iiiii iiiiiitt 1. Stljjittlll StM'tiftU l)f it'inilii- |u-i \ ijN, >in n^ I im II nil 11 >iii II ji 1 jiiiii I II iMfi I nil i 1 1 iniiii' stnicliircs ciiiiiiKisiiiu' tlic |ii'lvic llonr: 1, pi'lvii' lii^-cin, \\ liidi iil wliili' line splits: (■-') mill nliluratnr Ciiscia ■ li, ii lliiii inMitiiiiiiil slii'ct, tlic .iiinl l'as<'iii i^li, ciivcriiiu tin um-i i.n :.iii im i- m mi li'Viiliir inii liiMscli'; ."i, (l, tlic sin>riinr iinil iiifcrior liiycrs ul' tlu' liiilliKUliir li;.'aiiK'lit ; 7, .s, lU'cp illiil silpiT liciiil liiyi'is (if till' puriiit'iil fasciii; 'J, skin. iniiiil anil ulistitiical iliaiiutiTs, i I)in>;niin of the into rcctu-Yi'sical fascia iiforior surliicf of the f^ |;f AXATOMV OF TIIK GENERATIVE ORGANS. 21 supplies (lata comparable with the recognized average of the internal diniensionii Thus, the distance between the lower edge of the spinous process of tho last hinihar vertebra and the middle of the upper margin of the syni})hysis, meas- twed by the pelvimeter, is 20 centimeters; from this are deducted the 9 centi- meters which represent the c()nd)ined average thickness of the vertebral bixly and the pubic symphysis, the remaining 11 centimeters corresponding closely with the conjugate of the superior strait as determined by dirctt measurement. The size of the female pelvis, although presenting many individual varia- tions, is not inifavorably iuHuenced by stature, since short women often rossess pelves of more than average breadth. The distincftive characteristics of sex are acquired after puberty, although, according to Fehling, indications of these peculiarities are present ever, at biri'i. Some asymmetry of the pelvis, as of other parts of the body, is usually to be detected. Fio. ;!.— Male pelvis (slifjlitly less tliim uiietliinl iinturni size). The following table exhibits the average dimensions of the ftdly developed female pelvis, the measurements being taken from the dried pelvis : Ceiuimeters. (ireatest iHstaiKv betwi'on crests of ilia -JS I)ist;miv lietweeii :iiiterii>r superidr iliiic spines -J.') l>i>taiii'e between last Imiibar siiiiu' ami front "I" sviiiphysis ]mi)is 'JO TiUK Pi:i,vis. Antero-pnsterior niaiiieter Transverse l>iiimeter OMiciue Diiuneter (Centinietors). u'entiineters). (.Centimeters). Plane (if (lelvie inlet 11. i:i,.") l-J.") I'laiie (if presitest expansion .... 1'_>.7.') \'1.'>0 Plane of greatest contrai-tion ... 11. 11. Plane of iielvic outlet l>.o (increased to ll..') em. \\, \\J^ liy ilisphK'enieiit of eoeey.xi. The (lifttiiu/ulfiliin;/ rlinrdcfn-isficK of the femtde pelvis (Fig. 1) as C(mtrasteoth the inlet and the outlet are larger in the female, the outline of the pelvic brim approaching uu»re nearly the circular form, owing to the slighter ])roJection of the sacral promontory. In the female pelvis the sacrum is broader and less concave, the depth of the symphysis is less, and the subpubic arch is wider, embracing from 90° to 100° as against 70° in the male. In addition to individual peculiarities, the iuHuences of race markedly impress the general form of the pelvis, particularly tiie relation of the antero- posterior to the transverse diameter : the broad, cordiform outline of the Caucasian lemale pelvis is replaced by one nearly circular among the native Australians ; among the Bushman and ^[alay women the usual ratio between the conjugate and transverse diameters becomes so altered that the outline of the pelvis is an upright oval, the antero-posterior dimension surpassing the transverse. Articulations of the Pelvis. — The comjionent bones of the pelvis are united with one another by four articulations (Fig. 4): one in front, between Fii:. -4.— Wiimlo jii'lvis (viowoil from nbovo) witli linamoiits (niic-tliinl natural size). the two pubic bones ; two behind, between the iliac bones and the sacrum ; and one between the sacrum and tiie coccyx. The opposed bony surfaces are closely united by til ro-cartilaginous jtlates and external ligamentous bands, and admit of very limited motion ; these articulations, tlieretbre, are usually classed as amphiarthroses or symphyses. The pubic articulation, or i^i/tnjihi/si.s puhis (Figs. 5, 6), is formed by the approximation of the two oval articular facets occupying the mesial borders of the pubic bones, which are connected by the interj)osed fibrous disk and the sur- t: ANATOMY OF THE GEXERATIVE ORGANS. 23 Ituiu ; Ls aro ■iiially \y the ?rs of sur- rounding external ligaments. The slightly convex surfaces are covered with i)lat('s of cartilage which fill up the inequalities of the bones, the opposed sur- faces being held together by the intervening mass of fibrous tissue and fibro-car- V*: 'irptn r Fig. ">.— Section across symphysis pubis, sliowing interpubic disli. tilage constituting the interpubic disk (Fig. o). This layer, which projects ante- riorly and posteriorly beyond the adjacent bony margins, is thickest in front ; the tlcrti'iency of the intermediate tissue above and behind sometimes results in the formation of an interspace or fissure. The fis- sure within the interpubic disk extends usually about half the length of the cartilage, and is produced during life by the absorption of the tlljid-cartilage : it aj)pears after the seventh ycai', and is of larger size and more constant ill tlie female. While undue tension exerted upon the joint during labor may j>redispose to tlic production of this fissure, the latter is not a sequence necessarily of pregnancy, as is siidwn by its existence in pelves of males and of virgins. A slight separation of the pubic syiiipliysis during pregnancy is regarded by iiKiiiy as probable; this tendency, however, is reduced to a minimum through tlie bracing effected by the decussating fibres i>f the oblique muscles. Tiie external ligaments which additionally strengthen this articulation are the ante- ridi', the posterior, the superior, and the inferior. The (interior pnlm lir/ament, of considerable thickness, consists of several strata of interlacing fibres, the deepest of which passes directly across between tlic l)oiies in front of the interpubic di-k, with which they are blended ; the superficial layers include oblicpie interlacing fil'.res continued from the tendons (pf tlie external oblifpie and the recti muscles, and of the more superficial adductors of the thigh. The jtnxterior piihic lif/amext consists of a few sparingly distributed fibres which unite the bones behind, and it is little more than the somewhat thick- ened ])criosteum. The Kiiprrior pxhic lif/atnent is represetited by a meagre bundle of fibres occupying the upper surface of the articulation. Fiii. (■).— Frontiil soctidii tlirnuch syiui>liysis pubis, oxpusiiiK interpubic cleft (Fnrabcuf). ^T* 24 AMERWAN TEXT-BOOK OE OBSTETRICS. The inferior or subpubic lif/avienf, on the contrary, is thick and triangular in form, and it contrihtites the smooth boundary to the summit of the sub- pubic arch. Througliout the middle of its span the ligament is closeh' united Sufifrior peh'ic h[^at'tent. Inferior pubic ligiinit'}it. Fig. 7.— Anterior view of synipliysla iml)is. i 1(5 \i\ 1 with the interpubic disk, being attached at the sides and below to the descend- ing pubic rami (Fig. 7). The sdcro-iliac articukdion (Fig. 8) lies between the lateral surfaces of the sacrum and the ilium ; the rough articular surfaces of both bones are covered by thin plates of cartilage, that on the sacrum being thickest. With the ad- vance of age these cartilages often be- come roughened and partially separated by spaces containing a glairy fluid. Not infrequently the apposed bones are united by intervening bundles of fibrous tissue, these bands constituting the intei'osseous ligament. The prin- cipal bonds of union are the anterior and posterior ligaments. Tiie anterior sdcroiliae lir/ament comprises :i nundxT of thin irregular fibrous bundles stretching between the front of the sacrum and the adjacent border of the iliac bone. Associated with the upper and lower margins of this ligament are thickened bimdles of fibrous tissue that spread over the ilium respectively as far as the ilio-peetineal line and the posterior iliac spine; Fig. 8.— Section tlirouuli tlic Kit Micro-iliiic iirtiiu lution il.usi'liku). A.YATOJrV OF THE GEXERATIVE ORGANS. 25 4 these bands constitute tlie supe)'ior and the inferior sacro-iliac ligaments sonio- tiraes described. The posterior sacro-iliac lir/ament, which is of jrreat strength, extends be- tween the back of the sacrum and the posterior border of the iliac crest. The general direction of the fibres is downward and inward from the ilium ; some of the fasciculi, however, pass almost horizontally, while a special bundle extends nearly vertically from the posterior superior iliac spine to the third and foiirth sacral segments, and forms the obli(iHe sacro-iliac li(/ament. The sacro-coccygeal articulation includes the oval fawt at the end of the sacrum and the base of the coccyx, and it corresjiontls in its ligamentous struct- ures with the intervertebral joints, to which series it belongs. The bones are united by the anterior, the posterior, and the lateral bands as well as by the interposed intervertebral disk. The anterior sacro-coccygeal ligament is the continuation of the anterior common ligament of the vertebrae, and it consists of a few irregular bands of fibrous tissue that pass from the anterior surface of the sacrum to that of the coccvx to blend with the periosteum. The liosterior sacro-coccygeal ligament, stronger than the preceding, is the prolongation of the posterior common ligament, and it descends from its attach- ment around the lower orifice of the sacral canal, the lower hind wall of which it lartjoly forms, to the posterior surface of the coccyx. Additional posterior bands descend from the sacrum to the coccyx as con- tinuations of the interspinous ligaments intimately blended with the aponeuro- sis of the erector spinse ; the lateral expansions which connect the corinia of the ,ered the ad- ?n be- rated luid. )ones of :uting pr in- terior amcni >gular Ml the jacent us of ■r the pine ; 'xM ii 'im M fe 1 w '.^ iH -{,''■ M '■Jj Fiii. 9,— Variation in sacral curves (Hirsf) : P, jironiontory of sacrum ; C. coccyx. the last sncral segment to the coccygeal cornua constitute the supracornual or lateral liga,nents. The intertransverse ligament is reprcsentod by fibrous bands wliicli pass tVom the lower lateral angle of the sacrum to the transverse pro- cess of the firsi piece of the coccyx. The Intervertebral dixk is a rudimentary member of the series of fibro-car- tilagiiious plates interposed between the vertebrie ; a distinct cavity sometimes exists within this disk (Cruveilhier), especially mIicu tiie coccyx is freely movable; this mobility seems increased during pregnancy. 2G AMEIilCAy TEXT-BOOK OF OBSTETRICS. The coccviroai sct;iiioiits lire lield togetlier In- the extensions of the anterior ami posterior li^iunciits and In* the rndinicntary intervertebral disks which lie between. The indivi»hial pieces remain distinct in the t'eniale dnring early adolescence, bnt become nnitcd bv tiie close of the childbearinj; period ; in later lite ossification l)et\vecn tiic sacnnn and the coccyx sometimes takes place. Closely associated with tiie boundary of the true pelvis are the important sacro-sciatic ligaments. The gmd or pontcrior sacro-fplement the fascia* in the formation of the septum, or pdrlc ortions of the nnisdo, the intervening and most extendeubis, about 1.25 <'enti meters (|- inch) from the middle of the symphysis, and 3.5 centimeters (If inches) below the ujiper Ixmlcr of the ramus. The pnxterior portion is narrow, l>ei!ig little over .5 centimeter (about -} inch), and arises from the inner side of the ischial spine in front of the origin of the coccygeus. The broad intcrreninrf portion of the muscle springs from fascia along a curved line extending from the back of the pubis to the ischial spine, the low- est point of its sweep lying 5.5 centimeters (2^ inches) below the ilio-pcctineal line. This curved line of tendinous origin closely corresponds with the posi- tion along which the division of the j)elvic fascia divides into the inner recto- vesical lamella and the obturator, the line of separation being marked by thickening of the fascia which produces the tendinous marking or the " white line." The origin of the muscular fibres is by tendinous bands, which may not, however, although closely ass(X'iaterincipally of adipose and areolar tissue. The vmco-vcKjinal Inner extends between the bladder and the anterior vaginal wall, and aids in coimecting these )>arts by its firm union with both, blending with the attachment of the j)osterior ])art of the bladder to the uterine cervix. The recld-vtif/iiial layer passes between the vagina and the adjacent wall of the lower part of the rectum ; the union, except l)ehind the U])per part of the vagina, is very intimate, while below, this layer is contimious with the fibrous tissue of the jH'rincal body. The rccff/l hii/er extends behind the rectum and is attached to its walls, becoming continuous with the corresponding layer of the opposite side. The Pelvic Floor. — The exact structures which should be regarded as taking ])art in the constitution of the pelvic floor has occasioned nnich dis- cussion, since by some authors its constituents are limited to those structures which directly contribute to the c'ontinuity of tlie se|)tum closing in the jielvic outlet, while by others all ])arts directly or indirectly contributing to the sup])ort of this septum, as the bladder, the upper part of the vaginal canal, the uterus, and the rectum, are included within the category of the floor. In the present consideration of the ])elvic floor only those structures will be included that directly contribute to its formation, thus excluding, with Symington, tlie bladder and the uterus, and reckoning as belonging to the floor only those ])ortions of the walls of the vagina and of the rectum that lie inti- mately united with the septum. The close relation which these excluded organs bear to the ])elvic floor, howev(>r, must not be overlooked, since by their intimate connection with the tissues of the floor, on the one hand, and by ^ A^^ATOMV OF TJII-J GENEltATIVK OliGANS. 31 lall of of the fibrous walls, <1(>. rdod as •h dis- Kictiiros polvio .ii]>]H)rt uterus, i'os will with 111' floor |io inti- ceUulocl |nce by ind bv I tiieir suspensory ajiparatus, on the other hand, they exert an important influ- ence, as eniphasizeil by Webster, in supportinjj the tissues closing the outlet of the pelvis. The pehlc floor, in the sense here accepted, is bounded externally by the skin and internally by the peritoneuni, and includes the several intervcninjj; structures which stretch across between the ossei»-Iiganientous boundaries of the pel VIS and enclose the irregular outlet of its cavity. Viewed in mesial sa<''ittal section, the floor is seen to be divided by the vaginal slit into two portions, an anteri<»r and a posterior, which have been designated by JIart, respectively, as the pubic and the sacral segments. Tile (inferior or juihit- wijmenf appears triangular, being attached to the pelvis in front, and including the structures lying between the symphysis and the vaginal orifice ; the urethral and the anterior vaginal walls, together with the dense intervening fibrous tissues, contribute largely to this portion of the floor. T\\c posierlor or sacral fief/mcnf includes the structures between the vaginal orifice and the posterior bony pelvic wall, to the sides of which it is closely attached. The portion of this segment interposetl between the vaginal slit and the anus constitutes the inijiortant perineal body (Fig. 13), whose elastic yet resistant tissues enable the septum to undergo great distention during labor. The perineal body is triangular in sagittal section, and its boundaries are the posterior vaginal wall in front, the anterior wall of the rectum bchiiul, and the integument between tiie vaiiina and the anus below. The base of tlie perineal body measures about 2.G cen- timeters, and the height from 30 to 36 centimeters. In addition to the strong bnudles of fibro-elastic tissue and invol- untary muscle that constitute the body, it is traversed by the muscles which join in the common tendinous perineal centre. The female perineum proper — by which term is to be understood the anterior portion of the pelvic floor included between tlie iscliio-j)ul)ie rami as far back as a line drawn through the tubera iscliii — corresponds in general with the similarly situated structures in the male, subject to the modifica- tion brought about by the mesial cleavage of the jnirts by the vulvo-vaginal opening. The perineum must be distinguished from the perineal body, the latter iiu'luding onlv the limited tissues interveninii between the vasxina and the anus. As in the male, so also in the female ])erineum, the fascia? constitute im- portant and resistant structures (Figs. 14-10). (^f these structures there are three : the deep layer of the superficial fascia (corresponding with Colics' OftA NAVl CUUOMf ^ Levator fbscia • .Ifiansuiar Lifmtt jupfrnciiUliyer. •Sup-Perintal faidi j/itrii( turi's (lilVsizi'V tvi AMKIilCAX Ti:XT-l}f>f)K OF fHiSTF/PlilCS. fiiscia), the superficial or inferior, and the deej) or superior layer (»t' the trian- ^liilar li;;anient. 'I'liese f;i>eial layers are attaelietl at various levoiis to the is«'hio-pul)ic' rami anteriorly and laterally, and eonverge as they pi'oeeed baek- /'.rtei Hill iiifir/icial /"• t ith'iil >rrf:-i\ /iitiriiu/ su/'iificial /l< ilHul IlilVC. Su/'i>fUitil /'vrinfal iH/.iy. /'i/'i y/,>y />tii/t'tu/ii/ Me>- c. l'iu/i\' iwrff. luliinal f'lulic artery. In/vriiir lumor- rhoiiliil artery. htjeri, r lt> nio} - rh.i/ttal nerT'i'. /*'«*// ;/('WA iiHtit' of f>t riiu'UHl. ni'ii Yw.. 11.- r,v..f.i- -ninTticiiil stnu'turi'S of tlu' fiiniiU' in'riiifuin (Wt.'issiO. ward to lieeoine continuous at the jwsterior free bonU'r of the so-oall(Hl "peri- neal shelf," the middle of which marks the j)erineal etiitre. The interval enclosed between the superficial fascia and the su{)erfieial or inferior laver of the triangular li"ament is divided l>v the irenital orifice into two trianLiular spaces which toj;ether correspond with the nupirficiid pcrhiati intii-HiKicc. The various strovtures contained within this space include the crura of the clitoris witl) tlic a^•(K•iat(•d ischio-eavernosus muscles; the bulbi vesti!)uli, with the spariiitily developed constrictores vajrinse, the homolojiues of the l)ull)o-cavernosiis; rlie Miperficial traiisversi periniei ; the tjlands of Bar- tholin ; toirether with the superficial perineal vessels and nerves. ( )n removal of the skin and the superficial fascia the ixcliio-cdi'irnoHUH muscles appear as slender hands which arise from the inner surface of the tuberosities and rami of the ischium and the pubic rami, and conver infill (•iiiliiiilit! )■■ ■ /i, iiior- :,/ artt-ry. r //. nil')- 'a/ iie'Ti'- ,tlis i I lit 1 1- of 'Clllll. ed " peri- ii'i' ticial or itice into pir'nicdl liulo tlu" the bulbi inoh>^tit'!^ Is of Bar- ((« nuipclos iherositics 10 anterior bodies of ale except oris, by attcn- Hilbi ves- aetion of le adjacent I va;iiiia, conipressioii o f thi- d I eanal heiiiir exerc iscd, al reativ s tate« tl contractions of tlie anterior pnitioiis df the levator ani innsi-le. The Kiini I'ticidl frininirrMii.s /nrinn i imiseles elosely resemble those of the male, beiiij;, however, redneed in >i/.e. They arise from the imier snrface of the tidierosities and rami of the ix-hinm, in close relation with the origin of the ischio-eavcrnosi, and extend inward towaril the perineal centre, where they blend with the fd)res of the sphincter ani and the constrictores vajrina'. The roof of the snperticial interspace is formed by the inferior or >i>iperfiri(d Uiijcr of the trianjfidar ligament, the somewhat thickened anterior part of tjie Ilorsai T4'in of clitoris. Ditisitlii rtiiy of clitoris. Inferior fi.«si'('tliiii 111' fi'inaU' |«'riiU'Ui" : nii tlic left siiU' tlu' piiiimil iiiiisclts an- cximihimI ))y the nllioliiiii uf tlu' pi'i'iiii 111 liix'iu : mi lln' rifjlit sido tlii' iiiiisclo mid tlu' suiiirliciiil InyiT oI'IIk' liiiiii'^'uliir li^Hiiiriit liiiVL' tii'i'ii ri'iiiuMil, tluTi'liy <.'.\|nisiiii,' till' (k'l'ii Iiiyir nl' tlu' liKiiiiu'iit iiinMlilioil riniii \Vl■i^.sL'l. (l('('|) fascia of the perineum. This layer is utta«'lu'd antero-laterally to the jMiho-ischial rami above the line of attachment oi' the stiperticial fascia, and stretches almost horizontally across the snbpnbic arch to the posterior perineal border, where it fuses with the other layers takin>i- part in the perineal ledt>e. The superior or anyin<; veins and (h>eper nerves, and the fibres of the deep transversus ju'ri- n;ei nniscle, liere divided by the ifcnital fissure, and represented by thin trronps of variable muscular tissue surroundinii' the urethra. On riMuovinii; th(~ skin and fascia, that part of the p(>lvic floor lyinsr ]>oste- rior to the perineum j)roper is divided by a median ridye extendinj^ from the ■ i 5 i' 1 Fk;. ir.,-Iiissi(lin!i of fcmiilc pcriiii'iiin. slinwiii',- tlir lici'iicr >tnuturc~ iiftir r'lnnvnl (if'tlir hviitur iiml >pllill(tr|- lllli imiM'lo illlllrll UKiililkil llnlll Wi'isM'i, jierineal centre to the tip of tlie coccyx, that consists of the lower end of the rectum surrounded by the tleep nniscnlar band of the KjJiiiirtn- aiu r.iiiriniN. Tiiis muscle comprises voluntary fiiscicidi wiiich extend from .he perineal centre in front, where they blend with the fd)res of the superficial transverse jH'riucal and va'ainent and the sacro-sciatic ligaments. Viewed in sagittal sections passing through these recesses, the ;l of the •.r/c/'/C'.v. Iperineal Inisverr-e [sing the led with jter; the |er, since of the |)er parts as two I'p.. iT.-lii.^sc'clidii i>r liiiiiilc iHTiiR'nni. sliDwiii!; sn|M'rli(iiil liloud-vi'sscls ntul iicrvi's 'SnvaEri'): C, clil.iri-; 1/, :iU'iitiis iiriimriiis ; T. v:i'^iiial ii|-ilicc; .1. iniu> ; ", ruccyx: T. Iiiliri' i>chii; /., Micin-M'iiilic liiiiiiiH'iil , 1, 1', iiiti'i'iiiil imilii' nrtrry, iiiviiitr us ; ,;', ^.-racilis ; "lviv' H lor include the arterial brai ehes derived fkMif 3(5 AM Eli IVAN TEXT-BOOK OE OBSTETRICS. :l I \ ! ■( (lifcctly (ir iudirictly iioiii the aiitorior division of the internal iliac, and the vcnons trunks accoiupanyinir the arteries, as well as the venous plexuses occur- riiiLT in close relation with the vesico-vauinal walls (Fi>r. 17). The iiill'rior vesical and the vaginal arteries, touether with twigs from the external pudie, siippU'ini'nt the branches derived troni the internal pudic, of which the inlerior hemorrhoidal and the superficial j)erineal especially supply the muscular structures connected with the pelvic Hoor, The superficial peri- neal artery pii'rces the superficial fiiscia and gains the superficial jierineal interspace, supplying the contiguous structures and giving off the transverse perineal branch. Tile eontinuatit)n of the internal ])udie artery maintains a more deeply situ- ated course, lying along the lateral boundary of the deep perineal interspace between the two layers of the triangular ligament. In this position are given off the arteries of the vestibular bulbs and of the crura of the clitoris, '"^he internal pudic terminates, after piercing the anterior layer of the triangular ligament, as the dorsal artery of the clitoris, from whicli twigs extend ♦•» the corpus cavcrnosuin, the glans, and the prej)uce. The n///N of the |)elvie floor consist of the trnidvs which dose'v cdrrespond with the arteries, of which veins the most important ari' the tributaries of thn pudic vein and those which pursue an independent course and take part in the formation of the rich vesico-vaginal and hemorrhoidal ])lexuses. The iniTcti sup|tlying the structures of the Hoor are derived principally from branches of the sacral nerves, either directly or after their formation of the plexus, snpplementeil i)y some few filaments from the ilio-inguinal as well as Ity nuiucnuis l)ranches from the neighboring hyjxigastrie ]>lcxus of the sympathcti<' (IM. 4). Th(> anterior division of the fourth saoral nerve supplies important nniscu- lar structures, including the levator ani, the sphincter ani, and, in conjunction with the fifth sacral, the coeeygcus. 'i'he small sciatic nerve chiefly provide for the integument and tli'- nioi'e -nperticial structures of the pelvic Hoor, including the perineal miiscle.- (ihe ix'hin-cavernosi, the constrictor vagiiuv, and the transvcrsi pcriinei) and the more external portions of th<' genitalia; the ilio-inguinal contributes fila- ments to tlie Ial)ia. The terniiuation of the pudic nerve ])asscs forward as the diminutive dorsal nerve of the clitoris. Sympatlu'tic filamcMits from (he hvpoga>tric plexus are additionally distributed to those part abundant vascular tissue. contaiuMii; 11. Anatomy of the Female Generative Organs. 'i'he structures coii-iituting the female reproductive apparatus consis, ^>i' thi'ce group. (1) the external, (_) the intermediate, and (.'>) (he interna! generative organs. 1. External ■ rgaiis of generation (I'! o), ,^r he i/n.'!"!l(i, include the mon- veneris, (he labia maioia and minora, the i''ti r! l!)- ;■■ >tibule with the d the occur- )ni the lie, of supply 1 pcri- ClilK'ill iisvcrse Iv sit\i- ei^pacc given ;. 'Hie angular 1 ♦.. the ■s of thc^ It in the incipally lation of I as well s of the niuscu- unt'tinn ->u* londal nid til" nuiscU' luei) and )utfs lila- •ward .IS roni the ()ntainiii;j; UdUSlS, >'! intt'rn;i' icluth' llie with tlie ANATOMY <»F TllK I'KIAIC IT.OOi;. I'l.ATi.; 1. 'J ■/. :, ^ ■r. U i~ t~ 7. ,i^ ^"^ H I, St W^ 4- ANATOMY OF THE GENERATIVE ORGANS. 87 meatus iirinariii.s, and the vaginal orifice. These parts are collectively known as the vulva or pmkmJum. The mons vcnerk presents an eminence surmounting the pubes in advance of the vulva, and is composed of stout integument abundantly supplied with crisp hail's, and a thick cushion of subcutaneous adipose and areolar tissue upon which the rounded contour of the part depends. The labia niajora, the homologues of the scrotum in the male, arc two con- sj)icuous longitudinal folds of integument extending from the mons veneris downward and backward to within about 2,5 centimeters (1 inch) in front of the anus. The elongated fissure included between these folds, the uro- f/cnital orifice, occupies almost a horizontal position in the ertKit posture, and is limiteil by the anterior and the posterior commissure, formed by the union of the labia in front and behind. Immediately within the posterior commissure a crescentic fi)ld extends transversely and constitutes the fourchette ; the space between the latter and the posterior commissure is the fossa navicularis. The labia majora are continuous anteriorly with the mons veneris, and are thicker in front than behind ; they present the usual ai)pearance of integument, being covered on their outer surfaces with scattered hairs and pigmented epidermis; their protectent, produce a structure resendding erectile tissue. The converging and often unsynunetrical lal)ia min(»ra, just l)efore meeting anteriorly, separate into two divisions, the outer and nj)per Itaflets continuing mm h 38 AMERICAN TEXT-BOOK OF OBSTETRICS. ;U 5 : « ^1 »; ! i \ 1 1 || : 11 ovor tlio clitoris to unito to form tlio prcjuifiinn vlitoridis, tlio lower or inner lamina' joininii: Ih'Iow tlic jilands to eonstitutc the //■(■/(» m c/i(ori(liK. The f//7o/7.s', the homoloyiK' ol" the penis, presents i^reat similarity to the male orojan, possess ins; all the parts of the latter rethieed in size and inllneneed l)v the absenee of the urethra and by the cleft and nuxlitied condition of the corpns spon<::iosnm as represented l>y the hnlhi vestihuli. The somewhat laterally eom])ressed hody of the clitoris consists of the dimin- ntive corj)or(t cdrcriKmi, which diveriic behind and are attached by their ernra alono; the pnbic and ischial rami, the snspensory lij^ament aiding in niaintain- ijiu: the })osition of the origan. In front the cavernons bodies are capped by the rounded i//ini>< c/ifnridis, wlii<'h contains papilhe occupied by arterial tufts and the peculiar special nerve-endings, the (jctiitnl vorjuixch'n. The nerves of the clitoris are relatively better developed than the corrcsjiondinir ones of the penis, the organ beinii the especial seat of voluptuous sensation. Sebaceous follicles surround the glans, and they are also present in the outer layer of the prepuce, being almost wanting, however, on the glans itself. These follicles secrete s.il -tances prone to decomposition and to the production of a jteculiar odor. The erectile tissue constituting the dimimitive corpora cavernosa and the glans eovresvonds in structnr(> with similar tissues within the jtenis. Two small nnisei.'s, (he ischio-cavernosi or ercctorcs clitoridis, extend from the ischial tuberosities to be inserted in the crura of the clitoris, and correspond with the homologous muscles of the tnalc. The vcslihiilc includ(>s the triangular space lying between the clitoris in front, the vaginal orifice behind, and the nymph.'c at the sides. Its smooth mucous surface is broken by (he urethral o])eniug, the lorafus KriiKiriiis being situated in the mid-liiic of (he j^osterior v(>stibnlar wall about 2 to 2.5 centimeters (1 inch) behind the clitoris, slightly in advance of the orifice of the vagina. The iifliuti'i/ iiic(tti(s varies in form, but oftenest appears as an ov(»id cleft, frequently presenting short irregular lateral branches, surrounded by a border of .'^lightlv corruirated elevated iiiiicoiis membrane, due to the encircling ring of muscular fibres (PI. o). The /)ii//>l vrsfihiili are two elongated leech-shaped masses (about '2.5 centi- meters in length) situated on cither side of the vestibule a little behind the nymjiha', and attached above to the crura of the clitoris by means of a con- tracted iutermediate portion, the y^^/z'N iittcniicilid/ix. They are composed prin- cipally of close and intricate venous plexuses eorrespouding with the tissues of the male corpus spongiosum, of which part the biilbi vestibuli must be regarded as the cleft hoiiiologue. The eoiistrictores vagina' muscles lie in close relation with the bulbs, and by their contractions, as during sexual excitement, com- press the venous cliaiiiicls and render the tissue turgid aiid erect. The ghivdx of ItdrfJkol'nt, the homolognes of Cowpers glands, are two ronn I'l.ATi; ccilti- iiil the a <'()n- il priii- U(iANS. I'LATK H. I'l'lvic (iririitis in silii nf ii yniiiitf wuiimii nf sixteen yeiirs ; scon from ntiovo after eii refill removal nf the interlines \v itjiiiiit ilisliirliiii'/tlie reliitiniis : .(, iiliilniniiial aurtii ; \'i \ inferior Venn eava ; /'.-■. psnas niannus ; I'l. iMnninMlory of .".aenitii ; /.'. ent reetiun : /», |i. neli nf limmliis ; /.'/ , hi.dy of nierns ; /T. I'lnnius of nterus ; /; , M.iilder: '), ovary; 7', l'iillo|iian lulie; /,'/ , roiiinl liLiiiineiil ; (V, nivter- ii.\, uNarian aitery ireilrawii IVoni Walilevi'n. ffT^- ^li M: J l!i 'Mil' ri MXTKKN'AI. GKNEUATIVK ORGANS. I'l.ATi: 'i. M!flJ!lV\l(A '■ DlAGPAVi 1. \'iri;iii liyiiHti. J. ('hiinii'ti'ri>tii' hyiiu'ii iiiiil I'lHirclu'tlr of n nmrrinl unin.iii: \:iv^r u linkli'il luliiii iiiiiioia Mild |iri'|iiici'. :i. Miilliiunii. slmu in-; I'l'iiuiiml nl' liyiiirii, iH.uchiiiL; Miilrri..i- .iikI |m.-i Mmiiiicl uiill, si'iii- ill |>i riiii'iiiii, liil'^r l:ilii:i mil Ji ii;i. 1. |li)if,'nilM nil a ililViTrlit ^ciilr IViiin Ihr I'n'ii.HiiLi li.;iirf>. w %\\ i;\i'i;i:N.M. (ii;M:i;ATi\ !■; ()1;(;a.ns. l'U\TE 0. I I / > a I i -•a yr ^^ff-. i*» ■"-v;*:.v^-; ^v J I i s > fe a: < ll^ i A^ATO^fV OF THE GENERATIVE 01i(,'AJV,S. 39 the superficial perineal interspace, and not between the two layers of the tri- angular ligament. They arc niuco-serous racemose glands, and pour their secretion upon the mucous membrane by long slender ducts which, after an oblique course, open into the vestibule just external to the vaginal orifice. Dorsiil L rvi of liitor is. />.>r.\u/ tirti-ry of c/itt'ih. rtt'yy o/iorplts i'a7't'rn<>sutn. Deep f^et iiwtil artery. Artery i>/ lulb. Tentlit'ous peri- neal eentre. Kic. IS.— nissc'cHcm of foniale perineum, Rhowlnp the vestibular bull) and tin? clitoris (Weisse). TIk! liymen consists of a thin, usually cre-soentic duplicature of mucous niendjrane, strengthenetl by fibrous tissue, stretched across the posterior part of the vaginal opening, which it i)arHy occludes. The hymen varies greatly in form and in extent, at times being represented by a slight semilunar Ibid Fiii. 111.— Kroclik' strut'tures of tlio fi'malo K'l'iiitalia, iiarticularly tlic liiK'lily vascular bullii vcslibuU (Kobelt). whose concavity looks upward toward the pid)es, at other times forming almost a complete and imperforate membranous septum. The variations in the shape and extent of the fold and its (srifice ine'ude the circular, cleft-llk(>, cordiform, cribriform, and other types, well illustrated on Plate (J. Uupture of the hi* '.1 1 ^ i I!H . }l 40 AMERICAN TEXT- BOOK OF OliSTETElCS. hynieu usually, but by no moans necessarily, occurs durinj]j the first sexual intercourse ; in rare cases the septum persists until the event of parturition. In women who have borne children the orifice of the vagina is surroundeil by irregular j)apillary elevations, the cavuncalce myrtiformes : these are the remains of the ruptured hymen, but are usually present only after labor has taken place, since, as established by Schroeder, the rent hymen is converted into these eminences as the result of the pressure incident to chiklbeariug, and not to coitus. Dorsal neive. Poisal artiiy. Porstt/ 7't\'/i of clitoris. Moatus uri- >uirii4s. Art,-ry of /'ln carries the bladder, together with the peritoneum, well above the pubes, with the conse- (pient tendenty to backward displacement of the uterine fundus. 77ic Fniudc Ureter. — The urt>ter in the female (IMs. 7, 8) presents peculiar- ities in its relations within the pelvis tiiat deserve notice. After the usual relations of tiie abdominal portion of its course — proceeding downward and inward uj)on tlie i)soas muscle and its fascia, being erossetl by the ovarian ves- sels, and crossing the iliac vessels about 1.5 centimeters below the division of the common iliac artery — the ureter passes into the true pelvis in front of the sacro-iliae synehondrosis, thence upon the cjbturator interims muscle and its fascia toward its termination, rmming beneath the root of the broad ligament. About opposite the origin of the vesical and uterine arteries from the yt 42 AMERICAN TEXT-BOOK OF OBSTETRICS. internal iliac, the nreter forms a sweeping curve which is most pronounced where tiie uterine artery crosses the ureter, about on a level with the os exter- num. The ureter crt)sses the uterus at a point closely corresponding with the position of flexure of the uterine body upon the cervix, here lying between the vesical venous plexus laterally and the utero-vaginal venous plexus and the uterine artery internally. The h)wer part of the ureter passes at first at the side of the upper thinl of the vagina; it then reaches the vesico-vaginal septum, within which it lies for 1.5 to 2 centimeters before entering the bladder-wall. The ureter does not extend lower than about the middle of the anterior wall of the vagina; as it rests directly upon the latter, it is encloscHl for a :y Promontory. ,..' ■X hi. .cS> ..c»- Ovario-pelvic ligament. — Tube. -Ovary. Broad ligiimcnl. Uterus. ^' I'c^^' ^.^Hetropiibu ' triangle. Bladder. X I ; I , I •^■s^"' „„„„ I ! ' I ' I N '' I ' Inrernal sphincter anl. ""n 1 I r ' / •W I I lUilho-caTcrih ueral form, the base being above, corre- sponding witii tile greater sui)erior diameter of the canal. Tiie anterior wall is very conspicuously marked by transverse /vff/"' (Fig. 20), wliich are especially promiiienl in tlic virgin; an additional vertical fold, the anterior co/Hmn, is ■^"K 44 AMERICAN TEXT- BOOK OF OBSTETRICS. 'J pn sent at the lower part of tlie passage, where, also, this wall, distinctly thicker than its fellow, is most robust. riie posterior wall, nuieh the longer, extends from the vaginal orifice or the hymen to the apex of the dcc\) poderior fornix (Fig. 25) or retro-cervical fossa ; it lies in front of the anterior rectal wall, with which, thronghont its lower two-thirds, it is united by areolar tissue. The posterior wall measures about 9 cen- timeters, or about S^ inches, in length, being broader above than below ; its supe- rior third receives an imperfect covering of the peritoneum which forms the most dependent portion of the anterior wall of Douglas's pouch. While distinctly less corrugate^/ AXATOMV OF THE GENERATIVE OBGAXS. 45 ^/ (Fi<'. 27), tluiso on till' posterior wall often alino.'^t ciitirt'ly disappearing, leav- ing^the .somewhat pouched surface relatively smooth ; the folds of the anterior wall are retaine.1 to a much greater extent. Ill ,sfn(rfiiir the walls of the vagina consist of a mucous membrane, a nius- c:ilar coat and a Hhrous tunic. The mucosa is covered by a thick stratified, squamous epithelium, and possesses numerous papilla. The rugic include within their structure not only the tissues t»f the mucosa, but also bundles of involuntary muscle and large veins. True (jlawh, if found at all, are repre- sented bv a few sparingly distributed tubular structures within the upper part of the vairinal mucous membrane, the acid secretion which bathes its surface beiii"- the iiroduct of the general mucosa. The deepest part of the mucous mem- brane that corresponds with the submucous layer, is succeeded by the iims- cular coat, composed of an inner circular and an outer longitudinal stratum of u list ri pod muscle. The fibrous tunic consists of a dense coat, rich in fibro-elastic tissue, which is derived as a prolongation of the recto-vesical fascia and materially con- tributes to the strength of the vaginal wall. The lower extremity of the canal is encircled by a thin plane of muscular fibres constituting the con- strictor vatiiiiic muscle, and is closely attached to additional bands derived from the levator ani. Bhod-vcsscls and Xerves. — The vascular and nervous supplies of the vagina arc verv <>;enerous. The arteries are derived from the vaginal, the internal pudic, the vesical, and the uterine branches of the internal iliac. Correspond- iiif veins return the blood to a large extent, in addition to which the vaginal plexus surrounds the lower part of the canal and communicates freely with the iieiirliboriug vesical and hemorrhoidal plexuses. The urethral plexus around the upper jiortion of the urethral canal receives the dorsal veins of the clitoris. Witiiin the submucosa large and plentiful venoirs radicles, together with b;ui(ls of involuntary muscle, give this layer the charaftter of erectile tissue. Till' hjinphatics of the vagina constitute two groups, those from the lower and the upper portions of the canal. The former join the lymphatics of the external genital organs and end within the superior or oblique set of inguinal glands ; the latter, together with the vessels from the lower part of the uterine body and the cervix, proceed outward Avithin the broad ligament, joining with the lymphatics from the oviduct and the ovaries, and terminate in the lumbar glands. The nerves of the vagina are contributions from both the symjiathetie and tiie corcbro-spiual system. The branches of the former are derived from the infe- rior hypogastric |)lexus, those of the latter from the fourth sacral and the pudic nerve. The sympathetic fibres are largely distributed to the vascular tissues. ."5. Internal Organs of Generation. — The Uterus. — The uterus, the thick- ened and specialized segment of the generative tube for the reception, the reten- tion, the development, and the final expulsion of the product of conception, in its mature liut virgin condition is a slightly pyriform body whose thick, dense walls enclose a narrow, cleft-like cavity. The organ lies within the pelvis, 46 AMKIilCAX TEXT- BOOK OF OBSTKTIiTCS. li' w^ I. « lickl by sii|)i)ortiiii>' ptTitoiical folds and niiisi-idar hands oxtoudinii; between tlio bladder in front, the reetuni and the sacrinn behind, an«l the j)elvie walls at the sides; the most (le{)endent porticm of its lower and smaller segment, the cervix, projeets within the upper part of the vagina. The rit'f/in uterus (Figs. 28, 2!>) measures about 7.5 eenti meters (about 3 inehes) in length, 4 centimeters (about H inches) in its greatest widtli, and Tn/v. I\ouui/ h'^ti' ment. ffriionium. Fundus. Hotly. Internal its. Ct'irix. Exttiiial OS. — Anterior surjuee. Fl(i. 2f<.— Anterior vii'W of vir^'in utiriis. sli(i« - Fni. 2(1.— Sniiittnl section of virgin litems, show- inpr reliitioiis of cervix to eorpiis iittri and ivllee- iiif; ]>ositioii of os internum, fusiform cliiiriieter of tiou of i>eritoneum nt istlinuis. tlie cervical canal, iintl relations of the peritoneum. about 2.5 centimeters (1 inch) in thickness ; of the entire organ, approxi- mately three-fifths belong to the body and two-fifths to the neck, the latter being relatively much longer in the nulliparous adult than after pregnancy has ^i 1 ^ PORTlOtI/ VflCIN/lL PoRTIOHl, Fio. 30.— Diiieram illiistrntin!.' the reliitiuns of the uterus lo the vni.'inn, hladder, nnd peritoneum. occurred. The division of the uterus into body and neck is indicated exter- nally by the con.stricted ixihuutx uteri, which is situated about midway in the organ ; internally, hoAvevcr, this botuidary is uncertain, since the contours of the cervical mucous membrane gradually pass into those of the general uterine lining. A.yATO.W OF THK (! EXFIiATI VE OlidAXS. 47 ,cen tlie wallt? at ,cnt, the (about 3 ilth, ami Anh-rioy sui/itce. , uterus, show- 1 clmnutor uf If juTitoiiuum. }, approxi- the latter inancy lias |H' ritoneum. oatcd oxtcr- (hvay in the contours of leral uterine ,1 5! The pvritoriu I'ndi/ is almost flat on its anterior surface, hut i)osteriorly is (11 sti net Iv convex ; its superior and anterior arched border is thick and rounded, and passes over into the slightly convex lateral borders at the superior antrles. The upper part of the orgiui, includinjj its superior arched border, constitutes the fumhis and is completely invested with peritoneum. The serous covering of the'anterior surface extends oidy us far as the isthmus, whence it is reflected to the nei'^hborino; vesical wall. I'he peritoneum on the posterior wall is complete, since the serous membrane is prolonged downward and backward about 2.5 cen- timeters bevond the cervix upon the posterior wall of the vagina before passing to the rectinn. The later.'-.l borders mark the attachment of the broad ligaments. The ccrri.r, sli- lile views of easts of the l"i(i. :U. -Casts (if tlie eaviliis of uteri frmii i"i) a uulliiiara of sixty uterine eavity of a iiew- ei'.'hl years, mid K'n from a iiarmis siilijeet of seventy years iiiiodilied from liorn infant (modilied from Jla;,'eiiiaiinl. HaKeiiiann). opening of the cervical canal. On account of the encroachment of the uterine walls, the cavity of the uterus between the angles presents concave outlines. The vdvUji of fhe cervix is fusiform, being of larger diameter at its niiddh: than at the vmh,t\H' "■•< inlcnunit and the o.s (wtcnniin. Theos internum, which marks the point of greatest contraction, possesses a lumen of circular outline; the AXATOMV OF TJll-: (1 KNKIiATI Vl-l OlidANS. 4!> 1 ol' the ore than Vicwwl llaci'iiiinnil- I'lirs who had (Midinj; l>f- i the inner l-l'nint mill )>r(v I' (•ii>l> iif Ihf ity 111' II IH'W- (iiiuiliUcdl'nim the uterine I outlines. its niiddU: hnini, which Lutline; the OS externum heforf i)r(\LMiaucy appears as a narrow, lransver>ely phiced oriliee. Tlie antcriiir ami posterior walls of the virgin eervical eaiial exhihit coiispic- u.iMs plications (lepeiitlinii' upon the arruntreinent of the hundles (if inuseular ti-.eil asprin<'ipal loiijiitudinal l"olds, the anterior and posterior eohunns, from whieh seeonply of glands the mucous nuMubrane of the lower part of the cervix still further resembles that of the adjacent vaginal surlace. The mitsmldr coat (Fig. 37) of the uterus consists of bundles of luistriped nuiscle (Fig. 38) .separateil by bands of connective tissue and surrounding vas- cular channels. Although irregularly arranged, the muscidar tissue is disposed no AMi:iil<'A\ TEXT- HOOK OF OUSTKTltWS. I in tliree geiuTal .strata — an inner, :i niiihllc, and an uutcr layer. 'J'iie inner layer, Yvi. :'.T.— Arruiimiiuiit of uturiiu' iniisiU', us f,vv\\ from in fnmt after rcmovul of siTcms coat (llulii'i. composed prineipally ut"luiigitiKlinal biiiKlles, is in direct contact with the nni- Fi(i. :;>.— A, i.suliitfil iiaisi'li-'ck'iiu'nts : |)articidarly robust. The nmsculatnre ol' the cervix is distinj;uished by greater regularity in its arrange- , (Hc'lio). the mu- 1 '^lisM*"' roaiiJKrnmcnt. X.,. ^-'t*-- I'lDidus, l-'ii., :;'.i.— lir.iiiil li^'iiMicnts viewed IVdiii the piisterini .-iirl'iice, sllll\vin^' uterus, nviiliU'ts, ami ovaries ; tile iiiitunil |iipsitiiiii nC tlie latter has beeu ili.stiirlieil iu eciiiseiiuenee nf tlie separation (if lliu supiiortiug atlaeluiieiits. Iiurtly after •rtroi)hied mont, which includes a distinct inner longitudinal, a middle eircnlar, and an outer longitiulinal layer. 'Pile ticroiiH ciHit of the utenis comprises the usual constituents of the peritoneum. Lir/ainctitK. — The supporting aj)paratus of the uterus consists of two parts, the folds of peritoneum and the muscular bands which extend froiii the uterus to adjacent structures. The first group includes two anterior, two lateral, and two posterior ligaments ; the second group, the so-called " muscular ligaments," is represented by the utero-inguinal, the ntero-ovarian, the utero-pelvie, and the utero-sacral imiscular bands; the last of these, the utero-sacral, are included within the posterior jieritoneal folds; the remaining ones lie between the layers of the lateral or broad liiraments. 52 A^n^:/i'/(•A^' thxt-book or onsTETiucs. V I ; TliL' atitirior /if/(iiiuit(f< inv two iiK-()ii.uction nf liroiul lit-'iiiiu'iit, showing ri'latimis of tlio u> uitiit.'(l stnicturos. little lower and anti-riorly an' siliiatctl the round ligaiucnls ; jiosteriorly, the ovaries and their muscular attachments ; numerous blood-vessels, nerves, and lymphatics, together with the parovarium, the ))aro(>phoroii, and the utero-pel- vic bundles of involuntary muscles which ])ass from the uterus and the vagina to the obturator fascia, are additional structures inchiiii|i..-iiiu iIh- l.ioail li(;ii- lurlll-- mill llic lltcrii rrrtlll I'uxmi < liimliliril IViilil lliiilu'i'l. ccssiis vaii'iiialis of the male, it is ii-iially (.blitrratcd after earlv life, but iiiav jicrsist, and, in I'arc rases, be accompanied ! an abiK.niially descended ovarv, ••^m 54 AMERICAN TEXT- BOOK OF OnSTETRIVS. which then occiipios a position within the hibia, behind the peritoneal sac. In structure the round lii>'anient consists of bundles of connective tissue and blood- vessels, together with plain ninsenlar tissue derived from the uterus. The jtosfcrinr QV ircto-u((fi)ie. VKjimivHtH are two peritoneal folds which pass backward from the cervix and the upj)er part of the vagina to become con- tinuous with the serous covering of the second portion of the rectum. The deep fossa included between these folds laterally, the uterus anteriorly, and the rectum posteriorly constitutes the poKch of J )oiiglo.s///rj*( of the norma! uterus (Fig. 22) during life has received considera- tion from many investigators, whose conclusions, however, have been s(» contra- dictory and uncertain that almost every situation of the organ has in turn been regarded as representing its normal relation. This discrepancy has been due in large measure to the methods of examination employed, which include observations on the cadaver, biniMMual examination of the pelvic organs of the living subject, and I'ro/.en sections of tlie parts shortly alter death. The examination ol' the viscera in the cadaver in the usual way, even when carried out with -kill and j)reeaution, nui.-t necessarily be untrustworthy JXATO^Vr OF THE (lEXERATIVE ORGANS. 55 sac. In id blood- lich pass jiue con- 111. The jrly, and c'li is fre- postorior •ro-sdcnil 'I Tt '';(-- as to the details of topos^rapliical relations, on account of the uncertainty in- trodiicwl bv icason of the unavoidable post-mortem alterations and ine\ itable distortions affecting the organs. The apparent exactness of the method of fro/en sections likewise is iiiifavoral)]y influenced by the relaxation after death of the sui)porting bands which during life maintain tlic positions of the organs ; it follows, therefore, that the testimony of sections cannot be accepted as unim- peachable evi(l(>nce as to relations during life, since the relations presers'cd are oiilv those existing at the time of fix- ation ; likewise, the possibility of en- countering the effects of pathological chansres in fro/en s(>ctions must also be appreciated. The testimony of the most competent and careful investiga- tors points to the conclusion that the most valuable and trustworthy observa- tions as to the norn;.d position of the uterus are to be gathered from careful examinations of jiroporly ])reserved bodies, where the organs have been hardened in situ immalidtc/i/ after death. The results of such investigations closely agree with the opinions of tiie most expert observers derived from repeated examinations on the living subject. Fig. 44.— DiiiKnuiis illustratinK rniifro df va- rintiou in ])i).sitiuii of uterus as nllVctcd liy ilis- tontlon of the bladder (Van do Warker). the cervix ;e bands, Items, are tube they anteriorly eiiiisidera- ■o conlra- tiirii been s been due li include fans of the way, even •ustworthv Fn;. 4ri.- T.ciimitudinal portion of iMiUopiaii tulic, expivsimr llu' coiiipliciiti'd loiiL'iludiiiiil plications of tlie iii.H'osa wliicli e.Npami into tlie liuilniie (.Sappeyj. In accordance with the conclusions ba.>sts on the bladder and is directed forward and upward, while the cervix forms a slight deflt>ction with the axis of the uterine bodv and looks down and backward auaiii.^^t the riC, AM hi? /('AX TKXT-JIOOK OF OBSTETRICS. %i I * i-; i i - ^ III I I \ \ posterior vaginal wail. Wliotlu'r tiic uterus lies most frequently to tlic right or to the left of the mid-line is still in dispute; the latter position, to the right, is probahly most usually encoinitored (His), although the opposite con- dition, as shown on IMate 8, is certainly uot uncommon. The topographical relations between the uterus and tiie bladder are so close that the position of the womi) is materially iuflnenced by vesical distention. The range of varia- tion in tiie position of the normal uterus is diagrammatically represented by Figure 44. The ofi8), the representatives of the un- united portions of the fetal Miillerian ducts, extend from the superior rounded angles of the uterus, within and along the free upper margin of the broad ligaments for a distance of from 10 to 12 centimeters, to the vicinity of the t)varies, wiiere each terminates in an expanded fumiel-shaped orifice, the pavil- ion or i)ift(nition of parts, the tube at first passes outward closely related with the pelvic Hour; it then turns ujnvard along the altached anterior border of the ovary, when, after reaching the upper pole of the gland, the tube bends downward upon the free posterior border and the inner surface of the ovary (Figs. 22, 41), which are by this means partly masked (Waldeyer). The oviduct commences at the iinier attached extremity as a narrow tube, the istlnnus, about 2 millimeters in diameter; during its further slightly wavy course it gradually gains in width until the tube measures 4 millimeters or more, when it again becomes somewhat nai'- rowed, but beyond the ovary it rapidly expands into the ampulhe and the fimbriated extremity (Fig. 4G). The lumen of the tube is narrowest at its inner end, where it opens into the cavity of the uterus by a minute orifice, the osfhtm infcrinoi}, which scarcely admits a bristle ; the diameter of the canal gradually increases until it presents, just l)efore its fnial ex])ansion into the fimbriated orifice, a distinct opening, the oxtimn (thdoinind/c (from 4 to tJ millimeters in width), situated at tiie bottom of the cleft-like (le[)ressi()n leading from the attached border of the fimbriated exj>ansion. Sfriichiir. — The ovichict consists of three coats — an inner nuicous, a middle muM'ular, and an outer serous. The iini<'fiitf< lining presents numerous longi- tudinal folds (Fig. 47) ; these become more consj)icuous within the inf"undibu- hnn, where they greatly increase in size and complexity and terminate in the sinuous border of the fimbriie. All parts of the canal, including its ex](anded ri'.. Ii'i,— I'liiti^n nl'liri)H(l li!.'iuiifiit stri'tcli'"' '-■■ : Imw tlio imnivnrimii (i>i lyiiin ln'twci'ii Um.- fulils lunl I'oi - .stiiiK or the lioini-tuli(.' and fi'oss-Hiliuk'S (lii'jioiibiuir). AXATOJfV OF TIfl': GENERATIVE ORGANS. hi niitor (-11(1, :uT clothed by a .single lavor of ciliated columnar cells, whoso ciliary current sweeps from the fnnhriic toward the uterine end of the tube. At the free cdce of the fimbria} the columnar epithelial cells give place to the low, i)late- lil<(' elements of the peritoneum covering the exterior of the tube. (Jlands are al)sent within the nuicons membrane of the ovi(hict. The viKscnhir fiuiic includes a i)rincipal inner layer of circularly-disposed bundles of involuntary jcle and a sii'ditly-develoj)ed outer layer of longitudinal binidles. The muse a middl(> lis longi- lundibn- ite in the xpanded 1 Fir,. I".— Traiisvt.Tsi' si^ction i>f l-'iillnpinn tiiln', slKiwiiiir the ciiiiiiiliciitcil nrrniiKcmcnt fjf tlic I/o«(/-C('.s.s(7.s of the oviducts arc branches from the ovarian and the uterine arteries and the corresponding veins, the arteries possessiug an tunisu- ally tortuous course. The ncrirn are derival from the ovarian and uterine plexuses, and consist of both meduUated and ])ale fibres. TItr OvdricK. — Each ovary jireseuts a flattened ovoid mass, somewhat almond-shaped, which appears as an appendage of the posterior surface of the broad ligament (Fig. 'V,)), to which the organ is attached by its straighter anterior l)order. The dimensions vary with the individual as well as with the condi- tion of function:il aetivitv ; the longest diameter usnallv measures about 3.0 oontimcters, the width about 2 centimeters, and the thickness a little ov«'r 1 centimeter. The weight of the ovary is ordinarily between (! and 7 grams, the right being eoiniuouly slightly heavier and larger than the left ovary. The anterior border alone is attached ; the arched posterior border and the broad surfaces arc free and are covered with modilicd peritoneum, the f/enninal ^^"9 58 AMERICAN TEXT-nOOK OF OBSTETRTCS. ; '^ epithelium, directly coiitinnous with tlio serous eoverinj; of the broad ligament. The position of the ovaries in fiita (PI. 8; Fij;s. 22, 41) and ^ince, as pointed out by Ili.s, the f ,: AXATOMV OF THE GEXERATIVI': ORGANS. 59 igamcnt. rt life, at en place, null of the uterus when not occupying a mesial position predisposes to increased ol)li(luitv of the ovarian axis of the opposite side. The smaller and lower end of the ovary, or the uterine pole, points toward the uterus witii which it is united by means of the fil)ro-muscular bands consti- Fuflihfi of' iltrrus. y-thrcf years cal (Wal- ])lane, so lal rather rum Kiclmnl - a factor His, tlie I CoilToiiiti::/ tul'i\ ()ritry. CV;T7*.r. Fiii. .'ii,— rtcnis, tiiln's, mill uvurii's (if ii fliilil (SuUolll. Yfi.. ,'.11— Ovary mid tiilic> iimtiiriil size) nt' ii wnii . of sixty-riiilit yi'iirs (SiittmO. tutiii"' the (iriiridu /If/dinent ; the uj>per and blunter end, or the fiibol pole, after being embraced by the arching oviduct, receives the lower border of the finiiiriated extremity of the Fallopian tube, and is further connected to the wall of the pelvis by the nntfio-pelvic folil of the j»eritoneuni. The ovary lies within a ])eritoi)eal recess, the_/b.s'.sa onirii (dandius), which occu})ies the posterior part of the side wall of the pelvis, usually boimded by the internal iliac aitcry and the ureter behind and the obturator vessels and nerve in front. i>oth the anterior an;e contin<,rent The mcdnlla contrasts with the corte.\ l>y .' Kxjser structure and the numl)cr and size of its vascular, and particidaily its venous, canals. A con- siderable amount of involuntary muscle is intermingled throughout the fibrous tissue soijarating the blood-vessels. Irreguhir groujjs of polyhedral cells aiv encountered between the fibrous bundles of tlie medulla ; these elements, the intcvMitial cclh, represent the remains of atrophic parts of the fetal WoUHan bodies. On the escape of the ovum, surrounded by the cells of the discus pro- lii>('rus the ruptured and partly collapsed follicle becomes filled with blood i)oured out li'om the torn vessels of the walls of the follicle. Subse(pieut chaii<''(' cells containing yellow pigment, hitch), being the most active ele- ments in the process. The history of the corpu- luteum is materially affected bv the occurrence of pregnancy, since, instead of being almost entirely absorbed within a few weeks, as is the rule with the ordinary bodies, when fertilization takes place they ])ersist until after the end of gestation. It is usual therefore, to distinguish the corpus hitcvm of pref/iuoieif, or the corpus vcrniii, from the corpus hifeum of iiictistruation. The mode of growth is iden- tical in both, the stinudus of impregnation leading usually to excessive devel- opment. The primary blood-dot occupying the ruptured follicle becomes invaded bv the eidarged and thickened wall, which soon beeouKs corrugated, the plications encroaching upon tiie clot and increasing to such an extent that the folds crowd against one another and eventually form an irregular broad envelope surrounding the remains of the central clot. When jnvgnaucv occurs the processes are continued beyond their usual length, resulting by the enil of the first mouth in the production of a mass from 12 to '20 millimeters in diameter, characterized by a brilliant yellow ])eri])heral zone siu'rounding a lighter centre. This condition is succeer some months later the ]>osition of the corpus is distinguishable. The characteristic yellow color of these bodies is due to the presence of a peculiar pigment, hdchi, and not merely to disinte- grated blood. r ni it :-<«. f 1 ! i 1 i ^ (i2 AMKIilCAX TEXT-nOOK OF OllSTKTnWS. Tl»c pf'ctiliaritiis distiiijinisliiiiji' the forpiis liitciim of pregnancy from that of mc'iistnuitioii havi' Iniijjj km regarded as of especial signilicaiiee as stipplv- iiijj;' positive evidcnec that ])r<'i;iiaii('y has tak ii phiee. WhiU' the presence of the typical yellow liody iiiiist he rejiarded as stro .<>;ly iii the head-tube is identical with the u|)per ])art of the Wolff- ian duct. Wlii'U this latter canal persi.-ts throughout the greater part of its original extent, it constitutes Udrtner'x duct, the homologue of the vas deferens; the entii'e parovarium corresponds morphologically with the tubules constituting the globus major of the epididymi>. Additional fetal remains in the form of rudimentary tubules are sometimes encountered within the broad ligament in the vicinity of the ovary, although situated rather nearer the uterus than the parovarium. These strnctui'cs con- stitute the jxiraojilinraii, ;md represent the atrophic transverse tubules of the lower ])art of the ^\'ol^iau body, being homologous with the paradidymis of ANA"'K)fV or Tin-: aEXEliATlVE OltdAXS. 6;', tin tliiit siipply- «'ll(-'(! of li fojuli- (»f" (Mtr- )1(1('(1 l)V ry (llirsi). 1 ibr cor- sigus of nrf/(ni of ithin the attached series of lei, their opposite luliiig for 1)11 les are elenieiits )rtions of e tuhules le Woltt- part of the vas le tuhiiles )iiietiiues although iires eon- les of the (Ivniis of Fi(i. .^fi.-siHlUcd liyiliitiil iit- tiichcd tu liuiliriiiti'J cxtrfiiiity of l''iillii]iiini tiilic (NfW Yiirk llos|iital C'llljillL'tl. the male. The closed tnhules of the paroophoron are lined with low cohinniar epitheliinn and are often oceludcd hy partially shed cells. The tubules of these atrophic organs possess a practical interest from their liability to become diseased and converted into cysts which may assume Iarg(! diameters. 'fhe .st, in front of the ureter, toward the cervix uteri. After giving oif twio-s wliicii surround this part of the uterus the artery ascends along the body (if the uterus, sending oif branches which anastomose with those from the oppo- site -iile to encircle the organ. The upper terminations of the uterine freely (■(imiiiuiiicate with the branches of the ovarian and the funicular arteries. The (iniriiin arterij, the homologue of the spermatic, is a l>ranch from the alidfimiiial aorta, and gains entrance through the iufundibulo-pilvic band into the liinad ligament, within which it divides into its two principal branches — the i)il»(l ;iiid the ovarian. The tubal branch extends along the border of the oviduct, .-ending numerous twigs for the nutrition of the tube and the tissue of the limad ligament. The ovarian proprr is of larger size, and passes close to the tree holder of the ovary, which it particularly supplies, tiiially anastomosing with the nieriiie and funicular arteries iicai- the upper angle of the uterus. The /iiiiiri(/ar artcrif is given off from the vesical, after which it joins the round liuanieiit at the internal abdominal ring and divides into ascending and (hseeiiding iii'anclies, the latter jiassing into the labium along with the liga- ment, tiiere to anastomose with the external jmdic ; the former ascends back- ward within the liLiameiit as far as the angle of the uterus, where it Joins the ovarian and the uterine arteries. The riliis of the uterus and of the ovaries are large and numerous and tend to tiirni plexiibrm netwin'ks. Those of the ntrriiK, always large, but of enornioii- size during ])rcgnancy, form a plexus within the broad ligament, which |)h'\iis subse(|ueutly gives place to a trunk which accompanies the Miteiy and terminates in the internal iliac vein. The ovariim reins are pMititiihii'ly well developed in the vicinity of the hilum ; within the broad ■iili 6J .ij//;A7r.i.v Ti:.\T-r,(K>K or oiisTi/rix'ics. m lijrniiiciit tlicy (in'iii :iii iiitriciitc incsliwork, the jxiiiijiinij'onii jih.niH, wliicli siirroiiiids tlic iirlt'iy and uii tin' ri tcniiiiuitcs in tlu' inl"i'ri(»r cava, on tlic k'f't ill flic I'ciial vein. Tlic siili|icritoii( al tissue cdiitains irrcat nnmhcrs oi' vciKiiis cliaiincls, tlic presence ni' wliieli is a iiiatter oi" practical import. Tlic fi/iiijtIiti/irK (IM. 9, Fi;rs. 2, 8) e(Hinccte(l with tlic internal (irjrans ol' "fen- eration iM'ifin as intcfstitial lyiuph-clel't.sand radicles which these viscera, in coin- uterus. ^ i .,u Fiii. 'iCi.— Nerves III' llu> pelvic (irfiiiiis of tlie feiimle ( Kninkriiliiiusein : 1. nerves to fundiis of uterus ; '.'. ri^'lit Fiilliiiiiiin Hibe: ;l, ri«lit nmiiil liKiinieiit; I, nerves tn Fiillnpiiiii Hilie; ."., edMiinniiieiUion between oviiriiui iinil uterine nerves; i\, civiiriim plexus nf veins: 7, ovariim vein; s, nerve (nissinn tci join oviiriiiu plexus ; 'J. liniliriiited extremity (if Fiillopinii tulie ; in. relleeteil peritcmeDUi ; II, uterine nerves; p.", supe- rior liypnpistric jilexus ; i:!, briinehes from liypofiiistrie plexus to uterus ; 11, inferior liyponiistrie plexus ; l-'i, vi'sieiil nerves ; 1(1, eonimunicMtinn briinehes to vesical plexus; 17, eervieiil n'ln^'lion ; !.'», brunches of hypoi-'iistric plexus to cervical ^'aim'lion : I'.i. first siicral nerve; jn, branches i>assini.' .obladil.'r ; 'Jl, brunches jiassins: between bladilcr ami rectum; 'JJ, commnnicatiiii.' brniiches from second sacral to cervical ^iin- KJion ; ■-';!, branch from third sacral nerve to cervical pini-dion ; 'Jl, second sacral nerve : '.'."i, branclu-s from third sacral nerve to vagina and bladder: 'Ji, branches jiassinn from fourth sacral to cervical Kan^rlion. iiion with others, po.s.se.s,s in larj^e luiinbers. The ve.s.sels thus orijiinatiii<:; are arranjfed as three principal groups : 1. The .set conipo.sedof tho.-^e coming from the body of" the uterii.s, the ovary, and the oviduct, which end in the prevertohral lymph-glands in front of the aorta and the interior cava ; 2. Those from the IIS, wliicli r cava, on t inimhcrs 11 import. IIS of ircll- •a, ill coin- I — 1 — 2 111 us (if iitcrns; lion lii'twi'cii I join oviirian vos; IJ, sM]ii'- istric iilcxii." ; Ijraiiclu'S ; from evortehral from tlie rsmmmmm "v^^fp^niF'p.w ujn' w^i' ■' ti EXPLANATION OF I'l.ATK ',». Fl(i. 1.— I.yni|iliiili L'lanils lniiind intenuil iliac vessels, which ulaiuls (:"i) vary in niiiiihi'r and volume. iiiiiiion iliacs ; c, eyteniiil veins; ii.nnlers; i, reelniu; K, iitenis; i,. II, (I, ovaries ; ij. i), romiil li^tamenl ; J, siiperlicial iiverKiiii; trunks ol' same, emptying into lymph ulanils {I); 7, 7, lyniphati<' plexus mrse of iilero-ovariaii veins; 10, 11, lining' ovarian iilexiis, with l''|i.. J.- l.yniphiilics of the iielvic \ iscera .■iml the aliclomeli (Sappey i : ii Mini in; rnal iliacs; o, vena cava inferior: o, common iliiK cervix; M. M, section of vniiina: N, N, Fallopian tiihes renal lymphatics; :',, eonverKiin; trunks of same, eiiip . ol tho ovarii's; ><, ii, trunks lei'eiviiit,' ovarian plexus followiiiK' ( «lanils receiving the lymi.liatics from ovaries; r_', lymphatics from fiiinlus, |omiii^ oviinaii pie.Mis, n.yu same lermiiiatioiis ; II, ulanils receiving (le) trunks from siirliices and hi.rilers of liody of nteriis; I'l, lymphatics ori^'inatinu; in lower liart of cervix, mucous memhrane of uterine cavity and va^:inlll for- liices; 1(1, lymph-ulands occnrriiD-'aloiiK' the course of these vessels; 17. elVerenl vessels of these ^-lands takiMt; their course to the glands lieiieatli external ilia(; vessels ; Is, lymphatics which proceed from the posterior surface of the cervix, ti'rminatinu' in the lihiiids accompanyini.; the internal iliac; I'.', excep- tional lymiih-lrnnk from cervix passinj.' to filand in front of lifih liimhar verlehra; Jn, another excep- tional lyinph-ulaiid anil vessel situated alon^r the course of the common iliilc. Fiii. :f.- Lymjihatics of the breast (Sappey): a, celliilo-adipose cnshioii siipportinn mammary ulaiid ; II, contour of mammary Klaiid : i , superlicial blood-vessels; 1, network of siiperlicial lymphatics; '-', net- work of lymphatics orinliiatihi,' in and draiuiii); the lobules of the uhiiid ; :i, lartrc lymphalic trunks orii;- inaliri),' in the |ieripheral network ; I, plexn.s of lymphatics haviim their origin in the di'eper parts of the t;liiiid; .'i, large vessels orik'inatinj,' in the inner jiart of tills plexus; (i, 7, .s, larizc lymphatic trunks. ' t h (iKNKKATlVK oltd ANS. Pi, Air, 0. 11, (MlllllllOIl iliiic veins; 1 ; 1, lyiui'li- •,,111 l""ly I'f ■(■I'iviiiK llH> il'siurmT 111' 111 vnlllUU'. ; r. (•yli'riiii\ K, uliTUs ; I , ■J, i.ii|u'rli(iiil iliiitic I'li'xiis veins; m, H. jilcxiis, Willi >f iitiTUs; l,"i. I viiniiiiil I'lT- llirsc ^'Imiils |inil'l'l-'il IVnlll lie; I'.i. cXKii nlluT I'XCl'p- iiiniy ultunl : ilics; ■-', ml- \v tniiili!' iii'iK- r p; Its 111' llic Iniiilcs. > - 1 I \ iii].liiiiir- ■i| Uii' uliTii^, u lilrli luis lircM turin'il lonMH il Mipi'i'V . J. I ymi'liiiiii'v III till' |irl \ II' \ 1^11 111 Mini mIiiIiiIih'Ii ,-ii|i|M'y , '.\ I > iii|iliiil ii - ■ I' llir lui n-l -ii|i|iiy ^"mmm ;: i m I l! f I ! I f II % ■4 ,,i ! AXATOJfV or THE (i KXERATIVi: OlidAXS. Go •ft cervix anil adiacciit part of the vagina, whicli extend along the base of the broad licrament and terminate within the internal iliac u;lands of the pelvis near the iltao arterv at its point of divi.-^ion ; •■'». 'I'hose which accompany the ronnd lig- an'ient and eni]»ty into the in>;ninal irlands. These latter, as in the male, hichide two groups, those lying along the conrse of Poupart's ligament, wliich constitute the ohiiquc s(!t and receive the lymphatics from c"ie genitalia, and .1 :irraii"'C(l about the sai^henous opening as the vertical set, into which emptv the suporlicial lynii)hatics of the lower limb. The great abundance of the Ivmiihatirs of the uterus, the cervix, and the vagina is a matter of nnich prac- tical importance, since tluse channels furnish the paths by which septic mat- ters mav invade and affect parts widely removed from the focus of infection. The nerves (Fig- 5^) of tlie uterus, the ovary, and the oviduct are derived partly from the sacral nerves, particularly the third and the fourth, and partly from'the svm])athctic sy>tem as represented by the hypogastric and ovarian plexuses. The nerves include, therefore, both medullated and pale fibres, the latter beiii"- especially destined for the blood-vessels and the masses of invol- untary nniscular tissue. The Mammae. — The mammary glands, being really but highly specialized and urcatlv developed sebaceous follicles, belong to the integument, and, strictlv reirardcd, have no place among the sexual organs. The closely asso- ciated functional relation of these organs in furnishing the nutriment for the ni'wlv-born animal, however, as well as convenience, has made it customary to describe them in connection with the organs of generation. The present pur- pose will rc(iuire the consideration of the glands as developed in the female alone, the rudimentary organs of the male being disregarded. The iiiaimnary glands of the human female (Fig. 57), as seen in well-devel- oped women prior to pregnancy, protected by the integument and the fascia' and the associated masses of adipose tissue, collectively form a j)air of hemispherical ])rominences, the breasts, surmounted by the conical mainmi/kt or nipples. The breasts as a whole are not (piite circular in outline, since their attached bases present slight extensions inward over the sternum as well as outward, above and below, toward the axilla. Neither is the gland always limited by the deep fascia, since small aggregations of the glandular tissue may pierce the fascial septum and lie upon or become ind)edded within the pectoral muscle — a matter of much practical moment in amputations of the mamma for malig- nant disease. The size of the breasts depends so evidently upon the functional condition of thi> glandidar tissue and the quantity and tonicity of the surrounding adi- pose tissue and other ]n'otectiiig structures that the dimensions of the organs must iiichidc a wide latitude of variation. The breasts may be said ordinarily to extend from the third to the seventh rib and from the sternal bonier to the anterior axillary margin, with a pi'ominciicc depending nnich upon the amount of tilt or updu the condition of the gland. The nijiple is usually siiuated on a line correspdnding with the level oi' llie fourth rib, being directed somewhat outward and iipwanl. :! ^ ^: i' ;; l! 1 , '.-'■ M ■I m AMi:i;i< AX TKXT-JIOOK OF (UlSTETIilVS. Viii'viiii:' witli the uciicriil ('(implcxidii, tlic nipple is of a roseate or a ])iiil<- isii-l)ro\vii tint, and is siirroiiiided at its base hy tlie (ircola, an area ol" niodilied intesinrsl n'fi. ifilli iii/i'xiiiiiiiit. ■ — (ii.tiufNiiir ti.^sUt-. Mass 0/ a,Uf'osi '/mtt' /.iwst'r /r, /(';•((/ muscle. Intt^rirstal muscles. /nfrr/i'/'it/uf (/.r'.'/r'A- ;i\sut\ Illili/l ll'IIS i/lIlt Aifif'uUa . -. CiitHiiltlai ff'sxur. . r*'y!phi-ial ia. Intyguiiii'iit lln izoiitiil axis of Si.xth yib. Extt-rna! fl'li iu< tiiH^Lii'. — i' I'll.. .''T.—l/'iitzituiliMiil xTtinii III' iiiMiiiiiiiiiy t-'liiinl in siVk ,■ friizi'ii siitiji'ct iif twi'iily yours iTi'sHit). jrainiiiL!.- its former tint ; in lijiht Itlondes the darkeninji; of the areola uecom- panyiim' |)ret:naii<'y is often very sliuht. and mav sphsecpiently almost entirely disappe;'!'. The skin eoverinu' the areola i- eharaeterized by its variable j)iy it> delicacy. i)y the absence of siilxiitancons adipose tissue, and bv the prest'nee of larI!(;axs. 67 a pinU- nodiiuHl ' nipplt'. innlT ol" I'VIT IV- ' ''"' :"'«'"'''• ^'i'' acccssorv -^.rfi and radlatin-- til'n-, which ivsp.md to „.,.rhanical ^ timuhition. The contrac- tion of the ciivnlarly disposed fil.res ,.iiuses the lupple to iH'conio ni(.rc .^ p'ron.iu.'nt nr ••erected;" tlic radial : til.rcs. nil thi i.trary, tend to depress ,„• ivtraci the iiijiph'. ^^ Thi' ,v(ry,///(.v //••>•••<■'" oi" the niannna >;j|t', consists of an aunn'Mation of pyramidal masses I frnm fifteen to twenty in nnm- 1),,,.) nf acini and Awi^ wliieli corre- spond with I hr l.ihescomposinjj: the oru'an (Fit:'. •">''^)- ''•"■'' '"'"' I't'P'"'"'*'"^'^ '' •'^'",-'<' hiiihlv developed and spcciali/ed seha- ceims -ilaiul. \vho>e excretory tnhe is tiio htcfifcr(iii''< or (/(ilroiis duel, and whose secretoi'v pnrtioii is the associated ^roiip i»l' acini. The individual component u'land^, of hrciisi, the rm iiHvini: iiccti rcuK.viMi to >iin\v 11 • ill.. »1.,. ...... .1..,. I tho ducts mill acini I. Vslk'V CiMiiviTi. tli(> lolies. are invested hy the .-nrroiind- ' in"- connective tissue wliieh constitutes the liictyi: •!, n, liplmlcs nl' ^ccrcliiiu tissue, cdii- slsliiii.' I'l' iicliii 'li.hs liiiccl with nctivc c|iillicliuiii , i , r, sccliuiis (if cxcicluiy ilui t^ ; c|)ta. The latter penetrate within llic aiihdivide the lohes into loltiilcs. ^m 68 AMEIilCAX TEXT-BOOK OF OBSTETRICS. In > f 'Ifi I ^^h Before the occurrence of ]>re«::imncy and of the functional activity asi^o- ciated with lactation the secreting tissue forms hut an insignificant portion of the entire voluni(> of the nianinia (Fig. 59), hut during lactation the acini become enormously developed, tiie lobules of true glandular tissue being readily discovered as nodular masses within the more yielding areolar adijKtse envelope. Under the stimulus of the unusual demands made upon the organ under such conditions, it is ])rol)able that new glandular tissue is formed as extensions of the existing a(!ini. The (tcini of the fully developed but non- functionatiny; or<>an are lined bv a siny-le laver of >liort columnar or polyhedral e])ithelial cells, the protoplasm of which appears gran- ular. Th(! cells rest upon a delicate mem- brana propria which envelopes the aciiuis and which is continued on to the minute excretory ducts with which the acini are connected. These passages, lined with a modilication of the glandular epithelium, join with others to form larger tubes, whicli in turn tal\(> part in forming the interlobular canals. These canals are superseded by the wider excretory tubes draining the entire lobe, which, directly or after joining other tubes, become the con- verging lactiferous or galactoj)hor()Us ducts. The /(K'fifrroHfi diictt^ (Fig. (30) on reaching the areola undergo dilatation and form the utnpulhv, or vii/k-si)iuses. These amptdlic lie beneath the areola, and during lactation attain each a diameter of from 4 to millimeters, constituting important reservoirs for the milk secreted during the periods intervening be- tween the evacuations of the gland. At the base of the nip])le these ducts undergo a re- duction in size and become closely collected, the larger tubes occupying the centre of the grouM ; siuTo'inded by areolar and liiusciilar tissues, they ascend to the summit of the mammilla as indc])eudcnt tubes, whei'e they ternunate by distinct orilices which open into minute . apex of the nipple. The ( pithelium lining the ampullie and tli(> lactiferous ducts is of the low (•olumnar or ciil)oirciisl, slmw iw susiiciisMy li^'iinu'iitx uiiil iiulk - (A.-^ll- y CiiMiPi'r). [XATOMY of the CENI'UiATIVK ORGANS. (59 ty asHO- ii'tion of he acini le bcinp; • adipose ho orpm that now )ns of the \)iit non- lolo hiyor opitholial >arrt ^ran- •ato nioni- loiniis and exoi'ctory K'tod. ludilication kith others take part Is. These r excretory c'h, directly >e the con- is (hicts. M\ reachinji; 1 iorni the ii\ipiillic lie ation attain nilliineters, or the milk venin^ 1)C- hd. At the Idcrii'o :» ''''- V coUeeted, tntre of the the snnunit inet oriliees ph'. ,,f tlie low Imination n'''' ^'•^^'^^ t''*-* elements oecnpying the central parts of the 4 1 lo- iind'i"" li'tt^' degeneration, some becoming disintegrated, while others .'i . „• ,,, iirwses whicli constitnte the colo.stnim-corhi(.sc(cfi fonnd in the % are cast on .!•' ""■■ -t ,„il|. .lurino- tlw lirst feu- days. Tl ' iii)ii"i'iii'^' ui'iundar protoplasm of the cells at rest becomes invaded by - ., |,.,,p, v,iirii (iinctionalaetivity begins, and, as secretion progresses, it becomes , ,. una;.! displaced by the aecnmnlation of oil-globnles within the cell. i rpi , ,,,j„,iir /li-diops exist at first as sejiarate particles, which gradnally increase ^ . ^j ,j|,,ji (i](.v become confluent and form a single large globule occupying r 1 ,,,,.,,. I j, ;■ n;itt (if the cutirc ccll. The nucleus in consequence is displaced . ' I (1,,, Mcilnherv, next the basement membrane, where it lies imbedded jj]iji, ii, . diiii belt of protophism occu])ying the outer zone of the cell. ^ r|'jii. .,(1].; within a single acinus generally contain very unecpial amounts of 1 oil • -^iiiix' "' ''"' <'k'iii*-'"ts are so loaded that the entire cell is occupied by the ■'k oil-driip. wliilr. ou tiio other hand, tiie neighboring cells may contain so little % oil that till' ]>r(scuce of the fatty particles is masked by the protoplasni. 1 I'xtwccii diiM' extremes all gradations may be found. ,| ['iKiii atiiiir-ing a certain tension the contained oil-globules, escaping in the % (lin'ctiiHi I i' liii-t resistance, are discharged into the cavity of the acinus, where tlicv tonctliii' with the graiudar debris of old epithelial cells, are collected wiiliiii ail iiKiiiMiinous fluid and cctnstitute the /(icfiferous secretion, or milk. Diuini'' scent inii the acini possess a comparatively wide lumen, the epithelial lavor fiirmiiii: l>iit a thin lining to the irregidar spherical or tubular spaces. At tlic cr-sation of lactatiou the acini bceome once more reduced to narrow tiiliiili's, iiianv lu'iug atrophic, siu'roundcd by t\u\ thin jirejmnderating areolo- ailipii^e tis-iH'. \\'ith each succeeding ])rcgnaucy a new period of cellular aiiiviiv and mw giowth takes place in the preparation of the gland for its active I'tMc during lactation. Tlirclo-c (if the jK'riod of sexual activity is followed by gradual ]icrmancnt ati'dliliv of tlic secreting structures, so that secretions of the uuuunue of aged wdiiicii sIkiw little more than the atrophic remains of the sometime conspic- uiiiis uland-aciiii iinl)ed(led within the connective tissue which, with a variable aiiKiimt III' lilt, now constitutes almost the entire bulk of the organ. Tlic hliioil-nKsc/s of the mamma are derived from two sources : principally fnim the iiuci'iial mammary artery, through its j)erforating branches within the -■ retiu'uing the blood from the deeper part of the organ follow the (•(irrespoiiding arteries ; the superficial veins form a subcutaneous plexus which liecdiiM's conspicuous during lactation. a|P 'I'lw hjiiiiihitlivx are very iniinerous, as denionstrated by the brilliant prepa- ratidiis made by Sappey (IM. !•, I'^'ig. ;j), and they constitute a superficial and a (lee|ier ,-et. flic former exist as an intricate subcutaneous network in which ^r^mm '•: 70 AMi:iiI('AX TEXT-nOOK OF OliSTETlilCS. i ^l I:,,' 4 I! t the larpjer vessels are situated at tlie |)erij)lierv, and join the lympli-j>ath.s cun- verfijin;hinds ; the other takes its eourse into tlie thorax and eonininnieates with the eliain of lynipliatic no(hdes sitnated behind the sternuni. The profuse supply of lyniphaties and the intimate rehi- tions these hear to tlie lymph-<:>;hinds situated deeply and at some distanee greatlv facilitate the conveyance of infectious materials to other jiarts, there to establish, as in the case of carcinoma mamnue, new foci of disease. The itcrrcn supplying the mammary gland are derived from the cervical plexus through the superficial descending supraclavicular branches, and from the fourth, fifth, and sixth intercostals ; mnnerous sympathetic filaments accompany the latter into the substance of the gland. Variations in the munber and position of the mamma; have frerpieiitly been observed. While reduction in number or absence of these organs is extremely rare, increase in their munber, as well as abnormal location, is by no means of great infrequency. The nipple alone may be involved, being either nudtiple or supi)ressed, or entire additional glands may be present. tSajH'ntninci-ari/ inanniKv have been observed in many locations, among which the arm, the axilla, various parts of the anterior body-wall, the back, the buttock, and the thigh are the most conspicuous. The interesting observations of (). Sehultze on the presence of definite "milk-ridges" along the antero- lateral aspect of the trunk in embryos, extending from the root of the upper limb to the inguinal region, suggest the location in which supernumerary manuiue are most freijuently encountered, such superfiuous organs resulting from the j^ersistence and develoj)ment of areas which ordinarily disappear. The presence of such markedly aberrant mamniie as those found on the back, the arm, or the l)uttt)ck is less easily exjilained, since they arise probably in consequence of the uniisual development of structures representing the ordi- nary sebaceous glands of the integument of the part. Til. Physiology of the Female Generative Organs. 1. Ovulation. — The diifereutiatiou of certain of the cells derived from the ingrowth of the germinal (■j)itlielium coveviug the young ovary into the scwual elements proper, the ova, takes j)la('e very early, so that at birth the formation of the ova is already nearly eoiiq)lete(l, the production of new cells aftei- l)irth being very limited, ;uid probably entirely ceasing after the se<'ond year (I)isehotf, Waldeyer). The ovaries of the child of two years, therefore, eon- tain the full tored up within tiie ovaries of the young child has been esti- mated at about seventy tliousand. While it is probable that a variable number of the inunature ova umlergo partial development befi)i'e puberty, yet the advent ol' sexual matiu'ity at that ju'riod marks the establishment of the full A.\.\TuMy or Tin: (iexhuativi-: sexual urination ,rlls alter coiid year cibre, eon- ■lls always jirimitive .; lu'di esti- )\v number V, yet tlie of the full 1 r(MPiil;U' (li'V('loj)Mieut of the (Jraafiau follicles and tiieir contained ova, niiKUiit'd l)v thi' usual attendant phenomena of menstruation. TliroU'dinut the entire childbearing peri(jd, or from about the fifteenth to I lit tiic loriv-lifth year, the development of the (Jraafian follicles, terminat- ■ If III till' nipiiiic of tlie follicles and the discharge of the ova, is eontinualiy ~......;i.., riie liberation of the ova usuaiiv takes i)lace at dcHnite times, oeclll I Miii. 1 11^ .1 J liieji ill >'i'iieral coincide with the menstrual epoclis, one or mon^ ovu being ^ .f free ;il eiieli period. This agreement, however, is by no means necessary jiiviiinlile. -iitee nrithttio)!, as tiie ripening and discharge of the sexual cle- Piits i- lei'iiiid, undoubtedly proceeds independently of menstruation. The rioe Inuiuni ovnin is a typical spjierical cell, about O.'i millimeter in ji'iineter. euii-isting of granular protoplasm or the rlf(//i(s, in which lies a luicleii- iir '/(/v;i//irf/ nWc/r, about 0.040 millimeter in diameter, containing a \vell-iii:iri opposite wall of the sac. The most |iruiiiiiieiit part of the ripe follicle is less vascular than those jiarts subjected to l('s> pi-es>iire, one spot, the lii/nin fal/lcii/i, being free from blood-vessels, and eorrc-poiKJiiig with the point at which the distended matured sac, from 2 ti) ] iiiilliiiieters ill diameter, liiially ruptures. i /ir^m 72 A mi: HI CAN TKXT-IiOOK OF OnSTETRICS. I I - -I I ! I 2. Menstruation. — At ivk, and is followed, when pregnancy has not occurred, by dcgeuerative changes. (2) The second or (Icfifriirfirc xUir/c is marked by the destructive ])roeesscs which give rise to the usual phenomena of the menstrual ])eriod, including the discharge of mucus, blood, and disintegrated uterine mucous membrane. Five days constitute the average duration of the menstrual flow, although its continuance may be extended or curtailed, owing to individual peculiarities. (3) The third or veparatiir sUu/c is one of re])air, during which the dee])cr and unaffected parts of the uterine mucous membrane institute constructive processes which within the short period of from three to four days result iu the formation of a new nuicosa. (4) The fourth or qi)lcsce)d star/c includes the remaining twelve or four- teen days of the menstrual cycle, and represents the (|uiescciit period j)rcceding the initiative changes marking the beginning of the next ju'riod. The relations b<>tweeu ovulation and menstruation are of great interest, fi)r, although the discharge of the ripened ovum and of the degenerated uterine decidua takes ))lace usually simultaneously, it is well established that it is neither invariably nor necessarily so, since authenticated observations have shown that menstruation mav be unattended bv the liberation of an ovum. While these A.y.iyoMy of the nEXEIlATIVK (JliUAXS. 7;j •iiijT period jjrcpare a ii.so of tlic '•jratioii of" aiul tissiic- juvfriiancy lat the ern- es al"t( r the n oi' ini'ii- II reeiirriiifjj ral ex])laii- lot oblitcr- ■inbraiic of e very rare lhI with an istaiices of sufIatinn hetween the diseiiarged ovum and the uterine chan-'es coin- ,.id,.ntly takiii- place i.s not yet positively estahli.shed. It may be assumed that the til-! nr constructive staj^e in the eycle of uterine ehanj,^es is particularly favorable Im tli<> reception of the ovum : this being the case, it is evident that the prepaiMlinn of the uterine mucous mendn-ane cunnot be directed toward the n..rptl..n nf the ovum, whose discharge takes place with the coincident meii^tiiKil i.h.'ih.ii.ena, since it is probable that at least a week is occupied in the tran^it of the <'.i:g from the „vary to the uterus. Marshall's eonclu.ions that "the ^l.ri.!iia o( a particular menstrual period is related, not to the ovum' discharo..! ar lli;i( period, but to the ovum discharge.l at the preceding period " :uv lullyunnntcd by the more exact data furm'shed l)v ean-ful observ ition The well-k.H.vn coincidence of ovulation and menstruation finds its partial explauatinn, nt least, in the marked congestion of tlu, ovaries and the eonse qiient -.inniilatiu,, and vascular engorgement which the nterus experiences by reason ot th.' .lose arterial anastomoses between the vessels of these oro-ans the iv^iiltin^ inrgescence probably being an important factor in establis^iin'i; die inciistnial Mow. " eight days, in regular ?ception of idiia in the iient of the This stage cv has not c processes , including meiubraiie. Ithough its iliarities. the deejier 'onstriictive )s result in ve or fonr- l1 })reeeding nterest, for, ited uterine it is neither shown that While these IMAGE EVALUATION TEST TARGET (MT-3) 1.0 1.1 |50 ^^~ lii^^B *^ Ui 12.2 2.0 lb |40 Ml nmSsBSE '■25 11'-^ 1'-^ ^ 6" ► ^ ^ /: c% Photographic Sciences Corporation rs WiST MAIN STRKT WnSTER.Nr. usto (716)872-4903 4^ \ iV r^\ r ^^ ^\ ^oN , o^ , li 'll li II. PHEGNAISl Y. I. PHYS10J.0GY OF PlIEGXANCY. 1. Development of the Embryo and the Fetus. 1 . Maturation and Fertilization. — Cuincidi'nt witli tliogrowth of'thcGraaf- iaii I'olliclc, wliidi ciilininutcs in the rupture of the i^ac and tlie disdiarge of" the liiju*)!' i'ollieuli and the egg surroundeil by the di.seus ])roligenis, the ovum |)a.s.ses through a series ot'ehanges eolleetively termed VKitnratiou, hy whieh the female sexual cell i.s prepared lor the reeeption of the male element, without the com- pletion of "ivhieh preparation fertiii/ation of the ovum is impossible. The iuaturation of the ovum consists essentially in the very nneosed of nuoleiu iiiul puraiiueleiu (c) ; il, iiueleiir s|iiiiille in pmeess of I'nrniutinn. tiw j)of(ir bodiex, ore extruded ; the remainder of the cell after the completion of this cycle returns to a «|uicscent condition to await the advent of the male sexual element, ^[aturation takes place entirely independently of the inHu- Kiii. f)H.— Forinit ^t^•■:^ \itln-iiis e 11 111 i)asscs he liMuale t the coiu- etjxml and substance, vesicle nt the f iiui'leiu anil completion the male the intlu- l)U', first polur Itliy ovum migration (Fig. 02); tion of the * 4' unclear Hi)iii(llc anil other elements of the coniplicat«I (Tcle of iiulireet eell- divisioii • ((•) tlif extrusion of a minute portion of the ovum as the jirHt polar Imlii (Fig- <»'^'/ ('0 '^'""'t quiescence followed by a rejietition of division, n-siiltiii"'- ill giving ott' the second polar boily ; ( ) the establishment of e(|iii- libriinu tlic iiupiaraiice of a new and smaller nucleus, the female pvonuclem A « » I: ■-■ ■ • ^ ■■•■■ v,-'"iV#'**'^.'-*'* •■i'l V-..---- . ■••v^'i •■.,'^ Ki(i. (U.-A.niatnrc nviim (if ochiiuis : v, feniole pronucleus; it. imnmturc ovarian ovum of cclilnus (llertwiK). (Fig. ()1). ami the return to a condition of rest. Maturation usually takes i)lace just lu'fore the rupture of the folli(!le and the escape of the ovum. On tlie (diiipletion of the phenomena of maturation, the ovum is prepared for the reception of the male element, the met^ting of the sexual cells in mam- mals iisiiallv taking jilace within the iipj)er portion of the oviduct. Tiie iimiiher of the more vigorous seminal elements deposited within the vaiiiiia that work their way through the uterine cavity and into the oviducts must l)e l»iif an insigniticant part of the entire number lodged about the exter- nal OS. Of thdse, moreover, fortunate enough to overcome the obstacles pre- "•ViV-''".'-''i^')i-V-'f'^ I'll.. I'm.— I'lirl inns nCtlii' iivii i>{ AnliiiiiK filttriali/', sliowintillu'miiiniHcli iiiiil fiisiim nf tlic s|icrnialozip(in Willi till' iivuiii I lli'ilw iiii ; (1. t'lTtillziiii; niiili' clcniint ; 'i. cli'vatinn "f iiriilu|ilii.sni iif I'trn ; '>', li", stiij-'i's (pI lllvinli III' Ilir liiail III' lln' siHTniato/rinll witll till' iiviini. seiiteil ti) tiieir progress within the uterus and tubes, but a single spermatozoon actually takes part in the fertilization of the ovum. .\fter reaeliing the surface of th(> egu and penetrating the Z(»iia pelliicida tlie siiceessfiil spermatozoon is met by a slight jirojectioii of the protoplasm of the ovum, with which the head of the male element soon becomes blended (Fig. ' (ti) iiml tlio tViiiiilc proniicU'iiK iU) arc npiiroiicliiin:: iji It llicy liiivi' iiliiiDSt fusoil ; c, iivum nf ofhlnus nftor coinpU'tiKii uf fi'rtili/iitinn (Uort- witri: f.ii., si');iin'iitiiti(iri luii'lcus. which the original egg-cell gives rise to an extendinl series of generations, leading to the ])ro(luction of the blastoderm. Since the youngest human embryo carefully examiiunl and recordinl — that of Iteichert — was already j)robabIy twelve days old, the early phenomena of impregnation and segmentation have never been observed in man. Direct observations upcm higher mammals, as the dog and the rabbit, have supplied our hnowledgi! of the details of these early stages of «levelopnu'nt, which, in the main, probably closely correspond with the changes taking place within the luunan ovum. Nagel's examination of a ripe human ovum and the dis- SKci.MKNTAl'lo.N oK IIIK oVIM. I'l.AlK 10. -IM (Fig. nuuking ; tlu' «<'.V iitioiis of iUhI. ii«)st <:on- oinatiii, a ss of li-r- •n-mu'leus lion to the , siiHV the rcMtt* have 1. tozoon, the ioil tlir/mg 1 variously :ion of this "ore the egg female pro- if mentation- -division by fi'V-.^... Oiil,'' ..// i->!,l.-< ,rlh ihiUi ••■li' , ,/A hin>-y '/•// r i«^. >• (■(•//.i. iM Itlllziitlou illort- jreneratiot>s, lorded— that Lnoniena of (lan. l>irc<'< Live sujudi*''! It, \vhi<'h, in Iplaee within land thedis- I i St..Mi\iMiciN,- I ■:. I'liiirriiin'. illii^lr.iliii'j llic ■icuiii'iil.'ilinii irrilii' iiiiniiiii.'iliiiii nvmii > \ll"ii ni.iiii|iM,ii,anfr !■; \. llc'Ui'iliMi. I. Iiiiiui'iiiii i<|.ii -iiiliiiu llir icliiliiiii i.r ihi' |iiliiiiii\ liiyii> III iln- liliislmlcnii ' Hniiiu'tl, friT!^ PJIYSIOLOdY OF PltEdNANCY. 77 •ovcrv of the nroscnco of two polar ImmHos, as in other manimal.s, still further jiistiHcs the assumption of this similarity. The minute amount of food-yolk possessctl by the nianinialian egg is uni- fornilv (listril)'''tetl throughout ita protoplasm, and is not colla;ted as a distinet hodv • siieh ova are therefore known as akcithul. As inttuenewl by the amount and arrangement of the yolk, these ova experience entire cleavage diniu"' their division, and are said to undergo total segmentation, being thcrc- fori' liohhl""!!''- •'^'"^'*^ t''*' resulting cells may be regarded as practically e(pial in >^i/.t' tli'i'' '^I"' "^'^ segmentation may further l)e designatcnl as aptttl. The huniaii ov'iiii. therefore, is technically described as an alecithal, holoblastic ocr ill tiiiii "hccome the seat of similar activity by which four cells are pro- (liKcil, the i)n'i'ess of cell-division continuing until the original element is rep- resoiitcil l)v niMiiv generations of direct offspring. "While, for convenience, the s(M.|ii(iitatioit of the mammalian egg may be regarded as etpial, yet, when cIiM'lv oxaiiiiiit'd after the third or fourth cleavage, a slight difference may be noted in the >iz<' "f the resulting elements, or hldatomeira. This discrepancy, iiisiiniiticaiit in its individual variaticm. Incomes gradually manifested by the separation ol'tlie blastoineres into an inner and an outer ccU-grnup, the cells of the (iiitpr irrniip undergoing n>ore rapid increase than those of the inner group, which latter "clls, in conseiiuence of this inequality in growth, gra(lually are invested hv an enveloping layer composed of the outer cells (PI. 10). This iiroeess of eovering-in progresses until the outer cells constitute a complete envelopo, the entire segmcntetl ovum now corresponding with the nndberry mass, or morula, of the older anatomists. Examined in section, the ovum at this stage consists of the single layer of outer cells, to the inner surface of which at one point adheres the less- expaiidcKl gnmp composeil of the inner cells, the space between the two, the xrt/iiiniMioii-i-drll;/, being ocn'tipiinl by a clear albuminous fluid. This stage of tlio liolldw sphere of the mammalian ovum is known as the bhistula or bktslddirniii- vesicle (PI. 10, Fig. 4). The flirt lier changes within the blastida are marked by the rapid and enormous increase in the size of the oviun, in consequence of which increase the outer cell-layer undergoes great extension, with corresponding attenuation di' its elements, which are changeri>liftTutiiiii, known as the "nmU' of llcnsi'n." With (lie f^rowtli of tln' ft-tcMlcrmic hiyor the primarv oiit'T cells l)eeoine more atteiiiiiite*!, and alter a time hleml with the (levi'lopiiijj eetoroduetion of the f/aatrnfa nfdffc. In contrast with the usual appearance of mammalian ova, the early human ovum is characterizcil by the precocious development of villous projections, so that as early as the twelfth day, as represented by Reicliert's ovum (see Fig. 8-1), its exterior presents well-marked elevations. These villi, however, are not luiiformly distributed over the ovum, but are limited to the marginal zone of the compressed spherical oi:\r^ the two flattened sides being smooth aiul devoid of villi. The embryonic area corresponds in position with one of the poles of the shorter axis of the ovum that connects the smooth sides, although at this stage little if any trace of the embryo is to be seen. I'llYSlOLOGV OF rJlKdXAXVY. 79 s l)ecoinc lie tissue, tlu> early lucturt' i« I covorod n profile, [), Fij?- -*)' ingly take ion of the ires. The lie remains le primary umis on all veil as the ua is com- abont this surl'aee, the klo presents greater »len- thc blastula irly a linear irance at the grows for- X prolilerat- >n of all the Initive streak u'oovc. The li discussion. fomplieatetl iiple f^rounds ve streak of of the hlm- liition of the utagc. early human projections, s ovum (see |iUi, however, he marpual |)oin(T smooth with one of ;niooth sides, )(' seen. Coineidently with the fiirtiier growth and differentiation of the two- iavercil blastula, a third layer, the mmidcnn, makes its appearance (Fig. 08). riio ori""in of tills laiM-na is still a subject of" nuieh discussion, but it .uay be •iccrpted as denionstratetl that the mamnialiasi mesmlcrm arises from two ^^^,„.^.^,^ principally by a splitting ofl' or dclamination from the cntoilerm, ii.r. re It tnt ,,, HI 'II i.'i, r.- - -., I tioi .11 nis* llic jirlniitlvo stroiik of raliMt embryo (Kiillikor) : rr, prtodcrm ; nx. rr. i\xinl rrto- .liiiii uii'l' I i.' '"'•- prolifLTiitlon, iw shown by kiiryokini-tic ligur(.'S (k) ; enl, vuUhK'Tui ; m, mcMoileriu. ^iipulinirni"! by a jtroliferfition involving the e<'toderm along the anterittr iiiirt 111' ill'' I'liniitive streak. This latter structure therefore marks the axis jiluiiL' wlilili coiuplete fusion of the three blastodermic layers takes pla(»i Ixlure til"' rciiiialion of the true embryo has started. The primitive streak is a transient structure, and gives rise to no part of the embryo; later it ciitiivly (lis:i|>p('ars. Tlic jrrowtli of the mesoderm is rapid, and s(»on protluces a layer partic- iilarlv (Icvcliipt'd toward the caudal pole of the embryo, expanding in broad Intcnil tit'kls on cither side. Viewed as a whole, the mestKlermic sheet ap|X}ars i>vrit'oriii, with its smaller end directed anteriorly or opposed to the corre- snoiitling part of the embryonal area. At first a continuous layer, the / 'rimitivf s''i>"ve. Ufginning amnion foiti. ixtMl I I" l\ir:,/,l/ I'liii-iiil liiyer ,'/ mrsi'ilerm. Entothrm. Y\u. I'.'.i.-TninsviTsc siTdon of the ombrymilt" nroa of a fourteen and a half day ovum of shcop (Bonnet). mesoderm later l)ecomes displacxxl along the immediate axis of the embryo, this division resulting in the formation of two closely approxinmted but Bepanitod halves : in each of these a paraxidl and a lateral (rod are further to be vei'(tAoic/(/i»>y>/«M/'t" (Fijr. 70). Tlio.«e Htriictures hiter prinhice the iMKly-walla and the wall;-* of the primitive liitts/or boiiy-ivtitii. iMileral pUitis/or giil-tr4tit. — I'ariital mtiodtrm. ritu rot>er)lonfiit Liivily. M,;iulU>y fihlltS. _ Mttiulliiry Jurrmv. Viteitine ?'(•/«. FKi. 70.— Tninsvorso sci'ticni nf ii scvcntcrii ami a half day slu'i'|i ombryo (lionnot). the primitive streak, which, as above stated, is a transient strnctnre havini: nothing directly to do with the embryo, the fundamental developmentiil pnx-esses include the formation of the neural fnldn and the neural camil, the chorda dorsalis or noto- i'hoyil, and the somites or provcrlcbra: Neural Canal.— T\\c de- velopment of this strneturc consists first in the aj)|x>ar- ance of the neural or medul- lary folds, which together constitute a A-shaped dupli- eature embracing the anterior extremity of the primitive streak ; by the thickeniiit: and the approximation of tlio summits of these folds tlio neural or medullary (jroove is j)rotluced (Fig. 71). This furrow is later convertctl into the neural canal, the early reprer>entative of the nervous system, by the further growth and union of the folds along the dorsal line of contact, the closure Iwing lir«t eftected near — not, however, at — the cephalic extremity of the embryo, imt some little distance farther caudally, at a position which later corresponds with Kiu. 71.— Siirliice vii'W of ana )pi'lluciila (if an eighti'ou hour c'hii'k I'lnbrvu (llalfniin. i rj/ys/ftLoffV or rJiKaxAycv. 81 to form upon the addition to ,1/ nitioii"')'!. imnet). u'turc liavinu flcvolopini'"*"' ncuvv „,,i.__Tlio d.- this strnctun' in the apiwar- ural or vmM- •hich together -shapetl dueli- ng the aiitcrinr the primitive he thickcninir ximation of tlio l,esc fohls tlio Hilary yroove is |ig. 71). This oonverteil into anal, the early of the nervtms further growtli >sure being lir^t ihe embryo, imt irresponds witli ^ ,< I tlic ctTvical region of the spinal eord. The extrt-nie e<'phalieend of the neural ( ■ nil nndergoefi expansion into three primitive hrain-vesieles. The neural Inl.js of tlie caudal portion for a long time remain widely separated. ( 'hordii Dorsiilix. — Tiie appearance of the chorda ^loraalin, or tlie notochorfl, -I' lili-lie-; tiic earliest representative of the IttwjiUuUual axis which constitutes the fiuulaiiuiital characteristic of all vertebrates. While the earliest develoj)- t of this striK'tnre has not been observed in man, it is fair to assiune a ■In-e (i.irespoiideiuie with the prcK-ess as studiwl in other niannnals. In these the mesial p(>rti"ii of the entoderm gives rise to a eell-group (Fig. 72) which rpidiiiilK- iMcoiiies separated from the inner layer and displaced, so that the /• .:•,/•■"» C/i'Slllf.' Amnion. rarifial mesoderm. Celhma^s/or U'o/Jjian iody. - Celom. - Afesotlielium. Vtisnitive iiii/olluliuiM. y/siirni mesoderm. Xofcc/iord. I- ii. :.'.- rriiiisVLisi' M'ltiipii of II llrti'on and a half day shepp embryo posscsHing seven somiteH (Bonnet). rc^ullini: (cll-iiiass forms a slender cylinder which stretches from the anterior extreiiiitv nt'the end)ryo to its caudal pole. On section the notochord appears as an oval irnnip of wlls situatinl immediately beneath the neural groove or e;iii;il and ahove the entotlermic layer (Fig. 74). The notochord, for a time represpiitiii^f the longitudinal axis of the embryo, is usually replaced Sy the pcnnaiu'iit vertei»ral axis, at first cartilage and later bone. The remains of this eiuliiyonal structure in man are seen in the central areas of spongy iiiiiterial oeeiipying the intervertebral disks. Si,mit(''<- — flie formation of the somlfm or provcrfvbrw marks the estab- lisliiiient of the segmentation which later is permanently efik'ttnl by the devel- o|)ment (»f the vertebra and the associated parts of the trunk. The production of the somites is so closely related to that of the mesoderm that the primary arr:ii)i:(iiieiit of this important sheet must be rwalletl. After its origin from the (loiihie source of entoderm and ectoderm, the mesoderm rapidly expands laterally, the growth being particularly active toward the caudal pole of the enihrvo, in eonsecpiencc of which the layer becomes pyriform in outline when stH'ii from its upper surface. At first a contimtous sheet, the further develop- ment iif the neural groove from above downward and of the notochord from If «2 AMt:iil<'A\ TIIXT-JUHJK OF OliSTKTJtlCS. Iff t Im'Iow n|>\vHr(l s iiicscHlci'inic tnti-t aloii^ the cinhrvonic axiis into two j;rt".it wiiifTs ( Fij;. ".'>). Facli of tlicso wiiijjfs iiii*l(>i'^i' ditUM'ciitiatioii into a paraxial Itantl no.xt till* uiitUlino, an*l a lateral |)latt> which hliMids away laterally into the l»ini,n. Msoiit'im l\i>i,i,t/ ff/i i,'t/i-rfH /Vr«»'> (I II) ■ I'l' iiiinlhil liiiil i.ii-,ily. f'liiiii. Yv,. 7;l.— Tnilisversf scctinii of n sixteen iiiid ii liiilf iliiy sliee|(emliry(i (f<l(im-hnnpleure. The sj)ace included l>otwcen the two leaves of the cleft lateral iiiestMlerm is the primitiir body-nmty or celom, which afterward Ixxjomcs the pleuro-peritoncal cavity. DKVKI.orMKNT OF THK FKTAI- MKMnUANKS. Pixtk II. iixirt inti» into llif Jixtf'i^"'" IH't). 1 rospoctivi'ly "tho rt'sult- 11(1 iiHH r oiH . //..«" |s..inilos(Bonm'ti fes of the ch'tt rwaril becc>">»'" hnniot/i sif. r.iiiltrvo. lu'iioH \ M). Iiiiigniiiis illiutriiting thu furiimtion of the maiiimitliiin fetal nivnibniiu's (inndilU'd fnnu Koulc). WftW^ Mil ^ n: ■i * i i ( DKVELOl'MKNT OF TIIK FKTAL MEMHKANKS. 1'latk 12. AliautoU Site. Amnion I / 'itvllim- Vfskif. Vasiula* villi of piaicntai chorion. Ewhrvo. Non-p/tuental thorion. f I'illi o/chori.m \ jroniioutw. Mlantoit. btOod-Z't'sst'U, I, 'J. DiH^nniis fUustratin^ tlu* Inter sitiuts nf (lie rnnnalioii of tlio iiuitiiinMliaii iVtiil inoniltrant's llMDililir*! tVollI iv(Mllr). ^ '! i ! ; I II ! , i I' I 1 PHYSIOLOGY OF PREGNANCY, 83 S t The paraxial band of inosoderm does not undergo doavajre as do the neighboring hiteral niesoderiuic areas, but instead it suffers a transverse divis- ion into a series of small quadrilateral luvi-.s, the .soriutcn or pimrrtehrtv. These areas first appear immediately behind the cephalic expansion of the neural canal and progress toward the caudal pole, at particular stages of tho luuuan embryo, as from the twenty-first to the thirty-fifth day, forming ;; series of eonspicnous markings on each side of the dorsal mid-line as far as the extreme caudal extremity (Fig. V2d). The somites are transient and are not represented by adult structures, since tlie segmentation of the permanent vertebrse which later appears does not cor- respond with that of the somites, the areas producing the vertebra- falling in such manner that portions of the somites are embraced by a single vertebra. While not directly related to the formation of the vertebral colunui, the somites con- tribute to the production of the important muscular tissues, since the outer portions of their masses become converted into peculiar flattened bands, the ,niis<>h'-pkdes, from which proceeds the development of the great tracts of vol- untary muscle, at first of the trunk, later of the limb appendages. 3. Petal Membranes. — Coincidently with the ])rogress of the fundamental ))r()cesses just described, the formation of envelopes for the j^rotcction and establishment of means for the further nutrition of the embryo takes place : tliese envelopes are known as the fetal mcinhrancii (Pis. 11, 12), which, in con- nection with the structures derived from the thickened uterine lining, con- stitute the membranes thrown off at birth. The amnion (Pi. 11, Figs. 4, 5), the earliest of the envelopes, ai)pears soon at't(>r the formation of the neural folds and groove as duplicatures of the soma- toplenre which start in front, behind, and at the sides of the embryo. The anterior amniotic fold in luan grows with unusual rai)idity, and, aided by the lateral folds, soon covers in the embryo from before backward, the caudal extremity being the last to be enveloped. The line of union of the several (lii|)licatures has received the name amniotic fiuture. Examined in section, the amnion is seen to comprise not only the ectodcrmic tissue, but also the exten- sion of the parietal or somalopleuric layer of the mesoderm. On reference to the Figures of Plate 1 1 this relation will be seen illustrated, as well as the mode by which the fi)lds meet over the dorsal siu'face of the embryo to form the anmi- otic sac, which, when entirely closed, contains the anuiiotic fluid separating the envelope from the developing animal. While union and fusion of the innermost layers of the ecto-mesodcrmic folds of the somato])]eure produce the true am- nion with its contai.t.etl sac lined with ectoderm, the separation of the fused outer lamina; of the duplicatures from the amniotic portion gives rise to a sec- ond externally-lying envelope, the falxc amnion, or xcronx membrane, in which tile disposition of the component layers is reversed, since the ectoderm lies with- out, and the mesodcrmic tissue next the included space. The latter is directly eiintinnons with the interval between the parietal and visceral lamina? of the cleft mesoderm, and is the cxtra-cndnyonal portion of the primitive body- eavity, which thus extends widely beyond the limits of the embryo proper. 1!1»/ /TTT 84 AJ/EItlCJX TEXT-BOOK OF OIiST£TIlICS. ; t h With the acciimiihitioii ot' the liquor aninii the iUuiiiDii becomes separated iVoiii the embryo aiitl is pushed a};ainst tlie surroiuidiiijif eiivelofies. 77ui amnlotk'jiukl, or liquor (iiiniii, is a serous fluid prochioetl probably bv the amnion itself, having a spceitic gravity varying from 1.007 to 1.008; it contains from 1.07 to 1.06 per cent, of dry solids (ProehownicU). The amount of the amniotic lluid is subject to great variation, the average quantity at full term being between 700 and 800 cul)ic centimeters, or less than one liter. Not- withstanding numerous investigations, there appears to exist no constant rela- tion between the quantity of the amniotic fluid and the weight of the chiUl or of the after-birth. In addition to the evident use of the fluid for the mechanical protectiftn of the end)ryo, it is probable that it affords a source of water to the developing animal, since there is stung evidence to show that the fluid is con- tiimally swallowed during the greater part of intra-uierine existence. Toward the later months of gestation the pressure induced by the growing fetus and the large amount of the amniotic fluid pushes the amnion into close contact with the surrounding false amniim, the two becoming closely, although not inseparably, unitetl by the end of gestation. As the embryo gratlually assumes a more definite general form, the roots of the true amniotic folds sink more and more ventrally until they meet, thus closing in the body-cavity and forming its anterior wall. In the early stages, when the yolk-sac or umbilical vesicle communicates with the widely open gut-tract by means of its broad stalk, approximation of the somatic plates is prevented. With the decrease of the umbilical vesicle and the corresponding diminution in its stalk the ventral plates grow together and rapidly close the ])I('uro-peritoneal cavity excej>t at one point, the umbilical opening, through which ])ass those structures that conntvt the embryo with organs lying with- out its IkkIv, as the umbilical and allantoic blood-vessels and stalks with their acconqtanying liunina. Tlic Alhudoix. — The allantnis appears as an outgrowth from the hind-gut (PI. 11, Figs. 5, 6) after the primitive digestive tube has become well defined and j>artially closed. When typically developed the allantois grows out as a free sac into the space between the true and the false amnion, raj)idly increasing in size. In man, however, the allantois at no time exists as a free vesicle, since it almost at once forms attachments with the structures extending from the cautlal extremity of the human embryo as the abdominal .stalk (Fig. 7o), in which is included the lumen of the imprisoned allantoic sac. The primary function of the allantois is to act as a receptacle for the excre- tory allantoic fluids thrown ofl' by the Wolffian bodies, by which primitive orjrans the effete matters are removed as bv tiie kidnevs at later stages. Sub- .sequently the allantois takes an imj)ortant part in building up the chorit)n, from which the fetal contribution to the nutritive apparatus of the placenta is directly derived. The abdominal stalk is peculiar to the human embryo, in which it very early appears as a pedtmcidated extension of its caudal portions to the sur- rounding false amnion, over wliich it expands and with which it fuses, tlie PHYSIOLOGY OF FREGNANVY. 85 I separated >es. iibly by the itcontuin:s niut of the t full term liter. Xot- nstant rela- ichiUlor of nieehanieal water to the HiiUl is eoii- ;e. Toward ig fetus and •lose eoutact dthough uot , the roots of 'V meet, thus early stages, widely t)peu latic plates is •orresponding idly elose the ling, through lying with- is with their the hind-gut well defined ows out as a ly inereasing free vesiele, tending from %,dk (Fig. 75), for the exere- lieh primitive stages, ^^nb- the ehorion, le plaecnta is which it very ns to the sur- li it fuses, the allantoic tissue taking part in the formation of the ehorion (Pi. 12, Fig. 1). The allantois in man, therefore, is never free, and finds its expres-sion in the entodermie diverticulum, which passes from the hind-gut through the abtlom- iiial stalk toward the diorion.* Wliatever its initial moir characteristic leaf-like, club-shaped processes. These processes often consist of a main i>rimarv stalk from which second- ary twigs branch, from which diverge the ultimate leaves. * Tlip term ''chorion'' is hero nscil in a restricted sense as indicntintr the nieiiihranc resiiitiiiK from the fusion of tlie false amnion and the aUantoie tissue : l)y some authors (Minot) (lie "chorion" represents tlie entire extra-embryonic somatopleure, which gives rise alike to the true and the false amnion. I i «G AMKRICAX TKXT-JiOOK OF OBSTETIilCS. Tlic form and arraiim'iiu'iit of tlio villi varv soinowliat with tlio duration of prcjiiiancv : at the tiiinl month, or when the phu'onta is formed, the villi are >short, thiek-.set, and of irregular shape; later they become less irrej^ular, and the sceondarv branches leave the parent stems less aeutelv ; finallv, at full terni, the villi are more regularly dispostnl and their branches have bec<»me long and slender and less closely set. The recognition of the villi of the cho- rion is often a matter of much practical importance, since their ])resence, as determined by microscopical examination of suspicious matters discharged ^tcr raffiiKiiii, is positive evidence of the existence of pregnancy. Their j)eculiar arrangement, and their flattened, petal-like fornj, together with their vascular connective-tissue stroma and epithelial covering, usually suffice to establish the diagnosis. T/if Plactida (ind Ihrifluw. — The primary uses of mechanical protection atforded by the membranes in mammalian end)ryos are supplemented by the important rofe of assisting in establishing an efficient nutritive organ through which the maternal tissues may extend the necessary aid to the maintenance of the developing animal during the latter two-thirds of its intra-uterine life. Such organ is the placenta, in whose ])rodiiction both fetal and maternal struct- ures take an active part. The early villi of the chorion are practically identical in all parts where developed. Very soon, however, the villi occupying the area which later will correspond with that of the placenta exhibit unusual growth, and outstrip in size and vigor those of the remaining parts of the envelope. This ditlerence in the dcveIo])nicnt of the villi marks the division of the mend)rane into the cliorioti frnn(l(>.-ir vai ■C'U liar ifular ;tal)lish the pr DtOOtlOIl lUed by tlio ran tbroniiii nti'iiance o utonno life prn [il striK't- parts where t'h later will (I outstrip in litVereiu'c iito the us ( ane J iiav t oi' the g! 7G). The >near. fil>pe tl le ovit liict, :('ne(l imieons ut, whieh step; eiiu vkes to fold whieh thin the mw ■d at the close (hridua ; nf [, or that por- ; rcva, or that if the nteriiie lude.1 The nin<>; me it contribults II pv )liferatinii lartred both in i;r.l.ATH>NS ol- rKTlS ANI> iniciwr.K I'l.Aii: i:t. ^■5 ^ > I tD _J rilYSIOLOGY OF PREGXANVY 87 size aiul in the nnml)or of the tubules, the increase particiihirly involving tiicir deeper parts. Subsecpiently the j)ressnre exerted upon this hypertro- i)iiied tissue by the rapidly growing embryo and its surroiuiding structures induces atrophy and degeneration, so that i\w outermost part of the thickened uterine nuicosa becomes the ntnitum compada, and the middle part the stratum snoin/ioauia (Fig. 77). The limited zone embracing the fundi of the tubular uterine glands remains unaftected, and, after the expulsion of the structures Mucous /fhii; -vitliin it-fi'iitt/ itttia/. Fi(i. 7(i.— Uittgram illustratiiis ri'lations of structures of the humnn ntorus nt the end of the seventh week of pretinaney inioditied from Allen Thompson). constituting the after-birth, institutes the processes of repair by which the new mucous membrane of the uterus is produced. As the result of the secondary degeneration of the epithelial jwrtions of the titerine mucosa the vascular cho- rionic villi are brought into close relations with the vascular connective tissue of the uterus, by which the interchanges between the fetal and Uiaternal cir- culations are facilitated. The relations between the fetal and the maternal parts of the placenta, in m 88 AMKlilCAX TEXT- HOOK OF OliSTKTIilCS. the simplest type such as posspssoil hy the hog, consist ossontially in the rccoj)- Kiii. 77.— Scrtion tliriiiii;li iiterint' wnll nnrt nttnclii'd )ilii(>i'iitii (WnnmT): », iilciiiic wall rciKlcri'iI spotii.'y liy urciilly-iU'Vi'luiicd iili'iilU' siinisis (h.frnliiiii ; f, line of si'|iiinitii>ii ;./';<. rcliil imrlinii nf iilnci'iiin, tmisisliiiu' nf a miiss of viis<'iiliir fcliil villi ir.r.i.i, sur- roiindiil liy tlic iinitiTiiiil liluoil .'•iniisi's : mn, iiiiinioii coviiiiit; fri'i' iuliriml Mirliicc of pltici'iita. tion of tlic simple chorionic villi within ccdTcspondinj; »lc|)rcs^ions in the Fi'i. (>.— I'lari'iitii vifWLMl from iiliriiic surfaci' of aitacliiiu-iit, slmw iii'_' ilivi>ions iiitocotylcdoiis (Itidloo). niatornal tifisues, the circnlation of the villi coining int(» close ap]>ro.\imation ^ i)i:vi:i,(>r.MKNT or tiik rirn s and ris ai'1'i;m»a(;i:s. |'i.\ti:ii. tlio rcccj)- iMiII niKlcrfd i» xriiliim ; x, " K'l'-i.', Mir- iitii. 'IIS ill t\ le I ■/. T 1, 5 3 * - » i • ^» — C . 'r C:T 3 — r -I ~ r i :: 1 si-- ■■ I." (Hidldo), iniiitioji Ci5! ! ■! ,Twr- I rilVSlOUKlY or I'UFJiNAycV, 89 with tlic ciiliirfr^Hl l)ljr„lar fonn and centimeters in thiek- uiss. It pre>eiits an inner smooth siu'faee, eovereil by the amnion and look- ing toward the fetus, and an outer rough, spongy, uterine surface of attaeh- nu'iit sidulivided by furrows into numerous more or less distinct areas or votjilalonx (Fig. "8) composed of the lacerated decidual tissue and vessels torn through at the time of the separation of the placenta, the decidua serotina split- ting, one |)art adhering to the outer surface of the placenta, the other remaining attached to the lUerine wall. In contrast with the dark blood-clot hue of this tissue, the smooth, shining amniotic surfice appears of a generally lighter, somewhat mottled tint, made uj) of reddish-gray patches alternating with yellowish areas, which depend respectively upon the contained blood and the fetal villi, whose colors shine through the superimposed transparent anniion. riu' j)laceutal blood-vessels (Fig. 7{() — the two umbilical arteries and the single umbilital vein — s]ireatl out in all directions from the usually eccen- tric point of insertion of tlu- umbilical cord, when t the entire thickness of the organ. ( 'loM'r investigation shows that the spongy layer is composed of the loosely held masses of chorionic villi (Fig. SO), with the intervillous blood-spaces, separated into the I'otyledonous areas by con- nective-tissue se|)ta. The outer mem- wianous boundary consists of the con- densed portion of the decidua serotina, which atlhcres t(» the fetal villi and sup- plies the outer wall to the blood-spaces ; the inner boiuidarv incluiles the denser portion ol' the chorion together with the adherent anuiiou. .Microscopic examination of' the spongy placental tissue, as seen in sections ]•■;,;. VII _|>,,,-[|,in nf illji'clrcl \\\\\\> \'T'<\\ ii'iilii ■•(■ nliniii livi' mmillis i Mini.t 1.1a- it cnial blood, )thclial w;ill A' tho aftor- L'li irrcfi'iilar ITS in tliit'k- m and looU- of attacli- iict areas or vi'ssels torn •rotina split- T rcniaininu: t hno of tills idly liii'litcr, iiatint; with lood and the rent amnion, 'rit's and tlio ■nally cccon- l)lo(»d tlicir 10 ovc'rlyiiii>; S wliicli arc the smaller placenta l»e llie unaided ii'lass, the niposi'd of nemltranoiis nehiiK'd a iiiii' alnio>t ■an. CloMT le spongy insely held iT. SO), with , separated l»y eon- iiitei- iiiein- f the enii- la serotiiia, i and snp- ind-spaees ; •ether with in sections riiYsioiJx.y or i'ni':(ixAy<'y. 91 tFi.rs. SI S-J), .-hows the villi, althongh ditlering greatly in si/e, to lu' made ■I J"i,,. s) -..<(, ,.(j,,,| (I,,., |||,_r)| jiliici'iitii t "f :i vinii> ; r/. si'i'tidii-i 111' niniiliciitiiiiis nl' Ilic villi iinioiis.' Ilu' liinli'iiinl liluud spiici's ; /», (Ircp liiviT of the iliiiiliia, >liouiin.' iciniiiii^ nl' ciilniiicd L'lniicls (if sUiiHim s|i(m);ioMiiu ; IV, uliriiiL" Ii1(iuiI-vi.'ssl'1 ConiU'i'lfil Willi |iliii'('iiliil >iinis : )li\ miiM'iiliir wnll of mIitus. up of a stroma of eiiihryoual connective tissne containing large liranched cells I I if I 1 > 1/ 11- 92 A.VERIf'AX TEXr-BOOK OF OBSTEmiCS. and hi ood- vessel. s ; these latter consist of the larger twijjjs, eneased hv the rohiisl ])riniary stalks, and of all i^radations of size to the slender caiiillarv lodps supplying the terminal petal-like processes. The extei'ior of the very yoiiiiu villi is covered hv a layer of chorionic e])ithelinni, but this soon becomes I( -s distinct, and after the fourth month it no longer c(mstitutes a continuous lavi r but is present only in patches. The ectodermic epithelium covering the clio- Klc. sj — A. si'ctidii tlirdUL'li iimrf-'iii nf iilnceiitu at fuU tcnii (Miiidti: /'. /', ilcop liiycr iif lU'ciilim . )V, c>liiirii>nic villi viiriimsly cut. Mnnil-vcsst'ls iiijrcli'il ; >/. iiiiirL;iiiiil s)iiicc nearly fvcc fnnii villi; n, alrniiliic ('Xtra-|ilai'cmal villi: I'h'i. clKnidii : h, vi'ssel of uliTiiif wall; I'ih. caiializiMl tiliriiic (UTivr.l ri-Miii laiKliiiid clKniuuic fctoilenii. B, - tinctwall to the bloo(l->;|)ace has given rise to nmch discussion an case, seems to be fdiiml in the more careful study of the developmcMit of tiic tissues, which study ha^ shown that in the earliest stages the fltal villi arc separated from the maternal blood-vessels bv an intervening laver of decidua as well as bv the endotheliiiin PHYSIOLOGY OF PREGNANCY. 93 by the robist apillary loojis lie very yoiinjx 1 becomes Ir^^s itinuoiis lavi r, erinj!; the cIm- '&^ (7 :i^ liiycr (if . islsts oi" a tli'ili tciK'il, sealo-lilic III fail to I'cvciil villi and tlic tiitact with tlic )seiire of a (h»- i(l<'onrti('tiiv/:is- eius to be Iniunl ,hi('h study ii;i- )in the inatcnial the eiKU)theliiiiii t'( w of the vessel- With the progressively increasing capacity of the enormously dilated blood-capillaries into the blood-spaces the compression and atrophy of the' interposed structures follow-first of the decidual tissues, and finally of the VKCular endothelium, during the later months of pregnancy the external surface of the chorii>n and its villi constituting the immediate wall of the maternal blt>od-si)ace. ,. , , i -i- i i • 4 Umbilical Cord.— The formation ot the human umbilical cord is closelv related t.. the primary abdominal stalk. The latter, as already noted, mav i)e reoanlod as the extension of the embryo— a^ a sort of pedicle connect- imrits caudal parts with the chorion and containing the allantoic diverticulum. In°the early statics the somatic folds which form the amnion bear the same relation to "the al)dominal stalk as they do to the more anterior parts of the embryo ; later they bend around the stalk to meet and join on its ventral surface, the amnion in consequence becoming separated from the stalk, which thus becomes gradually enclosed within a tubular amniotic sheath. The closure of the soinatoplciuic folds around the abdominal stalk imprisons the umbilical or vitelline duct within a space which is, in fact, part of the celom. This space soon becomes giratly reduced, and finally is obliterated. The foregoing rela- tions point out the iact, strongly emphasized by Miuot, that the umbilical cord is covered with the direct extension of the emltryonic somatopleure, and not with theanminii, :is is often asserted, since the amnion gradually becomes sepa- rated from the embryo along the cord as far as its distal end, where it still remains eoiiiiccted. The iiicst important constituents of the umbilical cord in its earlier con- dition are flic two iiiiibilieal arteries, the two umbilical veins, the allantoic diverticulum, and the extension of the celom containing the vitelline duet and, possibly, traces of the vitelline vessels. Ijater, the umbilical veins fuse and constitute a single vessel ; the allantoic lumen and the celomic space atrophy and disap])car. The atrophic vitelline or umbilical duct long remains, even after I)irth tlie vesicle ami its duct appearing as a minute sac and stalk lying between the amnion and the chorion, in close proximity to the placenta. The liiimaii iimbilital cord at birth measures about 55 centimeters (22 inches) in leiio-tii. with tVo.'n 15 to 160 centimeters (6 to 64 inches) as the extremes of its variations ; its diameter is from 10 to 15 millimeters {'^ to f inch). The cord usiiallv joins the inner smooth surface of the placenta eccentrically, its insertion at times being marginal, or, in rarer cases, even altogether outside the immediate area of the placenta. The apparent twisted condition of the cor'i i.s often very marked, the spirals, sometimes to the number of thirty or more, being ('m|)hasized by th(> contained blood-vessels. While this phenomenon has long been known, a satisfactory explanation of the twisted appearance, which begins ix'fore the third month, still remains to be given, notwithstanding nu- merous theories and discussions. A point of especial interest, as poiiit(>d out by Minot, is tliiit tliere is no evidence that i\w entire cord really undergoes torsion, but rather that the blood-vessels become coiled within the soft ti.ssue as the result of an excessive unequal growth still insufficiently tinderstood. ■}]' ■■ ( '^r ff 94 AMU RICA X Tr-:XT-JiOOK OF OBSTETRICS. The structure of" the cord includes an external covering of epithernuii directly continuous at its distal end with that of the amnion. The bulk df the cord consists of the peculiar form of enibrvonal connective tissue known ;is the jel/i/ of Wharton, rich in branched cells with anastomosing protoplasmic processes. Shortly beyond the iwnbilical opening both caj)illarics and nerves are apparently wanting ; lymphatics, in the sense of definite canals, are also absent. In addition to the lar^e umbilical blood-vessels, epithelial mfi>-(s indicate the remains of the allantoic diverticidum and the vitelline duct. o. Development of the External Form. — Adoptingthedivisionssuggotcd bv His, it is convenient to distinguish three stages in the development of the human subject. Tiie Mdfn' of the orntn end)races the first two weeks of gc>t;(- tion, and is occupied by the earliest developmental processes; the oiihri/nn,,! star/e includes from the third to the fittli week, during which time the cliaiac- teristic end)ry()iial features are pronounced and the principal organs and svmptoms are well established; the remr.ining weeks of pregnancy are devoud Xoi\w fetal .sVa^c, during which the cmbryi lal characters are gradually replaird bv those of the fetus and the full-term child. While it is evident that iki sharp demarcation separates these stages, yet certain well-jironounced chaiai'- teristics distinguish, in general at least, end)rvns of j)articular developmciitid epochs, and conse«piently serve to determine their ])robable age nofwithstandiiii; individual variation. Stage of the Orum. — Oj)]iortunitics for examining early human ova are rare, the youngest well-authciiticated and carefidly-observed specimen being iIk classical ovum of about twelve davs described bv Keichert (Fig. H'.)). The Fl(i. K!.— nuiiinn (iviiiii of iiliuut tuflvc diij s i lii'iclu'iti : A. rrmit view ; H. siile vkw. 'I'lic villi iirr xiii lu bf liiiiitcil ill ili.-tiil)Utiiiii. Iriiviiii; llic pules livo. a])pearanc<' of this ovum emphasizes the early and precocious devcdopmeiit nf the villi which encircle the flattened lenticular vesicle (o.o millimeters in ih greatest dianu'ter by '.).'.] millimeters in thickness) as a closely set e(|uatnrial zone. ( )f the embryo proper no trace was discoverable, a patch of thickcncil cells alon<' representing the embryonal area. The earlier processes of mu- mentation and blastulation hav(> never been observed in the human ovum, Sta(/f (f the Kinhri/o. — The thirteenth ami fourteenth days witness the evolution of the early emi)ryonal form as effected by the development of tin medullary groove and canal and their cephalic expansion. The embryo is attached by the allantoic stalk to the surrounding mend)raiies, the axes of tin I'HYSJOLOtiy OF PREGNANCY. 95 of epithelium The bulk nf ssue known ;is ; [n'otoplasiiiic es iiiul nerves anals, are siUd ithelial nl!l^H■s ■nine (hict. ision8snjr>r»'>'i'il lojMnent of the ,veeks of ire>lii- tlie ODhrjimial inie the ehanic- Kil orj^ans iiml ney are devntiil ichially replinvd >vi»lent that im uounced charar- • (k'velopnu'iilal notwitlistandiii",' lan ova are rare, •inien heinii' tlif (Fiir. h:\). The IV. 'I'lu' villi iiri' Mvii ilevelopnuMit nl' i meters in it- V set e(|natorial tell of tliiekciiiil n-oeesses of m'i.'- luunan ovuiii, avs witness tlif feiopinent of tlic riie enihrvi(lc hy niciUis (if tlu' iimliilicul ur iilltiiitnic stiilk, and is eiifldsi-d witliin tlu' auiiiicm ; the hiViXK- vilrlliiir snc I'nily niinimm catos with tlu' still widoly ojn'ii gut. the organ is foniicd ; slightly lai.er, these folds fuse into a single heart, which then :ij)pears as a coiispicuoiis projection between the yolk-sac and the cephalic vesicle. Tlic third week (Fig. Hit) is productive of many imjiortant additions to the exterior of the embryo, its form becomes more definite ; the brain-vesicles, together with the uptic vesicles and the auditory sacs, are difierentiated ; the visceral arciies and the corresponding fiu'rowsare formed ; the yolk-sac is much more constricted, and its narrower coimectitii with the gut foreshadows the later vitelline stalk. By the twenty-first day the first rudiments of the limbs appear. The finu'th week (Fig. 86) is marked by gretit increase in size and by conspicu- ous changes which give to end)ryos of this age distinctive features, growth being relatively more active at this period than at any other. With the termination of the third week the embryo is still erect. During the next day Hexion takes '^ '^'^^'^m'^mmmmim 'T «Hi 96 AJfKRICAA'^ TEXT-liOOK OF OBSTETRICS. ! • i ,: 1 place with groat rapidity, so that during the tweiity-tliird day the cephalic aiul caudal poles of the embryo actually meet or even overlap, the dorsal outline approximating a circle (Figs. 8G, 87). The individual brain-vesicles are bcitci' developed, as are also the visceral arches and furrows, the eyes, ears, and nn-o; the heart has increased in size, and the limb-buds have become more ]iin- nounced. At tiie end of the twenty-third day extreme flexion has taken place, from which time until the close of the fourth week the embryo gradually becomes less tightly coiled on itself, the larger and more conspicuous land slowly rising and leaving tiie tail. During the latter half of the fourth week, in addition to the iucrcax',! development of the visceral arches, the individual cej)halic flexures becdiiio F'lii. S').— Mumiiii iiiiliryn of nhdut the thirti'i'iitli day (His): the cimiiiil \\u\v (if tlio inibrvd i-imi iiiM'ti'il Willi the lilii^tciilcniiic vusirlf liy tiifiiiis of the lilpcloinimil oi- iillantcic >tiilk ; the iiiiiiiinn .ihiiiil; (MimpUli'ly rncliiscs tlu' I'liiliryii, luid tho lari.'f vitclliiii' sac ciimimiiiii'ati'S tliroiighout tlit' Krtalrr |»iit cil' t!\c iiiitriil siirfai'i' liy iiicaiis of the uiicliisi'd >;ut-tra('t. very conspicuous. These flexures consist of a sharp bending of the aiih- rior ])arts of the head upon the posterior half, resulting in a chauiic nl nearly 90° in the cephalic axis, with the production of a I'onspiciiiiii- ^ limine nee marking the position of the midbrain. Posteriorly, the ccrvinil iC\uro sharply imlicates the junction of the cephalic and trinik segments; t;i, the; caudally, the dorsal and citccygeal flexures mark less pnuioMnccd cliiingi'- !!i the direction of the embrvouie axis. On cither side of the (hirsil mid-line, extending from the cervical flexure to the tip of the caudal extremity, a series of prominent (piadrilateral areas indicate the position of tlie somites nr provertebrie (Fig. 8(5, 11 and 12). The (levelopnient of the vinwnd archeti reaches its highest expression by tlio ■C- '^■■S. vs. the ceplialic and le dorsal outline esidos are boitur , oars, and ik.-o; t'oiiio more pni- has taken place, nbrvo gradually •OUSpicUOUS ll(!l(l to the incrcaM',1 flexures beeuiin' • iif the ciiibrvd is ci'ii ;k ; till' aiuiiiipu nlriii.ly iKluiiit till' KTi'atii- I'iifl lin> f §ii 5 -> c - w c — ;rt .. y: ■S - — • ^r ^ .2 7 > "o H CJ i; ■s times day ■itclli •3 £ -* i> ire u =4 tc C y .C ' S s i-? '■5 •c 3 = V c > •» * " •£ •J o -, c S 3 = •i^ •" -r- c :'• o t; c S > ^ Hi ? -k 111 - 3 = S feS 5 ■• 3 1 S S O il "^^; s 1 - .^. K ^ S t; ti: — • —• t- w E- ':. ~ I * ■^ >■■£. e 3 = ^ s <" - « - Jl ^ ZJ C "t^ .' s- :j § £ i? . o E = .i 3 >. JZ t ~ r; *^ *-* w s ■^' i ! ^- § " 5"i i^ /. ^- -r >- 1 .' - «■ J= C- .i. ■■ « *; t- 7-. w . s — i- i> c i- •= .- .ti « -) *- fc. ~ - ' = c ■C B '2 O .5f .- S " 1) l visc'cnil iinli iirc cxlciuiiiin. li, ciiiliryu nf nljniit tliirly-lniir diiys : llii' j.'lciliiiliir, liitcnil, IVi'iiMl, ami iimxilliiry jirdi't'sscs lire in iiiiiKi.-^iticiii ; tho )iriiiiitivt' npcniiiK is imw bfttiT ik'liiuil. (', I'lrihrjn nf alicjut the i'if;litli Week: iiniiii'iliatr Ijniiiiilarirs of iiiniitli arc iimre lU'lliiitc and the nasal (irilicr- iirr jiartly fnrratil, cxtiTiial ear appearing. !•. eiiihryu at end of seeond nidutli. tion of the first, since they gradually become obliterated by the fusion ol' the surrounding arches. The first outer furrow, or hjiomandlhuhtr cleft, coiitrili- utes largely to the formation of the external aiiditoiy canal, while the sur- rounding portions of the mandibular and hyoid arches contribute the ti.-..«iii' from which the external ear is derived. '^_ plIYSIOLOaY OF I'RFAiNAXCV. 99 borders of llie ; outer wall ■ if l^hcse proces-os ! nose and the •OS jjivos rise tn onfifonital faciiil iirtli, and lilili itity ; a slniiliir with the exci |)- luiit twciily-ninc .layv If iimxilliiry )ii-nii-M'. lllllllir, lllUTIll, I'l-nlltill, ik'liiu'il. •'. uiiiliryiMif 1 the niisiil iirilicf- iiri' the fusion of the lav cleft, I'onlrili- 1, while the mh- tribute the ti«iie nc Second Mnnfli.— The fifth and sixth weeks (Figs. 8G, 88) add to the size and the general advanced development, altiiough the phenc.nienal rate of growth of the preceding week is replaced by more gradual increase. The limbs con- stitute the niost^characteristic features of this jjeriiKl, since what prior to the fifth week were but rudimentary limb-buds now undergo differentiation into distinct segments, at first two, then three. Toward the close of the fifth week the flattened terminal segments representing the future hands and feet exhibit distinctions as tliin marginal plates and thicker proximal portions. The man^inal areas very soon exhibit traces of the digits as small elevations sepanited by shalktw grooves which gradually extend toward the free ends. The fore lilnl)s appear slightly earlier than the hind limbs, and retain this lead throughout their development. By the middle of the sixth week the fingers are sufficiently developed to project be- yond the hand, although the toes are Fir., ss -lliimiin embryo of nhout six weeks, ciilart-'i'il livo times (lUs). KiG. 89— Hnmiin emiiryo of nbcmt seven weelvS, onlarfied live times (His). just beginning to bo outlined, and represent a stage of ten to fourteen days later. Coiiicidently with these changes the general development of the embryo has steadily progressed (Fig. 89), with the result of supplanting the embryonal characteristics by those of distinctly fetal type. The head, though propor- tionately large, has become partially once more raised ; the boundaries of the month have become definitely located ; the external parts of the eye, the ear, and the nose are well advanced ; and the general contour of the trunk has assumed more of the characters of the child. Tlie second month witnesses the disappearance of the cervical flexion and T '■"^ 100 AMUR/CAN TEXT-HOOK OF OBSTKTRICH. i t i i m h^ tlif fiirtlier liftinj; of the head, wliich is still very larj^e (Fig. 90). The i'acc shows distinct advaticemcnt toward its completed typo, although the nose is \v\ unduly hroad, and indications of the fissures surrounding the mouth arc dis- cernible. The limbs pn^joct from the body, and the fingers, including tlio differentiated thumb, and the toes are well defined. By the close of the secuud Fio 90.— Ilunian ciiil)rjii of ntioiit lijilit mid n liiilf wcoks, eiiliirciMl five times fUis). month the fetus measures from 25 to 30 millimeters (1 to 1^ inches) in leiiirth and weighs from 15 to 20 grams. The Third 3Ionth.— The third month establishes the htmian form, although the head still unduly preponderates. The limbs have acquired their definite shape, and the imperfect nails are present on both fingers and toes. Durinir this month the external organs of generatii>n become definitely differentiated, ?^.^.,J:^ :w. PHYSIOLOGY OF PRKCiXANCY. 101 90). The face 1 the nose is yet mouth arc dis- , inchuling ilie ise of the secom] 3 ^ times (Ilis). inches) in loiii:t!i 1 form, althdiiuh etl tlieir dciinitr 1(1 toes. Diiriiii: Iv ditferentiiitcil, ; y.it ahhoujrh tlicv niaUo their appearance several weeks earlier. At the end of this p(Ti(Hl tiie fetus measures about 7 centimeters (2J inches) in length and weighs alK)Ut 120 grams (4 ounces). The Fourth J/o/i//*.— Short hairs, devoid of pigment, appear on the scalp and on some other parts of the body, which is now coveriHl with firmer skin of rosv hue. The eyelids, nostrils, and lips are closed. The anus opens, and the coils of intestine, which before extended into the und)ilical cord, now lie entirely witiiin tiie ainlominal cavity. The point of emergence of the umbil- ical cord lies low down, close to the pnbes. The head forms about one-fourth of the entire body; the bones of the skull, while ossifying, are still widely separatcil. The sexual distinctions of the external organs are well defined. At the end of this pcrioil tiie length of the fetus has increased to about 12.5 cen- timeters (o iiiciics), and its weight to between 230 and 240 grams (7J ounces). The Fifth Mnnth. — Tlie heart and the liver share with the head in the undue preponderance wliicli tliese parts present. The contents of the small intestiiu^ — the meconiiMii — show traces of l)i!e, being of a pale yellowish-green color. The lower extremities are now longer tiian the arms; the nails are well formed. Hairs are more plentiful, but are devoid of color. At the termination of this month the fetus measures 20 pcntimeters (8 inches) in length and weighs about 600 iTams ( 1 ixtuiid). The fetal movenu^nts are now distinctly felt by the mother. The Si.rth .Uoiifli. — The surface presents many wrinkles and a dirty-reildish hue- the sebaceous coating, the veniix cascona, begins to appear. This whitish substance is composed of the dead and shed surface-epithelium, mingled with the secretions of the sebaceous glands; its primary function is the protection of the fetal integument fnmi maceration by the amniotic Hnid. Eyebrows and eyelashes begin to grow. The length of the fetus by the end of this period has increased to ."iO centimeters (12 inches), and its weight to about 1 kilogram or 1000 grams (2 pounds). The Scmitk Month. — The continued deposition of subcutaneous fat causes a general appearance of greater plumpness, although the surface is still some- what wrinkled ; hairs about 5 millimeters (^j inch) in length ; eyelids arc now permanently open. The liver is still relatively large ; meconium occupies the entire large intestine ; the testicles have descended as far as, or even into, the inguinal canals. Children born at the end of this period may survive, although they usually succund). The fetus now measures about 35 centi- meters (14 inches) and weighs about \h kilograms (3 pounds). The Ehjhfh Moiith. — This and the succeeding month are occupied by in- crease in bulk rather than by great gain in length. The skin assumes a brighter flesh-color ; the scalp is plentifully supi)lie(l with hair ; the nails almost reach the finger-tijis. The vernix casensa forms a complete coating ; the lanugo, or embryonal down, iK'gins to disappear. The subcutaneous fat has increased, giving less harsh outlines to the body. The close of this month finds the fetus measuring about 40 centimeters (16 inches) and weighing from 2 to 2| kilograms (4 to 5 jKtunds). The A'inth Month. — The fetus at full term presents usually a well-rounded 102 AMKRWAN TKXr-nOOK OF OIlSTKTRICfi. body, from wliicli tlio lamifio lias almost entirely ilisappearod. The skin is loss highly colorwl, and is covered in places, particularly the head, the axilla, the groin, and the flexor surfaces, with u layer of protecting irruix. Both l(>.s. tides have descended into the scrotum ; in the female the labia niajora an in contact. The intestinal tract contains the dark-greenish-colored mrcnn'n'm^ consisting of the setfretiuus of the intestines and the liver niixttl with the (pi- Ki(i. '.II.— Diatrriini illustnitinn tlic outlines (if tlio limiinii futus at viiriDUs stai^oB, from the end uf iliv seeiind tu the end of the eiglith week, niHuiiilii'd live times imoditied nfler Midi). tholium from the digestive tube, together with epidermis and lanugo •swalluwi'd by the fetus. The umbilicus has reached a position aImo.st exactly in tlic middle of the body. The first epiphyseal o.s.sification to apj)ear, that of tlio lower end of the femur, is often ti»e oidy erne present, but ossification niiiy have commenced also in the upper epiphyses of the tibia and the hum(m>, '4l... v. I'liYsioLOdv or piii'MXAyry. \0'.\ The skin i< [•ad, till' axilla, nix. Both tos- , majora ait in red mrcnii'h'iii, il with the ( pi- from tlio end '■I'llie fter Mi'.U). !lIlUfr<) SWallnWi'd t exactly in tlic )ear, that of tlif ossification iiiiiy 11(1 the hunicniN \ ro.iveiiicnt •^impl'' '"•■tl""l *•»' deteniiiiiing the approximate length of the A-tiis at a.iv period duriiiL^ g.-tation has Ihk,... given by iraasc. The length in c^.n(inu.t..rs ..lav roughly he estimated np to the ..i.l of the fifth month by , -:30 TXT) =r 35 S X •'> ^40 i) X 5 ^- 4.-) 0X5 r= oO The full-term fetus measures, on an average, iihoiit 50 centimeters (20 inches) in its entire length, and weighs from 3 to ^ kilograms (from to 7 ponnds), the average weight for boys being ;}340 gnims (7 pounds, (J uiinees), and that fiir girls 3190 grams (7 pounds). The individual variations in weight of new-born eliildreii include a wide latitude, as indicated by the extremes of 717 urams (1 pound, }>i ounces) and ()123 grams (13 pounds, 8 (-(inccs), as accepted by Vierordt. Cliildrcn really exceeding 5 kilograms (about 10 pounds at birth are very rare, notwithstanding numerous reputed eases. Waller, how- ever reports a case of a living infant, delivered by him with fi)rceps, that weighed lo pounds 15 ounces! [n addition to sex, boys being heavier than ifirls the size of the child is materially influenced by the conditions ot ma- ternal parentage; thus: (1) Young mothers have the smallest children, and mothers i»et\veeu thirty and thirty-five years have the heaviest. (2) The weight of the child increases with the number of previous pregnancies, providing that the successive children are of the same sex and that the pregnancies do not follow too rapitlly ; the children of primiparte, therefore, average less tliiin these of miiltipaiw. (3) The weight of the child increases with the weight (Gassner) and the length (Frankenhausen) of the mother. In addition, ob- viouslv, all causes adversely afi'ecting the physictil condition of ilther parent may exert an iiiifavor hie influence on the vitidity and develo])nient of the fetus. 6. Development of the Circulatory System. — The vtiscnlar system is formed by the development of two parts, at first entirely distinct — the extra- embryonic blood-vessels, and the central circulatory apparatus re{)resented by the heart and the great primary trunks. The extra-embryonic blood-vessels constitute successively two distinct systems, the vHcUlne and the (dhnfoic cir- culation. The first of these in mammals and in man is comparatively unim- portant ; the second is of the utmost importance, since it takes an active part jgk securing the nourishment of the embryo from the maternal tissues by means of the formation of the placental circulation which it becomes. m 104 AMERICAN TEXT-BOOK OF OBSTETRICS. i ,b m Very early in the development of the embryo the germinal area becoiiios mottled by the appearance at its periphery of an irregular network of braiK h- ing patches of darker *int than the surrounding tissue, due to the active 0( 11- prolifenulon. These patches are the blood-itilamh of Pander, so called fntiii the active rdlc playetl by them in the production of vascular tissue — vessels and blood-cells. By tiie extension of the blood-islands an;1 the newly-foriiuHJ vessels the circulation within the area vasculosa (PI. 15) rapidly extends ci n- trally and toward the embryo, with which communication is later established by the vitelline arteries and veins, large trunks which connect with the cephalic and cauilal extremities respectively of tlie primitive circulatory apparatus which has meanwhile been developed within the embryo. The significance of the vitelline circulation in mammals is probably merely suggestive of its lar greater importance in the lower types, where absorption of nutritive materials from the large and conspicuous yolk constitutes an evident reason for its development. In man and in mammals it is doubtful whether the vitclliiu' circulation contributes mitritive substances in any appreciable degree. Coincidently with the decrease in the yolk-sac and its vitelline circulation, the vessels supj)lying the allantoic tissues become more prominent, the growth of the two systems proceeding in inverse order. The conversion of a portion of the vascular chorion into the fetal contribution of the placenta advances the imjiortance of these vessels to that of the placental circulation, as iirst represented by the two umbilical veins and the two umbilicid arteries, tiic latter the direct continuations of the intra-embryonic hypogastric arteries. Later, the two veins fuse within the allantoic stalk, thereby producing a sinjrlc venous trunk which accompanies the arterial stems. Within the body of the fetus, however, the umbilical veins, which there remain separate, develop unequally, the right suitering atrophy and finally disappearing, while ilic left increases in size and persists until birth as the important umbilical vein euii- veving the blood to the liver. The Heart. — t\)incidently with the formation of the j)rimarv extra-einhrv- onic blood-vessels within the vascular area, the heart early begins its deveiop- Kl<:. !i'J.— Section nf iiirly cmliryo (if riilihit d'HTsoli, sluiwlm; tHu Mimnitc liciirt tulics (//, //i: •. Iiriniiti\c ciKldllicliiiiii: cm, iiu'sndcrm loniiiiii,' cure line wiill ; ic, i ctiMlcrin ; cii. cMHiiIcnii ; <(^', tolil> |iri- (luciiiK ventral wall nf ^tit-tract ; lnj, luad-KUt ; lacenta advaiioos •culation, as lirst lical arteries, tlio )ogastric arteries. iroducing a siiii^lc II the body of the separate, develop ng, while the hit inbilical vein cdM- lary extra-em lirv- )egiiis its devclop- VITKLUNE ClRCrLATION. Plate 15. r lii'iirttulH'S (//, II r. f, fi\ic«lcriii ; ;;/', I'nliU |ir"- 'iiiiiil. a ft tiding off ami he two heart-tiilx* '''■'■'///>,,, Vas..,n,u' ,,n^M nf H.vriMlny rnl,l,i( vnihryu MC. V. ll,.n,.,l,.,Mn,,l .iuli,-,,n : .•,,|,ill,,ri, s Mnt vhnu 'ji sinus is strii to hi., iiilciiiil. II : till' li'i'iiiiMiil I'-1.- Tn PHYSIOLOGY OF PREGNANCY. 105 tlins formed lie within the .splanchnic mesoderm and are at first widely sepa- rated from each other (Fig. 92). With the bending together and approxima- t" 1 .)f the visceral layers in the formation of the gnt-tract the heart-tubes are brought into apposition, and finally fuse, the union resulting in the production ■1 "m Fig 03— niiiu'iaiiis iiiiislratiiiff arrnngoment of primitive heart and aortic arches (modified from AWcn Tliuiii|i, 5, upper and lower primitive aorta;; 5', .V, continu- ation of iloublc aorta as vessels to eatulal pole of embryo ; li, vitelline arteries returning blood to vascu- lar area. of a short, straight reooptacle, into the caudal end of which empty the vitelline veins and from the cephalic extremity pass the primitive arterial trunks (Fig.'o;]). This early straight heart-tube, lying attached to tlie floor of the pharyngeal region, is very transient, since the rapidly increasing length of the organ, its A n Fill. HI.— .\, ; . of human embryo of li.iri mm. (His) : n, truncus arteriosus ; b, |)rimitive ventricle ; C, vencais sitfi, "' it. Iieiirt of human eml)ryo of about 3 uim. (His) : a, truneus arteriosus; 6, venous Mgnient ibihii. r , ' ii litivi vi'utriele (in front). ends luing rela»iv('ly fixed, soon necessitates tlexion, which take.s place in l)oth aagitta! :ind ti'ansver.>;e planes, and results in giving to the tube the S-form. The lower and posterior limb of the heart receives the great veins and is the ajnjts irnotiiLs (Fig. 94) ; the lower and anteriorly directed loop is the auricular 106 AMElilCAN TEXT-BOOK OF OBSTETRICS. or venous conipartiueiit ; the upiier and posteriorly ilireoted loop is the vcnti iV- ular or arterial compartment j the upper limb is the tvuncm artcr'wims, innw which arise the jirimitive aortic arehen. The heart, therefore, at this stage — about the fourteenth day — consists essentially of two imperfectly separntid Fiti. 95.— A, lu'iirt of human oinbryo of about -..a mm. (His): n, atrium; f(, portion of atrium cnrn.. spoiulinK with auricular appendage ; c, trunt'us artcriosu.s ; (/, nuric\ilar canal ; c, i)rimitivc vi'ntricli . ij heart of huma cmliryo of about the lil'tli week (His): a, left auricle; b, right auricle; c, trunci'S iirlirid- sus ; '/, intorve- tricular groove ; c, right ventricle ; .;', left ventricle. divisions — a lower and posterior venous chamber and an upper and anterior arterial compartment — into and from which pass the larger primitive venous and arterial trunks. The venous or auricular division during the third week develops two con- I !'.. Kiii. %.— A, section of heart of Imnian embryo of 10 mm. (His) : n. septum spurium : h. iiiterauricular septum; c, mouth of siiuis reunieiis; »^ right auricle; c. left Jiuriclc ; /'. auricular canal; ;/, ri^-lit vin- tride ; It. interventricular septum ; /, left ventricle. It. section of heart of human embryo of abmit tin fifth week (His): ii, septum spurium: h, auricular septum; c, opening of sinus reunieus (leader piissts through foramen ovaho; (/.right atrium; (.left atrium ;/, sci)tuni intermedium: ;;, right ventricU': J. ventricular septum ; (, left ventricle. .spiciions lateral dilatations which assnme a position above and behind thco^imv- ing arterial chamJK'r. The.se dilatations are the uuricnfa)' appanhtf/rs (Fiir. 951. which ft)r some time are the most conspicuous parts of the auricles. At tlii- PHYSIOLOGY OF PliKGXANCY. 107 s the veiitric- teriosus, IVdin ; this stagi — ctly scpariUuil tion of iitrium cim- ■iiuitivi.' vi'UtrirU'. It. li; ; c, truncfs iirHTio- per and antoridr primitive venous levelops two con- T "^ ■urium ■• ('. inU.nuir.cuto ll.iv -MiiiiU; ;/. rii:M v>* ,u .•ml.ryo >,f «l'"iitili' 1„- .„ rlKl.t vi'Ulriulo;).. |l behind the ^nt.w- kvuriclcs. At till. time the auricular and ventricuhir portions of the heart are imperfectly sepa- ,..,ted bv a marked constriction, the canalis auvkulark. Diii-iii"' the Iburth week the conversion of the single into a double heart iiu'Uf's bv the gi'adual growth of jjartitions from above downward within tlie auricle, and from below upward within the ventricle (Fig. 9G, a) ; in addi- . ^ ' ^1^^. p,-iiiiitive auriculo-ventricular canal becomes divided by the formation f .' '-inecial i):irtition, the ncptum intermedium. The division of the heart- 1 • uibcr- proLnv>- birth a- the foramen ovale. The entrance of the venous blood into the auricula!' c.Miij.artiueut is effected for some time through the single opening of tl e sinus veiiosus. Guarding this orifice are folds of the cardiac lining, one of which foMs becomes prominent as the Eustachian valve, directing the blood- current tlirouuli the foramen ovale. Later, the sinus venosus becomes included witliiu the wall of the heart, and the three principal venous trunks emptying within tlie sinus — the two ducts of Cuvier and the primitive inferior vena cava— open direct Iv into the auricular cavity by as many separate orifices; that ol" 1 lie left Cuvierian rogresses. The consolidation of the cardiac walls, however, never is coiv detely accomplished, indications of its imperfec- tions heiiig clearly seen in the arrangement of the conspicuous columH(V carneic of the adidt oriran, in which the more or less isolated bands represent the thickened remains of the bridging trabeeuhe connecting the endothelial heart tjrith the denser surrounding capsule. « Artcrii's nf flic luinx. — The early arterial circulation of the fetus dif- fers in many details from that of the later .stages. C\)nspicuous among these ^ffer(>nres is the development of the series of aortic arches which extend fnmi the anterior end of the truncus arteriosus around the primitive pharynx, ^thin the visceral arches, and converge into the dorsal longitudinal vessels, ' I r; •i' 108 ami:ricax text-hook of obstetrics. tlic- primlUvc aort; J'JirSIOLOGV OF riiEGNANCY. 109 within the tissues of the imperfectly defined fifth visceral bow. The first jjair •r '^t •ipiH'iirs and soonest disappears, all five at no time being found simul- iiii;raiii illiislnitiim: llio Into ol'tlio aortic arches in mammals and man fraodifieil from Rathkc). carotid artery and its brauchcs; the posterior or aortic limb aids in forming pe internal carotid artery. (2) The seooiid arch has a fate identical with that of the first, its straighter ▼entral and dorsal limbs taking part in producing the carotids. ' (3) Tiie third arch, whieli remains almost comj)lete, gives rise to the connec- flon iM'twcon the external and internal carotid arteries, to the latter of which the arch particularly contributes. (4) The fourth arch undergoes important changes resulting in its retention on the two sides, since from it are largely derived the innominate, together ifith the subclavian and vertebral arteries on the right side, and the important ilbh of the aorta on the left. > i 110 AMKIilCAX TEXT- no OK OF OBSTETRICS. (o) The fifth ai'cli is devoted to the production of the pulmonary arteries, a small portion of tlio right areh persisting as the right pulmonary artery, inul a larger part of the left giving origin to the corresponding pulmonary arti ry and the duetus arteriosus. During the fifth week, as betbre noted, the truneus arteriosus undergoes dl\ is- ion into two tuhes by the formation of the aortic septum ; the resulting aortic tube retains connection with the fourth arch, becoming the ascending portion of the arch of the aorta, while the right tube becomes connected with the filth arch and fornis the pulmonary vessel. The two primitive aortae for a time extend on each side of the notochurd as longitudinal vessels which almost completely terminate in the large omphalo- mesenteric or vitelline arteries supplying the circtdation of the yolk-sac, tiip early continuation of the aortic stems being slender, relatively insignificaDt branches which extend toward the caudal pole of the embryo. With the develt»pment of the earliest allantoic structures the posterior segments of tlio two primitive aortse unite to form a single trunk, the dorsal aorta, the fusion beginning about the junction of the cervical and thoracic regions and |)ro- cceding caudally. At a slightly later period the aortic trunk divides, at the end of the lumbar region, into the allantoic arteries, which pass along the allantoic stalk and are distributed to the chorion, and later to the fetal placenta; thcv are then known as the umlnlical arteries as far as the bodv-wall, bcintr continued within the embryo as the hypogastrics. The primitive allantoic arteries eventually become the common and the internal iliac arteries, the external iliaes being formed as new branches when the limbs arc developed. After birth, when the fetal placental circulation ceases, the distal parts of tlie hypogastrics beyond the bladder atrophy and remain as solid fibrous cords passing to the und)ilicus ; the proximal |)arts of these vessels retain their lumina and persist as the superior vesical arteries. Vcinx of the Fetus. — Toward the close of the embryonal period, about the fourth week, the venous arrangement includes three distinct sets of vessels rct'irning the blood to the heart (PI. 16) ; these are — (1) The Cuvierian vein?, returning flic l)lood from the body of the embryo; (2) the vitelline veins, re- turning the blood from the circulation of the yolk-sac; (3) the allantoic, later the umbilical, veins, returning the blood from the chorion and the developing placental structures. The early systemic veins consist of an up])er trunk, the anterior eardinnl or primitive jugular veins, by which the blood from the liciiil is carried to the heart, and the jtnsferior earifinafs, collecting the blood Inmi the triuik and the important Wolffian bodies. These vessels, along with the viti'lline and allantoic veins, pour their blood into a common receptacle, the sitiiis reiiiisits, which opens directly into the primary auricular division of the heart. For a short time these veins are about etpial in size and are evenly developed on the two sides ; soon, however, the results of unequal growth become manifested in the disproportionate advance of some and the retrogression of others. The vitelline veins in man, as may be anticipated from the relative insig- res. nonary arterit ^ , a )naiy artery, iiiul juluionary artery i undcrf^oes «li\ is- e resulting aortic isoending portion te|ii'('- tivi-ly lir-t, scc'oiiil. iliinl, iiinl rniiiili plmi-yiiL'ciil imiUcIics; 7', lliy''"iil l)iiily ; W, lii'iincliiis; /..liver; A', kid- iii'y. " 'I'lii' ildttcil liiK's iiiiliciito tlii.' f.\livmitii.'S. "»Jl., I>EV! F THE FETUS. Plate 16. i^k i-m m mniiirnMl 'jr) (liiimclcis rvinil. llK' finlitli 'IT- lius; /„ Mvit; A', ki'l- Iltimnn embryo, same ns prcreriin,!); fisure, b>it tnken nt a deeper plniie (nftcr F. Mall): //, divcrtieulum contriliiitiiii,' tlu'"iiral iinrtinii ul' tlic pituitary liody; Jl iiilmvi'l, nriiiiitive imiiitli; 1, '_', If, 1, pliiiryiideal poiiclii-.s: /;, liriiiiilius ; /', pancreas; /,. liver; II'. /.'., Wnlltiaii liddy; II'. /»., Wdllliaii ihiet ; K, kidiiey; C, cloaeii ; o, (ipeiiiiigs liy wliieli pleuru-iiorituiieul ciivitio.s eoiiuiuiiiicaie ; l\ papilUrunu projection into lower opeiiiii),'. M !'■' m ''iik.i niYSIOLOU Y OF PltEGNAXCY. Ill nifi.an.-c of tl.o lutuninalian yolk-snr, novor roach tho .lovclopmont .seen in lowiT tV|H-< M'lcr l)a>siii<,^ aloii^r tlio vitclliiit' stalk and iiitonn^r at the unibil- ionl ..|)enin.r. the veins im. in In.nt and then at tho sidos <.f that part of the priniitivo .mt-tract oorrospon.Unf; with tho (hiodonnin, and bcoonic dosoly asso- ciated with the Hvor (Fi)?. 99). The vitelline veins become connect(Hl by three newlv formed transverse trnnks, thns establishing two vascnlur ring's which -•^"irele the ^\\\. The early direct connniniication above these rings with the ^s' VA" TS l-f iVD VA' yy Yia. '.111.— Povfliipnu'iit uf the |»irtiil <'irrulation of tlio human cmliryo df iilidUt thnu und ii half woiks (Marsha I'l, a ft IT Mis) : /'.I. paiurfas; 7*/, i litest iiu's ; 7'.s', st(iiiia<'h ; 117), l>ili'(lu('t ; T.l, left nllantdic vein ; Kd'. rij-'lit allaiitnic vein: I'.l", anterior detaehed pDrtimis of the allantnic veins ; r/C, diietiis venosus ; VO, portal vein; IT. vitelline vein; VV, portions of sinus annulares which disapj)ear; H", liver. sinus venosiis becomes lost, and at the same time pctrtions of the remaining parts of the vitelline veins become interrnptod, while a new capillary system appears within tiie hepatic tissue, whieh lias meanwhile surrounded the vessels, and provides coinmiinication l)etween the veins themselves. Those portions of the vitelline vessels that ])ass from the up])er venous ring to the capillary network' are known as the vemv. advc/icntes : they become the branches of the |K>rtaI vein ; those ])ortions which pass from the capillary network to the sinus yenosus, forming now relations, an; the twmr. revehente.s and they become the hepatic reins. The vitelline veins at their lower communication become com- pletely I'liscd and receive veins from the intestinal tract, thus forming the main portal trunk. The allantoic veins after the establishment of the placental circulation are loiown as the umbilicnl vcinn, of which for a time there are two. They fuse within the allantoic stalk, but remain as distinct vessels within the embryo, IfOnniiig within the lateral walls, for a much longer period. During the Iburth week the comicction of the allantoic veins with the siims venosus is •lljet, and shortly afterward the right vein becomes much smaller than its ow, and finally undergoes atrophy. The mueh larger left allantoic or ..iSiS**' ,^ 1 . V 1^ I 1^ i|l!i t?, ;) 112 AMKniCAX TEXT-nOOK GF OBSTETRICS. umbilical vein joins the primitive purtal vein jnst as this vessel enteiv the hepatic tissue. The early condition of the placental circJilation for a time is siich tliat all blood retnrnini!; by tlie allantoic vein must traverse the ca|)illary netwink of the liver in order to <>;ain access to the heart, since both vitelline and allantoic veins have lost their direct communication with the sinus vcnusus. After a time, however, the liver is no longer capable of givint; passage to the rai)id]y increasing volume of the placental circulation, and then a direct (nin- munication is establislied between the portal vein and the right hepatic vein. This new jiassage is the duclus venoms, by which the greater ])art of the Mdud is carried to the heart without traversing the hepatic snbstance. The systenn'c veins arise partly from the primary venous trnnks ami jwrtly as new vessels. The ducts of Cuvier receive the primitive jiiuular veins above and the cardinal veins below. The primitive jngulars lat(>r become the permanent external jngnlars, the internal jngulars being formed a« new trunks. The Cuvierian ducts, which undergo change of direction and lengthening, take a position almost vertical, becoming the superior t'emr rdni, of which tiiere are at first two. The develoiiment of tiie heart induces tin- disappearance of the greater part of the left superior cava, the proximal end, however, remaining as tlie insignificant coronary sinus which directly (i|)(ii< into the right auricle. >i itli the atrophy of the left caval trunk a ikw transverse communication is necessitated to convey the blood from the left side to the remaining and enlarging superior cava\ This need is su])]ilie(l liv the formation of the transverse ju;/H/ar, which later becomes the greater pan of the left innouiinate vein. The fiite of the once important posterior cardinal veins is linked with tin history of the Wolflian bodies, whose venous outlet these veins largelv mv. AVith the atro])liy of the Wolt!ian bodies the cardinal veins become Ks. important, their final fate being ])artial disappearance and partial pcrsistcncv as the a/ygos veins of adult anatomy. The inferior vena erimitive Cardinal vein, that of the opposite disappearing. Tin external iliacs and tlie greater part of the left common iliac vein are ikh vessels. 7. Development of the Digestive Tract. — The formation of the digestive tube consists essentially in the fbhling otf, closure, and isolation of that iimi: esscl enters tlic lie is siich that ipillary notwdvk th vitelline ami e sinns veiinsus. itr passage In the icn a direct cDm- rlit hepatic vein, part of the lihiml anee. nous trunks ami primitive juiiular vc jugulars later 5 being formed ;i> of tlirectioM aiul \pct'ior vcmr runi, heart induces tlio the proximal cml, ich directly njxn. ival trunk a luw ood from the lift eed is supplii'd l>y es the greater \K\n is linked with tin veins lai'gely aiv, veins become hv partial persistcmv Pin'SIOLOGV OF PREGNANCY. 113 ( tn nt, for the (lct:\il- s of Iloclistctt.r, trunk, and paitK V new vi'-si'l i> 1 the point wlidv uperior mesciiti'iii irimitive cardiiiak lierior vena i-ni o-ht common ili;i'' the lower p;ui "t isappearing. Th iliac veni arc m« ion of thediut'^tivt dation of timl i<;ir; of the v(dk-sie innncdiatelv in contact with the axial portions of the ento- derm ''rhi< ditrcrcntiation is efleeted by the ventral extension and appn)xi- niation of the widclv expanded splanchnopleure, which, bending together mir JOG) .n-ad.iallv doses to form the primitive gut— at first freely openuig into the yorU-sac, finally completely isolated from the latter except through the communication maintained by the narrow und)ilieal duet. Bv the fifteenth dav the gut has become defined to such extent that three parts" are distiniruishahlc-the fore-gut, the mid-gut, and the hind-gut. The fore-xtend bet'.v(>en the visceral arches, and constitute the p/ii'r riscrml furvowi^ [F\^. lOG ; IM. IH). Tiiese evaginations of the pharyngeal lining are of interest, since the first pouch becomes converted into tiie Kustachian tube and the tympanic cavity, the third pouch into the early epithelial tiiymus body, and the fourth pouch into the Jateral ))ortion< of tiie early thyroid body. From the ventral surfiice of the fore-gut, at the end of its pharyngeal division, there grows out the diverti'U- fatm, which gives rise to the respiratory tube and the epithelial parts of the julnionary tissues. 8 1 if I i|l(i 114 AMERICAN TEXT- BO OK OF OBSTETRICS. The mid-gut, at first in free communication with the yolk-sac through tho wide yolk-stalk, gradually becomes tubular and elongatetl, forming a narrow- V-shaped loop whose straight and almost parallel limbs are attached behind to the dorsal wall of the body-cavity, above to the terminal part of the fore-gut at the stomach, and below to the hind-gut (Fig. 102). The apex of the loop receives the reduced yolk-stalk or umbilical duct, thereby becoming attached A '5 - -->-v Fii;. 101.— RoronstriK'tiona of huiiinn emliryo of nbcmt liftei-n rinys (His) : nn\ mci\ pcv, anterior, mid- ille, Hiiil iiiislerior inimiiry tpriiiiivi'siclts ; nr, n/, iiptic iiiwi otic visiclcs ; ^^ soptuin lictwifii jjriiinlivc (iriii cavity mid liciidtrut ; /»/, iiriniitive mil; r, /ii. vciitriciiliir iiiid iiortic.' si'tiiiii'iits ol' liciirt ; n', iiorlic iirrl) : ivi, ; IT, vitelline veins; »r, un, uiiihilieal veins mid arteries; it!, allantois. to the ventral body-wall. The mid-gut gives rise to the entire small intestiiio and to the greater ])art of the large intestine. The liver and the pancreas aic formed as diverticida and outgrowths from tho lumen and the epithelial lining of the duodenal portion of the mid-gut. T/ic hind-f/nt soon loses its individuality and contributes the lower segment of the large intestine. In its j)rimitive condition the hind-gut PHYSIOLOGY OF PREGNANCY. 115 ough tho a narrow jehind to 5 fore-gut ' the loop ' attached hi -a ^ - tV ^ -,/,/ i.:.. • • •"1 — V-, y ti, r^.._ ir, , iintcrior, mii\- wt't'ii (iriiuitivc iirl ; 'i', iinilii' sinus rt-'Uiii"."*; lall intestine )ancreas arc lelial linin.i; the h>\vleeii. Greater curva- ture. Pancreas. Duodenum, Posterior body- ivaii. Large intestine. /tectum. trnet of human embryo of : arrangement of primitive dilated clo.sed end of the tube constitutes the cloaca, the for a time of the excretions of both the alimentary and A Lung. Stomach. common receptacle the urinary tracts. B Bile-duct. -. Vitelline diu -—.. Rectum. Pancreas. Rectum. Fi(i. 101.— A, alimentary tract of human embryo of thirty-two days. H, alimentary tract of human embryo of thlrty-tive days ^His). Tlie lumen of the allantoic sac, surroiuided by the tissue of the allantoic stalk, extends from the ventral aspect of this space. At a later period communi- cation with the exterior is established by the formation of the anal oririce. The external position of this opening is indicated by the anal invaf/ination of tlie ectoderm or > jctodcmii. ■'rTT '1 r:> m 1,1 ■ 1 I. i I*' :1 116 AMERICAN TEXT-BOOK OF OBSTETRICS. During tlie early part of the fourth week the intestinal tube, composed of its several characteristic segments, lies in the sagittal plane attached to the dorsal wall of the body-cavity by the straight primitive mesentery (Fig. 10;)). A few davs later a period of rapid growth is inaugurated, the intestinal tiihe increasing in length with far greater rapidity than the abdominal cavi'v expands. In consequence of this inequality in growth the small intestines become twisted and coiled, while the large gut takes up a position in fidiit or ventrally, and above the turns of the smaller tube. During the fifth week (Fig. 104) the esophagus elongates and the stomnch acquires its characteristic form as well as an obliquely transverse position, its A Fig. lori.— a, nutliiio of iiliiiu'iiliiry <'iiiiul of Inimnn Piiibryo of Iwi'iity-t'inlit iliiys (His); i>h, pituitiiry fiissn ; ^/, tciiitnii.' ; /j-, priiiiitivo larynx; (i, csoiilianus ; //■, traclioa ; hj, Imifr ; .-•, .stiiiiinch ; >), pancri'iis, M, lii'iiatic iluct; vil. viti'lliiic liiict; al, Hllantuis; /(ati{,' duct; p, ccriini: ri, climca; A-, kiilncy; ii, anus; ,<;;y, Kciilal eminence ; (, caudal process. former left side becoming directed anteriorly and upward, its former right >i(lc looking backward and downward. The cecum for a time is situated high ii|i and in dose reiatittn with the transversely ])]a('ed jtortion of the large intestine; later the blind end of this part of the gut de.'^cends, owing to the developnuiit of an intermediate portion which a.ssumes the position and characteristics of the ascending colon. The cecum for a time is of uniform size ; its further growth, however, is marked by the failure of the apical p>, piliiitiiry ;), pilniTl'lls , hd, liiii'y. 1!, outliiK' tmiKiiL' ; Ix, iiriiui- duct ; c, ci'iMim: ner right >itli' latod high up rtrc intostiiu'; clcvclopiiunt (U'istics ol'tlif rthcr growth, pace with the , that portion as a narmw lis appemhiiije 11 m. PJIVSJOLOGY OF PREGNANPy. 117 The connection of the yolk-stalk or vitelline duct (Fig. 105) with the intes- tinal canal rapidly hcconies less conspicuous, and by the end of the fifth week the yolk-stalk has but slight connection with the gut. The position of the A h Viv,. KW.— lU'CMiiistructioiis of human embryo of iibout sovontoiMi Jiiys (His): or, optic and nt, otic vesicles; ni\ iic', luitoeliord ; hil ^m^. 118 AMERICAN TEXT-nOOK 07' OBSTETIilCS. through the uinbilit'al Dpciiiiig into the alhintoic stalk, in which, up to t!ie twelfth week, t ley are normally present; after the third month, however, the coils are permanently withdrawn into the abdominal cavity. The liver first apj)ears about the fifteenth day as a diverticulum (Fig. Kiii) from the ventral wall of the fore-gut, surrounded at its end by a thick la\i'r of cells. The organ is rapidly formed, the single diverticulum almost iminc. diately dividing into two, which in turn send ott" secondary and tertiary spront- like extensions of solid cell-masses. These cylindrical masses anastomose and form networks of cells throughout the mesodermic tissue assigned to the pro- duction of the liver. The spaces within the meshworks are occupied by the ricldy vascular mesodermic tissue which suii])lies the connective tissue and tlie contained blood-vessels and bile-ducts. The pancreas (Fig. 105) and the salivary glands are developed as solid outgrowths from the epitheliuiu of the digestive tract. The cylindrical ceil- masses at first are slender, solid, and rather dub-shapod at their free ends. They later acquire a lumen and expand into the characteristic compartments of a racemose ghi'.i. 8. Respiratory Tract. — The respiratory tract is closely related in its devel- opment with the digestive canal, since it is formed by a direct evagi nation from the ventral wall of the lower portion of the ])rimitive pharynx. The primitive trachea grows downward for some distance parallel with the esophagus, ami tlicn divides into branches which correspond to the primary and secondary bronchi (Figs. 104, 105); subsequently each of these undergoes repeated dichotoinoiis division, the resulting twigs in turn giving rise to smaller branches until the ultimate compartments of the pulmonary tissue are developed. The smailci- primary bronchioles are solid cylinders at first, their lumina appearing later. The cntodei'niic jiortion of the res])irat()rv iivict, directly derived from that of the j)riniary digestive tube, forms the epithelial parts of the organs, the cdii- nective tissues and vascular constituents of the same being products of tlie mesodermic tracts into which extend the epithelial masses. 9. Development of the Genito-urinary Organs. — The early stages of the human end)ryo, as well as of other mammals, mark the a[)pearance (u' the paired Wolffian bodies and the Wolffian ducts, which for a time repre- sent a functionating excretory apparatus (IM. 16), the ancestor of the per- manent kidneys. The Wolffian duct, appears about the fifteenth day as a longitudinal cell- mass extending throughout the posterior half of the end)ryo. The duet is fi)rnied by the evagination and isolation of ])ortions of the mesothelial liniiii; of the body-cavity, the resulting cylindrical cell-mass forming a cord that extends at first to the surface ectoderm, with which it has temporarily close relations (Fig. 107). These a|>pearances have given rise to the views advanced by sev(!ral investigators, according t(» which the Wolffian duct is ectodermie in origin. Careful examinations of suitable |)reparations show that the relations of the developing Wolffian duct to the ectoderm are only secondary, and that the initial steps in the formation of the duct occur, as stated, as evaginations ot' t ' ■' "'!*. PHYSIOLOGY OF PREGNANCY. 119 1, tip to tlie owever, tlie 1 (Fig. lOi!) thick layer nu).st iniiDc- iary sproiit- stoinose and I to the piD- ipiod by tlio ssue and the ped as Sdlid imlrical n II- ir free cuds. arapartaK'iits in its devcl- ;ination fmin 'he priiuilivo giis, and tlit'ii dary bronclii dichotoiiioiis les until the The snialh'i' leaving later. from that of uns, the t'oii- )ducts of the y stages of )pearance oi' time ro|>ro- of the pei- itudiiial ecll- The duct is helial liiiiiiir a cord that )orarily close Avs advanced 'ctodermic in the relations ary, and tiiat iigiuations of the inesotlicliuin ; the Wolffian duct therefore is a product of the mesodorn.. After a time the blindly terminating distal ends of the duets sink centrally and accpiire a communication with the cloacal expansion of the hind-gut. At first the ducts are solid cylinders ; subsequently they possess a lumen. Fi(i. HIT— Transverse section of sixteen day sheep embryo (Bonnet) : ec, ectoderm ; en, entoderm ; pm, pn'rictiil inesdilerni ; rm, viscernl mesoderm; am, amnion; nrnx, amniotic sac; t, »', somites; a, a', aor'tie ; «( , nutocliord ; », neunil cuiial ; Wd, Wolffian duct ; \Vb, Wolffian body. Some days later, usually about the eighteenth day, the Wolffian bodies appear as a scries of short cylinders (Fig. 108) which form as buds from the mesotiiclium of the body-cavity entirely independently of the development of the Wolffian duct. These rcxls of cells at first are solid ; during the fourth week tiicv acqiiire lumina and become the Wolffian tubules, and later grow toward and join with the Wolffian ducts. The closed ends of the tubules iiw IIW IVb Kit;. IDS.— Transverse section of seventeen day sheep embryo 'Honnet) : n»i, amnion ; ns, amniotic sac; n, neural canal ; x, smiiite rimitive aortic ; i, intestine. become expanded and then invaginated by the apposition of blood- veis.sels sent into the bodies from the aorta. The tufted blood-vessels and the invaginated tubule constitute the Malpighian bodies of the W^olffian bodies, the predeces- sors of the similar structures of the permanent kidney. All parts of the Wolffian bodies, therefore, are derived from the mesodermic tissues. Second- ary tubules are formed as outgrowths from the primary ones whose origin has been sketched above. Trf^¥J^: I. .1 120 AMERICAN TEXT-BOOK OF OBSTETIIICS. The Wolffian bodies iiicrea.se rapidly during the .second month, ganiinff in size by tlie growth of the primary tubules and by the formation of new ones. These bodies act for a time as fiuietionating excretory organs, the period of tiieir greatest development l)eing about the eighth week. After this time tlioy undergo retrogressive change, so that by the fifth month the Malpighian bodies have largely disappeared and the eiitire organs become atrophic. In view of important ditferences in growth, functional activity, and UKtr. phological signiticaiit-e of various parts of the Wolffian body, there are reeog. ^i I Fl(i. init.— Heoonstnicti'd luimnn embryo of nbcmt twenty-cinht days (His): /-/I', brnin-visicUs, »ii', nriinil canal; ncli, nutuclKiril : nt. (illlutury )iit ; i\itu, cardiac ventridt' and anridc; rii,tln, ventral and dcirsal aorta' ; dn', termination of dorsal aorta ; th, median jiart of thyroid body ; Ir, larynx ; In, liiii); ,■.■, stoniHcli : ;i, imncreas; /, Intestine: /'. intesto-vitelline duct: nl. allantoic duct; k. kidney; nv, li.ft superior vena cava : cr, cardinal vein : ;ir. portal vein ; iii.«, vena ascendens, collecting blood from iniiliil leal and jiortal veins ; ui\ iiniliiliial vein. iiized an anterior xcgmcnt, corresponding with the head-kidney of lower types, always backward in its deve]t)pment in mammals ; a middir scfpneiif, wliidi from its relation to the generative organs in their formation may be regiudoil as the sexual portion of the orgtui ; and a posicrior xri/mrnf, likewi.se nuli- mentary in development and in the nature ol' the organs to which it contributes. The middle .segment is of most imi)ortance both functionally and mor|)lio- logically : this portion is sometimes designated the mefioncphron. The Mitlkridii JJucf. — Coincidentlv with the ibrmation of the WolHiaii >^i!A»jlL. PHYSIOLOOY OF PREGNANCY. 121 ga'Ping in f new ones, i period (if IS time tlicy ;hian bodies ,-, and nior- •e are recog- -da -th -ti -va -cv ■P P' -da , brnin-vi'sick's; : I'd, art in the further development of the Malpigliian bodies of the kidnev. Bv the end of the second month the definite character of the renal structure has become established. As tiie permanent organ increases in size and functional importance the Wolffian body rapidly atrophies, so that by the end of tlie fonrtli month its activity as an excretory organ has disappeared, the parts still remaining bearing relations to the sexual apparatus alone. The bladder is the j)ersistent and expanded proximal j)ortion of the allan- toic duct which retains its lumen, while that of the distal segment of the same duct lo.ses its lumen about the fifth week, becoming converted into a solid fibrous cord, the Hrachi(i<, which stretches from the summit of the urinary blad- der to tiie umbilicus. Tiie bladder therefore differs from the kidney and the ureter in possessing a lining derived from the entoderm, and in not being entirely of mesodermic origin. The formation of the internal generative organs consists of two distinct developmental processes, the development of the sexual glands and that of their excretory passages. At the end of the first month the mesothelial cover- ing of the Wolffian bodies, along their inner borders, shows an extended area of thickening and proliferation, the resulting elevated bands, the genital ris in which the larger primitive (.v;i I'ccinne central figures. Microscopical examination of the .sexual primitive glands even at the end of the fifth week is capable of dis- tinguishing the future sex of the being. It is highly probable, as emphasized f? ' v 122 AMJ':n/f'A.\ TExr-itooK or onsrETnrcs. End ,■/ Mtil- 1)\ Xiifjol, that inherent sexual differenees exist in the glantls Irom their oarli(-t appearance, and that the recognition of the indiflerent stage depends large Iv upon our iuiperlivt appreciation if these distinctions. The development of the second ]>;iit of the sexual apparatus, the system cf excretory passages, depends upon the ;i|)- ])ropriation and modification of alrcalv existing tubes, the tuhules of the Wolil'. ian l)(Kly, the WoltHan duct, anil the Gi'Mitat process ( /<■«;> or c/itoris). Genital fohls. Fig. 110.— iJiiiKram roprcscntiiiR tlio inililTirciit stnge in the devoli)i)iiu'iit of tlic KiiiiTiitivu uigiiiis (modifiiMl from AUl'Ii Tlioniiisoiii. Kio. 111.— Intcrnnl penerative orgnns of a luiile fi'tiis of i\t)out fourtoi'ii weeks (Wiildeyer, ■ t, Ws- tick'; >, epididynils ; «■', Wipllliim duct; «•, ;, /..r jiiirt of WoHlinn body; [U Kii'ierimculiim tc'sti^. ^rrdlerian duct. The fate of these .structures varies with sex. In the feniiijo (Fig. 112) the Miillerian ducts are mo.st important ; they develop into the ovi- t'intbria. Piirfi-uriiini _^^ I'tiroophoron. llicl. Bartholin s l^iitiui. Fiii. ll'J.— iJianrnm illustriitiiif: cliinii,'cs tiiliiiic place in dovelopinent of female u'ciierative ornaii.s Uiioditied from Allen Thompson i. Kif^ IIH.— IntiTiial orcans of a female fitusnf nhoMt fcjnrteen weeks (Waldeyer): o, ovary; '.ipo- iiplioron or parovarium ; ic', Wollliaii duct ; w, .Miil- lerian dnct ; u\ lower part of the Wdlllum l.nilv. ducts, and, after becoming fused, into the uterus and the vagina, while tlic Wolffian bodies and duct give rise at best to atrophic structures. The \\M- 1 I » -* iicir oarli( -t >iuls largely ociation < systom t't' upon the :i|)- n ot" ali'oaily ,fthoWolli- Lict, aiul the e (iri;nns <( » "i"le Wnldfyor, '. tis- m duct ; "■, ''■ ■•■r iiu'uliim testis. In the toiiiale ) into the nvi- if a fumnle fitns nl ■ r): o, ovary ; c, I'l'O- lllian iliict ; m. Mul- II' Wuiman Imdy. ;ina, while tlic The Wclrt- riTYSIOLOGY OF PRKGNANCY. 1'23 i'ln hodv ill the female contributes the transverse tubules of the parovarium or e',)oo|)horon the upper part of the WoltHan duct renuiining as the head-tube of the same atropine organ (Fig. 113). When the Wolffian duct persists it con- stitutes Gartner's duct. In the male subject (Fig. 114), on the contrary, the E/iiiliih'inis. liiilymis. heryans. Flo. lU— Pingrani illustratiiiK chnnfjcs tnkiiK; pl'icc in devclnprnont of male generative ot.'ans (modified from Alien Tlunnpson). Wolffian tubules and the Wolffian duct contribute the important system of excretorv tubes represented by the vasa effisrentia, the coni vasculosi, the tube of the e-Mdi(lvmis, and the vas deferens, while the Miillerian duct is atrophic, its extreme eiuls alone remaining as the sessile hydatid of IMorgagni, closely connected with the globus major of the epididymis, and as the sinus pocularis or nternx nnm-nVinuii, o])ening into the prostatic portion of the urethra. The atrophic tubules of the lower segment of the Wolffian body in both sexes contribute rudimentary organs, the 'pnrndldxjmh and the parodjtlioron resiteetivelv, which consist of a few tortuous tubules situated in the epididymis and in the broad ligament near the parovarium. The stalked hydatids of Morgagni, which are common to both sexes, probably represent portions of the atrophic liea in tlie same individual. 10. Development of the Nervous System. — The initial stage in the pro- duction of the great <r /'rain-7'esich-. l-'ore-brai>i. Primary optic I'esicic. Stalk 0/ o/'tic ■■i-siile.^ --' into -brain Miii-brain Uiittihrain Intel 'hi ain^ Cefhalicfl,: Fofi'-brain. Ol/actoiy lobe. OftiL stalk: Ml,i-h.,in. llln.l: [t'tn- I'.iin Ccicbral porlin ,/ pituitary Iviiy. Pontine Jh.xiirc \'\i.. US. liiiiiinims ilUistriitiiii; tlio iiriniiiry iiiicl soc- uiuliirv si'iiimiitiilinii ul' tlu' Imiiu-tulu' iHniiiU't). l"i(i. llii.— Diiinrain shdwiiiK rolntimis nf liiain- vi'siclos anil lU'xuros (lidiiiuH. even before closin*e, becomes expanded into three jtriiuarj/ bfdiii-rcxirliK, tin. anterior, tiie middle, and the posterior. The anterior and the posterior nf these vesicles very soon subdivide into sccoixhtri/ compartments, the arraiii;v- ment of the brain-segments then being, from before backward, tho forc-hriiin, the iiif('i'-/>r(ilu, the iiiid-hniiii, the liiiid-bnuii, and the (iftcr-hrain (Fig. IIS), Coincidently with tliese changes the cerebral axis has sntFered marked tl(- flection ( Fig. 11!*) from its original aliiK^st straight condition. By the lllicciitli day the cranial tlcxure is strongly jironounced, a bend of almost 00° tiikiiis; place opposite the mid-brain (Fig. 120, a). During the fourth week fnrtlur marked changes appear; the bend opposite the miil-brain, or mcKou'CjilKili,' Jfc.i'Uir, has increased almost to 180°, so that the ventral surfaces of the iiitn- brain and the hind-brain lie nearly in contact (Fig. I'iO, n). The jiiiiitinii ol' the brain and the sjtinal cord is marked by the ccrfli'dl Jlcrtirc, wliiih forms ail angle of about !(0°. A third bend, the miiourplid/ic or froiitnl tli.r- lire, apjM'ars oj)posite the primitive cerebellum and the pons, and has its ciiii- vexity directed ventrally or in a manner opposite to the disposition of tin other curves (Fig. 1*20, r). The development of the individual jiarts of the brain dejiends lariiclv upon local thickenings of j)arts of the walls of the cerebral vesicles, wlicivliy areas of notable thickness arc produced, as in those which give rise to tin corpus striatum and the optic thalamus ; the cleavage of the fore-brain and iL ingrowth of connective-tissue structures accompauying the growth ol' tin l)rimitive falx likewise exert a profound iiiHuence in shajiiug the parts ardiiiii lay the no;;ral the l)eginirmg vc hasbeconio mil by the uji- ■keiictl utiinil litl-iine. Tlu' > neural canal, Cephalic flc.xu 'v. MU-l'.iin. llitui-. utiii. .Af'tcrhain : r-'liitious of I'laiii- rdiii-vrxiclix, \\w ]w ]n>storior dt' nts, the arraiiiii. the fori'-lmiiii. In (Fiii'. H^l rcil nuivkiHl do- \y the tit'ti'iMitli lost 00° takius: til week t'urtliiT ■OS ol' the illtrr- The jmiitiiin flexure, wliiili (' or frouliil thi'- xud has its cou- sposition oi" tlii' depends lari;ilv vesicles, \vluT(l>y jrive rise to tin' .re-hraiii ami tli' ivrowlh I't till the )»arts avdUiM J'JIYSIOLOdY OF PRKUyA.WY. 127 the lateral and tl.ir.l ventrieles. The ai>pearanee of sueh eou.miss.n-al bands as the corpus calk.sum and the fornix still further njodilies the adjacent struy- Fl(i iL'd— Hriiiiis (iriiiniiiiii fiiiliryos I'niiii rt'constniclii'iis liy His. A, hmiii fnuu lil'tcfii diiy iMiil)ry(); B, from tliivi" niui .1 linU-vvofk nnl.ry.. ; C. from sovon iiii.l a hiilfwook fetus ://., il<, mh. hh. „h. foiv-. inter-, mid- hind-, mill alU'rl>riiin vesieles ; -). optie vesicle; or. otie vesiele; in. infnnililmlnm : in. nuiinmilliiry process; ;)/', pontine tlexniv; IVr. I'onrtli ventriele ; )''.-, eervieiil lloxure ; ul. ollaetory lolie; h, basilar artery ; ;), pituitary reeess. tures. Tlie brain-vesicle UMderu;oinf>: least chanjic is the niid-braiu, since its walls remain niiclct't and retain their primary relations to (he enclosed canal. I! •3v— c/t ry lolie: ;>, pitniliiry luuiy ; nii), Jncdiilla ohliincala : iv/, corpora iiMaiiriucniimi ; eh. cen'liclUim. II, lirain of linnnui t'elns of three nmntlis ■iJHish (i/>'. iill'aetory lohe; Cfl, corpns striatum; ii/. I'orpora iiiniclrij-cinina ; e/i, cereln'Uum; vio, nu'iluUii siblonj;ala. mhe relative position of tlit> initl-brain, however, iin. iiittTparictal lissurc ; jii/c, iiariito-uccipilal lissiirf ; p//, purallel lissuri' ; calhii, calldso-niarfiinal lissure; uiw, uncus; ('(i/c, cilou. riui' li..iiri- ; ve- dibiilinii ; I'or- liiiii iiitrrpiis- piira nuiiiiniil iluni. :!. Cerebral pedini CurpnrM (|uad- ilenieulale .\(|Ue(luet .Mill-brain. eles ; pusle riueniina. i bodies: , of Syl- ri(ir perliirated i braeliiil. i vius laniinit. I. Tuns \'arn!ii. .Xnli'rlnr nieil- Superior anil llind-braiu, ullin y mIuiii ; middle pe- eeri-b'eillllil ; dlllleles id' i |His|eriiir tiled ei'reliellmii. ! iillarv velum. Kuurtli venlri- (de. Ji. .Medulla ublnU- 'lliiu e..\eriiiL' Ilileriiir pe- After-bniin. pita. of pn-lerinr diiiiele« nf purl 111' I'liinill eereliellum. ventrli li'. PHYSIOLOGY OF PREGNANCY. 129 by the rajiid- of tlio \\\\i\. pora quinlri- toad of tiioir L'bral inantlo ii'rior, B, liiliiiil.c. itrrparii'tiil li-Mirc. uncus ; cah\ mXai cerebellimi, U ornnn^ntiiiMT- tho piiK'iil and )|)ment of tlio )ceial works (ni witr, will sci'vc n the more iiii- nts: A. HriiiiiiiiiuitUv id li, Uniiii "l"lk i- I The spinal cord i.< formed primarily by the thiekening of the lateral wall of the neural tube, the latter becoming reduced to a narrow passage, later the centrd oaual At first grav matter alone exists, but with the formation of the nerve-fibres the white tracts appear (Fig. 123). The nerve-fibres connected Ecttidirm. White matter. \ Dorsal commissure Spin'ilga Di'isat root. l\ii:>itl >i«'t: S/>iiial nerzc. ,/^^ ^m^'' / Outer mei/nliitrv :oi:e. Central ciinui. S'otochord. Ventral commissure. Y\\\. IJM.— Traiisvor^f scLtiou of (Ifvoloping spinal coril (if a twenty-two day sheep embryo (Bonnet). with the spinal cord ditfer in origin according to their function whether they are motor or soiisorv, the former proceeding as outgrowths from the nerve-cells within the cord, the latter as processes from tiie cells of the spinal ganglia ; these latter centres, in addition to the sensory fibres i)assing into the cord, send to the lU'iipiicry fil)rcs l)y which sensory impressions are conveyed. The s\jm- patludc iicrroiiti si/stcin originates from the spinal ganglia, from which portions are separated as tiic organs of the sympathetic ganglia. It may therefore be acce|)tcd as an axiom that all nerve-fibres are produced as direct outgrowths from j)rc-c.\istiiig nerve-cells, and, further, that all portions of the great nervous svstcm mav he referred to the primary neural folds. 1 1 . Development of the Organs of Special Sense. — The history of the specialized organs of touch, taste, and smell, as represented by the various forms of tactile lu'rvc-endings, such as the corpuscles of Mei.ssner, Vater, etc., the taste-buds, and the Schneiderian mucous mendirane, belongs to a consider- ation of the histogenesis of these structures rather than to a brief outline of salient featiwes in general development; suttiee it here to add that the organs of taste and smell consi, elements consisting of modified epithelial cells bearing close relations to the nerve-fibres. The various forms of tactile corj)nscles receive more or less highly developed sheaths from mcsodermic tissues. The organs of sight and of hearing, on the contrary, claim greater attention on account of the profound embryological proeei^ses in.stituted in Itheir formation. The development of the cjic consists e.-;sentially in the formation of two ni Ml I [Mil t I ! (■ i i .•'I' 130 .lJ/J5'/?/CJ.y TEXT- BO OK OF OBSTETRICS. ectodermic epithelial pDiiclies, the optic vesicle and the lens-sac, around wliili the adjacent luesoderm dilierentiates into vascular and fibrous envelopes. '! ho Fig. I'Jl.— Scotioti through Fic. 12'v— Se( uon through lu'iiil of ton day nibliit I'lii- (ievi'lopiii),' ojo cif ulfvoii diiy liryo.o.xliiliitiiit-'priinary nptic riibliit inihryo (I'iursol) : H, vi'ssc'l (Oi ]initni(linK frniii fnii'-liriiiii ciuini'cttMl by stalk fore-lirniii (7)t iiiul cciminjr in with ojitic vosii'lo (o), whose oontnct withsurfiic'ei'Cto('.orni antoridr wall Is partly invaRi- (f); m, surrounding mesodorm natod: /, thickenod and du- (Piersol). prtssod lonsareii. Fl<;. 12fi.— Suction through dcvil. ),i||,_, cyo of ck'von and a half day rahlii; ,1,1. bryo (Tiorsol): IS, foro-bniin coniirrud with dptii' vesicle (<;), nearly etlin-..! |,y ap|iositinn of Invnninated anterinr x;.. nient u'l with jposterior wall (/ens into the ccicbial cavity by means of the o])tic stali<. tlir latter communicates with the inter- brain. The original optic vesicle -noii exiiibits indentation ,;.. ir wall ( id: '. Inis- imii soimniti'il rn.iu hill si-'('(iii(Iar\ 'iptic lUiidiiiuinfMiiliTiu. th tlay — :i> tliu es (Fig. 1-J8I, iteral ov;ii:iii:i- rt of the aiitc- Ic ; later, \\ lien ito the eerel)ral optic stalk, tiir ith the iiitcr- tic vesicle m"iii ts anterior \v;ill ition pro>- ,l:iy chick I'lllliryir ilircc wci'k^ dlis' (ijltic Vl'sirlcSUIl'l ,h, iiitiT-brain. "'. erior and mitrr PHYSIOLOGY OF PREGXANCY. 131 undi of the auditory apparatus of man includes the formation of the external, the middle, and the internal ear. The external ear is closely related to the history of the first outer visceral furrow, the external canal being, with some minor variations, the representa- tive of this cleft, and the expanded parts constituting its pinna, resultiiii.r from the fusion and metamorphosis of the auditory tubercles (Fig. 129) >iir. rounding the outer end of the visceral furrow. The middle ear is formwl by the persistence and further expansion of tlio first pharyngeal pouch, hence possesses an entodermic lining. The tyiii|)aiii( membrane includes contributions fntm all three layers, its outer epitlicliinn being ectodermic, its inner epithelium entodermic, and its fibrous tissue niexi- dermic, in origin. The /;(/'r/(a/ rrn- consists of the morphologically older ectodermic ])orti(iii, which is rejiresented by the complicated membranous labyrinth, and the surrounding mesodermic cnvelojic, which becomes the bony capsule, and \\\v connective-tissue structures intlnddl between the osseous and the nieinlna- nous labyrinth. The earliest appearance of the ear< takes place about the fifteenth dav, when on each side of the hind-brain ;i depression lined by thickened ectoderm (Fig. 130), the (ific pit, is formed. Al- m(»st immediatcdy these pits becmn' converted into sacs, the otic ve.vrle.s, In the closure of their mouths, and sodii lose all connection with the ectodenti, 't'j.A.jNa. ■•,1 ..■„ 4/ \-^*rf-, ' X ii Flii. l:W.— Si'ctiiin tliriiuj.'h i. liiiiiif; nf iicunil tiihc; r. bliMiil-vrssel. King entirelv surrounded bv iiic-d- dermic tissue some little distance hc- neatli the free surface. The otic vesicle appears pyrifi)rm, that part corresponding with the closed mouth becoming ex- tended ; this elongation soon becomes more pronounced, so that the now sumk- PHYSIOLOGY OF PREGNANCY. 133 i (Fig. 127). growth, and tinning as a itreous bodr, nea with llio ct'.Mlerinic in (I luontli, arc it the end of nd nnite, the 3 lids poriua- ce the geiusiv ! external, tho outer vis('(>ral he reprcsciita- nna, resuhine Pig. 129) Mir- pansion of tlic The tyniitanic tor opitlicliiim IS tissue iiu'>(i- orniic portinn, intli, and \\w psulc, anm\ tho octiidt'iiii. lod l)v iix'Sd- (> distanrc lit- riio otic vcsiclf II hoooininir ''X- tlie now sdiiii- what flattened sac presents a conspicuous outgrowth, the reccsms labyrlnthi (Fig. 131, a). The otic vesicle a.ssnnies greater irregularity on account ot the appearance, durin.r the fifth week, of a blunt diverticulum, anteriorly and vontrally directed, which is tlie earliest trace of the future nienibranous cochlea, and, shortly after, of dorsal projections on its outer side, which foreshadow tho scniiciVci.lar 'canals (Fig. 131, H, c). Before the end of the fifth month, the chief coinpartiuent of the vesicle, by this time of considerable size, undergoes Km. iai.-I)L'vi'l('|iiiU'nt dltlie mcmViranous lahyrintli of tlie human ear (W. ITis, ,Ir.1. A. lift laby- rinth of eniliryi) of ahoiit four wooks. outor .sitie : v. c, vestibular and cochlear portions; rl, reees>us labyrinthi, H. Kit liibyriuth with parts of facial and auditory nerves of embryo of about four and a half weeks: r/, recessiis labyrinthi; ,»,■.(■, jiw, esc, superior, posterior, and external seniicirc\ilar canals; .'-■.sac- cule; f, cochlea; rn.jn, vcstibulnr and facial nerves; vg, eg, gg, vestibular, cochlear, anil geniculate tian- glift. (', left labyrinth of embryo of about five weeks, from without and below : labelling as in preceding figure. subdivision by the formation of a coiLstricting fold into a dorsal division, the priinitivo utricu/ut^, and a ventral division, the primitive sdcciilm. Tho nidi- mentary .soniicircular canals and tho jirimitive ooohloar duct open rospectivoly into the ntriclo and the saccule. Tho rece. acusticre, for the perception of transmitted stimuli. The mosoderm immediately surrounding tho membranous labyrinth later undergoes imjiortant oliaiigos, whereby tho tissue next the opitludial structures is converted into the connective ti.ssuo enveloping and supporting the delicate I&0' f''-^ ^ mI i in f l;]4 AMERICAX TEXT-BOOK OF OBSTETIilCS. DESCilDING.«t VENA CAVA Flii. I3'.'.— i)i;iL;r;ii]i nC fftiil circiiliiticiii ln'luri' liirtli ; tin' iirinws iiidiciiti' tlii' cuiirsi' (if Ihu tiluoil- cumTit ; the i-iilcirs slmw llic (■ImnicliT 'if the lilncul ciirrifil liv tlic ililfcTriit vi'ssrls. I »'»"-' - m-^^ *^l m PHYSIOLOGY OF FREG.XANCY. 135 mmi liirsodf the blucil- •nt vcssi'ls. Fig. IX).— Diagram of eirculatiim aflor liirtli ; llic ihictiis votinsus. the fniamon ovalo, and the iluctus arti'iiiisus arc now clostHl and iin hinjior tnii.siiut iMirtimis of tlio bhiud-current. 136 AMEIilCAy TKXT-liOOK OF OBSTETlixCS. II I . / I • ,t 1 1 1.- ■ I ''I cpitliolial labyriiitli, wliilc tlif tissue slightly removed ^nves rise to the periitio cartilaginoiis eapsule which later is replaeed by bone. The important spicks oceupietl by the perilymph are formed relatively late, since the\ arise by ih,, breaking down and channelling of the mesoderm surrounding the j)itli' linl tubes. In the cochlea, for example, the ductus cochlearis, with its epitli. lial lining, represents genetically the oldest l)art, while the scala vestibuli ami tlic scala tympani are of more recent origin, since they are formed by partial ills. ajipearance of the mesodermic tissues. 2. Physiology of the Fetus. Nutrition and Growth. — It is evident that the life of the ovum, what- ever its character, whether vertebrate or invertebrate, picean, amphilujin, reptilian, avian, or mammalian, can only be maintained when the fundaiiK ntnl necessities of life — adetpiate supplies of oxygen, water, and suitable noiiiisli- ment — are provided. The ovum and the early embryo being witliout means df securing these advantages, such provisions must be ensured by the arraiigenu'iu of the immediate environments, whether these be within the maternal tissue. or within the protecting structures (»f the shell or the surrounding medium. The loss of yolk, which there is good reason for believing the mammalian ovum has suffered during its evolution, is compensated by the nutritive inato- rials supjdied to the developing ovinn by the adherent discus proligerus. and by the secretions of the oviduct and uterus which are taken into the intciiur of tlie egg by osmosis through the zona pellucida and the jirimitive ehdridn, The Fetal Circulations. — The earliest circulation, the vitelline (PI. 15), j, well established during the third week. The blood passes from the network i>\' the vascular area, by means of the large vitelline or ompliah-mcscnfcric irin^. into the sinus vcnosus, and then, after mingling with the blood returned Iv the systemic veins from the body of the embryo, into the auricular seginent of the young heart. From the anterior or ai'terial end of this organ tin blood is carried by the truncus arfcr'iosus into the aortic arches, hence into tin ])rimitive aortte, a small portion ])assing into vessels su])plying the enihrvu, while the greater part enters the vitelline arteries and once more gains tlu vascidar area. The development of the allantoic vessels and the jilacental circulatidii necessitates additional blood-currents, in the direction of which the imw rapidly developing heart and liver exert an important influence. For a tinu all the bloml returning from the placenta passes through the liver iiclinv reaching the heart ; later, when the hepatic capillaries can no longer aecoimiid- date the entire placental circulation, the arts of the hypogastric arteries first occurs, and is usually completed by the third or the fourth day after birth. The ductus veno- sus and the umbilical vein are generally closed bv the end of a week. The duc- tus arteriosus usually closes within a few days, and is completely impervious by the third week after birth. I'ermanent closure of the foramen ovale is delayed for some time, the blood being excluded from the left auricle by the Upposition of the edges of the valve, which are kept in jdace by the increasing pressure from the left side exerted by the blood rettu-ning from the lungs. :After a time the edges of the valve coalesce with the margin of the foramen ovale and the opening becomes permanently closed ; not infrequently, how- jT-'-'TYTm l:\H AMi:ni('Ay ti-lvt- no oa' or oustktiucs. i ! f i ) i| ^" I I M...-^ I'vcr, iiioiitlis elapse belore the union heeonies eoniplete. In ea.se tliis union j^ never perfeetlv elleeteii, ii suiiill e(iniinnnieation may remain tlinaigliont 111; as a eonjfenital deteet, of sli^'lit or grave import depending upon tlie extent uf the fanhy union. Tlie estahlisliiiient of tlio vitelline eireulation, the Hrst one of the pnilnyo, marks the introdnetion of an important nutritive apparatus in animals jKKssessiiijr large volks, which in tiiem eonstitute sourees of nourishment of great eoiise- (pienee. In man and other mammals, however, the appeiU'ance of the vitelline eireidation must be regarded rather as the expression of formative proe( sses whose usefulness has largely disappeared in eonsequenee of the profound modifieations whieh the diminutitm of yolk and the greater dependence on tlic maternal tissues have witnessed. ^Vhile in mammals the exposure ot the fetal blood-stream over the extended walls of the vitelline sac or umbilical vesicle affords an opportunity for a limited exchange i)f gases, the amount of nutritive materials directly taken up and appropriated by the end)ryo nui>i li|. very insignificant. The deficiencies of the vitelline circulation in mammals, iiowever, are coin. pensatcd by the active development of the allantoic ves.sels and their fuitiiei' specialization into the all-important placental circulation, whereby the nspi- ratory and nutritive necessities are secured to the fetus throughout the last two-thirds of gestation. The j)lacental eireulation, by means of which the respiratory interchange nt' gases and the passage of nutritive sul)stances from the maternal blood to tiiat of the fetus is effected, is undoubtedly the principal, and practically the sdlc, source of those substances necessary to maintain the life of the developing ani- mal. The /it/KO)' (tiniiii has long been regarded as an additional source of initii- tive materials, in view of the fact that this ffuid is undoubtedly swallowed by the embryo and taken into its intestinal canal, as .sliown by its presence, a< well as the presence of hairs and epidermal cells at a later .stage, within the gut. The comi>osition of this fluid, however, renders it highly improbi.!;!;i that it contributes in any appreciable degree to the nourishment of the (ctiis. containing as it does nearly 90 per cent, of water. Tlic liciuor aninii, never- theless, serves an important purpose in supplying the water neees.sary fur the fetal tissues, since the latter must contain \>ater in excess, according to Preyer, in order to extract the albumen and the salts from the blood broujrlit by the umbilical vein. The fetal jdacental vessels convey albumen, salts, and water from the mater- nal blood into the circulation of the fetus, as well as the oxygen absorlKiJ by the red blood-cells during their sojourn in close proximity to the siriuse* filled with the blood of the mother. The soluble .salts probably pass Inmi the maternal blood into the fetal blood by simple osmosis. That the alliii- minous substances, however, are so transferred is very doubtful, but the soliitinii of this question, it must be admitted, so far has been unsatisfactory. The ingenious explanation advanced by Rauber, that a physiological transmigration of leucocytes from the maternal tissues into the fetus furnishes the means of this union is iighout lil us the extent nf f the onil)rv(i, luls possessing' t' jrrcat cdiise- ;)f the vitelline itive proe( >sw the proi'diiiiil cmlenee on tlic cposiire oi' the :; or iunl)ilic;il the ainoiiiit of inhrvo nui-( lie «r I'over, are cmn- d their fiirtlur ■reby the rcspi- itlhont the \a>\ interchaii^o of »1 blood to tiint tieully tli<> siilf, developinji ani- souree of niiti'i- V swaUownl liy its presence, ;i< tage, witliin tlio dy iinprobi.M" 3nt of the fetus, anmii, never- r necessary fur !, aeoordini; to blood bronirht Tom the inatcr- xvgen absDi'bcil to the siinifc* ably pass fiMiu That the alltii- biit the solntinii isfaetory. Tlii' transmigration !S the means of V rjiYSJOLoav or PUKaxAXCV. r.vj trans) nsportation of particles of albumin, fat, lecithin, and similar substances, lacks eontirniati(Ui. 15y some the evidence is regarded as strong that they pass over in tlu- form of soluble peptones. That substances in solution pass from the maternal circulation into that of the fetus has been provetl by direct exiwrimcnts with iodin ((Jusserow, Kru- kenlurg, Ilai.llcn), salicylic" acid (Henicke), and pc.fassium ferrocyanid (Fehl- ing). The investigations of /weifcl demonstrated the free and rapid passage of chloroform administered during parturition from the maternal blood into the uml)ilical circ.dation, and, cousecpiently, the highly pn.bable inHuence of the anesthetic upon the fetus. The result of attetupts t(. introduce substances in a condition of fine division, but not in solution, such as vermilion, India ink, fat, etc., have been negative, the seeming exceptions where such particles were found in tlu,' fetal circulation after injection being attributable to injury of the blood-vessels. Tlie migration of formed elements, such as the pathogenic bacteria of anthrax, typhus, etc. or the colorless blood-corpuscles, from the circulation of the motlier into the ti'tal blood is a (piestion about which there is nuich dirtcrence of opinion. Regarding the blood-cells, moreover, the investigations of Sanger point to the improbability of such migration taking place, since in leukemic conditions of either mother or child the blo{Hl of the remaining organism may retain its normal proportions. The experiments of Savory and (Jusserow have shown that in animals in which the fetus is poisoned by strycliiiia the poison may pass from the letal circulation into that of the mother. Certain substances administered to the mother pass into the liquor amnii, as in the case where iodin is given (Krukenberg). That the fetus takes no part in producing this eifect is shown by the fact that the drug is found in the liquor amnii even when the product of conception is dead (Haidlen) ; further, that coloration of the amniotic Hnid after the injection of sodium sulphindigo- tate into tiie jugular vein of the mother is unattended by the presence of the substance within either the kidneys or the lu-ine of the fetus (Ziuit/). The staining of tiic maternal tissues composing the decidua by the pigments con- tained within tiie meconium emphasizes the fiiet that substances within the liquor amnii may in turn affect the mother. The respiratory and metabolic changes within the fetus are carried on by means of the oxygen taken up from the maternal circulation by the fetal blood-stream in its passage throtigh the placenta, in exchange for the carbonic acid and other products of tissue-change. So long as this interchange of gases takes place without interruption in the placenta, the fetal circulation contains an excess of oxygen, since, notwithstanding the small amount derived from the mother, the (piantity of this gas thus obtained more than snttices for the nectls of the embryo, and induces a condition of apnea. When the placental circu- lation is interrupted, however, as by compression of the umbilical cord or bv premature se])aration of the placenta, the fetus perishes with all the symptoms "of asphyxiation. 140 A ME RICA X TEXT-BOOK OE OBSTETIUCS. I i Till' direct jinidf of" the source of oxygen from the ulaeenta has been .-up. plied bv the investigations of Colinstein and Znntz, who examined the blodd of the umbilical vein in sheep, and found it richer in oxygen than tliat wiiliin the umbilical arteries, although the difference between the arterial and the venous blood during intra-uterine life is nuich less marked than after liiith (Ilallibin-ton). The sj)ectroscopic analysis of blood from the human umbilical vessels bv Zweilel showed the presence of the oxyhemoglobin bands before respiration was established. The consumj)tion of oxygen by the fetus, as measured by the necessities of its own heat-production, is relatively small, since the maintenance of its tem- perature is greatly facilitated by being surrounded by the lifpior amnii, the warmth of which is almost 0(]ual to that of the fetal blood. The fetus is still further favored by being sjiared the necessity of taking within its lung- and alimentarv tract substances which nuist be warmed to its own temperatun' at the expense of its own heat. The presence of the warmed liquor amuii als, prevents caloric loss by cither radiation or evaporation. The pre-natal functions of the fetus include limited activity of the ki(hi(v> and preparatory exercise of the organs and glands connected with the alimentarv tract anrecedc- tlio development of the fetal kidneys. There is, however, a similarity between the usually alkaline allantoic fluid and the later secretion of the fetal kidiiev-, the fluid often, i)ut mtt invariably, containing m-ea, uric acid, the alkaliiu chlorids, phosphate*, and sidphates, as well as iron, calcium carbonate ami allantoiil. The early jiresence of urea annp- loil tl'o li'udd in that wiiliiii oriiil ami the lan aft or I'irtli man uniliilicnl bands b( lovo ^ ncoc'Sfiitic- of lice ol" '\y tiiii- nor aninii. ilic ho ibtus is -till I its hnisr- ami toniporatiiic m nor anniii al> . of tlio kiihu'vs I the aliiiuntarv bv tho Wolflian collootod within inot be ri'irai'did in\vn jiali nneeted with tin ,,f the diiiiaiiil> . ferment- ncir- (■rent ditli'iiliif attending the investigation ..f the subjeet in the human fetus have left our knowledge on inanv points still far from satisfaetory. The siliva of the fetus has reeeived mueh attentii)n with a view of deter- niiniii.- the p'lrseiiee or al.seuee of ptyalin. While the results of the observa- tions by various investigators are contradietory, the positive evidence of the presenee of tliis ferment in the saliva of the new-born obtained by Hehiffer is important. This olwerver demonstrated the unmistakable presenee of ptyalin in the salivary secretion of three new-born children, thus showing that the capal)ility of coiivertintr starcii into sugar exists in the saliva from birth— a iLt the more remarkable when the absence of the opportunity for the exercise of this power is icealled, tiie character of the early food recpiiring neitlier stareli nor dextrin. It has been sliown that the ptyalin i~ : «t elaborated in- ditfereiitlv by the salivary glands, but that its presence is limited to the .secre- tion and tissue of the parotid. The relatively tardy development of the labial and other glands of the oral cavity is in accord witii the observed slight activity of the secretory function of the moutli of the fetus. Tlie trii^tric secretions of the new-born iiave been fotnid to contain pepsin and remiiu immediately after birth, pepsin digestion and the power of curdling milk heiiiu; estaldislied within a tew hours. Tlie observed ditferences in the amount of pepsin contained in specimens of the unicous membrane of new- born eliildreu probably depend upon tiie variability in the development of the gastric jisin, which resembies ptyalin in possessing the power of attacking starch. liangendorH' demonstrated the presence of trvpsiii in the j)ancreas of the fetus at tiie fiftii and sixtii month ; Zw'cifel, tliat I . ! ; i absent before this secretion is i)t»nre(l into the intestinal eanal, as well a- in eases of malformation in which the elaboration of bile is wantinfi:. The \ icw attribnting to the swallowed liiiuor amnii an active rv/c in the formation of the meconium is opj)osed bv the presence of this substance in malformed fetuses in which the ])ossibility of entrance of the amniotic fluid into the inus- tines was jirechulcd. Jjcfore the secretion of bile meconium is not present, llennijr obsi :\(.,1 liifht vellowish-green meconium in a fetus at the ben-innino^ of the Iniinl, month. The l)eancreas, and of tiie >\v;il- lowcd amniotic li(|ui(l, together with such remains as leucocytes, intestinal cpi- thelium, lamigo, epidermal cells, and fat from the vcrnix caseosa carried jnt,, the gut-tract along with the li(]Uor anniii. The chemical composition of meectniuni, as ascertained by Zweifel, indiulo-: from 20 to 27 per cent, ol" solids, of which about 1 per cent, is inorganii', tho remainder organic; the amount of fat and fat-acids and of cholesterin is the same — about .75 per cent. The inorganic constituents include the ])hospllat^^ and sul|)hates of magnesium and calcium, Mxlium chlorid, and oxid ol' iron, The i)rineipal organic substances are the more or less changed bile-salts, tin unaltered bile-pigments, bilirubin and biliverdin, and mucin. .'). Multiple Conceptions. The fecundation of more than a single ovum, or, as often less accunitdv termed, " nndtiple ])regnancy," is by no means an infrequent occurreiicc, ;i> the munerous births of two or more children testify. Afnltiple conci ptioib may result in the birth of twins, triplets, and, as great rarities, (pia(lni|il(t.«; a nund)er of well-authenticated instances of five children at one time niv recorded ; and even an apparently trustworthy case of the birth of six, i;,i|i bovs and two girls, has been reported by Vassalli. The reputed biiilis in excess of this nundjcr arc apocryphal. The most extensive series examined with a view of determining tlir iv|;i. five frc(|ueiicy of multiple conceptions is that studied by (}. Vcit. wiiici, included the records of thirteen million births in I'rnssia. According tn tlif-i statistics, twins occur imee in (SS births; triplets, once in 7910; ami (|iiail- ru])lets, once in .'571. 12(). About a dozen autlicntic cases of liv(~ at a liini: arc recorded in medical literature ( Kaltenbach). The statistics of (lilllivii; countries seemingly point to considerable variations in the fre(iuency (if twin-. thus, in Bohemia twins occur once in about GO births, while in I'^-aiKv ilnv appear only once in every lOd. Keccnt statistics supplied by the linaid >: Health of \<'W York and of I'iiiladelphia ])Iace the frc(pieney of twin liiiili- in these cities at 1 in every \'2*^ i)irths. In acc(>pting such conclusions, linw- ever, ])ossible errors arising from ditlerences in the character and coniplctoiii- of the statistics compared niu-t not be overlooked. ', ^^^^W^*"" ■* .iJr.i... ,ui PHYSIOLOGY OF PltEGXAyCY 143 as well u in ct. TIU' \ U'W ', Ibrmatidii df in inaH'oi'inwl into the iiius- of tlio t'li'irili K' period lidiii addition tn tlu' ('US and juicos. ml of the >\v:il- 3, intostiuiil cpi- iisa carried iiitu 'iWeifel, iiu'ludo- is inorganii', tlio ■holesterin is tlie I' the ])hosph!ito> lid oxid of iron, rod bik'-saUs, the in. n loss aeeiu'iitcly nt oeeurreneo, ;!• tiple eonecptiom ties, quadnii»k't>; at one time aiv birth of six. U\\ repnted hiilli> in rmininu; tlic ivla- V (I. Veit. wliii'ii Aeeordinir '" du-i 7910 ; and ^\\\\\\- „f |iv(> at ;i I'ii'ii. iti^ti<'s of ditVcivn: •ctiueney of t«i'i- 1,. in FraiHv ili.v by the r«":>i'.l '■: ■ney of twin Im'ili- conclusion-, li"«- ■r and eomitletom- Of loO.OOO twin i)regnancies .studied by Veit, in one-third both children were bovs ; in shglitly le.-gi'(l twins almost invariably anastomose, so that the placental become more or less completely fu.sed, the conunon nutritive area then consisting of three parts, an Intermediate, indiffl'rent area being enjoyed in conunon, in addition to the par- ticular i)art which mini.sters es|)eeially to each fetus (Ilyrtl). The anastomosis of the placental vessels may result in the mo.st profound impressions in those case"- where marked diirerences exist in the developmeiU and vigor of the two fetuses, since the circulation of the weaker fetus may be unfavorably inffu- enced, even to the extent of reversal (Ahlfeld), by the overpowering force of %t of its stronger brother. Disastrous atrophy and the production of an aoardia are among the results attributable to such conditions. When one fi'tus succundxs, the press,,,.,, exerted during the growth of the living child gradually r^ luces the mass of the dead product of conceptii.n, until . /i ■t i "ii Bpii 144 AMKlilCAy TEXT-liOOK OF OliSTETItlCS. fllMi! ;:j fiiiallv it is ropro.seiitcd by tlio groatly flattened ami atteiiiiattd remains inijiii>- oned against the uterine walls, then eonstitnting the " letus papyraeeus " u\ tJK.. teratologist. CVtnspieuoiis, and sonietiincs remarkable, disparity in the pcrllr- tioii of growth and development may exist in twins at birth, the more t'a\,ircd fetus sometimes exeeeding the smaller threefold in weight, the difference depend- ing upon the nutritive advantages enjoyed by the one at the expense of \{> Ic,. fortunate fellow. In eonsequence of this disparity it sometimes, though vciv rarelv, happens tiiat the fully-matured fetus is expelled at term, while the -till imperfeetiv developed fetus is retained for a time within the uterus until \u devck>pment has p?'ogressed farther toward completion, when it in turn is Imm, Two remarkable ea^es in which double uteri were present have been recdidcil bv Jiarker and (Jeuerali,. where intervals of forty-three and thirty days rc-pcc tivelv intervened between the births of the two fetuses. It is the occunciic, of such cases which is erroneously regarded as a fact in support of the jkiv. sibility of super fetation. Triplets may originate, it is evident, from a single ovum or from two dr three distinct eggs, a fmpiciit arrangement ijcing that one child is dirivd from a distinct ovum and tw(.> from a single ovum. U|.on the nianiK r nf their origin depend the arrangement and relations of the placenta and incm- branes, (Quadruplets may exist as double twins, or they may residt Innna combination of a single birth with triplets. Plural conceptions, on the one hand, may result from a .single coitiH, \vhcrcl)v are impregnated ova which have simultaneously been discharged tVuin the sexual glaml, ])repared for the reception of the male elements; on the other lianil, rc|)eMted impregnatiou< may occur after ditlerent, though cIuhIv following, sexual acts, tliesc resulting in the fecinidation of dill'crent ova wiiidi have been lilierated at -lightly separated 'uomcnts, but which belong to the same ovuhition. This possibility has received recognition in the term .\////(/'- j'{Viin(J lc>s ■;, thoiijili .crv while tlif -till torus until is in turn is I'uni, ■ bt'i'U rooordcil ty days rc~|Kr- thc OCCUl'K'lHV ort of the |l(l^- or from twd uv hihl is (liiivwl the manner (if LMita ami iiuiii- V resuh in 111! ;i a single enitiis ilischariiX'd t'lMiii enients ; oii tlif , thoupli il(i>(ly erent ova wliidi I beloujj; tn ilic the term ^"//(i- fce\uulati(Mi ni ;. C'onspielKill- a neji-ress givis siipcrjctdlinih 111' 'riotls, and lluTi- 'xual acts widely )irtli of a .-('('(mil itv of suivrfcta- •rcnee an iiikui- When tlie r:i|iiil (>nt that l(illii«- ;ichin}ij iuul ill'- tlic ovum, evtii nterus, »\\ tin' ■rfctation iHT;ill •owth anil ilevil- PIIYSIOLOGY OF PREGXANCY. 145 opnient of twin eoneeptiuns, where this disparity results in the delayed deliv- erv of tlie less favored fetus. " rinial births frequently occur before term, twins being born a few weeks before the end of gestation, (juadruplets and quintuplets in the earlier months of pregnancy. 4. Changes in the Maternal Organism Induced by Pregnancy. 1. Local Changes.— 'riie pre.senee of tlie fecundated ovum inaugurates a season of inereased nutritive energy, which not only effects changes in those organs in inimediate relations with the developing fetus, but also induces chaniies involving the entire organism of the mother during the continuance of pro'-'nanev. The clianges thus indu(;ed in the general system being discussed in a separate section (p. 153), consideration in the present place will be directed to tbcj.-e ehaiiires manifested l)y the sexual organs and the parts intimately con- nected with the processes of gestation and parturition. The iifrnifi, as may be expected from its especial relation to the developing fetu,- earlv manil'ests the profound changes which it undergoes; indeed, the preparatorv alterations affecting its nmcous lining and va.seularity preceding each menstrual epoch must be regarded as the beginning of the cycle of chanro(hu't of conception and the protecting structures. The hvperiniphy of the nmcous membrane of the uterus and the greatly i'ncrea.sed va.scidar supply which take place coincidently with the liberation of the ripe ovum from the ovary, under usual conditions, are succeeded by the destructive changes giving rise to the phenomena of men.struation. Should impregnation, on the contrary, occur, the liypertrophic proce,s.scs are continued with inereased vigor, and result in the alterations already described in con- nection with the formation of the decidua (p, 86). The most conspicuous consequence of the changes in the uterus is the not- able increase in the size and weight of this organ. From the insignilicaut dimensions of the small, rigid virgin uterus, which include a length of 7 cen- timeters {2'-l inches), a breadth of 4.5 centimeters (1|^ inches), and a thickness of 2.5 centiineters (1 inch), there is developed a huge flaccid sac which meas- ures at the elo.se of gestation from 37 to 38 centimeters (15|^ inches) in length, 26 cemimeters (lO^^ inches) in breadth, and 24.4 centimeters (0| inches) in thickness, with a circinnti'rence at the level of tiie oviducts of from 70 to 73 centimeters (2!) inches). The weiti'ht of the virgin uterus is about 40 grams n| oumx's) ; that of Ibe uterus at term, about 1000 grams (2 pounds), an increase of twenty-live llines taking place. The ca|)aeity of the uterus at the clo.se of gestation is between 4000 and 5000 cubic centimeters (from S to 10 pints), or over five hundnd times that of the virgin org.iu. The increase in the bulk of the uterus occurring during the earliest mouths ff pregnancy is attributable to the general hypertrojihy atfccting its walls, and net din'ctly to the developing ovuuu since only aticr the latter completely Mils 10 >* H!, ■ifp, i "ill-- . ' il I hi; i 140 AMKIUCAX TEXT-BOOK OF OliSTETRICS. the utcrino cavity, at tlio exj)irati()n ol" the fifth month, is the aii<;monto(l , izo of tho uterus pHxhiccd l)v tiic nicchanical distoutiou caused by the ra]>iHv p'owinii' fetus. The enhu-gement of the uterus, moreover, is not dirctlv dependent u])()u the ])reseiiee of the oviuu, hut is (hie to actual increase oi' tis- sue, as shown l)y the iiict that the liypertrojjhy of the organ ju-ogresses ujitu the fourth month in extra-uterine pregnancies, the same as if the ovum wopo present within the uterine cavity. The livpertropliy of tlie uterus at first affects cfpially all parts of the vi.cns but later the fundus and the body grow more rajiidly than the cervix. Tlio changes which atfect the uterine walls consist of thickening of the nuu'oiis membrane, increa-e of the nuiscular tissue, augmentation of the connci tivi tissue, and enlargemej-.t of the blood-vessels, the lyiuphatics, and the m ivcs, As a result of these alterations the walls for a time reach a thickness ol' 1.5 centimeters {^ inch): but this excessive growth is followed by a niiirkcd reduction resulting from the distention iucident to the later mouths of pivo. nancy, Avheu the extended uterine walls measure but 5 millimeters (y'ir inch) in thickness. The increase of the muscular trmic is etTected not only by excessive growtli of the already existing involuntary muscle-fibres, which increase from ten tn eleven times in length and from three to five times in breadth, Imt also hv tin formation of new muscular elements which likewise soon acquire the (IIiikmi- sions of .0 millimeter in length by .02 millimeter in breadth. The himinaof the uterine blood-vessels are materially increased, the artcric^ becoming wider and longer — without, however, entirely losing their tortiKi-itv — and the veins dilating into large venous chamiels, the .s'//(((.s nfcrivi, wliidi penetrate lietween the nuiscular fasciculi and v,-hich are particularly well of the body (Webster). Late in ))r(i'- nancy the pyriform or egg shape once more ])redoniinates, owing to the (loiih- lik(! distention of \hv fundus and the broadening of the lower segment. During tiie early niontii- all part< of the uterus incri'ase with ecpial rapidily: after the fiftli month, howev <'r, the cervix |)articip.".ie but slightly ill ( n!ii|ii son with the rate of growth manifested in the upiier part of the organ. Wliil' hypertrophy of t!ie cervix is admitted by all, the (>xteut to which this portim: 4 PIIYSIOLOaY OF PltEa.XANCY 147 rmontcd ;izc the rapnlly not tlirc'tly loroiiiro ol' tis- ((jrossos 11)1 t(i ic ovum were t)ftbo vi-in*. cervix. '\\w ){■ tlio mu.'.)u> the eoniK'i tivr ul the luivcs, lieknoss ol' 1.5 bv a in;irkc(l lonths ol' pivi;- letcrs {-^^; iiMli) j.(.p<5i;ivo e;ri>\vtii aSO IVoiU till tn Imt also liy the uire tho (Vhiumi- aseil.the avtoric^ I thciv tortuosity i(,s ntrr'nii, wlucli hirly well ilcvi'l- are iiiti mutely nc'ctive tissue in do IK^t ('tillu|W' tnphatics of tlic rvcs (lislriluUfil (/(nnjlioii I'lrri- ,(.es (luriii'i JMV'.;- retained ; suIk- nent, and Uvtli. a'l a..d til.' pyii- sterior diiiu'ibi"ii Late ill iivi":- vintr to tli<' iluiii'- v sejrment. th e(Hi:d raiiiility: iirlitly in rnini»;\i"- he or^an. ^^l"'' ,\l,ieh thi- l"iiW' of the uterus euiitrihiites to the formation of the excessive uterine sac present iit tlie close of ])regiiancy is a parating the thicker and more voluminous upper segment from the more dependent lower ]iart. This projection was described by Bandl as the dilated true os internum, and as defining, consequently, the upper limit of the cervical canal ; by Schrouder the same structure was r(>gai'de(l as a coitfracfion- rivg which marks the juncture of the upper contracted and the lower dilated vierinc siymcntx. Some distance lower a second ridge, slightly marked 148 AMi:iiICAS TEXT- BOOK OF OBSTETJilCS. I i II ^^1 \ •', '\ anteriorly, but more foiispicuons on the posterior wall, eonstitiitcs IMiilln's ring, wiiieli JJancU regards as indicating the upper bonier of that j)art of the cervical canal which is uiiatleeted until the dilatation of labor takes plaop, Sehroeder, on the contrary, views this ridge as the true os internum, and tlic zone included between his contraction-ring above and the one in qucMidn below as the inferior segment of the uterus. From the foregoing it is evident that the significance of the zone inclndcd bctwci'U these two rings is the principal (piestioii at issue, some authorities regarding it as a j)art of the true uterine sac, while others consider it to n piv- scnt the upper jiart of the cervical canal, that unfolds before the terminntidn ot' gestation and thereby contributes to tlie extension of the uterine sac. Ac- cording to the tirst view, the cervical canal retains its integrity tlirougliout pregnancy ; according to the second, the canal })articipatcs to a limited d(ir|.,.^, in the tbrmation of the fetal receptacle by dilatation of its upper portion toward the close of gestation. While both views claim distinguished iiMiiies in their support, the weight of evidence seems to lead to the acceptance of tlio doctrine attributing a limited jjarticipation of the cervix in the formatiuii of tiie uterine sac of pregnancy. The cervix of the uterus of the sexually mature virgin is about e(|ii;il in length to the body of the organ, and only in women who have borne childivn is the neck relatively shorter (Kussmaul). During the first three months (,f pregnancy the cervix partakes equally in the general hypertrophy afTectiiiu; tlie uterus (see Fig. 137), and reaches a length of 6 centimeters (2| inches) or iiioic, While it is only from the seventh month that the os internum exhibits a tendency to exi)and into the adjacent uterine cavity, the forces leading to this unfolding i)egin their inHiience very much earlier — in fact, as soon as tlii< portion of the uterus has readied its maximum hypertroj)hy, or from ai)iiiit the fourth month t)f gestatit)n. In addition to the effects of the presence of the fetus, the traction exerted by the muscular bands — retractor fibres nt' liayer — which pass from the outer layers of the uterus into the round and the sacro-uterine ligaments is an important fai'tor in causing the gradual uiitliM- ing of the cervical canal. The dilated, funnel-shaped cavity contributed In- the cervix for a long time retains its fiattened plicse and is covered by ciliated columnar epithelium ; its nuicosa finally undergoes conversion '\\\U\ tlie decidiia by changes identical with those taking place in other parts of the uterine mucous membrane. As a residt of these changes the cervical eiin;il shortens, and at the close of gestation measures from ?t to 4 centimeters (l||n H inches). The nnfblding of the cervical canal takes place earlier in primi- jjarse, owing to the greater resistance t)f the comparatively rigid nuiscularti- sue of the body of the uterus, until now unaffected by th:> changes of prcL'- nancy. These changes residt in a general softening and elasticitv of the IhhIv of the uterus from the begimiing of gestation, the cervix retaining its iisiial firmness during the earlier months almost unimpaired. Toward the closoul pregnancy the vaginal portion of the cervix projects less and less, the scein'Mi; shortening being probably due, in part at least, to the swelling and greater i^T* — I'llYSIOLOaV OF rilFJiXAXCY 149 ites Miiller's t part of the takes place. luin, aiul the > in qiuvtidii zone included ae authorities or it to repre- e torminatidii i-ine sac. Ae- tv throujiliout limited decree upper portion ^uisheil niiines ■eptanee of the I Ibi'uiatioii of about o([nul in borne ehihlreii bree months of iby afti'ftiii'j; tlic inebes) or more. i-num exhiliitsu 5 U'aclino; to tliis as soon as tlii< , or from alioiit tbc presence of raetor fil)rcs of round aiitl the jjnidual uiifnU- contributi'd liy ered by cifiatfil orsion int" i'"' icr parts of tlio If cervical canal nti meters (lit" earlier in \\nm- fid muscnhiv ti- ■bano;es of \mp citv of the hotly ■tainin^^ its usual •ard the closei.t less, tbc scoiio'i': liu'T and '^'renter proniinencc of the snrronnding walls of the vagina as well as to traction exerted l)v asecnd by the observations of Barbour and Polk. Tiie arrangement in front and behind, however, is not so clear, and the statements of authorities are conflicting. Polk maintains that the lowest situation of the peritoneum in front and behind the uterus, with the ex "ciition of Douglas's poneli, in the non-pregnant condition is indicated liy a line passing from the centre of the 'J ?■ I , ! ,& ■y^ '■''prM,-.; loO AMKIilCAX TEXT-IiOOk' OF OIiSTi:TliICS. k I \M svniplivsis to the jiiiu'tiirc i)t' tlic tliird anil lluirtli sacral viTtcbiu*. At iho tenniiiatioii of pregnancy, l)iit lMli>rc the usual sinking of the uterus wiiliin the pelvis has occurred. tli<' lowest limit of the peritoneum, aceonling to the .-aino observer, has ascended and is now marked by a line passing from the centie of the symphysis to the sacral promontory. These conclnsioiis arc not eontii'med i>y examinations of frozen sections n)ade bv Webster, since this author finds the inferior limit of the peritoiicul pouches during picgnancy as low as in nidlipara'. The changes in the ante- rior relations of the peritoneum of the vesico-uterine fossa, whereby the piri- toncum becomes -tripped from the bladder, are usually regarded as due ti, ili(. elevation of the uterus and to the coiise(|ncnt mechanical effect, which togi ihep are also supposed to exert an influence by which the floor of the poucli nf Pouglas is raised. Wi'bstcr attributes the stripping of the peritoneum I'ldin the bladder, on the contrary, to the drag caused by the gradual sinking of tjic pelvic floor, since the delicate subserous tissue gives way under the trat- ing in the uon-prcgnaut condition, as when these are ample less displaccniem follows than when the traction camiot be met with supplementary fi>siie. According to Webster, the central portion of the pouch of Douglas at no time during pregnauey becomes elevated ; this author further points out that the sinking of the uterus may be progressive from the middle of pregnaiuv, resulting in the marked downward displacement of the organ sonietiiiies observed before the end of gestation. The nujiiui also exhibits changes resulting from the exaggerated uutritien of i)reu:iiancv. These changes include irreativ increased vascidaritv, thickeiiiiiir and softening of its niucous membrane, whose folds become less rigid and (.'(iii- spicuous. and hypertrophy of the uuiscidar tunic with great dilatation of tin' blood-vessels. In couse(|ui'Uce of the large (piautity of blood contained within the less compact tissues, the vaginal surface presents a bluish tint in contrii-t with the bright red of its usual condition. This change of color is rcganleil bv some as a valuable objective sign of pregnancy. llic e.vfcriKi/ (/iiilldln likewise participate in the increased hyperemia uf the generative tract, the unusual development of the blood-vessels and the lyiiijili- atics inducing a condition charactcri/cd by softening and greater infiltratiim et' the tissues, hence the vulva ap|)ears particidarly prominent. The exetssive vascularity of the parts finds expression in the dusky hue and the unusual activity of the sebaccnus follicles and the sweat-glands of the labia. T/ic (trllcii/(ifli)iis of (he pclrin exhibit to a limite manifested by an unusual softening and v;wii- larity of the iuterarticular cartilage, particidarly that of the symphysis, in consequence of which there takes j)lace a certain amount of loosening, attciidul in some cases with slight movement. Whatever temporary increase in tlie pil- vie boundary may thus be secured, the gain at best is j)robably very insignilieaiit, '■^■A* vx. At ilio Items wilhiu i>; to the i^aino n the eoiitre ;)/.en soctiiiiis he peritiiiitiil i in the antc- rehy the pciM- as (hie tn the liich to<:( ilior tlie poucli (if itotieiini 1111111 iinkin^ nl' the • the t radii III, r wall of till' ^ ."ierous I'livcr- ml loUls (■xi^t- s disphicciiicm leiitary tis.-iu'. ifhiH at no time ts ont that tin- ot" pret I>i. \:\W<- ol l)i.- tllMC'l' 1.1 Th ickllr^ <; u Df |.th of lltl Dh tilllCC ot. \)\> tllllCl' ol Piftiiiici' ol Distiiiici' of iirnji'dioii • ■ •r from cnccvx losyini'liyl!* iirilhnU oriiicc liclow liriiii . ^ invllinilorilHvlii'lowsyiiiiplivMM . . . juiKiiiiM 111 liliiilil'T mill iiri'llini lirlow brim f Ilsxuc liclwciii i>ubi'S mill viif,'iiiii ,.,•,, vi-inil I'l'Uili I'i'l""' l'""> •, • ■ • • ,,< rxtii'iiuiii l"l"v\- brim posteriorly .... oscxti'rniiiu li'low brim iiiitrriorly .... o< iiitrrimm b>'low brim posteriorly .... osiuterimm belinv luimuiiteriurly .... NcL- ' Fifth Ekhith Ninth LiPAKA. Month. Month. , Month. Cm. Cm. Cm. Cm. i") 4.1 .").(l «.,5 !;)..-> 14.0 10..S •£xb fi.i 0.7 0.7 ■J..^ 0.0 U'.f) •A:l ■A:l i\.\ 7.6 o.:i 7.0 i.ii '.'.8 ;i.r. 4.4 :^.i r..'> 0.7 0.0 0.3 11.1 8.7 .H.O 0.:! 11.1 8.7 IJ.J :..7 7.1) 7.0 0.0 0.7 7.9 7.0 0.7 The (ilxlniiiiiKil lail/ff manifest the enormous distention to which they arc subiceted bv tiie formation of more or le,})ear c manifes- tations of tlie nnusnal tension of the integument. The veins are also enlarged, juid show through the tightly drawn skin as a network of blue lines. The nipple shares in the general hyj)ertrophy of the organ, Wcoming enlarged, more readily erwtile, and sensitive. The surrounding rosy areola of the virgin (Fig. 135) is gradually replaced by a more deeply colored area, whose tint by the middle of pregnancy varies from the slight brownish discol- oration seen in women of light complexion to the dark brown or almost black .'olor seen in bnniettes (see PI. 17). The areola by the eighth or the ninth week Ix^omes softer and more elevated than usual, and its sebaceous glanils, from one to two dozen in number, greatly enlarge, those at the periphery i)econ>ing particidarly conspicuous. These enlarged sebaceous follicles consti- tute the glands of Montgomery (Fig. 136). The mammary areola varies from 'J. 5 to 4 centimeters (1 to 1^ inclies) in diameter, although these dimensions iiiiiy greatly \w exceodwl. In the fifth or the sixth month of pregnancy an additional irregularly pigmented area, the so-called '* secondary areola," some- times appears (see PI. 17). After the third month of gestation the breasts contain a thin fluid, the colostrum, which may bo pressetl out of the newly formed glandidar tissue. This fluid consists of a thin albuminous medium containing numlH>rs of fat- drops, displaced epithelial cells, and characteristic aggregations known as "colostrum-corpuscles." 2. General Chaneres. — Pregnancy, while a purely physiological con- dition, creates great and important changes in the maternal organism. These changes pertain to the different systems and organs of the Ixxly ; to some more than to others. The general changes in the maternal organisni dcpeiul to a great extent on the alterations in the blood and in the functional modifications of the nervous system. The jiregnant woman has to provide nutriment, to breathe, to maintain blood-circulation, to secrete and to excrete tor two individuals — herself and her fetus. All this means that extensive changes in the general system must occur. If these changes are carrii'd to a reasonable extent, health is maintained and the system liecoines fortified, as it were, for the coming parturition ; but when these changes are developed to excess, disorders complic"ating the pregnancy are jiroduced. Changes in the Circnlaton/ Sydem. — Formerly it was supposed that preg- nancy was accompanied by l)lo(Kl-changes like unto ])lethora, and it was almost universally inferred that the attending symptoms — the headache, the ring- ing in tl:a ears, the flushed face, the cardiac palpitation, and the dyspnea — were the results of these alterations. Consecpiently it was a very common |)ractice with physicians many years ago to bleed pregnant women from one to many times at intervals during the latter months of pregnancy. Enormous ((uautitics of blood were thus extracted by venesection. A wonderful revolu- tion has taken place in the treatment of pregnant women during the past twenty-five years, owing to more rational ideas of the real condition of the circulatory fluid. 154 AMKIilCAX TKXT-liOOK OF OBSTETRICS. hll' ( I 111 pregnancy the composition of the bloiHl, which is increased in quantity, is profbtmiUy ahercil, as many careful analyses prove. The quantity of blood present beftn'e pregnancy would Ixi iiKuUHpiate to meet the condition of preg- nancy. Thus, the blo(Rl is increased in its watery elements and white corpus- cles, but is made deficient in the element of albumin, is increased materially in the amount of fibrin, and is diminished in the proportion of retl corpuscles — conditions of anemia, hydremia, and liyj)eriiiosis. This hyi^rinosis is also augmented after parturition, because at this time large quantities of effete materials are thrown into the circulation. Instead of a blood-change called "plethora" being present, it should be recognized as one of anemia and hydremia orof ehlorof is. If called " plethora,'' it should be named scroun plethora. Individual variations in the quantity and quality of the blood are depenortant rela- tion to the quantitative change in the circulatory fluid. A fatty degeneration shows itself in both the liver and the spleen in women who have suddenly (lied after labor. Xuinerous small yellow spots are seen scattered through the liver — fatty deposits in the hepatic cells. The thyroid gland is increased in >izo. In women in whom there is a predisposition to this enlargement, preg- nancy may further stimulate the growth and bring about permanent structural clianges. The eidargement, of this organ is thought to sustain some relation to changes in the heart and the blood-glaiu'.idar system. Changes in liespi ration. — Pressure of the enlarging uterus, through mechanical action, causes changes in the respiratory organs. An upward movement of the diaphragm lessens the longitudinal dimensions of the thorax. Some embarrassment of the respiration follows this decrease, notwithstanding that there is some increase in the breadth of the lower thorax. In the last two weeks of utero-gestatioii, owing to the limited shortening of the cervix iitiTi and to the settling down of the fetus in utero, respiration and circulation Ixrome easier. As more blood must naturally be jM'ovided to noin-ish the woman and her child during pregnancy, this extra blood nuist not only be properly circu- liitid, but must also be duly purified. The elimination of carbonic-acid gas l>y respiration is therefore increased in pregnancy. The resj>iratory organs nmy be dcrangitl by cough and dyspnea originating tVoin nervous sympathy in the earlier months of pregnancy. In the later months of gestation the derangement is from encroachment of the gravid uterus, interfering with normal respiration. These phenomena are mostly (>l)sorved when there is twin pregnancy or dropsy of tin; amnion. ClKUi[/Cfi in the lYKjextivc Si/ntem l in Xutrition. — The pregnant woman provides the nutritive pabidum by which the growing organs are sustained and by which the fetus and its apjK'udages are built up. She must therefore digest more food, form more blocnl, and increase the activity of the secretory and exi-retory organs. Very few W(»men escape such troid)lcs of digestion as nausea and vomiting. In the earlier months the appetite is, as a rule, capri- eioiis. Further al(»ng the appetite and the digestion increase in activity, thereby assisting in improving the general nutrition. An increase of weight takes place in normal cases, irrespective of the grow- ing uterus and the ovum. The average gain anu>iu)ts to from ten to fil"teei> pniinds in the whole nine months, being greatest in the last two months. This increase is not far from one-thirteenth of the whole body-weight, and it is progressive from the beginning to the end of jtregnancy, notwithstanding the n:iiisea and vomiting. The adipose tissue increases most in bidk, especially in the latter half of gestation. These deposits are most noticeable in the mammary glands, in ' V ; 166 AMERICAN TEXT- HOOK OE OBSTETRICS. ill iM;l«, i i' i^' ! M j ! the alKlominal parietcs, in the hips, and in tlie omentum. The wliole figure becomes fuller and rounder. All this increase is but so much stored-uj) ])()ten- tial energy, to he utilize*! after delivery, when this energy, by the metabolism of the body, assists the manimary function. Rokitansky has spoken of the lamelltp of osseous material on the inner sur- face of the skull and the frontal and parietal bones external to the dura mater, called "puerperal osteophytes." Those lamellte, which are irregular in shape, consist of calcium carbonate, traces of phosphates, and organic matter. They are not jKJCuliar to pregnancy. Robert liarnes thought they sustained son)e relation to the calcareous changes found in the placenta and to the forthcoming milk. The temperature of the bmly in pregnancy is not materially changt 1, although, according to some authorities, it is slightly lower in the morning than during the day. CImnyca in the Skin, the Gait, and the Osteons Elements. — The functional activity of the sebaceous glands, the sweat-glands, and the hair-follicles of the skin is increasetl by pregnancy. It has Iwen ssiid by Robert IJarnes that the growth of the hair is invigorated during pregnancy when prior to ges- tation the hair had been falling out. Pigmentations are quite generally observal in spots over the body, the linejB albicantes being most noticeable. They are also seen about the aber (if cases. The writer, who instituted these examinations in a large clinical experience in hospitals, has found the frcipicncy to be at least 30 jKir cent. This frequency must Ik? inquircKl into with reference to its etiology. In the fust place, quite a nuniber of pregnant women have a physiological albumi- nuria. The trace of albumin is then small and of short duration ; there are iKt tube-casts, and no attending morbid symj)toms. Every authority must coiu- clih' with Miirickc, that all>uminuria is relatively commoner during labor than (luring pregnancy. A proh)nged labor is oflener thus accompanied than is a short and easy labor. Albuminuria is often confined exclusively to the periml i.r labor. The (Hrcnrrence of albuminuria during labor is explained by the tlieory that the reflex vaso-motor spasm of the renal arteries, resulting from uterine contractions, causes renal anemia. This theory has the support of Tvler Smith, Spiegelberg, and others. Renal albumiiuu'ia may appear early in pregnancy, before there is any possible renal venous stagnation from pressure, being the result purely of reflex irritation. Why should not this irritation at times be transferred from the uterus to the kidneys as well as to the stomach ? Such an explanation must Imhl good, if albumimiria is present early in jjregnancy, the urine having been iiurnial iM'forethat time. There is an intimate comiection between the nervous ganglia of the pelvis and the nerve-filaments of tiie kidneys. The hydremic state of the bhuKl incident to pregnancy is at times a cause of albumimu'ia. An increased arterial tension which exists in pregnancy may he productive of albuminuria. The urine of a pregnant woman may be alhntninous from causes not nephritic, yet morbid. Thus, it may be albumin- ous from blood, from mucus, or from pus in the tirine, each of which may be cystic, vaginal, or uterine in origin. The prevalence of albuminuria during ))regnaney may be classified as fol- lows: {(() Crises in which it was present when conception took place, a chronic Hright's disease of some type, with albumiiuiria, having existed before jH'eg- nancy ; (/>) Cases in which albuminuria from sub-acute or chronic Bright's disease, the result of scarlet fever, etc., hapearance of the last menstrual flow. Hut not invariably is nienstruation suspended following an inipregnation. The most frequent ex- ception to the general rule is found when menstruation returns (mceonly ; then it is usually for a somewhat shorter time and in diminished quantity. The occurrence of a menstrual flow in diminished quantity and for a shorter time in a married M-oman who has had her menstrual periods regular as to time, quantity, and duration is very significjuit of a possible pregnancy, and the conception must have occurred several days before this function last appeared. DIAUXOSLS OF PREGyAWY 161 us. It lotioiml ■ highly iicut of soH; hilt re i»roh- ime, hilt 1 iiiorhid ble uc'ul-^ , Slid I as ^tuste Ihr atulency, less whon by nigl't (Ui nit ion »r mouths :oothtv<:he, syiiiptoni Llvhig tho |ji niorhul he hones AL'iiiii, hy way of cxecj»tion to the rule, there are recorded notable instances in which the peritnl of prej^naney was attended by a rejijular incnstruation. The writer recalls in his experience the case of u woman, now living and in health, wiu> never menstruated Ix-'fore marriage, nor during her married life of several years unless she l)ecanie pregnant. She had no menstruation the first two yeare ot' her married life until pregnant, and there was no return of the menstrual ilow until she was again pregnant; in other w(»rds, menstruatictn in this case wiis never present except during pregnancy, when it was normal in all regards," having thus appeared in three distinct pregnancies. Possibly the periodic lii'inorrhage in this case was of cerviral origin, but no ])athologicid lesion of tiie uterus ctndd ha detected. Menstruation ot!curring during the first three iiinnths of pregnancy may come from the decidual cavity of the uterus, not vet closed, before the decidua vera and the decidua reflexa have become ai:;iiN .li\ilii|i(il. Veins i"iii>iiii: "MT iIh' IpIvhsI iinil piiiiiiirv iiicula, Willi iiii'Kiilai' I'ipiiii'iitaliHii liii a Mnihlii Eil'eotility "l nil'I'lia'; 1 iniiuaiya la. Milk, Willi lailil ^' >oiMlai\ ali'i'la liii a liliMiilli' Secoudiiry iireoliv ui "Mia! .«i/.i' (in a iiiiin.iic). Becondnry areoln. pruiniin'iitly maiki.i iS . w iiu wi'tl<'i. Miimiiiiiiy -inns nf iiir^iiuiicy in llK'ir nnU r it»niliiiil> lilc >i/.iM. i I 1 PREGNANX'Y. KIrvaliiiii III piiiiiaiv aiinla (10) in |ii'iitiU', <'ij|ii- piiM'tl witli all art'ola wliii'h is nut t-lfvat^'il (cnni* liusitu iili>>t<I'l>)- Plate 18. 1 Wi'll roniKMl, lirni lui'a^t ami iiii'pli' (in a liruiictte). Typii'iil i^i^'hA in a lnnni'lti'. inrlmlint; tnllicli'H ami |)i'inmi'.v anil Ki'Cdmlai.v ari'ula'. T}|ii('al ni^nit in tlin blniidi': K, fnllii'U'Hi I'A, |>i'i- niary aronla. i.. I:i Miminiuiy sl^ns at progniini'y. 'if i \^ m. DIAGNOSIS OF PREGNANCY. 163 rarely occure during pregnancy, from coughing or from sneezing, when the bladder is somewhat distended. Kiesteine, sometimes present in pregnant women, is a proteine substance, consisting of triple phosphates, fungi, and infusoria, that forms like a flocculent cloud on the urine kept standing for a few days at a tem- perature of 70° F. It occurs in the urine from the eighth to the thirty- second week of pregnancy, then disai)pears. It has practically no diag- nostic value, as it is found in the urine of non-pregnant women, and at times in that of men. 5. Intrapelvic Sigrns. — Certain changes in structr.re take j>lace in the uterus in the earlier mouths of pregnancy, when the organ is confined within ilie true pelvis, before it ascends within the abdominal cavity ; tliese changes, carefully studied and detectal by vaginal touch and by bimanual exami- nation, possess a significance far greater than any of the aforementioned symp- toms. Associated with some of the other symptoms, these changes become extremely probable evidences : {(i) Softening and Enlargement of the Cervix Uten. — These changes, com- ])ared with the physical conditions of the same parts in the virgin or the never-pregnant woman, will be observed to be quite characteristic — less so in women who have borne children. The cervix uteri softens and enlarges in all directions. The lips of the os uteri become patulous and puffy, a condition most noticeable in primiparse. The softening of the infravagi- nal cervix, beginning below, extends upward. The cervical secretion of nuu'us, the so-called "cervical plug," is increased. The diminished resistance to touch and the increasing width of the tissues i^oemingly shorten the cervix. These changes, while beginning in the first month, are not recognizable until the second month ; from this time they are progressive. Erroneous views as to changes in the cervix uteri during pregnancy existed ill years past. It was believed that the cervical canal was greatly shortened to form ])art of the corporeal cavity, and that toward the last of pregnancy no cervical cavity existed, it having lost one-half its length by the sixth month, and so on, until it was obliterated in the eighth and ninth months. These views, long entertained, were in 1826 called in qiiestion by Stolz, whose views most moilern obstetricians now u))hold. Post-mortem examinations made of women in advanced pregnancy — the best proofs — have established the fact that the cvrvix maintains its length of 'J. 5 centimeters (1 inch) or more to the last days of j)regnancy (Fig. 137). Digital exploration through the patulous cervix substantiates this fact. iJut during the fortnight preceding j)arturition a genuine broadening of the cer- Kui. 137.— (Vrvix nt end iif pn'Riiaiioy (Winter). i 'A\l r!!ir 1 i 1 1 1 'i 1 i j ■ j ■ i ■ i , ' 1 ) ^'1 ^ : 164 AM/:/i/('AX TEXr-BOOK OF OBSTETRTCS. vix takes plaw, when the cervical canal is merged into the upper uterine cjivity — a result, no doubt, of the incipient uterine contractions i)reparatory to labor, as pointed ont by Matthews Duncan. The broadening ot" the cervix in the last stage of pregnancy, prior to eight and one-half months, then, is, seemingly, not real until the last fort- night. More or less of these changes remain even after parturition ; in other words, tho cervix does not completely resume its pristine virgin firmness and smoothness of siu'face or its original size. While these changes are noticeable from pathological as well as from physiological causes, their value in the diagnosis of pregnancy is only to be relied upon, when associated with other signs and when taken in conjunction with certain other symptoms. {h) The Violet Color of the Vulvar and Vaginal Mucouh Membrane. — Dr. Jacquemin of Paris first discovered this sign, and Dr. Chadwick of Boston has fully dwelt upon its diagnostic significance. Insj)ection reveals its pres- ence. It is of importance in the earlier months of pregnancy, when there is seen the then pale violet color, becoming nu)re bluish as pregnancy advanc(;s. But this sign is not of positive value. While arising from a venous stag- nation in tiie vaginal vessels, it may come also from vaginal or uterine con- gestion due to disease. This sign is valuable often as early as the second month, and in the latter half of pregnancy it is highly diagnostic ; then its recognition possesses great value. ((•) Jlef/ar^s .w/», which has been given to the profession within the last decade, possesses a great advantage. In all doubtful contlitions of early preg- nancy this sign ought to be searched for. It is to be detected by vaginal touch and by bimanual exann'nation. Its presence implies a change in the consistency of the lower uterine seg- ment. The greatest changes in the uterus must and do take place in the body of this organ — the l)ed,as it were, for the growing oviun. The neck of the womb is less supplied with blood, and it receives comparatively little of the stimulus of pregnancy. The develop- ment of the cervix is largely comj)leted by the fourth month. During the first six or eight weeks of gestation Fi(i. isx.-i'roKnnnt litems cif early part of the body of the utcrus enlarges, espe- tliinl iiidiitli il)ni\iii's Croziii secliDiii, with iimb- . ,, . . ... ui)ieiM,stii...rte.nrein,vei-si.m: I., i., .kei.iua vera. <'ially HI its autero-jjosterior diameter. Bimanual, recto-vaginal, or abdomino- vaginal touch will detect some enlargement in all directions — anterior, pos- terior, and lateral. The lower uterine segment becomes soft, compressible, and pulsating; above there is the j)rojecting or bulging uterine wall, hard and i DIAGNOSIS OF PREGNAXCY. 165 resisting; diiriii}; uterine contmction, l)<)ai'eiit, not real, the aiitero-postcriin" diameter of the organ being thickened. Hegar's sign, reeognized, as it may be, so early as the seeond month, and the overhanging and softness of the eorpns, the changed position of the uterus, and the violet color of the vagina and cervix uteri, while not abso- lutely positive signs, are highly pri>bable evidences when associated with some of the rational symptoms referred to. They jwssess a diagnostic sig- niticance ever to be watched for and carefidly es'. lUated. They are a com- plexus of physical signs that gives a reasonable diagnostic certainty. (j. Abdominal Changes. — Under this head are included all those cliangcs in size, shape, and ai)pearance of the abdomen that may take i)lace. (a) EHlairfemcnt, Size, and Slutpc of the Abdomen. — At first, diu'ing the first six to eight weeks, there is somewhat of a flattening of the abdominal snrface, due, doubtless to the descent of the uterus into the pelvic cavity, thus slightly dragging the bladder downward and making traction on the tu-achns, thereby drawing the umbilicus inward. The navel in consecjuence becomes dei)ressed ; hence the conunon expression, " A blank before a bank." I^ater in the fourth month, as the growing uterns rises for proper acconnnodation in the abdominal cavity, a slight abdominal enlargement will be observed, and the umbilicus is no longer sunken. By the fourth mouth the fundus uteri has risen about 5 centimeters (2 inches) above the symphysis pubis. The vertical enlargement jiiogresses at the rate of fully two lingers' breadth each four weeks, reaching the umbilicus at the end of the sixth month, and touch- ing the ensiform cartilage at the end of thirty-eight weeks, or eight and a half lunar months (PI. 19, Fig. 1). The umbilicus for many weeks prior to that time lias been protruding. During the last two weeks of utero-gostatiou the upper portion of the abdominal walls protrudes less and the girth of the woman seems smaller (PI. 19, Fig, 2). The patient feels more comfortable. The cer- vical canal is now eflaced, the child in idem has sunken, and the pelvic liga- ments are relaxed — changes preparatory to the coming i)artm'ition. During this time it will be noticed that the enlarging pregnant womb is symmetrical, snujoth iu its contoiu", larger vertically than transversly, and by proper pal- pation it will be felt to contract spontaneously. (h) Coloration. — On inspection of the abdomen of ])regnant women there will be recognized not only the condition of the navel, but also a changed color of the abdominal surface, and the presence of stria;, due to distention of the abdomen. The pigmentation may extend from the pubis to the xiphoid cartilage — the brown lines. On the sides of the abdominal walls and dowu the thighs red, blue, or white markings, like cicatrices, may be seen. (c) Fi((d Movcmnd.'<. — Fetal movements are generally visible after the sixth month through the abdominal parietes. 7. Ballottement. — Hallottemeut is a passive motion of tlie fetus, consist- ing of the peculiar sensation felt by the examining fingers upon giving the fetus a motion //; ufcro. A'aginal ballotteme;.'^ is usually emj)l')yed, although abdomiuid ballottement is also pract .cable at times, and may be noticed for a I'HK(JXAN(Y. I'l.Air, 111. halt' ) that n the voiuan .' c'or- lijra- )m"niij :!tncal pa 1- there anjif lion o iphdiil lowii sixth pnsist- llir thi' Ihoutili ll tor a s ■« I S "3 i Ok ■--',. j f "■-■' -J_ / r II DIAGNOSIS OF PREGNANCY. 167 longer period of time, even during the Ix'ginning of labor. F«)r the ballotte- ment impulse to be perceptible there must be a mobile fetus, not too large, and a sufficient quantity of the liquor amnii to permit the entire fetal displace- ment in idem. The woman stands or reclines during its performance. In the vaginal ballottcnfient the Hnger is placed within the vagina, anterior to the cervix, the pulp of the finger being applied to the anterior vaginie fornix by a direct brisk motion. The fetus is propelled upward into the uterine cavity, and, falling back by its gravity, an impulse is imparted to the finger against which it falls. Ballottemeut distinctly noticed is a pathognomonic sign of pregnancy, there being no other condition in which a solid body is found Hoating in the uterine cavity. The absence of this body does not preclude the possibility of pregnancy, lor different conditions may prevent its being noticed, such as ex- cessive or great dinunutiou in size of the fetus, hydramnios, multiple preg- nancy, some abnormal presentation, or a faulty insertion of the placenta. Vaginal ballottemeut can sometimes be practised successfully as early as the latter part of the fourth month. It is more easily recognized in the fifth month, is most distinct in the sixth, continues in the seventh, is doubtful in the eighth, and is absent in the ninth month. 8. Intermittent Contractions. — As soon as the uterus is developed suf- ficiently to be felt by the hand through the abdominal wall, there may be perceptible intermittent uterine contractions which are constantly going on at intervals of a few minutes throughout pregnancy. Purely independent of volition, they may become valuable, in a diagnostic sense, in corroborating other signs. Uterine contractions are not positive signs, because the uterus undergoes somewhat similar contractions to free itself of clots of blood, of polypoid or fibroid tumors, and of retained secundines, or they may be simu- lated by a distended bladder. The method of procedure for detecting uterine contractions is to grasp the fundus uteri for from five to twenty minutes, with the patient recumbent on her back, the uterus meanwhile being lifted by the right finger per vaf/inam, the abdominal walls being relaxed by some flexion of the lower limbs. The characteristic hardening will then Iw felt, the contraction lasting for several minutes. To IJraxton Hicks we are indebted for the thorough elucidation of this sign, which is often referred to as " liraxton Hicks' sign of pregnancy." 9. Quickening and Fetal Movements. — Quickening is the sensation ex- perienced by the mother as the result of active fetal movements. The period when these active movements are felt is quite uncertain. Usually quickening is considered to occur about the middle of pregnancy, consequently the time of expected parturition is based on this event, but very unreliably. Certain sensations of motion, sutih as fluttering or ]>ulsating, are sometimes felt by the mother earlier than these active motions. As pregnancy advances these active motions increase in frequency and become more marked, and toward the last they are seen very generidly. When felt or seen by the physician, as can be (lone after the sixth month, fetal movements constitute a very valuable and s n ' 4 \ } / w. "K-- >iii 11 ; 1 i i I I .i. M < i ./• 168 AMKRICAX TEXT-BOOK OF OBSTETRICS. positively reliiiMe sifjjii not only of pirj^imncy, hut also of a live child in nfero. This sign slioiiM ni'vor hv iiiti'iTcd to exist from the statements of tlie patient. Supposed fetal movements are fretpiently felt by the patient, and are thought to Ih>, but are not, evidences of pregnancy ; frequently they are only illusory. These seemingly fetal motions come from the abdominal walls in false preg- nancy or fronj the intestines in tympanites. Failure to detect letal movements does not negative pregnancy, for the cliild may be dead or its motion may not be felt. To detect tlu'se movements, place the patient on her back njxm a table or a bed, with the thighs flexed and the abdominal walls relaxed. All clothing should be removed from the abdo- men. Uy palpation and renewed prt'ssure at ditlerent part.s of the alxlomen the active fetal movements may be detected ; better, .sometimes, by applying the hands to the abdomen, after fir.st wetting them with cold water to excite a refl<>x action of the fetus. 10. Uterine Souffle. — This murnuir has been called '* placental," because it was thought to be due to the movement of the blood through the placental sinuses; it has also been named the "abdominal souffle," because it was thought to result from the ])ressure of the gravid uterus on the abdominal ves.sels. Neither of these two theories is correct. This ])lacental niurmiu' is doubtless due to the movement of the maternal blood through the uterine blood-vessels ; hence it should be called " uterine .'iouftle." Heard first in the fourth month, on the sides of the upper part of the uterus, especially the left side, which lor obvious reasons is brought nearer the anterior abdominal wall, the murmur is at all times synchronous with the maternal pulsation. It is very uncertain as to its presence, tone, piti'h, duration, and locsation ; if once lieard, it soon leaves, to return at another time or at another jdace. It is thus usually heard irregularly as to time, ])lace, ])itch, and duration until the end of pregnancy. Uterine souffle is no longer regarded a.s a ct>rtain ]>roof of pregnancy. A sound exactly resembling it is not unfrequently hearil in inter- stitial fibroids of the uterus, and it may be heard when ovarian tumors are present. In the majority of cases of parturition it is heard for the first two or three days in the lying-in state. 11. Petal Heart-sounds. — These sounds are a comparatively modern dLscoverv. Maver of Genoa first heard them in 1818, in examining the abdo- men of a pregnant woman. The fetal heart-sound cjumot, as a rule, be heard earlier than the fifth month in utero-gestation. A practised ear may .sometimes detect it a i\>\v weeks earlier, as in the fourth month. As this sound becomes stronger and louder in advancing pregnancy, its detection in the last few months becomes very easy. The sound may, of course, be (|uite feeble. If normally vigorous, .some non-conducting material, as a tumor, may intervene, impeding its transmission, or there may be a ])osterior position of the child, thus making it less distinct ; hence the inability to hear the fetal heart-sound ought not to negative a pregnancy. When attempts are made for its detection, the room should be (piiet and the patient should be in the dorsal posture, with the head on a pillow and the thighs flexed lightly to '"*i. '■^'^ '-■^^■_ «>!^'.-'*' ^ i '-f DIAGNOSIS OF I'UK^^aNCY. 169 the body or extended. 'P ,e stethosroiK" ouf,'lit to l)e utilized, from motivoa of modesty, in loeii'- " ^ the .soimd of the fetal heart. This instrument should l)e applied t|\the alnlomen below a tnuisverse line passin^j^ through the umbili- cus, oeduise the head of the fetus is more often lower than the breeeh. Since the occiput in most instances points toward the left side of the maternal pelvis, the fetal heart-sound is most frequently heard with greatest distinctness upon the left lower sjmce of the abdomen (space D, Fig. 141). If not heard in Fio 141.— Locution nnd intensity of fetal heiirt-sounds in the left occiplto-anterior position (the four quttdnints nro indicated by flie reti lines ; tlie poce is from Spigelius). this space, search for it should be made over other spaces (as b, c, a). If heard well in regions c, D, the inference is that the head is the lowest part of the fetus, and that the back of the fetus is anterior; if heard best in regions A, B, it is to be inferred that there is a pelvic presentation. The mean frequency of the pulsations of the fetal heart is about from 135 to 140 to the minute; they are less frequent in large than in small children, and probably are less frequent in males than in females. A tcm]>orary variation iu their frequency and force is very common. The sound is double and i L. _<./ u 11 : ( !i/ H 1 I i »l I 170 A.VKIifCAN 7'/y{^'y-/^<''>^>A' OF OliSTETPTCfi. ! ihytlunic, tlie first soiiiul boiuj; more clonr iiiid (,'"''t>.i»'t tliuH the second ; then conies 11 hrief pause, wlien tlie secontl sound is iieard ; ^ longer pause follows before th(> double rhythniie sound is a^ain heard. The al)ove-.?iP"t'«"«^ ^«*o- queney indicates that there is no relation of the fetal heart-sound to'^^inii- sations (>f the lu'^t' .'r's heart. These two sounds are perfectly independent. lieeause of the varying frc(|uency of the fetal heart-sounds, attempts have been made to bjise some reliable predictions as to the eex of the fetus hi ulero ; but experience has proven that but little reliance can be placed on such attempts. The sound of a fetid heart well heard when the uterus is relatively small — too small to accommodate a fetus ^)f five or more months' development — should at once create suspicions of an extra-uterine pregnancy. As auscultation with the stethoscope reveals the presence of the uterine souffle and the fetal heart-sound, the practised ear may also detect the funic or umhilmd muffiv — an intermittent hissing sound synchronous with the fetal heart. It is referable to the umbilical cord. It is heard in but the smallest number of cases, and its causation is conjectural. As a sign of pregnancy it has very little value. There are also heard sounds produced by active movements of the fetus m uhro. Fetal movements, for instance, may be heard by the ear instead of being felt by the hand. Their value is significant. 12. Petal Contour. — Inspection of the shape of the alxlomen in preg- nancy is also valuable ; a careful, well-trained touch by palpation may detect the size, shape, and presentation and position of the fetus, as well as, at times, the presence of twins in ntevo. 13. Mental and Emotional Phenomena. — Pregnancy quite generally motlifics the nature — i)hysical, mentid, and emotional — of a woman. At times, she is more vigorous, buoyant, and cheerful than in the non-pregnant state. More generally, however, she is more or less irritable, excitable, and fretful. As the physical appetites for foixl in quantity, quality, and variety are fre- quently changed, so also is the moral sense sometimes seriously deranged. Classification of the Phenomena of Utero-gestation. — The symptoms and signs of pregnancy may now, for convenient study, be classified as to the time of their occurrence. For instance, the nine calendar months of utero- gestation may be divided into three periods, and a classification may be made of the aforesaid phenomena as to these three periods. Fii'd Period of rtero-r/cstafion. — This period comprises the first three calendar months — the time during which the gravid uterus is enclosed within the true pelvic cavity. The si/mptoms are — (1) Menstrual suppression; (2) gastric disorders ; (3) mammary changes ; (4) vesical irritation. The signs are — (1) Beginning jmtulousness of the os uteri ; (2) softening of the infra- vaginal cervix, gradually extending higher ; (3) uterus slightly lowerei;ar's siirn (contpivsHihility of lowi'i* iktcriiKt seg- ment), with Hot'tened and ronnded ntcrine Ixxly. Second Period of Llero-f/eddtton. — This period enii)iiu'es the fonrtli, fifth, and sixth montlis. The hh/uh and xijiiiptouiH are — (1) Menses still absent ; (2) subsidence of the gastric disturbances; (.'!) increasing and j)rogressive development of the mammary signs ; (4) vesical irritation imj)roved ; (5) the uterus higher, ascending into the alHlominal cavity ; (6) cervix higher in vagina ; navel no longer depressed ; (7) fundus uteri two fingers' breadth above pubes at the end of the fourth month ; at the und)ilicus toward the end of the sixth month ; (8) cervix more softened and patulous ; (9) fetal active motion (quickening) experienced toward the end of the fourth or in the fifth month; (10) ballottenjent detected, becoming more «listinct ; (11) intermit- tent contnietioui, also detected, increasing in force ; (12) uterine soufHe audible in the fourth or fifth month ; (1.'}) fetal heart-sounds easily detecteil, usually first in the fifth month. Third Period of Utero-gestation. — This period embraces the seventh, eighth, and ninth months. The m/m and symptomn are — (1) Menses continue absent ; (2) gastric symptoms slight > • only occasional ; (3) further progressive develop- ment of the mammary signs, colostrum sometimes present ; (4) uterus continues to rise in the abdominal cavity, reaching midway between the navel and the ensi- form cartilage at the end of the seventh month ; reaching the ensiform car- tilage in the first two weeks of the ninth montli ; after which period it grad- ually becomes lower; (6) ballottement continues until the eighth month, when it is doubtful ; it is absent in the ninth month ; (6) umbilicus commencing pro- gressively to protrude ; (7) vaginal cervix seemingly shortened, more thick- ened, soflened, and patulous, getting higher; (8) fetal movements felt or seen after the sixth month ; (9; in last two weeks the fundus uteri, having reached its maximum height and size, begins to descend, when the cervix undergoes a real shortening. Now the cervical lips become thinner. The presenting part of the fetus, having partially entered the pelvic inlet, is more easily detected by vaginal touch. Pi'essure-symj>toms of the chest and the stomach disapi)ear, though edema of the limbs and the genitals may show themselves. Relative Value of the Symptoms and Signs of Pregnancy in Point of Diagnosis. — Very properly we may classify all the symptoms and signs of pregnancy as medical evidence of the presumptive, the probable, and the positive kind. They naturally rank in value inversely in the order named. The presumptive evidences ofj-'ef/nanct/ are — (1) Menstrual suppression ; (2) morning sickness ; (2) irritable bladder ; (4) mentid and emotional phenoiuena. The probable evidences are — (1) Mammary changes ; (2) the bimanual signs ; (3) abdominal changes in size, shape, and color ; (4) changes in cer- vix uteri in size, shape, consistency, and color; (5) uterine nuirnnu'; (6) intermittent contractions. The positive signs are — (1) Active movements of the fetus ; (2) passive movements of the fetus (ballottement) ; (3) fetal heart-sounds. Differential Diagnosis of Pregnancy. — Nothing can be of greater ill rm Wf ; I! ! i 1 .1 ( ! ^i i "1! i I II. 172 AMIJRTCAX TEXT-BOOK OF OBSTETRICS. moment, on tlie one hand, than a correct diagnosis of pregnancy, and on the other of the many conditions sinuilating pregnancy. Not only does a correct estimate of the actnal condition concern the patient and her family in a physi- cal, mental, or moral sense, bnt the professional repntation of the physician is also serioHsly involved. The legal and social relations of some pregnancies possess a deep and painfnl interest; therefore let no opinion be expressed in any case nntil a reasonable certainty can be arrived at. Time niay be needed to clear np all donbts. As pregnancy im])lies a certain variable amonnt of abdominal enlarge- ment after the fourth month, its existeni'e must necessarily be differen- tiated from the many other conregiiancy associated with chronic retroversion, but then a careful analysis of the presumptive symptoms will always be helpful in dif- ferentiation. A clear study of the j)hysical signs of the cervix and the corpus uteri as to color, size, shape, and consistency are of inestimable value in the first three months. A search for Hegar's and the other bimanual signs ought never to be neglected. Pregnancy may be concealed, feigned, and imagined. These possibilities must be considered and be cleared up. When ])regnan(y has created material abdominal enlargement, the diagno- sis ought to be differentiated from all other conditions attended by the same sign, such as ascites, ovarian tumor, uterine fibroid, distended bladder, tym- panites, pseudo-cyesis (false ])regnan('y), enlarged uterus from gas (physo- metra) or from water (hydrometra), retained menses (hematometra), obesity, enlarged abdominal viscera, malignant disease, etc. In differentiating these con- ditions the three ])ositive signs of pregnancy should always be borne in mind. In ascites finctuatiou is most distinct ; the resonant note (m j>ereussi()n is always changeil in location according to the ])osition of the patient. Cardiac, hepatic, or renal disease can usually be detected as a causative factor of the ascites, and the symptoms of pregnancy are absent. \ DIAGNOSIS OF PREGNANCY. 173 Til ovarian tumor a fluctuation of the abdomen is also present, though less distinct; the aMominal enUirgcment has come on more slowly and has n peculiar shape. INIenstruatioii is ordinarily present, and the signs — iiitra- polvic and abdominal — ot" pregnancy are entirely absent. The area ofdulness jind tympanites is not essentially altered by posture. As pregnancy and an ovarian tumor quite often coexist, a constant watch ought to be made for this pt)ssibility in every case of an abdominal enlargement. The presence of two tumors of different consistency with an intervening sulcus is quite significant ; when both are present, the uterus itself by a vaginal examination shows enlargement, and there are present the presumptive symptoms of pregnancy, while there are also the signs of an ovarian cyst. A uterine fibroid creates an abdominal enlargemeiiC which is more firm, hrrd, and dense than any of the above-mentioned conditions ; it is nodular ami very often asymmetrical, is quite slow of growth, and menstruation is not only present, but, as a rule, is also increa^ied in quantity and lengthened in duration. While the uterine murmur may be very well marked, there are present no positive signs of pregnancy. A distended bladder is of comparatively short duration, is attended with much discomfort, is associated with dribbling of the urine, and is quickly relieved by the use of a catheter. Fecal accumulation is dissipated by a copius rectal enema and free catharsis. Tympanitic distention of the abdomen is always very resonant on per- cussion, is variable in size on diflerjiit days, does not fluctuate, and quickly disappears by ])roper treatment. Pseudo-cyesis, or false pregnancy, occurs oftcnest toward the menopause, and its false appearances are quickly unmasked by the administration of an anesthetic. Obesity shows the abdominal walls soft, doughy, and easily palpated between the fingers of either liand, and there are uo intrapelvic signs indicative of pregnancy. Hydronietra and physometra are extremely rare. There is always with ihem an absence of most of the probable and all the positive signs of preg- nancy. The uterus in both diseases enlarges more slowly, and never to the extent of an advanced pregii;uicv. Diagnom of Krtra-Hfcri)ic I'lrrfnnncii. — A judicious differential diagnosis of intra-uterine pre i;nancy implies a careful consideration of the possible or ])robal)le existence of extra-uterine pregnancy. This is especially the tiict wiien the gravid uterus or the extra-uterine sac is still within the true pelvis, for if the diagnosis is the best guide for treatment, now is the time of all others to know the exact condition of atlliirs. The following symptoms and signs are worthy of most reliance from a diagnostic point of view. When extra- uterine pregnancy exists, there are — 1. The general and reflex symptoms of pregnancy ; they iiavc often come on after an uncertain period t)f sterility. Nausea and vomiting appear aggravated (Winttkel). /il I I 174 AMERICAN TEXT-BOOK OF OBSTETRICS. ; 2. Then comes a disordered menstruation, especially metrorrhagia, accom- panied with gushes of blood, and with pelvic pain coincident with the above symptoms of pregnancy. Pains are often very severe, with marked tender- ness within the pelvis. Such symi)toms are highly suggestive. 3. There is the presence of a pelvic tumor characterized as a tense cyst, sensitive to touch, actively pulsating. This tumor has a steady and pro- gressive growth. In the first two months it has the size of a pigeon's egg; in the third montli it has the size of a hen's egg; in the fourth month it has the size of two fists. 4. The OS uteri is patulous ; the uterus is displaced, but is slightly enlarged and empty. 6. Symptoms No. 2 may be absent until the end of the third month, when suddenly they become severe, with spasmodic pains, followed by the general symptoms of collapse. 6. Expulsion of the decidua, in part or in whole. Numbers 1 and 2 are presumptive symptoms of extra-uterine pregnancy; Numbers 3 and 4 are probable signs of extra-uterine j>regnancy ; Numbers 5 and 6 are jjositii-e signs of extra-uterine pregnancy. Some of the above-mentioned symptoms resemble those of early abortions. In all cases with the history of a supposed abortion, when an intrapclvic mass is then or afterward felt, there should be suspicion of an extra-uterine preg- nancy. In consideration of the possibility or probability of extra-uterine pregnancy, based on the detection of a lateral extra-uterine sac, we are neces- sarily obliged also to exclude in the difi'erentiation a small ovarian tumor, an enlarged ovary, a hydrosalpinx or a pyosalpinx, and pelvic exudates (cellu- lar or peritoneal). A distinct sulcus between the sac or the tumor and the uterus may be a physical sign to guide in the diagnosis. The symptoms of a severe and overwhehning pain are quite generally manifested by the end of the third month, because most cases are tubal in some form. Tiiose symptoms are not noticed when the extra-uterine pregnancy is entirely abdominal. The possiI)ility of mistakes in diagnosis is to be considered with reference to — (a) Retroflexion of the gravid uterus ; (b) pyosalpinx with amenorrhea, or causing abortion; (c) malignant tumors of the abdomen with ascites; ((?) normal ])regnancy complicated with abdominal tumors; (r) coincident intra- and extra-uterine pregnancy ; (_/") pregnancy in a deformed uterus. Didc/noxis of MuUiph' J'ref/na))ci/, — Susj)icions of a twin pregnancy are rarely excited ; but the presence of nuiltiple ])regnan('y may be conjectured from the following data : (i It is un- leriencotl rnaneies occur in married womeu, we canuot base any calculations on a single act of coitus. Even if there has been but one coitus, all physiologists admit that there is a variable period in different women, and in the same woman at dif- t'oreut times, between insemination and the fertilization of the ovum. When the impossibility of ascertaining the precise time of fertilization and the probable variation in the length of gestation itself are considered, the reasons for this uncertainty become apparent. Recognizing with His that the moment of fecundation marks the beginning of pregnancy, the pos- sibility of fixing this occurrence becomes of great interest. The uncertainty becomes still greater owing to our inadequate knowledge as to the length of time during which the sexual elements, the ova and the spermatozoa, retain their vitality after liberation from their respective sources. Wiiile the exact time during which the matured but unfertilized ovum retains its power of successfully receiving the male element is unknown, the obsc-rvations conducted on lower animals render it probable that the ovum is capable of impregnation at any time during its sojourn within the oviduct and l)ef"ore reaching the uterus, or, probably, for a period of about one week from its escape from the Graafian follicle. The remarkable vitality of tlie spermatozoa even under far less favorable conditions — direct observation showing that these elements retain their move- ments for over nine art of pregnancy the gravid uterus has risen to and presses upon the stomach, hence food has to be taken in greater moderation and at shorter intervals, A milk diet is at times especially needed. Albuminuria is a condition calling for the use of milk, as recommended by Tarnier. Its absolute use, strictly enforced, gives very good results in tliis complication. Exercise. — Moderate exercise can almost always be well borne. Violent exercise and excessive fatigue are invariably to be avoitled. Extraordinary exercise, such as riding horseback or over rough roads, dancing, or lifting heavy weights, is injurious. Long journeys by water or by land should be postponed if i)ossil)le. Is parturition made more easy by unusual physical exercise? Affirmatory ojiinions have been entertained. Doubtless, women whose habits have accus- tomed them to considerable jjliysical exercise can, all things being equal, undergo parturition easily and quickly; but those unaccustomed to any special physical exercise should undertake only what can comfortably be borne. If active exercise is not well borne, then ])assive exercise may be highly bene- ficial. Riding in the open air gives the j)regnant woman the necessary fresh air and sunlight. Crowded and ill-ventilateil rooms are to be avoided. HYGIENE AND MANAGEMENT OF PREGNANCY. 181 tirin- fuatory accus- eqiial, I special |e. If beiio- f'rcsli wided. While moderate exercise is needed in many or in most cases, its continnance is objectionable in cases where the normal relaxation of the pelvic jointK becomes excessive. The pubic joints, most often atte(!ted, are so relaxed at times that locomotion is impeded and rest is demanded. Rest. — A pregnant woman needs abundance of sleep, because of its health- tjiving, restoring influence. A portion of each day, after the mid-day meal, may well be selected for the assumption of the recumbent posture, to obtain lor an hour or two either rest or sleep. Clothing. — Great care is to be taken that the clothing is so adjusted as not to compress the alMlomen and the chest. While the quantity and the quality of the clothing are to be determined by the season of the year, the garments ))]aced around the waist are to be as light as ])racticable consilient with com- fort. The clothing is best suspended from the shoulders. The corset and tight-fitting skirts are injurious, impeding as they do the expansion of the Sii'owing uterus and its contents, and favoring the development of symptoms of a not uncommon complication of pregnancy — albuminuria with uremia. Multipara! with relaxed abdominal walls often experience comfort by giving support to these parts with an abdominal bandage, thereby maintaining the uterus in a more normal position, wherein there is better accommodation of the fetus. All possible pressure of the pelvic and renal veins is to be removed. Bathing is to be administered to the body at the usual intervals observed in health — daily in warm weather, and at least twice a week in cold weather. The baths are to be general, with an abundance of water and soap. The tem- ])erature of the bath may be either warm or cool, according to previous habits and to the season of the year. The functional activity of the skin, quite often impeded in the last weeks of pregnancy, should be maintained carefully by the free use of the bath. Vaginal injections are not required if there is no leucorrhea, vaginal or uterine. If an injection is given because of this complication, there is nothing better than a saturated solution (one quart) of boric acid given with a fountain syringe in a very gentle current. Sexual intercourse is to be regulated carefully, for very often it is found to be injurious to pregnant women. While especially enjoyetl by some pregnant women, coitus is distasteful to most women at this period, and it be(!oraes the source of nuich pelvic discomfort to not a few ; it may create an abortion. Even uncivilized nations have condemned the privilege of sexual intercourse during the period of pregnancy, and have visited ])unishment on the offender. During the first few months of pregnancy, wdien so many abortions occur, and toward the last of pregnancy, it is best for the husband and wife to occupy separate beds. May local treatment to the diseased cervix and canal be carried on during pregnancy? With proper precautions and due care, this question is answered in the affirmative. INIost of the accidents causing the induction of abortion by local interference have arisen from a neglect to investigate atid deter- mine the condition of the body of the uterus, and to ascertain whether it may 182 AMKltlCAX TKXT-nOOK OF OJiSTETRICS. :!? have boon gravid. l'rc, Sig. Apply daily as directed. .5ss ; .?ss.— M. As no two pregnant women are alike, and as no two ])regnaneies in the same woman are alike, no absolute rule can be framed for all. The expectaut treatment is largely called for. Discretionary powei-s are necessarily given the pliysiciau in charge. Only general principles cjui be laid down for guid- ance. Special (lirections are called for when there are special disorders and complications. A very frequent danger is that an abortion or a premature delivery may be precipitated by uterine contractions. Any constitutional dis- ease, especially syphilis, nuiy require special medication. Doubtless there are remedies which often favor uterine tonicity and become prophylactic against abortions. Viburmun j)rnnifolium, aletris, and cimicifuga doubtless favor the normal completion of gestation. In all eases as little medicine as possible ought to be given. Pregnancy is a purely physiological condition, and it is best managed by an observance of the hygienic instructions. ' i TlIK PATllOLOUY OF PltKd NANCY. 185 IV. THE PATHOLOGY OF PREGNANCY.* I. Diseases op the Several Systems. Thk remarkable clianj^es occnirriii}'; in the genital organs of woman, and also tliroiigliont her entire body, as gestation advunees, occasion conditions which often transcend the bounds of health and Iwcome states of disease. As these changes are most pronounced in the uterus and its appendages, it will be appropriate to consider, first, the pathological conditions of the uterus and its appendages induced or exaggerated by the pregnant state. It will then be proper to study those geneial derangements which the condition of pregnancy invites ; next in order, to treat of the influence of the various infectious agents upon the pregnant organism ; and finally, the surgical injuries and processes observed during this period. 1. Pathological Conditions of the Uterus and Appendages. The Uterus during Pregnancy. — While the position of the jiregnant uterus is subject to frequent change, it has been found by Ferguson ' and others to be rotated to the right in 80 to 90 per cent, of all pregnant women. hases of gestation : its peritoneal covering, its interlacing niu.scular and elastic tissues, and its glandular lining membrane, all become enlarged by production of new elements from nuclei already exi.sting. The enormous increa.se in area and in blood-supply is especially remarkable in the ])regnant woman : although the deciduous njembranos represent the greatest development of its epithelial elements, still the eiulonietrium shares extensively in the general hypertrojihy. It is readily seen that this condition of plethora naliu-ally favors the rapid development of any neoplasm previously existing in the uterus, especially any neoplasm whose elements closely resemble normal uterine structures ; such neo})lasms are — Myomata of the uterus, sometimes termed fibro-myomata or uterine fibroids. As has been .'•hown by C'room' and others, although myomata exist frequently among childbearlng women, they do not alway* attract attention during pregnancy, and are often undetected at labor. Such tumoi-s grow, * The guperinr figures (') occurrinj; throughout tlie te.xt of this article refer to the bihli- ography given in the Kefereuce List on page 'M'.\. ! :i il V ' ^|! l' is! j If ?: g. > ■' i» p 186 AMERICAN TEXT-BOOK OF OBSTETRICS. however, with groat rapidity during pregnancy, often interfering with the circuUition in the lower extremities. Many cases in which early pregnancy is complicated by edema of the legs, and in which abortion occurs at four or five months, accom^^anied by profuse hemorrhage, are cases of fibroids complicating pregnancy : their bulk causes interference with the functions of the bladder and the rectum, while they alter the position of the uterus, causing abnormal presentations of the fetus and prolapse of the cord at labor. Their encroachment upon the uterine muscle interferes with its normal contraction and retraction ; hence the rhythmic contractions of the uterus commonly exist- ing dnring pregnancy are unusually painful, and sometimes are excessive in strength. The substance of the uterus may be so altered that rupture of this organ may occur, as in a case described by Hogan,* where a fibroid pregnant uterus ruptured spontaneously at about the fourth month of gestation. When rupture docs not take place, spontaneous I'cduction of a displacetl fibroid uterus sometimes results from the stimulus to growth and intermittent contractions furnished by pregnancy. Spontaneous reduction is frequently followed by rup- ture of the membranes and abortion, as pointed out by Loviot.* Although fibroid tumors of the uterus are often supposed to prevent conception, cases are on record where sterility persisting for some years in such patients had been replaced by pregnancy so late as forty-five years of age.® Pregnancy exerts a remarkable influence upon fibroid tumors of the uterus, not only in causing their rapid growth, but also in frequently bringing about a condition of well- marked softening and fatty degeneration : this pathological condition sometimes decides the choice of a method of treatment in these cases. The treatment of pregnancy complicated by fibroid tumors when interference is necessary is by operative procedure. Submucous tumors, if they become pedunculated and distend the lower uterine segment, frequently present before tho fetal head, and, excitiiig premature labor, may be removeil by the obstet- rician in advance of the child. Intramural tumors require no treatment during pregnancy unless the results of their pressure upon important viscera oblige the obstetrician to perform hysterectomy. Subserous fibroids in the pregnant patient may often be removed without terminating the j)regnancy, as in cases reported by FronuneF and others. Should extensive fibro-cystie changes in the uterus occur, complicating pregnancy, this condition should not be allowed to go on to term, but hysterectomy should i>romptly be performed. Routicr* reports a successful myomectomy during pregnancy, and he has collected, with his own, 15 eases in which the operation was performed, ten of which recovered. Strauch ' also reports the successful removal of a fibroid as large as a goose-egg from a pregnant uterus by abdominal section. Phillips '" gathered reports of 282 cases of fibroids complicating pregnancy : his statistics indicate a high mortality from radical jiroccdures. Pozzi, " from his collection of these cases and his personal exj)crience with them, considers simple myomectomy the preferable procedtu'e in suitable cases. The occurrence of s])ontaneous abortion sometimes necessitates immediate operation in cases of pregnancy complicated by fibn id tumors ; thus Bourcart '^ .J i, iii THE PATHOLOGY OF PREGXANCY. 187 erence ecouio before (bstct- iiring blige pliant cases cs in owed lo has \\, ton of a lotion, lincy : 1 from jidors 'diato ■art" reports t^.e case of a pregnant patient whose gestation was coniplioatcd by iiiyonia of the uterus and by excessive ;;orsion of the uterus and its append- ages. Spontaneons abortion was followed by chill and fever. Taking advan- tage of a fall in the t>^uaj)erature, liourcart performed hysterectomy. The result was successful. Attention has recently been called by Hofmeier '* to the intlu- encc which myomata exert upon pregnancy in causing abortion. He cites from the records of others 796 cases of pregnancy with this complication, and finds that aboilion occurred in 6.9 per cent, of the cases. He naturally concludes that the majority of patients who suft'ei- from myomata during pregnancy pass through gestation but slightly influenced by the tumor of the uterus. Ott reports a case of pregnancy nearly at term complicated by fibromyoma of the uterus and bronchitis.'* Amputation of the uterus was performed ; the stump was covered with peritoneum and dropped. The patient and her child made a good recovery. Gordon "' rept)rts a successful myomectomy by which a fibroid was removed from the anterior wall of the pregnant uterus : although the uterine wall was left thin and vascular, hemorrhage was controlled by stitching the peritoneum and the base of the wound with fine catgut. Recovery was rapid and pregnancy was nninterru])ted. Staveley '" collected a considerable number of cases of fibroid tumors com- plicating pregnancy, and he adds from the records of the Johns Hopkins Hos- jiital two oases in which myomectomy was performed successfully during preg- nancy without interrupting gestation. Staveley's tables embrace 33 cases with a maternal mortality of 24.25 ])er cei^t. Statistics show that in late years nivomectomy for this condition is more successful than before antiseptic sur- gery attained its present perfection in technique. During the last eight years the mortality-rate of myomectomy in these cases has fallen to 11.75 per cent.* Cancer of the uterus, complicating pregnancy, increases in oases of .•arcinoma with great rapidity during the pregnant state, and with even greater vigor during the puerperal condition. Wl-.cn pregnancy has not advanced beyontl the fourth iiionth, \ ..w dor Veer" and others practise vaginal extirpation of the uterus. In oases whore carv. noma attacks the cervix the prognosis is most uiifavorable. If delay is practised, the tissues surrounding the cervix soon become infiltrated, and delivery by abdominal section, should life persist to full term of ]irognancy, is the only alternative. The fact that caroinonm grows with greatest ra]>i(lity during tho puerperal condition obliges the obstetrician, whenever possible, to perfor.n oomploto extirpation of the uterus, either at the time when the fetus is '^"li veered or as soon as possible thoroaftor. The danger of septic infection follow i'lg Cesarean section is so groat that the majority of operators prefer hystere. ^oniy or total extirpation. Cancer ocoasioually involves the uterine tissue so ex, 'nf.vely as to result in rupture of the uterus. This extensive involv(>ment vjctMirs in cases where preg- * Tlie literature of this subject given on page 313 will iiiteitst (lK>-,e who desire to [tursue it fiu'tlier. wwwm \i 14 'I 1 i 1 i ' 1 ; \ ;i ■ i 188 AMEBIC AX TEXT- BO OK OF OBSTETBICS. nancy supervenes upon the existence of the cancerous condition. The great stimulus which pregnancy causes in malignant growths results in the rapid dissemination of malignant tissues, which gradually destroy the elasticity and the resisting power of tl»e muscular layers of the womb. Rupture occurs in these cases during abortion or during labor at term. The prognosis is exceed- ingly grave, for, even should the patient rally immediately from the rupture, the malignant growth must sooner or later end her life. Auvard repoits the case of a patient in her eleventh pregnancy who had ute- rine cancer for two years.'* Labor was exceedingly slow, the pains being very weak but persistent. When partial dilatation was present the os was incised in several directions and the fetus was found in breech presentation. Extraction by the feet was performed, and persistent hemorrhage ensued ; on exrjnination the uterus was found ruptured transversely at the upper edge of the lower uterine segment. The patient succumbal to shock. Cancerous infiltration of the tissues of the cervix often necessitates multiple incisions in any necessary manipulation during pregnancy or at labor. Von Herff " illustrates the value of free incisions in cancerous cases. Cesarean section had been decided upon, but, as a last resort, multiple incis- ions \vere freely made, and they proved efficacious. Early pregnancy compli- cated by uterine cancer invariably demands total extirpation, from which even unfavorable cases recover and the operation has prolonged life, as illustrated by Moller.^ In his patient the cancerous uterus was extirpated with great difficulty by reason of the infiltration of surrounding tissue. A rent was left in the peritoneal cavity, through which rent a loop of intestine protruded. Notwithstanding these unfavorable features, the patient made a good recovery, and some time after the operation was comparatively free from cancer. Sutu- gin reports two cases of amputation of the uterus at term for cancer, in each of which cases the life of the child was saved. Tayhtr of Jaj)an records*' a very unfavorable case of cancer in which vaginal extirpation was performed with great difficulty. A favorable result followed. In cases where the cervix only is involved the diseased tissue should at once be removed by the knife and cautery, with the ho])e that the progress of the disorder may be checked temporarily while the pregnancy advances, thus affording the child a better opportunity for life. In carcinoma of the preg- nant uterus complete extirpation is the only treatment that promises a favor- able result. If the i)atient is seen for the first time in pregnancy advanced bevond the fourth month, delav mav be advised in the interest of the child so long as the tissues about the uterus do not become involved. Under the improved methods now followed in performing total extirpation the prognosis for the nujther is no longer desperate, a fair chance for recovery from the opera- tion and the prolongation of life being thus given her.^^ In epithelioma of the cervix complicating i)r(>gnancy, Edis^ reports a ease in which an epitheliomatous mass was found involving nearly the whole cervix and extending down upon the posterior vaginal wall, rendering the pas- sage of the fetal head ini})ossible. The ch'ld was delivered by Cesarean s( „ $ THE PATHOLOGY OF PREGNANCY. 189 i tion, and seven months after the operation the epithelioma had made but little progress. The decidual lining of the uterus may occasionally become the seat of malignant disease, as observal by Sanger and Chiari.^* This form of cancer is describctl by these writers as a true sarcoma of the dccidua : its symptoms are foul discharge and hemorrhage persisting after labor, and its fatal termi- niition usually occurs within six or seven months after delivery. Metastatic deposits are not uncommon, the cells of which bear the characteristics of decidual cells. There \z an innocuous form of this growth, also described by Siingcr,^ that is not to be mistaken for decidua remaining adherent after a i'onner pregnancy. Hypertrophy of the decidua occurring during pregnancy may be non- nialignaiit and not dependent upon the existence of syphilis; thus, Hermann'^ ilcscribes cases of decidual hypertrophy in which the tissue measured one-fiftieth of an inch in thickness : microscopic examination revealed the presence of large cells, with large nuclei, five or six in number, without intercellular sub- -tance, but infiltrated and containing leucocytes. A similar condition has also I Ml described by Virchovv, ^ Strassman,^ Dohrii, ^ Gusserow, ^^ Klebs,** and Matthews Duncan.^^ Sponttineous rupture of the uterus occasionally happens during preg- nancy. Such cases are usually found to have been complicated by a fibroid tumor or by displacement of the uterus, with adhesions binding it in its dis- placed position. ^Manipulation intended to replace the uterus has sometimes hastened its rupture; thus in a case reported by Dickey^ the patient was in the third month of her fifth pregnancy: an eftbrt had been made to replace a retroverted womb, the effort causing the patient considerable distress. A few days afterward something was felt to give way, and the patient perished ill a few hours from shock. Post-mortem examination showed early p -"ancy and the ui( riis ruptured transversely from one Fallopian tube to the otiier. Spoi'hmcoiis rupture of the uterus may result from the rapid development of a largo fetiis in a uterus whose tissues have been weakened by previous disea ?. I'lio lietus may escape into the abdominal cavity, as illustrated in a case repon, '1 bv Aladurowicz,'* in which fatty degeneration of the uterine wall at tiie jn.iction of the fundus and cervix was found. The fetus had heco.ne partially encapsulated. Purulent jieritonitis ensued, and the ab- doiiinal wall opened spontaneously with the discharge of pus. The patient died of exhaustion. Endometritis during pregnancy results from an aggravation of a pre- existing inflammatory condition, and it is a familiar and frequent cause of ear! I'oortion. In patients who complete the jieriod of gestation the existence of !' . .'undition nuiy be susjiected when occasional discharges of blood or of watciy aiicus occur. While the pregnancy is not likely to go to term, still its coiitiiuiance must not be despaired of because of these discharges. An endo- metritis set up or aggravated by ])regnancy not infrerpiently causes adherence of the membranes about the cervix and the lower uterine segment, often com- m 190 AMERICAN TEXT-BOOK OF OBSTETRICS. \ ! ; I )i i I plicating labor by premature rupture of the bag of waters and protracted dila- tation of the birth-canal. It is noticed in women who conceive shortly after an abortion that an endometritis arising at the abortion may persist through- out pregnancy, becoming aggravated, and resulting finally in the firm adhe- rence of the placenta and in complicated labor; thus, Lohlein** reports a case of tills character in which the pregnancy went to term, its latter portion being complicated by intermittent pyrexia and by a very firmly adherent placenta. The treatment of this condition is entirely in the interest of the mother, as the prospect of her retaining th.e ovum to maturity is so slight that exhaust- ing hemorrhage or febrile disturbance should lead to the prompt emptying of the uterus : this should only bo done in the most thorough surgical manner and under strict antiseptic precautions. Sufficient dilatation to permit the use of the sharp curette and of draiii q;e should be secured by using the fingers or solid metal dilators. ShouL t.?ptic infection and fever be present, the blunt-edged douche-curette may I j red to great advantage, thoroughly emptying the uterus under a stream antiseptic fluid. Where sepsis and fever are absent the sharp curette followed by antiseptic irrigation will be found eflficie it. Drainage with iodoform gauze, with repeated intra-uterine irrigation, is indicated, should fever and foul discharge continue. Curetting is best performed at the time of abortion or premature labor, or, if this oppor- tunity is omitted, it should be done when the patient has recovered strength and the interior of the uterus has ceased to furnish a foul discharge. Salping-itis existing during pregnancy complicates the pregnant condi- tion largely by reason of the adhesions and the inflammatory exudates usually present with the salpingitis. As the uterus increases in size, tension upon these adhesions causes very considerable pain, and if the adhesions are firm, binding down the uterus, abortion is not infrequently the final result. A frequent cause of retroversion and retroflexion of the gravid uterus is to be found in salpingitis and in the adhesions and exudates which accompany this condition ; in such cases obstinate nausea and vomiting, and finally abortion, may bo the direct consequence of the salpingitis present.^® ^' Salpingitis is by no means a trifling complication of pregnancy, as cases are recorded in which acute sepsis, with general peritonitis developing twenty-four hours after labor, has caused death. It is certainly true that a patient suffering from salpingitis should avoid preg- nancy, and should subject herself to prompt and thorough treatment if the lia- bility to pregnancy exists. Diseased conditions of the ovary complicating pregnancy are usu- ally made worse by the gravid condition ; thus, ovarian cysts, solid tumors of these organs, and inflammatory conditions are greatly aggravated during preg- nancy. Acute oiiphoritis complicating pregnancy is of rare occurrence, and it may result from an exacerbation of a chionic process or septic infection from a previous abortion. Three cases of this affection are rejiorted by Coe ;'^ in each of two cases tubal and ovarian abscess formetl and was emptied. All three patients recovered, although convalescence was prolonged. The treat- THE PATHOLOGY OF PREGNANCY. 191 ineiit of this condition is largely expectant, abdominal section being most successful before the fifth month of pregnancy. Thomson^' has shown that while the tubes undergo a marked hyper- trophy during pregnancy, the ovary itself does not. The alterations observed in the ovaries during pregnancy are caused by foreign growths, and not by the increase of elements normally present. In addition to the danger of abortion which the size of an ovarian tumor occasions, there is possible risk tliat such a tumor may twist its pedicle, and that gangrene may be added to the complications of labor in this condition. It has repeatedly been shown that the operation of ovariotomy is safe and satisfactory during pregnancy, and this fact calls for the removal of ovarian tumors as soon as their presence is detected. In these cases adhesions are not often present, nor does the preg- nant condition predispose to their formation. The rapid development of a cystic condition of the '^vary may completely mask an early pregnancy, as in a case reportetl by Polaillon,^'^ in which preg- nancy could not positively be diagnosticated until a cystic ovary and an adherent tube were removed. This operation did not interfere with the preg- nant condition, the patient going to term and being delivered of a healthy child. Spontaneous cure of a pelvic cyst complicating pregnancy occasionally happens in the case of broad-ligament cysts, which disappear by spontaneous rupture. Rnge"*^ describes a case four months pregnant in which under anesthesia a pelvic cyst was pushed up above the brim of the pelvis, relieving pressure upon the uterus. Abortion followeractice of dermatology. The second class is those cases in which no diseased condition of the general organism can be found to account for the pruritus, and in which the disorder is purely local. This class is treated by local applications, and in obstinate cases resection of the diseased tissues may prove the only alternative, Sanger** has shown that in these cases partial or total extirpation of the vulva is thoroughly legitimate, and should include the removal of the glans clitoridis. Where the entire vulva is affected plastic operation may be necessary to cover surfaces exposed in the extirpation. In circumscribed pruritus of the vulva it may be possible to limit the extirpation to the affected part. Elephantiasis of the labia may complicate pregnancy, and prove an annoyance to the obstetrician at the time of labor. The appended illustration (Fig. 142) is taken from a case under the observation of, and described by, the writer. The patient, who wa'* pregnant for the first time, gave no history of venereal disease ; the growth persisted for several months before the occurrence of pregnancy, and increased slowly during gestation. Aside from its bulk it occasioned no suffering. During; labor it rendered thorough vaginal examina- tions difficult, and at tlie moment of delivery impeded somewhat the dilatation of the birth-canal. Especial precautions were taken to maintain the parts in an antiseptic condition at the moment of delivery. The patient's convales- \i ' I r Fi(i. 142.— Elephantiasis of the labia ((int'-fourtli liff ^izo). cence was uninterrupted, as no serious wound of the iiypertrophied tissue occurred during the labor. During tiio puerperal period the injured tissue decreased verv sliglitlv in size. I. i-:-,i THE PATHOLOGY OF PREGNANCY. 193 The presence of bacteria in the genital tract of the healthy pregnant ]):itient is an interesting qnestion which lias occasioned extensive research. The results go to show that pathogenic bacteria are not present in the healthy pregnant patient. Among the most thorongh of such investigations are those of Winter,*' made at the suggestion of Schroeder : he found that the Fallo- l)ian tubes containefl normally no micro-organisms : this is also true of the normal uterine cavity. In half the uteri examined germs were present at the internal os ; in the secretion of the cervix, antl also in the vagina, there were found abundant micro-organisms. These germs were found to be patho- genic, but not ])ossessing the virulence which characterizes them when observed ;iniid tissues in a pathological condition. It was found, however, that when pathogenic organisms were introduced from without the germs already present ill the genital canal assumed a virulent character. Diseased conditions of the vagina occasionally comjilicate the pregnant condition ; thus, Rissrnan*" reports a case in which a polypoid degeneration of the connective tissue of the vaginal wall attained such proportions as to pro- hipse before the fetal head during labor and to offer an obstat'" to delivery; in this case the condition was accompanied by gonorrheal infection. Vesico- vaginal fistula caused by pressure in a previous labor may become a serious complication at labor, by reason of the thickened condition of the tissues about the fistula and the excessive pain which pressure occasions.'* Displacements of the pregnant uterus are not infrequent, often causing great discomfort, and sometimes seriously complicating and even terminating pregnancy. If the patient has already borne children, the supports of tlie uterus are frequently so weakened that when repeatetl pregnancy ensues dis- placement readily occurs. The most frequent uterine displacement complicating pregnancy is retrover- sion of the gravid uterus : this produces the usual symptoms, pain and drag- ging sensation in tiie back, interference with the functions of the rectum and often of the bladder, and a sensation of weight and heaviness relieved only by the recumbent position upon the side or the assumption of the knee-chest posi- tion. On vaginal exaiiiination the os and cervix are found directed upward and fijrward, and the fundus of the uterus is below the promontory of the sacrum. In uncomplicated cases, where no peritoneal adhesions exist binding down the uterus, retroversion of the pregnant womb is a comparatively simple matter. As the uterus increases in size the womb gradually rises in the pelvis, until at four or five months it passes above the brim and remains permanently ill the abdominal cavity. The treatment of uncomplicated retroversion of the pregnant uterus con- sists in supporting the womb by tampons of autisejitic mooI smeared with an antiseptic ointment. A preparation containing 10 grains of powdered boraeic acid to the \ ounce each of lanolin and vaselin is most useful in these cases. Oner in four or five days such a tampon should be removed and the vagina be irrigated gently with warm water or with a saturated solution of boraeic acid. A Sims speculum should then be used, and the pelvic floor i;i J T ■ If ; Mil 1 ■ :- j 'i i 1 , i '1 III Hm 1/ i;,' ^M 1!I4 AMERICAN TEXT-BOOK OF OBSTETRICS. be (Iruwii downward nnd backward, when a tampon of antiseptic wool, rolled into a shape fitting the pelvic floor, should be introduced and carried across from side; to side, puttinj; the utoro-satTal ligaments slightly upon the stretch and raising the fundus of the uterus, Snch tampons have the great advantage over the hard-rubber pessary that they create no irritation, support the uterus comfortably, and mould themselves perfectly to the contour of the parts. Their use, however, re(iuires discrimination in fitting the tampon properly, and calls for regular supervision of the ])hysician at comparatively frecpient intervals. Cases are occasionally met with in which it is impossible for the patient to have the services of a physician except at intervals of several weeks : it is then often advantageous to fit a carefully-moulded hard-rubber pessary which shall raise the uterus to its proper level. It is often asserted that such a pessary n)ay cause abortion : the fact, however, remains that it is not a well-fitting pessary that produces abortion, but it is the displacement of the uterus resulting from a lack of such support as the jKJssary should give. Cases of habitual abortion caused by displacement of the womb are not infre- quently tnu'cd by raising the pregnant womb. ^lany cases of retroversion of the uterus are associated with chronic pelvic peritonitis, and are complicated by ])rolapse of one or both of the Fallopian tubes and of the ovaries, and the presence of adhesions binding the displaced organs in their artificial situation. With these patients the pain as the uterus increases in si/e is vei-y distressing, and residts from traction uj)on adhesions which occasionally yield, greatly adding to the patient's comfort. In other cases the separation of these peritoneal adhesions is accompanied by very considerable shock, which simulates to some extent the shock of rupture of the sac in tubal ectopic gestation. In still other cases these adhesions are so firm and tense that spontaneous separation of them is impossible, the womb remaining fixed in the position it occupied at the time of the original perito- neal infiammation. The continued growth of the uterus may so stretch these adhesions as to enable the wond) to rise into the abdominal cavity. Should the peritoneal surfaces not yield, however, a retroverted and incarcerated uterus will be tiie result, and, as the fetus increases in size, the adhesions not yielding, abortion is inevitable; and should fresh septic infection occur and the patient survive, her condition will be aggravated by fresh adhesions, and chronic invalidism will restdt. The frcf|uency of this eomi)lication may be estimated by the report of Martin,''^ who found in 24,000 women 121 cases of retroversion and retro- flexion of the titerus persisting dm'ing pregnancy. In 27 of these cases the defi>rmity was congenital, and one ease is cited in which a jiatient sufl'cred for three and a half years with congenital retroflexion and with gonorrhea, but conceived after recovery from the gonorrhea. Sterility in cases of congenital retroflexion depends upon a diseased endometrium or diseaseaper reports an interesting case imder his own observation in which the retrovertcHl pregnant uterus ]iroduced intestinal occlusion without ileus. He Fi(i. lis.— Frozen soction of retroviTted utonis of performed abdominal section, but was throo ami a half to four months. Doath from rup- m.able to save the patient. '"'^" ^'^ '•'"-'''^■■- (•"•'"-'• '••""■ '"""• "• i'"'- ^' ^- '»■ Ecto])ic gestation may be sinudated by a retroverted pregnant uterus, as in n case re|)orted by Barbour,*'' in which the physical signs of retroversion in the pregnant Jiterus were perfectly present. In the treatment of this con- dition Colin stein,'"' in treating five severe cases of incarceration of the preg. nant uterus, first emptied the bladder by a stiff catheter, and then drew down tiie cervix and vaginal wall with a tenaculum, while the cervix was pressed backward by downward pressiuv behind the symphysis. While the cervix was drawn downward and backward by a tenaculum the fundus was raised with file free hand of the operator. Retroversion of the pregnant uterus is occasitmally found complicated by the existence of disease of the pelvic bones; in these cases the pelvic^ deform- ity is often such that spontaneous restitution of the uterus is impossible. It is then necessary to relieve the patient by operative means, and, as a last I ■ 1 1 I I,; i ii f Pp '( 190 AMERICA X TEXT-nOOK OF OliSTEriUCS. resort, to extirpate the uterus per vaginam if possible. An interesting ease of osteomalacia eoni}>lieating retrofl(!xiou of the gravid uterus is reported by Jienckiser ;" efforts had previously been made to produce abortion and to puncture the fetal sac through the posterior vaginal wall. The. treatment of retroversion of the pregnant uterus when adhesions are present must be conducted with great caution. A gentle effort should be made to stretch the adhesions, gradually allowing the womb to regain its lost position : this is best accomplished by the use of the antiseptic wool tampon, combining with it an alterative api)lication which shall aid in the absorption of exudates in the pelvis and shall loosen adhesions. At present a favorite remedy fortius purpo.se is ichthyol, as follows : Ichthyol, Lanolin, Vaselin, aa 5j; .Ijss. An ointment stronger in ichthyol is occasionally employetl with good results. Once or twice weekly the patient may take, with advantage, a hot vaginal injection if this bo practised very gently. In cases of sudden and severe abdominal pain with great shock occurring in patients in the early months of pregnancy and with retroverte kidneys share with the other viscera the congested and hypertrophietl condition common during pregnancy. This peculiar engorgement of the kidney has given rise to the term " kidney of pregnancy." Much discussion has been elicited in the effort to differentiate the "kidney of pregnancy" from beginning nephritis. It is evident that only the systematic and microscopic examination of the urine can accurately determine whether simple congestion is present, or whether the kidney is being damaged in its essential elements, the secreting cells of the tubules. When such study of the urine finds only hyaline casts, crystals of various sorts, and the slight epithelial dehrk which may be found in healthy individuals, there is no reason to believe that nephritis exists ; but when, on the other hand, '.piihelial, granular, or fatty casts are persistently present, the diagnosis of nephritis can scarcely Vr denied. It is upon such comparative examinations that a diagnosis mnfl be based, and not upon the mere presence or absence of serum-albumin. Attention has recently been called by Trantenroth ''' to a coiulition of beginning fatty d(>generation in the kidney which causes no symptom in the urine, and which may suddenly become so acute as to destroy the patient by sudden kidney failure. Infective process as present ill these cases is so flir wanting, and i)atients thus affected, if they survive pregnancy, do not become nephritic afterward. An acute inflammation of tlie kidney cannot be caused by pregnancy, and is only observed in the rare cases where infective bacteria find entrance to the genito-urinary tract 1 1 f I I ( • )l! I. 1/ «» 19H AMh:iiIC'AX TEXT-nOOK OF OliSTETIiTCS. of the pregnant. This coiulition of conjjostioii (hiring prcgimnoy is iiiciriisod (hiring hihor, and ronal all)niniii is prosont (hiring th(! progress of hibor in eonsiderable ainonnt. J'atients suffering from diseased ki(hieys and becoming pregnant have the ki«hiey disorder greatly aggravated, often to a fatal issue. The causes of this condition, known as the " kidney of pregnan(y," arc the increased intra-abdominal tension to which all tiic viscera are sid)jected ; disturbances in the nutrition of the kidney through an altered condition of the blood of the pregnant patient ; and an engorgement of the spermatic veins and ureters by mechanical pressure. It is possible for eclampsia to develop without lesion of the kidneys, although in most cases of cclamj)sia a diseased condition of the kidneys can plaiidy be discerned. Fischer, in studying the same subject,'*' found in 70 cases evidence that the " kidney of })regnancy " was present in tifty-eight ; eight cases of nephritis occurred among the 70 ])atients. Fischer found red blood-corpuscles in eonsiderable amount in cases where acute nephritis occurred. Gramdar and epithelial casts indi- (\ited chronic nephritis. Tlu^ occurrence of chronic endarteritis accompanying chronic nephritis e\])lains the rupture of blood-vessels within the uterus and the intra-uterine hemorrhage which sometimes destroys these j)atients. Schauta"' describes a typical case of fatal hemorrhage in which chronic inter- stitial nephritis and degeneration of the muscle of the heart and uterus were found. The life of the child was also sacrificed. Albmninuria is of such fre«juent occurrence during ])r(>gnaney as scarcely to rc(]uire serious consideration, except as a symptom in connection with others of ni^phritis. Among others, Meyer *^ from an elaborate study of this subject at Copenhagen found albuminuria in 5.4 per cent, of pregnant women. Casts accompanied the albumin in 2 p(M' cent. This may be taken as an indi- cation of the relative frequency of kidney involvement in cases manifesting albu- nunuria. As pregnancy advanced, albumin became more abundant until during the last thirty days but 28.9 \wy cent, of urine examined was free from albumin. Premature births occurred in 8 percent, of patients witii albiuuin, and in 21.0 per cent, of patients who had casts in the urine. He adds other clinical details which emphasize the significance of the presence of casts as indicating nephritis. Lantos ^^ in the clinic at Budapest found albumin so fivquently in pregnant l>atients that he considers it ]>hysiological during pregnancy and a diagnostic symj)tom of the condition. Herman calls attention in this" and in other l)apers presented at the Obstetrical Society of London to two conditions of renal disease in the pregnant woman : one is acute kidney failure with extreme diminution in the (piantity of urine and deficiency in the excretion of urea, which quickly ends fatally if the excretion of urea is not rc- estal)lished. The otlr-r process resi'^mblos interstitial nephritis in its shnv course and idtiniately fatal termir , 'on. The interesting fact that a patient may have uremic convtdsions din-ing pregnancy without eclampsia is illus- trated l)v Boudin,"" who d(^scribes a patient seven months pregnant admitted to the hospital unconscious with unMuic convulsions. On establishing the secre- tion of urine and purging the patient, con.sciousness returntKl, and the follow- THE PArifOLOGY OF PREC! NANCY. l!ll> iiig (lav a seven months' fetii.s was stillUoni. Syniptonis of iironiia siipcr- vc'iiod, l)iit recovery linally ensued. Tlie patient inanilested no symptom of eclampsia and had no tnlema. The very interesting^ (piestion of the proj^nosis in nephritis (hiring pregnancy has recently received consideration at the hands of Kohlaiuk.®" In a series of 77 patients, r)!).7 per cent, showed nothing pathological in the urine after their recovery from labor; KJ.H per cent, mani- fested slight involvement of the kidneys as shown by hyaline casts and leuco- cytes, with a trace of alhni-iin ; in \hA per cent, a catarrhal condition of the urinary tract was evidently present ; in (i.o j)er cent, the patients were the victims of nephritis. The presen(;e of sugar in the urine during pregnancy has l)een the subject of inv(!stigation by lierberotf c"^ his tests were thorough and ndnute, and his results were largely negative, a trace of sugar being present in some i)atieiits in early pregnancy, and disappearing as labor a|)i)roached. Polyuria may be observed in the pregnant patient without a pathological condition of the urine, as in a eas(3 reported by Voituriaz,** Among the most signiticant of the symptoms presented by pregnant patients sulfering from nephritis may be reckoned albuminuric retinitis. Abundant evidence of the signiticanee of this complicati(>n is afforded by the literature of ophthalmoloi:!v upon the subject. Tn a recent paper Randolph** reports 5 eases, with a pa ihologieal study and drawings of the tissues involved : he regards visual disturbances occurring in the first six months of pregnancy, associated with violent headache, as very significant of albuminuric retinitis. If this condition be found, to save sight pn^gnancy should at on(!e be terminated. Visual disturbance-* during the last seven weeks of pregnancy are of less grave im)>ort. The occurrencte of renal retinitis in one pregnancy does not necessarily mean its recurrence in a succeeding pregnancy. The treatment of disorders of the urinary tract occurring during pregnancy necessitates, first, a careful examination of the j)osition of the uterus, inasmu(>h as j)ressure upon the bladder, ureters, and kidneys by a disphu^ed pregnant uterus is so frequently a cause of disease. A retroverted uterus should be raised and be sup})orted in proper ])osition by tampons of antiseptic carded wool. Cystitis may be treat(Ml by douching the bladder with creolin or lysol, 30 drops to the pint or (piart of warm water, as the patient's tolerance will permit. The administrati(»n of salol, of boracic acid, or of sodium salicylate internally is also of advantage. If the ureters become involved, catheterization of these ducts, the bladder having first been rendered aseptic, is indicated to determine which kidney is affected if pyelitis is present. Should this ]>ro- c(Hlure show the presence of pus and bacteria in one kidney, the extirpation or the drainage of this organ is indicated. Such disorders, however, compli- cating pregnancy, are unfavorable and dangerous to the life of the patient. Should recovery occur, the ])atient is liable, after the birth of the child, to become the victim of some form of chronic nephritis. Suppuratingr hydatid of the abdomen is an infrequent but dangerous complication of pregnancy. The diagnosis is made by the presence of an inwr . ! il 1 ;( J 1 1 j J 1 i 2()(» AMEJilCAX TEXT-BOOK OF OBSTETRICS. abiloniiiial tumor not attacluHl to tlie uterus, aii'l by the contents of this tumor obtained through tapping. An incision, shoukl be made throiigli the abdom- inal wall, and tiie edges of the sac of the tumor be sewn to the edges of the alxlominal incision. So soon as adhesion has taken place the cyst should be opened and its contents thoroughly removcnl. Pregnancy is not necessarily interrupted by this complication. Peritonitis during pregnancy/" as has been stated, rcsidts in most cases from previous iiiftammation of the endometrium, the Fallopian tubes, or the connective tissue of the pelvis, causetl by septic germs or their spores. There remain, however, cases in which no infection can be traced, but in which sudden exposure to cold or to dampness may produce rapidly-extending and fatal peritonitis ; thus, instances are recorded where a cold bath taken while the patient was overheatetl, and accompanied by the drinking of cold fluid, was followed by rapidly-developing and fatal general peritonitis. Mechanical iiijurv or a severe strain may be followed by peritonitis in a ])regnant patient. Gow ^' reports the case of a patient advanced in preg- nancy who slipped through a hole in the floor of a building ; peritonitis supervened ; the patient was delivered by version, but ceased breathing during delivery. Abdominal incision disclosed no blood in the peritoneal cavity, but lymph was found upon the peritoneum and uterus. No evi- dence of rupture of the uterus or other organ was discovered. Xo focus from which the inflammation could have begun was found upon examination. Concealed accidental hemorrhage is among the most dangerous com- plications of pregnancy. One of the most extensive recent collections of such cases is that by Storer," who contributes an account of 46 in his own observation, and adds the collection of 84 oases by Goodell and 23 by Braxton Hicks, making a total of 16.">. 46.7 per cent, of the mothers perished, and of the chiklren 514 per cent. Of 63 cases which received no treatment, 64 per cent, died, while in 79 cases in which the contlition was detected and treated, 29 per cent. died. It is thus apparent how insidious is the danger and how difHcult is its recognition in these patients. There is contributed by Jardrin" a further series of these cases, the results of which differ in no partic- idar from those observed in the more extensive series of Storer. As so nuich importance naturally attaches to a diagnosis of this complication, it must be remend)ered that the hemorrhage is concealed, and that the i)atic:it may be thrown into a condition of danger without a])parent flow of blood : her symp- toir.s then will divid(> themselves into two classes — namely, those j)ertaining to her general condition, and those which have to do with the uterus itself; of these, the first furnishes the best indications of danger and the most rational suggestions for treatment. A rapid, weak pulse, lacking in tension ; an indifl'crent, languid attitude of mind ; respiration becoming more and more shallow; a jiale or pallid face; a clammy skin; thirst; dimness of visit)n and "air-hunger;" a restless irritability which is a very significant symptom of a certain kind of shock, — these furnish an array of symptoms which shoidd attract the attention of the physician. THE PATHOLOGY OF PREGNANCY. 201 If conc'caletl iU'cidoiital heniorrhnge occurs during labor, labor-pains may coa-^e or may grow weak, and the usual sensation of pain in the uterus may be replaced by a dull constant ache above the pubes. It is occasionally noticed tliat the os uteri is dilating without apparent labor-pains. The uterus may become enlargetl, forming an asymmetrical timior of the abdo- men which can be appreciated by palpation. As regards those symptoms which can be observed on making an examination of the genital tract, the o« liter! is usually slightly dilated, and the cervix is s(>ftened, although it may not be effaced. Slight uterine hemorrhage is generally observed. The lower uterine segment becomes distended with clot ; as the hemorrliage persists the sensation conveyed to the linger resembles that in placenta pncvia. Inetfectual and spasmodic uterine contractions and the accumulation of blood between the Ictus and the wall of the uterus will cause irregular enlargement of the womb. Concealed accidental hemorrhage from some other source than the uterus or the placenta may occur during pregnancy, the blood escaping into the abdominal cavity. An illustrative case is reported by Sutugin" of a multi- gnivida who, three days before ailmission to the hos})itaI, had fallen while carry- ing a heavy load. Two days after her fall she was seiziHl with weakness, and felt no fetal movements after this time. When examined, no dilatation of the OS and cervix was present. The fetal heart-sounds were absent. The patient complained greatly of pain in the uterus, probably caused by uterine con- tractions. Shortly after rmit delivery, the uterus should be emptied, and the bleeding be controlled by abdominal incision and hysterec- tomy or by total extirpation of the uterus. The use of the tampon of antisep- tic gauze is indicated in cases where hemorrhage externally is considerable and 202 AMERICAN TEXT- BOOK OF OBSTETRICS. it )i 'i the OS and cervix are too tiglitly closed to permit of rapid delivery. In intro- ducing the tampon it is well to pack the end of the strip of gauze into the os and cervix, thus furthering dilatation and checking external hemorrhage. The "prognosis for the fetus in these cases is exceedingly grave and is almost necessarily hopeless. Loss of blood induces rapid asphyxia, and the rapid fetal movements accompanying the partly asphyxiated state may explain some of the obstinate uterine pains from which these patients suffer. The causal relation existing between involvement of the kidneys and intra-uterine hemorrhage has been describetl in treating of Nephritis and its consequences. In a series of clinical lect ires upon the subject of hemorrhage during pregnancy Budin ''^ describes the case of a patient suifering from hematuria with albuminous urine. Profuse intra-uterine hemorrhage com- plicated labor; the child perished. The Posture and Bearing of the Pregnant "Woman. — Accompany .; the changes in the jx'lvis peculiar to pregnancy we find certain variations in the posture and bearing of the patient as pregnancy advances. This has been the subject of study by Knhnow,^^ who found two types among patients in the latter months of pregnancy. The most frequent is a back- ward curve of the entire body, while in 20 per cent, of cases a backward bend of the trunk only was present. Tiie cervical vertebrse are straightor, the thoracic curve is greater and more projecting, the lumbo-dorsal region is straighter, its curve being lower and flatter, while the pelvic curve is often lessened in the later months of pregnancy, and is sometimes unchanged. The hip-joints are usually carried ))osteriorly, while the sternum projects at its lower extremity, increasing the diameter of the thorax. Relaxation of the Pelvic Ligaments. — Among the general changes caused by pregnancy are those affecting the joints of the pelvis. The fact that an increased secretion of synovial fluid is present in the pelvic articu- lation during pregnancy has long been recognized, and has been accurately studied by Driver:" in his examination of 300 cases he found the amount of relaxation is ])roportionate to the general strength and firmness of the patient's tissues. Age has nothing to do with it, nor does the amount of relaxation influence the patient's walking. Some of those whose joints were most relaxed could walk without difficulty ; conversely, consid- erable motion produced in some patients marked lameness. Pain at a sacro-iliac joint showed that the ilium moved upon the sacrum upon that side. This phenomenon is sometimes observed in patients who are not preg- nant. Some patients recovered spontaneously from a serious condition of lameness, while others were not benefited by prolonged and thorough treat- ment. A slight degree of relaxation may facilitate delivery and obviate the use of forceps. The most successful treatment described was an abdominal bandage of twilled cotton 5 inches wide, with padded perineal bands 1 incli wide. Where the ])atient was deficient in general strength cold baths auid massage were sometimes useful. The Toxemia of Pregnancy. — The interesting metabolism characteristic THE PATHOLOGY OF PBEGNANCY. 203 ! of pregnancy has not yet been sufficiently elucidated to explain clearly the origin of toxic material which not infrequently jeopardizes the lives of mother and i;hild. The fact that nutrition and its converse are going on in two organ- isms, each dependent upon the other for proper assimilation and excretion, explains the ease with which these processes may pass the bounds of physio- logical activity and become disease. The character of the poisons produced in the body of the mother and the fetus places them, so far as we know, in the class of animal poisons, alkaioidal in nature, denominated toxins. The symptoms they produce upon the pregnant patient are especially addressed to tlie nervous system, hence the study of toxemia in pregnancy appropriately leads to a consideration of nervous disorders during this condition. Various observers by differing methods of investigation have isolated several poisonous principles from the urine of pregnant women in whom elimination was deficient: Diihrssen^* lays great stress on the retention of creatin and creatinin in the kidneys of the pregnant patient. Actual nephritis ho rarely observed, but congestion and accumulation of urine through pressure upon the ureters and by hydronephrosis are common. Creatin and creatinin accumulating in the vessels of the cerebral cortex produce cerebral irritation. It is natural that such a condition should be commonest in patients in whom excretion is habitually deficient. Poisons absorbed from the intestinal tract stand in close relation to the toxemia of pregnancy, as shown by Budin.^' This is especially true where retr(»version of the pregnant uterus produces intestinal stasis. In many of these cases the bacterium coli communis pene- trates the wall of the bowel, causing peritonitis in adjacent tissues. Culture experiments by inoculation demonstrating the toxicity of urine in pregnancy have been performed by Ciiarpentier,*' who, following Bouchard's researches, injected such urine into rabbits, producing tetanic convulsions and speedy death. Acute congestion in the kidneys of these animals was the only lesion found to account for the fatal issue. Similar injections beneath the skin of other animals less susceptil)le than rabbits produced death after longer intervals. The condition of congestion of the kidneys in patients suffering from toxemia in jiregnancy is also described by Prutz.*" He notes a verv interesting point, that but slight structural alterations were present in many exceedingly severe cases of toxemic poisoning. In the kidneys of infants burn from mothers suffering from toxemia there were observed congestion and transudation of serum, witii the formation of casts in the tubes and great distention of the veins. A similar congestion in the livers of toxemic patients is described by Pilliet and Delansorme."^ This condition of con- gestion in the kidney of the pregnant wonian was found in two-thirds of the cases examined by Fischer during the second half of jiregnancy.*'^ The state of the blood in these patients has been studied by P»Ianc,*^ who made cultures and inoculated animals with their jjroducts, producing alinimi- nuria and siip])ression of urine. Convulsions were also caused, and intense con- gestion of the kidneys was observed. Additional testimony as to the extensive disorganization of the blood and tiie pathological condition of the liver in the '\ ;i fii l! k (1 m 204 AMERICAN TEXT- BOOK OF OBSTETRICS. I . t ! ■(■ toxemia of pregnancy is affordwl by Papillon and Audain.*'' The accumulation of ptonia'ins in sufficient quantities to produce poisoning has been observed by Koffer and Kuudrat.** Paultauf and Kundrat have also reported similar cases in the Records of the Pathological Institute of the Vienna University. Among many interesting contributions to the bacteriology of this question is that made by Gerdes.*^ In common with other observers, he is inclined to ascribe to bacteria a causal relation in these cases. As bearing upon this point we note the observations of Tarnier and Chambrelent,** who found in toxemic pregnant w^omen that the degree of intoxication present could well be estimated by observing the toxicity of the blood-scrum of these patients. It is interest- ing in this connection to note that any disorder caused by bacterial invasion predisposes to toxemia in pregnancy; thus, Lang®* finds that twice as many pregnant women who are syphilitic show symptoms of threatened toxemia in pregnancy as are observetl in non-syphilitic pregnant patients. The precise toxic agent responsible for the gradual development of toxemia with threatened eclampsia has not yet been isolated, although a number of sub- stances have been charged witii this result. The significance of a diminished quantity of urea in these cases has been brought to the attention of the pro- fession by Hermann** and Davis:" the latter in 84 cases, vitli a total of 5G4 examinations to determine the amount of urea present in the urine of pregnant and parturient women, found that the average percentage of urea in the urine of a iiealthy })atient before labor was 1.4. After delivery this percentage increased to 1.9. Considerable diminution in this quantity was first accompa- nied by symjitoms of irritation of the nervous systeru and threatened intoxica- tion, and, where the patient's excretion was not stimulated and the amount of urea brought up to nearly normal, eclampsia develojted. Davis does not ascribe to retained urea the causal role in toxemia, but he regards it as a valuable index in estimating the excretory activity of the patient. A well-marked example of ptomain-intoxication during pregnancy is the case described by Gustav Braun.'^ The patient, seven months pregnant, died from pulmonary edema after premature labor. The urine contained casts and albumin. Tiie ])()st-mortcm examination was made by Paultauf, who found fatty liver, fluid blood, nejiliritis, and cerebral edema. Multiple rupture of capillaries was found iu the viscera. The fact that the blood of patients suffering from toxemia may contain pathogenic germs has been illus- trated by Blanc,'^ who made cultures from the blood of such a patient, obtaining in forty-eight hours germs which caused albuminuria and toxemia in ral)l)its. It was foiuid on experimenting that chloral in the proportion of 4 parts to 1000 of tiie culture-liquids effectually destroy these germs. Blanc"* continued his experiments by injecting the urine of ])regnant j)atients into the bodies of rabi)its and observing tlic result. It was found that while tiie urine of some uon-j)regnant patients was poisonous when injected, the urine of pregnant patients was far more toxic, causing distinct phenomena of decided poison. Van Santvoord '"* from clinical observation ascribes toxemia during pregnancy very largely to deficient action of the THE PATHOLOGY OF PREGNANCY. 205 liver, by which an insufficient formation of urea causes the patient to retain in her blood toxic material. The imnmnity which the kidneys display in some of these cases is illustrated by Prutz's description of the condition of tiie kidneys in 22 cases of fatal toxemia. In many of these, beyond a general congestion, no pathological condition was found. Micro-organisms were absent from the kidneys, and there was no relation between the severity of the intoxication and the condition of the kidneys. The belief that peptones are among the substances causing toxemia has led observers to study the urine of pregnant patients with regard to tiie presence or absence of these substances. Thomson ^ examined the urine of 23 pregnant and puerperal women for jH'ptone ; the results of his examination were negative. Koettnitz"'^ made 140 analyses of the urine of 31 pregnant patients, but could not discover that peptone is a significant ingredient in these cases. It is often present in the urine of patients who suffer during pregnancy from any severe complication. While the entire subject of the toxicity of urine offers a vast field of inves- tigation and has produced a large literature, so far as the obstetrician is con- cerned there is abundant proof that no one substance is especially dangerous to his pregnant patient, but that the gradual accumtdation of nitrogenous waste, of potassium combinations, and of animal alkaloids produces a condition of toxemia, the symptoms of which are first observed in a disordered state of the nervous system demanding the attention of the physician. Following the line of Bouchard, additional observation is required for a more precise determi- nation of the relative toxicity of the various substances retained in the blood ill these cases. The jn-ophylaxin of the toxemia of pregnancy resolves itself into mainte- nance of excretion. Remembering the interference with the circulation to which the patient is subjected by pressure, a first and very important precau- tion is to secure suitable clothing. There can be no question of the advisability of laying aside completely the corset or any other form of support for skirts that com|)resses the abdomen and forces the viscera down upon the brim of the pelvis. The art of dress has advanced sufficiently to enable the patient to obtain comfortable and shapely clothing supported /entirely from the shoulders. Poor patients can make for themselves from cheap materials waists which fulfill the same indication. While the intelligent physician will ailvise and strongly urge that the corset be laid aside, he will remend)er that this is one of the pieces of medical advice which is expected and is rarely followed. The responsibility, however, is not his after ho has stated the case fairly and clearly t(» his patient. Constriction of the blood-vessels should also be avoided by wearing loose shoes, by dispensing with garters that encircle the legs, and by the avoidance of constipation so far as possible. In this latter difficult ])r()l)lenj it will be found that a proper mode of dress is of the utmost importance by avoiding pressure upon the large intestine. In avoiding con- stipation it is well for the patient in addition to select a diet not rich in nitrogenous elements. The heavier and less digestible meats should be omitted. Birds, lamb, mutton, fish, and oysters are best adapted for such ;i 1 l7 H 20f5 AMERICAN TEXT-BOOK OF OBSTETRICS. patients. A i abundance of raw fruit, or cooked fruit if the digestion re- quires it, is oT great importance. Whole wheat, Graham, and rye bread is of vahie. The avoidance of large amounts of sweets and stimulants of every form is also indicattKl. While vegetables are useful, they are inferior to fruits for the needs of such patients. An abundance of water is a prime necessity. If the patient cannot obtain bottled waters, ordinary drinking- water wiii(:!i has been boiled and filtered may be taken in abundance. If her means allow her to choose, she will find the lightest Vichy or any of the slightly alkaline and effervescing waters agreeable and advantageous. Milk is to be taken freely by those with whom it agrees ; many, however, cannot use it without producing obstinate constipation. The medicinal treatment of intesti- nal torpor threatening toxemia consists in the use of such laxatives as can be employal for a considerable time without violent purgation and without losing their eUcct. Compound licorice powder in small (piantities, rhubarb or colocynth in combination with extract of belladonna, small quantities of the lieavier mineral waters (such as Himvadi Janos) and cascara sagrada in com- bination with the substances mentioned, have been found efficient. Where the liver is evidently at fault, the occasional use of calomel and soda, followed by a saline, is distinctly indicated. W^here hemorrhoids complicate the patient's constipation, rectal suppositories of glycerin 1 drachm, extract of belladonna \ grain, and iodoform 5 grains will be found advantageous. In addition to avoiding constipation, the prophylaxis of toxemia embraces such care of the skin as shall promote constant and free elimination. Fre- quent bathing in tepid water, flannel (varying in weight in accordance with the climate) worn next the skin, massage of the limbs and the upper portion of the triuik, and gentle exercise are not to be neglected. Remembering the important part wiiich the lungs ploy in excretion, and the necessity for a free supply of oxygen, the patient must have an abundance of fresh air. A mild and equable climate is naturally the best for such cases, but, as this is seldom available, the patient, properly clad, should be out of doors in all weathers. It is of imjiortance that tlie amount of urine secreted be observed, lieiice tlie patient should be instructed to take such precautions that this information is availal)le for the physician. He may inform her that an amount varying within certain limits is what is expected and desired, and that any marked decrease from this should at once be reported to iiini. Examination of the urine of ])regnant patients should be an invariable cus- tom not to be omitted in any case. It should be done at least once a month through the entire pregnancy, or, l)etter, i>nce in two or three weeks. While this imposes additional labor upon the physician and inconvenience upon the j)atient, yet in all eases of primigravidie, especially in women whose nutrition and excretion are not of the best, " Paternal vigilance is the ])rice of safety." If this be reasonably explained to a patient, she will rarely object. The examination of the urine in pregnancy requires ciiemical and microscopic investigation. By the first we search for albumin, sugar, and urea in all cases. Important as this examination is, it is second in value to the microscopic THE PATHOLOGY OF PREGNANCY. 207 study of the specimen. By tliis study we derive positive and valuable infor- mation as to the condition of the parenchyma of the kidney, and this informa- tion can be obtained in no other way. Hence in pregnancy an examination of tlie urine that does not include its microscopic study is certainly superficial and deficient. In cases where a suspicion exists that toxemia is developing, in addition to the substances already mentioned we must examine chemically lor indican, acetone, peptone, pus, and blood. In complicated cases micro- scopic examination must be patient and thorough. D'uKjnoHts. — In diagnosticating the toxemia of pregnancy two clinical signs are of especial value: first in importance are the amount and character of the excretions ; second is the condition of the nervous system. The first sign is to be ascertained by careful questioning and accurate observation. The second sign must be determined by closely interrogating the various functions of the jiatient's nervous system. The presence or the absence of pain, head- ache, thirst, lassitude, disturbances of vision, of hearing, or of taste, sleep- lessness or lethargy, irritability or apathy, melancholia, and nausea and vom- iting, are all symptoms to be recognized or be eliminated. The condition of the skin, as affording evidence of the functional integrity of its excretory apparatus, is of great value. Of secondary importance are the occurrence of swelling of the feet and legs and the presence of serum-albumin only in the urine. The treatment of the toxemia of pregnancy consists in the prompt stimu- lation of all the elimiuative organs of the body. In view of the hepatic condition present there can be no question regarding the efficiency of mer- curials in a few repeated doses. The remarkable diuretic effect of calomel is also of value in these cases. In selecting saline cathartics it is best to avoid those containing potassium salts, as potassium has been shown to be ail irritative element in the urine. Those purgatives producing a free flow of watery fluid from the bowel, such as colocynth, elatcrium, and jalap, are ospe(Mally indicated. Rectal injections of glycerin, combined with sodium salts and spirits of tiu'peutine, are excellent in [)roducing copious watery evacuations. The beneficial effect of such elimiuative treatment on the ner- vous system is remarkable in many cases, the patient passing from a condition of melancholia and great restlessness to a feeling of comfort and good health. Warm and hot baths in these cases, taken befi)re retiring, are an excellent moans of treatment. If the patient's symptoms are threatening and a con- dition of hysteria is present, the hot pack will i)r()vc a most valuable resource. The diet in cases of toxemia should be restricted to milk, fruit, l)iead, and, if tiie patient requires more than this, fish, oysters, and gruel. Meats, eggs, vegetables, pastry, and all forms of stiundants, including tea and coffee, should absolutely be forbidden while symptoms of toxemia are present. In examining the urine two points are especially valuable : one is tlie smiount i)assed daily ; the second, the amount of urea excreted by the patient. If the condition of the kidney passes beyond congestion to actual nephritis, the practitioner will be aware of this through the microscopic study (I '■".■ ■ I i: 208 AMERICAX TEXT-BOOK OF OBSTETRICS. of the urine, wlieii casts, bloody, epithelial, or fatty, will be prep^iit. The presence of senun-albuinin and hyaline casts is of very little moment so long as a free amount of urea is excreted, and microscopic study of the urine finds no evidence that the parenchyma of the kidney is diseased. It is evident from what has been stated regarding the toxemia of preg- nancy that simple albuminuria is of little moment in the pregnant condition. The com])licatio'.is of pregnancy ascribed to albuminuria do not result from the presence of S!>rum-albumin in the urine, but from the circulation through the body of the mother and her placenta of blood rendered irritating by toxic material. The occurrence of thickening and induration in the walls of the placental blood-vessels, the partial separation of a placenta in fatty degeneration following this process, with the consequent hemori-liage and asphyxia of the fetus, are familiar complications of the toxemia of pregnancy and they follow the diffusion of toxic material in the placental blood. Simple albuminuria is often seen in multigravidic in whom, by reason of the large size of the fetus or by tiie relaxed condition of the uterus and the abdominal walls, the ureters are pressed upon and the kidneys are in a constant state of congestion and accunui- lation of urine. Many of the women thus affected have edema of the extremities, they remain entirely free from those disturbances of the nervous system seen in toxemia. The condition of such patients docs not demand the production of abortion, but it requires that the heart-muscle be stimulatetl, the circulation be maintained in every way, and, if possible, that the pressure of the pregnant womb upon the ureters be relieved by a supporting bandage when it can be used. In sharp distinction to these cases are those of the toxemia of pregnancy, where, notwithstanding prompt treatment addressed to the organs of elim- ination, the patient's nervous symptoms continue, while her excretory processes are plainly deficient. In such cases, in the present state of our knowledge, the prompt termination of pregnancy is the only rational and conservative treatment. If the toxemia of pregnancy be recognized and the patient will submit to her physician's advice, eclampsia should become more rare than puerperal septic infection. The tenilency which patients who suffer from toxemia of pregnancy exhibit to pass into nephritis after pregnancy or during a subsequent gestation must be borne in mind. In a woman who has once shown marked evidence of the toxemia of ])regnaney each succeeding gestation brings added risk of fatal poisoning. If her condition be undetected and her general health after parturition be neglected, she will not infrequently become the victim of nephritis. Disorders of the Nervous System ix the Pre(ixant Patient. — Neur- algia. — The ])rcgnant patient is peculiarly susceptiljle to various disorders of the nervous system. Conuuon among these affections, and occasioning great distress, are the various forms of neuralgia often observed diu'ing gestation. As is gen- erally the case, these neuralgias usually have as a starting-point some portion THE PATHOLOGY OF PREGNANCY. 209 of the nervous system in which a patliological condition is present. The decay of the teetii so often seen during pregnancy accounts for many of tiie cases of obstinate toothaclie which annoy and distress these patients. In women who sutier from habitual constipation during pregnancy, and in whom the size of the fetus is so great as to cause pressure upon tlie nerve- trunks at the brim of the pelvis, obstinate cramp and sciatic pain may occasion great distress and may seriously depress the patient's general health. Some of the worst of these cases result from the pressure of hardenetl fecal matter upon nerve-trunks above the brim of the pelvis, and upon branches of nerves so situated that they may be pressed upon in the pelvic cavity. In some of these cases the uterus will be found retroverted, thus preventing proper evacuation of the bowels and adding to the pressure which retained fecal matter causes. In other patients there is great complaint of cramp and of sudden spasmodic contraction of the muscles of the thigh, often worse at night. Where the disorder is severe an obstinate i)ain, radiating down the tliigh as far as tiic knee or even below the kuee, is often observed. In dealing with these cases the fii-st duty of the obstetrician is to ascertain accurately the position of the uterus : if it be found retrovertetl and not bound down by adhesions, it is a comparatively simple matter to raise it to or above the brim of the pelvis, and to sustain it by tampons of carded wool. If the uterus be found bound down by adhesions, the problem is much more difficult. If the patient be put at rest in bed and the bowels be thoroughly moved by salines, a very efficuent form of tampon in these cases may be found in a strip of surgeon's lint 3 or 4 inches wide thoroughly soaked with glycerin. A Sims speculum is introduced, and this strip is packed with the aid of dressing-forceps thoroughly behind the cervix, pushing the uterus up as far as possible without causing positive pain. This application is followed by a very copious discharge of watery mucus, greatly relieving congestion and softening adhesions which are not extraordinarily tenacious. The growth and development of the uterus will frequently separate such adhesions, and sur- prisingly good results are observetl in cases where the uterus has been partially bound down in the pelvis. The fact that pregnancy exists contra-indicates, naturally, uterine massage and any instrumental interference. If the uterus be in good position, the next step to be taken in relieving pelvic pain radiating down the thighs is to empty the bowel thoroughly : this should be done with the same care exercised in preparing a patient for an abdominal section. In addition to the purgatives usually employed, the colon should be flushed thoroughly by frequent and copious injections of warm water and sulphate of magnesia, or injections containing soapsuds and castor oil to which turptntine is added. If impaction of feces is present, an ounce of ox-gall dissolved in a quart of hot soapsuds should be injected through a rectal tub? as high into the bowel as possible. This injection is to be retained so ioiig as the ])atient can do so, and when an inclination to evacuate the bowels is felt a second injection of sulphate of magnesia, glycerin, and turpentine will usually result successfully. Some cases of obstinate pelvic u t ! % • ,- r li:) I! . I I'! ■> r 1/ 210 AMERICA X TEXT-BOOK OF OBSTETRICS. neuralgia occurring during pregnancy are cured by erai)tying the bowel of hard and irritating feces. Where the uterus is in proper position and the intestine is free from fecal matter, if pelvic neuralgia still persists, it will be found to depend upon anemia, depressing causes which affect the nervous system, or, possibly, upon malarial infection. Treatment appropriate for this condition will result in the gradual relief of the neuralgia. Facial neuralgia with hemi(!rania is often observed in pregnant patients in whom no exciting cause in bad teeth can be discovered. Many attacks follow exposure to cold or to damp ; others are caused by loss of sleep. The pain is often paroxysmal, and frecpiently an irregular interval may be observed between tiie attacks ; thus, some patients will sleep during the night, but are seized with violent pain in the early morning ; others suffer more in the afternoon or at night. The face and scalp are often tender to pressure in these cases, and tlie conjunctivae on the affected side are frequently reddened. Wl'.ere painful spots can be isolated local treatment may be instituted by painting the part with menthol or with iodin, or by spraying it with ether or with some other anesthetic. The constitutional treatment of this condition consists in thoroughly emptying the intestine to relieve the patient of fecal poison which may be depressing the nervous system. Absolute rest in a darkened warm room of ecpiable temperature, systematic feeding of easily- digested food, and tonics — irouj arsenous acid, and quinin — and, if the pain be severe, alcohol, at regular intervals are to be recommended. When sleep is impossible by reason of pain, jihenacetin with caffeine and sodium bicarbonate is often used to advantage. If pelvic neuralgia be present, phenacetin may be given by rectal suppositories of 10 grains each. Morphia and atropia mav be given hypodermatically when other remedies fail. Chloral and the bromids are of comparatively little value and often disappoint in these cases. It should be explained to the ])atient that the loss opium she takes the sooner she will recover ; and where her suffering is n(»t severe ever}' effort should be made to imjirove her general condition by tonic treatment rather than by narcotizing her with opium. Salivation. — Derangement of various secretory nerves is sometimes observed during gestation; the salivation of pregnancy is a faniiliar instance. Hyperse- cretion of tears is seen in patients suffering from salivation, as shown in a case reported by Xeidon.*' So abundant was the secretion as to keep the eyes con- tinually suffused and to cause an eczematous eruption of the lids. The tear secretion was weakly alkaline, the eyes W'Cre normal, and no appreciable cause was found for the condition ]iresent. The patient was finally cured by a 5 jier cent, cocain solution. Salivation of pregnancy is a most obstinate and annoy- ing condition often re])eated in subsequent pregnancies and resisting all forms of treatment. It is without apparent cause, as a rule usually affecting women of nervous tem])eraraent, especially if the general health be depressed. Treat- ment is usually palliative only, and it should consist in the free administration of tonics and in those milder sedatives which interrupt least of all the patient's THE PATHOLOGY OF PREGNANCY. 211 imti'itioii. The bromids have boeii given freely, both by the stomach ami by spray applied to the interior of the mouth. Cocain may also be sprayed into the mouth, the effort being to cocainize the mucous membrane near the opening of Steno's duct. Tliis condition rarely if ever becomes serious. Another form of al)normal secretion occurring in pregnancy is that of excessive perspiration, wliich is commonly met with in poorly-nourished and neurasthenic cases. Herpes is found among the interesting disorders of the nervous system to which tlie pregnant patient is liable. Fournier"' rejwrts a case in which the lesions were distributed irregularly over the body, especially upon the i'orearms, the anterior part of the thorax and feet, and the abdomen. Accompanying these lesions were patches of nnlness, in some instances these areas being covered with biillse as large as an olive or a small (jherry. Tiie usual j)eriod of pregnancy at which this disorder occurs is between the liiird and the fifth month, occasionally i;s late as the sixth or the eighth month. In other cases, more rare, the lesion does not show itself until the second or the third day of the puerperal period. There is a strong tendency in this disorder to recur during subsequent pregnancies, and instances are given where the patient has suffered from herpes during five successive gesta- tions. Although intolerable it(;hing and burning accompany herpes during prcirn^ncy, yet the general health remains remarkably unaff>"c!ed. The occur- rence of gestation is not influenced by this complication, anJ patients usually recover promptly when gestation terminates. Herpes in the puerperal period is often characterizetl during its onset by fever, persj)iration, and general pruritus. In from twenty to twenty-four hours after these symptoms occur the characteristic eruption appears. The remarkable tendency of herpes to recu:' is illustrated by the cases of Cottle, Wilson, Gale, and Hardy, the last of whom describes a patient who suffered in nine out of ten pregnancies with this disorder. There is no evidence that the fetus and its appendages are affected in this disease. Occasionally mixed forms of the eruj)tion, are seen, some of them resembling pemphigus and others assuming a sy])hiloid type. It is noticed that young women are oftener attacked by herpes than those older. The treabnent of herjies consists, first, in j)roperly regulating the functions of the body. Herpetic patients are generally depressed or in some manner are tlcfioient in nervous energy, and they will be found to improve under the pro- iongcd use of arsenic, hypophosphites, and iron. The great number of reme- dies which have been administered as specifics in this disorder, and their failure to influence the course of the disease, show that it is not amenable to specific treatment. When the ern])tion first begins borated vaselin, glycerol of starch, and lime-water and oil will be found soothing a])plications. When tlic eruption is fully developed bismuth and starch and starch-and-talcum powder are useful dressings. For the intolerable itching, applications of carbolic acid, hydrate of chloral, menthol, or corrosive sublimate in solution have been found useful. Wlicn a large portion of the body is involved, baths containing starch, gelatin, or bran may be employed. }'| II "PI If f 'i (^ 1/ 212 AM Kit [CAN TKXT-BOOK OF OliSTKriilCS. While the progiiortis of herpes eoiiiplicatiug gestation is f'avornhlo ho fur as the coiitimiance of pregiuuicy is eo'icenied, still this coinplieation exercises a most depressing iiiHiienee, and r,my lead to eoinplieated labor by reason of oxhuustion. Care shonld be tiiken, then, to snpport the general strength of the patient in every possible way, to promote her nntrition by a earefidly- ordereregnant patients. Cerebral thrombosis and hemorrhage during pregnancy are illu trated in a case reported by Horroeks, '"^ in which a patient in her second preg- nancy developed stupor and drowsiness with rectal and vesical incontinence during the last month of gestation. The pupils were etpial and symptoms of palsy were wanting. The urine contained neither all)umin nor sugar. The heart seemed normal, and labor subsequently came on spontaneosly. Con- sciousness, however, was obscured, and derangement in the motor a]>paratus of the brain and nervous system was evidently present. After death many of the cerebral veins were found occludeil by thrombi. There was also recent THE PATIIOLOCY OF PliKaXANCV. 21. 'J t'xtravasutioii of bloixl al(»iij; the intornul oapsiilo. Cystitis and supimrativc iicpliritis on one Hide oxistod. Menineritis duringr preernancy is almost invariably fatal to tlio niotluT, and fro(|iit'ntly to her child. Cliund)rc'Iont "" describes 7 cases of aente meningitis dnring pregnancy, in six of which labor was terminated artificially with the birth of a living child. In one case birth was spontaneous before the mother's death. In view of the grave natiu'e of this coniplication labor should be indnceil in cases of meningitis during pregnancy where the fetus is viable, in the hope of saving the life of the infant. Spinal Irritation complicatingr Pregnancy and Labor. — The hyperemic and hyperesthetic condition eharaeteri/ing pregnancy exaggerates all forms of functional nervous disturbances or jiathological conditions in the nervous sys- tem. Spinal irritation is not infrc(iuently observed, and it is well illustratetl by cases reported by Napier."" The symptoms w(n'e great tenderness on pres- siu'c al(»ng the spines of the vertebrie, and iji one patient fatal albuminuria grad- ually developed. These cases followed an epidemic of diphtheria which pre- vailed four or five years prior to these observations : the poison of diphtheria seemed to lose its activity by attenuation. Cases of cerebro-spinal meningitis (leveloi)ed as the epidemic died away, and last of all occurred the eases of pregnancy complicated by great tenderness along the spine, which tenderness seriously impaired the patients' strength and hindered convalescence. A toxic condition following widespread diffusion of diphtheritic poisim should be con- sidered as the cause of these cases, but the phenomena of spinal irritation were predominant. Maternal impressions are familiar to all obstetricians of extensive reading and experience. It is not the writer's purpose to consiiler the matter in detail, but simply to draw attention to the fact that a pregnant patient may undoubt- edly so profoundly be influenced by nervous shock as very markedly to alter the development, the shape, the size, and the appearance of her offspring. In recent literature on the subject Mackay "" describes five cases in which fright produced distinct birth-marks nptm the fetus. The writer may add a case under his personal observation in which a ])regnant woman was informed that an intimate friend had been suddenlv killed bv being thrown from his ' trse : the immediate cause of death was fracture of the skull, produced by the corner of a dray against which the rider was thrown. The mother was ]); f'ouudly impressed by the circumstance, which was minutely described to liif l)y an eye-witness. Her child at birth i)resented a red and sensitive area upon the scalp exactly corresponding in location with the situation of the fatal injury in the rider. The child is now an adult woman, and this area upon the s('al[> remains d and sensitive to pressure, and is almost devoid of hair. Space notnl not be taken to discuss the question of maternal impressions. There is certainly more than coincidence in the fact of fright and shock and the subsequent malformation or marking of the fetus. The well-known " elephant-m;; ' " of England, and the "turtle-man" exhibited in the United States, with other instances, are familiar evidences of this statement. '■ f ; m 214 AMEIiTCAN TEXT-BOOK OF OBSTETRICS. M' m \ k 1 Hi IMP i 1 ■;■■ r i Chorea during Pregnancy. — There is no disorder of the nervous system so nianilestly aggravated by pregnancy as eliorea. The physiological plethora characteristic of normal pregnancy seems to exaggerate the functional activity of the nervous system, and it results in marked exacerbation of all pathologi- cal phenomena. The chara(;teristic choreic jnovements occasionally extend even to the uterus, as in a case reported by Braxton Hicks.*"" The patient was a young woman who had suffered from chorea in childhood : the uterus, which could be outlined distinctly in the abdomen, presented marked altera- tions of form, accompanied by very evident choreic contractions. These uterine movements became less violent as the patient was treated by rest in bed and by the administration of arsenic : she was subscfjuently delivered in normal labor, making a good recovery. In an elaborate essay upon the subject McCann'"^ divides cases of chorea occurring in pregnant patients into cases of true chorea, of hysterical chorea, and a mixed form. It is rare to find chorea occurring in patients after the eighteenth year, except during pregnancy. Primigravidte are more susceptible to chorea than are multigravida;, especially to true chorea. In ])atients free from rhemnatism it is rare for true chorea to occur in any but the first preg- nancy. When the exaggerated reflex condition which occurs in chorea is called to mind, it is natural to expect that the great majority of cases will occur in the third and fourth months of gestation. The reason for this occur- rence seems to be the irritating effect upon the nervous system of fetal move- ments which begin to be felt at about that time. So far as the etiology of chorea in pregnancy is concerned, acute rheumatism is the n^ st immediate cause, and next comes an hereditary history of distinct rheumatic taint. Epilepsy and other disorders of the nervous system predispose to chorea during pregnancy. Fright, emotion, and profound anemia also favor its occurrence. For the actual outbreak of chorea, however, there must be present an hysterical predisposition to nervous excitability, a depreciated condition of the blood, and an actively exciting cause, which is usually found in fetal movements. Post-mortem examinations of patients who have died from chorea during pregnancy show that in severe cases the motor cortex, the intel- lectual centres, and tiie spinal cord are all involved. In mild cases the motor cortex only is imj)licated, and the spinal cord least often. The effect which chorea produces upon ])regnancy depends entirely upon its severity. In mild cases am(>nable to treatment the ])regnancy is not interrupted, while in severe cases abortion occurs, sometimes followed by fatal termination from coma and high temperature. Severe cases of chorea which do not result fatally may end in mania persisting for a considerable time. Paralysis and delirium are also occasionally observed to follow this disorder. If the preg- nancy is at term when the mother is attacked by chorea, the risk to the child is but very little, if any, increased. The earlier in pregnancy that chorea occurs, the great(>r is the danger to the existence of the fetus. Although the physician natiu'ally hopes that choreic movements will cease after delivery, .such is rarely the case ; they die away very gradually, and they have been THE PATHOLOGY OF PREGXAyCY. 215 observed to continue for five months after labor, Pregnancy predisposes greatly to the recnrrence of chorea, so tliat a girl who has been choreic iu early life will almost snrely again become i-horeic should pregnancy occur. As in the non-pregnant, chorea during pregnancy is sometimes more severe than a former attack, and, again, ma\ be less violent. Chorea during child- hood is very apt to reappear in subsequent pregnancies in the same indi- vidual. It is also interesting to note that the younger the patient, the greater is her liability to u recurrence of chorea. The great liability of pregnant patients to hysterical manifestations restdts to a very per|)lexing degree in introducing this element into cases of chorea during pregnancy. The ditt'erential diagnosis is best made from tiie character of the movements, which in hysteria are more sudden and occasionally are riiythmical in character. Impairment of sensibility is noted as a prominent symptom in cases possessing a strong hysterical clement. A history of pre- vious hysteria is sometimes obtainable. In making a diiferential diagnosis imitation movements must be borne in mind, as they an; sometimes calculated to deceive skilled observers. As regards the jxirtion of the body most often iilVccted by choreic movements, (rowers"** out of 64 cases found eleven in which the right sitle oidy wiss alfcctcd, and thirteen in which the lefl side alone was artwitcxi. During ])regnancy chorea is most often bilateral, the reason for this being that as the disease is more severe than in the non-preg- nant, its manifestations are more widespread. It is usually found in these cases that in the begiiming the movements were unilateral, afterward becoming biiatcM'al as the disorder increased in severity. The physiognomy of the l)reg- nant patient suffering from chorea is characteristic, being listless and vacant iu expression, and when the facial muscles are affected peculiar grimaces result- intr. General relaxation of the muscular system often occurs earlv in the dis- ease, and in the later stages mental apathy is not infrequent. Dilated pupils are often present, and are thought to depejid upon a generally relaxed con- dition of the muscular system. In a large number of eases the face is alfcctcd ; in a few, however, it is r >t, Speech and the nKn'cments of the tongue iiecome involved in the severe case% Sighing and irregular respiration have been described by Iloniberg and others. It is interesting to note that chorea mure severely involves the memory of ]>regnant patients than of non-preg- nant. The cessation of choreic movements is promptly followed by improve- ment in memory. Patient.-' who become maniacal after chorea often give utterance to a ptrnliar cry described by Ilond)erg and others. The analogy iK'twceu the cry of chorea and that of the patient about to be seized by an (■|)il( ptie ]>aroxysm is interesting. The prognosis of mania or delusions co:m- plicating chorea in pregnancy is often unfavorable; shoidd the patient not have chorea after her delivery, she may be found the victim of delusions or of chronic mental apathy. Sijmjttomx of dmira especially referable to the pregiiant state are, first in iinportunce, tluwc produced by the (|uickening of th(> fetus. The ])resenee of II nervous temperament in a choreic patient, or its absence, will (h'tcrmine the m "hiw m 216 AMERICAN TEXT-BOOK OF OBSTETRICS. j severity of tlie symptoms. As regards the influence of chorea upon labor, choreic movements often cease when labor-pains set in ; such movements gen- erally die away during the stage of uterine contraction, often to recur so soon as the labor-pain is over. The labors themselves are often normal, and in many cases during the pains, especially when the patient endeavors to assist them, the choreic movements become more than usually pronounced. While there is a temporary lull in the choreic movements after the birth of the child, the effort to expel the placenta is usually followed by their exacerbation. It occa- sionally happens that choreic movements become more than usually increased during the puerperal state about the third or the fourth day. The irritation incident to the formation of milk has been cited to explain this fact. Abdom- inal pain, which often accompanies movements of the bowels at this time, is also thought to cause increased choreic movements. Pressure on the uterus and the abdomen sometimes increases choreic movements during the puerperal state. The irritation of luirsing their children has aggravated chorea in some patients, the convulsions becoming so violent that the nipple was jerked out of the child's mouth. In choreic cases endocarditis is sometimes observed as a complication, and it makes the prognosis much more serious. Hemic murmurs dependent upon anemia are exceedingly common in these patients. An examination of the urine shows an excess of urea and phosphates, probably the result of the increased muscular activity of the convulsive seizures. In diagnosis the chief difficulty arises in distinguishing the true chorea of pregnancy from the hysterical and mixed forms. Attention nuiv again be called to the fact that in true chorea movements are irregular and spasmodic, and are increased by motion and vol- untary effort, especially if such effort be sustained. In the hysterical form movements are sudden, isolated, and often rhythmical especially in the iugers. Hysterical chorea never becomes so intense as greatly to exhaust the patient. Delirium, acute mania, and delusions may complicate chorea during pregnancy, as illustrated in the eases described by Jones;"** one of his cases was com- ])licated by sejitic infection following jiremature birth of a decomposed fetus at seven months. In another case ])aralysis of the left arm occurred as a com- })lioation. Children born of choreic mothers sometimes show marked tendency to convulsive movements. line"" describes two cases in which the chorea of the mother reapj)eared in conv ilsive movements of the child. Maniacal cliorea is to l)e distinguished from the mania of ])regnancy and the jHier- ])eral state by a jirevious history of choreiform movements. In defaidt of such historv an <>xaet diajjuosis is often difficult. In maniacal chorea the patients are less sullen and are more garrulous than in true mania. In esti- mating the dangers of chorea in ])regnan(y the violence of choreic movements, the amount of slc(>p lost in conscciueuce, and the intercurrent com])lications must all be considered. The jirognosis of maniacal chorea is usually good as regards the menial condition. Occasionally mental defect persists for a long time after labor, and it may ultimately become permanent. Sejjticeniia and ])yemia very seriously complicate such cases. JAM; L^s.v THE PATHOLOGY OF PREGNANCY. 217 So fur as treatment is concerned, sedatives and narcotics liave been used extensively with but indifferent success. The indications for treatment are to secure bodily and mental rest, to procure sleep, and to bring about an improved condition of the patient's blood and nutrition. It is often necessary to protect the patient's skin from friction caused by the severity of the movements. A profoundly depressed mind and nervous sys^omcall for an entire change of sur- roundings. In the medicatitm of these cases arsenic, intelligent feeding, and the maintenance of proper digestion are of the greatest importance. Rest in bed, freetlom from annoyance and excitement, bathing, and gentle friction are also of value. To procure sleep, chloral in doses of 30 to 40 grains has given good results. Gairdner '" relates the case of a girl, eight years of age, who took by mistake 60 instead of 20 grains of chloral to procure sleep ; she recovered from the drug, and was permanently cured of her chorea by the dose she had taken. Trousseau and Gowers have used in these eases strychnia, ' pushed to a ])hysiological effect. Sodium salicylate, wet packing, and the appli- cation of cold to the spine have also been recommended. So far as the obstet- ric treatment of these cases goes, the obstetrician must guard against hemor- rhage, to which the anemia so generally present predisposes. Violent choreic movements also render it difficult to control the uterus during the third stage of labor. The debilitated condition of the patients exposes them to additional risk of septic infection. When chorea persists after delivery nursing should be prohibiteregnaut state, as in a ease recently reported by Shoot of Ijunwarden."* The ])atient was a robust woman, aged forty-four, who had borne eleven children ; in youth slie iiad suilered from typhus, and after recovery became subject to fainting fits, but throughout her marrieain in the right side of the abdomen in the fifth month of pregnancy. Labor was induced, but the child was dead and decom- posed. Tlic patient died, and no cause for the fatal issue could be found on post-mortem examination. Frerichs discovered in a patient, in the eighth month of pregnancy, who suffered from diabetes and who perished after delivery, a tumor of the medulla oblongata. Diabetes may occur during pregnancy only, being absent at other times. It may cease with the termi- nation of pregnancy and may recur afterward. The ]>rognosis fi)r subsecjuent pregnancies is not invariably bad, as a patient, if cured of diabetes, may in subsequent pregnancy escape its return. The existence of dialwtes does not militate against conception. A possible explanation of the occurrence of diabetes during pregnancy is found in the results of the study made by Oddi and Vicarelli : "" these observers found that during pregnancy there is a largely increased consiuiip- tion of hydrocarbons derived from the waste of nitrogenous material resulting from fetal nutrition and growth. This was seen by analyzing the air respired by ))regnant patients. It is rational to conclude tiiat cases in which this met- abolism is seriously disturbed may furnish the complication of diabetes diu'ing pregnancy. Diabetes seems almost unifi)rmly fatal to the fetus, and that at a compara- tively earlv period of gestation. The amnion seems to be the seat of tlic diabetic process, tind dropsy of the anuiion or the formation of saccharine 1W\ i i I 1 t i ■ , ( 'I 220 AMERICAN TEXT-BOOK OF OBSTETRICS. matter in the amniotic liquid is the condition most commonly observed. Fry "^ reports the case of a patient in her second pregnancy who suffered from great thirst and who was easily fatigued. Examination of the urine showetl 9 per cent, of sugar, which was reduced by treatment to 5 per cent. The child perished during pregnancy. The mother died five days after delivery. The treatment of diabetes complicating ])regnancy is that which the prac- tice of medicine enjoins in such cases. The fact that the life of the fetus is usually lost shoidd lead the obstetrician to disregard it, and to empty the uterus promptly if the diabetic condition is pronounced. The prognosis for the mother, should she survive labor or abortion, is unfavorable, as the diabetic condition commonly persists and ultimately proves fatal. The fact that diabetes occurs in pregnancy, and that it is attended with peculiar fatality, emphasizes the necessity for the examination of the urine in pregnant ])atients. The presence of more than a trace of sugar should lead to a thorough examina- tion of the patient's processes of assimilation, when it may be possible to avert further development of diabetes, and thus save the lives of mother and child. T/ie patholof/y of diabetes mellitus complicating pregnancy is well illus- tratetl by a case reported by Hehir."* The patient, a ro.ultigravida, suifered from diabetes during pregnancy, and gave birth to a dead fetus nearly at term. Amniotic liquid was turbid, having a heavy, mawkish odor, and being very abundant. An infusion was made from the epidermis of tho fetus, and traces of sugar found in this infusion. The liquor amnii was also examined, and in it sugar was found. The patient had been greatly annoyed during her pregnancy by excessive corpulence, and had suffered from polyuria and diabetes mellitus. Hehir also describes a case of diabetes in pregnancy in which abortion occurred at the fifth month ; similar phenomena were observed in this case. Idiopathic universal pruritus as a complication of pregnancy may occa- sion great distress and may seriously interfere with a patient's rest and nutri- tion. In two cases reported by Feinberg "" the disorder became worst at the time when menstruation would have occurred had pregnancy not been present. Palliative treatment mitigatwl the patient's sufferings to some extent, but it was unsuccessful in relieving the disorder. Both patients were exceedingly nervous, easily excited, and one of them aborted under great excitement. I'ruritus limited to the vulva and vagina is frequently observed as a com- plication in patients suffering from diabetes during pregnancy. In such cases any form of treatment whidi lessens the amount of sugar in the urine decreases the ])atient's suffering from pruritus. In cases not associated with diabetes local apjilications are indicated, such as antiseptics, in strong solution, painted over the part. Tims, bichlorid of mercury (1 : 1000) followed by an application of salt-solution or ])lain water, carbolic acid, 3 to 5 per cent., tincture of iodin, glycerin, and carbolic acid, are oft(!n employed. In patients not unduly susceptible cocain is used to advantage, altiiough the extensive area to which the api)licati()n must be made renders it a dangerous one to patients readily influenced by the drug. The ai)plication of electricity by ])lacing a THE PATHOLOGY OF PREGNANCY. 221 moist electrode upon the inucoiis membrane of the vulva has been beneficial in some cases. The observance of cleanliness is of great importance, esjie- cially where a vaginal discharge amioys the pregnant patient. Douches of carbolic-a(!id solution, of crcolin and green soap, of boracic acid, of alum in solution, or of a hot soluti(m of sodium bicarbonate should be tried faithfully. Sitz-baths of a warm solution of boracic acid, of sodium bicarbonate, or bran sitz-baths are also indicated. The local application of starch and laudanum or lead-water and laudanum is another resource of service. Where extensive irritation and excoriation are present the application of an ointment contain- ing belLtdonna, opium, and iodoform is often a source of great comfort. Pen- cilling the nuicous membrane with nitrate of silver is occasionally of value. In the majority of cases, however, the best treatment for pruritus of the vulva and the vagina com])licating pregnancy is to be found in careful cleansing, etteoted by gentle irrigation of the parts with non-irritating, antiseptic fluids, and by constitutional treatment addressed to improving the condition of the patient's nervous system and assimilation. Hysteria during pregnancy furnishes an interesting illustration of the fact that the pregnant condition exaggerates any previous defect or susceptible point in the patient's mental and physical organization. The belief once entertained that pregnancy exercises a favorable influence upon women already hysterical is certainly erroneous. It occasionally hap})ens that a pregnan , greatly desired and occurring amid the most favorable circumstances, furnishes a healthy stimulus and assists a patient in cultivating self-control, but such cases are the exception and not the rule. Mild forms of hysteria during pregnancy often take the shape of melancholia and fear of approaching con- finement. Such cases require ])atient encouragement on the part of friends and physician, and should stimulate the obstetrician to take every precaution that he be surprised by no unforeseen complication during the labor. If the physician makes a thorougli study of his patient before labor, and demon- strates to her that he has exercised every precaution in her behalf, it will go far in allaying her ap])rehensions. In the experience of the writer prelimi- nary examination of pregnant patients by ))alpation, auscultation, and pel- vimetry often exercises a very favorable influence in such cases. Hysteria com- plicating pregnancy becomes dangerous when it ])asses into a condition of maniacal excitement. While the ju'ognosis in such cases is not unfavorable so far as the recovery of the mother goes, yet these patients require prolonged and careful treatment, and sh, iild labor occur during mania injury to the fetus or to the mother may result. Such cases require constant watchfulness, kind and systematic restraint, and when any obstetric manipulation is required the use of anesthetics is usually a necessity. As one of the dangers that threaten in these eases is exhaustion through a refusal to take food, feeding of such patients is a cardinal point in their treatment. As is so often seen in deal- ing with the insane, it is better to attemjit no deceit in tluir management, but to win the patient's confidence by faithful and patient attention without dis- simulation. i I : I \l m ■ if +■ f 4 222 AMERICAN TEXT- BOOK OF OBSTETllICS. Mania complicating pregnancy is of importance chiefly as influencing the course of labor and the puerperal state. Mania is observed during pregnancy in patients of very neurotic organization, in those having a heredity of insanity, in women who have been alcoholic, hysterical, or in other ways neurotic, and in women who sutter some great mental shock while in the pregnant condition. Unhappy marriages form a considerable element in the causation of mania during pregnancy. The diagnosis in these cases is to be made by eliminating hysteria, delirium tremens, hystero-epilepsy, and the temporary delusions and hallucinations whit.-h sometimes accompany toxemia from deficient excretion. In the former, observation will usually make diflerential diagnosis a matter of ready accomplishment. In cases of toxemia a study of the patient's exci'e- tions is required to arrive at a correct result. The prognosis in these cases depends upon the underlying condition which is the exciting cause of the mania. In those of highly neurotic organization, but whose physical con- dition is googinning, and where the patient, if she escapes eclampsia, passes ii.to a con- dition of pronounced and fatal nephritis after labor. The trcdtment of mania during pregnancy varies with the condition which excites the mania. What has been said regarding the treatment of hysterical mania applies to cases where the patient is neurotic, but is physically in good condition. In women who become maniacal in the presence of calamities or of sudden bereavement the free use of narcotics for a time is often indicatcfl to se- cure sleep. If the life of the child continues, the hope of its birth and maternal affection should be used as jwwerfid mental tonics in dealing with the mother. Perfect seclusion and protection from all intrusion are absolutely essential. When tlie first sluK'k t(j the mind and the nervous system has passed, all the resources of the therapeutic art are required in promoting the nutrition of the brain and nervous system. The treatment of mania complicated by toxemia through deficient excretion calls for the avoidance of narcotics and sedatives and the prompt securing of active elimination. As soon as the patient is freed from the poisons which an; irritating the brain her condition usually is marked- ly improved. Nausea and Vomiting of Pregnancy. — On the border-line between the physiology and the pathology of pregnancy, nausea and vomiting have been con- sidered by some as an inevitable result from the irritation occasioned by the development of the pregnant uterus, and by others as purely a pathological phenomenon. Like the kidney of pregnancy, the pregnant uterus and its THE PATHOLOGY OF PREGNANCY. 22.} nervous supply are in a condition of plethora which borders upon an actual pathological change. The progress of our knowledge in the pathology of pregnancy gives good reason at present for the belief that nausea and vomiting are not a physiological, but a pathological, accompaniment of the pregnant con- dition. As many patients pass through pregnancy with no pathological lesion of the kidneys, so many women bear children without the nervous irritation and the anemia, slight or profound, that accompany nausea and vo' iting. The predisposing causes for thlienomenon may not recur until the next morning. In such cases the matter vomited is mucus, sometimes of strongly acid reaction, sometimes of Heutral reaction. In more severe cases the sensation of nausea begins as soon as the patient awakes ; assuming the u])right posture is followed by vomiting but little relieved by emesis. The material ejected is mucus, often burm'ng and bitter to the taste, frequently excessively sour. Although the l):itieut may succeed in retaining food, the sensation of nausea persists often iMitil mid-(l,iy or even later: the sight or the presence of certain articles of food greatly increases her distress. Perturbation of any kind exaggerates the sensation of nausea. If vomiting is repeated, it is accompanied by straining and retching. After mid-day the patient is better, and may eat heartily at evening. Such eases are accompanied by anemia and often by considerable loss of weight. A third class of cases is well characterized by the term per- W. ■ > l«. I 11 li) ^'•. m \m\ • ^h i ■■ 1 1 ^>|; 1 ili 224 AMERIVAN TEXT-BOOK OF OliSTiyTRICS. If V m nicioun ; in thorn the sensation of nansea is present at intervals during the ])atient's waking hours. Hor cravings are lor varied articles of food and drink, and they are no sooner satisfied than a new craving arises. Vomiting is accompanied by straining and ret(!iiing, by dryness of the fauces, or by pro- fuse salivation. The matter ejected is, first, mucus and the UkkI taken, bile, and, in severe cases, niiufus stained with blood or with coffee-ground material. Food is no sooner swallowed than it is ejected, although there occur surprising periods of tolerance in which the patient eats greedily, and which occasion hope in the mind of the physician that substantial improvement has taken place. As the case proceeds distress and pain are felt beneath the stermim, not located at any fixed point. The sensation is described sometimes as that of smothering, but more often as that of distress which has nothing to do with breathing. In dangerous cases it is worst at night. Emaciation is progressive — in some cases rapid, in other cases slow. A more deceptive phenomenon in these patients is acute fatty degeneration of the tissues, that gives to the pa- tient a plump ap|)earauee which may deceive the physician. As the case pro- gresses the clinical picture of pernicious anemia becomes more and more apparent. Signs are present of disintegration of the blood in the vomit, in hematogenic jaundice, in sordes, and in pur{)uric extravasations. The urine contains the debrifs of broken-down corpuscles, the feces are dark in color, the mucous membranes dark and reddish in appearance, and the nujutal condition is one of apathy or of delusion so often seen in these cases. A further explanation of the process is observed in the condition of the eyes by a necrosis of the cornea, and dimness of vision may be noted. The j)ulse and the cardiac action of the patient in severe cases of nausea and vomiting of pregnancy show the effect upon the heart and the arteries of the gradually developing anemia. The pulse is rapid, soft, and weak. Arterial tension is usually diminished, the first sound of the heart grows less and less distinct and forcible, and in fatal cases cardiac syncope develops. The temperature is subnormal at first ; later in severe cases it increases as a fatal issue a])proaches. In other cases the temperature varies slightly from the normal, and in all cases it is not an important factor in diagnosis or in prognosis. The ])ulmonary signs are usually negative : the patient occasionally complains of an irritable cough which accompanies a dry condition of the fauces, or in others of the accumulation of an excessive amount of mucus. Palpation of tiie abdomen may detect a dislocation, of the uterus, and in the early stages of the more severe cases the abdominal walls are often excessively irritable, the practice of palpatitm increasing the nausea. Liver-dulness is usually slightly increased in area as the liver becomes the seat of acute parenchymatous, fatty degeneration. The patient's reflexes are much increased, although ])aralysis or atrophy, otiicr than that attending emaciation, is seldom observed. The nutrition of the skin, except in purpuric (^ases, is usually fairly maintained ; bed-sores in cases well cared for are of rare occurrence. A clammy sweat is frequently seen, especially upon the face. The symptoms of an improvement in the condition of the patient suffering THE PAriroLoav of PUKayANVY. 225 from nausea ami vomiting of pregnancy arc a dimiiuition in the uansoa and the eniesis ; tlie ability to take anil to retain food ; a normal eondition of the excretions, especially of the urine; the absence or the diminution of excessive perspiration ; considerable periods of sleep without emesis, and the absence of substernal distress, especially at night. The pulse falls gradually to 100, and the temperature reujains normal. Symptoms of danger in these cases are the continuance of the nausea and vomiting and the gradual dev('k)pment of the signs and symptoms of pernicious anemia. Among the most important of these are a persistently rai)id, feeble pulse, substernal pain and distress, and colfee-ground vomit. The pailiohf/icdl anafomy of tliese eases may be dividi'd into — first, those of the organs of the body other than the generative organs ; and, second, tlutse of the uterus and its ai)pendages. In the first class of cases it is evident that lesions which may produce obstinate nausea and vomiting in the non-pregnant may also by coincidence be present in gravid women. Thus, cancer of the stomach ; chronic gastritis, whether gouty, alcoholic, or caused by arterio-sclerosis ; nephritis in its various forms; brain-tumor; chronic displacement of the stomach by the pathological condition of adjacent viscera ; hysteria producing emesis ; emaciation, vomiting, and acute yellow atrophy of the liver, — may be present and cause vomiting in pregnant patients. ( )f these conditions but one stands in a possible causal relationship, and is by some considered dependent upon the condition of pregnancy. It has been shown by Lomer and by Frerichs that tliis disorder nniy atfect pregnant women in fiu'ms of varying severity, and that the milder cases of acute yellow atro})hy of the liver, in which death does not occur from this complication, often show themselves through nausea and vomiting only. As regards the changes to be met with in the genital organs in these cases, they are, first, those of jiosition ; and, second, those of structure. In the former we have acute and chronic dislocations of the uterus. Couimoncst among these dislocations is retroversicm, which generally follows straining or lifting, and in which the relation be- tween the dislocation and the nausea and vomiting is that of evident cause and effect. This complication is serious in proportion to the condition of the surrounding parts : if no adhesions bind 1 11— Voiiiitinir nf preRixiiK'y- Cyst in iiuti'vinr wall (if eorvix ^Davls). • \ > 1 M, rft[7 ^ ^X^^ 1/ i ( f i I :1 p 226 j.v/;/i'/r.LV Ti:xT-Booh' of oiisrF/rnrcs. ihe utiTiis in its abiiuriiial position, tiio reduction of the dislopution is readily ellectcd and tiio excitinj; cause is at once removed. Wiierc, however, the prcjfnant womb hccomcs retroverted and bonnd down by adliesions in the process of pelvic inthunmation, the patholofjical condition is far more compli- cated and jjrave. Chronic «lislocations of the prej^nant womb are those in which that organ as a whole is forced downward in the pelvis and impacted with its fnndns against the symphysis pubis. This condition of the womb is the result of persistent wearing of tight clothing before and after the occur- rence of pregnancy, and it has been well described and its imi)ortance has been urged by (Jrailey Hewitt in a brochure entitled Severe Vomiiiitg ilitriii;/ Pre()H(tncji, published in London in 1800. This condition of impaction is not infreciuently accompanied by congenital malformatit)n of the pregnant uterus, evidenced by extreme anteHexion, with a patlutlogical condition of great importance in the cervix. It has repeatedly been observed in such cases that tlie cervical canal was tightly closed and that the tissues of the cervix were excessively dense and resistant. Attention has recently been called by Davis,'^" in a case of this sort, to a condition of excessive development of connective tissue in the cervix accomjianied by the presence of a retention- cyst of considerable size in the anterior wall of the cervix (Figs. 144, 145). Fiii. 1 l."i.— Vomitiiif,' iif pri'Kiiuiicy. Delist' coiiiRTtivi; tissuo In cervix (Diivis). In addition to these gross chaiige:^ in the uterus, tumors of the ovary and enlaro-ement of the tid)es have been observed in cases of nausea and vomiting of pregnancy. Microscopic examination of the endometrium in many oi' these cases lias demonstrated the presence of endometritis of various forms : that this of itself is a cause of the nausea and vomiting is not demonstrated ; the condition is apparently the accompaniment and the result of the congenital malformations or dislocations already described. Through the researches of Lindenmann of Moscow'-' we are in possession of the interesting restdts of microscopic examinations upon the tissues of a mother and her fetus perishing from pernicious vomiting complicated by polyneuritis. A gross examination revealed enlargement of the spleen with the appearance usual in inanition, with cirrhotic kidneys and liver. Micro- TIIK PATJIOLOaV OF PliEaXAMT. 227 s('(»pic examination rpvoaknl noiiritis of the jjlircnio, piK'nnioijastrit', inoilian, and pcronwil nerves, bcinj^ espoeially well marked in the phrenic. Tho liver siiowed fatty degeneration and elondy swelling. The blood-vessels of the spleen were dilate«l, and the bhx^l-eorpnseles could not be stained by coloring agents. The epitheliiun of the kidneys showed fatty degeneration. The organs of the fctns exhibited fatty degeneration of the liver and necrosis of the kidney. The entire pathological |)icture was that of infection by a toxine, and Tiindenmann considers the infection as anto-intoxication, In his control-experiments upon this case he describes interesting observation,' on the pathology of inanition in animals, and from these comparative studie.- he excludes simple inanition as a cause for the lesit)ns in j)ernicious nausea. The rational lirahnvnt of the nausea and vomiting of pregnancy is im- possible without a thorough knowledge of the co'idition, first, of the patient's ])roccsses of assimilation, and, second, of the condition of the genital tract. The patient nuist be examined thoroughly to exclude any cause tor the malady that lies outside the genital tract. This examination will eliminate the rarer complications of this disorder. A thorough and painstaking examination of the uterus, its si7,e, shape, consistence, position, and the condition of the pelvic tissues surrounding it, is then imperative. In cases where the sensitiveness of the j)atient is so great that an examination aggravates the vomiting, anes- thesia by chloroform or by bromid of ethyl is indicated. The i)hysician in tills examination nuist broadly ditfereutiate between two conditions: he may tind a simple dislocation of the uterus in retr('V»»rsion or prolapse of the uterus, and partial impaction anteriorly ; or he may detect a congenital mal- t'ormation manifested in sharp anteflexion with thick and resisting cervix, or a retroversion bound down by pelvic adhesions. In the first and simplest of tlieso conditions the restoration of the uterus to its normal position is indi- cated, and is almost invariably successful in relieving the condition. The explanation of this relief seems to be that the constant irritation to the reflex nervous system which pressure upon the pelvic nerves maintains is relieved by replacing the uterus, hence the pathological jihcnomenon ceases. If retrover- sion be present, the bladder and the rectum should be emi)tied thoroughly, the patient ]ilaced preferably in Sims' position, when, under anesthesia if neces- sary, the perineum shoidd be retracted and the cervix drawn downward and backward with one hand, while with the fingers of the other hand the fundus should be directed gently u]>ward and forward. Reposition having thus been elTcctcd, it is well to sustain the uterus in its position, at first by a jMicking of antiseptic gauze, then by tampons of carded wool. If the pregnancy be an (arly one and no pathological condition in the ])elvis be present, a Ilodge pessary may be worn to advantage. In prolapse and anterior imi>action of the gravid uterus a thorough cmjitying of the bowel is of great importance before attempting replacement. The uterus should then bo raised gently upon the fingers of the physician, and if difficulty and resistance be experienced, tiie knee-chest jiosition should I)e tried. It is often observed in these cases that but slight change in position is sufficient to relieve the patient, and this I UA 2-2S ^^^E^rcAN text-book of obstktrtcs. I ;- (7 gain, liowovor small, is to hv inaintaiiu'd by tamponing the vagina with anti- septic soft material. As soon as tlic patient's strength permits, it" the uterus is not in its normal position, it siionhl again be raised by gentle manipniation and the tampon be replaeed. In this manner, under thorough antiseptic ])rc- eautions, it is possible by gentle manipulation to restore vi'ry nearly to its normal position a uterus prolaj)sed and anteriorly impacted. In cases where the ])hysician detects an abnormal c«)ndition of the cervix, the result of congenital nialformatii>n anil pathological processes, the case is far more serious and the treatment is more ditlieult. It is here that dilatation of the cervix, found by (.'opeman,'" by a fortunate accident, to be cllicient, is the method of treatment to be employed. The proil'ssion is huniliar with Copeman's I'lfort to induce labor in a jiaticnt pregnant six months and almost dead from nausea and vomiting. Having dilated the cervix as much as he (H)uld with his lingei's, he attempted to rupture the nien)branes and failed. The improvement caused by the dilatation was so great that no fmllier interference was practised, and the patient recovered. Tiiere can be no (piestion but that in cases where a patlu)logit'al condition of the cervix is present, dilatation is demandeil, anil without delay. The physician shoidd not be misled by a soft lition of the external os, for oftentimes a chronically congested mucous f the o'lands of the cervix give to the casual cun( membrane and liypersecretion o d h tl (il)server tlie nnj)ress ion that tl le cervix is so ftenec w lile this mav be true of its external portion, the internal os will be found tightly contrattol and its walls in a condition of dense resistance. Dilatation should be jiraetised under anesthesia, preferably by chloroform or by bromid of ethyl. The finger is a safe instrument, but in cases where the tissue resists the linger it is necessary t(» use, first, stei'l-bladed dilators, as is done by Wiley and others, and then complete the dilatation to the j)oint of admitting the finger by solid metal bougies. This procedure of course exposes the pregnancy to danger of inter- ruption, and rupture of the membranes may occur during the dilatation. Tin; l)hysician should be prepared for this coni])lication by having ready a suitable curette and douche-tube with which to thoroughly curette and douche iIk^ uterus. Following the complete removal of the ovum by the curette and douche, the uterus should be packed with iodoform gauze and be carried well "1 ) into the pelv I n uiu lertaliing to treat a case of the nausea and voinitiii of pregnancy it is impossible for the physician to do his duty without making a thorough examination, and without |)ractising interference such as his judg- ment may dictate. If he is hampered in this examination by the pn'judiccs of his patient, he must decide whether to place the responsibility upon her and her frieiuls or to retire from the case. In milder cases, where a condition of simple irritability and hypersecretinn ill the OS and cervix are dett'cted, local applications to these parts are of great value. Where the mucous meml)rant' is angry and red, following a cleansing; douche of creolin and green soap, the ])hysiciaii may apply nitrati- of silver 1)\ jiencil with advantage. In raising a simply dislocated uterus in the pelvis anti- septic and analgesic ointments may be incorporated with the tampons employed. IS THE PATJIOLOdY OF PRFAiyAyVY 229 Irctioii kiisiiKj; [•or l)v aiili- iovi'il. TiiiKS an ointmout of" bollailoiniM, iodot'onii, and morphia is somotimos of use in tliose cast's. If oxcossivo secretion he present, io(K)fonn, belhulonna, and glycerol of tannin form a useful mixture. The. mt'dh'inal (rcdfinoit of the nausea and vomiting"; of preixnaney consists, first, in eliminatinji; hy examination the necessity for operative interference, or in promptly rcmedyinu; a pathological condition of the uterus. A strict con- trol of the patient is then an absolute necessity, and here the services of a skilled and competent attendant arc of the greatest value. The patient should he j)Ut to bed and her strength preserved in every possible way. Tlie subject of nausea and vomiting should not be dwelt upon with iier. Siie slioidd bo fed by carefully-prepared nutriment — if possible, '>y th(> mouth — at r(>gular intervals, [f the stomach is non-retentive, rectal !;),ections of nutritive sub- stances are demanded. Among these substances are various j)rcparations of beef in the form of peptonoids, peptonized beef, beef-juice combined with brandy, with milk peptonized and pancreatized. If it is desired to adminis- ter alcohol and the stomach cannot tolerate dry champagne or brandy and soda, brandy may he given by rectal injection. The list of remedies which have been employed by administration in the stomach in these cases is exces- sively great, and it shows how eomparativt'ly niiimportiuit all have been in radically relieving the disorder. Where evidence of chronic catarrh of the stomach was present, lavage of the stomach has been found of the greatest value. The soft-rid)ber stomach-tube should be ])assed, and a solution of sodium chliirid, sodium salicylate, or a dihit(> solution of bicarbonate of sodium should be employed. The administration of animal ferments In con- nection with food is also of great valiu\ Thus, ingluvin, pancreatin witii sodium bicarbonate, with nux vomica, or strychnia and pepsin, are of decided v;ilue. Solid food must not be attempted until the patient's strength has con- siderably improved and the condition of the tongue warrants its trial. It is well at times to consult tl>', j..v- nt's appetite and craving when solid food is given, if this craving does M.)t call for articles of an injurious character. When solid food is tai.< n, scraped raw-beef sandwiches, oysters, junlwt, milk with lime-water or with ' iehy, and freshly made broth in which bread is dipped, are usually of value. Prugs are of use in the tn>atment of this complication only in so far as they iissist in ])reserving the ])atient's strength. It is folly to drug a patient with narcotics while the ])hysician is ignorant of th(> position and condition !»f the pelvic organs, and the prolonged administration of iHor])hia is often sim])ly a mask
ii> has been attended witli THE PATHOLOGY OF PREGNANCY. 231 excellent results. The accompanying illustration (Fig. 146) sliows the air-ball pessary in position and raising the uterus in the pelvis. Kingman '^® also describes cases in which the reduction of uterine dislocations has terminated nausea and vomiting. Ptyalism complicating this condition has been well described by Ahlfeld/^ Avho believes that these cases are primarily neurotic in origin, and treats them accordingly. With the same view of the causation of vomiting, Gunther '^ treats these cases by galvanism, the positive jiole being placed against the cer- vix, the negative between the eighth and twelfth doi'sal vertebrae. From 2i to 5 milliampcres were emi)loyed for from seven to ten minutes ; so long as the current was uninterrupteil he did not observe danger of disturbing the preg- nancy. Siinger and Hcnnig '^ describe cases in wliich the exciting cause of vomiting was a pathological condition, either in the uterus or some abdominal organ. Ascites complicating pregnancy may arise from a lesion of the abdominal viscera interfering with the return circulation and also with the lymphatic circulation of the peritoneum. l*rcgnancy itself sometimes occasions ascites through a pathological condition which atfects the peritoneum of the mother and the amnion of the fetus by a similar jirocess. An interesting case illus- tr;iti!\g this condition is reported by Florentine.'*' The patient was a young v(yn:,n married three years who had borne one living child and had one abortion. The cessat'on of menstruation was followed by obscure pain in the abdomen, increase in size, and the evident presence of fluid. Pressui'e- symptoms became so pronounced tliat suffocation was threatened and pains like those of lal)or supervened. The membranes were ruptured, when the entire fetus with a large amount of amniotic liquid was sudd 'uly expelled. Distention of the alidomen was relieved by paracentesis. The presence of an ovarian cyst was then diagnosticated and the tumor removed a month later. Recovery ensued. Tubercular peritonitis complicating pregnancy is also a cause of ascites, and it may develop gradually as gestatioii advances. The treatment of al)- (loniinal dr()])sy complicating pregnancy is, j)referably, by exploratory incision. If a tubercular process be ])reseiit, the prognosis for very great imjirovcment, if not recovery, is excellent. If a [)athol()gical condition of tlie lymphatic system of the peritoneum is the cause of tiie condition, free drainage by incision is much the safer treatment. The immunity displaytnl by jircgnant ]>aticnts to operative jirocedures when ])ropcrly conducted renders such inter- ference safe and highly appropriate. Phantom pregnancy, or pseudo-cyesis, may result from a strong desire for pregnancy in a ]>atient sutfering from ascites. An illustrative ease is reported by (May.''" Phantom jiregnniu-v without |>alliological lesion is not a rare condition. ()i)served in nervous pat'< :. Ml I I M 'K 1 ' : i h' ■ i r •' lilii f^K! ' • 1 ' ■ ■ 1 1 ! j II p 2:U AMERICAN TEXT-BOOK OF OBSTETRICS. largo amount of potassium salts. In general it may be said that the presence of albumin or of peptone in the urine of a pregnant patient is not of itself a l)athologieal phenomenon, and it is only when the presence of albumin is asso- ciated with casts and deficient excretion, as indicated by deficient urea, that albumin becomes an indication of disease. Abnormal conditions of the mouth and teeth during pregnancy may occasion cousideraljle distress and inconvenience to the patient. The gums fre(piently become abnormally soft, and a condition known as " white caries" is often seen in the teeth. The edges of the gums are thin, pale, somewhat shrivelled in appearance, and retracted from about the teeth. A jirominent ridge along the free border, often of deeper tint than the surrounding mem- brane, is sometimes observed. In other cases the gums are reddish and are apparently softened, exuding a thin fluid or pus from around the neck of the tooth. Such a condition does not imply neglect of cleanliness, but it seems a passive congestion and transudation from the tissues. It has been shown by Elliott '^° and others that this condition of caries in the teeth results from the altered secretions in the oral and buccal cavities. The secretion of saliva is much increased, ptyalin being often absent. The saliva early in the day is often of acid reaction, and this is thought to have a potent influence upon the development of curies of the teetli. This disorder is sometimes known as "brown caries" when extensive discoloration of the teeth is ])rcsent. The margins of cavities in these cases are black. A line of brownish discolora- tion sometimes occurs upon the upper incisors or the canines. The enamel is opacjue. This form of caries generally begins in the region of the bicuspids of the upper or lower jaw, and is usually found among ])atients of the lower classes. Softening of the dentine of the upper bicuspids and molars is some- times observed, apparently liecause the bicuspids are those teeth against which fluid is most forcibly ejected in the emesis of pregnancy ; tli(y are also in con- tact with the tongue at rest. General softening of the teeth without actual decay, and loosening of the teeth in their sockets from jiartial absorption of tiie alveolus, are also observed. White or soft caries is often found in an inexplicable manner in patients apparently well nourished, and in its j)atIiology resembles osteomalacia. Affections of the nerves of the face and the teeth often accompany the structural conditions mentioned. I?y some, altered nervous conditions in these ])arts are referred to pathological conditions in tlie mucous nuMnbrane of the stomach. Occasionally pain in the mouth and teeth is purely reflex from the utci'us, as in a case described by Garrettson in which pain was felt about a carious tooth. Its removal brought no relief, l)iit tiie healing of an ulcerated cervix uteri caused the pain to disappear. Tlic frrcidiicitf of these conditions is to be found in a pro]U'r attention to the general condition of the patient. Ijoeally, chhcate <>l' potassium ami bromid />{' potassium arc usefid when the gums ii:e irrital)le. Powdered l)oracic acid may be brusiied upon the teetii with a soft brush, or e(|nal ])art> of charcoal and preeii)itated chalk may be used for short periods. In I'dlcv THJ-: PATHOLOGY OF I'REGXANCY. 2:50 pain, felt in sound teeth, a i)li8tei' over the fourth or Hfth dorsal vertebra has been of use. Absohite alcoht)! and eoHodion may be painted over a tooth attacked by soft caries. AVHien carious cavities require filling, this should be accomplished with as little distress to the patient as possible, and the filling should be of a non-irritating character. When a tooth occasions severe sutl'er- ing during jiregnancy there arc many reasons for advising its removal, as preg- nancy has been interrupted as the result of such distress, while the ])resence of continued pain has an undoubted influence upon the development of the child. Exophthalmic goitre and simple goitre may develop rapidly during pregnancy, and by the associated changes which occur in the circulation may result disastrously to the fetus. Thus in a case reported by Haberlin '^' the rapid develojjment of exophthalmic goitre was accompanied by premature separation of the placenta, with death to the fetus at eight months. The termination of labor was followed by immediate cessation of the development of the goitre. In severe cases such patients become excessively nervous, the hands tremble violently, palpitation of the heart and a sense of constriction about the throat are present, with considerable emaciation. Vomiting is also a symptom in well-marked cases. While palliative treatment nuiy temporarily relieve these j)atients, if the symptoms be urgent a removal of the goitre should promptly be undertaken. Abnormal conditions of the blood are not of very infrequent occurrence. The normal condition of the blood during pregnancy in ill-nourished women is that of temporary anemia, which soon gives ])lace to a development of physiological plethora and hyperemia. It has been shown by Dudner'** and others that so sooi as the balance of nutrition becomes established a steady increase in the amount of corpuscles and hemoglobin is to be observed. Narse"-* found the specific gravity of the blood during pregnancy to be 102o. The amount of fibrin increases, while the (|uantity of salts and hemoglobin diminishes. Winckclmann '" found that as pregnancy advances the quantity of hemoglobin increases. Scliroeder '^' considers anemia in pregnancy as the exception and as a pathological condition, while neither he nor Meyer '^' observed a g' at decrease in hemoglobin or corpuscles. The observations of Ingersletf,'" '^""ehling,'^'' and Meyer '^'•* upon the comparative composition of the blood in the pregnant and the non-pregnant show that in the fornu>r the mind)er of red corpuscles is slightly decreased and also the amoutit of liemoglobin during early pregnancy. Aiiriiita in tiie pregnant is produced by the same causes which influence the non-pregnant. Its recognition is effected i)y the same methods of examina- tion and diagnosis employed in the study of internal medicine. The condition of anemia complicating pregnancy was early recognized by American physi- cians, whose contributions to the literature of the subject are among the first. Cazeaux and the I'^rench school ascribe to anemia many of the disorders of ]tregnancy. A curious ;iversion to the treatment of anemia diu'ing ]M'cgnancy by methods usually employed in non-pregnancy is shown in the records of i ' > ' *: r '1 if r ^ • ilfi % i m I, 1 '/ p 2:}() AMERICA X TEXT-BOOK OF OBSTETIUCS. a malpnictice suit reported in 1871 by Woodniaii to the Obstetrical Society of IjOIuIoh, when a physician was sued for using the ainnioi)io-eitrate of iron in the treatment of this condition. It was claimed that he had thus ]iroduced abortioji. The verdict of the society was in favor of the physician. Gus- serow '•''*' reports five cases of extreme anemia in tl>e prcj^nant state. The eiglith month seemed the perioven fatal. In double n\itral lesion seven out of Hart's 8 cases perished. In one-half of the cases recorded pregnancy has been inter- rupted without interference. Half of these patients died and half of them rm M \t 238 . I .}fEIf /( 'A X TKXT- li O OK OF O liSTETn K 'S. recovered. The pretloiuiiiaiiee of piilinoiiiirv syin|»t(»ms in mitral stenosis sliould l)c borne in mind in makinj^ a diagnosis and in instituting treatment. Wliile tlie mortality ol" pregnaney eomplicated by mitral stenosis is more than ')() por cent., aortic lesions give u mortality of 'J.'] per cent. Mitral insnllieieney is aci redited with 1.3 per cent., wliile in complex lesions (»f tin; heart a mortality of 50 per cent, is a conservative estimate. The prognosis for the continuance of pregnancy and for the life of the chihl is distinctly tinfavorable. Mack ness '"^ reports a case of pregnancy complicated by aortic and mitral disease in which labor was indiiccil. Partial reeoverv ensned. The patient's condition of prostration became so excessive (hiring the latter })ortion of her pregnancy as to require vigorous stiinnlation. She was greatly prostrated by ])ersistent emesis and ))aroxysnis of oppression, which were relieved by the administration of nitrite of aniyl. Mcrklen "'* reports an illustrative case in which pulmonary tuberculosis ■was associated with stenosis at the mitral orifice. Dilatation of both sides of the heart was present, with general anasarca and exaggerated pulmonary con- gestion. Venous stasis in the kidneys was well pronounced. I'ulmonary liemorrhage occurred, and it was a temporary relief to the patient. Hemoptysis complicating pregnancy may occur from simple pulmonary congestion in eases of valvular heart disease, or may result from disease of the parenchyma of the lung, most commonly tubercular. ^Cartin'®^ describes the case of a patient four months pregnant who sutt'ered from obstinate and j)ersistent hemoptysis. There were jiulmonary signs of consolidation an- teriorly below the right clavicle. Bleeding occurred at about the time when the patient would have nnnistruated had she not been pregnant. Kjjistaxis subsequently develoi)ed, and later a profuse red rash, resembling that of scarlatina, covered the body. This rash gradually faded, and was not attended by fever or any signs of other complication. I'ulmonary signs gradually improved, especially under treatment by a succession of blisters upon the ch(>st, that gave marked relief. The j)aticnt entirely recovered and went to the usual termination of pregnancy. Hemorrhage from the Uterus. — The fact that ])rofuse hemorrhage from the uterus may occur during pregnancy and still the ])atient go cm to the end of gestation is well illustrated in a case descriljcd by llobertson.'^'' His patient was a multiy-ravida who had several liemorrhaues so severe as on each occasion to cause the supposition that abortion had occurred. Her pregnancy continued to a successful termination. Internal hemorrhage is observed asacom])lication in patients sufl'ering from nephritis during ])regnancy. To such an extent may syni])toms of shock and acute anemia l)e ]>resent that placenta prfevia has been susjiccted in these cases. Schauta"'® reports the ease of a \vonian, aged forty-ibur, who had borne nine children, and in whom profuse hemorrhage caused a diagnosis of placenta pra3via. Although the jiatient was not in lalxjr, the os was sufficiently dilated to permit a diagnosis to be made that placenta i>ncvia was not present. Transfusion by normal salt-solution was iminetliately performed, and when the patient rallied. i'. THE PATHOLOGY OF PliEGNANCY. 2:50 as tho diild was (load, it was extracted by craniotomy. A larj;c amount of clotted blood was found in the uterus and vaj-ina. Tin- patient siiecuinbed from tiie hemorrhage shortly after delivery. The post-mortem examination revealed chronic nephritis as the only complication accounting for the con- dition. Winter observed three similar cases in Schroeder's clinic. 3. Acute Infections during Pregnancy. The condition of pregnancy renders the patient peculiarly liable to the rapid development of infective germs. The body of the pregnant woman presents that condition of plethora and hyperemia in the viscera that invites the growth of bacteria. It is not, then, difficult to understand why these complications of pregnancy are among the most severe. First among these disorders may be considered those in which the infection usually gains access to the body through the genital tract. Such disorders are gonorrhea, syphilis, and cancer. Gonorrhea is by no means an uncommon complication of pregnancy, and in an ignorant woman no intelligent history attracting the attention of the physician to the condition present may be afforded. The complaint, howes'cr, of difKcidty in micturition and of burning and irritant discharge should occasion an examination, when specific vaginitis may be detected. The symp- toms and treatment of this disorder in the pregnant are essentially those in the non-pregnant, but the pathology of the condition is more complex and of greater import. Not (july may the gonococci infect the nuicous membrane of the vagina, and possibly cause abscess of JJartholini's glands, with oc- casional acute inflammation of the rectum and the surrounding tissues, but the endometrium also may be attacked, and even the fetus may be infected in ntero, by the gonorrheal virus. Children have been born with gonorrheal o])hthalmia and under circumstances which precluded the possibility of in- fection during birth. Such infection, however, is of comparatively little importance when compared with the dangers arising to the mother from the development and retention of gonorrheal infection in the tissues about the uterus and in the tubes and t)varies. The entire genito-urinary tract of the mother is liabU? to such infection, the consequences of which may not become apparent until some time after delivery. Thus, in the writer's observation a patient })erished from the sudden and acute septic inf(L>ction occasioned by the spontaneous rupture of a small gonorrheal ovarian abscess occurring two weeks after delivery. This ))aticnt's puer[)eral period had apparently been nor- mal, and the infection n'ust have l)een received before or during pregnancy. The same observer witnes d death from nephritis in which the genito-urinary tract had been the cat during jircgnancy of gonorrheal infection. In this case the tubes and ovaries escaped, but the bladder and ki<]neys showed abundant infective germs. The presence of gonorrhea as a complication of pregnancy should lead to prompt antise])sis of so nuich of the genital tract as is accessible. If the bladder is invaded, it should also be subjected to the same thorough antisepsis. At the time of labor all possible precautions J '5' .^. ^. V«^. w; .O^,^^ IMAGE EVALUATION TEST TARGET (MT-3) 4' 1.0 ■i^lM 12.5 1^ l&i 12.2 2.0 I.I 1-25 IIIIII.4 IIIIII.6 P^ <^ /2 ^> »». •'-> y y^ Photographic Sciences Corporation 25 WeST MAIN STMIT WfeCiSTER.N.Y. M5S0 (716) •72-4503 ft^^ hilis exercises a very dis- tinct influence upon the prognosis of the pregnancy : the longer the woman has been syphilitic before pregnancy occurs, provided she has not been sub- jected to efficient treatment, the worse is the prognosis for the eontimiance of the pregnancy and the life of the fetus. The prognosis of pregnancy is also very serious the earlier in the pregnancy the infection occurs ; thus, the majority of pregnancies complicated by syphilitic infection occurring during the flrst four months result in the death of the fetus. When infection occurs from the fourth to the sixth month of pregnancy 50 per cent, of children are lost. During the last three months of pregnancy the comnlication of syphilis results in the death of less than half of the children. General fetal mortality in ayj)hilis is under the best circumstances 75 per cent. The mother's iiealtli in pregnancy complicatwl by syphilis is liable to rapid deterioration if tin' syphilitic process be acute. The stimulus of j^reg- nancy seems to exaggerate the sj)read of the poison and the various lesions which it causes. To l)e efficient, aiitisyphilitic treatment should begin as soon as the infection occurs, anil the earlier in the pregnancy such treatment is THE PATHOLOGY OF PBEGNANCY. 241 begun the better are the results obtaineil. Local treatment of syphilitic lesions complicating pregnancy consists in thorough cleanliness and in the maintenance so far as possible of local antisepsis. Ulcers should be dusted with calomel and iodoform ; the parts should be kei)t thoroughly clean with antiseptic douches, and the discharges from syphilitic patients should be received upon absorbent material, which is then burned. Antisyphilitic medication is to be conductetl in accordance with the therapeutics of this disorder in the non-pregnant. The biniodid of mercury, the bichlorid of mercury, calomel, gray powder, and the bichlorid hypodermatically are all of use. Inunctions with mercurial ointment are found advantageous in many cases. In those patients with whom mercury does not agree iodid of potas- sium in combination with iodin may be used to advantage. The following mixture has proved efficacious in a number of cases : Iodin, Iodid of potassium, Compound syrup sarsaparilla. Dose, one tcaspoonful after meals. gr. IV ; .^iv ; .Siv. Besnier'*® obtained good results with a pill containing ^ of a grain of bichlorid of mercury with y^ of a grain of extract of opium and ^Jj of a grain of extract of gentian, rubbed up with glycerin. Equally important with the specific treatment of syphilis in pregnancy is the tonic treatment wliich these cases demand. Well-ordere<.l feeding, in which an abundance of fat in cod-liver oil or other forms is includetl, and tiie persistent administration of iron, arsenic, nux vomica, and such substances as stimulate digestion, are of the greatest importance. The aim of the physi- (jian must be not simply to tear down diseased tissue, but to build up that which is sound. The results of such treatment are often most gratifying. The characteristic lesions of syphilis fade with great rapidity in these cases ; the l)aticnt who may have repeatedly aborted goes on nearly or quite to term, and a fairly-devoloped and healthy child is born. Neglect, however, or inadequate treatment for these patients often resjilts in sad ravages in the mother's tissues, resulting very frequently in fetal death. Oincer complicating pregnancy affects the course of gestation chiefly in its local manifestations in the genital tract. In rare instances multiple sar- comata develop with great rapidity in various portions of the body, causing (loath by constitutional infection. In otiier instances cancer of the uterus by metastasis sjieedily retluces the patient to a condition of threatened collapse, often resulting in constitutional septic infection. In such cases the interruption of pregnancy seems of very little avail for the patient, except i » so far that tlio malignancy of the cancerous process seems less acute if the uterus is emptied. Ti/phoid infection during ])regnancy seriously complicates the mother's chance of convalescence from labor, and frequently results in tiie deatii of 16 i ■■ '"I 242 AMERICAN TEXT-BOOK OF OBSTETRICS. V u the fetus. In a case clcscribcd by Findlay "' the hnsbaiul had been ill for 8otue time w'th typhoid infection. The patient's pregnancy was terminated at about the expected time, labor occurring with a temperature of 103° F. and the pulse I-IO. The uterus contracted well, although during labor intestinal jMjristalsis was active and the patient had diarrhea, M-hich subsided after delivery. The secretion of milk did not occur, the breasts remaining without signs of activity. The skin of the child was shrivelled, and after a few days it showed an eruj)tion with bullous spots, the scars of which persisted when the child had reachetl adult life. Pregnancy is interrupted in these cases by continuetl high temperature, by hemorrhage in the endometrium or in the membranes of the ovum itself, and by a depi-essed condition of the maternal circulation, with asphyxiation of the child. Kaminski, Zulzer, and Scanzoni observed in two-thirds of their cases the interruption of pregnancy. The fact that the fetus may become infccteil by the transmission of the germs of typhoid through the ])lacenta has been demonstrated by Giglio."" The latter examinwl carefully a fetus and its appendages born from a mother suffering with typhoid fever in an epiden)ic at Palermo. Pregnancy terminated forty- six days after the beginning of the fever. Although the specimen seemed normal on casual examination, cultures of the maternal blood demonstrated the presence of the typhoid germ, while cultures from the milk revealed bacteria exactly resembling those obtained from a typhoid non-i>regnant pa- tient. The fetus and its apjwndages also contained typhoid bacilli. Boyd "' reports a ease in which a week after the fever began premature labor occurred. The i)atient finally succumbed after continuetl high temperature. The fUagnosis of typhoid fever complicating pregnancy presents no especial difficulty. Should the physician see the case during the puerperal pericKl, it must not be mistaken for puerperal sepsis, nor should puerperal sepsis com- plicated by diarrhea be mistaken for typhoid fever. It will be remembered that in septic cases diarrhea is a not infrequent symptom. The treatment of typhoid fever during pregnancy should be addressed to controlling the temperature and to maintaining the patient's strength. Such cases are especially fitte i.« IClll unit icral nro- THE PATHOLOGY OF PUEGXANCY. 243 cautions are observed. Erysipelas of the genital tract — or of the lower extremities, where the infective germ gains ready access to the genital tract — resnlts almost invariably in puerperal septic infection. The symptoms of erysipelas complicating pregnancy do not differ essentially from those of the disorder in the non-pregnant patient. The treatment consists in supporting carefully the patient's strength, and in avoiding all unnecessary examinations and manipulations in the genital tract, as interference with this portion of the patient's body is an addetl risk of infection. Smith '" reports the case of a woman six months pregnant who injured her knee. Erysipelas develojied in the thigh eight days afterward, and it was followed by a large abscess burrow- ins: beneath the muscles. Premature labor occurretl at seven and a half months. The puerperal period was normal and the child survived. In a recent case of facial erysipelas under the observation of the writer the mother suffered but slight inconvenience from the infection, but gestation terminated prematurely, the child surviving. Erysipelas of the face and head seems to affect the fetus in many cases quite as markedly as in erysipelas of the pelvic organs. Cohn '" reports a case of facial erysijielas at eight months' pregnancy. The fetus, prematurely born, showed upon the corresponding portions of the head and face an edematous red swelling which gradually faded, followed by desquamation. Examination of the infiltrated tissues for erysipelas-germs gave negative results. The child perished from multiple abscesses in the kidneys. A similar condition of the fetus has been described by Runge, Kaltenbach, and Stratz. Measles. — Of about the same relative virulence as erysipelas is the infec- tion of measles attacking the pregnant patient. The symptomatology of this disorder occurring during gestation does not differ essentially from that ordinarily observal. If the bronchitis usually accompanying measles l)e severe, the incessant cough and movements of the abdominal walls thus occurring greatly increase the probability of abortion. The child may be born with an anomalous eruption or it may apparently escape. The prog- nosis of measles complicating pregnancy is to be based upon the severity of the infection, and especially the continuance of high temperature. The infection of measles may be transferred from mother to child, as illus- trated by a case described by Lomer;'" the child perishef being susceptible to modification by vaccination. While pregnancy renilcrs the mother more liable to the infection of small-pox, in those cases in which variola occurs in women who have formerly l)ecn vacc'inatcd the disease runs a com- paratively mild and favorable course. Vaccination during pregnancy is to be performed without hesitation v.henever variola is epidemic. Especial care .should be exercised in procuring pure virus, and antiseptic precautions are necessary in performing the vaccination. There is abundant reason to believe that the fetus is protected by such vaccination. Pneumonia during pregnancy is a serious complication for mother and child. The interference with respiration ocr'asionwl by the size of the preg- jiant womb, and the unfavorable conditions under which the heart labors ihiring pregnancy, account in large part for the st^verity of the couiplication. Jurgensen, among 247") women suffering from pneumonia, found 43 who were pregnant. Of this number more than half aborted. As in the other infiK;- tious, the degree of fever present is of great importance in prognosis. The symptomatology of pneumonia in the pregnant does not differ from that of the disorder in the non-pregnant. It is observed, however, in pregnant patients that embarrassment of the circulation is very often present, and that heart failure develops more rapidly than in the non-pregnant. Mann '^' reports the case of a woman aged forty-two with typical pneumonia at eight months' jiregnancy. Tiie fetal heart-sounds ceased five days after the initial chill. Shortly after the crisis of the pneumonia the child was born with the aid of forceps. During labor the patient became cyanotic, and she was allowed to bleed freely from the umbilical cord : although an unfavorable prognosis had been given, the patient made an iMiinterru])ted recovery. The writer reports in this connection the case of a young primigravida aged twenty who developed pneumonia when near the end of gestation. A temperature of lO-'i'^ F. rapidly developed, and an acute pneumonic process catarrhal in nature was found over both lungs. Although the os was partly dilated, no labor- pains v.ere present. 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'1^9^ ' pti 09 «l l' tf 1.1' is' "■',''■ A'"'i ..,, ■■■■ Uf'i. p- .... 0(1 ftfl ; *;■ ■ , , ,1' 'M* --r 1 r' ttr 77 " ^"tifL /^i' w1 s ■ Ull ■j.M-Ue* lii- \Ln^ '. • . . »»' |»? 1 j' •' .... .,.. . .ii(.i 1. 1 .... tti .09 I' -i .-; . t . n ,.., .... ■•,;i W.I J ^ 1^1- ■ y^ 1 , 1 l~ ^f it fi jif 1 i '■ If 'ii -^•'i ( « t/ THE PATHOLOGY OF PREGNAyCY. 24r, Although the mother's urgent symptoms were relieveil tcnjporarily by her hihor, she i)erisho wiien it begins, and to scHUiro good nterine contractions (hiring and after the lalxtr. A more unt'avorahle view of the prognosis for the mother is given by (Sallianl."^ In Ids ca^v,-. tlie hietie- acid nietiuKl of treatment was extensively employed with negative resnits. In ndid cases a nnmber of his patients recovered. Tvtnnnx in I'ra/iKinvif. — Among the acnte infections that attack with great viridence the nervons system of the pregnant patient tetaims is the most fortnidable. Onr knowledge of infection explains by the tetanns bacillns the exciting canse of this complication. A predisposing cause is to be fonnd in the snsceptibility which pregnant patients manifest dnring the first three months of this period. Indeed, the first half of gestation shows by far the greater nundx-r ut' cases of this infection. Tetanns develops usnally after some minor manipulation in the early niontlis of j)regnancy, and especially where abortion requires interference on the part of the physician. Tliiw Vinay'*" in lOG cases found but one after craniotomy and one after C'esirean section ; the infection is one ttf early pregnancy, and is not usnally cwnnectcil with parturition at ternu Patients most apt to be attacked by the tetamis bacillus are nudtipartx; above the average age anil those who have been living in damp and stpialid lodgings. The direct conveyantf of the infection has been noted by Henricins and by Anion. The latter, while treating a case of tetanus in the husband, infected the wife, who aborted, dnring the manual delivery of the placenta. Tetanus is most frecpient among pregnant patients in the tropics, where the condition of the soil is favorable to the growth of the infecting germ. An association of tetamis in pregnancy and the pueiperal period with endt)metritis has been pointed out by Markus.'*' The treatment of tetanus in pregnancy is largely prophylactic. Remem- bering the peculiar susceptibility of pregnant patients, especially during the first months, any minor operation or examination shoidd be conducted with scrupulous antisepsis. When once tetanus infecti has occurretl, but little esui be d(»ne to save the patient. Tetany is a condition which is commoner during pregnancy than is tetanus. It is characterized by tonic spasms beginning in the muscles of the extremities, especially those of the hands. In severe cases spasmodic move- ments may extend over the entire muscular system. The spasms are symmetrical wher not artificially produced. Attacks of tetany are not accompanie;i'iieral temperature is not afFiH-twl. Any nieehanieal irritation of tlie |)oripheral nerves, <>yA\ as tappin^r tlie trunk of the faeial nerve in front of the ear, results iii spasm. The disorder is generally s|H)radie and in rarely epidemic. It is most usually observetl in women during the childhearing pcritMl or during menstruation. TrousHcau foinul, of 44 cases, forty amid mu'sing women. Kussmaul found transient allniminuria present, and Stiel observed glycosuria. Dakin"** reports the cast; of a mnltigravida of nervous tem|)erament who in the third month of her fourth gestation was seized with frecjuent vomiting during the re<'eid gland removed. Between the attacks of tetany the patient is normal to all appearances. In non-fatal cases the pregnancy is tiot interrnptetl nor is labor influencec kept in mind. Tetamis is commonest among men, who by virtue of their ocends not only upon the condition of the nervotis system in these cases, but also upon the normal or abnormal state of the uterus and its lining membrane. In a woman in perfect health a considerable injury or a surgical shock may be received without the interruption of ]>regnancy, while if the patient is of extraordinarily susceptible nervous system or if the endometrium is in a con- dition of disease, interruption of pregnancy is almost inevitable. Accompany- ing the premature ending of gestation serious hemorrhage, shock, and greatly increased susceptibility to septic infection are observetl. Those operations most frequently demandeil during pregnancy are surgical proceilures undertaken for some condition of the uterus or of its appendages. Thus cancer of the uterus demands the complete extirpation of that organ as soon as the diagnosis is made, irrespective of the existence or tiie period of gestation. One of two methods of ojjcration may be chosen— (extirpation per vaginam when the diseased uterus is small, or the com])lete removal of that organ through the abdominal cavity when its size precludes the possibility of its removal through the vagina. In either instance the prognosis for the recovery of the mother is by no means desperate if the operation be per- formed before her strength has been reduced by the development of cancerous cachexia. It is sometimes possible to combine the two methods of operation, as in an interesting case reported by Stocker,'*** in which a multigravida was found to have cancer of the cervix. At the sixth month of pregnancy the cervix was removed per raf/innm, and the conij)lete extirpation of the uterus was accomj>lished by t>pening the abdominal cavity. The patient made a good recovery from the operation. Myomotomy and myomectomy are demanded during j)regnancy for fibroid tumors (complicating the development of the pregnant uterus. The choice of operation will depend upon the size and location of the tumor, and upon the amount of pressure which it is exercising or which it will cause upon the growing womb. Flaischlen '* found two fibroid *^umors behind the uterus in the case of a patient pregnant three months ; one tumor sprang from the cornu of the uterus, the other from the base of tiie womb. Both tumors were ligated and removed without the interruption of pregnancy. Amputation of the pregnant womb is a familiar operation for contracted pelvis. It may, however, be performed at any period of gestation when the interests of the patient demand hysterectomy. The method of procedure best adapted to such cases is abdominal incision, ligation of the ovarian and uterine arteries, and amputation of the uterus, leaving a short stump to close the vagina and stitching the peritoneum over the surface of the stump. Tumors of the ovary are justly considered serious complications of prcg- THE PATHOLOGY OF PREGNANCY. 24!) lie 1st lie lie nancy. Dsirne'" colloctcil 135 cases in which pregnancy was complicated by tnmor of the ovary. He finds that the gravity of this complication increases as pregnancy advances. There is rarely any reason in this complication for delay in removing such a tumor by abdominal incision. Puncture of an ovarian cyst and the artificial interruption of pregnancy are to be avoided : they are to be consideretl only in the light of proceilures adapted to an unforeseen emergency. The preferable time for operation in such cases is before the fourth month of gestation. The fetus is least likely to be lost when operation is performed in the third or the fourth month. No period of preg- nancy, however, contra-indicates ovariotomy, but this complication uniformly demands operative treatment. Double ovariott>my during pregnancy may be successfully performed, as exemplified by Polaillon.'** His patient, agetl twenty-three, had a good-sized ovarian cyst upon one side and a diseased ovary upon the other side. Her general condition at the time of operation was not promising, and numerous adhesions complicated the removal of the tumor. Operation was performed in the third month of gestation, and it resulted in the continuance of pregnancy, which terminated in normal delivery with a healthy child. The patient's pulse and temperature showed little reaction following operation. Kreutzman "® reports two cases in which ovarian tumors were successfully removed from pregnant patients without interrupting gestation. One of these women, who was in her second pregnancy, had gone two weeks over time. She had a large ovarian cyst in the loft ovary, the pedicle of which had recently become twisted, the contents of the tumor being tinged with blood. Affections of the Fallopian tubes may call for operative interference during pregnancy. The prognosis in these cases is equally good with that of opera- tion for the removal of ovarian tumors, and the reasons for prompt interfer- enci! are quite as cogent as in the former case. In hematosalpinx it is often impossible to make a differential diagnosis between this condition and eetojiic gestation. Tliis fact is well illustrated in the experience of Doraii,"** who re- moval both tubes and ovaries from a patient who had suftered from attacks of violent pelvic pain at various intervals. One tube had ruptured, allowing the free escape of blood ; the tube contained a structure in the midst of a clot resembling an aborted ovum. It is probable that double ectopic gestation existed. The patient made an uninterrupted recovery. Aocuh'ntu and Injuries. — As regards tolerance to general accidents and injuries during jiregnancy, American observers have noted the remarkable tolerance displayed by negro women under such circumstances. Thus, Tiffany'" reports the case of a negro woman wlio fell, striking the abdomen violently against the edge of a tub. Peritonitis with retention of urine fol- lowed. The patient, however, under faithful attendance recovered without the interruption of jiregnancy. Stab-wounds oi" the abdomen occurring durin.- the pregnant period, but without interrupting gestation, are reported by Belin,"^ in whose patient a considerable portion of tiie (>piploon protruded from the wound. Sloughing ensued, but the patient made a good recovery. m '■ '■; 250 AMA'IilCAA' TEXT-BOOK OF OBSTETRICS. Tf V / if-.' Richard "* describes the case of a pregnant woman who fell, lacerating the abdominal wall near the umbilicus. A mass of intestine protrudetl as large as a man's head. The woman was at term, and soon after normal labor ensued, from which the patient recoveretl. Harris '" describes the case of a woman pregnant six months whose abdomen was torn open by the horn of a bull. Although omentum and intestine protruded, pregnancy was uninter- rupted. The viscera were replaced and the wound was closed by suture. A similar case in which a lacerated wound of the abdominal wall 5 inches long was made is reported by Corey.'** In this case the pregnancy was at the third month. The patient went two hundretl and two days longer in ges- tation, and had a normal labor. Obstruction of the intestine calling for abdominal section is described by llydygier,"* who operated in the sixth month of gestation upon a patient who had symptoms of strangulation for seven days. Recovery without abortion ensued. In fractures retardetl union is reported by Petit "^ and others in pregnant women sustaining this accident. An interesting operation for stone in the bladder upon a patient eight months pregnant is I'cported by Keelan.'^* The calculus, which weighed 12 J ounces, was successfully removed without the interruption of pregnancy. Gunshot wounds not penetrating the uterus do not commonly inter- rupt gestation. A remarkable instance is cited by Prozowsky.'^ The patient was wounded in many places by pieces of lead pipe fired from a gun but a few feet distant. Neither she nor her child suffered, so far as gestation was concerned, from the accident. A pistol-shot wound of the lung occurring during pregnancy, followed by hemorrhage and shock, is reported by Ban- croft.^ A healthy child was born at term. A remarkable case is described by Lihotzky,^' which illustrates the fact that the changes occurring in pregnancy may bring into active irritation a foreign body that had previously been inert ; he describes the case of a patient perishing from rapid peritonitis in the eighth month of pregnancy. At the autopsy the duodenum was found perforated by a s})oon which the patient had swallowed two and a half years previously — an occurrence almost forgotten. The remarkable tolerance shown by the pregnant woman to direct injury from mechanical causes is illustrated in a case reported by JMilner.™^ The woman in the sixth month of pregnancy was accidentally shot through the abdominal cavity and the lower part of the thorax, the missile penetrating the central tendon of the diaphragm and lodging in the lung. Localized pneu- monia and peritonitis seemed to limit the injury, the wound draining through the lungs by very free expectoration. Recovery ensued, the patient giving birth to a healthy child sixteen weeks later. Direct mechanical injury may rupture the pregnant uterus, usually causing the death of the i)atient. It is interesting to observe that the membranes may remain unruptured in these cases, thus obscuring the diagnosis of rupture of the womb. Neugebauer ^'^ describes a case of suicide in which a primi- gravida threw herself from the third story of a house upon a stone pavement ; THE PATHOLOGY OF PREGNANCY. 251 the immetliate cause of death was fracture of the skull. The uterus ruptured, and the fetus in its unbroken membranes was found among the mother's intestines. The patient's pelvis also sustaineartum hemorrhage, which is so liable to result from uterine atony after over-distcntion. Oligohydramnios means a deficiency ' f the amniotic liquid. Its pathology is unknown. Adhesions and bands are frequent in this condition. It cannot be detected prior to delivery ; it is revealed at that time only. Fetal malformations are frequently encountered in oligohydramnios. The fetus is subjected to an abnormal pressure which results in deformities. Webbed toes and fingers are alleged to arise from this condition. Amputation of a fetal extremity may follow the abnormal deficiency of fluid. Malformations of the inferior extremities are ascribed to this complication. B. Diseasp:8 of the Choriox. Vesicular Mole (CVstic mole ; Hydatidiform degeneration of the chorionic villi ; Dropsy of the villi of the chorion ; Myxoma of the placenta; Molar pregnancy). — The villi of the chorion occasionally undergo myxomatous degeneration, which produ(!es a vesicular mole. The mole is a mass of pedunculated vesicles resembling in aj)pearance grapes or gooseberries. There may be as many as five or six thousand of such vesicles. The vesicles vary in size from a millet-seed to that of a filbert, and they conUiin a fluid, usually colorless, transparent, liquid as water, holding albumin in solution. Rarely the fluid is reddish in color. If all the villi of the chorion are involved in the degeneration, the life of the ovum is always sacrificed. If only a small portion of the villi are involvetl, the life of the ovum is not necessarily destroyed and development to term may proceed. In twin preg- nancies one chorion may un-'Ugo myxomatous degeneration M'liile the other ovum may proceed to full develoj)meut and be born at term. Often in double pregnancy the development of a cystic mole in one chorion seriously compromises the life of the other ovum, resulting in a miscarriage. Vesicular mole is very rare. One author reports only one case in over twenty thousand deliveries. It is oftenest found in multiparte of from twenty-five to forty ycai's of age. Nimierous recorded cases of women who have repeatedly developed vesicular moles exist ; one case developed this condition in eleven pregnancies. PatJioloffi/. — An endometritis is generally supposed to be the factor predis- posing to the development of a molar pregnancy. The villi of tiie chorion undergo hypertrophy and myxomatous degeneration. Three cases have been reported wherein the chorionic villi grew so rapidly as to penetrate the uterine wall even to the peritoneal covering, rer.dering successful removal impossible without a fatal hemorrhage or a subsequently fatal peritonitis. Symptomntolof/y. — Three symp jms characterize molar pregnancy: first, an abnormally rapid increase in the size of the abdomen ; second, uterine hemor- rhage ; and third, the expulsion per vaginam of the vesicles of the mole. THE PATirOLOaV OF PREGNANCY. 266 It may be possible to feel the grape-like masses through the cervical canal. Exsanguiuation of the patient and septic infection are the chief dangers. As a rule the fetus dies. Rarely, a bunch of the vesicles may lie expelled without the course of the pregnancy being interruptal. Treatment. — No active interference is demanded until the hemorrhages occur. If they are small, rest and an oi)iate may suffice. If severe, the uterus must be dilated and very carefully curetted, subsequent hemorrhage being prevented by an intra-uterine tampon. The possibility of the growth hav'ng penetrated and thinned the uterine wall makes it necessary to use the curette cautiously to prevent perforation of the uterus. C. Decidual Endometritis. One of the commonest diseases of the ovum is decidual endometritin. Four varieties of this disease are described to-day : the polypoid, the hyper- trophic, the cystic, and the catarrhal. The names of the different varieties indicate the predominating characteristic of the endometritis. In catarrhal endometritis the discharge of a watery fluid is so abundant as to receive the name hydrorrhea gravidarum. It may occur as early as the third month, but usually it is not encountered until the last months of pregnancy. It is more frequently seen in multi})ar8e than in primiparfe. It is found upon close observation to be a mucous secretion rather than the yellowish amniotic fluid ; the latter is further differentiated by containing urea. The sudden appearance of the fluid in a large quantity is generally mistaken for premature rupture of the membranes. In most instances it is repeated several times before delivery occurs. Should pains follow, quietude and an opiate are indicated. The etiology of hydrorrhea gravidarum is obscure. It has been attributed to syphilis, to overwork, to an exaggeration of a pre-existing endometrial inflammation, to gonorrhea, and to an infection following the death of the o"um, to be followed sooner or later by a miscarriage. The frequency of miscarriage from an old endometritis is a well-known fiicfc in obstetric observations. The treatment of this malady during pregnancy is absolutely nil. All that can be done for it must be done in the intervals between gestations. D. Diseases of the Placenta. Placentitis, inflammation of the placenta, is a very rare disease. Its origin is very obscure, but it is supposed to start from the decidual tissue or from the larger fetal arteries. It soon terminates in induration, oftentimes resulting in strong adhesions between the placenta and the uterine wall, con- stituting the adherent placenta. Apoplectic infarcts are often found in placentitis. Calcareous Degeneration (Placental calculi ; Ossiform concretions; Pla- cental ossification). — By this term is meant the deposits of lime on the edges of the cotyledons or in their s\ibstance in the shape of particles of sand or of needles or of scales. They consist of amorphous carbonates and phosphates 1*11. m m K i I 256 AMERICAN TEXT-nOOK OF OBSTETRIVIS. w m^ of lime and inafjiiasia. The presence of these secretions is without therapeutic significance, and has no ill effect on the functions of the placenta ; so many as five hundred have been found in one placenta. Patty Degeneration. — A fil)rous, fi)llowed by a fatty, degeneration of placental villi is of very common occurrence, especially toward the margin of the placenta. When it involves a small area no serious interruption of the function of the placenta follows. When a large area is involved the death of the fetus occurs. The etiolof/t/ of this condition is unknown. A fibrous degeneration, undoubtedly the condition denominatetl by the earlier writers " aclerases," or "scirrhous" or "cartilaginous degeneration" is regarded as the precursor of fatty degeneration, because it diminishes the blood-supply, which leads directly to fatty degeneration, or, in some cases, to amyloid degeneration. The diagnosis of this condition is quite impossible during pregnancy. Apoplexy. — Blootl escapetl from a ruptureti blood-vessel and occupying circumscribed cavities formed in the tissue of the placenta is called " placental apoplexy." It is occasioned, as a rule, by the rupture of some of the maternal blood-vessels. The effused blootl rarely comes from the placental vessels. The clots vary in size from that of a millet- or a hemp- seed to that of a ]>igeon egg. Usually there are several clots, a large number being twenty or more. They are situated at various depths in the substance of the placenta, from the fetal to the uterine surface, upon which some of them have a small and irregular orifice. Owing to the spongy nature of the substance of the placenta, the normal condition of the tissue is disturbed only a few lines from the boundary of the cavities. The cffuboi.1 blood soon separates into two parts, one solid, the other liquid. The serum disappears by osmosis, while the solid part contracts, becomes denser and smaller, and loses its color. These whitish homogeneous masses have been denominated concrete pus or tuberculous matter. Cutting into the cotyledons of a placenta often reveals apoplectic clots in the various stages of chronological consecutive changes. The results of placental apoplexies depend upon the period of gestation in which the hemorrhages occur, and upon their number and the extent of territory invaded. Aboi'tion or premature labor is rarely produced. If the infarcts arc small and few in number, the gestation will be com- pleted and the fetus will continue to live, its nutrition suffering little or not at all. If, however, the effusions are large and numerous, the offspring will be born feeble, puny, and emaciated. If the apoplectic attacks recur at short intervals, there will occur a progressive diminution of fetal motions and heart- pulsations until they cease altogether. In all cases of a dead-born fetus pla- cental apoplectic infarcts shoulil l)e sought after carefully. It is by no means rare that women miscarry repeatedly from this cause, and when they do com- plete their gestations their placentas will be found to contain a number of effusions, both old and recent. Symptoms and Treatment. — The occurrence of placental apoplectic infarcts THE PATirOLOGY OF PREGNANCY. 257 varcly betrays itself by any recognized symptoms, providetl the hemorrhage is limited in amount. In some cases there may be present indications of internal hemorrhage, whose occurrence will Imj suspected, chiefly in women who have experienced this condition in previous gestations and in whom placental apoplexy was found. Should placental apoplexy be susjwctcd, especially in women predisposed to the affection, the prophylactic treatment of uterine hemorrhage is indicated. Absolute rest, small phlebotomies, and saline cathartics, repeated pro re nata, are the most rational treatments. Tumors. — Both solid and cystic tumors of the placenta have been described. They are very rare. They may originate in the meshes of the cellular tissue or in the glandular cavities of the decidua serotina. Solid tumors may cause death and expulsion of the fetus, while the placenta may remain for weeks and even months before being expelled. The presence of tumors can be determined only after delivery, for there are no known symp- toms indicating their presence. Syphilis. — Syphilis of the placenta is a well-established condition. The observations of Fninkel are classic, and comprise all that is fully settled, to- day, upon this subject. The appearances of the placenta with syj>hilis derived from the father differ from those of the placenta with syphilis derived from the mother. In the former the fetus ?8 diseased and the villi are filled with fatty granulations, their vessels are obliterated, and their epithelial coverings are thickenetl or absent. In the latter there may be present one of three conditions, which vary according to the time of infection : 1. If the mother be infected during the generative act at the same time as the fetus, syphilitic foci will often develop in the maternal placenta (placental endometritis). 2. If the mother is syphilitic before conception or becomes so shortly after, the chances of the placenta remaining healthy arc about even. 3. If the mother is not infected until after the seventh month of preg- nancy, both fetus and placenta escape entirely. A syphilitic placenta is heavier, larger, and paler than normal. Its general color is pale red, but in its diseased parts it is yellowish-white. Here and there the tissue is firmer, more resistant, compact, and friable than normal placental tissue. Anomalies of the Placenta. — The more important anomalies of the ]ila- conta arc anomalies in position, size, weight, shape, and number. At the end of pregnancy the placenta is normally situatal at the fundus of tiie uterus, anteriorly or posteriorly ; it is from 2 to 3 centimeters (1 inch) thick at its central portion and from 17 to 18 centimeters (7 inches) in diameter. It weighs about one pound. The abnormal position of the placenta of greatest clinical imjwrtance is placenta pra;via, by which is understood a situation of the placenta in any portion of the lower uterine segment — that is, in that portion of the uterine body which is dilated during the progress of labor. The size of the placenta is exceedingly variable ; sometimes it is very thin 17 I Itl i' I* 2rj8 AMK/i'/CAX TJ'L\T-li()()K' OF OliSTKTJtlCS. and correspond iiifjjly \i\r^v. This nhiiornmlity is most remarkably exhibited in the so-called " placenta meinhranaeea," a placenta formen with the production of septic infection. When these accessory placental growths serve as a channel of conununication between the blootl-sinuses of the decidua and the main placental growth — in other words, when they arc finictionally active in carrying nutriment to the growing fetus — they are ciillcd " jdaccnta; succentiu'iatie " (1*1. 22, Figs. 4, 5). Placcntte spu- riie are analogous accessory formations whose villi have no direct communica- tion with the maternal blood. Ji/ \i i f t I ( ' n ■ Si E. AXOMAIJES OF THE COUD. Coils. — One or more coils of the funis may be around the botly of the child or around one or more of its members. The neck is the part most commonly encircletl. As many as eight coils around the neck have been reported. They are found more often with male than with female children. They occur more frequently in multiparae than in primipara;. Their injurious eifect is to pro- duce sufficient constriction of the vessels to result in fetal death. In cases where the coil passes over the portion of the fetus lying against the anterior wall its presence can sometimes at least be inferred by the detec- tion in it of a murmur which is synchronous with the fetal heart-sound. A positive diagnosis cannot be established before labor. Coils are found at least once in five or six deliveries. In breech presenta- tions and when around the neck they are the most dangerous to the child. Cases of amputation of the members by the pressure of the cord coils have been reported, but it is generally thought that these aniputations result from amniotic bands rather than from coils of the cord. Knots. — When the cord is abnormally long or the liquor amnii very abundant, knots in the cord are liable to be found. They may be double or be single. One case is reported where five knots were found. In recent knots the Whartonian jelly is not displaced, the cord diameter being normal. In old knots the jelly is displaced, and the diameter of the cord is decidedly lessened in the knot. Ordinarilv the circulation in the cord is not molested, rUKCNANCY. Tl.MK -J-'. ANdMAi.iKs (PF riii; I'l.Ac inta: 1. I'liiciMitii «itli iiTCLMiliir lulics i.\\iviir(11. 'J. riacttita in twn iiiiri|uiil Inhi- I Aiivimli. :i. liTi'L'Ul.'ir |.liici'iil,i (Aiivnnii. 1. Sniiill iirci'>siPTv iiliuciilii iliilx'iiioni l.fpiiL'i'i. .'i I'liuTiita Hicccntuiiiitii .Itilu'iMiiiii Lrpimri. r. '■ lliillli'ilun'" pliwiiiin, nviil lAuviiicli. 7. I'liii'i'iilii with vi'liiiiu'iiluus Itiiclllllfllt 111' cnlll I l;iln'lllnlll l.l'pil^^' I'liUrlHii Willi twofiiuiil liiln'S (Itiln'IMiiMt l.ciiil;,'!' :tl n I! I t ii ! k ai til re til ;v( ox sio iiil I'Ol liii inu sill oiii "t( iiiO( 0S|)( km: IIIOI tlioi OXC( fr('(j cut has iron liav( nil-: I'ATiKHjjdY or ritiJiXAxrv. 269 Imt twcasionnlly the knot is so tifilitly drawn as to cause fatal fotal aspliyxia. Ono case of twins is reportorion and the deeidua reflexa (this latter allowing of the easy accumulation of blood between the membranes), as well as to the inability of the ovum at this early stage to offer sufficient resist- ance to disease-processes. The changes incidental to ])lacenta- formation is no doubt also an imjwrtant factor in the pro impossible, and in the absence of positive signs we can only presume that preg- naniy does or does not exist. It may be deniercgh'Uicy, prove most disastrous, such as septic intox- ication from putrefaction of retained membranes, rapid disappearance of the symptoms is the rule in abortion under appropriate treatment. But while the immediate danger to the mother's life is less than it is at the termination of pregnancy, the pernicious consequences of neglected or badly-managed abor- tions are far more common, and not nearly so amenable to treatment. The nature and severity of the sccpielaj vary with the causes. Anenn'a, with great debility, consequent upon excessive hemorrhage at the time of 2(i6 AMERICAN TEXT- HOOK OF OBSTETIUCS. \A W -I i/ ■uld also receive treatment both before' and after i>regnancv has begun. As «\j)'iilis is probably resimnsible for a much larger number of abortions than aay olacr single cause, its presence in one or both parents should receive })roni[)t and thorough attention. In those instances where no other cause can be found and there is no indication of syphilis existing in either parent, father and mother should be placed under antisyphilitic remedies, as an apparently cured syphilis may still exist sutticiently to affect the ovum. During preg- ' 'I THE PATHOLOGY OF PREGNANCY. 267 nancy the jifi-oatcst care should be taken to avoid all jjossible sources of irritation, such as fatiguinj; work, too long walks, riding, dancing, lifting, reaching, stair-climbing, jumping, sea-bathing, corsets, tight clothing, conta- gious diseases, poorly-ventilated or overheated rooms, crowded theatres or crowded churches, emotional excitement, late hours, etc. The diet should be regulated carefully, in order that acute dyspepsia, fla*^«lence, colic, diarrhea, and constipation may be avoided, and the kidneys and the bowels should be r(>gidated properly. Coitus should be prohibited. The patient should, if possible, spend several days in bed at the times corresponding with the men- strual periods. A retroflexed uterus should carefully be righted and be held in position by an aj)|)ropriate pessary. In cases of habitual abortion it would be well for the patient to allow an interval of six months or a year to elapse between the last abortion and the next pregnar.cy while under treatment. In some cases confinement to bed the greater part of the time seems to be the only way in which pregnancy can be carried through to term. Treatment of Threatening Abortion. — If upon examination the os is found undilated, the cervical canal unexpanded, hemorrhage not profuse, and pains absent or moderate, the case shoidd be considered as preventible and be treated accordingly. If we knew for a certainty that the fetus was dead, there would be no reason for treating the case as preventible, but as there are no reliable signs of fetal death where abortion is only threatening, we must treat it as though the fetus were alive. Our aim is to prevent, if possible, any further separation of the ovum from the uterus, and to allow of the healing of the already injured surfaces. To this end we endeavor to control hemor- rhage and uterine coiitractionn. Absolute rest and quiet are essential to the proper treatment of threatening abortion. Tlie patient should be put to bed in the quietest, best-ventilated room in the house. She should maintain a recumbent position for sevei-al days or until all danger is past. She should not rise, even to a half-sitting ])osition, for any purpose, the bed-pan being used for defecation and urination. Everything having a tendency to produce nervous disturbance should be avoided, such as talking, visitors, and worry of any kind. Secure free move- ment of the bt)wels each day by sufficient doses of castor oil or other mild laxative, aided, if necessary, by enemata of glycerin and water or of sweet oil. The clothing should be cool and light, the diet nutritious and easily assim- ilated, but non-stimulating. In tiie way of drugs, opium in one of its forms is mostly to be relied upon as a general sedative. It should be given in full doses, and repeated often enough to preserve systemic quiet. In some cases it may be advantageous to give with the opium such nerve-sedatives as chloral hydrate, the bromids, or j>Iienacetin. These drugs should be given per rectum if the stomach is sen- sitive. The fluid extract of viburnum prunifolium in drachm doses is said to assist materially in quieting uterine contracticMis. Ergot in small doses (15 to 20 min. of the fluid extract) may be of benefit in selected cases (where there is 1' I ■ !"^ ';i^ 1 4'| ! I ■ 1^1 ; 1 , I i I 268 AMERICAN TEXT-BOOK OF OBNTETIiWS. little pain, hut much lioniorrhn<;o) in assisting in tlio control of hemorrhage by contracting the arterioles, bnt as a general thing it shonlil not be used, owing to the tendency for even small doses to excite uterine contractions. The vaf/lnal (ampnii, as a rule, should never be used in threatening abor- tion, on account of its action in exciting uterine contractions. In exceptional cases, however, where there is not much pain, but considerable hemorrhage which cannot be controlled by other means, the tampon may be useful in connection with the sedatives already mentioned. A vaginal injection of hot alum-solution (.^ss-Oj) may be used instead of the tampon. Any malposition of the uterus siiould l)e remedied by the gentlest manipulations. Treatment of Actual Abortion. — If the os is dilated and the cervical canal is expanded, or the pains and hemorrhage continue notwithstanding treatment, and there seems to be no prospect of checking the progress of the abortion," the expulsion of the ovum becomes inevitable. The main indication now will be to control hemorrliar/e and to secure complete evacuation of the uterus. If it has not been done before, the vagina and the external genitals should be placed in as nearly an aseptic condition as can be done with hot water, soap, and an antiseptic solution. The physician's hands and the instruments should also be rendered surgically clean before an examination is made. If the ovum is protruding with membranes unruptured, it may easily be dis- lodged from the cervical canal, but we should refrain from manipulations that miglu cause rupture before its complete extrusion. Before the fourth month we may best meet the indications — to control hemorrhage and to expedite delivery — by the use of a vaginal tampon. Properly applied, the tampon will surely con- trol hemorrhage ; further, it hastens the com- plete separation of the ovum by causing an accumulation of blood between the uterus and the membranes, and it is a powerful exciter of uterine contractions. The tampon may be made of a long strip of aseptic or antiseptic gauze, of pledgets of aseptic or antisejitic ab- sorbent cotton or wool, or, in the absence of these materials, of "My soft fabric, such as a silk handkerchief, a soft towel, or strips oi' pieces of sheeting, cheese-cloth, an ordinary roller bandage, etc. Whatever material is used, it is understood it nuist be stcrili/ed thor- oughly by boiling, by dry heat, or by steam, or it may be scalded thoroughly in some hot Fm.iio.-sims'simsition for tamponing autiscptic Solution. If a large number of aiulciiretlinK (.skonu). . ' .... j>ieces are used, as of antiseptic wool, they should be so secured to each other by a string as to facilitate their withdrawal. If the material has previously been prepared or if it can be sterilized by dry heat before using, it is better to use it without soaking in an antiseptic solii- -li s THE I'AriiOLoav or PiiixiXAXvY. 269 tion, as more accurate tamponade can l)o done when the tampon is dry than when it is wet. For introducing the tamjion the patient shoidd be placetl across the bed, or, better, on a table, in the dorsal or in Sims's position, with the hips at the edge of the bed or the table (Fig. 149). A very cojiioiis hot-water or hot antiseptic vaginal douche shotdd next be given, after the Fifrtr Abortion. — If tlioro is, after the apparent com- pletion of abortion, more or less hemorrhaj^e, either eontinuons or interrupted, with slijrhtly dihited os and flabby cervix, especially if there be pain and an odor of drcomposition, it is evident that some portion of the ovnm still remains in the ntenis. In tl>e mildet^t cases, in which there is as yet no infection of the retained j)ortion and the os is contracted, conservative measures might l)e ailvisable in tliose cases tliat could Ih' kept under observation and in those in which the treatment could properly be carried out. Such conservative treatment woidtl consist in keeping the j)atient quietly ih bed, stimulating uterine contrac- tions by repeated moderate doses of ergot and by the use of the vaginal tampon, and by keeping the vagina and the vulvu in a strictly aseptic con- dition. In neglected cases, where there is nuich hemorrhage or pain, and especially if there be even a minimum amount of fetid odor to the lochia as it comes from the uterus, the indications arc clearly to empty the uterus com])lctely and at once — with the fingers if possible, with tlu' curette if necessary ; to render the uterus and the vagina as nearly aseptic as possible by antiseptic irrigation, and to keep them so. In the treatment of incomplete abortion, whether the case is seen early or late, there should be observed the same rigid adherence to the principles of asej)tic or antiseptic surgery as is observed in any other case. After-management of Abortion. — There is no valid reason why the woman who has aborted should not require as much time for the repair of uterine lesions and for the proper involution of her eidarged uterus as does the woman who has been delivered at term. Owing to the inn)erfect develojiment of the enlarged uterus after abortion, the process of involution is even shnver than the same ))rocess after labor at term. There would be a marked decrease in the number of pelvic disorders, and there would be almost as great a falling off in the number of abortions, if wonien \ ere treated after aborting more nearly as they arc after a normal labor. Missed Abortion and Missed Labor.-- Am a child at full term may die and may remain in ntero for weeks or for months afterward, this condition is called *' missed labor." A similar conditicn — missed abortion — is observed in the earlier months of pregnancy when the fetus dies, the ovum remaining in utero for weeks or for months. The symptoms of pregnancy are then arrested ; the liquor amnii is absorbed, the abdomen becomes smaller, and milk appeals in the breasts. The child in ntero, surrounded by the placenta and the mem- branes, becomes macerated or mummiHcd. It does not necessarily become putrid, because the unbroken membranes prevent the entrance of atmospheric germs. In these cases labor does not come on at all, or, having commenced, the ])ains cease and the fetus is retained. Oldham was the first to ai)ply the term "missed labor" to cases in wliicli occurred ii the iiqiioi- to whether access to tl condition I somewhat, tion of all parts beinj; uterine wal through th( peritonitis, ,' hut convale.' and the fctu Hed product it n)ay cause results. I}es may lead to i A dead : generally ser ('onseqiiently iew weeks, an to induce lalx <';uition is safi WJien nature active efforts be emj)loyed Ijc exercised t «'mia. Lapa very thing to > Miiller of are really case.* <'-\'pulsion, bee; it may be sai( fetation of the ft'tii.- in a biloh History. — E pathology, and sions and 'las c or twenty years attention. Froi of many jiractic 'lot quite unkno 18 Tin: PATiroLoav or pjiKayAxrv 273 occurred ineffective uterine eH'orts to expel the fJ'tns ami other contents except the litpior aninii. Air does or tloe.s not enter the uterine cavity accordiii}; tis to whether tiie membranes are or are not ruptured. If atmosplicrie air lias access to th(? fetus, the hitter undergoes putrefactive ciianges, i^ivinj; rise; to a condition Iviiown as jihi/xomrtnt, or fi/inpaniltH uteri ; the soft jtarts licpjefy somewhat, then escape, k'aviii}^ tlie osseous structure. A coinph'tc evacua- tion of all the fetul structures is rarely effected l)y riture alone. Some of the parts beinijj retained, the projectiui:; hones may ))enetrate the surrounding uterine walls, and find their way into the vaji^ina, the rectum, the bladder, or through the abdominal walls. A similar action may lead to suppuratitm, peritonitis, septi(!emia, and death. Most cases, however, eventually recover, but convalescence is long and very tedious. If air is excluded from the uterus and the fetus is retain<;d, the latter may become mummified, and this mummi- fied pro(hict may remain indefinitely without creating special harm. Possibly it may Ccausc irritation, suppuration, and uterine or pelvic abscess and their results. Jk'sides maceration and mummification a prohniged fetal retention may lead to adipocerous changes. Calcification very rarely oreurs. A dead fetus within the uterine cavity, although no air has entered, generally seriously impairs ti.j health and endangers the life of th(> woman. Conserpiently, in cases of this kind it is always prudent, after the la|)se of a i'iiw weeks, and when there is no physical evidence of a commencing expulsion, to induce labor artificially — an oltstetrical procedure which under careful pre- (•aution is safe, infinitely more so than allowing the dead fetal mass to remain. When nature is successful in partially eliminating some of the fetal portions, active efforts by the hand or by instruments, after cervical dilatation, sliould be employed to aid the woman. Every known antiseptic precaution shoidd be exercised to prevent or to control hectic symptoms, peritonitis, and septi- cemia. Laparotomy, laparo-hysterectomy, or a Porro operation may be the verv thing to do under certain circumstances. ^liiller of Xancy has shown that many cas(>s of so-called " missed labor" are really cases of extra-uterine pregnancy, with ineffectual attempts at fetal expulsion, because of a certain position of the fetal body. With fair propriety it may be said that most of these cases are those of advanced extra-uterine fetation of the intramural (interstitial) or tubal Viiriety, or (>f retention of the fetu- in a bilobed uterus. 7. Extra-uterine Pregnancy. History. — Extra-uterine pregnancy from the standjioint of its etiology, pathology, and operative treatment has provoked such numerous discus- sions and 'las called forth so many valuable essays within the past fifteen or twenty years that the historical side of the subject iias received but little attention. From this one-sided view the impression has arisen in the minds of many practical men that this anomalous form of gestation was almost if not quite unknown even to our immiMliate predecessors. A research into the 18 Ml f^^ 'IP 'p ,' ; ' i:l :i ' lii ^\^- i/ 274 AMKIx'ICAN TEXT- HOOK OF OliSTF/riilCS. niodioal litoratiire of the past four ccnturios, however, brinj^s to lifjlit many clear descriplioiis of well-recoirnizcd cases of extra-uterine prejinaiiey. Israel Spacli ii his extensive fiyneeolot;ieal work, ])nl)lishe(l in 1597, figures a liiliopedion drawn m i^Ua upon a fnll-lent;th cut of a wofuan with the belly laid open. He df>di<'!ited to this ealeified fetus, which he rejjjarded as a rever- sion, the followinj:; eurio'.s i-pij^rani, in allusion to the classical niytii that after the flooil the world was re|)opulated by the two survivors, Deucalion and Pyrrlia, walking over the earth casting behind them stones which on striking the ground becaiue jieople. Roughly translated from the Tiatin, this epigram reads as follows : " Deucalion cast stones behind him and thus fashit)ned our tender race fi-oni the hard marble. How comes it that now-a-days by a reversal of things the tender bodv of a little babe has limbs nearer akin to .stone?" We find many of the earliest writers mentioning this form of fetation as a curiosity, but offering no explanation as to its cause. One of the first and most natural suggestions was that the fetus had died in idcro, and aftcrwarii had become displaced into the abdominal cavity, where it excited suppuration and thus was finally discharged. An important discussion was called forth in 1669 by the case of Benedict Vassal, a surgeon in Corrari, Italy. The great obstetrician Mauriceau's draw- ing (Fig. l'")2) of the specimen obtained shortly after the autopsy is remark- ably clear, and it well supports his judgment that this was not a tubal preg- nancy as asserted. His description of tiie case is well worth quoting even at this day ; translated freely, it is as follows : " History of a woman in whose abilomen there was found, after death, a small fetus about 2% inches long, together with a great quantity of coagulated blood. " The history of this ease deserves to be carefully considered to decide whether the fetus, as believed by many, was generatetl in tlie ejaculatory ves- sel, called the tube of the womb. On the sixth of January, 1669, in the village Corrari, I saw in the hands of a surgeon named Benalict Vassal a uterus which he had removed a short time before from the body of a woman aged thirty -two, who had died after three days of the most agonizing pains in the stomach, from which she had fallen into frequent fainting spells and th(> most violent convulsions. This woman had borne eleven children at term, but in her twelftli pregnancy, at about two and a half months, the womi) dilated in the direction of the riglit horn, and, unable to withstand this disten- tion, ruptured. The fetus was expelled into the abdomen, and was fi>und with a great quantity of coagulated blood among the intestines of the mother. Many physicians, surgeons, and naturalists betook themselves to this surgeon to see the uterus which was exhibited by him as a prodigy, as he insisted thai the fetus was formed in the ejaculatory vessel, which Fallopius calls ' the triun- pet of the womb.' They ac<'epted at once, without further investigation, that this was just as the said surgeon claimed, and that this case confirmed stories of a like nature narrated by Riolanus. However, I examined the parts of thi- TIIK PATirOLOGY OF PTiT-MXANCY. 27r> ntonis most carofully and minutoly, and it was evident to mo that those wlio aoecptod this opinion had been letl into error ; for this reason, tliat at tlie time I made a (h'awing of the womb as it tiion appeared, and this is a more faithfnl a>ul aceurato repnuhiction than that which tiiis snrjjeon had engraved npon eopper after a n;onth had ehipsed, as tlie uterus then retained ahnost nothing of its i)rimitive form, and was spoiU'd by the handling of a tliousand men or more who had seen the utcrns, pulled it, disturbed it, and tin'ned it inside out that they might examine it. " Many have addneetl this ease to prove to us that the testes " [ovaries] " of women are full of little ova which at the moment of coitus free them- selves and emerge from the body proper of the testes, and are thence borne into the uterus through the tube, to serve for the generation of the fetus. They claim that one of those so-called ova had by chance romainetl in the tube of this woman, instead of passing forward into the uterus, and that this was the cause of her death. " Regner de Graaf among others holds this opinion, for the confirmation of which he brings forward the figure of this uterus, which the surgeon of whom I have spoken had already given to the public ; as one finds it on the 260th page of his book on the ' Generative Organs of Women.' Any one .^f^^^ Km. 152.— Cast' (if I'Xtni-iili'riiU' prcnimncy liuiiviMl by Mimrici'iiu, ri'dniwii, Imt p n.'Ucnlly unrhniiKod. The Ictus is here slunvii iiltiuhiil to tlu> siic, wliich wiis not the caso in liis lii;ui . Tlic ilistiiict in'ck IwUM'i'll tile sue Mild llu' llti'lMis is ovidolll •, tlic n>illid liniiiiifiit cniiu's mil nf llii' iiiu t'l siirl'iicc (il'tl.c sue iimri' tcixviird its outor polo. Tlio roliitiiiiis of ii tioniml iitorus iirc in lii •■|lf ; consequently the child was engen- dered in a ])art of the womb that was elongated." It is interesting in this connection to note that Mauriceau, in this differen- tial diagnosis, anticipated some of the results of our latest investigations con- cerning the differences between tubal and corinial interstitial pregnancy and Fiii. 153.— Koduci'd (iguro of Dciitsi'li's cn»c of iitnlomiiml prciriinnpy dm norouiit nf which was putilishiil ill ITUSt witli lifi'-si/t' cdpiior-iplati' onuraviii),'.-). pregnancy in a rudimentary horn. From the above it is evident that Maiiii- ceau was positive that impregnation had not occurred in the Fallopian tiilic, but in one cornu of tiie uterus, and that the ovum had devcl(»i)ed as a hcrni;i from the uterus. I find that liegner de Graaf, just as Mauriceau states, accepted the view of Vassal, and in his description of the Fallopiiin till' reports the case and reproduces th< figure from tlie copper plutc wh" u Man.' IsUcM THE PATHOLOGY OF PREGNANCY. 277 eoau condemns. De Graaf believed this to be a case substantiating his own tlieory regarding the function of the ovaries and the Fallopian tube. He says, " AVe Judge that the tulxs called Fallopian in women and in every kind of female arc true vasa deferentia, or, if you prefer, oviducts, inasmuch as the ova are transmitted through them to the uterus." He further says, "The tube or horn [Falloj)ian tube] of the wond) is dilated and affected by semen corrupted there and seeking an outlet ; but it is remarkable that the male semen should reach that point and that a fetus should have been conceived there, as is proved by histories." De Graaf believed that the ova were fertilized in the ovaries and that they were then carried downward into the uterus, where they remained until the full term of gestation was eomj)leted. He does not offer any explanation for the arrest and development of the ovum in the tube ; on the contrary, he dis- tinctly states that he does not know why it occurs. He recognized, however, the dangers of this anomalous pregnancy, as indicated by the following state- ment : "The ovum already fertilized is detainetl in its transit in the tubes, and by its increase in size brings death to the mother." In his critical remarks upon Vassal's case he says : " And from this our opinion it is not difficult to explain how a fetus occasionally develops in the abdominal cavity among the intestines, inasnmch as the ova already impregnated fidl from the testes" [ovaries] " outside the cavity of the tubes and are nourished by the neigh- boring parts." From these references to the earlier literature it will be seen that ectopic gestation was clearly recognizetl, its symptoms graphically described, and the theories advanced those that are accepted by many writers of the present day. Numerous other coiuributions are found in the literature of this subject, following De Graaf and Mauriceau, one of the most interesting being figured in the obstetrical work of Peter Dionis of l*aris, published in j . early part of t!>e ei$rhteenth century. Evn so early as J 741, Bianchi constructed an elaborate classification of the foi'ViS oC extra-uterine pregnancy, that was simplifietl by Boehnier in 1752, ,vlic 'K-iiibed three forms — " gestatio ovariea," " gestatio tubaria," and " ges- tatio a lop iiijlis." From the time of Boehmer a period of fi)rty-nine years intcrveucii in which this classification remained practically unchanged. In 1801, Schmidt described the interstitial fi)rm of ectopic gestation, and with this addition Boehmer's classification must practically be accepted even at the ])resent day, with the exception of a primary abdominal form. Mhlogi/. — Xo entirely satisfactory conclusions have yet been reached "e.'^iii'ding the cause of this anomalous form of pregnancy. Among many il;"ories none have been demonstrated. One great difficidty lies in the fact tii;' it has not yet been determined at what point in the female genital tract ii.'.r'ial impregnation of the ovum takes place, and until this question is settled the primary question, whether extra-uterine fetation is an abnormal ectopic impregnation or is simply a detained impregnated ovum, must remain unanswered. Many claim that the seat of coalescence of the male and the • jj mMi> |ffi|^)' 1 H^^ti u it mm M^i - ■ -ran, -VTH?-. 278 AMERICAN TEXT- BO OK OF OBSTETRICS. '1 ill \f I i| female elements is nornially in the Fallopian tube. If this claim be admitted, it can readily be seen how u variety of causes might operate to detain the ovum in the tube, where it may continue to develop extra-uterine. Chief among the causes ascribed a few years ago, at the revival of this subject, was the loss of the tubal ciliated epithelium, which would manifestly conspire to prevent the ovum from being carried on down into the uterus ; other causes cited have been flexions of the tube, dilatations and diverticula, constrictions from inflam- matory changes, and polypi in the tube, closing its Itniien like a valve. While a variety of causes may operate, it is most jirobable, from the frequency with which old inflammatory disease is found coexisting on the other side, that most cases of tubal gestation arise from ileus of the tube, resulting in an inability to transmit the contents of the tulie, due to adhesions. An imjiortant '"a''.se, operating in cases where the pregnancy is toward the outer end of tli iMue, is the })resence of a diverticulum, as pointed out by J. W. Williams. Clasfiificafion : Prhnanj Foi > -The primary forms of extra-uterine preg- nancy are classified as follows : ( Tnbo-uterineor interstitial. 1. Tubal : <^ Isthmial. 2. Ovarian. ( Ampullar. Secondary forms are derived from the primary, as follows: / X 7-. ,1 r Uterine; / \ -e ii f Tubo-ovarian ; {(t) trom the ) „ , ,.' , (c) Irom the I 41 i • , ' ^ ' .... 1 < Jiroad ngament; ^ ' u \ Alxlomnial: rstitial: .1 i .*^ 1 ' ampullar: ) ,, , ,. ' . (^ Abdoninial. ' (^Jiroad ligament. f Abdominal ; {(1) From the J Abdominal ; 1^ Broad ligament. ovarian : | Tubo-ovarian. In tubal pregnancy, when the fertilized ovum develops out near the fimbri- ated extremity of the tube it is called ampullar ; at the inner portion of tlie tube it is called idhiaial ; while in that part of the tube which tras'crses the uterine wall it is designated intrrxtitial or fnljo-uterinc. It is in the latter form that the term extra-uterine pregnancy becomes a misnomer, as the conception is not, strictly speaking, extra-uterine, being enclosed in the wall of the uterus, although outside its cavity. For this reason Mr. Tait suggested the term ectopic gestation. Many writers, more ])ractical than scientific, were mis- led by ]Mr. Tait's dicta to go so far as to hold that there is but one form of ectopic gestation — namely, the tubal — and so able a pathologist as IJIand Sutton gives them countenance by his denial of the ovarian and abdominal forms, as he considers the cases which have been reported do not sufficiently demonstrate their existence. Xo criticism, however, has yet succeeded in destroying the claims of cases of Leopold, Patenko, and ^Fartin, which wo must accept as primarily ovarian. In Ijcopold's case the j)atient was operated upon for a pelvic tumor of twenty-five years' standing that jiroved to be iu\ ovarian tumor containing a lithopedion. In the walls of the tumor ovarian stroma was clearly demonstratetl. Patenko's case is even more striking. The right ovary was the size of a hen's egg, and it contained a cvst with smootli walls in which was found a yellow body, the size of a hazel-nut, composed of niterstiti (h) From the isthmial Tin-: PATHOLOGY OF PREGXAM'Y. 279 cyliniiinriiiii showing pi'lvit' lu'iniitoccU' posto- rior to tlie utorus, whicli is crowdi'd forwanl willi tlio blndcU'r bi'himl tlio symphysis imbis, wliilo tlio ri'Ctiiiu is romi)ri'ssf(i l)oliin(l n>;iiiiist tlu' siioniiu (Skenrl. 4i>\\X^ ,;f '! /-^ \o> %>«j,. *<'>■• .:m^ " '.• ?;t> -. .. Fig. irifi.— Riipturcil loft tulml prt'j;iimu'y, IVtiis still iittuclicil iiiiil lylnn within the pi'lvis. Hydnisiil- piiix and ndln'sidiis on the rinht side. I'tiTiis disphu rd towiml tlio rinht by tho sac: » is the fiuulus uteri; r, the rectum; t, the rinht closed tube; ,/', the fetus; and .-•, the ruiiturcd extra-uterine sac. to secondary rupture at any time up to term. Here again the situation of the placenta is of the same importance in the prognosis as in the primary rupture. The Fetus. — The question as to the possibility of life for the fetus is iuHu- enced by the location of the ])regnancy. In the tubal variety the most favor- THi: I'ATIIOLOGY OF PliEGNAXVY, 283 llSlll- al)lo attuclnncnt of the plucenta is on the floor of" the Fallopian tube, as there may be .sli<>l)t it" any distnrbance of the fetal circnlation if the rnpture be in the .superior wall of the tube, when the child may <;(> on to full term (Figs. 156, 157). Even, however, if the ectopic fetu.s be delivered alive, it i.s often deformed and puny and rarely lives more than a few day.s. For this reason its life should be but little regarded in the tieatnient of ectopic gestation. The f 'V f ■ 284 AMKItlVAN TEXT- BOOK OF OliSTETRICS. sucli bodies liave stayed for ten and fifteen years, in one instance for fifty-four years, in the pelvis without ^ivinj^ rise to serious trouble. On account of the close anatomical relation between the gestation-sac and the rectum and intestines a slight rupture of the intervening walls may occur at any time, or a diapedesis may take place and pyogeni(! organisms gain access into the sac; and induce suppuration. The fetus is then converted into a putrid mass, which may be discharged into the rectinn, the vagina, or the bladder. Occasionally the sup- piu'ating mass i-uptures at some point on the anterior abdominal wall even so high as the umbilicus. The latter termination is frequently noted in the older medical literature. Symptoim, — All the symptoms characteristic of normal pregnancy may be present. Frequently, however, the subjective symptoms are entirely absent, and the patient may be quite unconscious of her condition. The increase in the areolar circle around the nipple and other mammary changes, the gastric disturbance, pain on the affected side, associated with amenorrhea, are th.e most characteristic symptoms. Too much stress, however, ranst not be laid upon the absence of the menstrual flow, as it is subject to the greatest variations. In some cases instead of amenorrhea there will be profuse metrostaxis with the expulsion of small bits of decidua. It is of importance not to confuse the decidua of ectopic pregnancy with that of membranous dysmenorrhea. In the latter condition the decidua is usually expelled in small pieces and rarely as a cast of the interior of the uterus. When floated out in water numerous delicate velamentous processes are seen. This membrane is rarely more than one or two lines in thickness, and it is usually very friable. The decidua of ectopic pregnancy is much thicker, varying from 6 to 20 millimeters (^^g^ to | inch); it is much less fri- able, the uterine surface being covered with a thick, shaggy, villous coat, and instead of small bits it is usually expelled in large pieces or as a complete east of the interior of the uterus. Pain is variable, in some cases being almost constant, in other cases absent. The character of the pain before rupture may be sharp and lancinating, or there may be dull and heavy aching. The statement of the patient that she considers herself pregnant is of some value, as that ill-defined sense upon which she bases her opinion may be the only subjective indication of her condition. The appearance of the external geni- talia may be the same as in norn -d pregnancy. Under these circumstances the vaginal mucous membrane appears purplish in hue, the cervix is soft, the OS uteri is usually closed with a plug of mucus, and the uterus, instead of its pyriforin shape, is now globular and enlarged to the size of a one-month pregnancy. If an examination be made before rupture, the Fallopian tube of one side will be found enlarged, and if far advanced the uterus will be forced from its position in the median line by the growth of the tumor. If the pregnancy is advanced to the third or the fourth month, a circumscribed tumor, well defined as an area of dulness on the anterior abdominal wall, may be outlined by percussion. Vaginal examination reveals this tumor lateral Till-: I'ATJIOfAJGV OF I'RKGXANCy. 285 and posterior to the titcnis, with a well-marked sidoiis between it and the uterus. Unfortunately, it is only in the rarer instanees that a ])hysieiau is called before rupture occurs, when, unless he is a skilful spt'cialist, the prob- abilities are that ectopic gestation will not be suspected. The growth of the tuujor may give rise to pressure-symptoms, such as constipation and dysuria, but they are of little special significance, as any pelvic tumor may be attended with similar disturbances. Ruptui'c. — The sym])toms of rupture are very characteristic, and they usually are so definite as to cause little doubt in diagnosis. A j)aticnt pre- viously healthy or only slightly (!omi)laining is suddeidy seized M'ith severe abdominal pains, sharp or lauciiuiting, cutting or agonizing. The attack in many instances cannot be ascribed to external violence or to undue exertion on the part of the jnitient, as she may be in the midst of light household work, or walking on the street, or even be in bed when the rupture occurs. Previous to the attack she may have had no discomfort or oidy the slight disturbances of preguantiy. If the hemorrhage is extensive she may fall unconscious as if struck a blow. The pulse, at first rapid, soon becomes almost or quite imper- ceptible; the respiration is quickened, then becomes jerky, and finally the air- hunger so chara(ieristic of severe hemorrhage becomes ])ronounced ; vertigo, nausea, and vomiting are present. The symptoms soon merge into those of profound shock, the extremities being cold and clammy, the skin pale, the conjunctivae pearly, and the lines about the mouth drawn. If the patient is conscious and is able to talk, she will usually complain of intense abdominal pain. Death may follow soon after intraperitoneal rupture, or it nuiy be delayed for a day or even longer. In some instances the bleeding ceases for a short time and is followed by gradual improvement in symj^toms, but it again begins a few hours or some days later, and the patient survives only a few minutes. In extraperitoneal hemorrhage from ru])ture into the broad ligament the symptoms may not be so urgent. The initial attack in both instances is simi- lai', as the peculiar sharp pain at the onset is due to rupture of the tube. The blood as it accunndates usually checks the hemorrhage by its own pressure, and the patient may have no further troid)le. If the embryo dies at the time of primary rupture into the broad ligament, no*fnrther discomfort ' ;'^ It, as a rule, as a harmless hematocele is all that remains. Unfortunate I v, in many instances this is r jt the termination, and the fetus continues to develop, and sooner or later a secondary rupture occurs, attended by the same symptoms as the primary rupture. In the rarer cases, which go on fiir nine months, labor-like pains come on and closely simulate those of normal i)artiu'ition. These pains may continue for houT's or even for days, and then cease. The escape of blood and of por- tions of the dccidua occurs in a majority of cases at this time, and may mis- lead the attending physician into the diagnosis of abortion if the constitutional symptoms are not urgent. The subjective symptoms of pregnancy are almost always present in such advanced cases. The fetal movements may have been -ji*i '2SG A.y[Kl{l(\\N Ti:XT-lt()<)k' OF oitsTKrnics. so luiicli on OIK' side as to call tlic inotlior'M attontion to this pliononu'iion. Tlic fl'tal la'art-souiuls arc distinct, bcin^ heard w itii unusual clearness. In cases siu'vivin;; the rupture the sharp labor-like pains jrradually sub- side, the secretion in the breasts tlisappears, the tumor decreases rapidly in size, and as soon as the patient recovers I'roin the shock and loss of blood she may rej^ain her health. It is in these cases that absorption or one of the other chanfjcs that rendt'r tlu^ fetal body innocuous takes place. Infection of the incarcerated fetal mass may occur at any time, even years after the death of the end)ryo, followed by a train of symptoms similar to those attending pus- formation from other causes. J>iti(/noxiK. — 'Plu! history, if carefully reviewed, often directs attention strongly toward ectopic gestation. The pregnancy usually occiws in a mul- tipara some years after the birth of the last child, although it may follow shortly. There may have been an intervening attack of acute intlamination (»f the tube or of pelvic peritonitis. This is strongly insisted upon by those who advocate the theory that tubal gestation is diu? to an old inflammatory l)rocess which has changcHl the normal histology of the tube. A characteristic history is as follows: A woman who has borne one or more children, after an interval of from five to twenty years of sterility observes symptoms of another j)re;,nancy. Her menses, which have been regular, cease, and the mornin;^ nausea, \v,\'u\ in the breasts, darkening of the areola, and other symptoms characteristic of her former pregnancies appear. In addition to these symptoms, slie has in one ovarian region dull ])ain, at times so severe as to cause her to seek the advice of her phy- sician. This pain may continue until it culminates in the acute paroxysms caused by rupture, or it may cease, and not be noticed again until the rupture occurs. The most characteristic symptom of all is the sudden sharp pain of the rupture. If followed by a marked anemia it is still more decisive. The bimanual examination, taken in conjunction with this history, points with absolute certainty to the nature of the pregnancy, and the diagnosis is com- paratively simple. In the atypical cases, on the contrary, a positive diagnosis is often difficult or even impossible. In the normal uterine pregnancy, as the embryo develops the uterus is dis- tended equally in all directions, but occasionally the ovum develops in one corner, distending the uterus on that side, which may prove misleading. In ])regnancy occurring in the rudimentary horn of a bicornuto uterus the symp- toms are so nearly alike that a differential diagnosis is not likely to be made. Kussmaul collr;'ted thirteen cases of pregnan(\v in rudimentary cornua, the majority of wiiicli had been reported as tubal pregnancies. If an exploratory section be ])erformed in these doubtful cases, the anatomical points insisted up(m by Mauriceau are of the greatest value in making a differential diagnosis. They are as follows : In cornual pregnancy the round ligament is situated anterior to the outer side of the gestation-sac. In tubal pregnancy the round ligament is situated on the uterine side (Figs. loT, 158). Pregnancy occurring in one horn of a well-developed bieornute uterus may 77//; /M TIKH.OU V OF PltKiixWANCY. 2H7 go to term ami jjjivc riso to no untoward symptoms. A profx'iant uterus devi- ated to one side by a myoma may l)e mislalven for ectopic gestation. Tiie diag- nosis, however, can usually he made it' the examination is eonchicted under anesthesia, as it will be I'ound tiiat the tiuuor varies its position with that of the cidarged uterus, and is directly continuous with it, in addition to being densely hard. The <|ne-tion of interstitial pregnancy naturally arises in these cases, and if the character of the tumor cannot be recognized a( the (irst exam- ination, the patient's symptoms shouhl be observed carefully, and she should be examined again lat(!r to decide whether there is any inerease in the size of tlie .suspected tumor. If there is a perceptible increase, the probabilities are that it is interstitial pregnaiuiy. An adherent retroverted gravid uterus may also give rise to misleading symptoms, such as sharp pains, obstinate eonstipatiou, >•■.. .in"-- y^"- /"'f\. :>^ \v.:::. -ji.y Ve y '-T' i :--^i^^ Via. I"i8.— Dianrnmnintir sketch sliowiiiii rclaticuis of iiu unniiiturt'd siic (») to utpnis (u), nmnd lignmcnt (rl), and bladder (h). The nuiiifnms adliesloiis are .siigK^'s^tive as to the etioldtiy. pelvic pressure, dysuria, etc., but it is readily differentiated by a bimanual rectal examination, if necessary drawing the uterus down with traction for- eoj)S so that the fundus may readily bo pal|)ated. Ovarian tumors and enlargements of the Fallopian tubes, associated with intra-uterine pregnancy, may cause confusion, especially if the tumor lateral to the uterus gives rise to sharj) pain, as may occur in pyosalpinx. In such instances the question of a twin ])regnan('v, one intra-utcrine and the other extra-uterine, nuist be considered. As fever accompanies jiyosal- pinx in the majority of cases, it nuist carefully bo considered in the differ- ential diagnosis. If it be im|>ossiblo to arrive at definite conclusions con- cerning the suspected mass, and the life of the patient seems in peril, an exjiloratorv celiotomy is justifiable, otherwise expectancy is the safer coiu'se. Occasionally a pedunculated ovarian cyst becomes strangulated by axial rota- tion : such an accident is accompanied by pain, vomiting, rapid pidse, and other constitutional disturbance, at times amounting to ])rofound shock. Rup- ture of an ovarian cyst may also be difiicnlt to differentiate from the rupture I ili! I ft .l«i re " i • 288 AMKIilVAN TJ'LXT-nOOK OF OliSTETlilCS. of an ectopic g:\station sac; in such c .ses the history and the vaginal examina- tion will cl','ai' np the diagnosis. To snnunarizo briefly, it may be said that the diagnosis of ectopic gesta- tion depends npon the following cardinal points : 1. A iiistory of probable pregnancy. 2. Paroxysmal pains, usnally located on one or the other side of the pelvis. '^. Irregnhir metrostaxis. 4. The expnlsion of bits of deeidna. 5. Coincident eidargement of the nterus and softening of the cervix and discoloration of the vagina. G. Tnmor lateral or posterior to nterus and indirectly connected with it, nterus moderately or not at all enlarged. 7. Changes in the breast. 8. Anemia. Tiie diagnosis of ectopic gestation after tlie death of the fetus is largely dependent npon the clinical history ; if this be deficient, the diagnosis is fre- qnentlv impossible, especially if there has been a long interval between the rupture and the time when the patient consults the physician. If the fetus has undergone calcification, It may be felt as a hard mass, but even this is not conclusive, as a calcified myoma may present similar characteristics. Treatment. — From the operative standpoint it is best to divide ectopic pregnancy into the following periods : 1. J^efore rupture; 2, at the time of rupture; 3, after rupture; and 4, after calcification, saponiflcation, munnnification, or suppuration of the fetus has occurred. 1. lirforr Ixiipfiirc — Tlie electrical treatment, so much advocated a few years since for the destruction of the fetus, while valuable in its day as pio- neer work, has deservedly fallen into disrej)ute, because of its uncertainty in terminating the fetal life and of its dangers to th(> mother through subsecjuent inflammation. The injections of fluids into the sac for the same purpose is so utterly fonMgn to present ideas of treatment that it is oidy mentioned to be condemned. The proper course to pursue is the removal of the atfoeted tube. Precipitate operation, however, is not advisable, as the diagnosis should be as accurate as possible before resorting to radical measures. Cases with a history suggestive of ectopic gestation and a mass lateral to the uterus detected by vaginal examination should bo operated upon without hesitation. A pro- portion of such cases will prove to be pyosalpinx or hydrosalpinx, but an error is not serious, as in either instance operation is indicated. 2. At the Time of h'liptuir. — If called at the time of rupture, the siu'geon must exercise considerabh* judgment in his decision whether or not to operate immediately. Tf the patient is in collapse, the pulse weak and rapid, and the skin blanched and clammy, an immediate examination should be made to discover if ])ossiblo whether lupture has occurred into the broad liga- ment or is intraperitoneal. If the rupture has taken i)lace into the broad ligament, a lateral tumor-mass closely connected with the uterus will be THE PATHOLOGY OF PREGXAyVY 289 morrhage will soon cease if it has not already done so, and that the patii'ut will recover, leaving )■ 11.. IV.l.— 1'iii^'rnni (if inlmiu'iilciiu'al viiptmc of liilml incu'iininy. I'rrc IiIiimI in Huiinliis's ciil dc sue mill iiiiiHiii; tlu' iiiti'sliin's IiickiiiMini ; S, syiiiiiliysi> ; i;, rccliiiii. a hematocele to be dealt with later if necessarv. If examination reveals free lliiid in the cul-de-sae (Fig. 159), and there are no signs of improvement in tlie patient's condition, the natural inference is tliat (he rupture is intraperi- toneal, and an immediate operation is indicated, as every moment detracts from the cliances of recovery (Fig. IGO). PrejHivation for Opcra- limi. — The chances for re- covery I'ollowing operation ill extra-uterine pregnancy depend upon the careful (it)scrvation of al' the de- tails of antiseptic and asep- tic technique. For this „,,..,,. ' _ _ 1' Hi. liid.— Dr. IVi'k s cast' O "''11-^'"" II. oluci) ot ixtni-ntiTJiu' reason a precipitate opera- lirotiiiniiiy in Ww tliinl munth; din'ration lit time of ru|iturc; tioii is always attended with ■"''•'"^ '■ > • greater danger, as of necessity care in details must be sacrificed. The surgeon should always have a com])lete set of abdominal instruments and accessories sterilized and packed ready for use. If the operation is hurritnl, select a wcU- 19 I g n ft I r F'T t ftl' 1^ . J£l :■ ■ 1 ■ ' 1.: ■ f I 290 AMERICAN TEXT-BOOK OF OBSTETRICS. lightal room or provide a portable electric light; remove all unnecessary fur- niture, dampen the floor to prevent dust rising, but do not disturb the curtains and other hangings further than is absolutely necessary. A common kitchen table can be turned into an operating-table, with a chair inclined against one end, upon which the patient's feet may rest. Cover the table with a folded blanket, lay upon this a Kelly ovariotomy pad, and place a small pillow at the head. As it may be necessary to irrigate, a douche-bag should be suspended in a convenient position near to, and ibout 4 feet above the level of, th(( table. Two smaller tables are required for the instruments and dressings, and three or four chairs for the wash-basins and sponge-dishes. A room thus hastily improvised serves admirably for an operating-room. An abundance of boiled water is necessary. Directions should given immediately after deciding to operate concerning the preparation of the water. A wash-boiler or other large tin vessel must be scalded thoroughly, and be partially filled with water which is allowed to boil for an hour if possible. It is best to let the water cool to 110° F., but if time is pressing })ure cold water from a well or a hydrant may be used for reducing it to proper tem- perature. This method of cooling the water, however, is not advisable except under stringent necessity. Great care nuist be observed by the physician in disinfecting his hands : they should be scrubbed thoroughly with a nail-brush with soap and water, followed in succession by immersion in permanganate of potassium (hot sat. sol.) and oxalic acid (hot sat. sol.). A (juart of each of these solutions is sufficient. The patient, under anesthesia, is then transferred to the operating- table and is rapidly prepared for abdominal section. The anterior and lateral surfaces of the abdomen are thoroughly washed with soap and water, followed by alcohol, then by ether, and finally by bichlorid solution (1 : 1000). As it may be necessary to open the sac through the vagina, this passage should be washed thoroughly with soap and water, followed by bichlorid solution (1 : 1000) and an iodoform pack. All dressings, towels, and gau/t; to be used in immediate proximity to the field of operation must be i)rovidcd by the surgeon, who slioidd always carry them among his accessories, as the s^teriliza- tion of these articles cannot be entrusted to an untrained person. Instruments are taken from their sterilized envelope and j)laccd on towels or in trays. During the preparation the patient should be given a stinndating enema, also strychnia (gr. ^'j^) and brandy hypodermatically. In such cases as these the infusion of normal salt-solution into the radial artery is often of the great- est service in sustaining the patient's vital forces, and occasionally it is abso- lutely necessary to save life. It is umiecessarv to carry a special infusion aj)paratiis, as an ordinary aspirator adnurably serves the purpose. To prepai-c normal salt-solution dissolve 6 grains of sodium chlorid in one liter (a quart) of boiling water and boil for some minutes. Select one of the smaller blunt- pointed aspirator needles. Fill the aspirating bottle three-fourths full of tin' solution, cork tightly, and, instead of making a vacuum in the bottle, force in aii- THE PATHOLOGY OF PREGNAXCY. 291 until the pump works with diffifulty, then turn the entrance stopcock. The radial artery is the most accessible for infusion, as it can be utilized if neces- sary for this purpose by an assistant while the abdominal operation is in prog- ress. Cut down somewhat obli(piely on the artery, and place a provisional ligature above and below the point of infusion. When ready to introduce the fluid invert the bottle, turn the exit stopcock, and insert the needle into the artery while the fluid is flowing, thus preventing the possibility of intro- ducing air. The dangers of this accident, however, are practically of no moment if the fluid is injected centrally into the artery. If the exsanguination is extreme, a liter (a (|uart) of solution at a tempera- ture of 105° F. may be infused. After the needle is withdrawn both ligatures are tied and the wound is closed with a subcutaneous stitch. It is remarkable how quickly the pulse improves under this infusion : it may grow weaker shortly after, but if the bleeding is completely checked the chances for recov- ery are far greater if infusion is emj)loyed. The fluid used must be perfectly free from dirt or bits of cotton, etc., which produce emboli and cause gangrene. The Operation. — The abdomen should be opened freely in the median line ; the clots should be turned out, exposing the ovarian and uterine arteries, which are caught either with forceps or between the fingers. If on attempting to clear the pelvis of clots fresh blood wells up, no further time should be lost in attempts to expose the bleeding points, but the operator must introduce his hand into the pelvis, grasp the arteries, and then apply hemostatic forceps. Having controlled the active hemorrhage, he can then carefully cleanse the abdomen of clots, inspecting closely the ddbris as he does so for the embryo or the tubal mole. If the pregnancy is in the first or sec- ond month, the operation consists of a simple sal pi ngo-oophoreetomy ; if, how- ever, the term is farther advanced and the placenta is extensively attached to the interior of the tube, or in ease of previous rupture to the intestiiies and pelvic walls, the operation is not so simple, and calls for good judgment to know how best to deal with the i)lacenta. It is exceedingly hazardous to attempt the removal of a placenta which is firmly attached, as the hemorrhage following its dislodgoment may be so extensive as to defy control. In such cases it is best to leave the placenta in xHn, for lo attempt its removal would take away any chance the patient has for life in her condition of shock and exsanguination. Xo means further than those necessary to save life at the time of operation sliould be undertaken, as the essential principle is first to control hemorrhage, leaving subsidiary conditions for subsequent consideration. If the placenta be attached exclusively to tlu? floor of the tube or the pelvis, its blood-supj)ly may be derived from numerous vessels, and an attempt to control these by ligation would be impossible. The best course to pursue in such cases is to cliec^k the hemorrhage, tie and cut the cord close to its placental origin, and leave the placenta undisturbed. Drainage should not be employed in these cases, because of the increased danger of sepsis. The jiroper treatment is to clos' the abdomen completely, and after the i)atient has recovered a second m mm i' 4 ill? ) r 1 1 ■t* )' ' 1 S-^lf ' V,f J I I Jr] d? 292 AMERICAN TEXT-BOOK OE OBSTETRICS. iff ' H !> r'j -^l operation may be performed for the removal of the placenta if it cause unto- ward symptoms. The greatest care in aseptic and antiseptic details should be observed, as upon the absence of infection depends the patient's chance for recovery when the placenta is not removed. If the operation is absolutely aseptic, the prognosis is good, as the placenta atrophies and gives no further trouble. If, however, the case is infected, suppuration of the placental mass occurs, terminating in general peritonitis or in a pelvic abscess. Often in the course of an operation the placenta becomes detached and may be removed with the fetus. In all cases in which the operation follows the death of the fetus by some days or weeks the placenta is only held by the slightest attach- ment or it may lie free in the gestation-sac. It is for this reason that the operation is more favorable at such a time, as the dangers of hemorrhage are much decreased. In some cases, especially those in which there is a temporary cessation of the bleeding, the slightest disturbance of the sac after the abdominal cavity is opened causes a renewal of the hemorrhage. Bold surgical measures are then demanded : the operator should sweep his hand rapidly around tiie ectopic sac, loosening the adhesions, after which the sac is delivered from its bed of adlic- sions. The points of bleeding can then be reached and controlled. Adhesions to the omentum should be tied off in small sections to prevent necrosis en masse. If the intestines crowd down into the field of operation, and if the opera- tor is unable to pack them back satisfactorily with sponges, the patient should be placed in the Trendelenburg position. In case there is extensive oozing on the floor of the pelvis after the removal of tlie ])l!icenta, that it is dif- ficult or impossible to control by ligatures, a strip of iodoform gauze should be packed down upon the bleeding points. If tliere is a large amount of debris scattered throughout the abdominal cavity, free irrigation with steril- ized normal salt-solution (6 per cent.) at a temperature of 110° F. should be employed ; 3 or 4 liters (3 or 4 (juarts) of the solution may be necessary to cleanse the cavity. There is no danger from the distribution of this material in the abdomen by irrigation, as the ectopic product is sterile except in the rarest cases. In all ectopic eases that undergo operation the ojiposite tube and ovary should closely be examined, and if normal or if only slightly adherent tlioy should not be removed ; otherwise their extirj)ation is demanded, for to allow a diseased tube and ovary to remain, which can be of little if any further func- tional value, would only subject the patient to the dangers of a subsequent ectopic pregnancy or to the discomfort and pain due to adherent appendages. 3. After liupfior. — Contrary to the natural Inference, cases are not usually submitted to operation at the time of rupture, as by the time the surgeon is called the patient is either recovering or is dead from extensive hemorrhage. In a certain proportion of cases the i)atient, although feeling the sharp pain accompanying the rupture and being compelled to keep to her bed for a day or so on account of weakness, does not call her physician, as she considers it THE PATHOLOGY OF PREGXANCY. 203 only a trifling matter associated with her pregnancy. There Is undonbtetlly a considerable number of cases like the latter In which the death of the fetus occurs at the time of rupture and no further symptoms are observed, and the patient makes a perfect recovery. It is for this reason that a statistical table compiled for the purpose of ascertaining the rate of mortality in extra-uterine pregnancies due to rupture is fallacious. If the surgeon sees the patient imme- diately after rupture, and there is a general tendency to improvement in all her symptoms, he should defer operating until a future date, to be determined by the patient's condition. If the rupture be extraperitoneal in a case in which the pregnancy has advanced only to the first or second month, an operation should not be per- formed ludess the fetus continues to develop in its new location or untoward symptoms arise from the hematocele. To subject a woman to an operation for a hematocele which is giving her no trouble is, to say the least, bad judgment. If the life of the fetus is not destroyed at the time of rupture, the operation should be performed as soon as the patient has recovered from the primary rupture. The life of the fetus must not influence the determination to operate, and under no circumstances should operation be delayed on account of senti- ment in its behalf. As the dangers of operation greatly increase as the pregnancy advances toward term, on account of the development of the placenta increasing the dangers of hemorrhage, the earliest date possible should be selected for ojjera- tion. A free incision should be made in the central line of the abdomen. If the pregnancy is in the early weeks, the operation may be no more difficult than a salpingo-oophorectomy for pyosalpinx or for hydrosalpinx. The dan- ger of hemorrhage, however, from the broad ligament is somewhat greater than in the ordinary salpiiigo-oophorectomy, on account of the increased vas- cularity of the ttibe, and great care should be exercised in placing the ligatures so that they will control all blood-vessels. The "transfixion needle should not be employed for this purpose, as the subse(juent shrinkage of tissue following the removal of the vascular tube is liable to dislodge the ligature, as more tissue Is usually included, and a larger size of silk is employed, than when the ligament is tied off in small sections. The pregnant tube when the ligatures are laid should be lifted well out of its bed with a medium-sized curved needle armed with a carrier. The medium-sized silk suture is the best In this loca- tion, as it stands sufficient strain easily to contrc)l hemorrhage, and yet does not strangidate the tissues en masse. Each suture should overlap, in an imbri- cated mamier, the one placed immediately before it ; thus no vessels can pos- sibly escape ligation. If pregnancy is further advanced and adhesions have formed between the gestation-sac and the adjacent viscera or the pelvic floor, or if it is a broad- ligament gestation with the placenta firmly implanted on the pelvic floor, the operation becomes one of the most diflicult in abdominal surgery. The adhe- sions should be dissected off carefully, all bleeding points should promptly be ligated, and the sac should be emicleated in the ordinary manner. Drainage iU ill '/ 294 AMERICAN TEXT- BOOK OF OBSTETRICS. sliuukl 1 ot lie used if it can possibly he avoided ; only persistent oozing which cannot b3 controlled by ligatures justifies its employment, as the dangers of infection are greatly increased by leaving the abdominal cavity open. The fact that particles of clots and other dfibris are scattered throughout the abdominal cavity does not indicate drainage, as such material is innocuous if the field has been kept aseptic, and it will give no trouble if the wound is hermetically sealed. It is in these densely-adherent or broad-ligament cases that enucleation of the sac is often impossible, and that other measures must be resorted to for the relief of the i)atient. The treatment of the ectopic sac then becomes a question of great imi)ortance, as the adhesions to neighboring viscera or to the pelvic floor may be so extensive as to preclude its removal, as the danger of hemorrhage following its enucleation is too great in such cases. This question should usually be decided after the abdomen is opened. The extent of adhesions and the vascularity of the sac and adjacent tissue should be noted carefully, and if of such a degree as to contra-indicate removal, the next measure, that of making an extra])eritoneal opening, nuist be resorted to. Extra peritoneal Evacuation of Gextat ion-sac. — The j)oint of opening depends entirely upon the location of the sac : if it is situated low in the pelvis and is of easy access tlu'ough the vagina, unquestionably the best method of procedure is to evacuate the contents of the sac into that canal and establish free drainage. The best method of o])ening the sac is as follows : After carefully examining the pelvic mass and deciding where the accessible point for opening is — usually in the fornix — the operator thrusts a pair of medium-sized sharp scissors, guided by the index finger of the vaginal hand, into the sac, and withdraws theiu jiartially open ; this is followed by larger scissors, which are also withdrawn in the same manner. While doing this it is usually best for the operator to have his assistant press the sac gently down- ward through the abdominal incision. After evacuating the embryonic debris with the fingers or with placental forceps, the sac should be irrigated freely with sterilized water or with a very weak bichlorid solution (1 : 20,000), fol- lowetl by warm water. After cleansing the sac thoroughly it can be nacked with iodoform gauze, care being taken to leave a free opening for subse- quent discharge. The greatest care must be observed in passing fivim the abdominal to the vaginal operation, as to niake a vaginal examination followed by the manip- ulation necessary to evacuate the sac by the vagina, and then to close the abdomen without the most careful disinfection of the hands, would be an unpardonable mistake. It is usually best for the operator to entrust the closure of the abdonien to his assistant. If the sac, instead of being in close relation with the vaginal fornix, is found to be ])ushetl up above the uterus, and is situated nearer the anterior abdominal wall, the vaginal method of treatment is not advisable, as there may be an intervening sj)ace comunuii- cating with the general j)eritoiieal cavity between the ectopic sac and the vagi- nal fornix, making it both difficult and dangerous to reach the sac. In these THE PATHOLOGY OF PREGNANCY 295 cases it may be necessary to stitch the sac to the abdominal woimd, and then to make an extraperitoneal opening into it. As a rule, however, the sac will be attaclied by close adhesions to the abdominal wall above Ponpart's liga- ment, and should be opened in this region. The sac shoidd be washed out freely as in the vaginal method, and be packed with gauze. The after-treatment in these cases is often of great importance, as the sac fills up very slowly and there is constant purulent discharge. The fistula must not be allowed to close. As a rule, the ganze which is inserted at the time of operation should be withdrawn one piecic at a time. After the removal of the last piece, usually about the second or third day, fresh gauze should be inserted, the cavity I,»ing first freely irrigated with some mild fluid, such as boracic-acid solution (semi-saturated). 4. Operation after the Fetus has undergone Mummifieittion, Calcijicatlon, Haponifieation , or Suppuration. — The fetus may remain for years in any one of these conditions, except that of suppuration, without injury to the mother's health. Soon after the death of an ectopic fetus the licjuor amnii is absorbed, the placental circulation ceases, and the vascular connection between the fetus and the mother is broken. The liquid portion of the cctoi)ic product is grad- ually absorbed, leaving in many instances the fetus isolated in its sac as an in- nocuous body. In such cases operation should not be performed so long as the patient's health remains good, but on the first indication of constitutional dis- turbance, especially if febrile in character, celiotomy fi)r the removal of the foreign body should promptly be resorted to. If suppuration occurs and the pus-sac opens into the rectum, the vagina, the bladder, or externally through the abdominal wall, the fistula should be enlarged and the fetal debris be removed. The sac should tlien be irrigated frequently until it fills with gran- ulation tissue. These sinuses heal with difficulty, and they may be persistent. 8. Diseases op the Fetus in Utero. Under this head only a r^sumi' of the diseases occurring before birth will be noticed. There are many conditions which give to the fetus immunity to disease and to injury during the pre-natal state, such as the protection given by the liquor amnii, the uterine wall and bony pelvis, etc., but there are also many predisposing causes, such as hereditary influences from the mother and from the father, nervous disturbances, high temperatures, bad nutrition, diseases of the womb and its appendages, and certain infectious diseases, which have their influence upon the growth and development of the fetus, and which are not only accountable for disease, but sometimes also for the death and expulsion of the child before it has reached its full term. Certain tendencies to disease are inherited : this pertains more particularly to abnormal conditions of the nervous system and to disorders in nutrition. Drunkenness, epilepsy, diabetes, phthisis, and cancer of either parent are unfavorable to the health and development of the child. Frequently a fetus of such parentage dies In utero. 1. Infectious Diseases. — Pregnancy does not give immunity to infec- 'V,X : ,'* I '■''"' ^ ' V\ ! I 1 ;i i ! i ' -^ 1 ■ i , ■ i 1 ■' 1 : ' I'ij 1 h 29G AMKIilCAy TEXT- BOOK OF OBSTETIIJCIS. tious diseases. If tlio niotlior is suttbring from one of the infecL'oiis diseases, the fetus may eseape iiiieetion, hut generally it suffers, either indirectly througli tiie low state of nutrition or the high degree of temperature of the mother, or directly by a transmission of the disease itself. In either event the pregnancy may be interrupted by premature death and expulsion of the fetns, or, if the fetus is born alive, it usually dies s(xm after birth. The mod'j of infection is often obscure, and the path or paths of its trans- mission are siill unsettled questions. Ziemsscn holds that the poison circulates in the blood. The transmission of disease-germs from mother to fetus has in some instances been demonstrated. Placental infection producing sepsis hi vtvro will be considered later. Pus-organisms have been found to be trans- mitted to the fetus in septic disease of the mother, and well-formed collections of pus have been t)bservcd in a fetus at the time of birth. All infections of the mother do not seem to be equally severe in their effects on the child, rrcgnancy complicated by la grippe, cholera, diphtheria, typhoid and malarial fevers in the mother is very likely to be interrupted. It seems probable that in most of these eases the death of the fetus is produced by direct transmission of the infection from the mother, and in many cases this has been demonstrated bv findino- the disease-germs in the fetus. So far as his researches into the subject have gone, the writer is not aware that there are any instances upon record of children being afflicted with diphtheria, mumps, or whooping-cough at birth; but children are born with all the patho- logical indications of malarial disease, such as enlarged spleen, etc., and Play- fair states that the agitation caused by the chill is even felt by the mother as her child in ntcro ])asses through this partictdar stage. Cases of cong(>nital recurrent fever have been reported. The fetus usually dies, and shows all the pathological changes which characterize this disease — enlarged spleen, pigment in the spleen and portal blood. Albrecht reports a case in which he found the spirilla ) through the areas of tuberculosis, such as the peritoneum, intestines, etc., and (c) from the outer world through the genital tract. Fetal Syphilis. — Perhaps the most important as well as the most fatal disease which affects the child in idem is syt)hilis. It is one of the chief causes of abortion. Mode of Transmission, — Syphilis may be transmitted by either parent. If a mother who is healthy becomes infected during pregnancy, the child may escape if this infection takes place in the last month, unless the chiUl again becomes infected at birth or ■while nursing. Prof/nosis. — The earlier in pregnancy infection of the mother takes place, tlie more likely is the fetus to die. If the infection occurs during the first three months and is not subjected to treatment, the fetal mortality during the iirst few days i^fler delivery reaches 100 per cent. The prognosis is a trifle better if infection occurs during the fourth or the fifth month (fitienne). As a * Tho tliodi-y of con<;enitiil tuberculosis lias foniul support in the experimental research on lower animals, also in cases of the human fetus, described by Johne (Fig. 1, Foiischritle d. MM- ii-iii, ltd. iii., No. 7) Merkel (Fig. 2, Zcilschrifi f. ktinische Medicin, 1884, Rd. viii.), Bircli- llirschfeld, and others. Iff ill!. i W-^ 298 AMFJilVAM TEXT-HOOK OF OnSTETlilCS. rule, iiifootion of tlic mother i ■ safer for the fetus than infwtioii of tlic father. Whether tlie speriiiato/oa of the iiifeeted father may infeet the mother is uii- deciiled. All authorities do not admit the possibility (»f infeetion of the fetus unless the mother is syphilitic, hut modern authorities (Tarnier, Schroeder, Charpentier, Priestley, antl others) assert positively their belief in the trans- mission of syphilis to the ovum without infection of tiie woman. Diaiinon'iH of FvUtI ISi/jihi/in. — The infection of the fetus may be inferred if either parent had accpiired syphilis at a day not too far remote from the time of i)rocreation. The limit ot" safety has not been discovered, but the more recently the father has suffered with this disease the more likely is he to trans- mit it in severe form. Often the sipis of fetal syphilis can be looked for oidy in the fetus after its expulsion from the uterus. In many cases the child is pre- maturely born, and there are traces of the disease; in other eases the child is born apparently healthy, the disease developinjjf in the course of from two to six weeks. The evidence of syphilis, whether the baby is born dead or wh(!ther the disease makes its a])pearance soon after birth, is usually charac- teristic. (I'rcmature death of the fetus, due to syphilis, is considered on page 310.) If born alive, the child is often prematurely born, and presents durin<>; the whole of its infancy, and j)erhaps during childhood, a ]>rematin'elv old look. There is usually marked general debility. Among the first manifes- tations of hereditary syphilis is snuffles. The eoryza is foUowwl by a charac- teristic rash consisting of erythema and erythematous patches about the amis, the genitals, the thighs, and the forehead. The U])per lip is likely to become excoriated and fissured. The mucous mendirane of the larynx may be affected, producing hoarseness, and there even occurs ulceration of the larynx. Pemjihigus is one of the most characteristic of syphilitic lesions. A little later roseola, the maculo-syphilin of premature birth who an; either born dead or live only a few hours. In these children are found all the changes which characterize congenital syphilis: numerous extravasations of blood under tho skin and in the internal organs, also at times great (piantities of blood in the stonuich and intestines, in the perito- neal cavity, and in the membranes of the bniiu. If such children live for a little while, then fmiuently new hemorrhages appear in the skin and in other organs, Ruge saw a syphilitic child present hemorrhage about the anus, at the j)oint of the tongue, and, finally, about the eighth day of lifii', severe mnbilical hemorrhage. The hemorrhage occurred tlircctly out of the skin like drops of sweat. Further, upon the ninth day severe icterus develoj)ed and the child died. Tho autopsy showed well-(levci>ped syphilitic changes in the internal organs. Edema freiiuently occurs in this hemorrhagic form. Teudorness and swelling of the long bones arc strong evidence of hereditary svphilis. Tho most characteristic change in fetal syphilis occurs in the bones. The white line which noruudly marks the junctinv of the epiphysis with the ♦liaphysis becomes broader, often irregular, and yellow from fatty changes following a i)rcmaturo attempt at ossification ; in marked cases there is also thickening of the periosteum and perichondrium. Tho diaphysis is sometimes sclerotic. Some authors (INIiiller and others) reganl these ])rocosses as quite different from those of rachitis ; others consider them idcnti<'al. Tho (pies- tion of identity between the two must be considered unsettled. The thynuis gland is often nuich enlarged, and may present multiple abscesses. The (rcdtmnd of fetal syphilis is mainly prophylactic. In parents who are svph'iitic the disease may be eradicatcMl by long-continued treatment. (Jreat benefit may bo derived from treatment of tho mother during pregnancy. If after thorough treatment for the disease, coucoptiou docs take ])lacc, tho result may bo a child free from syphilis. Etiemie, from a sttidy of thirty-two cases of pregnancy in sy])hilitic women, concludes that the mortality of the fetus in cases whore the mother has never been under treatment is enormous, reaching nr).5 per cent. If treatment be a]i])lied throughout pregnancy, wo may hope to obtain complete innnunity from this infant mortality. If a mother who has been infected recently, or who has had a number of miscarriages due to syphilitic infection, is again pregnant, antisyphilitic treatment should at once be instituted. Mercury and iodid of potassium are tho most reliable remedies. 3. CoxcKXiTAi- P'KKOUMITIKS AND MAi-FORMAxroNs. — Amniotic Bands. — One of the conditions to which manv deformities are duo is the formation of .rX\ \\<)- • 1 r I ( t n i ! i ^ .* t i liii 1 1 i 1 1 ! ^ . '■] : .'^00 AMERICAN TKXT-IiOOK OF OliSTKTRTCS. nmniotic bands. Simoimrt (lifroroiitiatos three classes of amniotic bands accord- ing^ to their origin and insertion — tlie i'eto-amniotic, the fetal, and the amniotic. Verv often the anomaly consists only in the existence of these bands, but some- times their existence is the cause of serious disturbance in the normal develop- ment of the fetus, giviufi^ rise either to cleavage or to strangulation, which in turn explains many of the malformations. Adhesions between parts of the fetus and the amnion are favored by a deficiency in the amount of the amniotic fluid. If these points of adhesion l)ecome firm(>r or vascular, they may pi'rsist, and if the process develops at an early term of fetal life, the regular dev lopment at that point will be arrested, giving rise to morphological anomalies which consist in the failure of union between two parts, such as hare-lip, extroversion of the bladder, etc. If these amniotic bands are attached to the etlge of the fetal cleavage, the cavities are j)articularly likely to remain open, giving rise to ectopia (Miiller). iStranf/u/dlioii. — Anuiiotic bands disturb the development of the extremi- ties chiefly by producing constrictions, causing at the peripheral end edema or atrophy. If this strangulati(in takes place at a very early date of fetal life, then the growth of that part will be greatly arrested, so that the periph- eral end beyond the constriction is propttrtionately small ; in other cases it produces death of the j)art and the so-called "spontaneous amputation." Intra-nierinc Amputation. — It is now generally admitted that the exist- ence of aiuniotic bands is one of the causes for intra-uterine amputation (Fig. 161). This amputation usually takes place early in fetal life. Sometimes there are a number of these bands, and they persist to the time of birth. The other causes recognized as such ^^ "" V ki^^'i^*^ are inflammatory processes and intra- Sjl^ \ [^ ' ■!►' "^ uterine fractures. Virchow attributes ^KKLla*"*-'^'*^^^^^ them to primary inf1ammati(m fol- lowed by cicatrix and disturbed nu- Fki. ir,i.-K(tn.mcUis(intra-utorinL-umputution). tritioii. Simi)son hoUls that thcrc is a causative relation between intra- uterine fra(!tnre and spontaneous amputation, the healing processes being unf;i- vorable for fractures. The bone-ends may perforate the vessels and laro before birtli, but u.sually it is a union witii bad ilctbrniity. In rachitic t'ctusort tlio conditions I'or good union arc particularly iiutavorablc. If these fractures remain ununited, or if they have healed, but have producetl markoil disloca- tions, they may cause difTicult labor. Congenital luxations occur in certain Joints, and produce such secondary changes on the surface of the joint that in some cases restoration at the time of l)irth is impossible. Various joints may thus be afleeted, but this accident occurs most frequently in the lilp-joint. In Prof LangenbecU's clinic there occurred 90 cases of luxation of the hip-joint to 5 of the humerus, 2 of the head of the radius, and 1 of the knee. According to Kriiidein, luxations arc more common on one side. Luxations are apt to be associated with otiier malfornhitions ; they are commoner in females than in males, 87.6 per cent, occurring in females. Etiolnffij of DiHlocatUmx. — As to the etiology, many theories have been advanced to account for the occurrence of dislocations, of which the Ibllow- ing four are the most plausible : 1. That it is due to true traumatic dislocation resulting from injury inflicted before birth or during delivery. 2. That it depends on a relaxed condition of the ligaments or upon hydrops of the joints. .'J. That it is a deformity caused by .spasmodic muscular contractions during fetal life. 4. That it is due to a malformation of the acetabulum characterized by the pi'oduction of deficiency of the socket in which it is normally held. Since in most cases of congenital dislocation the labor has been easy and natural, the first theory will hardly liold. It has also been demonstrated (Midler) that the same force which in an adult woidd produce a dislocation will in the fetus produce epiphyseal separation. The theory accepted by most writers as the most plausible explanation for the cases which have been examined is the fourth — congenital malformation of the acetabulinn. This theory, which was advanced by Paletta, has found adherents in Dupuytren, Hrechet, and most recent writi-rs. The deformity is not usually noticed until it is time for the child to walk. The atl'ected limb is slightly shortened. As the child grows older oblirpiity of the pelvis and compensatory lateral curvature of the spine may follow. Further discussion as to symptoms and treatment would liardly come within the scope of this work. Congenital Tumors. — Alxhtniual Tionors. — The fetus occasionally pre- sents at birth abdominal tumors of considerable size. The abdomen may bo enlarg* . on account of ascites, which is usually of syphilitic origin. Disten- tion of the bladder sometimes produces an immense enlargement. Other abdominal enlargements which have been observed are produced by hydro- iiophrosis, dilateeration should be perfi)rmed. A consideration of the methods of operating would hardly be within the scope of this work. THE PATHOLOGY OF PREGNANCY. 303 Congenital occlusion of the posterior nares occurs, but very rarely. Con- genital cysts of the floor of the mouth sometimes manifest themselves in the form of a swelling under the tongue or the chin. Toiif/t'e-tie. — Very frequently the frenum of the tongue binds this organ to the floor of the mouth, immobilizing the tip of the tongue more or less. This condition interferes with suckling, and if not corrected will prove an inipediment to speech. The treatment consists in operating, as soon as the discovery is made, by raising the tongue either with a spatula or a finger, rendering the freiiimi tense, snipping the membrane with scissors, and making any further separation by tearing with the finger. Care must be taken not to cut too deeply, to avoid profuse hemorrhage. In the second jiart of the digestive tract strictures or pouches may occur. Malformations of the stomach arc not common. The " hour-glass " deformity sometimes occurs. Congenital obstruction of the bowel may be located in the duodenum or the jejunum, but more fre(piently in the ileum. Portions of the intestine m.-xy entirely be absent, or be represented only by a band of fibrous structure running along the free edge of the mesentery. Volvulus and hernia may cause obstruction. Couf/euital im/nitial hernia is due to a patulous condition of the inguinal canal, through which a loop of intestine protrudes. A few cases of perforation of the intestine are recorded. In these cases death occurred within the first few hours after birth. In three cases the rup- ture was found at the sigmoid flexure ; in one case in the splenic flexure ; in one case the transverse colon was perforated. The etiology is tissue-necrosis, probably accumulation of meconiiuu. Tiie large intestine, including the sigmoid flexure and the rectum, is liable to various malformations. The commonest malformation is obstruction of the bowel, due to deficient development. In an imperforate rectum there may be a well-defined exterior opening or it may bo absent ; the rectum is usually deficient to a greater or lesser degree. In imperforate anus the rectum is well developed, but the external opening is hi'-king. In some of these cases where the amis is absent the rectum passes into the anterior or genito-urinary segment. Hydrocele is a not infrequent atfection, and is dependent somewhat upon congenital defi)rmity when the processus vaginalis remains patent. Congenital defects in the generative organs of female children are not so com- mon as tliey are in the- male, and they are fre([uently not noticed until a later period in life. The defects of the internal organs are gynatresia and defect of the uterus and of the ovaries. INIalformations of tiie organs of generatit)n of the female are usually due either to absence of Midler's ducts, to failure of union or bicftnniity, complete or partial, or to persistence of tiie septum, giving rise to the double formation of uterus and vagina. Persistence of the canals of (jiirtner sometimes gives rise, later in life, to cysts of the vagina, and persist- ence of the ducts of the Wolffian body may «levelop into parovarian cysts. Nmuerous cases of cystic tumors of the ovaries existing at birth have l;een recordetl, but there are still controversies concerning the embryonic origin of 304 AMERICAN TEXT-BOOK OF OBSTETRICS. ( ! , I 11- 'f / '1 1 t these tiimoi's, some assuming that all cystic ovarian tumors are already formed in the embryo (Poz/i). This origin applies especially to the dermoid. J, Bland Sutton, who has devoted much time to the study of fetal ovaries, says : " I have never succeeded in detecting an ovarian dermoid at birth, neither can I refer the reader to a trustworthy case." Malformations of the Extremities. — Numerical excess, supernumerary digits or toes, is another variety of maltbrmations. The treatment for super- numerary digits is amputation. Congenital union of digits (syndactylism) occurs in varying tlegrees, there being sometimes a firm fusion of the two adjacent members, at other times a webbed condition. The fusions are treated by incision. Club-foot is only a modification of a ]>hysiological position in utero. Too small an amount of amniotic fluid tends to produce chilnfoot, the foot being pressed against the breech ; this long-continued pressure of the soft ])arts tends to shortening of the bones by I'ctarding the progress of growth ; thus the position becomes fi.xed (Ivanderer). This congenital malformation usually produces talipes varus or equino-varus. There is usually moi'c or less ])aresis, and sometimes paralysis of the nniscles of the aft'ected side and tonic contrac- tion of their ()j)ponents. The treatment consists in ])roper bandages, which should be applied as soon as the deformity is discovered. Malformations of the Circulatory Apparatus. — Malformations of the heart are very common, esj)ecially persistence of the foramen ovale. Fetal endocarditis, with its consequent valvular lesions and transposition of the aorta and jndmonary artery, also occurs. Sometimes there is but a rudimentary sep- tum between the ventricles. As this system resembles the arrangement of the heart of the lower forms of life, it is called " reptilian heart." Persistent cyanosis is the most marked symjitom of these malformations. Frequently the fetus is not viable. Malformations of the Brain and Cord. — Cerebral hernia, or men inr/oceJe, is a tumor varying in size from a hazel-nut to that of a child's head. It occurs usually on the occiput, occasionally at the root of the nose or on one of the fontanelles. Sj)i))a bifida, which is not uncommon, may o<'cn])y any part of the length of the spinal colunni. It is a congenital malformation in which the lainiuie fail to unite in one or more of the vertebra^ allowing protrusion of a sac com- ])osed of the spinal cord or its membranes. If the spinal membrane only protrudes, it forms spinal meningocele; if the cord and spinal nerves as well as the membranes ]>rotruregiiant woman arc rre(|uontly transmit- ti'il to her child, and if these sights and imj)rcssions are particularly friglit- tul. they cause marks and defects on the child. One of the arguments 20 Kiu. KVJ -Thoracdpajjiis (douljlo foriiiu- tiiiii). v\ ft- ! : I, ; I.: -^ i ?i: 1 lilt ?^-t . i 1 v I 1 I i • i I ; \' I 1 306 AMERICAN TEXT-BOOK OF OBSTETRICS. advanced in favor of this view is that a belief so universal and adhered to through centuries is rarely entirely fallacious, especially when the subject is based upon observation. The advocates of this theory adduce one of their most reliable arguments from the Scriptures (Gen, xxx. 37-35)) : " Jacob took him rods of green poplar, and of the hazel and chestnut tree ; . . . . And he set the rods which he had pilled before the flocks in the gutters in the wator- ing-troughs, .... that they should conceive when they came to drink. Antl the flocks conceived .... and brought forth cattle ringstraked, speckled, and spotted." At the present time authors, practitioners, and teachers differ, but up to the beginning of the eighteenth century they were nearly unanimous in the belief that fetal marks, deformities, and lack of development were due to impressions received by the mother. Wherever the truth may lie, it is very evident that manj' of the cases cited have been taken from individuals whose testimony would hardly pass as conclusive in other matters. During the past forty years many articles have been written strongly opposed to the previously accepted theory of maternal impressions. It lias always been extremely difficult to demonstrate that any deformity or mark or lack of development in the child was due to an impression which the mother may have received before its birth, inasmuch as there seems to be at least one unanswerable argument in that mc Hnd no direct nerve-connection existing between mother and child. The late Fordyce IJarker has been credited with demonstrating the correct- ness of the theory of "maternal impressions" in a paper read in 1886 befoi-e the American Gynecological Society. He quotes freely from physiologists to show that the weight of authority must be conceded to be in favor of the doctrine that maternal impressions may affect the growth, form, and character of the fetus. His opinions, however, were very largely based upon references and arguments adduced from older writers. Barker, in concluding, quotes the following from the Bnt'iHU-Amerkan Journal: "When, in the early weeks, structural development is proceeding at no tardy rate, an interference to luitritiim of the mother cannot but impress the fetus detrimentally, and the organ interfered with would be that one in the condition of the most active development, or that which could less easily bear any arrest, however transient, with inq)Mnity." Again: "Then, too, although no nervous connecticm has been demonstratetl to exist between the mother and the fetus, yet the latter possesses nerves; and alterations of the nutrient ])ower of the mother cannut but act on the nerves that are governing, though it may be only to a sligiit extent, the growth of the fetus itself" As a matter of fact, only a few cases — exceedingly few — of defective or marked children are born compared witli the multitudes of perfect ones ; then, too, the testimony in many of these cases is absolutely worthless. One of the ablest articles opposing this theory is written by J. G. Fischer. A few of his conclusions, and those epitomized, will be given. Tliey arr briefly as follows : Tiiat traditional superstition has perpetuated the notion, ^ THE PATHOLOGY OF PREGNANCY. 307 and that the medical profession is in no considerable degree responsible for its continuance ; that intense emotions and apprehensions are experienced, and malformations are expected by many gestating women, yet the abnormal births arc extremely rare ; that there is no law in the alleged result, and that the occasional apparent relation of cause and effect is due to accidental coincidences. There is, in addition, against the theory, another argument, which is that the assumed causes are alleged to have operated upon the embryo subsequently to the named period for the evolution of the part which is found to be the site of the malformation, implying not otdy a formative process, but a retro- formative power. This argument, it appears to the writer, is particularly strong. For instance : a child is born with a profuse growth of hair upon a spot of the body whore it should not exist. The mother and Ik.t friends, after considerable coaching, remember that some of the impression? somewhat similar to this were received at a certain time. As a matter of fact, that time occurred a considerable ])eriod after or before the period when, according to the study of embryology, we know the hair to have been developed. Several years ago Norman Bridge wrote a strong paper against the theory. Among other things, he says : " To endow the blood with such a weird intelligence as this would n^quire is too great a load for our credulity. There is no philosophy that it so acts. There is possibly enough in this theory s(j that we should, on account of the comfort of the pregnant woman, advise her not to indulge in violent emoiions, or to see peculiar sights, or to do any- thing which is outside of the proprieties of life." It is desirable, in the writer's judgment, to give this advice to all pregnant women. Many cases have been brought forward that seem almost to prove tiie position assumed by both parties in this controversy. In the writer's judg- ment, nothing is really established, and we must continue to believe that if a pregnant woman sees a sight and gives birth to a marked baby, it is usually only a coincidence. We must still regard the relation of cause and effect as largely an accidental coincidence bearing in mind, however, the fact that, exceptionally, very profound emotion can and does in some unknown manner influence the growth and developin(>nt of the fetus. 5. Intua-itterine Diseases of the Bones. — RaohUh of the new-born occurs in two distinct forms — the fetal and tie congenital. Although rachitis as it occurs in early childhood was recognized by the ancients, it is only recently that the existence of the fetal form has been fully recognized and described. Since Bohn and Winckel described these two forms the investigations of Vir- cliow, H. Mliller, and others have given support to this classificaiion. Both i'nrnis originate in the pre-natal state, but in the fetal form the disease-process is fully develoi)ed at birth ; in the congenital form it continues to develop. Petal rachitis (Fig. KiJJ) has been characterizcci as a disease of the periosteal cartiliige, giving rise to an active growth in tiie w roiig dircctictn ; at the same time there is a deficiency in the deposit of calcareous matter. In rachitis the cartilaginous and subperiosteal cell-growth is excessive and irregular, wliilc the process of ossification itself is also irregular and sometimes wanting (?('.' ■JL.r ' . i I, *. 308 AMERICAN TEXT-BOOK OF OBSTETRICS. (Fig. 1 64). The line of ossification between the epiphyses and diaphyses is irregu- lar, likewise is the zone of calcification ; newly-formed bone- and marrow-cavities may be in the midst of cartilag , and masses of cartilage may take the place of bony tissue. At the same time there is an excessive proliferation of cells on the inner layer of the periosteum ; these various abnormal processes lead to bony deformities. The long bones develop more laterally than longitudinally ; the extremities are short, thick, and usually curved ; the skull-bones are thick ; the ribs show nodular enlargement (beaded ribs) ; deformities occur in the spinal column and pelvis, and the thorax shows the " pigeon breast." There is a general disproportion between different parts of the body. The head is often large, the neck thick and short, tiie abdomen large. Associated with these characteristics we may find hydrocephalus and enlargement of the thyroid gland. Rofei-ence has already been made (page 300) to the frequent occurrence of in- trauterine fractures in cases of con- genital rachitis. There are other conditions which affect the growth of the skeleton in ntrro, and which resemble rachitis — Schmidt's, Bidder's, and Miiller's dis- eases. Bidder's Disease. — In Bidder's disease (osteogenesis imperfecta) the lines of ossification are normal ; tlio epiphyseal cartilage is normal, but Fig. 163.— Fetal rachitis. Fig. 104.— Skvill (front view) in fotal racliitis; ubsL'iice (if frontal bone. ossification does not fully take jilaco either in the epiphysis or in the diaphysis. Tiie bono-production from the jieriostetmi is commoiu'od, but in the dia])hysis tiic ('((mpact portion is imperfectly developed ; in the marrow-cavities tiiero is no d<'j)(»sit of calcaroous sub.stancc. The bones remain short and ])liablo ; tlie sagittal suture remains broad. The bones of the face and skull are particu- larly apt to be affln'ted. Sometimes this condition affects in a slight degree tlic bones of the skulls of infants wlio are otherwi.se perfectly developed. Schmidt's disease is charMctc'rized by great ])redisposition to fracture nl' the bones. The jteriosteum and the epiphyseal cartilages are normal, but (he bony canula; do not j)resont the concentric arrangement which normally exists. THE PAT/IOLOOV OF PREGNANCY. 309 The bone-corpuscles are large, and usually remain empty. The spongy sub- stance contains much connective tissue and many undeveloped cells. Miiller's disease is a diseased condition of the cartilage. The embryonic development of cartilage, which normally extends chiefly in a longitudinal direction, expands in all directions ; at the same time the development of bony structure from the periosteum continues. This action leads to the pro- duction of thick, short bones. The skull-bones are also very thick. 6. Intra-utkrine Diseases op the Skin, Connective Tissue, and Serous Membrane. — Diseases of the skin, the connective tissue, and the soi\/US membrane that manifest themselves in the pre-natal state are usually due to fetal syphilis. Cases of congenital ichthyosis, pemphigus, and other eruptive diseases have also been observed. Pemphigrus. — Pemphigus neonatorum in its epidemic form is considered on another i)age ; it must not be confounded with the congenital form. Al- though the pemphigus is usually syphilitic when present at birth (Roeser says always), still some cases of non-syphilitic pemphigus have been observed. Erysipelas has been observed to be transmitted to the fetus in utero. Anasarca. — Under this head belong hydrothorax, ascites, and hydro- cephalus. These conditions often produce mechanical obstruction to delivery. Occasionally anasarca is seen in connection with dropsy of the mother. This condition is frequently due to obstruction of the umbilical veil accompanying syphilis. Excessive distention of the body may result from ascites and hydro- thorax. Ascites is often due to syphilis ; also to organic lesions of the heart. Tumors. — Among congenital tumors of the skin, nevus is the most com- mon. Although not always noticed at the time of birth, the nevus is prob- !il)ly always present at that time. These tumors belong to the angiomata. Hairy and pigmented moles often occur congenitally. Peritonitis. — Fetal peritonitis is usually due to syphilis. It manifests no symptoms at this period, but if not destructive to the life of the fetus, it is likely to produce some constriction of the bowel. It also occurs in infants in connection with puerperal fever, especially in lying-in hospitals. The path- (tlogieal conditions correspond with those found in similar cases in adults. Pericardial and endocardial inflammations rarely occur, and the latter is more often located in the right side of the heart, and may leave lasting val- vular changes. 7. Struma. — Struma of the thyroid gland must not be confounded with edonia of that structtu'c. While edema occurs as a traumatic injury, true struma is an hypertrophy of the thyroid. Edema results from face presenta- tion ; hypertrophy may produce the same. Struma may be complicated with ('(lonia, which, however, will only be temporary. 8. Intra-uterine i/isEASEs OF THE Xervous System. — There are of the brain a uund^er of defects which are congenital in their origin, and which Inter manifest themselves as some forms of deaf-niutism, cretinism, idiocy, and otiier forms of ])artial or complete loss of development. Hypertrophy ul" tlie brain sometimes occurs, associated with rachitis. m If r ill •" ' 310 AMERJi'AN TEXT-nOOK OF OBSTETRICS. i I r; Hydrocephalus. — Fetal hydrocephalus is not common and its etiology is not understood. According to Meigs, it is due to an inflammation of the lining of the ventricles. Jt often ])r(xluces a hideous defornuty, due to pro- trusion of the eyes and ])rojection of the Ibrehead (see page 259). Cretinism is endemic in some mountainous districts of Europe. It is often associated with eniargement of the thyroid gland. Syphilitic Idiocy. — Manifestations of syphilitica idiocy are recognized after the period of infancy. 9. Dkath iw THE Fetus. — In presenting this subject a repetition of what has been said under Abortion (page 259) can hardly be avoided. The causes resulting in death of the fetus before maturity may be consid- ered under the following heads : (1) In the father, — alterations of semen, as in phthisis, albuminuria, etc. (2) In the mother, — general diseases, excitability of the uterus, and marked lesions of the same. (3) In the fetus — or faulty development. (4) In the annexes of the fetus — membranes, placenta, cord. (5) External violence. (1) Causes resuU'my from the Father. — Conditions producing great debility in the father are liable to manfest themselves in a low degree of vitality in the oflfspring, and often before the time of birth ])roduce death in the embryo. Old age in the father, chronic poisoning, albuminuria, and phthisis are likely to be followed by this residt, but the most frequent cause from the parental side is the transmission of syphilis from the father. The embryo may show signs of this disease without the mother being infeoted. Death of the fetus is explained in various ways. The fetus itself may be of low vitality, or the membranes may become affected in a way to interrupt life. Syphilis may produce hypertrophy of the villi of the chorion (Schroedor), jiroducing sufficient pressure on the maternal vessels to render imperfect tlic interchange of nutrition between mother and fetus. The more recent the infec- tion of the parent the more likely is it to produce death of the fetus and abor- tion. Rupture of one of the viscera may cause death of the fetus. J. W. Ballantyne cites three cases in which rupture of the spleen was the immediate cause of death within two days of delivery. One case occurred during Prof. A. II. Simpson's service, and the post-mortem examination was made by tlic writer; death occurred two days after labor. The second case is one reported by Charcot (1858), in which a stillborn infant had been resuscitated and lived half an hour. The third case was reported by Kleinwiichter (1872) : a pre- maturely born infant, weighing four and a half pounds died in four honis. 2. Cmm:s reuniting from the Mother. — The influences from the mother lead- ing to death of the fetus are numerous. Acute infectious diseases of the motliei come under this head. It has been demonstrated that high temperature and anemia of the mother are liable to interrupt gestation by premature uterine otrntraetion. Tuberculosis, carcinoma, nephritis, and diabetes of the motlier often cause peculiar excitability of the embryo; the nervous system of the THE PA'nH)lA)(iY OF PRKUNANVY 311 motlier will likewise bring about this comlition, the motor nerves responding to very slight irritation and setting tip uterine contraetion. IMithisis of the mother sometimes produces premature labor, sonietimes abortion. Death of the fetus on account of tuberculosis of the mother is not usual, but frequently the child is poorly developed, and if it survives remains feeble. Wliether this feeble condition is due to lack of resistance or to intra-uterin< jr latent disease cannot now be decide. II ml ObMvlncn, l.S!t4, No. Ti. 1". \'im (liT Vi'LT ; Jiiiirnnl Aiiuriain MiiUcitl ,U-«iri1, No. .'")(). 4.S. 20. Moller : Cenlntlblalt /. Uijiiakijlixjii', 1802, No. (i. 49. 21. Taylor: M,,Url. .StrasMinann : Munntxrhri/l f. Geburtshiilfe, ' 55. ]{(1. xix. S. 242. I 29. Dolirn : Momlxclirift /. Geburtshulfe, Rd. 56. xxi. .S. 375. 30. Giis.>. 484. (io. 38. Coe : Ameriran (TynecologiculJounuil,l><9l, No. 9. i liG. 39. Thomson : Deiilnrhe mecUcinische Wochen- Kelirifl, 1SS9, No. 44. Cu. 40. I'olaillon : ArrhiivH de Tocologie et de Gyne- 08. cologie, xix. p. 729. 41. Ruge : CentralbUitt f. Gymikolnc/ie, 1890, I 69. No. 30. ... I 42. Schroeder, Olshausen, and Flaischlen : 70. Zeitxchnft /. Geburtshulfe, 1894, Rd. 71. 29. 43. Dsirne : Archie f. Gyncikologie, Rd. 42, .S. 72. 41."). 44. Manj^iagalli ; Berliner klininche Wochen- i 73. xchrifi, 1894, No. 21. j .Vcconci . "I)ei cistotne ovnrici in rap- porto allc funxioni Ki'"i''''itive," Milano, Tipiiyr. Jierhiri, 181S9. Terrillon : Airhiren de Tneologie, .\pril, 18SH. Klirendorler: Archie /. Gyniikolni/ir, Rd. 34, Hit. 1. SiiUKer : ( 'enlrnlbliill f. (lyniikolni/ie, 1894, No. 7. Winter : Zeitxchri/t /. Gebiirtxhiil/e, Rd. 14, Hit. 2. Kissman : Centralblnll J. (lynaki)logie, 1892, xxiv. J). 452. Virginin Mediiol Monthly, 1888-89, xv. (!7<). Martin : Dentxehe medicinixche Wochen- xchrifl, 1889, No. 39. Trenh : yeilerlondxch tijdxvhrift rimr Ver- liixkiiiideen Gynipcolngie, Jalirfjf. iii. No. 3. (cottschalk: Archie J\ Gyniikulogie, Rd. 40, Hft. 2. Rarl)our: Edinburgh Meuicid Journal, Kept., 1894. • Cohnstein : Archie f. Gynlikologie, Rd. 33, Hft. 1. Renckiser: CentridblattJ. Gynlikologie, 1887, No. 51. Davis; InlernationnI (linicx, 1894, vol. 3, S. 4, p. 275. Trantenrotli : Zeitxchri/t f. Geburtxhiilfe mid Gynlikologie, 1894, 15(1. 30, lift. 1. Fischer : I'rager inedirinixehe Wochenxchrift, 1892, No. 17. Scluuita : Internationak klinixche Itnndxi'limi, 189-\ No. 27. Meyer : Zeitxchri/t /. Gebiirtxhid/e, Rd. Ill, lift. 2. Laiitos : Archie /, Gyniikulogie, I'l'.. 32, Hft. 3. Herman : Lancet, .Jan. 13, 1894. Roudin : Journal de Medecine de Paris, 1893, No. 22. Kol)liUick : Zeitxchri/t /. Gynlikologie, 1894, Rd. 29, S. 208. Rerlieroft': Vnich, 1893, No. 10. A'oituriaz : Archieex de Tocolngie, 1890, No. 12. Randolph : Bulletin Johnx Ilopkiux Jlns- pital, 1894, vol. v. No. 41. I'^chroeder : Lehrlmeh der Geburtxhiilfe, IS'.ll. Gow : Edinburgh Medical Journal, 18.SS, part ii. Storer : Boxton Medical and Surgical Jour- nal, 1892, cxxvii. pj). 377, 379. Jardrin : Glaxgoie Medical Journal, 1892, xxxvii. 417, 422. TITK rATHOLOaV OF PREaXANrV .315 71. Sutii)fiii : ZfilMhriJI J. (ieburtMlfr, xxiv. 103. |>. *2M(I. 75. ISiulin : Pmirh Midirtile, 1888, Nos. 2, .'<• 104. 70. Kiiliiiow ; Airhir f. (lyHahtlmjii', 15(1. ;<•'), lift. ;«. lor). 77. I)rivfr: limttm Mfrlintl iiiiil Siirfilrnl Jintr- mil, St'pt. 1"), 1887. 100. 78. DiilirsHi'ii : Archil' /. (hjudkohijii; Ikl. 43, lilt. 3. 107. 79. Budiii : Iai Neimine Mfilicnk, 1893, No. .\ix. p. 141. 108. 80. Cliiiriionticr: ArckireA ik Tornhr,i,; 181)2, lO'.l. No. 2. 81. Prutz: Zeilwhri/lf. Gehnrlshiilf,; IM. xxiii. 110. lilt. 1. 82. I'illiot and Delimsornu' : liiilhlln tie In So- | 111. rit'le Aimhmuiiiic ili- J'nri^, 1802, No. 8. ' 112. 83. Fisi'liiT ; PriKjer iin'ilieinixchf Worlifnxrhrijt, 1892, No. 17. 113. 84. IMiuic; Lnoii.1 Medicali; 18<)0, No. 38. 8"), Piipillon iiixl Aiuinin : Hiilhiin de la Sii- 114. riele Aiidinmique di' I'lirlx, 1891, vol. vi. I p. 303. I 11. -J. 80. KofltT and Ktiiulrat : Wlfiiir klinkche \ Wiirh'UHvhnfl, 18111, No. xx. 87. (ierdcs: Mihivhrner inrdifiiii.irln' Wiichen- 110. schri/l, 1892, No. xxii. I 88. Tarnier and ('liaml)rc'lont : Aiimden di- (lijiivciiliKjii', Nov., 1892. 117. 89. LauK : Arrhiivn dr Tnrohf/ie, 1892, No. xi. 90. Herman: ^lincricdii Jiiiini., I8,S1I, p. IM). NapiiT : yorth Carolina Medical Journal, March, 1888. Mackav : Lomlon Lancet, 1891, vol. ii. p. 1.388. Braxton ilicks: Tranmctinn* London Ob' Hletrirnl Sorietij, 1811], xxxiii. p. 48(), McCann: Triiiinaetionn Lomlon Obnletrical Societji, 1891, vol. xxxiii. pp. 413-48.'). ( towers : IHxeaM's of the Xernniit Si/steni. Ilandlield -Jones : TrannaetionK London ObMetrical Societij, 1889, vol. 31, p. 243. Bue : La Prenne Mi'dicale, Sejjt. 1, 1894, p. 279. ( lairdner : (llaMi/oir Medical Journal, 1870. I'antzer: Cenlralblatt f. llyniikoloijie, 1890, No. xxxii. Shoot : yederlamlKcli, tijdxchrifl voor Genees- kinide. SolowieiF: Ccntralhlalt f. Gyniikologie, 1892, No. xxvi. Matthews Unncan : Traumctionn Obxtet' rical Society, 1882, vol. xxiv. pp. 250- 285. ( )ddi and Vicarelli : Lo Sperimeutale, Fitseicolo No. 2, 1891, Memoire Origi- nali. Fry : J'ranKactioun American Gynecological Society, 1891, vol. xvi. Ilehir: Indian Medical Gazette, March, 1892. Feinl)erg : Centralblull f. G yniikolof/ie, 1890, No. vii. Davis: 7V((/i.s(/W/o».s American Gyneco- logical Society, 1S1I4, vol. 19, p. 110. Lindcnmann : ( 'entralblutt f. I'athologie, 1892, No. XV. Copeman : "A Novel Treatment of Obsti- nate Vomiting in l'ref;nancy," liritiKh Medical tlourual, May 15, 1875. (irant: Montrrid Medicid Journal, 1891, vol. xix. Koland : Xourellex Archiren d'ObKlitrique el lie (lynceoloijie, 1893, No. vi. Blanc: Archirexde Tocoloi/ie, No. vi. 193. Kinjrman : lio.slon Medical and Surgical Journal, vol. 77, p. 427. .Mdt'eld : Cenlralblatt f Gyniikologic, 1891, No. 17. (innther: Cenlralblatt f. Gyniikologic, 1888, No. 29. Siinger and Ilennina;: Miinrhencr medi- cinisehe Worlien^chrift, 1888, No. 28. Florentine: American Gynecological Jour- nal, 1892, vol. ii. p. 149. J 316 AMERICAN TEXT- BO OK OF OBSTETRICS. , ! I r 131. Clay: Chim, p. 321. 176. BallaiityneandMilligan : Edinburgh Med- ical Journal, July, 1893. 177. Meyer : Zeitschrift f Gelmrtshiilfc. M. 14, lift. 2. 178. Remy: Archives de Torologic, 18^4, No. (!. 179. Mann; London Lancet, 1891, p. 610. 180. Wallich : Annales de Gynecologic, June, 1889, p. 439. 181. Klaiitsch : Miiuchener medicini.ichc Worh- ensehrift, 1892, No. 48. 182. \ iiiay : Archives de Toeologic, 1893, No. 3, 183. ^larkus : Prayer medicinische Wochch- schrift, 1890, No. xxi. 184. Dakin : Transactions Jjondon Obstetrical Society, vol. 33, p. 163. 18.5. Stocker: Centralblatf f Gyndkologic, \S\t2. No. .32. 186. Flaischlen : Ccntralblatt f. Gyndkologic, 1892, No. 10. THE PATHOLOGY OF PliEGXANCV. 317 187. Dsirno : Archiv f. Gyniihtlmjie, lid. 4;5, 200. lift. 3. 188. Polaillon : IhiUelin dc I'Academie ile 201. Mdecine, Paris, 1892, vol. 28, p. 14(). ISit. Kreutznuiii : Occidental Medical TiniCK, 202. Aug., 1892. 203. 190. Doran : Transacliom London Obstetrical Society, 1891, vol. 33, p. 112. 204. 191. Tiffany : Transact iom American Surgical Associntion, 1888, vol. C. 205. 192. Beliii: JMletin MMical du Nord, 1878, vol. 17. 193. Richard: BiUletin Medical du Nord, 1878, 20(). vol. 17. 207 194. Harris : American Journal of Obstetrics, vol. 20, j). t!73. 208. 195. (,'orcy : American Practitioner, ^i\\)t., 1S78. 19(). Rydygier: Proceedinys Congrens Go-vian 209. Suryeon-s, 1887, No. 12. 210. 197. Petit: Thesis, 1876. 198. Keelan: lirilish Medical Journal, 1887, 211. p. 825. I 199. Prozowsky : Vrach, St. Petersburg, 1879, 212. No. 6. I IJancroft : Medical and Surgical Reporter, 187t), vol. 34. Lihotzky : Centrnlblatt /. Gyniikologie, 1892, No. xxiv. 489. Milner : Medical Xews, Ixi. 24.3, 244. Neugebauer : Centralblatt f. Gyniikologie, 1890, p. 88. Fancoii : Journal rftvf Sciences Medicates de Lille, 1883, p. 241. Tift'auy : Transactions Medical and Chi- rurgical Faculty of Maryland, April, 1884. . Tiffany : Medical News, Ajiril l(i, 1887. Hint: American Journal of the Medical Sciences, vol. 81, p. 18(>. Pilclier : Provincial Medical Society, King's Co., 1879, vol. 3. Keen : Medical News, March 2(), 1892. Rasch : Zeitschrift f. Geburtshiilfe u. Gynii- kologie, \k\. 25, Hft. 2. Vickory : Boston Medical and Surgical Journal, 1890, p. 413. (jerilcs : Centralblatt f. Gyniikologie, 1890, No. 45. w \- l(>. Ill . I i I II m m-i ^ i I;-, 1 l^ww 1 1 1' ^! ■ ■ If III. LABOR. V \i% I. THE PHYSIOLOGY OF LABOK * Definitions. — Labor is the complex process by which the ovum is severed from its connection witli the motlier and extruded or extracted from the ma- ' ternal oriranisifi. The term normal hibor (eutocia) may be restricted to labors with normal factors that are terminated by the natural forces, or it may be narrowed down to include only vertex presentations in anterior positions under right conditions. Di/Kfocia, or ditticult labor, includes all forms of abnormal or complicated deliveries near term. Premature labor refers to the premature birth of a fetus which has reached the period of viability or of sufficient de- velopment to live independently of the mother. Mm-arr'uKjc, or inunature delivery, is usually restricted to the expulsion of the fetus from the third month until viability, although it is often used as a synonym of abortion, and is the lay term for that event, "abortion " to the layman denoting criminal intent. The word abortion is reserved for the expulsion of the ovum in the first three months. Causes of Onset of Labor. — What constitutes maturity or ripeness we do not know, and in the indetiniteness of our knowledge " we refer the matter to a law of the organism — a law the cause of which we do not know." The termination of j)regnancy is due to some combination of conditions, no one of which, singly, will account for the occurrence of labor at two hundred and eighty days after the date of appearance of the last menstrual period. Briefly stated, the chief fiictors are — 1. Increasing irritability, witli strengthening intermittent contractions. 2. Changes in the decidua — loosening, thinning, and thrombosis. 3. Excess of COo and lessened oxygen in the placental blood acting on the motor centre for the uterus in the medulla. 4. Increasing tension on fully-developed muscular walls. 0. Stronger fetal movements in more confined space. G. Partial relaxation of the cervix. 7. Menstrual periodicity (tenth period). 8. Habit and heredity. 9. Exciting cause — exercise, sM'^uch as the second, third, and seventh, it is espe- cially marked, and there is evident disturbance both of the neighboring nerves and of uterine ganglia in the first and last trimesters. InteraiitteuL contractions occur regularly in the non-gravid uterus, they * The ifiiprrior fifiiires ( ' ) occurring tlirougliout the text of this section refer to the bibliog- riipliy givt'ii nil ]i;ige ;i40. .318 tht THE PHYSTOLOGY OF LABOR. 319 arc distinct from the very boginniiig of pregnancy, tliey stcatlil)' gain in strength daring its progress, and at its end hardening and prominence during contractions may always be found. The dividing-line between contractions and true labor-pains is not easily drawn, and as soon as the ovum becomes a ibreigu body by beginning separation more vigorous action is ensured. 2. The changes in the decidua arc well epitomized by Lusk:' "The re- searches of Friedliinder, Kundrat, Engelmann, and Ijcopold have demon- strated that the decidua vera of pregnancy is distiuguisiiable into an outer dense, membranous stratum, comj)oscd of large cells resembling pavement epi- thelia, probably mctainorphos(!d cylindrical cells, and an — in appearance — underlying mesliwork, ibrmed from the walls of the enlarged decidual glands. It is in this spongy layer that the separation of the decidua takes place, the fundi of the glands persisting even after the expulsion of the ovum. By many a fatty degeneration of the cells of the decidua has been observed toward the end of pregnancy, but Leopold, Dohrn, and Ijanghans have shown that this is not of constant oceuirrencc. The traljcjcuke w'hich enclose the spaces of the network diminish in size with the advance of pregnancy. Thus, while they measure at the fourth month about j,^ of an inch in thickness, they become gradually reduced in the subsetpient months to -^-^ of an inch — a change which materially facilitates the peeling off of the decidual surface. "From the fourth month onward large-sized cells make their appearance in the serotina, especially in the neighborhood of thin-walled vessels. The largest of the so-called giant-cells contain sometimes as many as forty nuclei. Though a physiological product, they resemble for the most part the so-called specific cancer-cells of the older writers. They are of special obstetrical inter- est from the fact, observed by Friedliinder and confirmed by Leopold," that they penetrate the uterine sinuses from the eighth month, and lead to coagula- tion of the blood ami to the formation of young connective tissue, by means o!" which a portion of the venous sinuses becomes obliterated before labor besrins. The subtraction of these vessels from the circulation tends to increase the amount of the venous blood in the intervillous spaces of the placenta." ;3. Brown-Se(piard found by experiment that an excess of COg circulating in the blootl of a gravid aninutl excited uterine contractions, ami he claimed that this excess of the gas was the pi-oximate cause of labor. His theory lacks conclusiveness, however, because it does not explain why the COj postpones its irritant action until the end of the ninth month. Lcopohl believes that the excess of Qi)., in the placental blood is the result of venous hyperemia of the placenta, produced by the spontaneous thrombosis in the veins of the placental site at the end of pregnancy, while Flassc credits it to certain changes in the circulation of the fetus — chiefly in the crossing blood-currents of the right auricle and shrinkage of the ducius venosus and arteriosus. Spiegclbcrg tcaciics that at maturity the fetus rc(pii:'"s some new sub.-tance not supi)lied by the ]»lacenta, and that it dies (as in extra-uterine ])regnancy) if it does not obtain it. wliile chemical substances no longer required accumulate in the l)lood and act as irritants to the spei'ial nervous centres. ' <1 : >^ IM ■:. I .i"' > \-»ii^L^ >■■■ ^Mt^ i ■ ■ 1 I m 320 AMERICAN TEXT-BOOK OF OBSTETRICS. 4. Power iu 1819 called especial attention to over-distention of the uterus as a causative factor iu labor ; it can admirably be demonstrated by analogy. As the over-loaded stomach or the rectum rejects its burden, so the over-dis- tended uterus rebels and expels its contents by the contractions of labor when the mouth of the organ begins to be distended. The occurrence of ])rematuro labor iu hydraninion aud multiple pregnancy sustains this theory, but, on the other hand, it does not account for labor-pains in extra-uterine pregnancy. The extensibility of the uterine wall has a limit, and when this is reached the ovum. in its growth presses more and more upon the iuternal os. This })ressure excites a special set of nerves and brings about uterine contractions, just as the contact of the drop of urine at the neck of the distended urinary bladder ex- cites contraction snd evacuation of that organ. A theory of this nature brings up the question of the innervation of the uterus. Through what set or sets of nerves does the uterus receive its motor impulses during labor? The nerve-supj)ly is largely from the hypogastric and ovarian plexuses of the sympathetic system. The cervical ganglion receive:-!, in addition to its extensive connections with the lympathetic, filaments from the second, third, and fourth sacral nerves. Rut Lusk and Jacquemart report cases of successful labor in patients sutf'ering with paralysis of the lower ex- tremities, retention of urine, and incontinence of feces — a state of affairs which would lead one to discount the imjjortance of the rdle ])layed by the filaments from the sacral nerves. On the other hand, the experiments of Schlesinger'^ argue against the exclusive source of motor-supply resting with the symi)a- thetic, for he was able to elicit reflex movements of the uterus by stimulation after severiiiLT all the branches of the aortic plexus. Whether he may not have overlooked some of the slender nerve-filaments in cutting the branches of the aortic plexus is a question worthy of consideration, and the possibility of such an error detracts from the value of his experiments and the weight of the conclusions to be drawn from them. The uterine ganglia have a certain independence of action, such as the cardiac ganglia possess, since rhythmic con- tractions by both may be kept up after separation.^ Brandt has shown that massage of no part of the pelvic contents will prodMc< contraction in the non- gravid uterus so rapidly as manipulation of the (supravaginal) cervix, and the writer has demou«+rated this for the early weeks of pregnancy.'^ Whatever the chainiels of nerve-force may be, there has been ])roved to ex- ist in the medulla oblongata a motor centre for contraction of the uterus that may be excited to action by COj in the blood, by anemia, and perhaps by tlic toxic substances retained in the blood of one suffering from nephritis. At full term something stimulates this centre to acdvity, with a complex, co-ordinated .set of muscular contractions as the resultant. Moreover, it is supjwsed l)v Schat/ (hat the uterus possesses an inhibitory centre which is active throughmit j)regnancy, but wliicli for some reason ceases to ad at term. G. A diminished resistnnce in (lie lower birth-canal is to be noted. The cervix is fully softened, the pelvic floor is edematous and relaxed, and (he uterus and its contents often sink low in the pelvis. THE PHYSIOLOGY OF LABOR. 321 7 Tlift tlioory udvuiioed hy Tylur Smith to the olfwt that the tenth period of ovarian excitement incites the nervous ap|)aratus of the uterus to activity is of some force, since prej^naney is often interrupted at menstrual epochs ; but it is open to the same objection as that just mentioned, for it does not make phiin wily the nintli or eleventh j)eriod iliils to effect the same result. ^lore- over, single ovariotomy has been jx-rformed many times, and double ovariotoiny a few times, during pregnancy, without perceptibly influisncing its course. 8. Many multiparie tbllow the same rule in a series of pregnancies. Tu other cases great variations are seen. 9. Filially, with all things ready, an unimportant, i)erliaps accidental, occurrence, such as slight increase in intra-abdominal [>ressure from walking, stair-climbing, coughing, or straining at stool, as well as any mental irritation (anxiety, care, anger), may be the exciting cause. We iiuve been dealing, then, with deteriiiining causes, factors in a phe- nomenon, noiK^ of which can establish a claim to be considered singly and absolutely causative. Wiiickel sums up by saying that labor is the total of several causes which may enter into different combinations to accomplish the same result. liusk takes substantially the same ground, and Barnes observes that the determining causes act synergetieally, not singly. The fetus is mature, ready to undertake the complex acts of respiration and digestion ; the imperceptible uterine contractions of several weeks have loos- ened the attachments of the decidua, whose trabecuhe have grown much thin- ner and capable of easy rupture ; the uterus by distention, pcrhaj)s by increas- ing pressure of the fetus oi> the internal os, has grown very irritable, the lusty inmate augmenting this condition by the force and frequency of its movements. The maternal blood contains an increased (juantity of C"()^; venous thromboses in the uterine wall near the serotina and in the si'rotina itself obstruct the cir- culation and cause stasis of the maternal l)lo(,(l reMirning from the ])Iacenta ; the cervix uteri becomes soft and dilatable ; the advent oi" the tenth menstrual (late, with increased congestion and irritability of all the generative organs as a conse(iuence, adds fuel to the pile ; the unknown factor deposits the spark at the centre of uterine contraction in the me(lulla, and lal)or has be juii. The Phenomena of Normal Labor. The ])hysiology of the processes concerned in the expulsion of the fetus includes a stutly of the action of the uterine walls, the uterine ligaments, the abdominal muscles, and the vagina; the changes induced by labor in the cervix, in th(> lower uterine -(•gment, and in thf IxmIv of the uterus; the viuiations in the |)resenting pouch of membranes; and the character of the li(jiior anuiii, the formation of the caput succcdanenin. and the ciianges in the |H'lvi(^ floor. Then the t-linical character of the three stages of labor will i)e ciinsidered, leaving i[iic>tions of mechanism and management for later sections. Uterine Contractions. — The uterine ciintriictions of labor go by the name III' "pains" in all language-^, including tiie speech of the scienti.st, because 111' the sulfering iiiscjiarably associated with tiicin. The <'nnxr of this sulf'criiif/ 21 I '4 ■ ':1IH1' |i >;: 'V «K Hi i; P- ''^-i rMi t w 'j 1 1 '■' : ■ (i M: 'iM »'■"■*■-■; T ' 1 I; [■ , i, ■ <>' 1 I / '1 1 I 1 3'22 AMERK'AX TEXT- HOOK OF OIIHTKTRIVS. is the coinprcssiuii of" the uterine nerves hetween the contracting nuiscular fibres, the tension of tiie external os and lower uterine segnjcnt, the stretching of" the nterino ligaments, and the pressure of" the advancing fetus on the nerves of the vagina, the vulva, and the neighboring structures. ^Moreover, hyper- emia of the lower end of the cord and its envelopes is jirobably in part respon- sible for the distress. The looaVion of the ^)nm is, at first, in the hunbo-sacral region, and later in the abdomen or down the thighs. The most severe degree of ])ain is felt at the vulva as the head passes. The onset of the contraction is more ra])i(l than the decline. The pain begins suddenly a few seconds after the beginning of the contraction — as may be seen by the bulging foi'ward of the fundus or be felt by the examining hand — reaches and retains f"or a f((w seconds its acme of intensity, and then gradually subsides. If each pain l)e divitled into ])eriods of increase, acme, and decrease, the acme will occu])y the greatest length of time of the three divisions, the total duration of a pain being about one minute. The suffering is commoidy more severe in very young or in elderly priniiparje than in those in the prime of ]>liysical life. Susceptibilitv to pain, and general vigor, have nnich to do with the anunuit of anguish experienced, it being among serene women and dull-witted and sturdy-limbed hospital patients that we oftenest see quiet labors. Painless deliveries have been reported, but they are rare. The muscular fibre of the uterus is non-striated, and the contractions, as in all organs of like histological stri'.cture, are pcrifi/(i(\ invninntavy, and intrr- mitfcnt. Contractions sweep over the uterus in a peristaltic Avave, probably travelling from the opening of the Fallopian tubes down to the cervix, reaching a swift acme, and subsiding within twenty or thirty seconds. Waves in both directions have been observed in the uteri of .some of the lower animals. Though mainly controlled by the sym])athetic system of nerves, and hence inde- ])endent of the will, the pains are nevertheless influenced to some extent by the brain — a fact demonstrated by the ef!"ect of fright or of excitement in retarding or even in stopping labor. The pains last from thirty to ninety seconds, and the peristaltic action from twenty to thirty seconds ; the interval is about thirty minutes at first, whereas at the end of labor it is but two t(j three mimites, and nearly disappears as the head emerges. Symmetrical pains often occur in groups, f"ollowed by shorter or almost abortive pains. As to tho force exerted. the pressure during the height of a pain never exceeds 100 millimeters (4 inches) of mercury, the average being 60 millimeters ('JJ| inches ; Schat/), TiCaman measured the force with which the head atlvanced (r^ot the force with Mhich it was proju'lled), and found a high pressure to be five jiounds. Forcep- was required where it did not exceed two and a lialf pounds.'' The force of the pain remains about th.e same during the entire labor, or it may increase by a fourth, and this with no regard to weariness on the part of the patient. Tin force does not increase with the resistance offered, but the ]>ains sinqdy beconi" niore frequent and last longer. The type of the pains is nearly constant in \\\v same patient (Schatz). anc |i THE PHYSIOLOGY OF LABOR. 323 Fui. ICC).— Pulpntion of the cervix before la- bor. The two rintrs ure shown, with tlie tinner-ti)) toueliiiif; wlmt iiiay lie called clinieally the " iii- ternnl os " (one-lialf natural size). The amount of force exerted by the pains \s sui)p().>^o(l to riiii;ter- iiig tifty-Hve pounds as the maxinnun. An ob.stctrician knows that all the nni,<- cidar ])ower he possesses is sometimes insufficient to prevent rapid expulsion of the head. The changes in shape in the uterus during contraction are markei]. In the quiescent state it re.sts against the spinal column, ovo'd in shape, the transverse exceeding the antero-posterior diameter. During contraction these diameters be- come about e(pial, the titerus assumes an ovoid or somewhat cylindrical form, and by means of this increase of «^he antero-posterior diameter and the con- ti'actile action of the broad anil round ligaments the fundus is forced forward ay-ainst tlie abdominal wall. At the same time the uterus becomes longer at the expense of the lower uterine seg- ment and the cervix (Fig. 23(5, p. 42")). Action of the Ligaments. — The uterine ligaments — the round ligaments, the lower part of the broad ligaments, and the utero-sacral bands — contain much muscular tissue which is directly continuous with that of the uterine wall. Contraction of this muscular ti.ssne occurs with each pain, and serves to fix or to .steady the uterus in position at the brim, and to a.ssist in lifting and liolding it at an angle favorable for exi)ulsion of the fetus (Fig. 211, p. 38S). Action of the Abdominal Muscles. — Next to the uterine contractions the force of the abdominal muscles is the important expulsive agent. We include all those nuLscles that fix the thorax and pelvis or narrow the abdom- inal cavity. The resultant of the forces ofthe.se muscles lies parallel with the axis of the superior strait (Winckel ; see Fig. 211, p. 38S). The action BiX'>"">'.^' i/iiattition of intiriiiil OS, Flirt Iwr liilatation of iutt'yniil os. Conif*lcte fj^tiLCtitt'nt of inti'riuil os, iK'ith sharp t'xtt-rnal os. £-o Fifi. 1(')7.— Diagram showing; the sensation to the exaniininn linger of wiileninj.' and elliiee- iiii'nt of the internal os dnriiin dilatation of the iervi.\, and the knife-like eil^e of the external OS (one-liulf natural size). r ^&>\ .11 in ' Uii \ ■ \ ■ Hi i :| 324 AMERICAN TEXT-BOOK OF OJiSTETRIVS. \ ( 1 : I' ■ J on tlic part of the woman is V(jluntarv at first, bnt bocKMios loss so as labor advance's, as sliown by her inability to withlioUl strong prcssnro at the time when tlie pelvic floor is endangered. .i/,-(///' y. n,\iili<,t. '^ ' J^',Lf>;vrr uterine se/;ment. 'ostmor vaciutil 'vail. Fid. If*.— Secliuii ul' iiTvix at torin (Wiil- deyer). Tlii' iiTfuuliir hlutU'il lilack marks with- in till' ciTvical canal, riiiiiiiii!,' to tlii'iiii'inliraiies, (li'iKito iiiiiciiiis iiiciMliraiu' nf cervix ; llio dc- ciiliia runs in a wavy line bcnc.Uli tlic nieni- branes. Such assistance to the uterus is not absolutely necessary, for labor nuiy be accomplished in the absence of the action of these external forces, as in paralysis ; but when the head lies in the pocket Ibrmed by the curve of the sacrum and the partly stretched |)elvic floor, having to turn nearly a right angle in its course, the power brought to bear by the abdominal muscles is of very great moment. From the atrophy of the truidv-museles due to corset-wearing, failure of force at this crisis often calls tor forceps extraction. The uterus is raised by the round ligaments so that abdominal pressure acts to better advantage. The uterus is compressed from all sides, is supported by the pelvic walls, and is arrested in attempts to slip downward by the utero- saeral and brt»ad ligaments and the sacral ciu've, while its contents are j)ressed out. The increased tension on all the contents of the trunk sends blood to the extremities and flushes the face of the patient. Be- low the pelvic brim the pressure is not brought to iu'ar, and conges- tion produces edema ;ind softening of the cervix and pelvic ilonr. At times the child is expelled with considerable force by means of this added power, and the uterus may even be inverted by these ettbrts of the external nuiscular structures. Action of the Vagina. — At first the vagina opposes some obstacle to the advancing head. When, however, a large circumference has passed, any onwai'd motion may receive slight aid from contractions of the vagina. Figiue 185 (p. l)-'»()) shows how the vaginal walls are smoothly fitted to the ehikl even after the exit of the head has <>i'eatly distended the passage. Changes in the Cervix during Labor. — Although palpation of the exter- nal surfiice of the cei'vix may give the impression of a smooth ex])ause of stretched rubber around the opening, yet when the finger is passed within tli<' cervical canal as far as the membranes, is hooked forward, and then slowly withdrawn, one detects two well-defined rings with a 1- to 2-inch (.'?.5- to "i- centimetcr) pas.sage l)etween them, and fiiuls that this pa.ssage has yielding siili; Viis^lna. Kiii. liv.i.— Cervix of multipara at bcu'liiniiii.' of lal)(ir; the internal us is at llio edge of the crater (frozen section, Winter). THE PIIYSlOLOfiY OF LAIiOJi. 325 Rt-jU'i tt'ti iiitttihyaiu's. posttrior \~ V Ktxtunt, Fi(i. 170.— Cervix of five iind a hnlf months' primipara in •lilatation period, witli marliiMl irregularity in i>ro(;ress of tlilatalion ol" posteri the trne iiitornal os, or only the ui)per limit of the vaginal jjortion of the cervix, we may he allowed to call it, for dinicjil pni- poscs, the internal os, since we need to watch it.s be- havior during the dilatation .stiige. At the beginning of labor in the primipara the cervix i.>; barely pa.-guii. But an inner edge may u.-^ually be distin- guished (Fig. 170) until the early labor-])aius* or the threat e n i n g preliminary pains begin. The effect of such early pains in com- mencing the dilatation of the cervix in certain cases is shown in Figure 175. In multipara; labor is likely to pull back the whole cervix bodily, but with .some thinning and with a somewhat irregular edge, (iradually the circle widens until it merges imperceptibly into the uterine wall, leaving, as a rule, to represent the external os, a slightly raised encircling ring in the wall of the curved birth-tube 3 millimeters (3, inch) in thickii(>ss, located against the back of the symphysis in front and halfway up the sacrum behind (Fig. 134). The wall of the cervix is then 2 millimeters (^\ inch) in thick- ness, and the cervix is said to be ctlaccd. The anterior lip may be nipped betv een the bony ring (pelvis) and the ball of bone (fetal head) and become elongated Fin. 171.— Dilatinj; cervix of eitilit months' primipara, with Iironouneed thinninK of posterior lip (Winter ; frozen section, two-thirds natural size). ;^- i m 1 326 AMKRIVAX TKXT-IiOOK OF OBSTETRICS. aiul odt'iiiatous, even to the cxtt'iit of ivppoariui; at the vulva , usually coincide. The lower segment dilfers distinctly from the upper, to which it belongs f^^-^. rO^ 1^. ^ \N ».\5 i!>< % A, IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I L^12.8 |2.5 us lii |2.2 I," u 114 I lio 12.0 L25 iU lil.6 Photographic Sciences Corporation 1i WI'.T MAIN STRIBT WEBSIIR.N.Y. 145S0 (71*) «/2"*S."J ^o 6^ ■ »■ 1/ t al. HODY OF UTEKl'S. LOWKIi ITKHINE \ SKO.MKNT Contract Ion ring. CEKVIX. Internal n». I (Miillor's riiij;.^ [ External on. /iriiUH, A'Ushtt-r, Buyer, et al. Iiiteriinl os (or Kiiigof Bandl). (Braun's isthmus.) ExternnX oh. Bony OF urnKus. isvHonytiti'its H'ith /,>-,ivr uterine sef- Hunt). Fi(i. 17:!. — Dingrnin illustratiiiK the two ti'BchlnKs luicnt tlio lower ulorine si'Knicnt and the cervix Oil tlie left side nil iiiteriial os has l)een added for the sake of eleariiess, althuiigh in tlic frozen sections of women with full dilatation it is rarely apparent macroscupically (one-third imtiirul size). the briefest outline, however, t)f the voluminous controversy ^^ can be given, and the opposite side stated. The older theory held that toward the end of pregnancy the upper portion of the cervix was expanded and drawn up to form part of the general uterine cavity, leaving only the small vaginal por- tion of the cervix below. Braun, whose section is given in Figure 134, l)elieves that the semicircular ledge with the large vein (Kranzvcne) is the in- ternal OS, 10 to 11 wntimeters (4 inches) above the external os; Bandl confirms this. He now believes,'^ with Kiistner, that in first labors the mucous nvm- brane of the dilated portion of the cervix — the lower uterine segment — becomes torn or stripped off, and subsequently there is formed upon the denuded surface a new membrane not distinguishable from that of the corpus, which in future pregnancies is capable of forming a tlecidua. Bayer '^ concludes that " the ex- , 'II THE PJIYSIOLOGY OF LABOR. 329 Closely iMlerwdfen \ layers. « :? Limit of firmly ail- hereHt peri- toneum. I 6; (3 RetriUtion-ring. << Easily sepa ral'le layers. cessivcly tliin decidna of the lower uterine segment pusses into eervical mucous membrane on the jiosterior wall of that segment, and that the lower uterine segment and supravaginal cervix are one and the same thing. It envelops the presenting part during labor, it is thinnev External os. V'a^itta.^ Kifi. 171.— Section (if tlie waU of tlio pregnant utiTiis (UiifnifRTi. The (HtViTonco in Icxtnre bo- twt'i-n <'L'rvix and lower uterine segment, aecortl- ing to Hofnieier, is clearly shown, as well as the loose-meshed and close-meshed muscle-layers of the vipper and lower uterine segments. ^'■1- :kn — 'i\ 330 AMERIVAy TEXT- BOOK OF OliSTF/TItlCS. measured on eight frozen sections — namely, 7 millimeters (^ inch). Toward the close of the expulsion stage it is, on five sections, from 9 to 18 millime- ters (\ to J inch), averaging 1 ,, ; , centimeter (^ inch). Bag of Waters — Pore- waters. — Through the dilating cervix the fetal envelopes are tclt, growing tense during the pains or just before the sensa- tion of suffering comes. The ovum is being peeletl off the lower uterine segment and pro- truded. We note the amount of tension, the shape of the pro- truding sac, and its volume, and, later, the location of the tear. The tension is usually intermit- tent, as above stated. At times we detect a permanent lesion and look out for hydramnion or twins. The shape of the sac depends on the shape or size of the pre- senting part, the elasticity of the membranes, and the amount of liquor anuiii. It may be (1) Flat; (2) watcii- glass — this is usual with vertex presentations (Fig. 176); (;i) hemispherical — it may bulge fidl and round (Fig. 177) ; (4) glove-finger — it may be elongated Fi*;. 17'i.— Ppotinn of primipiira of twcnty-iiiiith week, slioHliin beKiiiniiiK (liliitutiuii of the eeivix in the iit)sem'e of paiiilul oontractions ■ mi>, luiicous jiIiik; i", internal os, with attachment of membranes (Ahlfeld; burdcneil prepa- ration, une-thirU natnrul size). I"i(i. ITii.— rorm of nienihianis iluriuK ililala tliin, WHtchnhiss I Varnien tlie presenliiiti partis lari;e and tills the cervix lonesixtli natural sizei. Fl(i. 177 —Form of membranes with less elll- cieiit lillin^riif cervix and pelvis, and larger iiimii- titv of f(jre -wiiters imodifled from Varnier). in shape when the cervix is narrow and the ])resenting part does not fill it, as in knee or shoulder presentations (Fig. 178); (o) pear-shapctl (Fig. 179), as Tine riiYsioLoay of labor. 331 whore the fetus is dead and niaeoratcd ;'' (({) double, as with twins — but very rarely. The membranes are slightly permeable tnider pressure (Tarnier and Pinard), and at times the amnion will leak into the chorion, jriving a double pouch. Some of the vajrinal flow ha.-- been eredi*^earated, nuUcrnal and fetal membranes parting at the level of the lower pole. In certain cases before rupture the chorion jind amnion may already be separated throughout or far up on the cord. X/tCENTA TnBRANO I"l(i. 1811.— riiicoiitii ninl iiu'iiiliniiics after ili'IiviTV, tn sliow linw tlu' rolatloii of tin.- opi'iiiiiK to the liliict'iita iiidicatt's the site of the hitter: 1., htteral iiiiphmtation : II., fiiiulal iniplaiitation; III., placenta , .aviu marginaliij. Xormally the membranes give way on full dilattition of the cervix when |ti<'ssiiig on the pelvic floor. At times rupture occurs days or hours before labor, from low implantation of the placenta.'' In PouUet's case the mem- I 'ii ^i»*ll ':^-. 'fffipH^ |ij^R'>< *',VJJ. -Kf ^ K-'v ■ ^'1 be painful, so that labor is supposed to be under way, the pains often being grouped in certain parts of the day or night, and being most commonly seen among multipara\ Late in pregnancy tile vagina and the vulva are relaxed, a glairy mucus lubricating them and facilitating internal pelvic measurement and examination. The only certain method of determining whether labor is under way is by digital exploration of the cervix. JJy passing the finger within the cervix and iiooking it forward we may determine whether the internal os is widening or • lisappearing (Fig. 166), and the whole tubular canal of the cervix is being thimied and drawn up ; for we must remember that in over-distention of the uterus, as in cases of hydrainnion or twins, or in the relaxed state of some iiiultiparous uteri, or where there has been wide laceration, the cervix gapes in the last month, and that a low i)osition of the fetus flattens the cervix between tile head and the pelvic floor (Fig. 172). i i 1534 AM/:/i'/(A.\ Ti:XT-li(KtK OF OllSTKTRH'S. n : Wo are warned that labor is actiiallv under wav l)v the foUowint; sijjns : 1. Irritahility ol" the bhuhh-r and the reetuni l)ee(in)in. Expulsion of the mucus plug fntm the cervix — a sign not often detected. 4. Increased secretion. Jioth cervical and vaginal mucus is jwured out in such a manner that when the passages seem soaked and softened with free mucilaginous discharge we may expect to find cervical dilatation making good progress. 0. Rhythmical uterine pains. The most conclusive symptom of beginning labor is the occurrence of regularly recurring pains, with lessening intervals auressiire, the contractions gradually run closcrtogcther until, toward the end of dilatation, they give but momentary intervals of relief. The pain is located as a rule in the sacral region, and later extends to the lower abdomen or down the thighs. The patient is restless, standing, sitting, moving, tossing, wringing her hands, seizing on a support, calling for pressure against the sacrum, or begging for re- lief. Her outcry is invohmtary, high-pitched, or apologetic, an impatient pro- test, or a plaint. She can be persuaded with difliculty that any progress is being made by such colic, seemingly futile. Her cries are not like those of the second stage, which is marked by a transition to the groan or grinit of efl'ort as she closes the glottis and strives to expel the child. The maternal jiulse increases in fre(|uency during a uterine contraction, while the fetal pidse is Kin. I8H.~FuIly-erceptible, the cervix being flattened against and practically continuous with the vaginal walls. The duration of the stage of dilatation varies from two hours to several m n H -■>^^a AMKRHAX TKXT-nOOK OF OUSTETJilCS. (lavri. Ill tlu> priniipiini twenty-ioiir lunirs is not iiiicuinnion, and tlie length incroasos with the patient's ajje, avera{j;ing over thirty hours at forty years (I)octerliii). To j;ive a figure lor the student to remember, we say that tiie averanc duration in the primipara is fifteen hours, in the multipara ei»/.s/o« .v/m/r varies from ten iiiiiiiitos t(» six hours. In priniipanu tlic avcrajjc is t\v(» lioiirs, in tniiltipanc on(> hour. Chaneres in the Pelvic Floor. — Tho polvic floor is the fleshy diaphrafrin dovetailed int() the bony outlet of the pelvis, ft is about o eentinioters(2 inehes*) Fi(i. 185.— Pelvic floor nftcr the escupe of the head (one-thinl naturitl size); eoiistruoted from the /vM'ifel frozen section to show tlie pusliinn forwiinl of tlie anterior vulvar eomniissiire also, and the rciimrl^ahle way in which llie child is paelied into tlie liirtli-eanal. Tlie passage of tliis liead tlirough 111!' pelvic cavity mi(,'ht well result in rupture of tlie uterus. ill thickness, concave above and covered with peritoneum, and convex in shape (111 its lower skin-surface. Between these surfaces lie fascia?, muscles, coinieetivo tissue, and fat, named in tho order of their physiological importance. Through tlio floor run three slits, the urethra, the vagina, and the rectum-anus. The axes of these openings are oblique (Fig. 1H4), so that direct pressure from above 22 i! 1 1' ;WH AAfKItlCAX TEXT-noOK OF OJtSTKTIilCS. teiuls to diet! tlio openings by prt'ssinij their walls tojj;etlier. Ordinarily tlieir capacity for distention is limited, but the remarkable character of the |M'lvic floor is that, whereas the chief function of this nni<|iie strnetnre is to form a Holid and luibroken support for the or<;ans above it under all conditions uf strain, at certain moments it nnist, without injury, etl'ace its<'lf, and ojm'u up to the size of its entire length and bn'adth. Wc shall consider the change- that bring about this rcsidt. Hart, studying fr»»zen sci'tions maiidy," observed that the vaginal slit sterior part, the mivritl nq/mnit, between the rear vaginal wall and the |M»stcrior Imiuv wall, including the anus and part of the rectum. Symington'* considers flmt the rectum and bladder and the upper vagina, like the uterus, should not lie regarded as parts of the flo(»r, but as organs resting u|»on it. Webster'" hulcU that the bladder is indM>dde■ ""• 'I."".,,,!;,,,; |„, ' Tt;^XL:ir;!:r' '"■■' '■''--'' """ " "- '"""■"' " ' ',-• '■'■ "■<•" t" 2 ,„illi„„.,,,.. ( 4 „-,"".'", ""-"""I l'.v™...i-l i, „„„„. / ''° "'■' » '"".v '"• ^ X.I :: ,;t!:!':i' '""•''"'■■xi'v. ..4, ,,, ,,, ,° Tliickiiess of die n,.!..;,, n ■ „ " " ".!" "?:"• '" '^-'X <•<• -lu- anus, in „.,,.•„,,„ ,,.. . ^ *>■.'..„..,..«. ,„,.„.. '■■■"- ■'^-'■-".";'^:;:;r'";:- ■■-■:::::::'J \ „ ■■" «'"<-'-''U's| (lislfiili,,,, .7 .), """■ ""■■«'"». « y are wanted for use. Chemical Antiseptics. — Among the chemical agents most commonly em- mv- V ' ; ■ 1 Eii- i/'i JM ' : !' 344 AMERICAN TEXT-BOOK OF OBSTETRICS. ployed for obstetric antisepsis are the mercuric chlorid dissolved in water, in .strength of from 1 : 2000 to 1 : 500, the mercuric iodid in similar proportion, the peroxid of hydr(»gen ' (lo-volume solution), the liquor sodoe ehlorinatse diluted with 9 volumes of water, a 2 ])er cent, creolin mixture (in water), a 2 to 5 per cent, solution of carbolic acid, and a 1 : 1000 solution of hydro- naphthol. The order in which they are named is substantially that of their germicidal potency. The j)ractical efficiency of mercuric chlorid (corrosive sublimate) is greatly increased by the addition to the solution of five parts of hydrochloric, tartaric, or acetic acid for each ])art of the sublimate, since in neutral solutions of that salt the mercury is preeipitatetl as an albuminate on contact with blood or with other albuminous liipiids. The acid, moreover, serves to protect the solution against impairment of strength by contact with the alkaline fluids of the tissues. The mercuric chlorid is decomposed by alkalies. The mercuric iodid (biniodid of mercury), recpiires the addition of on equal weight of the iodid of j)otassiura to render it freely soluble. With this salt no acid ia required. Neutral solutions of the mercuric i(xlid yield no precipitate M'ith albumin. The chlorinated-soda solution, the ])eroxid of hydrogen, and the creolin mixture have the advantage of being practically non-poisonous, and they are therefore more suitable to be trusted to the nurse than the mercurial preparations. The Obdeti'ician. — The obstetrician should always be clean ; especially must Jiis hands be clean, and he should wear clean clothing. It is well to avoid con- tact with ])athological material and, so far as possible, with other sources of wound-infection. Yet attendance on post-mortems and contagious diseases is not necessarily inconsistent w-ith the safe conduct of confinements, provided a rigorous antiseptic cleansing be always observed as a preliminary to the care of the obstetric patient. After a septic exposure an entire change of clotiiing and repeated and conscientious use of disinfectants nnist be practised before taking charge of a case. The writer has repeatedly attended a prolonged labor, has delivered by forceps, and has repaired perineal rupttu-es within one or two hoiu's after having the hands bathed in offensive pus, witiiout infect- ing the patient. Repeated scrubbings with hot water and soap and with dis- infectants, including the final use of the permanganate method, will, if properly executed, ensure complete asepsis of the hands within an hour after the worst exposure. When summoned to a case of labor immediately after a septic contact, besides the usual care in disinfection, in simple labor all internal examina- tions may be avoided. In addition to this, it is possible, if thought necessary, to manage the birth even without contact with the external genitals of tlio patient, tlie required manipulations being conducted through the intervention of a fresh towel well saturated with the antiseptic solution. It is impossible, however, to lay down rules which alone will make an aseptic practitioner. The obstetrician must be ])ossessed of an aseptic instinct, ' The l)e8t j)roparation of tlip jieroxid of liydrogen is pyrozone. 10 In In THE CONDUCT OF NORMAL LABOR. ,'J45 and this is a matter wliich comes of training and a keen appreciation of the ])ossible sources and modes of infection. In liospital practice the obstetrician should, during attendance upon a hibor, wear a fresh-laundered gown or a clean ai)ron large enough to prevent contact of his hands with his clothing. His hands and forearms arc to be cleansed thoroughly and disinfectetl before the first examination, and before each subse- quent contact with the genitals if they have in the mean time touched anything that is not aseptic. For the disinfection of the hands the following method, which is substanti- ally that of Fiirbringer, is reconuuenoled : 1. Clean the nails dry. 2. Scrub the hands and forearms for not less than three minutes with a hand-brush, with soaj) and water as hot as can be borne. Special care must be taken in brushing the nails and finger-tips, and the water should be changed two or three times. 3. Soak well with alcohol (not below 80 per cent.) and, before it evaj)orat('s, 4. Immerse for three minutes in a hot solution of mercuric iodid or chlorid (1 : 2000 to 1 : 500), or in a 3 })er cent, solution of carbolic acid. Undoubtedly, the most essential step in the process is the soap-and-water scrubbing. It not only removes the greater part of the offending material, but it is also indispensable to the proper action of the antiseptic solution. The latter can penetrate the skin only after the oily matter has been removed and after the skin is thoroughly wet. The use of alcohol helj)s the action of the chemical solution by dehydrating the skin and rendering it hygroscopic, thus favoring penetration of the solution. Welch, of the Johns Hopkins Hospital at Baltimore, recommends the fol- lowing procedure, which is known as the pennanr/anate method. By it tlie hands, it is claimed, may be rendered practically sterile to culture tests : 1. The nails are cut short and carefully cleaned. 2. The hands and forearms are serul)t)ed for three minutes with soap and water. The brush before using is sterilized by steam, and the water, which is as hot as can be borne, is frequently changed. The soap is rinsed off with plain walor. 3. The hands are next immersed in a warm solution of permanganate of potassium and are scrubl)ed with a sterilized swab. Distilled, or at least boiled, water should be used for the solution, w'hich should be saturated. 4. The hands are next held in a warm saturated solution of oxalic acid in boiled water until the permanganate stain is entirely discharged. 5. After rinsing in sterilized water the hands are immersed for two minutes in a 1 : -500 mercuric-chlorid solution. The Nurse. — The nurse should be no less careful than the obstetrician in the observance of all antiseptic details. The Patient — In hospital practice the patient has a bath and a change of clothing at the onset of labor. Before the fir-it internal examination the abdomen, the thighs, and the vulva are cleansed by the nurse with soap and \ ^ I I ■ ;j4() AMUR/CAN TEXT-BOOK OF OBSTETRICS. warm water. The soapy water is rinsetl off and the parts are well bathed with the antiseptic solution. It is a nseful precaution to cover the limbs of the patient, when she takes the 1)C<1, with a pair of muslin leggings fresh from the sterilizer. The leggings should be closed below, so as completely to envelop the feet. In addition to this, the patient and the entire cot may be covered with a sterilized gauze sheet. During the first tage a vulvar dress- ing saturated with Thiersch's solution may be worn. Similar precautions are not all practicable in private practice, nor are they all necessary. The clr'iij^e of clothing, the preliminary cleansing and disinfec- tion of the external genitals and adjacent surfaces, and the aseptic cleanliness of everything that comes in contact with the birth-canal nujst always be insisted upon. The utility of prophylactic vaginal douches is a question which has pro- voketl much discussion. Stetfeck ' recommends vaginal irrigation during labor with mercuric-cMorid solution at intervals of two hours, rubbing the antisep- tic well into the mucous membrane with the lingers. Doderlein ^ advises scrubbing the vagina with a preparation of creolin and mollin, followed by a ten-minutes' douching with the creolin solution. Hofmeier^ favors preliminary disinfection, especially in maternity hospitals where students are allowed to examine the patients during labor. He concludes, from a comparison of the records of the Wiirzburg clinic with the published statistics of other like institutions, that, with preliminary disinfection and the carefid observation of all possil)le antiseptic precautions, instruction by means of examinations during labor does not necessarily increase the danger of infect- ing the patient. He further contends that thorough disinfection of the birth- canal is not a source of danger to the mother, as has been claimed, but that it results in a diminished puerperal morbidity and mortality, FrommeP reports over five hundred cases in which vaginal injections of the corrosive-sublimate solution (1 : 2000) were en>i h, 'etl, and where in manv abnormal ciises from sixty to seventy examin? lL)us vere made during the patient's stay in the hospital, the clinic being oiwu to about one hundred students, and being also used for the training of midwives. In this number of patienis there were two cases of sepsis whose infection was traceable to his clinic. The morbidity-rate was from 5.5 to 7.5 per cent. In another series of cases, where external disinfection alone was praetisetl, the morbidity rose to 11.1 per cent. Mermann ^ reports the results of seven hundred cases without the employ- ment of vaginal douches for preliminary disinfection. He records a morbidity- rate of 6 per cent., with no deaths from septic infection. In the last two hun- dred births there were two cases of mild ophthalmia, and in all less than ten ' " Ueber Disinfection des Weiblichen Genital Canals," Zeitschrift /iir GeburtshiVfc, vol. xv. p. 395. '■' " Disinfection des Geburts-Canal," Archiv JUr Gyiidkologie, vol. xxxiv. 111. ' Deutiichi' mcd. Wochcmchrijt, 1S!)1, No. 49. ♦ Ibid., 1892, No. 10. » Centralblatt fiir Gyndkologie, 1892, No. 99. THE COyOCVT OF ^OIi^fAL LABOR. 347 of conjunctivitis anionjT the children. Merniann omits internal exaiiiinations whenever practicable, observing the progress ot" the labor by abdominal palpa- tion and auscultation. LeopoKl and Goldberg' publish the statistics of several thousand deliveries with and without the eniploynient of vaginal disinfection. Their tables show the best results where the vaginal douches were not used. They recommentl the employment of abdominal palpation as a means of noting the progress of labor, and th(! restriction of vaginal examinations to cases of dystocia, except when necessary to confirm a diagnosis made by the abdominal method. They advise douches in operative cases and in all others where previous infection is suspected. Fischel in an experience of 880 births at the Prague Maternity lost nine women from sepsis with the employment of preliminary disinfection. After sto|)ping the use of the irrigations, iu a scries of 933 cases there were but two deaths due to infection, and a year later, in 521 women delivered, there were no deaths from that cause. The safer course, at least for general use, is undoubtedly the restriction of internal examinations as much as practicable, and of the preliminary vaginal douche to cases in which the scd'ctions are pathological. In the presence of purulent gonorrheal discharges both the vaginal and cervical canal, as well as the vulva, ought to be cleansetl carefully with soap and water and gentle fric- tion with the fingers, and subsecpiently washed well with the antiseptic solution. In extreme cases the disinfection may be repeated at intervals of two or three hours during the labor. This is required not only in the interests of asepsis for the mother, but as a i)rophylactic against ophthalmia in the child. Mer- curials, however, are not suitable for the purpose, owing t'> the danger of mercurial intoxication, Merctuy has been found in the stools after a single vaginal irrigation. Some of the non-toxic disinfectants, such as creoliu, peroxid of hydrogen, or the chlorinated-sotla solution, are to be recomnit-nded. Doderlein has calliHl attention to the litmus-rea^'tion as a ready means of distinguishing healthy from morbid vaginal secretions. He points out that while in health they are strongly acid, in pathological conditions of the secre- tions their reaction is feebly acid, neutral, or alkaline. These observations have been confirmed by Williams ol Baltimore. The litmus-reaction of the vaginal secretions therefore affords a convenient guide to the conditions in which preliminary internal disinfection is indicated. Ant'HepHis in the Use of flie Catheter. — Should the patient require to be catheteriz(> 6.il iji iy!|i I ■ i 348 AMERICAN TEXT-BOOK' OF OBSTETRICS. result by extension of the septic process from tlie vesical mucosa through the ureters. The strictest asepsis must therefore be observed in catheterizing the bladder. The instrument should be boilitl in water for fifteen minutes imme- diately before using, and this is pctssible even with soft-rubber catheters with- out material injury to tiie instnmient. It should then be haiulled only with hands that have been previously sterilized. The patient lies \\\wn the back with the knees drawn apart. The labia are to be held apart, either by the jiatient herself or by an assistant, so as to com- pletely expose the meatiis urethra^ and so held until the instrument is passed. The meatus, the vestibule, and all the surrounding surfaces are to be cleansed with soaj) and water, and subsequently be washed with the disinfectant solu- tion. The catheter, well lubricated with sterilized vaselin, is then passed with clean hands and with the parts fidly exposed to the eye. Precautions must be used to prevent urine from trickling over the wounded surfaces or into the vagina as the instrument is withdrawn. The catheter, after using, should be cleanstMl carefully with water. Care must be taken that irritating chemical antiseptics are not carried into the urethra upon the catheter; otherwise a troublesome urethritis may result. 2. Management op Normal Labor. Essential to the proper management of childbirth is a watchful super- vision of the health and habit^ of the i)atient throughout pregnancy, and a previous knowledge, so far as possible, of the conditions to be dealt with in each case during labor. Next to Listerian cleaidiness, nothing is destined to do more for improv ■ I results in obstetrics than the practice, now happily growing with obstetricians, of studying their cases before labor. It is desirable, therefore, Miat the jiregnant woman be under the observation of her physician from an early period of gestation, and especially if the experience be her first. Much-needed information and advice may be im- parted with reference to the hygienic requirements of pregnancy. Knowledge may be gained of conditions likely to complicate the parturient or puerperal process, and much may often be done to fortify the health and strength of the ])atient. Dystocia, if it cannot be prevented, is more successfully managed with the aid derived from previous knowledge and preparation. I]ven w'hen all is normal, both jiatient and jjliysician are amply rej)aid for their pains by the increased confidence with which the result of labor is awaited. The patient should be atlvised with reference to the selection of her nurse. Instructions will be needed pertaining to the care of the nipples. Siie should be directed to cleanse them daily during the last month or two of pregnancy, and, if they are very small or suidven, to draw them out with the fingers. This manipulation also helps to inure them to nursing. Daily inunction of vaselin or of fresh cocoa-butter during the same period keej)S them supple, and is a better preparation for suckling than the use of astrin- gents so commoidy practised. THE CONDUCT OF NORMAL LABOR. 349 Especially Important is it tliat tho functions of tlic kidneys he watched. Dnrinji; the last one or two months before labor the urine should be examined weekly. An occasional examination at an earlier period is generally advisable. If albumin be found, the microscopic study of the urine will best reveal the character and extent of the structural chanfjes in the kidneys. In doubtful cases the best evidence of the manner in which these or}j;ans are performing their functions is afforded by occasional quantitative tests for urea. Obstetrical Examination. In the later months it is the duty of the jjhysician to make a preliminary obstetric examination. Tlie most suitable time is usually about the end of the eighth month. The object is to determine the position and presentation of the child, the relative size of head and pelvis, and the poi-sible presence of patho- logical conditions that may conjplicate the mechanism of labor. It is to be assumed that full information has already been obtained, at the time of engag- ing to attend the patient in confinement, with reference to her obstetric history, including the number of previous pregnancies, term labors, and miscarriages, all important facts pertaining to the character of the pregnancies, labors, and childbed period?, and particulars relating to the course of the present pregnancy. In hospitals it is the rule to make an external and an internal examination. Ill private practice an internal examination, while always desirable, need not in all cases be insisted upon. Usually all that is necessary to know may be determined by the external methods. In the presence of pelvic deformity, and in all cases in which for any reason the external examination is not satis- factory, exploration of the pelvic cavity should not be omitted. It is essential that the bladder and the rectum be empty. The patient lies upon a bed or a lounge, covered with a sheet and with the limbs outstretched. Her clothing is to be loosened and the skirts drawn above the abdomen. The necessary manipulations are conducted under the sheet or through it, without exposure of the patient. In this maimer the abdominal examination and the external measurements of the pelvis may be made without causing discomfort or giving offense. The hands of the examiner are first bathed in warm water to render the skin soft and the touch more acute. This precaution, too, helps to prevent reflex contractions of the abdominal and the uterine muscles, which are more liable to occur when the hands are applietl cold to the abdomen. The examination should be methodical. Errors of diagnosis are more fre- quently the result of carelessness than of ignorance. Success here, as in most other undertakings, depends upt)n a capacity for taking jiains. All manipula- tions are to be conducted gently, and need never cause the slightest pain, except rarely when deep ])ressure is rc«|uircd to map out the lower fetal polo. A definite order of procedure is recommended in accordance with the following scheme : ■|i"1 '•&'h^' 'til, !'i' a 3o() AMi:iiivAy Thwr-nooh' of onsTiyntics. 1. DrACNOSIS OK TMK KkTAL I'KKSKNTATION AMt POSITION. Lncftfinn of the Dnrxnl P/inic initf Suui/I Ptirfs, — Tlic sitiiatinii of the (If)rsal plane and small parts of tlie fetus may, as a rule, easily l)e made ont hy palpat- ing; tliealxlomen. The palmar surfaces of the finger-tips are applied with lij;lit iiitermittinj; touches (Fig, 1H7). Heginniiigat the lo\v(>r part of the abdomen, a narrow zon«' is palpatetl entirely across from one side of the tumor to the other. The palpation is repeated over a similar area just above the first, and so on until the entire surface of the timior has been explored. The situation of the f«'tus will usually be learned by the first t<»uclies. It presents to the examining fingers the feel of a solid body, while elsewhere over the tumor only fluid is felt. The location of the child niav more readilv be made out bv J)laei'ic: one hand flat upon the middle section of the abdomen and pressing firmly back- ward (Fig. 188). The licpior amnii is thus displaced to one side and the child to the other, where it can more easily be j>alpated. Fic. IST.— (ii'iicral palpiitiDii of iiliilomcn for Icu'iitiiif; ilcirsal plimo ami small parts of futiis (from a liliotnuraph). The child's back is identified by the length and breadth of the resisting j)lane which is offered to the examining touch, and by the absencie of a suIcmis between it and the fetal head. The side of the child presents a narrower i:it- icr. iitil ■tiis luid otic hil.l III)'. Ivcr coNnrcr ok nokmai, kahoh. I'l.Mi: "J.-l. KXA.MINATlciS lii;i()IIK I,. Midi!: llxiimilllltinll (if IdWtT I'cllll |icilf ilVolll II |illnl(,i.'ni|ill I 1 1 .'I I Iter i( lIlC 11)1 cf the ;-; '. -r «,, i™: t;;;,"" :■ -'— > '- '-> ,1,. ■'"tt'rior position of the child'- I I /' . l"j-'ituoi position '"■""'» «"' "I«.n .1,0 alKl.„„c.„ „v,. , w"""-' "'" "'""■■■'■'« fc., .0,1,,. ^ft"'nit of the iitmis(I'|.2;}). 'ill.! "|i,' ifi ' ii iil 'i 111 l8 Ii I :i: 1 o;'»-2 ami:rivax text-book of obstetrics. With tlio liaiuls irstiiij; upon the sitlos of the tumor, thoir palmar Kii; sinks (U'opiT in llic ,Sll rfacrs nearly laoiu}; each otlii-r and the tin II I'' Mi|ini p I MW , ' r . f ! 1 J. '? 1 / i ; i 1 ' r r t( iij Ml til if* ill I / i I > bri diK put the the ri<,Wi ci'tl tlesc men liciic / siiniil upon tiiwai I'llCOU pillar , pivs.si: l''iii(ll • '.•Itcs { "I' flio I" fill' THE COX DUCT OF XORMAL LAliOJi. 353 thrust downward into the hriin of tlie pelvi^i. Tlie pelvic excavation is then explored to learn if it contains the presentinjj; fetal part. If it is tilled before labor, the i>resenting ])art is the vertex. Xo other fetal part sinks into the lesser pelvis nntil labor begins, and even this sinking very rarely occurs except in priniipara\ In the latter the fetal head is normally always in tho j-.clvic brim. Dnriiig labor either pole, whether the woman has previously borni^ children or not, should be found in the lesser }K>lvis. The head when it lies above the lesser pelvis is not usually so accessible to palpation as when in the excavation. A useful nianeuvre for locating the liead, if it is not readily found by direct palpation, is to i)lace the hands in the usual position over the sides of the lower uterine seg- ment and proceed as for external ballottement, bringing the hands more ;ind n\ore nearly together initil the head is found. The head will be ivcognized as a solid globular body which can be tossed from one band to the other. The cephalic extremity is distinguished from the breech by its greater mobility when it lies above the excavation, by its hardness and globular shape, and by the presence of a sulcus between it and the fetal trunk. The breech alone, is smaller, with the interior extremities larger than the head. It lacks tlie hard and globular character of the head, and presents no sulcus between itself and the trunk. An imperfect ballottement of the heatl is frequently ol)tainable when it lies in the lower segment of the uterus above the pelvic inlet. C('i>haliG Promiucncc. — When the head is in the excavation one side of the brim will be found more completely tilled than the other (Fig. 189). This is due to the fact that the occiput sinks deeper into the pelvic cavitv than the sinci- put. On one side the frontal portion of the head, on the other side the najie of the neck, occupies the pelvic brim. That side of the cephalic tumor which is the more prominent, therefore, is the sinciput. Cephalic prominence to the right indicates a left, to the left indicates a right, fetal position. The situation of the greater prominence will be observed in the course of the pal|>ation above (lesiribed. It may also be made out by arching the hand across the abdo- men innnediately above the ))ubes (PI. 24; Fig. l!*.'i). The cephalic promi- iicni'c will be found most marked in rior, position (if the fetus. In left ])ositions the shoultler lies to the left, in right positions to the right, of the median line (Fig. 15>2). 2:t lU- %i%\ 'mm. ).' : a }Sn ill liifeM: iv.:,.i:'E .'. / !r sr)4 AMEIIK'AX TEXT-BOOK OF OliSTETRIVS. Kxianinntlon of the rjt/tcr Fetal Pule. — The cxaiuiiier next faces the mother's fiioe and phu-es his hands over the sides of the fnndns (Figs. 190, IDl). The finiihil poh- of the fetus is then examined hv palpation. The head is differentiated from the breeeh by the characters ah'eady Km. I'.il.— Kxainiimtinii df uiiper Mai polo (from a photograph). mentioned and by a more pronounced ballotteinent than is usually pos- .sible when the head presents. By reason of its smooth, globular shape, and especially of its flexible attachment to the trunk, the head is very movable, rebounding distinctly under the touch when in the roomy upper uterine segment. Location of the Fetal Heart-to)ie,s. — The stethoscope may or may nol be u.'^ed, according to the usual habit of the examiner. The point at Mhich to listen first is directly over the supposed location of the upper part of the child's back. Failing here, the entire surface of the tunmi may be .searched. The hen it -.sounds are usually heard over an area of about 3 inches in diameter, but, since they are .sometimes more widely diffused, it is importaii! to locate the point of greatest intensity. The point upon the abdomen ;i! which they are mcst intense is termed the j'(tcH.s of aniicultafion. As a nil''. this point overlies the fetal heart. Exceptionally, the sounds are most di- Is vorv KT upi ay not |)int ill tumor llies in l>ortan! Lieu ill |i rill''. St (li-- THE COXDiCT OF yORMAfj LAliOli. >)i> tiiictly heard at some remote point, owing to firmer contact of the i'etus witli Fi of vicious i!!.-;ertion of the placenta is therefore sometimes ])ossible by abdomi- nal examination. A liydrocephalic head of a siz(! sufficient to give rise to dif!ieulty in delivery ought to be recognized by external palpation. Its size may be determined ksibility |)ari« ill |ing till' ision of >logioal in ov<'r n- Nvall llpat'uiii \gno!?i> j[)doini- ■ 'liven huiiu'd TIfE CONDn'T OF XORMAL LA/iO/f. i]r>7 more accurately by moasureincnts taken with calipers throujfh the abdominal walls, and by tryin}>; whether it can be crowded into the excavation. In twin pre}i;nancies, as in hydramnion, the abdominal tumor is usually large and persistently tense, and there is suprapubic edema. Indeed, multiple pregnancies are generally associate HXAMINATIOX. Before examining per viiginam the obstetrician's hands and the external genitals of the patient are to be cleansed with the same care that is observed during labor. Lt limit. led Avitli Incn'mnl liiotors). fdicatc- Ion. eternal Iservcil (ONDITT Ol' NOIJMAL 1,AI!()K. I'l.ATi: -J'). Mt'iisuriiif; tlie oxtiTiiiil Kinjugato : llio Murk ilots show tlio points from wliich tlio moiisuroinciits arc iukeu (from a photograph). ku, Bft' JM |w:Hi; Ifl it I ' v\ w r t HI jHli ri; li i ! r I I .\atniiu><1 for injuries iiillietod (liiriiij; previous lalxirs. In all <'ases the (lia;i;oiial eoiijiitiate and the aiitero-posterior and hisisehial diameters at the ontlet should earel'nlly ho nieasin-ed and the width and curvature of the saernin be noted. The method of measuring:; the diagonal conjugate is shown in Fij;ure lJ»r) and Plate 2<). With the patient in the lithotomy position, two Hnjiers of the exainininjjf hand are passed into the vaj^ina, and the tip of tlie second fniffcr is made to rest by its outer mari^in against the most prominent part employed. The Lying-in Room. In pi'ivate practice the patient is generally confine AM/:iU(Ay Ti:xT-nooh' of obstetrics. ■f , ! : V^ -\r, I The iiiirso shoiiKI also provitlc j)l('iity of clean sheets and towels, one or two pieces of niihleachcd nnislin for alxlorninal hhulers a half yard in width by one and a (jnarter yards in length, one or two snrgically clean rnbber sheets large enough to cover the ent're width of the bed, plenty of nuislin sheets, a nig or oil-cloth lu protect the carpet beside the bed, safety-pins of convenient size for pinning the binder, a fountain syringe, a suitable bepe(i with basins, briislies, milisoptics, etc., for the pliysiciaii's use. ! li hi length. Over this rubber covering is .spread a nni.slin sheet, the two cover- ings being pinne \)ed clean and protected l)y the first rubber and its mti.>^lin covering. Two or three fre.sh-Iaundered sheet.s, each folded to four thicknes.ses, may be placed upon the bed in jnisition to receive the tli.scharges. In phux* of the sheets a good absorbent dressing is a pad specially made for the purpose. It consists of a cheese-cloth sack or bag, which i,^ filled with jute, absorbent cotton, cotton waste, or other absorbent material that has j)revi- ously been prepared and sterilized. The stick rctiuires (o be from 2^ to 3 feet «nuiioiiIv eninlMxv. i • ^ ^' absorbent pad i* ihn t- n »l"tio„ ir,; ** "■'"''(«• A ..apfet „. 1 " "'• ''"""8 "«' firs' «ta J i ^^'J; a Jialf-dozeii iicedJes, ''"'•"•'-^<">"t«'spo.vi.„etor ••'hout 2 i„eI,o.s i„ K,„,,.. . , C:';::; ::::£-•- -k™ 2t,:r' '^v•■'"--- •' ''N>"".-i...i. ,,^ ,?;;t ;';'''''f ''-!•'■ ■■'-:., ::'?,"" -'■■■ ■■' ■^""■' U i (.; •/ i.li\ 362 AMERICAN TEXT- Ji 00 A' OF OBSTETRICS. The bag should also be supplied with two or three ouuces of chloroform, twice as much ether, a few ounces of carbolic acid, and a drachm or two of chloral. Mercurial antiseptics and also obstetric cmergeuts, such as niorphin, elaterin, digitalis, ergot, and veratrum viride, are most conveniently carried in tablet form. 3. Anesthesia. Of anesthesia in obstetrics for the usual surgical indications little need be said. The eniplovnient of anesthetics in obstetric operations is governed by the well-established usages of surgical practice. ]iy obstetric anesthesia is understood something entirely distinct and apart from the surgical use of anesthetics. It is intended to diminish, not to abol- ish, pain. Its object is merely to mitigate the severer sufferings of ordinary labor, not to cause complete insensibility. To what extent anesthetic agents may be used to advantage in a simple labor is a question that calls for the exercise of tact and judgment. That, on the one hand, obstetric analgesia accomplishes a distinct gain, in so far as it spares the {)atient the exhausting effects of severe pain and prolonged nervous tension, cainiot be doubted ; nor has the obstetrician any more pleasing duty than to save the needless sufferings of childbed. On the other hand, except in moderate doses and during the most active period of labor, anesthetics are lia- ble to impede the progress of the birth. The careless and long-contimied use of these agents, especially in excessive quantities, is fraught with serious dan- ger to the j)atient. Their abuse is doubtless at times an unrecognized factor in grave and even fatal accidents of childbed. These objections obtain more csj^cially against chloroform. With reference to the influence of anesthetics upon the strength and the frequency of the uterine contractions we have some recent observations from Ponlioff.' lie administered chloroform, in various degrees, to five parturients, studying the effect upon the pains with the aid of a tokodynamometer. Even under small doses the labor was retarded. In eight observations the muscu- lar pressure sank nearly to one-half that present before the administration, and the strength of the uterine contractions was not fully restored for several minutes after the inhalations were stopped. That the use of anesthetics during labor ])redisposes, in some degree, to relaxation of the uterus in the third stage, as claimed by Ijusk and others, is abundantly exemplified in the writer's experience. The foregoing facts, while they do not forbid the employment of obstetric anesthesia, call for the exercise of caution in its use. When rctpiircd for no other purpose then to mitigate the sufferings of the patient, anesthetics should be reserved until the latter part of the second stage, and even then they may be withheld so long as the ])ains are well borne. Tlieir employment is per- missible at an earlier period in the labor when, recpiired to subdue great ' Archil' fur Gi/n., Hai.d xlli, 12. (1 the from jionts, ^vcn luscu- lition, Ivcral ["C, to Irs, is totric Lr no konUl 1 may per- brcat THE COXDUVr OF NORMAL LABOR. 363 nervousness and excitement or to relieve pains of extreme and unusual severity. In cxeoptional oases these agents may act to accelerate the labor by counteracting the inhibitory effect of pain upon the uterine contractions. In the third stage of labor the uses of anesthetics are chiefly surgical. When anesthesia is recjuired to the surgical degree, it nnist not be assumed that the obstetric jiatient enjoys any special innniuiity from the usual dangers of anesthetics. The relative safety of obstetric anesthesia lies not in any peculiarity of the subject, but in the mode of administration, the limited dosage, the slow and gradual inhalation, and the intermittent use of the drug, during the pains only. Under complete anesthesia the parturient woman is exposed to the same dangers as are other patients. In eases in which an operation must be performed requiring anesthetics, neither disease of the heart, of the lungs, nor of the kidneys, nor the exhaus- tion of the third stage, forbids their use. These conditions, however, neces- sitate increased caution in their administration. In cardiac disease, even in lesjons of the myocardium, anesthetics lessen the danger by subduing the rt i' Kos. Choice of Anesthetics, — For mere obstetric analgesia chloroform is gen- erally preferred. It has the advantage of being pleasanter than ether and is less bulky to carry. The latter agent seems to be growing in favor, however, for obstetrical use, and it is claimed to be no less manageable than its rival, chloroform, for partial anesthesia. Hirst thinks analgesia is even more promptly produced by ether than by chloroform. The satisfactory use of ether for this purpose, however, depends ujion its jn'oper administration. It must be given very gradually in quantities of a few drops with each inspira- tion. The difference in the safety of the two agents is insignificant when .^ed in the obsteirio method. When couiplcle insensibility is required for surgical interference, chloro- form should, as ti rule, give place to ether. The general mortality of chloro- form when push(j.l to the surgical degree is four or five times greater than that of . thiM*. 0\ the two agents, chloroform is the more potent and its effects persist i -ngor r,%>r inhalation stops. Ether, since it is used in larger (piantities, is nv \^ irritant to the air-passages than is chloroform ; hence the former pgent should be replaced by chloroform in inflammation of the air- passage,', especially if it be acute. Ether is generally believed to be more dangerous in nephritis than is chloroform, but this question is not fidly set- tled. Owing to the tendency of the former agent to produce high arterial tension, it is dangerous in marked atheroma. Methi ' of AdminiKtrnfioH. — The patient is prepared for anesthesia by looseniii :• .i'^ clothing, by lowering the head, and by attention to such other l)recaution>. arc commonly observed in surgical practice. To protect the skin from the irritating effects of the chloroform vapor the lips, nose, and chin may be smeared with vaselin or with glycerin. A towel spicad in one thickness over the head, and lifted by the middle so as to form a large air- chamber about the face (Fig. 198), makes a suitable inhaler. An Esmarch w r'' I., !i ;};t ;■ ' . i 304 AMERICAN TEXT-BOOK OF OBSTETRICS. mask is also a convenient apparatus for administering the anesthetic in the lying-in room. On the first premonition of a coming pain the inhaler is placed over the face of the patient, and the anesthetic is dropped upon it opposite the mouth. With chloroform, one drop or, at the most, 2 drops should be let fall at each breath. In case ether is used, .3 or 4 droj)s with each inspiration will suffice. When sufficient effect is not obtained in this manner, the patient may be requested to breathe rapidly as the pain is coming on. For convenience in graduating the administration a bottle specially con- structed for the purpose may be used, or a dropping-bottle may be improvised by cutting a longitudinal slot in the side of the stopper (Fig. 198). The foregcing methods of administration ensure abundant dilution of the anesthetic vapors with air and a safe and gradual development of anesthesia Kio. li»8.— Mi'lliod ; GO tp?. itlu! THE CONDUCT OF NORMAL LABOR. 365 patient usually bears the pains with little complaint, and sleeps quietly in the intervals. Chloral in the (piantity mentioned has no inhibitory effect upon the uterine contractions. In disease of the heart, either organic or functional, the wisdom of its emj)loynient is questionable, owing to its depressant effect. It is said by some authorities to be unsafe to give chloroform to a patient who is already under the influence of chloral. The coal-tar analgesics relieve the i)ains of lab(»r, but they also tend to cause uterine inertia. The hydrochlorate of cocain applied to the cervix and vagina has proved of little service, its action being merely superficial. It is especially objection- able on the ground that it necessitates interference within the passages. From an eighth to a quarter grain of the sulphate of mor{)hin, admin- istered hypodermatically, as a rule acts kindly in unusually painful labors, but it is rarely to be recommendeil in strictly normal conditions. Examination during the Labor. The first duty of the obstetrician on reaching his patient in resjionse to her sunnnons is to satisfy himself that she is, as she assumes, actually in labor. The beginning pains, however, are not necessarily to be taken as ovidence that active labor is near at hand. Painful uterine contractions are sometimes ex])c- rienced at intervals for days before the birth. Rarely, after they are fully established, they may wholly cease for hours. Inquiry is made for the usual i)henomena of beginning labor, the time when tiie pains began, and their character, strength, and fre(juency. Most distinctive of labor is the rhythmical character of the j)ains and the contraction of the uterus during the ])ains as felt by the hand laid upon the abdomen. The first uterine contractions of childbirth frequently give rise to little more than a sense of i)ressurc in the sacral and the lumbar region. As the labor progresses they are felt in front over the lower abdomen, and finally radiate down tiie thighs. If the labor is in actual progress, a systematic external and internal examination is to be made. The general object and method arc substantially the same as in the preliminar ' examination, with the addition of certain details which pertain more especially to the labor. The abdominal examination aims to determine whether the (ihild is living, what is the presentation and position, the quality and frequency of tlie fetal pulse, how far the lir d has descended in the pelvis, the presence of anomalies that may com})licate the birth. The relative si/e of the head and pelvis can be eslimated by observing how far the head has suidv or can be made to sink into the excavation. In doubtful cases measurements of the head may be taken with calipers through the abdominal wall. Distention of the bladder is recognized by palpation over the supra])ul)ic region. The diagnosis of presentation and position by abdominal pal|)ation is not usually so readily made at this time as l)efore labor, but in most cases it offers no special difficulty. The character of the fetal heart-sounds affords im- portant information as to the prognosis for the child, and they should fre- !.i 1 . t (■ fi ''■m. ., ■ i: 366 AMERICAN TEXT- BOOK OF OBSTETRICS. \:\ II m I ■« * :,M h b: quently be Ustcned to throughout labor. A fetal pulse-rate much above or bel'^'w ^'.'.0 liornial range, or a pulse which grows progressively weaker, indi- cates danger to the child. When a systematic preliminary examination has been made, little additional information remains to be gained by examining internally after labor begins. For the detection of possible complications that may have developed at the onset of labor, such as prolapse of the cord or of a fetal member, as well as for more precise information of the stage of progress, a vaginal examination is usually desirable, even though the obstetrician be expert in abdominal palpation. Before examining internally the nurse is directed to cleanse the abdomen, the vulva, and the inner surfaces of the thighs witii soap and water, and finally Avith an antiseptic solution ; meantime the obstetrician sterilizes his hands and forearms. The object of this examination is to learn — (1), the condition of the vulva and the degree of resistance it will be likely to ofter as the liead descends; (2), whether the vagina is well lubricated by the secretions, and the presence or ab- sence of obstruction ; (.3), the condition of the cervix, how far dilated, whether dilatable as judged by the extent of softening and thinning; (4), the size and protrusion of the bag of waters; iv J {'i), the presentation and ptsition of the child in confirmation of tlie abdominal examination. Vertex presentations iire recognized by the hardness and the globular shape of the cranial portion of' the head and by tracing the sutures anil fontanelles. As the anatomical characters of the presenting j)art are often somewhat obscured by the caput succedaneum, the examination nuist be made with care, using firm pressure and searching as far as the fingers can reach. In other than vertex presentations still greater pains will generally be needed to identify the presenting part. During the vaginal examination the hardness of the child's head should be taken into account as an important element in the prognosis. The position is determined by finding in which quadrant of the pelvis the small fontanelle lies. This is best locatwl by first tracing the sagittal suture. (For diagnostic signs of other than vertex presentation the reader is referred to the (;lui])ter treating of those presentations.) The examiner will learn whether the membranes are still intact, and liow far they protrude during a pain, and will make sure that a loop of the cord has not ])r()lapscd into the bag of waters. It is perhaps unnecessary to say that in this part of the examination care will be needed lest the membranes be prematurely ruptured. To the question which is invariably asked, " How long will the labor last?'' a guarded answer must be given. Definite predictions are seldom possible at the beginning of labor. The prognosis, so far as it can be estimated, must be based on the strength and the frecpiency of the pains, the extent of dilatation and the dilatability of the cervix, the position, size, and hardness of the head, and the degree of descent. When nothing abnormal has been discovered assurance should be given accordingly. -- -— o. .on.u, ,,,„,. _ Management op thp Pr« « Duni,g the first ,st«ire nf . i . "'®'" '^^^OE. «"^^' to tl.e bed u„ti til • "' "'^ ^'•''*'*^"t o,„.J,t not . , "H'ted. Much „. 1. '''^-^'^^^''^^ room and fl "'^"""r '"ore eon,- "■<"'- being re, iJ?',™'"""" "f «>.-.«,i„ bt^ " " '; «»• ';»g break, before ,, eta 'f''" °' "«= "'^'bra,, 1, I '"«' "* be "•P"l»ive elibrt. " * ""'•'■ '» n«ma,T, ,„ b7 j ,' "' '" b" all„„.„l ova™a,«l, ''--" «b.,„l., bo el™,. ".,„ '^' ■";"/'- J--"., ..Z „ »'"■'« «"■« sfage i, ;, , „, , " """'""■ «-l'.on,l, 'bepaliejitiiiifilir , *'™™' ™le for tl,e . 1 ■. ; '!""o.. :.:!„t,r,H "■"'"'"• "- ^•- - : ^ict?, ■"" '<> ■«--, „,,b '""'H.|f f,,,,;, „,e r„.' ' '""""■'" ■•-1"b«l, be ,,■,■'''■'■"•'■■ ''=™" after ),i, """b 'be ,„a,er„a| „„, ,, ,. , " """"''' *" be left t„ 1 : I. 1 1 1 3G8 AMERICAN TEXT-BOOK OF OBSTETlilCS. Management of the Second Stage. In the second stage of labor, as in the first, so long as all is nornuil the duties of the obstetrician are few and simple. From the time dila- tation is nearly complete the patient must not, as a rule, be allowed to leave her bed, not even for evacuations of the bladder or the bowels. She is to be dressed in the usual night-clothing, which the imrse will keep well tucked under the arms, beyond the reach of soiling. A folded sheet hung like a skirt from the hips still further conduces to cleanliness. AVhen the pains are feeble, their intensity may be increased by retjuiring the patient to move about in bed or even to assume for a time a sitting or a half-sitting jiosture. The uterine expulsive efforts should be reinforced by the voluntary muscles. Direct the patient to " hold the breath and bear down with the j)aiiis," Most women during the expulsive pains instinctively brace their feet and catch the hands of the nearest bystander to assist the straining etfort by pull- ing. Except in precipitate labor this pra(!tice is to be encouraged. A sheet rolletl into a loose rope and fastened by one end to the foot of the l)ed makes a convenient and efficient sling for the purpose. An abdominal binder is frecjuently useful in helping the progress of labor during the second stage, particularly in multipara) having lax abdominal walls. The distressing sacral pains so common in the expulsive stage of labor may be relieved in some degree by pressure over the painfid region. For this pur- j)ose the nurse, taking jmsition on the bed behind the patient as she lies upon the side, supports the back by pressing firmly against the sacrum with the palms of the hands during the pains. Cramps in the lower limbs are best overcome by powerfully contracting the antagonistic muscles. In case of crami)s in the calf of the leg, for exani))lc, the patient should forcibly flex the foot and hold it so until the muscular spasm subsides. Rupture of the Membranes. — When the bag of membranes does not burst spontaneously by the time it reaches the pelvic floor, it should be ruptured by the obstetrician. Care nnist first be taken to see that a loop of the cord has not slipped down beside the head, as that condition of things would seriously be complicated by the escai>e of the waters. It is not usually difficult to tear the sac with the finger-nail during a pain. Failing by this method, a sharji- pointed scissors, previously sterilized, may be used. A convenient instrument for tl " purpose, generally to be found in the lyiiig-iu room, is a coarse hairpin. It is li. t straightene<' "f'^v'^iZt ""r''.""-<»'si. .1.0 "■"'« •■vposo 2 ^ '"*""' "'"' ••"«„ib„i,„ ," "' "'*■■' «'" "-"ally 1,0 <-«<'".l into ' • ' •"■'"^"la.-l.v i,, ,1,;,, ,1,0 1 ,;'"'■ "■T"' "'««a,tor i... to ,„„ .,„. '"" "■"* a,,., rnsei., „„;, noZ,,:':'' ^^ilt' '"'' '- """ ''avo boc°, „„l!f, ^'""''«'"«i„„ i„ t|,i, ,,. '" !'""'"'"" of ,,o,-i,„,,l .^'•''•■" wo ,,,fl« „,,, ,, "■'""■ " '"" "on „„■._ ► i; ' .- 1 IftVr: i i I >. i •''I 'v.i f Ji < ' ' w ( t/« V ■ f I Ip ^ ■ I t ■f t 'i i ^r • J |L ) |||t ' ^ f Um i '1 Wfk l-i; ,1 kM i "^i ;i IM ■f 370 ^^rI•:^iI('Ax text- hook of oustktrics. and (listc'iisibility of tlic pelvic fl(n)r, or to lessen the teiision to which it is Hubjected (hiring the birth, or both. The former object is best accomplished by the slow and gradual delivery of the head, permitting time for the tissues to stretch ; the latter, by so regulating the expulsion of the head as to keep its sujallest circumference in the grasp of the resisting girdle and the propel- ling power directed in the axis of the outlet. The rate of descent is perfectly at conunand of the obstetrician. The Kiii. I'.i'.K— lU'Kuliuiiifj; the liirlli (j1' tlio liciiil (I'nmi a iilmtoKnipli)- expulsive force of the abdominal nuisclcs may sometimes be suspended by rc([uiring the i)atient to breathe rapidly during the pains. This, however, is not always possible. The action of th(> abdominal nuiscles is at this stage frequently involuntary and wholly beyt)nd the jjatient's control. ]\Iost effect- i,l by lor, is llVect- TlIK VONDL'CT OF yoiiMAL LMiOIi. 371 ual for the regulation of tlio pxpclling ])()W('r.s is tlie use of anesthetics. Cliloroform or ether shouhl he given at this jx'riod on the a|)i»earance of tlio slightest danger of laceration. \\y the jntlieions use of the anesthotie the strength and fretjuency of the pains and the rapidity of expulsion may bo reutdated at will. The advance of the head, however, can still further be controlled by pres- sure with the thumb and Hnger held constantly upon the occiput. With the thund) a])plied to the head inunediately in front of the tense border of the perineum, and with two lingers resting upon the occiput, the rate of descent is easily watched and regulated. To keep the tension of the vulva at a niininiuni, the hmg axis of the cephalic cylinder must be kept at a right angle with the jilane of the outlet of the soft parts Too rapid extension of the head must be prevented. 1'he forehead should not be permitted to pass the j)erineum until the occiput is fully expelled and the nape of the neck rests in the subpubic arch. Moreover, to guard against too great strain upon the i)elvic Hoor, the direction of expulsion must be regulated by crowding the head well up in the pubic arch, especially at the time when the e(juator of tiie head passes the vulvar ring. The expelling force is thus directed in the axis of the outlet, and the least possible downward thrust is exerted upon the jK'lvic floor. The foregoing manipulations arc best conducted with the patient in the left lateral position. In first labors, therefore, and in others in which the ])erinouni is liable to be torn, the jnitient should, as a rule, be placed upon the left side, with the buttocks close to the edge of the bed, as soon as the head has reached the floor of the pelvis. There is rarely danger of laceration until after the occipital pole appears in the vulvar fissure. Up to this point usually the ])rogress of the perineal stage, when not over-rai)id, may be noted by the touch alone. With the finger upon the perineiun just behind the posterior vulvar comnussure the occiput can be felt through the soft parts some time before it licgins to distend the perineum, and the rate of descent can be observed as accurately as by passing the finger within the ])assages. From the moment the occiput ap])ears in the vulvar orifice the parts ought to be under ocular inspecttion. The vaginal discharges are occasionally washed away with a cloth which is kept lying in a warm antiseptic solution. 'S ! c tension of tiie resisting rinj"; may be tested by now and then passing the finger within the vaginal orifice dm-ing a pain. The head is allowed !:o a(',ance during a pain until the perineal edge becomes as tense as is deemed safe. Its further progress is then arrested by direct pressure with the fingers in the line of descent (Fig. iOO). Until about Fi„.jon K,..„i.ui„j,M.x. ° _ ... IMllsKill lit IIk' llOlKl With to be expelled, driven down with the pains, it recedes tho lini-t is of .mo iiami in the intervals, and by this to-and-fro movement the '"'"''"^' •"^' '"■'"^"'■ jiolvic floor is moulded as it were to the re(|uired degree of distention. AVhen the bregma apjM-ars at the edge of the perineum, the head no longer recedes between the pains and is on the verge of expulsion. During the Am M m^ i i! 4' I > li .']72 . I Mi:ni< \ 1 S TEXT- HOOK () /•' OliSTKTliK 'S. passaj^o of tlic ei|iiaf: the expulsion of the heatl is the fol- lowing : The |)atient lyintr upon the left side close to the etlgo of the bed, the operator, >ittini( AMl'UilCAN TEXT-BOOK OF OBSTETJilVS. Most essential is it that the cuts be made parallel with the long- axis of the mother's hody, not with the vaginal axis. The cuts will then he found on exaujination after labor to run parallel with the outlet of the birth-eanal. If the knife be held in line with the axis of the vulvo-vaginal outlet as the latter appears at the time of incision, its point will be liable to invade the very struc- tures the operation aims to save; the ])os- terior ends of the incisions will be ibund after delivery nnich nearer the median lijie than was intended, and the trans- versus perinei and other iiuportant struc- tures will possibly be divided. This result is well shown in the accompany- ing illustrations by Dr. R. L. Dickin- son ' (Figs. •202, 20;3). If j)referred, the resisting ring may be divided with scissors. Alter labor the cuts should immediately be reunited with stitches. A running or an inter- rupted sutiu'c with fine catgut best an- swers the purpose. The wounds may generally be closed without waiting for the delivery of the placenta, thus saving the necessity for renewing the anesthesia. During the suturing the patient may lie on the buck or on the side opjiositc the one being repaired. jraiKif/ciiicnt of the Cord. — Tlie moment the head is born a finger is slipped within the passages to ascertain if the cord is coiled about the child's neck. When so fotmd, the loop or loops should be drawn down one by one over the licad. Should the coil be so taut that it cannot be brought down — an accident that nuist be extremely rare — the cord may be tied at two points, and be cut between the two ligatures and the trunk promptly delivered. Jk/ivcri/ of t/i:' Trunk. — The head should now be held in the hand to keep it in the axis of expulsion. Contrary to the usual teaching, the writer prefers to deliver the posterior shoulder first. While the anterior shoulder lies behind the symphysis the finger is passed over the dorsal aspect of the posterior shoul- dc!" and is slipped into the axilla. The j)osterior shoulder is then folded for- ward and is cautinMsly liftetl over the ))erinenin. Kxcept in emergency calling for immediate delivery in the interest of mother or child, the expulsion of the truidv is left to nature. It is not good jtractice to drag the child out of the uterus. The uterus should be compelled to expel it. The presence of the trunk and the extremities stimulates contrac- ''Tlif l)iiV('tion of tliL' Incision in lOpisintDinv," Tniiin. Am. (lyn. Sor., 1S92. Kli,. JiiJ.- Double i|ii>iiitiiniy(skctc'li, just aftor delivery, liuMi iiiilure. K 1.. Diekiiisoui : A.diree- tiiMi (if iiieisiiiii laulty. iinintinj,' tnwiinl the )mis- teriiir viiL'iniil will I ; li, enrreet line of iiieisiuu. nimihii.' ii:n-iille! willi llie iixis nl' the vulviir (ipeiiiMi,'. ^^^/^ mv/>6YT OF Js^oPU^r if ■ • * • i! , -^ ill* , 376 AMKRIVAX TEXT-BOOK OF OnSTKTJilCS. of the weight of" the cliild in the tir."■•"«.( of ,1,0 „„•,,, «,,:,;'';■'''*'' •*'''-''^ "'"I -"'''im-oiuCr' -"'-< iv of relatively small vulvo- vaginal oritice, narrow ])ubic arch, un- usual rigidity of the pelvic floor, in breech extraction, and in other rapid (icliveries notable injuries are inevi- table in a large proportion of cases. The type of laceration most fre- i|uently encountered is one that riuis nearly in tiie median line of the super- litial structures and to one side of it in tlie vagina (Fig. 205). Sometimes the wound presents the shape of a Y with one arm to citiier side of the inctlian line. Time for Ixcjiair. — I 'nlcss the con- dition of the patient at tiie close of I;>l)or is such as to forbid — and this is vciy rarely tiic ease — lacerations of the pelvic floor shoidd innnediatoly be sutured. Vet perfect union may be obtained ¥%"'" '' ^' ' '^iMV'" "^^ -jmmmg^ B ^' .. i ^^ ^S -% WF' VJ Wk wi ik^ Mm :^^^^m*' ^i^-'^' imM w^^^^e^tm 9^K l-'|i;. JO."..— l.iici'ratinii cif tlii' [n'lvic llimp. cxIciiiHiiK liiilf wiiy tci till' rL'clnm nml runiiiiit; tDWiinl llir ritjlit v.'iL'innl siilcii-; (t'ruiii n ski'Ich ill tliu I'losu (if liilicir liy Uiilurt I.. Ilickiiisnii, M, I),). 380 AMJ:iiIC\N TEXT-BOOK OF OBSTETRICS. t 1 / 11 .! I ii •/ i»i l)y nporatinj. at any tiino within twcnty-f'our honrs. Tho j^nturing may generally be clone with ('oinplete sncceiss even after so long a period as a week if for any reason it has previonsly bi'en negleeteil. AVhen perfornieil thus late the wound-siirfaees are first to be vivitied by rubbing theiu with a told of cheese- eloth, and then made smooth by trimming with seissors. The writer has frequently repaired laeerations while waiting for the delivery of the jilaecnta. This praetiee saves time, and generally, too, the renewal of the anesthesia. It is not to be advised in extensive and complicated injuries. Siifwe Material. — For ordinary use prepared silk is recommended. Silk- worm gut or silver wire is less likely to cause suppuration along the needle- track, but neither is so easy of ai)])licatit»n nor so comfortable for the pa- tient. Catgut is best reserved for buried sutures, owing to its tendency when j)artially exjjosed to decompose and to lead septic niaterial into the needle-track. The writer's method of sterilizing silk by immersion for two hours in melted paraffin at a temperature between 240° and 260° F. has iri his hands ])roved sa«^isfactory. A thermometer specially made for the pur])ose, which can be kept immersed in the melted wax, must be used for regulating the temperature, otherwise the silk is liable to be overheated and charred. The wax employed should be soft, as the harder varieties crumble in hand- ling the thread. A No. 7 silk is a gooel size for the larger wounds ; somewhat smaller sizes mav be used for slight lacerations. Needles. — For use in the external and more accessible portion of the wound the needle should be straight or be slightly curved and about 2 inches in length. For suturing tears high up in the vagina a needle as much shorter as the depth of the wound will permit, and having a more pronounced curve, may more conveniently be used. Xeedlo.-? of ihe Hagedorn pattern will be found most satisfactory. Jfethod. — An anesthetic is usually necessary. Ether is to be preferred here, as usual for surgical anesthesia. Small tears may be repairal under coeain anesthesia if for any reason it is desirable to avoid the use of the general anesthetic. Coeain is most effective when injected at several points in the lips of the wound. Not more than a grain at most can safely be used in this manner, and the solution should be rendered sterile by boiling. Many women, however, suffer very little pain from the introduction of sutures, since the tissues have largely lost their sensitiveness by the j)ressure and contusion received during labor. If care is taken to plunge the needle quickly through the skin-margin at the mf)ment the greatest amount of pain is produced, lacerations not very extensive n>ay be sutured without anesthesia. The ])atient lies in the lithotomy position, crosswise of the bed, with the hips close to the edge of the latter, or upon a table. The knees are held by assistants or by some of the numerous appliances eonuuonly em])]oved for the purpose in gynecological practice. The sheet sling of Dr. Dickinson has the advantage of being always available. One of the chief difficulties in determining the extent and character of the ^'//A' coy DUCT OF voru,, r , ,. '"'*^ J-Ajion. no, iaceration arks f"i-,>i.. fi . "°* '■""» "P one «,■ lH„|, ,,M,„ „/-,l' '"'">■ """ "i'l', •« ,„«i,„„|,. ":'?■ -..Uy, o„.,„Vee,, „„ „„,„ ;,«■-';'■«"■. TU. aim t t'' "' flio lacerati.,,,. I, ,i,„ ,l„ ,'""■'"" '" «"fart tlir„ii»|,„Mt lli, • , '-»""' to,.,,,,, „,;,,;* "'■: J";',™'. o"e b, o„cr,b ^: :';''^'f Tir 1 1 3H2 AMI'llilCAX TEXT-BOOK OF onSTKTJtICS. 5t» ti ^1 ( 1 iniK'otis nionibi'iiiu", and the rcinainiiit; wound is sntnrod on cither Ine perineal, the vaginal, or both surfaees as may be tbnnd most expedient. When the rent .shown in FiK'uii. 'J05, with sutures jior attention to the mother: soiled portions of her jiropcrly placed I'L'tuly fur tyinj;. '■ body ar(> to l)e cleansed, best with an antiseptic .solution ; her linen, if necessary, is changed ; and all blood-stained articles are removed from the bed. For bathing the genitals a piece of fresh-boiled 10 edge "^ uanislied from fi,,, i • . '"•^''^••<' of a snoiKm u '■"•■'^•'•-"•'■t.vinB.-/, miiNcli.-,.,,,!^ . iTf, milinjr """"""-'■"»'"-- looMai ;:;;,;';3^ I^K;. 20S.— Shows fllll . "' ^-"-' '^"-^-S'^ "-■ :>St»i»S5<«-- '=" -P-ecos are attached to the J,, ,1 H' '"^''"'^■^ ^^''^'^' ='"<' 2 i.,e es th •':•« b.,rned after „sing. Tl,oso'. • " '"'^'"'"^^ ^" ^''^^ '^'-Hler T ' i " <''='tely before use F .„ ''"'""^^ «'-^" ^ct .sterilised b T ^""''''■' l\H4 AMKIilCAX TKXT-lUtOK OF onSTKTIUCS. A (Imw-slu'ot [tlacod midcr tlio pati-'iit's Iiips is a ('«mv('iiit'iit drossinj? for pru- tc'C'tiiiii; tlio 1)('(1. Till' (Iriiw-slicct consists of a coinmon iniisliii slicet folded to four tliic'Iviu'sscs, It is replaced hy a fresh one as often as soiled. Instead of tlio draw-sheet an aseptic pad siniihir to tiie hihor-pad, bnt thinner and smaller, in.iy he preferred. AbdoiiiiiKil Hinder. — The ahdoniinal hinder is usefnl to steady the uterns, and it [)roniotes thecond'ort of the patient, especially when the abdominal walls are very lax. The nsnal material is a piece of nnhleaehed nuislin 1| yards in leniith and abont 18 inches in width. 'J'liis y-ives width onony-h to reach from the ensiforni to a point below the trochanters (I'l. 27, Fig. 1). Unless the binder overreaches these bony prominences it is liable to slip up, and in a few hours is reduced to a mere ro])e around the body. Binders ready made with gores to fit the body offer no advantage. The pinning of the binder shoidd begin at the lower border, and at the first application should be fairly tight. If the uterus shows any tendency to relaxation, three folded towels, used as compresses, may be placed on the abdomen under the bandage, one on either side of the uterus and cme immediately al)ove it. The binder may be dis- pensed with aft(>r one ov two weeks. IJcfore leaving it is well for tiie piiysician to take final note of the pulse and the general condition of the mother, and the nurse should receive all ueeded instruction in regard to the general care of both patients. III. THE MECllANlt?M OF LAUOR. Labou is a natural process, and it is the province of the accoucheur to restrict himself to watciiing tiie processes of nature so long as they are normal and ctHcient, and to interfere with them only when they become disturbed or inefficient. He is at his best when he is able to compel the faulty efforts of natural labor into a normal course, and he makes a comparative failure when- ever he is obliged to sul)stitute for the acts of nature the relatively crude process of an artificial delivery. An ability to restore the normal by making trifling alterations in the mechanical conditions presiipposi's, however, a most accurate knowledge! of the details of the mechanism which governs the usual course of labor, and of the alterations in them which determine the advent of any deviation from the normal. When, moreover, it is remembered that obstetric operations are but efforts to direct an extrauel thiit IflCl'll- iirst It the 'tio-. 1. Al ilniiiiiiiil liiink'r ami liiriist-liiiulcr in |i1iiic din (ln>m II {>liMtnm'M|>li |ilinl(if;rii|ili). '-■ Uii'ii>t-liiMiUr ill jilnt'L' m I l^ in , 1 ' 1 ' 1 H 1 i 1 4 , i 1 j: ' ^B; i ^^■l ^^^|i 1 \ I^H i i^H ' ' :> 1 I ( ■( Tin: MHVJfAXISM O/' l.MiOli. 385 Iff tlic shape and dimensions of tlie obstetric eaiial, and (»(' the i'etiis whieh is to pass tlironffJi it. He is then in a position to a('((i:ire an int( llihalic presen- tations — that is, presentations of the vertex, of the brow, and of the face; pres- entations of the pelvic extremity, whieh are sidxlividcd into lireeeh and foot- ling proscntati w; and transverse iircsentations, under which are included presentations of the hip, of the trunk, and of the shoidder. 25 iii ? i,5' I V. iS^- y%-% \M\ •w \n I? 5 I ^'« I 386 AMi:iiICAy TEXT-BOOK OF OBSTETRICS. Position. — 111 obstetric use the word jiosHion is restricted to a meaning in wliicli it is used to define the relation that the dorsum of the child bears to the dorsum of the mother during its passage tlirough the ])elvic canal. Kach ]>resentation is subdivided into i)ositions according as the dorsum of the child is directed anteriorly or ptisteriorly and toward the right or the left side of the mother. Thus we recognize under each presentation four positions, according to whether the part wiiich gives the name to the jiosition is directed left- anteriorly, right-anteriorly, right-posteriorly, or left-posteriorly ; for example, vertex jtresentatioii, occipito-left-anterior, breech presentation, sacro-right- posterior. Classification of Labor. Presentations. — Tlie presentations are first of all roughly divided into l())if/iiu(lin(i/ and ohliresentations of the fetus in two other ways, ill a<'coi'danc(> with the results which may be expected to accrue from their occurrence — namely, into normal and abnormal, natural and unnatural, presentations. Normal and Abnormal Presentations. — A ])resentatit)ii of the vertex occurs in about I'T ])cr cent, of all labors, and, both from its frecjuency and from the favorable character of its results, is considered to be the only noriiKil presentation, all otliers being elassifie'-■■- .-""i:^: : ;;r;v r™'"-' -' '>>•"» "°Sr£S;S":^';:n::: "" - '- -» „„„. I »».'• '""• ""■" ""-"■'■■•■" i« »,, ;:;;;:,;|;:tr' ';':",""i ■■" ....... j,.ut'u to til (ioniain of i . . !l u. 1 ^flWF" ''' \\f 1 ffl^fl '!'■'• f ^ 1 ' '' 1 ■'•% 1 nm f ly ' ' •f ' ''*'■ m ^ t' 'i; i i; :f i7 !■■ I I / i ••; 388 A.VEliJCJX TEXT-BOOK OF OBSTETlilCS. Anatomy op the Pelvis. The anatomy of tlie bones and the soft parts which together make np the j)elvis is (lesc'ril)e(l in detail in another portion ot" this work, bnt for tlie com- prehension of the medianism of hibor it is necessary to add to the anatomical description a discussion of the shape and dimensions of the parturient canal as a whole, before its mechanical relation to the fetus which is to pass through it can intelligently be discussed. The porfui'icnt cannl (Fig. 211) may be divided, for purposes of descrip- tion, intt) three i)arts — the supra pe/vic, the pelvic, and the infrapelvic portions. Kl(i. ■JU— Tlie imrlurii'iit ciiiml: at. axis (it iiliriis; aI, axis iif inlet; iti!, ri'tfiictioii-riiiB ; lo, iiiU'riml (|^ . Ko, (.■xttTiml ns iciiR'-tliird imtiiriil sizcl. The xKpraptlvic or abdominal portion of the parturient canal is made up of the uterine ctivity anil the large or false pelvis. This portictn of the ju'lvi- is classified with the uterine cavity on account of the similarity of their finictions; that is, the obstetric function of the large pelvis is simply that of affording a resting-place to the lower [)ortion of the child during the whole ( r THE MECHANISM OF LABOR. 389 tlie greater portion of pregnancy, and of guiding the presenting part to the inlet at the beginning of hibor. The pdch- portion of the ])arturient canal consists of the small or true ])elvis. The infra pel I'k portion is made up of tlie soft parts lying below the pelvic bones, which jiarts, though small and inconspicuous in the non-parturient state, are stretched out during labor into a tubular canal which considerably prolongs the parturient canal, and completes the curve of its lower portion, known as the chitc, of Cams. All adequate comprehension of the shape and the mechanical functions of die parturient canal in its entirety will best be attained by postponing the description of the canal as a whole until its subdivisions and component parts have been described in detail. Suprapelvic Portions. — Fterhw Cavity. — The uterus at term is a hollow, ovate-shajwd viscus, whose cavity, although anatomically a part of the ])ar- tiu'ient canal, is, from a mechanical standpoint, less a part of the passage than the engine by which the passenger is to be propelled. The function of the uterus as the source of the propulsive jiower by which labor is accom- plished will be discussed later. Its function as a portion of the canal ictjuires no special description. ./'W/.sr Pelvis. — The false or large pelvis is that portion of the pelvis lying above the linea terminalis. It is composed of the lumbar vertebrse, the upper surfaces of the latei-al processes of the first sacral vertcbi-a, and the Hliiamous portions of the iliac bones, and functionally it is completed In- the lower portions of the anterior abdominal nuisclt's and their attachments to the horizontal rami of tlie pubic bones. The whole thus forms a I'umiel whose sloping walls terminate in the inlet of the true pelvis, and are admirably suited to their office of directing the presenting part into the ])elvis in the initial stage of labor. Apart from this point, the chief practical value of the lidse pelvis is in the light which alterations of its sha])e or of its dimensions throw upon the diagnosis of ])elvic deformities. To be in a jiosition to detect anv departure from the normal shape of the pelvis, it is especially important to be familiar with the normal shape of the iliac crests and with the normal curve of the linea terminalis. Although the crests of the ilia are classically described as presenting an S- curve, it must be remembered that only one portion of this curve — iiamelv, tiiat which possesses an anterior concavity — enters into the formation of the basin of the false pelvis; the other portion of the curve is entirely without the pelvis, and is utilized solely for the attachment of the saero-iliac ligaments ;uid the erector spiuic muscles. The shape of the anterior portion of this curve is such that the greatest distaiic(> between the crests is normally '2.5 centi- iiieters (about an inch) more than the distanci> between the anteri(»r superior spi- nous processes, the distance between the crests being normally 'J") centimeters (about 10 inches), and that between the spines 22.5 centimeters (about 9 inches).* Under normal circunistances the anterior ])ortion of the linea terminalis * TIr'sp (linu'iisions aro found to 1)0 soiiu'whiit v;\ii:ilili' iiiiinni,' dilli'ioiit nurs. Tlic lifjiiri's ijivt'H are belifvi'tl to lie !i]ii)ro.\iin;iti'ly i-orreot for Anii-riciui women. tWJ ' r If l.iSi,;-' i' ,1 hi i 390 AMKRICAX TEXT-BOOK OF OBSTETRICS. presents ii uniform curve with an internal concavity, and there is bnt little, if any, projection of the crest of tlie piibes in or about tlie niecliaii line. Pelvic Portion. — The true or small pelvis comprises all that portion of the pelvis lying- below the linea terminalis, and it is divided into three portions — the superior strait or inlet, tlie inferior strait or (Hitlet, and the excavation. It is formed by the sacrum, the coccyx, the lower portion of the ilia, the ischia, and the pubes. These bones taken together form a deep basin-shaped cavity, whose posterior wall is formed by the sacrum and coccyx and is Yk :;12.— I'l'lvis soun from above, showiiiK tho (k'crcaso in tlic trnn^iviTso ilianu'tiT from above downward (ouo-third natural size). sharply curved with an anterior concavity. The anterior wall is formed by the symphysis, and is short and nearly straight. The lateral walls, which are formed by the lower portions of the ilia, the ischia, and parts of tlie descend- ing rami of the ])ubes, are irregular in outline and slope gently inward, so that the transverse diameter of the pelvis is markedly less at their lower than at their upper extremities (Fig. 212). At its upper and lower limits, which are known as the superior and inferior nfniit.s (Fig. 213), the dimensions of the pelvis are much less than in the inter- vening space, called the "excavation." An accurate knowledge of this por- tion of the parturient canal is of the greatest importance, and on account of its complexity is most easily given by sejiaratc descriptions of the excavation and of each of the straits, after which description it will be easy to include that of the pelvis as a whole in the general description of the parturient canal that follows at the end of this section. T/ie .siij)cri(tr .stniil is bounded by the promontory and ihe anterior surface of the first sacral vertebra, the linea terminalis, and the pubic crests. The shape of the inlet or superior strait of the pelvis varies considerably in accord- ance with the point of view selected, but if the eye of the observer is placcil in (he probable position of the axis of the cliiKl at term, it will be seen that the shape of the inlet is approximately circular (Fig. 212). THE MECHANISM OF LABOR. 391 It must be remotuberod that the presence of the soft parts somewhat alters •*^''-'-5:jirii«ws'*'L.^_ / Fir,. Ji;!.— Lateriil viuw of the pelvis, showing superior and inferior straits (one-third natural size). tlie shape of the brim. The importance of this fact, however, is lessened by V':^>. Ittkrcristal ■ ' "' Jfansverse Intersjfmal .V^* -V, F\G. 21 1.— I't'lvis seen from aliove, sliow inn tliiinu'ters of lirini fmu'thinl natural size). the fact that the vessels, ihe connective tissues, and the rectum, as well as the 1 ( r V ^ hi Cl' IM teiiit si ii I i / i I i: ! f) I "I ,1 ) I ? 1 ' 4' -I I ! ^4 ( I 392 AMERICAN TEXT- BOOK OF OBSTETRICS. psoas-illaciis muscles, which together form the only important soft parts in the inlet, are concentrated in the sacro-iliac notches, where the space is already most abundant and where its decrease is of least importance. The dimensions of each of the straits are determined by measuring the antero-posterior, the transverse, and the two oblique diameters. The antero- posterior, or, as it is more commonly termed, the conjugate, diameter of the superior strait (Fig. 214) extends from the upper border of the symphysis pubis to the promontory of the sacrum; its normal length is 11 centimeters (4} inches). A little less than half an inch from the upper border of the sym- physis pubis is found a point which, owing to the thickness of the pubic bone, is decidedly nearer to the promontory than the uj)per border itself From the promontory to this point the distance is 10 centimeters (about 4 inches), and this is called the "obstetrical" diameter or true conjugate. The greatest transverse diameter of the superior strait averages 13 centi- meters (5^ inches) in length ; this is the diameter referred to whenever the transverse diameter of the superior strait is mentioned. This diameter lies, however, so far back in the pelvis — that is, so near the promontory (Fig. 214) — that it can never be occupied by any of the diameters of the fetal head. The transverse diameter, which could, in fact, be occuj>ied by the fetal head, lies some distance anterior to this, and is so much shorter as to be of little im])ortance, being, in fact, less than are the oblique diameters. In point of fact, the head never enters a normal pelvis transversely, and the transverse diameter is therefore measured merely as a means of comparing one pelvis with another. The oI)lique d'-uneters extentl from the ilio-pectineal eminences to the sacro- iliac articulations; their length is 12.5 centimeters (about 5 inches). Since the terms rigid and left oblique diameter are differently used by different author- ities, it seems best to distinguish these diameters as tlu; first and second oI)li(pie diameters of the inlet, in accordance with the frequency of their importance in the mechanism of labor; the first being that which extends from the left ilio-pectineal eminence to the right sacro-iliac synchondrosis. The inferior strait is bounded by the subpubic ligament, the descending rami of the pubcs, the rami, tuberosities, and spines of the iscliia, the saero- sciatic ligaments, and the coccyx. Its shape, when looked at in the direction of its axis, is that of a lOzenge whose anterior sides arc formed of the ])ubic and ischiatic rami, while the posterior are made up of the saero-sciatic liga- ments.* When looked at from a point somewhat anterior to the line of its axis, it is seen to present a roughly triangular shape ; but when we rememl)er that the sacro-sciatie ligaments become very distensible during labor, and that the softening of the sacro-iliac and sacro-coceygeal articulations that occurs * Owing to tlie projection downward of tlie tuberosities of tlie iscliia, it will be seen that tlip surfaet' of the inferior strait is bent upon itself to form an external I'onvexity (Fig. "Jl'ii. I'Or practical j)nrposes it is, however, convenient to neglect this bend, and to deal with tlu' inferior strait as though it did, in truth, lie in a plane between the tip of the coccyx and the subpubic ligament. Fl(: JAjU. / lor- 'ond their iVoin acro- otion )Ub'H' liga- )f its iuImt tluit Iccnrs |i that •21'> • 111 tli>- .1 till' T///; MECHANISM OF LABOR. 393 during pregiiaiicv ])orinits of a considerable movement of these bones upon each other, it will be seen that when the soft parts of the inferior strait are T- / / / / Kiii. 'Jlo.— I.iitiTiil vk'w (if tlu' pelvis, slidwiiiK cxtiTiinl convoxity of tlio inferior striiit. distended by the heatl, its aspect from either position will be that ut an ovate or egg-shaped orifice (Fig. 216). The antero-posterior diameter of the inferior strait extends from the lower border of the symphysis to the extremity of the coccyx. Its length in the non-parturient state is 9.5 centimeters (about 3J inches), but when the move- .'■\ ^ M ^■-'•* '^:^^'\ H Flii. 2Ui.— View of distended outlet. Tlie dotted lines sliow the possible position of the sacro-sciutic ligament and tlie eonseiiuent inerease in the transverse diameter duriiifj extreme distention. inents of distention spoken of above are fully effected, the length of this diam- eter is increased to 11.5 centimeters (4^ inches), or perhaps even to 12.7 cen- timeters (5 inches). The transverse diameter, which is drawn between the inner borders of the tuberosities, measures 10.5 centimeters (4| inches), and it is the only nnyield- wm m\ M:, Cl?/ll,i:f i;-! V I \\ \ ' J 'U. n V c ,M 394 AMERICAN TEXT- BOOK OF OBSTETRICi^. '-I iug diameter of the inferior strait. The divergent direction of tlie tuberosities makes it possible, however, for the transverse diameter of the head to corre- spond with a much wider transverse diameter of i\u\ outlet whenever the con- ditions of the case permit the parietal protuberances to occupy a position pos- terior to the tuberosities (Fig. 216). The oblique diameters are manifestly rendered unimportant by the uncer- tainty as to their length, the result of the elasticity of the sacro-sciatie ligaments. -f The excavation, which is bounded by the inferior and superior straits, com- prises all that portion of the pelvis lying between them. The backward curve of the bodies of the sacral vertebrae and the straightness and shortness of the anterior wall of the pelvis render the excavation much more roomy in an Fi(i. 217.— Iiiiigram showiiiKn (iivision of tlir liitcnil wall of tlie I'xrnvation into sections In nccordancu witli tliiir iiailiuniL'al functiiins. i -I antero-posterior direction than is either of the straits, and this increase of space is, of coiu'se, greatest in the middle j)ortion of the excavation. The oblique diameters are correspondingly increased for the same reason, and, indeed, in the middle of the excavation they are often longer than any of the diann>ters of a small fetal head — a fact which is sometimes oi' inii)ort- ance in the mechanism of posterior positions of the vertex and of presentations of the face. If the transverse diameters of the excavation were similarly ample, this portion of the pelvis would be devoid of obstetrical interest ; but this is far from true. The transverse diameter of the excavation is at one point the smallest and also one of the most rigid diameters of the whole pelvis, and the importance of the anatomy of the lateral walls of the excavation is so great that its comprehension is the key-note to the whole sid)iect of obstetrical mech- anism. The anatomy of the lateral walls is so difficult of description that it (^ ^ of he jiul, l)rt- Tin-: MECHANISM OF L Alio II. 395 IS possible to comprelieiul it only l)v means of a stilxiivisioii of the lateral walls of the excavation into three parts (Fijj;. '217) : An iipjur jtortion {A, Fijjc. 217), which is ronj^hly triangular in shape; a sccontl jioiilon (/>'), which lies hclow and in front of the first ; and a //(//•(/ portion (C), which lies below and l)chin, into a spiral groove which deepens as it descends and turns forward. When the rigidity of portion ^1 and the yielding nature of portions B and C are considered in connection with the fact that even in the bony ])i'lvis the foramen ovale and the sacro-seiatic notches ar(> regions of recession separated from each other by the projecting ischial spines, it will be seen that when distended by pressure from within, the lateral walls of the excavation may be considered as consisting, for mechanical purposes, of two deep grooves separated from each other by a prominent ridgo of unyielding bone (Fig. 218). The anterior of these grooves pursues a spiral course downward and forward from the anterior end of the oblique diameter at the brim, to end under the pubic arch at the anterior end of the conjugate diameter of the inferior strait. The posterior groove pursues a similar s[)iral course ilownward and fui ward ; ' > -J' h b' - » . 'pHiPiiJII \' n V *' f .1^' 39(J AMKIilCAX TEXT-nOOK OF OliSTKTIiK'S. from the posterior end of the , cross-section through the ischial spines, which here eniphasizu dellection inwanl of the bony rid^e (.\. Ki).'. 217). K, cross-section near the inferior strait. The jiosterior half is distensible, ami in the anterior half the bony duscendins; ramus of the jiubes <'urves outwardly to contiinie the c\irve formed by the yielding tissues which cover in the foramen ovale, as seen in the sections (' and 1) The oblique diameters drawn toward the bottom of the anterior groove I ! THH MHCIIAXISM OF LAJlOIt. 397 jve upon on under the influence of a (;onstant intraiielvic pressure, it must necessarily follow tli-' \-M\ of least resistance — that is, the course of the i;roov(( in which it started — to end its course under the pidjic arch at the outlet. The imp(»rtance of these considerations will be apparent w lien the section on the Mrc/mniHin of (lie Sccoiuf S(a(/c of Labor is reached. Infrapelvic Portion. — When the soft parts below the inferior strait are distended by the head, they inchule a hood-shaped space of considerable si/e, bounded upon its upper border by the edj^e of the pubic arch, the tuberosities of the iscliia, and the lower edj^e of the sacro-sciatic ligaments, and upon its other (»r inferior border by the (triticc of the distended vagina. Its anterior wall is from a ((uarter to half an inch in length. Its posterior wall, when fully distenetween each pair of these points (Fig. 219), a curved line passing through the centre of each of these planes forms what is known as the axin of the pclric canal ; if this curved line is continued forward, it will reach the abdomen of the mother at about the situation of the umbilicus in the non-j)arturient state. This prolongation of the pelvic axis is known as the curve of CarHi<. The centre of any body j)assing through the pelvic canal nuist travel through a path closely approximate to this curved axis. Were the jielvic canal exactly cylindrical and the fetal head exactly spherical, the mechanism of labor would l)e limited to an observation of the abovi -related fact; but in reality the irreg- ularities in the contour of the pelvic canal and the corresponding irregularities in the shape of the fetal head are matters of the greatest importance. It will be remembered that although the transverse diameter of the superior strait is nominally the greatest, yet the ra])id convergence of the ilio-pectineal lines as they stretch forward renders the length of the practicable transverse diameter in fact less than that of the ol)li(pie diameters, so that any ovate body presented to the inlet of the pelvis will tend to enter the brim in the oblique diameter. At the inferior strait the transverse diameter is the narrowest of the whole ) Tr- ill I IIH I f i i > ^ i A / 31)S AMi:itI('AX TKXT-IiOOK OF OliSTr/mil'S. pelvis, iiiid, since the ()l)li(|no diameters at tlie moment of delivery are shorter than the distended eonjiiLrate, any ovate Ixidy which attempts to pass the ontlel will do so most readily it' its lon^- diameter corresponds with the antero-posterior diameter of the inli'rior strait. It is therefore evi«lent that the process of Klii. 21',t.— SuKittnl Sfctioii nf the iiclvis, .showing the pflvic axis "Mil tlu' ciirvi' nf Ciinis. labor will most easily he aceomjilished by the occurrence of a rotation of the longest diameter of the presenting parts from an oblique position at the supe- rior strait to an antoro-posterior position at the outlet ; in point of fact, the mechanical relations which lead up to this rotation lie at the bottom of the whole subject of the mechanism of labor. It is to be noted that when the woman is in the erect position the axis of the suj)erior strait * forms an angle of about 30° with the horizon ; that in the same ])osition of the woman the axis of the inferior strait is directed down- ward and a little forward ; and that the axis of the vaginal outlet of the par- turient canal loftks almost directly forwanl and but very slightly downward. Differences between the Male and the Female Pelvis. — It is important that the obstetrician should clearly understand the normal characteristics ol' the female pelvis in contradistinctioti to those of the masculine form, because the approaches to a masculine type — which are not uncommon and may occur in any portion of the pelvis — are not unim])ortant as a cause of dystocia and * .\ line (Innvn from tlie ct'iitre ol' tlie superior stniit in a diri'ctioii iierpeiuliciilar to ils jilane. t' J^JL the ., the \ the Ito 11- 77//; MIJIIAMSM <)l I. Mian. 3!Ji) of alterations in the nioeluinisiu ot" lalutr. Tlie (lilH-rences between the male and tlie female pelvis will be ren»lerer spoken of, decreases the importance of the descen«ling rami in the formation of the anterior wall. Jtij'erior >Str.s in,,,, 7/50 ^^^ g^^„ 4QJ ^^-^ ^, " ^"^^'•««'tie.s, greatly j X> / '"'■ --'•-J"'"srMni.n,-i(; . „,,,,„ "('<'t;il)iila. and tU • " *''"'' '^ ■•' iii'catcr ,.,.l.,- .'"" ''■"^ *''' wnipan i" "■"....■„ ,M„i i;„. V " '"■' '^ I".- .1 n,„ , , '.'"■."""■""" "f .1, "■'■■■' "'■■-^^^•t:^^':;:i:;;:::';";:--:n;:;/;;:r::^ '''"■''^!l!'<.l..rmo- I,|,„, ■ , •''" "' ""• '••'••-I lica.l an.l „• '" a (lior'diii^li illi (lie iiiiiprc- I h ■J^ f 1,, i, Ik-t' 1. T ( ■ ]'. •1 I'ii ^'ff ;ff^ 1 J i i :\ * ! i I 402 A^f/'JIUCA^' Ti:xT-ii()OK of onsrKTi^rvs. sliapo nnd i(»n.s of tiu iv'tiiniiidcr of the fotiis in tlio attitiido it onli- iiarilv assiiiiios, tlnniii'li loss often of iniportaiieo, is iievortlieless essential. The Fetal Head. — The head is obstetrieally divided into two portions, the face and the cnniiiun. T/ir face is iniieh smaller in ])roportion to the cranium than that of the adult, and is of l)ut little iiuportanee in normal labors. It is, however, well to ri'meinber tiiat the i'aee is made up of the most solid and ineom])ressii)lc bones which enter into the eomjiosition oi' the head, and that its eoufiguratiou i,s altei'ed but little, if at all, by the jiroeesses of labor. I'/ic crctniiua or brdlii-atnc is to be divided for purposes of description into two ])ortions. the fxtnc and the vaitlf of the skull. The base is formed by the basilar portion of the oeeij)it;d bone, the petrous portions oi' the temporal bones, the s])heuoid and ethmoid, and the orbital processes of the I'roiUal bones. Tiiese bones, even at birth, are firmly united, and they foi'ui a coiii- ])aratively small but almost totally iueomi>ressible mass. Th(> vault is made up of the parietal bones and the scpiamous ])orti(;ns of the occipital, tempoi'al, and fi'outal bones. These bones are all wide, flat, and sliLihtly curved. The scpiamous portion of the occipital bone is attaciicd to the basilar |)ortiou liy a band of fibro-cartilaiiiuous tissue which permits of (piite free motion between the two portions. All the bones of the vault are united at their (>dtres l)y n>eud)ranous commissures formed of the dura matci' and the uuossificd exterual jK'riosteinn. Tiie vault of the cranium, thouiih much lariicr than the base of the skull, differs from the i)ase in its ]V)ssession of compressibility and of a marked capacity for alteration of shape under the mouhliuii' influences of the constant pressiu'e of labor. It nuist be remembered, however, that difl'erent lieads present very different detri"«'i''< <^1 ossification at the tinu' of birth, and, indeed, vary widely, from eases in which the flat bones are so slightly ossified as readily to ho bent by the jnrssure of the finoer, and in whiv'h the mem- branous intervals are extremely wkh. and well marked, u]) to cases in wliicli the ossification luiil union of the hone- are .>!ii tl liafi'- ir ti l)llt'.ll LAIioH. I'l.AlK -28. ■> ^-•ti .CI c^ K vs Ocap/h* -fFoiital * ^ Occipul ^^s Biparletal S .S diparktal ^ cmspn- Ver Tex ^'nfane/Ze ^\ (brejwa) ^ Bitemporal Scmdlm-j hstprior ^ioi**^ Tontande >V* OcapiTal Prvtukruncc Biparietal 5' inciput t Bitem voral I Kktai. IIi;aii: !. Kcliil skull scon Imni tlir siilc ; j I-'itnl skull sr.n finm hIkivi': ;i. Kctal skull situ Crniii lii'hinil. I Kiliil -kull sciii I'nitn in Irmit showing sulmis, l.inlHii.llrs. iinil cliaiiifli'i-s. t i| e UT^ ^*^y- ; ' ' i ;: :ii: i,i- >', ; 1 I I THE MICHANISM OF LABOR. 403 sagittal, and coronal sutures moot in a inonibranous space or fontancllc wliicli is rliouiboidal in shape and is ordinarily of considerable extent. Tliis space; is known as the (interior or large I'ontanelle, and sometimes as the hrcr/tiui (1*1. 28, Fig. 2). Of its four sides, the two anterior are usually tlie longer, and when this diilerence is well marked the resulting fontanelle may more ])roperly be said to assume the shape of an Indian arrow-head (Fig. 22G, a). The junction of the sagittal and lamixloidal sutures at the point where the occipital and parietal bones meet forms a small triangular space, known as tiie posfrrior occipital, or small fontanelle (PI. 28, Fig. .3). In well-ossiiied heads ihis space is frequently small or wanting, and the ])osterior i'.)ntanelle is then I'cpresented only by the jiuietion of the three suturi's. It is to be remembered, moreover, that when the bones are closely crowded together by the jiressure oi' severe labor, either fontarielle, however well marked, may ]nu'tially or Avholly be ciTaccd for the time l)y an overlapping of the edges oi' the l)oncs which bound it. Fxceptionally, a locally defective ossification along tlic edges I if tiie bones may result in the ])roduction of either Wormian bones or I'alse I'liiitauelles, hoth of which are most connnon in the course of the sagittal suture, and which may result in considerable coul'iision of diagnosis if the ])ossil)ili!y of tiicir existence is not borne in mind.* Dimensions of the Fetal Head. — Tlie size of the i'ctal head at term varies greatly with the size of the individual fetus, but. iiowevcr great this variation may be, the relative proportions between the ditferent parts of the head remain approximatclv cdustanl, and for the sake of clearness it is usual, in the discussion of general principles, to ignore this variation of siz(> and to use as the basis of argument the dimensions of the average head, 'llie diam- eters that have been found most useful in the description of the head are as ^(lllo^i•s: The (iiiftro-itnsfrrlor >ll(niuii ri^ — the oecijiito-mentid, the oc>'ipito- i'lMutal. the snl)occipito-l)regmatic ; the traiixrcrxc lUamdcrs — the biparietal, the hitemporal, and the bimastoid ; the vcrliral (liaiiu'fcrN — the fronto-mental and the cervico-bregmatic. Antrrn-poHtcrior Diduicfcrs. — The occipito-niental diameter (PI. 28, Fig. 1) is drawn from tluM-hin to the most distant jiortion of the occiput. The occipito- frontal (PI. 28, Fig. 1) is drawn from th<' ]ioint of union of the supraori)ital ridges to that portion of the occiput which is most distant from them. The suboecipito-bregmatic (PI. 28. Fig. 1) is drawn from tlu' jinint of junction hctween the occi|)ut and the neck to the centre of the anterior fontanelle, Tnnii^rcrxc Diaincfrrfi. — The biparietal diam<'t(>r (PI, 28. l'"'igs. 2, 4) is drawn li'om the a]>ices of the lti|)ari(>tal protuberances — naiii ''y, throuLi'h that portion It is WL'll to Iiciir in niiiid, in luldilioii to iln' iiiitciiiir :inil ))osti'riiir tontniiollcs, tin ocia- >iniiMl I'xislctici' of ;i tiiiiil. tlu> hiliriil fontiuirlli'. Tills lontjiiu'lle is iinxMii nnly in ]ioorlv-ossi- liid Imids, nnd wlu'ii ]irt'scnt is found at tlir jmu'tion of iho c>tTi])it!ii. piirit'ial, and ltin]ionil I'oiu's, ni'ar tiio l)as(' of the mastoid j'roct'-s ;inaid tlial llic mastoid iitorcs'. iWU lil;nosis <>( lids region of tl skull. ' m ■ m e' ff I I fl ni'ui Hi ■ 404 AMEIUVAN TEXT-BOOK OF OBSTETRICS. of" the skull at wliicli tlic lateral .siirlht'cs arc most widely distant from eaeli other; the bitemporal (PI. 28, Fij-s. 2,4) extends transversely between the most distant ])()rtions of the coronal sutures ; the bimastoid extends between the mastoid processes at the base ot" the skull. To these diameters is some- times added a less important diameter, which is that lying between the base of the zyj^omatic ])rocesses, the bi/,yi>'omatie. Vcii'mil J)i\ 1) is drawn between the junction of the neck and the chin and the centre of the anterior fontanelle. The lengths of the several diameters, as obtained by Tarnier and Clian- treuil, are given as follows: ('I'litimclcTs. Iiii'lii's. Occiiiilo-iiifiitiil (liaiiH'ter {'A oj Oc'ci|iilii-fri>iitiil " 11.5 ^ 4.] Siili()(ci]iilo-lin<,'iiiiiiii' (liaiiietcr !)..') = 3if jiipiuiutaldiaiiiftor 9,5 =: 3:} r>itciiipito-mental diameters an; almost e(|ually compressible, but the degree of danger to tiic Ictus that com- ]>ression of these diameters involves is vastly greater than is the case with the biparietal and bitemporal iliameters ; and with obliijtie compression the degree ol' danger inci'cases as the direction of the force approaches to the antero-posterior diameters, '{'he bimastoid and bizygomatic diameters arc I'or j)ractical purposes totally incompressible. The Relative Value of the Diameters of the Head as Compared with the Diameters of the Pelvis. — It will be observed that the lengths of the suboccipitip-i)rcgm;itic and biparietal diameters are nearly equal, so that a cross- section of the head through these diameters { I'^ig. 227, A) is very nearly cinui- lar ; ansented to it in any obstetrical position. Since this is the cross-section which is always jiresented to the jielvis by wcll- llcxcd heads, the study of position would !)e of litth' im|)ortance if the exist- oneo of Hexion could alway.s be depended upon and if the remainder of the lom- Ivitli tlic tin- n.r ath he Ircu- liiss- ruin- Icll- ;ist- iUv THE MECHAXJSM OF LAJiOIi. 405 lioad could be iu'<;locto(l ; but two factors in labor equally contribute to render this cross-section of the licad bv no means the only one which nnist be con- sidered. In the first j)lacc, we nuist be prcjiared to consider the mechanism of brow and face cases, and, in addition, those cases of vertex labor in which the Hexion of the head is, from one cause or another, imperfect ; and, moreover, even in the best vertex labor good flexion is seldom attained in the early stages A 1! Fif:. 2J7.— niiiiiu'tcrs (if tlie fotal lioiid : A, rrosssrctinn nf the fi'tnl head tlir(Hii;li tlio snlxK'ripito- l]rff,'mati<' ami hiparictiil diaiiictiTs , H.cross-scctinii of the fetal licail tliniiii;li the hiparii'lal and dccipito- fnnital diaiMctiTs; (', iTciss-si'c'iiai cif the fi'lal head llirouuli tlir liiparii'tal and ()('ci|>ili)-nic'ntal diaiu- iliTs; 1), cross-sL'ction of tlio fotal head tlir ■^^dl tlii' siibuccipilnCrnnlal and bitruipural diaincti'i-s, ol" engagement at the brim. Secondly, even when good flexion is present and this circular cross-section is in the inferior strait or excavation, the brim is occupied by the fnmtal portion of the head in combination with the neck — a by no means luiimportant factor in the mechanism of even the most normal cases. It is therefore important to renunnber the shape and dimensions of the cross-sections, which include, first, the biparietal and oceipito-frontal diameters (Fig. 227, b) ; second, the biparietal and occipito-mental diameters (Fig. 227, c); third, that which cuts th(> head and neck through wiiat might be called the " suboccipito-frontal" diameter* and the bitemporal diameter (Fig. 227, d). If the diameters of thes(> cross-sections be compared with those of the pelvis, it will be seen that all the transverse diameters are ca|iable of an easy ])assage througli any of the diameters of the pelvis. The occipito-frontal and sub- occipito-l'rontal are too large to ])ass any of the conventional f diameters except the oblique diameters at the superior strait and the dist('nsii)Ie anteni-postcrior * A|i|)r().\iinii(('lv (lie ('ci'vico-lnvfjnuUii' [iliis the tliickiu'ss of tlio lu'ck. t 'I'liost' wiiicli liavu iianu's. ;.a^ 'if-.- 1 1 ; i , 1.* ': ji u 1 ,.,„, il ^^; ■? wiit I 4()f; amehivax Ti:xT-ji(K)K of oiisrirrnns. (Iiaiiu't(M's of till' iiiCci'iur strait ; wliilc tlu' occipito-iiiciital is toit larfi'c cvt-n tin- these, and may coiiscmieiitk l»e rei;ar(Ic(l as an ini[)i'artit'al)k' ur impossiljle (liaiiieter, A careful reiiiemhraiiee of tlie relative values of tliest; diameters will he found of nfeat service in the comprehension of normal laltor, and of still more valne in mider-tandinu; ahnormal lahor. The Articulations between the Head and the Spinal Column. — The articidations hy which the head is joined to the tnmk are, it will he remem- bered, the occipito-atlantoid, the atlanto-axial, and those hetween the other cervical vertchra*. The oci'ipito-atlantoid articulation admits of hnt little motion except that of extension and llexioii, while even that motion, when carried to extremes, is lifcatly assiste(l hy a similar mov(MMent in the other cervicai arti( illations. So, too, the rotatory movement which alone is possihlo in the atlanto-axial Joint is nrcatly assisted i)y the movements in the other articulations of the iiech. The capacity tor lateral llexion resides wholly in the intervertehral articulations and is limited hy their liii;aments. iiotatioii of the heail to either side is safely possihie only tliroiii:li an are of ahoiit !)()^ ; that is, when the chin of the ll'tiis is in the jilaiie of the shoulders the limit of ^aftly ill rotation has heeii reached. ^ViitcM'o-posterior flexion is limited only hy contact hetween the chin and the hreast. Extension can he carried to a point at which the occi|nit rests airainst the hack of the neck and the chin is in a line with its anterior surface. The Fetal Body. — The compressihility of the fetal trunk renders impossihle and worthless any statement of the ahsolute len<>th of the diameters which the fetal hody presents to the ])elvis diirini;' lahor ; hnt the relative leiiuths of the transverse and aiitero-jiosterior diameters as compared with each other is of importance, and is constant in at lcapreciatcd only by those who possess it. It is ccrtaiulv a liict that to the experienced hand abdominal pal|)ation yields rcsidts fully as valuable as those which can be obtained by digital examination per vaginam, and that ther(> are but few cases iu which rept'ated examinations during the progress of labor will fail to establish a diagnosis by palpation and auscultation alone. Abdominal Inspection. — Insjicction is mainly valuable as affordiug a hint of the existence of ti'au-^vcrsi' presentations and of nndtiplc pregnancy. Abdominal Palpation. — Palpation is the most important part of the abdominal (wamination ; it .-liould hv performed only iu the intervals between the pains, all |tressure of the hand being intermitted with the appcaraiic(,' of * Aitli(Mi<;li lilt' iiictli(i(ls wliicli iiuist ln' n-.r(l In luiikiiiL; tlir ili;i'^ii(i>is of pfi'^t'iiliitinu mihI |insitiiii\ ;irc iiidiciilod in Mimtlu'r (iMil nf tiii- wmk, siicli w ili;ii:'iiii>is is so fS'-t'iili;il tii tlie iiu'cli;iiiii"il iii;in;ii;(im'iit nf IiiImii- tli;il it si'i'iiis wisr to i\'[)i.';a tlu- tcciiniiiiu' of tin- .several ItU'llloils of rXMIllilliltiiill ill lili> svclioll. 1v a ii I I II I f. < 1 ! 1 408 AMKlilCAX TEXT-liOOK OF OJiSTKTUHS, cacli coiitrat'tioii. 'I'lic |tliysi('iiin slioiild stand l)y tlic patient's side fa<'ing toward licr litad, and slioidd apply the palm of each hand flat aL^ainst tlic cor- I'cspondini;; side of tlic nt( rns. 'riiroii<;li()iit tlio examination it is all-important tiiat the motions of tlu' haiul shoidd he slow and j>;entle, uny (puck or jerky imj)nlse heinir almost certain to result in rijiidity of the ahdondnal walls and the litems, tints frnstratini:- tli" purpose of the examination. Kvery elfort slionld l)e made to divert the attention of the |)atient, t() soothe her fears, and to assure her that the examination will not he painfnl. It not infrecpu ntly happens that the first attempt will he a total failure, while the second will yield satisfactory results owintr to the chanu'cd mental condition of the patient. D'HKjuoHix (if Prcsfnfdfioii Itj/ J'd/jxtHon. — The fiiiiicr-tips of eacii hand should l)c ])ressed with a i!;ra the occi)>ut is nnich the more di>tinct. The fundus should then he pal])ated carefully as a I'urthcr means of excluding the possibility of a breech jiresentation. The head may be i()'('rt)iti((l Diiif/noxix of I'rixcnldtionK hi/ Pii/patinn. — ('cj)hii(ic J'lrsnittt- tloiis. — Tliu most (listiiKJtivc si^ii of licad prcsoiitatioiis is to be found in tlio recognition of the licad by deep jialpation bcliind tlio symphysis. Tlic diat;- nosis should tlu'U hv clici-Ucd by asirrtainin<5 the absmcc of the signs clianu'- t('risti(! of tlic head at the fundus. J'ilrii- ]'irfifiital!<))iti. — In Iji-cccli presentations the obstetrician's attention is generally first arrested by the absence of the transverse cheek to the fnigcrs, due to the presence of the head, on ticep palpation behind the symphysis. Ho should then be able to recognize the presence of the head at the fundus by the signs just emimeratcd. 7Vo/(.N7V/'.sv Priif(tlio)is. — In transverse presentations the long axis of the child is felt to be transverse. The din'erential but deep pressure toward each other (Fig. 221)) — that is, with the uterus and child directly between their Kli:. JJ'.I. — |lill'_Mlnsi« nf pnd linnly against the '^M I k Wtfi 1i>, ^ ▼^ .Q. v' C IMAGE EVALUATION TEST TARGET (MT-3) 1.0 1.1 1.25 Himm 2.5 2.2 ^ 1^ 12.0 •UUu 1.4 1^ 1.6 v3 V] / fliotographic Sciences Corporation 33 WfST MAIN STREET Wi:itST»i^ N.Y. MSSO (716) 873-4S03 '*> %^ & ^Iff 410 AMERICA y TEXT- HOOK OF OBSTETRICS. uterus ; the luuul.s slimikl then be niovctl gently up ami down along the uterine wall in an endeavor to recoirnize the irregularities due to the presence of the fetal limbs. During this search it is necessary to guard against the error of nustaking either of the round ligaments for the fetrd nicnil)ers. These ligaments, which at term are of nearly the size of the adult finger, extend obli(|uely from the coriuia of the uterus downwaril, outward, and Ibrward to the pelvic brim. They may be recoguizeil by their situation and by the pain of which the patient invariably complains when they are rolled about tnider the fingers. Tlu; existence of small subperitoneal fibroids is another jiossiblo source of error. With thin and flaccid abdominal walls it is sometimes possi- ble by this method to recognize the fetal lind)s with the utmost distinctness, but in the majority of cases an irregularity in the contour of the fetus is all that can be hoped for. liy palpation, then, we can hope to distinguish not only the presentation, but also the position, since the latter must correspond with the quarter of the pelvis in which the letal back is Ibiuid. Owing to the infrc(piency of O.I). A. and O. L. P. posititms, it is generally safe to call all cases in which the back of the child is found ttnvard the left, O. L. A., and those in which it is found toward the right of the mother, (). D. I*. Abdominal Auscultation. — Auscultation of the fetal heart givTS confirn;- atory evidence about the presentation and position, informs us of the condi- tion of the child, and is the most important sign in the recognition of nudtiple pregnancy. In vertex p;.'sentations the heart is most plainly heard over the back of the child and below the mother's umbilicus;* in breech presentations the heart is heard over the back, but its greatest intensity is generally above the mother's umbilicus ; while in presentatitms of the face it is most readily heard over that portion of the uterus which corresponds with the chest of the child, ibut is again below the umbilicus. In transverse presentations the heart is usually plainly audible when the back is anterior, but is often found with difficulty in the ])osterior varieties, and is of comparatively little value in the diagnosis of position. In interpreting the evidence of position furnished by the situation of the fetal heart it must not be forgotten that, owing to the fiict that sound is better con- ducted by solids than by lirocess of palpation, describe*! on page 409, enables one to deter- mine whether the presentation is cephalic, pelvic, or transverse, and this result is cheeked by the j)ositi(jn of the fetal heart as obtained by auscultation ; that is, in cephalic presentations the heart is found below the umbilicus, in breech presentations al)t)ve it, and in transverse presentations a little toward that side of the abdomen to which the hea«l is directed. The position is determined by the situation of the fetal back, as established by the second method of palpation, sitions ■ and it is even well to artaiice of avoidiiif; rupture of the membranes in such presentations is, however, so great that it is usually best to trust to the results of external palpation. Presaifdfious of the Kiire and the FJbnv. — The knee may sometimes be dis- tinguished from the elbow by the presenc' of the patella; but, sinee the latter is small and not always easy of recognition, it is best to distinguish between these two joints by following the course of the limb to its termination in a hand or a foot as the case nuiy be. TranHvcrse Pirfimtutioua. — The shoulder is liable to be mistaken only fur the breech, from which it may be distinguisheil by the presence of but (uic limb in place of the two which are attached to the jielvis, and by recognitidii of the smooth riilge of the scapula as opposed to the rough spines of tlic sacrum ; recognition of the clavicle and the ribs will also assist the diagnosis ; but tlio recognition of a shoulder by vaginal examination is extremely dilli- cult, and the existence of the presentation is ])ractically ascertained, in tlic majority of cases, by external palpation, without assistance from vaginal examination. In presentations of the hand it is sometimes possible to make a diagnosis of position by observation of the hand alone ; to this end it is first necessary to determine which hand of the fetus presents, this being best ascertained bv attempting to shake hands with the presenting part, the right hand of the fetus coming into position to shake hands with the right hand of the physician, and the left with tiie left. If the presenting hand be turned by rotation of the forearm into forcetl supination, the thumb points to the side on which lies tlic fetal head, and the back of th.e hand corresponds with the back of the fetus ; l)nt in actual practice the attitude of the chihl so seldom corresponds exactly to any one of the four classical positions that this evidence is of comparatively slight value, and is only to be use^_,, ...-4J 418 AMERICAN TEXT- HOOK OF OJiSTETRICS. different olwervors, the key to tliis tlifferencc of opinion beinj; probably found in their adoption of different pcrimls of labor for the deternii nation of the position. In a larj^e proportion of those cases in whieh the occiput is to the rifrh^ and somewhat anterior at the vc 'v lK«jjinninjj of labor — that is, before the head is even pressal iiito the superior strait — the position becomes right j)os- terior as soon as engagement owiu's. It is probable that some observers have classified such cases as O. I). A., and others as C). D. P. Again, the enormous majority of right posterior positions become right anterior by rotation during the sec(md stage of labor. An observer who made his diagnosis only during the latter part of the second stage would class all such cases as anterior posi- tions. It is certainly a fiict that the vast majority of right positions are right posterior positions at the time when the greatest diameter of the head occupies the sujKTior strait ; and if this peritxl of labor be selected as the time when the j)osition should be determined, it is safe to say that nearly 75 per cent, of all cases are primarily O. L. A., and almost 20 per cent, are primarily O. D. P. Of the small remainder, almost 4 per cent, are primarily O. D. A., and but a little over 1 jier cent, are O. L. P. Etiology of Presentations. — Three conditions have Iwen urged as chiefly contributing to the fre(iiiency of cephalic presentations, and it seems probable that the true cause must be found in a combination of all three conditions, which probably vary in their importance in individual cases. These three causes are — first, the effwt of gravity ; second, the easier adaptation of the fetus to the uterine cavity in head presentations; and third, the effect of active movements on the part of the fetus. In estimating the relative im|)()rtance of these factors in the etiology of head presentations, it is evident that to attain the truth it is necessary to reach a conclusion which will explain the results of clinical observation recorded aoove, and whieh will make evident not only the reasons for the great prepon- derance of cephalic presentations of the fetus, but also for its variability in accordance with the period of delivery and the condition of the fetus. The lujfuence of Gravity. — It has been found by experiment that if a re- cently-dead fetus at term be immersed in a saline fluid of the specific gravity of the liquor aninii, it tends, under the influence of gravity, to assume an obli(|ne position, with the head lower than the breech and the right side lower tliiiii the left. This fact is exj)laincd by Matthews Duncan, who has shown that the specific gravity of the fetal head is greater than that of the decapitated trunk, and that the greater specific gravity of the right side is due to the enormous relative size of the liver in the new-born child. It is evident, then, othtT conditions being equal, that we may expect, in a preponderance of cases, to find the head and right shoulder of the fetus in that portion of the uterus which is horizontally lowest in the ordinary positions of the mother. The ordinary positions of the mother may be considered in this connectidu to be three — the vertical position of the trunk, the horizontal position in a dorsal decubitus, and the horizontal position in a lateral decubitus. Wlun THE MECHANISM OF LABOR. 419 obably ion of ^ rl^lit )re th(( it JHtS- rs have ormous (luriiifr tedly a |>r(XM;ss of slight rhythmic contraction going on through- out the whole of the latter part of pregnancy, it is evident tiiat the uterus must be regarded as a IkmIv which has, to some extent at least, a definite, in- trinsic sha]H>. It has, moreover, Ixjen determined by post-niortom examina- tions that tiiis 8ha|H< is one which alters, and alters in a definite direction, during the development of tiie uterus. At and for sonic time Ixjfore the fifth month tlie uterine cavity is nearly spherical (Fig. 232), and is very large as compared with the still small and undeveh)i)eresentations ; that is, we may assume that the shape and contractility of tiie uterine walls tend to ])reserve a cei)halic presentation whqji this is once well established, and that the rhythmical contractions would probably tend to rc- eatablish it when lost. It is safe to assume, then, that the shajKi of the uterus may be considered an imjiortant factor in preserving a cephalic presentation THE MECHANISM OF LAJiO/i. 421 Fin. 2^.— Adaptation J>cfwpoii the fetus and the \itt'ru.s Hi term in breeiii prenvntHtlon. when tliis has once l)oen estnblishal by the inflnencc of gravity, and that its in.sonsil>le contractions fnrnisii an influence of ini|)o;tan(rf> in re-establishing a hcatl presentation when this has been lost. Injliient'c of the Feiul Movemenl»f, — Since the fetal movements arc accidental and independent of any volitional impulse, it is probable that their occurrence would be insufficient to effect any con- siderable change in the relation of the fetus to the uterus unless in an ex- tremely relaxinl condition of the uterine mid abdonunal walls, and that even in siurh uteri the change would Ihj likely to (K-cur oidy when the position of the mother addcnl the influence of gravity to the effect of fetal movements. It is evident tiiat even in such cases the operation of the same causes would probably tend to a spee|ic presentation. Couehmonii. — It is now necessary to Oil. ider how far the ctmditions just enumerated explain the observed facts quototl at the beginning of this section . First, that cephalic presentations pre- ponderate in tiie proportion of 97 to 3 ; necond, that this preponderance is much decreaser V ''■>^- cephalic presentations is oorresponilingly decreased, and that spontaneous changes of presentation arc corresiM)ndingly muc'h more frequent than at the end of pregnancy ; we a'^>, then, justifietl in onr belief in the importance of these factors. Fourth. — These considerations are in fidl accord with the observed fact that both abnormal presentations and changes of presentation occur most frequently in multipara) with relaxetl uterine and abdominal walls, and are but rarely seen in the more rigid condition of the muscles that is characteristic of first pregnancies. So, too, it is fully establishe rectun^in the left ilio-saoral notch renders the second oblique diameter of the pelvis less ample than the first, so that if the oblique cross-section of the head that is ordinarily ])resentetl to the pelvis at the inlet rests with its long diam- eter in correspondence with the second oblique diameter at the brim, the head is less easily areommodated than if it is presentetl to the first oblique diameter. It will, then, as the adaptation becomes progressively tighter and tighter, tend to remain in the first oblitpie diameter for longer periods than in the second ; that is, it will be dislodged with diffit-ulty from the first oblique diameter, and with ease from the second by any slight cause ; and since the influence of gravity tends during the greater part of the time to turn the occiput forward, a head which occupies either an O. D. A. or an O. L. P. position will tend to become (). L. A. rather than anything else. The maintenance of an O. D. P. position is, moreover, rendei-(Hl comparatively unlikely from the fact that the shape of the head is loss well adapted to that of the pelvis in this jiosition. Changes of position are, in fact, extremely I'requent until within the last few- weeks before delivery, and the position, moreover, is never finally determineil until the head engages at the brim. Diaernosis. — On abdominal examinatUm the head is found at the inlet ; the TUK MF.VIIANli^M OF LABOR. 423 fotal liiul)s ami the most nocossiblc end of tho head arc found on one side of tlie alnlonien, and the heart on the otiier. On vof/inal examhiafion the finger ^honld recognize the small fontanelle on one side of the pelvis, and bv follow- ing the sagittal sutnre should find the large fontanelle on the other. The ears should always, and the mastoids and lateral fontanelles shoidd usually, be felt at the ends of the lanibdoidal sutures. Prognosis. — The prognosis for both mother and child is better than in any other variety of labor."^ A. Mechanism of the First Stage of Labor. It is customary to divitle labor into three stages. Tlie first stage comprises the time occupied in the dilatation of the os ; the second, that expended in the descent and expulsion of the child ; while the third is occupied by the birth of the placenta. For purposes of description it is well to consider the three stages as being sharply divided from one another, but it must bo remembered that clinically tiie division between the first and second stages is often difficult and indefinite, since the final stages of dilatation are not infre<|uently accomplished only dtu'ing the descent of the head ; and for clinical ])urposes it is well to define the end of the first stage as occurring whenever the os is fully dilated or dilat- able, it being understood that the expression '' fully dilatable" refers to a con- dition in which the os, though still iii'.perfectly dilated, has become so soft and elastic as not to offer any efficient obstacle to the descent of the presenting part. To understand exactly the njcchanisni of labor it is necessary to discuss first the forces by which the process is accomplished, and next the manner in which each force acts during the different stages of labor. The forces by which labor is effectetl are those produced by the contraction of the uterine antl abdominal muscles, together with such inHucnce as can be effected by the weight of the child and the waters. The uterine muscle acts in two ways: first, by diminishing the intra-uterine urea and thus creating a general intra-uterine fluid-pressure due to ti»e contrac- tion of the uterus upon the fluid contents of the utn'uptured ovum ; second, by the fi)rce of dii'cct contact between the breech and the fimdus of the uterus whenever a rupture of the membranes and the consequent escape of the waters jiermit this contact to occur. Direct contact may also occasionally oc(!ur, as will be seen later, before the rupture of the membranes. The abdominal muscles when set into voluntary contraction reinforce both forms of action of the uterine muscle. When the uterine muscle is in direct contact with the breech, the abdominal nniscles, lying in close contact with the uterus, add their force to that which the uterus itself exerts against the child ; when the child is protected from contact with the uterine walls by the ])resencc of a quantity of liquor amnii, the contraction of the abdominal muscles again adds ii, elf to that of the uterine wall, and thus adds its incrcn)ent to the general intra-uterine fluid-pressure. The force of gravity is inactive in many positions of the mother, and is at most an increment of but small importance. ^;l I II 8' ■■ m u- :j ''i it> •i -i 'if !in- '!' |i#|il lit ' 424 AMERICAN TEXT-BOOK OF OBSTETRICS. it*^ «-«^ In considering the manner in which the above-mentionetl forces are employed in effecting the dilatation of the os during the first stage of labor, it is neces- sary to consider several variations which may occur in the mechanical con- ditions. When the waters are abundant and the membranes persist unbroken throughout the first stage, the dilatation is usually accomplished by the action of the membranes only. This may be considered the normal mechanism of dilatation, and must be describelicable to tlie dilatation of the os is represented by tlie length of the line A. Fiii. 2.18.— Diagram illustrating the dilata- tion of the OS by the membranes. All the con- ditions are identical with those of Figure 'Jl!7, ex- cept that the membranes have a greater con- vexity ; tlie direction of the arrow is therefore more obliart with the margins of the OS (Fig. 239). In this condition the presenting i)art forms with the circle of the OS a ball-valve ; the general intra-uterine pressure is concentrated upon its upper surface, and its descent is opposed only by the comparatively feeble resistance of the cervix. When this condition occurs the portions of the fetus that correspond with arrows marked A' and li' are still affected by pres- sures whicih are opposite and exactly equal to the propelling force exerted upon the portions which correspond with the arrows A and B, but the propel- ling force represented by the arrow C is opposed only by the resistance of the mm I ■|| i^l I: M * 4," '•i'. 428 AMERICAN TEXT-BOOK OF OBSTETRICS. unsupported cervical and vaginal tissues, against which the head is pressed by a force equal to the effect of the intra-uteriue fluid-pressure upon an area c Fio. 239.— DiaRram illustratlnf; the mnnner in which the gviieral intru-utiTiiie fluid-pri'ssure lioconu's propulsive after the rupture of the memlinmes. Fig. 240.— PiaRram illustrating the dilatation of the OS by the head. The total force is again repre- sented by the oblique line, and the force which is ap- plicable for dilatation is represented by the line .rl. equal to the transverse area of that zone of the uterus whore the head Hrst conies in contact with the walls — that is, the surface R to R'. From the coni])arative rigidity of the spherical head it can exert but little direct expan.^ive force upon the margins of the OS during the early stages of dilatation (Fig. 240) — a fact which ex- plains admirably the relatively slow progress of dilatation after early rup- ture of the membranes. When, how- ever, the OS has so far dilated as nearly to admit the greatest circumference of the head, its action is that of a slightly tapering wedge, by which almost the whole power of the propelling force is transmitted into an outward pressure of the margins of the os, and which must compel an extremely rapid com- pletion of the dilatation * (Fig. 241). It will be seen that in this second form of the mechanism of the first stage the force employed i.s still that of the general intra-uterine fluid-pressure, but that the dilating agent is now the head. * It will be seen tliat this fact is an adequate explanation of the greater frequency of laceration of tlie cervix when a rupture of the membranes results in the completion of the dilatation by the direct pressure of the rigid head. Fio. 241.— PiaRram illustratinR the diliitation of the OS by the head. The total force is repre- sented by tlie obliiixtli niitiiral size). Fig. 'J4(>.— Piannnn of head lover. vertebral column to the skull at a point much nearer to the occipital than to the frontal end of the head ; second, the mechanical effects of the irregular shajjc of the skull. Unequal Lenyths of the Ends of the Hmd, — The effects of the excentric position of the occipito-atlantoid articulation iiujst be investigated separately for each of the three forms of force that may be active — that is, for the force of gravity, the general fluid-pressure, and the force of direct contact with the uterine muscle. Force of Grarlti/. — Whenever the force of gravity is active, it is evi- dent that the weight of the body will be transmitted to the skull through the occipito-atlantoid articulation. If the fetal head is supjmsed, at the begin- ning of this motion, to occupy a position midway between extension and flexion, the occipital and sincij)ital ends of the head, marked o and F resjK>ct- ively (Fig. 246), will rest against the uterine walls, while the force A is applied at the occipito-atlantoid articulation. Since the force is applied nearer to the THE MKCUANISM OF LAJiOJi. 433 occipital end of the head, it is evident that a greater nmoimt of impulse will be conuminicatetl to the occiput; and since the resistances an; of nc(!es,sity (■(pial, the occij)ut will tend to advance more rapidly ; hut advance of the occiput with relative delay of the sinffput is, in effect, flexion. The head, in fact, becomes a lever of the third class, in which tiie pressure of the resist- ances applied to tiie longer end is more effective in delaying progress than the cijual pressure applied to the shorter end of the lever. It is further to be noticed that as flexion progresses the relation between the lengths of these arms is so altered as to make them progressively more unequal, so that, as the head flexes, the point at which the pressure of the resistance is applied to the occipital end of the head becomes progressively nearer to tlie vertebral articulation. General Infra-uterine FtuUl-pressurei — If Figure 247 represents the situ- ation of the child at the end of the first stage, we see that the forces A and B are applied directly and with equal force to the ends of the head ; but it is evident that the pressure (C) exerted upcm the breech of the infant will be transmitted to the head more readily by the vertebral column than by the soft tissues of the trunk, and that a large portion of this force (C) must therefore be conceutrated on the con- dyles. So far as this force (C) is con- cerned, the argument used in ex{)lain- ing the i)roduction of flexion by the influence of gravity applies, then, with ecjUiU force to this condition. Direct Contact between the Breech (tnd the Fundus. — The whole effect of a direct pressure upon the breech by the fundus will be applied to the condyles of the occiput, and, the resistances ujion the occiput and sinciput being of neces- sity equal, w'hile the o])posing forces are concentrated at a point much nearer tiie occiput, it is evident that the occipital end of the head will tend to advance more rapidly than the frontal end ; but advance of the occiput with relative or absolute delay of the sinciput of course results in flexion. Irregidar Shape of the Fetal Skidl. — The occurrence of flexion is like- wise aided by the second factor referred to above, the irregular shape of the skull. As will be seen by analysis of the opposing forces exerted at R and B' (Fig. 248), if the effect of the equal resistances at R and B' be represented by the length of the equal lines S and S' drawn perpendicular to the surface of the skull at these points (the direction in which these resistances must, according 28 Fio. 247. —Diagram illustrutint? the upplicdtion of n prepoiidurnncL' of tlii' intra-uterini' Huid- prossnro to the occipital cml of tlio licad. It is evident from tlie condition of tlie lioad lever (see FiR. 2lti) tliat the sinciimt is exposed to Ihe force H, ])lns a small proportion of the force C, while the occiimt receives the force .1, plus the greater part of the force C. •I ;' It i' ■ .ti, i'^ m 434 A^fi:iU('AX TKXT-jiooh' OF oiisrKTiirrs. \\ to wi'll-kimwii inccliiiiiical laws, Itc i-xcrtod), the coiistnictioii of tlu; imrallcl- of^ram of fonrs sliows that tlic line T (wliose length represents the |)ortioii of the resistance! H which is exerted in direct opposition to desci' its accomplishment. ^ Rotation.- f he movements of descent and flexion make up the whole iiK'chiuiism of the earlier part of the second stage of labor ; but another factor — rotation — is necessary to its completion. The mechanism of rotation is, unfortunately, extremely difficult of com- ])rehension ; and, as nothing is more difficult than to teach mechanical prob- lems involving the use of three dimensions without the aid of models, the student will be wise if he supplements the words and figures of any written description by a constant inspection of the dried pelvis and by the results of the iiitrapelvic touch in actual clinical work. A complete comprehension of the mechanism of rotation is seldom acquired in any other way. The student iiuist, at all events, grasp the fiuidamental flict that it does occur, and nuist (ihcuj/n occnr, before expulsion can take place. The hea!l;", I :i ' --^A till contact with the lower portion of the sacrum, and tlie occiput, tliough steadied on both sides by the bones, finds its descent opposed only by the yielding tissues of the vaginal outlet (Fig. 250). Under these circumstances (p. 432) the propelling force from above concentrates itself upon the occiput until the perineum is fully distended. The occipital end of the head is then freed from the resistances, while the whole bregniatic region and the sinciput form a rigid slanting surface which is opposed to the slanting surface furnished by tlio sacrum and the perineal tissues (Fig. 251). As a consequence the driving force of the uterine j^rcssure is converted by the shunt of these shelving surfaces into a forward thrust, under the influence of which the head, as a whole, moves forward until its progress is arrested by contact of the nai)e of the neck with the anterior pelvic w-all. The large fontanelle is now at the fourchette, the whole of the occipital half of the head is free from pressure, while the fore- head is still exposed to the driving force of the uterine muscle above and to the forward shunt of the posterior pelvic wall. The necessary result is a for- ward motion of the head with arrest of the neck ; that is, the head extends, the bregma, the forehead, and the face successively pass the fourchette, and the head is expelled by extension (Fig. 252). It is then a convenient nniemonic that in normal labor the hearocess of expidsion the arms normally remain crossed upon the chest in the 11 uM fi m ;■ i :| I i i.i ■l i'rllt i; I, riiii u f I I Ml % 440 AMERICAN TEXT-BOOK OF OBSTETRICS. usual attitude of the fetus, but they are uot iufre(|ueutly helil hack by the fric- tiou of the pelvic wall, aud are thus forced iuto a position of partial exten- sion in which the forearms lie across the abdomen. The mechanism t)f the second stage in O. D. A. positions differs from that l'"lii. J.M.— Expulsidii of till' sIkiuIiUts. of O, L. A. only in the substitution of the word right for the word left throughout the description. C. Mechanism and Management of the Third Stage of Labor. Mechanism of the Third Stage of Labor. — After the expulsion of the child the uterus shuts down upon the placenta, and there is usually a period of from five to ten minutes during which little or no contraction is api)arcnt, this interval being occupied by the process of retraction of the uterine fibres. The first active contractions of the uterus after the expulsion of the child necessarily lessen the area of the uterine surface over wiiich the placenta is attached, and thus in ])art or in wlK)le separate the placenta from the uterine wall ; during the next relaxation blood escapes from the torn sinuses in the placental site, and the mechanism by which the placenta is expelled (lei)ends upon the escape or non-escape (»f this blood from the uterus. li' the first retraction is sulHcient completely to detach the placenta, but does not succeed in exi>elling it, any blood which may be effused will usually find its way to the external worhl by dissection of the membranes from tiic uterine wall ; during the next fi'W contractions the uterus will be able to shut down nj)on the placenta, and will compel it, by the force of direct contact, to pass through the os edgewise and in the most compact possible form — that is, in the shape shown in Figure 255, in which the thin caUe-like placenta is seen to have been folded upon itself in a roughly fusiform shape. When, however, the attachment of the placenta is too firm to permit an immediaie separation, or when, as probably more freipiently happens, the con- traction of the fundus is more energetic than that of the lower portion of the uterus, so that only tlie upper ])()rtion of the placenta is detached, the relaxation following each contraction will be ai'companied by an effusion of blood whicli is confined behind the placenta. The upper part of the placenta will then Ix; THE MECHANISM OF LABOR. 441 {'orct'd downward, and as the detachment proceeds the position of the phicenta will be so far altered that its fetal surface presents at tiie os, the uterine cavity heliind it being occupied by a mass of blood (Fig. 256). When this occurs, Kio. 255.— The more favorable mechanism of expulsion of the placenta (Varnier). tilt' placenta presents in so much more bulky a form that it is usually expelled so slowly and with so nuich dithciilty that the process is not completed until tiie elfuscd mass of blood attains sufficient size to redistend tlie uterus slightly. l"i(i. 250— Tlu' loss favornWe of the common mi'tliods of exp\;lsion of the placenta (Varnier). and thus permit of the occurrence of more forcible contractions. The placenta is then expelled, not by the force of direct contact, but by an intra-uterine lluid-pressure cxcrteil through the mass of ctfused blood. Tliis second form of the ii:cchanism of the third stage of labor, though OKsentially normal, is much the Ics,-! easy and favorable f(»r the patient ; although the amount of blood lost is not usually sufficient to etlect any perceptible altera- tion in her pulse. In either mechanism the elastic and collapsible nature of the membranes rciitk'rs them less likely than the ])lacenta to be thoroughly detached, and as the latter emerges through tlu; h()le in the membranes tliiit corres|)onds with the OS they, are necessarily invi'rted, and, becoming detached by the traction (hie to the advance of the placenta, follow after it in a loose mass. 1 ! IT 1 Tv '■ i i;'^' / I ■^ U: V \ ■V-.:: if t 5 %•.' M I! . H* I, ■It I :■ 442 AMfmiCAN TJ: XT- BOOK OF OBSTETRICS. Managrement of the Third Stage of Labor.* — The iii drawn across the pelvic brim (Fig. 257), the cue (a) from the right side of the sacral promontory to the right ilio- Fio. 257.— Adaptation between the fotal head and the brim of the pelvis In anterior positions of the iii'cipiU. Ifel pectineal eminence, and the other (i{) from the left sacro-iliac notch to the pubes, it will be seen that when the head enters (). L. A., the wide biparietal diameter of the head corresponds with the greater space affoi'ded by H, the longer of these diameters; while the lesser bitemporal diameter is in corre- sponden(!e with A, the shorter of these parallel diameters. The entrance of the head is therefore mechanically easy in anterior posi- tions ; but, conversely, when the head enters (). D. P., its wide bij)arietal diameter is opposed to the uari-ow oblique space between the promontory and the ilio-pectineal eminence of the right side, while the narrow biparietal diameter is loosely fitted into the wiilc space afforded by the antei'ior portion of the pelvis (Fig. 258). Two factors of difficulty are tiius j)rodu(!ed : first, the widest portion of the fetal head finds itself in apposition with a nari-ow portion of the pelvis, and therefore rcipiircs a jiowerful driving impulse to force it through the brim ; second, this retarded widest ])orti()n of the head is situated on the occipital end of the head lever, while the sincipital end is almost free. This situiition, therefore, always tends toward a tt)o I'apid descent of the sinciput — that is, toward the production of extension — but the degree •;!::: A"-^ 1 ^ •fi; w 'i I 1 i<> : i \ 1¥ ii 'S'i 1' n I It iii 17 : H 444 AMERICAN TEXT-BOOK' OF OBSTZTRICS. of extension produced varies with the relative sizes of the pelvis and the head. If the disproportion between the biparietal diameter of the head aud the portion of the pelvis in which it finds itself (that is, A, Fig. 258) is not extremely great, the protliictioii of an extension sufficient to cause a light pressure of the forehead against the pubes may be enough to equalize the Fig. 208,— Adttptntiou between the fetal head and the brim of the pelvis in posterior positions of the occiput. resistances at the opposite ends of the cephalic lever, and may thus permit the greater pr()j)ulsive force applied to the occiput (sec page 433) to accom2)lish its descent wliile the sinciput is still above the brim. The head in this ease will enter the excavation in a fairly well flexed condition. If the disproportion between the occiput and the jmsterior portion of the pelvis is more extreme, the process of extension will continue until the occipito- frontal diameter occupies the first oblicpie diameter of the brim. The head may then pass the brim, after long l;d)or, in an extended position ;* it may be arrested at the brim by becoming a brow presentatit-'. or it may exceptionally be converted into a face presentation. PatonKje of the Exvandion. — After its escape frt)m the superior strait the head occupies the first oblicpie diameter of the excavation O. D. P., aud the accomplishment or non-accomplishment of tiie remainder of the labor by the normal mechanism of rotation depends wholly, and only, on the degree of flexion ju'csent. RoUdinn in Wcll-Jfc.ved RUfhl-posterio)' Pos'dlom. — When the occiput enters the excavation — that is, passes below the promontory — while the sinciput is still delayed in or above the brim, it occupies for the moment so roomy a posi- * It will l)e remembered tli.at the ocoii)ito-frontal diameter is too large to pass even the oblique diameters at the brim witii ease. n ! • THE MECHANISM OE LABOR. 445 tion that it is enabled to (lescen! i '! i? I- MJ >;ni- 'i. "1 11 446 AMERICAN TEXT-BOOK OF OUSTKTRH'S. the polvif Hoor; hut at the time wlieu the occiput hcgiiis to feel the forward impulse of th(! (K-ep h)\ver portion of the posterior jjroove of tiie right pelvic Mall the sinciput is not, as l)efore, in contact with the smooth surface of por- tion A of the left lateral wall, hut has, on the contrary, already entered the upper portion of the anterior groove on that side. Under these circumstances rotation may exceptit)nally be accomplished. When this does happen the mechanism is as follows: As the occiput is urged forward, the posterior side of the sinciput is j)ressed firndy against the slightly rising edge of the upper portion of the anterior groove, and under tavorahlecirciunstauces this increased pressure may residt in flexion of the heail in the manner illustrated in Figure 259, which is a horizontal section of the jjclvis through the spot where the sinciput impinges against the lateral wall. The rotation force due to the for- ward motion of the occiput urges tl»e sinciput backward in the direction (tf the force represented hy the arrow A. If upon this arrow we construct tiie parallelogram of forces, we see that by the shunt of the shelving surfaces of the sinciput and the pelvic wall there is produced a small pressure (b) upon the sinciput that tends directly to flexion, and that nuiy, under favorable cir- cumstances, actually produ(;e flexion to a degree sutticient to permit the sincij)ut to slip by on to the smooth surface of portion A (Fig. 217). The sinciput is free io then glide back into the posterior groove as the occiput moves forward, and tlie mechanism of rotation described above goes on as before. This process, however, is mechanically so extremely difficult that it can occur only under the most favorable conditions — that is, when the adaptation is easy, when the jjains are powerful, and, nu)st important of all, when the loss of flexion is so extremely slight that but a slight change is needed to restore it. Mcclumwti of Rotation vhcn the Head enfrrf* Cnfiexed in Posterior Poni- tious: the Mechmmm of the PaHnaf/e of the Hrearation in Pemident Jiight-pot<- terior Positions — When the head passes the brim so far extended that the sincijjut is as low, or nearly as low, in the pelvis as the occiput, the forehead reaches the deeper portion of the anterior groove at about the same time that the occiput reaches the deeper portion of the posterior groove. Both ends of the head are then urged to rotate forward by the forward trend of their re- spective grooves ; since neither one can rotate forward unless the other turns back, there residts a dead-lock which can be broken oidy by the intervention of art — that is, by a manual or an instrumental flexion of the head. In rare cases, however, this dead-lcK^k may be avoided by the occurrence of a second and abnormal mechanism, by which the occiput is rotated directly backward into the hollow of the saerinn. This rotation can occur only when the adaptation between the head and the pelvis is exceptionally easy, when the sacrum is exceptionally hollow, and when its lateral concavity is but little marked. The occurrence of a backward rotation is then due to the fact that the posterior edge of the anterior groove, formed by the isehiatic spine, is more prominent than the corresponding portion of the posterior groove, formed by the edge of the sacrum. W, under these circumstances, THE MKCHANISM OF LMiOR. 447 I he occiput iiMil the sinciput arc at ('([iial depths in the pelvis, it results that I he sinciput is more Hrnily fixed in the anterior groove tiuiii u the (K'cipnt ill the posterior; and if the adaptati(»n is exceptionally esv-sy or the lower portion of the sacrum is wantini; in prominence, the occiput may be able to escape from the posterior sjroove and turn backward over the sacrum as the sinciput rotates forward. This escape of tiu^ occiput into the hollow of the sacrum usually so far diminishes the pressure on the occiput as to permit of its rapid advance, while the descent of the sincij)ut is still delayed by the normal resistances of the anterior wall of the pelvis. The rapid descent of the occi- put as compared with the sinciput thus re-establishes flexion, with the head in a directly o(!(!ipito-posterior position. Expulsion of the head in a persist- ently posterior ])osition by the natural forces or by the aid of forceps is then possible, thouostorii>r iiositions of tho occiput; mcclianism of fuce to pubos delivery. Figure '2G0 with Figure 251 it will be seen that when the occiput is anterior the curved axis of the child's head and body corresponds with the curved axis of the pelvis, but that when the occiput is posterior these curves are reversed iipt)n each other, and that to etfect t!ie delivery in this position the uterine foi'ces must alter the shape of the child by elongating the occiput, by com- pressing the sinciput, and by imxhu^ing an exaggerated flexion uniil the normal curve of the fetal axis is reversed. Although the fetal head is surprisingly tolerant of the excessive compression necessary for this change of shape, the process always results in the stillbirth of a large proporticm of the children; while the |)rominence of the occiput, even after the most extreme moulding, always exposes the soft tissues of the pelvic floor to a degree of tension that almost invariably results in deep laceration of these structures during the stage of expulsion. The expulsion of a persistent occiput posterior, more- over, always requires, iu addition to lax adaptation, the presence of very ^'i •'■!l 1 vj 4- '*'fi ■ i '1 I 448 AMERICAN TKXT-nOOK OF OliSTKTIiTCS. j)owcrfiil uterine contractions or tlic application of powerful traction by tlic forceps; and even when tlie.se conditions are present the process is a lontr one. The head remains in ])osition nntil the |)rocesses of the change in its shape and the prcHluction of extrenie flexion are snfficiently far advanced to permit the occipnt to travel downward along the median line of the posterior wall under the influence of the pressure from above. The region of the small fbnta- nelle finally appears at the vulva, and the ])erineum retracts, or, more com- monly, tears across the (H'ciput to the base of the neck. The occipital end of the head is then free from pressure, while the sincipital end is still expost'd to the driving force of the uterine contractions. The excess of pressure upon the sincipital end of tlu^ head then causes extension, by which the fbrehearul pusi- tion. pressure against either the bed or the thighs of the patient ; tliat is, the thighi* siiould be vertical (Fig. 2G2). The postural treatment is especially powerful when instituted before aiiv labor-pains \\w'2 occurred. If this treatment is conscientiously carried out for beveral days, the physician M'ill almost surely find the position anterior when summoned to th^ j^ntient in labor. Even if the patient is not seen until labor is present, it is still worth while to adopt a postural treatment so long as the membranes are unruptured and the head is unengaged. The patient should then be encouraged to maintain this position so long as her strength permits, or until a vaginal examination without alteration of her attitude dem- onstrates the fact that rotation has occurred. She should then be placed in the latero-prone position upon .lie side to which the occiput is directed, and should remain in that position until the head is firmly engaged in the new position. Should the head, after once becoming anterior, sliow any tendency to revert to the posterior position, it may even be wise to ruj)ture tiie membranes in order to prevent any such reversion. Should the postural treatment fail, no special treatment is necessary until after the rupture of the membranes has occiu'red ; but both before and after rupture frequent examinations are advised, in order to detect early aii\ tendency to the production of marked extension. Passage of the Superior Strait. — In the majority of cases the head in pos- terior positions passes the superior .strait by the natural efforts only after some delay, and often only after the occurrence of some extension and of considerable moulding of the iiead. The attitude of the physician should be determined by the degree of exten- sion jiresented. When the extension is not extreme, he siiould not be alarmed by a failure of progress, but should avoid interference, and expect the best results so long as the condition of both patients remains good. When extension becomes so extreme that the eyebrows are below th<' brim of the i)elvis, tliere is but little prospect that the head will pass the superior strait by the natural efforts, and unless active progress is present it is wise, after a single hoin- lias passed without alteration of the condition, to abandon the expectant method of treatment and resort at once to the oi>erative treatment of a high arrest of the posterior occiput. Operative treatment at the superior strait sidwlivides itself into the operative re-establishment of flexion and the delivery through the superior strait of tlie flex(!d but arrested head. Operative Flexion. — If, at the tiuie when operative flexion becomes neees- THE MECHANISM OF LABOR. 451 s!iry, the membranes are still intact, it may occasionally be possible to raise I lie forehead by making pressure upon it with two fingers placed within the •ervix, the woman being in the recumbent or knee-chest position, in order to all'ord the assistaiice of gravity to the efforts of the accoucheur. Since it is impossible, however, to obtain complete flexion of the head in this way, and ^ince the extension is almost certain to recur if no further change is made, it is essential that the iiead as a whole should be freed from the brim by pres- sure! upou the vertex, after flexion has been secured, in the hope that on its en- trance it may be better situated, iiud may thus be able to maintain its flexion. Shoidd extension again recur, it is best to etherize the patient, introduce tlie hand into the vagina, and dilate the os manually to a degree sufficient to permit the passage of tlie half hand within the uterus. Should the membranes 1)0 ruptured at the time when interference is decided upon, this must usually 1)0 the first maneuvre. When sufficient dilatation has been attained, the half iiand should be i)assetl within the os until the fingers cover the forehead, which should then be pressed gently upward until complete flexion lias been secured and the head has been freed from the brim. The hand should then 1)0 withdrawn, the fingers placed as high upon the forehead as possible iu order to maintain flexion, and the head forced into the brim by external pres- sure. The ether should be removed, and the fingers should maintain pressure upon the anterior portion of the head until a firm engagement in a flexed posi- tion has been effected by the efforts of the uterus. Should extension become re-established, an operative delivery of the head is necessary. Operative Belnrt'i/ of a Hiyh Arrest of the Posterior Occiput. — If extension is present, flexion should be established by the introduction of the half hand. Three methods of delivery are then possible : The child may at once l)e turned, the head may be rotatod manually and forceps applied to the anterior occiput, or forceps may be used while the occiput is still posterior. The latter method is to be recommended only when t!ie other methotls are, for one reason or another, contra-indicated or iiiipi.ssible, and the choice ordi- narily rests between the procedures or a manual rott>*:iou of the oc:iput to the front with a subsequent ap}»lication of the forceps, anu version. "« Manual rotation and the application of forceps is a difficult, and version in nor.nal pelves is an easy, operation. The head after manual rotation not infrequently returns to its original position during the manipulations incident to the application of the blades, and in any event it is necessi.ry to apply the forceps to the head when freely movable above the brim, Widch operation is always difficult. The writer believes, however, that aft' ' 'ho forceps has successfully been applied to the head in an anterior position, :k\ extraction with it is less dangerous to the sof*^ parts of the mother than is tl c extraction of an after-coming head ; the forceps operation should (l';'"'^^if'ore, in his opinion, be chosen by those who are thoroughly skilful iu tix n« of the instrument, but the primary performance of version should l)e el<'cte.l by operators of small experience. Should manual rotation and the use ot forceps '»(• d( cided upou, the whole h ^ ■ 4^. \'i. H ''d\i m. if ill t- II r/ (' ' ' ^i w 452 AMERICAN TEXT-BOOK OF OBSTETRICS. hand should be passed into the uterus and the licad be raised gently until the whole surface of the hand can be applied to the forehead, the fingers lying over the face of the child ; whereupon the hand and the forearm of the operator should be rotated with the head until the occiput is well anterior to, and even, if possible, to the left of, the median line. During the introduction of the hand careful counter-pressure must be made at the fundus by an assistant or by tlie other hand of the o])erator, and during the rotation the external hand nuist be used to promote the rotation of the trunk. The rotation should always be slow and be procural with the utmost gentleness. Unless the rotation of the trunk accompanies that of the body, the head will return to its original position as soon as it is free from pressure. In ditticult cases it may occasionally i)e per- missible to apply the internal fingers to the shoulder of the child to ])roniote this rotation. The whole nianeuvre is frequently so difticult that, unless the waters have been but recently evacuated, it should not be attempted until a fair experience in version has furnished the operator with some adroitness in intra- uterine manipulations. After rotation has been effected the head should be urged into the brim by counter-])ressure upon the fundus, and it should be maintained in position by gentle abdominal pressure upon the head itself, from the hands of an assistant, while the forceps application is made. The forcejis should be api>lied, if pos- sible, to the sides of the head, and, as in all high operations, the use of an axis-traction instrument is to be recommended. If version is decided upon, the head shoidd be flexed before it is raised, as this always requires less force thaji an attempt to raise the extended head. If version is absolutely contra-indicated and manual rotation fails, an attempt should be made to bring the head through the sui)erior strait by the application of forceps without alteration of the position ; but as a preliminary even to this operation an extended head should gently be flexed. In the use of forceps while the occiput is still posterior, it is inadvisable to make any attempt to ajiply the blades to the sides of the head, as the position of the parietal bosses in the narrow space between the ilio-pectineal eminence and the promontory makes it extremely difficult to adjust the forceps to the ends of the biparietal diameter. Even when it is so adjusted a very slight forward inclination of the line of traction may cause the forcei)s to slip forward along the head to the temporal region. In this position the forceps is extremely likely to slip from the head altogether ; even if the forceps holds its position, the sole and necessary result of tnictiou is a reproduction of the extension, which, of course, results in an arrest, or at least requires the use of increased and unnecessary force. The blades should therefore be applied to the sides of the pelvis, where they will take an oblique grip upon the head. This application is always very difficult, and the operation too frequently results in a fi-actuiv of the skull or in the birth of a stillborn child from cranial compression. A> soon as the head has passed the brim the forceps should be removed ; if neces- sary, the forceps may be reapplied in the manner shortly to be recomr i 'rded f«)r the operative treatment of the loi, head in posterior positions. )lo to ition inenco the sliglit rwanl eint'ly ition, hie!.. 1 and if tht' I'ation c'turo As licces- lulfi THE MECHANISM OF LABOR. 453 Management of the Passage of the Excavation in Posterior Positions. — Flexion. — Ais was said ia the discussion of the mechanism of posterior posi- tions, the maintenance of complete flexion is the first and most essential con- dition of the progress of the liead through the excavation. It follows that the maintenance of flexion when possible, and its re-establishment when it has been lost, must demand throughout the case the most careful attention from the obstetrician. When the adaptation is easy and good flexion is present from tho start, descent and rotation to an anterior position are sometimes so quickly performed that no assistance is needed ; but in a large proportion of cases the head enters the excavation in a condition of partial extension, and in such cases an early iidoption of certain very simple measures frequently makes the difference between difficult and easy labors. The various expedients which may be used to promote or to re-establish flexion form, then, the first and most important division of the treatment of the low head in posterior positions; but, since it not infrequently hapixjns that even a well-flexed head fails to rotate from over- tightness of adaptation, from relative inefficiency of the pains, or from minor variations in the shape of the head and the pelvis, it is necessary to add thereto a second division, which consists of the expedients that may be employed to tlivor or to produce rotation during extraction, whenever, from any cause, a well-flexed head is arrested in a posterior position in the excavation. Maintenance of Ffe.vion. — Unless progress goes on with unusual rapidiiy, the maintenance of flexion by counter-pressure should be undertaken as soon as the head has entered the excavation and the forehead is within easy reach. As soon as the degree of descent permits, the fingers should be placed against the frontal bones as far forward of the large fontanelle as the pelvic space allows, and any further descent of the sinciput should be retarded by a ntenance of pnssiirt against the forehead throughout the whole of each pain until the occur- rc'i'i' of rotation carries the frontal bones backward and out of the reach of the tii'gcrs In this process a simple retardation of the descent of the sinci[)ut is {]'. ihfii U to be aimed at or desired, since flexion is supposed to be already ])resei: . and "ts maintenance is all that is needed. This maintenance of flex- ion, w'.iv.i/ is unusually easy, is always a very much more simple matter than is an attempt to raise the forehead by pressure after extension has once occurred. If this precaution is carefully observed from the start, loss of flexion is extremely rare, and a recourse to the more heroic methods required for its re-establishment may usually be avoided. Re-cstahlishment of Flexion. — When extension occurs, it must be reduced "ifore any further })rogress is jiossible. Flexion may be re-established either in pushing the sinciput up, by drawing the occiput down, or by a combination t>i ;;o(h methods. The forehead may occasionally be made to recede by pres- sure upon the frontal l)ones with the fingers ; it should thou be held in position until the uterine efforts have effected complete flexion by descent of the occiput, and until rotation has occurred. This method, the simplest and safest, is, how- ever, possible only in very easy (lases. h* i i 454 AMERICA X TEXT-BOOK OF OBSTETRICS. ' i ; ; i: I t 1 ! ,i/ ;^ t: ': I It is occasionally possible to reinforce this niethotl by hooking the fingers of the hand around the occiput, and thus drawing down upon the occiput witli one hand while the sinciput is pressed up by the other hand. This method is possible only when the extended head is very low and the soft tissues of the outlet are very lax ; in the majority of cases in which extension has fully been established it is necessary to resort to instrumental methods. The recti's (Fig. 26.'i), which was the precursor of the forceps, was originally used to promote the descent of the head by the application of leverage motions to the sides of the head in alternation. The vectis is never used to-day except for the reduction of exten- sion, and, in the opinion of the writer, cannot be recommended even for this purpose, since, in the first pli; e, its efficiency depends on its possession of an ex cr^'eratcd cephalic curve w'hich renders its intro- du( i 'icult, and, in the second place, it can rarely be pre\ r'ed from slipping, without the use of a degree of force which exposes both the vagina of the mother and the scalp of the child to serious risks of laceration. If employed, the vectis is passed around the occiput and is used to draw it down, while the delay of the sinciput is entrusted to the friction of the j)elvic walls or to counter-pressure by the fingers. For this purpose the hand of an assist- ant must be utilized, since the employment of the vectis always requires both hands ; that is, while one hand makes traction on the handle of the vectis, the fingers of the other hand must always be placed between the vagina and the instrument to protect the tissues from laceration. Beversed Forceps. — A far better operation, when manual efforts at flexion have failed, is to be found in the application of reversed forceps. This opera- tion is in reality a mere extension of the ancient jnnnciple that the tips of the forceps should always be directed toward the leading point on the presenting part ; but when the forceps is applied to an extended head in a ])osterior posi- tion with the tips directed posteriorly, its grasp is directed so far toward the occipital end that the instrument is almost certain to slip after flexion has occurred. It is therefore important to remember that this application should be utilized only for the production of flexion, that during each traction tlic fingers of the unemployed hand should carefully note the motions of the head, and that as soon as flexion has been established the blades should be removed, if necessary being reapi)lied for the delivery of the head in the manner recommended for the delivery of a well-flexed head in posterior positions. Technique of the Application of liei'ei',se(l Forceps, — The forceps should hv placed outside the vulva, in the position in which they are to lie when applicil to the head — that is, with the transverse axis of the blades at right angles to Fig. 263.— The >ectls. THE MECHANISM OF LABOR. 455 the sagittal suture, and with the tips directed backward. If the lock is of tlie ordinary form, the handle of that blade which would be the left iu the ordinary position should be held in the right hand, and, under the guidance of two fingers of the left hand, should be inserted into the vagina and passed into position as near as possible to the occipital end of the head (Fig. 264). xion )era- )f the ntinti posi- tlio las lould n the the 11)0 the erior id be plied es to Fio. 'J64.— The iippliciition of reversed forceps. The arrow indicates the iiTect of the forceps in pro- moting the descent of the occiput while the sinciput is delayed by friction against the anterior pelvic wall. Tlie other blade should be adjusted to corroppond with its fellow, and simple traction upon the handles should be made in the direction of the handles, all leverage motions being avoided. The force of the instrument is then directed against the occipital end of the head alone ; the sinciput is delayed by the friction of the pelvic walls, while the occiput descends under the force of traction, and flexion results. As soon as the small fontanelle has been brought to the centre of the pelvis — that is, when the head has been flexed — the forceps should be removed and the process of rotation be entrusted to nature, since lacerations of the vagina are far less often |)roduced wiien rotation is ofl'ccted by the uterine force than when it is procured by instrumental means ; unless, indeed, the condition of the patient •-lectssitates an immediate delivery. Low Forceps in Wclf-ffcxcd Heads in Poftterior Positioihs. — When rotation fails notwith hmding tlie ])resence of good flexion — that is, when a well-flexed head is delayed in a posterior position until the signs of exhaustion occur — this failure is usually the result of a relative want of eis-a-terejo, which must be compensated for by the substitution of the vis-a-fi'onte of the forceps ; but it is the first essential to success in this operation that the instrument should be so applied that its ])resencc in the vagina ofl'ers no impediment to the rota- tion of the head. If in this position of the head the forceps is applied to the sides of the pelvis, its obliiiue grasp upon the forehead and the occiput will almost certainly prevent rotation ; while, even if it is applictl to the sides of the head, it is liable to cause extension and consequent delay, with laceration u 1 ll M . 456 AMERICAN TEXT-BOOK OF OBSTETRICS. \ t !' I! i W " m^ ':] of the perineum, aud frccniently the death of the fetus, unless special precau- tions are taken to ensure its grasping the occiput. So long as the occiput is dit.tinctly posterior to the transverse line of the pelvis, the forceps should he applied to the sides of the head with the concavity of the pelvic curve toward the forehead — that is, with the tijjs anterior ; but care should be taken during the aj)plication of the blades to keep the handles well raised, or, to use a better expression, to direct the tips far backward into the pelvis, in order to ensure their grasping the occiput aud thus promoting rather than retarding flexion during the tractions. The tractions should be directed as far backward as the perineum will allow, at least until rotation has occurred ; since it is sometimes difficult to secure this line of traction in the ordinary position of the hands, it is often well, in the extraction of posterior positions, to place the left hand upon the shanks of the instrument near the vulva, and with that hand draw backward while the right hand steadies the extreme end of the handles. It must not be forgotten that the maintenance of flexion and the conse- quent production of rotation are essential objects of thio tirst application, since descent is dependent on them. The production of forced rotation by a rotative movoment of the handles of the forceps is so extremr 'y (\.;igorous to the soft parts of the mother as to be permissible to none but tlie most experienced operator. The operator who has really acquired sufficient skill to justify such a maneuvre will infallil)ly have acquired so active an impression of its dangers as to use it with the most A B '^1 ' |'|:^ t Fio. 205.— Lateral motion of the handles of tlu' cnrved forcops rlurinR the rotation of a posterior posi- tion of t)ie lu'uil : A, position of tht' liuntlles when tirst upplie< at the Brim. — The measures which must be considered in the management of face presentations when detecteil while the child is still in or above the brim are as follows : The case may be left to nature; an attempt may be made to niise the (Fig. ('(.' of -iitly verv IT i 0(1 of a 1100(1 TllK Mi:%IlA\IS.V #/•• LMi^H. chill, and «o roston- a vcrtox pnsoiitatioii l>y idiiiiikiI jiexinn »f tin' litail, aftor wliicli it may bo loft to nature <»r l)o dolivorod l»y tlio forcops ; fonrjtn may Ik; applied to (lie face as aiioli, or the rase may at once he delivered by irrni(>n. NntnrdI Labor. — The first expedient, that of leaving the case to the «'are of nature, is applioablu only under one set (tf cireiimstaiu'es. Wlieii the chiu Fi(i. '_>7I.— Posterior position of tlie faro deeply engnKed in tlie pelvis (Smellie'. is anterior ; when the woman is a multipara who has liad a succession of easy labors; if the accoucheur is able to satisfy himself by a thorough examination that the soft parts are soft and dilatable, that the ])elvis is ample, and that the child is small, the latter point having been determined not only by palpation of the abdomen, but also by palpation of the head with the half hand introduced into the vagina ; when the uterus is j)owerful and the pains are frequent ; and, finally, when no ])athol()gieal complication is present, — it is often wise to adopt a conservative policy ; but the conse(piences of delay are so serious even in anterior positions of the face, and the prediction of an easy labor is always so (litficult, that the obstetrician should feel that in making this prediction and adopting a policy of inaction he is taking a very grave responsibility. When the chin is posterior, or when, in anterior positions, the conditions are anything but the most favorable, it should bo the rule that the detection of a face pres- entation at the brim is to be followed by immediate interference. Interference at the Brim. — The choice of methods rests between manual fcvion of the head into a vertex presentation, version, and the application of forceps to the face. The choice between version and the production of a head presentation by manual flexion rests mainly on the position of the chin. If the chin is pos- terior, flexion of the head will result in the production of an anterior position ,L! -i'- iV^, r-^: ',:^ d", 1 ''!? iLiliJJJ m > i , y 1 ": ; * I ! ' III '. ' ! I ^ ji: . ; I ^^ AMERICAN TEXiP-BOOK O^ OBSTETRICS. of the vortex — the most favorable position for a subsequent delivery by nature or for an extraction by the forceps ; if the chin is anterior, flexion can produce only the unfavorable posterior position of the vertex.. In posterior positions of the chin manual flexion should ordinarily be the first expedient, and the head, when flexed, should be urged into the brim by external pressure with the hand, in the hope that it may become engaged in this position under the influence of the pains, after which the case should, of course, be left to nature ; but if an engagement does not follow promptly, it is host to apply forceps at once, since the conditions which originally produced the face presentation may usually be relied upon to reproduce it. If the manual reproduction of a vertex presentation proves difticult or impossible, the attempt should be abandoned and version be performed. If the chin is anterior, flexion of the head would result in the production of a posterior position of the vertex ; and siuce, as has been seen, posterior positions of the vertex at the brim are usually best treated, when interference is necessary, by a resort to version, it follows that in anterior positions of the chin, when interference is necessary, a primary version is the operation of choice. When in such cases a version is contra-indicated, the choice lies between an application of the forceps to the face and a manual flexion into a poste- rior position of the vortex, to be followed by an attempt at a manual rota- tion of the occiput to the front and the application of forceps. If the conditions are such as to render this latter operation possible, it is generally preferable to the use of forcoj)s to the face ; but since the conditions which contra-iiidicate version very generally render manual rotation of the head diffi- cult or impossible, it will sometimes be necessary to resoi't in such cases to the use of forceps to the face. The u„e of forcops to the face at the brim is always a difficult operation. The delivery of the child through the brim without injury to either mother or child can be accomplished only by the utmost accuracy in the adjustment of the blades ; and oven in anterior positions the prognosis is serious. The use of forceps to the face higii is, then, never permissible to any but a thoroughly skilled operator, and even in such hands it should be reserved for a last resort. In posterior positions the forcops is ncvcv permissible, and it should be forbid- den both from its inherent difficulties and because success in the passage of the brin; can (»nly result in the production of that very dangerous condition, a jwstcrior jiosition of the face within the excavation. Manaf/euicnt of Face Frcsentatlonx, Low. — Chin Anterior. — When a face presentation has been allowed to pass the brim or has not been discovered until it is within the excavation, its j)rogress should be watched with great care, and the utmost pains must be taken to maintain complete extension throjighout the second stage. A constant watch over the processes of nature must be main- tained, since any considerable delay is attended by great danger to the life of the child, from the likelihood that an interruption of its cerebral circulation may occur as a result of the extreme tension necessarily put u{)on the vessels of the neck or of their compression against the sides of the pelvis. \ y THE MECHANISM OF LABOR. i!^ by nature 1 produce ily be the 2 brim by ngaged in houlcl, of iptly, it is produced be manual le attempt )roduction , posterior iterf'erence jns of the jratiou of is between o a poste- mual rota- If the ! genemlly ions which liead diffi- ases to the operation, mother or istmeut of The use lioroughly list resort, be forbid- )assage of couditioii, leu a face ered until care, and ghout the be main- he life of irculation he vessels It follows from these dangers that even moderate delay furnishes a sufficient indication for the use of low forceps in face presentations. Complete exten- sion, as has been said, is of the utmost importance, and, fortunately, may easily be maintainetl by pressure with the fingers upon the under surface of the lower jaw. Should interference become necessary, it is absolutely important that the forceps should be applied to the sides of the cranium, and with the tips so far posterior as to be entirely clear of the neck. In anterior positions, if this necessity be borne in mind, the application of forceps is easy, and the extraction of the child ordinarily presents no great difficulties ; but it must not be foi"- gotten that pressure upon the tissues of the neck by the tips of the blades nmst almost invariably result in loss of the child. Chin Posterior. — As has been said, the face should never be allowed to enter the pelvis chin posterior. If this abnormality is not discoveral until it has occurred, the patient should at once be etherized, the hanvl be introduced, and the possibility of raising the head above the brim should be tested. If this is possible without grave risk to the mother, it should at once be done, and the face dealt with according to the principles already outlined for the operative treatment of the face high (p. 463). If elevation of the iiead proves impossible, the obstetrician should content himself with the maintenance of extreme extension by traction upon the chin in combination with a constant attempt to promote rotation by drawing the chin forward with the fingers. This process should be persisted in so long as there is, in his judgment, any possibility of rotation. When this prospect becomes hopeless, forceps may be applied and an attempt be made to extract the face as a persistently posterior chin presentation. Any atteu'pt at rotation by the forceps must be forbidden, both because of the grave danger of j)rovoking extensive lacerations of the mother that neces- sarily attends this maneuvre, and because any slipping of the blades upon the child or any oblicpie application of the forceps would necessarily involve com- pression of the vessels of the fetal neck, and therefore the loss of the fetus. A straight forwps should be used if it is at hand. It should be applied care- fully to the sides of the head and with the tips well anterior, so that the grasp of the blades may be wholly upon the cranial vault. The tractions should be directed slightly backward until the perineunj is thoroughly upon the stretch, tlion forward and upward until the chin emerges, and then well downward, that the occiput may emerge under the arch and the head be born by flexion. Since lacerations of the pelvic floor are inevitable in this operation, and since every possible advantage nmst be taken, the j)erineum should be incisal by deep lat- eral Incisions as a preliminary measure. This [)rocess has not yet been successful in the extraction of a living child ; but since it has never, so far as known, been adopted while the child was in good condition, and as it has several tisnes succeeded in extracting dead but uninjured children, it deserves a more extended trial whenever a childin this posititm is still in fairly good condition. If the child's vitality is already seri- ously compromised, its chances of life are so small that the prospect of preserv- •3; • » J s ■fi, . fit V466 AMERICAN TEXT-BOOK OF OJiSTI-yTRICS. f ! i ' I \\^^i ' i i| ;/ ing the mother's soft tissues would, in the judgment of most obstetricians, justify the choice of craniotomy.* 8. Brow Presentations. Frequency. — As face cases liave usually, if not invariably, passed through the stage of brow in the process of their conversion from a vertex presentation, temporary presentations of the brow must be at least as frequent as those of tiie face; but if only those brow presentations which remain such until altered by the obstetrician are included in the list, the freijuency becomes less — jiro- bal)ly not more than 1 in 1500 labors. Relative Frequency of the Ponitious. — Brow (). L. A. and brow (). D. P. arc almost equally freciuent. The others are much less common. Etiology. — Brow presentations are due to the same causes th produce ])rcsen tat ions of the face, but it \s of course a fact that if the process of exten- sion is arreste .. {that i,s, brow O. D. P. and brow (). J,. P.). — In the rare cases in which a jircs- entation of the brow succeeds in enter- ing the pelvis, this possibility is due to the fact that the mouhling of the liciid lias [)rogressed until the occipito-mental diameter has become sufficiently sniiili to pass the oblique at the brim, and this change is compensated for by a corre- sponding increase in the ocicipito-frontiil diameter (Fig. 272). The increase in the length of this diameter necessarily carries the forehead much deeper into the pelvis than any other part of the Fio. 272.— fonnpurntlon nf tlio fetal lii-nd nftiT its (li'livcry lis a brow pR'ni'iitatioii. * Since tlie aliove w;is writton the greiit success of syniphysiotoniy has led most ohstetriciniis to believe that a division of the symphysis shoidd jirecede all aj)i)lications of tlie forceps to a peiT^istently posterior position of the face. THE MECHANISM OF LABOR. 467 liead, so that lu auterior positions of the brow the projecting forehead engages in tlie auterior groove of the lateral pelvic wall as soon as the brim has been passed, and reaches its deeper part by the time the occiput escapes from the sacro-iliac notch and enters the shallow u|)per part of the posterior groove of the opposite pelvic wall. If the conditions are so exceptionally favorable as to permit of the expul- sion of an unchanged brow presentation, the forehead moves forward along tiie course of the anterior groove, while the occiput, being still in the shallow up])er part of the posterior groove of the opposite side, moves back into the liollow of the sacrum ; the root of the nose conies to the pubic arch, and the pntgress of the anterior portion of the head is then arrested, while the occiput travels down along the jxtsterior wall of the pelvis and across the perineum. The nose and the chin then appear beneath the pubic arch, and the head in anterior positions of the brow is thus expelled by extension. External rota- tion, of course, carries the occiput to the side to which it was originally directed. Posterior Pomtions of (he Brow {that is, brow O. L. A. and brow O. D. A.). — Should an unchanged posterior position of the brow succeed in passing the l)rim, the forehead would enter the posterior groove and the occiput would lie against the shallow portion of the anterior groove. If the case went on to delivery, the rotation of the forehead along the posterior groove would be similar to that of the occiput in occipito-posterior positions of the vertex ; but when the enormous difficulties incident to the expulsion of the brow under the most favorable circumstances are increased by the inherent difficulties always attached to rotation in posterior positions, the sum-total of the obstacle becomes so great that a delivery is almost unknown, and it may be laid down as a practi- cal rule that |)osterior positions of the brow always become arrested. Manag'eiuent of Brow Presentations : Management at the Brim. — When a brow presentation is detected at the brim, we may deal with it by any one of the four following methods : the case may be left to the care of nature ; the brow may be converted into a vertex by manual flexion ; the brow may be changed into a face by manual extension ; or the case may be delivered by innneiliate version. The choice between these methods of treatment depends primarily on the position, but in posterior positions of the brow — that is, when tiic occiput is anterior — the indications are considerably modified by the pres- iiu'c of excessive moulding of the presenting part. Anterior Positions of the Brow. — The class of cases which should be left to the care of nature is extremely limited, and includes only those few cases of auterior positions of the brow which, when detected, are raj)idly changing into anterior positions of the face, and in which the conditions of the case are such that, if the face becomes established, its progress is certain to be rapid and easy. Flexion of such a brow would jirodnce a j)osterior jiosition of the vertex, and there is then but little hope of a spontaneous delivery of the new presentation, since the marked tendency to extension which always character- izes uie posterior positions of the vertex woidd almost certainly reproduce the «•;■ t fj^T : mm 1,1 •iff let : „ 468 AMERICAN TEXT- BOOK OF OBSTETRICS. i r n 1 \i iiSiia / brow, while if an operative delivery is to he undertaken, vei-sion is the opera- tion of election in posterior positions of the vertex. It follows that vei-sion is the operation of choice in anterior positions of the brow (see Management of Face Freseutatious at the Brim, p. 462). All other anterior positions of the brow should be dealt with by iinniediato version as the o|)eration of choice, the production of a vertex by manual flex- ion being ruled out for the following reasons : In freeing a partially-engaged brow from the brim of the pelvis as a pre- liminary to version, it is essential thai the first effort at raising the head should be directed against the forehead, siiice a preliminary flexion of the head re- places the long occipito-mental diameter by the shorter occipito-frontal diam- eter, and the subsequent elevation of the head therefore exposes the tissues of the mother to far less risk than would be involved in an attempt to force the extended occipito-mental diameter bodily upward. Moderate flexion is, more- over, an important element to success in the subsequent manipulations of the version, since its production minimizes the obstacle offered by the projecting sincip.it. When in anterior positions of the brow which ]>romise a difficult delivery an attempt at version fails, a manual extension of the brow to an anterior posi- tion of the face, to be followed by forceps, is the only alternative to craniotomy, unless the condition of the child warrants a resort to one of the major cutting operations (see The I'^se of Forceps to the Face at the Brim, p. 464). When the brow presents in a posterior position — that is, with the occiput anterior and with the head unmoidded — its treatment by mainial flexion results in the production of an anterior position of the vertex, and a manual flexion is therefore in these cases the operation of choice. After the re-establishment of flexion the head should be held in position by the hands for a few pains; but, unless its engagement occurs promptly, it is usually best to resort to an imtnediate a])plication of the forceps, since it may fairly be presumed that the conditions which originally led to the loss of flexion are still present, and will probably reproduce the extension if the case is left to itself. In this position of the brow a manual extension is contra-indicated, since it could only result in the production of a posterior variety of the face, which in itself is so danger- ous that it demands an immediate version. If, therefore, in these cases a manual flexion is ruled out, version should again be selected as the o})eratioii of secoiul choice. When the brow presents in a posterior position — that is, with the occiput anterior and with the head already much moulded — the oj)eration of manual restoration of the vertex must be ruled out in the interest of the child, for the following reasons: Fii-st, if a marked change of shape is apparent at the time the presentation is detected, the restoration of a vertex presentation by ii manual flexion of the head ))resents great difHculty ; moreover, the conditions are so much altered by the change in shape of the head that its re-extension into a brow would almost certaiidy occur as soon as the pains reappear or the forceps is applied. Second, a vertex delivery involves so extensive a re- THE MECHANISM OF LABOR. 469 moulding of the head to its original shape as to expose the child to great risk of danger from cerebral hemorrhage ; while the delivery of a much-moulded brow by version — that is, by the extraction of the after-coming head — results in but little change i'l shape, and is therefore nmch the safer for the child. Version is, then, the only operation which should be considered in these oases. The operative treatment of brow presentations, high, may be summarized as follows : In anterior positions, version is the operation of choice. In the posterior positions of unmoulded brows a manual flexion to au anterior posi- tion of the vertex and a subsequent application of forceps to the head should be preferred ; this failing, version should be the second choice.* In the pos- terior positions of much-moulded heads version should be selected. A high application of forceps to the brow is ordinarily more dangerous to the mother than a craniotomy, and but little more ho{)eful for the child. The abdominal operations would be indicated only in the interests of the child, and would usually be contra-indicated by the fact that the vitality of the child is usually considerably lowered by the time the ordinary operations have become impossible. Management of Brow Presentations after their Entrance into the Pelvis. — Since the brow never enters the pelvis until after an excessive moulding has been produced, and since the adaptation is then always so close that any alteration of the presentation is impossible, it is unnecessary to discuss in this connection any other prol)lem than the delivery of the brow as such excessively moulded and closely adapted to the pelvic cavity. If the sinciput is anterior, the forceps should be applied to the sides of the head with the concavity of its pcilvic curve anterior, and the mechanism of the natural delivery of a persistent brow should be imitated. The tractions should be directed downward and backward until the root of the nose engages at the arch, and their direction should thou gradually be moved forward and upward until the occiput sweeps forward over the perineum, then downward again to permit the emergence of the face ; but the chance of extracting a living cliild in this way is so small, and the risk to the mother's tissues is so extremely great, that the application is never permissible unless the child is in fairly good condition. If its vitality is already seriously lessened, it is probably the best practice to deliver by craniotomy. Such cases are, fortunately, almost never seen during the life of the child, and perhaps never at term. If the brow has entered the pelvis with the ninciput posterior, and the child is still alive, a very cautious attempt to promote rotation by the forceps might be justifiable ; but success would be extremely unlikely, and a resort to crani- otomy would almost certainly be necessary. This condition, however, is so extremely rare that it is almost unnecessary to refer to it. * An extension to a face and a subsequent rotation of the chin to the front are occasionally possible, but this operation is always diflicult, and should not be attempted by operators of small experience. !.' M it ''I ' I if ■[ ■! i'; ! i. WM ■n 1? i'i ffl^ ' . VI ■ I-- f 470 AMERICAN TEXT-BOOK OF OBSTETRICS. 4. Pelvic Pkesentations. Pelvic presentations are commonly divided into breech, knee, and footling presentations ; but knee and footling presentations are so similar in every respect to those of the whole breech that it is convenient to treat them as sub- variations. Frequency. — Pelvic presentations occur in about 1 in 30 labors when mis- carriages and i)reniature labors are included. Among laboi"s at term, however, their frequency falls to about 1 in 60 cases. Thus, Pinard found among 100,000 cases 3301 pelvic i)rosentations, but on excluding the premature cases the proportion fell to 1 in 62. Among pelvic presentations about 60 per cent, are presentations of the breech. Etiology. — Pelvic presentations are produced by the failure of the condi- tions which ordinarily ensure the existence of cephalic presentations (see p. 418). They are, then, especially frequent among premature and macerated children, when the liquor aninii is excessive and when the uterine and abdom- inal walls ."'.e very lax. They are the rule in hydrocephalus, and one out of every four twins is a breech child. In deformed pelves, too, in which the head is unlikely to become fixed at the inlet during the last weeks of jM-eg- nancy, breech presentations become more frequent. S. D. A. and S. L. P. — that is, the two positions in which the long diameter of the breech occupies the first oblique diameter of the inlet — are much more common than S. L. A. and 8. D. P. Knee and footling presentations are probably always secondary, and are due to an active movement of the fetal limbs. Diagnosis. — On ahdommal examination the head is found at the fundus and its absence is noted at the brim; the heart is heard above the umbilicus. On v\-h\ the occipito-meutal or tlie occMpito-fVontal diameter, and an absolute arre t usually follows. Delivery by the efforts of nature then almost never oecurs, and is only possible when the adaptation is so easy that the uterus is able to drive the occiput through the brim, while the chin slips upward and forward over the horizontal ranuis of the pubes in order to make room for it. If this happy release of the chin happens, complete extension follows, the occiput appears under the fburchette, and the head is born in extension. This move- ment of extension is, however, usually accomplished only by traction on the body or by the application of the forceps ; even then it is likely to involve so much delay that the preservation of the life of the child is unlikely. Management of Breech Presentations. — Nothing more thoroughly tests the skill and judgment of the obstetrician than his management of a breech presentation. Upon the one hand, it is of the first importance that he should remain inactive so long as the natural processes are progressing satisfactorily. Upon the other hand, he must be prompt to foresee the appearance of danger to the child, and to interfere as soon as this danger is manifest. He cannot be warned too strongly to avoid premature interference, since the use of trac- tion instantly disarranges the delicate balance by which the normal attitude of the child is maintained. As before stated, the maintenance of flexion in natu- ral breech labor is due to the facts that the legs, arms, and forehead are driven down by the action of the intra-uterine-fiuid pressure upon their upper sur- faces, and that this pressure is more than sufficient to overcome the friction of the pelvic walls against the lower surfaces of these parts ; but when traction is made upon the breech, the additional force thus supplied is distributed to the members only through the knees, the shoulders, and the occipito-atlantoid articulation respectively, while the very fact of its application —that is, the promotion of a more rapid descent — increases the force of friction exerted against the feet, the hands, and the forehead. Traction is then almost invari- ably followed by extension of the legs, the arms, and the head, with all its inherent difficulties. When, however, interference is demanded, speed in extracting the arms and head is essential. After the scapula) appear five minutes is an average time, within which the mouth should be brought to the vulva. He who interferes in a breech delivery should feel that unless unusual good fortune attends his effi)rts he is likely to be confronted by the necessity of a manual delivery of each and every portion of the child's anatomy as these por- tions successively approach the pelvis. ICven in the most skilled hands this process is attended by much more danger to the child than is involved in a natural delivery. Since natural delivery is ordinarily possible only when complete flexion is maintained, since a single traction is likely to produce extension, and since, ■when extension has once occurred, delivery is ordinarily possible only by the immetliate adoption and subsequent prosecution of an operative extraction, it becomes evident how important it is that the obstetrician should remain abso- lutely inactive unless there arise circumstances which show him that nature is THE MECHANISM OF LABOR. 475 likely to fail — that is, that the best chances for the child have been lost, and that the second best must be taken ; for if it be true, upon the one hand, that a prompt natural delivery is i«afer for both mother and child than the best operative interference, it is equally true, upon the other hand, that when nature fails in promptness the only hope for the child and the best prospect for the mother is to be secured by the immediate performance of an o|K'rative delivery. Management of Nonnal Breech Labor. — In breech labor the obstetrician's duty, so long as progress is normally rapid, is reduced to the following details : It is wise never to }xing out the legs. As soon as the umbilicus is within reach of the finger he should gently draw down a loop of the cord, to avoid the danger of undue tension upon the cord or up(m the umbilicus during the subsequent descent of the body. The hips and the body should still be held constantly forward toward the mother's abdomen, in the curve of Cams, in order that the rota- tion and expulsion of the head may not be interfered with by the weight of tli(! body; but no traction should be made during this process. As the elbows appear the forearms should be drawn out, and if the fetal body is sufficiently elevated the head should follow without delay. f Rapid Extraction of the Breech when Arrested High. — When a breech is arrested at the superior strait until the signs of exhaustion of one or the other * Wirm in order to lessen the danger of a jjremature resi)iration, sterile on account of its contact with the vnlva. t For the procedure of extracting tlie Ijcad and arms low, see page 480. I' )' ■X t>b. AMERICAN TKXT-liOOK OF OBSTETRICS, patient appear, or when a rapi^l delivery becomes necessary by reason of some condition which threatens tlio life of mother or child, five methods of securiiiir descent are applicable : Traction may be made npon the anterior j;roin with the finycr, the JilUt, or i\\i blunt hook ; forceps may be applied to the breech ; or the hand may be inserted into the uterns, and be made to briiKj down a f(y for use as a handle by v^jiich to make traction. Of these metliods, the use of finj^er in the groin is always preferable when its employment is possible, but in high arrest of tiie breech the finger seldom has sufficient power to secure descent ; and if the breech is but slightly engaged in the brim at the time interference becomes necessary, the introduc- tion of the hand to bringdown a leg is ordinarily the metiiod which should be chosen when the finger in the groin fails. If the breech is already so far engaged as to render this maneuvre ditficult or dangerous, the cautious employment of the blunt hook or the fillet is permissible. An ojierator of practised skill may succeed by the forceps, but the application of this instru- ment to the breech at the superior strait is not to be recommendeil to begin- ners. llie Use of the Fim/er. — In applying this metluKl the half hand should be passed into the vagina, the forefinger be hooked into the groin in any manner convenient to the operator, and traction be made downward and backward in the axis of the superior strait. Care should be taken to direct the line of traction rather toward that side of the pelvis to which the back of the child is directed, in order to lessen the dan- ger of snapping the femur (Fig. 274). The Blunt Hook.— Yioth the fillet and the blunt hook can usually be ap- plied to the groin, without s|)ecial diffi- culty, in any jjortion of the pelvis, and both furnish fairly effective means of traction ; both instruments, however, labor under the disadvantage of subjecting the tissues of the child to great risk of injury, the blunt hook, when skilfully used, being perhaps the less daneri - ous. The hook should be passed, under the guidance of the finger, betwo- anterior hip of the child and the pubic bones until it can be so rotated tl.>. its point passes between the child's thigh and alxlomen. The finger should tin ■ be passed between the thighs and be brought into contact with the point of the hook, which should then be settled downward by gentle traction until its curve fits snugly into the flexure of the groin. The shank of the hook should then be grasped by the hand to which the finger belongs (Fig. 275), and traction should be made with the other hand, the finger lying in contact with the ^' ^"^SC'f ' Fio. 'J:4.- -Proper (A) imd improper (B) directions of traction upon the thigh.* * Though represented with tlie fillet, this Figure illustrates equally the manner of employ- ing the fillet, the blunt hook, or the finger. THE MV.VHANISM OF LAIiOR. 477 point of tlie hook tlirotiglioiit tho cxtniction, in ordor to protect the soft pnrtH from injury as f'nr as |>ossil)l»'. The liiit> of traction .should iw dirertcd toward (he side on which the sacrum lies, in onler to avoid fnicture of the thigh. ■■\tl Fui. 27.').— Mf thod of gruHpIng the blunt hook. The Fillet. — The fillet may be made of a i>iece of broad tape, preferably linen on account of its greater strength, or of a wide .strip torn from a silk handkerchief; the best fillet known, however, is that made by pa.ssing a stout cord through a piece of rubber tubing about three-eighths of an inch in diameter. The fillet may occasionally be passed through the groin by the un- aided fingers, but in high arrest it is seldom possible to succeed in adjusting it l)y this method. Several instruments have been devised for the special j)urpose of placing the fillet, but their place can be filled equally well by a piece of string and a large English webbing catheter. The disinfected catheter should he threaded with a double looj) of disinfected string or of narrow bobbin, and with its stilette, should then be bent to the shape of the blunt hook (Fig. 276). The catheter shoidd be pas.sed into the groin in the manner directed for the use of the blunt hook, and the finger should dnvw down the projecting loop of string until the end of the fillet can be passed through it, when, by the removal of the catheter, the fillet is jjlaced in posi- tion in the groin. The .same precaution as to the direction of the line of trac- tion must be observed with the fillet as that recommended for the blunt hook and the finger. The Use of Forceps. — If the forcej^s is used in high arrest of the breech, its application is similar to that which is to be described under low arrest (p. 478 although it is much more difficult. The Extraction of a Leg. — In the introduction of the hand into the uterus to bring down a leg, the breech should be pres.sed back gently through the brim before any attempt is made to pass the hand. The utmo.st gentleness sh' 'Id be observetl throughout this maneuvre, and undue ten.sion on the utero- vaginal attachments should be avoided by a careful maintenance of counter- FiG. 276.— t'sc of the cfttheter as a porte-fiUet. ( * -lA, ^i.-:!- s ;i mi ■II 478 AMFJilCAN THXT-BOOK OF OBSTETRICS. prt'ssiiro against the fiiiuliis with the other liand. The operator should always be careful to ascertain the position of the cord, to avoid the production of an uiHiecessary prolapse. If the foot is within reach, it should be seized and gently drawn out fnMn the os. He should seize the anterior leg whenovcr that is accessible, as the line of traction on the anterior leg can be kept nearly in the axis of the inlet, while a pull on the rear leg brings the anterior but- tock to a sitting position on the brim, and the traction in a line running from the child's hip, located near the mother's i)romontory through the vulva. If the legs are extended across the chest, two fingers should be placed along the crest of the tibia, and be used to so flex the leg tiiat the foot passes down the median line of the child's abdomen until it reaches a position in whitii it «ui be seized and withdrawn. When the foot appears at the vulva, the h'g should be wrapped in a towel which has been dipped in a warm solution of corrosive sublimate, and traction should be made upon it in a line which shoidd at first be directed as far back- ward as the perineum allows, in order to pull, so far as possible, in the axis of the superior strait. As the breech descends the line of traction should swing fi)rward, until, when the hips clear the vulva, it is directed nearly vertically upward, the woman being in the lithotomy position. As soon as the knee is well outside the vulva the grasp should be shifted to the thigh, as any pro- longed traction on the lower leg is apt to overstrain the ligaments of the knee-joint. If there is any difficulty in bringing the breech to the vulva, its delivery may be assisted by hooking the forefinger into the other groin as soon as it is within reach ; as the breech distends the perineum it should be drawn well forward, and every effort sliould be made to prevent a laceration precisely as is done in the delivery of the fore-coming head. When the second knee appears at the vulva, it should be drawn outward along the side of the child and toward its back, until the fingers can reach the leg and release the foot by flexion of the leg ui)on the thigh ; but all pressure upon the shaft of the fenuu* nnist carefully be avoided, since fracture of the fenuir during this process is always easy. Care should be taken to bend the knee only in the natural direction. littpid Extraction of the Breech leliea Arrexfed Low. — Low arrest of the breech can usually be overcome by the use of the Ji)i(/er in the groin, which method should always be the first tried, li this method fails, the use of the Jiflety or, better, the hliail hook, is decidedly less dangerous to the child in low than in high arrest, the method of applying them being exactly the same; the Joreepx is here, however, easy and is almost invariably eflicient; moreover, if due care is exercised, this instrument is fiir less likely to injure the child than is the blunt hook. Applk'dtio)! of the Forcej)^ to the Jireedt Lojr, — If the breech lies in an antero-posterior or obli(pie position, the tip of one blade of the forceps should lie against the upper sacral vertebne, while that of its fellow should bo pressed into the flexor surlace of the most easily accessible thigh (Fig. 277). If the position of the hii)s is transverse, each tip of the forceps should THE MECIIAyLSM OF I.AJiOR. 479 of tlio wlik'h of tlio ill low 110 ; the )V('r, if tiiaii ill iiii uild 1)0 277). slioukl impinge upon a foimir just above or Itovond the trocliaiitor, whicii then furnishes a firm hold for the blades (Fig. 27proxi- inately correct position upon the breech, locked, and held lightly in this posi- tion. A hand should then be passed into the vagina until the tinger-tips can touch the exact spots at whicli t!ie tips of the blades should lie; an accurate adjustnieut is then easily attained by direct movements of the tijis of the blades with the internal fingers. The small size of the tapering breech, iu comparison with the diameters of any pelvis through wiiich a living child can be ex- tracteil, renders it easy to obtain an accuracy in the adjustment of the forceps that is impossible of at- tainment when the forccjis is used upon the head. It is this fact which renders the forceps valnai)le in this connection, since the avoidance of injury to the child and the attainment of a secure grasp of the breocli are to be eH'ected only by the adjustment of the tips to exactly the points to which they were directed, and the utmost care nuist be observed in verifving the position of the forceps before any traction is made. When the operator is sure that the instrument is satis- Fm. JT-.-Forcops applied to IV;. OT,-lM,r..,.ps,.pplu..l t,. lilCtOI'ilv in Ilosition the "" "I'liilUL' piisiUuii nl the u tnuisvcrso positldU ot lliL- , 111 111 I bret'uh. Ijri'i'cli liaiulles should he grasped sufliciently tight to ensure a firm pressure, which shonld then be maintained without intermission until after the (k.'livery of the child. The ordinary forceps is better adapted to this application than any special forms which have yet been devised. When the instrunient is used u|)oii the high lireeeh the advantages of axis-traction are perhaps more t'ully apparent than in juiy other obstetric operation. l\(ipi(l Krfrdcfinn of the Tridili. — As soon as the legs and the jielvis of the child have cleared the vulva, they should be grasped (througli a warm as(>ptic towel) in the manner shown in Figure 279, in which each thigh is grasped by V.I [ U .1' ' '1' : ! 'i I ■!-:g: ,'■ 1 * i'^'^i 480 AMERICAN TEXT- HOOK OF OBSTETRICS. V'i \i the fingers of one hand, the thumbs of the operator lying along the sacrum ; this grasp should he maintained tliroughout the extraction, no other grasp being so secure, and any pressure upon the crests of the ilium or upon the ab- domen of the child being dangerous to its bones and abdominal viscera. The line of traction should be directed as far backward as the perineum allows, in order to facilitate the passage of the shoulders through the superior strait, and the back of the child should bo kept steadily directed upward — that is. toward the anterior portion of tiic mother's jwlvis — to secure an anterior position of the occiput for the after- coming head. When the umbilicus a])- pears at the vulva a loop of the cord should be drawn downward, as is done during the normal delivery of the breech. liaijid Extmdlon of the AftiT-cominf/ Fio. 279.-Method of RraspinR the thighs during lJ^.^^^l ^,„,^ AnilS.—H, bv any chaUCC, tht! extraction of the breech. . . either arm remains flexed upon the in- fant's chest, it may easily be drawn out when the elbow appears at the vulva ; but in the great majority of cases both arms will be extended beside the head, and their extraction is then more difficult. The method that should be chosen for their release must depend upon the point of the pelvis at which the shoul- ders become arrested. Low Arrest of the Arms and the Head. — I.i easy extractions it is very often possible to bring the shoulders into sight outside the vulva by simple traction upon the thighs. In such cases it is frequently possible to extract the after- coming head and arms by the very easy and simple numeuvre known as DetH'titer'i^ method. In this procedure the body of the child is dropped down- ward as soon as the points of the shoulders are in sight ; the feet are grasped with one hand, the Hngers of the other hand being pressed upon the upper sur- face of the shoulders, and the child is drawn vertically downward toward the floor, the mother being in the lithotomy positicm. Under this traction the occiput appears at the vulva, and the forehead and face follow coincidently with the arms. The mechanism by which this somewhat surprising dtilivery is accomplished is as follows : The method is applicable only when the pelvii' space permits the head and the arms to enter the brim togeti)er, and both arc then contained in the excavation when the shoulders are at the vulva. The arms are tiien in contact with the elastic sacro-sciatic ligaments, which stretch before them and permit them to lie by the side of the head. The chin is arrested by the pelvic floor; the head extends, and thus brings the occiput to the vulva. The head is then delivered in extension, and the arms follow ) via ^s^rn^ THE MECHANISM OF LABOR. 481 (Fig. 280). The original advocates of this method claimed that it rarely if ever tears tho perineum, and the writer's experience with it certainly supports this claim. When t;,e conditions permit the head and the arms to enter the pelvis together — that is, when the shoulders can be brought to the vulva by traction upon tl'.e thighs — Deven- tor's method, though not the most powerful, is cer- tainly by far the most rapid and easy of all the inaneuvres for the release of the head and the arms, and it should always be given a trial. It is nec- essarily inapplicable when the head and the arms are arrested at the sui)erior strait. Trac- tion then only increases the difflcidty. If the shoulders appear at the vulva, but Deventer's method fails, the liiothod known as combined traction on the face and the shoiddcrn should be tried. Two fingers slu)uld be passed along the upper surface of the most easily accessible arm until their tips rest in the bend of the child's elbow. The elbow should then be urged backward and toward the median line by the fingers, and be swept across the child's face to the vulva, at which the elbow, forearm, and hand apjiear in the order named. This process should then be repeated with the other arm. Pressure upon the shaft of the humerus should carefully be avoided, since it is certain to snap the bone. The child is then laid astride of one of the operator's fore- arms, and the hand belonging to this forearm is passed into the vagina until its first and second fingers lie upon the canine fossie of the child. The other liand is hooked over the shoulders, the nock being between its first and second fingers, with the finger-tips upon the supraclavicular region (Fig. 281). The iiand that is hooked about the shoulders is then used to make traction upon the ciiild, while the internal hand exerts itself to preserve the flexion of the head. The direction of the first tractions should be in the line of the axis of that part of the pelvis in which the child lies, and as the head emerges the line of traction should sweep fi»rwar(l in the curve of Cams until, at tlie end of the extraction, the body of the child rests upon the other forearm and along the abdomen of the mother (Fig. 282). When the mouth appears at the vulva ai Fio. 280.— Deventer's iiicthnd of extraction of the urter-eoiiiiuK head iinU arms. \V' fM' ,t 1. 1 ,' f i'5 ' > I.' .i i:l V:i: I" i I i ^ !' i • i ';M. ■(! '■ re ^,i ; I 482 AMElilCAN TEXT-BOOK OF OBSTETRICS. and tlie moiitli and pharynx have been cleared out, all hurry ceases, and tin- Fk;. ;!81.— Delivery of the ufter-coiiiiii}? liead liy coinlnned triictiou on the lieud niid shoulders. operator's efforts should be direc^^'Hl to the preservation of the perineum. But little traction should now be used, and the hand that was apj)lied to the face should be used to shell out the head by })rcssure on the forehead through the perineum, or, if necessary, by passing two fin- gers into the rectum. Il'uih Anrd of the Art)}>< and Head. — When the adap- tation between the head and the pelvis is not sufficiently easy to permit the simulta- neous entrance of the head and the arms into the pelvis, the arrest of the shoulders at tlie superior strait may be known by the fact that the child ceases to make progress, - ^.m. ^^ under tractions of ordinai'v -s/s^ _^^^ strength, at about the time ' when the tips of the scapula' Fi(i. 282.— riisitioti n( tl't' cliiM Itnnii'diiili'ly after the eseupe , , a 1 • of the unereoiuiii),' heud from the vuivu. ap})ear at the vulva. At tlllS THE MECHANISM OF LABOR. 483 ])oint of the extraction it is therefore important to watch for a marked increase of resistance, and when this is observed the tractions shouhl immediately be intermitted, since their continuance only serves to lock the head and the arms t-ccurely in the brim, thus rendering the subsequent maneuvres for their release more difficult. The body of the child, in such an event, should be pressed slightly upward, and be rotated until t!ie back is directed to one or the other side of the mother's pelvis. The hips should then be elevated gently toward the mother's abdomen and toward the side to which the back of the child is directed, moderate traction being exerted upon them at the same time. The object of tills maneuvre is twofold: first, tiiat space may be afforded for the passage of the hand into the vulva alcmg the abdomen of the child ; secondly, that the jiostcrior shoulder, which is usually the most accessible, may be brought as deeply into the pelvis as possible. The hand of the operator that naturally faces the abdomen of the child should then be passed rapidly into the vulva, with its palm flat against the abdomen and chest, until two fingers can be passed up along the arm of tlie child and their tips placed in jwsition in the bend of the elljow. No pressure upon the arm should be made until this position is reached, but when it is attained the elbow should be drawn down across the child's face until the forearm and liand are within easy reach and can be brought to the vulva. If the hand passed along the abdomen fails to reach the elbow, the latter may sometimes be found by seizing the feet in tliat hand and drawing them gently upward and to the opposite side, so that the hand which before held the feet can be passed along the back of the child close under the pubic arch to the back of the posterior shoulder, and thence along the arm to the elbow, which, however, must, as before, be brought downward a(!ross the child's face. The hips of the child should then '■ swept downward and traction be made upon the thighs, in the hope that tlie pelvic space may permit the entrance of tiie head with the remaining arm ; if this does not occur, the body of the child should again be pressed backward into the pelvis, and the child be so rotated that the arm which was anterior becomes posterioi-, wiien it should be released by the same method that was used in tlie extraction of the first arm. During this rotation the back of the child should sweep across the front of the mother's pelvis. This rotation may be effected either by grasping and turning the thorax with both hands or by drawing the already cxtraifted arm Ibrward along the side of the pelvis, between the labium and the back of the child. In rotating the child it must always be remembered that the articulations of the neck are so arranged that if the point of tlie chin be carried beyond tlie point of the shoulder a dislocation of the atlas upon the axis is the result. l''or this reason the thorax should be ])uslie(l strongly upward whenever an attempt at rotation is made, in order to free the head iVom the superior strait ; and the hands of tiic assistant should wateli the heatl from above, that he may warn the operator if it fails to follow the shouhlers. In the extraction of the Jiead from the superior strait the method of combined traction upou face and !ililfcili-i rP 'i r [if iiil Ms f W4 ^S'^ i ' t M-i !i :■ f: ! ■ I 484 A ME RICA. Y TKXT-nOOK OF OliSTETIilVS. shoulders is usually tlio host, hut it should then he reinforced hy suprapuhic pressure applied in the axis of" the brim hy the hands of an assistant. iJiJfictilt Ki'trdction of Hie Hend and the Anns, — Arrcd of ia(/uoKis, — On (thdomhml examination the longest diameter of the uterus is transverse; the head is found in one flaid\, and the breeeh in the other. On vaf/inal iwaminatiun the finger may be able to recognize the clavicle and the spinous process of the scapula, and to ascttrtain that there is but one liiiil) attached to the presenting part, but the vaginal diagnosis is ai)t to be obscure unless an arm is prolapsed. Proynosi)t. — As the termination of a transverse presentation by natural labor is extremely rare, the prognosis for both mother and child is necessarily that of the operation undertaken. AVhen the abnormality is detected and treated early, the prognosis for both patients should be fairly gt)od, but it becomes worse in j)roj)ortion to the length of time during which the case is allowed to go on untreated. Mechanism and Management of Transverse Presentations. Mechanism of Transverse Presentations. — Since natural delivery so rarely occurs in transverse j)resentations, the later stages of the mechanism by which it is effected are of small practical importance ; but, notwithstanding the rarity of its completion, its earlier stages are rendered not unimportant by the fact that success in the delivery of impacted shoulders rests upon a thorough comprehension of the processes by which the imj)action waseilected, this being, in fact, the first stage of the mechanism of natural delivery in transverse presentations. The jirocc^s is commonly known as the " spontaneous evolution of tlie fetus." Any part of the trunk may present at the beginning of labor; but as the fetus is crowded down into the brim, the shoulder inev- itably enters deepest in persi.stent transverse piesentations, and, .since the shoul- der always becomes anterior early in labor, it is only uece.s.sary to describe the anterior form. In the anterior form the supraclavicular region corresponds, at the time of the entrance of the shoulder, with the anterior end of one oblique diameter at the brim, the lower portion of the thorax lying at the posterior end of tlio same oblique diameter. The full width of the shoulder enters tin; pelvis, and this portion of the child is then fixed in position by contact of the neck with the horizontal ramus of the pubes. Under the influence of the driving power of the uterus above, the lower portion of the thorax is forced more and more deeply into the posterior half of the pelvis by a lateral inflection of the body of the child upon it.self. The trunk then dips into the excavation, the true ribs, false ribs, abdomen, and ]>elvis of the fetus entering in the order named (Fig. 287). If the child is sufficiently flexible and if the uterus is sufficiently ])owerful to complete the delivery, this process of lateral inflection of the trunlc goes on until the pelvis of the child appears at the vulva, and with its expul- sion the case is converted by spontaneous evolution iiito a presentation, or TlIK MJJCJiAAJ^M OF LABOR. 489 ri'her an expulsion, of the breieli, in which, however, one tiliouldcr is already witliin the pelvis anil (»ne arm is already delivered. A second and very nuich more rare lorni of tielivery in ju'rsistent trans- verse presentations is seen oidy with immature fetuses, and it can seldom occur unless maceration is far advanced. In it the prolapswl shoulder is driven forward throuffh the pelvi-, the head of the child beinj; crowded into the pel- vis with the body (Fig. :i88). The alioulder is the leading point, uud it should A Fi(i. 'J87.— Spontuni'ous evolution, first form of nicclinnism. rotate to the arch, but when this process is possible the body is always so small and soft that the mechanism is usually but little marked. Management of Transverse Presentations. — The prognosis of sponta- neous evolution is so bad for botli child and mother that transverse presenta- tions should never be left to nature, and the question of the treatment is sim- j)ly the question of the choice of the operation to be adopteil. Three opera- tions are applicable to the treatment of transverse presentations in its various stages — the several savxaiwa oi' version, decapitation, 'a\v\ exenteration, the choice between them depending upon the stage of labor at which the presentation is detected. Version. — If the presentation is detected before any portion of the trunk is deeply engaged, and while the membranes are still unruptured, one or the other of the external ver.sionx should be chosen. If the abdomen or the hip presents, pelvic version will usually be the easiest, and for this reason should generally be preferred ; if the conditions are such as to render cephalic version easy and if the pelvis is normal, cephalic version should be ])erformetl. If the shoulder ])resents, cephalic version should be chosen, except in a flat pelvis, where the shape of the inlet makes a breech presentation the presenta- \l^ im I . m {r^ ] % ... . I d, v--^ W^y: 490 AMj:iil('A\ TEXT-BOOK OF OliSTFTltlCS. ) , . 1 i\ tloii of clioiff. In such oases an oxternal ju'lvic version would naturally ht chosen. It, at the time an (tperation is undertaken, the shoulder has alread) entered the pelvis, but the conditions of the case are still such us to permit of version, a bipolar, C(ji/i(di<', or peteic version should he performed. If, at the time when interference is decided upon, the membranes arc already ruptured, and especially if the shoidder is already well crowded into the pelvis, the external and bipolar methods will usually he impitssible, and internal podali(! version must be chosen. Infer mil Podalic Vernion in Tr(in,s- rerne I'resenf((tion,s. — This operation ditl'ers from internal version in head presentations oidy in the choice and method of introducing; the hand, in the Kio. 'J88.-Sp(intaiico\is ovdlutloii.sot'diid and riirc Fkj. 2R0.— Krozi'u suction of shoulder prcscii- formofnu'clianisiii, known lis l)irtli \vitl\d(>iil)k' body tiitkm (Cliiara): tlie distortion and tlii' ulont;a- (one-sixtli natural size, ri'drawn from Kiistnor). tion of the nci'k are noteworthy. frequent occurrence of a prolapsed arm, and lU the method of raising an impacted shoulder. In raisinj; the shoulder it is necessary to remember the mechanism o^' the method by which nature deals with a neglected transverse presentation — that oi' spontaneous evolution. In this process, as has been said, the trunk enters the pelvis at the brim in an oblitpie diameter, bnt as it is forced farther down the shoulder rotates to the front and becomes fixed there, while the thorax and the abdomen are crowded into the posterior portion of the pelvis by flexion upon themselves (Fig. 287). Now, so long as the j)osition is still ol)li(pie, and if flexion of the trunk has not begun, the presenting part may easily l)e raised by pressure upon the shoulder in the axis of the superior strait ; but so soon as the shoulder has rotated to the front antl the thorax has entered the ju'lvis, it is essential that the process of relieving the impaction should begin by the return of tiie part which entered last — that is, of that portion of the thorax and the abdomen still lying opposite the sacro-iliat; synchondrosis. No j)ressure must be exerted upon the shoulder itself until the trunk again occupies an oblitpie position. It will be seen that the process of unlocking the impaction is by a direct reversal of the mechanism of spon- ?ii; fmmmmmm Tin: MKCIIAXISM OF LAIiOIi. 491 tiiiit'du.s evolution. Of course, (liiriiij>; tliis wliole process tlio most careful vdiiiiter-pressure must be maintaiued at the fundus. In simple eases a prolapsed arm may he used as a convenient handle hy wiiieh to jtush up the shoulder, and in all cases it is w'll to he^in the operu- A'< ;;.'('/(■ 'oot. JVt,ir foot U/t Fig. 290.— nlrcrt nirtlnxl of si'lzinp a fciot in vit- aion fiir ♦.^llIl^svL•rsl■ iiri'Sfiitations. Fi(i. '201.— Oircct ini'tlKiri of soizini; a fmit in vor- .siun I'cir transviT.si' priseiitations. tion by noosing a fillet around the prolapsed wrist. This Hllet answers a double purpo.se: First, it may be used to draw the arm out of the way of the operating liand ; second, during; the |)rocess of extraction slight tractions oa the fillet will prevent the extension of that . arm, thus greatly facilitating the delivery ; but care nuist be taken to remove the noose as soon as possible, for cases arc on record in which sloughing of a member has followed the too prolonged or violent u.se of a fillet. In the .search for u fi)()t two methods may be u.sed : The hand that corresponds with the position — that i.s, left position, left hand — may be passed along the back and over the buttocks to the thigh and leg (Fig. 292), or the hand may be pa.-^sed across the ab- domen and directly to the feet (Figs. 290, 291). The first, which is the surer way, should, as a rule, be preferred, but the latter method is often the easier, especially iu ab- domino-antorior positions. Much has been writt(!n on the advantage to be gained by se- lecting the superior foot in version for transverse presentation; but as this view has never obtained much credence outside of England, and as Galabin, one of the latest British authorities, not only di-sajiproves of this practice, but gives a very convincing mechanical proof of the fallacy of the theory which prompted it, Fiii. L".i'.'.— ^f(■tlllMl (if rcacliina tlu' fnDt by lirst passuij,' llio liaiid ainuiiil the breech. ^ ! i M : * V_ U AMERICAN TEXT-BOOK OF OBSTETRICS. the subject need only be mentioiicil here. Unless special care be taken to select the superior foot, the lower foot is almost inv'arial)ly seized. Treatment of Neglected Transverse Presentations. — Wiien ;. transverse pres- entation has been so lonjf neglected that the release of the shoulder is thoiiglit to involve more danger to the mother tiian it wotdd be justifiable to incur in the interests of the child, or wlien the child is already moribund or dead, one or the other of the appropriate destructive operations must be undertaken. If the neck is at this time within reach, devapUation should be selected. If the process of spontaneous evolution has gone so far that it would be ditti- cult or impossible to apply the decapitator to the neck, an c.venterarly in the first stage, the uterus retracts upon the child's body, thus being subjected in * Tlie miperior fijjurus ( ' ) uci'iirring thi'oiinhinit liic text of this iU'ti(Je refer to tiiu bibliog- riniiiy Kiven on pngt' ST'J. / I ;, •» -^ 'I 494 AMERICAN TEXT-BOOK OF OBSTETRICS. \ ; i cei'tain regions to sevciv and long-continued pressure, and becoming in those spots anemic and fViaMe, while in the areas free from the pressure of th( child's body the uterine wall becomes congested, swollen, and edematoir-. Above all, the uterine :,iiiscle may become fatigued. This is the commonest cause t)f uterine inertia. It is seen oftenest in primiparje, in whom inertia is more than twice as common as in multiparte on account of the diffi- culty of dilating the rigid cervical tissues. Inertia may appear in con- sequence of any serious obstruction in labor. At first the ))ains are feeble, infrequent, and inefficient, but as labor continues the uterine contractions gather force. The inertia from this cause is bkcly to be only temporary, seen at intervals between periods of stormy uterine action or of long-contimicd tonic spasms, until finally exhaustion of the whole organism threatens the patient's life or the uterus ruptures. It has been asserted that an anomaly of innervation in the anatomical sense, a deficient supply of the terminal nerves in the individual nniscK'-cells, is a cause of uterine inertia, but it is not yet clearly demonstrated to bo so. An inhibitory nervous impulse to the uterine nnisde, on the contrary, is a frequent cause of uterine inaction. It is the result of some emotion or of excessive pain. That the " doctor has frightened the pains away" on his first arrival has become proverbial in tiie lying-in I'oom. The presence of any one who is a cause of embarrassment or is disagreeable to the patient may have the same effiL>et. In hyperesthetic women the uterine contractions may be so exquisitely jiainful that their first onset is followed by an inhibitory impulse which cuts them short almost inunediately. Every clinical observer has seen the phenomenon of rajiidly-recurring, very painful uterine contractions, which are, however, of short duration, and wiiich secure no a])preeiable dilata- tion of the cervical canal. A woman may be tortured thus for hours in the early part of the first stage of labor, when this inliibitory nervous impulse is commonly observed. With the continuance of labor the individual becomes more or less indiffi'rent to her surroundings or more iinired to suffering, and the inhibitory nerves, probably derived from the spinal cord, apparently lose the power of responding to the stimulus of pain. Among the mechanical causes of incnicient uterine action during labor are fibroid tumors of the uterine walls, displacements of the womb, old peritoneal adhesions, and fresh outbreaks of periuterine* inflanunation. J)l(i(/)i()sis. — The n'cognition of uterine inertia should always be easy. The contractions of the muscle are of short dni'ation and are separated usually by long intervals, and by palpation the observer may convince himself that tluy are feeble. The uterus during the [laiii does not assume that intensely hard consisteiKy which normal vigorous action of the muscle in labor oct ;isions. Tlie ])atient's expression, action, and demeanor point to deficient force during the ])ains. The woman is more placid, the fa<'e is less contorted, and there is less outcry during the contractions than in tiie normal ])arturient patient, except in those cases 'm which excessive pain inhibits ut(>rine !;"ti()n. In these cases, however, abdominal palpation and the short duration of the jiains are sr.f- U Tlic y '•}• tlicy iiu'd idllS. iriiii; IV is ;•'('))( uses, si:!- DYSTOCIA. 495 ilcicntly plain signs of the inertia. Finally, labor is delayed. During the lirrit stage dilatation is slow or does not progress at all, and in the second stage the presenting part does not advance. One fatal error in the diagnosis of inertia uteri should be avoided : the physician shoidd be sure that labor is not (lelaved by some obstruction. It lias happened in a careless and superficial cxiiniinatiou that the observer has taken the distended and thinned lower uterine segment for an inert womb. En such a case the measures adopted to stimulate the supposedly inactive uterine muscle to overcome an obstacle lliat is insui)crablo might easily be interrupted by rupture of the womb. A methodical and careful examination will guard one from this error. The source of obstruction will be discovered. The firmly, jierhaps tctanically, contracted upper uterine segment may be contrasted with the inactive lower segment by palpation of the whole anterior surface of the womb. The con- tra(^ti()n-ring should be visible, and the whole uterus stands out with unusual prominence, from the anteversion that always accompanies prolonged and powerful uterine contraction. Treatment. — From the diversity in the causes of inertia uteri it follows that no single plan of treatment can be depended upon. If uterine action is inhib- ited by emotion, the cause of nervous disturbance should, if possible, be removed. An objectionable person should leave the room. If excessive pain prevents effective contractions, an analgesic should be admim'stered. Nothing is better for this pur])()se than chloral administered in 15-grain doses, repeated, if necessary, twice at intervals of fifteen minutes. A quarter of a grain of morphia hypodermatically comes next in order of efficiency. If the uterine nuisde is simjily apathetic, it can be aroused by some direct irri- tant. The insertion of a bougie as for the induction of labor answers the purpose well. A more effective but more troublesome measure is the dilata- tion of the cervical canal by Barnes's bags. These not only irritate the ute- rine muscle and thus bring on strong contractions, but they also artificially dilate the cervical canal, and thus relieve the uterine nniscle of a great part of its task in the first stage of labor. If tlie head should be well engaged in the pelvis, however, the insertion of the bags is difficult and they are likely to cause malpositions of the head. In such cases, if the os is dilated to the size of a silver dollar, nothing is so effective as the application of forceps — not with the idea of dragging the head through the luidilatiMl cervical canal, but to ])ull the head at intervals iirudy down upon the cervix. Tiie impact of the head upon the cervix acts as a powerful rcHex irritant, and will excite as strong contractions as any direct irritant can do. Not only so, but the ])ull of the head upon the cervix will gradually dilate the canal as effectually as coidd strong propulsion from above. As soon as effective ])ains arc established and the dilatation of the cervical ci'ual ])rogresses satisfactorily the forceps should be removed. Inertia uteri so profiuind as to (lcii;:>ud the somewhat radical measures just described is, fortunately, rare. More commoidy the pliysician sees the minor grades, in which there is simply a ilagging of uterine eiTort during the first ■U* 4''t^-i AMERICAN TEXT-BOOK OF OBSTETRICS. stage, ef^pecially in priniiparje, accompanied by every evidence of temporary physical and mental exhaustion. After a period of rest effective contractions will reappear, even if nothing whatever is done to aid the patient. The more complete the rest, the more vigorous will be the uterine action when it is resumed, and for this reason the administration of chloral and opium is often followed after a time by a satisfactory progress in labor. But these drugs necessarily retard the termination of labor by the time of rest they secure. It is ordinarily desirable, therefore, to resort to drugs of a stimulant character that shall at once revive the flagging uterus and so hasten the delivery. ^Nfanv medicaments have been recommended for this purpose, but, of them all, alco- hol, quinin, and ergot alone deserve consideration. The last was employed extensively at one time, but clinical experience forbids its use to-day. The contractions of the womb induced by ergot are likely to become tetanic. The uninterrupted contractions interfere with the fetal circulation ; they niav cause fatal intra-uterine asphyxia, and they often produce such exaggerated blood-presssure and stagnation of the current in the fetal body as to in^luco extravasations in important viscera, especially the brain. Further, the cir- cular fibres of the cervix come under the influence of the drug, and by their firm contraction neutralize the contraction of the longitudinal fibres of the uterine body, and thus retard labor almost indefinitely ; and, worst of all, should there be some obstruction to the descent of the child in the maternal pelvis or in the fetal body, the administration of ergot predisposes to rupture of the uterus. For these sufficient reasons this drug as a stinndant to the uterine muscle in the first and second stages of labor should be banished from the obstetrician's pharmacopeia, except in the single instance of the birth of the second of twins (see p. 509). Owing to the recommendations of Albert H. Smith and of Fordyce Barker, quinin has had, and still has, a great reputa- tion as a stimulant to the uterus in labor. The writer's experience with the drug, however, does not permit him to subscribe to a belief in its efficacy as a uterine stitnulaiit in labor. Quinin has the positive disadvantage, moreover, that it will occasionally in certain susceptible individuals produce a violent post-partum hemorrhage. In the minor grade of inertia under description, so often seen in j)rimipara', and almost always the result of exhaustion, the writer has found nothing so useful as alcohol, in the shape of a wineglassful of sherry, taken slowly with a cracker, and given with the positive assurance that it will bring back the pains and hasten the conclusion of labor, for the patient needs moral and mental supjutrt as nnich as she requires a physical and muscular stimulus. An impression prevails among general physicians that inertia uteri in the first stage of labor, before rupture of tlie meinl)ranes, may safely be disre- ganled. In a n\easure this view is correct. Tiie writer has seen in a number of instances a partial dilatation of the os and then an entire cessation of ute- rine contractions for many hours and even for days. In one case the cervical canal was sufficiently dilated to receive foin- fingers, and it remained so for more than a week, the patient all tli(> while going about on her feet in per- itsmmmmum' f DYSTOCTA. 497 feet comfort, without a single painful contraction of the womb. But should inefficient uterine contractions be accompanied by much pain, as happens in some cases of inertia, the long-continued first stage should not be regarded with indifference. The patient will in time show the irritant and depressant iU'eots of long-continued suffering in an elevated temjierature, an accelerated ]nilse, and a lessened resisting power of body-cells, the last playing an import- ant r/)le in the predisposition to sepsis after labor. Another consequence of delayed, painful labor may be seen in a sensitive, nervous individual, who is thrown into a state of excitement — who from gloomy foreboilings of harm to herself and to her infltnt passes into an almost maniacal condition of terror and dread. It should be a rule of practice, therefore, to watch carefully all cases of inertia uteri, and to interfere as soon as the patient's mental condition or her jMilse, tem])erature, and general vigor are demonstrably affected by the delay in labor. 2. Excessive Po^\'Eu in the Expulsive F(jrces of Lahor. An actual excess of power in the expulsive forces (the uterine and abdom- inal muscles) in labor sufficiently great to expel the fetus })recipitately is extremely rare. A relative ex'cess is not uncommon. The child's body may be so small, the pelvis so abnormally large, the maternal soft parts so relaxed, that the ordinary power exerted by the uterine and abdominal nuiscles is far in excess of that required to overcome the weak resistance offered, and the child is fairly shot out of the birth-canal. The rapid delivery may cause serious residts to both mother and child. In the woman the structures on the ])elvic floor may be lacerated severely ; the sudden evacuation of the womb ])ro(lis])oses to hemorrhage from inertia ; the placetita may be detached pre- maturely ; and the sudden evacuation of the abdominal cavity predisposes to dangerous syncope. For the child the chief danger is the possibility of unexpected delivery of the mother in tiie erect posture. The umbilical cord may rupture, and the chikl, falling to the ground, may be injured fatally. I'rccipitate and unexpected labors occur mrst frequently when women are seated U2)on the water-closet. The child i' evacuated into the waste-pipe or renmrkiible nceurrence. It liappened on llie (amulian I'acilic Huilroad. 33 |i ;i: "■(■ !<: t lit- i-\ r ' ■ Ik' ■in 45)8 AMERICAN TEXT-BOOK OF OliSTETRICS. was fished out of the bed of niaiitire in wliicli it was iinniersed to the neck, unharniod and in good condition. Unfortunately, the i)hysician is usually not at hand to prevent a precip- itate delivery and to avert its consequences. Shoidd he find an infant descend- ing the birth-canal with a rapidity dangerous to itself and to its mother, he can easily retard its progress by pressure with his hand against the presenting part. 3. DEF()R>riTIES OF THE PELVIS. Comprehensive and satisfactory knowledge of deformities in the female pelvis has been gained only in the latter half of the present century, since the appearance of Miciiaelis' work in 1851.' Until the announcement bv Arantius in the last quarter of the sixteenth century that a contracted pelvis is a serious obstacle in labor, the prevailing belief had been that difficult labors from mechanical obstruction by the maternal bones were due to a failure on the part of the pelvis to expand sufficiently for tiie passage of the child. This idea continued in force for a number of years after Arantius' time. According to Litzmann, Heinrich von Dcventer (LGol-1 724) should be re- garded as the real founder of our knowledge of the pelvis and of its anomalies. He described the inclination of the pelvis, the axis of the pelvic inlet, the contracted pelvis, and the flat pelvis. Pierre Dionis was the first to point out (1718) the relationship between rachitis in childhood and a deformed ])elvis in the adult. William Smellie's contributions to the study of the female pelvis were remarkably full and clear, when one considers how little was known before his time. His description of the rachitic pelvis, his reflections on its cause, and his accounts of illustrative cases may be read with profit to-day. Roederer, Stern, Cooper, Vaughan, Denman, Haudelocque, and 1' re- mery added nuich to the stock of knowledge during the latter half of the eighteenth century. The men of the present century to whom we owe most of our present information about the pelvis and pelvimetry are Naegele, Kilian, Rokitansky, Michaelis, Robert, Litzmann, Xeugebauer, and many others to whom reference will be made in the sections devoted to the particular varieties of deformed jielvis.- Frequency of Deformed Pelves. — It is difficult to estimate the frequency in America of ])elvcs sufficiently deformed to influence decidedly the course of labor. Statistics from our lying-in hospitals affi)rd little aid to a correct conclusion, because the inmates are chiefly European immigrants and negresses. In the Boston Lying-in Hospital, however, deformed pelves wen- foiuid in 2 per cent, of native-born and in per cent, of foreign-born women (Rey- nolds).' The writer's experience in private and consulting practice convinces him that deformed pelves are by no means rare among native-born women in the densely-popidated centres of the Eastern States. Xo general practitioner, in a large city at least, can hope to avoid such I'ases, and it is likely that each year will affitrd him one or more striking exap.ple.s. It follows that an ability t(» recognize deformities of the female pelvis is a necessary c(piipment for every DYSTOCIA. 409 practitioner of medicine \vlio may be called upon to attend women in confinc- iiicnt, and that a knowledge of" pelvimetry i.s as essential to the intelligent and successful practice of obstetrics as are jjcrcussion and auscultation to till' practice of medicine. European statistics bearing on the frequency of contracted pelves give the following results: Michaelis found in 1000 partu- rient women 131 contracted pelves; Litzmann, 149. Winckel found in Ros- tock per cent., in Dresden 2.8 per cent., and in Munich 9.5 per cent, of con- tracted pelves among pregnant and parturient women. Winckel believes that 10 to 15 per cent, of childbearing women have cojitracted pelves, but that in only 5 per cent, is the obstruction serious enough to be noticed. Kaltenbach puts the frcHpiency of contracted pelvis at 14 to 20 per cent. In Marburg it was found to be 20.3 per cent., in Dottingen 22 per cent., in Prague IG per cent. Schauta estimates it at 20 per cent. Classification of Anomalies in the Female Pelvis. — All classifications are merely a convenience for the teacher and .student. It is rarely possible to draw sharply-defined lines between varying manifestations of a condition. The majority of German authors follow Ijitzmann's classification of abnormal- ities of the female pelvis, by which they are broadly divided into those of size and those of shape. Modern French authors ado})t the still less satisfactory division of over-size, under-size, and anomalies of inclination. The writer linds Schauta's classification the most convenient, and therefore utilizes it, with some slight modification.* ANOMALIES f)F THE PELVIS TJIE RESILT OF FAULTY DEVELOPMENT. Simple flat ; Generally equally-contracted ( justo-minor) ; Generally contracted flat (non-rachitic) ; Narrow funnel-shaped, fetal or undeveloped; Imperfect devehtptnent of one sacral ala (Naegele pelvis) ; Imperfect development of both sacral aUe (Robert pelvis) ; Generally cijually-eidarged ( jnsto-major) ; Split pelvis. ANOMALIES DUE TO DISEASE OF THE PELVIC I50NE.S. Rachitis ; Osteomalacia ; New growths ; Fractures ; Atrophy, caries, and necrosis. ANOMALIES IN THE ( 'ON JUNCTIONS OF THE PELVIC HONES. Abnormally firm union (syiU)stosis), which is apt to be found in elderly juMuiiparje, particularly at the sacro-coccygeal joint: Of symphysis ; Of (lue or both sacro-iliac synchondroses; Of sacrum with coccvx. k ■p.. I irrrrr 500 AMERICAN TEXT-BOOK OF OBSTETRICS. Tf Vv, ■' m ! I s 'i J i I Abnormally loose union or separation of the joints : llelaxation and rupture ; Luxation of the coccyx. AXOMALIIvS DIK TO DISEASE OF THE SUPERIMPOSED SKELETON. Spondylolisthesis ; Kyphosis ; Scoliosis; Kyplio-scoliosis ; Lordosis. ANOMALIES DUE TO DISEASE OF SUBJACENT SKELETON. Coxalgia ; Luxation of one femur ; Luxation of both femora ; Unilateral or bilateral club-foot ; Absence or bowing of one or of both lower extremities. Diagnosis of Pelvic Anomalies : Pelvimetry. — Deformities of the female pelvis may be detected by the history of the patient, by her a])pear- ance, by ])alpation of the exterior and interior of the pelvis, and by external and internal measurements of those pelvic diameters that are accessible, or of Fi(i. 293— Modem c iiiibiiiation t>{ Hiui- (li'l(ii'iiiii.''s mill (isimiiUT:- iu'lvimL'tiT. Fit!. 201.— Osinnik'r's pclviniL'tLT. Fig. 2'j:i.— Martin'.s pt'lvimetor. salient points on the woman's body corresponding as nearly as po.ssibIe with the internal measurements desired ; the relations between the two la.st haviiiiz; been a.scertained l)y many observations on dead and living bodies. For taking DYSTOCIA. 601 ])elvic measurements the examiner's fingers, a tape measure, and a modified mathematician's callipers — a pelvimeter — are usually employed. Baudeloctpie (1775) was the first to devise the pelvimeter in ordinary use. He laid the luundations of pelvimetry, and his instrument and methods are in use at the present time (Figs. 293-25)6). It is convenient to describe the measurements ot' the diameters of the pelvic iidet, pelvic cavity, and pelvic outlet separately. 3feasai'ctnent of the Antero-posterior Diameter of the Superior Strait. — This measurement, the most important in ihe pelvis, cannot be taken directly. It must be estimated by several plans. Baudelocfjue was the first to point out the relation between the measurement from the depression under tlie last spinous process of the lumbar vertebrte to the upper edge of the sym- physis pubis, and the true conjugate diameter of the pelvic inlet. To this external measurement the name "ex- ternal conjugate" was given, but it is often called " the diameter of Baude- locque " (Fig. 208). Its discoverer be- lieved the relation between the external and internal diameters to be constant — that the one exceeded the other by 8 to 8^ centimeters — but in this he was mis- Fia. 'JlU'i.— Harris-Dickinson yiortiiljle polvlmetLT. Fig. 2U7.— Measuring oxtermil conjugate. taken. The line of the e\ternal diameter does not usually coincide with the line of the internal, anly serves to indicate the i)rohal)ility or tlie improbability of pelvic contraction. An exter- nal conjugate of IG centimeters or under means certainly an antero-jiosteriorlv contracted pelvis ; between 10 and 19 centimeters the ])elvic inlet will be con- traetetl in more than half tlie cases; between 19 and 21.6 centimeters there Fig. 2US.— MonsurltiK the I'xtoriml cdiijugnto (liametcr uikiii the living fcmiile. will be but 10 per cent, of contracted pelves; and above 21.5 centimeters it is almost certain that the conjugate diameter of the pelvic inlet is not contracted at all. The external conjugate cannot be measured accurately without some prac- tice. The begiimer in pelvimetry will do well to remend)er the ftdlowing rules: Have the patient dressed for bed. Place her upon her side, with the thighs slightly flexed and the clothing rolled well up out of the way, the lower part of the body being covered with a sheet. The examiner stands at the patient's back, facing her head. The de])ression below the last spinous process of the lumbar vertebrie is found l)y rubbing a finger-tip over the lumbar spines from above downward until the finger sinks into the depression sought and feels no more prominent spinous processes below.* The knob at the end of one branch of the ])elvinieter is placed firndy in this depression, and is held * Micliaelis preferred the nicisurenieiit from the tip of the hist liinibar spinous process, instead of from the depression l)eh)\v it. DYSTOCIA. 503 tlicre with ono hand wliilc the fingers of the other hand find a pouit on the .>;viiij)hy.si.s pnhis about \ of an inch lx'h)\v its nppor eilgo, on wliich j)oint tiie other l)ranfh of the ju'lvinu'ter is firmly set; tlic pelvimeter having heen so placed that the indicator is turned toward the examiner, the measurement is thcrefijrc easily read off as soon as the pelvimeter is in proper position. It i- (tn the average, in well-built women, 20\ centimeters. The best means for determining the length of the antero-posterior diameter of the pelvic inlet are the measurement taken from the lower edge of tiie symphysis pubis to the promontory of the sacrum, the diagonal conjugate diameter, and the distance between the upper outer surface of the symphysis jiubis and the pronjontory of the sacrum. The diagonal conjugate diameter is one side of a triangle the other two sides of which arc the height of the sym- pliysis and the true conjugate. The distance between the outer ujiper surface of the symphysis and the promontory of the sacrum differs from the true con- jugate by the thickness of the upper portion of the .symphysis. SnicUie was accustomed to estimate rougidy the length of the true conjugate by a digital Fi(i. 2li'J.— Stfin's iiistniiiR'nt Inr diivct iiR'asuri'inoiit of tlic ciPiijuKatt.'. examination, basing his estimate on the ease with which the ])romontory could be reached. In the latter pai't of the eighteenth century .lohnson '" proposed fi»r estimating the size of the pelvic inlet a method which consisted in inserting the fingers of one hand in the mouth of the wond) and then spreading them between the pntmontory and the sacrum. A few yeai-s later the elder Steiu devised a graduated rod for measuring the distance between the lower edge of the symphysis pubis and the division between the second and third sacral vcrtebric. This distance he believed to be \ to 1 inch greater than the true conjugate. Stein later constructed the instrument fi»r the direct measurement of the conjugate shown in Figure 299. Many instruments have since been constructed on this principle, but they are impracticable in the living female, fi)r obvious reas' .is. I>audelocqu(! was the first to propose the measurement of the diagona' conjugate and the subtraction from it of an average figure (i inch) to dett'rniine the length of the true conjugate. His method, exactly as he described it, is still in use, with the exception that two fingers instead of one are emjdoyod in measuring the distance between the symphysis and tlie promontory. To measure the diagonal conjugate correctly the examiner must have the skill that comes of practice, and he must conduct his examination in ^ ! ^. IMAGE EVALUATION TEST TARGET (MT-3) // 1.0 I.I li^lM |2.5 ja yi2 112.2 II 2.0 m. 1.25 1 1.4 1.6 ^ 6" ► % %' Photographic Sciences Corporation 23 WIST M'«H JTRSIT WEBSTH.N.Y, U:»SO (716) 873-4503 V iV 4 ■^^ <^ V ;\ ^'^^ fe ^io % r 6^ r>04 AMEIilCAX TEXT-BOOK OP OBSTETRICS. a careful anU methodical manner. The patient is put in the lithotomy posi- tion and is brought to the edge of the table or bed on which she lies, so that the buttocks project well over it. The examiner cleanses \\\i. lefl hand and anoints the first two fingers with an unguent ; he then inserts these fingers, held stiffly extendetl, inward and up- ward till the tip of the second finger finds and rests upon the promotory of the sacrum. Care must be exor- cised not to take the last lumbar for the first sacral vertebra or vice verad, nor the second for the first sacral vertebra — mistakes easily nuide in cases of so-called "double promon- tory." Witii the tip of the second finger resting firndy in place u[)(>n the middle line of the promontory the radial side of the hand is elevated until upon it is plainly felt the im- press of the arcuate ligament under the lower alge of the symphysis. With a finger-nail of the otlier hand a mark is made upon this point of the examin- ing hand, whicii is tiien withdrawn (Fig. ,'}n(i). Tiie listance between this mark and tiie tip of the middle finger held extendetl is taken by a l''iii. :!iMi.- -Mfiisurinn the iliau iliaiiiLtor. iiiiil ciinjiignte /./ Kin. I'lOl— KlTcot nf ilitrcrciil Incliimtlmis of the imliis upiiii the ri'liilioiisliiii ln'twci'ii tho trui' 1111(1 tin- iliiiK'ciiinl ('(injuKuti.' illiimcttT (Kilirlllnlltlll'SSllinnes). Fio. ;«)2.— EflVct of different thlekiicRses of the sym- physis upon tlie relationship between the true nnil tho diiigonul eotiJURUte diameter (Uibemont-UessaiKncs). pelvimeter. This distance is the diagonal conjugate. By the observation of DYSTOCIA. 505 many subjects, alive and dead, an agreement has been reached that 1 J centi- meters should be subtracted from the diagonal conjugate to obtain the true conjugate diameter. But the acceptance of this average difference depends upon a normal height of the symphysis, 4 centi- Fi(i. 303— Effect of (liffiTcnt hctpthts of the promontory upon tlio relntionship iK'tweon the (rue nnil the dingoiml conjugiito (Kibemont-Des- sniKnes), Fio. 304.— Kffect of different heights of tlie symphysis upon the relationship between the true nnd tlie ilingonal conjugate diameter (Kibeinont- Dessaigncs). motors, a normal angle between the axis of the pubis and the true con- jugate, 105°, a normal thickness of the symphysis, and a normal height of the promontory (Figs. 301-.'i05). Those factors, however, are not constant, and if they vary much from the normal the most skilful and most experienced obstetrician may be misled wofully in his estimation of the true conjtigate. The writer has had under his care a rachitic dwarf in whom there was more than 3 contimotors' dif- ference between the diagonal and true conjugates, and Pershing found among 90 pelves in the miisoiuns of Philadelphia a dif- ference varying from 0.8 centi- meter to 3.6 centimeters. It is declared that these soiu'ces of error may be eliminatohysis, a much more important source of error, can only be surmised. The writer much prefers the measurement between the upper outer edge of tin; synij)hysis pubis and the promontory of the sacrum for the estimation of the true conjugate, having demonstrated its superior accuracy in practice.* For taking this measurement the patient is put in the dorsal position, with the Fk;. aiJii. — Hirst's ju'lvimctiT: a, fur monsiirintr tlie tnio cimjiiKiiti' iilus the tliicknoss of the symphysis; n, witli extra tip iidileil for iiieasiiriiit; the tliiciciiess of tlie syinphysis. buttocks projecting beyond the edge of the table or bed on which she lies. A mark with the point of a lead pencil is made on the skin over the sym- physis pubis, about J of an inch below the upper edge. The two fingers of the left hand are inserted in the vagina as in measuring the diagonal conju- gate. The tip of the middle finger, having found the middle line of the promontory, is moved a little to the patient's right, and tip B of the pelvi- meter, shown in Figure 30(5, is made to take its place. While the examining physician holds the shaft of the pelvimeter firndy in place an assistant adjusts tip A of the movable bar over the mark made on the symphysis. This bar is then screwed tight, the whole pelvimeter is removed, and the distance between the t'ps is found by a tape measure. This distance is the conjugate plus the 'hickness of the symphysis (Fig. 307). The latter the writer has found to be DYSTOCIA. 607 ijiliysis 2 IK'S. sv ni- l's ['OlljU )1" til bol VI- tiniiig llj lists IP tl I to be Flloy this jirinciplo in jielvinictry. Ilis polviiiictrr was imjtrovi'il npim by Van IIiiovcl, ami in ri'cont tinius iiy Skiilscli ami t)y niilliti i Dniiscln- iiuili- clnixchf WocliciiKrhrift, No. 18, 1S!K); Aiiiiriritii Joiinial nf ObnMriri', IHW ; Miiller's Ilundbuch der CicbitrtMil/<; vol. ii. pp. 2')'), 'J(>0, 'JGl). Flo, ;j(JS.— MeiisurinB the thli'kni.'ss of thu sympliysis. !IM' L - 4 '^ i i f mmmm %9 508 AMERICAN TEXT-BOOK OF OBSTETRICS. transverse diameter of the pelvic inlet cannot be nieasnred directly, nor can it be estimated accurately. Fortunately, this is not necessary. It answers the I'equirements of practice to determine whether there is a diminution of this measurement, without determining the exact degree of lateral contraction. To do this the following measurements are relied u^wn : The di.'-tance between the anterior suj>erior spinous processes of the iliac bones, which in well-formed women is 26 centimeters ; the distance between the crests of the iliac bones, 29 centimetei*s ; the distance between the tr()chantei*s, 31 centimeters; the dis- tance between the posterior superior spinous processes of the iliac bones, 9.8 centimeters ; the distance between the subpubic ligament and the upper ante- rior angle of the great sacro-sciatic notch, which, according to Lohlein, is 2 cen- timeters less than the transverse diameter of the inlet ; finally, an estimation of the width of the pelvic inlet by a vaginal examination. In taking the external measurements the woman is placed upon her back. The salient points are easily found except in the case of the iliac crests. They are discovered by ^ ■";,.^«'j Fio. 3()9.— Skutsch's method of measuring the conjugate diameter. moving the knobs of the pelvimeter evenly along the crests of the ilia until the two opposite points most widely separated from each other are foiuid. If the crests are no farther, or even less, separated from each other than the spines, points 5 centimeters back of the latter are arbitrarily selected as the sites of the crests. The posterior superior spinous processes are t)ften marked by distinct dimples on tiie woman's back. The internal measurement of Lohlein is made by the fingers in the vagina. If all these measurements are much less than normal, a lateral contraction of the pelvis may be assumed, and the degree of contraction is roughly estimated by the amount of decrease in the measure- ments, although the relations between these measurements and the distance sought is very variable. The efforts of Skutsch and of others before him accurately to measure the transverse diameter of the pelvic inlet by combined internal and external measurements camiot be said to have vet been crowned by success. The softness of the tissues externally permits the external knob of the pelvimeter to sink into the flesh to a varying degree, and the same is true of the structures within the pelvis. It is difficult also to keep the pel- DYSTOCIA. nm vimeter in the same straight line when the internal knob is changed from one siilc to the other (Figs. 309, 310). Moreover, better results in practice luay be obtainetl by an estimate formal by a vaginal and a combinetl examination, under anesthesia if necessary, of the relative size of the transverse diameter of the pelvic inlet and the antero-posterior diameter of the child's head. Measurement of the oblique diameters of the pelvic inlet is rc<|uired only in obliquely-contracted pelves. It will be referred to in the description of these pelves. The Measurement of the Capacity of the Pelvic Cavity. — The capacity of the pelvic cavity must be estimated by vaginal examination. There is no plan by which accurate meas- urements can be made. It Is sufficient to estimate the size and the shape of the pelvic canal by palpating the lateral •;•. walls of the pelvis ; by dcter- // mining the curve, perpendicu- \l larly and laterally, of the sa- :• crura ; by noting the height ;/•■ of the sacro-sciatic notches, Kio, 310.— Skutsc'li's inothoil of iiicnsurint,' the trans- verse diiimeter of the jielvie inlet. Fig. ol!.— Munsnrcment of the nntero-iKistcrior diumeler of the pelvic outlet. the approximation of the tuljcrositics of the ischia, the depth of the pelvis, and the direction of its canal ; by detecting, pt)ssibly, the presence of an exos- tosis, an osteosarcoma, an abnormally-projecting spinous process, an old frac- ture, or asymmetry of the pelvic walls from any cause. Measurement of the Transverse Diameter of the Pelvic Outlet. — The atitoro- posterior diameter of the inferior strait is enlarged during labor by the displacement backward of the coccyx. The transverse diameter between the tul>erosities of the ischiatic bones is constant, and if there is contraction of the outlet the greatest resistance to the escape of the fetus is furnished by these firm bony eminences. The transverse diameter of the pelvic outlet can be measured directly with ease. The woman is placctl in the dorsal pt^ition with thighs and legs flexed. The distance between the tuberosities of the jcdttM*><'4^' ii' dim !■(■ 1 f# 51 AMERICAN TEXT- BOOK OF OBSTETRICS. iscliia is mcasuretl with a ix-'lvinicter, or the examining physician places his thumbs squarely on the tuberosities, and an assistant measures the (listaiu-e between the physician's thiuiib-nails. If it should be tlesireelvis ill fitted to bear it on account of weakness of its ligaments. It is probable that in the majority of these pelves the form is * Eiifrolken has descriljod a specirni'ii with a true conjugate of 4.S oentimeters, a diajional conjugate of 7.-") pcntiiut'tepi, with transverse and ohli(|ue diameters of the inlet 13.3 and 12.4 centimeters respectively. This specimen is iini(|uc. t Crfde found in nine pelves with a double promontory the conjugate from the true prom- ontory longer in four and shorter in three cases than the conjugate measured from the false promontory. In two cases the two conjugates were of equal length (Klin. Vortriige ueber Gebuiishiilft; Berlin, 1853). DYSTOCIA. 511 iiilioritci and congenital. It has been loiuul by Feliling in a number of fetuses and new-born infants. J)iaf/no8ix. — The simple flat pelvis is easily overlooked. There is nothing in the patient's appearance or history to suggest the deformity, unless she has had difticulty in previous labors. The characteristic signs are the diminished antero-posterior dianjcter, determined by internal and external measurements, and a transverse diameter as great as, or greater than, normal, or prhaps a trifle under the normal nteasurement. This last point is determined by meas- urements externally and by the internal palpation of the iielvic canal. In measuring the conjugate diameter of this pelvis one must take into account the lessened inclination of the sym- physis outward, its height, some- what below the normal, anil the low position of the promontory. Usually the average sum of 1 1 centimeters is a suflicient amount to subtract from Fl(i. 31J.— Plinpk- lliit pi'Ivis (mixk-l in Hirst Colk'ctioii, liiivLTsity nf IViiiisylvaiiiii) ; e. v., Ku;. 313,— TIk- two oonjuiintos of n (lou))k> proiiKintory 85 cm. ; tr., l;U cm. ; obi., I'.'l cm.* (Kil)cm(itit-l>cssait!iies). the diagonal conjugate. If there is a double promontory, as is frequently the case in this form of pelvis, the ccmjugate must be measured from the promon- tory nearest to the symphysis, usually the lower (Fig. SVl). Jiijfucm'c upon Lahor. — From the failure of the presenting part to enter the pelvis during the last weeks of ge.«tation there is frequently some degree of pendulous abdomen, especially in women with abdominal walls relaxed from previous pregnancies. The uterus is sometimes broader than common, and is often tiltetl to one sienting |>art, if the head, may be lo().«e al)ove the superior strait, resting on one iliac bone or on the symphysis, or it may be pressed down firmly upon the brim in a transverse position, to accom- modate its longest diameter to the longest diameter of the pelvic inlet. Mal- prcsentations are common, as is also prolapse of the cord and of the extrem- ities. The meml I'anos may protrude in a cylindrical pouch from the external OS as the liquor amnii is forced out of the uterus without obstruction from * Tlie !il)l)reviii ions ti: nnil <>lil. will be iiseil throughout to designate the transverse and oblique diameters of the iielvic inlet. .ill r)i2 AM ERIC AX TEXT- BOOK OF OliSrETlilCS. \\ ! » 111' -4 :i- . r to tlicsiiiittal f^iiturcl Fii;. WW). Sinuctiiuos a suocos- sioii of tli('S(! ilcprcssioiis or a ;roov(' uiay lu' noted in a lino nui- ning outward and iorward on the oiiild'.s. skull. More l"rc(|ii('iilly the course of Fiii. ;!1.'>.— Murks iimde liy the promontory on the child's hend mid fiiee (Fritsch nnd Kii.stner). the head and face over the promontory is marked by a red streak runninj; from the depression before noted in a line parallel with the coronal siitiu'c toward the temple if the head is well flexwl after cnjiajjjement, or to the outer corner of the posterior eye, or, in case of extreme Hexiou, to the cheek (Fig. 315, A, B, c). 33 / ^6 r'r!? 514 .1.1//v7.'/r.l.V TEXT-lKiOK OF (Hi.STirmKS. I'siiallv tlic posterior parietal hone is tlcprossc*! Iwlow tlu! anterior, wliieli over- lupH it at tlie .sagittal suture. The posterior side of the skull is also Hatteiieil t'ruiii the greater and more prolonged pressure to which it is suhjeeteil. Ordi- narily the lateral ineliuation of the child's head is in a direction front hefore backward, so that the anterior parietal l)one presents at the centre of ♦',o supe- rior strait. < )eeasionally this inclination is so exaggerated that the ear is the ])resenting part. Kxceptionally the lateral inclination takes the opposite direc- tion, the anterior parietal hone catches on the rim of the puhic bones, and the ])osterior parietal bone is the first portion of the child's hea«l to enter the pelvis. The i)resentatii»n of the posterior fontiuielle occurs even in normal ])elves as a rare exception, but is seen in about 10 per cent, of co:itractc(l pelves (Schauta), and is the residt in them very likely of firm alMlominal walls ancri!Hs what he calU an "extra-median" engagement of the head in eases of flat pelvis in which there is considerable h^rdosis of the lund)ar vertebra'. The head in extreme flexion is forced down upon half of the pelvic inlet, an not joined by bony union, but are separated by cartilage as in the infant. The innominat(> bones are divided inio iheii three parts, and the s;H'ral vertebra* are distinct from one another (1*1. 2J), Fig. 2). The justo- minor pelves pass by insensible gradations into the simple flat, the transversely- contracted, and the generally-contracted flat pelves. In the larger cities of the United States the justo-minor jx'ivis is very frequently encountered. It is cer- tainly !is common here as is the simple flat ])elvis, and if one were to judge ftiwn lios])ital patients, among whom there is a largo |)roporti(m of shop- and factory-girls, this variety of cimtraeted pelvis would be regarded as the commonest. ('/Kintctcristics. — While it is convenient to speak of the justo-minor pelvis jis the normal female pelvis in miniature, the description is not strictly accu- rate. There are peculiarities due to an arrest of ilevelopment which give to the e(|iially general ly-contraoted pelvis some of the features of an infantile j>elvis. The alie of the sacrum are narrower than they .should be in eompari- I DYSTOCIA. Platk 2fl. r. V. idici Tr. (irili'ti ' 4 Tr. (uutli'tl 7 em, Aiit, iKiat.iiiitlt't Ti I'lii, 1. .Iiisto-iiiinor jK'lvis iMiittiT Musi'uin, CulUw nf I'hysicinns, I'liiIacU>l|i)iiiiK inlet n pprt'frtly sjniiiu't- riciil (ivciid, ■_•. Mwiirl' pelvis. ;;. .lustniiiiiinr pilvis with nipliiri'il pelvic jniiit'^, fulldwint; I'urci'ps iippli- ciiiiiin illirst tullictiun, l'iiivir>ily ni' rinnsylviiiiini. I. Narruw, I'unMcl-slmpfil pilvi.s i^piiiiiini in tlic Hirst ((illcitinii, rniviT>ily ni rcunsylviiiiitn. ■'>. h'cttil illclrvilnpecl pelvis, pinlialily an ,irn>lii| divi-lnp- iiirnl I'niiii racliili> ( Miillci' Mii-runi, rulli'uT of I'liysii-iansi. il. Minm- uraclc ..f n,iii-.iH . im 1 .h.-ipcil pi'l- vi> uilli cunlriKli'il puliie an'li. 7. i ililic|iiclyccintnicti'cl pelvis ^^^u'gl■l('l. ,>. ( ililii|Mi'ly i-uiitni(;ii| pelvis iplintu'.'iaphed Iniii a pla.-ler ea>tj. 1: 'fi H ! i» ! ,*! :• . ' ) ' n« DYSTOCIA. 515 soil with the bodies of the vertebrte. The sacrum is short and is not pushed as far forward between the iliac bones as it usually is; it shows also a dimin- ished forward inclination, and on its anterior surface a greater lateral, and a less marked perpendicular, concavity than common. The distance between tiie posterior superior spinous processes of the iliac bones is relatively great, on account of the posterior position of the sacrum and its slight rotation forward. The conjugato-symphyseal angle is greater than normal, by reason of the lessenen of the head the obstruction to the progress of labor is in great part obviated. If anything interferes with this movement of the head, as a faidty application of the forceps, engagement and descent may become impos- sible. Pelvic presentations in labor are a great disadvantage by reason of the difficulty experiencetl in freeing the arms and in bringing the head last through the generally-contracted pelvic canal. To secure its rapiil passage, the child's head must be flexed strongly by the operator's finger in its mouth before an attempt is made to secure engagement in the superior strait. While the woman escapes localized necroses of the soft tissues following labor in the justo-minor pelvis, there is greater likelihood of rupturing pelvic joints in this than in any other variety of contracted pelvis, and there is also an extraordi- nary liability to eclampsia (PI. 29, Fig. 3). Tiie caput succedaneum, which is very large on account of the early fixation of the head and the long labor, is situated directly over the smaller fontanelle. There is an overlapping of the cranial bones both laterally and antero-posteriorly. The generally-contracted, flat, non-rachitic pelvis presents the com- binetl features of the flat and the generally-contracted pelvis. Characteristics. — All the diameters are below normal, but the conjugate is less in proportion than any of the others. This pelvis has many of the feat- ures of a rachitic pelvis, but the anterior half of the pelvic circumference is not markedly broadened ; indeetl, it is often the reverse. The sacrum is small and is not rotate .M lit- ter Miiseuiu, Ciilletje iif I'tiysieiaiisi. 'I'lie pruiiiiiiitnry nl' the saeniiii pruji'ets sn I'ar Inrwanl tluit the tnio traiisv'.Tso diaiueter is hiseeled liy it. s. I'lat raeliilie pelvis, with uim^ual ciesceut of lliu itroiuulitury, riitu- tion (if the saeniiii, and lordosis (Miitler Mu.seiiiii, ColleKi' of I'hysieiaiis). vj'r ''5' I ,!/■ .Wl i . ^ '«• I i IF DYSTOCIA. 521 Transversely-contracted Pelvis the Result of Imperfect Develop- ment of both Sacral Alse. — This pelvis was first described in 1842 by Hubert, and is generally known as the "Robert i)elvis" (PI. 30, Fijjs. 1,2). It is the rarest of all contracted pelves. Schauta was able to find but six examples recorded in childbearing women. Ferruta has recently rejwrted another case.'" Herman gives eight as the number of recorded cases. The anatomical conditions are the same as in the Naegele pelvis, except that both sides of the sacrum are aft'ected instead of one. Other parts of the sacrum besides the alse may show imperfect development. There is a case reportwl in which the whole lower portion of the bone was absent (PI. 30, Fig. 3). The sacnnn in this pelvis is extremely narrow, and the posterior superior spinous processes of the iliac bones are brought close together. The degree of con- traction in the transverse diameter is so extreme that natural labor is out of the question. An asymmetry of the Robert pelvis has been observed, one side showing a greater degree of the deformity than the other, and thus approaching the type of an obliquely-contracted pelvis. The cause of this deformity is an absence of the bony nuclei in the sacral aloe of both sides. Secondarily, as in the Xaegcle pelvis, there is apt to be an ankylosis of the sacro-iliac joints. That this ankylosis is secondary and not primary is demonstrated by the same condition which proves that anky- losis is not a primary cause of the oblique contraction and ill-development of one side in the Naegele pelvis — namely, a displacement of the ilia on the sacrum necessarily occurring before the ankylosis. The treatment of labor obstructed by a transversely-contracted pelvis of this kind simply resolves itself into the performance of Cesarean section. Justo-major Pelvis. — A generally equally-enlarged pelvis nuiy be found in women of gigantic stature, but it may also be demonstrated in a woman of medium height. The pelvis of the Nova Scotian giantess was large enough to give passage to a child weighing 28f pounds. The largest pelvis that has ever come under the writer's notice was found in a woman somewhat below the average height, without an abnormally great development of any other portion of her frame. Diar/nosis. — The diagnosis of a justo-major pelvis is made mainly by exter- nal measurements. If all of them are found far in excess of the normal while preserving their normal relative proportion, the diagnosis of a justo-major pelvis is justifiable. The internal examination, if considered necessary, will show that the promontory is quite inaccessible, and that it is much more dif- ficult than common to reach the lateral pelvic walls. This anomaly of the pelvis does not, of course, obstruct labor ; on the contrary, it predisposes to precipitate deliver^-, although the resistance of the soft parts may be quite sufficient to delay the process considerably, even though the pelvis present no obstacle whatever. During pregnancy it is noted that the uterus has a tend- ency to sink deep within the pelvic canal, so that pressure-symptoms of the pelvic viscera and blood-vessels are common in the latter weeks of gestation, and these symptoms may become so exaggerated as to make locomotion diffi- kl Kr yr it f / l-:i) 522 AMERICAN TILXT-UOOK OF OliSTKTliJVii. cult. In l!il)(»r tliorc may be noted anomalies in the mechani.sm (lo|>enileiit ujHtn insiilHcient resistance to tlie enj^af^cmeiit of tlui liead. Thus imperiecl flexion at tiie superior strait may be observed, and there may be a tardv rotation of the head on the pelvic floor. Split Pelvis. — The split pelvis, which is due to a defect in the develop- ment of the hnver portion of the trunk in front, is almost invariably associated with exstrophy of the bhulder. This pelvis has very rarely been observed in tiie childbearinj; woman ; there are on record but seven examples complicating^ labor. This form of pelvis presents n<» obstacle in parturition. There are the same peculiarities in labor as in the justo-major j)elvis — namely, a tendency to precipitate birth, and anomalies in the mechanism the result of imperfect resistance. After labor it is almost certain that there will be a prolapse of the uterus. The didf/iiositi of this detbrmity j)resents no difHcultie^, and no obstetric treatment is called for in labor (PI. 30, Fig. 4). The Rachitic Pelvis. — In the healthy life and growth of bones two opposed processes are found : on the j)erif»hery there is an active proliferation of cells to form the bone-structure, while in the interior, l)one-substance is being constantly ab.sorbed by the marrow. In rachitis the absorption of hone- substance goes on more rapidly than it does in healthy bone, and at the same time there is in the perij)herv a very mu« h more rapid proliferation of cells, which do not, however, develop normal bone-structure. Their growth and multiplication result in the formation of an osteoid material poor in lime-salts and much more jtliable than healthy bone. The result of this pathological process in the pelvic bones is to make the pelvis more sensitive than it should be to the mechanical forces that are brought to bear upon it. In the rachitic pelvis the size and shape of the pelvic canal are modified by three factors : the pressure from the trunk above and the counter-pressure from the extremities below ; the pull on the pelvic bones by ligaments and muscles ; and an arrested development the conseciuence of an interference with normal growth that this disease occasions. ChavaderiMics — The effect upon the shape and size of the pelvic canal of rachitis in the pelvic boiK's is not unif()rm. Several varieties of contracted pelvis may result. The commonest is the fiat pelvis with .some contraction of all the diameters, but a most marked diminution in the antero-posterior diameter (PI. .'!(). Fig. 7). There may, in addition to this conmion form, be found a simple flat rachitic pelvis without alteration of the transvcr.se diam- eters, a generally e(pially-contractcd rachitic pelvis (PI. 30, Figs. 5, 6), and a so-called " pseudo-osteomalacic " pelvis, in which the effect .seen in osteomalacia is jiroduccd by pressure upon the bones .softened by rachitis. There are other rare forms of asymmetrical development, in connection usually with spinal disease of racihitie origin, that will be described elsewhere. CliaracteriNticfi of (he Fltif, ( h'HVi'aUii-cnntraded Rdcliitic Pelvis. — The sacrum is |)resscd forward and downward between the iliac bones, and is rotated on its transverse axis, mainly by the pressure of the trunk upon it, but partly by the pull downward of the psoas muscles upon the spinal column i; ■ i' DYSTOCIA. Plate 31. ('. V, .'i riu. Tr. liiiliti 11 cm Tr, l"iiil.-ti llj .ni. 1. Fliit riichitic pelvis, sin iwinu' tititcTior pnsitinii df ncctiilnila iMillliT Musiiiin, ( •nlh'i.'c i.f riivviiiaiis, I'liilinK'lphiiii. ■_'. I'liit railiitic pelvis, slmwiiiir reltitive iiieasiircnieiils df iiiiieni-pnsteiidr ami tniiisverse iliuiiieti'i-s lit inlet (Miitler Museiiiii. Ciillei:!' nf riiysicMiiiisi. :i. Kliil riiehitie |ielvi< willi Imueil I'eiiinni i Miit- ter Museum. Cullene of riiysieiiiiisi. I. l-'l.-it racliitic pelvis, slinwiiit; reliilive iMeii-iireiiieiit- ..f inlet Mini (unlet ^.Miitter Museum, Culletie nf i'li.vsieiansi. .V7. I'seiiilo-dstenmalaeiii. ur.i Ma DYHTOCIA, o2.J and the p''ll upward u|K)n the ixjsterior surface of the saertun by the ereotores spime miiscli's (PI. 30, Fijj. 8). Tlie effect of tins movement would naturally be to throw the tip of the sacrum and the coccyx directly backward, so that the pos- terior surface of the sacral bone would rim an almost horizontal course lus the woman stood upon her feet. The attachments of the sacro-sciatic ligaments and muscles to the lower sacrum and coccyx, however, prevent this backward movement of the bone us a whole, and, pulling the lower portion of the bone forward, cause a sharp bend in it, usually at the junction of the fourth and fifth sacral vcrtebrse. The sacrum is narrowed in its transverse diameter, and the lateral concavity of the anterior siu-fact; is ctJaced, by the forward movement of the bodies of the vertebrte between the alte. The anterior surface of the sacrum, indeed, may be convex from side to side. By the pull of the strong sacro-iliac ligaments running from the sacrum to the ])osterior superior spinous processes of the iliac bones the latter are pulled downward and forward by the descent of the sacral promontory, and are consequently made to apjjroach one another bel. !nd, but they do not keep pace with the movements of the sacrum, and co: .iccpiently project more prominently than common on either side. The natural result of this movement forward and inward on the part of the posterior superior portions of the ilia would be to throw the anterior half of the innominate bones outward, but this movement is opposed by their junction at the symphysis, and to a less degree by the attachment of Poupart's ligament to their anterior superior spinous j>rocesses. The ilia, however, restrained by a somewhat yielding force, are thrown to a certain degree out- ward and backward, so that their upper edges run almost horizontally outward, and the distance between their anterior spines becomes little less than, the same as, or even greater than, the distance between their crests (PI. 30, Fig. 7). A further result of these combinetl forces pulling the innominate bones inward and forward behind and holding them in place in front is to produce in them an abnormal curvature, as in the case of the sacrum, or as in a bow bent between one's hand and the ground (PI. 31, Figs. 3, 4). The point of angulation or greatest curvature is found on the ilio-pectineal line, back of the median transverse line of the pelvic inlet, near the sacro-iliac joints. On account of the flexion of the innominate bones the transverse diameter of the rachitic pelvis is relatively increased, but as the whole pelvis is com- monly below the normal in size, this diameter rarely exceeds, if, indeed, it equals, the normal transverse measurement. A further consequence of the exaggerated curvature of the innominate bones is to throw the ace- tabula forward, so that the counter-pressure of the lower extremities is exerted more antero-posteriorly than in the normal pelvis (PI. 31, Fig. 1). The pubic rami and the symphysis are diminished in height and show a lessened slant outward. The cartilage at the junction of the symphysis projects inward upon the pelvic canal, standing out above the level of the bones to such a degree that it is sometimes a source of injury to the head or to the maternal structures. The force of resistance at the symphyses to the out- ward movement of the innominate bones sometimes bends the ends of the , \s^A .11., i \i: 'm :¥m pwm ifpllite , , , If- ' 'i ■'■;:. "' i— fM' .■ vm \l 524 AMEIifCAX TEXT- BOOK OF OJiSTETRICS. H pu])ic bones inward upon the pelvic pjinal, Jijivinji; to the pelvic inlet the shape of a Hiiiire S. From the traction of tlu' adductor and rotator muscles of the thi contraction is relativeiv much less than in the conjugate of the inlet. The whole ])clvis is lilted forward on its transverse axis, so that the inclination of the superior strait is increased and the external genitalia are displaced backward. The bones of a rachitic pelvis arc usually slighter and more brittle than conunon. They may, pcrhaj)s, show no peculiarities iik structure, or in rare cases they may be tbund much thicker and heavier than normal. In the generally etpially-contractcd rachitic ])elvis — a rare +ype — is seen mainly an arrest of development, the consequence of rachitis in very early lii'e, Avhieh retarded growth without much atfecting the shape of the pelvic inlet and canal, from the fact that the pelvis had not been subjected to the pressure of the tnmk diu'ing the active stage of the disease, because it ran its course to complete recovery before the child attempted to sit up or to walk. Possihiv also the disease in some of these cases is not severe and lasts but a short time. As the detbrmity is the result of arrested development, we find a transverse contraoiion as in th(> fetal ill-developed ])elvis (PI. .'JO, Figs. 5, G). The ilidfpiosifi of the rachitic origin of this type of pelvis is made by the relations of iliac spines to crests, by the history of rachitis in early iid'ancy perhaps, and ]K)ssil)ly by the signs of the disease in other portions of the body. In the psci((fo-ofn at length the bone disease has riui its course the pelvis is firndy set, by the hardening of the bones, in its unnatural position and shape. The dilfcrential diagnosis between this ju'lvis and the true osteomalacic ])elvis is made by the direction of the iliac crests, by the tb'in constitution of the boi.cs after the disease has been arrested, and by the signs ol' rachitis in other portions of the body. Osteomalacia, besides, has certain peculiarities of its own that enable one to recognize it without ditlieulty (IM, :M, Fig^. 5, (J, 7; Pi. ;52, Fig. 1). Diaf/uosiK. — The diagnosis of a rachitic ])elvis is made by external and internal measurements, by ])alpation of the exterior and interic. of the pelvis, by the woman's history, and by her appearance. An individual who has had t the shape ninsck's df rachitis hv I hUtor arc iileuod and ^4). Tiic the cxccss- i rehitivcly is is tihcd I'l'ior strait irittle tiiaii or in rare )c — is seen early liic, e inh't and ressure of s eonrse to Possihly short time. transverse ade by tlie •ly infancy 'the body. 1 cliaracter isease was iggeratcd lire of tiie nds to an far down Dwnward ; ihnhi are sease has les, in its lis pelvis ei'csts, by I, and by sides, has ilifliciilty I'lial and lie pelvis, has had DYSTOCIA. Pi .n: 32. e. V. lioni 1st mill tiiiiii 4 2il mil', vi'i't. Ill rm. Ti-, IJi iiii. 1. I'si'udii-iislCdinnliiciii. 'J. Kiicliilii' lu'lvis with I'nntriicti'il liiiti'i-ii-iiostcfionliiiiiiilii' llniiiiu'liiiiil llic |n'l- vie I'll Mill I M lit If r MllM'Mlll. Cnllri^r of l'll\siriillis, l'llil;|i|i'l|illill '. "., I'rilcllllnll- lirl 1) nl' lilillil h , ( 'h.-i T'lu'M- lirll. 1, Uiirliilir Iu'lvi^ with il.Mililr |ironiniiiiiry i Mullrr Miim'Uiu. i 'nil rL:r .■!' I'li> -iii.iii^ ■. :•.>'' Miii 'i' miiilrs uf usll'iUMUllU'il' Iil'lvrs. 7. 0.-|i'"lllu!lli'ill, ^Imw ilii; , »\ linin;lriri,l rMllU'ilrlinll Ml .illlirt / DYSTOCIA. 525 rachitis in childhood '.?, usually of ^niall stature, with short, thick, curved extremities, a low broad brow, a large square head, a flat nose, a "chicken breast,' and enlarged joints. The lumbar lordosis and the rotation of the sicruni produce a sway-back, most noticeable when the woman lies on her back upon a hard surface. When she stands erect the pregnant uterus near term falls abnormally forward and downward, on account of the short abdo- men and lack of engagement of the presenting \vAvt (PI. 32, Fig. .i). riie most characteristic facts in her history arc that she walked first at three or four vcars of age and was late in getting her teeth. By the pelvimeter the normal relation between the iliac spines and crests is found disturbed. Tlie ditfcrcnce in distances between the former and between tlie latter is much reduced. The posterior superior spinous pmcesses arc apprdxiiiKUcd, and the Kk;. :Ui; — Afipcnr.'iiiii' iliiriiv.: liO' of tli(> liicrh- Fn;. :U7. -'^K-i'lrtnn nf m rncliitic duinr M.iliriil csl ;;r.iili' nl" ^ll(■llili^; iiscUiln(i>liiiiiiiiliiriii (I'il'- Milsiinii, 1 ni\ri>iiy nf IViiii^\ l\ aiii;n. |piii^>h jiilili. depression luider the last spinous process of the lumbar V('rtel)ra approaches or is actually in the line drawn between them. The external antcro-posterior diameter of Baudelocque is below the normal. Internally, the diagonal con- jugate is found considerably reduced. The symphysis has less of a slant out- ward than it should have, the promontory is found low an^i prominent, tli(( sacral bone is sharply bent upon itself, and the pelvic canal is remarkably shallow. On account of the increase in the conjugate-syinphyseal angle due to the lessened slant outward of the symphysis, at least 2 centimeters should be subtracted from the diagonal conjugate. The difference between the two would be greater were it not for tlie low situation of the j)romontory, which compensates to a certain extent for the lessened slant of the symphysis, but does not entirely neutrali/.e it. A double promontory in these pelves is not F»>»i ►! J6 ^^f^ 1 Si V J?: : r ■' :?i'S f'^i 526 ylJ/^72/C^l.A^ TEXT-BOOK OF OBSTETRICS. uncommon (PI. 32, Figs. 2, 4). If found, the mtasurement should be taken from the promontory nearest the symphysis. Occasionally the lordosis of the lum- bar vertebra;, the result of spinal rachitis, is so great as to constitute itself an obstruction above the pelvic inlet. In such a case the effective conjugate must be taken from a j)oint above the sacrum to the symphysispubis(Pl. 30, Fig. 8). Injiuence on Labor. — The influence on labor of a flat rachitic pelvis is mudi the same as the influence of a simple flat pelvis, except that the contraction, and consequently the obstruction to labor, is greater in the rachitic form, and that the promontory of the sacrum is more prominent and more '^barplv defined. The anomalies of mechanism at the inlet are the same in both forms of pelvis, but they are exaggerated in the flat rachitic pelvis. As soon as the obstruction at the inlet is overcome the descent of the head and its esca]ie is more rapid in the raciiitic pelvis, because of the shallow canal and the expanded Fiii. 318.— I'ressuru of tliu iiruinoutory \ipon the hcftJ in a contniotod pelvis (Sraellic). outlet. Injuries to the child's head and to tlie maternal tissues from pressure are common. In the former a sharp indentation may be seen on that portion pressed against the promontory in tlie efforts to secure engagement (the so- called " sjxKJU-shaped " depression, witli fracture of the parietal bone; Figs. 314, 318, 3I9j. lA)cali/ed Jiecroses are not infrequently seen in the mater- nal structures where they have been nipped between the child's head and prominent portions of the ])elvic bones — namely, in the cervical tissues over the j)romontory, or very rarely in the ])osterior vaginal vatdt, and in the ante- rior vaginal wall behind the symphysis and the ridge of the piibie bones. AA'hen the slough sej)arates openings may be established between the birtii- canal and the peritoneal cavity, the bowel, the bladder, and a uretcir. Osteomalacic Pelvis. — Osteomalacia, a soft condition i>f tlie bones in consequence of an osteomyelitis and an osteitis, is exceedingly rare in DYSTOCIA. o27 America. There are certain jiarts of the world where it is frequently seen, notably Italy, Germany, ami Austria, but in America there are but three !)!■ i'oiir examples on record. The bones of the pelvis in this disease become ,~() soft that they yield to every force imposed upon them. They bend before llio pressure of the trunk from above, tlu; extremities from below, and the |)iill of the muscles attached to the pelvic bones. The flexibility of the pi'lvis in extreme cases of osteomalacia can bo appreciated when it is stated that the superior iliac spines may be bent backward until they touch the spinal column; the horizontal rami of the pubis maybe jjushcd inward imtil they almost obliterate the pelvic inlet ; and the tuberosities of the ischium mav be approximated until they nearly close the pelvic outlet. Xot only are the pelvic walls so compressed that they almost obliterate the pelvic canal, but tlu> spinal column also, sinking under the weight of the trunk, bends liir forward ih I'lu. 319.— Ovfrlapping of the criiiiiul bDiios in a futile attempt to engage in the superior strait of a rachitie pelvis (Smellie). and descends low into the pelvis, occupying the little remaining room in the inlet and canal, and becoming itself a serious obstruction to the engagement of the i)resenting part. From the lateral pressure of the thigh-bones the ischia and ])iibcs are pushed inward and backward, making by the former movement a sharp beak-like projection of the pelvic inlet between the jjubic rami, and by the latter much diminishing the s-ize of the pelvic canal (PI. 32, Figs. 5, (i, 7). Tile sacrum is rotated on its transverse axis and is driven low into the pidvic canal — an exaggeration of the nioveinont seen in a rachitic pelvis. The lower portion of the sacrum and the coccyx are pulled sharply forward by the mus- cles attached to them, so that the sacrum is bent at a sharp angle in its lower third. The innominate boucs are bent laterally at a jioint slightly anterior to the sacro-iliac junction, and the iliac bones may be folded upon themselves horizontally. The inclination of the pelvis as a whole is much increased. t ,i •i-^: !; r m \ AMi:ni<'A\ TEXT- nook' or oustktrics. The (luifpi()Ni.s may Itc based ii|)(iii tlir flillnw inu- symj)tuiiis : Tlic (IImmt bc'jrins usually (liirini"' prcoiiaMcy or l:icl;iti<.ii. w itii dull ai'liiii;: pain- in ii„. extroniitics, tlii' back, (he li!uil>ar rcuion, and over tlic ante rinr iidrtiiai nf il,,. jK'lvis, Every umveineMt incica-cs iIksc pains. As ijic di>ea>e pi'(ii;if>., . the bones of the spinal eolunin are -o iicnt and eoni|nvstalnre to an exiraordinarv decree. She nia\ lo>e a> nnicji ,i~ Fli.. HJiJ.— ll:i>l .s (use nl' u^icdiimliiciii ilmiit iiinl prnlilo vii^ws in (lill'trfiil |>i'rs|icctivc!. ;. I and a half in hci il: u". In order to compensate for the approximation of the thighs brought aUoUi i)y t'.ie collapso of the ]>elvis the imhvidual nuist turn almost through a half circle in order to bring one foot in front of the other. Upon examination of the pelvis tenderness upon presiiure is discovered over its anterior wall. The flexibility of the pelvic bones may bo denutustrateii by direct pros.sure, antl an DYSTOCIA. Pl,ATK 33. I- ill li, II III' III. I'dLlI'"'-- iili\li|i| lllllcli :i- iclll |> •dlliillt illli'll :i Cltioll TIlc tul nil 1. ExoRtosi's nt tho sacro-iliai' juiictliiiis. 'J. KiiDblikf oxnstosis on the promontory (SohiuitiO. 3. Ai'nn- tlicipi'lys. t. Kiichitic jii'lvis with "Imormiil bill hhiiit proji'i I'i'lion of iU'ii-pi'i'tincal riiiliicin'cs iMiittcr Mu- lliii'linriilnniiii Ot<'hnn. il. Knictuii' nl' tlic ju'lvis (Otto). 7. iri' of tlii^ acotabuhi in coiisoiiik'Iku of coxalnia (Ottoi. S. Fracture of tlie ri(,'ht ahi of the sacrum (Kritscli). '0 m scum, Cnllou'c of rhysiciuiis, I'liiliic '.oliii Kractu DYSTOCIA. o2{) internal oxaminatioii discovers in the early stage of the disease the peculiar licak-like space behind the symphysis, and later the almost entire obliteration of the pelvic outlet and canal by the sinking in of the pelvic walls. Jf it is possible to make a satistiictory internal examination of the pelvis, the low po-ition and tiie projection of the promontory at once attract attention, and tlie sharp angulation on the anterior face of the sacrnm can be felt. On account of the exaggerated inclination of the pelvis it may be necessary to iriakc an examination with the patient upon her side. An osteomalacic pelvis lias been taken for a kyphotic, a Robert, a pseudo-osteomalacic, a cancerous, or a fractured pelvis, but a careful, methodical examination of the patient will always lead to a correct diagnosis. liiffuciice upon Labor. — The results of labor in osteomalacic pelves show ;H. I' irt m\ fC- ''X\i-\y I'm. oL'l.— Cystic enchondrnma (Zweifel). Fi(i. S22.— Button-like exnstdsis on tho promontory (Sphiiuta). that the obstruction is a serious one in spite of the flexibility of the pelvic liones, by rcascm of which flexibility in some cases the head can distend the pelvic canal sufliciently to pass through. In 80 cases collected by Lit/maun forty-seven ended fatally. In another series of 128 cases the labor had a spontaneous termination in twenty-seven cases, in four there was premature delivery, and in five abortion ; four times the labor was naturally terminated ; ill eight cases version was ])erformed, in four the child was extracted by the feet, in twenty-five forceps was employed, in eleven craniotomy was performed, and in thirty-six Cesarean section ; rupttu'e of the uterus occurred in five women before any operation was undertaken. In still another series of cases reported from ^lilan the flexibility of the pelvis was so great that the child was delivered in only two instances by Cesarean section. The most successful 530 AMElilVAX TEXT-BOOK OF OJiSTETRIVS. Flo. ;>j;!.— Exostosis on the symphysis (Sclmutn). treatment in modern times fur this obstriietion in labor ninst be the perlbrin- ance of Cesarean seetion, and the oi)erat<)r should at the same time remove the ovaries, or, what is better, do a eoniplete Porro operation. It is bewjnd dispute that tlie eessation of sexual funetions favorably modifies or aetuallv cures the tliscase. Tumors of the Pelvis. — The commonest ])elvie tumors are bony excros- cences, usually Ibund over one of the pelvic joints. The excrescences are oriji- inally cartilaj^inous projections which become ossified by an extension of bonv tissue from the two bones between wliich they lie. These exostoses mav be found over the saero-iliac joints, over the symphysis pubis, and over the prom- ontory of the sacrum (Figs. 322, 32."i ; ri.33,Fijrs.l,2). They may reach t lie size of a pigeon's egg, though they aic nstially not larger than a pea or a nut. In the exostoses occupying the seat of the pubo-iliac junction, 3, Fig. 3), or a "yWm npinom." Another possible seat for a bony projec- tion is along the crests of the pubic bones, the exostosis taking here the form of a long, sharji edge, and j)robal)ly owing its origin to an ossification of the attachment of the iliac fascia, a transformation of tissue analogous to the ossi- fication sometimes seen in (Jimijernat's ligament. These bony outgrowths con- stitute a serious form of obstruction in labor, not so nuich fron; their encroach- ment uj)on the room of the pelvic inlet as from the sharply-locali/od pressure which they exercise ujiou the maternal structures and upon the fetal head. In the four cases repcjrted by Kilian, death, it was claimed, resulted in each case from a i)erforate(l uterus. Other tumors of the pelvis offering an obstruction in labor are enchondromata, fibromata, sarcomata, carcinomata, and cysts (Fig. 321 ; PI. 33, Fig. 5). These tumors are rare, and their importance as an obstacle in labor depends, of course, upon their size. Cysts of the ju'lvis are formed usually in sarcomata and in enchondromata, or are hydatid cysts. Cancer of the pelvic bones is always a secondary growth or is metastatic. It may result in a number of small tumors in the bony pelvic walls, or may take on the form of cancerous infiltration with a consequent softening of the bones like that of osteomalacia. The treatment of labor obstructed by tumors of the pelvis is ordinarily the performance of Cesarean section. There is one case on record (Abernethy's) in which the tumor, an enchondroma, was removed by an incis- ion in the j)osterior vaginal wall, but in the vast majority of cases these growths cannot be reached or cannot safely be excised. In 49 cases of labor obstructed by a pelvic tumor 50 per cent, of the women and 90 per cent, of the children lost their lives (Winckel). DYSTOCIA. r>;n Fractures of the Pelvis. — Out of 13,200 fniotiircs roportcd from nine lar.ii;e hospitals in America and in Kuropo, but 0.8 of one por cent, were i'racttn'os of the pelvis. When one considers that almost all grave injuries of tlie pelvis end fatally, the rarity of a pelvic deformity dependent upon a united fracture of a pelvic bone in a woman of childi)earin excessive callus-formation, or to ossification of the pelvic joints near- est the seat of fracture. In a fracture of the acetabulum the result of hip- joint disease the head of the fenuu" may project into the pelvic canal (PI. .'{;}, Fig. 7). Fracture of the pubes results in an irregular distortion of the pelvic inlet, most marked, of course, on the injured side (PI. 33, Fig. 6). A fracture of the upper portion of the sacrum mav residt in Fk;. ;i24.-Trnn8Vfrsi' fracture nC thf sacrum with ,,,.,. 1 ,. * . /T-i. .siioiidylolisthctic (lefiiruiitv iNcUKcbaiRT). a spondylolistlietic deiormity (r ig. 324). Fracture of the lower portion of the sacrinn is followed by a dislo- cation of the lower fragment inward. In a case seen by the writer the lower half of the sacral bone was turned in at right angles to the rest of the bone by the pull of the pelvic muscles attached to it. A fracture of the sacral aKT may cause an oblique contraction of the jielvic inlet like that of the Xaegele pelvis Pi. 33, Fig. 8). Neugebauer" reported an extraordinary case of bilateral fracture of the pubic rami in which there was union with callus-formation on one side and an ununited fracture on the other, the fragments moving on one another 2 or 3 centimeters when the woman walked. Caries and Necrosis. — The only effect of this disease of the pelvic bones is the production, in rare cases of tid)erculosis of a sacro-iliac joint, of an oblique contraction of the jielvis. When the sacro-iliac joint is affected the idtimate result is the same as that produced by imperfect development of the sacral ala^ in a true Xaegele pelvis. There is loss of tissue, ankylosis of the joint, and an arrest of development in the affected part if the disease occurs in early childhood. Ankylosis and Relaxation of the Pelvic Joints. — Synostosis may develop iu any of the pelvic joints ; in the symphysis it occurs not infrequently, and often at an early age. A number of operators have encountered this dif- mf r 'J' • f 1 f I ih:\ ^. I I: m> 1.^1 r-ii i}:\'2 AMEJtICAX TKXT-liOOK OF OliSTKTIilCS. ficiilty in jittriiipts rcci'iitly to jx'rform symphysiotomy. In otliiTwisc iiiuili- stnictcd labor synostosis of the piil)ic symphysis is not a serious comlitioi*, aUhoiijfh it limits the slij^lit c'xpan>ion wliioli every nurmul j)elvis .shoiiUI exhihit preparatory to and ihn'iiifjf labor. If synostosis of the saero-iliac joint deveh)ps in tlie individual's early ehildhood, it is followed by ill development of the sacral alio on the alTeelcd side, and of that portion of the imiominate bone eoneerned in the formation of the joint, an oblicpiely-eontraeted ju'lvis of the Xae<;ele type beiiiir the result; but suHi eases are rarer than those in which lack of development in the sacral alie is the primary oeeurrence. If the synostosis of the joint occius after puberty, the etfect upon the pelvis and upon the eoiu'se of labor is prae- ticallv nil. If both joints are early ankvlosed, a form of laterallv-contractcd pelvis like the Robert pelvis is the result. This kinii of contracted pelvis is rarer than the transversely-contracted pelvis due primarily to lack of develop- ment in the sacral ala>. The sacro-coccvjieal joint becomes ankvlosed, as a rule, between the thir- tieth and fortieth years, but as the joint between the first and second coccyfr(!al vertebra; is ordinarily nnatlected, the pelvic outlet is capable of expansion dnrinaratorv to labor. It is more likely, however, to be due to some patho- logical condition within the ])elvic joints, as an inflammatory process follow(Hl, perhaps, by suppuration, the eollecticm of fluid witli'n the joint, osteomalacia, caries, or new growths. In pregnancy the patl;oloi:;eal relaxation of the ])elvic joints may occasion some difficulty in locomiilion. During labor an exaggerated relaxation of the joints predisposes to their rupture. The Spondylolisthetic Pelvis. — The spondylolisthetic pelvis was first described in 1839 by Kokitansky, who reported two cases; Kiwisch and Kilian followed with a description each of a specimen ; bnt we owe our knowledge of the condition mainly to the indefatigable researches of Neu- gebauer, '- who collected more than ninety cases and specimens, and to the discoveries of Lane, who has done much to clear up the etiology. The name "spondylolisthesis" * indicates the condition — a slipping down or dislocation of the vertebrje. To affect the ])elvis the spondylolisthesis must be in the luni bo-sacral region (Figs. 325-327). Charactcristir.^ — As the name denotes, there is a dislocation of the last * a-6v(h'?.nCj vertebra, and uXiafii/air^ a slipiiing out or down. DYSTOCIA. Mil liuiibur vortclini ir. front of tlio siuu'iiin, the body of the formor sli|)|)in^ down ill front of the first .sacral vertebra, so that its inferior border, or in advanecil eases its anterior surface, comes in contact with tlie anterior fiice of tiie sacrnni, to which it becomes united by bony union, Tlicre is also, of necessity, an cxairirerated lordosis of the lumbar vertel)ra and a descent into the nclvic inlet of at least the fourth and third, and even of the second, lumbar vertebra*, which diminish by their bulk and anterior projection the antero-posterior diameter of the pelvic canal. Ft is only the body of the last Inniliar ver- tebra that is displaced, and not the arch, held fast by the lower posterior articular surfaces, nor the lamime surrounding; the spinal cord, so that the latter does not necessarily suffer compression by the displacement of the ver- tebra, although this result has been noted in a few cases (Fig. 320). To allow the displacement of tlu! body of the last linnbar vertebra the inter- Kk!. "Jti,— Spondylolisthesis, beginning (Schautn). Flu. :'.'J7.— Last Inmhnr viTti'hni of sjioiKlylo- listlu'sis Ml) ciiiitriisttil with a normal ti.th lum- l''i(i. :i'23.— Spondylolistlu'sis, woll markoil (Scliauta). , bar viTti'bra iNcug.baut'r). articular segment of the spinal arch and the jwdieles are enormously lengthened from behind forward and are bent at an angle ilownward (Fig. .'527). After a time this segment may exhibit a transverse fracture or a solution of continuity from i)ressnre and attrition. The deformity is always gradual in development. If it develops during the childbearing period, successive labors become increasingly difficult. As the vertebra descends it pushes the sacrnin backward and downward, and with it depresses the pos- terior portion of the jjclvie brim. To compensate for this movement the anterior half of the pelvic brim rises and the height of the symphysis is increased. This movement of the pelvis diminishes very markedly its inclina- ■.¥ ;.4 V- i r4iiJ m ,»■>, ff,< •'n' B*: ^k' ;'> ■ f 1"^ ^ ^ 'X' i^ ■ "* ■ ti^j ' '■*■ :•<■ ■;i. j;.;-f i.: ' Mi '• 'I'l Hi"* ' r 1 f " h ryM AMERICAN TEXT-BOOK OF OBSTETRICS. tion, and disturbs tlie normal relationship between the bones and the soft structures tliat overlie them. The base of the triangle formed by the jiubic hair in women is well below the upper edge of the symphysis, and the exter- nal s'enitalia are so pulled forward that the vulvar orifice is directed anteriorlv as the patient sits or stands. There are, moreover, the same displacements of the pelvic bones that are seen in kyphosis — a rotation backward of the sacrum on its transverse axis, and a rotation outward of the upper portions, and inward of the lower portions, of the innominate bones on their antero-pos- Fi(i. 328.— Wini'lii'l's lase of spondylolisthesis of modornte degroe. terior axes. The descent of the lumbar vertebra) drags the large arteries of the lower trunk into the pelvic iidet, so that the iliac vessels and the bifurca- tion of the aorta can be felt in the vaginal examination. The degree of con- traction in the conjugate diameter of the iidet depends upon the descent of the last lumbar vertebra and the degree of the lordosis. The contraction is usually not excessive, but it may be so great as to preclude the possibility of the engage- ment of the fetal head. Miolof/u. — The etiology of spondylolisthesis at the lurubo-sacral junction is still involved in considerable obscurity. It has been attributed to ilireet injuries of, and to faults of development or ossification in, the interarticular segments of the spinal arch. It is certain that these are predisposing causes, but the observations of Lane appear to demonstrate that the commonest cause of this deformity is an exaggerated pressure from the truidv above exerted often upon healthy bone. As the result of this pressure a joint is formed in the intervertebral ilisk, and the interarticular segments of the last lumbar DYSTOCIA. 535 tU..J VPi't'bra undergo stretching, pressure, angulation, and atrophy until the hone is actually severed. Following or accompanying these changes in the arch, the body of the last lumbar vertebra is displaced farther and farther down- >\ard and forward. Dkujnosis. — The di:»gnosis of a spondylolisthetic pelvis is not easy, and can be made only by close attention to the patient's history, by u careful observation of her appearance, by an internal and external examination of the pelvis, and by pelvimetry. In the history of the case it may appear that the individual was the subject of a serious accident, such as a fall from a lioight or a fracture of the pelvis by the passage over it of a heavy weight, or it may be learned that she has carried excessively heavy burdens for a long time. The woman's height is diminished and the length of the abdomen is short- ened. Viewing the patient from behind, there appears what is called the sad- dle-shaped or "sway " back, the lumbar vertebne projecting visibly far forward Fl<;. 3'J9.— Ahlfi'Ul's ciiso i)f spdiidylnlistlK'sis. l"l(i. 3oO.— Broisky's case of spondylolisthesis. and being displacetl downward, throwing into bold ^'elief the posterior superior spinous processes and the rims of the iliac bones, ai.d producing quite a dee]> furrow along the course of the spinous processes of the lumbar vertebrje. The apposed articular proce> ulders fai back; as the individual walks 'I.- ^! imp- , nil. • A\ / i . \ jflt J J 11'' \ "i ft i v. M: i^^ms^:% i : I M I r,:]U A.}n'JIi'I('AX TEXT-BOOK OF OJiSTL'Th'ICS. a disposition to fall forward may !)o noted, and showill state |)erliaj)s that slic i- nnable to earry any load npon her arms in front of her hody, for fear of to])pliiit; over upon her face. She may also complain ot' a ait is |)ecnliar; the toes are nm tnrned ontward, and the feet are swnnjj aronnd one another so that the foot- ])rints fall in a straij^ht line. Upon an internal examination of the pelvis — best condneted, aeeordinj; to Ncnu'chaner, in an nprijfht or lateral position — the lordosis of the Inmhar vertebra* is at once discovered. The an<>;le formed bv the attacliment of the last hnubar vertebra to the saernm may be detected with ease, and it is noted that the body of this vertebra does not possess lateral ])roj<'etions, transverse processes, or ahv. J{y their absence one i> snre that he is not feelinj^ a projectin outlit. The internal conjngat*' diameter must be measured I'rom the lumbar vertebra nearest the symphysis pubis — usually the fourth. This is called the " false" or "elTcctive" coii)ugate diameter of the spondylolisthetic! pelvis. On account of the decreased inclination of tiic pelvis it is not necessary to subtract more than the ordinary sum from the diagonal conjugate. In liict, tlu; diagonal conjugate may approach very neaily the length of tli(> true, or may actually measure less than it. Jiijfitcticc iijxiii Ij(l)t)i\ — The iulliience of a spondylolisthetic pelvis upon lal)or is that of a fiat pelvis. The obstruction in the former may be over<'(iine iuor(> easily mi account of the l)ow-Iike shape of the projecting vertebra and tiie coincidence of the uterine and ]»elvic axes. The obstruction to labor depends entirely upon the ]>rojectiou of the liuubar vertebra". This projec- tion may be so slight as scarcely to intluence the progress at all, or it may be so great as to make delivery by the natural channel (piite im])ossible. There is noticed in labor something of the same mechanism that is seen in the flat pelvis llir the purpose of overcoming the obstruction — namely, deerea.-ed flexion, transverse position, and exaggerated lateral inclination of the head. < )n account of the forward dislocation of the external genitalia aiul of the jM'Ivic floor, lacerations of the latter are the rule, and the tears arc often com- plete into the r(>ctum. This liability to injury is explained by the fact that the presenting ])art impinges directly upon the middle of the pelvic floor as it hotic pelvis was first adequately described in 18G5 by Breisky, although its ju'culiarities had been recognized before by [jitzmann iri 1861 and by Neugebauer in 1863. The condition was called by Herr- gott " s]iondyl-izema," a name adopted by Neugebauer and others (Fig. 331 ; PI. 34, Figs. 1, 2). Characteristics. — The degree of deformity in a kyphotic j)('lvis depends upon the situatiim of the hump: the nearer this is to the sacrum, as a ru\o, the greater is the deformity in the pelvis. Ordinarily the kyphosis will be near the (lorso-luiid)ar junction. There is a compensating lordosis of the lumbar spine, but not enough to' keep the centre of gravity of the tnnik from being too far forward. In con- s('(pience the weight of the trunk is transmitted in a direc- tion from before backward, so that the sacrum is rotated on its transverse axis in a direction the reverse of that seen in rachitis — namely, backward and downward. The result of this movement is to Uiake the sacrum straighter, narrower, more curved from side to side, and longer (1*1. 34, Fig. 2), to jndl the posterior superior spinous processes of the iliac bones closer togetlu^r, and to separate the anterior spines more wide' The diminished width l)etween the posterior superior spinous ])rocesses is caused partly by the pull of the sacro-iliac; ligaments. The sacrum cannot move in any directi(m without dragging the ilium on each side by these ligaments, thus approximating their up])er pitsterior surface's. It depends also upon the narrowness of the sacrum. To compensate for the movenuMit of the upj)er portion of the sacrum backward, the lower portion of the bone |)rojects forward into the pelvic outlet. To preserve the bo«ly from falling forward, the knees and thighs are slightly flexed and tiie pelvic inclination is almost entirely lost. This posture puts on a stretch the ilio-femoral liga- K|(i. :i;il.— Kypliosis; (iri'iiti'st tniiisviTsc di- aiiU'tiT lit outli't, 7 cm. (MiittiT Museum, <'iil- Iffrc of I'hysicimis, I'liiliiili'lpliiiil. I I ! iKr. ■ 'I ; t '■" i' ■ '):}>< AMERICAN TEXT-BOOK OE OBSTETRICS. iiK'nt.-', whicli pull oiitwanl the upper portions of the innominate bones. To for.iponsate for the movement outward of the iliae bones, the lower segments of the innominate bones move iin -ard upon the pelvic inlet ; in other words, /i'/d/ /wad Spini' (*/ Isc/nttm. hchiutit . Kiii. ;a2.— Uiiiil iir"''stf(l tiy spiius nf iscliia in a kyphotic \iv\\ s (Hurtiii). there is a rotation of the innominate bones upon their iiLtero-jiosterior axes. The result of these movements in the pelvic bones is to enlarge somewhat the pelvic inlet, espeer.ily in its antero-posterior diameter, but to contract the h\tal I'u'iii/. Intersfthwus liiantt'lt-y- ■-^ ^-' Fiii. :i;;;!.— ViTtlcHl soction rif kyiihotio ja'lvis, slidwiiin \\w licaii nrrcstod liy the pjiini's (if tlic iscliia (Itiiilin). canal toward the outlet, where the diminution of the diameters is most marked, especijdly in the transverse (I'l. 34, Fig. 1). In the rare cases of lumbo-sacral kyphosis the upper portion of the sacral bone may be involved in the necrotic process, and the sacrum may exhibit deformities by destruction of its tissues (PI. 34, Figs. 3, 4). The other cha- racteristic deformities of the kyphotic ])elvis are most marked in this type, unless, as in one instance, the boily is bent almost double, and it is necessary ■ 11 . I u ones. Tu r sogiuciits lier words, terior axes, newliat the [)iitract the if the isrliia :'S is incst the sacral lay exhibit other eha- this type, ^ necessarv DYSTOCIA. I'l.ATK 3"). 1. I.uxiitioii 111" rijjlit ('(■iimr. 2. ('miixfiiitiil liixiilinn nt' Imih I'finuru. H. l-uxatiim i if left ffiiuir mi ddr- sum iif iliiiui, with liilsc joint iilmvi' iicrliilnihim. I. ('niiticiiiliil hixiilimi nf hdth Irnioni tiihiitii^'niph nf UKiiU'll. .'). t'dXiilKii' pi'lvis I Miltlcr Miisnim, t'ollocf "'' l'lijsiciiin>. riiiliuli'lpliiii). li. Aiiti'iidi- ili>lo(iiti(m nf fi'innr. 7. Coiigoiiitiil dislociitioii of the fciuurii. S. IVlvic ilcl'oniiity, Iho r'jsult uf ilouhk' I'Uib-tout (Mi'.viT). ft*- I ^ !, 'rX ^ w ; ■ i ; w'' ' i! ffijji; '\ sii \ ; J ii] w. ah, ■ ■:! J'il'ii J'S!): tJ!'!J' Si -1;J DYSTOCIA. ;■):«» to rest the anterior portion npon an artificial snpport, as a cane. In this case tiie pelvis, althongh relieved of the weight of the trunk, is obstructed by the overhanging Inrnbar vertebraj to such a degree perhaj>s that the inlet is practi- cally obliterated (pelvis obtecta). In all cases except the slightest of lurabo- .^acral kyphosis the projecting lumbar spine blocks the pelvic inlet and seriously obstructs labor. In 21 labors complicated by this deformity of the j)elvis (JG per cent, of the mothers and 75 per cent, of the children were lost (Winckel). Influence on Labor.— TXw influence of the kyphotic pelvis upon labor is usually not felt until tiio presenting part has descended to tiie pelvic floor. In consequence of the shortened perpendicular diameter of the abdominal cavity there is a tenilency always to transverse position of the fetus in utero, but this position is ordinarily corrected by the first few labor-pains. When the head arrives at the pelvic floor, if the occiput is directed backward, anterior rotation will very likely be prevented and there v.'ill be a persistent posterior position. If the occiput is directed anteriorly, the transverse diameter of the head may be caught between the approximated tul)erosities of the ischiac bones, and labor be brought to an indefinite standstill (Figs. 332, 333). Occasionally spontaneous delivery is possible on account of the extreme mobility of the pel- vic joints in the kyphotic pelvis; in any case, as the progreas of the head is retarded only when it reaches the pelvic ontlet, the labor ordinarily is easily managed. The application of forceps may be sufficient to overcome the obstruc- tion, but if it is not, a symphysiotomy will pretty surely do so unless the con- traction is extreme or asymmetrical. Should the child be dead, craniotomy is readily performed with the head so accessible as it is on the pelvic floor. DiagtiOKiii. — The diagnosis of a kyphotic pelvis presents no difficulties. The hump-back is obvious, and the history is easily obtained that the spinal deformity was developed early in life. The pelvic measurements diagnostic of this deformity show an increased separation of the iliac crests and the ante- rior spines, a diminished distance between the posterior superior spines, an approximation of the tuberosities of the ischiac bones, and some diminution in the antero-posterior diameter of the pelvic outlet. Care should always be exercised to detect asymmetry in these pelves, to discover an arrested develop- ment with general contraction, and to diagnosticate lateral contraction at the pelvic inlet. These complicating deformities constitute often insuperable obstacles in labor. Frequency. — The kyphotic pelvis is said to be somewhat infrequent, but the practitioner in active practice will surely encounter several examj)les in the course of his career. The writer has had under his care four well-marked cases of kyphotic pelvis, in one of which Cesarean section was necessary. In the other three delivery was spontaneous. Scoliosis. — In the scoliotic pelvis there is some degree of oblique contrac- tion. The innominate bone toward which the lumbar vertebra arc bent, receiving the greater part of the weight of the trnnk, is pushed upward, inward, and backward by the extra ]>ressure exerted npon it by the head of the femur. The acetabulum on this side is displaced anteriorly and upward ; '\ti n fe :^H:^!'v. i ?- V ,:: vfi'm^^^^m- ■:'■■» f , 'Htm''"- '" ' I m 'mm* ^ ;VK) AMI.IUCAy TEXT-liiiOK O/' OIISTKTIUVS. tho syinpliysis is ])nsli('(I over on tli(> opposite side. Tlio dcfrrcf of asyniinotrv is nirt'ly stillicieiit to constitute an ol)strnetion in laltor. The scoliotic pdvi- is, however, most often rachitic, and in addition to tlie asymmetry of scoliosis there may he the contraction of a racliitic pelvis (IM. .'54, Ki;;s. 6-S). • — — •; - , - ~ - ; Kyphoscoliosis. — In a combination i of kyphosis and scoliosis of tho spinal colnmn tiie pelvis will show, pcrhap-, the cond)ined featnres of both, hnt thi' kyphosis, heinj; of rachitic, not of carious orij::in, will not he antrnlar, and will lie situated hiirh in the dorsal rojiion, where it may he compensated for entirely l>v Ininhar lordosis (Fij;. 3.")4 ; 1*1. .'5(), Fi^. 1). Tho kyphoscoliotic pelvis is nsuallv an asynnnetrically-contractod rachitic jk'I- vis(iM. 35, Fijr.l). Lordosis. — Primary lonlosis, not the rostdt of pelvic deformity or of spinal disease, is very rare. Aside from some illustrations ^f it in an article by Xeu- ijobanor (/oc. e/V.), the writer knows of no reference to the subject except his own (Fl. 36, Fij;. '1]}^ ft may readily 1)0 seen what an influence this deformity would have upon coition and ])artnrition, and how it mii;Iit bo an insu])orable obstacle to natural completion of the latter. Anomalies due to Diseases of the Subjacent Skeleton : Coxalgia. — The deformity of the jtelvis due to coxaliiia in early childhood is of two tyj)os. In one there is an oblicjuc contraction by a dis))laceinent of the innominate bone on the hc'.thy side U])ward, backward, and inward, on account of the i)ressiu'e of the femur, the weiixht of tho body boinu- re- ceived mainly ujwn the sound leji. This form of coxalgic pelvis, as a rule, pre- sents no serious obstacle to delivery unless it is associate*! with a rachitic dei'ormity (PI. 35, Fiu". '); IM. 3<), Fiiiii\1 muscles illirst). ;>. Skil- cton of 11 \!\r\ with coxiiljiiii iMiMlicnl Muscmn, t'liiver.sity of l'fiiii~ylvuiii;ii. 1. liriii- viru. ■"•. Siiir view, of lui (il]lii|iicly-c(iiilnicti'rl pelvis, Hk' resiill nf tiiliereilliius UjsvU.H.' ill ulie knee jniut illiist). (i. Seiiliosis frcini uiiiliitenil Mti'npliy nf Ihe spiiiiil iiiusele.s (Hirst). iC : I i ^l 1 I 1' r' I 1 H 'p.i DYSTOCIA. 641 wliicli is (Irivci) inwnni upon the pelvic canal. Tlii.s (lisplaeonietit of the iiiiioiiiinatc boiif is tlic result of an arrested (levelnpment on the correspond- iiiir side of the pelvis, and is very likely associated with an atrophy of tiie siiTuI alii and an ankylosis (tf the saero-iliac! j(iint. The contraction of the pelvic <'anal is nuieh more serious in this form, and there may be all the ditliciilties in labor onconntercd in the true \ae>;ele pelvic. Luxation of the Femora. — Dislocation of the thi<;h-bones, if congenital or oeciirrint; early in childlinod and n<»t corrected, has some elfect npon the hize and shape of the pelvis, bnt usnally not onoiifjh serionslv to oi)strnct lalior. If t»ne tliijjjh is dislocated, the weight of the IxMly may be thrown r— - I'Ki. ;!;!.'). — CimKenitiil liixiitinii 111' liiitli I'l'miini : c, crest of ilium ; F, tnicliiintur of ft'inur (Henry). Kid. ;!;!fi.— ( 'use of t'onRenltal lii.\iitioii of tliu foinorii. maiidy njmn the other leg, and this may prodnce an oblique contraction of the pelvis of the kind already described (PI. 34, Fig. (j). If the thigh-bone i.s displaced forward, the anterior half of the pelvis may be driven in a little npon the pelvic canal, and the head of the thigh-bone, as in one case re])ortc(l, may project over the horizontal ramus of the pubis into the pelvic iidct{ 1*1.. 'Jo, Fig. G). In the congenital lu.xatiou of both femora backward npon the iliac boiics there is an exces.sive rotation forward of the sacrum, an increased width of the pelvic canal, and from tlu; drag of the attached nni.scles and ligaments between the thighs and the pelvis the ischiac tuberosities are ])ulle ■!. •r 642 AMERICAN TEXT-BOOK OF OBSTETRICS. patient walks, and the distanoo between the lower edge of the symphvsis and the inner body mainly on one leg may produce the same effect, as is shown in a case of the writer's (PI. 36, Figs. 4, 5), in which there was tuberculous disease of a knee-joiiit early in infancy, followed by marked shortening and atroj)hy of the leg. The weight of the body fall- ing maiidy on the sound leg, the cor- responding innominate bone is pushed upward, backward, and inward, dimin- ishing the area of intrapelvic space on Fl(i. :i:)7.— Alilfcld's (iisi' uf luxatioii nf Imtli fcmorii. Flc. ":w.— l.uxiitiiiii unci )uiriily>i.s of the ri^ilil lower liml) (Wiiii'ki'l). its own side (Fig. 33S). Torggler reports an interesting case i>f this kind in which the disability of one leg was due to scleroderma.'^ Iji the absence of both lower extremities there is the characteristic " sitz-pelvis," in which tlio innominate bones are usually rotated on an antero-posterior axis, so that the crests of the ilia are aj^proximated and the tuberosities of the ischia are sepa- rated. Minor deformities of little ])ractical importance may be the result of unilateral or bilateral chd)-foot or of the bowing of one or both lower extrciu- itios. In the former there is an increased inclination of the pelvis, an approxi- mation of the acetabula and of the ischiac tuberosities, and a narrow pubic arch (PI. 35, Fig. 8). * Pratique des Accouchemenia, iii. p. 413; according to .Scliauta, the only case on record. DYSTOCIA. 54;^ .). The Management of Labor Obstructed by the Commonest Forms OF Contracted Pelvis : a Simple Flat, a Rachitic Flat, and A Generally-contracted Pelvis. There is no situation in medicine where experience and good judgment count for more than in the management of labor obstructed by a contracted pelvis. It is extreniely difficult to formulate hard-and-fast rules for tiie ('•nidance of the inexperienced where so many factors must be taken into account. The rules given below govern the writer's practice in the average case, but due attention must be i)aid to the history of past labors, the size of the child, the age of the woman, the build of both parents, and the probable strength of the expulsive forces, greatest in the primipara and less with successive labors. If tlie diagnosis of a conjugate diameter of 9.5 centimeters or less is made (luring pregnancy, the physician must choose either inui.ction of premature labor, or forceps, version, symphysiotomy, or Cesarean section at term. If the conjugate diameter measures as low as 9.5 centimeters, it is a safe plan to induce labor four weeks before the expected termination of i)rcgnancy. This entails no additional risk upon the child if its parents are in a jiosition to afford it the best care and nursing, and it is much the safest plan for the mother, the induc- tion of labor, done properly, having no maternal mortality.* It is true that many women with a conjugate of 9.5 centimeters can deliver themselves with- out difficulty at term. Spontaneous delivery with a measurement as low as 8 centimeters and under has been recorded. But the majority of women with a conjugate of 9.5 centimeters will experience abnormal delay and difficulty in labor, with added risk to themselves and to tiieir children; and in a certain proportion oi' cases a conjugate of 9.5 centimeters proves an insuperable obstruc- tion in labor, and is the cause of ru])tured uterus or death from exhaustion in the mother or of injin-y to the child's brain. These results aii. t<» be feared especially if the child is overgrown or if the mother's expulsive powers are weak — two conditions impossible to predict with absolute certainty. For these reasons, then, the rule to induce premature labor when the conjugate is at or below 9.5 centimeters is a safe one. If the conjugate measures 8 centime- ters or under, the most successful treatment is the induction of premature labor at the thirty-sixth week, and then, if necessary, the performance of svm- ])liysiot()my when it appears that natural forces, aided, perhaps, by forceps, are not sufficient to secure the engagement of the head. By this plan the majority of women with a conjugate of 8 centimctci's or a trifle less will be delivered spontaneously or with no more serious o|)eration than the application of forceps. The conil)ination of prematin-e labor and symphysiotomy will usually be suc- cessful with a conjugate diameter at or above G. 5 centimeters. If the conjugate measures 7.5 centimeters or less, the induction of premature labor four weeks before term cannot be exjiec^ted of itself to secure a spontaneous delivery. Symphysiotomy also will be required in the majority of instances. \n such *Tlii8 statement is based upon tlio writer's exptirieiice in private pnict ice, and not upon hospital statistics. It does not liold good for labors induced before tlie tiiirly-sixtli weelt. ^.k^: W'W i? *' m Ifl-^fi 'i ^ ' h- F ' * 1 * ^^ ir" ^■' '^! C' C'l ii 544 AMERICAN TEXT-BOOK OF OBSTETRICS. In ' ' ' 'I 'i, h f ■ !l t^i I ' If cases, therefore, tlie operator may wait until term before he operates. But it the ohiUl may exj)ect good care, the writer prefers tlie induction of prematuK; hibor in addition to tlie symphysiotomy, for the following reasons : The extraction of the child after the division of the symphysis will be easier, quicker, and attended with less risk to the maternal soft structures ; the i)o.ssi- bility of an overgrown child and of a failure to extract it after the symphysis is divided is avoided ; and by inducing labor the operator may set the time iw the operation, and may consequently make his preparations without hurry or inconvenience. With a conjugate diameter of the superior strait below (J.o centimeters the woman should be allowetl to go to term and shoidd be deliv- ered by Cesarean section. If the physician sees the patient for the first time in labor, or only discovers the deformity after labor has begun, he must choose out' tlic following modes of delivery : A waiting policy to allow the cngaj,oU!ent of the head by natural forces ; the a[)plication of forceps ; the performance of version; symj)hysiotomy ; or Cesarean section. So long as the child is alive craniotomy shoidd not be considered. The selection of the best mode of delivery in contracted pelves is one of the most difficult problems in obstetrics. If the patient is a primipara and the conjugate is above 9 centi- meters, natural ibrces will in the majority of cases, provided the child be not overgrown, secure the engagement of the head,* although it may be by the expenditure of considerable force, after long delay, and oidy after prolonged moulding and an adaptation of the size of the head to the size of the con- tracted inlet by apparent anomalies in the position and flexion of the former. It is wonderfid liow successfully an obstruction may be overcome even in cases of contracted ju'ivcs with a conjugate of 8 centimeters or less. But while waiting for spontaneous i'r KaiacmchniU it. seine Stdhini/ zur kinittt- lirlii'ii Friihiji'lmrl, Wi'iiihutij, iihijiiKrhin /iDiiiiiiiiiirrdlioiirn, KraiiiitUnnir l)fi ii. zu deti nininldinii (lihurli'H, Wien, ISSS, ii. p. 144). In the Musrow Maternity there were 84 eontraeted iielves anion^r 40(10 hirtiis in lsi)4, 71 per eent. of these ciises were spontaneously delivered iKiister, Vaifntlhl. /. (,'yii., No. 10, ISflo). 1 t DYSTOCIA. 545 soft structures, he will occasionally succcctl in securing an engagement with the instrument that would otherwise, perhaps, be impossible. As a rule, how- over, it is safe to say that the choice lies between inaction and the performance of version. By the latter operation the smaller end of the wedge represented bv the child's head is engaged in the contracted inlet, and there can be exerted upon the head ciomiug last, both by traction on the body from below and by in-cssuro on the head through the abdominal walls above, a degree of force that is impossible with forceps. It is well, however, to bear in mind the dan- ixer entailed upon fetal life when version is performed in a contracted pelvis, '{'hero is a considerable risk * that the head will be retained long enough above the superior strait, or in it, to asphyxiate the child beyond revival. f Or the pressure upon the head by the pelvic walls may fracture the skull and crush the l)rain, and the force employed in extraction may break the neck. If in the judgment of the operator the danger entailed upon the fetus by version is too groat, natiu'al forces having faileil to secure engagement, and if he has tried tlic forceps cautiously without success, his choice nuist rest between symphys- iotomy and Cesarean section.;): The ibrmer must be the operation of election if the conjugato is above 7 centimeters ; the latter, in eases of greater contrac- tion. These rules for the treatment of labor obstructed by a contracted pelvis pr('sup])ose, of course, a fetal body and head of average size. This point must always be investigated carefully by abdominal palpation, although, it is most (litHcult to determine. § If the physician has reason to believe that the child is over-size, he must allow himself sufficient latitude to ensure delivery. This advice applies particularly to cases in which the operator is in doubt whether fo select syuiphysiotomy or Cesarean section. \{\ on the one hand, there is good reason to fear that the child cannot with safety to itself be extracted through the birth-canal after the former, his choice should rest upon Cesarean section. On the other iiaud, if the child is under-size (a condition easier to detect by palpation than is overgrowth), spontaneous delivery may be expected through a pelvis that would not permit the passage of a child of normal size. *Tlie infantile deatli-viUe will be at least 25 per cent., or more likely higher (Nagel, "Die Wcnihing bui engiu J5e('ken," Arch. f. iliju., I'd. xxxiv.) t Nagel reports 60 cases of version for contracted pelvis, with a fetal mortality of 25 per rent. ^ //)/le or septate uterus may complicate labor in several ways. The bulk of the i i M '1 I X 'i i.|(r Fig. 339.— rterus septus (Cruvoilhier). Fi(i. 340.— rtcTus sujitus ((irouzL'l r. tlilv MB It Fig. 341.— rtorus bicuiiiis (WiiickL'l). Fio. 342.— I'tenis didclphys. Fig. .343— Vagina si'pta (uterus liiforis). unirapregnatetl half may obstruct delivery, especially if this half is retrovortod and is increased considerably in size in sympathy with the development of the impregnated side and is hardened iu consistency by sympathetic contracti(ni DYSTOCIA. 547 tliiring the labor-pains. Tlie septum itself may prove an obstacle in labor, and sometimes labor is obstruete womb. Retention of tiie placenta is not unconunon, partly because of insufficient expulsive force, partly on account of its situation, perhaps attached in both divisions of the uterine cavity. Tlievard" reports the retention of the i)lacenta in a double uterus for fifty days, when it was spontaneously dis- charged. It has happened in cases of double uterus and vagina that the jiiivsician examined the wrong side, anated —as often as once every fifteen minutes if necessary. Chloral inter- nally and belladonna ointment applied directly to the cervix have been rocoiii- niciided, but these remedies arc not to be depended upon except in the slight rigidity characteristic of all primipara'. If there is delay in such cases, 10 grains of chloral evi'ry fifteen miimtes for three doses may advantageously Ix; given. An anesthetic, after all, is the most valuable medicinal agent that we possess for the relaxation of" this as well as of other rigid tissues. The rigid cervix yields at length to the steady pressure of the presenting part, and it is rarely necessary on account of rigidity alone to resort to artificial dilatation or to incisions. In the course of a slow tlilatation of the cervical canal and external os the anterior lip of the cervix may become incarcerated between the head and the ])elvic walls. In conseciuence of tlu^ pressure and the disturbance of circu- lation in the part the cervical tissues I'apidly become edematous, and the bulk of the anterior lip becomes so great as actually to <'onstitute a me- chanical obstruction to the descent of the head. It is usually possible in such cases to push up the anterior lip over the head and above the sym- physis in the intervals between the pains. If there is hypertrophy of the anterior lip in consequence of an old laceration and eversiou, or, all the more, should there be hypertrophy of the whole infravaginal portion of the cervix, the obstruction may become (piite serious, and it may be impossible to ])ush the ci'rvix above the head. In such cases forcible traction on the forceps or radiating incisions in the cervix may be necessary. Longitudinal septa in the cervical canal are usually seen with duplicity of the uterine cavity from failure of the jMiillerian duets to fuse completely. Occasionally the lack of fusion is confined to the cervical canal alone (uterus biforis). Rarely transverse septa have been found in the cervical canal.* It may be necessary to cut these before the child can pass into the vagina. * Cases are reported liy Miiller, IJreisky, Budin, Henry, Bidder, and Bliinc (Pozzi's Gyiw- eolixjy, vol. ii. p. •loG). Fiii. oil.— Dimlilc viiKiiin. y jzzi's Gim- DYSTOCIA. 54!) Closure and Contraction of the V .gina or Vulva. — Tlicrc may be ()l)stnu;tioii of the lower birth-canal by hjiigitiuliiial and tran.svcrso septa, by cicatrieert, by heniatoniata, by partial atresia, especially at the upper third of liie vairina, by uiiniptured hymen, by amis va m'<:i i.. t-^i' ; pr I ! |i M TmO AMi:iiIVAy Ti:XT-li()OK OF OliSTETltlCS. tlio present iii<;; part ruptured the liymeneal inenibrane without diftieultv, but it has been found necessary by othjrs to incise it.'" Atresia (if till' Vafjina. — This anomaly of developnient has its scat usualK at the upper third of the canal, where the vagina may be contracted to a nar- row trat't barely ailmittin<>; the uterine probe, or the canal may be obstructed b\ an annular membrane like the hymen. Although Cesarean section has been done for thi:< condition, the majority of eases on record have not resia of the vulvar orifice it was necessary to cut the perineal structures upward from the rectum toward the pubis in order to permit the escape of the child's head. Cydio and Solid Tumors of the Vagina and Vulva, Edema, Suppuration, and Gangrene. — In the ease of solid tunior.s excision may be neees,sary, by transfixing the palicle if they have one, and ligating it to prevent hemorrhage, or by i.n incision of the vaginal wall over them and their enucleation, followed by the immediate extraction of the child, and the control of hemorrhage by the needle and thread or by direct pressure. In the case of large cystic tumors a puncture is sufficient to remove the obstruction, (iiider" collected 60 ca.ses of vaginal tumors complicating labor — 23 cysts and echinococcus sacs, 18 fibroids, fibromyomata, and jwlyps, 14 carcinomata, 1 sarcoma, and 4 henia- tomata. Delivery was accomplished by the following diverse methods : s])on- taneously, 14; l)y forcej)s, 18 ; by version and extraction, 2; by traction on the feet, 1 ; by removal or puncture of the tumor, 16; by Cesarean section, 7 ; by induction of premature labor an avcjid them if possible, for they are apt to be Ibllowed by infi'ction and gangrene. DYSTOCIA. .5.51 An abscess of liurtliulin's gluiul is seldom large enough to retard labor, though it has done so (Miiller), bnt it is likely to canse trouble afterward. It should be opened freely in the early part of the first stage of labor, ciu'etted, swabbed out with earbolie aeid and glycerin, and packed with iothj- lonn gau/e. (langrene of the vulva is very rare before the termination of labor. Should it exist, it might determine an operator in favor of Cesarean section Fi(i. ;547.— Kdi-mn Hiul bc'Binning gangrene of the vulvn from prolonged pressure in an obstructed lubor (Hirst). in a doubtful case, on account of the rigidity of the vulvar tissues, the cer- tainty of laceration, amK the likelihood of grave infection. Enlarged Carimculiv Myiilformcs and Varicoxe Veins. — These tumors do not possess sufficient bulk, as a rule, seriously to obstruct the last stage of labor. They may, however, be so bruised by the j)assage of the head as to slough after- ward, or the veins in them may be rupturetl, giving rise to subcutaneous or fraidv bleed- ing of an alarming character. VaginisniUH may be overcome by an anes- thetic. Congenital narroxcness of the vagina and vulva is usually overcome by the ad- vance of the presenting jiart, though often at the expense of vaginal and perineal lacera- tions. It may be necessary to resort to hydrostatic dilatation, or even, in rare in- stances, to Diihrssen's plan of multij)le incis- i(>ns. In the case of extreme narrowness of the vulva there may be a central teor of the perineum, through which the presenting part begins to emerge. To avoid a rectal tear in such a case the perineum should he cut from the anterior border of the perforatiim to the posterior commissure of the vulva (Fig. .348). Rigidity of the tissues in the cervix, the vaginal wall, and at the outlet Fl(i. 348.— Central tear in the peri- neum, with CDtitraetv'il vulvar orlliee (Ivilieuiiint-Hessaignes). > ">ii ;' ^ ..\s 'h\ /\ m 1^. .•< t ] ■'.■:• .552 AMKRICAX TEXT-nOOK OF OBSTETRICS. ooeasioiis delay in the majority of all priniipara), but especially in the case of elderly priinipane — those over thirty years of age. Kokluird found the infantile mortality in such eases to he 19.81 per cent., the maternal niortalitv to be three times as great as in younger primiparje ; and the necessity for operative interference increases steadily with the age of the primipane until, in those ])ast forty, alnjost two-thirds are delivered by some operative pro- cedure, usually forcejis. Craniotomy should be done if the child is dead. A^'ersion is the least successfid ojjcration in tlii'se cases. Displacements of the Uterus. — The uterus in labor may be displaced forward; to either side ; downward; or backward, by the so-called "saccula- tion " of the womb. It may b(! twisted on its ])etlicle, the cervix, or it mav form part of the contents of a hernial sac in inguinal or ventral hernia. Anterior Dkplaccment of the Uterus in Labor; PetuJiUous Belly, — This is a Fit;. :M'J.— Hernia of the t,'riivi(l womb through tlie liiieii alba common anomaly in labor, seen to some degree in all cases of obstructed labor, as in deformed pelvis, and in all cases in which the length of the abdominal cavity is decreased, as in kyphosis. A peculiar example of forward displace- ment is seen in those rare instances of hernia of the parturient womb between the recti muscles or to one side of the median line during the second stage of labor (Fig. 345)). The pregnant wond) may fall forward also into an umbil- ical hernia or into a ventral hernia following celiotomy. The removal of the obstruction to labor in the first class of cases will or- dinarily obviate the anterior displacement. If the displacement depends not upon obstruction, but upon flaccid abdominal walls, the application of an abdominal binder surely corret^ts the anteversion. In cases of hernia of the uterus through the anterior abdominal wall artificial delivery with forceps or by version may be necessary ; when the uterus is evacuated it can easily be returned into the abdominal cavity. A tight abdominal binder and the dim- DYSTOCTA. 653 inntion of intra-alKlomiiml pressure after delivery will proinoto the a|>|)r()xima- tiou of the .scjiaratod recti museles. In iiifjninal hernia the pre<;naiit womb in the hernial sac is ustially unicorn «>r hicorn (Fij^. .".oO). Delivery may ho eH'ccted hv version, anil this may he followed by a reduction of the hernia, l)ut it is hest to lay open the sac, incise the womb, extract its contents, and then amputate it.* Lateral Dlxplacemeni, — A tilting of the uterus to the right side is a phys- iological occurrence in pregnant and parturient woiuen. The lateral inclination is sometimes exaggerated to such a degree that a great ])art of the expulsive lurce is lost by the propulsion of the ])resenting part agan'st the lateral wall Fiii. ;!5(l.— Innuiiiiil luTiiia coiitiiiiuiig a gniviil womb (Wiiii'kol). Flu. ;i')I.— Saci'ulatinii of tlie uterus (Oldham). of the pelvis. The displacement can be corrected by turning the woman on her side — usually the right — toward which the fundus uteri is inclined, and placing under her flank a rolled blanket or a pillow. Sacculation of the Uterux. — A baiikward displacement of the gravid womb in rare cases goes on to full development by what is called '' posterior saccula- tion," the di.stention of the uterus to accommodate the full-grown fetus being accom[»r.shed by stretching the anterior uterine wall, the posterior wall and the fundus remaining fixed within the pelvis (Fig. 351). In these ca.ses the cervix is high above the jielvic inlet and is pressed close against the anterior abdom- inal wall, the posterior vaginal wall bulges outward and downward, and fetal parts can be felt through it with a distinctness that suggests abdominal preg- nancy. Cesarean section has in one instance at least been performed on account of this anomaly, but a study of recorded cases .shows it to be unneces.sarv. By the artificial dilatation of the cervical canal and the perfi)rmance of podalic version delivery can be effected without difficulty. Partial Prolapse vith Hjipertrophic Elongation of the Cercix. — Tt is irapos- * Adams'"' lias collected 10 cases of ineniiial hernia of the fri"iviil wonili, iiicliiding Dor- ingiiis', >vhicl) iie calls "trural." In eight Cesarean section was done. In one the delivery was spontaneous. -^l-- isl N( i If |i. I- " ! I '1 P, H :!'!*;■ 564 AMrJilCAX Ti:A"r-JiO()h' or OliSTKTliirS. sil)l<' for projiiiaiicv tn uroccod tc toriii with coinplcti' j)n»Inj)si' of the woiiil), although the size of tlu' iitcriiic tiiiuor projci'tiiij,^ from th(; vulva in some cases Fi(!. 3')2.— Prolapse atment for labor obstructed by carcinoma of the cervix, and this operation should be selected if there is guod reason to doubt the j)ossil)ility of spontaneous or artificially-assisted delivery by the natural passage-way. The woman's life is surely doomed in the near DYSTOCIA. 557 future, and the child at any rate should be saved, even at considerable risk to the mother. It may be desirable to operate before the fetus has reached maturity if the disease is making such rapid progress that the maternal life ia not likely to endure until the natural end of pregnancy. Fibromata. — Fibroids of the uterus and cervix low enough in situation to l)ooonie incarcerated in the pelvis are likely to constitute insuperable obstruc- tions in labor, besides complicating parturition by favoring abnormal positions of the child, by predisposing to adherence of the placenta, to prolapse of the oxtremities and cord, and to hemorrhage during and after labor. If the tumor srows on the anterior wall of the uterus, the first few labor-pains and the con- traction of the longitudinal fibres of the cervix may dislodge it above the pel- vic brim, though it had been impossible to do this before by manipulation. The writer has seen one such case. It is also possible for tumors on the ante- rior wall of the cervix to be pushed out of the vulva in front of the presenting ])art, thus making room for the escape of the latter. \\\ however, the tumor is situated laterally or posteriorly, its artificial displacement upward into the abdominal cavity, so that the child may escape jiast it, is often imprac- ticable (Kig. 357). On the contrary, the attempt at descent of the present- ing part in labor must fix it more firmly in tlie pelvic cavity.* In this case, if attempts under anesthesia to dislodge the tumor and to push it above the pelvic brim fail, a Porro- Cesareau t)peration should be per- formed, even though the tumor is not of such great size as absolutely to |trevent the delivery of the (ihild. The physician nuist consider ti-.c etfeet upon it, owing to its low vit.ility, of the pressure to whicii it will l)c sub- jected l)v dragging the child past it (Fig. .■J5S). Sloughing, gangrene, and fiital infection are likely to follow. This was the history of the case illus- trated in Figure .'55S, communicated to the writer by J)r. J. P. iSii;ipsoii of South Carolina. If tlic fibroid is submucous and grows from the cervix, it may be eimcleated when labor begins. The bed of the tumor shoidd be packed with gauze after labor, f * It is !i:iivly possible tliat ii tumor low down on tlie posterior wall of the eervix, tlie most 'iiifiivoriible of all positions, may lie siiildenly elevatetl after many hours of lalior, and thus allcnv a spontaiieons delivery; lint this I'vent is not to he counted (>n in ]wactiee. tSulnf;in is an cntiuisiastie advoeaie of vauinal (i|ierations for all cases of liliroids impacted in tlie small pelvis. For intraniura! tnniors the cervix is split until the tmnor is reached. For suhseroiis tnniors the vaginal vault is opened. Nine such o|)eralions,<((fc partn are rejiortcd, with only one death {Jahvenb. ii. d. (•'oi-I.'-tIi. a. li (iihicle drr Gehitituh., lic, vol. v. p. 17')). Vu;. Ij.'is.— Small liliniid past which the child was cxtracteil. The tiiiiKH' l)ecMiiie jj;angreiiuus and the woman died (Simpsdu). ' 1} J 't'j t .' 1 r : m * • :■;:;■ w ^''•er cent, for the children.^^ Poljipi. — Polypoid tumors obstructing labor usually spring from the cervi- cal canal or the anterior lip, and are mncous in character. They may, however, be fibromyomatous, fibrous, or sarcomatous, and may have a situation high in the uterine cavity or in its wall. They may increase very markedly in size during pregnancy. Their pedicle is usually small, and in the case of cervical poly])s their removal is easy. The operation should be postponed, however, until the woman falls into labor, for any operative interference in this region would very likely interrupt gestation. When the dilatation of the os begins the pedicle can be transfixed and ligated and the tumor be cut awiiv. Even if these growths are not sufficient in bulk to obstruct parturition mechanically, they have been known to give rise to jirofuse hemorrhage in the first few days of the puorperium, and their removal is desirable, therefore, even though they be small in size. In the case of fibromyomatous polyps of the uterine body, the tumor has on rare occasions been torn from its pedicle during labor and expelled in front of the child. Tumors of Neighboring- Organs. — Ovarian OyMs. — An ovarian cyst is a rare complication in labor. In 17,832 births in the lierlin Frauenklinik an ovarian cyst was fi)und only five times. Tiie number of abortions in preu- nancies complicated by ovarian cy^ts is somewhat larger than common, but still a large proi)ortion of these cases proceed to term. Of 321 jiregnancies complicated by the ])resence of ovarian cysts, there was premature interruption in fifty-five (Ucmy). If the cyst is discovered during pregnancy, its removal should be attempted. Ovariotomy during gestation is not necessarily a dif- ficult or dangerous oju'ration, nor does it, as a rule, interrupt pregnancy.* It' * Dsirnc has collected statistics of IS.") operations with a niorfality of ").() per cent. I'roK'- naiicy is interruptwl hy the operation in about 20 per cent, of cases (Flaischlen, ZfitachriJ't /iir Geburlshillj'e, xxix. p. 49). DYSTOCIA. 559 tlie tumor is first discovered after the woman has fallen into labor, and if it lias become displaced downward into the pelvic cavity and is incarcerated, resisting all efforts to displace it upward even under anesthesia, its puncture through the vaginal vault, after a thorough cleansing of the vaginal mucous membrane and with a thoroughly aseptic technique, is said to give the best results. It is a matter for serious consideration, however, whether Cesarean section followed by the removal of tne tumor is not better. It is the writer's conviction that it is. By this plan many dangers in the pucrperium are escajjcd. Twisted pedicle, intracystic bleeding and shock, occlusion of the bowels, rupture of the cyst, suppuration of the cyst-contents and consequent ])eritonitis, are all surely avoided. A number of cases treated thus should give a better mortality record than has hitherto been secured. In Heiberg's statistics of 271 cases there was a maternal mortality in pregnancy of more than 25 per cent, and a fetal mortality of more than G() per cent. In deliv- eries by forceps without puncture of the cyst the maternal death-rate has been 50 per cent. ; with puncture almost as great ; and after version without punc- ture more than 50 per cent. Flaischlen recommends the vaginal puncture, or if necessary a vaginal incision and thorough evacuation of the tumor, then the delivery of the child, and on the ft)llowing day at the latest an abdominal sec- tion for the removal of the tumor. This procedure does not seem to the writer so good a ]>lan as the coincident Cesarean section and ovariectomy. Should the physician prefer vaginal punctuie — which requires, of course, no .'ipocial surgical skill — he should remember that if the tumor be densely adhe- rent, possess thick walls, and possibly be a dermoid cyst, puncture through the vaginal vault is likely to be folk)wed by gangrene of the tumor-contents and walls and by general infection. This will necessitate a hurried abdominal section in the pucrperium, with the patient in a bad condition to endure it. Moreover, if the cyst is multilocular, it may be impossible to reduce its size sufficiently by vaginal puncture to permit the delivery of a living infant. The writer has experienced both the disadvantages of this plan of treatment. Spontaneous delivery in spite of an ovarian cyst incarcerated in the pelvis lias been noted after the cyst ruptured, after it had been spontaneously dis- lodged upward above the brim, or had perforated the vaginal vault or the rectum. As an ovarian cyst must be impacted in the pelvis to obstruct the delivery of the child, it is easily understood that there is more difficulty and danger in labor from a small than from a large tumor (Fig. 350). After the child is born a cyst that had before been above the brim may descend into the pelvis and obstruct the delivery of the jilacenta. Vdc/iiKil Entevocdc, — Vaginal hernia is a very rare obstruction in labor. The writer has been able to collect but 27 cases from medical literature. Of tliese, only two were anterior enteroceles ; the others were lateral and ])osterior. The distention of the hernial sac in labor is apt to become excessive, and to tlu'caten its rupture with protrusion of intestinal loops. An effi)rt should bo made to nMluce the hernia as soon a:* it is discovered. The reduction may be facilitated by placing the woman in the knee-breast posture and by inserting ajl iwJ, f 4» : t aT iti 560 AMERICAN TEXT-BOOK OF OBSTETRICS. the wliole hand into the vagina. If this treatment is instituted in pregnancy, it should be followed by the insertion of a large tampon or a globe pessary and by prolonged rest in bed ; in labor the presenting part should immediately be brought down past tlie hci'nial ring. If there are adhesions about the latter, preventing the reduction of the hernia, the tumor should be supported and held to one side by assistants while the child is artificially extracted by forceps or after version. Should the sac rupture and the intestines i)rotrude, the child must be delivered hastily, the intestines be cleansed thoroughly and re])laee(], and the opening be sewed up. In the case of a very large irreducible vaginal hernia the writer's preference would be for Cesarean section in a labor at term. Other growths or tumors in the lelvic inlet and cavity obstructing labor have been fibrocystic tumors o^ the ovarian ligament, requiring an abdom- Fic. ;5,jt).— Oviiiiiiii tiiMiiir iiiciiictTiitc'cl in tlio pelvis (liiriiiK liilior. Fio. SfiO.— Cysldcc'lo (ibstruc'tinf; Inliiir. inal section ; fibroma of the ovary ; sarcoma of the ovary ; a displaced adherent kidney at the pelvic iidet, nocossitafing version and forcible extraction;* hydatid cysts of the pelvis, demanding Cesarean section; a displaced and enlarged spleen ; masses of exudate ; and an aneurysm of tlic gluteal artery. Cvstocolpocele and I'ectocele should be re]>lac('d if they protrude to a great extent in front of the head, and i)e held back until a forcej)s is applied and the head is brought past them with the iiistriunent (Fig. 3G0). Version and extrac- tion have occasionally been found necessary. T^arge fecal masses in the rectum must be removed by an enema or must be dug out.f Calculi in the bhi'ltler should, if possil)Ie, be discovered and removed by the urethra or by vaginal lithotomy before the second stage of labor. They may become nipped between the head and the pubic bones, and pinch a hole through the anterior vaginal * Kiinpe reports fdiir ciises ( Arrhir fiir Gjiniikrilo./li; xli. p. 'J9). Tlie writer liiis liiid «iih'. All)ers Sclioenberg reports aiiotlier in wliieli the uterus ruptured {Ci-iitrnlblnll fiir Giiiiiiknloiiii, Dec. 1, 1S94). t Corradi tells of a ease in wiiieh seven jiounds of iiardened feces were removed i)efore the woman was delivered, DYSTOCIA. 561 gnancy, it »sury and (liately he the hitter, )()rte(l and by forceps , the child rephiocd, le vaginal I hibor at ting labor lU abdoni- ip labor. displaced I forcible section ; a ,sm of the to a great h1 and the nd extrae- he rectum u! bladder )y vaginal d between or vaginal las liiid villi". (IjliiiUcohti/ii', (I hefoiH' the wall and bladder if they are overlooked or neglected.* The diagnosis of vesical calculus in the jiarturient woman appears to be somewhat diflicnlt : it has been taken for a pelvic exostosis or some other pelvic tumor, and in one ease at least Cesarean section was performed on account of this mistake. For- tunately, vesical calculus in the female is rare. In 10,000 women examined by Winckel in fifteen years it was found only once. The following conditions in and about the rectum may present mechanical obstacles to delivery : Cancer, anus vestibularis or vaginalis, foreign bodies, eoiitractioii of the levator ani muscles, benignant tumors such as cysts of the rectum, ovarian cysts which have perforated the rectum, and retro-rectal dermoid cysts. Each of these conditicnis must be treated according to the individual indications. Incisions in the perineum may be reciiiircd, foreign bodies must be removed, resisting muscles on the j)elvic floor may be over- come by an anesthetic and by the application of forceps, and cystic tumors siiould be punctured or removed after ligation of their pedicles. Cancer of the rectum may demand the performance of Cesarean section by reason of the size of the tumor and the cicatricial infiltration of the birth-canal, as in KrcHuid's case. 7. ()nsTuu(;TioN in Lauou on thk Part of thk Fktus. Overgrowth of the Fetus. — Excessive overgrowth of the fetus is rare. The writer searched the records of more than 1000 children in the Maternity Hospital of Philadelphia before he found one that weighed more than twelve pounds; weights, however, of fifteen, sixteen, eighteen, twenty-three and a half, and twenty-eight and three-quarters pounds have been recorded. The causes of overgrowth in the fetus are prolongation of pregnancy, over-size and ad- vanced age of one or both parents, and multiparity. Rarely it may be inex- plicable. The first named is in the writer's experience the most common cause. In 6 per cent, of women pregnancy may be expected to bo prolonged beyond the three-hundredth day, and for every day that the fetus is retained in the womb beyond the usual time there is commonly some little increase in its size and weight above the normal. So much diffi(ndty and danger may be expe- rienced from tbis cause that it is a good rule in practice to allow no woman to exceed the normal duration of pregnancy bv more than two weeks. By induc- ing labor at that time one will occasionally interfere unnecessarily, but he will often avoid complications and difficulties of the most serious nature. Over-size and advanced age of oiu; or both parents may be a cause of over- growth in the fetus — the latter usually because it jiredisposes to a prolonga- tion of pregnancy. It is commoidy asserted that the size of children increases in successive pregnancies up to the fourth or fifth, and then remains stationary * Kotschurowii has reported a case in which labor lasted three dins. .\t the end of that time a Ki'iik^rcnmis tumor protruded from the vulva, which tumor proved lo he the bladder and anterior vaginal wall. Tiie midwife in atteniiiiiiee iif^rforated the tnrnor with her linger, where- upon a calculus eighty-five grains in weight wiis discharged (JdhresbcrichI it, d. Forlschr. n. d. G.hietc ikr 'leburtxh., etc., vi. 225). If I i- ! 1 1 ii s *, I !: Ii I • ! , I i 562 AMFJilVAN TEXT-BOOK OF OBSTETRICfi. or even (lecroa.scs ; but theiv arc important exceptions to tliis rule. The writer has seen the teulii child va.stly exceed in size the nine preceding; it weighed Kiu. ;!(')l.— Dlcc'plialus Flu. Sfi;!.— rioi'plmliis. ^I'^f'^^^^^^^ Klu. ;'>(;4.— Cninio|iiiKi'^ Kiu. ;it)5.— Isdiioim.mis. fifteen pounds, and it was necessary to deliver it by Cesarean section. The other children had been born naturally through a flat pelvis with a conjugate Kici. ::i;ri.— lii|iyiriis iWrlls). Ku;. ai". — Diiiygus imrasitlods. diameter of i) centimeters, 'flic increase in size of successive children mu-t bi' bonic in mind in cases of coutractcd ju'lvis. The first two or three inhuii> I ! feJ DYSTOCIA. I'l.ATK ■HI " ■' ■^''- M ■HI I I. lii|>niso|iiis (IIii>l mill rirrsnlV ■_'. |ii|.rciMi|iii- i I'lr Hirrl.lulhl-, I. I. Ilur I'S-lir kii|ll(V> il''ilssrlli. :>. l.iirui' nu'MiiiLMccli' niul >|iiiiii Mllilti illirsi .iiliI I'IiTmiIi. h. ( ■..ii'jmil.il i\ ^lir ili|!liiiiiiiiisi> iWilsmi). 7. riiiirii<'(i|iiiyiis illii'st ami l'ii;i-siili. s. |ii>toiiil(il liliuMiT (Alillclili. I i i. .[ MIMI IWldll ■ ! 1 . i y J H^^^^^^^^BJPIWgi .,1 I I .11 M • tV- t^ 'f |! i m >f J-i 1 g I I f! y DYSTOCIA. 663 niav be delivered spontaneously, bnt the larger size of the fourth or fifth may make natural delivery impossible.* Overgrowth of the fetus is the most difficult condition in obstetric practice to diagnosticate with precision. A careful palpation of the head and body and an attempt to pusii the former into the pelvic inlet may give one an approximate idea of the relative size of fetal body and pelvic (jaiial, but as a matter of fact the large size of the fetus is usually discovered .. practice only ^'f^^-. Fill. 3C8.— Prosopothoracopagus. l''i(i. 3G9.— Xiphopagus. Fi(i. 370.-Janicops. after prolonged delay when attempts at artificial delivery^ especially by version, have failed. By this time the fetus is commonly dead, and should be deliv- ered by embryotomy. But the ])raotitioner nuist be on his guard again.st futile attempts to deliver an infant too large, even when mutilated, to pass through the pelvis. The writer has seen in consultation practice several maternal deaths due to this cause. Prcmafure Omfieation of Cranium; Wormian 7?onps;t Larr/e Heads; Mal- formations and Tumors of the Fetus. — No single rule of treatment can be laid down for the management of these ca.«es. Forceps, version, or some form of emljryotomy is usually demanded. Spontaneous labor, however, is jw.ssible even in ea.ses of monstrous bulk in which delivery through the birtli-eanal woidd seem out of the question. Thus in double monsters Joinoil loosely by the front or back (xiphopagus, the Siamese twins ; pygopagus, the Hungarian sisters), one child will be born by the head, the other afterward by the breech, or tnce nrsa. In dicepluili one head may be pressed into the neck of the other or may rest upon the iliac bone till the first head makes its escape from the vulva. Even in thoracopagus, the commonest double monstrosity, in which two trunks * I.rliiiiiinn in 712 Inbors tlinuiKli I'JS contracted pelves foinul increasing difliciilty in de- livery with eiich siiceeedina; lal)or. In first lalinrs 50 per cent, ended spontancc)iisly ; in second, 4li.S ; in fimrti), 3iS.4 ; in fifth, '•i'ih'j ""il in labors after the fifth only '••.S per cent, (fiitiitri. />)'.<., Berlin, 1S91). t Or. (trace Pcckani (AVic Yark- Mi'dknl liimnl, April 14, 1SS8) has reported three still- hirths, attrilinted in each instance to the development of Wormian hones in the smaller fonta- nelle, and to the conse(|ueiit interference with overlapping of the cranial bones at the sutures. This ob.scrvation ha.s not vet been verified bv others. i*^iK-': !'t 1 ^ f lilt ^, i f i , 1 I li' i .5(54 AMKRICAN TEXT- HOOK OF OJiSTETIilCS. arc iiitimatJ'ly joined front to front (IM. ;}7), spontaneous labor is possible by the inechanisin siiown in Fij!;ure.s .'>74 and 875. On the other hand, the {great- est dillieuity may be eneountered in hibor, and the most sei 'oiis operation may be demanded to deliver the woman.* Fetal tumors obstrueting delivery may be hydreneephaloeeles, lymphan- giomata, myxomata, saeral teratomata. Cystie tumors should be ptmeturcd. Solid tumors may call for version or for embryotomy. C'ranioton)y may be re- <|uired in monstrous eidargement of the eephalie extremity, as in syncephalus or in diprt)sopus. Decapitation may be neees- sary in duplicity of the cephalic extrem- Fk;. 371.— Myxoma of Fif;. 37'J.-Siicnil tumor (Miittcr neck (l.oiiKuktT). ilus., CuUfgc iif I'lijsiciiiiis). Fui. 371.!.— Annsiirca. ity, as in dicephalus or in thoracopagus. In Keina's case of tricephalus the first head was perforated and then amputated, the second was perforated, crushed, and amputated, and the third was amputated. /^- 5n Fui. 374.— .Meclianism of labor with dicophalus (Kiistner). Ki(i. 375.— Mi'i'hanisni of labor in thora- copafius ^Kiistnl'r). Diseases and Death of the Fetus. — All diseases of the fetus that increase * Tlieri" are two recorded deliveries of thorucopagi by Cesarean section (Hirst and Piersol, Human Monstroaitks). I)YST(MIA. I'l.AiK :iK. lossiblt' by tlu' <>;r('iit- ratiun may lyniphan- j)unctur((l. rc'ii ( pliaUis till' perlbrated, in tliora- hat increase :st ami I'iersol, t. Ski'Ii'tiiii (if lijilroi't')ilmliis (tlirsl ('(illcrtiim, I'liiviTsity nf ri'iiiisylviiiiitii. 'J. HyclincciilmUis illirsti. :i. Uyilrciici'iiliiildrclc pDstcrinr illirst iiMil I'iorsiili. I. llydrci pliiilni>ilr Mi|iciiur. :,. llyilni- ci'liliiiliis ilisti'iiiliiiK IdWor utcriiio sokiiumiI ( Viiniicri. ti. Tti|i|iiii'^' ti liy(lriiccpliiilii> iIhuiil'Ii the spiiml ciiiiiil. i- 'M iff. •'., . li !■ (, "/■•. ,, 1 !'^ I f m'iJ 1 I t i-, ■; t'^'-' i' •H I ■'. :.i't i'i' li, -I J 41 -I a 1 r - y. "^^ \ U: i ■ .1 ; 1. 1^ DYSTOCIA. 505 its bulk may constitute thcrohy an obstrut-tioii in labor. Cystic tumors, ctTu- sions in tlic serous cavities, anasarca, an enlarged liver, polycystic disease of the kidneys,'" and distended blad") births; I.achapelle and l)uu;es, fifteen times in 43,555; ilerriman, once in 000. In 159 cases tiiere were 38 maternal deaths, twenty of which were from rupture of the uterus. V»;fr TTTV Si *!f1^-»' ! • ■■ If ,-' nw I Hi .5()() AJfJ'JJilCAA TEXT-BOOK OF OliSTETRICS. llio largo sizo of tlio head appreciated hy biiuauiial exaniiiiatioii, and possihlv tile abnormal mobility of the cranial bones, and in some cases their extreme temiity, indicate the ct)niliti()n. irydrocej)halns is very oltcn overlooked in jM'actice as the resnlt nsnally of a careless, snperficial examination. A pains- taking and methodical investigation of a suspected case shonld avoid this error. There are cases, however, in which there is no increased width of the sntnres, no enlargement of the Ibntanelles, and such slight enlargement of the head that it cannot be appreciated; and yet the Hnid contents of the cranium j)revent coinj)rcssion of the skull and make the engagenu'ut of the head impos- sible. The writer has seen one such case. Hydrocephalus should always be suspe<'ted if the head in labor remains above the brim, although the j)elvis is nt»rnuil in si/e and no good reason can be found for the failure of engagement. The traitiiK lit of labor obstructed by hydrocephalus 's puncture of the cranium with a perforator and evacuation of its fluid contents. A child with this disease deserves no consideration. Alter the reduction in the size of the head the labor n)ay be left to the natural forces. If these prove insulllcient, a cranioclast may be fastened to the skull and the child be extracted artifi- cially. A cardinal rnle in the treatment of these eases is to avoid attempts to deliver with forceps — a common error in practice, and one that has cost many a woman her lile from ruptured uterus, from tleep tears when the instrument slips, as it will, and from extensive sloughs after delivery. If the pelvic extremity of the hydrocephalic fetus |)reseuts — as it does in almost a third oi" all cases — and if the head remains inaccessible above the superior strait, so that it cannot easily be piuictured, the spinal canal may be ojx'iied, a catlu'ter be passed throngh it into the cranial cavity (Van Iluevers methoil). and the fluid thus l)e evacuated (I'^ig. ;}7()). Tsually, howev<'r, then- is no special dillicidty or danger in tlie delivery of the afler-coming head of a hvdrocephalic infant. The force n^piired tor its extraction not infre(piently ruptures the walls of the ventricles and converts the case into one of exlci-nal hydroce])liahis, or possibly drives the lliiid out of the foramen magnum into th(- tissues of the neck and back, so riMlucing the bulk of the head as to per- mit its extraction. At any rat<', the condition can scarcely escape the notice ot' the medical attendant, and a diagnosis is made before the lower ntei'ine segment is dangerously stretched or ruptured. The diilicnlty in the delivei-y of a hydrocephalic fetus is not in direct pi'o- portion to the (piantity oi' lluid in the ventricles ;;nd the si/e ol" the head. In eases of extreme distention (he cranial vault is likely to rupture, while in moderate grades of hytlrocephalns the (piantity of brain-substance surronndii\g the ventricles and the strength of (he brain-membranes forbid (his means of spontaneous delivery. M(i/jirifti'iiltifiniis inul Jitiilhi posilions (1*1. .")!>) include shoulder, face, brow, deviated vertex, and compound presentations. All but the last are considered elsewhere. \>y compound presentation is meant, the presentation of two or more parts at the same time, as a head and a hand, a head and a foot, a hand and a fool, nuchal position of the arm, or the head and all four ex(remi(ies. DYSTOCIA. I'l.ATi: ;?!). iiiraircMiicnt. , lace, hniw, (> coiisidcrcil 1 ol' two or Coot, a liaiid ti-ciniti('s. m I If: I 1 K'' li if'i H" ; a-. j 1 r ■ i ■ i i'-. - I. J Nile l|,-|l |.nsi|i |- iin ■'i. l''illl|PUUIIi| l.liM'lllluicill. 'I'M 11.1 |ilVvrllljlinlM.Mll|iMi I (' |..ilni.| |.lrMlll,lli,.|| l|||t>l) ; t ! ."! ( ' 'i M m DYSTorlA. I'l.ATK 10. I.'J. 'I'wiiis, triiiisvcisf iiml liirr<-li. :',. 'I'h iti.-. \",[U (i;iii^\rr.-v. 1, Tuiii-^, In a. I anle from Spiegelberg, based on 1 1;!r.se position is found in 1().G7 per cent, of cases. .Mcchauiciil dillit'idties in hibor are fre(|uent, the uterine muscle is usually weakened by overstretching, ;ind there m;i, le trouble in the third stiige of lai)or in the 7.s.— l.dcliiiig of lu'.-iils in twin liibor. head of the second diild is cautj;ht by the chin of the first and pushed into the pelvis (Fioj. 378) ; one child sits astride of the other, which is transverse. If both children should be found atteniptinoj to en>z;a<>;e ity the head in the superior ^ strait at one time, one child should be retarded while the other is artificially extracted. If this is impossible, the first head should be extracted by forceps, the second be treated in like manner, and then the trunks should be delivered one after the other. Embryotomy is a last resort, but is scarcely ever necessary. A eoilint; of the cords (Fi^. 379) and their eii- tano;lemeut may be a source of difficulty and delay in iniioval twins. It may be necessary to cut one or both cords between ligatures before the children can i)e delivered. In cas(> one child pres(>nts by the head and the other by the feet, both may come down together, and the two heads, the child presenting by the breech should be extracted immedi.atcly, for it is in immi- nent DYSTOCIA. 669 111 any case of twin labor, as soon as the first cliild is born, and the oord, liirated with a double ligature, is cut, the attendant should ininiediatily inves- tiirate the position and presentation of the second eliild. A negleet of this rule loads very often to the inipaetion of an unreeogni/ed shoulder presentation in the mcond child, and its eonsecjuent death. If an abnormality is discovered in the presentation of the second child, it should at once be corrected. Then, after wait- ing perhaps half an hour, the anuiiotie sac should be ruptured, and ergot may be administered in a full dose to secure a speedy delivery, or, if the stomach will not retain it, the hypodermatic svringe should be used, for, the birth- canal having been dilated thoroughly, there is no obstacle to the birth of the soc(md infant in twin lab(»rs, and con- sequently no objection to the employ- ment of ergot, which not only hastens the conclusion of labor, but j)romotcs subserpient contraction of the much- distended uterus, and so prevents ])ost- ])artum hemorrhage. As a further ])recaution against this accident the fundus shoidd be compressed for a long time after birth by the nurse. There may be difficulty in the delivery of the placentte in twin labors. Commonly the children are horn first and the placenta; .'ifterwavd. Their bulk may make expression dif- ficult, and it is oflen necessary to make some traction upon the cords — first upon one and then upon the other — to determine which j)lacenta will come first and to assist in its expul- sion. Occasionally one and rarely both placciuje may be expelled after the birth of the first child. Tn a case of the writer's the ])laccnta of the first child, prolapsing in front of the second, necessitated a dillicuU forceps operation titr the extraction of the second. On account of the frequent and extensive anas- tomoses between the vessels of the placenta* in unioval twins it is a necessary precaution to tie the cord of the first child with a double ligature and to cut it between the ligatures; otherwise the second infant might bleed to death. The prof/)ioNi,s of twin labors is always doubtful. There are so many possible dangers for both mother and childnMi that nudtiple labors nnist be regarded as distinctly pathological. Albuminuria in the mother is the rule in multiple pregnancies, and eclampsia is ten times more frequent than in single births.* There is a disposition to inertia uteri during and after birth from distention * Of 027 cases (if cnlatii|isi:i, sixty-iiino were multiiile iin'jjiiiuicies (Wiiu'kel). iNi.— Twins, linid iiiiil hrci'cli. if M ! . t ' if U' 570 AMEBICAN TKXT-liOOK OF OB:STETRICS. ^■:\. I III of the cavity, aiul ('oiiso(|iioiitly a likelihood ot" post-partiim hoinorrhago. Some operative interference or iiitra-iiteriiie iiianipiilatioii i.s called tor in about 25 per cent, of cases, and this, in addition to tiie frecpicncy of kidney insufficiency, pre- disposes to sej)sis. Finally, there may he insiij)eral)le obstruction in labor if locked twins are not nianau;cd properly, and the woman may die of ruptured uterus or of exhaustion. The maternal mortality in the Budapest iNIater- nity was foiu' times as ;erated pain at the jjlacental site, marked r('<'cssion of the head after each pain, and an obvious retardation of labor I'lii. .Jxl.— rinliilical imuiI. cuu'-.'lit in llio iixillii, (■iH'ii'cliiiu' llu' shnuMiT iiiul iimlupscMl. without otiier ascertainable cause. Forceps sliould be applied in such a case it' the prcsentati(»n is cephalic. If the cord is too lonu', it may possibly prn- liipse slioidd there be other conditions in the labor I'avorablc to stich an ai'ci- ilctit ; or it may l)e coiled about the child's neck, tnud<, or extremities, and may cousecpieiitly be fatally com|)ressed duriiiti' labor ( Fi>i'. 381 ). Obstruction of a mechanical character in labor on the part of tln^ placenta i-^ seen only in placenta pnevia and in jirohqwe of the placenta. The placenta may be adherent as the result of syphilitic or other inflammation of the cikId- iiH'triuni durinti' |)retaij;e, i -:|; im iv I a~. 'St' r i B*; I i>h nm \'' '^'jw' ' ^m ii: i I fW, r,72 AMKRIVAN TEXT- HOOK OF OBSTETRICS. may cause alarming liemorrliago. It i.s very commonly .simply retained in tlic lower uterine .segment or in the vagina, whence it may be cxpresised by the proper application ot'Cre(le'.s method. In .some cases the atmospheric pre.ssiiir obstructs tiie delivery of a retained placenta .so ett'ectually that it is necessarv to hook one's finger over the edge of it, to allow the a(!cess of air behind it. before its expre.ssiitn is possible. Retention of the placenta may be due to its great bidk, as in twin placenta;, or to tumors increasing its size. In such cases it may be necessary to extract the placenta manually. REFERENCE LIST. 10. 11. 12. 'I: /)((.'( rn(\e Urrkrii. Lit/niann ; " Drei VortriiKe iiber die (iesi'liiohte von der Lclire der (lehiirt bt'i I'liffi'in lic'fken," in Iiis Ueburt bei ('iit/nii Jicrkrii, tic, 1884. Tr(innactioiii< of the American Gynecological Sodrti/, 181)0, p. 8()7. Miilli'r'.s llunilhnck. Robert Wallace John.son : ^1 AVic Si/nlem of Midu'iferij, etc., London, 17(1!). Hirst : I'niirrsit;/ M,/.«. liKutf/., Miincbcn, 1878 ; " Ziir Kentniss der extra-median Einstellinii; de.s Kopl'es," Kobn, Vraijer ZeitKehrij} flir Hrilhtnde, Bd. ix. rrai/er Ziitichriftfiir Heilkumle, I5d. ix. II. 4 and •"). Die ILiftelherf/er kliiti^chen Annalen, I5d. x. ]). 44i). .More elaborately described in his folio atlas, Jhis Selirii;/ reretii/te Jieckeii, tiebM eineni Anhaiuj iiber die irich- ti;/nte)i Fehler des Weibl, liee/cetin l^eber- liaupt, mit IC) Tallen, Mainz, 18;}.7. Stiiilil di (Mefriria e (;iiuTi,l., .Milan, 18<,I0, Jahrc.fherirht iiber d, Furtnehr. b)on the Shape and Size of the Pelvic Canal," UiiieerKitj/ Medic(d Mmju- zine. Centr(dbhitt fiir Gi/niikohfiie, 1889, [i. ()12. XouvelleK ArchircK d' Obxtctriiine et de Gijw'- coloi/ie, 1890, p. C40. Soutbermann : lierliner medicinixche W'url,- ensrhrijl, 1879, 41. Jeutzen : Archives de Tocologie, Paris, 189it, If. 8. Ablfeld : ZeituchriJ't fiir (leburtahiilfe uml Gijniiknlogie, Bd. xxi. p. 160; ibid., Hd. xiv. p. 14. " Ueber (icscbwiilstc der Vagina i\\> Schwangei-schaft nnd (ieburts-konipli- kationen," Disn. Innng., Bern, 1889. Adams: "Ilerniji of the Pregnant I'tc- rus," Amerirnn Jimrmd of Obslelrle.<. vol. xxii. p. 22."). Xouvelles A rehires d'OhMeiri. Tli(> cord iLsimlly meusuros about 20 inches, but it may have twice or thrice that length, or may even be lonj^cr. In v'onse(|neuce of this Increased len'th of the cord at least permits more or less iHMiierous coils or "circulars" of the finils about the fetus or its members. In consequence of these circulars the cord may i)e shortened, or there nuiy be a natural shortness of the cord. The cord has been known not to exceed 10 centimeters (4 inches) in leni>;th, but most generally iUs shortness results from its coiling around the fetal parts. This brevity, whether natural or accidental, interferes with labor, and may cause conditions more or less grave to the child and to the mother, for a ruptured cord, a detached placenta, or even an inverted uterus, may be among the accmlents resulting from the anomaly, t'ompleti' absence of the cord has been observed, the vessels pass- ing directly from tlu^ abdomen of the child to the adjoined placenta. The reason is therefore plain for including in a single group anomalies oi", and accidents to, the (H)rd. Prolapse of the Cord. — By prolapse is meant descent of the cord with, or in advance of, the presenting part of the fetus. The prolapsed loop may be ielt mobile in the waters when the membranes are unrnptiu'ed ; or, the amnial liquor having been discharged, the loop may be in the vagina ; or, finally, it may be external to the vulva (Fig. 381). Thus there are threef varieties of pro- lapse, thnugli some authorities describe the first variety as presentation of the cord. The second variety of prolapse may be met with though the first was not observed or even did not occur, the loop having suddenly been carried into the vagina by a free discharge of anmial licjuor. In most eases the two liaK'es of the loop are in a))position, but in some cases the i)resenting part may intervene. Thus in presentation of the head one half of the loop may be on one side and the other half on the other side of the presenting i)art; or in presentation of the pelvis the cord may be between the thighs. The frequency of j)rolapse of the cord is variously statcil. According to Winckel, clinics give from 1 in 65 to 1 in 500; this accident is oftener observed in hospital practice than in private practice. Etiolopy. — The essential cause of prolajise of the cord is want of corre- spondence between the presenting part and the lower portion of the uterus, for if the former 'illy occupies the space, there will be no room for the cord. Among causes :.iat contribute to this accident are great length of the cord ; the woman starding or sitting when the membranes rupture ; an excessive quantity of amnial liquor; smallness of the fetus; multiparity ; implantation * The superior figures (M occurring throiighoiit tlie text of this .irticle refer to the hiliIiogra|ihy given on jiage 644. t The elussificution nutdu hy Jucquemier, Manud ilea Accoitrhement.-i, 184t), has been adopted. Bii :> f, -i ■; i .ff^. V] yl / IMAGE EVALUATION TEST TARGET (MT-3) Photographic Sdences Corporation 4^^ 1.0 ^Bi 1^ 1.1 l^^ ^ "" nm 1.25 II 1.4 1.6 ^ ,#/ kJ ^— V 1 23 WEST MAIN STRUT WEBS^iiH.Nt 14StiO (716) 872-4503 7.^ ^ 6^ w 574 AMERICA y^ TKXT-BOOK OF OBSTETRICS. of tho placonta in tlic lower portion of the nteriis ; marginal attac-luncnt of the cord ; pendulous abdomen ; plural proffnancy ; the birth of a male ; a com- plex presentation — as, for example, descent of a hand w'th tho head ; present- ation other than of the vertex or the face ; and, more important than any of these, narrowing of the pelvis. Kaltenbach ' remarks that prolapse of the cord in presentation of the head occurring in a primipara should alwavs excite suspicion of a narrow ])elvis. Predisposition has also been mentioned as a cause, the accident having been observed in suc<;essive pregnancies ; but. of course, to admit i)redisposition as a cause no other obvious cause must be present. Roper ^ has given a case in which the accident occurred in three suc- cessive pregnancies, but there was notable lessening of the conjugate. The prolapsed loop usually descends in front of one of the sacro-iliac joints or in front of the cotyloid cavity, and rarely directly anterior or posterior. The (Ikuinos'iH of prolapse of the cord can immediately be made if the membranes have ruptured and the loop is in tho vagina, and still more readily if the cord is external to the vulva. A mistake in either case woidd seem impossible ; but with the membranes intact and with the pulsation absent the diagnosis is more difiicidt. The obstetrician feels with his fingers, in tho in- terval of uterine contraction, a soft, floating body, the thickness of a finger ; he can define it as the cord by hooking his finger in the loop and pressing it against the i)rosenting part or against the uterine wall : if pulsation is detected, there is no possibility of doubt. Winekei ' called attention to the fact that if, in auscultating '^he fetal heart, the sounds become slower, there is probable pressure upon the cord, and an examination may leail to the discovery of prolai)se of the cord. PrognoHix. — Danger to the mother is exceptional in prolapsed coid. In eonse([uence of the cord being stretche cord over one of the lower limbs to prevent its again falling was probably first recommended in 1786 by Croft." By whatever method the cord has been replaced, pn)lapse is very liable to recur. So great, iudee one or several circulars ; for example, the cord, while usually around the neck once or twice only, may encircle it six, seven, or even eight times. The optimism of Jacquemier led him to believe that cii'culaires were a wise provision against prolapse of the cord. This anomaly is generally associated with great length of the cord, but in some cases the length is normal, and in a very few it is less than normal. Etiolorjif. — Winekel ' mentions as causes of circulars a long cord, a largo quantity of amnial liquor, the yielding uterine walls of multiparae, marginal and velamentous insertion of the funis, and smallness of the child. Of cours<' the movements of the fetus are the immediate cause of the anomaly. Chan- treuil observes* that experience does not confirm the opinions of Michgorius, nvsToru. 677 Mine. Boivin, ami others, who attribute ciiciUarH to the excessive raoveiiK'nta ot' tlie mother. The injurious results of circuhirs, so far as hihor is concerned, usually arise {yam brevity of the cord — a Iv-evity which is then called "accidental," tliouj^h l)v njany the adje«'tive "relative" is applied to the condition to distinguish it Iroin "absolute" brevity. The accidents resulting from shortness of the cord will be considered in the next secition. Natural or Accidental Shortness of the Cord.* — By natural short- i)(>s of the cord is meant that the length measured fntm the uml)ili(;us to ilic placental insertion is insutli(;ici:t lo permit expidsion of the child without rupture of the cord, placental devaehment, or uterine inversion. Accidental slmrtness, usually arising from coils alwut the neck of the child, is similarly (Icliucd, cxce|)t that the pctiiit of the fetus from which the measurement is liikcn is no longer the umbilicus, but is the neck. It is evident that the length (»f the cord will vary, in case of absolute lircvitv, with the degret? to which it can be stretched, and in aci'idental brevity uitii this elasticity, and also with the tightness of the coils caused by the strain. Fiu'thcr, the point of placental attachment, either in the upper or the lower part of the uterus, and the insertion of the cord, whether marginal or (•out ral, must also Ix' taken into consideration. Matihews Dinican* assumed (iiat " it is impossible to make a (piite exact statement of the length of any mrd while i>roving itself a cause of difficult labor." Lamare says, accepting the statement of Xegrier that the length of the genital canal at the time of expulsion of the fetus is '22 centimeters (8j inches),'" that true brevity begins at 2") centimetei-s (10 inches), and that only belo\. this length does the cord inevitably cause accidents.f Shortness of the c(»ril does occur, notwithstanding the scepticism of DeweeSjJ though the instances of it arc infrc(pient. The consequences of this condition are painful, protracted labor; in)possibility of spontaneous deliv- ery ; there may be fatal pressure upon the cord, or it may be torn and there may be hemorrhage from lacenta, and even invei'sion of th(> uterus. Rigby gives an instance of a cord which was only 2 inches long l)cing torn at its placental insertion, the delivery being spontaneous. Kales" delivered with the forceps in a case in which there provetl to be accidental sliorteiiing of the cord. On making traction during a pain he foiuid there then occurred a notable depression at the fundus of the uterus, the depression disappearing when the traction ceasetl — one of the signs of this anomaly, according to some authorities, although denied by others. Werder'* reports * Most authors use the terms uhsnliile imd relalhv, but the writer tliinks thiit tlie adjectives wliicli lie licre employs are preferable. t Kalteuhach { Li-lirhiich ranes the child and placenta were expelled, the cord being tbund to be 2 inches and 8 or 1) lines in length. In a case reported by Leroux '" the umbilical cord was so short after tlu- escape of the fetus that the umbilicis was closely applied to the vidva, and the child could not be taken away until the ])laceuta was cxjiclled. It has been establishtnl by Xegrier '^ that if there be accidental shortening of the cord because of a loop around the neck, ]>artial delivery may occur, the child breathing, and then, unless suitable assistance be rentiered, the child will be strangled from constriction by the «)rd. Maekness,'^ in a ease of placenta pnevia, after iwrforming j)odalic version, bringing down one foot, and finding the hemorrhage not arrested, brt)Ught down the other foot ; after extracting the boily further i)rogress was arrestwl because of the cord passing between the child's leijs. It was necessarv to cut the conl before the head could be delivered. DUignonlii, — The signs usually given of brevity of the cord are severe pain at the place of the supposed placental attachment ; depression of this part during a uterine contraction or when traction is made with the forceps; marked recession of the head in the interval of contractions, this recession beintr yrreater than can be attributcnl to the resistance and elasticitv of the lower part of the birth-canal; irregular discharges of blood; and arrest of pains. Napier '* regards uterine inertia as a more important diagnostic sign than retraction of the head. Dr. King," who has made several important con- tributions on the subject, states as a characteristic sign that the patient has ii persistent desire to .sit up. Coils about the body niay be known in some eases by auscultation, in still rarer cases by abdominal palpation. Ilaake was the first (in IHGo) to discover coils around the neck by rectal touch. But the only certain way to ascertain that there is shortness of the cord is to feel it and actually to know that it is tight and stretched. This niay be done in breech presentations, when the child is astride of the cord or after the breech is born, by j)assing one or twn fingers up to the umbilicus, and finding, by judling toward the placental end. the cord so taut that it is impossible to draw any ])art of it down. In \>\\'<- entation of the head, after expulsion as far as the umbilicus, a similar method 3 '■ DYSTOCIA. 579 nul could 1)0 of oxaiuination may also be employwl. Hicks " narrates a case in which he iiiiulc the diagnosis of short cord ; after the delivery of the breech he luul to tliviile the cord before the rest of the child could Iw born. The cord proved to l)e Init 4 inches long. Treat menl. — In regard to the treatment of shortness of the cord but little can l)e said. Koederer, and many obstetricians since his day, urged the importance of pressing the uterus downward, the obvious benefit of which, of coiu'se, is to bring the placental attachment nearer the fetus. King" seeks to iiccoinplish the same object indirectly by having the woman " take a kneeling, sitting, or sfjuatting ))osition, or by so elevating the shoulders that she is placed midway between lying upon her back and sitting." Jn comicction with J)r. King's method the following citation from Dcnman* is of interest: " If the child shoidd not be born, when we have wait(!il as long as we be- lieve to be proper or consistent with its safety or with that of the parent it will be riHpiisite to change her position, and, instead of sufl'ering her to remain in a recumbent one, to take her out of bed and raise her upright to permit her to bear her pains in that situation ; or, according to the ancient custom of this country, to let her kneel before the bed and lean forward upon the edge of it ; or, as is now ])ractised in many places, to set her upon the lap of cue of her assistants." It is better that the child should be delivered by ]>resstn'e, fetal expression, than with the forceps. Instrumental delivery is the last resort. Of course, when a short cord is discovere AMKIiK'Ay TEXT- HOOK OF OliSTKTHJCS. that tlio liviiij; cord — that is, tlip cord liaviiij; its vessels filled with warm water — breaks with a slightly less force than the dead cortl. It is evident that, as has repeatedly Iwen provcnl, the cord may Ix* torn simply hy the weigiit of the child, expulsion taking place while the nutther is erect or even semi-erect. Moreover, there are instances of the cord giving wav in childbirth while the woman was lying in bed. Spaeth's ease* illustrates this : In a primipara, the first stage of labor being tedious and the second stage lasting btit half an hour, a violent contra<'tioii m-curred while the mid- wife was placing a cushion under the patient's hips, and the child was driven out a distance of ')0 centimeters from the genital organs. The cord, thick, gelat- inous, and friable, was broken : it was 30 centimeters l<»ng, and the rupture was in its middle. liudin "■" has given a similar case : The patient, a secundip- ara, made violent expulsive efforts, and the child was rapidly expelled. The cord, which encircle1..„„..4-.. *„ ^..^i^^i^ :.,*« Fio. 382.— Partial placontii prcDVia, The uterus is may cause tl placenta to project into ^5,;,,^.^ j^^^ ^^^^^, ,„„^,, . ^^^J , , j^ j,,^. ,4,,^. ^^.,,.,,„ the area of expansion of the uterus, marks the boundaiybetwuens.z, the .superior zone, I 1 onr\ TT i> • w 1 1 1 J- anil E.z,thee(iuntorial zone ; 3,4, is tlie line (" lUirnes' hi 1890, Hotmeier'™ COncludal trom boundary-line") which murks the limit between the the examination of the uterus of a eq'mtorial zone, K.z.imd the inferior zone, i.z. A- is , . . 1 /. /. 1 1 /> *''^' ITievial Map of tlie plaeenta, upon which the woman dying 111 the hftli month ot a head rests lUames). '■it i> tf ' S:;'iiP 5:f : km A is m i ffrrr .^. I" 682 AMHIilVAX TEXT-HOOK OF OUSTKTR/CS. twill j)ivj;nnii<'_v that in "most if not all caHt's" placenta |>rii«via orilace with- in the reHexa of the inferior pole of the ovum." The under surface of the present- in}; placenta is c<»ver(Ml with smooth reflexa which later is united with the opposite vera. The explanation of the orijjin of placenta pnevia |i;iven by Hofmeier and Kaltenbach has been aceeptetl by many ob.stetricians, among whom may bo mentioned Olshausen and Martin ; but there are some who dissent — for ex- ample, Ahlfold, Winckel,* Berry Hart, and Gottschalk.^' Hart, in expressing his dissent, gave the following statement : " I must now state the view I advocate for the occurrence of placenta prsevia. It is that of primary iniplaii- tation ofthe impregnattnl ovum low down, or even over theos internum. The forcible objection that Kaltenbach urges against this view seems to me not quite valid. He hoUls that the small ovum wotdd pass into the wrvieal canal and be lost. \Vc must rememl)er, however, that the hypertrophied and foldeil decidua there will practically obliterate the os internum, and thus implantatinii over it may (jccur. But why should such a l(tw implantation happen? Wo * Winckel remarks, referring to the views of Ilofnieier and Kaltenbach : " Ahlfeltl liii.< justly disputed the correctness of this explanation, and from a case in which the placenta w:is entirely situated in the lower uterine segment lias given ground for the old ojiinion of tlw primary grafting of the ovum in the inferior third of the uterine cavity " ( Lehrbuch der Gebwis- hulfe, '2d ed., 189:i). Fio. 383.— riiicenta pntvia in pregnancy with twins (Hoftncier). :ij. nVSTOC/A. 583 iiiilv know that it is niorc apt to iHt'iir in cases where the nuieons nienibrunu has been nnliealtliy. The iiyintthesis 1 would advance', but merely as an livpothesis, is that the human ovum can graft only on a surface denudcil oC epithelium, and that thus it docs not graft in the Fallopian tube, but in nonie piirt of the uterine cavity where the epithelium has been removed by menstru- ation. If, then, the ovum does i,ot meet with the eon ncctive-t issue surface until it has passed low down in the uterine cavity, some form of placenta prievia will hapiM'U." Dr. Robert Harnes first announced in 1847 his theory of placenta prievia, ;md ho has made several contributions to the sidtject since, the most recent of tlicse being a paper road by him in 1892 before the International Congress of Diseases of Women and Obstetrics, in Hrussels. In justice to one of the most eminent anil able obstetric writers and teachers, as well as in justice to the theory itself, which certainly was an important advance, and from the fact that the |)nu'tice founded upon that theory is upheld by some obstetricians, {u-om- incnt among whom is Murphy of Simderland, — the latest public exposition of his views is hero presented. The paper referred to being in French, a trans- lation of a part is here presentetl. Dr. Barnes, after having stated that his theory is represented in Figure .'J82, proceeds as follows: "It is seen from the illustration that the uterus is divided into three /ones : (1) The superior or fundal zone; (2) The equatorial or middle zone ; (3) The inferior zone. The superior zone is separated from the e((uatorial by an imaginary line (1, 2) which may be called the ' superior polar circle.' This line, it is true, has not been anatomically demonstrated. IJut it serves to mark a distinction, which I be- lieve real, between the characters of the superior and eipiatorial zones in their relations to the placental attachments and to hemorrhage. "The equatorial zone is separated fn^m the inferior zone, otherwise called the inferior uterine segment, by the line .'], 4. This line is the line of demar- cation of Barnes, Barnes' boundary-line (1847-1 8;")7). This line was called ' the internal os of Branne ' in 1 872 ; it became the ' ring of Bandl ' in 1876 ; and later, the * contraction-ring ' of Schroeder. It may also be called the ' inferior polar circle.' " The superior zone (s. z.) is the seat of fundal placenta ; it is the safest region of attachment. The equatorial zone (e. z.) is the seat of lateral or ('(|natorial placenta. The lateral placenta may give place to that form of liomorrhage called 'accidental ;' nevertheless, the equatorial zone may be con- sidered as site of attachment normal and safe. This security is still greater when the placenta is attached in part in the superior zone and in })art in the ef|uatorial zone. The danger begins when the placenta is attached in part in the inferior zone — that is, when there is partial placenta praivia. The portion of the placenta which encroaches upon the interior zone (r. z.) is liable to nsi AMi:iii<'Ay Ti:\"r-ii(K)h' or onsTirmics. prcinatiiro s<'|)!iratii)ii. ('i)iii|)l(>t<' placenta pru'via, calKKl also phicetitd pniiia fcnfrii/in, is t'oiiixl wlini the ciitirc plarcnta or tlie greater part of it is attaclicti ill tlu' inferior zone ainl covers the internal os. •' In the last case the jfcstation would Ix-, justly s|H'akinjr, an •• ^.pioficstation (or out of place), for the ovtiiii, or an iinportani part of it, is (levelo|MHl in the inferior /one 4»f the uterus, a part which is not (lesijfiiey nature tor tiii> function. The eurveii in wiiicii (he internal o> is entirely covoreil hy placenta. It corresponds with what many others have (ill le»- seqiiently he has the right to say that this vnriety is excci-^lingly rare. Liileial implantation of the phurnta includes those cases in which the great mass of tlie placenta is at the &ideof the uterus, a margin more or less near the interiitd /'CTiijf vnp ant Os aUrn ^~^ Vrtlhrft Cor/i cavtrrX'- diior.-^ ■ — ^Sis Pmc/iiU cUtor-^^ CUUns. --- ^'-^H Ifii mm (ttxt "' ^__^ laimydext — ' I'J Fio. 385.— Placenta pracvia : child removed, placcr'n remaining (Winter). OS ; indeed, in some eases the margin may partially extend over the os. The lateral variety is much the more frequent. Figure 385 shows a not infrequent c r.idition, a single cotyledon over the os, while the great ma.ss of the placenta is at the side : the fir.st is known as j)la- centa suceenturiata. Authorities generally agree that lateral is much more frequent than comj)letc or central placenta. Nevertheless, Trask ** gives 169 of the complete to 88 of the lateral, and Mi'iller's statistics, which include tho.se of Trask, show a slight prcKlominance in favor of the complete variety. Read's statistics^* show a ?:i.^: i^K' H*. ^ 586 AMERICAN TEXT- BOOK OF OBSTETRICS. l\ :i ■I f similar result. UnfortiUiritely, in many of the cases given by Read there is a failure to state the placental presentation, and some others are described as "almost complete" or "nearly complete," and hence nncertain conclusions onlv can be made. Miiller has shown that in complete placenta praevia the smaller lobnle was situatwl at the left in thirtv-seven out of 56 cases. In Via. 386— Partial placenta priiviti (Alilf'cld). lateral placenta pnevia the placenta is in 50 cases at the right side to 31 at the left side. As will be seen, there is a correspondence between these results. Frajucnci/. — The proportion of cases of placenta pra;via to the entire number of deliveries is usually given as 1 to 1000, 1 to 1500 (Winckel), and 1 to 1500 or 1600 (Kaltenbaeh). I'azzi*'' gives the proportion of 1 in 748. As illustrating how misleading limited statistics may be, we quote the statement of Townsend'* as to cases of placenta pnevia in the Boston Ijying-in Hospital : In the last twenty years there were 28 cases of placenta prajvia in DYSTOCIA. 587 Road there is doscribetl as I conclusions II prievia the >6 cases. In side to .31 at these resuhs. to the entire no (Winckel), ortion of 1 in we quote the )ston Lyinjjj-iii nta proovia in (1700 deliveries. Thus there was 1 case of placenta praevia in 239 labors, or more than 4 in 1000. Of course, as Townsend remarks, tiiere are more cases of this anomaly in hospital than in private practice, but still such a liu'lie proportion as he found is not the expression of a general trutii. No iiije is exempt, for placenta pra?via has occurred in a girl of thirteen years and in a woman of fifty. It is most frequent from thirty to forty years, tor out of 248 cases 127 of tiie subjects were in that ten years (Miillcr). A uoma/ica of the Placenta when it is Pnvvia. — The placenta is not oval, hilt is irregular in form ; tiie prajvial placenta extends over a larger surface, hut is thiimer, than the placenta having a normal site. • A placenta succcntu- riata is not infrequent, or, again, the placenta nuiy be composetl of twt) lobes, and the bridge of tissue connecting these lobes may be directly over the os ; lionce an error in diagnosis is possible. Tiie form of the placenta presents otlier varieties.''^ Thus it lias been found in the shape of a half-mpon or a horseshoe, or it is pyriform or cordiform ; Gilroy ^ described one as lozenge- sliapcd, the cord being attached to one of the angles. In placenta prtevia there are frequently abnormal adhesions between the placenta and the uterine wall. Miillcr found such adhesions in fifty-four out of 142 cases, and Sabarth of Reichenbach in seven out of 14 cases. This condition may cause more or less serious delay and difficulty in the third stage of labor, and of course it gives a certain liability to infection. The insertion of the cord in numy cases is marginal and sometimes is velamentous. DepanP" directetl attention to the fact that the membranes in placenta prrovia seem thickened as if infil- trated, and, further, that the chorion presents externally (juite characteristic rugosities which alone suffice, even when the placenta cannot l)c felt either by its surface or at its border, to authorize one in affirming that the j)la- ccnta is near. (hitscK. — Spicgelberg^ states that pre- vious abortions predispose to placenta \)rie- via, and that it is more frequent in the poorer classes, }H)ssib]y owing to hard work at the beginning of pregnancy, and still more to the subinvolution of the uterus which is so common in this class. So far as tlie first statement is concerned, it seems to ., ,„,„..,, , ,, ' _ Kio. 3«7.— Purtiiil pliu'i'nta imrviii, wr- the writer that both abortions and prrovial tox iiresoniution : the os biKimiint,' to j)lacenta should be attributed to a common ""t^' (■'"*'■ cau>e, a diseased condition of the endonu^truim. The accident is more fre- (pu'iit in nuilti))ar!e than in primipane — two- or three-fold (Winckel) — and according to Miillcr" 85 per cent, are multipara?. Anomalies of the uterus, such as uterus bicomis and unicornii*, cancer anil myoma of the uterus, relax- U 'Ai l> hi < < (if > », ,y i. <■{■ i^iiS^': ' ii ■ri nnrr Ih'h mm U !; I! :4 ■' '3 588 AMERICAN TEXT-BOOK OF OBSTETRICS. atioii of the uterine walls, opening of the oviducts in the lower part of the uterus, as in two cases reiK)rte(l by Ingleby, and, more important than most and more frequent than any of these, endometritis with hypersecretion, aiv causes of placenta prajvia. Osiander^" believes that lying on the back favors insertion of the ])laconta at the fundus, lying upon one side lavors a lateral attadunent, and standing Fig. 388.— Central placenta proDvJa, the os partly tlilntcd (Hunter). or sitting favors implantation over the os ; hence ho considered lying on the back or on one side, continueti some time after copulation, as necessary for a fortunate situation of tlie ovum. Stein and others attribute the origin of placenta prsevia to the sjwcific gravity of the ovum. Miillcr .states that others accu.se conception during menstruation or while the uterus has a more vertical position, thus coitus while standing, as a chief ground. DYSTOCIA. 589 '%%^. In 1874, Angus Macclonald *' reported a case of twin pregnancy, the ti'tnses being transverse and each j)h»centa presenting at the internal os. He regarded phicenta prtevia with twins as a very rare anomaly, and assortal that " the expectation of the concurrence of twins with placenta pran-ia is only 1 in 44,500 cases of labor," and that, of course, the prob- ability would be much less with both placentse presenting. Miiller found it YWiv in plural pregnancy, but Barnes has spoken of it as not uncommon, and \Vinckel states that plural pregnancy pretlisposcs to placenta prrevia, the acci- (li'iit in his experience beinj; relatively four times more frequent in plural than ill single pregnancy.* Roamy ^^ suggests that placenta prasvia may originate in sexual intercourse being deferred until fifleen or sixteen days after menstruation for the purpose of avoiding conception. If this delay were a cause, probably the number of cases would be much greater. Pinard has asketl if travelling early in preg- nancy, with conse(juent jolting in I'ailroad cars or in carriages, may not cause placenta pnevia. The retnirrence of placenta pra}via in the same subject has been observed. The cases recorded by Ingleby are explaineregnant with twins, and in eacii pregnancy iiad placenta prnpvia. Ui m A M l.'5 3 • 1^ I I PL .vj. ^ '' V >\ ■ » i ' ::! .. I? ,' 590 AMERICAN TEXT-BOOK OF OBSTETRICS. w J. placental, it is now usually conceded that it is uterine, and should the child die its death would be not from loss of blood, but from asphyxia. From tlie fetal circulation may come a small quantity of blooil in case the chorionic villi are torn. Why the blealing occurs in the latter part of pregnancy is a (juestioii that has had different answers. Jacquemier held, on the one hand — and his view, with qualifications, was accepted by Depaul — that the development of the lower part of the uterus was more rapid than that of the placenta, henco detachment of the latter; on the other hand, Legioux assertetl that the pla- centa grew more rapidly than the uterus, that is, grew away from the uterus. Barnes has been especially prominent in upholding the latter view. Spiegel* berg, first referring to placenta prsevia predisposing to abortion, said : " Owing to the loose vascular connections of the placenta and to the higher blood-pressure in the placenta when inserted low, any shock is liable to cause rupture of its vessels and detachment ; perhaps, also, shocks affect the lower portion of the uterus oftener than the upper during the first months of pregnancy (coitus, especially straining at stool). For the same reasons premature labor, too, is relatively common ; indeed, I am convincal that even the hemorrhages which occur during the latter months of pregnancy depend upon commencing labor — that it is not the hemorrhages which induce premature labor, as is generally su])posed, but that the converse relation is the true one." The hemorriiage is not only abrupt and apparently causeless in occiu'rence — though this first hemorrhage may be fatal — but usually it ceases after lasting a few hours, or even in less time, and often spontaneously. The hemorrhage returns at irregular intervals, and is greater, occurs earlier, and is more frequent in those cases in which the placenta completely covers the os7> Auvard *® mentions as symptoms unfavorable presentation of the fetus — presentations other than those of the head * are found in from 20 to nearly 50 per cent, of cases, according to different authorities — the occurrence of prem- ature labor, and premature rupture of the membranes, Winckel remarks that in the relaticjn of the funis in ]>lacenta prsevia there is also offered a certain predisposition to bleeding. He states that Scanzoni, Hugenberger, and the author found marginal and velamentous insertion of the ciu'sued, except that it is advisable to bring down a foot. In transverse presentation, of course, podalic version is indicated. But now supp.,. o the physician is called to a ease of placenta pra?via in which the Meeding is severe, whether in pregnancy or in labor, and the os barely admits the finger and is rigid, or the cervical canal is not readily penetrable : most obstetric authorities agree in advising a tampon. f •! DYSTOCIA. 593 W'iiickol uses for this purpose iodoform cotton, and others advise iotloforn) "iiuize (Fig. 389);creoIin j^aiize would be just as useful and has no unpleasant r which a tiunpou was used ; a montii after this there was slitjht flooding, whicii yielded to rest, etc. ; labor came on two w(M'ks siih- 80(piently, and there was considerable hemorrhage. Upon examination the os was the size of a crown. As the pains were now frecpicnt and strong and the «lischarge eontimied, after placing a regulating bandage — one end l)eing fa-t- ened to the be«l and the other held by the mirse and tighteniHl as required — I passcnl my hand, and first detached a considerable portion of the placenta, and then ruptured the membranes. The bandage was drawn so as eiiuaily and firndy to supi>ort and compress the uterus as its si/e lessene force it nuist sustain at each pain, when the os uteri has to be dilatetl by the head of the child after the membranes have been rupturetl." The ])oint of interest in c(»mparing these methods is that each obstetrician i, accordiuj; to Dunal, was the true inventor, or rather promoter, of this obstetric operation ; hut in recent years many of the cases reported us necnnchement Jarre aiv instances simply of rapid delivery, no violence heinjj employed, and the term has thus lutii changed in its signilicntion. [y of absiM-jt- cn, n'f"»'rcnc( I obstt'tru'iaii cgiiaiu-y had •r this there o \v(H*ks suli- iKition the us roiifj iuhI the 1(1 boitij; i"a-t- is rcHiuiretl — the phicoiita. so as c(|ually h1 1)V coiitrae- r botli mother thus : " I «le- Kissago of the he risk of th<> \ at each ])aiii. the nieiubraiies ch obstetrician u'tion of labor II every case m before then, le is delivered. s now had 01 w\ when iirst used, for the the ballon nf 1 results from tehie** narrates were saved by i)ni premature •idental " (Fi.ii'. is much niore latter bai)pens he placenta is s Vht(- saiil it w:'-* thod i)f (lelivt ly. promoter, of tlii- iiclivmriil J'oiri :ni' in lias thus Ikch DYsTOrlA. nWl lint a common event, for Goodell in 1H7() collected only 105 cases of the iieeidont. J'!llol(t(/if. — Amoiifx the causes of accidental hcmorrhaf^o some of the acute infectious diseases, such as variola and scarlatina, have been assertcil ; but more obvious and more jicncraily accepted are traumatisms, as from falls, blows, concussion, joltiuj;, etc; so, too, direct pressure upon the* abdomen, violent sneezinj;, couj;hin<;, strainin<;, or V(»mitin<;. Hut in how many him- dnnls of eases many of these may occur without the placenta bcinj^ separated I'rom the uterine wall ! lirevity of the cord, fi'i'laiii)isla (aftiT l>r. Winter). A blood mass undor the placenta. assumetl that changes in the inner portion of the serotina have made the tissue friable and readily torn. The importance of nephritis as a cause for prema- ture separation of the placenta has been established by Winter; but, as Veit has said,'"'' we cannot explain the origin of the bleeding in renal maladies without the medium of endometritis ; he maintains that the chief cau,*ie of premature detaehnunt is disease of the decidua\ That the plai-euta in these cases is diseased has been ]iroved by .several ob.scrvers; infarcts have been found, also indammation, and, in the case reported by Coe,"* fatty degeneration. Of 81 cases of accidental hemorrhage recorded by Johnston and Sinclair (/'/Y»'//m^ J/Zf/HvYf'/v/), no cause could be foimd for its occiuM-ence in forty-six. Uiaefe''^ has recently published a case of premature |)Iacental detachment in if*, ■ I" ■ i ^^,. { / a'%. '1 nns AMHliK'Ay TKXr-IiOOh' OF OliSTKTItlCS. 'i: which shortncHH of tho cord wiis the (juuhc of the accident ; the lonnth wa.s only .'! I centimeters. The patient was a priniij^ravithi, and th(' first l)le(Hlinj; (MX'iirred about the time of the descent of tiie head into the pelvit; cavity — that is, al)oiit four or five weelis i)efore the mtrmal end of prej;nancy, btil in this case ten days before hii)or. It was believeil tliat partial detachnient resulted from the strain upon tiie cord in tiie th'scent, th«! primary separation l)ein^ in tlie loltc t(t whicii the cord was attaciied ; after birtli tlie navel was immediately in front of the vulva. Underhill"* has published a case in which severe pressure upon the abdomen was the innnediato cause of the d<;tachment : A large, powerliil woman, quite heavy, in the ninth month of pregnancy, was engaged hanging clothes out of a window to dry, the greater part of her weight being siip- portetl by the window-sill, upon which her alxlomen pressetl. Violent uterine lieniorrhagj^ at once occiu'red, and the loss of bUxtd was so great that she fainted. The writer had a case in which partial separation of the placenta was caused by a fall, the woman being at the end of the seventh ujonth ; nearly a quart of blood was almost immediately dischargetl, and then the flow ceased. This patient went to term, being then deliverctl of a living, well-developed child. Si/mpfomt*. — The bleeding is internal (that is, latent) or external. The illustration (Fig. 392), from Winter, shows a partially detached placenta with a mass of blood effused l)etween the placenta and the uterine wall and also penetrating between the membranes and the uterus. In some instances the central portion of the placenta is first detached, and then the adjacent part, until tlu; entire organ is separated except at the margin, whi(;li remains firm ; there is thus formed a large ciq)-shaj)0(l cavity filUnl with blood. Dr. Coe gives the following as the signs of latent accidental hemorrhage: Irreg- ularity and feebleness of uterine "pains," the fundus only contracting; the uterus is excessively .sensitive; the .sounds of the fetal heart are irregidar and feeble; af\er a time increase in the si^-o of the uterus, ami the patient coin- j)lains of its excessive distention ; palpation of the fetus is diflficidt or inipos- sible, and in some cases there is a notable proininei. -o at that part of the uterus in which pain has been felt ; finally, there are the constitutional mani- festations of great loss of blood.* Graefc, in considering the diflf'erential diagnosis of this accident, refers to the possibility of confounding the condition with rupture of the (itern.s, or with hemorrhage into the sac of the ovum or into the abdominal cavity in ectopic ])regnancy. The cases in which there is no external bleeding are rare. Usually after a longer or shorter time blood escaj)es externally, and then the diagnosis can- not be doubtfid. The accompanying illustrations (Fig. 393, A, b) show the blood escaping externally in accidental hemorrhage. * Kritsch in the dia^nn.sis states that the l)aK of waters remain.s tense and resistant dnriiiL' tlie intervals of uterine contractions, and tliat it is impossible by touch to reach the placenta (Klinik der GebuHnhuljlichen Opemlioneii). DYSTOCIA. r)!i«) I'luxjunHiH. — The |>n));nosi.H in iicMtlciital li(iii<)i'rliii^i> is had for tlio niotlu r, or at least very j^ravc, and still worse for tlu' cliild. (JckmIcH's statistics in- clude 1()<) eases, and the maternal mortality was tit'ty->oi:r, while of 107 chil- dren only six lived ; ninetiHMi mothers were saved ont of .'$"2 reetyrdwl hy Hrnn- ton. (ialal)in in the statistien of (iny's Hospital fonnd .>1 casen of aeeidental hemorrhage, twenty-one of them heinj; severe ; five of the mothers and (56 ])er cent, of the <-hildren |M>rished. Johnston and Sinclair in HI cases had ordy |i)Mr deaths of mothers; and in (Jraefc's 14 eases only two mothers died. As Schidt/e has pointed out, the death of the child in premature detachment dl" the placenta is to he attril)Ute<1 not to loss of blomi, hut to tlie failure in (lie elimination of carhonic acid. The i)ro<;no8is is more favorable in external than in internal hleedinjj;, and more favorable, too, if the condition of the os uteri permits prompt delivery. Fl(i. 3911.— SliouinKHopnnitioii of tin' |iltu'oiitii witli fxtoriml lilfcdini;. Treatment. — If external hemorriiage should occur durinj; pregnancy, and if the fjuantity of blcuMl discharged ;,hould not be great, the obstetrician will l»e content with enjoining the recumbent posture, cold drinks, the body lightly covered, and giving an opiate ; in short, he will pursue a course similar to that re(]uirere has been a copious dis- ciiarge of blood, but bleeding has ceased, his (^hief efforts will be to relieve the patient from her prostration, no dirt>ct interference with the uterus being indicated. Possibly, as in the case under the care of the writer that has been previously mentioned, the pregnancy will not be interrupted and a living child will 1k' born at term. Nevertheless, such a patient uMist be carefidly watched, and the practitioner be jirepared to act promj)tly should serious bleed- ing return; in brief, his state will be that of armed expectation. Shoidd there be continuous and considerable flow in pregnancy or in labor, and the os not be in a condition to admit innualiate or speedy delivery, 8pie- i! J I I ' i 'I I' ft" S> I I ^ : i i': ' ) ()f)0 AMERICAN TEXT-BOOK OF OliSTETlilCS. {^olberg regards tlie tampon as the best treatment. It should, however, l)c borno in niiiul that thereby an open may be eonverted into a eoneealeiorm-j>;auze tampon ot tlie uterus was claimed to have arrested bleeding, the presumption is tiiat many of these were cases in which tiie hemorrhage was slight. It might be added that in so large a nnmbiT of eases some were proofs of careless obstetrics, for, as Spie- o-elberg has said, "I certainly do not exaggerate when I say that severe post- partum hemorrhage is almost without exeej)tioi> ;'..> fault of the attendant." h'tio(o(/i/. — Atony of the uterus is the most fre(ptent eau'^e of liemorrhage alter the child's being «lelivered ; this hemorrhage, indeed, is frecpiently calUH 1 "at onic hleedniir. The ciMises of this failure of the uterine muscle to Th contract j)roperIy, eiosnig the moutiis or bleeding vessels, are many. 1 he con- dition has been observed after a brief as well as after a long labor; it may follow a ease of great distention of the uterus, as from plural preguaney or from ainuial dropsy ; prolonged and profound anesthesia predisposes to it. The bleeding may be in consecpience of albuminuria or of hemophilia, in still other cases from delicient imis»'ular development of the uterus. Veit" refers, under atony of the uterus, to paralysis of that portion of the uterus to which the placenta has been attaclied — a c<»ndition which has been described by Kiigel, Rokitansky, JJurchardt, Kiwiseh, Chiari, and others. In this local uterine atony there is found upon abdominal examination of the uterus a depression, while internally, corresponding with the external depression, is a |)r()iecting mass. Fritsch "^ observed a ease of local atony in which he found on se(!tion a ('oinplete varicose degeneration of a part of the uterus ; the paralytic portion was composed almost entirely of wide veins. The same author mentions a very dangerous f )rm of uterine atony the eonsequenee of i'lfection occurring early in labor, stating that it is not wonderful, when we observe that paralysis of the infected muscular coat of the bowels leads to meteorism, that the eon- tiv'i'tile activity of the uterus should fail from a similar cause. Penrose.*^ in his paper upon the treatment of post-j)artum hemorrhage, remarks: "A cause sometimes of dreadful post-partum hemorrhage is the ]>iiitial morbid adhesion of the placenta to the uterus ; here there is often the reverse of uterine inertia; the uterus may be in a condition of firm contrac- tion, but the adherent placental mass, occupying no little space in the cavity of the organ, j)reveuts and renders impossible that degree of shrinkage in si/e indispensable to the complete obliteration of the uterine blood-vessels, and hemorrhage is the inevitable result. To this cinss of causes might be achlcd those eases where the hemorrhage is caused by the presence of fibroids in the wall of the uterus or of a jxdypus in the cavity." Placenta privvia may cause post-partum hemorrhage, for the lower segment of the uterus has not the contractile power which belongs to that portion of the uterus in which the placenta has its normal site, hence the closure of torn "i .. // il .rus, filled with blood, reached above the umbilicus. Of course an external hemorrhage reveals itself, and an internal bleeding will be readily recognized by the hand of the obstetrician placed upon the patient's abdomen, for thereby lie finds the uterus greatly enlarged, relaxed, and probably its boundaries not easily defined. It ought to be noted that a bladder distended with urine may simulate an enlarged uterus, and, even if it does not, causes great ascension of that organ. To mention the possil>ility of the error is to avert it. Post-partinn hemorrhage has been divided into ])rimarv and secondary. Unfortunately, authors differ as to the boundary-line between the two, some including imder the latter a bleeding that begins a few hours after labor, while others advance the limit to twenty-four hours or even some days. In the present di.scussion all hemorrhages occtu'ring within the first twenty- four hours will be regarded as primary, and these oidy will now be considered, secondary hemorrhage being subsequently di.scussed. Prof/uoNht. — The prognosis is graver the earlier the bleeding occurs, and. of course, graver, too, the greater the loss of blood. The character of the dis- charge is also of prognostic significance, for if the blood is thin, serum-like, tat'hed, in the lie prevention anagemeut ol' I)YSTii fur nililiciiil ^riiiinitimi nl' thr .■ulliriTiil \,]i iilil. u ■ ¥■ « r i i L i. ,1a i.::p: I: If . -.^ !. .j}^,rp i I 1 , 1 1 ? ; 1 ■ ' '/ HMbik.., L. ^ Lmt DYSTOCIA. 603 niul without clots, the fluid itself is at fault and the danger of death is imminent. .S(;vere pain in the back is regarded as testifying to uterine activity, and there- fore as ground for encouragement. Hippocrates made iiiccough and spasms (iininous in hemorriiage, and Lachapelle counted dilatation of the pupils a s;rave prognostic sign. Treatment. — It is of immediate importance to lessen the flow of blood and to excite uterine contraction. One step in the accom])lishment of the first is to lower the patient's head, taking away pillow and bolster, and to raise the toot of the bed. Let tlie obstetrician by his words and acts prevent panic on the j)art of those present and inspire confidence and hope. Instant compres- sion of the uterus is made, and the effort is exerted to promote its contraction liy this pressure and by friction. The introduction of one hand into the uterus with the other upon the patient's abdomen may be necessary to remove the pla- centa or a part c»i" it or coagula or membranes (PI. 41 ). It is important before this nianiindation that the genital canal be disinfected, which may be done by carbolic acid, creolin, or lysol, washing it out with hot water containing one of these antiseptics ; furthermore, the hot water has this advantage, it stimulates the uterus to contract. Disinfection of the operator's hand and tbrcarm is still more important, and this may be accomplished, Fehling states," in five minutes by Fiirbringer's method. This precaution is esj)e- cially necessary if a partially free ])lacenta is to be detached, for, as Stumpf lias said, the manual detachment of the i)lacenta is the most dangerous obstetric operation. The introduced hand by its contact with the uterine walls may evoke the action of the organ, and the removal of the uterine contents permits n^iactiou. Tn the removal of the separated placenta it is usually better that both hand and placenta be expelled rather than withdrawn. Meantime ergot niav be used hypodermatically with the hope of stimidating the uterus to con- tract. If the patient is very much exhausted by hemorrhage, stdphuric ether, as originally advised by Hecker — 20 drops, for example — should be injected deeply in the thigh, three such injections being made. Among the older means of evoking uterine contraction are striking the exposed abilomen with a wet towel, and the introduction of a lump of ice into the uterus. The obstetrician now generally prefers to the use of cold the iiijeeting of hot water into the uterus. Penrt)se has for many years warndy iidvoeated vinegar as an invaluable help in jiost-partum hemorrhage. He lias given the following as his method of using it ;•" "I pour a few tablespoon fills into a s'essel, and dip into it some clean rag or a clean pocket-handkerchief. 1 tlieii carry the saturated rag with my hand into the cavity of the ntenis and s(|ueoze it ; the effect of the vinegor flowing over the sides of the uterus and tiiroiigli the vagina is magical. Tiie relaxed and flabby uterine muscle in- stantly responds. The organ at once assiunes what I will term its giz/ard- like feel, shrinking down and compressing the oj)erating hand, and in the vast majority of cases all hemorrhage ceases instantly ; should one application of vinegar fail to secure sufficient contraction, the hand can be withdrawn, and a second or even a third application can be made, until the uterus shall con- ' ' •: 1 •'% l; ii IK' r,\ I ' I n 1 t H ^1i f 604 AMERICAN TEXT-BOOK OF OBSTETRICS. tract .sufficiently to stop the flow of blood." Contaniin in his monograph'''^ states that " irritant substances placed in the uterine cavity act in the same manner as ice, and are more readily eni[)loyetl. In the time of Hippocrates a pomegranate from which the bark had been removed was introduced into the uterine cavity. In our days a lemon has been employed (Evrat, jNIoreau), or a sponge saturated with vinegar (liigest, Desgrange). iVll these agents reailiK excite uterine contractions when they are immediately in contact with the walls of the womb." Uterine injections are as old as the time of Hippocrates, but prol?ibIy Pasta in 1750 first advised the introduction of a solution of "calcined vitriol " for the arrest of hemorrhage. Dr. Robert Barnes in 1857 strongly advocatcil injection of a solution of perchlorid of iron. The formula recommended by him is 1 J ounces of the liquor ferri j)erchIori(li (British Pharmacopoeia) and 8^ ounces of water. The following are liis directions for the use of this solu- tion :®^ (1) "Be sure that the titerus is empty of placenta, blood, and clots; (2) com])ress the body of the uterus during the injection ; (3) have two basins at hand, one containing hot water, the other the ferric solution ; pump water well through the syringe (a good Higginson's will do), so as to ex])el air, then pass the uterine tube into the uterus, and inject first hot water, so as to wash out the cavitv and give a last op|)ortunity for evoking diastaliic contraction ; then shift the receiving end of the syringe into the ferric solution, and slowly, gently inject abont seven or eight ounces, earef illy keeping up steady pressure on the uterus throughout and afterward." Spiegelberg®^ objects to the strength of the solution advised by Barnes, and suggests that half an ounce of the liquor ferri perchloridi be added to a pint of water, stating that "a high degree of concentration would undoubtedly corrode the internal surface of the uterus, and might thus lead to extensive and deep thnmibosis of the uterine wall and to its setpielse ; it njight also produce gangrenous endometritis and secondary infection, or cause the thrombi to be broken down and carried away by the veins." Some have advised, instead of injecting the uterus with an iron-salt solution, swabbing the bleeding surface with a sponge that has been dipped in the solution. In recent years, however, the employment of the Barnes method has had few advocates, not only because some fatal cases have followed it, but also because of the prompt hemostasis usually resulting from injections of hot water. Dr. Attliill,*" in December, 1877, in reporting to the Dublin Obstetrical Society some cases of post-partum hemorrhage in which he successfully usent was to the following effect : When house-surgeon at the New York State Women's Hospital in 1874 he saw the uterus contract firmly and instantly upon being washed out with hot water after an operation by T)r. Marion Sims ui)on a sarcomatous growth of the fimdiis uteri. The result led him to try the same treatment in ])ost-]KU'tum hemorrhage, and he met with perfect success. He afterward succeeded in having the treatment tried in the '\ "'^ ! 'A- ' V 1 /^ c I'' DYSTOCIA. 605 Lyiii{?-in Hospital at Prague, and the luethod was so successful that it was adopted as a regular routine treatment. Windelband,™ in January, 1875, stated that by the recommendation of an American physician living in New l'\)iuidland he had for a year employed hot-water inje(!tions, vhieh were advised hy this physician for the hemorrhage of abortion. Windelband used them not (inly in the hemorrhage in miscarriage, but also in that occurring in two cases of ])r8evial placenta, in hemorrhage from uterine fibroids and other growths t'rom the uterine walls, in bleeding after birth when the uterus was relaxed, and in profuse menstruation — in fact, in all cases of uterine hemorrhage. The water should have a temperature of 112° F., and an irrigator or a fountain syringe is preferable to the ordinary instrument. A little vaselin or cosmolin should be applieil to those parts of the external sexual organs with which the fhiid comes in contact as it escapes from the vagina, for without this precaution the patient will com])lain of severe burning. The nozzle of the syringe or inigator should not be passed into the uterus until the stream has begun, thus guarding against the possible introduction of air; it is gradually carried as high in the uterine cavity as desired, the escaping stream making a way, as it were, and facilitating this movement. Another method of arresting uterine hemorrhage is bimanual compression (Fig. 394). The patient lies upon her back with the lower limbs drawn up ; Fi(i. ;!iM.— Bimanual comprossidn of tlie uterus. tlio obstetrician introduces one hand into tiie vagina, both hand and vagina having been carefully disinfected, and passes two or three fingers up to the pos- terior vaginal vault, so that he can exert a firm pressure upon the posterior |)art of the cervix ; the other hand, placed upon the ])atient's abdomen, grasps tiio fundus and the posterior M-all of the uterus, drawing them forward, the vaginal fingers at the same time pushing the cervix in the same direction ; tliiis the uterus is anteflexed and firndy held, so that hemorrhage for the time is impossible. The vaginal fingers may be ap])lied to the cervix anteriorly, and the external hand to the fundus and the anterior surface of the uterus, and thus the organ may be retroflexed and arrest of bleeding be accomplished. Fritsch" speaks favorably of what he calls tlie " rational bandaging " of the P''v^?llli->^il ,i':!; «^ , ?; -If. I I 1 ;! i.. « } 1t- \ \ i5V< lit! f.^ t i! I i ' 1 - th I r ^'} I I 1 60(5 AMERICAN TEXT-BOOK OF OBSTETRICS. abdomen, saying : " Long prior to my injection of iron, and before Diihrsson recommended the tain|>on, had I applicil bandaging the abdomen in snitabic cases, and with the best results. It is especially to be recommended in those cases in which, some time post-partum, the uterus is again distended with blood and the anemia has reacheas said that the puerperal uterus will hold two ball-dresses I This being true, one need not be astonished at the quantity of gauze required. 1 w W^\:: - P^^v' 1 ■ fir ' I'il^i^ L f\ ()()8 AMEIilCAy TEXT-BOOK OF OJiSTETlUCS. < A I. >i mi ] ^ ^ « ' ,1 vossc'l at tlic jdiKTiital ssitc. He adds tiiat in such cases the removal of tin uterus by supravaginal amputation may be considered in a well-c(»n(hiet((l clinic, but in private practice wouhl not as a rule be thought of. The prop.,- siti(m of Kocks he rcf^awls as worthy of consideration. This sugjicstion i- to invert the uterus, anil after thi> orjian has been brouj^ht down it is to !»• encircled by a piece of rubber tubing or by a firm bandage, best of a strip of iodoform gauze, so placed that the placental site shall be below it. Ncco- sarily the bleeding will be thus immediately arrested, and at the end of six hours the bandage is removed, and, the hemorrhage not reappearing, the uteni> is restored, this restoration, according to the communication of Kocks, being accomplishetl without difficulty. Kaltenbach states that the introduction of a gauze tampon is very difficult in case of a flaccid uterus, and often it is incompletely done, and thus tlic bleeding remains internal. He fiu'ther states, after referring to the dangerous embolism which may result from injecting an iron solution, that the gaii/c tamp(m is especially applicable in eases of deficient coagulability of the blo(Ml. Herman," in criticising the gauze treatment, remarks that we must judge the effi^ct of treatment of post-partum hemorrhage rather by the fewness of the failures than by the number of apparent successes. Fritsch has reeord((d a case in which death occurred from atonic hemorrhage notwithstatiding the tampon • and other cases, in which the cause of death was not clear, have been published. One ease of fatal air-embolism, occiu-ring while the tampon was being introduced, has been reported. To the assertion that the treatment is neither certain nor eafe he adds that it is imphysiological, for the uterus camiot bo completely contracted while the gauze is in it. (.'ertaiidy the eases are very rare in which this treatment will be required. (iuite exceptional, too, are those cases in which a departure from the rule, long established and almost universally held, that the uterus must be emptied of clots, is justifiable. " Tiu'u out that clot!" has been the injunction of obstetric teachers for a century or more ; yet it may be that in some very rare instances the direction shoidd be, " Do not turn out that clot." In Containiu's paper the following case is narrated : " There are, nevertheless, cases in which clots seem to oppose a barrier to the flow of blood. In one of his patients Professor Bouehacourt three times emptied the uterus of clots. After each evacuation the hemorrhage rectu'red and clots were again formed in the uterine cavity. The patient was exhausted and syncope was imminent. As the si/.c of the uterus was not very great and did not seem to increase, this fact indi- cating that the hemorrhage was suspended, the clots were left in the uterus. " The hemorrhage did not recur, and the following day the clots were spon- taneously expelled. In this case the clots had the fvle of an obstacle to tlic flow of blood, and it might be asked. What woidd have happened if the nh- sti^trician had determined at all hazards to empty the uterus? In exceptional cases only can this practice be followed. Xcvertheless, we are justified in tem- porizing when the hemorrhage seems arrested, and especially if the firmness of the uterus indicates return of its contractions." To this case mav be addcil DYSTOCIA. 000 (die recorded hy Dr. James F. Ilibbertl/* in whicii a similar practice was siiccessrully followed. There was this ditferencc, however : Dr. Ilibberd's patient fainte:" \K ' ' ! lI' i .;Ul ' I the lower angle of tlu; wound, and tie it round the vein by a double knol, cutting the ends short. With the disseeting-fbreeps pineh up the vein and make a small nick in 't with scissors, taking care not to sever tlic vein com- pletely. Introduce the cannula (silver or glas.s) into the vein, and tie it in by means of the upper ligature, leaving the ends long as in the Figure. Tli. blood will How down the camuda, and when it is full the rublK«r tubing, pre- viously attached to the glass funnel and tilled with the saline solution, is tixcd on the end. The funnel is now raised, and as the water flows it ia replaccij by pouring in more of the saline solution from a jug (pitcher) held close to the rim to prevent air-bubbles being formed. As long as the funnel is kept above the level of the camuda, air-bubbles will always rise to the surface and escape. Another method of introduction, and one recommended in severe cases, is to fix the funnel and the cannula in the tubing, fill the apparatus with salt-solution till it runs out warm, and then to introduce tiie cannula into the vein, the funnel being held by an assistant slightly higher than the cannula, so as to keep up a gentle flow which washes away the oozing blood and ensures the absence of air. The speed at wliich the fluid is injected can be regulated bv raisintr or lowering the funnel. In most cases a distance of about .'{ feet is sutticient, and the flow is found to be about a pint every four minutes. When enough has been injected, remove the canntda from the vein. Cut the latter completely across, and tie the upper end with the long ends of the ligii- ture. Sew up the wound with a continuous or interrupted fine silk or other suture, and fix a clean pad with a bandage." Horroeks states that enough fluid should be injected to cause the pulse to be perceptible at the wrist, and that the worst cases require about six pints. Further, in the treatment of the ))rostratc condition Kaltenbach commends a rectal injection of red wine and the whites of two eggs with from 20 to 30 drops of tincture of opium. lie also sjieaks favorably of an injection once or oftener, in the up])er ])art of the thigh, of ether, tincture of musk, or cani- ])horated oil (1 : 9). Convalescence from the anemia resulting from severe bleeding will he best prouKjted by keeping the patient in a horizontal position, not even permitting her to sit up to nurse her child or to urinate. Milk, eggs, and animal broths should constitute the thief part of the diet, and alcoholic .stimulants may be advisable in some eases. If the hemorrhage has been from the placental site, and esi)ecially if the flow is profuse and its bloody character is prolonged, ergot or fluid extract of hydrastis is indicated. The first getting out of bed will be delayed several days after the usual time in patients who have suflered from post-partum bleeding. Many patients will require the early administration of tonics — quinin and iron, for exani- ])Ie, or the elixir of phosphate of iron, quinin, and strychnin, or the eoiii- jiound of ** beef, wine, and iron." Lacerations and Rupture of the Uterus. — These lesions are found almost exclusively in the lower segment of the uterus; most of them con- sist in tears of the uterine wall that run more or less transversely (Fig. DVSTOC/A. Gil .?9G). Tlioy nro callod " complete " rnptnroa of the utoruH wlion tlir wouimI |>('iiotrnte.s all throt- fonts of that organ, and " incomplete " when cither the serous or the nmcoiis lining of the womb remains nnimpaired. Laccrutions in the upper portion of the uterus are exceeilingly rare. CdHncs. — Sliarp ridges projecting from the pcjlvic hones have sometimes Iteen known to sever the vails of the uterus. These projections are most likely (c> be found at the promontory and along the ilio-pectineal line, ff there is any mechanical disproportion between the inlet of the pelvis and the fetal I'lc. 3%.— Trnnsverso rupture of lower set;- Fii!.;i>J7.—IrapeniliiiK rupture of utcnis in iishoul- iiicut of uterus (Spiejjelbern) : a, probe inserted der iiresentiition (niueli ruoililieil from Scliroeiier): or, external os; oi, internul os ; r,\ eontraetion- ring. miller the peritoneum. head, the latter in its descent will press the lower segment of the womb against these sharp ridges with so mucli force that they may grind their way into the uterine tissues. Any attempt to pull the head into the j)elvis with forceps will under these conditions only help to increase the amount of injury to the uterus. Incomplete rupture of the uterus, with the inner portion of the wall entire, can have originated only in this manner. By far the greatest number of ruptures of the uterus, however, are caused ill an entirely different way. They are the direct result of the uterine con- tractions and of over-distention of the lower segnjent of the uterus. This mode of origin \\as first jwinted out in 1875 by Bandl, and since then his statements have generally been accepted as correct. During labor the upper |i(ii-tion only of the uterus contracts, while the entire cervix and that portion of tlie body immediately above the inner os are subjected to a stretching process until they form one wide cylindrical canal. While this dilatation is going on we find that the wall of the lower segment gets thinner during each labor- |)aiii, whereas the wall of the contracting portion of the uterus thickens and iiardons. The border-line between the upper and the lower segment of the womb is marked by a ring-shaped projection of the contracting portion, the so-called "contraction-ring," which is found at a variable distance above the inner os. During the contractions the uterus has a tendency to move upward . ' 1 1! j ' 1.- ' : > i ijl ! J.! ..Ai -:;r*ir 612 AMERICAN TEXT-nOOK OE OBSTETRICS. toward tho diaphragm and to pull the dilated lower segment upward and awa\ from the presenting part, the latter usually deseending at the same time, thi- partial evacuation of the iiterus preventing an undue stretehing of the lowoi- segment. If, however, a malpresentation or some other mechanical impcdinieni ])revents the fetus from descending, tlie stretching of the lower segment con- tinues. The uterus, as a rule, tries to overcome the obstacle by an increase iii the intensity and duration of the contractions, thereby augmenting the chances for a ru|)ture. When there is unequal dilatation — as, for instance, in shoulder prescntalion, in which the greatest stretching of the lower uterus takes jihuc on that side to which the fetal head has escaped — the rupture becomes still more imminent (Fig. .'J97). The administration of ergot during labor is at times directly responsible for uterine ruptures. The writer remembers a case of a multipara with eentril placenta pra>via in which the attending physician had plugged the vagina very effectively, and at the same time had given the patient a teasp^onful of ergotol. The tampons together with the mass of the placenta nuulc it impossible for the presenting head to enter the pelvis; it escaped to the left iliac fossa, ami when the writer saw the patient two hours later he found a transverse laceration on the left side of the uterus a little above the inner os, through which the head had entered the abdominal cavity. From what has been said above it is evident that these ruptures nnist always originate in the lower segsiient of the uterus; which fact, however, does not preclude the possibility of the tear extending upwanl into and above the contraction-ring. Si/mpfoinx. — In a minor number of cases the rupture takes place without premonitory symptoms, but usually these symptoms are well marked. The parturient wt>man does not rest between the uterine contractions ; she complains of constant and severe pain in the lower abdomen on account of the intense stretching to which the lower segment of the uterus and the uterine ligaments is being sul)jectetoms may bo missing, with the exception of a change in the character of the pulse. The abrupt cessation of the uterine activity is also very constant. On examination the presenting part will ije found to have receded, or it may have entirely disappeared. Part or all of the chihl has escaped throuiili the rent, and it can (Nearly be outlined through the abdominal wall. If the tear does not extend through the peritoneum, then this membrane is detacheil so as to form a large cavity which contains the escaped fetus and a greater or lesser quantity of blood. Frcqunu'i/ of the Accidait. — No reliable statistics as to the frequency »l' rupture of tlie uterus can be procured, as in maternity hospitals, to which com- ho tVeqiioncv of , to which coin- BYSTOCIA. |)licat(xl oas^os arc constantly forwarded, there will naturally he found a greater [icrcentagc of sncli accidents than if all labor cases from a large territory were collected for statistical purposes. In countries in which osteomalacia ;ind rickets are common the frequency of pelvic contractions must necessarily increase the number of ruptures of the uterus. The ireijuency of this awi- (lont will vary also with tlie greater or lesser ability of the obstetrician. IJandl found one case of rupttn-cd uterus among 1200 continements, while (Jarrigucs states the frequenev as 1 in from 3000 to 5000; the latter statement seems to be apj)roximately correct for the Uniteil States Frog)WHis. — Rupture of the uterus is one of the gravest complications of l;il)(>r. Over 90 per cent, of the children are born dead, and of the mothers liiliy 60 per cent, succumb to the accident. Many women bleed to death before help can reach them ; others die within the next few days from septic infection or from secondary hemorrhage. Before antiseptic times the outlook was even more gloomy, but it has greatly iini)rovcd within recent years, and we may hope that in the future a still greater percentage of mothers will be saved. According to statistics published by Sciiultz and quoted by Winckel in his text-book, the following percentage of cures was effected in the 11)3 cases collected from modern literature: Complete ruptures without treatment, 20.2 jier cent. Complete ruptures treated with drainage oidy, 36 per cent. Complete rupuires treated by laparotomy, 44.7 per cent. Treat incut. — Whenever during labor the over-distention of the lower seg- ment of the uterus can be diagnosticated, an attempt must be nuule to deliver at once and to accomplish this without increasing the distention of the parts. Tlie patient should be anesthetized, as the narcosis will lessen the intensity ol' the uterine C()ntra<'tions. The mode of delivery nuist be clu)sen according to the nature of the case. Tn shoulder presentations version carefully executed is the proper procedure, providing the child 's living. IShould the child be (lead, then embryotomy would bo itrefoiablc, as i' does not increase the tension of the uterine walls, an, while version, no matter how skilfuUy performed, will cause some additional distention. In licail presentations a gentle attempt with the forceps should be made, always taking it for granted I'lat the child is living. Failing with the forceps, the onlv choice lies between Cesarean section and craniotomv ol' he livins; child. N'ersion in these cases is out of the question, because t'le stretching of the uterus in a transverse direction is very nuieh greater ^\hon the operation is |i('rformed in head presentation than when it is resorteil to in shouhh'r pres- ciilation, where the child lies already with its long axii more or less trans- versely in the uterus. U«ider favorable surroimdini^s Cesarean section should always be the operation for treating this emcr}^ .ic; \ and craniotomy should be performed in those eases in which the «. hild has censed to live. After the rupture has taken ])lace a spoci^ delivery is also called for. 1 1' a part of the child '"■^ retained in ! le . ^^nis, delivery through the natural passages shoidd at once be attempted. Usually w. are able to extract the child ;.v| i. .Z . •l^J" ij, * I ■' 1m ^' ' I' ', >u . • ! ^ ,, ' i I ; 31' 614 AMEBICAN TEXT-liOOK OF OBSTETRICS. by the feet. The placenta is removed next, and the parts are then cleaned and examined. Hemorrhage may not be very great, as the uterus gcnoi- ally contracts well as soon as it is completely emptied. The patient should lie allowed to rest, and she may be stimulated with hypodermatic injections ol' ether, brandy, and like agents. If she rallies, the further treatment must lie decided upon. The question will be : Shall the abdomen be opened, the rupture be closed by sutures, and the peritoneal cavity be cleansed of the blood ami meconium that have entered it, or shall the treatment be confined simply to cleansing the vagina with disinfecting irrigations and introducing a glass tuho or a roll of iodoform gauze into the rent in the uterine wall to provide drain- age for the infected peritoneum ? When the accident has happened amid sur- roundings that would not be objectionable to laparotomies for other causes, there is no good reason why the patient, provided she has rallied, should nut be given the full benefit of the modern advance in abdominal surgery. Laparotomy performed under these conditions cannot expose the patient to any additional danger, but it can greatly improve her chances fur recovery. AVhen the child has entirely escaped from the uterus or when it cannot be extracted through the v'las naturales without greatly increasing the laceration, there is no choice in the mode of treatment. The abdomen must be opened and the child be taken away after ligating the umbilical cord ; the placenta is best removed by compressing the uterus, when the after-birth usually glides down into the vagina, whence it can be extracted by the hand. The tear is now repaired by suturing, care being first taken to unite the muscular coat of the uterus, and then to close the peritoneum separately with the edges folded in, so as to ensure a good and speedy union. Incomplete ruptures, with the peritoneum detached from the uterus, do not necessitate laparotomy. The newly-formed cavity is washed out through the rent and a drainage-tube or a roll of iodoform gauze is inserted to give escape to the secretions. The same treatment is pursued in complete ruptures, as already stated, whenever laparotomy is decided against. In the latter ease no attempt should be made to wash out the abdominal cavity through such a tube : the tube should serve only for drainage. Iryuries to the Infra vaginal Portion of the Uterus. — Physiologically there is a laceration of the vaginal portion of the cervix in all primipane and also in some nuiltipara;. This laceration, wliich is usually bilateral, runs in a transverse direction, so that in women who have borne children the external OH is no longer a small round opening surrounded by a perfect ring of tissue, but is a more or less funnel-shaped aperture placed transversely between two well-marked lips. It is only when these tears arc excessive that they gain pathological im- portance. This is the case when the laceration extends upward to the vaginul vault and above it, or when it is accompanied by considerable li'> iior»!i!i^";'. In some cases the anterior lip oi the cervix is wedged in bet^i een the tU'-' head and the pubic arch, and it may be torn off more or less ccnplLtely, By DYSTOCTA. 615 aiiiuilar lacerations of the cervix (Figs. 398-408^ are meant those very rare cases iu which the external os is unyielding and in which the whole lower sec- tion of the vaginal portion has by the descending head been forced off in the >liape of a circular flap containing the external os in its centre (Fig. 404). Cuuses. — The nioie extensive lacerations of the cervix arc almost always caused by obstetrical operations at a time when the cervix uteri is not suf- liciently dilated to allow an easy passage of the fetus. In some few instances ))athological ciianges in the tissues of the cervix are to blame for these injuries. Fici. ;>1)8.— Cervix of virgin (Keitzmann). Fig. 399.— Another form of exteriiul os in tlie virf,'in (Ueitz- mann). Kl<;.-1(K).— Cervix iifler niiseiir- riuge (Ueitzmiinn). At limes the uterine contractions are so severe and frequent that they force tlie presenting ])art through the cervix before the latter has had time to dilate. Not unfrequently the administration of ergot during the first stage of labor, or rupture of the bag of waters before the os is fully dilated, has provoked these dangerous labor-pains. It is stated that prolonged labors are more K'' . .1.-- Cervix of mnltipara Via. WJ.— HllHteral Iiieeration Vm. -103.— Kxtensivelnecrnticpu (Heitzmunn). to vaginnl walls with eversion involvinfj sii)ira-vaKinal cervix (Heitzmann). and vaginal wall (Ueitzmaun). Klj fertile ciiuses of cervical injury than rapid labors, ou account of the long- continued compression of the cervical tissues. iSipnptoms. — It is only in a minority of cases that there are symptoms ])resent of sufficient gravity to lead to immediate discovery of the excessive laceration of the cervix at the time of its occurrence. Intcnst; pain is somc- iiues present, more particularly in those cases in which the rent extends uj)- ward through the vault of tiie vagina to the neigliboriiood of the peritoneum. TIk^ hoMiorrhage, usually trifling, is now and then so sevens as directly to endanger the life of the patient. When a post-])artum hemorrhage is noticed while the uterus is firmly contracted a close examination nmst l)e made of the .^ . H i.; ' .! vm:,\/fil I' 'i-i ill \h 1 !■ ( < 1^ I i, I ^ I I i ' 616 AM/'JIilCAiV TEXT-BOOK OF OBSTETRICS. lower portion of the genital canal ; if it is foiind that there is no lesion of tlir vulva or of the vagina that could cause the bleeding, it will l)e an eas\ matter to trace its origin to an injury of the cervix. If needs be the cervix- may be pulled down into the vaginal orifice to allow of inspection. During- the puerperal state an extensive lacera- tion of the cervix increases the danger of ])uerpt'ral septicemia and, at a lat(!i' period, it may lead to chronic uteriuf disease. Treatment. — The prophylactic treat- ment necessitates deferring all obstetric operations until the cervix is fully dilated. This waiting is not always practicable, and we often have lo choose the lesser to anticipate the greater evil, but we should never ope- rate under these conditions without tlie most urgent indications. The administration of ergot dui'ing labor at any time before the birth of the child is accompanied by so many dangers to both mother and offspring that no terms are too strong to denounce this nefarious practice. Profuse hemorrhage from a tear in tiie cervix will sometimes be arrested by hot-water injections or by direct compression of the parts either by the Fui. 404.— External os aiul a |)i.' rorvix liiulitT ii|>, which have been (luring delivery (Winekel). i)f the irn oil' Fl(i. lO.'i.— l.iici'nitiDU throuiih the left side of the cervix intcitlie hroad lijranienl to the ischial Rjiine and along the vagina through the perineal pyramid. Fiii. 4fX'i.— The two lower corners of the latciiil laceration of the cervix seized hy a double teiiiu - nlnni and drawn down to make ready forsuturini,' (Dickinson). finger or by a tampon ])laced against the bleeding surface. In most cases, however, it is j)referable to unite the torn ti.ssuos by sutiu'cs. The vagina is held open l)y vaginal specula or holders and the cervix is ])ulled down with a volsella or with a pair of Muzeaux forceps until it appears in the vulva, when the sutures can usually be applied without nuich difficulty (Figs. 405, 400). Inversion of the Uterus. — Wy complete inversion of the uterus is meant that cliange of position and form in which the fundus is the lowest and the cervix the highest i)art of the organ, and the external surface is the internal ; DYSTOCIA. (317 *! , I el osion of tlic be au easy e the cervix the vaginal jn. Duriii- nsive laceni- s the (hui<;( r lul, at a lat(!r ronic uterine lylactic troat- r all obstetric •vix is fully i not always ten have in nticipate the Id never opc- is without till' labor at any anirers to both this nefarious es be arrested either by the liriicrsol'tlif liiUval l)y 11 (Imililc toiim- : ready iDrsuturiiij; [n most oases, I The vagina is II down with a [e vulva, wilt 11 405, 400). Items is nionnt lowest and tlic the internal ; the shortest definition of uterine inversion is, the uterus upside down and inside out. Varieties. — We have here to consider only what is known as puerperal inversion, and of it there are two or three varieties, according to the degree of the displacement of the organ. The first degree, constituting one of the I'orins of incomplete inversion, consists in cupping or depression of the fundus (if the uterus. Should the fundus descend so that it is at, or partially projects tVoin, the OS, the inversion is still incomplete ; but if the fundus and the body of the uterus have passetl through the os, the inversion is complete. If the inverted organ is external, the vagina also being inverted, the greatest displace- ment is present, and it is complete inversion with prolapse. Into the funnel- slia])ed cavity formed by the organ internally, and lined with peritoneum, the Falloj)ian tubes, the ovarian ligaments, rouuu and broad, the ovaries in part, or a portion of intestine or of omentum, may enter (Figs. 407, 408). Kic. 40" iviTsiim "f utoriis : (liiiwiiiK from an nlil [ipi'cimi'ii in alciiliol. Tlio iitonic cliief site of |iliic( iitiil iittiiclnnoiit ((') is slirunkcn liy the alco- liol.anil llms its lessenint; is explained ; li.eoiitrue- linii-riu);; ((.external os nteri (alter .1. Veit). Flfi. 40«.— Inversion of tlie nteriis. The Ininen of the reetuni is seen, and also the inversion fun- nel in whieh are the tubes and an ovary (after J. Veit). Frequcnci/, — We have no conclusive stati.stics as to the frequency of this accident. Winckel ^^ in more than 20,000 labors has not seen a case of com- plete inversion, nor had Braun one in '200,000. Denham in 100,000 cases of labor in the Rotunda Hospital, Dublin, found one ca.se of inversion. Kehrer" states that the accident is thought to occur once in 2000 labors. Probablv uterine inversion is more frequent than published reports of cases would lead f^^m^^ 1 % ■fiw I ; \ ! If ' ' > <' ,«•' i 618 AMERICAN TEXT-BOOK OF OBSTETRICS. one to believe. It may be that in some cases if the displacement was recog- nized the fact was concealed ; in other instances the accident was not dis- co veretl. Etiology. — Relaxation of the nterus necessarily precedes inversion. Mat- thews Duncan has stated : ^* ** Four kinds of uterine inversion occur after delivery : 1. Spontaneous passive uterine inversion ; 2. Artificial passive uterine inversion; 3. Spontaneous active uterine inversion ; 4. Artificial active uterine inversion. The only uterine condition essential to the production of all these kinds is paralysis or inertia or complete inaction." Without entering into the various explanations of uterine inversion given by Duncan, this accident may originate in three ways : 1. There may be spontaneous inversion. Paralysis of the uterus at the placental site existing, simply the weight of the placenta may cause sinking of that portion of thd uterus in the cavity. Such ot<3urrence is more liable to happen if the placenta is attached at the fundus; then, the remaining portion of the uterus being a( tivo, t' > introcedent part becoties a foreign body, and by peristaltic action is forced farther down, just as happens in intussusception of the bowels. So, too, in complete paralysis of the uterus the organ may be inverted by the \veight of the placenta. Each of these forms of spontaneous inversion is rare : some, indeed, regard them as doubtful. 2. The inversion may be caused by abdominal pressure or by the pressure of the hand upon the uterus. Kaltenbach states that he saw an inversion produced by the practitioner, in endeavoring to express the placenta, con- tinuing to press after the uterine contraction had ceased.* Denuce^' quotes a passage from Galen showing that this great physician knew uterine inversion could be caused by spontaneous abdominal pressure. 3. Inversion is most frequently produced by pulling upon the cord, and this may occur in spontaneous expulsion or in extraction of the child, there being absolute or relative shortening of the funis. Again, it may hapi^en if the child is expellei lod sensibility to pain is much lessened — the depression tormetl by the entrance to the new uterine cavity can be recognizetl. Denuce gives the following diagnostic marks of inversion and polypus : 1. The circular, not lateral, implantation of the pedicle; 2. The openings of the tubes upon the inferior portion of the tumor ; 3. The special sensibility, sometimes acconpanied by special contractility, that it otters to pressure and to acupuncture • 4. The half reduction which can always be made in inversions, never with polypi ; 5. The absence of the uterus from its ordinary place, ascertained by rectal and vesical examination. Now, we have to say as to these diagnostic marks, first, that finding the ojionings of the oviducts is not always easy under the circumstances, and that we know that an invertetl uterus may reveal no contractility, and that it may be insensitive, possibly in consequence of the utter prostration of the subject, to pressure and to acupuncture, so that the absence of these ])articular signs does not prove that the suspected tumor is other than an invertetl uterus. Prognoms. — x4ccording to Crosse,*' one-third of the women with puerperal inversion of the uterus die either immediately or within a month. In seventy- two of 109 fatal cases collected by him death occurral within seventy-two hours, usually within half an hour. Crampton*'^ in 1885 collected 120 cases; there were eighty-seven recoveries, thirty-two deaths, and one remained unre- lieved. Winckel, after quoting Crosse's statistics, states that in 54 recent cases only twelve died. But even this comparatively low mortality proves that in- version of the uterus is one of the gravest accidents of labor. Patients may die from shock or from bleeding; the death may not be immediate, and then it may occur from incarceration of a loop of intestine in the inverted uterus, from jieritonitis, from puerperal infection, or from gangrenous inflammation of the uterus. In very rare instances recovery has followetl the separation by sloughing of this organ. Spontaneous restoration of the uterus has occasion- ally taken place. Schiitz '^ states that ten such cases are known. Sometimes this has occurred after the failure of artificial means. Treatment. — Of course the prophylaxis is of primary importance. Ijct the rooiimbeut position be insisted upon in delivery. If brevity of the funis be ivcognizwl, promptly dividing the cord is indicated. In removing the placenta let no traction be made upon the cord, or at least no traction except during a pain. If compression of the uterus is made in efforts to express the placenta, S- ,**«7 •i: I > .'I i I i! ■I ^^M InKi''.^ p 1. I ei 11 ■liki 622 AMERICAN TEXT-BOOK OF OBSTETRICS. let the obstetrician be assiirod that his hand is so applied to the organ that im depression of a part of its wall is possible. The accident having occurred, restoration of the inverted organ is to Ijo made : this restoration will be more readily effected the sooner it follows the accident. If the ])lacenta is undetachetly he iiichuh'd imdcr puerperal eehimpsia. In the ^reat majority of eases in which the disease iiappens in prej^nancy the time (Votu Hcvon to nine inontiis oilers tiu! jjjreatest liability ; nevertheless, eases have been observed at the sixth, the tifth, or the fourth month, even at the sixth week, and Tissier re|M»rted a case at the seventeenth day, and Prestiit one in the se(!ond week. I'reinonilori/ Si/inp(ovi». — The first atta(tk may oeenr without warninj;, the patient appanaitly having been up to the seizure in good health. IVit usually there are precursory phenomena, lasting only a few hours or begimiing a few (lays before. These phenomena are nausea iuul vomiting, restlessness, weariness upon exertion, mental irritability, headache, disturbance of vision, dizziness, iiiiiscular tremors, ringing in the ears, and severe epigastric pain. Delore calls attention to lumbago as a premonitory sym|)tom observed in some eases, this symptom being the expression of renal changes. Special importance is, prob- ably with justice, to be attached to three of these — namely, the epigastric^ pain, tlie headache, and the disturbance of vision — and therefore fidler consideration must 1)C given them. The cpif/dntric suffering is I'v no means a constant nuin- ili-tation ; but if it occurs, it is (piite significant : according to liailly, it rarely lasts more than a few hours, and when it becomes very severe and continuous one may almost be certain that the convulsive attack is imminent. Dyspnea is connected with epigastric pain, antl is attributed to the poison in the blotxl, which, as will presently be seen, seems the essential cause of eclampsia. The hcadaclm is usually frontal, occupying the entire forehead, or it may be upon the one or the other side; rarely is it occipital. The dixturbatice of vixixm may be simply asthenopia or amblyopia or diplopia, or even absolute blind- ness ; in one case we have seen loss of vision twenty-four hours before fatal eclampsia at the fourth month of pregnancy, and v/v have had a patient who became amaurotic during labor — it was a plural pregnancy, and she had had for some weeks albuminuria; the amaurosis continued several days after the delivery of living twins, and then spontaneously disappeared. According to Vinay, if headache is accomj>anied by flashes of light, by ringing in the ears, by tingling and numbness of the lower limbs, the attack is at hand. In some cases, rare, however, ati aura immediately precedes eclampsia. A patient of Olshausen's uttered her husband's name, and in- stantly the convulsions came. Another may have the sensation of falling, still another may utter a cry of terror, and others have been known to raise the arm before the face as if to protect it from a threatened blow. If some of the premonitory symptoms that have been mentional, such as disturbance of stomach, of vision or hearing, headache, numbness of the lower limbs, be observed in a woman who is edematous, if she has scanty urine, and, above all, if this contains albumin and casts, convulsions will surely come unless proper means arc promptly usetl to avert them. Phenomena of Eclampsia. — The patient lies fixed in position, while her eyes are apparently directed to some distant object ; she has become nncon- 40 ! ] llsw 626 AMERICAX TEXT-BOOK OF OBSTETRICS. I nt observed by Tarnier for twenty mimites. The return of the patient to consciousness is only gradual, and the time intervening between the first onset of the convulsions and the end of the coma is a complete blank in her memory. Very rarely there is but a single attack, and the jiatient is restored to ))er- feet health. Still more rarely death results from this attack ; such a case li:i< been recently reported :"' the ])atient was delivered just at the beginning of a broncho-pneumonia ; at the end of nine days she had eclampsia, and died in fortv-eijiht hours after the attack. In almost all cases after an interval of half an hour, or even of several hours, the eclampsia recurs, and attack may follow attack with no restoni- tion to consciousness — indeed, in grave cases the consciousness may imt return after the first attack. The number of seizures may be very great ; Kaltenbach refers to eighty in some cases, and A'^inay says there may l>r more than a hundred. Winckcl has seen but one ease of recovery al'ti i' eighteen attacks; but \ inay states that a patient recovered after twenty-six, If ^ -.I^f erally tvinud niilly remains )f tlie nostril> II toward oiu' brief jerkiiii: nil Hexed, the ■i jaw; beeoinc is arrested hy he entire body ie eonvnlsioii- seles ot'aniiiiiil iration returns, lien faee, wliidi ic stage, gradn- it frothy saliva, ns, after lastiii;j; )v an nnusnally naining uncon- [•erebral conges- cins by the con- spiration during twenty minutes, rs — more rarely •overed with an ■ginning of tlic iring it, but bc- ie rarely lastinir [nier for twenty radual, and the |l the end of tlii' restored to per- sueh a ease lia* I' beginning of a [iia, and died in even of several ,'itli no restor:i- lisness may n^t be very gre:ii ; |s there may !"' recovery al'ti i' ifter twenty-i^i-^, DYSTOCIA. ^627 and Olshaiisen had six patients, having from twenty-two to thirty-six, who irot well. It is rare for the attacks to continue longer than forty-eight hours ; indeed, the fate of the j)atient is usually determined within the tirst twenty-four iK)urs, for if there are several attacks during this time, unmitigated in severity ;ind undiminished in frequency, a fatal result is almost inevitable. Winckel lii'st called attention to the progressive elevation of temperature with suceessive attacks, so that it may reach 102° or 10-4° F., and after death the thermom- oter marks a still higher degree. Investigations by others, especially by Bom-- neville, followed those of Winckel. Bourneville claimed that not only did the thermometer lurnish important ground for prognosis, but by it only could puerperal eclampsia be dilferentiated from uremia. If the temperature of till' eclamptic continued to increase, reaching a high degree,* the prognosis would be unfavorable, while a {)rogressive diminution pointed in an opposite direction. The results of experience do not give absolute contirmation of this view, for though usually the temperature increases during the continuance of the eclamptic attacks, yet in some instances the danger may be imminent, (liaili at hand, witiiout such increase,! or the temperature may even be sub- normal. So too in regard to the diagnosis between eclampsia and uremia : wliile it is true that there is in the latter a lessened temperature, there are exceptions % to the rule. The urine of the eclamjitic is usually scanty, contains albumin in large |)i'(t|)oftion, various casts, epithelium from the urinary tract, and blood-eel h; : ill somc^ cases there is com])lete anitria. Nevertheless, all albuminurics are not (■('huii])tics ; Hubert makes the number only 2G per cent., and Charpentier has collected 141 cases of eclampsia without albuminuria. The writer, a few years ago, had under his care a primipara who was attacked with eclamjisia a lew hours after labor, and the quantity of urine was not lessened, and showeil only a faint trace of albumin. The Iiijfuence of Ju'/((iii}tsia upon the IIcvuh and ujion the Fctut^. — In case eclamptic; attacks occur in pregnancy, more especially in the latter weeks, in tlie majority of cas(>s action of the uterus is excited and its contents are <\pelled after the fetus is death The death of the fetus may be followed by a disappearance of the eclampsia, and in case no uterine action has Ix'gnii, the pregnancy may continue for a time, or even until term ; meantime, if alijumiiiuria has been jiresent, this gradually ceases. In still other cases, by IK! ineanv numerous, the fetus lives, the patient recovers, and the preg- lUack stall's thiit in a- ing occurred, kidneys show iturbed. with apople(>- umonia — may ?at an import- lent and mo>-e d present the it is increased e and hemor- , and, again, [lit, as several recognized as ko (1) Predis- |ce among pre- Ifrom 1874 to all the nine to seven tini(>s Id liability has n'ia in a first nervous exei- in women ili'inl I nephritis, soiiu'- Inces; in 5 eiisis Biterus and tiiln's I jiarenchynu\t(uis Is rfe GynecoUxjie, DYSTOCIA. ()3I tability : the longer labor is also a cause. If the priniipara be old, the liability is increased. Plnri[)arity predisposes to eclampsia. In Olshausen's statistics sixteen out lit" two hundred gave birth to twins. Here, again, we have similar or rather the same factors which are present in primipanc and have been mentioned. Tliere must also be borne in mind that in plural i)regnancy additional work is thrown upon the eliminating organs of the mother, but this will be pre- sented in considering the essential etiology of the disorder. When the pelvis is narrow or the child's head of unusual size, the eclamptic attacks are more likely to occiu" than in oj)posite conditions. Eclampsia is more frequent, too, i)etween the ages of twenty and thirty : here, probably, the true factor is priniiparity. Hereditary influence has rarely been observed. One of the most striking eases of this influence has been recorded by the late Dr. George T. Elliot:^* The jjatient's mother had given birth to four daughters, and then died of ei'lam])sia at the birth of a son. Of these daughters one died of eclampsia at the sixth month of her first pregnancy, a second, after having two miscar- riages, died of eclampsia in her third pregnancy, the tliird had eclampsia about the sixth month, and recovered ; while the foiu'th was attacked in the (Mglith month, and perished after artificial delivery. Lohlcin states that a jxitient in Schroeder's clinic died of eclampsia, and her two sisters had con- vulsions in their first labors. Independently of heredity, as manifested in the cases quoted from Elliot, and also independently of the mental distress referred to, as predisposing causes, it will readily be admitted that the susceptibility of the nervous system jrreatly varies in diflcn-nt subjects, and that some from excessive irritability may have an eclampsia liability. Of course such condition alone cannot pro- duce the disease, but it may greatly assist in 'ts production. Kaltcnbach has said that a generally-contracted pelvis corresponds usually with an infantile liobifux, which is shown in an increased irritability of the nervous centres; yet, according to Wiedow, such pelvis must sometimes be looked upon as indicating degeneration. Thus predisposing causes may be combined in action. The mental condition may be a predisposing cause, and thus unmarried women, sutFering with shame and anxiety, are more liable. What shall be said of the opinion expressed some years ago by Johns of Dublin, tiiat indcss the vertex presented there was little liability to eclampsia? When it is proved that there is in proportion to the entire nund)er of the various presentations an undue predominance of eclamptic cases in which the vertex descends first, the action of this alleged cause would be Justly considered. It may be of interest, in comicction with this view of Johns as to the etiology uf eclampsia, to quote a sentence from Denman's "Introduction to Midwifery," as showing the possible first inspiration of the view : " I was for many years persuaded that convulsions oidy happened when the head presented ; but experience has proved that they sometimes occur in preternatural presentation of the chihl." .^ . ;j'rl! i1 •&/, ' I.J ^1 s ' t.M ! ai f:f.;y.5 ■/i. 632 AMERICAN TEXT-BOOK OF OBSTETRICS. 2. ExcMlng CauHcu. — When essential and predisposing causes combine, tlie exciting cause of the convulsive paroxysm may be in itself a very slight one, just as the electric spark or a lighted match causes explosion of a powder magazine, or careless handling that of dynamite. Thus the outbreak ol" eclampsia may occur from touching the os uteri, from pressure of the hand upon the abdomen, from distended rectum or bladder, from a uterine con- traction, or from movements of the child. 3. Essential Etiology. — Various theories as to eclampsia which once pre- vailed — the nervous theory, that which made the disease the result of cerebro- spinal congestion, the uremic theory and its derivatives — have passed away. True, Herff *^ contends for the disease resulting from the physiological irritations of pregnancy, but this is given by him as oidy one of the causes. True, too, that the term uremic is still applied by some to these convulsions, but no intelligent physician now claims, as was done by Wilson and others, that urea retained in the blood is the cause of spasms : it is probably unfortunate that any continue the use of the word in this connection, for etymological ly and as originally employed it is now misleading. The theory which makes the essential cause toxemia — not one, but several different poisons, it may be, concerned — is now generally upheld. So, too, the toxemia, while usually associated with renal failure, and dependent uj)tm it, does not in all cases have such association and dependence, for the disease caused by the toxemia may occur without renal disorder ; moreover, it is a question in some cases whether this disorder is not the consequence ratlior than the cause of the toxic condition. Admitting the microbian theory of the origin of the disease, now Jiei(i by a few — a most improbable supposition — it could only explain the toxic condition of the blood, and could not invalidate the opinion that the innnediatc cause of the convulsions is such condition. As stated by Kaltenbach, the theory of blood-poisoning is sustained by tiio clinical history ofthe disease and by post-mortem appearances. " The prodro- mata — gastric and cerebral symptoms — the rapid occurrence of serious disturb- ances in the action of the brain, the post-mortal increase of temperature, tlio nature and frequency of nervous disorders that follow, and which find their analogy in the neuroses consequent upon typhus and diphtheria, probably causetl by toxalbiuuins, are scarcely to be oxi)lained unless by the theory of blood- poisoning. The nature as well as the extent of the anatomical lesions also corresponds with such theory." Admitting the toxemia, the (juestion naturally arises. What is the source of the toxic agent or agents ? Are we to concede the truth of the position taken by Riviere, for example, that autointoxication is the true answer ? Bouchard has said ^ that man is constantly menaced by poisoning ; he labors each instant for his own destruction, makes incessant attempts at suicide; nevertheless, this intoxication is not realized, for the organism has multiple resources to escape it. The liver plays an important part in the destruction of poisons, and elimination by the skin, by the lungs, by the kidneys, and by the intestines assists in the protection of life from poisoning : the most important agents in elimination are the kidneys. DYSTOCIA. 033 The urine, according to Bouchard's investigation, contains several toxic ]irincij)les. Further, it has been found by experiment that tlie toxicity of tills secretion is greatly lessened in the eclamptic, while that of the blood- serum of the ^ame subject is notably increased. It is not the failure of the kidneys to eliminate urea that determines the convulsions, for the non-jjregnant woman may have anuria for several days without eclampsia, and while the nmount of urea eliminated by the woman in gestation each twenty-four hours is increased nearly one-third, there must be arrest of elimination for more than ten days in order that intoxication become j)ossible. We can readily under- stand that if the poison or poisons which jiroduce eclampsia are retained in tiie blood, renal inefficiency or failure may add to the gravity of the condition, in tiiat were the kidneys healthy they would cast out the offending matter. Ac- cording to Bouchard, the kidneys are ca})al)le, when sound, of eliminating infinitely more toxic material than they habitually do ; nevertheless, there are limits, and if the quantity of poison is such, notwithstanding their integrity, that they cannot accomplish their task, accumulation is produced and intoxi- cation results. Thus in the etiology of eclampsia the non-elimination by the several emunctories mentioned must be placed at the very beginning of the trouble — and the toxic matter may l)e maternal in origin. Yet may not the fetus, and even the placenta, have a part in the etiology of the poisoning? Tiie non-pregnant woman may have her abdomen as greatly distended by an ovarian tumor as from plural pregnancy at terra, and she does not suffer from eclampsia. Often if the fetus dies the eclauipsia ends. So, too, the eclamptic attacks are more frequent as the labor occurs and progresses ; uterine contrac- tions may cause now poison to pass into the maternal blood from the fetus and placenta. It seems, therefore, at least not improbable that from the latter source a part of the poison ])roducing eclampsia is derived. The microbian theory recognizes infection, attributing, however, the poison- ing, not to maternal life-processes, pois m-producing, and failure of poison- eiiinination, but to the action of microbes, toxins being formed by these. This theory was first suggested * by Delore ten years ago. A few have, from experimental studies, sustained the theory, but the majority of investigators liavc rejected it. Moreover, in order to explain the entrance of microbes, the hypothesis of a previous endometritis has been assumed. But as the eclamptics are, in the great majority of cases, primiparse, who rarely are subjects of endo- metritis, while multiparse, in whom the disease is not infrequent, are compar- atively seldom eclamptic, the microbian theory must be regarde ^iW' m Ijt ■iU 1 .W "!"' V:> .15 i i' I ■Pi ■■''■'! i " '■ ■ 1' 1 \v : ... ' 1 m 034 AMIJIilCAX TEXr-nOOK OF OliSTETRTCS. M 'ir A-i. I \l ^4 ihf ' i m 1 ,;,<'■;■, Halbcrtsma attributes the eeiampsia chiefly to K'ssened excretion of uriiK resulting from eompresit is accomplished, as advised by Winckcl when there is any notable albumi- nuria, by the administration each morning of a pill composed of extract nf aloes and extract of colocynth, in sufficient cpiatitity to cause free, watery evacuations. The hot bath is the best means for producing activity of the skin ; this bath should have a temperature of 100° F., the patient to remain in it at least fifteen minutes, and upon coming out of it be wrapped in warm blankets, drink a glass of hot milk, and remain in a warm room for two hours : abundant perspiration will thus result. If an absolute milk diet is not directed, at least milk should be the chief food ; Winckel allows the spar- ing use of meat and vegetables. The diuretic action of the milk may be pni- moted bv alkaline mineral waters. For the albuniimiria Duff"" recommends 1 DYSTOCIA. G35 one drop of nitrof^Iyoerin tliroe times daily, and Vinay speaks hiplily of cliloral. The latter refers to a patient, a primigravida, haviiif]f at the end of the eighth month 22 j^rams of dried albumin in the iirine in twenty-four liours, who took duriiij!; the ninth month 120 grams of chloral, or 4 grams per day, and was delivered at term of a living ehild, no eonvulsions oceur- ling: in most eases he advises 3 grams daily, or 4o grains, lie also states that when the albumin is al)un(lant, and headaehe, irritability, restlessness, vertigo, disturbance of vision, etc. are present, chlorali/ation of parturients is (if the greatest value; from the beginning of the pains from 4 to G grams (if chloral arc given by the mouth, and the patient soon sinks into a profound sleep, uninterrupted but at the moment of contractions. In grave and persistent albuminuria, no benefit having been obtained by hygienic and medical means, and eclampsia threatened, the artificial interrup- tion of the pregnancy may be clearly indicated. In case the convidsive attack occurs, the immediate duty of the ])ractitioner is to prevent the patient from injuring herself; the greatest liability is that she may bite her partially prdtruded tongue, which, therefore, should be held back by means of a napkin stretched between i\w teeth and grasped on each side. Kaltenbach advises, for this purpose, inserting between the jaws the handle of a spoon wrai>ped with gauze. Of course the patient is jireventcd from injuring herself by striking against hard objects, or even falling out of bed during clonic convulsions — a possibility, but not a probability. If after a convulsion the tongue falls back, iirrcsting respiration, it must be drawn forward. Kaltenbach emphasizes the imiiortance of cleansing the pharynx by means of small sponges with a handle, t(i prevent the entrance of the secretions from the mouth and pharynx, mixed with bloody slime, into the lungs, stating that many patients die, after recovery fioin the convtdsions, in consequence of SvhluckpnvHmonicn, or deglutition- pneumonia. Is she to be bled? Doubtless oiu* fathers were wrong in making vene- section the common remedy in eclampsia, but their sons are equally wrong in entirely rejecting it. Though Winckel and jNIartin condemn it, though indeed it has little professional support from great authorities in general, yet we find Kaltenbach wisely, as we believe, saying that in strong, plethoric women, with great cyanosis, bleeding has undoubtedly a favorable effect. Tills bleeding removes a certain amount of poison from the circulation ; the removal, too, is instant, and it further removes from the convidsive centres tlio [loisoned blood by restoring contraction of the small vessels as claimetl l)y Peter. We believe, therefore, that bleeding in some cases of eclampsia is rational, and rests upon a sound clinical basis. (See especially the st;itistics of Charpentier upon this jioint.) Of course it is only in exceptional cases that this treatment is indicated. The administration of chloral by the rectum is generally adopted ; Winckel oinploys 1 to 2 grams of chloral thus, repeating the dose after each attack until 12 grams or more are administered in twenty-four hours; Plant suc- .^•■^'■ i 't ' .i-S' ^^'': ! . ■ i ■ ) ' 636 AMERICAN TEXT-BOOK OF OBSTETRICS. ■r, 1 ! I f''l 'A I >m!« cessfully used 150 grains, or about 15 grams, in the same period. Clark ill America (Oswego, N. Y.) and G. Veit in (Jermany arc the most promi- nent advocates of morphia hypmlennatically, and each uses what many would regard as heroic doses. Olshausen employs one-third of a grain, increasing to nine-tenths, and only resorts to chloral when morphia cannot be emj)l(tye(l : he has given 11 to 12 grains of morphia in four days. But all have not been as successful in using the morphia treatment as Veit, only two deaths in sixty cases ; and moreover a fatal narcosis of the infant, if not of the mothei-, has sometimes been observed. Anesthetic inhalation, chiefly of chloroform, is generally recommended, though Olshausen reserves it for exceptional cases, and Kaltenbach objects t«i the protracted narcosis with chloroform, for, on the one hand, it readily leads to fatty degeneration of the heart and other organs, and, on the other hand, impairs the activity of the kidneys; on the contrary, Vinay refers to patients having Ix^n kept under its influence six, ten, or even twenty-four hours. The potassic bromid may be rejectetl because requiring large doses, slow, uncertain, and feeble in its action ; moreover, according to Bouchard, the potash is the most toxic of mineral salts. Pilocar]>in is a remedy condemned by Braun, Fordyce Barker, and, more recently, by Winckel, Kaltenbach, and Vinay. Purgatives are generally recognized both from theoretical reasons and from experience as important. In addition to those previously mentioned, el:i- teriuin and croton oil, administered by the mouth, and infusion of senna, witii the sulphate of soda or of magnesia, by the rectum, are frequently employed. Professional evidence seems conclusive as to the great value of tinctiu'c of veratrum viride, first used in 1859 by Dr. Baker '"^ of Eufaula, Alabama, and long a favorite remedy with practitioners of the South and West of the United States. The method of administering is hypodermatic, and the dose, accord- ing to Jewett,"^ is from 10 to 20 minims ; the smaller dose rejieated in half an hour will doubtless suffice in the majority of cases. Dr. Jewett asserts that experience seems to justify the statement that no convulsion will occur while the i)atient is sufficiently under veratrum to hold the cardiac pulsations below sixty to the minute. If the pulse is not sufficiently reduced by the first injection, a second is given in thirty minutes : five-minim doses at longer intervals are used to keep up this lessened frequency of the pulse. The Cesarean operation performed after the mother's death has in a very few instances saved the life of the child, but Halbertsma"" has proposed, and several times done the operation, to save not only the life of the child, but also that of the mother, in grave cases of eclampsia. The entire number of operations by him and by others is 14, but as two of the patients wen- dying, the number is reduced to twelve ; of these four dietl ; that is, the operation gives a mortality of a little more than 36 per cent. Recogniziui: that the subjects operated upon were in imminent danger of death, the result does not seem discouraging. Maygrier^ has reported the case of a primipara who had eighteen attacks of convulsions; she was treated by venesection, and then, by a sound passed DYSTOCIA. 637 into the stomach throii}]fh the nose, 150 firams of milk were introduced every hour ; anuria, whi<'h was present, was almost irametliately relieved, and tlic patient recovered. Porak and Bernheim '"* advise in every case in which the urine is sup- ])rossed or is scanty and dark colored that salt water shoidd he used hypoder- iiiatically, to promote diuresis and thus elimination. A liter of sterilized warm water containiiifr 7 to 7.-5 grams of chlorid of sodium is introduced into one of the huttocks, the skin hih'ing been first disinfetJted, and either a needle or a siphon employed : twenty minutes is required for the operation ; the fluid injected has a tenijKjrature of 88° to 90° F. ; the results have been (piite satis- iiu'tory. There is a general agreeni'^nt of the profession that if eclampsia occur in labor or labor come on during it, delivery should be effected as soon as possi- ble without violence. So, too, the majority agree that eclamptic attacks that do not yield to appropriate treatment furnish an indication for ending the ])reg- iiancy. Diihrssen ®* has gone further, reviving accouchement force, which in tiiis day of antiseptics and anesthetics is by no means the perilous proceeding it once was ; he does not shrink from ending the pregnancy, even when the child is not viable, in eclampsia and in the pri.nigravida when no efforts at labor are made, overcoming obstacles presentetl by the cervix or by the peri- neum and vulva with incisions, so as to ensure rapid delivery. This method has not met with the approval of Olshausen, for example ; it has received from Oliarpentier a searching and severe criti(;ism,"'* and he declares it dangerous and that it ought to be absolutely proscribed. In his conclusions Charpentier states that the induction of premature labor should be reserved for some exceptional oases in which the medical treatment has entirely failed. He also gives the following statistics of mortality in eclampsia : After spontaneous labor, 18.96 ; after artificial labor, 30.04 ; and after accouchement force, 40.74. Goldberg gives the following statistics in eclampsia : 5 times labor was induced, 4 deaths ; 6 dilatations of os by incisions, 4 deaths. Haultain'"^ reported three cases of eclampsia successfully treated by the iiKhiction of premature labor; he dilatetl the cervix with the fingers, dilatation sufficient to apply the forceps being accomplished in from sixty-five minutes to an hour and a half, and then the gentlest traction is sufficient to cause the head to act as a most efficient dilator. All the patients recovered, and two of the children lived. Should eclampsia come on after labor, chloral is the most important remedy ; in many cases, however, veratrum viride has proved suc- cessful. Milk diet is important in all cases during convalescence. Hyperemesis. — Excessive vomiting in labor is very rarely seen. Should it occur, however, its injurious effect is shown by weakened uterine contrac- tions and by early exhaustion of the patient. Etiology. — Naegele and Grenser,'^^ who find the immediate cause of hyper- emesis in extraordinary sympathetic excitement of the nerves of the stomach, state that it is most likely to occur in nervous, feeble persons, in the chlorotic, and in those who have previously been subject to gastralgia and to hyperesthesia *;' ■V- i' 638 A.VKIt/rAX TF.XT-IiOOK OF OliSTKTlilCS. \ •'! .1 ? I I Ji I e '! I ■ of the gustric norvos. Ilypt'roniortis may rosult from excessive distention nt the stomneh by fo(Ml o'- by tlnids. Tliesc observers refer also to a nioi-al impression as sometimes a cause. Treat iiii'iit. — Usual means slionld be employed to arrest the vomitinj? : if it results i'rom irritatinji; matter in the ttomach, whether foinl or secretions, cojiiuiis draughts of warm water should be given. Sinapisnis or the application of etlifi- spray to the epigastrium, and the hypodennatic injection of morphia, will lie employed; carbonic-acid water or champagne may be useful. But it is ol" the greatest importance that the delivery, whether manual or instrumental, shall take place as soon as practicable. Hemorrhagres. — Discharge of blood outside the genital sphere, such as epistaxis, hematamesis, hemoptysis, is occasionally seen in labor. Epistaxis, unless excessive, is to be regarded not as a conipiication of labor, but ratiicr as a salutary condition relieving congestit)n of the head. If pulmonary Dr gastric hemorrhage occurs, it has been recomnjcndcd that the jiaticut should sit rather than lie upon the betl. Ice, cold acid drinks, muriated tincture of iron, and in pulmonary hemorrhage small doses of ipecacuanha, as advised by Graves, may be useful. In either form of the disease, if grave, ])ronipt delivery is indicated. If the os is not sufficiently dilated to permit delivery with the forceps or by podalic version, acconcheinoU forcC has been recom- mended. A ease of rapidly fiital pulmonary hemorrhage in a woman at term has been reportctl by Budin.'"" The labor had not begun, and soon after death the Cesarean operation was performetl and a child extracted that lived a few hours, and then perished with trismus. Hernia. — Several instances of hernia causing dystocia are recorded. For example, Smellie's*" case. No. G3, was one of crural hernia on the left side, the patient suffering from it during her entire pregnancy. In labor the hernia was forcwl down during every pain and gave her great uneasiness. Smellie says: " The labor being pretty far advanced when I arrived, I took the opportunity of reducing the hernia upon the cessation of the pain, pressing my fingers upon the part, and directing her to lie on her left side with her left tliigli close up to the abdomen — a position which favored its keeping up ami prevented the anguish which I'ctarded the labor. She was accordingly saf< 'y delivered." Winckel published a case in which there was a left labial ho ■ size of a man's fist. In the second stage of labor, while an assistan lil l)ack the mass, the forceps was applied. Reposition was madj after the lai <\\ iwA retention was secured by a truss. He also saw a congenital left ovari ,11 hernia in a parturient. The ovary, the size of a walnut, was irreducible, was not especially painfid, and presented no obstacle to birth. Smellie narrates two cases of perineal hernia. Of the one of these (:i?es seen during labor he states : " The hernia was, however, reduced by opening the OS externum, introducing my hand into the vagina, and i)ushing the intes- tine above the os sacrum." Spiegelborg, in describing vaginal enterocclo, states that the hernia is almost always found at the posterior vaginal wall, and its DYSrOVJA. (j.jy cdiitcuts are iiHiinlly formed In* loops of small intestine, rarely hy loops of the l;irfj;e intestine. Smellie reporteil a case, oectirring in the practice of Mr. Stiibhs, in which tiie vaj^ina and the pelvis were filknl by a tnmor which probably procetHUnl from the intestines beinjj; pnshed down at the back part of tlic vagina. The tnmor was rednced by pressnro, and the head immediately descended into the ju'lvis, the forceps then being applied. Dr. Hirst" col- lected 27 cases of vaginal enterocele complicating prcgnainy and labor. The lieriiia was posterior in all except two cases. Such a hernia existing, uterine contractions niay cause it to descend so lo\v that it partially protrudes from the vnlva and presents a serious hin<1erancc to birth. The tumor is soft and (•(impressible at the beginning of labor, and the percussion sound, according to iNriillcr,'^ plainly indicates its character. Heposition, as successfidly performed ill the case reported by Smellie, is still the essential in treatment, the labor being ended by the forceps or, in case of pelvic presentation, by manual extraction. Eventration. — ^^hen diastasis of the recti muscles occurs in an abdomen greatly distended by pregnancy, ])art of the uterus protrudes in the interval. This condition gives rise to inefficiency in the action of the abdominal muscles in the second stage of labor. The remedy will be found in a )iroperly-ap])liero- noiiiiced that it may be believed there is a real paraplegia." Should the injury not be detected at the time of its occurrence or while the patient is in bed, it is recognized when she gets up and attempts to walk ; if she succeeds, she, as Trousseau states, waddles, dragging one leg after the other and leaning greatly to the right or the left according to the foot she advances. Barker found that one of his patients could stand with comparative ease rest- ing iipon either leg, but could not balance herself upon both legs at once. If this accident occurs in labor, it is imjiortant to redouble antiseptic precautions, so that all danger of infection shall be averted so far as possible. Tf suppu- ration follows the injury, it is essential, as urged by Diihrssen, that the purulent (•ullcction shall promptly be evacuated. In one of the 13 cases given by Schauta the urethra was torn, and in lotiier the bladder and the vagina. Four of the women died, but perfect recovery occurred in the others, save one who was bedridden, at the end of twelve months. The period of recovery varied from a few weeks to several iiKiiiths. In the case occurring to Havajewicz deatii followed on the nine- teenth (h\y, delivery having been made with forceps. The child, which was iiiiiisiially large, perished half an hour after birth. In Diihrssen 's 33 cases of suppuration following rupture only seven recovered of twenty-four treated without incision, while of nine in which tiiis treatment was employed all recovered. 'flic essential treatment of rupture or o'' great relaxation of the pelvic artieiilations is a Hrin]y-a])plied bandage encircling the pelvis. " A girdle re(niires to be placed around a pelvis which has its staves separated. It is iKHossary to supply the temporary deficiency of intrinsic contention by an 41 fTT^IfW 642 AMERICAN TEXT-BOOK OF OBSTETRICS. \l\ ^f ,•! i .."i i< \ . • /' extrinsic contention — tiiat is to say, by the tight a])i)lication of a bandage in such a way as to bring into contact the separated surfaces of the symphyses" (Trousseau). Most authorities* agree that a towel answers well for a pelvic girdle. Tho union of the joint may take place in from ten to fourteen davs, but sometimes several weeks or even months are required. Diseases of the Heart. — Cardiac disease is not uncommon in pregnant women, the most frequent form being valvular, the mitral valve being often- est involved. The longer the lesion has existed and the more incomplete \\\c compensation, the greater tlie liability to premature arrest of the pregnancy. This accident was observed (Vinay) in ninety-two of 220 eases, according to the statistics of Courrejol united with those of Porak. The question of the interruption of pregnancy is determinetl by the con- dition of the patient. Fehling"'' includes among the indications for inducing premature labor chronic bronchitis with great pulmonary emphysema and insufficiently compensated cardiac disease. Kaltenbach, too, makes uncompen- sated valvular disease of the heart an indication. Vinay '" states that in the severe forms marked by gravido-eardiac accidents, when bronchitis is united with pulmonary congestion and edema, and there often supervene visceral con- gestions, anasarca, and ascites, and the dyspnea is constant, ]>reventing nourish- ment and sleep, energetic intervention becomes necessary. " Peter insists upon the good effects of bleeding, whicli is immediately useful in calming the dis- tress and dyspnea. There may be added inhalations of oxygen, subcutaneous injections of caffeine and ether, infusion of digitalis or digitalin. But it often happens that the disorders of compensation camiot bo ameliorated l)y medical treatment, and the life of the patient is in peril from increasing dyspnea and the cardiac astiienia; it is then necessary to induce labor." In a recent valuable monograph by Allyn '^* the author states that labor should be induced when dangerous pulmonary symptoms j)ersist in spite of suitable treatment; he further advises bleeding before labor is induced. Winekel regards induction of labor as uncertain in its effect upon the diseaso of the mother, and says that it ouglit to be restricted to the severest cases. When labtn* occurs it is agreed that anesthesia may properly be employed, chloroform being preferable to ether, and that the travail should be ended with as little exertion on tlie ])art of the mother as possible. If the forcejis is used, it is advised that extraction be made slowly, to avoid sudden lowering of tlic^ intra-abdominal pressure. To compensate for this lessened pressure foUowinL^ birth, Lahs and Fritsch '" recommend bags of sand upon the alxlomen. Dr. AVebster '"'' advocates chloroform as //«^ anesthetic in labor; he stato that occasional lii/podcnnicn of ether may be required, and especially recom- mends nitrite of amyl as first tried by Frascr Wright, capsules eontaim'ng 4 or 5 minims being broken and the drug being held to the ])atient's nose. " It *It is rt-markiible tli.it Meigs should liave fi)uii(l "every iiltenji-.t iit l):ini1aKii)g a I'liliire. "ii acromit (if the impossibility of well adjiistiiiLr aiiut of fifty-seven dying, according to Charpentier's sta- tistics. It is only exceptionally that the labor is protracted in the hemiplegic. La Motte (Observation CCXIX.)'^'' gives, in his usual graphic manner, the history of a woman attacked with convulsive movements three days befi)re laltor; they were followead when so long a time passed before labor. He regarded the disease simply as apoplexy. I lemiplegia occiu'ring during labor will most probably result from cerebral hemorrhage in connection with eclam|)- sia, and it then presents an additional argument for ))rompt artificial delivery. Paraplegia. — In paraplegic women the anesthesia of the abdominal wall *■■■ I,; 644 AMERICAN TEXT-BOOK OE OBSTETlilCS. 11? ',< rl h,4g I s'S M %\ may bo so complete that the subject is never conscious of the movements of the fetus and does not fool any pain in labor (Vinay). " In a patient of Beni- luird's atfeoted with progressive locomotor ataxia labor passed almost entinlv without the j)atient's knowledge, suffering being felt only when the head win disengaged. In a case published by F. Benicke the patient had Pott's disease wilh compression of the cord. The accouchement took place at term withtnit suffering, and so unexpected was it that the woman was first advised of the labor by the crying of the child." A patient of Bernays,'^" a victim of syphilis, was *' totally paralyzed in her lower limbs and in all the muscles of her trunk which are supplied by nerves originating from the cord below tlic seventh cervical vertebra." The entire labor lasted only about thirty minutes, and its "peculiarity was, that in place of the usual interrupted labor-pains, there was but one continued contraction of the uterus, which resulted in the expulsion of a large, well-formed, healthy child." In Epley's patient"" delivery was effected by forceps after labor had lasted a day. In the case reported by I^itsckus,''^' the woman suffering from progressive locomotor ataxia, the labor was very slow, lasting five days. Garnet, quoted by Vinay, states that the final period in lal)or may be long in overcoming the resistance of the ])erineum — not from the muscles which are paralyzed, but of the aponeurotic and fibrous paits. Shock. — If sliock occurs to a woman in labor, it is most frequently the result of a grave accident — for example, rupture of the uterus. Apart fVoin the causal treatment of the condition, tiie practitioner should seek to obviate the tendency to death and to bring about reaction as soon as possible. Among the means he may employ are the external apjdication of heat, alcoholic stim- ulants, ammonia, camphor, and the hypodermatic use of sulphuric ether and of strychnia. Labor in Pneumonia. — By most obstetricians the occurrence of labor in a patient suffering with pneumonia is regarded as very unfavorable, and tluy therefore seek to avert any threatening of this event ; but if parturition is inevitable, the latter is facilitated as much as ])ossible. Great encroacluncnt upon the chest-cavity by tiie uterus may be lessened by early rupture of the membranes, and the injury to the already overtaxed heart by labor-pains is avoided as soon as possible by artificial delivery. Sudden Death in Labor . Delivery of the Child. — The chief causes of sudden death of the ])arturitiit are apoplexy, eclampsia, rupture of (he uterus, of the li(>art, or of the aorta, exhaustion from protracted labor, uterine hemor- rhage, pulmonary embolism, and, quite rarely, rupture of the spleen. In sudden death in labor it is important that the child be delivered promptly. If the dilatation of the os is sufficient, the application of tlic forceps is indicated in vertex presentation ; in that of the pelvis, the immediate bringing down of one or both feet, and extracting. Accordiiii: to Kaltenbaeh, not even one-tenth of the children delivered after the deatii nf the mother live. He quotes Pnech's statistics showing that in 453 operations one hundred and one children gave signs of life, but only forty-five survival. iJ DYSTOCIA. G4o Nevertheless, though the child be dead, its delivery should be made, " out of lonsideration for the relatives and friends of the woman and for the profession to Avhich we belong, especially if the accoucheur has been in charge of the labor for some time and has already made attempts at delivery " (Spiegel berg). Some advise that when the mother is dying from pulmonary tuberculosis, (Voin severe apoplexy, or other hopeless disease, delivery be made while she is vot alive, if consciousness and sensibility are lost. If the mother die from slow asphyxia or from hemorrhage (either uterine or from rupture of the heart or of a large blood-vessel), the probability of saving the child is very slight, but if her death be from a sudden injury, from embolism, or from apoplexy, the chance of the child's living is greatly iinjiroved. It is usually held that if more than ten minutes intervene between tlio death of the mother and the extraction of the child, its living is doubtful ; vet there are a few eases in which this period was considerably passed and the oliild was extracted alive. As proving that in some cases a much longer period than ten or fifteen minutes may intervene between the death of the mother and the removal of a living child, the following facts are of value : '^^ During the Connnune of Paris, Tarnier one night at the Maternity was called to an inmate who, while lying in bed near the end of pregnancy, had been killed by a ball which fractured the base of the skull and entered the brain. He removed the child by the Cesarean operation, and it lived for several days. He states that the delivery may have taken place three-quarters of an hour, or even an hour, after the death of the mother. In another case a j)regiiant woman fell to the pavement from a window a distance of more than 30 feet, instant death resulting ; thirty min- ute's at least after the death of the mother an infatit was retnovcd, which after some (lifHculty was resuscitated, and which lived for thirteen years. Tarnier also quotes the case, recorded by Hubert, of a successfid Cesarean operation two hours after the mother's death : the woman, who was eight months preg- nant, was instantly killed by a locomotive while crossing a railroad track. In case the os bo not sufficiently dilated for immediate delivery, Depaul stated that he could not too nmch insist, with almost all those wiio have studied this question, upon the advantages ofliered by extraction of the infant pn- vids naturalcs. One need not fear multiple incisions of the cervix by a bistoiny ; there can thus be obtained in a few seconds dilatation sufficient to iiiai. 3(i. Annedcs il' Ifjir/ieue publiqne ct de Meilecinc 3/. (cfialc, 1S41. 3S. Transactions of the Edinbnr^/h Obstetrical 39. Societji, vol. xvii. 40. Transactions of the I-Jdinbiirr/h Obstetrical ' Societii, vol. viii. American Jonrnal tf Obstetrics, 1881 ; ibid., ISSd; Transactions of the American Gi/nc- 41. coloejieid Societii. Dennian's Introduction to the Practice of 42. Midwifenj. 43. Transactions of the London C)bstetrica! So. 44. cieti/, vol. xxiii. ProijrI's Medical, 1888. i 45. Pro(,ris Medical, 1887. London Lancet, 1S44. I'roeeedln(/s of Dublin Obstetrical Socirti/ ; The Ob.ttetrical Journal of Great lirilain and Lreland, 1880. Philadelphia Obstetrical Swietij, 18S8. Traitc Complet des Accouchcments, 1835. Monatsschrift fiir Gebnrt.ihiilfe, 18()3. Die Menschliche Placenta, 1890. Lehrbueh dcr Geburtshiilfe, 1893. Conffres periodiijnc de Gipiecologie et d'Oh- stetriipie, Brussels, 1892. Proi/res Medical, ISltO. Transact ioii.'< of the American Medical Asm- ciation, 1855. Placenta Pran-ia; its Ilistort/ and Tnul- ment, 18(11. Annali di Olistetricia e Ginecolor/ia, No. 5, 1894. Poslon Medie(d anil Suri/iral Jonrn, Journal, lS'.i:>. ''Idccntd I'rirrin. jiiir P fii/'i'i'liiiii ml rt Ir ('"I 'I' Diiiiid, Mtiiit- -IC). 17. 48. •lit. r.d. r.i. :■,•> .VI. .")t;. 58. r)it. f.(). fii. (iii. o:!. G4. 05. (Jt). 07. 08. Oil. 70. 71. I M. ~t> I >>. 71. 7'). 70. Trnite pratique iP Aecoueheuienix, TrauiiactionK nf the Lomhii Obntetrical So- eiety, vol. .\x.\i. Le(;i)iin de Cliniijue obnltiricale, Brussels, 181)2. AmericHii JnuriKil of Obatetricn, 1880. CiiiH/rtu periodiqtie Inlcrmilional, Brus.sels, 1802. Lehrbuch dcr Geburtxhiilfe, 1891. .\(]ilress on " ( Jbstetriiw iiiid Disejuscs of Women," Britixh Medieid Anftociation, I8U3. American Journal of Obstetric.t, 1894. I'mnmrtidnn of the Auie.ricari Gynecotogiad Socictij, vol. xvii. Miilk'i-'.s JLindbuch. Tnumictionx of the American Qynecoloyical Societi/, vol. xvl. "I'eber Vorzeilifre Losnnff der Placenta bei Normalon Sitz," Zeitachrift far Gc- burlMUfe und Gjindkoloi/ic, 1892. ObMetrical Journal of Great Britain and Ireland, 1878. American Jouruid of ObstetricD, 1870. liriti-^h Medical Journal, 1892. Klinik der Geburti>hiilliichen Operationen, 1894. Ifaudbuch der GeburtMlfe (Miiller). Transactions of the .Imerican G t/necoloyical Societij, vol. iii. Verliandlun;/ der Gescllschaft file Gebtirtii- hiilfe und Gyniikoloiiic zu Berlin, July 13, 1894. J/'{(H.s'(«'/ ('«;(.< (//" the ^Imerican Gynecological Society, vol. iii. Etude liurlcK lleniorrhayien (pii xurvcnicnnent pcmlant lex unites de Couches, 1876. System of Obstetric Medicine and Surgery, London, 1885. Text-book of Midwifery, Sydenham Society's translation, 1888. (Jhstetricid Journal of Great Britain and Ireland, 1878. Allijemcine meilicini.^che Central-Zrituny, .Jan. 27, 1875. Klinik der Geburtshiilllichen Operationen. Lehrbuch der Gehnrtshiilfe. Ilritish Medical Jcurnol, 1892. Trausactions of Jie St(de Medical Society of Indiana, 1884. Tea nxaet ions if the Londiox OhMetrieid So- ciety, vol. XXXV. Lehrbuch der Geburtshiilfe, zweitc .Vullafii'. 1893. Hundbuch der Geburt^hi'ilfe, iii. Band, 1889. liCKcarches in ObMetrics. 79. 80. 81. 82. 83. 84. 85. 80. 87. 88. 89. 90. 91. 92. 93. 94. 95. 9(). 97. 98. 99. 100. 101. 102. 103. 104. 105. 10(i. 107. 108. 109. 110. 111. 112. 113. 114. 115. 110. Traitc clinique de F Inversion utirinc, 188,3. Transactions if the American Gyneeuloi/ical Society, vol. ix. " Es.-('.i PnrnhjdvH pwrper(deK, 18(il ; I'rnili pnitiijiir dex Aecoiirlteme.ntx. Tniile diK Aecoitrlinnrnln. St. Louis Medical und Snr to the usual stand- ard. In twenty strictly normal cases selected from the writer's hospiud service the average temperature at the close of labor was 99.67° F., the maximum being 100.5° and the minimum 98.4° ; at the end of twelve hours the average temperature was 99.18°; twenty-four hours after labor it was 98.()5°, the maximum being 99.5° and the niinimum 98° F. For the first four or five days of the puerperium 99.5° F., and for the balance of the period 99° F., should be regarded as the physiological upper limit of thermometrieal range. Transient elevations of temperature, however, may occur from comparatively unimportant causes, such as emotional excite- ment, digestive disturbances, or ccmstipation. A slight rise is sometimes observed on the establishment of lactation if the breasts are much engorged and painfid. This rise is most likely to occur in debilitated and weakly women and in those unable to nurse. A temperature persistently above the foregoing limits must be regarded as evidence of some comj)lication. Secretions and Exartioiht. — The general effect of labor upon both secre- tions and excretions is to increase the activity of these functions. The skin acts freely. If the body is kept warm, perspiration is usually profuse. Hyperemia of the skin and consequent exudation into the hair-follicles sometimes result in partial loss of hair. There is a notable increase in the volume of urine during the first week. Its specific gravity is a little lower than usual, the amount of water elimi- nated being greater than during pregnancy, while the total excretion of uri- nary solids per diem remains nearly or quite unchanged. This superabundant secretion of urine is one of the causes of over-distent ion of the bladder to which the patient is exposed after labor (Fig. 411). Other contributing causes of retention in the first few days are the posture of the patient, the lessened intra-abdominal pressure, urethral spasm, and the dread of pain during micturition owing to the bruised and fissured condition of the vesical neck, the urethra, and the vulva. Glycosiu'ia is observed in a considerable proportion of instances for a short time after as well as before labor. This is due to resorption of lactose, and the ])roportion of sugar in the urine fluctuates with the fulness of the breasts. It disa])i)ears as soon as the balance is established between secretion and con- sumption. Peptoiuu'ia exists for several days, jieptone being a product of uterine involution. Zoss of Weir/ht. — It is stated that during the first puerperal week there is a loss of weight, variously estimated by different observers at from one-twelftli to one-eighth the body-weight at the close of labor. This loss is attributed to the increased activity of the secretions and excretions and the small amount of food ingested during this period, together with the retrograde changes wliicii normally take place in the pelvic organs. Under the present practice of allowing the patient a moderately full diet after labor the loss is generally confined to the first few days post-partum, and is soon made good. riiYsioLOdV OF Tin: Pi'i:iirKi{ir}f. (Ml Uterine Contructiom. — Rliytlimical utorino contractions, .similar to those of labor, continue tor a variable Iciij^tli of time after the delivery of the placenta. X.-:., ^., •nitiliiji>iickinson, M. 1).). Tiie contractions t»f tiie nteriis tend to exclude blood-clots from its cavity, to establish complete retraction, and thus to accomplish the permanent ligation of its vessels: by diminishing the blood-supply they promote in the uterus the retrograde changes which normally take place in the j)uerperal period. In primipara) they are seldom painful. In mnltiparje, in whom there is greater relaxation of the uterus and gi-eater tendency to the retentiun of clols, they arc more intense and are freijuently accomj)anied with pain. After-pains in exceptional cases may continue for two or three days. Usu- ally they cease after a few hours. They are intensified when the child nurses by the reflex influence of the mammary irritation. Even in women who have borne children they are, to a great extent, i)reventcd by the use of measures to secure full and persistent retraction of the uterus immediately after the expulsion of the placenta. Sometimes uterine contractions of a painful character occur, without the retention of clots, from jnirely neurotic causes. Pains of unusual severity, unduly prolonged and accompanied with great sensitiveness to pressure, may suggest the possible jiresence of beginning peritonitis. Thv Digestive Orr/ans. — Usually the ai)petite is diminished for the first few •lays after labor and the digestive j)owers are enfeebled. Owing to the rapid (■liMiination of fluids by the skin and the kidneys, thirst is increased. The bowels act sluggishly in consequence of the small quantity of food ingested, the increased secretory activity of the skin, the diminished peristalsis, the lessened tonicity of the abdominal muscles, and the complete rest in bed. Gknital Ougaxs. — Cumlition of the Fartavient Tract. — By palpation over the lower portion of the abdomen at the close of labor the uterus may be felt as a hard, irregularly rounded mass reaching about halfway from the pubic bones to the umbilicus. Owing to the relaxation of the abdominal If': 4 fmr ■ I ■' u ■} "I 1' .1 1 A rV'i A :) V : i [M» iV :!=' -■ ' IBP <;:)i AMKIiKWX TEXT-HOOK OF OtlSTETRirS. walls, tlio fundus may be jjrasjuHl in tlio hand, and evon the round lij^ainonts and ovaries ean generally be mapped out. Within a few iiours the uterus will be found somewhat relaxed, with the fundus at the level of the navel or a little above it. Usually it is slightly anteflexed, and its position is one of partial dextroversion and dextrotorsion. It is somewhat larger in nudtipane than after the first eonfinement. 'V\w placental area is somewhat elevated ; its surfiiee is uneven, and is studded with thrombi lying in the mouths of the utero-plaeental vessels. The outer layer of the decidua and fragments of the inner layer remain for a time, to be gradually east off with the lochia! dis- charge. A layer of blood or bloody mneus covers the entire wall of the uterine cavity. The cervix remains soil and relaxed for several lionrs after labor, having an almost gelatinous consistence. Its length is 2| inches or little more. The os internum presents the feci of a resisting ring, and in the intervals between uterine contractions it is suflfieicntly open to admit two or three fingers. The lower border of the cervix is always bruisetl and fissured, sometimes deeply torn. After twelve hours the neck of the tjterus begins to regain its former shape. Even in the absence of notable lacerations the vagina and vulva are swollen, abrade. / •'III ii ,'/ nuiix/iis. J'li'iiit'iitory. Cil-'i/y of lit,- 1 ' iu\ tlllll . _L_ I'dll, ll of i'fllghis. ri,-l,>-7;si\.l/ pollJl. Os t-Ait'r/iitiii. mm^ ll I / - 1 i 1 lit the level nf 1. V,.rti,.„l „u.si„l M.,.ti„„ ,„■ ut,.,us Mt rlns.. nf lal.nr. (iv.. xniuntr. niu;- .Mn;-n .MthT W.hM.n ■> Vvrti.,.! musial s,.,n,,i, ,,1 iitiTus sfc,,i„i ,l,i.v .,(■ i.iK-ii„Tiiiiii ,jUUt UVliMcn. I \ w l( * ) 1 "■ i IM i*ii:Hi*KHir>F. I'l.ATi; 43. I 'I,- 1 II!. - - H/a,/,/,-, . — S_\in/itiysis />u/-ii — Kt-tr,>/>ii/'ii- //.\sitt'.\ — L'l't-tlntilofif'ue - — - — rroinoutory. I — Uteiim- iUTit). I'tero-vi'ihiil /(>«i/(. I'oiich of />ciut;/iti. Reiliim !('il/i /'lii's. S\in/>liysis I'uhh ( 'i i-.lfi'rUHiil. ' Vi.tht.il oiifice. ^r* .'fuontoiy. h'tiiuius r/ ittt nts. Onily itiini ,1/ ii/;ht Kill I .wji III/ /i[t;iim,iit . r>'ii(L'i i:'y /,'yni.v. -A\\ tunt .w. V.rtU'Ml III, •Mill M'Ctinll nf lilrrilv, -ixtll .ImV n|- flUTlHTlUIM Uld.T W.'I.Mofl. J. Wl'lirlll lllrsilll s, lilirniili iliiy ,,r piiiTiPiTiuiii ^nltor WrhsU'r). PIIYSIOLOCY OF TllK PUKRPKRHJM. (jr):5 the Fallopian tubes, and its npper 8ep;ment is from 3 to 4 centimeters (1^ to \\ iiu'lu's) in tliii/kness. The cavity is from 15 to 18 centimeters (6 to 1\ inches) in depth. The following sonnd measnrements are from Hansen: Tenth dav, 8. to 13.5 cm. Fifteenth day, 8.3 to 11. o Third week, 7.5 to 10.5 Fonrth Fifth 7. to 9.3 G.5 to y. Sixth week, 6.2 to 9.1 em. Seventh " 6. to 8.5 " Eighth " 5.6 to 8.5 " Tenth " 5.4 to 7.5 " The fnndns nteri lies ahont midway between the lunbiliens and the pnbic hones at the close of labor. Within a few honrs it is jnst above the nmbili- ( lis, and is at the level of the pnbic bones by the tenth day. The elevation of the fnndns, however, varies with the fnlness of the bladder and the rectum. The nterns is pnshed nj) bodily when these viscera are distended. Involution is retarded in non-nursing women, after twin births, much hemorrhage, retention of secundines, sepsis of the endometrium, or getting up too soon. Utvrhw Mui^cnlnrh. — Various theories have obtained with reference to the nature of the changes in the uterine nmscnlar structure during involution, some authorities holding that a part, others that all, the muscle-fibres are destroyed by a process of acute fatty degeneration, and that there is partial or total re-formation of muscle-elements. Sanger has shown by a large num- Ikt of observations that the regressive process is one of atrophy, by which the muscle-fibres are reduced to their primitive dimensions. The nuiscle- fibres are not destroyed by complete fatty degeneration : they undergo a true involution initil they have reached their earlier size and form. Similar con- clusions have been reached by Dietrich. The nutritive activity in the uterus is greatly diminished by the lessened blood-supply conse(iuent upon uterine retraction after labor, and atrophy ensues, fat-globules appearing only in the interior of the muscle-cells and never externally to the fibrilla\ The fat- lilobnles " do not enter as such into the circulation, but are oxidized in the place where they occur. The intermuscular connective tissue experiences a similar involution in its cellular and fibrillar elements." />Voof/-jr.swAs' of the llcnix. — Thrombosis takes place in some of the siinises at tiic placental site during the ninth month of pregnancy. The remaining (UK'S ai'c ))romptly closed by compression and by the formation of coagula after labor. A portion of the blood-vessels become atrophied as the icsult of pressure. Fatty dcgenera'iou takes place in the media. Th(> larger arteries Mi'c partially or wholly obliterated by connective-tissue ])rolifcration of the iiitima. In women who have borne children the coats of the uterine arteries ninain permanentlv thickened ar.d the arteries larger than in the nidliparous uterus. The walls of the venous sinuses are thickened and (Convoluted for sc\i!'al weeks after delivery; the location of the placental site is disi'crnible many months after labor. The nuieous membrane is studded with pigmentary deposits, an unfailing sign of recent childbirth. / I ] .'U. E ff^^TWUHMJW ii II, 1 m r I m.m ii III '! "m 654 AMERICAN TKXT-BOOK OF OliSrETRICS. lieconstnidion of the Uterine Mueomt. — Tiie deep glandular layer of the decidiia, together with IVagments of the snpi'rticial layer, remains attached to the uterus after the expulsion of the placenta. From the glandular layer the regeneration of the mucous membrane takes place. All the remaining decidual structure not concerned in the development of the new nuicous membrane suf- fers factv degeneration and is gradually thrown (tif in the lochial discharyre. The glands are crowded close together by the uterine retraction. About the mouths of the glands islands of new epithelium are formed, developed from the gland fundi. These coalesce until the surface of the uterine wall, includ- ing, last of all, the placental area, is ciovered. By the end of the fifth week, as a rule, the new mucous membrane is complete. Loc/tia. — The genital discharges of the puerperium are termed the lochia. They have their origin in the cavity of the uterus, and continue during the greater part of the period of involution. They consist at first of blood with clots and decidual shreds, and usually are of a distinctly bloody character for three or four days — lochia rubra or cruenta. During the next two or three days they are pale in color, are thinner, and consist mainly of scrum — lochia serona ; they contain blood-corpuscles, epithelial cells, and shreds of decidua. Finally, after about seven days, the discharges assume a grayish or a yellowish color and are of a creamy consistency — lochia alba. The microscopic elements are chiefly leucocytes, new epithelial cells, connective-tissue cells, fat-globules, and cholestevin crystals. The reaction of the lochia is neutral or alkaline duriii"- the first week; later it is acid. The discharge gradually diminishes in quan- tity, ceasing altogether by the end of from two to six weeks. The average amount for the fii'st eight days is about three and a quarter pounds ; the quantity, however, varies. It is greater in multiparaB than after first labors ; it is more abundant and lasts longer in non-nursing women and in those wiio menstruate profusely. There is frc(]uently complete or partial sujipression of the flow on the establishment of the milk-secretion. The lochia rubra persists longer in retroversion of the uterus and after getting up too soon. Normally, tlic lochial discharge has oidy a faint odor and is never fetid. J^ven in normal conditions micro-organisms are i'ound in the genital dis- charges after the first two or three days. Their abundance varies in difl'ereiit cases and increases with the progress of the fl(tw. The principal varieties ;irc single cocci, staphylococci, and bacilli. Tlicir occurrence in the lochia is explained partly by th<' ju'cscnce of bacteria |)rimin'ily in the vagina, pni'llv by entrance from williout. The uterine lochia, as a rule, are free from bactci'ia in normal cases. Lactation. — Important changes in the mammary glanse proportions, however, arc subject to con.sidcrable fluctuation. They are affected by the health and habits of the woman, and even by emotional disturbance^, and they vary, too, with the period of lacta- tion. There is an increase in casein until the second month ; thereafter it (limiiiishcs until the ninth month. Similar variations occur in the ])ercentage (if fat. The sugar increases after the first month. Authorities, however, are not agreed on the nature and the extent of the changes which take place in ilie composition of breast-milk from month to i;:"nth. Tlu! composition of the lacteal secretion dc|)arts soi lewhat from the n>ual normal standard on the return of the menstruation. These chauges arc gcn- ei'iilly of short duration, lasting but a few days after the menstrual period. In exceptional cases tiiey I'cmain to a greater or lesser extent perniaMeiit. Fre- i|iieiitly no harm comes to the mother or the child from the continuance of nursing even when the menstrual functicma is resumed in the early weeks of lactation ; in exceptional instances it may l»e necessary in the interests of the child, and possibly of the mother, to discoiitir'ie nursing. The liquid })ortion of milk is derived, with some modification, from the .u nPT .i/,- '^^ I '12 -B. • I i ) : 1'. 1 1 1 ' ' .'I +■ ( 1 1 6')G AMERICAN TEXT- HOOK OF OJiSTETIilCS. blood ; the fat, sugar, and casein are i)rodiicts of the metabolic changes in tlio protoplasm of the secrctorv cells of the mammary glands. Thc^ fat or butter is held in suspension in the liquid portion in niimite globules of variable size, forming a fine emulsion. The average normal period of lactation is about one year. In most mu's- ing wohien, however, the milk begins to fall otf in both quality and quan- tity after the seventh or eighth month. Both the abundance and the diu'ation of the secretion vary greatly in different cases according to the health and vigor of the woman. \\\ normal conditions the (juantity increases during ;it least the first six months proportionately to the needs of the child's nutrition. In non-nursing women the secretion continues for a few days, then rapidly declines, and soon ceases altogether, the parenchyma of the gland undergoing involution. II. DIACJXOSIH OF THE PUEIIPERAL STATE. The puerperal condition can usually be recognized with little difficult v within the first one or two weeks ; later the diagnosis is not so readily estab- lished. The evidence of recent delivery is to be sought ]n'incipally in the condition of the breasts, the abdomen, and the genital tract. After the first two days the breasts are enlarged and tense. The mammary glands are firm and nodular and milk is freely secreted. The abdominal walls are lax, and the skin can be taken up in folds over the underlying muscles ; ntrice gravidarum and the pigmentary changes are evidence that advanced pregnancy has at somi; time existed, other causes of abdominal enlargement sufficient to explain the presence of strite being excluded. The external genitals are gaping, swollen, bruised, and fissured for several days after childbirth, and for at least two weeks they present the marks of recent injury of greater or lesser degree. The vagina is enlarged and relaxed ; the rugre are ef!aced and the introitus stretched and torn. Tlio uterus is enlarged, the (;ervix is notched or deeply fissured by recent tea^s, and its canal admits one or more fingers. The size of the uterus in normal conditions diminishes daily. The lochial discharges are found flowing from the cervix, and the placental site presents to the examining finger the nodular surface and fresh thrombi characteristic of recent delivery. The lochial dis- charges are distinguished from hemorrhage of non-puerperal origin by their microscopic constituents. When the importance of the question justifies it, conclusive evidence may sometimes be obtained by curetting the uterine cavity. The ])resence of decidual shreds or chorial villosities in the scrapings aifurils in(lul)itai)le proof of recent jiregnancy. The length of tim<' that has elapsed since confinement may during the first two weeks be estimated approximately by t!ie condition of the breasts, the si/c of the uterus, and the character of the lochia. For the first two or three days the mammary secretion is colostrum ; for several days subsequently the glands are swollen and hard and milk is abundantly secreted. The fundus uteri is MAXAdKMKXT OF TUK JTKni'Klil I'M. 657 just alnn'o tlio umbilicus on the day fbllowiiij^ dolivery, and it gradually sinks t(i tiie synipiiysis by tlio tcntli. Tho cliangcs in the lucliia indicate roughly the jiiogross of" tlie puor|KM'al jicriod. The vulvar wounds arc in a stage of repair [iidportionate to the number of days that have passed since the birth. in folds over 111. MANAGEMENT OF THE PUERPERIUM. PoHlmr. — During tiie first few hours after labor the best jiosition for the patient is the dorsal decubitus, ff she turns u{)ou the side, owing to the lax (•(iiulition of the abdominal parietes the uterus I'alls forward, and air may be drawn into the passages, exposing the patient to the jntssible danger of air- iboli After the uterus has bee itlv retracted and th ■1. I'onie perni! al tlic i)lacental site are firndy closed by thrond^i, the posture of the patient may be left to her own choice. Rixt. — A sound sleep of several hours after delivery is a favorable prog- nostic. It not oidy sj)caks well for the condition of the patient, but is a |)iitciit restorer. Care slioidd be t;dciice of after-pains, and how severe they are. Tin; ])ulse and temperature ill!' to be noted. The binder should be loosened at each visit, and the uterus (xainincd through tiie abdondnal walls for the rate of involution as indicated l»y flic height and widtii of tiie fundus ; the degree of tenderness over the iil( rns and broad ligaments should be noted. It is especially important at the lii-t visits to examine tiie suprapiil)ic region by palpation to learn whether tlie lilaildcr is distended. The urinary secretion is, as a rule, greatly increased liming the first few hours after delivery. Injurious distention of tlie bladder iVcijiieiitly results. The assurance that the ])atieut has passed water freely is not t(» be taken as ])roof that there is no retention. When overfilled the Madder may easily be made out as a fiiiid tumor between the ut<'rus and the alnloiniiial walls. Pressure with the hand over this region, too, will cause a ile-ire to urinate. Marked fulness of the bladder fre(pieiitly presents a visible [■2 \ i-fe larj II flfnpT" ! I: m ■ -fK'^ ! :» : ll ■ W'i 1 1 i .''.'l i ' 1 ' ' ! ■■!■■ •! I .111 I Uo8 AMKIiJCAX TEXT-HOOK OF OliSTF/fniVS. tumor alxivo tlio pulios (Fiir. 41 1). Tlio foiiditioii of tlio broasts and ni|)j)l(v and the aiuouiit of milk secreted should be watched, especially diirinj; the first week. Daily inquiry should bo made with reference to the child — wiiether it nurses properly and shows sif^ns of tlirivinj;; the condition of th'; eyes, mouth, skin, the stump of the navel cord, or the und)ilical woiuid should lie learned, and whetiier the bladder and bowels are properly evacuated. It i: well for the first few days to know the rectal temperature. The nurse, if slic be capable, will keep a systematic record of the foregoing and other facts f Ije strictly avoided in normal cases. If the discharges become fetid notwilli- standing proper external precautions, an antiseptic vaginal douche should lie given two or three times daily or often enough to suppress all ])utrid odor. The approaches must first be rendered aseptic: the douche-tube, sterilized l>y boiling, is introduced for only 1 or 2 inches, with care to avoid abradin*; the mucous surfaces. ^Mercurials shoidd not be used for the purj)ose, owiiiu^ J/AXAChMhWT OF TIIK IT EL'I'FJil LM. (JO!) to the (laiififer of inoroiirial iiitoxifjitiijii. A 1.5-voliiino solution of liydrogen •lioxiil, in full .strength or diluted with tiircc or four volumes of water, or Labarraque's solution in water (1 : 0), is suitable. It is unneeessarv to say that otlier soiled portions of the body should be cleansed as often as soiled, and no blood-stained linen should be permitted to remain about the ])atient or the bed. The lying-in woman perspires actively , hence her .skin ought to be frequently cleansed by sponging with tepid water or with water and alcohol. This bath should be followed by gentle frietii)n with a towel until a warm glow is j)ro- duced. Cleanliness of the bed is pmmoted by the use t)f a draw-sheet, which consists of a common bed-sheet folded to foiu' thicknesses, it is placed upon the bed beneath the patient's hips, and is changed as often as soiled. Vnitihttion. — The atmosphere of the lying-in room nnist as nearly as pos- ible be Air should be admitted as freelv b d. Slide oe pure. Air snould l)e admitteil as ireely Dy open windows as is con- sistent with a proper temperature of the apartment. As the air is constantly vitiated, so the ventilation, to be effective, must be continuous. Light is essen- tial to the healthfulness and cheerfulness of the lying-in chamber. The practice of darkening the room, exce[)t when temporarily necessary to promote sleep, is irrational and has justly become obsolete. Even the full sunlight may be admitted, provided the child's eyes are properly protected. For the first few weeks the eyes of the new-born infant should be shielded from strong light from whatever source. Diet. — The diet for the first twenty-four hours is to be restricted, as a rule, to liquids. In most cases even liquid food is to be withheld until the patient has had a few hours' rest. After the use of anesthetics no nourishment will 1)0 borne until she has recovered from the effect of the anesthetic. Excep- tionally, when the labor has been an easy one without anesthesia, a little warm liquid nourishment, such as clear soup, bouillon, gruel, or cocoa and milk, may be allowed, if the patient requests it, directly after the close of lal)or. On the second day soft-boiled eggs, boiled custards, panadas, and similar easily-digested semi-solid foods are suitable. From this time on a moderately full diet is generally to be recommended. The dietary, however, must be varied to suit the needs of the individual case. As liberal a diet as tiio ])atient can digest is essential to the normal progress of convalescence and to tlic proper quantity and quality of the inilk-secretion in ntirsing women. Retention of Urine. — The enfeebled control dver the bladder in the first lidiirs after delivery frequently leads to retention of urine. Tiiis is esj)ecially liable to occur from the added effect of refiex disturbance when the jierincum Ikis been sutured. Owing to the copious secretion of urine, which is common at this time, painful and injurious distention of the bladder often results. Xot only may serious injury thus be done to the bladder, l)Ut uterine hem- iirrliage after delivery is liable also to occur from ovcr-distcntion of this vise us. The patient must be warned, therefore, of the importance of passing lur urine within six or eight hours following the close of labor and at similar intervals thereafter. The difficulty of urination dei)ends partly upon the rrcuiiilx'nt position, and it may frecjuently i>e overcome, therefore, by allowing 1 ^ p sip 1 y ■'■.J( 1^ ■rrfT ji ,' 1 1 If 'iH I ■■•' <;<)(> A.v/:/i'f('A\ Ti:xT-iiooK or onsTF/nucs. the jiatit'iit to assiiini! a sittiiij^ or lialt-sittiiif^ posture (liirin<^ attempts at niietiiritioii. Tlie soiiiul of rimnin<^ water, warm fomentations over tlic meatus urctlirju, and moderate pressure ap{)lied with tiie hand over the supnt- puhie rej^'ion are iisetul aids, and are frecpiently eil'eetive even in tlie reelininjj; ])osition. The eatheter should l)e withheld as a last resort, owinj:; to the dan^^cr ol' settiiij^ up a more or less intense eatarrh of the vesieal neek from infeetidiis material earried on the instrument. The nmeosa of the lower portion of the bladder is liable to lu; bruised and fissured duriuj^ labor, and its resistiiii:; power thereby imjjaired. In rare cases the ureters and the ])elvis of liic kidneys may b(! invaded by tiie septic process which frequently takes its orijfin from catheterization. Unc of the Catheter. — When catheterization is unavoidable, every iirc- caution nuist be used to prevent inlection of the bladder. The soft-rubbci' instrument, which is least liable to do nieclianical violence to the vesicnl mucous membrane, is generally the most suitable catheter for use by the mu'se. The Kelly or other glass catheter, which consists of a short glass tube with a foot or two of rubber tubing attached, has the advantage that it ]>rcsents a perfectly smooth ])olislied surface, and causes, therefore, a mininniiu amount of urethral irritation, lioiling in water for ten minutes inunediatciv belbre using the instrument renders it aseptic. It is jierhaps needless to say that after boiling the catheter is to be handled only with hands that have been carefully sterilized. The instrument must never be ]>asscd blindly by the sense of touch alone. AVith the i)atient in the dorsal position and the thighs separated, the labia •should l)e held well apart, either by the patient herself or by an assistant, so as to exj)ose fidly the meatus urethrte to view until the eatheter is introduced. The vestibule and labia are then to be cleansed with soap and water and washed with a suitabU; antiseptic. The catheter, well lubricated with vaselin previously sterilized by heat, is then passed — only far enough barely to enter the bladder — until the urine begins to flow. Care should be taken on with- drawing the instrinnent that no urine be permitted to trickle into the vagina or ov(>r the vulvar wounds. If the ))arts accid(.'iitally become soiled, tiny should l)e cleansed by ])ressing them with a clean damp cloth. The catheter is to be washed carefully with soaj) and water and rinsed with clear water after using. The bladder should be emptied at the same intervals as in vol- mitary urination. Ju-((ci((if!(»i of the Jioirelti. — It is a long-established custom to open the bowels on the third day. There an; good reasons for adopting the practice, now so generally followed after abdominal section, of evacuating the bowt'ls soon after labor, not later than thirty-six hours. The most suitable measure is a mild saline laxative. An eligible saline for the purpose is the solution of citrate of magnesiinu (lifiuor magnesii citratis). The action of the bowcis may, if necessary, be assisted by a rectal injection of warm water or of sweet oil. llsefid stimidating enemata, if required, arc salt water, soap and wali r, a drachm or two of undiluted glycerin, or one or two oimees of a satiu'atrii ittcmiits !it s over till' • tlio supra- ic nH'liiiiii;j; • tlio (liuio is introduced, id water and with vaselin [irely to enter Ikeii on with- u the vaji;in!i soiled, they The catheter 1 clear water als as in vol- to open the the practice, lo- the bowels lable measuiv tin; sohitiiiii pr the bowels Ir or of sweet Ip and water. If a siiturated .i/.i.v.u//;.i//;.V7' o/' the I'Veiu'ERhm. oui ihition of Kpsom salts. Tiie bowels should l)o oiH.'iied daily after the first day. Lacfatimi. — In the interests of i)oth herself and her infant the mother niijrlit, as a rule, to nurse her own child. In certain conditions, however, this may be inadvi.sd)lo or even impossible. Syphilis contracted late in pre;riiaiicy and tuberculosis are coiitra-iiidications to maternal nursinjr, owinj; to thedanjijer of infectinj; the child. Rarely, suelast-milk by attention to hygienic measures. IP w / ^ -O^- A u -,%. ^, ^^^''^-^k o .*'*^.^« IMAGE EVALUATION TEST TARGET (MT-3) 1.0 ^1^ 1^ ^ lii |2.2 I.I I us Hi m 1.25 III 1.4 1.6 < 6" ► ss / Photographic Sciences Corporation 23 WIST MAIN STRtET WEK&VeK, i^i V MS SO (716)872-4503 <^ '^ ^ o^ I 6()2 AMERICAN TEXT-nOOK OE OHSTETRICS. rii lif^n )' tl The l)est galacta^o^iies are tonics, a generous diet, including the use of ni!'k, and attention to the habits and liygienie surroundings of the mother. Precaii- Fiecial reference to the shaj)e and position of till' uterus. In hospitals it is the rule to explore the pelvic contents shortly iK'fore the patient's discharge. If the uterus be retrovertetl, it should be rcposited, and be held in place by a suitable pessary. Often persistent retro- version may thus be preventetl. The pessary may be disusetl after two (»r tlu-oc months. Undue persistence of the ret! flow or an abnormally open cervix is generally to be taken as evidence of endometritis. For the treat- iiu'iit of this condition applications within the uterus of tincture of iodin or iodized phenol (carbolic acid and tincture of iodin equal parts) at intervals of a few days are useful. Most effectual is a currettage with drainage of the uterine cavity with iotloform gauze. This procedure should be conductetl with strict antiseptic precautions. The gauze is to be removed in from three to five days. 7i ( V-.-i^.i-r i '• ^^^Kt f ■■'■ ■, . , ' 1 1 ' ' ] 11 'i .' 3 i!!l i; • i I C(>4 AMKItlCAX TEXT- BOOK OF OliSTETRICS. litynlutioti of the Lyiufi-in. — Tlic loiigth of time which it is desirable that the wotnaii shoiihl ho kept at rest after hibor will obviously vary with tlio rate of uterine involution and with the general progress of eonvaleseence. During the first week she ought not to leave her bed. Ordinarily she may be all()\veart of the day be removed to a lounge or may lie upon the outside of the bed, and may sit erect when taking her meals. During the third week a large portion of each day may be spent in a chair. The ])afient, however, shoidd not, as a rule, be allowed on her feet. In the fourth week she can have the liberty of the room, and at the end of the j)uer- pcral month, if all goes well, may be permitted to leave her room. It is advisable, however, that she should not fully resume her usual duties for two or three weeks. Caim-; ok Tin-; Nkw-uoux Infant. Innnediately after birth of the head the child's face should, when opportun- ity permits, be bathed with warm water, the eyes cleansed and carefully dried. Tliis is done as a ])rophylacti(! against ophthalmia. As a still further preven- tive, within an hoiu' after birth a drop of ('rede's solution (a 2 per cent, soln- tion of nitrate of silver) should be instilled into the conjunctival .sacs of eaeli eye. The latter precaution, when properly exetuited, is absolutely protective. No permanent injury is d(»ne to the delicate structures, and the serous oozino wliicii fre(|uently results subsides within a few days. Should it be excessive, it may be promptly controlled l>y a single application of a drop or two of a | per cent, solution of the sulphate of atropin. The ligation of the fiuiis and the dressing of the stump have been already cousideretl. Usually respiration is promptly established at birth, partly l»y the air-hunger developed by interruption of the utero-plaeental eirculatinii. and partly by the reflex effect of the contact of cool air with the moist sni- laces of the body. When the new-born infant does not breathe properly soim after birth, means should be employed to seciu'e the full expansion of the lungs. Useful measures for this purpose are blowing forcibly upon the face, dashing a few drops of cold water up(,u the chest or the face, or gently slap- ping the buttocks with the hand or with the end of a wet towel. These elforts shoidd be continued until the child cries lustily. When respiration is obstructed by mucus in the throat, the offending material may be removed by the finger wrapped with a soft rag. Still better for the purpose is a soft-rubber tube with a bidb attached. The tube is passed deeply in the j)harynx and suctimi applied by means of the bidb. Two or three repetitions of this process will MAXAf:i:}fi:xT of the prKUi'F.imwf. GC,-) usually serve to clear the throat of the ohstructiiig niucus. Susix'ndiii}? the child by the ieet facilitates drainage of liquids Irom the air-passages. The tieatineiit of asphyxia does not fall within the seojw of this section. Care must be used to protect the child against injurious chilling. It must not be forgotten that an abrupt transition has taken place from a temj)erature of about 100° F. to one nearly or (piitc thirty degrees lower, and harm wa\ be (lone by prolonged exposure. The child, therefore, is to be wrappctl carefully ill flannels, and as soon as the cord is cut it should Ik* laid in a warm place until the necessary attentions to the mother are compIctcMl. The head while moist should be covereriucipal measurements of the head are niattei-s of scientiflc interest : the weight especially ought to be noted for comparison with the results of subsetpient weighings as a means of (leterinining whether mitrition is going cm properly. A small and awurate spring balance, therefore, may well be a part ol' tlu; obstetrician's outfit. A ^^(•hidtze pelvimeter or other simple calipers is a suitable instrument for meas- uring the head. It is well to direct the nurse to administer to the child, within a few hours alter birth, a rectal injection of a tablespoonful of warm water ibr the ])iu'])ose of determining the ])resence or the absence of atresia ani. If the rectum be impervious, the water retiwns as last as injected. Should no incconimn be passal within a few hoiu's, the physician must ex|)lore the lower bowel for possible occiusion. The nurse is also to observe whether tlic child urinates as evidence that the urethra is pervious. Failure to pass urine for several hoiu's, however, need not excit(! alarm. The bhuhler is usually emptied in course of the birth, and but little in'ine is secreted until the child begins to nurse. Atresia of the urethra is much los i"re(|uently met with than that of the rectum; it is, in fact, extremely rare. Usefid informa- tion may sometimes be attbrdod by taking the temperature per rectum. The notion that the new-born infant should be placed upon its right side to favor the closiu'c of the foramen ovale has no foundation in fact. It may lie iiidif- Icrcntly upon the back or upon either side, changing its position occasionally. Bnlh'inf). — The first bath, if the child be robust, may be given soon after it is separated from its mother. Jji case of feeble children the ftdl bath should he ])ostponed for several days. In the latter, iinuu'tions of sweet oil, vaselin, or fresh cacao-butter are to be substituted for the general bathing. As a pre- liminary to the first cleansing the skin is to be well rubbed with sweet oil or similar fatty material to facilitate the subsequent removal of the vernix oiseosa. TJK! temperature of the water should be !)H° F. The regidation of the tein- |)(raturc nnist not be trusted to the hand. A bath-tliernKinieter should be used. While the temperature ought not to I'all below 'J8° F., it must not I t/1 i^iri '^V-'^jS^ '^rt. m GGG A.yrKiiicAX TExr-iiOOK OF oiisiKrnics. nuu^h excoofl that |K)int, owing to the danger that too high a temperature iii:u- inthice trismus. As a safeguard against injurious chilling the nurse should U- taught to bathe the child by inunersion. An infant's bath-tub is the most convenient vessel. The head is first to be wet, and the Ixnly is then gradually lowercnl into the water to the neck. The head is supported above the water hv the ntu'se's hand. Sea-sponges should Im) replaced by soft cheese-cloth servi- ettes, which can Im; destroyed after once using, or if usetl again should first lie boiled. Care njust be taken that the soap used is bland and non-irritatiiio. Most suitable is white castile or a glycerin soap; nor should even this he usi^d too freely. The skin, too, of the new-born infant is easily injured by much friction. More harm than go(Hl will often l)e done by too great thoroughness in the first bathings. The duration of the bath ought not to exceed five minutes. On rem()val from the water the child's bcwly is quickly dritnl by wrapping in a large soft towel. Little or no friction is permissible for the first week or more. The scalp and the ears must be dried ciu'cfully. The full bath may be re|)eated daily in warm weather, and three times weekly in the colder m«)nths. Soiled portions of the IxMly, however, should be cleansed as often as soiled. Especial attention is to be direetetl to keeping the scalp clean. The l)est time for the bath is a morning hour, midway between feeurp()so alter the navel has healed. It is a mistake to suppose that a tight abdominal bandage helps to prevent Hinbilieal protrusion. On the contrary, by increasing the iutra-abt and legs are to be prottx-ted with woollen socks reaching to the knees. Tlie undershirt and dresses may be fastened with tapes. All clothing shoidd he laundered before using, and should be changed daily. At night the muslin .111(1 flannel slips may be replaced by a suitable night-dress. The weight of these garments is to be adjusted to the reijuirements of the season. XitrKiuf/. — As a rule, when the mother's nipples are of normal size and wc^ll formed the fully-developed and healthy child instinctively suckles wIumi first placed to the breast. Not infrequently the new-born infant does not take the nipple willingly, particularly if the nipples are small or nn'sshapcn or the cliild is jiuny or feeble. Much trouble nuiy be saveil by teaching the child to nurse before the breasts become engorged. Patience and tact will usually ensure success. Wetting the nip])le with a few drops of milk squeezed from the breast, or with a little sugar and water, before aj)plying the child may be tried if necessary to induce it to nurse. The infant should be put to the breast as soon as the mother has rested, usually within six or eight hours after birth, and should nurse once in four hours until the milk-secretion is established. Subsecpiently the average interval is once in two hours. The intervals should be lengthened, as a rule, to three hours by the end of the third month, and thus continued until the sixth. About six hours shoidd be allowed, however, between the last nursing at night and the flrst in the morning. From ten to twenty minutes is enough for each nursing. As the child usually falls asleep easily after its meal, it is well, if necessary, to wake it on the hour. Regidarity of feeding is of the utmost importance in the interest of good digestion and ])roper nutrition, and the habit should be established early. It is generally best to apply the child to b(jth breasts at each nursing. Regurgitation of food soon after feeding is usually to be taken as evidence that the stomach is overfllled. For the first two or three days after birth the child gets but little nourishment from the breasts, but it neerepared yields the prt)portions of albumin, fat, and sugar found in breast-milk. The formula for the Kotch-Meigs mixture is as follows : Cow's milk, mixed-herd milk, Cream, Water, previously boiled, Milk-sugar, Lime-water, 51.). 5>'j- 3vi gr. xlv, 5j.— M. To ensure the correct percentage of fat in the mixture it is necessary that the cream used in its preparation contain 20 per cent, of fat. Such a cream will 1)1' moderately thin. Ft is scarcely necessary to emphasize the importance of attention to the jjrimal milk-supply. For obvious reasons mixed milk from a Ik rd of cows is more likely to be of uniform quality than that of one cow. Much impurity is preventable by scrupulous cleanliness in milking and in tlic subsequent handling of the jiroduct. Attention to the health of the ani- mals is ((f ])riniary importance, and the sooner the milk is fed after milk- iiiir the i)etter is its condition, other things being equal. The milk-sugar ill the market is frequently unsuitable for use by reason of gross impurities, ("arc must be used to procure an article which has been fully purified by rccrystallization. Cream obtaineil bv the ordinary method of allowinir the milk to stand until th cream has risen has necessarily suiiered some degree of decomposition, fo be liad fresh, it must be separated from milk directly after milking by means of the centrifugal machine. Unfortunately, cream by the centrifugal process is in most localities not obtainable. For a i\'\\ years ])ast a milk lahoratory for the preparation of infant foos, marks an im])ortaiit advance in the scientific feetling of infants. But these refinements in infant feeding are not always practicable, nor aic they in all cases indispensable to successful nutrition. In exceptional instances the new-born child thrives on cow's milk simply diluted with one volume ol" water to one or two volumes of milk. A lairly goourely animal food. This fact would seem a sui- ficient reason for excluding also all farinaceous materials from substitute foods during the first year. Condensed milks, like ordinary cow's milk, when diluted sufficiently to reduce the proportion of albumin to the required standard, must obviously yield a result which is deficient in fat, and, in the case of unsweetened prejia- rations, must be poor also in sugar. JJut this is not all. Analyses have sh(»\\ ii that nearly all brands of condensed milk lack primarily the due proportion ot' fat. With one or two exceptions they are made from milk from which a jxn- tion of the cream has first been removed. Moreover, the sweet brands are sweetened with cane-sugar, which is not an ingredient of natural milk, and is, furthermore, open to the objection that it is more likely than milk-sugar to favor butyric-acid fermentation. A condensed milk, however, to which no MAXAf{j:.vj:xr of the puEitPKituM. 671 h laboratniy selccttHl ani- ivcnnl at tlic aiiicntages of its nutritive constituents arc known, nu»y M rve as the basis from which to construct a pr(»pcr flxHl for infant feeding. Water, cream, and sugar-of-milk are to be addeitiiiM of the fetus, or any of the lunnerous complications of lalnir, endangers <'itlicr the nu>thcr or the child, and calls for (vperativc interference ( instrumental «»r manual I on the part of the obstetrician. They are iiUcly to be especially great wlicn this ojH'rative interference bect)mes imperative at a time when the parturient canal is only incomi)letcly dilated. The most common of these injuries .ousist in contusions and tears of the vulva, the perineum, the vagina, and the neck of the uterus ; some of the rater accidents, such as lacerations of the body of the womb, inversion of the uterus, and injuries to the pelvic bones, have been described under Dysfocid. Injuries to the Vulva. — At times we find transverse lacerations of the vidva that involve the deeper tissues, perforating the nymplue and leaving them fenestrated for the rest of the patient's lite, or going completely through either labia minora or majora or both, and causing these structurv's to hang in shreds. Ti\e most frecpient accident to the vulva, however, consists in tcai- of the nuicous membrane, which are most numerous in the vestibulum and (ni the inner surfaces of the labia minora. Sometimes the tears are near the urethral orifice or they extend into it, and under these conditions will cause a burning pain during urination or will lead to retention of urine on account nt' the accompanying swelling. These injuries do not, as a rule, cause miieli hemorriiage, but at times they will do so, especially if one of the eonvolutinns of blood-vessels known as the hxfbs of the trxfibufe is involved. Trvaimcnt. — Superficial tears of the mucous mend)rane of the vulva will heal without much treatment. They should be kept clean and may be dusted with iodoform. All deeper lacerations and those followed by henu>rrhage are best closetl by fine silk sutures. Union by first intention takes place aliiidst invariably, and the stitches may be removed on the fourth or the fifth d:iy. When there is retention of urine it may become necessary to use the catheter * Tlie sup'rior fifjuros ( ' ) occurring througliout the text of this section refer to the bililinj,'- rapiiy given on page SO-1. ■'^.U, r H PATiioLoav OF Tin: I'ri'Jx'i'HmiM. ♦I7;l nil til th II ir swollllij; liiis siihsKlct ( )tt('ii I, liowcvcr, tilt' iKitii'iit will lu' t'lia l)l.-(l V\n. li;i.- I'rriiKiil Imcralidiis: A, liiciriit'oii I'XicncliiiK tllrlHl^;ll the siihimliT i. > iiitu tli" riM'tuiii, siilclics iMtnKliiciil tlimiiyli t \i If > 1 K m^ ^^^^^ ^■' ^ w^ , "*i mimL..^^^^ i M 0^ ^ : .j- ^m liP'j"aWPiiBifc\^M ■ ^mmmn^^m^ mm- '■^'■'^y'^M ^Im "IT- ^^kq f^i f C. V-'" ■ ' :.^ ^ W* L^ m '''M Fig. ■115.— Perineal liicerution.s : A, luceratiDii I'.xti'iKlint; up riKlit Ititerul sulcus. H, lucoratidii involviiin both lateral sulci. rencc, and the resulting injury to the levatores ani muscles destroys in varyiajj; later Si/tnptonis and Sif/)is. — The swelling formed by the extrava.sated blood usually does not appear until labor is ended, and in some cases even .several days later, the time of its appearance depending upon the kind of injury tlie veins have received. When the vessel has been ru|)tured early and the |)re- senting part has not advanced sufficiently to exert direct pressure upon the injured veins, the tumor appears at once, and, immediately reaching its fid! size, may seriously obstruct labor ; if, however, the presenting ])art exerts sufficient prcssjire to control the bleeding temporarily, tiie tumor may be vdv small or may not be noticed until after labor. When the vein which is sid)- jected to prolonged compression is only contused, and which later gives w;i\ either s]>ontaneously or after sudden exertion, as coughins;, straining at stool. or (luring micturition, the tumor first appears in the ])uerperium, usually within a day or two, but very rarely so late as the twenty-first day, as in ;i case reported by Heifer. The situation of the tumor varies ; anatomically it is determined by the d' itribution of the fascia, either of the pelvis or of tlio perineum. Usually the blood is ettused below the pelvic fascia, and the tniiior appears in the labium, or beneath the vagina, or in the perineum, extcndiiij: exceptionally to the anus, to the gluteal region, and in front to the abdominal PATHOLOGY OF THE PIERPERIUM. 681 (rf v" :!onifortal)ly. 1)0 continucil (crf'ect appli- iir a oircuni- tliat may \w KHix, all sys- oiis, and llio : is a lowered riiis accidont, used by pi'«"^- been able to during labor, rcgnancy, and teil by Hinion. posing causes, all by disease. , and, a priori, )t' lieniatonialu kodly varicose factor of first of the uterus, )sterior vaginal } pelvic canal, ze of the head, e ett'orts have iv asated blood ■s even several of injury tlie and the pre- isure upon the whing its full ig part exert> )r may be vfiV which is sub- Hater gives w:iy Lining at stool. leriuni, usually [st day, as in :i lanatonueally it lelvis or of the and the tumor kitn, extendiii;-' the abdominal walLs. If the bleeding has occurred above the pelvic fascia, the effused blood may be situated in the broad ligaments or the periuterine connective tis,sue, and it may extend even to the diaphragm. Very rarely the tinnor may be found in the cervix. Clinically, the commonest site of the swelling is at the side of tlic vagina near the vulva. The size of the tumor also varies. Usually not larger than an egg or one's fist, the tumor may be as large as a cocoanut, or, widely distributed, it may contain a very large (juantity of blood. A hematoma, polypoid in shape, has been observed hanging from the vagina. The formation of a hematoma is generally accompanied by pain in the region affected, this pain being very severe when a large tumor is formed. There are at the same time constitutional evidences of hemorrhage that also vary in their severity in direct jirojjortion to the volume of the timior. Should tiie swelling reach its fidl volume at once, and burst — an unusual complication — the loss of blood may rapidly be fatal. In some instances the tumor con- tinues to enlarge for twenty-lour hours. Soon after its formation it assumes a livid or mottled appearance, at first giving tense fluctuation, but later a dot- Hke firmness. IJy pressing upon the bowel or the bladder the functions of these organs may seriously be interfered with, and when the swelling reaches a considerable size during labor it may impede the birth of the child or the pla- centa, and later may obstruct the lochial flow. The synn)toms being practi- cally characteristic, tiie (liaguo,si,s, therefore, is generally easy when the tumor is visible or is easily accessible in the lower parturient tract. The tumor might he mistaken for prolapse or inversion of the uterus or the vagina, for varicose veins, or for vaginal enterocele. AVhen the eff'usion has taken ])lace within the jjclvis, the diagnosis will be made by a bimanual examination, together with the mode of onset and the constitutional signs of internal hemorrhage. The (erminafion of a hematoma may be any one of the following : (u) Ab- sorption ; (b) recovery after evacuation of its contents ; (c) septic infection Ijefore or after ruptiu'e ; (d) hemorrhage, wiiich may prove rapidly fatal before rupture or at the time of rupture. Rupture niay be the result of undue or sudden eflbrt, or, at a later jieriod, it may occur spontaneously from slougliing. The idtimate result, which in any case will depend ujion the size and situation of the tumor, is also largely influenced by the treatment pursued. Small tinnors not larger than an orange are usually absorbed, while those of larger si/e fre- (|iiently burst spontaneously and thus add to their gravity. Of 30 cases col- lected by Winckel, twenty-three spontaneous ruptures occurred within eight days. If, on the one hand, the larger tumors are opened before necrotic eliiuiges or renewed hemorrhages have occurred, the prognosis is favorable, and with rigid antiseptic treatment death should be oxce])tional ; if, on the other hand, delay permits such changes, the mortality is 12 jn-r cent. (Winckel). The situation of the tumor influences the prognosis to the extent of its being accessible, and thus being more readily dealt with. Intrapelvic tumors, therefore, are more dangerous, the hemorrhage being less readily controlled and the danger of suppuration being greater. Tumors appearing during labor have had a higher mortality than those occurring after delivery. ^vr.f I 1r i1 1 'M? * I 4 11 n .: !* •S'i.;,!! It- '■. It. '-tiivn iiii I m, 682 AMERICAN TEXT-BOOK OF OBSTETRICS. The treatment of a hematoma varies with the time of its appearance, its size, and its situation. Should the swelling occur before or during labor, and offer a serious obstruc- tion to the passage of the child, the tumor should be laid open in its dejwndent portion, to favor subsequent drainage, preparations having previously been made to control the free hemorrhage almost certain to follow evacuation at this time. Manual compression by an intelligent assistant can be utilized to control free bleeding while the bleeding vessels are being searched for and ligated. If this cannot be done readily, forceps should be used to draw the head into the vagina until by the pressure of the head the bleeding is con- trolled. Even when the tumor is not large enough to impede the passage of the child, it is best to anesthetize the patient to prevent excessive straining on her part, and to apply the forceps and to employ cautions extraction to pre- vent further bleeding and increase in the size of the swelling. If the forceps is not employed, or in case the swelling first appears after labor, an attempt should be made to control the hemorrhage by the application of cold and by pressure, both of which can conveniently, and usually effectually be applied by means of the largest Barnes' bag or by a colpeurynter placed in the vagina and filled with ice-water, ice poultices being placed against the labium. If the swell- ing ceases to enlarge — an indication that bleeding has been controlled — and if the tumor is not larger than one's fist, efforts should be made to promote its absorption by cooling applications, such as compresses wet with lead-and-opium wash or with diluted alcohol. Meanwhile the vagina must be kept clean by frequent antiseptic douches, and the patient should be cautioned to avoid all ei;urts at straining. It is therefore desirable to use the catheter and to keep the stools soluble. After waiting a few days, if there are no signs of absorption, and if the tumor, which had been hard, now becomes soft, and the overlying skin or mucous membrane is tense, discolored, or vesicated, indicating, as these changes do, beginning suppuration or threatening spontaneous rupture, the time has arrived for prompt evacuation of the tumor. An incision 5 to 7.5 centimeters (2 to 3 inches) in length should be made along the inner surface of the labium, the clots turned out, bleeding vessels ligated, and the cavity daily cleansed and packed with antiseptic gauze. When symptoms of internal bleeding and physical examination point to the occurrence of a heniatoma within the pelvis, care must be taken to exclude free hemorrhage in the peritoneal cavity from a ruptured broad ligament or other vein, since the latter condition would necessitate opening the ab- domen, while in the former, if the hemorrhage is confined within the con- nective tissue, the shock and collapse should be combated, and effort be made to limit the hemorrhage by cold and by the internal administration of hemo- statics. Subsequently the tumor should be watched, and, if not absorbed, it is best to evacuate it through the vagina. If not extensive, and if there an' no marked constitutional evidences of internal bleeding, the condition will probably go unrecognized until spontaneous evacuation occura or until incision ,M-; M' PATiioLoay OF riiK pverpeuivm. 683 learance, its is made after several weeks or months, as in a case of" Terfj^rif^oriantz, in wliicli ease a broad-ligament hematoma through pressure-necrosis comnuini- (•at«l with the posterior vaginal vault, and was emptied of stinking, blootly fluid after four months. n. Diseases of the Sexual Organs. 1. PlKRl'KItAI. InKKCTIOX. By "puerperal iuf'eetion " is here understood all the manifold diseases conditions in a puerperal woman caused by microbes except eruptive fevers ; iion-inflammatorv diseases of the nervous system, sucli as tetanus, tetany, and insanity ; and inflammation of the breasts, — all of which are discussed in otlicr parts of this work. Puerperal infection in almost all cases is a wound-infection, and, just as this may be slight or be serious, puerperal infection may be a local affection of the external genitals of little importance; or it may be a more serious affection (if the internal genitals, especially the uterus; or the whole system may be drawn into the morbid process. In most books this condition is treated of iMider the name " puerperal fever," a denomination from which the writer entirely abstains, for the reason that it is absolutely impossible to draw a distinct line anywhere on this field as a limit for something worthy of that name. The old idea of puerperal fever as an essential fever, a nosological entity mi generis, is given up by all. It is impossible to define puerperal fever, and it ought to follow the terms dropsy, lung fever, and brain fever, which have long ago been relegated to the scientific lumber-room for terms fiillen into desuetude and given way for definite and correct expressions. The term " puerperal fever" ought the less to remain in scientific language as in some of the worst cases there is no fever at all. Of late years, instead of " puerperal fever," the term " puerperal septi- cemia" is used by many, which is certaiidy an improvement, in so far as it reminds us of the identity of puerperal infection with wound-infection ; but the expression is both too wide and too narrow for our purposes — too wide, l)ecause the same word has a more restricted sense of a certain form of puer- peral infection in contradistinction to other forms ; too narrow, because the word by its etymology means a condition where septic material circulates with the blood through the whole body, and because the term cannot projicrly he made to encompass many diseased cond!tit)ns foutid in the puerperal woman, wliich conditions in most cases never lead to a general infection of the whole system. The term " puerperal infection " is open to the criticism that it means a cause, and not the effect producal by this cause, but this is not without analogy in common parlance. The word " cold " meant originally a low ti'in])erature, but by extension it has been made to comprise as well the disturbance in the human body caused by ex])osiire. Hy using the expression "puerperal infection" to designate the diseased H K'- i < I'M t V / ! 'I l^w mnm " i! ; „ ' n'x % 'im'^': i -'1 '■ ii t. (iS-l AMEIill'AX TEXT-noOK OF OliSTF/riilVS. coiKlitioiis produced \>\ infection diiriiij; jn'c^niincv, childbirth, and the pncrpcrid state \vc have tlie advantage of liavin^ a general term whieli covers tlic whoh- groinul, iniM and serions ca>es, local and general distnrli- anccs in the ct|iiilil)rinni of health. We are furthermore reminded of the |>os- siltilitv of jfuardin^r otn- patients a<>ainst a |)est that not lonjr aii'o was thouuht to he due to a deterioration of the atmosphere, or even to a direct retrihution of an irate deity ; an'monons abscesses in other diseases. Lust ii>- of Turin ^ found this same streptococcus in the blond of the spleens and the hearts of women who died from puerperal endouu'tritis and peritonitis. Jiumm,^ who made extensive researches with ample material, likcwi-e arrives at the <'oiielusioii that the streptococci found in ])uer])eral infection an' identical with those found in inflrted wounds. Mironow'^ also identified tin' streptococcus of erysipelas with that jrathered from the uterus of sick puerperal women. Doyen, rnshini>:, Hunim, and others" found that puerperal infection iiiny be (bie to other cocci. J)oderlein ^ found the streptococcus ])vo!i-- I 'mli'rtidii ini\y I'lKIM'KltAI. INri:rTI(>N. I'l All II. > iviii-'i'iu's in I'lis ml I'lcifU'D. .^ Spi'i'iiiifii fniiii a inLtii'lit wlm ilU'il soiitic, sIkiwi'iiil: tin- mntcriiil tliiil wmilil !»• loimil In !»' iriimviil liy till Tiinttf (ir the liiiixiT mi the " nniiilu'iu'il iiliHoiiliil silo." "fldts in tlii' \Ut'iinr ^.inn^o^ " Aiiiiy Micliciil Mii^ciini, \Vii.sliiiii.'tnii, II. C. .No. 10,(ily.i. W ■ '-:■<:''' I 1 MkMm k.ul^ P li t ;l s? PATIlOUKiV OF Till': I'l'h'h'/'h'If/f'M. <>85 I'licriMTiil fovor, HO cjillrd, is tlicrcforc not a nosolojjjioul entity, but is a c'onipU'X plicnoineiioii (Ino to (litrcrciit niiot'olirs. lHjf'n'nit Fonm of Jtifcclinn. — First oi' all, we must distin^iiisii hctwt'cu iiKM'c local atlrctions and a (jinvt'dl infection nactiin^ tlio whole sy.''tfin. Tlio Hiriiicr arc, of Conrsc, niiicli less danjjcrons than the latter. Next, we must separate the y>»^vV/ I'roni the jien nine N<'y>//c' inf'eetion, hotii oC which may he local i>r he jjcneral. (Jcneral putrid iiitection is! calknl Mprcmid, and general M'ptic inteetion is called xrittitrmia. I'ntrcf'action and sapremia are due to many dillerent sehizoinycetes, the so- called xdpropliiftcs — minute organisms which are allied to algie, and are found all over the world in streams, plants, animals, etc. By their growth and multiplication these organisms produce certain cijcmieal suhstanecs, the so- called (oxiiiH, a kind of ptoma'ins wiiich give rise to fever. Ptoma'inx are alkaloids produced in dead vegetable and animal tissues during putrefaction ; /i'iicor"i"niii arc similar alkaloids producotl in living animal tissues as a result (if their activity. Pt(»mains are only pniduced by microbes. Leueomai'ns arc harmless unless their excretion is interfered with. The changes occurring in puerperal infection may be produced by ptouiains or by leueomai'ns alone, without the presence of microbes, but in the vast inajority of cases the microbes are present. The saprophytes are generally brought into the interior of the uterus mechanically. 8ej)ticemia is due to a few well-known micrctbes that actively enter the tissues, which they injure through their growth, and by their distribution thronihout the body may so change the chemical processes anil normal {'imctions that death ensues. These microbes are, as we have stated, almost exclusively streptococci, and are idcntibes, whom their miiMite bodies engulf and ai)sorb. Hence they have received the name of " phagocytes ;" that is, "devouring cells," a species of giant-killers on a small scale. While the nccr()bioti(! layer is covered with all kinds of saproi)hytic bacilli and cocci, these never enter the granulation layer. Septic endometritis differs according to its being a local affection or an r II <- ' '. < I i- 680 AMERICAN TKXT-nOOK OF OBSTKTIilCS. inflainination I'ollowod bv gt'iirnil iiifoctioii. In loml .^cpllc ('H(lometritii< the oii(I()iiu'ti'iuiu is miicli liko tliat in putrid eiuloinetriti.s, except that, besides iiu)rc or less nimierons germs oi' putref'aetioii, streptoeoeei are tbimd. (uiicral septic endoinctrififi appears under two (lillerent I'ornis — the /////;- plutth' and the l/iroiiiho-jiltlchitic. In the /ipiiplidtic form tiiere is a mixture nl' sapro[)liytes and streptoeoeei on the necrotic surface, but the granuhition-wall is much thimier than in putrid endometritis, and in the worst form of sepsi> it is altogether absent. On the placental site the veins are well closed, their walls being in contact and without thrond)!. In the severest cases the infec- tion-carriers go through the finest lymph-spaces between the tissue-element-. In less rapid cases they generally follow the larger lymph-vessels. From the wall of the lymph-vessels they enter the surrounding tissue, causing necrosis. The lymphatic form often starts from injuries of the cervix. Ill the ihvombo-plilchitic form of general intection the endometrium is like that of localized endometritis, the germs never entering the layer of granula- tion tissue filled with leucocytes except at the placental site. Here the veins have not been closed by collapse and apposition of their walls — the normal process — but are ])lugge(l with thrond)i. In some of these thrombi we find, superficially, saprophytes and streptococci, but the latter, finding a favoraltle .soil in the thrombi, enter into their interior, while the saprophytes remain near the surface. The invaded thrombus soon forms a detritus, a process that extends into the broad ligament. The thrombo-phlebitic is a more rapid and a more dangerous form. In septic peritonitis the infection is not propagated through the Fallopian tubes, but it takes place through the lymphatics of the walls of the uterus. The danger in different cases of puer- peral infection may be accounted for in many ways. The different power of resistance may coiuit for something, one organism succumbing to an attack which a stronger constitution successfidly resists. The mere nund)nr of microbes seems to be of importance in all infections, the invaded body beiiii:' capable of neutral./ing a small munber, but losing in the battle with the many. Tli(> anatomical structure and eonneetions of the part invaded explain maii\ peculiarities in the result produced. An infection attacking one lymph-vesM'l leading to a gland may be cut short there, while if the infecting material enter- ai\other lymph-vessel it is carried to the peritoneu'n, thence, perhaps, throu'jli the stomata of the diaphragm to the pericanlium and the plenr;'. ( )r a throm- bus in !i vein breaks down, and part of the detritus is carried away with tip blood-eurrent through the vena cava, the right aui'icle, the right ventricle, anil IMKKrKHAI, INTKCTION. ri.Aii: to. Hhvm'tritiK tlic t that, bosiiU's tbuiul. rms — the ///'"- s u luixtmv ol i-iumlnti()ii-\v;iU form of scepsis L'll flosod, tlioir oases tlio infi'c- tissiuM'UMncnts. ;els. From tin- causing noorosis. )niotriiim is \\\r of linir to an attack licre mnnbiM- <>l ided body beiii'j battle with tlu' od explain manv |)ne lyniph-vesM'l material eulcr- [•rhaps, throu'ji . Or a throiii- jd away with the Iht ventriele, aii'l I ..4- I'liTii-. Willi slin ilily tMiilriiiil iM, Ml Ml 1 ^IciU'jliiii'^ ~lri|i " I'liiiirliii'j iiiliiti;il ii-"i-,m; linm MnliiMl Mu-ciiiii. \\ii>liiiit;iii|i I' I'., Nn. y.i.'iTi. i-Uh ■I i.V, ■'> ■ 1 i ■ 1 ,'" , J % >£■;?■? riKIM'KliAL INKKCTloN. I'l.ATi: 4t), 1 •fH-!li!i Iff 1 IJff r ((• l'i>l'li r |il.lirlll;l .n t'llllllilliM'^ '" "'' '■"■■ illlllll IVnlll v,.|,vi^ livi' iImJ^ II I'll I ilrliMiy ill II l\ l.hiiiil cnll- ililiuii. I'nlurcil uirl. niiii'li'1'11 \ciii> nl.l. ^^ iilnlitic. u iili iliinl Ulu- iii u-.ii i ,\riii\ Mr.linil Mu>.iMn, \\a>li- iii'JI'ili. li. ('., No. TTMl. r-f ij'. '' e J> ! PATHOLOGY OF THE PUERPKRIUM. 687 is deposited in a fine brancli of the pulmonary artery, torniing an abscess, from which the microbes are carried to other parts of" the body to form new foci of suppuration. Most important of all seem to be the different degrees of virulence of the microbes themselves. Virulence is a property of the protoplasm that shows itself in energetic proliferation and increased { ower of resisting the influence of the cells in the organism invaded. This virulence is diminished by artificial culture, and is increased in the anin\al body, but in what way is unknown. The virulent streptococcus rapidly invatles the tissues. Infection starting from the genitals takes place through a wound, many niii'robes being found in the genital tract of every puerpera, besides the placental site, which has been compared to the stump left after the amputation of a limb. It is not so in animals. AVith animals, as a rule, the process of expelling their offspring is not more difficult than the act of defecation, and tlioir placental site either regains its epithelium before the loosening of the placenta, or recovers it in a very short time after delivery, almost in minutes. This fact explains why puerperal infection is not produced in an animal by tlio injection of septic fluid into its vagina and uterus. As soon, however, as the same fluid is injectetl under the mucous membrane infection follows.® In the opinion of the writer the so-called " puerperal fever " is nothing but the most serious form of puerperal infection. Localized is less dangerous tiiiui general infection ; putrid infection is not so important as septic infection ; but any local infection may become a general infection, and putrid infection may end in death. S.j/tk'cmia in Children. — Identically the same disease above described in puerperte is often found in new-born children. The mother of the child may or may not have the disease. Infection in the child generally takes ]>lace tiu'ough the navel, but it may enter through sores in the mouth or through an accidental wound, or it may be aspiretl into the lungs in the putrid liquor amnii or be inhaled through the air, or it may even pass from mother to child through the placenta. If not acquired from the mother before birth, the poi- son may be carrieil to the child by doctors or by nurses, or may cling to any object with which it comes in contact, or niay float in the air. The sources of the j)(>ison ill children are the same as those we shall now describe in regard to the mothers. ExroiiOGY. — Experience shows that a ])uerpera is more lial)le to disease tiian is a woman in other conditions, and it is not difficult to give many good reasons why this must be so. The causes of puerperal infection arc prcditi- jiDfiinii or ex('iti)u/. I'lrditijio-sin;/ Cuuncs. — During pregnancy the chemical composition of the lilood undergoes considerable change ; the total amount of blood circulating in the body increases, but it is more watery than in the non-pregnant con- dition. In other words, the woman suffers from plethora and hydremia. Tlie red blood-corpuscles diminish, while the colorless corpuscles increase in number. Hemoglobin, albumin, fat, ])hosphorus, and iron are found in too small amount, whereas thequautity of fibrin is considerably greater than in the :».•. ■.P::] ,r >S 688 AJMERICAN TEXT-BOOK OF OBSTETRICS. ini f \ non-prcgnaut woman. The plethora, liyperiiiosis, and leneocytheniia predis- pose to intlainmation. The heart, especially the left ventricle, becomes hypertrophic. The walls of the blood-vessels become thicker and their calibre larger, esi)ecially those in the uterus and the breasts. The lymphatics of the pelvis become so dilated that they look like veins. This dilatation of blood- and lynii)h-vessels pre- disposes to the formation of thrombi, which not only constitute a fertile soil for the pathogenic microbes, but also may break down and be carried away by the circulation to remote parts that become new centres of infecfion. The nniseular tissue of the uterus grows enormously in order to afford room fur sheltering, and force enough to expel, the fetus. The nervous system is in a high state of irritation, as may be concluded from the headache, toothache, neuralgia, vertigo, and longings and aversions so common in the j)regnant condition. Parturient and puerperal women are highly emotional. The ])resence of a disliked or dreade ■ ' , ! mediate stage being fatty degeneration. While before delivery there is a .-strong current of plastic material toward the uterus and the child, after (k'livery the direction is reversed, and a strong current carries ett'ete material tVom the genitals, especially the uterus, to the rest of the body. Primiparffi are still more exposed to infection than those who have before hcrne children, labor being longer, the canal to be traversed being narrower, iiiid the parts composing it being softer. Delivery in general hospitals exposes the patients to greater dangers than delivery in special lying-in institutions or in their own homes. Parturient women ought not to be in the same room with pnerperte, the discharges from tlio latter being particularly dangerous to the former. The crowding of too many puerperie into one room is in itself dangerous. The less the space the greater becomes the difficulty of obtaining absolute cleanliness, and the greater is tlio danger of noxious substances being carried from one patient to another. The exciting cause of puerperal infection is, as we have seen, the introduc- tion of certain microbes into the body of the woman, as a rule into her genital tract. Sources of the Poison. — The infection may come from a woman similarly affected, from suppurating or decaying tissues, from putrefying substances within or without the body, and from zymotic diseases, especially erysipelas and diphtheria. Contarjion. — That the disease may be brought from one patient to another was discovered by British physicians, and, while in America it was denial by the leading obstetricians of the day, Hodge and Meigs, nevertheless it was ])roved to be contagious by the masterly essay of Oliver Wendell Holmes, wlio so distinguished himself in another line that his merit as a physician is apt to be overlooked.'" N'ow-a-days the contagiousness of puerperal infection is universally admit- t(Hl, and the only mooted point is whether it is essential that the microbes be carried from one patient to another on solid objects or whether they may float tliroiigh the air — a point to which we shall presently return. Siipjmration. — That the source of puerperal infection may be suppuration was pointed out as early as 1847 by Semmelweis." Students who had examined a patient with a cancerous ulcer of the uterus caused puerperal fever in and (leatii to fourteen women. Ill America was the celebratal case of Dr. Rutter of Philadelphia, who in 184!^ had forty-three cases of puerperal sejjticemia in his practice, while neighboring practitioners had none. He bathed, changed his clothes, shaved off his hair and wore a wig, stayed ten days away from the city, and did not take with him to his next patient anything he had before worn or carried. She had an easy confinement, yet she died from puerperal fever. The groat Meigs taught his students that such a fatality was God's providence.'^ It remained for the present generation to find the solution of the riddle in the taet revealed by a contemporary of Dr. Rutter, that he suffered from an obstinate muco-purul nt coryza." It is easy to understand now how by 44 :i^i !,'i|5 H' 1 « • i 1 m m ■ ft m 1 ff T m 1 1 . i kT j. li - I ( 1 I & 690 AMERICAN TEXT- HOOK OF OBSTETRICS. toudiiiig his nose with his fingers Dr. lluttor hronglit staphylococei aiKi streptococci into the vagina or the uterus of his unfortunate patients. A French i)hysician who had delivered eight hundred women without accident was seized with suppiu'ative adenitis, for which he wore a draiuago- tube. Witliin three weeks he had three cases of ))uerperal septicemia." During the time of the great morbidity and mortality in the New York Maternity Hospital immediately preceding the new era an assistant suffend frequently from pustulous eczema of the hands. A dentist, Dr. Pedlcv, called attention to decayed teeth in doctors and nurses as a jiossible source of puerperal infection.'* In 1889 there was in the Xew York Maternity Hosjiital a paralytic patient liaving a carbuncle in the sacral region. There were two puerperte in the same ward, and all were in the hands of the same nurse. One of the two puerjjenc, who had been perfectly well up to the eighth day after her confinement, got a chill and her temperature rose to 105.6° F. On the cervix was found a di|)li- tlieritic infiltration. The patient with the carbuncle had no puerperal affection of any kind. Pat refaction. — Semmelweis showed conclusively that the enormous mor- tality prevalent in the lying-in hospital of Vienna was due to cadaver-poison brought by the students from the dissecting-room to the wards in which women were examinetl and delivered. Tiie hospital has tw'o departments, one for students and one for niidwives, admission taking place to eaci; department on alternate days. Nevertheless, the mortality in the students' department was three times higher than that in the midwives' department. A similar instance is reported from private practice. A Scotch physioinn, Dr. Renton, and a friend practised in the same place. During a so-called "epidemic" of puerperal fever all Renton's patients remained healthy, while all those of his friend were taken sick. The difference between the (wo was owing to the fact that Renton did not, while his friend did, perinnn autopsies.'^ The infection may originate also from a decomposing part of a liviiiif body. Thus, frequently pieces of placenta or of membranes, left behind in the uterus, become the starting-point of ,.uerperal infection. The writer once had a patient who gave birth to a macerated fetus, and from whose uterus a decomposed plai'cnta was removed without doing the least harm to tlie parturient, but it gave rise in another patient to one of the worst cases of puerperal infection in the writer's experience. The assistant who delivered the first woman was allowed bv his colleague in charge of the second to examine her, and, although he disinfected his hands with bichlorid, lio doubtless brought on his fingers the germs that came near costing the woman her life. Some years prior to the date of the writer's coimection with the New Ymk Maternity Hospital there was erected on Blackwell's Island, N. Y., a new- building designed as a maternity hospital. The building had scarcely Ikih opened before such a so-called "epidemic" of puerperal fever broke out in it k:f m vlocncci aiiti ients. men without ■e a ilraina«r('- septiceniiii." a New York ■itant sutli'icd Dr. Pedlcy, osrsible source ralytic patient •aj in the same two pucrperie, inement, j^ot a found a dipli- rperal affeetion mormons mor- eadaver-poison ards in whicli o departments, phice to eacl-. n the students' es' department, oteh physieian, 'insr a so-ealled healthy, while 'tween the two did, peril inn \rt of a living; left behind in The writer once whose nterns a harm to tlio worst cases of who delivered th(! seeond to biehlorid, 1k> ting the woniau the New Y"il< N. Y., a nrw Id searcely l^'cn 1 broke out in it PATIIOLOaV OF Tin-: PCERPKniUM. 4!' that it had to be vaeated. The cause of tins epidemic was probably dnc to the iriiano w^ith which the surrounding grounds had been covereil in order to make a garden. Feliling" observed an epidemic of pue-; ^ral fever, diphtheria, and ciysipelas as the consecjuencc of a bursted waste-pipe, the dirty water soak- ing into the ground on which stood the hospital. Gustav Braun'* in 1889 had so serious an epidemic in the Vienna lying-in liospital that during one month nearly 18 per cent, of the puerjiera; were taken sick, and nearly 9 per cent. died. He attributed the troid)le to the fecal matter from the hospital and that of a neighboring barrack being evacuated into a canal flowing past the hospital. The immediate contiguity of a churchyard, a dunghill, a privy, a stable, a slaughter-house, a cess-pool, a sewer, a pool of dirty stagnant water, or similar jilaees where organic substances are imdergoing decomposition, is therefore dangerous to a parturient woman. Zi/inotie Diseases. — The exact relations between puerperal infection and zymotic diseases are not definitely settled. Since it is now known that it is tlie same streptococcus which gives rise to both diseases, there can hardly longer be entertained any donbl of the jjossibility of puerperal infection being (hie to the poison brought from a jierson affected with erysipelas to a jiuer- pera. The same observation applies probably to diphtheria, since a diphthe- riti(! local affection entirely like that which occasionally develops in a woiuid, and which commoidy appears in the n])per air-passages in diphtheria, is one of the commonest forms of puerperal infection. Scarlet fever may attack a puerpera, but it remains scarlet fever and follows a similar course to that in other patients. Typhoid fever is so well cliaracterized by the intestinal ulcers, and is so ditferent from puerperal infec- tion, that the two must be distinct diseases, but this fact does not prevent one disease from leading to the other. \V(ti/s by v'hich the Poison enters the Bodi/. — In the vast majority of cases tlic ]ioison causing puerperal infection is brought mechanically into the genital tra(!t by the fingers or by the instruments of doctors, midwives, or nurses. It may lurk in a lubricant or may adhere to a sponge, a rag, or to any other substance coming in contact with the genitals. ]\[any think that this mode of entrance is the only one, and deny inteclion through the air — a view which, in the writer's ojiinion, is contrary to many well-authenticated facts. There have already been quoted on the precetling page instances where e])idemics in hospitals could only hv traced to the ground, tlio walls of a building, or the air near it being infected by fecal matter and otlier refuse. Now, it does not seem at all likely that the doctors and luirses hronght the microbes from the guano lying on the ground outside the new hospital on Blackwell's Island referred to, nor from the feces floating in tlie canal flowing past the Vienna hospital, nor from the wet ground that was soaked by the bursted waste-pipe described by Fehling. It is certainly more probable that the streptococci were carrietl through the air into the hospitals I ■1 ■.■ ■h f1 (\\)2 AMimrcAx Thxr-nooh' or oitsTF/nurs. aiul woiH! doportitt^l on clothing, instnimciits, drcssiiij^-inatcrials, or oven on the lianda of the pliysii'ians and nni-scs. Soino years aj;o tlu'iv was in tlio Now York Infant Asylnm p,'ieal eonehision that the niierohes (h'vehiped in tlie dead ho floor through the whnl,' bnihlinn? This methtxl of dissemination is so nmeh tiie more likely, in!i>- mueh as we have exaet observations showinjj the existence of the streptoeoci i in the air. Humm '" fonnd the eoeei in the dust floating in the air. Depaul*' roportisi the ease of a pupil-midwife who, while wiishiufr di,. genitals of a patient alfcH'tiHl with puerperal fever, felt an nnpleasant seiisi- tion, was taken siek in the evening;, and died on the third day "with all the symptoms of the most eharaeteristie puerperal fevr." The diajj;nosis of |)M( r- peral fever was eontirmed by the autopsy ; she was found also to be a vir^;in and not menstruatiuir. The natural inference is that she inhahnl through the huigs the poison that eaustnl her death, ('reik'-' has shown that puerperal iidectidii in children may start from the mouth. The theory t)f air-infv'ction in a limitinl space is also borne out by the <'l1l(t of sanitary measures. Before the present syst«'m of antiseptic midwifery in the New York Maternity Hospital was practised, patients were always free frmn fever during the first week after a ward had been fumigated with sulpiuir. Jiusch ■" fouuil that he prevented puerperal fever in the Herlin lying-in hos- pital by heating the wards before using them to (10° Reaumur (— 1(. They can always be traced to an individual carrier or to the ncighborhdiHl of a focus from which the di.scase spreads. Att(oiiif wiishin^; tlic )loasiu)t sciisii- ' "with all \\w rnosis of pill r- Ih' a virjiin and t)U^h tilt! 1 lilies •jHTal infcctitiii ho transmission but this api>ru's n jfonoral is imt , do not oxi>t. > noinhborlitinil oOon hiivo Hoxual intoroonrso up to tlio day of thoir oonfnioniont, tlu're is no liirticidty in supposing that fhoy iiavo, at (ho (iino of thoir oonfnioinont, suoh cocoi in tho vagina, and that, in a oortain sonso, tln'V may infoot th«'insolvo«, not oidy with saprophytos, hut also with patho^onic oo(xm. Fnrthornioro, |iiiorporal iiifootion may Ih', duo to disoascHl ntorino appondagos, or since a woman always has innnorous sapro])hytes, and s(»inetimes pathogenic; eoooi, in Ik r vajjina, these orfjanisms may Ix' earried honoo by a perfectly disinfected liiiircr into the uterus and cause infection, which in a certain sonso is also an Mil toinfection. Wo must also remember that few vafjinio are absolutely healthy. It is iii<; staphylococci, and streptococci find a favorable soil, and autoinfection boc(»mes possible. Time of Infection. — Infeetion <'ommonly takes place durinrc the introduction of antiseptic treatment puerperal infection often prevailed in so-oallod "epidemics," of which, accordinj; to Fordyce IJarker,"** iiinre than two hundred had been described since 1740 ; independently of suoh periods of a conj;lomeration of fatalities tho number of those carried olf by the disease was and is very lar^o. Fn the niary 1,000,00().'*2 Injfiioiee of Antisepsin on Mnrta/ifi/. — The above very important and con- villeins'; statistical researches have boon eontinued, and they show an im))rove- iiient, whieh generally is attributed to the oblijiatory use of antisoptit! druf^s in the manajijoment of conlinemont oases. Thus tho puerperal mortality from all ciuises was in Prussia during; the eleven years followinj; 1875 (1S7(J-8G) 0.0833 per cent., an improvement of 27.5 per oont.'^^ Jjimitinj^ the investiga- tion to the child-bearing age (fifteen to forty-five), tho mortality from "puer- peral fever" was in the first period (1816-75) 12.01 per cent., and in the second (1876-8(5) 9.97 per cent., an improvement of 16.9 per cent. Similar investigations in Demnark load almost exactly to tli(> same results, both as to the groat mortality and to tho improvomont since tlu; introduction of antiseptic precautions.^* Still, with the sole exeeption of tuberculosis, "l»uerperal fever" is the most fiital disease for women between fifteen and ■i" ./y the inetlicieni v of the midwives, wiio do as much harm as good by their way of using ann- sepsis.'** I'a I iroi,(MiY. — A peenliar feature of puerperal infeetion is the great diver- sity of the pathological changes — a circumstance that has given rise to nuirh perplexity, hut which can easily he accounted fnr, since it is known that the true agents at W(»rk are living organisujs or a poison prodn<'ed by them. Vulvitis and Vaerinitis. — The external genitals may he the seat of ;i vdtdrrhdl or of a diphihcritii' inflammation. In th<' catarrhal form the mucous UHMuhrane is swollen and red, and it secretes a n»uco-purulent fluid. In the diphtheritic l()rm small whitish or yellowish false mend>raiies appear, spread, and join one another until there is formed a more or less thick ami large patch intiuKitely coiuKvtod with the sm-rouuding tissue, which is sw»»lleii, infiltrattHi with serum, and of a dirty greenish or a brownish color. Endometritis. — The endometrium is the chief point from which iul('<'- tion spreads throughout the body. The endouulrium may be the seat nf a catarrhal inHammation, when it is red, swollen, covered with a purideiit fluid, and sometimes studded with small roimd pustules. The lips of the os are swollen and covered with gramdatious that easily l)le<'d. Other forms nl' endometritis soon implicate the deeper layers of the uterus, and need no speciiil description apart from that to bo given under MvtrUk. Metritis. — INfetritis may assume four (litfereut forms — the .simple, the diph- theritic, the dissecting, and the putrescent. Siuijifc JfttrHiK. — In the simple form the ntorns is much enlarged, its walls are thick, the tissue is soft and friable, and near the inner surface almost dilllii- cnt, cherry-colored, and bathed in a dirty greenish-brown fluid. The cervix is often torn or bruised. Dijihthrrific iiK'frids is characterized bv a condition similar to that just de- scribed in the external genitals. A- ;i rule, the process begins in the cervix. It may, however, begin als(» at the uterine ostium of the tube, and spread through the wall as a yellow layer out to the peritoneal coat of the uterus, Diiisectinf/ nirlrHis (Fig. 41i>) is a form that has been little heeded.* In this form a large piece of the uniscular tissue of the uterus is severed from its surroundings, and is expelled sometimes so long as seven wwks after confmc- ment. Putrescent Mrtritis. — In the putrescent form the walls of the uterus are so *Tlie writer has personally observed and describwl eiglit cases. He lias given the aHiMtimi its name, ami was iliL' first to point out its relation to the puerperal state (AVic York Mt'il'md Jnuniiil, 188'2, vol. xxxvi. p. i)X~ ; Arrhinv iif Mii'ioi' Iimii^s in discolorctl shrctls, or i( is casilv iiioviil)l(' over the subjacent tissue. Tlie submucous eonneetive tissue may Ik; clian^'ed to a wliitisli mass, and tlu^ nuiseiilar tissue may Im! red and llal)l»y ; lull sometimes the (k'struetion extends deep into tlie mus- iidar tissue, forming irre^idar cavities tilled with a choco- l.ite-coh)red or a l)hicl\ pulp, or with a more ichorous or I'lU'idcnt fluid. It is particidarly the phutental site wiiieli i-allected hy this deep lanM'owinj;, the pathojieniv" niierohes lindinj^ a favorahh; soil in th<> thromWi <-losin^ the veins. In oth«'r eases the infection follows tho lymphatic vessels. Salpineritis. — The Fallopian tubes are more rarely llic road followed hy tho infcctinj^ microbes, but we may iiave lioth catarrhal and diphtheritic inflammation ex- lending from the endometrium to this locality. Oophoritis. — The ovaries very frecpiently are affect<'d. We may find u.snperfi(Mal inflammation, the so-calle: connective tissue. Peritonitis. — Peritonitis is the commonest atVection in the graver cases of puerperal infection. The abdomen is swollen, the intestines being distended with gases. The inflammation may be local — that is, limited to the pelvis — m swrs- 696 AMERICAN TEXT- BOOK OF OBSTETRICS. or ho general, exttnuliiig over the whole abdomen; or it may ho adhesive or l)c jmt'ulent. The peritoneum is injected ; its opitlielium is thrown oif', and it i> in places covered with plastic lymph, which binds the knuckles of the intostiiios together or to the other pelvic and alxlominal organs. In the peritoneal cavitv % i Fin. 420.— Lyniplmtics of the ntorus : 1, lymphatics I'nmi the hody and fundus of the uterus; 2, ovnrv; 3, vatfinii ; 1, Kalloiiiaii tube; '>, lymphatics I'roiii the cervix ; li, lymphatic vessels from the cervix Koiiii! til tlie iliac Kaniilia ; ". lyiuphatii' vessels from the hody and fundus Koiiid to the lunitiar KaiiKl'a ; s, aiuis- tonioses of cervical and uterine vessels ; '.i, small lymphatic vessel in the round ligament Roins; to the iMi;iii nal glands ; Kt, 11, lymphatic vessels of the tubes which empty into the large lymphatic vessels from llie body of the titerus; I'J, ovarian lis;unient d'oirier). is found a fluid that may be serous, fibrinous, or jiurulent. Often this fluid very much resembles milk, and contains large clots like curdled milk. The inflammation starts in most cases from the endometrium and spreads through the lymphatics. Pleurisy and Pericarditis. — From the peritoneum the microbes find o:i\- on'r, is rnre. Acutest Septicemia. — In the sevcie ^ .-ases of puerperal infection the ahove-menti»med inflammations hardly find time to develop before tiie patient 698 AMERICAN TEXT-BOOK OF OBSTETRICS. Ufl i| I ' r if m iii succumbs. Still, there are traces of lymphangitis or phlebitis of the uterus, swelling of the connective tissue, and a little blootly fluid in different cavities ; the glandular organs of the abdomen are large, sofl, and friable, the micro- scope showing their cells to be in the condition called " cloudy swelling;" the blood is dark, thin, and only slightly coagulable. SYMPTO>ts, Diagnosis, and Procjnosis. — In treating a case of puerperal infection one would first like to know if he has to deal with pathogenic or with non-pathogenic bacteria. In some particularly well-appointed clinics an expert bacteriologist makes daily microscopical examinations and pure cultures, but most physicians have to form an opinion by the phenomena ob- servetl in the patient herself. In this respect three points are of great import- ance, namely : If the infection is caused by pathogenic microbes, the disease begins earlier, perhaps within a few hours after delivery, and certainly within a few days; the general condition of the patient suffers much more, and sh ' soon becomes somnolent; and, finally, the frequent, weak pulse and the l!it>li temperature bear witness to the presence of higher fever. But even an infec- tion that begins as non-pathogenic, or a condition that originally is not lausod by infection at all — for instance, a marantic thrombosis — may later change in character and end in sepsis. Some groups of cases arc so well marked in many respects that it facilitates the description to point them out. Thus there are localized cases, where the dis- turbances are limited tt) the genital canal and hardly affect the system in genernl. There is a lyiaphatlc form, in which the invasion takes place through tlio lymph-vessels, and which begins early and implicates the serous !i,embrancs, causing j)eritonitis, pleurisy, and pericarditis. There is a phlehiflc form, in which the microbes enter through the thrombi in the uterine sinuses. Tlic latter form begins later, progresses more slowly than the preceding form, and it is characterized by repeated chills and metastases in remote organs. Finally, there are cases of ro])er treatment the patient generally re- covers. Rupture into the peritoneal cavity is fatal, unless laparotomy is per- formed. If cellulitis appears as part of the general infection, the result is very doubtful. Lymphangitis. — livmphangitis may start from the vulva and the lower part of the vagina or from the uterus. Vufvar lipnf)ha)i(jith is of little importance if it is arrested at the superlieial inguinal glands. The patient presents the usiud fever-symjUoms, and rod lines may be seen on the skin extending from the vulva to the groin. Tlio t .3 '■ •Tf" ■ ■ ion beo-ins in tlu> a and tho lower PATHOLOGY OF THE PUFAIPERIUM. 701 labia swell and smart. The glands very rarely snppuratc. If the inflamma- tion implicates the deeper inguinal glands, it may lead to peritonitis. Uterine lymphangitis (Fig. 420) is the most common beginning of general puerperal infection, but it may also continue as a local process. The patient -liows the usual fever-symptoms. The uterus is enlargetl and tender, cspe- rially near the cornua. The pulse is full. There may be a little vomiting and some tympanitis. Diagnosis. — Uterine lymphangitis differs from cellulitis and local perito- nitis in the absence of swelling at the vaginal roof; from general peritonitis ill the limitation to the lower part of the abdomen, the full pulse, and the absence of green vomit. Peritonitis. — On account of the diffp'-enoe in the severity of the symptoms and the prognosis it is expedient to consider local and general peritonitis s('|)arately. Local peritonitis, like tiie other localizations hitherto described, begins with a cliill, but this is much more protracted, lasting from ten to twenty minutes, and it is accompanied or is followed by a peculiarly intense pain in the lower part of the abdomen, which is extremely tender to the touch. The tempera- ture rises suddenly to 103° or 104° F. The pulse beats from 100 to 120 times per minute, and it is small and hard. The respiration is rapid. The t'over is continuous, with an exacerbation toward night. The patier.t has no appetite, but has an umiuenchable thirst. The tongue is coated. The bowels, at first constipated, later become loose. There is usually some vomiting of food, nniciis, and bile, and sometimes moderate hiccough. Tiie lower half of the abdomen is distended, and in order to lessen the tension the patient lies on licr back and draws up her knees. The secretion of milk is normal or is <('ant. The lochial discharge is diminished, is of a dirty color, and often is of utVensive odor. In the coui-se of a week or two a distinct tumor is felt in the pelvis and the lower part of the abdomen, which tumor is composed of the uterus, the append- ages, the intestine, the omentum, — all mattetl together with exudation and new- t( iined adhesioi.s. Below, the exudation is usually situated in Douglas's jwuch, jMisliing the uterus forward, but it may also be plai'tnl more laterally, pressing the uterus over to the other side, and at the same time canting it forward. The I'xndation pushes the fornix of the vagina in front of it, so that the cervix seems to disappear, and together with the corpus uteri it forms a pear-shaped body, witliout distinction between the two. The abdominal siu'tiice of the swelling is iMU'ven, and it offers a different degree of resistance in different parts. Often a peculiar sensation, much like that experienced in pressing a snowball, is felt on slight pressure, due to fresh adhesions being torn, as can be inferred from what we find in laparotomies performed after this crepitation has been i\'h. The swelling usually ends in resolution in the course of two or three weeks. Pain, fever, and swelling subside and the patient gradually regains her health. But the swelling may end also in suppuration, in which event ^if' -.^i; *' :'»■ 702 AJflJIilCAiY TEXT-BOOK OF OBSTETRTCS. W. the fever increases; tlu- patient lias repeated chills; the swelling softens and b(Hx)nies boggy, and sometimes fluctuating. If the alxscess tends toward the vagina, fluctuation may here be felt. If it progresses to the bladder, tlic patient feels a frequent desire to emjity this organ, and the act of niicturifiou is more or less painful. If the rectum is being imjjlicated, the patient com- plains of tenesmus. Wherever the abscess breaks a large amount of offensive pus, mixed with grumous masses, is evacuated. The most common, and at the same time the most fortunate, place of evacuation is through the vagina. In some cases after breaking the abscess may close at once, but in other cases, especially if there is a communication with the rectum, it may refill, or, if the pus is found in separate foci, the ]>rocess of elimination may be very protraetetl and exhaust the patient's strength. The pus may also follow tiw; vagina downward and oi)en in the ischio-rectal fossa. Enteritis, cystitis, or pyelo-nephritis may develop. PrngnoHis. — As a rule, local peritonitis ends in recovery, but it may become general and speetlily end the patient's life, or it may take so pro- traetevi ino tlcation should be guard k1. Peritonitis leaves a ]>redis- positioii to new attacks. It often causes chronic oophoritis and salpingitis, makin*;" the patient more or less an invalid, and it is a frequent cause of sterility ; or, if she again conceives, she is more apt to have trouble in subse- quent confinements. General periton if is has symptoms similar to those of local peritonitis, but nuu'h intensified. It appears, as a ride, from two to four days after delivery, but it may also begin immediately after parturition. The chill lasts from half an hour to several hours. The pain is excruciating, and it sjireads over the entire abdomen. The pulse beats from 120 to 160 per minute. The temperature is 104° F. or higher. The respiration ranges from 26 to 56 per minute, and it is shallow on account of the pain produced by the movements of the diaphragm and on account of the compression of the lungs by the inflated intestine. The patient lies on her back, with the knees drawn up. Siie shuns every movement and dreads every approach. Even the weight of the bed- clothes may be intolerable. Her face expresses tiie greatest anxiety and pain. Her features are pinched, the corners of her mouth drawn down ; the eyes sink deep into their sockets, a black streak showing under each lower lid. The skin is ])ale ; the tongue is dry, red at the point and the edges, and brown in the middle. The thirst is Jinquenchable. The patient vomits continuously, and the vomit soon has the peculiar appearance of chopped spinach. Com- monly the patient has diarrhea, and is often racketl by hiccoughs. The urine, which is scant and often contains albumin, must frequently Ih' drawn with a catheter. The milk-secretion soon ceases. The lochia are scant, often fetid, or disappear altogether. The abdomen is enormously di>^- tended ; the percussion sound is tympanitic in front, dull at the dependent parts ; and the pectoral organs are |iMs!ied up and compressed. The patient often suffers from insomnia, and at the same time, as a rule, PATHOLOGY OF THE PUEllPERIVM. 703 g softens and s toward the hUuWor, the )t' micturitiim patient coin- it of offensive iiinion, and at srh the vagina. in other eases. may refill, or, 1 may be very ilso follow the tis, cystitis, or y, but it may ,y take so pro- )lete restoration leaves a preitant rales, bronchial respiration, and dull or flat j)ercussion-sound. l*rof/nnsiK. — Pneumonia is a dangerous affection in a puerpera. Pericarditis. — Pericarditis may be pro]>agated through the lymph-vessels of the diaphragm from peritonitis, or may be due to emboli from a venous thrombus. Tlie Kj/mpfoms generally become merged into those of other inflammations. Siiinetime,s, however, a friction-sound or an increased dull area reveals the presence of false membranes cm* of exudation aroinid the heart. Phlegmasia Alba Dolens. — Tlie thromho-ph/chitic form of phlegmasia may begin during ]>regnancy, and is accomjianied by fever and a sensation of heaviness in the limb. Commonly the inflanunation begins in the .second week after confinement. Sometimes the local affection is preceded by anorexia, a l>a(l taste, a coated tongue, constipation, and eructations. The phlegmasia begins with fever and, perhaps, a chill. The urine is concentrated. If the 704 AMERICAN TEXT- HOOK OF OBSTETUICS. fi li. !, thrombosis begins in tlie leg, tlie latter swells from the foot upward ; but if the leg is seeondarily att'ected after tlie pelvic veins, the swelling spreads in tli(! opposite direction. The extremity is painful ; the skin is white, tense, hard, sometimes covered with blisters, or it may become red and be perforated l)v an abscess. The Jift'ecttHl veins may be felt as hard strings. Both extremities may be atl'ecteil, the thrombosis passing from one side to the other through the vena cava, or beginning independently in cither extremity. The phlegmasia usually runs its course in from three to six weeks, and ends in resolution. It may pass into suppuration and the patient still ret^over. Sometimes gan- grene sets in anil leads to death, or sejjtici'mia may develop. Varicose veins are more lial)le to the formation of thrombi than healtiiv veins. If the deeper veins are affected, the skin luis a peculiar purple color, which variety has been distinguished under the name of phlegnmsia ccemlva dolena. As a rule, the thrombus is reabsorbed, and the swelling subsides. In other cases there ibrms a periphlebitic al)scess that breaks on the skin ; and in still others the thrombus may become infectetl and give rise to metastases just like those which will ]>resently be described under Uterine Phlebitis. The celluUtiG form of phlegmasia is characterized by high fever, by con- siderable pain, by redness of the skin, by the appearance of bullae, and by extensive suppuration and mortification of the subcutaneous and intranuis- cular connective tissue. Large shreds of connot'Jve tissue may be expelled and the sores heal, but there is great danger of the patient falling a ])rev to gangrene or to septicemia, or of being exhausted by the protracttnl suppuration. Uterine Phlebitis. — The veins of the uterus may be blocked by simple thrombosis, which may extend more or less into the pelvis. If the iliac vein becomes implicated, j)hlegmasia alba dolens supervenes. If pathogenic microbes find their way into the uterine simises, there develops infectious uterine phlebitis — one of the severest forms of puerperal infection. Uterine phlebitis begins with a long and severe chill, followed by similar attacks at irregular intervals, and it is characterized by metastases in one or more organs. The chills are due to the entrance into the blood of microbes or of their chemical products. During the chills the temperature rises to from 104° to 108° F., the pulse beats from 140 to 160 per minute, the res- piration becomes as frcfpient as from 36 to o6. Rarely the patient, instead of real chills, has oidy chilly sensations. In the interval between the chills, especially after the first chill, she feels great relief, the temperature sinking to 100° or 101° F., and the pulse and respiration betHMuing less frequent, in this form of puerperal infection there is no pain, little tenderness, and no tympanitis. After the lull of the first interval new chills follow, and the more meta- stases are developed the more the fever becomes contiimous. The skin turns yellowish, and sometimes complete jaundice develops. The nose becomes pinched; the eyes lie deep ; the cheeks are hollow; the tongue is dry and coated. The patient has no appetite, but has great thirst, headache, insonmia, PATIlOlJHi V OF THE PI ERPERIL'M. 705 ard ; but it' jreuilrt ill th(i tense, hanl, ortbratal l)y li extremities [•through the c phlegmasia in resohitiuu. iiuetimes gau- than heaUliy r purple color, rnuisJrt ccendca subsides. In c skin ; and in metastases just bit'iH. lever, by con- l)»dl«, and by and intramus- lay be expelled foiling a prey the protracted ,ekeiting. Frequently the breath has ;i peculiarly disagreeable smell, designated as "sweet." The urine is scant, iiiul it almost always contains albumin. The secondary infection appears first in the lungs, then in the pleura, tlie heart, the liver, the kidneys, the spleen, the intestine, the meninges, the brain, the eyes, the articulations, the skin, and the connective tissue. Pneu- monia, pleui Isy, and pericarditis have already been describetl, and the other !(l(•alizatitnl^ will presently be noticetl. J)i(i(/nosL'i. — Uterine phlebitis in the beginning is somewhat like malarial J'cvcr, but the chills are repeatetl at irregular intervals and the fever soon becomes continuous. Swollen veins may be felt in the pelvis, and phlegma- sia alba dolens may supervene. There is often metrorrliagia. The appearance of metastases is characteristic. If adynamic and ataxic symptoms develop, the disease may be mistaken for fiiphoid fever. First of all, we must know if the patient is or is not a piu'i'pera. If she denies having recently given birth to a child, it can easily be proved by the presence of milk in the breasts, by the flaccidity of the abdominal wall and the presence on it of purple-colored strioe, by the large size of the uterus, by tears in the cervix, in the vagina, or in the vulva, and l»y the presence of lochia. Typhoid fever may develop in the puerperal state, but that is a very rare occurrence. It is ciiaracterized by the continuous fever, by ochre-eolortnl stools, by tenderness on pressure in the right iliac fossa, and by the appear- ance of a few discrete, small pink spots on the abdomen. Visceral complica- tions are rare, and at the end of the third week a decided change takes place for the better or the worse. In uterine phlebitis there may be gargouillement, but no tenderness, in the right iliac fossa. There may be cutaneous eruptions, but they are spread over larger surfaces as erysipelas, general erythema, large blotches, papules, or pctc'chite. There is no regular fever- curve. The disease begins with very high temperature and a pronounced chill. The temperature then falls sud- denly nearly to normal, to rise again with the next chill. Complications in ditterent organs are a chief feature of the disease. The distinction between iiter'nia lipnphauf/itis and phlebitis is more of scien- tific than of ])ractical interest, and frequently the two are combined. Lym- phangitis usually begins from two to five days after delivery ; phlebitis usually begins at the end of the first week. In lynqihangitis there is pain in the lower ]>art of the abdomen ; in phlebitis there is hardly any pain. In lym- phangitis there is great tenderness on pressure ; in phlebitis there is none of the abdomen and little in the pelvis. In lymphangitis the uterus is large ; phlebitis has less influence on the involution. Ijymphangitis spreads rapidly upward, and may cause peritonitis, pericarditis, pleurisy, hypostatic pneumo- nia, but it does not affect the head or the limbs nor cause pyemia with infarc- tion and abscesses in the viscera. Lymphangitis may begin with a chill, but this is not so severe as in phlebitis, and it is not repeated. In lymphangitis 45 U.'!, 1 i' TOO AMKIiJVAX TEXT-BOOK OF OBSTETRfCS. 'm l;i I; »» I , 'il tlio fever is more coiitinuoiis; in phlelntis there are very niarketl fever intcr- luissions or r('inis.si()iis. Endocarditis. — Eiulooarditis appears late in the piiorperiuin — from ten u> fifteen days after delivery. It is ac(;ompanie(l by an inerease in fever ainl somnolence, and jjives rise to a rasping sound, especially at the apex, more rarely at the base. This nun'inur is jjenerally synch rolious with the fii>t heart-sound, but it may also be heard with the second. It shows a peculiiir mobility, beiiifj heard one day at the apex, the next at the base, or vice irrmi. Endocarditis iscommoidy ulcerons. When the small abscesses in the cndo- cardinm break, they empty their contents — pus, microbes, and their cheniicil products — into the blood-current, which carries them throuj^h the entiic system, causing new localizations of the infection ; but the symptoms of (licsc abscesses are so merged into those already |)resent that they camiot be distin- guished. The supervention of endocanlitis in uterine phlebitis makes the pro(/)wsix still more unfavorable. The (dlmentdrij cantil does not suffer much in uterine ]>hlebitis. We have, however, mentioned the complete anorexia, the unquenchable thirst, the pro- fuse diarrhea, and the occasional vcmiting. Sometimes thrush appears on tlie dry tongue. In rare cases abscesses are formed in the parotid, the tonsil, or the thyroid body, the appearance of which abscesses makes the prognosis more unfavorable. Hepatitis. — The liver is very frequently implicated in puerperal metro- phlebitis. There is pain in the right hypochondriura. The organ is eidargcd, as can be found by percussion and ]>alpation, and it is tender on pressure. The skin has a yellow tint, and often real jaundice develops. The serous coat is often implicated in peritonitis, and then sometimes, on slight pressure, tliero can be felt the crepitation characteristic of new-formed adhesions. Nephritis. — Intlamination of the kidneys, which is a very frequent occin-- rence, is characteri/ed by the presence of albumin and casts in the tu-itie, whereas the other symj)toms, such as headache, somnolence, disturbed eye- sight, vomiting, and ])ain in the lumbar region, are so covered by the general condition that they lose their diagnostic importance. An inflammation of tlip loose coimective tissue in which the kidtiey is imbedded may cause constant tenderness on ]>ressure in the lumbar region. Splenitis. — An inflammation of the sj)leen may sometimes be diagnosti- cated by palpation and an increase in the normal dull area in the left liypo- chondrium. The patient may com])lain of pain and tenderness in this locality. If an abscess ruptures into the peritoneal cavity, she collapses and dies. Generally the symptoms due to localization in the spleen are, however, so blended with those due to other localizations and the general condition that they are not recognizable. Nervous Disturbances. — Manifold distiu'bances occur in the nervous system during the puerperal state, such as neuralgia, paralysis, convulsions, tetanus, tetany, insomnia, delirium, etc., and need not be due to infection, but to anemia or hyperemia of the brain, hysteria, pressure on a nerve-trunk, or a nrn, /'AT/lO/J)(,'y or Till': PVEItPKHltM. 707 li ii-^ I fever intci- — from ton tn in fovcr iiixl nc aiH>x, move with the tiiM ,()ws a pcculiiir ? or t'KV cccs". ort in the ciulu- tlioir ehcmitiil ujvli the entire iptoms of these uuiot he (hstin- Ditis makes the hitis. We have, ; thirst, the i)ro- \\ appears on tlie id, the tonsil, or es the prognosis puerperal nietro- DVgan is enlar>r;e»l, uler on pressure. The serous ooat it pressure, there ions. k- frequent oecnr- ists in the urine, :e, disturbed eye- •ed by the general flammation of the lay cause constant ,iics be diagnosti- in the left hype- .ss in this loeulity. Dllapses and dies. are, however, so L-al condition tbut Ir in the nervous Ilvsii*, convulsions, |,e to infection, but , nerve-trunk, or a reflex action. Severe affcH'tions of the nervous svsteni niav be due. however. » • 7 / to tlirond)osis of the cerebral veins or to purulent meningitis, produced l)y metastasis from an infected endometrium. Arthritis. — Sometin.es the infecting agents in metro-phlebitis are carried lo the joints. At the beginning nuuiy articulations may be allectod, but wliilp I lie inflammation subsides in most of them, it may remain in one or two, i'-|)e('ially tlioise of the knee and shoulder. Of the articidations of the trunk, the symphysis pubis, the sacro-iliac, and the .steru»)-clavicidar are most fre- quently affected. Puerperal articidar inflammation differs from rheumatic inflammation by its .stability, and from both this and the gonorrheal type by its pronounced tendency to suppuration. The aflected joints become ])ainful, the j)ain being ninch increa.sed by movements or by pressure. The skin becomes red and hot, and if there is an abscess in the artietdation, the joint may i)e perforated. All tlic tissues composing tlie joint, even the cartilage and bone, may be destroyed. If the patient survives, the afTected joint may remain ankylosed. Abscess and DiflFuse Cellulitis of the Limbs. — lioth the subcutaneous and the intenuuscular connective tisstie may become the seat of localization of puerperal infection. The lind) swells and is painfid. The skin be<;omes nnl and hot. Cireinuscribed ab.scesses may form, or, especially in the sid)fascial form, a diffuse phlegmon may extend over a large area — a form which is very tiangerous, and which may cost the patient her life or it may leave her in a crippled condition. Skin Diseases. — A puerpera may, as well as another per.son, be attacked l)y eruptive fevers, such as measles, .scarlet fever, small-pox, or erysipelas, as an accidental complication. She may likewise have .some kind of eruj)tion in consequence of the use of certain drugs — for example, copaiva, quiniu salicylic acid, or iodoform. A milUwy eruption, consisting of small white vesicles, sometimes each sur- rounded by a red ring or springing front a red skin, is often found in an otherwise well woman, and is only due to increased perspiration. This eru])- tion is generally found on the trunk. Sometimes an eruption of red macula) or papuhe, or a general erythema, accompanied by more or ''■>■ s 'ever, appears on the skin in pue-pera? who present no other sign of disea.se. Ihit in othe»' cases the skin-eruption accompanies other symptoms of severe puerperal infection, and it must then be regarded as ])art of the infection. An erythema may spread more or less far from the genitals, or large erythema- tous blotches may apjiear on any part of the body. Small dark hyperemic spots of the size of a hempseed — so-called "petechite" — that do not vanish on jtressure, may appear in very severe, generally fatal, ca.ses. Sometimes there is a pemphigu.s-like eruption, the epidermis being rai.sed by a serous exudation, forming large vesicles. In other cases, again, bullte fillet! with pus develop, rupture, and leave sores. Finally, infected puerperre are very liable to have bed-sores, especially on the sacrum and the heels. In all those cutaneous aflections that appear as 7(W AMinni'AX riLXT-nnoK of oiisTirntics. part ul" a griiiTal iiil'wtit»ii the syiuptorns <(t' the latter cover thoae (»1' tin Ibrmcr. Acutest Septicemia. — Tlii.s form, the iiutst (laiij^erourt of all forms ul Ijiierperal infection, lias, fortunately, become very rare, and lias entirely (li>. appeared from well-conducted lyiiifj-in hospitals, institutions where it formerly raged in the so-called ''epidemics" of puerperal Jvrcr. It l)e'l i>onil phlebitis I'Orf are {)ii»el>iy nd mortality fn"" [rid of mercury, it lia^s, however, been proved that tlic true <'anso of the improved result-; i:« not 1) be .sought in the drug, but in its application ; that is, the xtfift disinf«>etion i)f hands, instruments, dressing-material, etc. Some large clinics, such as those of Copenhagen and \'icuna, yet cling to the use of carbolic acid,'*^ and obtain just as goo«l results as tluwe in which this drug has been supplanted by liiehlorid of nwreury. If ever a medical fact has been proved by figures, the latter have proved ti»e value of the antiseptic trciUment in midwifery. The testimony from over the entire world, inde|)endently of geographical position or climatic ditt'erenccs, is unanimous. Counting by thousands, hundreds of thousands, and millions, the liiiures are too large to be vitiated, the new treatment l)eing now in the elev- enth year of its probation. It would be tiresome and unprofitable to enter deeply into statistics, but the writer can hardly begin the discussion of the treatment of puerperal in- t'retious diseases in a better way than by showing, in a few lines, what the mortality formerly was and what it now is in the institution to which he iiail the honor of being a visiting obistetric surgeon for a period of over ten years (1881-02), and with which he is yet connected as consulting obstetric surgeon. The records of the New York Maternity Hospital .show the following mortality before and after the introduction of strict antiseptic treatment with bichlorid of mercury : Year. Dt'UviTli's. Deaths. I'cr t'lMil. IST.'i 570 5S6 480 255 254 149 ,S82 431 447 15 20 32 7 11 8 9 14 30* 2fi3 1876 1S77 3.73 6.67 2 75 1878 1870 4.33 1880 1881 5.37 2 3(5 1882 1883 3.25 6.71 Total 3504 14G 4.17 * All during the first nine months of the year. During the last six months before the change in treatment was made there wore delivered 237 women, nineteen of whom, or 8 per cent., die 1.12 1.30 0.79 0.32 1.13 0.42 0.32 O.OG 0.87 From St-psis. 1884 522 537 44ti 389 377 314 345 240 314 305 3789 8 3 5 5 3 1 4 1 1 2 33 4 1 1 1 0.70 1885 0.0 188() 0.22 1887 1888 ... 1889 0.2(j 0.0 0.0 1890 18 same bed never being used by more than one and the same patient before liciug throughly disinfected. On the ninth day the patient is transterred to the convalescent ward, where she .stays until well enough to leave the hospital. Pregnant women ought to be kept in special waiting wards apart from partu- rient and puerperal patients. The former often stay for months in the Maternity lli.spital, and it is more difiicult to keep discipline among them. Pregnant women need other food and regimen ; they are less clean and less (piiet ; they would be exposed to mniecessary anxiety by witnessing the suHerings of the ]>artin"ient or sick puerperal women ; and they might, perhaps, even become iiifccteil before their delivery. The parturient woman ought to be delivered in a spe(;ial delivery-room, a so-called " j)ony-room." * As the infection most tmpieutly takes place dur- ing parturition, the woman shoidd be delivereliverv-room and the wards, so that patients need not be carried far or be expo.sed to inclement weather; yet there shonhl be no direct eomnnmication. In the Maternity Hospital this condition is obtained by having small covere to ventilation, and offer an easy way of disposing of small unclean substances, which otherwise mav accumulate and vitiate the air in tlr a1. Stoves com- bine to some extent the (pialities of a radiator and an op. ii flrc, and they are more economical. IJy the evaporation of water the air should be prevent(>(l from becoming too dry. The isolating department should be separated entirely from the eomtnoii wards, and each patient should exclusively cMxnipy a room. This departnunt should have a special doctor and special mirses, who are not allowed to enter the wards. The physician-in-chief alone shotdd see the whole service. Water-closets should be of the very best kind, and never be situated in the wards or in the rooms. They should not even comnHuiicate directly witii the wards or the rooms, but should hv separated from them by vestibules with two doors. In the space between the doors a window should constantly Ix' open, and tlie doors should close automatically, There shoidd be a place where all linen and bed-clothes used by sick puerperse can be disinfected by immersion for an hour in bichlorid solution (1 : 1000) before they are washed ; if mattresses are used, there should be a room where they, as well as the blankets, can be fumigated with sulphurous acid by burning sidphur or be disinfected in' exjxtsure to sujx'rheated stcaii). No visitors should be admitted to the wards, as they often come fnnii crowded tenement-houses in which there \\\i\\ be cases of measles, scarlet f'cvd', small-j)ox, or diphtheria. The members of the house-staff shoidd not be allowed to enter the wards occupied by otlier patients, the isolating-rooms, the dead-house, and still Ic^s be permitted to make autopsies or to handle anatomical or pathological specimens. DlsiXKrxTlON. — To niake the all-important point, disinfection, as clear as possible, the writer will first simply describe how it is carried out in the Ma- ternity Hospital, and postjione for the time being all the mooted points that are being discussed in tlie medical journals. The principle upon which the disinfection is based is the belief that puer- peral infection is due to bacteria foinid on the patient, on doctors and muses. on all surrounding objects, on everything brought in contact with the genitals, and in the air of the room. We will, therefore, have to consider the disiiil'ic- tion of the wartl with its furniture, of the patient and of those who minister iiiiJ IMP' PATIIOUXIV OF THE Pf!i:iil'i:iiJ(M. 71;^ to hor, of all instruments and materials that come in contact with her, and of the air that reaches her genitals. Ward Dmufccfiou. — When the last patient has been nine days in a ward it is not used again until thoroughly disinfected. The bed-clothes are taken oil" the beds, the linens are sent to the laundry, and the blankets are s[)read nver the ends of the bedsteads. All windows and doors are closed. Thirty jxHuids of sulphur are placed in an iron utensil composed of an upper and lower pan connected by three uprights. The sulphur is ])ut in the upper pan and is moistened with alcohol. The lower pan is filled with water, which would cxtitiguish the fire in case the upper pan was burnt through. After lighting the alcohol the ward is left closed for at least six hours. Afler that time all doors and windows are opened, and, if the ward is not needed immediately, they are left open for several days. The walls, the floors, and the furniture are scrubbed with soap and water, and thereafter with a solution of bichlorid ol" mercury (1 : 1000). So long as straw mattresses were used the straw was burned ; the patients now lie on woollen blankets spnuid over a woven-wire mattress. All iKHl-clothcs used by sick puerpene an; first immersed for an hour in the solution of bichlorid of mercury, and are then preliminarily washed before sending them to the hospital laundry, where they are mixed witii the other iMMl-linen. Patients and nurses wear only such clothes as can be washed. The clothing of the doctors, when required to be disinfected, is suspended ill a small room and fumigated with sidphur. Dwnfcsthif/ the Patient. — When a patient is taken in labor she is given a lull bath of tepid water, being thoroughly scrubbed witii soap, and dressed ii! clean clothes. She is next place/'/can/.s are used. Tlie creolin aatient being infected by the doctor or the nurse in private practice than in a well-appointed lying-in asylum. The young men composing the house-staff of a Iving-in asvlum are strictlv forbiilden to enter the wards ,'; fli !?;:■ '.1 I ' /"" ■■! 718 AMFJilVA.y TKXT-nOOK OF OliSTETlilCii. mi of a hospital ; tlicy lia^'c no ])rivat(' practicT ; tliov do not .see an antojisy ; and if, nnt'ortunatcly, the asylum is a dt'|)iirtnK'nt of a jfcni'ral hospital, the elothcs and the bodios of tiie nurses before goinj; from one ilepartnient to another arc subjected to thorough disinfection under the supervision of their superiors. In private practice, on the contrary, the physician nuiy have treated a case of diphtheria or of erysipelas a n\oinent before being called to a continenient ; and nearly all private inirses take prouiiscnonsly medical, surgical, and obstet- rical cases, disinfecting themselves as best they know how or according as (he combat between innate laziness and acquired conscientiousness ])rompts them. As a matter of fact, the mortality in ])rivate |)raetice is twice as large as that in hospital |)ractice, or larger. Out of cvcri/ hiimlird, viiivti/-Jin', or crrn ei(//iti/-iii)U' ii'oincn (Itlirtird i>i \cw York or other hirr/e ciflcs in j>rivatc })raf- ticc, one tliea; that is, up to 1.12 per cent, against O.G, O.o, or even 0.4 per cent, in the best lying-in establishments. Country practitioners are still greater opponents of antiseptic midwiferv than their jjrofessional brethren in the cities, the country practitioner relying on the purity of the atmosphere in which he works and on the robust constitu- tions of his patients. If, however, these conditions niay help the women to get well, they cannot to any great extent prevent thenj from being taken ill. In many respects country |>ractice exposes the patient even more to infection than does city life. In most places there is no drainage. Manure is spread over the fieltls or the garden close to the house in which live the fanner and his wife. The village butcher kills his cattle, lets the blood soak into the ground, and nails the skins to the barn-doors, whence their odor can be smelt far awav. The country practitioner cannot go home and change clothes and bathe : lie must make his round or he would never get through with his work ; and thus it happens that the same hand that was thrust into a ju'rineal abscess, that per- formed tracheotomy on a child sutl'ering from diphtheria, or that dressed a patient attacked by bullous erysipelas, at the next house is brought up to the fundus of the uterus in order to take away an adherent placenta. The same antiseptic precautions that have revolutionized lying-in asylums should be used as well in ])rivatc practice, be it in the city or in the coimtry. On October 27, 1892, the Obstetric Section of the New York Academy of Medicine unanimously passed the following resolution : " W/inrcui, Experience both in this country and abroad shows that by strict antisej)tic measures the total mortality in lying-in hosj)itals may be reduced to a few per thousand ; " ]yhere<(s, Deaths due to childbirth or to abortion are yet common in private practice ; " Bemlred, That in the opinion of the Obstetric Section of the New York Academy of Mwlicinc it is the duty of every physician practising niidwitcry to surround such cases in private practice with the same safeguards that :ire being used in hospitals." In practice in well-to-do families we should choose a large, airy, sunny room, situated as far as possible from the water-closet. Should, howevtr, \^ PATlIOIAUiV OF THE VVKUPElilVM. 719 finion in private tlio lyiiig-in room bo close to the watc'r-(!lo.st't with a door leading direc-tly from the one totiie otiier, this door shoidd he locked, and some of Piatt's chlo- lid or other powerful disinfectant should be poured frequently into the basin. Instead of lint, the writer uses for the pad in private practice absorbent cittton, and instead of oiled iiuislin he uses gutta-perclia tissue. The pad is not changed in tiie middle of the night. The patient is directed to have two liasins, two pitchers, and a Ibuntain syring(!, which articles are personally cleanseil by the writer before bringing them intt) use. In the dwellings of the poor tiie antiseptic precautions may bo nnich sim- pliHcd and yet be (juite elective. Tiic perineal pad may be made of common <()tton batting, and the gutta-j)ercha tissue may be disj)enscd with. A tin basin may be nswl instead of a bed-pan. Tiie do(!tor can easily carry in his satchel some tablets of corrosive; sid)limate and a couple of ounces of creolin, and thus be prepared to disinfect himself and his patient at slight expensr to give her a chance to throw off the poison that already has entered her tissuos or that circulates in her blood. Stimulants are therefore usc