HI H ■Hf HH V V v ^ ^ - o ~N ■^«s w > ■** '% tl A TREATISE THE SCIENCE AND PRACTICE OF MIDWIFERY. / BY W. S. PLAYFAIR, M.D., F.R.C.P., PHrsiCIAN-AOCOUCHEUR TO H. I AND R. H. THE DUCHESS OF EDINBURGH ; PROFESSOR OF OBSTETRIC MEDICINE IN KING'S COLLEGE ; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO KING'S COLLEGE HOSPITAL ; CONSULTING PHYSICIAN TO THE EVELINA HOSPITAL FOR CHILDREN J EXAMINER IN MIDWIFERY TO THE UNIVERSITY OF LONDON J LATE EXAMINER IN M ID WIFERY TO THE ROYAL COLLEGE OF PHYSICIANS J AND VICE-PRESIDENT OF THE OBSTETRICAL SOCIETY OF LONDON. WITH NOTES AND ADDITIONS BY EOBEET P. HARRIS, M.D. SECOND AMERICAN FROM THE SECOND AND REVISED LONDON EDITION. WITH TWO PLATES AND ONE HUNDRED AND EIGHTY-TWO ILLUSTRATIONS. PHILADELPHIA: H E K" E Y C LEA 1878. S2A no. Entered according to Act of Congress, in the year 1878, by HENRY C. LEA, in the Office of the Librarian of Congress, at Washington. COLLINS, PRINTER. TO T. GAILLARD THOMAS, M.D., PROFESSOR OF OBSTETRICS IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. Dear Dr. Thomas : I am desirous of marking my gratitude for the kind reception of my book in America, where so much valuable obstetric work has been done, by associating with the Second Edition the name of one whose many important contributions to the branch of Medicine of which it treats have gained for him so great and so well-deserved a reputation. I could wish that it were more worthy of the honor you do me in allowing me to dedicate it to you ; but, such as it is, I beg you to accept it as a mark of the high esteem in which you, as well as your fellow laborers in obstetric science, are held in the mother country. I am, very faithfully yours, W. S. PL A YF AIR. 31 George Street, Hanover Square, 1878. AMERICAN PUBLISHER'S NOTICE. In reprinting this work from the second London edition, the position which it has assumed in this country as an authoritative text-book seemed to call for such additions as would render it more completely suited to the wants of the American student. A careful scrutiny on the part of the Editor has shown that but little was required for this purpose ; the work, though condensed, being very complete and accurate. With the exception of numerous short foot-notes, therefore, his additions have been confined to points in which the experience and practice of American obstetricians differ from those of England, and to one or two matters of recent interest. These are chiefly the Cesarean Section; the varieties of forceps, and their use in the dorsal decubitus ; dystocia from tetanoid uterine constriction ; and the intra- venous injection of milk, as a substitute for the transfusion of blood. All additions will be found distin- guished from the text by inclosure in brackets [ — ]. Philadelphia, September, 1878. PREFACE TO THE SECOND EDITION. In presenting a Second Edition the Author has very gratefully to acknowledge the favorable reception which has been accorded by the Profession to his work, as indicated by the rapid exhaustion of an unusually large impression. He trusts that the revision to which the book has been subjected may render it still more worthy of being used as a guide in the study of the important and responsible branch of medicine of which it treats. He has again to tender his cordial thanks to his colleague, Dr. Hayes, for the trouble he has taken in assisting him in passing it through the press. 31 George Street, Hanover Square, March, 1878. PREFACE TO THE FIRST EDITION Those who "have studied the progress of Midwifery know that there is no department of medicine in which more has been done of late years, and none in which modern views of practice differ more widely from those prevalent only a short time ago. The Author's object has been to place in the hands of his readers an epitome of the science and practice of midwifery which embodies all recent advances. He is aware that on certain important points he has recommended practice which not long ago would have been considered heterodox in the extreme, and which, even now, will not meet with general approval. He has, however, the satisfaction of knowing 1 that he has onlv done so after verv deliberate reflection, and with the profound conviction that such changes are right, and that they will stand the test of experience. He has endeavored to dwell especially on the practical part of the subject, so as to make the work a useful guide in this most anxious and responsible branch of the profession. It is admitted by all, that emergencies and difficulties arise more often in this than in any other branch of practice ; and there is no part of the practitioner's work which requires more thorough knowledge or greater experience. It is, moreover, a lamentable fact that students generally leave their schools more ignorant of obstetrics than any other subject, So long- as the absurd regulations exist, which oblige the lecturer on mid- wifery to attempt the impossible task of teaching obstetrics in a short three months' course — an absurdity which has over and over again been pointed out — such must of necessity be the case. This must be the Author's excuse for dwelling on many topics at greater X PREFACE TO THE FIRST EDITION. length than some will doubtless think their importance merits since he desires to place in the hands of his students a work which may in some measure supply the inevitable defects of his lectures. Many of the illustrations are copied from previous authors, while some are original. The following quotation from the preface to Tyler Smith's " Manual of Obstetrics" will explain why the source of the copied woodcuts has not been in each instance acknowledged : " When I began to publish, I determined to give the authority for every woodcut copied from other works; I soon found, however, that obstetric authors of all countries, from the time of Mauri- ceau downwards, had copied each other so freely without acknowl- edgment as to render it difficult or impossible to trace the originals." The Author has to express his acknowledgments to many friends for their kind assistance by the loan of illustrations and otherwise, and more especially to his colleague, Dr. Hayes, for his valuable aid in passing the work through the press. 31 George Street, Hanover Square, March, 1876. CONTENTS PART I. ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED IN PARTURITION. CHAPTER I. THE BOXY PELVIS. PArJE Its importance — Formation of Pelvis — The os innominatum : its three divisions — Separation between the True and False Pelvis — the Sacrum and Coccyx — Me- chanical relations of the Sacrum — Pelvic articulations and ligaments — Move- ments of the Pelvic joints — The Pelvis as a whole — Differences in the two sexes — Measurements of the Pelvis — Its diameters, planes, and axes — Development of the Pelvis — Soft parts in connection with the Pelvis 25 CHAPTER II. THE FEMALE GENERATIVE ORGANS. Division according to Function : 1. External or Copulative ; 2. Internal or Form- ative Organs — Mons Veneris — Labia majora and minora — The Clitoris — The vestibule and orifice of Urethra — Passing of the female catheter — Orifice of Vagina — The Hymen — The glands of the Vulva — The Perineum — The Vagina — The Uterus ; its position and anatomy — The ligaments of the Uterus — The Parovarium — The Fallopian Tubes — The Ovaries — The Graafian Follicles, and the Ova 41 CHAPTER III. OVULATION AND MENSTRUATION. Functions of the Ovary — Changes in the Graafian Follicle: 1. Maturation; 2. Escape of the Ovum — Formation of the Corpus Luteum — Quality and source of the Menstrual blood — Theory of Menstruation — Purpose of the Menstrual loss — Vicarious Menstruation — Cessation of Menstruation 71 Xll CONTENTS. PAET II. PREGNANCY. CHAPTER I. CONCEPTION AND GENERATION. PAGE The Semen — Site and mode of Impregnation — Changes in the Ovum — Cleavage of the Yelk — The Decidua and its formation — Formation of the Amnion— The Umbilical Vesicle and Allantois — The Liquor Amnii and its uses — The Chorion — The Placenta : its formation, anatomy, and functions . . . . .84 CHAPTER II. THE ANATOMY AND PHYSIOLOGY OF THE FOETUS. Appearance of the Foetus at various stages of development — Anatomy of the Foetal Head — The Sutures and Fontanelles — Influence of Sex and Race on the Foetal Head — Position of the Foetus in utero — Functions of the Foetus — The Foetal Circulation 107 CHAPTER III. PREGNANCY. Changes in the form and dimensions of the Uterus — Changes in the Cervix — Changes in the texture of the Uterine Tissues, the Peritoneal, Muscular, and Mucous Coats — General modifications in the Body produced by Pregnancy . 123 CHAPTER IV. SIGNS AND DIAGNOSIS OF PREGNANCY. Signs of a fruitful Conception — Cessation of Menstruation — Sympathetic disturb- ances : Morning Sickness, etc. — Mammary Changes — Enlargement of the Ab- domen — Quickening — Intermittent Uterine contractions — Vaginal Signs of Pregnancy — Ballottement, etc. — Auscultatory Signs of Pregnancy — Foetal Pul- sations — Uterine Souffle, etc 133 CHAPTER V. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY SPURIOUS PREGNANCY DURATION OF PREGNANCY SIGNS OF RECENT DELIVERY. Adipose enlargement of the Abdomen — Distension of the Uterus by retained Menses, etc. — Congestive enlargement of Uterus — Ascites — Uterine and Ovarian Tumors — Spurious Pregnancy: its Causes, Symptoms, and Diagnosis — The duration of Pregnancy — Sources of Fallacy — Methods of Predicting Date of De- livery — Protraction of Pregnancy — Signs of recent Delivery .... 148 CONTENTS. Xlll CHAPTER VI. ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER- FCETATION, EXTRA-UTERINE FCETATION, AND MISSED LABOR. PAGE Plural Births, their frequency: Relative frequency in different Countries; Causes, etc. — Super-foetation and Super-fecundation — Nature — Explanation — Objections to admission of such cases — Their possibility admitted — Extra- Uterine Pregnancy — Classification — Causes — Tubal Pregnancies — Changes in the Fallopian Tubes — Condition of Uterus — Progress and Termination — Diagnosis — Treatment — Abdominal Pregnancy : Description ; Diagnosis ; Treatment — Missed Labor: its Symptoms, Causes, and Treatment 157 CHAPTER VII. THE DISEASES OF PREGNANCY. Some only Sympathetic, others Mechanical or Complex in their Origin — Derange- ments of the Digestive Organs : Excessive Nausea and Vomiting ; Diarrhoea ; Constipation ; Hemorrhoids ; Ptyalism ; Toothache and Caries of Teeth ; Affec- tions of Respiratory Organs ; Dyspnoea, etc. — Palpitation — Syncope — Anaemia and Chlorosis — Albuminuria 183 CHAPTER VIII. THE DISEASES OF PREGNANCY {continued). Disorders of the Nervous System : Insomnia ; Headaches and Neuralgia ; Paraly- sis ; Chorea ; Disorders of the Urinary Organs ; Retention of Urine ; Irritability of the Bladder ; Incontinence of Urine ; Phosphatic Deposits ; Leucorrhoea ; Effects of Pressure ; Laceration of Veins ; Displacements of the Gravid Uterus ; Prolapse, Anteversion, Retroversion — Diseases coexisting with Pregnancy ; Eruptive Fevers ; Smallpox, Measles, Scarlet Fever, Continued Fever ; Phthisis ; Cardiac Disease ; Syphilis ; Icterus ; Carcinoma ; Pregnancy complicated with Ovarian and Fibroid Tumors 196 CHAPTER IX. PATHOLOGY OF THE DECIDUA AND OVUM. Pathology of the Decidua — Hydrorrhea Gravidarum — Pathology of the Chorion ; Vesicular Degeneration, Myxoma Fibrosum — Pathology of the Placenta : Blood Extravasations, Fatty Degeneration, etc. — Pathology of the Umbilical Cord — Pathology of the Amnion, Hydramnios ; Deficiency of Liquor Amnii, etc. — Pathology of the Foetus : Blood Diseases transmitted through the Mother, Small- pox, Measles, and Scarlet Fever, Intermittent Fevers, Lead-poisoning, Syphilis, — Inflammatory Diseases — Dropsies — Tumors — Wounds and Injuries of the Foetus — Intrauterine Amputations — Death of the Foetus 212 XIV CONTENTS. CHAPTER X. ABORTION AND PREMATURE LABOR. PAOE Importance and Frequency — Definition and Classification — Frequency — Recur- rence — Causes — Causes Referable to Foetus — Changes in a Dead Ovum retained in Utero — Extravasations of Blood — Moles, etc. — Causes depending on Maternal State — Syphilis : Causes acting through Nervous System, Physical Causes, etc. — Causes depending on Morbid States of Uterus — Symptoms — Preventive Treat- ment — Prophylactic Treatment — Treatment when Abortion is inevitable — After- Treatment 229 PAET III LABOR. CHAPTER I. THE PHENOMENA OF LABOR. Causes of Labor — Mode in which the Expulsion of the Child is effected — The Uterine contraction — Mode in which the Dilatation of the Cervix is effected — Rupture of the Membranes — Character and source of Pains during Labor — Effect of Pains on Mother and Foetus — Division of Labor into Stages — Prepara- tory Stage — False Pains — First Stage — Second Stage — Third Stage — Mode in which the Placenta is expelled — Duration of Labor 242 CHAPTER II. MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. Importance of Subject — Frequency of Head Presentations — The different positions of the Head — First Position — Division of Mechanical Movements into Stages — Flexion — Rotation — Extension — External Rotation — Second Position — Third Position — Fourth Position — Caput Succedaneum — Alteration in shape of Head from moulding 255 CHAPTER III. MANAGEMENT OF NATURAL LABOR. Preparatory Treatment — Dress of Patient during Pregnancy — The Obstetric Bag — Duties on first visiting Patient — False Pains — Tbeir Character and Treatment — Vaginal Examination — The Position of Patient — Artificial Rupture of Mem- branes — Treatment of Propulsive Stage — Relaxation of the Perineum — Treat- ment of Lacerations — Expulsion of Child — Promotion of Uterine Contraction — Ligature of the Cord — Management of the Third Stage of Labor — Application of the Binder— After-Treatment 268 CONTENTS. XV CHAPTER IV. ANAESTHESIA IN LABOR. PAGE Agents employed — Chloral: its Object and Mode of administration — Ether — Chloroform : its Use, Objections to, and Mode of administration . . . 282 CHAPTER V. PELVIC PRESENTATIONS. Frequency — Causes — Prognosis to Mother and Child — Diagnosis by Abdominal Palpation and by Vaginal Examination — Differential Diagnosis of Breech, Knee, and Feet — Mechanism — Treatment — Management of Impacted Breech Presenta- tions 286 CHAPTER VI. PRESENTATIONS OF THE FACE. Erroneous Views formerly held on the Subject — Frequency — Mode of Production — Diagnosis — Mechanism — Four Positions of the Face — Description of Delivery in First Face Position — Mento-Posterior Positions in which Rotation does not take place — Prognosis — Treatment . . . . . . . . .297 CHAPTER VII. DIFFICULT OCCIPITO-POSTERIOR POSITIONS. Causes of Face to Pubis Delivery — Mode of Treatment — Upward Pressure on Forehead — Downward Traction on Occiput — Use of Forceps — Peculiarities of Forceps Delivery 307 CHAPTER VIII. PRESENTATIONS OF SHOULDER, ARM, OR TRUNK COMPLEX PRESENTATIONS PROLAPSE OF THE FUNIS. Position of the Foetus — Division into Dorso-Anterior and Dorso-Posterior Posi — tions — Causes — Prognosis and Frequency — Diagnosis — Mode of distinguishing Position of Child — Differential Diagnosis of Shoulder, Elbow, and Hand — Mechanism — The Two possible Modes of Delivery by the Natural Powers — Spontaneous Version — Spontaneous Evolution — Treatment — Complex Presenta- tion : Foot or Hand with Head, Hand and Feet together — Dorsal Displacement of the Arm — Prolapse of the umbilical Cord — Frequency — Prognosis — Causes — Diagnosis — Postural Treatment — Artificial Reposition — Treatment when Repo- sition fails ............. 309 CHAPTER IX. PROLONGED AND PECIPITATE LABORS. Evil effects of Prolonged Labor — Influence of the Stage of Labor in Protraction — Delay in First Stage rarely serious — Temporary Cessation of Pains — Symptoms XVI CONTENTS. PAGE of Protraction in the Second Stage — State of the Uterus in Protracted Labor — Cases of Protraction due to Morbid condition of the expulsive powers — Causes of Protraction — Treatment — Oxytocic remedies — Ergot of Rye, etc. — Manual Pres- sure — Instrumental Delivery — Precipitate Labor — Its Causes and Treatment . 324 CHAPTER X. LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. Rigidity of the Cervix : its Causes, Effects, and Treatment — Bands and Cicatrices in the Vagina — Extreme rigidity of the Perineum — Labor complicated with Tumor — Vaginal Cystocele — Calculus — Hernial Protrusions — CEdema of Vulva — Haematic Effusions, etc. ........ . . 339 CHAPTER XL DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE FCETUS. Plural Births, Treatment of — Locked Twins — Conjoined Twins — Intra-uterine Hydrocephalus : Its Dangers, Diagnosis, and Treatment — Other dropsical Effu- sions — Foetal Tumors — Excessive Development of Foetus . . . . .353 CHAPTER XII. DEFORMITIES OF THE PELVIS. Classification — Causes of Pelvic Deformity — Rickets and Osteo-malacia — The Equally enlarged Pelvis — The Equally contracted Pelvis — The Undeveloped Pelvis — Masculine or Funnel-shaped Pelvis — Contraction of Conjugate Diameter of the Brim — Figure-of-Eight deformity — Spondylolithesis — Narrowing of the Oblique Diameters — Obliquely contracted Pelvis — Kyphotic Pelvis — Robert's Pelvis — Deformity from old-standing Hip-joint disease — Deformity from Tumors, Fractures, etc. — Effects of Contracted Pelvis on Labor — Risks to the Mother and Child — Mechanism of Delivery in Head Presentation ; a, in Contracted Brim ; b, in Generally contracted Pelvis — Diagnosis — External Measurements — Internal Measurements — Mode of estimating the Conjugate diameter of the brim — Mode of Diagnosing the Oblique Pelvis — Treatment — The Forceps — Turning — The Induction of Premature Labor — Induction of Abortion 366 CHAPTER XIII. HEMORRHAGE BEFORE DELIVERY : PLACENTA PREVIA. Definition — Causes — Symptoms — Sources and Causes of Hemorrhage — Prognosis — Treatment 3S8 CHAPTER XIV. HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED PLACENTA. Causes and Pathology — Symptoms and Diagnosis — Prognosis — Treatment . . 399 CONTEXTS. XV11 CHAPTER XV. HEMORRHAGE AFTER DELIVERY. PAGB Its frequency — Generally a preventable accident — Causes — Nature's method of Controlling Hemorrhage — Uterine Contraction — Thrombosis — Secondary Causes of Hemorrhage — Irregular Uterine Contraction — Placental Adhesions — Consti- tutional Predisposition to Flooding — Symptoms — Preventive treatment — Cura- tive treatment — Secondary post-partum Hemorrhage — Its Causes and Treatment 402 CHAPTER XVI. RUPTURE OF THE UTERUS, ETC. Its Fatality — Seat of Rupture — Causes, predisposing and exciting — Symptoms — Prognosis — Treatment : when the Foetus remains in Utero ; when the Foetus has escaped from the Uterus — Recapitulation — Lacerations of the vagina — Vesico and Recto-vaginal Fistulae — Their mode of Formation — Treatment . . .419 CHAPTER XVII. INVERSION OF THE UTERUS. Division into Acute and Chronic forms — Description — Symptoms — Diagnosis — Mode of production — Treatment ......... 429 PAET IY. OBSTETRIC OPERATIONS. CHAPTER I. INDUCTION OF PREMATURE LABOR. History — Objects — May be performed either on account of the Mother or Child — Modes of Inducing Labor — Puncture of Membranes — Administration of Oxyto- cics — Means acting indirectly on the Uterus — Dilatation of Cervix — Separation of Membranes — Vaginal and Uterine douches — Introduction of Flexible Ca- theter 435 CHAPTER II. TURNING. History — Turning by External Manipulation — Object and Nature of the Opera- tion — Cases Suitable for the operation — Statistics and Dangers — Method of performance — Cephalic Version — Method of performance — Podalic Version — Position of Patient — Administration of Anaesthetics — Period wben the opera- tion should be undertaken — Choice of Hand to be used — Turning by Bi-polar method — Turning when the Hand is introduced into the Uterus — Turning in Abdomino-anterior Positions — Difficult cases of Arm Presentation . . . 442 2 XV111 CONTENTS. CHAPTER III. THE FORCEPS. PAGE Frequent use of the Forceps in Modern practice — Description of the Instrument — The Short Forceps — Its Varieties — The Long Forceps — Suitable to all cases alike — Action of the Instrument — Its power as a Tractor, Lever, and Compres- sor — Preliminary considerations before operation — Use of Anaesthetics — De- scription of the Operation — Low Forceps Operation — High Forceps Operation — Possible Dangers of Forceps Delivery — Possible Risks to the Child . . .458 CHAPTER IV. THE VECTIS THE FILLET. Nature of the Vectis — Its use as a Lever or Tractor — Cases in which it is appli- cable — Its use as a Rectifier of Malpositions — The Fillet — Nature of the Instru- ment — Objections to its use 482 CHAPTER V. OPERATIONS INVOLVING THE DESTRUCTION OF THE FCETUS. Their Antiquity and History — Division of Subject — Nature of Instruments em- ployed — Perforator — Crotchet — Craniotomy Forceps — Cephalotribe — Forceps- saw — Ecraseur — Cases requiring Craniotomy — Method of Perforation — Extrac- tion of the Head — Comparative merits of Cephalotripsy and Craniotomy — Extraction by the Craniotomy Forceps — Extraction of the Body — Embryotomy — Decapitation and Evisceration 484 CHAPTER VI. THE CESAREAN SECTION SYMPHYSEOTOMY AND LAPARO-ELYTROTOMY. History of the Operation — Statistics — Results to Mother and Child — Causes re- quiring the Operation — Post-mortem Caesarean Section — Causes of Death after the Caesarean Section — Preliminary Preparations — Description of the Operation — Subsequent Management — Substitutes for the Caesarean Section — Symphyse- otomy — Laparo-elytrotomy 499 CHAPTER VII. THE TRANSFUSION OF BLOOD. History — Nature and Object of the Operation — Use of Blood taken from the Lower Animals — Difficulties from Coagulation of Fibrine — Modes of Obviating them — Immediate Transfusion — Addition of Chemical Agents to prevent Coagulation — Defibrination of the Blood — Statistical Results — Possible Dangers of the Opera- tion — Cases suitable for Transfusion — Description of the Operation — Effects of Successful Transfusion — Secondary Effects of Transfusion 514 CONTENTS. XIX PAET V. THE PUERPERAL STATE. CHAPTER I. THE PUERPERAL STATE AND ITS MANAGEMENT. PAGE Importance of Studying the Puerperal State — The Mortality of Childbirth — Alte- rations in the Blood after Delivery — Condition after Delivery — Nervous Shock — Fall of the Pulse — The Secretions and Excretions — Secretion of Milk — Changes in the Uterus after Delivery — The Lochia — The After-pains — Manage- ment of Women after Delivery — Treatment of Severe After-pains — Diet and Regimen .............. 523 CHAPTER II. MANAGEMENT OF THE INFANT, LACTATION, ETC. Commencement of Respiration after the Birth of the Child — Apparent Death of the new-born Child — Its Treatment — Washing and Dressing the Child — Ap- plication of the Child to the Breast — The Colostrum and its Properties — Secre- tion of Milk — Importance of Nursing — Selection of a Wet-nurse — Management of Lactation — Diet and Regimen of Nursing Women — Period of Weaning — Disorders of Lactation — Means of Arresting the Secretion of Milk — Defective Secretion of Milk — Depressed Nipples— Fissures and Excoriations of the Nipples — Excessive Flow of Milk — Mammary Abscess — Hand-feeding — Causes of Mor- tality in Hand-feeding — Various kinds of Milk — Method of Hand-feeding . 533 CHAPTER III. PUERPERAL ECLAMPSIA. Its Doubtful Etiology — Premonitory Symptoms — Symptoms of the attack — Con- dition between the Attacks — Relation of the attacks to Labor — Results to Mother and Child — Pathology — Treatment — Obstetric Management . . .550 CHAPTER IV. PUERPERAL INSANITY. Classification — Proportion of Various forms — Insanity of Pregnancy — Predispos- ing Causes — Period of Pregnancy at which it occurs — Type of Insanity — Prognosis — Transient Mania during Delivery — Puerperal Insanity (Proper) — Type of Insanity — Causes— Theory of its dependence on a Morbid State of the Blood — Objections to the theory — Prognosis — Post-mortem signs — Duration — Insanity of Lactation — Type — Symptoms — Of Mania — Of Melancholia — Treat- ment — Question of Removal to Asylum — Treatment during Convalescence . 559 XX CONTENTS. CHAPTER V. PUERPERAL SEPTICEMIA. PAGE Differences of opinion — Confusion from this cause — Modern view of this Disease — History — Its Mortality in Lying-in Hospitals — Numerous Theories as to its Nature — Theory of Local Origin — Theory of an Essential Zymotic Fever — Theory of its identity with Surgical Septicaemia — Nature of this view — Channels through which Septic Matter may be absorbed — Character and Origin of Septic Matter often obscure — Division into Auto-genetic and Hetero-genetic cases — Sources of Self-infection — Sources of Hetero-genetic Infection — Influence of Cadaveric Poison — Infection from Erysipelas — Infection from other Zymotic Diseases — Contagion from other Puerperal Patients — Mode in which the Poison may be conveyed to the Patient — Conduct of the Practitioner in relation to the Disease — Nature of the Septic Poison — Local changes resulting from the ab- sorption of Septic Material — Channels through which Systemic Infection is produced — Pathological Phenomena observed after general Blood Infection — Four principal Types of Pathological Change — Intense cases without marked Post-mortem Signs — Cases characterized by Inflammation of the Serous Mem- branes — Cases characterized by the impaction of Infected Emboli, and Secondary Inflammation and Abscess — Description of the Disease — Duration — Varieties of Symptoms in different cases — Symptoms of Local Complications — Treatment . 570 CHAPTER VI. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. Puerperal Thrombosis and its Results — Conditions which favor Thrombosis — Con- ditions which favor Coagulation in the Puerperal State — Distinction between Thrombosis and Embolism — Is primary Thrombosis of the Pulmonary Arteries possible? — History — Symptoms of Pulmonary Obstruction — Is recovery pos- sible ? — Causes of Death — Post-mortem appearances — Treatment . . . 594 CHAPTER VII. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. Causes — Symptoms — Treatment 605 CHAPTER VIII. OTHER CAUSES OF SUDDEN DEATH DURING- LABOR AND THE PUERPERAL STATE. Organic and Functional causes — Idiopathic Asphyxia — Pulmonary Apoplexy — Cerebral Apoplexy — Syncope — Shock and Exhaustion — Entrance of Air into the Veins 607 CHAPTER IX. PERIPHERAL VENOUS THROMBOSIS (SYN. : CRURAL PHLEBITIS PHLEGMASIA DOLENS ANASARCA SEROSA (EDEMA LACTEUM WHITE LEG, ETC.). Nature — Symptoms — History and Pathology — Anatomical form of the Thrombi in the Veins — Detachment of Emboli — Treatment ...... 609 CONTEXTS. XXI CHAPTER X. PELVIC CELLULITIS AND PELVIC PERITONITIS. PAGE Two Forms of Disease — Variety of Nomenclature — Importance of Differential Diagnosis — Etiology — Connection with Septicaemia — Seat of Inflammation — Relative Frequency of the two forms of Disease — Symptomatology — Results of Physical Examination — Terminations — Prognosis — Treatment . . .616 [APPENDIX. The Intravenous Injection of Fresh Milk, as an Improved Substitute for the Transfusion of Blood 625] INDEX 629 2* ILLUSTRATIONS Section of a Frozen Body in the last months of Pregnancy (after Branne) . Illus- trating the Relations of the Uterus to the surrounding Parts, and the attitude of the Foetus, which is lying in the second Cranial Position . . Plate I Section of a Frozen Body at the termination of the first stage of Labor (after Braune) . The bag of membranes is still unbroken, the cervix is fully dilated, and the head (in the second position) is in the pelvic cavity . . Plate II. FIG. PAGE 1. Os innominatum ............ 26 2. Sacrum and Coccyx 27 3. Section of Pelvis and heads of Thigh-bones, showing the Suspensory Action of the Sacro-iliac Ligaments. (After Wood.) ...... 29 4. Outlet of Pelvis 32 5. The Female Pelvis . ,32 6. The Male Pelvis 33 7. Brim of Pelvis, showing Antero-posterior, Oblique, and Conjugate Diameters 34 8. Transverse section of Pelvis, showing the Diameters ..... 34 9. Planes of the Pelvis, with Horizon 36 10. Axes of the Pelvis 37 11. Representing general Axis of the Parturient Canal, including the Uterine Cavity and Soft Parts 38 12. Side view of Pelvis 38 13. Pelvis of a Child 39 14. Vascular Supply of Vulva. (After Kobelt.) 45 15. Longitudinal section of Body, showing Relation of Generative Organs . 46 16. Transverse section of Body, showing Relations of the Fundus Uteri . . 48 17. Transverse section of Uterus . . . . . ... . .49 18. Uterus and Appendages in an Infant . 49 19. Portion of Interior of Cervix. (Enlarged nine diameters.) .... 51 20. Muscular Fibres of unimpregnated Uterus. (After Farre.) ... 52 21. Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) . 52 22. Lining Membrane of Uterus, showing network of Capillaries and Orifices of Uterine Glands. (After Farre.) ........ 54 23. The Course of the Glands in the fully developed Mucous Membrane of the Uterus. (After Williams.) . ....... 54 24. Villi of Os I'teri stripped of Epithelium 55 25. Villi of Uterus, covered with Pavement Epithelium and containing Looped Vessels. (After Tyler Smith and Hassall.) 66 26. Bifid Uterus. (After Farre.) 58 27. Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) . . 59 28 Posterior view of Muscular and Vascular arrangements. (After Rouget.) . 60 29. Fallopian Tube laid open. (After Richard.) 62 XXIV ILLUSTRATIONS. FIG. PAGE 30. Ovary enlarged under Menstrual Nisus 64 31. Longitudinal Section of Adult Ovary. (After Farre.) ..... 65 32. Section through the cortical part of the Ovary. (After Turner.) . . 66 33. Vertical Section through the Ovary of the Human Foetus. (After Foulis.) 66 34. Diagramatic Section of Graafian Follicle 67 35. Bulb of Ovary 69 36. Mammary Gland 70 37. Section of Ovary, Showing Corpus Luteum three weeks after Menstruation. (After Dalton.) 74 38. Corpus Luteum at the fourth month of Pregnancy. (After Dalton.) . . 75 39. Corpus Luteum of Pregnancy at Term. (After Dalton.) .... 75 40. Sperm Cells and Nuclei . . . . 84 41. Ovum of Rabbits containing Spermatozoa 86 42. Formation of the "Polar Globule" 87 43. Segmentation of the Yelk 88 44. Formation of the Blastodermic Membrane. (After Joulin.) ... 89 45. Aborted Ovum (of about forty days), showing the Triangular Shape of the Decidua (which is laid open), and the Aperture of the Fallopian Tube. (After Coste.) 91 46. \ 47. > Formation of the Decidua. (After Dalton.) ...... 91 48. ) 49. An Ovum removed from the Uterus, and part of the Decidua Vera cut away. (After Coste.) 92 50. Diagram of Area Germinativa, showing the primitive trace and Area Pel- lucida 94 51. Development of the Amnion . . . . . . . . .95 52. Development of the Umbilical Vesicle and Amnion . . . . .96 53. An Embryo of about twenty-five days laid open. (After Coste.) . . 96 54. Development of the Chorion 97 55. Placental Villus, greatly magnified. (After Joulin.) 102 56. Terminal Villus of Foetal Tuft, minutely Injected. (After Farre.) . . 103 57. Diagram representing a Vertical Section of the Placenta. (After Dalton.) . 103 58. Diagram illustrating the Mode in which a Placental Villus derives a Cover- ing from the Vascular System of the Mother. (After Priestley.) . . 104 59. The Extremity of a Placental Villus. (After Goodsir.) . . . .104 60. Anterior and Posterior Fontanelles . . . . . . . .111 61. Bi-parietal diameter, Sagittal and Lambdoidal Sutures, with Posterior Fon- tanelle ............. Ill 62. Diameters of the Foetal Skull Ill 63. Mode of ascertaining the Position of the Foetus by Palpation . . . 114 64. Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan.) . 115 65. Illustrating the greater Mobility of the Foetus and the larger relative amount of Liquor Amnii in Early Pregnancy. (After Duncan.) . . . 116 66. Diagram of Foetal Heart. (After Dalton.) 119 67. Diagram of Heart of Infant. (After Dalton.) ...... 121 68. Size of Uterus at various Periods of Pregnancy ...... 124 69. \ 70. I Supposed Shortening of the Cervix at the third, sixth, seventh, and nine 71. j months of Pregnancy, as figured in Obstetric works .... 126 72. J ILLUSTRATIONS. XXV FIff. PAGE 73. Cervix of a Woman Dying in the eighth Month of Pregnancy. (After Duncan.) 127 74. Appearance of the Areola in Pregnancy ....... 137 75. Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa during the early Months of Pregnancy. (After Coste.) .... 163 76. Tubal Pregnancy, with the Corpus Luteum in the Ovary of the opposite side 166 77. Tubal Pregnancy. (From a specimen in the Museum of King's College.) . 167 78. Extra-uterine Pregnancy at term of the Tubo-Ovarian Variety. (After a case of Dr. A. Sibley Campbell's.) 169 79. Uterus and Foetus in a case of Abdominal Pregnancy .... 175 80. Lithopsedion. (From a preparation in the Museum of the Royal College of Surgeons.) . ........... 176 81. Contests of the Cyst in Dr. Oldham's case of Missed Labor . . . 182 82. Hypertrophied Decidua laid open, with the Ovum attached to its Fundal Portion. (After Duncan.) 213 83. Imperfectly developed Decidua Vera, with the Ovum. (After Duncan.) . 214 84. Hydatiform Degeneration of the Chorion . . . . . . .215 85. Double Placenta, with Single Cord 219 86. Fatty Degeneration of the Placenta 220 87. Knots in the Umbilical Cord 221 88. Intra-uterine Amputation of both Arms and Legs 226 89. An apoplectic Ovum, with Blood effused in masses under the Foetal Surface of the Membranes 231 90. Blighted Ovum, with Fleshy Degeneration of the Membranes . . . 232 91. Mode in which the Placenta is Naturally Expelled. (After Duncan.) . 253 92. Attitude of Child in first position. (After Hodge.) 258 93. First Position : Movement of Flexion 259 94. First Position : Occiput in Cavity of Pelvis. (After Hodge.) . . .260 95. First Position: Occiput at Outlet of Pelvis. (After Hodge.) . . .261 96. First Position : Head Delivered. (After Hodge.) 263 97. External Rotation of Head in first position. (After Hodge.) . . . 263 98. Third Position of Occiput at Brim of Pelvis 264 99. Fourth Position of Occiput at Pelvic Brim 267 100. Examination during the First Stage of Labor 272 101. Mode of effecting Relaxation of the Perineum 276 102. Usual Method of Removing the Placenta by Traction on the Cord . . 279 103. Illustrating Expression of the Placenta 280 104. First, or left Sacro-cotyloid position of the Breech 290 105. Passage of the Shoulders and partial Rotation of the Thorax . . .291 106. Descent of the Head 292 107. Second position in Face Presentation 300 108. Rotation Forwards of Chin 302 109. Passage of the Head through the External Parts in Face Presentation . 302 110. Illustrating the position of the Head when Forward Rotation of the Chin does not take place 303 111. Dorso-anterior Presentation of the Arm 311 112. Dorso-posterior Presentation of the Arm 311 113. Commencing Spontaneous Evolution 316 114. Spontaneous Evolution further Advanced 316 115. Dorsal Displacement of the Arm 318 XXVI ILLUSTRATIONS. FI«. PAGE 116. Dorsal Displacement of the Arm in Footling Presentations. (After Barnes.) 319 117. Prolapse of the Umbilical Cord 320 118. Postural Treatment of Prolapse of the Cord 322 119. Braun's Apparatus for Replacing the Cord . . . . . . 323 120. Labor complicated by Ovarian Tumor ....... 345 121. Twin Pregnancy, Breech and Head presenting ...... 353 122. Head Locking, both Children presenting Head first. (After Barnes) . 355 123. Head Locking, first Child coming Feet first ; Impaction of Heads from wedging in Brim. (After Barnes) ....*... 357 124. Labor impeded by Hydrocephalus 362 125. Adult Pelvis retaining its Infantile Type . . . . . . .369 126. Rickety Pelvis, with backward depression of Symphysis Pubis . . 371 127. Flatness of Sacrum, with narrowing of Pelvic Cavity .... 371 128. Pelvis deformed by Spondylolithesis. (After Kilian) .... 371 129. Osteo-malacic Pelvis 373 130. Extreme degree of Osteo-malacic Deformity ....... 373 131. Obliquely Contracted Pelvis. (After Duncan) 374 132. Robert's, or double obliquely Contracted Pelvis ..... 375 133. Bony Growth from Sacrum obstructing the Pelvic Cavity .... 375 134. Greenhalgh's Pelvimeter . . . ■ 380 135. Section of Foetal Cranium, showing its Conical Form .... 384 136. Showing the greater Breadth of the biparietal Diameter of the Foetal Cra- nium. (After Simpson) 384 137. Showing the greater Space for the biparietal Diameter in certain Cases of Deformity. (After Simpson) 384 138. Irregular Contraction of the Uterus, with Encystment of the Placenta . 406 139. Partial Inversion of the Fundus 430 140. Illustrating the Commencement of Inversion at the Cervix. (After Duncan) 432 141. Barnes's Bag for Dilating the Cervix 439 142. First Stage of Bi-polar Version 449 143. Second Stage of Bi-polar Version ........ 450 144. Third Stage of Bi-polar Version 450 145. Fourth Stage of Bi-polar Version 451 146. Seizure of the Feet when the Hand is introduced into the Uterus . . 453 147. Drawing down of the Feet and Completion of Version .... 454 148. Showing the Completion of Version. (After Barnes) .... 455 149. Showing the Use of the Right Hand in Abdomino-anterior positions . . 456 150. Denman's Short Forceps 459 151. Zeigler's Forceps 460 152. Simpson's Forceps ........... 461 153. Tarnier's Forceps 462 154. Position of Patient for Forceps Delivery, and Mode of Introducing the Lower Blade 466 155. Introduction of the Upper Blade 468 156. Forceps in position; Traction in the Axis of the Brim, downwards and backwards ............ 469 157. Last Stage of Extraction ; the Handles of the Forceps turned upwards towards the Mother's Abdomen ........ 470 [158. Hodge Forceps 474] [159. Wallace " 475] [160. Davis " 475] ILLUSTRATIONS. XXV11 FIG. PAGE [161. Elliot Forceps 476] [162. Sawyer " - . 477] [163. Application of Forceps at Inferior Strait 478] [164. Application of Forceps in the Head at Superior Strait, the left Blade held in place by an Assistant 480] [165. Direction of Forceps as Head is being Delivered 481] 166. Vectis with Hinged Handle 483 167. Wilmot's Fillet 484 168. -j 169. > Various forms of Perforators . . 486 170. ) 171 & 172. Crotchets . . .487 173. Craniotomy Forceps 488 174. Simpson's Cranioclast .......... 488 175. Hick's Cephalotribe 489 176. Perforation of the Skull 492 177. Foetal Head crushed by the Cephalotribe 495 [178. Straight Craniotomy Forceps 496] [179. Curved " " 496] 180. Method of Transfusion by Aveling's Apparatus 521 181. Section of a Uterine Sinus from the Placental Site nine weeks after delivery. (After Williams) .528 182. Haye's Tube for Intra-uterine Injections ....... 588 PLATE I Os Pubis Bladder. Clitoris Portio Vaginalis Vagina. Section of a Frozen Body in the last month of Pregnancy (after Brau.ne), illustrating the Kelations of the Uterus to the surrounding parts, and tlio Attitude of the Foetus, which is lying in the Second Cranial Position. PLATE II Liquor Amnii ;tiou of a Frozen Body at the Termination of the First Stage of Labor (after Brauuo). The Bag of Mem- branes is still unbroken, the Cervix is fully dilated, and the Head (in the second position) is in the Pel vie THE SCIENCE AND PRACTICE MIDWIFERY. PART I. ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED IN PARTURITION. CHAPTEE I. ANATOMY OF THE PELVIS. The pelvis is the bom* basin situated between the trunk and the lower extremities. To the obstetrician its study is of paramount importance, for it not only contains, in the unimpregnated state, all the organs connected with the function of reproduction, but through its cavity the foetus has to pass in the process of parturition. An accurate knowledge, therefore, of its anatomical formation may be said to be the very alphabet of obstetrics, without which no one can practise midwifery, either with satisfaction to himself, or safety to his patient. In a treatise on obstetrics, however, any detailed account of the purely descriptive anatomy of the pelvis would be out of place. A knowledge of that must be taken for granted, and it is only necessary to refer to those points which have a more or less direct bearing on the study of its obstetrical relations. The pelvis is formed of four bones. On either side are the ossa innominata, joined together by the sacrum; to the inferior extremity of the sacrum is attached the coccyx, which is, in fact, its continuation. The os innominatum (Fig. 1) is an irregularly shaped bone origi- nally formed of three distinct portions, the ilium, the ischium, and the pubes, which remain separated from each other up to and beyond the period of puberty. They are united at the acetabulum by a Y-shaped cartilaginous junction, which does not, as a rale, become ossified until about the twentieth year. The consequence is that the pelvis, during the period of growth, is subject to the action of various mechanical influences to a far greater extent than in adult life; and 3 26 ORGANS CONCERNED IN PARTURITION. these, as we shall presently see, have an important effect in deter- mining the form of the bones. The external surface and borders of the os innominatum are chiefly of obstetric interest from giving attachment to muscles, many of which have an important accessory influence on parturition, such as the muscles forming the abdominal wall, which are attached to its crest, and those closing its outlet and Fig. 1. Os InDominatuin. forming the perineum, which are attached to the tuberosity of the ischium. On the anterior and posterior extremities of the crest of the ilium are two prominences (the anterior and posterior spinous processes) which are points from which certain measurements are sometimes taken. The internal surface of the upper fan-shaped portion of the os innominatum gives attachment to the iliacus muscle, and contributes to the support of the abdominal contents ; along with its fellow of the opposite side it forms the false pelvis. The false is separated from the true pelvis by the ilio-pectineal line, which, with the upper margin of the sacrum, forms the brim of the pelvis. This is of especial obstetric importance, as it is the first part of the pelvic cavity through which the child passes, and that in which osseous deformities are most often met with. At one portion of the ilio- pectineal line, corresponding with the junction of the ilium and pubes, is situated a prominence, which is known as the ilio-pectineal eminence. Internal Surface. — The internal smooth surface of the innominate bone below the linea ilio-pectinea forms the greater portion of the pelvis proper. In front, with the corresponding portions of the opposite bone, it forms the arch of the pubes, under which the head of the child passes in labor. Behind this we observe the oval obturator foramen, and below that the tuberosity and spine of the ischium, the latter separating the great and lesser sciatic notches, and giving attachment to ligaments of im- portance. The rough articulating surface posteriorly, by which the junction with the sacrum is effected, may be noted, and above this ANATOMY OF THE PELVIS. 27 Fig. 2. Sacrum and Coccyx. the prominence to which the powerful ligaments joining the sacrum and os innominatum are attached. The sacrum (Fig. 2) is a triangular and somewhat spongy bone, forming the continuation of the spinal column, and binding together the ossa innominata. It is originally composed of five separate portions, anal- ogous to the vertebrae, which ossify and unite about the period of puberty, leaving on its internal surface four prominent ridges at the points of junction. The upper of these is sometimes so well marked as to be mistaken, on vaginal examination, for the promontory of the sacrum itself. The base of the sacrum is about -ij inches in width, and its sides rapidly ap- proximate until they nearly meet at its apex, giving the whole bone a triangular or wedge shape. The anterior and pos- terior surfaces also approximate in the same way, so that the bone is much thicker at the base than at the apex. The sacrum, in the erect position of the body, is directed from above downwards and from before backwards. At its upper edge it is joined, the lumbo-sacral cartilage intervening, with the fifth lumbar vertebra. The point of junction, called the promontory of the sacrum, is of great importance, as on its undue projection many deformities of the brim of the pelvis depend. The anterior surface of the bone is concave, and forms the curve of the sacrum; more marked in some cases than in others. There is also more or less concavity from side to side. On it we observe four apertures on each side, the intervertebral foramina, giving exit to nerves. The posterior surface is convex, rough and irregular for the attachment of ligaments and muscles, and showing a ridge of vertical prominences, corresponding to the spinous processes of the vertebrae. Mechanical Relations of the Sacrum. — The sacrum is generally de- scribed as forming a keystone to the arch constituted by the pelvic bones, and transmitting the weight of the body, in consequence of its wedge-like shape, in a direction which tends to thrust it downwards and backwards, as if separating the ossa innominata. Dr. Duncan, 1 however, has shown, from a very careful consideration of its mechanical relations, that it should rather be regarded as a strong transverse beam, curved on its anterior surface, the extremities of which are in contact with the corresponding articular surfaces of the ossa innominata. The weight of the body is thus transmitted to the innominate bones, and through them to the acetabula and the femurs. (Fig. 3.) There counter-pressure is applied, and the result is, as we shall subsequently see, an important modifying influence on the development and shape of the pelvis. Researches in Obstetrics, p. G7. 28 ORGANS CONCERNED IN PARTURITION. The coccyx (Fig. 2) is composed of four small separate bones, which eventually unite into one, but not until late in life. The uppermost of these articulates with the apex of the sacrum. On its posterior surface are two small cornua, which unite with corresponding points at the tip of the sacrum. The bones of the coccyx taper to a point. To it are attached various muscles which have the effect of imparting considerable mobility. During labor, also, it yields to the mechanical pressure of the presenting part, so as to increase the antero-posterior diameter of the pelvic outlet to the extent of an inch or more. Ossification of Coccyx. — If, through disease or accident, as sometimes happens, the articular cartilages of the coccyx become prematurely ossified, the enlargement of the pelvic outlet during labor may be prevented, and considerable difficulty may thus arise. This is most apt to happen in aged primiparse, or in women who have followed sedentary occupations ; and not infrequently, under such circitm- stances, the bone fractures under the pressure to which it is subjected by the presenting part. Pelvic Articulations. — -The pelvic bones are firmly joined together by various articulations and ligaments. The latter are arranged so as to complete the canal through which the foetus has to pass, and which is in great part formed by the bones. On its internal surface, where the absence of obstruction is of importance, they are every- where smooth; while externally, where strength is the desideratum, they are arranged in larger masses, so as to unite the bones firmly together. The pelvic articulations have been generally described as symphyses or amphiarthrodia, ,a term which is properly applied to two articulating surfaces, united by fibrous tissue in such a way as to prevent any sliding motion. It is certain, however, that this is not the case with the joints of the female pelvis during pregnancy and parturition. Lenoir found that in 22 females, between the ages of 18 and 35, there was a distinct sliding motion. Therefore, the pelvic articulations are, strictly speaking, to be considered examples of the class of joints termed arthrodia. Lumbosacral Joint. — The last lumbar vertebra is united to the sacrum by ligamentous union similar to that which joins the vertebrae to each other. The intervening fibro- cartilage forms a disk, which is thicker in front than behind, and this, in connection with a similar peculiarity of the fifth lumbar vertebra, tends to increase the sloped position of the sacrum, and the angle which it forms with the verte- bral column. It constitutes the most prominent portion of the pro- montory of the sacrum, and is the part on which the finger generally impinges in vaginal examinations. The anterior common vertebral ligament passes over the surface of the joints, and we also find the ligamenta sub-flava and the inter-spinous ligaments, as in the other vertebrae. The articular processes are joined together by a fibrous capsule, and there is also a peculiar ligament, the lumbo-sacral, extending from the transverse process of the vertebra on each side, and attaching itself to the sides of the sacrum and the sacro-iliac synchondrosis. Ligaments of Coccyx. — The sacrum is joined to the coccyx, and, in ANATOMY OF THE PELVIS 29 some cases at least, the separate bones of the coccyx to each other, by small cartilaginous disks like that connecting the sacrum with the last lumbar vertebra. They are farther united by anterior and posterior common ligaments, the latter being much the thicker and more marked. In the adult female a synovial membrane is found between the sacrum and coccyx, and it is supposed that this is formed under the influence of the movements of the bones on each other. Sacro-iliac Synchondrosis. — The opposing articular surfaces of the sacrum and ilium are each covered by cartilages, that of the sacrum being the thickest. These ' are firmly united, but, in the female, according to Mr. Wood, 1 they are always more or less separated by an intervening synovial membrane. Posterior to these cartilaginous convex surfaces there are strong interosseous ligaments, passing directly from bone to bone, filling up the interspace between them, and uniting them firmly. There are also accessory ligaments, such as the superior and anterior sacro iliac, which are of secondary con- sequence. The posterior sacro-iliac ligaments, however, are of great obstetric importance. They are the very strong attachments which unite the rough surfaces on the posterior iliac tuberosities to the posterior and lateral surfaces of the sacrum. They pass obliquely Fig. 3. Section of Pelvis and Heads of Thigh-bones, showing the Suspensory Action of the Sacro-iliac ■ Ligaments. (After Wood.) downwards from the former points, and suspend, as it were, the sacrum from them. According to Duncan, the sacrum has nothing to prevent its being depressed by the weight of the body but these Todd's Cyclopaedia of Anatomy and Physiology, article "Pelvis," p. 123. 30 ORGANS CONCERNED IN PARTURITION. ligaments, and it is mainly through, them that the weight of the body is transmitted to the sacro-cot)doid beams and the heads of the femur. Sacro-sciatic Ligaments. — The sacro-sciatic ligaments are instru- mental in completing the canal of the pelvis. The greater sacro- sciatic ligament is attached by a broad base to the posterior spine of the ilium, and to the posterior surfaces of the ilium and coccyx. Its fibres unite into a thick cord, cross each other in an X-like manner, and again expand at their insertion into the tuberosity of the ischium. The lesser sacro-sciatic ligament is also attached with the former to the back parts of the sacrum and coccyx, its fibres passing to their much narrower insertion at the spine of the ischium, and converting the sacro-sciatic notch into a complete foramen. Obturator Mem.br ane. — The obturator membrane is the fibrous aponeurosis that closes the large obturator foramen. Joulin 1 supposes that, along with the sacro-sciatic ligaments, it may, by yielding some- what to the pressure of the foetal head, tend to prevent the contusion to which the soft parts would be subjected if they were compressed between two entirely osseous surfaces. Symphysis Pubis. — -The junction of the pubic bones in front is effected by means of two oval plates of fibro-cartilage, attached to each articular surface by nipple-shaped projections, which fit into corresponding depressions in the bones. There is a greater separa- tion between the bones in front than behind, where the numerous fibres of the cartilaginous plates intersect, and unite the bones firmly together. At the upper and back part of the articulation there is an interspace between the cartilages, which is lined by a delicate membrane. In pregnancy this space often increases in size, so as to extend even to the front of the joint. The juncture is further strengthened by four ligaments, the anterior, the posterior, the supe- rior, and the sub-pubic. Of these, the last is the largest, connecting together the pubic bones and forming the upper boundary of the pubic arch. Movements of Pelvic Joints. — The close apposition of the bones of the pelvis might not unreasonably lead to the supposition that no movement took place between its component parts ; and this is the opinion which is even yet held by many anatomists. It is tolerably certain, however, that even in the unimpregnated condition there is a certain amount of mobility. Thus Zaglas has pointed out 2 that in man there is a movement in an antero-posterior direction of the sacro-iliac joints, which has the effect, in certain positions of the bod}^ of causing the sacrum to project downwards to the extent of about a line, thus narrowing the pelvic brim, tilting up the point of the bone, and thereby enlarging the outlet of the pelvis. This movement seems habitually brought into play in the act of straining during defecation. Observations in the Lower Animals. — During pregnancy in some of the lower animals there is a very marked movement of the pelvic articulations, which materially facilitates the process of parturition. 1 Traite d' Accouchements, p. 11. 2 Monthly Journal of Med. Science, Sept. 1851. ANATOMY OF THE PELVIS. 31 This, in the case of the guinea-pig and cow, has been specially pointed out by Dr. Matthews Duncan. 1 In the former, during labor, the pelvic bones separate from each other to the extent of an inch or more. In the latter the movements are different, for the sj^mphysis pubis is fixed by bony anchylosis, and is immovable; but the sacro- iliac joints become swollen during pregnancy, and extensive move- ments in an antero-posterior direction take place in them, which materially enlarge the pelvic canal during labor. Mode in which the Movements are effected. — It is extremely probable that similar movements take place in women, both in the symphysis pubis and in the sacroiliac joints, although to a less marked extent. These are particularly well described by Dr. Duncan. They seem to consist chiefly in an elevation and depression of the symphysis pubis, either by the ilia moving on the sacrum, or by the sacrum itself undergoing a forward movement on an imaginary transverse axis passing through it, thus lessening the pelvic brim to the extent of one or even two lines, and increasing, at the same time, the diameter of the outlet by tilting up the apex of the sacrum. These movements are only an exaggeration of those which Zaglas describes as occurring normally during defecation. The instinctive positions which the parturient woman assumes find an explanation in these observations. During the first stage of labor, when the head is passing through the brim, she sits, or stands, or walks about, and in these erect positions the symphysis pubis is depressed, and the brim of the pelvis enlarged to its utmost. As the head advances through the cavity of the pelvis, she can no longer maintain her erect position, and she lies down and bends her body forward, which has the effect of causing a nutatory motion of the sacrum, with corresponding tilting up of its apex, and an enlargement of the outlet. Alterations in the Pelvic Joints during Pregnancy. — These move- ments during parturition are facilitated by the changes which are known to take place in the pelvic articulations during pregnancy. The ligaments and cartilages become swollen and softened, and the synovial membranes existing between the articulating surfaces become greatly augmented in size and distended with fluid. These changes act by forcing the bones apart, as the swelling of a sponge placed between them might do after it had imbibed moisture. The reality of these alterations receives a clinical illustration from those cases, which are far from uncommon, in which these changes are carried to so extreme an extent, that the power of progression is materially interfered with for a considerable time after delivery. Pelvis as a Whole. — On looking at a pelvis as a Avhole, we are at once struck with its division into the true and false pelvis. The latter portion (all that is above the brim of the pelvis) is of compara- tively little obstetric importance, except in giving attachments to the accessory muscles of parturition, and need not be further con- sidered. The brim of the pelvis is a heart-shaped opening, bounded by the sacrum behind, the linea ilio-pectinea on either side, and the 1 Researches in Obstetrics, p. 19. 32 ORGANS CONCERNED IN PARTURITION. symphysis of the pubes in front. All below it forms the cavity, which is bounded by the hollow of the sacrum. behind, by the inner surfaces of the innominate bones at the sides and in front, and by the posterior surface of the symplrysis pubis. It is in this part of the pelvis that the changes in direction which the foetal head undergoes Fig. 4. Outlet of Pelvis. in labor are imparted to it. The lower border of this canal, or pelvic outlet (Fig. 4), is lozenge-shaped, is bounded by the ischiatic tuberosities on either side, the tip of the coccyx behind, and the under surface of the pubic symphysis in front. Posteriorly to the tuberosities of the ischia the boundaries of the outlet are completed by the sacro-sciatic ligaments. Differences in the two Sexes. — There is a very marked difference between the pelvis in the male and the female, and the peculiarities of the latter all tend to facilitate the process of parturition. In the female pelvis (Fig. 5) all the bones are lighter in structure, and have Fig. 5. The Female Pelvis. the points for muscular attachments much less developed. The iliac bones are more spread out, hence the greater breadth which is ob- ANATOMY OF THE PELVIS. S3 served in the female figure, and the peculiar side-to-side movement which all females have in walking. The tuberosities of the ischia are lighter in structure and further apart, and the rami of the pubes also converge at a much less acute angle. This greater breadth of the pubic arch gives one of the most easily appreciable points of Fig. 6. The Male Pelvis. contrast between the male and female pelvis; the pubic arch in the female forms an angle of from 90° to 100 3 , while in the male (Fig. 6) it averages from 70° to 75°. The obturator foramina are more triangular in shape. The whole cavity of the female pelvis is wider and less funnel- shaped than in the male, the symphysis pubis is not so deep, and, as the promontory of the sacrum does not project so much, the shape of the pelvic brim is more oval than heart-shaped. These differences between the male and female pelves are probably due to the presence of the female genital organs in the true pelvis, the growth of which increases its development in width. In proof of this, Schroeder states that in women with congenitally defective internal organs, and in women who have had both ovaries removed early in life, the pelvis has always more or less of the masculine type. Measurements of the Pelvis. — The measurements of the pelvis that are of most importance from an obstetric point of view, are taken between various points directly opposite to each other, and are known as the diameters of the pelvis. Those of the true pelvis are the dia- meters which it is especially important to fix in our memories, and it is customary to describe three in works on obstetrics — the antero- posterior or conjugate, the oblique, and the transverse — although of course the measurements may be taken at any opposing points in the circumference of the bones. The antero-posterior (sacro-pubic), at the brim (Fig. 7), is taken from the upper part of the posterior surface of the symphysis pubis to the centre of the promontory of the sacrum; in the cavity, from the centre of the symphysis pubis to a corresponding point in the body of the third piece of the sacrum : and ORGANS CONCERNED IN PARTURITION Fig. 7. Brim of Pelvis, showing Antero-posterior, Oblique, and Conjugate Diameters. Fig. Traus verse Section of Pelvis, Diameters. showing the at the outlet (coccy-pubic), from the lower border of the symphysis pubis to the tip of the coccyx. The oblique, at the brim, is taken from the sacro-iliac joint on either side to a point of the brim corres- ponding with the ilio-pectineal em- inence (that starting from the right sacro-iliac joint being called the right oblique, that from the left, the oblique); in the cavity a similar measurement is made at the same level as the conjugate; while at the outlet an oblique diameter is not usually measured. The trans- verse is taken at the brim, from a point midway between the sacro- iliac joint and the ilio-pectineal eminence to a corresponding point at the opposite side of the brim; in the cavity from points in the same plane as the conjugate and oblique diameters; and at the outlet from the centre of the inner border of one ischial tuberosity to that of the other. The measure- ments given by various writers differ considerably, and vary some- what in different pelves. Taking the average of a large number, the following may be given as the standard measurements of the female pelvis : — ANATOMY OF THE PELVIS. 60 Antero-poste rior. Oblique. Transvev in. in. in. 4.25 4.8 5.2 4.7 5.2 4.75 5.0 — 4.2 Brim .... Cavity .... Outlet .... It will be observed that the lengths of the corresponding dia- meters at different places vary greatly; thus while the transverse is longest at the brim, the oblique is longest in the cavity, and the anteroposterior at the outlet. It will be subsequently seen that this fact is of great practical importance in studying the mecha- nism of delivery, for the head in its descent through the pelvis alters its position in* such a way as to adapt itself to the largest diameter of the pelvis; thus as it passes through the cavity it lies in the oblique diameter, and then rotates so as to be expelled in the antero- posterior diameter of the outlet. Diameters as altered by Soft Parts. — In thinking of these measure- ments of the pelvis, it must not be forgotten that they are taken in the dried bones, and that they are considerably modified during life by the soft parts. This is especially the case at the brim, where the projection of the psoas and iliacus muscles lessens the transverse diameter about half an inch, while the antero-posterior diameter of the brim, and all the diameters of the cavity, are lessened by a quarter of an inch. The right oblique diameter of the brim is, even in the dried pelvis, found to be, on an average, slightly longer than the left ; probably on account of the increased development of the right side of the pelvis from the greater use made of the right leg; but in addition to this, the left oblique diameter is somewhat lessened during life by the presence of the rectum on the left side. The advantage gained by the comparatively frequent passage of the head through the pelvis in the right oblique diameter is thus explained. Other Measurements. — There are one or two other measurements of the true pelvis which are sometimes given, but which are of secon- cisay importance. One of these, the sacro-cotyloid diameter, is that between the promontory of the sacrum and a point immediately above the cotyloid cavity, and averages from 3.4 to 3.5 inches. An- other, called by Wood the lower or inclined conjugate diameter, is that between the centre of the lower margin of the symphysis pubis and the promontory of the sacrum, and averages half an inch more than the antero-posterior diameter of the brim. These measurements are chiefly of importance in relation to certain pelvic deformities. External Measurements. — The external measurements of the pelvis are of no real consequence in normal parturition, but they may help us, in certain cases, to estimate the existence and amount of deformi- ties. Those which are generally given are: Between the anterior- superior iliac spines, 10 inches; between the central points of the crests of the ilia, 10J inches; between the spinous process of the last lumbar vertebra and the upper part of the symphysis pubis (external conjugate), 7 inches. Planes of the Pelvis. — By the planes of the pelvis are meant imagi- nary levels at any portion of its circumference. If we were to cut 36 ORGANS CONCERNED IN PARTURITION out a piece of cardboard so as to fit the pelvic cavity, and place it either at the brim or elsewhere, it would represent the pelvic plane at that particular part, and it is obvious that we may conceive as many planes as we desire. Observation of the angle which the pelvic planes form with the horizon shows the great obliquity at which the pelvis is placed in regard to the spinal column. Thus the angle abi (Fig. 9) represents the inclination to the horizon of Planes of the Pelvis with Horizon. A. B. Horizon. CD. Vertical line. abi. Angle of inclination of pelvis to horizon, eqnal to 6')°. b i c. Angle of inclination of pelvis to spinal column, equal to 150°. c i J. Angle of inclination of sacrum to spinal column, equal to 130°. e f. Axis of pelvic inlet. i- m. Mid plane in the middle line. n. Lowest point of mid plane of ischium. the plane of the pelvic brim I b, and is estimated to be about 60°, while the angle which the same plane forms with the vertebral column is about 150°. The plane of the outlet forms, with the coccyx in its usual positiou, an angle with the horizon of about 11°, but which varies greatly with the movements of the tip of coccyx, and the degree to which it is pushed back during parturition. These figures must only be taken as giving an approximative idea of the inclination of the pelvis to the spinal column, and it must be remem- bered that the degree of inclination varies considerably in the same female at different times, in accordance with the position of the body. During pregnancy especially, the obliquity of the brim is lessened by the patient throwing herself backwards in order to support more easily the weight of the gravid uterus. The height of the promon- tory of the sacrum above the upper margin of the symphysis pubis ANATOMY OF THE PELVIS 37 is on an average about 3} inches, and a line passing horizontally backwards from the latter point would impinge on the junction of the second and the third coccygeal bones. Axes of the Parturient Canal. — By the axis of the pelvis is meant an imaginary line which indicates the direction which the foetus takes during its expulsion. The axis of the brim (Fig. 10) is a line Fig. 10. A. Axis of superior plane. ] D. Axis of canal Axes of the Pelvis. 5. Axis of mid plane. C Axis of inferioi Horizon. plane. drawn perpendicular to its plane, which would extend from the um- bilicus to about the apex of the coccyx ; the axis of the outlet of the bony pelvis intersects this, and extends from the centre of the pro- montory of the sacrum to midway between the tuberosities of the ischia. The axis of the entire pelvic canal is represented by the sum of the axes of an indefinite number of planes at different levels of the pelvic cavity, which forms an irregular parabolic line, as repre- sented in the accompanying diagram (Fig. 10, A d). It must be borne in mind, however, that it is not the axis of the bony pelvis alone that is of importance in obstetrics. We must always, in considering this subject, remember that the general axis of the parturient canal (Fig. 11) also includes that of the uterine cavity above, and of the soft parts below. These are variable in direction according to circumstances ; and it is only the axis of that portion of the parturient canal extending between the plane of the pelvic brim and a plane between the lower edge of the pubic sym- physis and the base of the coccyx that is fixed. The axis of the lower part of the canal will vary according to the amount of disten- sion of the perineum during labor ; but when this is stretched to its utmost, just before the expulsion of the head, the axis of the plane 38 ORGANS CONCERNED IN PARTURITION. between the edge of the distended perineum and the lower border of the symphysis, looks nearly directly forwards. The axis of the ute- rine cavity generally corresponds with that of the pelvic brim, but Fig. 11. [Representing General Axis of Parturient Canal, including the Uterine Cavity and Soft Parts. it may be much altered by abnormal positions of the uterus, such as anteversion from laxit}^ of the abdominal walls. The foetus, under such circumstances, will not enter the brim in its proper axis, and difficulties in the labor arise. A knowledge of the general direction of the parturient canal is of great Fig. 12. importance in practical midwifery in guiding us to the introduction of the hand or instruments in obstetric operations, and in showing us how to obviate difficulties arisino- from such accidental deviations of the uterus as have been just alluded to. Cavity of the Pelvis. — The ar- rangements of the bones in the in- terior of the pelvic canal (Fig. 12) are important in relation to the mechanism of delivery. A line passing between the spine of the ischium and the ilio-pectineal emi- nence divides the inner surface of side view of Pelvis. ischial bone into two smooth plane ANATOMY OF THE PELVIS. 89 surfaces, which have received the name of the planes of the ischium. Two other planes are formed by the inner surfaces of the pubic bones in front and by the upper portion of the sacrum behind, both having a direction downwards and backwards. In studying the mechanism of delivery, it will be seen that many obstetricians at- tribute to these planes, in conjunction with the spine of the ischium, a very important influence in effecting rotation of the foetal head from the oblique to the anteroposterior diameter of the pelvis. Development of the Pelvis. — The peculiarities of the pelvis during infancy and childhood are of interest as leading to a knowledge of the manner in which the form observed during adult life is impressed upon it. The sacrum in the pelvis of the child (Fig. 13) is less cle- Fig. 13. Pelvis of a Child. veloped transversely, and is much less deeply curved than in the adult. The pubes is also much shorter from side to side, and the pubic arch is an acute angle. The result of this narrowness of both the pubes and sacrum is that the transverse diameter of the pelvic brim is shorter instead of longer than the antero-posterior. The sides of the pelvis have a tendency to parallelism, as well as the antero- posterior walls ; and this is stated by Wood to be a peculiar charac- teristic of the infantile pelvis. The iliac bones are not spread out as in adult life, so that the centres of the crests of the ilium are not more distant from each other than the anterior superior spines. The cavity of the true pelvis is small, the tuberosities of the ischia are proportionately nearer to each other than they afterwards become ; the pelvic viscera are consequently crowded up into the abdominal cavity, which is, for this reason, much more prominent in children than in adults. The bones are soft and semi-cartilaginous until alter the period of puberty, and yield readily to the mechanical infliien to which they are subjected; and the three divisions of the innomi- nate bone remain separate until about the twentieth year. As the child grows older the transverse development of the sacrum increases, and the pelvis begins to assume more and more of the adult 40 ORGANS CONCERNED IN PARTURITION. shape. The mere growth of the bones, however, is not sufficient to account for the change in the shape of the pelvis, and it has been well shown by Duncan that this is chiefly produced by the pressure to which the bones are subjected during early life. The iliac bones are acted upon by two principal and opposing forces. One is the weight of the body above, which acts vertically upon the sacral ex- tremity of the iliac beam through the strong posterior sacro-iliac ligaments, and tends to throw the lower or acetabular ends of the sacro-cotyloid beams outwards. This outward displacement, how- ever, is resisted, partly by the junction between the two acetabular ends at the front of the pelvis, but chiefly by the opposing force, which is the upward pressure of the lower extremities through the femurs. The result of these counteracting forces is that the still soft bones bend near their junction with the sacrum ; and thus the greater transverse development of the pelvic brim characteristic of adult life is established. In treating of pelvic deformities it will be seen that the same forces applied to diseased and softened bones ex- plain the peculiarities of form that they assume. Pelvis in Different Races. — The researches that have been made on the differences of the pelvis in different races prove that these are not so great as might have been expected. Joulin pointed out that in all human pelves the transverse diameter was larger than the antero-posterior, while the reverse was the case in all the lower animals, even in the highest simise. This observation has been more recently confirmed by Yon Franque, 1 who has made careful measure- ments of the pelvis in various races. In the pelvis of the gorilla the oval form of the brim, resulting from the increased length of the conjugate diameter, was very marked. In certain races there is so far a tendency to animality of type, that the difference between the transverse and conjugate diameters is much less than in European women, but is not sufficiently marked to enable us to refer any given pelvis to a particular race. Yon Franque makes the general obser- vation that the size of the pelvis increases from South to North, but that the conjugate diameter increases in proportion to the transverse in southern races. Soft Parts in Connection with Pelvis. — In closing the description of the pelvis, the attention of the student must be directed to the mus- cular and other structures which cover it. It has already been pointed out that the measurements of the pelvic diameters are con- siderably lessened by the soft parts, which also influence parturition in other ways. Thus attached to the crests of the ilia are strong muscles which not only support the enlarged uterus, during pregnancy, but are powerful accessory muscles in labor : in the pelvic cavity are the obturator and pyriformis muscles lining it on either side ; the . pelvic cellular tissue and fasciae ; the rectum and bladder ; the vessels and nerves, pressure on which often gives rise to cramps and pains during pregnancy and labor ; while below the outlet of the pelvis is closed, and its axis directed forwards, by the numerous muscles form- ing the floor of the pelvis and perineum. 1 Scanzoni's Beitrage, 1867. THE FEMALE GENERATIVE ORGANS. 41 CHAPTEE II. THE FEMALE GENERATIVE ORGANS. Division according to Function. — The reproductive organs in the female are conveniently divided, according to their functions, into : 1, The external or copulative organs, which are chiefly concerned in the act of insemination, and are only of secondary importance in parturition: they include all the organs situated externally which form the vulva; and the vagina, which is placed internally and forms the canal of communication between the uterus and the vulva. 2, The internal or formative organs : they include the ovaries, which are the most important of all, as being those in which the ovule is formed; the Fallopian tubes, through, which the ovule is carried to the uterus; and the uterus, in which, the impregnated ovule is lodged and developed. 1. The external organs consist of: — Mons Veneris. — The rnons veneris, a cushion of adipose and fibrous tissue which forms a rounded projection at the upper part of the vulva. It is in relation above with the lower part of the hypogastric region, from which it is often separated by a furrow, and below it is continuous with the labia majora on either side. It lies over the symphysis and horizontal rami of the pubes. After puberty it is covered with hair. On its integument are found the openings ot numerous sweat and sebaceous glands. Labia Majora. — The labia majora form two symmetrical sides to the longitudinal aperture of the vulva. They have two surfaces, one external, of ordinal integument, covered with hair, and another internal, of smooth mucous membrane, in apposition with the corre- sponding portion of the opposite labium, and separated from the external surface by a free convex border. They are thicker in front, Avhere they run into the mons veneris, and thinner behind, where they are united, in front of the perineum, by a thin fold of integu- ment called the fourchette, which is almost invariably ruptured in the first labor. In the virgin the labia are closely in apposition, and conceal the rest of the generative organs. After child-bearing they become more or less separated from each other, and in the aged they waste, and the internal nymphae protrude through them. Both their cutaneous and mucous surfaces contain a large number of sebaceous glands, opening either directly on the surface or into the hair follicles. In structure the labia are composed of connective tissue, containing a varying amount of fat, and parallel with their external surface are placed tolerably close plexuses of elastic tissue, inters] >crscd with regularly arranged smooth muscular fibres. These fibres are described by Broca as forming a membranous sac, resembling the dartos of the 4 42 ORGANS CONCERNED IN PARTURITION. scrotum, to which the labia majora are analogous. Towards its upper and narrower end this sac is continuous with the external inguinal ring, and in it terminate some of the fibres of the round ligament. The analogy with the scrotum is further borne out by the occasional hernial protrusion of the ovary into the labium, corresponding to the normal descent of the testis in the male. Labia Minora. — The labia minora, or nymphae, are two folds of mucous membrane, commencing below, on either side, about the centre of the internal surface of the labium externum ; they converge as they proceed upwards, bifurcating as they approach each other. The lower branch of this bifurcation is attached to the clitoris, while the upper and larger uDites with its fellow of the opposite side, and forms a fold round the clitoris, known as its prepuce. The nymphae are usually entirely concealed by the labia majora, but after child- bearing and in old age they project somewhat beyond them; then they lose their delicate pink color and soft texture, and become brown, dry, and like skin in appearance. This is especially the case in some of the negro races, in whom they form long projecting folds called the apron. The surfaces of the nymphae are covered with a tesselated epithe- lium, and over them are distributed a large number of vascular papillae, somewhat enlarged at their extremities, and sebaceous glands, which are more numerous on their internal surfaces. The latter secrete an odorous, cheesy matter, which lubricates the surface of the vulva, and prevents its folds adhering to each other. The nymphae are composed of trabeculae of connective tissue, containing muscular fibres. Clitoris. — The clitoris is a small erectile tubercle situated about half an inch below the anterior commissure of the labia majora. It is the analogue of the penis in the male, and is similar to it in struc- ture, consisting of a corpus cavernosum, the two halves of which are separated by a fibrous septum. The crura are covered by the ischio- cavernous muscles, which serve the same purpose as in the male. It has also a suspensory ligament. The corpora cavernosa are composed of a vascular plexus with numerous traversing muscular fibres. The arteries are derived from the perineal artery, and give a branch, the cavernous, to each half of the organ; there is also a dorsal arter}- distributed to the prepuce. According to Gussenbauer these caver- nous arteries pour their blood directly into large veins, and a finer venous plexus near the surface receives arterial blood from small arterial branches. By these arrangements the erection of the organ which takes place during sexual excitement is favored. The nervous supply of the clitoris is large, being derived from the internal pudic nerve, which supplies branches to the corpora cavernosa, and termi- nates in the glands and prepuce, where Paccinian corpuscles and ter- minal bulbs are to be found. On this account the clitoris has been supposed by some to be the chief seat of voluptuous sensation in the female. Vestibule. — The vestibule is a triangular space, bounded at its apex by the clitoris, and on either side by the folds of the nymphae. It is THE FEMALE GENERATIVE ORGANS. 43 smooth, and, unlike the rest of -the vulva, is destitute of sebaceous glands, although there are several groups of muciparous glands open- ing on its surface. At the centre of the base of the triangle which is formed by the upper edge of the opening of the vagina, is a promi- nence, distant about an inch from the clitoris, on which is the orifice of the urethra. This prominence can be readily made out by the finger, and the depression upon it — leading to the urethra — is of im- portance as our guide in passing the female catheter. This little operation ought to be performed without exposing the patient, and it is done in several ways. The easiest is to place the tip of the index finger of the left hand (the patient lying on her back) on the apex of the vestibule, and slip it gently down until we feel the bulb of the urethra, and the dimple of its orifice, which is generally readily found. If there is any difficulty in finding the orifice, it is well to remember that it is placed immediately below the sharp edge of the lower border of the symphysis pubis, which will guide us to it. The catheter (and a male elastic catheter is always the best, especiallv during labor, when the urethra is apt to be stretched) is then passed under the thigh of the patient, and directed to the orifice of the urethra by the finger of the left hand, which is placed upon it. We must be careful that the instrument is really passed into the urethra, and not into the vagina. It is advisable to have a few feet of elastic tubing attached to the end of the catheter, so that the urine can be passed into a vessel under the bed without uncovering the patient. If the patient be on her side, in the usual obstetric position, the ope- ration can be more readily performed by placing the tip of the finger in the vagina and feeling its upper edge. The orifice of the urethra lies immediately above this, and if the catheter be slipped along the palmar surface of the finger, it can generally be inserted without much trouble. If, however, as is often the case during labor, the parts are much swollen, it may be difficult to find the aperture, and it is then always better to look for the opening than to hurt the patient by long-continued efforts to feel it. [In this country, the in- strument is almost always introduced when possible, with the woman on her back. — Ed.] Urethra. — The urethra is a canal 1 J inches in length, and it is inti- mately connected with the anterior wall of the vagina, through which it may be felt. It is composed of muscular and erectile tissue, and is remarkable for its extreme dilatability, a property which is turned to practical account in some of the operations for stone in the female bladder. Orifice of the Vagina. — The orifice of the vagina is situated imme- diately below the bulb of the urethra. In virgins it is a circular opening, but in women who have borne children or practised sexual intercourse, it is, in the undistended state, a vertical fissure. In virgins it is generally more or less blocked up by a fold of mucous membrane, containing some cellular tissue and muscular fibres, with vessels and nerves, which is known as the hymen. This is most often crescentic in shape, with the concavity of the crescent looking up- 44 ORGANS CONCERNED IN PARTURITION. wards ; sometimes, "however, it is circular with a central opening, or cribriform ; or it may even be entirely imperforate, and this gives rise to the retention of the menstrual secretion. These varieties of form depend on the peculiar mode of development of the fold of vaginal mucous membrane which blocks up the orifice of the vagina in the foetus, and from which the hymen is formed. The density of the membrane also varies in different individuals. Most usually it is very slight, so as to be ruptured in the first sexual approaches, or even by some accidental circumstance, such as stretching the limbs, so that its absence cannot be taken as evidence of want of chastity. A knowledge of this fact is of considerable importance from a medi- co-legal point of view. Sometimes it is so tough as to prevent inter- course altogether, and may require division by the knife or scissors before this can be effected ; and at others it rather unfolds than rup- tures, so that it may exist even after impregnation has been effected, and it has been met with intact in women who have habitually led unchaste lives. [It may also form an obstacle to delivery, and re- quire to be incised before the foetus can be extruded. — Ed.] Carunculse Myrtiformes. — The carunculse myrtiformes are small fleshy tubercles, varying from two to five in number, situated round the orifice of the vagina, and which are supposed to be formed by the remains of the ruptured hymen. Vulvo-vaginal Glands. — Near the posterior part of the vaginal orifice, and below the superficial perineal fascia, are situated two conglomerate glands which are the analogues of Cowper's glands in the male. Each of these is about the size and shape of an almond, and is contained in a cellular fibrous envelope. Internally they are of a yellowish- white color, and are composed of a number of lobules separated from each other by prolongations of the external envelope. These give origin to separate ducts which unite into a common canal, about half an inch in length, which opens in front of the attached edge of the hymen in virgins, and in married women at the base of one of the carunculse myrtiformes. According to Huguier, the size of the glands varies much in different women, and they appear to have some connection with the ovary, as he has always found the largest gland to be on the same side as the largest ovary. They secrete a glairy, tenacious fluid, which is ejected in jets during the sexual orgasm, probably through the spasmodic action of the perineal mus- cles. At other times their secretion serves the purpose of lubri- cating the vulva, and thus preserves the sensibility of its mucous membrane. Fossa Navicularis. — Immediately behind the hymen in the un- married, and between it and the perineum, is a small depression called the fossa navicularis, which disappears after childbearing. Perineum. — The perineum separates the orifice of the vagina from that of the rectum. It is about 1J inches in breadth, and is of great obstetric interest, not only as supporting the internal organs from below, but because of its action in labor. It is largely stretched and distended by the presenting part of the child; and if unusually tough THE FEMALE GENERATIVE ORGANS 45 and unyielding may retard delivery, or it may be torn to a greater or less extent, thus giving rise to various subsequent troubles. Vascular Supply of the Vulva. — The structures described above together form the vulva, and they are remarkable for their abundant vascular and nervous supply. The former constitutes an erectile tissue similar to that which has already been described in the cli- toris, and which is especially marked about the bulb of the vestibule (Fig. 14). From this point, and extending on either side of the Fig. 14. Vascular Supply of Vulva. (After Kobelt.) n. Bulb of vestibule, b. Muscular tissue of vagiua. c,d,e,f. The clitoris and its muscles, g, h, i, k, I, m, n. Veins of the nymphse and clitoris communicating with the epigastric and obturator veins. vagina, there is a well-marked plexus of convoluted veins, which, in their distended state, are likened by Dr. Arthur Farre to a filled leech. The erection of the erectile tissue, as well as that of the clitoris, is brought about under excitement, as in the male, by the compression of the efferent veins by the contraction of the ischio- cavernous muscles, and by that of a thin layer of muscular tissues surrounding the orifice of the vagina, and described as the constrictor vaginae. Vagina. — The vagina is the canal which forms the communication between the external and internal generative organs, through which the semen passes to reach the uterus, the menses flow, and the foetus is expelled. Koughly speaking, it lies in the axis of the pelvis, but its opening is placed anterior to the axis of the pelvic outlet, so that its lower portion is curved forwards. It is narrow below, but dilated above, where the cervix uteri is inserted into it, so that it is more or 46 ORGANS CONCERNED IN PARTURITION less conoiclal in shape. Generally speaking, its anterior and posterior walls lie closely in contact, but they are capable of very wide dis- tension, as during the passage of the foetus. The anterior wall of the vagina is shorter than the posterior, the former measuring on an average 2 J inches, the latter 3 inches; but the length of the canal varies greatly in different subjects and under certain circumstances. In front the vagina is closely connected with the base of the bladder, so that when the vagina is prolapsed, as often occurs, it drags the bladder with it (Fig. 15); behind, it is in relation with the rectum, Fig. 15. Longitudinal Section of Body, showing Kelatious of Generative Organs. but less intimately; laterally with the broad ligaments and pelvic fascia; and superiorly with the lower portion of the uterus and folds of peritoneum both before and behind. The vagina is composed of mucous, muscular, and cellular coats. The mucous lining is thrown into numerous folds. These start from longitudinal ridges which exist on both the anterior and posterior walls, but most distinctly on the anterior. They are very numerous in the young and unmarried, and greatly increase the sensitive surface of the vagina. After child- bearing, and in the aged, they become atrophied, but they never completely disappear, and towards the orifice of the vagina, where they exist in greatest abundance, they are always to be met with. The whole of the mucous membrane is lined with tesselated epithe- lium, and it is covered with a large number of papillae either conical or divided, which are highly vascular and project into the epithelial THE FEMALE GENERATIVE ORGANS. 47 layer. Unlike the vulvar mucous membrane, that of the vagina seems to be destitute of glands. Beneath the epithelial layer is a submucous tissue containing a large number of elastic and some muscular fibres, derived from the muscular walls of the vagina. These are strong and well- developed, especially towards the ostium vaginae. They consist of two layers — an internal longitudinal, and an external circular — with oblique decussating fibres connecting the two. Below they are attached to the ischio-pubic rami, and above they are con- tinuous with the muscular coat of the uterus. The muscular tissue of the vagina increases in thickness during pregnancy, but to a much less degree than that of the uterus. Its vascular arrangements, like those of the vulva, are such as to constitute an erectile tissue. The arteries form an intricate network around the tube, and eventually end in a submucous capillary plexus, from which twigs pass to supply the papillae; these again give origin to venous radicles which unite into meshes freely interlacing with each other, and forming a well- marked venous plexus. Internal Organs of Generation. — 2. The internal organs of gene- ration consist of the uterus, the Fallopian tubes, and the ovaries ; and in connection with them we have to study the various ligaments and folds of peritoneum which serve to maintain the organs in posi- tion, along with certain accessory structures. Physiologically, the most important of all the generative organs are the ovaries, in which the ovules are formed, and which dominate the entire reproductive life of the female. The Fallopian tubes which convey the ovule to the uterus, and the uterus itself — whose main function is to receive, nourish, and eventually expel the impregnated product of the ovary — may be said to be, in fact, accessory to these viscera. Practically, however, as obstetricians, we are chiefly concerned with the uterus, and may conveniently commence with its description. Uterus. — The uterus is correctly described as a pyriform organ, flattened from before backwards, consisting of the body, with its rounded fundus, and the cervix which projects into the upper part of the vaginal canal. In the adult female it is deeply situated in the pelvis, being placed between the bladder in front and the rectum behind, its fundus being below the plane of the pelvic brim (Fig. 16). It only assumes this position, however, towards the period of puberty ; and in the foetus it is placed much higher, and lies, indeed, entirely within the cavity of the abdomen. It is maintained in this position partly by being slung by its ligaments, which Ave shall subsequently study, and partly by being supported from below by the pelvic cel- lular tissue and the fleshy column of the vagina. The result is that the uterus, in the healthy female, is a perfectly movable body, alter- ing its position to suit the condition of the surrounding viscera, especially the bladder and rectum, which are subjected to variations of size according to their fulness or emptiness. When from any cause — as, for example, some peri-uterine inflammation producing adhesions to the surrounding textures — the mobility of the organ is interfered with, much distress ensues, and if pregnancy supervenes more or less serious consequences may result. Generally speaking, 48 ORGANS CONCERNED IN PARTURITION. the uterus may be said to lie in a line roughly corresponding with the axis of the pelvic brim, its fundus being pointed forwards and its cervix lying in such a direction that a line drawn from it would impinge on the junction between the sacrum and coccyx. According Fig. 16. Transverse Section of the Body, showing Eelations of the Fundus Uteri. m. Puhes. a, a (in front), Remainder of hypogastric arteries, <7, a (behind), Spermatic vessels and nerves. B. Bladder. L, L. Round ligaments. IT. Fundus uteri, t, t. Fallopian tubes, o, o. Ovaries, r. Rectum, g. Right ureter, resting on the psoas muscle, c. Utero-sacral ligaments, v Last lumbar vertebra. to some authorities, the uterus in early life is more curved in the anterior direction, and is, in fact, normally in a state of ante-flexion. Sappey holds that this is not necessarily the case, but that the amount of anterior curvature depends on the emptiness or fulness of the bladder, on which the uterus, as it were, moulds itself in the unim- pregnated state. It is believed also that the body of the uterus is very generally twisted somewhat obliquely, so that its anterior sur- face looks a little towards the right side, this probably depending on the presence and frequent distension of the rectum in the left side of the pelvis. The anterior surface of the uterus is convex, and is covered in three-fourths of its extent by the peritoneum, which is intimately adherent to it. Below the reflection of that membrane it is loosely connected by cellular tissue to the bladder, so that any downward displacement of the uterus drags the bladder along with it. The posterior surface is also convex, but more distinctly so than the anterior, as may be observed in looking at a transverse section of the organ (Fig. 17). It is also covered by peritoneum, the reflection of which on the rectum forms the cavity known as Douglas's pouch. The fundus is the upper extremity of the uterus, lying above the THE FEMALE GENERATIVE ORGANS. 49 points of entry of the Fallopian tubes. It is only slightly rounded in the virgin, but b°comes more decidedly and permanently rounded in the woman who has borne children. Fig. 1 Transverse Section of Uterus. Dimensions. — Until the period of puberty the uterus remains small and undeveloped (Fig. 18) ; after that time it reaches the adult size, at which it remains until menstruation ceases, when it again atrophies. If the woman has borne children, it always remains larger than in the nullipara. In the virgin adult the uterus measures 2J inches from the orifice to the fundus, rather more than half being taken up Fig. 18. Uterus and AppeDdages in an Infant. (After Farre.) by the cervix. Its greatest breadth is opposite the insertion of the Fallopian tubes; its greatest thickness, about 11 or 12 lines, oppo- site the centre of its body. Its average weight is about 9 or 1" drachms. Independently of pregnancy, the uterus is subject to great alterations of size towards the menstrual period, when on account of the congestion then present, it enlarges, sometimes, it is said, con- siderably. This fact should be borne in mind, as this periodical swelling might be taken for an early pregnancy. 50 ORGANS CONCERNED IN PARTURITION. Regional Divisions. — For the purpose of description the uterus is conveniently divided into the fundus, with its rounded upper ex- tremity, situated between the insertions at the Fallopian tubes; the body, which is bounded above by the insertion of the Fallopian tubes, and below by the upper extremity of the cervix, and which is the part chiefly concerned in the reception and growth of the ovum ; and the cervix, which projects into the vagina, and dilates during labor to give passage to the child. The cervix is conical in shape, measur- ing 11 to 12 lines transversely at the base, and 6 or 7 in the antero- posterior direction ; while at the apex it measures 7 to 8 transversely, and 5 antero-posteriorly. It projects about 4 lines into the canal of the vagina, the remainder of the cervix being placed above the reflection of the vaginal mucous membrane. It varies much in form in the virgin and nulliparous married woman, and in the woman who has borne children; and the differences are of importance in the diagnosis of pregnancy and uterine disease. In the virgin it is regularly pyramidal in shape. At its lower extremity is the opening of the external os uteri, forming a small transverse fissure, sometimes difficult to feel, and generally described as giving a sensation to the examining finger like the extremity of the cartilage at the tip of the nose. It is bounded by two lips, the anterior of which is apparently larger on account of the position of the uterus. The surface of the cervix, and the borders of the os, are very smooth and regular. Changes after Childbirth. — In women who have borne children these parts become considerably altered. The cervix is no longer conical, but is irregular in form and shortened. The lips of the os uteri become fissured and lobulated, on account of partial lacerations which have occurred during labor. The os is larger and more irregu- lar in outline, and is sometimes sufficiently patulous to admit the tip of the finger. In old age the cervix atrophies, and after the change of life it not uncommonly entirely disappears, so that the orifice of the os uteri is on a level with the roof of the vagina. , Internal Surface of the Uterus. — The internal surface of the uterus comprises the cavities of the body and cervix — the former being rather less than the latter in length in virgins, but about equal in women who have borne children — separated from each other by a constriction forming the upper boundary of the cervical canal. The cavity of the body is triangular in shape, the base of the triangle being formed by a line joining the openings of the Fallopian tubes, its apex by the upper orifice of the cervix, or internal os, as it is sometimes called. In the virgin its boundaries are somewhat convex, projecting inwards. After childbearing they become straight or slightly concave. The opposing surfaces of the cavity are always in contact in the healthy state, or are only separated from each other by a small quantity of mucus. Cavity of the Cervix. — The cavity of the cervix is spindle-shaped or fusiform, narrower above and below, at the internal and external os uteri, and somewhat dilated between these two points. It is flat- tened from before backwards, and its opposing surfaces also lie in contact, but not so closely as those of the body. On the mucous THE FEMALE GENERATIVE ORGANS 51 lining of the anterior and posterior surfaces is a prominent perpen- dicular ridge, with a lesser one at each side, from which transverse ridges proceed at more or less acute angles. These have received the name of the arbor vitas. According to Gruyon the perpendicular ridges are not exactly opposite, so that they fit into each other, and serve more completely to fill up the cavity of the cervix, especially towards the internal os (Fig. 19). The arbor vitas is most distinct in the virgin, and atrophies considerably after childbearing. Fig. 19. Portion of Interior of Cervix. (Enlarged nine diameters.) (After Tyler Smith and Hassall.) The superior extremity of the cervical canal forms a narrow isthmus separating it from the cavity of the body, and measuring about |ths of an inch in diameter. Like the external os, it contracts after the cessation of menstruation, and in old age sometimes be- comes entirely obliterated. Structure of the Uterus. — The uterus is composed of three principal structures — the peritoneal, muscular, and mucous coats. The peri- toneum forms an investment to the greater part of the organ, ex- tending downwards in. front to the level of the os internum, and behind to the top of the vagina, from which points it is reflected upwards on the bladder and rectum respectively. At the sides the peritoneal investment is not so extensive, for a little below the level of the Fallopian tubes the peritoneal folds separate from each other, forming the broad ligaments (to be afterwards described) ; here it is that the vessels and nerves supplying the uterus gain access to it. At the upper part of the organ the peritoneum is so closely adherenl 52 ORGANS CONCERNED IN PARTURITION. Fig. 20. to the muscular tissue that it cannot be separated from it ; below the connection is more loose. The mass of the uterine tissue, both in the body and cervix, consists of unstriped muscular fibres, firmly united together by nucleated con- nective tissue and elastic fibres. The muscular fibre cells are large and fusiform, with very attenuated extremities, generally containing in their centre a distinct nucleus. These cells, as well as their nuclei, become greatly enlarged during pregnancy (Fig. 21); according to Strieker, this is only the case with the muscular fibres which play an important part in the expulsion of the foetus, those of the outermost and innermost layers not sharing in the increase of size. 1 In addi- tion to these developed fibres there are, especially near the mucous coat, a number of round elementary corpuscles, which are believed Muscular Fibres of unimpregnated Uterus (After Farre.) a. Fibres united by connective tissue. Separate fibres and elementary corpuscles. Fig. 21. Developed Mi Gravid Uterus. (After Wagner.) by Dr. Farre 2 to be the elementary form of the muscular fibres, and which he has traced in various intermediate states of development. Dr. John "Williams 3 believes that a great part of the muscular tissue of the uterus, rather more indeed than three-fourths of its thickness, is an integral part of the mucous membrane, analogous to the mus- cularis mucosas of the mucous membrane of the alimentary canal. This he describes as being separated from the rest of the muscular tissue by a layer of rather loose connective tissue, containing nume- rous vessels. In early foetal life, and in the uteri of some of the lower animals, this appearance is very distinct ; in the adult female uterus, however, it cannot be readily made out. Arrangement of the Muscular Fibres. — On examining the uterine tissue in an unimpregnated condition no definite arrangement of its muscular fibres can be made out, and the whole seem blended in in- extricable confusion. By observation of their relations when hyper- 1 Comparative Histology, vol. iii., Syrt. Soc. Trans., p 47 7. 2 The Uterus and its Appendages, p. G.'>2. 3 "On the Structure of the Mucous Membrane of the Uterus, 1875. Obstet. Journ., THE FEMALE GENERATIVE ORGANS. 53 trophied during pregnancy, Helie 1 has shown that they may, speaking roughly, be divided into three layers : an external ; a middle, chiefly longitudinal ; and an internal, chiefly circular. Into the details of their distribution, as described by him, it is needless to enter at length. Briefly, however, he describes the external layer as arising posteriorly at the junction of the body and cervix, and spreading upwards and over the fundus. From this are derived the muscular fibres found in the broad and round ligaments, and more particularly described by Rouget. The middle layer is made up of strong fasciculi, which run upwards, but decussate and unite with each other in a remarkable manner, so that those which are at first superficial become most deeply seated, and vice versa. The muscular fasciculi which form this coat curve in a circular manner around the large veins, so as to form a species of muscular canal through which they run. This arrangement is of peculiar importance, as it affords a satisfactory ex- planation of the mechanism by which hemorrhage after delivery is prevented. The internal layer is mainly composed of circular rings of muscular fibres, beginning round the openings of the Fallopian tubes, and forming wider and wider circles which eventually touch and interlace with each other. They surround the internal os, to which they form a kind of sphincter. In addition to these circular fibres on the internal uterine surface, both anteriorly and posteriorly, there is a well-marked triangular layer of longitudinal fibres, the base being above and the apex below, which sends muscular fasciculi into the mucous membrane. Its Mucous Membrane. — The anatomy of the lining membrane of the uterus has been the subject of considerable discussion. Its exist- ence has been denied by many authorities, most recently by Snow Beck, 2 who maintains that it is in no sense a mucous membrane, but only a softened portion of true uterine tissue. It is, however, pretty generally admitted by the best authorities that it is essentially a mu- cous membrane, differing from others only in being more closely adherent to the subjacent structures, in consequence of not possess- ing any definite connective tissue framework. It is a pale pink membrane of considerable thickness, most marked at the centre of the body, where it forms from Jth to Jth of the thickness of the whole uterine walls. At the internal os uteri it ter- minates by a distinct border, which separates it from the mucous membrane lining the cervical cavity. The Utricular Glands. — On the surface of the mucous membrane may be observed a multitude of little openings, about ^th of a line in width (Fig. 22). These are the orifices of the utricular glands, which are found in immense numbers all over the cavity of the uterus, and very closely agglomerated together. They are Little culs- de-sac, narrower at their mouths than in their length, the blind ex- tremities of which are found in the subjacent tissues. Williams describes them as running obliquely towards the surface at the Lower 1 Recherches sur la disposition des Fibres musculaires de 1' Uterus. Paris, L869. 2 Obst. Trans., vol. xiii. p. 294. 54 ORGANS CONCERNED IN PARTURITION. third of the cavity, perpendicularly at its middle, while towards the fundus they are at first perpendicular, and then oblique in their Fig. 23. Lining Membrane of Uterus, showing network of Capillaries and Orifices of Uterine Glands. (After Farre.) Prom the body. From orifice of Fallopian tube. course (Fig. 23). By others they are described as being often twisted and corkscrew-like. One or more may unite to form a common orifice, several of which may open together in little pits or depres- sions on the surface of the mucous membrane. These glands are composed of structureless membrane lined with epithelium, the precise character of which is doubtful. By some it is described as columnar, by others tesselated, and by some again as ciliated. The most gener- ally received opinion is that it is columnar, but not ciliated ; therein differing from the epithelium covering the surface of the membrane, which is undoubtedly ciliated, the movements of the cilia being from within outwards. Williams, however, has observed cilia in active movement on the columnar epithelium lining the glands, and also states that at the deep-seated extremi- ties of the glands, which penetrate between the muscular fibres for some distance, the columnar epithelium is replaced by rounded cells. The capillaries of the mucous mem- brane run down between the tubes, form- ing a lace -work on their surfaces, and round their orifices. No true papillae exist in 'the membrane lining the uterine cavity. The mucous membrane of the uterus is peculiar in being always in a state of change and alteration, being thrown oft' at each menstrual period in the form of debris, in consequence of fatty degeneration of its structures, and, reformed afresh by pro- liferation of the cells of the muscular and connective tissues, probably from below upwards, the new membrane commencing Hence its appearance and structure vary consid- The course of the Glands in the fully developed Mucous Mem- brane of the Uterus, viz., just be- fore the onset of a menstrual period. (After Williams.) at the internal os. THE FEMALE GENERATIVE ORGANS. 55 erably according to the time at which it is examined. This subject, however, will be more particularly studied in connection with men- struation. Mucous Membrane of the Cervix. — The mucous membrane of the cervix is much thicker and more transparent than that of the body of the uterus, from which it also differs in certain structural peculiari- ties. The general arrangements of its folds and surface have already been described. The lower half of the membrane lining the cavity of the cervix, and the whole of that covering its external or vaginal por- tion, are closely set with a large number of minute filiform, or clavate papillae (Fig. 24). Their structure is similar to that of the mucous Fig. 24. Villi of Os Uteri stripped of Epithelium. (After Tyler Smith aud Hassall.) membrane itself, of which they seem to be merely elevations. They each contain a vascular loop (Fig. 25), and they are believed by Kilian and Farre to be mainly concerned in giving sensibility to this part of the generative tract. All over the interior of the cervix, both on the ridges of the mucous membrane and between their folds, are a very large number of mucous follicles, consisting of a structure- less membrane lined with cylindrical epithelium, and intimately united with the connective tissue. They cease at the external orifice of the cervix, and they secrete the thick, tenacious, and alkaline mucus which is generally found filling the cervical cavity. The transparent follicles, known as the "ovula Nabothii" which arc some- times found in considerable numbers in the cavity of the cervix, con- sist of mucous follicles the mouths of which have become obstructed, and their canals distended by mucous secretion. The lower third 56 ORGANS CONCERNED IN PARTURITION. of the cervical canal, as well as the exterior of the cervix, are covered with pavement epithelium ; while on its upper portion is found a columnar and ciliated epithelium similar to that lining the uterine cavity. Fig. 25. Villi of uterus, covered with. Pavement Epithelium, and containing Looped Vessels. (After Tyler Smith and Hassall.) Vessels of the Uterus. — The arteries of the uterus are derived from the internal iliac, and from the ovarian. They enter the uterus be- tween the folds of the broad ligaments, and, penetrating its muscular coat, anastomose freely with each other and with the corresponding vessels of the opposite side. Their walls are thick and well-devel- oped, and they are remarkable for their very tortuous course, forming spiral curves, especially in the upper part of the uterus. They end in minute capillaries which form the fine meshes surrounding the glands, and in the cervix, give off the loops entering the papillae. Beneath the uterine mucous membrane these capillaries form a plexus, terminating in veins without valves, which unite with each other to form the large veins traversing the substance of the uterus, known during pregnancy as the uterine sinuses, the walls of which are closely adherent to the uterine tissues. These veins, freely anastomosing with each other, pass outwards to the folds of the broad ligaments, where they unite to form, with the ovarian and vaginal veins, a large and well-developed venous network, known as the pampiniform plexus. Lymphatics of the Uterus. — The lymphatics of the uterus are large and well developed, and they have recently, and with much proba- bility, been supposed to play an important part in the production of certain puerperal diseases. A more minute knowledge than we at THE FEMALE GENERATIVE ORGANS. 57 present possess of their course and distribution will probably throw much light on their influence in this respect. According to the re- searches of Leopold, 1 who has studied their minute anatomy care- fully, they originate in lymph spaces between the fine bundles of connective tissue forming the basis of the mucous lining of the uterus. Here they are in intimate contact with the utricular glands and the ultimate ramifications of the uterine bloodvessels. As they pass into the muscular tissue they become gradually narrowed into lymph vessels and spaces, which have a very complicated arrangement, and which eventually unite together in the external muscular layer, espe- cially on the sides of the uterus, to form large canals which probably have valves. Immediately under the peritoneal covering these lymph -vessels form a large and characteristic network, covering the anterior and posterior surfaces of the uterus, and present, in various parts of their course, large ampullae. They then spread over the Fallopian tubes. The lymphatics of the body of the uterus unite with the lumbar glands, those of the cervix with the pelvic glands. Nerves of the Uterus. — The distribution and arrangement of the nerves of the uterus have been the subject of much controversy. They are derived mainly from the ovarian and hypogastric plexuses, inosculating freely with each other between the folds of the broad liga- ment, from which they enter the muscular tissue of the uterus gene- rally, but not invariably, following the course of the arteries. They are chiefly derived from the sympathetic; but, as the hypogastric plexus is connected with the sacral nerves, it is probable that some fibres from the cerebro-spinal system are distributed to the cervix. It is now generally admitted that nervous filaments are distributed to the cervix, even as far as the external os although their existence in this situation has been denied \>y Jobert and other writers. The ultimate distribution of the nerves is not yet made out. Polle de- scribes a nerve filament as entering the papillae of the cervical mu- cous membrane along with the capillary loop, and Frankenhauser says the nerve fibres surround the muscles of the uterus in the form of plexuses and terminate in the nuclei of the muscle cells. Anomalies of the Uterus. — Various abnormal conditions of the uterus and vagina are occasionally met with, which it is necessary to mention, as they may have an important practical bearing on parturition. The most frequent of these is the existence of a double, or partially double, uterus (Fig. 26), similar to that found normally in many of the lower animals. This abnormality is explained by the development of the organ during foetal life. The uterus is formed out of structures existing only in early foetal life, known as the Wolfian bodies. These consist of a number of tubes, situated on either side of the vertebral column, and opening internally into an excretory duct. Along their external border a hollow canal is formed, termed the canal of Miiller, which like the excretory duds, proceeds to the common cloaca of the digestive and urinary organs which then exists. The canal of Mullcr unites with its fellow of the • Arch. f. Gynak. Bd. vi. Heft i. 58 ORGANS CONCERNED IN PARTURITION. opposite side to form the uterus and Fallopian tubes in the female, and subsequently the central partition at their point of junction dis- appears. If, however, the progress of development be in any way Then we have produced checked, the central partition may remain. Fig. 26. Bifid Uterus. (After Farre.) either a complete double uterus or the uterus bicornis, which is bifid at its upper extremity only ; or a double vagina, each leading to a separate uterus. Pregnancy in cases of Bifid Uterus. — If pregnancy occur in any of these anomalous uteri, and many such cases are recorded, serious troubles may follow. It may happen that one horn of a double uterus is not sufficiently large to admit of pregnancy going on to term, and rupture may occur. It is supposed that some cases, pre- sumed to be tubal gestation, were really thus explicable. Impreg- nation may also occur in the two cornua at different times, leading to superfcetation. It is, however, quite possible that impregnation may occur in one horn of a bifid uterus, and labor be completed with- out anything unusual being observed. A remarkable case of this sort has been recorded by Dr. Eoss of Brighton, 1 in which a patient miscarried of twins on July 16, 1870, and on October 31, fifteen weeks later, she was delivered of a healthy child. Careful examination showed the existence of a complete double uterus, each side of which had been impregnated. Curiously enough, this patient had formerly given birth to six living children at term, nothing remarkable having been observed in her labors. It can only rarely happen, that, under such circumstances, so favorable a result will follow, and more or less difficulty and danger may generally be expected. Occasionally the vagina only is double, the uterus being single. Dr. Matthews Duncan has recorded some cases of this kind, 2 in which the vaginal septum formed an obstacle to the birth of the child, and required division. [It may also be associated with an obstinate form of vagi- nismus. — Ed.] 1 Lancet, August, 1871. 2 Researches in Obstetrics, p. 443. THE FEMALE GENERATIVE ORGANS. 59 Ligaments of the Uterus. — The various folds of peritoneum which invest the uterus serve to maintain it in position, and they are de- scribed as its ligaments. They are the broad, the vesieo-uterine, and sacro-uterine ligaments ; the round ligaments are not peritoneal folds like the others. Broad Ligaments. — The broad ligaments extend from either side of the uterus, where their laminae are separated from each other, transversely across to the pelvic wall, and thus divide the cavity of the pelvis into two parts; the anterior containing the bladder, the posterior the rectum. Their upper borders are divided into three subsidiary folds, the anterior of which contains the round ligament, the middle the Fallopian tube, and the posterior the ovary. This arrangement has received the name of the ala vespertilionis, from its fancied resemblance to a bat's wing. Between the folds of the broad ligaments are found the uterine vessels and nerves, and a certain amount of loose cellular tissue continuous with the pelvic fascia?. Here is situated that peculiar structure called the organ of Bosen- miiller, or the parovarium (Fig. 27), which is the remains of the Fig. 27. Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) Wolffian body, and corresponds to the epididymis in the male. This may best be seen in young subjects, by holding up the broad liga- ments and looking through them by transmitted light; but it exists at all ages. It consists of several tubes (eight or ten according to Farre, eighteen or twenty according to Bankes), 1 which arc tortuous in their course. They are arranged in a pyramidal form, the base of the pyramid being towards the Fallopian tube, its apex being lost on the surface of the ovary. They are formed of fibrous tissue, and lined with pavement epithelium. They have no excretory duct, or communication with either the uterus or ovary, and their {'unction. if they have any, is unknown. 1 Bankes, On the Wolffian Bodies. 60 ORGANS CONCERNED IN PARTURITION. Muscular Fibres between its Folds. — A number of muscular fibres are also found in this situation, lying between the meshes of the connective tissue. They have been particularly studied by Kouget, who describes them as interlacing with each, other, and forming an open network, continuous with, the muscular tissue of the uterus Fig. 28. Posterior View of Muscular and Vascular Arrangements. (After Kouget.) Vessels. — 1, 2,3. Vaginal, cervical, aud uterine plexuses. 4. Arteries of body of uterus. 5. Arteries supplying ovary. Muscular fasciculi.— 6, 7. Fibres attached to vagina, symphysis pubis, and sacro- iliac joint 8. Muscular fasciculi from uterus and broad ligaments. 9,10,11,12. Fasciculi attached to ovary and Fallopian tubes. (Fig. 28). They are divisible into two layers, the anterior of which is continuous with the muscular fibres of the anterior surface of the uterus, and goes to form part of the round ligament; the posterior arises from the posterior wall of the uterus, and proceeds transversely outwards, to become attached to the sacro-iliac synchondrosis. A continuous muscular envelope is thus formed, which surrounds the whole of the uterus, Fallopian tubes, and ovaries. Its function is not yet thoroughly established. It is supposed to have the effect of retracting the stretched folds of peritoneum after delivery, and more especially of bringing the entire generative organs into harmonius action during menstruation and the sexual orgasm; in this way explaining, as we shall subsequently see, the mechanism by which THE FEMALE GENERATIVE ORGANS. 61 the fimbriated extremity of the Fallopian tube grasps the ovary prior to the rupture of a Graafian follicle. Round Ligaments. — The round ligaments are essentially muscular in structure. They extend from the upper border of the uterus, with the fibres of which their muscular fibres are continuous, trans- versely and then obliquely downwards, until they reach the inguinal rings, where they blend with the cellular tissue. In the first part of their course the muscular fibres are solely of the unstriped variety, but soon they receive striped fibres from the transversalis muscles, and the columns of the inguinal ring, which surround and cover the unstriped muscular tissue. In addition to these structures they con- tain elastic and connective tissue, and arterial, venous, and nervous branches ; the former form the iliac or cremasteric arteries, the latter the genito-crural nerve. According to Mr. Kainey the principal function of these ligaments is to draw the uterus towards the sym- physis pubis during sexual intercourse, and thus to favor the ascent of the semen. Vesicouterine Ligaments. — The vesico-uterine ligaments are two folds of peritoneum passing in front from the lower part of the body of the uterus to the fundus of the bladder. Utero-sacral Ligaments. — The utero-sacral ligaments consist of folds of peritoneum of a crescentic form, with their concavities look- ing inwards : they start from the lower part of the posterior surface of the uterus, and curve backwards to be attached to the third and fourth sacral vertebra. Within their folds exist bundles of muscu- lar fibres, continuous with those of the uterus, as well as connective tissue, vessels, and nerves. The experiments of Savage, as well as of other anatomists, show that these ligaments have an important influence in preventing downward displacement of the womb. Alterations during Pregnancy. — During pregnancy all these liga- ments become greatly stretched and unfolded, rising out of the pelvic cavity and accommodating themselves to the increased size of the gravid uterus ; and they again contract to their natural size, possibly through the agency of the muscular fibres contained within them, after delivery has taken place. Fallopian Tithes. — 'The Fallopian tubes, the homologues of the vasa deferentia in the male, are structures of great physiological interest. They serve the double purpose of conveying the semen to the ovary, and of carrying the ovule to the uterus. From the latter function they may be looked on as the excretory ducts of the ovaries; but, unlike other excretory ducts, they are movable, so that they may apply themselves to the part of the ovaries from which the ovule is to come ; and so great is their mobility, that there is reason to believe that a Fallopian tube may even grasp the ovary of the opposite side. [This has been established by a case where impregnation look place in an ovary, the Fallopian tube corresponding to which was imper- vious and immovable. — Ed.] Each tube proceeds from the upper angle of the uterus at first transversely outwards, and then down- wards, backwards, and inwards, so as to reach the neighborhood of the ovary. In the first part of its course it is straight, afterwards it 62 ORGANS CONCERNED IN PARTURITION. becomes flexuous and twisted on itself. It is contained in the upper part of the broad ligament, where it may be felt as a hard cord. It commences at the uterus by a narrow opening, admitting only the passage of a bristle, known as the ostium uterinum. As it passes through the muscular walls of the uterus the tube takes a somewhat curved, course, and opens into the uterine cavity by a dilated aper- ture. From its uterine attachment the tube expands gradually until it terminates in its trumpet-shaped extremity ; just before its distal end, however, it again contracts slightly. The ovarian end of the tube is surrounded by a number of remarkable fringe-like processes. These consist of longitudinal membranous fimbriae, surrounding the aperture of the tube, like the tentacles of a polyp, varying conside- rably in number and size, and having their edges cut and subdivided. On their inner surface are found both transverse and longitudinal folds of mucous membrane, continuous with those lining the tube itself (Fig. 29). One of these fimbriae is always larger and more de- Fig. 29. Fallopian Tube laid open (After Richard.) a, b. Uterine portion of Tube, c, d. Plicse of Mucous Membrane, e. Tubo-ovarian Ligaments and Fringes. /. Ovary, g. Round Ligaments. veloped than the rest, and is indirectly united to the surface of the ovary by a fold of peritoneum proceeding from its external surface. Its under surface is grooved so as to form a channel, open below. The function of this fringe-like structure is to grasp the ovary during the menstrual nisus ; and the fimbria which is attached to the ovan* would seem to guide the tentacles to the ovary which they are in- tended to seize. One or more supplementary series of fimbriae some- times exist, which have an aperture of communication with the canal of the Fallopian tube, beyond its ovarian extremity. Their Structure. — The lubes themselves consist of peritoneal, mus- cular, and mucous coats. The peritoneum surrounds the tube for three-fourths of its calibre, and comes into contact with the mucous THE FEMALE GENERATIVE ORGANS. 63 lining at its fimbriated extremity, the only instance in the body where snch a junction occurs. The muscular coat is principally composed of circular fibres, with a few longitudinal fibres inter- spersed. Its muscular character has been doubted by Robin and Richard, but Farre had no difficulty in demonstrating the existence of muscular fibres, both in the human female and many of the lower animals. According to Robin the muscular tissue of the Fallopian tubes is entirely distinct from that of the uterus, from which he describes it as being separated by a distinct cellular septum. The mucous lining is thrown into a number of remarkable longitudinal folds, each of Avhich contains a dense and vascular fibrous septum, with small muscular fibres, and is covered with columnar and ciliated epithelium. The apposition of these produces a series of minute capillary tubes, along which the ovules are propelled, the action of the cilia, which is towards the uterus, apparently favoring their progress. The Ovaries. — The ovaries are the bodies in which the ovules are formed, and from which they are expelled, and the changes going on in them, in connection with the process of ovulation, during the whole period between the establishment of puberty and the cessation of menstruation, have an enormous influence on the female economy. Normally, the ovaries are two in number ; in some exceptional cases a supplementary ovary has been discovered ; or they may be entirely absent. They are placed in the posterior fold of the broad ligament, .usually below the brim of the pelvis, behind the Fallopian tubes, the left in front of the rectum, the right in front of some coils of the small intestine. Their situation varies, however, very much under different circumstances, so that they can scarcely be said to have a fixed and normal position. In pregnancy they rise into the abdomi- nal cavity with the enlarging uterus; and in certain conditions they are dislocated downwards into Douglas's space, where they may be felt through the vagina as rounded and very tender bodies. Their Connections. — The folds of the broad ligament, between which the ovaries are placed, form for them a kind of loose mesentery. Each of them is united to the upper angle of the uterus by a special ligament called the utero-ovarian. This is a rounded band of organic muscular fibres, about an inch in length, continuous with the super- ficial muscular fibres of the posterior wall of the uterus, and attached to the inner extremity of the ovary. It is surrounded by peritoneum, and through it the muscular fibres, which form an important integral part in the structure of the ovaries, are conveyed to them. The ovary is also attached to the fimbriated extremity of the Fallopian tube in the manner already described. The ovary is of an irregular oval shape (Fig. 30), the upper bor- der being convex, the lower — through which the vessels and nerves enter — being straight. The anterior surface, like that of tin 1 uterus, is less convex than the posterior. The outer extremity is more rounded and bulbous than the inner, which is somewhat pointed and eventually lost in its proper ligament. By these peculiarities l1 is possible to distinguish the left from the right ovary, after they Lave 64 ORGANS CONCERNED IN PARTURITION. been removed from the body. The ovary varies much in size under different circumstances. On an average, in adult life, it measures from one to two inches in length, three-quarters of an inch in width, and about half an inch in thickness. It increases greatly in size during each menstrual period ; a fact which has been demonstrated in certain cases of ovarian hernia, where the protruded ovary has been seen to swell as menstruation commenced ; also during preg- nancy, when it is said to be double its usual size. After the change of life it atrophies, and becomes rough and wrinkled on its surface. Be- Fig. 30. A A. Ovary enlarged under Menstrual IS T isus. b. Ripe Follicle projecting on its surface, a, a, a. Traces of previously ruptured Follicles. fore puberty, the surface of the ovary is smooth and polished, and of a whitish color. After menstruation commences, its surface becomes scarred by the rupture of the Graafian follicles (Fig. 30, A a), each of which leaves a little linear or striated cicatrix, of a brownish color ; and the older the patient the greater are the number of these cicatrices. Structure. — The structure of the ovary has been made the subject of many important observations. It has an external covering of epithelium, originally continuous with the peritoneum, called by some the germ-epithelium, in consequence of the ovules being formed from it in early foetal life. In the adult it is separated from the peri- toneum at the base of the organ by a circular white line, and it con- sists of columnar epithelium, differing only from the epithelium lining the Fallopian tubes, with which it is sometimes continuous through the attached fimbria uniting the tube and the ovary, in being destitute of cilia. Immediately beneath this covering is the dense coat known as the tunica albuginea, on account of its whitish color. It consists of short connective-tissue fibres, arranged in laminas, among which are interspersed fusiform muscular fibres. At the point where the vessels and nerves enter the ovary this membrane is raised into a ridge, which is continuous with the utero-ovarian ligament. The THE FEMALE GENERATIVE ORGANS. 65 tunica albuginea is so intimately blended with the stroma of the ovary, as to be inseparable on dissection ; it does not, however, exist as a distinct lamina, bat is merely the external part of the proper structure of the ovary, in which more dense connective tissue is developed than elsewhere. The Stroma. — On making a longitudinal section of the ovary (Fig. 31). it will be seen to be composed of two parts, the more internal of which is of a reddish color from the num- ber of vessels that ramify in it, and is called Fig. 31 . the medullary or vascular zone ; while the external, of a whitish tint, receives the name of the cortical or parenchymatous substance. The former consists of loose connective tissue interspersed with elastic, and a considerable number of muscular fibres. According to Eouget 1 and His 2 the muscular structure forms the greater part of the ovarian stroma. The latter de- scribes it as consisting essentially of inter- woven muscular fibres, which he terms T L a . , . ■ , . iin-p • 11 i i-ii i Longitudinal section of adult the "mSlIOrm tlSSUe, and WhlCh he be- ovary. (After Farre.) lieves to be continuous with the muscular layers of the ovarian vessels. The former believes that the mus- cular fasciculi accompany the vessels in the form of sheaths, as in erectile tissues. Both attribute to the muscular tissues an important influence in the expulsion of the ovules, and in the rupture of the Graafian follicles. Waldeyer and other writers, however, do not consider it to be so extensively developed as Eouget and His believe. The cortical substance is the more important, as that in which the Graafian follicles and ovules are formed. It consists of interlaced fibres of connective tissue, containing a large number of nuclei. The muscular fibres of the medullary substance do not seem to penetrate into it in man. In it are found the Graafian follicles, which exist in enormous numbers from the earliest periods of life, and in all stages of development (Fig. 32). Tlie Graafian Follicles. — According to the researches of Pfliiger, Waldeyer, and other German writers, the Graafian follicles are formed in early foetal life by cylindrical inflections of the epithelial covering of the ovary, which dip into the substance of the gland. These tubular filaments anastomose with each other, and in them are formed the ovules, which are originally the epithelial cells lining the tubes. Portions become shut off from the rest of the filaments, and form the Graafian follicles. The ovules, on this view, are highly developed epithelial cells, originally derived from the surface of the ovary, and not developed in its stroma. These tubular li laments disappear shortly after birth, but they have recently been detected 1 Journal de Physiol, i. p. 787. 2 Schultze's Arch. f. Mikrocop. Anat. 1865. 66 ORGANS CONCERNED IN PARTURITION. by Slavyansky 1 in the ovaries of a woman thirty years of age. These observations have been modified by Dr. Foulis, in a recent Fig. 32. Section through the Cortical part of the Ovary. s s. Ovarian Stromo. 1 1. Large-sized Graafian Follicles e. Surface Epithelium sizpd, and 3 3. Small-sized Graafian Follicles, o. Ovule within Graafian Follicle in the Stroma, g. Cells of the Membrana Granulosa. (After Turner.) 2 2. Middle- D1). Bloodvessels Fig. 33. Vertical Section through the Ovary of the Human Foetus. g g. Germ-epithelium, with no. Developing Ovules in it. s s. Ovarian Stroma, containing ccc. Fusiform Connective Tissue Corpuscles, dd. Capillary Bloodvessels. In the centre of the Figure an Involution of the Germ-epithelium is shown; and at the left lower side a Primordial Ovule, with the Connective-tissue Corpuscles ranging themselves rouud it. (After Foulis.) graduation thesis, communicated to the Eoyal Society of Edinburgh. 2 lie recognizes the origin of the ovules from the germ-epithelium 1 Annales de Gynak, Feb. 1871. 2 Proceedings of the Royal Soe. of Edinb., April, 1875. THE FEMALE GENERATIVE ORGANS. 67 covering the surface of the ovary, which is itself derived from the Wolffian body. He believes all the ovules to be formed from the germ-epithelium corpuscles, which become embedded in the stroma of the ovary, by the outgrowth of processes of vascular connective tissue, fresh germ-epithelial corpuscles being constantly produced on the surface of the organ up to the age of 2J years, to take the place of those already embedded in its stroma. lie believes the Graafian follicles to be formed by the growth of delicate processes of connec- tive tissue between and around the ovules, but not from tubular in- flections of the epithelium covering the gland, as described by Waldeyer (Fig. 33). The greater proportion of the Graafian follicles are only visible with the higher powers of the microscope, but those which are ap- proaching maturity are distinctly to be seen by the naked eye. The quantity of these follicles is immense. Foulis estimates that at birth each human ovary contains not less than 30,000. No fresh follicles appear to be formed after birth, and as development goes on some only grow, and by pressure on the others, destroy them. Of those that grow of course only a few ever reach maturity ; they are scat- tered through the substance of the ovary, some developing in the stroma, others on the surface of the organ, where they eventually burst, and are discharged into the Fallopian tube. Structure. — A ripe Graafian follicle has an external investing mem- brane (Fig. 34), which is generally described as consisting of two Fig. 34. Diagrammatic Section of Graafian Follicle. 1. Ovum. 2. Membniiiii granulosa. '■'>. External membrane of Graafian follicle, t. Eta vessel* Ovarian stroma. 6. Cavity of Graafian follicle. External covering of ovary. distind layers; the external, or tunica fibrosa, highly vascular and formed of'connective tissue; the internal, or tunica />r>>/>ri'f, composed of young connective tissue, containing a large number of Fusiform or stellate cells, and numerous oil-globules. These layers, however, appear to be essentially formed of condensed ovarian str a. Within this capsule is the epithelial lining called the membrana granulosa, consisting of stratified columnar epithelial cells, which, according to Foulis, are originally formed from the nuclei of the Gbro-nuclear 68 ORGANS CONCERNED IN PARTURITION. tissue of the stroma of the ovary. At one part of the circumference of the ovisac is situated the ovule, around which the epithelial cells are congregated in greater quantity, constituting the projection known as the discus proliger us. The remainder of the cavity of the follicle is filled with a small quantity of transparent fluid, the liquor folliculi, traversed by three or four minute bands, the retinacula of Barrj^, which are attached to the opposite walls of the follicular cavity, and apparently serve the purpose of suspending the ovule, and main- taining it in a proper position. In many young follicles this cavity does not at first exist, the follicle being entirely filled by the ovule. According to Waldeyer, the liquor folliculi is formed by the disinte- gration of the epithelial cells, the fluid thus produced collecting, and distending the interior of the follicle. Ovule. — The ovule is attached to some part of the internal surface of the Graafian follicle. It is a rounded vesicle about T i n of an inch in diameter, and is surrounded by a layer of columnar cells, distinct from those of the discus proligerus in which it lies. It is invested by a transparent elastic membrane, the zona pellucida, or vitelline membrane. In most of the lower animals the zona pellucida is per- forated by numerous very minute pores, only visible under the highest powers of the microscope ; in others there is a distinct aper- ture of a larger size, the micropyle, allowing the passage for the spermatozoa into the interior of the ovule. It is possible that similar apertures may exist in the human ovule, but they have not been demonstrated. Within the zona pellucida some embryologists de- scribe a second fine membrane, the existence of which has been denied by Bischoff. The cavity of the ovule is filled with a viscid yellow fluid, the yelk, containing numerous granules. It entirely fills the cavity, to the walls of which it is non-adherent. In the centre of the yelk in j^oung, and at some portion of its periphery in mature ovules, is situated the germinal vesicle, which is a clear cir- cular vesicle, refracting light strongly, and about g ! B th of a line in diameter. It contains a few granules, and a nucleolus, or germinal spot, which is sometimes double. From within outwards, therefore we find: — 1. The germinal spot; round this 2. The germinal vesicle, contained in 3. The yelk, which is surrounded by the 4. Zona pellucida, with its layers of columnar epithelial cells. These constitute the ovule. The ovule is contained in — The Graafian follicle, and lies in that part of its epithelial lining called the — Discus proligerous, the rest of the follicle being occupied by the liquor folliculi. Bound these we have the epithelial lining or mem- brana granulosa, and the external coat consisting of the tunica pro- pria and the tunica fibrosa. Vessels and Nerves of the Ovary. — The vascular supply of the ovary is complex. The arteries enter at the hilum, penetrating the stroma in a spiral curve, and are ultimate!}?- distributed in a rich capillary THE FEMALE GENERATIVE ORGANS 69 plexus to the follicles. The large veins unite freely with each other, and form a vascular and erectile plexus, continuous with that sur- rounding the uterus, called the bulb of the ovarj (Fig. 35). Lym- phatics and nerves exist, but their mode of termination is unknown. Fig. 35. u. Uterus Pampiniform ovarian plexus Bulb of Ovary. Ovary and utero-ovarian ligament, r. Fallopian tube. 1. Utero-ovarian vein. 3. Commencement of spermatic vein. The Mammary Glands. — To complete the consideration of the generative organs of the female we must study the mammary glands, which secrete the fluid destined to nourish the child. In the human subject they are two in number, and instead of being placed upon the abdomen, as in most animals, they are situated on either side of the sternum, over the pectoralis major muscles, and extend from the third to the sixth ribs. This position of the glands is obviously intended to suit the erect position of the female in suckling. They are con- vex anteriorly, and flattened posteriorly where they rest on the muscles. They vary greatly in size in different subjects, chiefly in proportion to the amount of adipose tissue they contain. In man. and in girls, previous to puberty, they are rudimentary in structure ; while in pregnant women they increase greatly in size, the true glandular structures becoming much hypertrophied. Anomalies in shape and position are sometimes observed. Supplementary mammae, one or more in number, situated on the upper portion of the mam- mae, are sometimes met with, identical in structure with the normally situated glands; or, more commonly, an extra nipple is observed 1>\ the side of the normal one. In some races, especially the African, the mamm;c are so enormously developed, that the mother is able to suckle her child over her shoulder. Their Structure. — The skin covering the gland is sofl and supple, and during pregnancy often becomes covered with fine white lines, while large blue veins may be observed coursing over. Underneath it is a quantity of connective tissue, containing a <■< >nsiderable amounl of fat, which extends between the true glandular structure. 'This is composed of from fifteen to twenty lobes, each of which is formed of a number of lobules. The lobules arc produced by the agg tion of the terminal acini in which the milk is formed. The acini are minute cul-de-sacs opening into little ducts, which unite with TO ORGANS CONCERNED IN PARTURITION. each other until they form a large duct for each lobule ; the ducts of each lobule unite with each other, until they end in a still larger duct common to each of the fifteen or twenty lobes into which the gland is divided, and eventually open on the surface of the nipple. These terminal canals are known as the yalactophorous ducts (Fig. 36). They become widely dilated as they approach the nipple, so as to form reservoirs in which milk is stored until it is required, but when they actually enter the nipple they again contract. Sometimes they give off lateral branches, but, according to Sappey, they do not anas- tomose with each other, as some anatomists have described. These excretory ducts are composed of connective tissue, with numerous elastic fibres on their external surface. Sappey and Eobin describe a layer of muscular fibres, chiefly developed near their terminal extremities. They are lined with columnar epithelium, continuous with that in the acini ; and it is by the distension of its cells with fatty matter, and their subsequent bursting, that the milk is formed. Nipple. — The nipple is the conical projection at the summit of the mamma, and it varies in size in different women. Not very unfre- quently, from the continuous pressure to which it has been subjected by the dress, it is so depressed below the surface of the skin as to prevent lactation. It is generally larger in married than in single women, and increases in size during pregnancy. Its surface is covered with numerous papillae, giving it a rugous aspect, and at their bases the orifices of the lactiferous ducts open. Here are also the openings of numerous sebaceous follicles, which secrete an unctuous material supposed to protect and soften the integument during lactation. Beneath the skin are muscular fibres, mixed with connective and Fig. 36. 1. Galactophorous ducts. 2. Lobuli of the mammary gland. clastic tissues, vessels,' nerves, and lymphatics. When the nipple is irritated it contracts and hardens, and by some this is attributed to its erectile properties. The vascularity, however, is not great, and it contains no true erectile tissue : the hardening is, therefore, due to muscular contraction. Surrounding the nipple is the areola, of a pink color in virgins, becoming dark from the development of pig- ment cells during pregnancy, and always remaining somewhat dark after childbearing. On its surface are a number of prominent tuber- OVULATION AND MENSTRUATION. 71 cles, sixteen to twenty in number, which, also become largely de- veloped during gestation. They are supposed by some to secrete milk, and to open into the lactiferous tubes; most probably they are composed of sebaceous glands only. Beneath the areolar is a circular band of muscular fibres, the object of which is to compress the lactif- erous tubes which run through it, and thus to favor the expulsion of their contents. The mammas receive their blood from the internal mammary aud intercostal arteries, and they are richly supplied with lymphatic vessels, which open into the axillary glands. The nerves are derived from the intercostal and thoracic branches of the brachial plexus. The secretion of milk in women who are nursing is accompanied by a peculiar sensation, as if milk were rushing into the breast. called the "draught," which is excited by the efforts of the child to suck, and by various other causes. The sympathetic relations be- tween the mammas and the uterus are very well marked, as is shown in the unimpregnated state by the fact of the frequent occurrence of sympathetic pains in the breast in connection with various uterine diseases, and, after delivery, by the well-known fact that suction pro- daces reflex contraction of the uterus, and even severe after-pains. CHAPTEK III. OVULATION AND MENSTRUATION. Functions of the Ovary. — The main function of the ovary is to supply the female generative element, and to expel it, when ready for impregnation, into the Fallopian tube, along which it passes into the uterus. This process takes place spontaneously in all viviparous animals, and without the assistance of the male. In the lower animals this periodical discharge receives the name of the oestrus or rut, at which time only the female is capable of impregnation and admits the approach of the male. In the human female the periodical dis- charge of the ovule, in all probability, takes place in connection with menstruation, which may therefore be considered to he the, analogue of the rut in animals. After each menstrual period Graafian folli- cles undergo change- which prepare them for rupture and the dis- charge of their contained ovules. After rupture, certain changes occur which have for their objed the healing of the rent in the ovarian tissue through which the ovule has escaped, and the filling up of the cavity in which it was contained. This results in the for- mation of a peculiar body in the substance of the ovary, called the corpus luteum which is essentially modified should pregnancy occur, 72 ORGANS CONCERNED IN PARTURITION. arid is of great interest and importance. During the whole of the childbearing epoch the periodical maturation and rupture of the Graafian follicles are going on. If impregnation does not take place, the ovules are discharged and lost ; if it does, ovulation is stopped, as a general rule, during gestation and lactation. Theory of Menstruation. — This, broadly speaking, is an outline of the modern theory of menstruation which was first broached in the year 1821 by Dr. Power, and subsequently elaborated by Negrier, Bischoff, Kaciborski, and many other writers. Although the se- quence of events here indicated may be taken to be the rule, it must be remembered that it is one subject to many exceptions, for un- doubtedly ovulation may occur without its outward manifestation, menstruation, as in cases in which impregnation takes place during lactation or before menstruation has been established, of which many examples are recorded. These exceptions have led some modern writers to deny the ovular theory of menstruation, and their vieAVS will require subsequent consideration. In order to understand the subject properly it will be necessary to study the sequence of events in detail. Changes in the Graafian Follicle. — The changes in the Graafian follicle which are associated with the discharge of the ovules com- prise — 1. Maturation. As the period of puberty approaches a cer- tain number of the Graafian follicles, fifteen to twenty in number, increase in size, and come near the surface of the ovary. Amongst these one becomes especially developed, preparatory to rupture, and upon it for the time being all the vital energy of the ovary seems to be concentrated. A similar change in one, sometimes in more than one, follicle takes place periodically during the whole of the child- bearing epoch, in connection with each menstrual period, and an examination of the ovary will show several follicles in different stages of development. The maturing follicle becomes gradually larger, until it forms a projection on the surface of the ovary, from five to seven lines in breadth, but sometimes even as large as a nut (Fig. 30). This growth is due to the distension of the follicle by the in- crease of its contained fluid, which causes it so to press upon the ovarian structures covering it, that they become thinned, separated from each other, and partially absorbed, until they eventually readily lacerate. The follicle also becomes greatly congested, the capillaries coursing over it becomes increased in size and loaded with blood, and being seen through the attenuated ovarian tissue, give it, when mature, a bright red color. At this time some of these distended capillaries in its inner coat lacerate, and a certain quantity of blood escapes into its cavity. This escape of blood takes place before rupture, and seems to have for its principal object the increase of the tension of the follicle, of which it has been termed the menstruation. Pouchet was of opinion that the blood collects behind the ovule, and carries it up to the surface of the follicle. By these means the follicle is more and more distended, until at last it ruptures either sponta- neously or, it may be, under the stimulus of sexual excitement. Whether the laceration takes place during, before, or after the men- OVULATION AND MENSTRUATION. 73 strual discharge is not yet positively known : from the results of post-mortem examination in a number of women who died shortly before or after the period, Williams believes that the ovules are ex- pelled before the monthly flow commences. 1 In order that the ovule may escape, the laceration must, of course, involve not only the coats of the Graafian follicles, but also the superincumbent structures. Laceration seems to be aided by the growth of the internal layer of the follicle, which increases in thickness before rupture, and assumes a characteristic yellow color from the number of oil-globules it then contains. It is also greatly facilitated, if it be not actually produced, by the turgescence of the ovary at each menstrual period, and by the contraction of the muscular fibres in the ovarian stroma. As soon as the rent in the follicular walls is produced, the ovule is discharged, surrounded by some of the cells of the membrana granu- losa, and is received into the fimbriated extremity of the Fallopian tube, which grasps the ovary over the site of the rupture. By the vibratile cilia of its epithelial lining, it is then conducted into the canal of the tube, along which it is propelled, partly by ciliary action and partly by muscular contraction in the walls of the tube. Obliteration of the Graafian Follicle. — After the ovule has escaped, certain characteristic changes occur in the empty Graafian follicle, which have for their object its cicatrization and obliteration. There are great differences in the changes which occur when impregnation has followed the escape of the ovule, and they are then so remarkable that they have been considered certain signs of pregnancy. They are, however, differences of degree rather than of kind. It will be well, however, to discuss them separately. CJianges undergone by the Follicle where Impregnation does not occur, — As soon as the ovule is discharged, the edges of the rent through which it has escaped become agglutinated by exudation, and the fol- licle shrinks, as is generally believed, by the inherent elasticity of its internal coat, but according to Kobin, who denies the existence of this coat, from compression by the muscular fibres of the ovarian stroma. In proportion to the contraction that takes place, the inner layer of the follicle, the cells of which have become greatly hyper- trophied and loaded with fat granules previous to rupture, is thrown into numerous folds. The greater the amount of contraction the deeper these folds become, giving to a section of the follicle an appearance similar to that of the convolutions of the brain (Fig. 37). These folds in the human subject are generally of a brignl yellow color, but in some of the mammalia they are of a deep red. The tinl was formerly ascribed by Raciborski to absorption of the coloring matter of the blood-clot contained in the follicular cavity, a theory he has more recently abandoned in favor of tin* view maintained by Coste that it is due to the inherent color of the cells of the lining membrane of the follicle, which, though not well marked in a single cell, becomes very apparent en masse. The existence of ;t contained blood-clot is also denied by the latter physiologist, except as an 1 Proceedings of the Royal Society, 1S75. 74 ORGANS CONCERNED IN PARTURITION. Section of ovary, showing corpus lute urn three weeks after menstruation. (After Dalton.) unusual pathological condition ; and he describes the cavity as contain- ing a gelatinous and plastic fluid, which becomes absorbed as contrac- tion advances. The folds into which the membrane has been thrown continue to increase in size, from the proliferation of their cells, until they unite and become adherent, and eventu- ally fill the follicular cavity. By the time that another Graafian follicle is matured and ready for rupture the diminution has advanced considerably, and the empty ovisac is reduced to a very small size. The cavity is now nearly obliterated, the yellow color of the convolutions is altered into a whitish tint, and on section the corpus luteum has the appearance of a compact white stellate cicatrix, which generally disap- pears in less than forty days from the period of rupture. The tissue of the ovary at the site of laceration also shrinks, and this, aided by the contrac- tion of the follicle, gives rise to one of those permanent pits or depressions which mark the surface of the adult ovary. Slavy- ansky 1 has recently shown that only a few of the immense number of Graafian follicles undergo these alterations. The greater propor- tion of them seem never to discharge their ovules, but, after increas- ing in size, undergo retrogressive changes exactly similar in their nature, but to a much less extent, to those which result in the for- mation of a corpus luteum. The sites of these may afterwards be seen as minute striae in the substance of the ovary. Changes undergone by the Follicle vjhen Impregnation has taken place. — Should pregnancy occur, ail the changes above described take place, but, inasmuch as the ovary partakes of the stimulus to which all the generative organs are then subjected, they are much more marked and apparent. Instead of contracting and disappearing in a few weeks, the corpus luteum continues to grow until the third or fourth month of pregnancy ; the folds of the inner layer of the ovisac become large and fleshy, and permeated by numerous capillaries, and ultimately become so firmly united that the margins of the convolu- tions thin and disappear, leaving only a firm fleshy yellow mass, averaging from 1 to 1 J inches in thickness, which surrounds a central cavity, often containing a whitish fibrillated structure, believed to be the remains of a central blood clot. This was erroneously sup- posed by Montgomer}^ to be the inner layer of the follicle itself, and he conceived the yellow substance to be a new formation between it and the external layer, while Robert Lee thought it was placed external to both the external and internal layers. Between the third and fourth months of pregnancy, when the 1 Archiv do Phys. March, 1874. OVULATION AND MENSTRUATION. 75 corpus luteum has attained its maximum of development (Fig. 38), it forms a firm projection on the surface of the ovary, averaging about 1 inch in length, and rather more than \ an inch in breadth . After this it commences to atrophy (Fig. 39), the fat-cells become Fig. 38. Fig. 39. Corpus luteum at the fourth month of pregnancy. (After Dalton.) Corpus luteum of pregnancy at term. (After Dalton.) absorbed, and the capillaries disappear. Cicatrization is not com- plete until from one to two months after delivery. Its Value as a Sign of Pregnancy. — On account of the marked appearance of the corpus luteum it was formerly considered to be an infallible sign of pregnancy ; arid it was distinguished from the cor- pus luteum of the nonpregnant state by being called a "true" as opposed to a "false" corpus luteum. From what has been said it will be obvious that this designation is essentially wrong, as the difference is one of degree only. Nor do obstetricians attach by any means the same importance as they did formerly to its presence as indicating impregnation; for even when well marked, other and more reliable signs of recent delivery, such as enlargement of the uterus, are sure to be present, especially at the time when it has reached its maximum of development; while after delivery at term it has no longer a sufficiently characteristic appearance to be depended on. Menstruation. — By the term menstruation (catamenia, periods, etc.), is meant the periodical discharge of blood from the uterus, which occurs, in the healthy woman, every lunar month, except during pregnancy and lactation, when it is, as a rule, suspended. Period of Establishment. — The first appearance of menstruation coincides with the establishment of puberty, and the physical changes that accompany it indicate that the female is capable of conception and childbearing, although exceptional cases are recorded in which pregnancy occurred before menstruation had begun. In temperate climates it generally commences between the 1 Ith and L 6th years, the largest number of cases being met with in the L5th year. This 76 ORGANS CONCERNED IN PARTURITION. rule is subject to many exceptions, it being by no means very rare for menstruation to become established as early as the 10th or 11th years, or to be delayed until the 18th or 20th. Beyond these physio- logical limits a few cases are from time to time met with in which it has begun in early infancy, or not until a comparatively late period of life. Influence of Climate, Race, etc. — Various accidental circumstances have much, to do with its establishment. As a rule, it occurs some- what earlier in tropical, and later in very cold, than in temperate cli- mates. The influence of climate has been unduly exaggerated. It used to be generally stated that in the Arctic regions women did not menstruate until they were of mature age, and that in the tropics girls of 10 or 12 years of age did so habitually. The researches of Koberton, of Manchester, 1 first showed that the generally received opinions were erroneous ; and the collection of a large number of statistics has corroborated his opinion. There can be no doubt, how- ever, that a larger proportion of girls menstruate early in warm cli- mates. Joulin found that in tropical climates, out of 1635 cases, the largest proportion began to menstruate between the 12th and 13th years ; so that there is an average difference of more than two years between the period of its establishment in the tropics and in temper- ate countries. Harris 2 states that among the Hindoos 1 to 2 per cent, menstruate as early as nine years of age ; 3 to 4 per cent, at ten ; 8 per cent, at eleven ; and 25 per cent, at twelve ; while in London or Paris probably not more than one girl in 1000 or 1200 does so at nine years. The converse holds true with regard to cold climates, although we are not in possession of a sufficient number of accurate statistics to draw very reliable conclusions on this point ; but out of 4715 cases, including returns from Denmark, Norway and Sweden, Eus- sia and Labrador, it was found that menstruation was established on an average a year later than in more temperate countries. It is prob- able that the mere influence of temperature has much to do in produc- ing these differences, but there are other factors, the action of which must not be overlooked. Eaciborski attributes considerable import- ance to the effect of race ; and he has quoted Dr. Webb, of Calcutta, to the effect that English girls in India, although subjected to the same climatic influence as the Indian races, do not, as a rule, men- struate earlier than in England ; while in Austria, girls of the Magyar race menstruate considerably later than those of German parentage. 3 The surroundings of girls, and their manner of education and living, have probably also a marked influence in promoting or retarding its establishment. Thus, it will commence earlier in the children of the rich, who are likely to have a highly developed nervous organization, and are habituated to luxurious living, and a premature stimulation of the mental faculties by novel-reading, society, and the like ; while amongst the hard- worked poor, or in girls brought up in the country, 1 Edin. Med. and Surg. Journ., 18." 2. 2 Amor. Journ. of Obst. 1871. R- P- Harris, on early puberty. 3 Op. eit,, p. 227. OVULATION AND MENSTRUATION . 77 it is more likely to begin later. Premature sexual excitement is said also to favor its early appearance, and the influence of this among the factory girls of Manchester, who are exposed in the course of their work to the temptations arising from the promiscuous mixing of the sexes, has been pointed out by Dr. Clay. 1 Changes Occurring at Puberty. — The first appearance of menstrua- tion is accompanied by certain well-marked changes in the female system, on the occurrence of which we say that the girl has arrived at the period of puberty. The pubes become covered with hair, the breasts enlarge, the pelvis assumes its fully-developed form, and the general contour of the body fills out. The mental qualities also alter ; the girl becomes more shy and retiring, and her whole bearing indi- cates the change that has taken place. The menstrual discharge is not established regularly at once. For one or two months there may be only premonitory symptoms : a vague sense of discomfort, pains in the breasts, and a feeling of weight and heat in the back and loins. There then may be a discharge of mucus tinged with blood, or of pure blood, and this may not again show itself for several months. Such irregularities are of little consequence on the first establishment of the function, and need give rise to no apprehension. Period of Duration and Recurrence. — As a rule, the discharge re- curs every twenty-eight days, and with some women with such regu- larity that they can foretell its appearance almost to the hour. The rule is, however, subject to very great variations. It is by no means uncommon, and strictly within the limits of health, for it to appear every twentieth day, or even with less interval ; while, in other cases, as much as six weeks may habitually intervene between two periods. The period of recurrence may also vary in the same subject. I am acquainted with patients who sometimes have only twenty-eight days, at others as many as forty-eight days, between their periods, without their health in any way suffering. Joulin mentions the case of a lady who only menstruated two or three times in the year, and whose sister had the same peculiarity. The duration of the period varies in different women, and in the same woman at different times. In this country its average is four or five days, while in France Dubois and Brierre de Boismonl fix eight days as the most usual length. Some women arc only unwell for a few hours, while in others the period may last many days beyond the average without being considered abnormal. Quantity of Blood lost. — The quantity of blood lost varies in dif- ferent women. Hippocrates puts it at 3xviij, which, however. Is much too high an estimate. Arthur Farre thinks thai from .si.j t<> ■£iij is the full amount of a healthy peri' »d, and thai the quantity cannot habitually exceed this withoul producing serious constitu- tional effects. Rich diet, Luxurious living, and anything that un- healthily stimulates the body and mind, will have an injurious eflfed in increasing the flow, which is. therefore, less in hard-worked countrywomen than in the better classes and residents in towns. 1 Brit. Record of' Obst. Med., vol. i. T8 ORGANS CONCERNED IN PARTURITION. It is more abundant in warm climates, and our countrywomen in India "habitually menstruate over-profusely, becoming less abundantly unwell when they return to England. [The same may be said of our Northern women when residing in the Gulf States, and of many natives of those States, who improve materially by removing to the Lake States. — Ed.] Some women appear to menstruate more in summer than in winter. I am acquainted with a lady who spends the winter in St. Petersburg, where her periods last eight or ten daj^s, and the summer in England, where they never exceed four or five. The difference is probably due to the effect of the over-heated rooms in which she lives in Eussia. The daily loss is not the same during the continuance of the period. It generally is at first slight, and gradually increases so as to be most profuse on the second or third day, and as gradually diminishes. To- wards the last days it sometimes disappears for a few hours, and then comes on again, and is apt to recur under any excitement or emotion. Quality of Menstrual Blood. — As the menstrual fluid escapes from the uterus it consists of pure blood, and, if collected through the speculum, it coagulates. The ordinary menstrual fluid does not coagulate unless it is excessive in amount. Various explanations of this fact have been given. It was formerly supposed either to contain no fibrine, or an unusually small amount. Eetzius attributes its non-coagulation to the presence of free lactic and phosphoric acids. The true explanation was first given by Mandl, who proved that even small quantities of pus or mucus in blood were sufficient to keep the fibrine in solution; and mucus is always present to greater or less amount in the secretions of the cervix and vagina, which mix with the menstrual blood in its passage through the genital tract. If the amount of blood be excessive, however, the mucus present is insufficient in quantity to produce this effect, and coagula are then formed. On microscopic examination the menstrual fluid exhibits blood corpuscles, mucous corpuscles, and a considerable amount of epithelial scales, the last being the debris of the epithelium lining the uterine cavity. According to Virchow the form of the epithelium often proves that it comes from the interior of the utricular glands. The color of the blood is at first dark, and as the period progresses it generally becomes lighter in tint. In women who are in bad health it is often very pale. These differences doubtless depend upon the amount of mucus mingled with it. The menstrual blood has always a characteristic, faint, and heavy odor, which is analogous to that which is so distinct in the lower animals during the rut. Eaciborski mentions a lady who was so sensitive to this odor that she could always tell to a certainty when" any woman was menstruating. It is attributed either to decomposing mucus mixed with the blood, which, when partially absorbed, may cause the peculiar odor of the breath often perceptible in menstruating women; or to the mixture with the fluid of the sebaceous secretion from the glands of the vulva. It probably gave rise to the old and prevalent prejudices as to the OVULATION AND MENSTRUATION. 79 deleterious properties of menstrual blood, which, it is needless to say, are altogether without foundation. Source of the Blood. — It is now universally admitted that the source of the menstrual blood is the mucous membrane lining the interior of the uterus, for the blood ma}" be seen oozing through the os uteri by means of the speculum, and in cases of prolapsus uteri ; while in cases of inverted uterus it may be actually observed escaping from the exposed mucous membrane, and collecting in minute drops upon its surface. During the menstrual nisus the whole mucous lining becomes congested to such an extent that, in examining the bodies of women who have died during menstruation, it is found to be thicker, larger, and thrown into folds, so as to completely fill the uterine cavity. The capillary circulation at this time becomes very marked, and the mucous membrane assumes a deep red hue, the net- work of capillaries surrounding the orifices of the utricular glands being especially distinct. These facts have an unquestionable con- nection with the production of the discharge, but there is much diffe- rence of opinion as to the precise mode in which the blood escapes from the vessels. Coste believed that the blood transudes through the coats of the capillaries without any laceration of their structure. Farre inclines to the hypothesis that the uterine capillaries terminate by open mouths, the escape of blood through these, between the menstrual periods, being prevented by muscular contraction of the uterine walls. Pouchet believed that during each menstrual epoch the entire mucous membrane is broken down and cast off in the form of minute shreds, a fresh mucous membrane being developed in the interval between two periods. During this process the capillary net- work would be laid bare and ruptured, and the escape of blood readily accounted for. Tyler Smith, who adopted this theory, states that he has frequently seen the uterine mucous membrane, in women who have died during menstruation, in a state of dissolution, with the broken loops of the capillaries exposed. The phenomena at- tending the so-called membranous dj^smenorrhoea, in which the mucous membrane is thrown off* in shreds, or as a cast of the uterine cavity — the nature of which was first pointed out by Simpson and Oldham — have been supposed to corroborate this theory. This view- is, in the main, corroborated by the recent researches of Engelman, Williams, 1 and others. Williams describes the mucous lining of the uterus as undergoing a Catty degeneration before cadi period, which commences near the inner os, and extends over the whole mucous membrane, and down to the muscular wall. This seems to bring on a certain amount of muscular contraction, which drives the blood into the capillaries of the mucosa, and these, having become degene- rated, rca over the formation of a new mucous membrane is begun, from proliferation of the elements 1 On the Structure of the Mucous Membrane of the Uterus, Obst. Journ., 1875. 80 ORGANS CONCERNED IN PARTURITION. of the muscular coat, and at the end of a week the whole uterine cavity is lined by a thin mucous membrane. This grows until the advent of another period, when the same degenerative changes occur unless impregnation has taken place, in which case it becomes further developed into the decidua. Theory of Menstruation. — That there is an intimate connection be- tween ovulation and menstruation is admitted by most physiologists, and it is held by many that the determining cause of the discharge is the periodic maturation of the Graafian follicles. There is abundant evidence of this connection, for we know that when, at the change of life, the Graafian follicles cease to develop, menstruation is arrested; and when the ovaries are removed by operation, of which there are now numerous cases on record, or when they are congenitally absent, menstruation does not take place. A few cases, however, have been observed in which menstruation continued after double ovariotomy, and these have been used as an argument by those physiologists who doubt the ovular theory of menstruation. Slavyansky has particu- larly insisted on such cases, which, however, are probably susceptible of explanation. It may be that the habit of menstruation may con- tinue for a time even after the removal of the ovaries, and it has not been shown that menstruation has continued permanently after double ovariotomy, although it certainly has occasionally, although quite exceptionally, done so for a time. It is possible, also, that, in such cases, a small portion of ovarian tissue may have been left unre- moved, sufficient to carry on ovulation. Eoberts, a traveller quoted by Depaul and Gueniot in their article on Menstruation in the "Dic- tionnaire des Sciences Me'dicales," relates that in certain parts of Central Asia it is the custom to remove both ovaries in young girls who act as guards to the harems. These women, known as hedjeras, subsequently assume much of the virile type, and never menstruate. The same close connection between ovulation and the rut of animals is observed, and supports the conclusion that the rut and menstrua- tion are analogous. The chief difference between ovulation in man and the lower animals is that in the latter the process is not generally accompanied by a sanguineous flow. To this there are exceptions, for in monkeys there is certainly a discharge analogous to menstrua- tion occurring at intervals. Another point of distinction is that in animals connection never takes place except during the rut, and that it is then only that the female is capable of conception ; while in the human race conception only occurs in the interval between the periods. This is another argument brought against the ovular theory, because, it is said, if menstruation depend on the rupture of a Graafian follicle and the emission of an ovule, then impregnation should only take place during or immediately after menstruation. Coste explains this by supposing that it is the maturation and not the rupture of the follicle which determines the occurrence of menstruation ; and that the follicle may remain unruptured for a considerable time after it is mature, the escape of the ovule being subsequently determined by some accidental cause, such as sexual excitement. However this may be, there is good reason to believe that the susceptibility to con- OVULATION AXD MENSTRUATION. 81 ception is greater during the menstrual epochs. Eaciborski believes that in the large proportion of cases impregnation occurs in the first half of the menstrual interval, or in the few da}'s immediately pre- ceding the appearance of the discharge. There are, however, very numerous exceptions, for in Jewesses, who almost invariably live apart from their husbands for eight days after the cessation of men- struation, impregnation must constantly occur at some other period of the interval, and it is certain that they are not less prolific than other people. This rule with them is very strictly adhered to, as will be seen by the accompanying interesting letter from a medical friend who is a well-known member of that community, and which I have permission to publish. 1 This fact is of itself sufficient to disprove the theory advanced by Dr. Avrard, 2 that impregnation is impossible in the latter half of the menstrual interval. This, and the other reasons referred to, undoubtedly throw some doubt on the ovular theory, but they do not seem to be sufficient to justif}^ the conclusion that menstruation is a physiological process altogether independent of the development and maturation of the Graafian follicles. All that they can be fairly held to prove is that the escape of the ovules may occur independently of menstruation, but the weight of evidence remains strongly in favor of the theory which is generally received. 1 10 Bernard Street, Russell Square, July 28, 1873. My dear Sir. 1. To the best of my knowledge and belief, the law which prohibits sexual intercourse amongst Jews for seven clear days after the cessation of menstruation, is almost universally observed ; the exceptions not being sufficient to vitiate statistics. The law has perhaps fewer exceptions on the Continent — especially Russia and Poland, where the Jewish population is very great— than in England. Even here. however, women who observe no other ceremonial law observe this, and cling to it after everything else is tin-own overboard. There are doubtless many exceptions, especially among the better classes in England, who keep only three days after the cessation of the menses. 2. The law is — as you state — that should the discharge last only an hour or so, or should there be only one gush or one spot on the linen, the five days during which the period might continue are observed : to which must be superadded the Beven clear days = twelve days per mensem in which connection is disallowed. Should any dis- charge be seen in the intermenstrual period, seven days would have to be kept, but not the five, for such irregular discharge. S. The "bath of purification." which must contain at least eighty gallons, is used on the last night of the seven clear days. It is not used till after a bath for cleansing purposes; and. from the night when BUch •" purifying" hath is used, Jewish women are accustomed to calculate the commencement of pregnancy. That you should not have heard of it is not strange ; its mention would he considered highly indelicate. 4. Jewish women reckon their pregnancy to last nine calendar or ten lunar months, 270 to 280 days. There are no special data on which to reckon an average, nor do I know of an_\- hooks on the subject, except Borne Talmudic authorities which I will look up for you if you desire it. Pray make no apologies tor writing to me: an\ information I possess is at your service. I am, dear Sir, vours verv truly, Dr. Playfair. ' A. Ajshrb. P.S. The Biblical foundation for the law of the seven clear days is Leviticus w.. verse 19 till the end of the chapter — especially \er>e 28. 2 Rev. de Therap. Med. Chir. 18G7. 82 ORGANS CONCERNED IN PARTURITION. Purpose of the Menstrual Loss. — The cause of the monthly perio- dicity is quite unknown, and will probably always remain so. The purpose of the loss of so much blood is also somewhat obscure. To a certain extent it must be considered an accident or complication of ovulation, produced by the vascular turgescence. Nor is it essen- tial to fecundation, because women often conceive during lactation, when menstruation is suspended; or before the function has become established. It may, however, serve the negative purpose of relieving the congested uterine capillaries which are periodically filled with a supply of blood for the great growth which takes place when concep- tion has occurred. Thus immediately before each period the uterus may be considered to be placed by the afflux of blood in a state ot preparation for the function it may be suddenly called upon to per- form. That the discharge relieves a state of vascular tension which accompanies ovulation is proved by the singular phenomenon of vicarious menstruation, which is occasionally, though rarely, met with. It occurs in cases in which, from some unexplained cause, the discharge does not escape from the uterine mucous membrane. Under such circumstances a more or less regular escape of blood may take place from other sites. The most common situations are the mucous membranes of the stomach, of the nasal cavities, or of the lungs; the skin, not uncommonly that of the mammae, probably on account of their intimate sympathetic relation with the uterine organs; from the surface of an ulcer; or from hemorrhoids. It is a note- worthy fact that in all these cases the discharge occurs in situations where its external escape can readily take place. This strange deviation of the menstrual discharge may be taken as a sign of general ill-health, and it is usually met with in delicate young women of highly mobile nervous constitution. It may, however, begin at puberty, and it has even been observed during the whole sexual life. The recurrence is regular, and always in connection with the men- strual nisus, although the amount of blood lost is much less than in ordinary menstruation. Cessation of Menstruation. — After a certain time changes occur showing that the woman is no longer fitted for reproduction; men- struation ceases, Graafian follicles are no longer matured, and the ovary becomes shrivelled and wrinkled on its surface. Analogous alterations take place in the uterus and its appendages. The Fallo- pian tubes atrophy, and are not unfrequently obliterated. The uterus decreases in size. The cervix undergoes a remarkable change which is readily detected on vaginal examination. The projection of the cervix into the vaginal canal disappears, and the orifice of the os uteri in old women is found to be flush with the roof of the vagina. In a large number of cases there is, after the cessation of menstrua- tion, an occlusion both of the external and internal os; the canal of the cervix, however, between them remains patulous, and is not un- frequently distended with a mucous secretion. Period of Cessation. — The age at which menstruation ceases varies much in different women. In certain cases it may cease at an unusu- ally early age, as between 30 and 40 years, or it may continue far OVULATION AND MENSTRUATION. 83 beyond the average time, even up to 60 years; and exceptional, though perhaps hardly reliable instances, are recorded in which it has continued even to 80 or 90 years. These are, hoAvever, strange anomalies, which, like cases of unusually precocious menstruation, cannot be considered as having any bearing on the general rule. Most cases of so-called protracted menstruation will be found to be really morbid losses of blood depending on malignant or other forms of organic disease, the existence of which, under such circumstances, should always be suspected. In this country menstruation usually ceases between 40 and 50 years of age. Raciborski says that the largest number of cases of cessation are met with in the 46th year. Is is generally said that women who commence to menstruate when very young, cease to do so at a comparatively early age, so that the average duration of the function is about the same in all women. Cazeaux and Raciborski, whose opinion is strengthened by the observations of Guy in 1500 cases, 1 think, on the contrary, that the earlier menstruation com- mences, the longer it lasts, early menstruation indicating an excess of vital energy which continues during the whole childbearing life. Climate and other accidental causes, do not seem to have as much effect on the cessation as on the establishment of the function. It does not appear to cease earlier in warm than in temperate climates. The change of life is generally indicated by irregularities in the recurrence of the discharge. It seldom ceases suddenly, but it may be absent for one or more periods, and then occur irregularly; or it may become profuse or scanty, until eventually it entirely stops. The popular notions as to the extreme danger of the menopause are probably much exaggerated; although it is certain that at that time various nervous phenomena are apt to be developed. So far from having a prejudicial effect on the health, however, it is not an un- common observation to see an hysterical woman, who has been for years a martyr to uterine and other complaints, apparently take a new lease of life when her uterine functions have ceased to be in active operation, and statistical tables abundantly prove that the general mortality of the sex is not greater at this than at any other time. 1 Med. Tinics and Gaz., 1 845. PART II PREGNANCY. CHAPTEE I. CONCEPTION AND GENEKATION. Generation in the human female, as in all mammals, requires the congress of the two sexes, in order that the semen, the male ele- ment of generation, may be brought into contact with the ovule, the female element of generation. Semen. — The semen secreted by the testicle of an adult male is a viscid, opalescent fluid, forming an emulsion when mixed with water, and having a peculiar faint odor, which is attributed to the secretions which are mixed with it, such as those from the prostate and Cowper's glands. On analysis it is found to be an albuminous fluid, holding in solution various salts, principally phosphates and chlorides, and an animal substance, spermatine, analogous to flbrine. Examined under a magnifying power of from 400 to 500 diameters, it consists of a transparent and homogeneous fluid, in which are float- ing a certain number of granules and epithelial cells, derived from the secretions mixed with it, and the characteristic sperm cells and spermatozoa which form its essen- tial constituents (Fig. 40). The sperm cells are large spherical vesicles, each containing from two to eight smaller cells, within which the spermatozoa are developed; and, as these soon escape and be- come free, the sperm cells are' only to be detected in the testicles themselves, while in semen that has been ejaculated they are rarely visible. The large parent cell, termed by Kobin the male ovule, forms within it several subsidiary cells by the segmentation of its granular contents. Within these secondarjr cells, or vesicles of evo- lution, which are believed by Kolliker to be developed from the nuclei of the parent cell, the spermatozoa are formed, and before ejaculation they may be seen coiled spirally in their interior. The external envelope then disappears, and a number of spermatozoa, one a,h. Sperm cells containing nuclei, each nucleus having within a spermatozoon, c. Nucleus, with nucleoli, d. Nucleus, with spermato- zoon, e. A cell, with a bundle of spermatic filaments. /, g, h. Spermatozoa. CONCEPTION AND GENERATION. 85 being formed in each of the secondary cells, may be observed in the interior of the original parent cell. Eventually that also is absorbed, and the contained spermatozoa become liberated, and move about freely in the seminal fluid. As seen under the microscope, the sper- matozoa, which exist in healthy semen in enormous numbers, present the appearance of minute particles, not unlike a tadpole in shape. The head is oval and flattened, measuring about g^'ptli of an inch in breadth, and attached to it is a delicate filamentous expansion or tail, which tapers to a point so fine that its termination cannot be I seen by the highest powers of the microscope. The whole sperma- tozoon measures from ^-^th to e^tli °f an inch in length. The spermatozoa are observed to be in constant motion, sometimes very rapid, sometimes more gentle, which is supposed to be the means by which they pass upwards through the female genital organs. They retain their vitality and power of movement for a consider- I able time after emission, provided the semen is kept at a tempera- ture similar to that of the body. Under such circumstances thev have been observed in active motion from forty-eight to seventy-two hours after ejaculation, and they have also been seen alive in the tes- ticle as long as twenty-four hours after death. In all probability , they continue active much longer within the generative organs, as many physiologists have observed them in full vitality in bitches and rabbits, seven or eight days after copulation. Abundant leucor- rhoeal discbarges and acrid vaginal secretions destroy their move- ments, and may thus cause sterility in the female. On account of their mobility, the spermatozoa were long considered to be indepen- dent animalcules, a view which is by no means exploded, and has been maintained in modern times by' Pouchet, Joulin, and other writers, while Coste, Robin, Kdlliker, etc., liken their motion to that of cili- ated epithelium. There can be no doubt that the fertilizing power of the semen is due to the presence of the spermatozoa, although some of the older physiologists assigned it to the spermatic fluid. The former view, however, has been conclusively proved by the experi- ments of PreVost and Dumas, who found that on carefully removing the spermatozoa by filtration the semen lost its fecundating properties. Sites of Impregnation.— There has been great difference of opinion as to the part of the genital tract in which the spermatozoa and the ovule come into contact, and in which impregnation, therefore, occurs. Spermatozoa have been observed in all parts of the female genital organs in animals killed shortly after coitus, especially in the Fallo- pian tubes, and even on the surface of the ovary. The phenomena <>i' ovarian gestation, and the fact that fecundation has been proved to OCCUr in certain animals within the ovary, tend to BUppoii the idea that it may also occur in the human female before the rupture ofthe Graafian follicle. In order to do so, however, it is necessary for the spermatozoa to penetrate the proper structure of the follicle and the epithelial covering of the ovary, and no one has actually seen them doing so. Most probably the contacl of Hi-' spermatozoa and the ovule occurs very shortly after the rupture ofthe follicle, and in the outer part of the Fallopian tubes. Coste mentions that, unless the ovule is impregnated, it very rapidly degenerates after being ex] 86 PREGNANCY from the ovary, partly by inherent changes in the ovule itself, and partly because it then soon becomes invested by an albuminous covering which is impermeable to the spermatozoa. He believes, therefore, that impregnation can only occur either on the surface of the ovary, or just within the fimbriated extremity of the tube. Mode in which the ascent of the Semen is effected. — The semen is probably carried upwards chiefly by the inherent mobility of the spermatozoa. It is believed by some that this is assisted by other agencies; amongst them are mentioned the peristaltic action of the uterus and Fallopian tubes ; a sort of capillary attraction effected when the walls of the uterus are in close contact, similar to the movement of fluid in minute tubes ; and also the vibratile action of the cilia of the epithelium of the uterine mucous membrane. The action of the latter is extremely doubtful, for they are also supposed to effect the descent of the ovule, and they can hardly act in two opposite ways. The movement of the cilia being from, within outwards, it would cer- tainly oppose, rather than favor, the progress of the spermatozoa. It must, therefore, be admitted that they ascend chiefly through their own powers of motion. They certainly have this power to a remarkable extent, for there are numerous cases on record in which impregnation has occurred without penetration, and even when the hymen was quite entire, and in which the semen has simply been de- posited on the exterior of the vulva ; in such cases, which are far from uncommon, the spermatozoa must have found their way through the whole length of the vagina. It is probable, however, that under ordinary circumstances the passage of the spermatic fluid into the uterus is facilitated by changes which take place in the cervix during the sexual orgasm, in course of which the os uteri is said to dilate and close again in a rythmical manner. 1 Mode of impregnation. — The precise method in which the sperma- tozoa effect impregnation was long a matter of doabt. It is now, however, certain that they actually penetrate the ovule, and reach its interior. This has been conclusively proved by the observations of Barry, Meissner, and others, who have seen the spermatozoa within the external mem- brane of the ovule in rabbits (Fig. -11). In some of the invertebrata a canal or opening exists in the zona pellucida, through which the spermatozoa pass. No such aperture has yet been demonstrated in the ovules of mammals, but its existence is far from improbable. According to the observations of Newport, several sperma- tozoa enter the ovule, and the greater the number that do so the more certain fecun- dation becomes. After the spermatozoa penetrate the zona pellucida they disinte- grate and mingle with the yelk, having, Fig. 41, Ovum of Eabbit containing sperma- tozoa. ]. Zona pellucida. 2. The germs, consisting of two large cells, several smaller cells, and spermatozoa. How do the Spermatozoa enter the Uterus? by J. Beck, M.D. CONCEPTION AND GENERATION. 87 while doing so, imparted to the ovule a power of vitality, and ini- tiated its development into a new being. Progress of the Impregnated Ovule towards the Uterus. — The length of time which lapses before the fecundated ovule arrives in the cav- ity of the uterus has not yet been ascertained, and it probably varies under different circumstances. It is known that in the bitch it may remain eight or ten days in the Fallopian tube, in the guinea-pig three or four. In the human female the ovum has never been dis- covered in the cavity of the uterus before the tenth or twelfth day after impregnation. Changes immediately before and after Impregnation. — The changes which occur in the human ovule immediately before and after im- pregnation, and during its progress through the Fallopian tube, are only known to us by analogy, as, of course, it is impossible to study them by actual observation. We are in possession, however, of ac- curate information of what has been made out in the lower animals, and it is reasonable to suppose that similar changes occur in man. Immediately after the ovule has passed into the Fallopian tube, it is found to be surrounded by a layer of granular cells, a portion of the lining membrane of the Graafian follicle, which was described as the discus proligerus. As it proceeds along the tube these surrounding cells disappear, partly, it is supposed, by friction on the walls of the tube, and partly by being absorbed to nourish the ovule. Be this as it may, before long they are no longer observed, and the zona pellu- cida forms the outermost layer of the ovule. When the ovule has advanced some distance along the tube, it becomes invested with a covering of albuminous material, which is deposited around it in suc- cessive layers, the thickness of which varies in different animals. It is very abundant in birds, in whom it forms the familiar white of the egg. In some animals it has not been detected, so that its presence in the human ovule is uncertain. Where it exists it doubtless con- tributes to the nourishment of the ovule. Coincident with these changes is the disappearance of the germinal vesicle. At the same time the yelk contracts and becomes more solid; retiring, in one spot, from close contact with the zona pellucida, and thus forming a species of cavity called by Newport the respira- tory chamher, which in some animals is tilled with a transparent liquid. After this occurs the very peculiar phenome- non known as the cleavage of the yelk, which results in the formation or the membrane from which the foetus is de- veloped. It is preceded by the forma- tion at one point of the surface of the yelk of a minute transparenl globule of a bluish tint, sometimes of three or four separate globules which subsequently unite into one. This has received the Fig. 42. Po matlon of the " Polar Globule." Zona Pellucida. oonl Vetlele. Yelk. •". and f. Germinal .-,. The Polar Globule. OS PREGNANCY. name of the polar globule (Fig. 42), and seems to be formed from the hyaline substance of the yelk, from which it soon becomes entirely separated, and remains attached to the inner surface of the zona pellucida. It indicates the point at which the segmentation of the yelk begins, and where the cephalic extremity of the foetus will sub- sequently be placed. According to Eobin these changes occur in all ovules, whether they are impregnated or not, but if the ovule is not fecundated, no farther alterations occnr. Supposing impregnation has taken place, a bright clear vesicle, called the vitelline nucleus, very similar in appearance to a drop of oil, appears in the centre of the yelk. The segmentation of the yelk (Fig. 43) commences at the point where the polar globule is situated ; it begins to divide into two halves, and at Fig. 43. Segmentation of the Yelk. A. Ovum with first Embryo cell. B. Division of embryo cell and cleavage of the yelk around it. C, D, E. Further division of the yelk. the same time the vitelline nucleus becomes constricted in its centre, and separates into two portions, one of which forms a centre for each of the halves into which the yelk has divided. Each of these im- mediately divides into two, as does its contained portion of the vitel- line nucleus, and so on in rapid succession until the whole yelk is divided into a number of spheres, each of which consists of a clump of nucleated protoplasm. By these continuous dichotomous divisions the whole yelk is formed into a granular mass which, from its supposed resemblance to a mulberry, has been named the muriform body. When the sub- division of the yelk is completed, its separate spheres become con- verted into cells, consisting of a fine membrane with granular contents. These cells unite by their edges to form a continuous membrane (Fig. 44), which, through the expansion of the muriform body by fluid which forms in its interior, is distended until it forms a lining to the zona pellucida. This is the blastodermic membrane from which the foetus is developed. By this time the ovum has CONCEPTION AND GENERATION. 89 reached the uterus, and, before proceeding to consider the further changes which it undergoes it will be well to study the alteration which the stimulus of impregnation has set on foot m the mucous Fig. 44. %K Formation of the Blastodermic Membrane from the cells of the Muriform Body. (After Joulin.) 1. Layer of albuminous material surrounding. 2. The Zoua pellucida. membrane of the uterus, in order to prepare it for the reception and growth of its contents. Changes in the Uterine Mucous Membrane consequent on Preynancy. — Even before the ovum reaches the uterus, the mucous membrane becomes thickened and vascular, so that its opposing surfaces entirely fill the uterine cavity. These changes may be said to be the same in kind, although more marked and extensive in degree, as the alte- rations which take place in the mucous membrane in connection with each menstrual period. The result is the formation ofadistinct membrane, which affords the ovum a safe anchorage and protection, until its connections with the uterus arc more fully developed. A tier delivery, this membrane, which is by that time quite altered in appearance, is a1 leasl partially thrown off with tin 1 ovum; on which account it has received the name of the decidua, or caduca. Divisions of the Decidua. — The decidua consists of two principal portions, which, in early pregnancy, are separated from each other by a considerable interspace. Oi f these, called the decidua vera ) lines the entire uterine cavity, and is, no doubt, the original mucous lining of the uterus greatly hypertrophied. The second, the decidua rejlcxa, is closely applied round the ovum; and it is probably formed by the sprouting of the decidua vera around the ovum al the point on which the hitter rests, so thai it eventually completely surrounds it. As the ovum enlarges, the decidua reflexa is necessarily stretched, until it conies everywhere into contact with the decidua vera, with which it firmly unites. After the third month of pregnancy true 7 90 PREGNANCY. union has occurred, and the two layers of decidua are no longer separate. The decidua serotina, which is described as a third portion, is merely that part of the decidua vera on which the ovum rests, and where the placenta is eventually developed. Views of William and John Hunter. — It is needless to refer to the various views which have been held by anatomists as to the struc- ture and formation of the decidua. That taught by John Hunter was long believed to be correct, and down to a recent date it received the adherence of most physiologists. He believed the decidua to be an inflammatory exudation which, on account of the stimulus of pregnancy, was thrown out all over the cavity of the uterus, and soon formed a distinct lining membrane to it. "When the ovum reached the uterine orifice of the Fallopian tube it found its entrance barred by this new membrane, which accordingly it pushed before it. This separated portion formed a covering to the ovum, and became the decidua reflexa; while a fresh exudation took place at that portion of the uterine wall which was thus laid bare, and this became the decidua vera. William Hunter had much more correct views of the decidua, the accuracy of which were at the time much contested, but which have recently received full recognition. He describes the decidua in his earlier writings as an hypertrophy of the uterine mucous membrane itself, a view which is now held by all physiologists. Structure of the Decidua. — W r hen the decidua is first formed it is a hollow triangular sac lining the uterine cavity (Fig. 45), and having three openings into it, those of the Fallopian tubes at its upper angles, and one, corresponding to the internal os uteri, below. If, as is generally the case, it is thick and pulpy, these openings are closed up and can no longer be detected. In early pregnancy it is well developed, and continues to grow up to the third month of utero-gestation. After that time it commences to atrophy, its adhe- sion with the uterine walls lessens, it becomes thin and transparent, and is ready for expulsion when delivery is effected. When it is most developed, a careful examination of the decidua enables us to detect in it all the elements of the uterine mucous membrane greatly hypertrophied. Its substance chiefly consists of large round or oval nucleated cells and elongated fibres, mixed with the tubular uterine gland ducts, which are much elongated and filled with cylindrical epithelium cells, and a small quantity of milky fluid. According to Friedlander the decidua is divisible into two layers: the inner being formed by a proliferation of the corpuscles of the sub-epithelial con- nective tissue of the mucous membrane; the deeper, in contact with the uterine walls, out of flattened or compressed gland ducts. In an early abortion the extremities of these ducts may be observed by a lens on the external or uterine surface of the decidna, occupying the summit of minute projections, separated from each other by depres- sions. If these projections be bisected they will be found to contain little cavities, filled with lactescent fluid, which were first described by Montgomery of Dublin, and are known as Montgomery 1 s cups. They are in fact the dilated canals of the uterine tubular glands. CONCEPTION AND GENERATION. 91 On the internal surface of such an early decidua a number of shallow depressions may be made out, which are the open mouths of these ducts. Fig. 45. Aborted Ovum of about forty days, showing the Triangular Shape of the Decidua (which is hiid open), and the Aperture of the Fallopiau Tube. (After Coste.) Formation of the Decidua Reflexa. — When the ovum reaches the uterine cavity it soon becomes imbedded in the folds of the hyper- trophied mucous membrane, which almost entirely fills the uterine Fig. 46. Fig. 47. Fig. 48. Formation of Decidna. (The decidua is colored black, the < i v 1 1 1 1 1 is repre- ti mted as engaged between two projecting folds of membrane.) Projecting Polda of Membrane growing np around tbe ovum. (After Dalton.) -ii..\\ Ing «> > urn completely ■arronnded by the Decidna Reflexa. cavity. Asm rule it is attached to some point near tbe opening of a Fallopian tube, tbe swollen folds of mucous membrane preventing 92 PREGNANCY. its descent to the lower part of the uterus ; in exceptional circum- stances, however, as in women who have borne many children, and have a more than usually dilated uterine cavity, it may fix itself at a point much nearer the internal os uteri. According to the now generally accepted opinion of Coste, the mucous membrane at the base of the ovum soon begins to sprout around it and gradually ex- tends until it eventually completely covers the ovum (Figs. 46-48), and forms the cleciclua reflexa. Coste describes, under the name of the umbilicus, a small depression at the most prominent part of the ovum, which he considers to be the indication of the point where the closure of the decidua reflexa is effected. There are some objections to this theory, for no one has seen the decidua reflexa incomplete and in the process of formation, and, on examining its external surface, that is, the one furthest from the ovum, its microscopical appearance is identical with that of the inner surface of the decidua vera. To meet these difficulties, Weber and Groodsir, whose views have been adopted by Priestley, contended that the decidua reflexa is "the primary lamina of the mucous membrane, which, when the ovum enters the uterus, separates in two-thirds of its extent from the layers beneath it, to adhere to the ovum ; the remaining third remains attached, and forms a centre of nutrition." According to this view the decidua vera would be a subsequent growth over the separated portion, and the decidua serotina the portion of the primary lamina which remained attached. In this way the fact of the opposed sur- faces of the decidua vera and reflexa bein^ identical in structure Fig. 49. An Ovum removed from Uterus, and part of the Decidua Vera cut away. (After Coste.) ". Decidua vera, showing the follicles opening on its iuncv surface, b. Inner extremity of Fallo- pian tube. c. Flap of decidua reflexa. d. Ovum. would be accounted for. The difficulty which this theory is intended to meet, does not seem so great as is supposed, for if, as is likely, it is only the epithelial or internal surface of the mucous membrane CONCEPTION AND GENERATION. 93 which sprouts over the ovum, and not its deeper layers, the facts of the case would be sufficiently met by Coste's view. Up to the third month of 'pregnancy the decidua reflexa and era are not in close contact, and there may even be a considerable interspace between them, which sometimes contains a small quantity of mucous fluid, called the hydroperione. This fact may account for the curious circumstance, of which many instances are on record, that a uterine sound may be passed into a gravid uterus in the early months of pregnancy without necessarily producing abortion, and also for the occasional occurrence of menstruation after conception (Figs. 49 and 75). Eventually, by the growth of the ovum, the decidua reflexa comes closely into contact with the vera, and the two become inti- mately blended and inseparable. Decidua at the end of Pregnancy and after Delivery. — As pregnancy advances the decidua alters in appearance and becomes fibrous and thin. In the later months of utero-gestation fatty degeneration of its structure commences, its vessels and glands are obliterated, and its adhesion to the uterine Avails is lessened, so as to prepare it for separation. As we shall subsequently see, this fatty degeneration was assumed by Simpson to be the determining cause of labor at term. Viev:s of Robin. — It was long believed that the entire decidua was thrown off after labor, leaving the muscular coat of the uterus bare and denuded, and that a new mucous membrane was formed during convalescence. According to Robin, 1 whose views are corroborated by Priestley, no such denudation of the muscular tissue of the uterus ever occurs, but a portion of the decidua always remains attached after delivery. After the fourth month of pregnancy they believe that a new mucous membrane is formed under the decidua, which remains in a somewhat imperfect condition till after delivery, when it rapidly develops and assumes the proper functions of the mucous lining of the uterus. Robin also believes that that portion of the decidua which covers the placental site, the so-called decidua serotina, is not thrown oil" with the membranes, like the decidua vera and reflexa, but remains attached to the uterine walls, a thin layer of it only being expelled with the placenta, on which it may he observed. Duncan 8 entirely dissents from these views, and docs nol admit the formation of a new mucous membrane during the later months of utero-gestation. He believes that the greater portion of the decidua is thrown o&\ l»ut that part remains, and from this the fresh mucous membrane is developed. This view is similar to that of Spiegelberg, who holds that the portion of the decidua thai is expelled is the more superficial of the two layers described by Friedlander, composed chiefly of the epithelial elements, while the deeper or glandular layer remains attached t<> the walls of the uterus. From the epithe- lium of the glands a new epithelial layer is rapidly developed after delivery. This theory hears on the well-known analogy of the uterus 1 Mrnioircs (Ir L'Acad. Imp. (]c Mnl. 1861. 2 Researches in Obstetrics, p. L86etseq. 94 PREGNANCY. after delivery to the stump of an amputated limb; an old simile, principally based on the erroneous theory that the whole muscular tissue of the uterus was laid bare. This, as we have seen, is not the case, but the simile so far holds good in that the mucous lining is deprived of its epithelial covering ; and this fact, together with the existence of numerous open veins on the interior of the uterus, readily explains the extreme susceptibility to septic absorption which forms so peculiar a characteristic of the puerperal state. Changes in the Ovum. — Before we commenced the study of the de- cidua we had traced the impregnated ovum into the uterine cavity, and described the formation of the blastodermic membrane by the junction of the cells of the muriform body. We must now proceed to consider the further changes which result in the development of the foetus, and of the membranes that surround it. It would be quite out of place in a work of this kind to enter into the subject of embryology at any length, and we must therefore be content with such details as are of importance from a practical point of view. Division of the Blastodermic Membrane into Layers. — The blasto- dermic membrane, which forms a complete spherical lining to the ovum, between the yelk and the zona pellucicla, soon divides into two layers, the most external, called the epiblast, and an internal, the hypoblast, and between them is subsequently developed a third known as the mesoblast. From these three layers are formed the entire foetus ; the epiblast giving origin to the bones, muscles, and integu- ments, the nervous system, the serous membranes, and the amnion ; the hypoblast forming the mucous membranes and the alimentary canal ; and the mesoblast the circulating system. The Area Germinativa. — Almost immediately after the separation of the blastodermic membrane into layers, one part of it becomes thick- ened by the aggregation of cells, and is called the area germinativa. Fig. 50. Diagram of area germinativa, showing the primitive trace and area pellucuia. This is at first round and then oval in shape, and in its centre the first trace of the foetus may be detected in the form of a narrow straight line, the primitive trace. Surrounding it are some cells more translucent than those of the rest of the area germinativa, and hence CONCEPTION AND GENERATION. 95 Fig. 51. ".T called the area pellucida (Fig. 50). On each, side of the primitive trace two elevated ridges soon arise, the laminae dorscdes, which grad- ually unite posteriori}' to form a cavity within which the cerebro- spinal column is subsequently developed. Anteriorly they join to form the thoracic and abdominal cavities, inclosing portions of the epiblast, from which the serous membranes of the body are devel- oped. The minute embryo thus formed soon curves on itself, with its convexity outwards, and a distinct thickening is observed at one end, which is subsequently developed into the cephalic extremity of the foetus, while, at its other end, a thickening less marked in degree forms the caudal extremity. Formation of the Amnion. — At each of these points, very soon after the formation of the embryo, two hollow processes may be observed which gradually arch over the dorsal surface of the foetus, until they meet each other and form a complete en- velope to it. At the ventral surface these processes are separated by the whole length of the embryo, but they here also gradually approach each other, and eventually surround what is subsequently the umbilical cord, and blend with the integument of the foetus at the point of its insertion. In this way is formed the amnion (Fig. 51), consisting of two layers ; the in- ternal, derived from the epiblast, is formed of tessellated epithelial cells, the external arising from the meso- blast, is formed of cells like those of young connective tissue. Before the folds of the amnion unite, the free edge of each is bent outwards and spreads around the ovum, immediately within the zona pellucida, forming a lining to it, termed by Turner the sub-zonal membrane, which is con- nected with the development of the chorion. The amnion is the most internal of the membranes surrounding the foetus, and will presently be studied more in detail. It soon becomes distended with fluid, the liquor amnii, and as this increases in amount it separates the amnion m<»re and more from the uterus^ Changes in the Mucous Layer. — During this time the innermost layer of the blastodermic membrane or hypoblast is also developing two projection- at either extremity of the foetus, and these gradually approach each other anteriorly. A.8 the hypoblast ia in contact with the yelk, when these meet they have the effect of dividing the yelk into two portions. One, and the Bmaller of the two. forms eventu- ally the intestinal canal of the foetus : the other, and much the larger, contains the greater portion of the yelk, and forms the ephemeral structure known as the umbilical vesicle, from which the foetus derives most of its nourishment during the early stage of it.- existence. Its. Development of the Amnion. Vitelline membrane. 2. External layer of blastodermic membrane. •'*. Internal layers forming the umbilical vesicle. 4. Umbilical vessels. .0. Projections Conn- ing amnion. 6. Allantoic 96 PREGNANCY. communication with the abdominal cavity of the foetus is through the constricted portion at the point of division called the vitelline duct (Fig. 52). An artery and vein, the omphalo-mesenteric, ramify on the vesicle and its duct. Fig. 52. I. Exo-chorion. 2. External layer ofblastodermic membrane. 5. Amnion. 6. Embryon. 7. Allautois increasing in size. 3. Umbilical vesicle. 4. Its vessels. Fig. 53, As the amnion increases in size, it pushes back the umbilical vesicle towards the external membrane of the ovum, between which and the amnion it lies (Fig. 53) ; and when the allantois is developed, it ceases to be of any use, and rapidly shrinks and dwindles away. In most mammals no trace of it can be found after the fourth month of utero-gestation ; in some, including the human female, it is said to exist as a minute vesicle at the placental end of the umbilical cord at the full period of preg- nancy. The umbilical vesicle is filled with a yellowish fluid, containing many oil and fat globules, similar to the yelk of an egg. The Allantois. — Somewhere about the twen- tieth day after conception a small vesicle is formed towards the caudal extremity of the foetus, which is called the allantois. It is well developed and persistent in many of the lower animals, but in man it is merely a temporary structure, and disappears after it has fulfilled its functions. Its study, therefore, in the human race has been a matter of difficulty, and it was long before we were possessed of any very re- liable information regarding it. There has been some difference of opinion as to its precise mode of origin. The most generally received opinion is that it begins as a diverticulum from the lower part of the intestinal canal. This, at first spherical, rapidly develops and becomes pyriform in shape, while, by a process of constriction, similar to that which occurs in the vitellus to form An Embryo of about twen- ty-five days laid open. (After Coste.) a. Chorion, b. Amnion. e. Cavity of chorion, d. Umbilical vesicle, e. Pedi- cle of allantois. /. Em- bryo. CONCEPTION AND GENERATION, 97 the umbilical vesicle, it becomes divided into two parts, communi- cating with each other, the smaller of them being eventually de- veloped into the urinary bladder. The larger portion, leaving the abdominal cavity along with the vitelline duct, rapidly grows until it comes into contact with the most external ovular membrane, the chorion, over the entire inner surface of which it spreads. In this part vessels soon develop : namely, the two umbilical arteries, de- rived from the abdominal aorta, and two umbilical veins, one of which subsequently disappears ; these, along with the vitelline duct and the pedicle of the allantois, form the umbilical cord. The main and very important function of the allantois, therefore, is to carry the foetal vessels up to the inner surface of the sub-zonal membrane. Fig. 54. I. Exo-chorion. 2. External layer of the blastodermic memlirane. 3. Allantois. 4. Umbilical vesicle. 5. Amnion. 6. Embryou. 7. Pedicle of Allantois. Besides this purpose, the allantois, at a very early period, may receive the excretions of the foetus, and serve as an excrementitious organ. According to Cazeaux, scarcely a trace of the allantois can he seen a few da} r s after its formation. Its lower part or pedicle, bowever, long remains distinct, and forms part of the umbilical cord; and traces of it may be found even in adult life in the form of the urachus, which is really the dwindled pedicle, and forms one of the Ligaments of t lie bladder. The Corps Reticule or Viiriform Body. — Between the chorion and amnion is often found a gelatinous fluid, with minute filamentous processes traversing It, called by Velpeau the corps reticul^ which is not met with until the allantois comes into contad with the cho- rion, and which seems to he formed out of the tissue <>r that vesicle. It is analogous to the so-called Wharton's jelly found in the umbilical cord. When firsl formed it is highly vascular, bul the vee entirely disappear alter the placenta is formed, and the remainder of the chorionic villi atrophy. Sometimes it exists in considerable quantities, and should the chorion rupture at the end of pregnai 98 PREGNANCY. it may escape and give rise to an erroneous impression that the liquor amnii has been discharged. Recapitulation. — Before proceeding to consider the foetal envelopes more at length, it may be useful to recapitulate the structures already alluded to as forming the ovum. In this we find : — 1. The embryo itself. 2. A fluid, the liquor amnii, in which it floats. 3. The amnio?i, a purely foetal membrane surrounding the embryo, and containing the liquor amnii. 4. The umbilical vesicle, containing the greater portion of the yelk, serving as a source of nutrition to the early embryo through the vitelline duct, and in which ramify the omphalo-mesenteric vessels. 5. The allantois, a vesicle proceeding from the caudal extremity of the embryo, spreading itself over the interior of the ovum, and serving as a channel of vascular communication between the chorion and the foetus, through the umbilical vessels. 6. An interspace between the outer layer of the ovum and the amnion, in which is contained the umbilical vesicle and allantois, and the corps reticule of Velpeau. 7. The outer layer of the ovum, along with the sub-zonal mem- brane, forming the chorion and placenta. Amnion. — The amnion is the most internal of the two membranes surrounding the foetus ; its origin at an early period of foetal life has already been described. It is a perfectly smooth, transparent, but tough membrane, continuous with the integument of the foetus at the insertion of the umbilical cord, round which it forms a sheath. Soon after it is formed it becomes distended with a fluid, the liquor amnii, in which the foetus is suspended and floats. This fluid increases gradually in quantity, distending the amnion as it does so, until this is brought into contact with the inner surface of the chorion, from which it was at first separated by a considerable interspace. Structure. — The internal surface of the amnion is smooth and glistening, and on microscopic examination it is found to consist of a layer of flattened cells, each containing a large nucleus. These rest on a stratum of fibrous tissue which gives to the membrane its toughness, and by which it is attached to the inner surface of the chorion. It is entirely destitute of vessels, nerves, and lymphatics. The quantity of the liquor amnii varies much at different periods of pregnancy. In the early months it is relatively greater in amount than the foetus, which it outweighs. As pregnancy advances, the weight of the foetus becomes four or five times greater than that of the liquor amnii, although the actual quantity of fluid increases dur- ing the whole period of gestation. The amount of fluid varies much in different pregnancies. Sometimes there is comparatively little ; while at others the quantity is immense, reaching several pounds in weight, greatly distending the uterus, and thus, it may be, producing difficulty in labor. Its Quality. — At first the liquid is clear and limpid. As pregnancy advances it becomes more turbid and dense, from the admixture of epithelial debris derived from the cutaneous surface of the foetus. CONCEPTION AND GENERATION. 99 In some cases, without actual disease, it may be dark green in color, and thick and tenacious in consistency. It has a peculiar heavy odor, and it consists chemically of water containing albumen, with various salts, principally phosphates and chlorides. Its Source. — The source of the liquor amnii has been much disputed. Some maintain that it is derived chiefly from the foetus, a view suffi- ciently disproved by the fact that the liquor amnii continues to in- crease in amount after the death of the foetus. Burdach believed that it is secreted by the internal surface of the uterus, and arrives in the cavity of the amnion by transudation through the membrane. Priestley — and this seems the most probable hypothesis — thinks that it is secreted by the epithelial cells lining the membrane, which become distended with fluid, burst, and pour their contents into the amniotic cavity. Functions and Uses. — The most obvious use of the liquor amnii is to afford a fluid medium in which the foetus floats, and so is protected from the shocks and jars to which it would otherwise be subjected, and from undue pressure from the uterine Avails. By distending the uterus it saves the uterus from injury, which the movements of the foetus might otherwise inflict, and the foetus is thus also enabled to change its position freely. The facility with which version by ex- ternal manipulation can be effected depends entirely on the mobility of the foetus in the fluid which surrounds it. Some have also su] >p< >se< 1 that it prevents the foetus, in the early months of pregnancy, from forming adhesions to the amnion. In labor it is of great service, by lubricating the passages, but chiefly by forming, with the membranes a fluid wedge, which dilates the circle of the os uteri. chorion. — The chorion is the more external of the truly foetal mem- branes, although external to it is the decidua, having a strictly ma- ternal origin. It is a perfectly closed sac, its external surface, in contact with the decidua, being rough and shaggy from the develop- ment of villi (Fig. 50), its internal smooth and shining. As the ovum passes along the Fallopian tube it receives, as we have Been, an albuminous coating, and this, with the zona pellucida, is devel- oped into a temporary structure, the primitive chorion. On its exter- nal surface villous prominences soon appear, which have no ascer- tained structure, and which seem to supply the early ovum with nutriment by endosmotic absorption from tne mucous membrane of the uterus. This primitive chorion, however, has not been observed in the human subject, although it may be readily seen in the ova of some of the lower animals, such as the dog and the rabbit. Some twelve days after conception, when the blastodermic membrane is formed, tne true chorion appears. This is. iii fact formed by the epiblasi layer of the blastodermic membrane, which everywhere lines the zona pellucida or primitive chorion, and, by pressure, causes its absorption and disappearance. On the surface of the true chorion thus formed, which IS now the external envelope of the ovum, villi soon appear. Formation of the Villi,- These villi are hollow projections like the fingers of a glove, which are raised up from the surface ^i' the cho- 100 PREGNANCY. rion (the hollows looking into the chorionic cavity), and they cover the whole external surface of the ovum, giving it the peculiar shaggy appearance observed in early abortions. They push themselves into the substance of the decidua, with which they soon become so firmly united that they cannot be separated without laceration. At first they are absolutely non-vascular, but soon the allantois, previously described, reaches the inner surface of the chorion, and spreads itself over the whole of it. Each villus now r receives a separate artery and vein, which gives off a branch to each of the sub-divisions into which the villus divides. These vessels are encased in a fine sheath of the allantois, which enters the villus along with them and forms a lining to it, described by some as the endochorion ; the external epithelial membrane of the villus, derived from the epiblast layer of the blasto- dermic membrane, being called the exo-chorion. The artery and vein lie side by side in the centre of the villus and anastomose at its extremity ; each villus thus having a separate circulation. Growth and Atrophy of the Villi. — As soon as the union of the allantois with the chorion has been effected, the villi grow very rapidly, give off branches, which, in their turn, give off secondary branches, and so form root-like processes of great complexity. In the early months of gestation they exist equally over the whole sur- face of the ovum. As pregnancy advances, however, those which are in contact with the decidua reflexa shrivel up and, by the end of the second month, disappear, being no longer required for the nutrition of the ovum. The chorion and decidua thus come into close contact, being united together by fibrons shreds, which, on microscopic ex- amination, are found to consist of the atrophied villi. A certain number of the villi, viz., those which are in contact with the decidua serotina, instead of dwindling away increase greatly in size, and eventually develop into the organ by wdiich the foetus is nourished — the placenta. Form of the Placenta. — This important organ serves the purpose of supplying nutriment to, and aerating the blood of, the foetus, and on its integrity the existence of the foetus depends. It is met with in all mammals, but is very different in form and arrangement in different classes. Thus, in the sow, mare, and in the cetacea, it is diffused over the whole interior of the uterus ; in the ruminants, it is divided into a number of separate small masses, scattered here and there over the uterine walls ; while in the carnivora and elephant, it forms a zone or belt round the uterine cavity. In the human race, as well as in rodentia, insectivora, etc., the placenta is in the form of a circular mass, attached generally to some part of the uterus near the orifices of the Fallopian tubes ; but it may be situated anywhere in the uterine cavity, even over the internal os uteri. As it is ex- pelled after delivery with the foetal membranes attached to it, and as the aperture in these corresponds to the os uteri, Ave can generally determine pretty accurately the situation in which the placenta was placed, by examining them after expulsion. The maternal surface of the placenta is somewhat convex, the foetal concave. Its size varies greatly in different cases, and it is usually largest when the CONCEPTION AXD GENERATION. 101 child is big, but not necessarily so. Its average diameter is from six to eight inches, its weight from 18 to 21 oz., but, in exceptional cases, it has been found to weigh several pounds. Abnormalities of form are not very rare. Thus, the placenta has been found to be divided into distinct parts, a form said by Professor Turner to be normal in certain genera of monkeys ; or smaller supplementary placenta? (placentae succentarise), may exist round a central mass. These variations of shape are only of importance in consequence of a risk of part of the detached placeuta being left in utero after delivery, and giving rise to septicemia or secondary hemorrhage. Attachment of the Membranes. — The foetal membranes cover the whole foetal surface of the placenta, being reflected from its edges so as to line the uterine cavity, and being expelled with it after delivery. They also leave it at the insertion of the cord, to which they form a sheath. The cord is generally attached near the centre of the pla- centa, and from its insertion the umbilical vessels may be seen dividing and radiating over the whole foetal surface. Its Maternal Surface. — The maternal surface is rough and divided by numerous sulci, which are best seen if the placenta is rendered convex, so as to resemble its condition when attached to the uterus. A careful examination shows that a delicate membrane covers the entire maternal surface, unites the sulci together, and dips down be- tween them. This is, in fact, the cellular layer of the decidua serotma, which is separated and expelled witli the placenta, the deeper layer remaining attached in utero. Numerous small openings may be seen on the surface, which are the apertures of the veins torn off from the uterus, as also those of some arteries, which, after taking several sharp turns, open suddenly into the substance of the organ. Minute Structure of the Placenta. — As regards the minute structure of the placenta it is certain that it consists essentially of two dis- tinct portions, one foetal, consisting of the greatly hypertrophied chorionic villi, with their contained vessels, which carry the foetal blood so as to bring it into intimate relation with the maternal blood, and thus admit of the necessary < -115111203 occurring in it connected with the nutrition of the foetus; and the other maternal^ formed ou1 of the decidua serotina and the maternal bloodvessels. These two portions are in the human female so intimately blended as to form the single deciduous organ which is thrown <>IV after delivery. These main facts are admitted by all, but considerable differences of opinion still exist among anatomists as to the precise arrangemenl of these parts. In the following sketch of the Bubjecl I shall describe the views most generally entertained, merely briefly indicating the points which are contested by various authorities. Fatal Portion of the Placenta,- The foetal portion of the placenta consists essentially of the ultimate ramifications of the chorion villi, which may be seen on microscopic examination in the Conn of club* shaped digitations which are given off at every | •« >- -i 1 >1« - angle from the stem of a parent trunk, just like the branches of a plant. With- in the transparent walls of the villi the capillary tubes of the con- tained vessels may he seen lying, distended with blood, and present- 102 PREGNANCY. ing an appearance not unlike loops of small intestine. The capilla- ries are the terminal ramifications of the umbilical arteries and veins, which, after reaching the site of the placenta, divide and subdivide until they at last form an immense number of minute capillary vessels, with their convexities looking towards the maternal portion of the placenta, each terminal loop being contained in one of the digitations of the chorionic villi. Each arterial twig is accompanied by a corresponding venous branch, which unites with it to form the terminal arch or loop (Fig. 55). The foetal blood is carried through these arterial twigs to the villi, where it comes into intimate contact Placental Villus, greatly magnified. (After Joulin.) 1. 2. Placental vessels, forming terminal loops. 3. Chorion tissue, forming external walls of villus. 4. Tissue surrouudiug vessels. with the maternal blood, in consequences of the anatomical arrange- ments presently to be described ; but the two do not directly mix, as the older physiologists believed, for none of the maternal blood escapes when the umbilical cord is cut, nor can the minutest injections through the foetal vessels be made to pass into the maternal vascular system, or vice versa. In addition to the looped terminations of the umbilical vessels, Farre and Schroeder van der Kolk have described another set of capillary vessels in connection with each villus (Fig. 56); This consists of a very fine network covering each villus, and very different in appearance from the convoluted vessels lying in its interior, which are the only ones which have been usually described. Dr. Farre believes that these vessels only exist in the early months of CONCEPTION AND GENERATION. 103 pregnancy, and that they disappear as pregnancy advances. Priestlev 1 suggests that they may not be vessels at all, but lymphatics, which Fig. 56. a. Terminal villus of fcetal tuft, minutely injected. 6. Its nucleated nonvascular sheath. (After F arre.) may possibly absorb nutrient material from the mother's blood, and throw it into the foetal vascular system. The existence of lymphatics, Fig. 57. Diagram representing a Vertical Bectlonof the Placenta. (After Dalton | a,ri. Chorion, b, h. Decldoa. c,c,c,c. Orlflcet of nterlne slnntea. ot nerves, in the placenta, however, bas never been demonstrated, and they arc believed nol to exist. 1 The Gravid Uterus, p. 52. 104 PREGNANCY. Maternal Portion of the Placenta. — As generally described, the maternal portion of the placenta consists of large cavities, or of a single large cavity, which contain the maternal blood, and into which the villi of the chorion penetrate (Fig. 57). Into this maternal part of the viscns the curling arteries of the uterus pour their blood, which is collected from it by the uterine sinuses. The villi of the chorion, therefore, are suspended in a sac filled with maternal blood, which penetrates freely between them, and with which they are brought into very intimate contact. Dr. John Eeid believed that only the delicate internal lining of the maternal vessels entered the substance of the placenta, to form the sac just spoken of. Into this the villi project, pushing before them the membrane forming the limiting wall of the placental sinuses, each of them in this way receiving an investment, just as the fingers of a hand are covered by a glove (Fig. 58). Fig. 58. Fig. 59. 0~. ... Diagram illustrating the mode in which a pla- cental villus derives a covering from the vascu- lar system of the mother. (After Priestley.) a. Villus having three terminal digitations pro- jecting into b. Cavity of the mother's vessel, c. Dotted lines representing coat of vessel. The Extremity of a Placental Villus. (After Goodsir.) a. External membrane of villus (the lining membrane of vascular system of Weber). b. External cells of villus derived from decidua. c. c. Nuclei of ditto. d. The space between the maternal and foetal portions of villus. e. Its internal membrane. /. Its internal cells. g. The loop of umbilical vessels. Theory of Goodsir. — Schroeder van der Kolk and Goodsir (Fig. 59) were of opinion that not only were the maternal bloodvessels con- tinued into the substance of the placenta, *but also the processes of the decidua, which accompanied the vessels and were prolonged over each villus, so as to separate it from the limiting membrane of the maternal sinuses. Each villus would thus be covered by two layers of fine tissue, one from the internal lining membrane of the maternal bloodvessels, the other from the epithelial cells of the decidua. Theory of Turner. — Turner, whose valuable researches on the com- parative anatomy of the placenta have thrown much light on its structure, points out that the placentae of all animals are formed on the same fundamental type, 1 in which the foetal portion consists of a smooth, plane-surfaced vascular membrane, covered with pavement 1 Introduction to Human Anatomy, part 2. CONCEPTION AND GENERATION. 105 epithelium, which is brought into contact with the maternal portion, consisting of a smooth, plane-surfaced vascular membrane, covered with columnar epithelium. The foetal capillaries are separated from the maternal capillaries only by two opposed layers of epithelium. In various animals the placentas are more or less specialized from the generalized form, in some to a much greater extent than others. In the human placenta the maternal vessels have lost their normal cylindrical form, and are dilated into a system of freely inter-com- municating placental sinuses, which are, in fact, maternal capillaries enormously enlarged, with their walls so expanded and thinned out that thev cannot be recognized as a distinct laver limiting: the sinus. Each foetal chorionic villus projecting into these sinuses is covered with a layer of cells distinct from those of the epithelial layer of the villus, and readily stripped from it. These are maternal in their origin, and are derived from the decidua, which sends prolongations of its tissue into the placenta. These cells, he believes, form a secret- ing epithelium which separates from the maternal blood a secretion for the nourishment of the foetus, which is, in its turn, absorbed by the villi of the chorion. Theory of Ercolani. — A view not very dissimilar to this has been advanced by Professor Ercolani of Bologna, who maintains that the maternal portion of the placenta is a new formation, strictly glandu- lar, and not vascular, in its structure. It is formed, he thinks, by the submucous connective tissue of the decidua serotina, and it dips down into the placenta and forms a sheath to each of the chorion villi, which it separates from the maternal blood. This new glandu- lar structure he describes as secreting a fluid, termed the " uterine milk,' 1 which is absorbed by the villi of the chorion, just as the mother's milk is absorbed by the villi of the intestines, and it is with this fluid alone that the chorion villi are in direct contact. The sheath thus formed to each villus is doubtless analogous to the layer of cells which Goodsir described as encasing each villus, but is attributed to a new structure formed after conception. Theory of Braxton Hicks. — The existence of the maternal sinus system in the placenta, is altogether denied by anatomists of emi- Dence whose views arc worthy of careful consideration. Prominenl amongsl these is Braxton Hicks, 1 who has written an elaborate paper on the subject. He holds that there is no evidence to prove thai the maternal blood is poured out into a cavity in which the chorion villi float, and he believes thai the curling arteries, instead of entering the so-called maternal portion of the placenta, terminate in the deci- dua serotina. The hypertrophied chorion villi at the site of the placenta are firmly attached to the decidual surface, into which their tips are embedded. The line of junction between the decidua reflexa and serotina forms a circumferential margin to, and limits the pla- centa. The arrangement of the futal portion of the placenta on this view is very similar to thai generally described, bu1 the villi are qo1 surrounded by maternal blood at all, and nothing exists between ( >bst. Trans., vol. xiv \06 PREGNANCY. them, unless it be a small quantity of serous fluid. The change in the foetal blood is effected by endosmosis, and Hicks suggests that follicles of the decidua may secrete a fluid, which is poured into the intervillous spaces for absorption by the villi. Functions of the Placenta. — It will thus be seen that anatomists of repute are still undecided as to important points in the minute ana- tomy of the placenta, which further investigation will doubtless clear up. The main functions of the organ are, however, sufficiently clear. During the entire period of its existence it fills the important office of both stomach and lungs to the foetus. Whatever view of the arrangement of the maternal bloodvessels be taken, it is certain that the foetal blood is propelled by the pulsations of the foetal heart into the numberless villi of the chorion, where it is brought into very intimate relation with the mother's blood, gives off its carbonic acid, absorbs oxygen, and passes back to the foetus, through the um- bilical veins, in a fit state for circulation. The mode of respiration, therefore, in the foetus is analogous to that in fishes, the chorion villi representing the gills, the maternal blood the water in which they float. Nutrition is also effected in the organ, and, by absorption through the chorion villi, the pabulum for the nourishment of the foetus is taken up. It also probably serves as an emunctory for the products of excretion in the foetus. Picard found that the blood in the placenta contained an appreciably larger quantity of urea than that in other parts of the body, this urea probably being derived from the foetus. Claude Bernard also attributed to it a glycogenic function, 1 supposing it to take the place of the foetal liver until that prgan was sufficiently developed. Degenerative Changes previous to Expulsion. — Finally, we find that the temporary character of the placenta is indicated by certain degen- erative changes, which take place in it previous to expulsion. These consist chiefly in the deposit of calcareous patches on its uterine sur- face, and in fatty degeneration of the villi, and of the decidual layer between the placenta and the uterus. If this degeneration be carried to excess, as is not unfrequently the case, the foetus may perish from a want of a sufficient number of healthy villi through which its respiration and nutrition may be effected. Umbilical Cord. — The umbilical cord is the channel of communi- cation between the foetus and placenta, being attached to the former at the umbilicus, to the latter generally near its centre, but some- times, as in the battledore placenta, at its edge. It varies much in length, measuring on an average from 18 to 24 inches, but in excep- tional cases being found as long as 50 or 60, and as short as 5 or 6 inches. When fully formed it consists of an external membranous layer formed of the amnion, two umbilical arteries, one umbilical vein, and a considerable quantity of transparent gelatinous substance surround- ing the vessels, called Wharton's jelly, which is contained in a fine network of fibres, and is formed out of the tissue of the allantois. 1 Acad, des Sciences, April, 1859. ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 107 At an early period of pregnancy, in addition to these structures, the cord contains the pedicle of the umbilical vesicle, with the omphalo- mesenteric vessels ramifying on it, and two umbilical veins, one of which soon atrophies and disappears. Iso nerves or lymphatics have been satisfactorily demonstrated in the cord, although such have been described as existing. The vessels of the cord are at first straight in their course, but shortly they become greatly twisted, the arteries being external to the vein, and in nine cases out of ten the twist is from left to right. Various explanations have been given of this peculiarity, none of them entirely satisfactory. Tyler Smith attributed it to the movements of the foetus twisting the cord, its attachment to the placenta being a fixed point ; this would not, how- ever, account for the frequency with which the spiral turns occur in one direction. Mr. John Simpson attributed it to the greater pres- sure of the blood through the right hypogastric artery, on account of that vessel having a more direct relation to the aorta than the left. The umbilical arteries give off no branches, and the vein con- tains no valves, nor can any vasa vasorum be detected in their coats after they have left the umbilicus. The umbilical arteries increase in size after they leave the cord, to divide on the surface of the pla- centa. This is the only example in the body in which arteries are larger near their terminations than their origin, and the object of this arrangement is probably to effect a retardation of the current of the blood distributed to the placenta. The tortuous course of the vein probably compensates for the absence of valves, and moderates the flow of blood through it. Distinct knots are not unfrequently observed in the cord, but they rarely have the effect of obstructing the circulation through it. They no doubt form when the foetus is very small. They may sometimes also be produced in labor by the child being propelled through a coil of the cord lying circularly round the os uteri. The so-called false knots are merely accidental nodosi- ties due to local enlargements of the vessels. CHAPTER 11. THE ANATOMY AND PHYSIOLOGY OF THE PCBTUS. It is obviously impossible to attempl anything like ;i full acoounl of the development of the various fceta] structures, or of tbeir growth during intra-uterine life. To do so would lead as far beyond the scope of this work, and would involve, a study of complex details only suitable in a treatise on Bi n bryology. It is of importance, how- ever, that the practitioner should nave it in his power to deter] e approximatively the age of the foetus in abortions or premature 108 PKEGNANCY. labor, and for this purpose it is necessary to describe -briefly the ap- pearance of the foetus at various stages of its growth. 1st Month. — The foetus in the first month of gestation is a minute gelatinous, and semi-transparent mass, of a grayish, color, in which no definite structure can be made out, and in which no head nor ex- tremities can be seen. It is rarely to be detected in abortions, being lost in surrounding blood clots. In the few examples which have been carefully examined it did not measure more than a line in length. It is however, already surrounded by the amnion, and the pedicle of the umbilical vesicle can be traced into the unclosed abdominal cavity. 2d Month. — The embryo becomes more distinctly apparent, and is curved on itself, weighing about 62 grains, and measuring 6 or 8 lines in length. The head and extremities are distinctly visible — the latter in the form of rudimentary projections from the body. The eyes are to be seen as small black spots on the side of the head. The spinal column is divided into separate vertebrae. The indepen- dent circulatory system of the foetus is now beginning to form, the heart consisting of only one ventricle and one auricle, from the former of which both the aorta and pulmonary arteries arise. On either side of the vertebral column, reaching from the heart to the pelvis, are two large glandular structures, the corpora Wolffiania, which consist of a series of convoluted tubes opening into an excre- tory duct, running along their external borders, and connected below with the common doaca of the genito-urinary and digestive tracts. They seem to act as secreting glands, and fulfil the functions of the kidneys before these are formed. Towards the end of the second month they atrophy and disappear, and the only trace of them in the foetus at term is to be found in the parovarium lying between the folds of the broad ligaments. At this stage of development there are met with in the human embryo, as in that of all mammals, four transverse fissures opening into the pharynx, which are analo- gous to the permanent branchiae of fishes. Their vascular supply is also similar, as the aorta at this time gives off four branches on each side, each of which forms a branchial arch, and these afterwards unite to form the descending aorta. By the end of the sixth week these, as well as the transverse fissures to which they are distributed, disappear. By the end of the second month the kidneys and supra- renal capsules are forming, and the single ventricle is divided into two by the growth of the inter- ventricular septum. The umbilical cord is quite straight, and is inserted into the lower part of the ab- domen. Centres of ossification are showing themselves in the infe- rior maxillary bones and the clavicle. 3d Month. — The embryo weighs from 70 to 300 grains, and meas- ures from 2J to 3J inches in length. The forearm is well formed and the first traces of the fingers can be made out. The head is large in proportion to the rest of the body, and the eyes are promi- nent. The umbilical vesicle and allantois have disappeared, the greater portion of the chorion villi have atrophied, and the placenta is distinctly formed. ANATOMY AND PHYSIOLOGY OF THE FCETUS. 109 Ath Month. — The weight is from 4 to 6 oz., and the length about 6 inches. The convolutions of the brain are beginning to develop. The sex of the child can now be ascertained on inspection. The muscles are sufficiently formed to produce distinct movements of the limbs. Ossification is extending, and can be traced in the occipital and frontal bones, and in the mastoid processes. The sexual organs are differentiated. 5th Month. — Weight about 10 oz. Length, 9 or 10 inches. Hair is observed covering the head, which forms about one-third of the length of the whole foetus. The nails are beginning to form, and ossification has commenced in the ischium. 6th Month. — Weight about 1 lb. Length, 11 to 12| inches. The hair is darker. The eyelids are closed, and the membrana pupillaris exists ; eyelashes have now been formed. Some fat is deposited under the skin. The testicles are still in the abdominal cavity. The clitoris is prominent. The pubic bones have begun to ossify. 7th Month. — Weight, from 3 to 4 lbs. Length, 13 to 15 inches. The skin is covered with unctuous, sebaceous matter, and there is a more considerable deposit of sub-cutaneous fat. The eyelids are open. The testicles have descended into the scrotum. 8th Month. — -Weight, from 4 to 5 lbs. Length, 16 to 18 inches; and the foetus seems now to grow in thickness rather than in length. The nails are completely developed. The membrana pupillaris has disappeared. Foetus at Term. — At the completion of pregnancy the foetus weighs on an average 6J lbs., and measures about 20 inches in length. These averages are, however, liable to great variation. Remarkable his- tories are given by many writers of foetuses of extraordinary weight, which have been probably greatly exaggerated. Out of 3000 children delivered under the care of Cazeaux at various charities, one only weighed 10 lbs. There are, however, several carefully recorded instances of weight far exceeding this; but they are undoubtedly much more uncommon than is generally supposed. Dr. Ramsbotham mentions a foetus weighing 16 J lbs., and Cazeaux tells of one which he delivered by turning which weighed lb' Lbs., and measured 2 feet 1J inches. Such overgrown children are almost invariably stillborn. On the other hand, mature children have been born and survived which have not weighed more than 5 lbs. [2| lbs. — Ed.] The average size of male children at birth, as in alter life, is some- what greater than that of female. Thus Simpson 1 found that oul of 100 cases the male children averaged L0 oz. more in weight than the female, and J an inch more in length. A new-born child at term is generally covered to a greater or fess extenl with a greasy, unotuous material, the vernix caseosa, which is formed of epithelial scales and the secretion of the sebaceous glands, ami which is said to he of use in labor, by lubricating the surface of the child. The head is gene- rally covered with long* lark hair, which frequently falls off or changes in color shortly after birth. Dr. Wiltshire 1 has called attention to 1 Selected Obst. Works, p. 827. ■ Lancet, February 11, L871. 110 PREGNANCY. an old observation, that the eyes of all new-born children are of a peculiar dark steel-gray color, and that they do not acquire their permanent tint until some time after birth. The umbilical cord is generally inserted below the centre of the body. Anatomy of the Foetal Head. — The most important part of the foetus from an obstetrical point of view is the head, which requires a separate study, as it is the usual presenting part, and the facility of the labor depends on its accurate adaptation to the maternal passages. The chief anatomical peculiarity of interest, in the head of the foetus at term, is that the bones of the skull, especially of its vertex — which, in the vast majority of cases, has to pass first through the pelvis — are not firmly ossified as in adult life, but are joined loosely together by membrane or cartilage. The result of this is, that the skull is capable of being moulded and altered in form to a very con- siderable extent by the pressure to which it is subjected, and thus its passage through the pelvis is very greatly facilitated. This, however, is chiefly the case with the cranium proper, the bones of the face and of the base of the skull being more firmly united. By this means the delicate structures at the base of the brain are protected from pressure, while the change of form which the skull undergoes during labor implicates a portion of the skull where pressure on the cranial contents is least likely to be injurious. The divisions between the bones of the cranium are further of obstetric importance in enabling us to detect the precise position of the head during labor, and an accurate knowledge of them is there- fore essential to the obstetrician. The Sutures and Fontanelles. — We talk of them as sutures and fontanelles, the former being the lines of junction between the sepa- rate bones which overlap each other to a greater or less extent during labor ; the latter .membranous interspaces where the sutures join each other. The principal sutures are : 1st, the sagittal, which separates the two parietal bones, and extends longitudinally backwards along the vertex of the head. 2d. The frontal, which is a continuation of the sagittal, and divides the two halves of the frontal bone, at this time separate from each other. 3d. The coronal, which separates the frontal from the parietal bones, and extends from the squamous por- tion of the temporal bone across the head to a corresponding point on the opposite side ; and 4th, the lambdoidal, which receives its name from its resemblance to the Greek letter a, and separates the occipital from the parietal bones on either side. The fontanelles (Fig. 60) are the membranous interspaces where the sutures join — ■ the anterior and larger being lozenge-shaped, and formed by the junc- tion of the frontal, sagittal, and two halves of the coronal sutures. It will be well to note that there are, therefore, four lines of sutures running into it, and four angles, of which the anterior, formed by the frontal suture, is most elongated and well marked. The posterior fontanelle (Fig. 61) is formed by the junction of the sagittal suture with the two legs of the lambdoidal. It is, therefore, triangular in shape, with three lines of suture entering it in three angles, and is ANATOMY AXD PHYSIOLOGY OF THE FOETUS 111 much smaller than the anterior fontanelle, forming merely a depres- sion into which the tip of the finger can be placed, while the latter is a hollow as big as a shilling, or even larger. As it is the posterior fontanelle which is generally lowest, and the one most commonly felt Fig. 60. Fig. Gl. Anterior and I Fontanelles. Bi-parietal Diameter, Sagittal and Lambdoidal Sutures, with Posterior Fontanelles. during labor, it is important for the student to familiarize himself with it, and he should lose no opportunity of studying the sensations imparted to the finger by the sutures and fontanelles in the head of the child after birth. The Diameters of the Foetal Skull. — For the purpose of understand- ing the mechanism of labor, we must study the measurements of the foetal head in relation to the cavi- ty through which it has to pass. Fig. 62. They are taken from correspond- ing points opposite to each other, and are known as the diameters of the skull (Fig. 62). Those of most importance are : 1st. The occi i n to-mental, from the occipital protuberance to the point of the chin, 5.25" to 5.50". 2d. The oc- cipito-frontal, from the occiput to the centre of the forehead, 4.50" to 5". 3d. The sub-occipito-breg- matiCy from a point midway be- tween the occipital protuberance and the margin of the foramen magnum to the centre <>i' tin- an- terior fontanelle, :\:l'>" '. 4th. The cervico-bregmatic, from the anterior margin of the foramen magnum to the centre of the anterior fontanelle, 3.75". 5th. Tr bi-parietal, between the parietal protuberances, 3.75" i<> 1". 6th. Bi temporal, between the ears, 3.50 . 7th. Fronto-mental, from the apex of the forehead to the chin, 3.25". i ft -j. 9 ft 1. 7& 8. to-frontal diameter. < 'cclplto mental. i-bregmatie. Pronto-mental. 112 PREGNANCY. Alteration of Diameter during Labor. — The length of these respec- tive diameters, as given by different writers, differs considerably — a fact to be explained by the measurements having been taken at different times ; by some just after birth, when the head was altered in shape by the moulding it had undergone ; by others when this had either been slight, or after the head had recovered its normal shape. The above measurements may be taken as the average of those of the normally-shaped head, and it is to be noted that the first two are most apt to be modified during labor. The amount of com- pression and moulding to which the head may be subjected, without proving fatal to the foetus, is not certainly known, but it is doubtless very considerable. Some interesting examples of the extent to which the head may be altered in shape in difficult labors have been given by Barnes, 1 who has shown, by tracings of the shape of the head taken immediately after delivery, that in protracted labor the oc- cipito-mental and occipitofrontal diameters may be increased more than an inch in length, while lateral compression may diminish the bi-parietal diameter to the same length as the inter-auricular. The foetal head is movable on the vertical column to the extent of a quarter of a circle; and it seems probable that the laxity of the liga- ments admits with impunity a greater circular movement than would be possible in the adult. Influence of Sex and Race on the Foetal Head. — On taking the ave- rage of a large number of measurements, it is found that the heads of male children are larger and more firmly ossified than those of females, the former averaging about half an inch more in circum- ference. Sir James Simpson attributed great importance to this fact, and believed that it was sufficient to account for the larger proportion of still births in male than in female children, as well as for the greater difficulty of labor and the increased maternal mortality that are found to attend on male births. His well-known paper on this subject, which has given rise to much controversy, is full of the most elaborate details, and so great did he believe the foetal influence to be, that he calculated that between the years 1834 and 1837 there were lost in Great Britain, as a consequence of the slightly larger size of the male than of the female head at birth, about 50,000 lives, including those of about 46,000 or 47,000 infants, and of between 3000 and 4000 mothers who died in childbed. 2 It is probable that race and other conditions, such as civilization and intellectual culture, have con- siderable influence on the size of the foetal skull, but we are not in possession of sufficiently accurate data to justify any very positive opinion on these points. Position of the Foetus in Titer o. — In the very large majority of cases the foetus lies in utero with the head downwards, and is so placed as to be adapted in the most convenient way to the cavity in which it is placed. The uterine cavity is most roomy at the fundus, and narrowest at the cervix, and the greatest bulk of the foetus is at the breech, so that the largest part of the child usually lies in the part 1 Obst. Trans., vol. vii. 2 Selected Obstet. Works, p. 363. ANATOMY AND PHYSIOLOGY OF THE F(ETUS. 113 of the uterus best adapted to contain it. The various parts of the child's body are further so placed, in regard to each other, as to take up the least possible amount of space. (See frontispiece.) The body is bent so that the spine is curved with its convexity outwards, this curvature existing from the earliest period of development; the chin is flexed on the sternum; the forearms are flexed on the arms, and lie close together on the front of the chest; the legs are flexed on the thighs, and the thighs -drawn up on the abdomen; the feet are drawn up towards the leg; the umbilical cord is generally placed out of reach of injurious pressure, in the space between the arms and the thighs. Variations from this attitude, however, are not uncommon, and are not, as a rule, of much consequence. Although the cranial presentations are much the most common, averaging 96 out of every 100 cases, other presentations are by no means rare, the next most frequent being either that of the breech, in which the long diameter of the child lies in the long diameter of the uterine cavity, or some variety of transverse presentation, in which the long dia- meter of the foetus lies obliquely across the uterus, and no longer corresponds to its longitudinal axis. Changes of Foetal Position during Pregnancy. — It was long believed that the head presentation was only assumed towards the end of pregnancy, when it was supposed to be produced by a sudden move- ment on the part of the foetus, knoAvn as the culbute. It is now well known that, in the large majority of cases, the head is lowest during all the latter part of pregnancy, although changes in position are more common than is generally believed to be the case, and presen- tation of parts other than the head is much more frequent in pre- mature labor than in delivery at term. In evidence of the last statement, Churchill says that in labor at the seventh month the head presents only 83 times out of 100 when the child is living, and that as many as 53 per cent, of the presentations are preternatural when the child is still-born. The frequency with which the foetus changes its position before delivery has been made tin 1 subject of investigation by various German obstetricians, and the fad ran be readily ascertained by examination. Valenta 1 found that out of nearly 1000 cases, carefully and frequently examined by him, in 67.6 per cent, the presentation underwent no change in tin- latter months of pregnancy, but in the remaining 42.4 per cent, a change could be readily detected. These alterations were, found to be mos1 frequent in multiparas, and the tendency was for abnormal presentations to alter into normal ones. Thus it was common for transverse presenta- tions to alter longitudinally, and bin rare for breech presentations to change into head. The ease with which these changes are effected no doubt depends, in a considerable degree, <>n the laxity of the uterine parietes, and <>n the ^renter quantity of amniotic fluid, by both of which the free mobility of the foetus is favored. Detection of Feel \a I Position by Abdominal Palpation.- -The facility with which the position of the foetus in iitero can be ascertained by 1 .M«»n. f. Geburt., 1866. 114 PREGNANCY abdominal palpation has not been generally appreciated in obstetric works, and yet, by a little practice, it is easy to make it out. Much, information of importance can be gained in this way, and it is quite possible, under favorable circumstances, to alter abnormal presen- tations before labor has begun. For the purpose of making this examination, the patient should lie at the edge of the bed, with her shoulders slightly raised, and the abdomen uncovered. The first observation to make is to see if the longitudinal axis of the uterine tumor corresponds with that of the mother's abdomen ; if it does, the presentation must be either a head or a breech. By spreading the hands over the uterus (Fig. 63), a greater sense of resistance can be Fig. 63. Mode of ascertaining the Position of the Foetus by Palpation. felt, in most cases, on one side than on the other, corresponding to the back of the child. By striking the tips of the fingers suddenly inwards at the fundus, the hard breech can generally be made out, or the head, still more easily, if the breech be downwards. When the uterine walls are unusually lax, it is often possible to feel the limbs of the child. These observations can be generally corroborated by auscultation, for in head presentations the foetal heart can usually be heard below the umbilicus, and in breech cases above it. Trans- verse presentations can even more easily be made out by abdominal palpation. Here the long axis of the uterine tumor does not corre- spond with the long axis of the mother's abdomen, but lies obliquely across it. By palpation the rounded mass of the head can be easily felt in one of the mother's flanks, and the breech in the other, while the foetal heart is heard pulsating nearer to the side at which the head is detected. Explanation of the Position of the Foetus in Titer o. — The reason why the head presents so frequently has been made the subject of much discussion. The oldest theory was, that the head lay over the- os ANATOMY AND PHYSIOLOGY OF THE FCETUS. 115 uteri as the result of gravitation, and the influence of gravity, although contested by many obstetricians, prominent among whom were Du- bois and Simpson, has been insisted upon as the chief cause by others. Dr. Duncan being one of the most strenuous advocates of this view. The objections urged against the gravitation theory were drawn partly from the result of experiments, and partly from the frequency with which abnormal presentations occurred in premature labors, when the action of gravity could not be supposed to be suspended. The experiments made by Dubois went to show that when a foetus was suspended in water gravitation caused the shoulders, and not the head, to fall lowest. He, therefore, advanced the hypothesis that the position of the foetus was due to instinctive movements, which it made to adapt itself to the most comfortable position in which it could lie. It need only be remarked that there is not the slightest evidence of the foetus possessing any such power. Simpson proposed a theory which was much more plausible. He assumed that the foetal position was due to reflex movements produced by pl^sical irrita- tions to which the cutaneous surface of the foetus is subjected from changes of the mother's position, uterine contractions, and the like. The absence of these movements, in the case of the death of the foetus, would readily explain the frequency of mal-presentation under such circumstances. The obvious objection to this theory, complete as it seems to be, is the absence of any proof that such constant extensive reflex movements really do occur in utero. Dr. Duncan has very conclusively disposed of the principal objections which have been ,a Diagram Illustrating the Effect of Gravity on the Fcetus. (After Duncan.) a, h, is parallel to the axis of the pregnant uterus and peh i<- brim. 0, -/. -. i- 1 perpendloular line. e, the centre of gravity of the foetus, d, the centre of flotation. raised against the influence of gravitation, and when an obi planation of so simple a kind exists it seems useless fco seek further for another. He has shown thai Dubois' experiments did ool accu- rately represent the state of the foetus in utero, and that, during the 116 PREGNANCY. greater part of the day, when the woman is upright, or lying on her back, the foetus lies obliquely to the horizon at an angle of about 30°. The child thus lies, in the former case, on an inclined plane, formed by the anterior uterine wall and by the abdominal parietes, in the latter by the posterior uterine wall and the vertebral column. Down the inclined plane so formed the force of gravity causes the foetus to slide, and it is only when the woman lies on her side that the foetus is placed horizontally, and is not subjected in the same degree to the action of gravity (Fig. 64). The frequency of mal-presenta- tions in premature labors is explained by Dr. Duncan partly by the fact that the death of the child (which so frequently precedes such cases) alters its centre of gravity, and partly by the greater mobil- ity of the child and the greater relative amount of liquor amnii (Fig. 65). The influence of gravitation is probably greatly assisted N Fig. 65. Illustrating the greater Mobility of the Foetus and the Larger relative. Amount of Liquor Amnii in Early Pregnancy. (After Duncan.) a, b. Axis of pregnant uterus. b, h. A horizontal line. by the contractions of the uterus which are going on during the greater part of pregnancy. The influence of these was pointed out by Dr. Tyler Smith, who distinctly showed that the contractions of the uterus preceding delivery exerted a moulding or adapting influ- ence on the foetus, and prevented undue alterations of its position. Dr. Hicks proved 1 that these uterine contractions are of constant occurrence from the earliest period of pregnancy, and there can be little doubt that they must have an important influence on the body contained within the uterus. Functions of the Foetus. — The functions of the foetus are in the main the same, with differences depending on the situation in which it is placed, as those of the separate being. It breathes, it is nourished, it forms secretions, and its nervous system acts. The mode in which some of these functions are carried on in intra-uterine life requires separate consideration. 1. Nutrition. — 'During the early period of pregnancy, and before the formation of the umbilical vesicle and the allantois, it is certain 1 Obst. Trans, vol. xiii. p. 216. ANATOMY AXD PHYSIOLOGY OF THE FCETUS. 117 that nutritive material must be supplied to the ovum by endosmosis through its external envelope. The precise source, however, from which this is obtained is not positively known. By some it is believed to be derived from the granulations of the discus proligerus which surround it as it escapes from the Graafian follicle, and sub- sequently from the layer of albuminous matter which surrounds the ovum before it reaches the uterus; while others think it probable that it may come from a special liquid secreted by the interior of the Fallopian tube as the ovum passes along it. As soon as the ovum has reached the uterus, there is every reason to believe that the umbilical vesicle is the chief source of nourishment to the embryo, through the channel of the omphalo- mesenteric vessels, which convey matters absorbed from the interior of the vesicle to the intestinal canal of the foetus. At this time the exterior of the ovum is covered by the numerous fine villosities of the primitive chorion, which are imbedded in the mucous membrane of the uterus, and it is thought that they may absorb materials from the maternal system, which may be either directly absorbed by the embryo, or which may serve the purpose of replacing the nutritive matter which has been removed from the umbilical vesicle by the omphalo-mesenteric vessels. This point it is, of course, impossible to decide. Joulin, however, thinks that these villi probably have no direct influence on the nourishment of the foetus, which is at this time solely effected by the umbilical vesicle, but that they absorb fluid from the maternal system, which passes through the amnion and forms the liquor amnii. As soon as the allantois is developed, vascular communication between the foetus and the maternal structures is established, and the temporary func- tion of the umbilical vesicle is over ; that structure, therefore, rapidly atrophies and disappears, and the nutrition of the foetus is now solely carried on by means of the chorion villi, lined as they now are by the vascular endo-chorion, and chiefly by those which go to form the substance of the placenta. This statement is opposed to the views of many physiologists, who believe that a certain amount of nutritive material is conveyed fco the foetus through the channel of the liquor amnii, itself derived from the maternal system, which is supposed either to be absorbed through the cutaneous surface of the foetus, or carried to the intesti- nal canal by deglutition. Tin- reasons for assigning to the Liquor amnii a nutritive function are, however, so slight, thai it is dimcull to believe that, it has any appreciable action in this way. They are based on some questionable observations, such as those of Weydlich, who kept a calf alive for fifteen days by feeding it Bolely on liquor amnii. and the experiments of Burdach, who found the cutaneous lymphatics engorged in a foetus removed from the amniotic cavity, while those of the intestine were empty. 'Flic deglutition of the liquor amnii lor the purposes of nutrition, has hen assumed from its occasional detection in the stomach of the foetus, the presence of which may, however, be readily explained by spasmodic efforts al respiration, which the foetus undoubtedly often makes before birth, especially when the placental circulation is in any way interfered with, 118 PEEGNANCY and during which a certain quantity of fluid would necessarily be swallowed. The quantity of nutritive material, moreover, in the liquor amnii is so small — not more than 6 to 9 parts of albumen in 1000 — that it is impossible to conceive how it could have any appreciable influence in nutrition, even if its absorption, either by the skin or stomach, were susceptible of proof. That the nutrition of the foetus is effected through the placenta is proved by the common observation that whenever the placental circulation is arrested, as by disease of its structure, the foetus atro- phies and dies. The precise mode, however, in which nutritive materials are absorbed from the maternal blood is still a matter of doubt, and must remain so until the mooted points as to the minute anatomy of the placenta are settled. The various theories enter- tained on this subject by the upholders of the Hunterian doctrine of placental anatomy, and by those who deny the existence of a sinus system, have been already referred to in the chapter on the Anatomy of the Placenta, to which the reader is referred (pp. 104-6). 2. Respiration. — One of the chief functions of the placenta, besides that of nutrition, is the supply of oxygenated blood to the foetus. That this is essential to the vitality of the foetus, and that the pla- centa is the site of oxgyenation, are shown by the facts that when- ever the placenta is separated, or the access of foetal blood to it arrested by compression of the cord, instinctive attempts at inspira- tion are made, and if aerial respiration cannot be performed, the foetus is expelled asphyxiated. Like the other functions of the foetus during intra-uterine life, that of respiration has been made the subject of numerous more or less ingenious hypotheses. Thus many have believed that the foetus absorbed gaseous material from the liquor amnii, which served the purpose of oxygenating its blood, St. Hilaire thinking that this was effected by minute openings in its skin, Beclard and others through the bronchi, to which they believed the liquor amnii gained access. Independently of the entire want of evidence of the absorption of gaseous materials by these channels, the theory is disproved by the fact that the liquor amnii contains no air which is capable of respiration. Serres attributed a similar func- tion to some of the chorion villi, which he believed penetrated the utricular glands of the decidua reflexa, and absorbed gas from the hydroperione, or fluid situated between it and the decidua vera, and in this manner he thought the foetal blood was oxygenated until the fifth month of intra-uterine life, when the placenta was fully formed. This hypothesis, however, rests on no accurate foundation, for it is certain that the chorion villi do not penetrate the utricular glands in the manner assumed ; or, even if they did, the mode in which the oxygen thus absorbed by the chorion villi reaches the foetus, which is separated from them by the amnion and its contents, would still remained unexplained. The mode in which the oxygenation of the foetal blood is effected before the formation of the placenta remains, therefore, as yet un- known. After the development of that organ, however, it is less difficult to understand, for the foetal blood is everywhere brought ANATOMY AXD PHYSIOLOGY OF THE F03TIJS. 119 into such close contact with the maternal, in the numerous minute ramifications of the umbilical vessels, that the interchange of gas >s can readily be effected. The activity of respiration is doubtless much less than in extra-uterine life, for the waste of tissue in the foetus is necessarily comparatively small, from the fact of its being suspended in a fluid medium of its own temperature, and from the absence of the processes of digestion and of respiratory movements. The quan- tity of carbonic acid formed would, therefore, be much less than after birth, and there would be a correspondingly small call for oxygena- tion of venous circulation. 3. Circulation. — The functions of the lungs being in abeyance, it is necessary that all the foetal blood should be carried to the placenta to receive oxygen and nutritive materials. To understand the mode in which this is effected, we must bear in mind certain peculiarities in the circulatory system which disappear after birth. 1. The two sides of the foetal heart are not separate, as in the adult. The right ventricle in the adult sends also the venous blood to the lungs, through the pulmonary arteries, to be aerated by con- tact with the atmosphere. In the foetus, however, only sufficient blood is passed through the pulmonary arteries to insure their being pervious and ready to carry blood to the lungs immediately after birth. An aperture of communication, the foramen ovale, exists between the two auricles, which is arranged so as to permit the blood reach- ing the right auricle to pass freely into the left, but not vice versa. By this means a large portion Fig. en. of the blood reaching the heart through the venae cavse, instead of passing, as in the adult, into the right ventricle, is directed into the left auricle. 2. Even with this arrangement, however, a larger portion of blood would pass into the pul- monary arteries than is required for transmission to the lungs, and a further provision is made to prevent its going to them by means of a foetal vessel, the ductus arteriosus (Fig. 66), which arises Diagram of Fatal n from the point of bifurcation of the pulmonary < A,ter Daiton.) arteries, and opens into the arch of the aorta. I' p°|" ta ' r , 2. riiiiimnarv artery. In consequence of this arrangement only a very 3|3 . Pni m0 nary i..-, small portion of the blood reaches the lungs at 4. Ductus arteriosus. all. 3. The foetal hypogastric arteries are continued into two large arterial trunks, which, passing into the cord, form the umbilical arteries, and carry the impure foetal blood into the placenta. 4. The purified blood is collected into the single umbilical vein, through which it is carried to the under surface of the liver, from which point it is conducted, by means of another special foetal v. the ductus venosus, into the ascending vena cava, and the righl auricle. Course of the Fa-fa! Circulation.— In order to understand the course of the foetal blood, it may be mosl conveniently traced from the point 120 PREGNANCY. where it reaches the under surface of the liver through the umbilical vein. Part of it is distributed to the liver itself, but the greater quantity is carried directly into the vena cava, through the ductus venosus. The vena cava also receives the blood from the foetal veins of the lower extremities, and that portion of the blood of the um- bilical vein which has passed through the liver. This mixed blood is carried up to the right auricle, from which by far the greater part of it is immediately directed into the left auricle, through the fora- men ovale. From thence it passes into the left ventricle, which sends the greater part of it into the head and upper extremities through the aorta, a comparatively small quantity being transmitted to the inferior extremities. The blood which is thus sent to the upper part of the body is collected into the vena cava superior, by which it is thrown into the right auricle. Here the mass of it is probably di- rected into the right ventricle, which expels it into the pulmonary arteries, and from thence through the ductus arteriosus into the descending aorta. By this arrangement it will be seen that the de- scending aorta conveys to the lower part of the body the compara- tively impure blood which has already circulated through the head, neck, and upper extremities. From the descending aorta a small quantity of blood is conveyed to the lower extremities, the greater part of it being carried for purification to the placenta through the umbilical arteries. Establishment of Independent Circulation.— As soon as the child is born it generally cries loudly, and inflates its lungs, and, in conse- quence, the pulmonary arteries are dilated, and the greater portion of the blood of the right ventricle is at once sent to the lungs, from whence, after being arterialized, it is returned to the left auricle, through the pulmonary veins. The left auricle, therefore, receives more blood than before, the right less, and the placental circulation being arrested, no more passes through the umbilical vein. In con- sequence of this, the pressure of the blood in the two auricles is equalized, the mass of the blood in the right auricle no longer passes into the left (the valve of the foramen ovale being closed by the equal pressure on both sides), but directly into the right ventricle, and from thence into the pulmonary arteries, and the ductus arte- riosus soon collapses and becomes impervious. The mass of blood in the descending aorta no longer finds its way into the hypogastric arteries, but passes into the lower extremities, and the adult circula- tion is established. Changes after Birth. — The changes which take place in the tempo- rary vascular arrangements of the foetus, prior to their complete dis- appearance, are of some practical interest. The ductus arteriosus, as has been said, collapses, chiefly because the mass of blood is drawn to the lungs, and partly, perhaps, by its own inherent contractility. Its walls are found to be thickened, and its canal closes, first in the centre, and subsequently at its extremities, its aortic end remaining longer per- vious on account of the greater pressure of blood from the left side of the heart (Fig. 67). Practical closure occurs within a few days after ANATOMY AND PHYSIOLOGY OF THE FCETUS 121 Diagram of Heart of Infant. (After Dalton.) 1. Aorta. 2. Pulmonary Artery. 3, 3. Pulmonary branches. 4. Duc- tus arteriosus becoming obliterated. birth, although Flourens states that it is Fig. 67. not completely obliterated until eighteen months or two years have elapsed. 1 Ac- cording to Schroeder, its walls unite with- out the formation of any thrombus. The foramen ovale is soon closed by its valve, which contracts adhesion with the edges of the aperture, so as effectually to occlude it. Sometimes however, a small canal of communication between the two auricles may remain pervious for many months, or even a year and more, without, however, any admixture of blood occurring. A permanently patulous condition of this aperture, however, sometimes exists, giving rise to the disease known as cyanosis. The umbilical arteries and veins, and the ductus venosus soon also become impermeable, in consequence of concentric hypertrophy of their tissues and collapse of their walls. The closure of the former is aided by the formation of coagula in their interior. According to Eobin, a longer time than is usually supposed elapses before they become completely closed, the vein remaining pervious until the twentieth or thirtieth day after delivery, the arteries for a month or six weeks. He has also described 2 a remarkable contraction of the umbilical vessels within their sheaths, at the point where they leave the abdominal walls, which takes place within three or four days after birth, and seems to prevent hemorrhage taking place when the cord is detached. Function of the Liver. — The liver, from its proportionately large size, apparently plays an important part in the foetal economy. It is not until about the fifth month of utero-gestation that it assu] its characteristic structure, and forms bile, previous to thai time Its texture being soft and undeveloped. According to Claude Bernard. after this period one of its most important offices is the formation of sugar, which is found in much larger amount in the foetus than after birth. Sugar is, however, found in the f'o-tal structures long before the development of the liver, especially in the mucous and cutaneous tissues, and it seems probable thai these, as well as the placenta itself, then fulfil the glycogenic function, afterwards chiefly performed by the liver. The bile is secreted after the fifth month of pregnancy, and passes into the intestinal canal and is subsequently collected in the gall-bladder. By some physiologists it has been supposed thai the liver, during intra-uterine life, was the chief seal of aepuration of the carbonic acid contained in the venous blood of the foetus. It is, however, more generally believed thai this is accomplished solely in the placenta. The bile, mixed with the mucous secretion of 1 Aead. 9 dea Sciences, 1 854, -' Acad, dee Sciences, I860. 122 PREGNANCY. intestinal tract, forms the meconium which is contained in the intes- tines of the foetus, and which collects in them during the whole period of intra-uterine life. It is a thick, tenacious, greenish substance, which is voided soon after birth in considerable quantity. The Urine. — Urine is certainly formed during intra-uterine life, as is proved by the fact familiar to all accoucheurs, that the bladder is constantly emptied instantly after birth. It has generally been supposed that the foetus voided its urine into the cavity of the am- nion, and the existence of traces of urea in the liquor amnii, as well as some cases of imperforate urethra, in which the bladder was found to be enormously distended, and some congenital hydronephrosis associated with impervious ureters, have been supposed to corrobo- rate this assumption. The question has been very fully studied by Jonlin, who has collected together a large number of instances in which there was imperforate urethra without any undue distension of the bladder. He holds also that the amount of urea fonnd in the liquor amnii is far too minute to justify the conclusion that the urine of the foetus was habitually poured into it, although a small quantity may, he thinks, escape into it from time to time ; and he, therefore, believes that the urine of the foetus is only secreted regularly and abundantly after birth, and that during intra-uterine life its retention is not likely to give rise to any functional disturbance. 1 Function of the Nervous System. — There is no doubt that the nervous system acts to a considerable extent during intra-uterine life, and some authors have even s apposed that the foetus was en- dowed with the power of making instinctive or voluntary movements for the purpose of adapting itself to the form of the uterine cavity. There can be no question, however, that the movements the foetus performs are purely reflex and automatic. That it responds to a stimulus applied to the cutaneous nerves is proved by the experi- ments of Tyler Smith, who laid bare the amnion in pregnant rabbits, and found that the foetus moved its limbs when these were irritated through it. Pressure on the mother's abdomen, cold applications, and similar stimuli, will also produce energetic foetal movements. The gray matter of the brain in the new-born child is, however, quite rudimentary in its structure, and there is no evidence of intelligent action of the nervous system until some time after birth, and a fortiori during pregnancy. 1 Acad, des Sciences, p. 301. PREGNANCY. 123 CHAPTEE III. PREGNANCY. As soon as conception has taken place a series of remarkable changes commence in the uterus, which progress nntil the termina- tion of pregnancy, and are well worthy of careful study. They produce those marvellous modifications which effect the transformation of the small undeveloped uterus of the non-pregnant state into the large and full}- developed uterus of pregnancy, and have no parallel in the whole animal economy. A knowledge of them is essential for the proper comprehension of the phenomena of labor, and for the diagnosis of pregnancy which the practitioner is so frequently called upon to make. Excluding the varieties of abnormal pregnancy, which will be noticed in an- other place, we shall here limit ourselves to a consideration of the modifications of the maternal organism which result from simple and natural gestation. Changes in the Uterus. — The unimpregnated uterus measures 2 J inches in length, and weighs about 1 oz., while at the full term of pregnancy it has so immensely grown as to weigh 24 ozs., and meas- ure 12 inches. This growth commences as soon as the ovum reaches the uterus, and continues uninterruptedly until delivery. In the early months the uterus is contained entirely in the cavity of the pelvis, and the increase of size is only apparent on vaginal exam i na- tion, and that with difficulty. After the third month the enlarge- ment is chiefly in the lateral direction, so that the whole body of the uterus assumes more of a spherical shape than in the non-pregnant state. If an opportunity of examining the gravid uterus post-mor- tem should occur at this time, it will be found to have the form <>[' a sphere flattened somewhat posteriorly, and bulging anteriorly. After tin- ascent of the organ into the abdomen, it develops more in the vertical direction, so that at term it lias the form of an ovoid, with its large extremity above and its narrow end a1 the cervix uteri, and its Longitudinal axis corresponds to the long diameter of tin 1 mother's abdomen, provided the presentation be either of the bead or breach. The anterior surface is now even more distinctly pro- jecting than before — a fad which is explained by the proximity of the posterior surface to the rigid spinal column behind, while the anterior is in relation with the lax abdominal parietes, which yield readily to pressure, and so allow of the more marked prominence oi the anterior uterine wall. Change in Situation. — Before the gravid uterus has risen ou1 of the pelvis no appreciable increase in the size of the abdomen is percep- tible. On the contrary, i1 is an old observation that at this ea 124 PREGNANCY Fig. 68. stage of pregnancy the abdomen is flatter than usual, on account of the partial descent of the uterus in the pelvic cavity as a result of its increased weight. As the growth of the organ advances it soon be- comes too large to be contained any longer within the pelvis, and about the middle of the third or the beginning of the fourth month the fundus rises above the pelvic brim — not suddenly, as is often erroneously thought, but slowly and gradually — when it may be felt as a smooth rounded swelling. Size at various Periods of Pregnancy. — It is about this time that the movements of the foetus first become appreciable to the mother, when " quickening" is said to have taken place. Towards the end of the fourth month the uterus reaches to about three fingers' breadth above the symphysis pubis. About the fifth month it occupies the hypogastric region, to which it imparts a marked projection, and the alteration in the figure is now distinctly perceptible to visual exami- nation. About the sixth month it is on a level with, or a little above, the umbilicus. About the seventh month it is about two inches above the umbilicus, which is now projecting and prominent, instead of depressed, as in the non-pregnant state. During the eighth and ninth months it continues to increase until the summit of the fundus is immediately below the ensiform cartilage (Fig. 68). A knowledge of the size of the uterine tumor at various periods of preg- nancy, as thus indicated, is of consid- erable practical importance, as form- ing the only guide by which we can es- timate the probable period of delivery in certain cases in which the usual data for calculation are absent, as, for example, when the patient has con- ceived during lactation. The Uterus Sinks before Delivery. ■ — For about a week or more before labor the uterus generally sinks some- what into the pelvic cavity, in con- sequence of the relaxation of the soft parts which precedes delivery, and the patient now feels herself smaller and lighter than before. This change is familiar to all child-bearing women, to whom it is known as "the lighten- ing before labor." The Direction of the Uterus. — While the uterus remains in the pelvis its longitudinal axis varies in direction, much in the same way as that of the non-pregnant uterus, sometimes being more or less vertical, at others in a state of ante version or partial retroversion. These variations are probably dependent on the distension or emptiness of the bladder, as its state must necessarily affect the position of the movable organ poised behind it. After the uterus has risen into the Size of Uterus at various Periods of Pregnancy. PREGNANCY. 12o abdomen its tendency is to project forwards against the abdominal wall, which forms its chief support in front. In the erect position the long axis of the uterine tumor corresponds with the axis of the pelvic brim, forming an angle of about 30° with the horizon. In the semi-recumbent position, on the other hand, as Duncan 1 has pointed out, its direction becomes much more nearly vertical. In women who have borne many children, the abdominal parietes no longer afford an efficient support, and the uterus is displaced anteriorly, the fundus in extreme cases even hanging downwards. Lateral Obliquity of the Uterus. — In addition to this anterior ob- liquity, on account of the projection of the spinal column, the uterus is very generally also displaced laterally, and sometimes to a very marked degree, so that it may be felt entirely in one flank, instead of in the centre of the abdomen. In a large proportion of cases this lateral deviation is to the right side, and many hypotheses have been brought forward to explain this fact, none of them being satis- factory. Thus, it has been supposed to depend on the greater fre- quency with which women lie on their right side during sleep, on the greater use of the right leg during walking, on the supposed com- parative shortness of the right round ligament, which drags the tumor to that side, or on the frequent distension of the rectum on the left side, which prevents the uterus being displaced in that direction. Of these the last is the cause which seems most constantly in opera- tion, and most likely to produce the effect. Changes in the Direction of the Cervix. — The cervix must obviously adapt itself to the situation of the body of the uterus. We find, therefore, that in the early months, when the uterus lies low in the pelvis, it is more readily within reach. After the ascent of the uterus, it is drawn up, and frequently so much so as to be reached with difficulty. When the uterus is much anteverted, as is so often the case, the os is displaced backwards, so that it cannot be felt at all by the examining finger. ition of the Uterus to the Surrounding Parts. — Towards the end sgnaney the greater part of the anterior surface of the uterus is in contact with the abdominal wall, its lower portion resting on the rior surface of the symphysis pubis. The posterior Burface on the spinal column, while the small intestines are pushed to either side, the large intestines surrounding the uterus like an arch. Changesinthi Uterine Parietes.— The great distension of the uterus during pregnancy was formerly supposed to be mainly due to the mechanical pressure of the enlarging ovum within it. If this were so. then the uterine walls would be necessarily much thinner than in the non-pregnant state. This is well known not to be the case, and the immense increase in the size of the ut«-rin<- cavity is to be ex- plained by tin- hypertrophy of its walls. At the full period of preg- nancy the thickness of the uterine pariet snerally about the same as thai of the non-pregnant uterus, rather more at the placental site, and less in the neighborhood of the cervix. T eir 1 : Researches in ( Obstetrics, p. i 0. 126 PREGNANCY. however, varies in different cases, and in some women they are so thin as to admit of the foetal limbs being very readily made out by palpation. Their density is, however, always much diminished, and, instead of being hard and inelastic, they become soft and yielding to pressure. This change coincides with the commencement of preg- nancy, of which it forms, as recognizable in the cervix, one of the earliest diagnostic marks. At a more advanced period it is of value as admitting a certain amount of yielding of the uterine walls to the movements of the foetus, thus lessening the chance of their being injured. Changes in the Cervix during Pregnancy. — Very erroneous views have long been taught, in most of our standard works on midwifery, as to the changes which occur in the cervix uteri during pregnancy. It is generally stated that, as pregnancy advances, the cervical cavity is greatly diminished in length, in consequence of its being gradually drawn up so as to form part of the general cavity of the uterus, so that in the latter months it no longer exists. In almost all midwifery works accurate diagrams are given of this progressive shortening of the cervix (Figs. 69 to 72). The cervix is generally described as Figs. 69, 70, 71, 72. Supposed Shortening of the Cervix at the Third, Sixth, Eighth, and Ninth Months of Pregnancy, as Figured in Obstetric Works. having lost one-half of its length at the sixth month, two- thirds at the seventh, and to be entirely obliterated in the eighth and ninth. The correctness of these views was first called in question in recent times by Stoltz, in 1826, but Dr. Duncan, 1 in an elaborate historical paper on the subject, has shown that Stoltz was anticipated by Weit- brech in 1750, and, to a less degree, by Eoederer and other writers. This opinion is now pretty generally admitted to be correct, and is upheld by Cazeaux, Arthur Farre, Duncan, and most modern obstet- ricians. Indeed, various post-mortem examinations in advanced pregnancy have shown that the cavity of the cervix remains in 1 Researches in Obstetrics. PREGNANCY 127 reality of its normal length of one inch, and it can often be measured during life by the examining finger, on account of its patulous state (Fig. 73). During the fortnight immediately preceding delivery, however, a real shortening or obliteration of the cervical cavity takes Fig. 73. Cervix from a Woman Dyiug in the Eighth Mouth of Pregnancy. (After Duucan.) place; but this, as Duncan has pointed out, seems to be due to the incipient uterine contractions, which prepare the cervix for labor. Apparent Shortening. — There is, no doubt, an apparent shortening of the cervix always to be detected during pregnancy, but this is a fallacious and deceptive feeling, due to the softness of the tissue the cervix, which is exceedingly characteristic of pregnancy, and which to an experienced finger affords one of its besl diagnostic marks. Softening of the Cervix. — In the non-pregnant state the tissue of the cervix is hard, firm, and inelastic. When conception occurs, softening begins at the external OS, and pr< tceeds gradually and slowly upwards until it involves the whole of the cervix. By the end of the fourth month both lips of the os are thick, softened, and velvety to the touch, giving a sensation, likened by Cazeaux to that produced by pressing or a table through a thick, sofl cover. By the sixth month at leasl one-half of the cervix is thus altered, and by the eighth the whole of it, and SO much so that at this time those nnac- customed to vaginal examination experience Bome difficulty in dis- tinguishing it from the vaginal walls. It is this Boftening, then, which gives rise to the apparent shortening of the cervix rally described, and it is an invariable concomitanl of pregnancy 128 PREGNANCY. except in some rare cases in which, there has been antecedent morbid induration and hypertrophic elongation of the cervix. If, therefore, on examining a woman supposed to be advanced in pregnancy, we find the cervix to be hard and projecting into the vaginal canal, we may safely conclude that pregnancy does not exist. The existence of softening, however, it must be remembered, will not of itself justify an opposite conclusion, as it may be produced, to a very con- siderable extent, by various pathological conditions of the uterus. The Os Uteri is generally Patulous. — At the same time that the tissue of the cervix is softened, its cavity is widened, and the external os becomes patulous. This change varies considerably in primiparge and multiparas. In the former the external os often remains closed until the end of pregnancy ; but even in them it generally becomes more or less patulous after the seventh month, and admits the tip of the examining finger. In women who have borne children this change is much more marked. The lips of the external os are in them generally fissured and irregular, from slight lacerations of its tissue in former labors. It is also sufficiently open to admit the tip of the finger, so that in the latter months of pregnancy it is often quite possible to touch the membranes, and through them to feel the presenting part of the child. Changes in the Texture of the Uterine Tissues. — The remarkable increase in size of the uterus during pregnancy is, as we have seen, chiefly to be explained by the growth of its structures, all of which' are modified during gestation. The peritoneal covering is consider- ably increased, so as still to form a complete covering to the uterus when at its largest size. William Hunter supposed that its extension was affected rather by the unfolding of the layers of the broad liga- ment, than by growth. That the layers of the broad ligament do unfold during gestation, especially in the early months, is probable ; but this is not sufficient to account for the complete investment of the uterus, and it is certain that the peritoneum grows pari passu with the enlargement of the uterus. In addition there is a new for- mation of fibrous tissue between the peritoneal and the muscular coats, which affords strength, and diminishes the risk of laceration during labor. Muscular Coat. — The hypertrophy of the muscular tissue of the uterus is, however, the most remarkable of the changes produced by pregnancy. Not only do the previously-existing rudimentary fibre- cells become enormously increased in size — so as to measure, accord- ing to Kolliker, from seven to eleven times their former length, and from two to five times their former breadth — but new unsiriped fibres are largely developed, especially in the inner layers. These new cells are chiefly found in the first months of pregnancy, and their growth seems to be completed by the sixth month. The con- nective tissue between the muscular layers is also largely increased in amount. The weight of the muscular tissue of the gravid uterus is, therefore, much increased, and it has been estimated by Heschl that it weighs at term from 1 to 1.5 lbs., that is, about sixteen times more than in the unimpregnated state. This great development of PREGNANCY. 129 the muscular tissue admits of its dissection in a way which is quite impossible in the unimpregnated state, aud the recent researches of Helie (p. 53) enable us to understand much better than before how the muscles forming the walls of the gravid uterus act during the expulsion of the child. The changes in the mucous coat of the uterus, which result in the formation of the decidua, have already been discussed at length else- where (p. 89). Circulatory Apparatus. — The circulatory apparatus of the uterus during pregnancy has been described when the anatomy of the placenta was under consideration (p. 103). Lymphatics. — The lymphatics are much increased in size ; and re- cent theories on the production of certain puerperal diseases attribute to them a more important action than has been commonly assigned to them. Nerves. — The question of the growth of the nerves has been hotly discussed. Eobert Lee took the foremost place among those who maintain that the nerves of the uterus share the general growth of its other constituent parts. Dr. Snow Beck, however, believed that they remain of the same size as in the unimpregnated state, and this view is supported by Hirschfeld, Robin, and other recent writers. Robin thought that there was an apparent increase in the size of the nerve-tubes, which, however, is really due to increase in the neuri- lemma. Kilian describes the nerves as increasing in length but not in thickness: while Schroeder states that they participate equally with the lymphatics in the enlargement the latter undergo. Which- ever of these views may ultimately be found to be correct, it is cer- tain that analogy would lead us to expect an increase of nervous as well as of vascular, supply. General Modification in the Body produced by Pregnancy. — Tt is not in the uterus alone, that pregnancy is found to produce modifications of importance. There are few of the more important functions of the body which arc not, to a greater or less extent, affected : to some of these it is necessary briefly to direct attention, inasmuch as. when carried to exec—, they produce those disorders which often compli- cate gestation, and which prove so distressing and even dangerous to the patients. Such of them as arc apparent and may aid us in diagnosis are discussed in the chapter which treats of the Bigns and symptoms of pregnancy ; in this place it is only necessary to refer to those which do not properly fall into thai category. Changes in the Blood. — Amongsl those which are most constant and important arc the alterations in the composition of the blood. The opinion of the profession on this subject lias, of late years, under- gone a remarkable change. Formerly it was universally believed that pregnancy was, as the rule, associated with a condition analagous to plethora, and that this explained many characteristic phenomena of common occurrence, such as headache, palpitation, singing in ears, shortness of breadth, and the like. A- ;i consequence il the habitual custom, not yet by any means entirely abandons treat pregnant women on an antiphl them on 130 PREGNANCY. low diet, to administer lowering remedies, and very often to practice venesection, sometimes to a surprising extent. Thus it was by no means rare for women to be bled six or eight times during the latter months, even when no definite symptoms of disease existed ; and many of the older authors record cases where depletion was practised every fortnight, as a matter of routine, and, when the symptoms were well marked, even from fifty to ninety times in the course of a single pregnancy. Composition of the Blood in Pregnancy. — Numerous careful analyses have conclusively proved that the composition of the blood during pregnancy is very generally — perhaps it would not be too much to say always — profoundly altered. Thus it is found to be more watery, its serum is deficient in albumen, and the amount of colored globules is materially diminished, averaging, according to the analyses of Becquerel and Rodier, 111.8 against 127.2 in the non-gravid state. At the same time the amount of fi brine and of extractive matter is considerably increased. The latter observation is of peculiar im- portance, as it goes far to explain the frequency of certain thrombotic affections, observed in connection with pregnancy and delivery ; this hyperinosis of the blood is also considerably increased after labor by the quantity of effete material thrown into the mother's system at that time, to be got rid of by her emunctories. The truth is, that the blood of the pregnant woman is generally in a state much more nearly approaching the condition of anaemia than of plethora, and it is certain that most of the phenomena attributed to plethora may be explained equally well and better on this view. These changes are much more strongly marked at the latter end of pregnancy than at its commencement, and it is interesting to observe that it is then that the concomitant phenomena alluded to are most frequently met with. Cazeaux, to whom we are chiefly indebted for insisting on the practical bearing of these views, contends that the pregnant state is essentially analogous to chlorosis, and that it should be so treated. Objection has not unnaturally been taken to this theory, as implying that a healthy and normal function is associated with a morbid state, and it has been suggested that this deteriorated state of the blood may be a wise provision of nature instituted for a purpose we are not as yet able to understand. It may certainly be admitted that preg- nancy, in a perfectly healthy state of the system, should not be associated with phenomena in themselves in any degree morbid. It must not be forgotten, however, that our patients are seldom, we might safely say never, in a state that is physiologically healthy. The influence of civilization, climate, occupation, diet, and a thousand other disturbing causes that, to a greater or less degree, are always to be met with, must not be left out of consideration. Making every allowance, therefore, for the undoubted fact that pregnancy ought to be a perfectly healthy condition, it must be conceded, I think, that in the vast majority of cases corning under our notice it is not entirely so ; and the deductions drawn by Cazeaux, from the numerous analyses of the blood of pregnant women, seem to point strongly to the conclusion that the general blood-state is one of poverty and PREGNANCY. 131 anaemia, and that a depressing and antiphlogistic treatment is dis- tinctly contra-indicated. Modifications in certain Viscera. — Closely connected with the al- tered condition of the blood is the physiological hypertrophy of the heart, which is now well known to occur during pregnancy. This was first pointed out by Larcher in 1828, and it has been since veri- fied by numerous observers. It seems to be constant and considera- ble, and to be a purely physiological alteration intended to meet the increased exigencies of the circulation, which the complex vascular arrangements of the gravid uterus produce. The hypertrophy is limited to the left ventricle ; the right ventricle, as well as both au- ricles, being unaffected. Blot estimates that the whole weight of the heart increases one-fifth during gestation. The more recent re- searches of Lohlein 1 render it probable that the hypertrophy is less than these authors have supposed. According to Duroziez 2 the heart remains enlarged during lactation, but diminishes in size immediately after delivery in women who do not suckle, while in women who have borne many children it remains permanently somewhat larger than in nulliparae. Similar increase in the size of other organs has been pointed out by various writers, as, for example, in the lym- phatics, the spleen, and the liver. Tarnier states that in women who have died after delivery, the organs always show signs of fatty de- generation. According to Gassner the whole body increases in weight during the latter months of pregnancy, and this increase is somewhat beyond that which can be explained by the size of the womb and its contents. Formation of Osteophytes. — Irregular bony deposits between the skull and the dura mater, in some cases so largely developed as to line the whole cranium, have been so frequently detected in women who have died during parturition, thai they are believed by some to be a normal production connected with pregnancy. Ducresl found these osteophytes in more than one-third of the cases in which he performed post-mortem examinations during the puerperal period. Rokitansky, who corroborated the observation, believed this peculiar deposit of bony matter to be a physiological, and nol a pathological condition connected with pregnancy; bu1 whether it be so, or how it is produced, has no1 ye1 been satisfactorily determined. Changes in the Nervous System. More or less marked changes con- nected with the nervous system are generally observed in pregnancy, and sometimes to a very greal extent. When carried to excess they produce some of the mosl troublesome disorders which complicate gestation, such as alterations in the intellectual functions, changes in the disposition and character, morbid cravings, dizziness, neuralgia, syncope, and many others. Thej are purely functional in their cha- racter, and disappear rapidly after delivery, and may be besl de- scribed in connection with the disorders of pregnancy. changes in the Respiratory Organs, Respiration is often inter- fered with, from the mechanical results of the pressure of the en- 1 Zeitschrift ftir Geburtehttlfe, etc., L876. ■ Ga«. dea BOpit. : 132 PREGNANCY. larged uterus. The longitudinal dimensions of the thorax are lessened by the upward displacement of the diaphragm, and this necessarily leads to some embarrassment of the respiration, which is, however, compensated, to a great extent, by an increase in breadth of the base of the thoracic cavity. Changes in the Urine. — Certain changes, which are of very con- stant occurrence, in the urine of pregnant women have attracted much attention, and have been considered by many writers to be pathognomonic. They consist in the presence of a peculiar deposit, formed when the urine has been allowed to stand for some time, which has received the name of hiestein. Its presence was known to the ancients, and it was particularly mentioned by Savonarola in the fifteenth century, but it has more especially been studied within the last thirty j^ears by Eguisier, Grolding Bird, and others. If the urine of a pregnant woman be allowed to stand in a cylindrical ves- sel, exposed to light and air, but protected from dust, in a period, varying from two to seven days, a peculiar flocculent sediment, like fine cotton-wool, makes its appearance in the centre of the fluid, and soon afterwards rises to the surface and forms a pellicle, which has been compared to the fat on cold mutton -broth. In the course of a few days the scum breaks up and falls to the bottom of the vessel. On microscopic examination it is found to be composed of fat parti- cles, with crystals of ammoniaco-magnesium phosphates and phosphate of lime, and a large quantity of vibriones. These appearances are generally to be detected after the second month of pregnancy, and up to the seventli or eighth month, after which they are rarely pro- duced. Eegnauld explains their absence during the latter months of gestation by the presence in the urine, at that time, of free lactic acid, which increases its acidity, and prevents the decomposition of the urea into carbonate of ammonia. He believes that kiestein is produced by the action of free carbonate of ammonia on the phos- phate of lime contained in the urine, and that this reaction is pre- vented by the excess of acid. Grolding Bird believed kiestein to be analogous to casein, to the presence of which he referred it, and he states that he has found it in twenty-seven out of thirty cases. Braxton Hicks so far corrobo- rates his view, and states that the deposit of kiestein can be much more abundantly produced if one or two teaspoonfuls of rennet be added to the urine, since that substance has the property of coagu- lating casein. Much less importance, however, is now attached to the presence of kiestein than formerly, since a precisely similar sub- stance is sometimes found in the urine of the non-pregnant, especially in anaemic women, and even in the urine of men. Parkes states that it is not of uniform composition, that it is produced by the decompo- sition of urea, and consists of the free phosphates, bladder mucus, infusoria, and vaginal discharges. Neugebauer and Yogel give a similar account of it, and hold that it is of no diagnostic value. That it is of interest, as indicating the changes going on in connection with pregnancy, is certain ; but inasmuch as it is not of invariable occur- rence, and may even exist quite independently of gestation, it is SIGNS AND SYMPTOMS OF PREGNANCY. 133 obviously quite undeserving of the extreme importance that lias been attached to it. [Although not a reliable test of pregnancy, it is a remarkable fact, that in all the cases of suspected impregnation in private practice in which we have employed it, Ave never found a woman pregnant who had not shown it in her urine. — Ed.] CHAPTEK IV. SIGNS AND SYMPTOMS OF PREGNANCY. Importance of the Subject. — In attempting to ascertain the presence or absence of pregnancy, the practitioner has before him a problem which is often beset with great difficulties, and on the proper solution of which, the moral character of his patient, as well as his own pro- fessional reputation, may depend. The patient and her friends can hardly be expected to appreciate the fact, that it is often far from easy to give a positive opinion on the point; and it is always advis- able to use much caution in the examination, and not to commit ourselves to a positive opinion, except on the most certain grounds. This is all the more important, because it is just in those cases in which our opinion is most frequently asked, that the statements of the patient are of least value, as she is either anxious to conceal the existence of pregnancy, or, if desirous of an affirmative diagnosis, unconsciously colors her statements, so as to bias the judgment of the examiner. Constant attempts have been made to classify the signs of preg- nancy; thus some divide them into the natural and sensible Bigns, others into the presumptive, the probable, and the certain. The latter classification, which is that adopted by Montgomery in his classical work on the "Signs and Symptoms of Pregnancy," is no doubl the better of the two, if any be required. The simplest way of studying the subject, however, is the one, now generally adopted, of considering the signs of pregnancy in the order in which they occur, and attaching to each an estimate of its diagnostic value Signs of a fruitful Conception.- From the earliesl ages authors have thought, thai the occurrence of concept] rrigh'1 be ascertained by certain obscure signs, such as a peculiar appearance <>f the ei swelling of the neck, or by unusual sensations connected with a fruitful intercourse. All of these, it need bardly be -aid, are far i<"> uncertain t<> he <>f the slightesl value. The lasl is a symptom od which many married women profess themselves able to depend, and one to which Cazeaux is inclined to attach some Importance. 134 PREGNANCY. Cessation of Menstruation. — The first appreciable indication of pregnancy, on which any dependence can be placed, is the cessation of the customary menstrual discharge, and it is of great importance, as forming the only reliable guide for calculating the probable period of delivery. In women who have been previously perfectly regular, in whom there is no morbid cause which is likely to have produced suppression, the non-appearance of the catamenia may be taken as strong presumptive evidence of the existence of pregnancy; but it can never be more than this, unless verified and strengthened by other signs, inasmuch as there are many conditions besides pregnancy which may lead to its non-appearance. Thus exposure to cold, mental emotion, general debility, especially when connected with incipient phthisis, may all have this effect. Mental impressions are peculiarly liable to mislead in this respect. It is far from uncommon in newly-married women to find that menstruation ceases for one or more periods, either from the general disturbance of the system con- nected with the married life, or from a desire on the part of the patient to find herself pregnant. Also in unmarried women, who have subjected themselves to the risk of impregnation, mental emo- tion and alarm often produce the same result. Menstruation during Pregnancy. — A further source of uncertainty exists in the fact, that in certain cases menstruation may go on for one or more periods after conception, or even during the whole pregnancy. The latter occurrence is certainly of extreme rarity, but one or two instances are recorded by Perfect, Churchill, and other writers of authority, and therefore its possibility must be admitted. The former is much less uncommon, and instances of it have probably come under the observation of most practitioners. The explanation is now well understood. During the early months of gestation, when the ovum is not yet sufficiently advanced in growth to fill the whole uterine cavity, there is a considerable space between the decidua reflexa which surrounds it, and the decidua vera lining the uterine cavity. It is from this free surface of the decidua vera that the periodical discharge comes, and there is not only ample surface for it to come from, but a free channel for its escape through the os uteri. After the third month the decidua reflexa and the decidua vera blend together, and the space between them disappears. Menstruation after this time is, therefore, much more difficult to account for. It is probable that, in many supposed cases, occasional losses of blood from other sources, such as placenta prsevia, an abraded cervix uteri, or a small polypus, have been mistaken for true men- struation. If the discharge really occurs periodically after the third month, it can only come from the canal of the cervix. The occurrence, however, is so rare, that if a woman is menstruating regularly and normally, who believes herself to be more than four months advanced in pregnancy, we are justified ipso facto in negativing her supposition. In an unmarried woman all statements as to regularity of menstrua- tion are absolutely valueless, for, in such cases, nothing is more common than for the patient to make false statements for the express purpose of deception. SIGNS AND SYMPTOMS OF PREGNANCY. 135 Pregnancy iclien Menstruation is Normally Absent. — Conception may unquestionably occur when menstruation is normally absent. This is far from uncommon in women during lactation, when the function is in abeyance, and who therefore have no reliable data for calculating the true period of their delivery. Authentic cases are also recorded in which young girls have conceived before menstrua- tion is established, and in which pregnancy has occurred after the change of life. Estimate of its Diagnostic Value. — Taking all these facts into ac- count, we can only look upon the cessation of menstruation as a fairly presumptive sign of pregnancy in women in whom there is no clear reason to account for it, but one which is undoubtedly of great value in assisting our diagnosis. Sympathetic Disturbances. — Shortl} 7 after conception various sym- pathetic disturbances of the system occur, and it is only very excep- tionally that these are not established. They are generally most developed in women of highly nervous temperament ; and the}' are, therefore, most marked in patients in the upper classes of society, in whom this class of organization is most common. Morning Sickness. — Amongst the most frequent of these are various disorders of the gastro-intestinal canal. Nausea or vomiting is very common ; and as it is generally felt on first rising from the recum- bent position, it is popularly known amongst women as the "morn- ing sickness." It sometimes commences almost immediately after conception, but more frequently not until the second month, and it rarely lasts after the fourth month. Generally there is nausea rather than actual vomiting. The woman feels sick and unable to eat her breakfast, and often brings up some glairy fluid. In other cases. Bhe actually vomits ; and sometimes the sickness is so excessive as to resist all treatment, seriously to affect the patient's health, and even imperil her life. These grave forms of the affection will require separate consideration. Cause of lb'' Sickness. — Very different opinions have been held as to the cause of morning sickness. Dr. Henry Bennel believes that, when at all severe, it is always associated with congestion and inflam- mation of the cervix uteri. Dr. (xraily Hewitt maintains that it de- pends entirely on flexion of the uterus, producing irritation of the uterine uerves a1 the seal of the flexion, and consequent sympathetic vomiting. This theory, when broached at the Obstetrical Societv, was received with little favor; it seems to me t<> he sufficiently dis- proved by the fact, which I believe to be certain, thai more or less nausea is a normal and nearly constanl phenomenon in pregnancy, for it is diflieult t<> believe that nearly every pregnanl woman ha- a flexed uterus. The generally received explanation is. probably, the correct one, viz., that nausea, as well as other forms or sympathetic disturbance, depend- on tin; Btretching of the uterine fibres 1>\ the growing ovum, and consequent irritation of tin' uterine nerves. It is, therefore, one, and only one, of the numerous reflex phenomena naturally accompanying pregnancy. It is an old observation that when the sickness of pregnancy is entirely absent, other, and gene- f 136 PREGNANCY. rally more distressing, sympathetic derangements are often met with, such as a tendency to syncope. Dr. Bedford 1 has laid especial stress on this point, and maintains that under such circumstances Avomen are peculiarly apt to miscarry. Other derangements of the digestive functions, depending on the same cause, are not uncommon, such as excessive or depraved appe- tite, the patient showing a craving for strange and even disgusting articles of diet. These cravings may be altogether irresistible, and are popularly known as " longings." Of a similar character is the disturbed condition of the bowels frequently observed, leading to constipation, diarrhoea, and excessive flatulence. Other iSymjjathetic Phenomena. — Certain glandular sympathies may be developed, one of the most common being an excessive secretion from the salivary glands. A tendency to syncope is not infrequent, rarely proceeding to actual fainting, but rather to that sort of partial syncope, unattended with complete loss of consciousness, which the older authors used to call "lypothemia." This often occurs in women who show no such tendency at other times, and, when developed to any extent, it forms a very distressing accompaniment of pregnancy. Toothache is common, and is not rarely associated with actual caries of the teeth. When any of these phenomena are carried to excess it is more than probable that some morbid condition of the uterus exists, which increases the local irritation producing them. Mental Peculiarities. — Mental phenomena are very general. An undue degree of despondency, utterly beyond the patient's control, is far from uncommon ; or a change which renders the bright and good-tempered woman fractious and irritable ; or even the more for- tunate, but less common change, by which a disagreeable disposition becomes altered for the better. Diagnostic Value. — All these phenomena of exalted nervous suscep- tibility are but of slight diagnostic value. They may be taken as corroborating more certain signs, but nothing more; and they are chiefly interesting from their tendency to be carried to excess and to produce serious disorders. Mammary changes. — Certain changes in the mammas are of early occurrence, dependent, no doubt, on the intimate sympathetic rela- tions at all times existing between them and the uterine organs, but chiefly required for the purpose of preparing for the important func- tion of lactation, which, on the termination of pregnancy, they have to perform. Changes in the Areolee — Generally about the second month of preg- nancy the breasts become increased in size and tender. As preg- nancy advances they become much larger and firmer, and blue veins may be seen coursing over them. The most characteristic changes are about the nipples and areolee. The nipples become turgid, and are frequently covered with minute branny scales, formed by the dessication of sero-lactescent fluid oozing from them. The areolae be- come greatly enlarged and darkened from the deposit of pigment 1 Diseases of Women and Children, p. 55 1» SIGNS AND SYMPTOMS OF PREGNANCY 137 (Fig. 74). The extent and degree of this discoloration vary much in different women. In fair women it may be so slight as to'be hardly appreciable ; while in dark women it is generally exceedingly charac- teristic, sometimes forming a nearly black circle extending over a Fig. 74. Appearance of the Areola in Pregnancy. great part of the breast. The areola becomes moist as well as dark in appearance and is somewhat swollen, and a number of small tuber- cles are developed upon it, forming a circle of projections around the nipple. These tubercles are described by Montgomery as being inti- mately connected with the lactiferous ducts, some of which may oc- casionally be traced into them and seem to open on their summits. As pregnancy advances they increase in size and Dumber. During the latter months what has been called "the secondary areola" is produced, and when well marked presents a very characteristic ap- pearance. It consists of a number of minute discolored spots all round the outer margin of the areola where the pigmentation is fainter, and which arc generally described as resembling spots from which the color had been discharged by a shower of water-drops. This change, like the darkening of the primary areola, is mosl marked in brunettes. At this period, especially in women whose skin is of fine texture, whitish silvery streaks are often Been on the l» r They arc produced by the stretching of the cutis \ era, and arc per- manent. By pressure on the breasts a small drop of serous-looking fluid can very generallv be pressed out from the nipple often as early as the third month, and on microscopic examination milk and oholos- trum globules can be seen in it. 10 138 PREGNANCY. Diagnostic Value of Mammary Changes. — The diagnostic value of these mammary changes has been variously estimated. When well marked they are considered by Montgomery to be certain signs of pregnancy. To this statement, however, some important limitations must be made. In women who have never borne children they, no doubt, are so ; for, although various uterine and ovarian diseases produce some darkening of the areola, they certainly never' produce the well-marked changes above described. In multiparas, however, the areolae often remain permanently darkened, and in them these signs are much less reliable. In first pregnancies the presence of milk in the breasts may be considered an almost certain sign, and it is one which I have rarely failed to detect even from a comparatively early period. It is true that there are authenticated instances of non-pregnant women having an abundant secretion of milk estab- lished from mammary irritation. Thus Baudelocque presented to the Academy of Surgery of Paris a young girl, eight years of age, who had nursed her little brother for more than a month. Dr. Tan- ner states — I do not know on what authority — 'that "it is not uncom- mon in Western Africa for young girls who have never been preg- nant to regularly employ themselves in nursing the children of others, the mammae being excited to action by the application of the juice of one of the euphorbiaceas." Lacteal secretion has even been noticed in the male breast. But these exceptions to the general rule are so uncommon as merely to deserve mention as curiosities ; and I have almost never been deceived in diagnosing a first pregnancy from the presence of even the minutest quantity of lacteal secretion in the breasts, although even then other corroborative signs should always be sought for. In multiparas the presence of milk is by no means so valuable, for it is common for milk to remain in the mammae long after the cessation of lactation, even for several years. Tyler Smith correctly says that " suppression of the milk in persons who are nursing and liable to impregnation is a more valuable sign of preg- nancy than the converse condition." This is an observation I have frequently corroborated. As a diagnostic sign, therefore, the mammary appearances are of great importance in primiparae, and when well marked they are sel- dom likely to deceive. They are specially important when we sus- pect pregnancy in the unmarried, as we can easily make an excuse to look at the breast without explaining to the patient the reason ; and a single glance, especially if the patient be dark-complexioned, may so far strengthen our suspicion as to justify a more thorough ex- amination. In married multiparas they are less to be depended upon. Other Pigmentary Changes. — In connection with this subject may be mentioned various irregular deposits of pigment which are fre- quently observed. The most common is a dark brownish or yellow- ish line starting from the pubes and running up to the centre of the abdomen, sometimes as far as the umbilicus only, at others forming an irregular ring round the umbilicus, and reaching to the epigas- trium. [It is well marked in pregnant women of the African race, even in those of quite a dark shade of skin. This line is narrower SIGNS AND SYMPTOMS OF PREGNANCY. 139 as a rule, than in the white, but darker. — Ed.] It is, however, of very uncertain occurrence, being well marked in some women, while in others it is entirely absent. Patches of darkened skin are often observed about the face, chiefly on the forehead, and this bronzing sometimes gives a very peculiar appearance. Joulin states that it only occurs on parts of the face exposed to the sun, and that it is therefore most frequently observed in women of the lower order, who are freely exposed to atmospheric influences. These pigment- ary changes are of small diagnostic value, and may continue for a considerable time after delivery. Enlargement of the Abdomen. — The progressive enlargement of the abdomen, and the size of the gravid uterus at various periods of pregnancy, as well as the method of examination by means of ab- dominal palpation, have already been described (pp. 114 and 124). We will now consider the well-known phenomena produced by the movements of the foetus in utero, which are so familiar to all pregnant women. These, no doubt, take place from the earliest period of foetal life at which the muscular tissue of the foetus is suffi- ciently developed to admit of contraction, but they are not felt by the mother until somewhere about the sixteenth week of utero-ges- tation, the precise period at which they are perceived varying con- siderably in different cases. The error of the law on this subject, which supposes the child not to be alive, or " quick," until the mother feels its movements, is well known, and has frequently been protested against by the medical profession. The so-called quickening — which certainly is felt very suddenly by some women — is believed to depend on the rising of the uterine tumor sufficiently high to permit of the impulse of the foetus being transmitted to the abdominal walls of the mother, through the sensory nerves of which its movements become appreciable. The sensation is generally described as being a feeble fluttering, which, when first felt, not unfrequently causes unpleasant nervous sensations. As the uterus enlarges, the movements become more and more distinct, and generally consist of a series of sharp blows or kicks, sometimes quite appreciable to the naked eye, and causing distinct projections of the abdominal walls. Their force and frequency will also vary during pregnancy according to circum- stances. At times they are very frequent and distressing; at others, the foetus seems to be comparatively quiet, and they may even not be felt for several days in succession, and thus unnecessary fears as to the death of the foetus often arise. The state of the mother's health has an undoubted influence upon them. They arc said to increase in force after a prolonged abstinence from food, or in certain positions of the body. It is certain that causes interfering with the vitality of the foetus often produce very irregular and tumultuous movements. They can be very readily felt by the accoucheur on palpating the abdomen, and sometimes, in the latter months, so dis- tinctly as to leave no doubl as to the existence of pregnancy. They can also generally be induced by placing one hand on each aide of the abdomen and applying gentle pressure, which will induce foetal motion, that can be easilv appreciated. 140 PREGNANCY. The Diagnostic Value of Foetal Movements. — As a diagnostic sign the existence of foetal movements has always held a high place, but care should be taken in relying on it. It is certain that women are themselves very often in error, and fancy they feel the movements of a foetus when none exists, being probably deceived by irregular contractions of the abdominal muscles, or flatus within the bowels. They may even involuntarily produce such intra-abdominal move- ments as may readily deceive the practitioner. Of course, in advanced pregnancy, when the foetal movements are so marked as to be seen as well as felt, a mistake is hardly possible, and they then constitute a certain sign. But in such cases there is an abundance of other indi- cations and little room for doubt. In questionable cases, and at an earlier period of pregnancy, the fact that movements are not felt must not be taken as a proof of the non-existence of pregnancy, for they may be so feeble as not to be perceptible, or they may be absent for a considerable period. Intermittent Uterine Contractions. — Braxton Hicks 1 has directed attention to the value, from a diagnostic point of view, of intermittent contractions of the uterus during pregnancy. After the uterus is sufficiently large to be felt by palpation, if the hand be placed over it, and it be grasped for a time without using any friction or pressure, it will be observed to distinctly harden in a manner that is quite characteristic. This intermittent contraction occurs every five or ten minutes, sometimes oftener, rarely at longer intervals. The fact that the uterus did contract in this way had been previously described, more especially by Tyler Smith, who ascribed it to peristaltic action. But it is certain that no one, before Dr. Hicks, had pointed out the fact that such contractions were constant and normal concomitants of pregnancy, continuing during the whole period of utero-gestation, and forming a read}^ and reliable means of distinguishing the uterine tumor from other abdominal enlargements. Since reading Dr. Hicks's paper I have paid considerable attention to this sign, which I have never failed to detect, even in the retroverted gravid uterus contained entirely in the pelvic cavity, and I am disposed entirely to agree with him as to its great value in diagnosis. If the hand be kept steadily on the uterus, its alternate hardening and relaxation can be appreciated with the greatest ease. The advantages which this sign has over the foetal movements are that it is constant, that it is not liable to be simulated by anything else, and that it is independent of the life of the child, being equally appreciable when the uterus con- tains a degenerated ovum or dead foetus. The only condition likely to give rise to error is an enlargement of the uterus in consequence of contents other than the results of conception, such as retained menses, or a polypus. The history of such cases — which are more- over of extreme rarity — would easily prevent any mistake. As a corroborative sign of pregnancy, therefore, I should give these inter- mittent contractions a high place. [These intermittent contractions are in rare instances accompanied by a sense of pain, and would 1 Obst. Trans, v. 13. SIGNS AXD SYMPTOMS OF PREGNANCY. 141 appear to threaten miscarriage. We saw one case in which they persisted for three weeks, and gradually subdsided under an opiate treatment. — Ed.] Vaginal Signs of Pregnancy. — The vaginal signs of pregnancy are of considerable importance in diagnosis. The)' are chiefly the changes which may be detected in the cervix, and the so-called ballottement, which depends on the mobility of the foetus in the liquor amnii. Softening of the Cervix.- — The alterations in the density and appa- rent length of the cervix have been already described (p. 126). When pregnancy has advanced beyond the fifth month the peculiar velvety softness of the cervix is very characteristic, and affords a strong- corroborative sign, but one which it would be unsafe to rely on by itself, inasmuch as very similar alterations may be produced by various causes. When, however, in a supposed case of pregnancy advanced beyond the period indicated, the cervix is found to be elongated, dense, and projecting into the vaginal canal, the non- existence of pregnancy may be safely inferred. Therefore the nega- tive value of this sign is of more importance than the positive. Ballottement, when distinctly made out, is a very valuable indica- tion of pregnancy. It consists in the displacement, by the examining finger, of the foetus, which floats up in the liquor amnii, and falls back again on the tip of the finger with a slight tap which is exceedingly characteristic. Method of Examination. — In order to practise it most easily, the patient is placed on a couch or bed in a position midway between sitting and lying, by which the vertical diameter of the uterine cavity is brought into correspondence with that of the pelvis. Two fingers of the right hand are then passed high up into the vagina in front of the cervix. The uterus being now steadied from without by the left hand, the intravaginal fingers press the uterine wall suddenly upwards, when, if pregnancy exist, the foetus is displaced, and in a moment falls back again, imparting a distinct impulse to the fingers. When easily appreciable it may be considered as a certain sign, for although an ante-flexed fundus, or a calculus in the bladder, may give rise to somewhat similar sensations, the absence of other indications of pregnancy would readily prevent error. Bal- lottement is practised between the fourth and seventh months. Be- fore the former time the foetus is too small, while at a later period it is relatively too large, and can no longer be easily made to rise upwards in the surrounding liquor amnii. The absence of ballotte- ment must not be taken as proving Hie non-existence <>!' pregnancy, for it may be inappreciable from ;i variety of causes, sucn as abnor- mal presentations, or the implantation of the placenta upon the cervix uteri. Vaginal Pulsation. — There are also some other vaginal signs of pregnancy of secondary consequence. Amongsl these is the vaginal pulsation, pointed oul by Osiander, resulting from the enlargement of the vaginal arteries, which may sometimes be Pell beating al an early period. Often this pulsation is very distinct, at other time.- it 142 PREGNANCY. cannot be felt at all, and it is altogether unreliable, as a similar pul- sation may be felt in various uterine diseases. Uterine Fluctuation. — Dr. Kasch lias drawn attention to a previously -undescribed sign which, he believes to be of importance in the diag- nosis of early pregnancy. 1 It consists in the detection of fluctuation through the anterior uterine wall, depending on the presence of the liquor amnii. In order to make this out, two fingers of the right hand must be used, as in ballottement, while the uterus is steadied through the abdomen. Dr. Easch states that by this means the enlarged uterus in pregnancy can easily be distinguished from the enlargement depending on other causes, and that fluctuation can always be felt as early as the second month. If it is associated with suppressed menstruation and darkened areolae, he considers it a certain sign. In order to detect it, however, considerable experience in making vaginal examinations is essential, and it can hardly be depended on for general use. Alteration in Color of the Vagina. — A peculiar deep violet hue of the vaginal mucous membrane was relied on by Jacquemier and Kliige as affording a readily-observed indication of pregnancy. In most cases it is well marked ; sometimes, indeed, the change of color is very intense, and it evidently depends on the congestion produced by pressure of the enlarged uterus. The same effect, however, is constantly seen where similar pressure is effected by large fibroid tumors of the uterus, and, therefore, for diagnostic purposes it is valueless. Auscultatory Signs of Pregnancy. — By far the most important signs are those which can be detected by abdominal auscultation, and one of these — the hearing of the foetal heart-sounds — forms the only sign which per se, and in the absence of all others, is perfectly reliable. Discovery of Foetal Auscultation. — The fact that the sounds of the foetal heart are audible during advanced pregnancy was first pointed out by Mayor of Geneva in 1818, and the main facts in connection with foetal auscultation were subsequently worked out by Kerga- radec, Naegele, Evory Kennedy, and other observers. The pulsations first become audible, as a rule, in the course of the fifth month, or about the middle of the fourth month. In exceptional circumstances, and by practised observers, they have been heard earlier. Depaul believes that he detected them as early as the eleventh week, and Kouth has also detected them at an early period by vaginal stetho- scopy, which, however, for obvious reasons, cannot be ordinarily employed. Naegele never heard them before the eighteenth week, more generally at the end of the twentieth, and for practical purposes the pregnancy must be advanced to the fifth month before we can reasonably expect to detect them. From this period up to term they can almost always be heard, if not at the first attempt, at least after- wards, to a certainty, if we have the opportunity of making repeated examinations. Accidental circumstances, such as the presence of an unusual amount of flatus in the intestines, may deaden the sounds for 1 Brit. Med. Journ., vol. ii. 1873. SIGXS AND SYMPTOMS OF PREGNANCY. 143 a time, but not permanently. Depaul only failed to hear them in 8 cases out of 906 examined during the last three months of pregnancy; and out of 180 cases, which Dr. Anderson of Glasgow carefully examined, he only failed in 12, and in each of these the child was still-born. They, therefore, form not only a most certain indication of pregnancy, but of the life of the foetus also. Description of the Sound. — The sound has been always likened to the double tic-tac of a watch heard through a pillow, which it closely resembles. It consists of two beats, separated by a short interval, the first being the loudest and most distinct, the second being some- times inaudible. The rapidity of the foetal pulsations forms an important means of distinguishing them from transmitted maternal pulsations, with which they might be confounded. Their average number is stated by Slater, who made numerous observations on this point, to be 132, but sometimes they reach as high as 140, and some- times as low as 120. It will thus be seen that the pulsations are always much more rapid than those of the mother's heart, unless, indeed, the latter be unduly accelerated by transient mental emotion or disease. To avoid mistakes, whenever the foetal heart is heard its rate of pulsation should be carefully counted, and compared with that of the mother's pulse ; if the rates differ, we may be sure that no error has been made. The rapidity of the foetal pulsations, re- mains, as a rule, the same during the whole period of pregnancy, while their intensity gradually increases. They may, however, be temporarily increased or diminished in frequency by disturbing- causes, such as the pressure of the stethoscope, which, exciting tumultuous movements of the foetus, may induce greatly-increased frequency of its heart-beats. So also during labor, after the escape of the liquor amnii, when the contractions of the uterus have a very distinct influence on the foetus, they may be greatly modified An acceleration or irregularity of the pulsations, made out in the course of a prolonged labor, may thus be of great practical importance, by indicating the necessity for prompt interference. Similar alterations, associated with tumultuous and unusual foetal movements felt by the mother towards the end of pregnancy, may point to danger to the life of the foetus during the latter months, and may even justify the induction of premature labor. This is especially the case in women who have previously given birth to a succession of dead children owing to disease of the placenta, and, in them, careful and frequently repealed auscultations may warn us of the impending danger. Siifi})fis<-f! ilijj'rn'iit'i: <>r' lid/iidiiif according to the Sex of Foetus. — The rapidity of the foetal heart has been supposed by some to afford a means of determining the sex of the child before birth. Franken- hauser, who first directed attention to this point, is of opinion that the average rate of pulsations of the heart are considerably less in male than in female children, averaging 121 in the minute in the former, as against 1 44 in the latter. Stembacfa makes the difference somewhat less, viz., 131 for males, and L88 for females, lie pre- dicted the sex correctly by this means in 45 out of 57 cases, while Frankenhauser was correct in the whole 50 cases which he spe- 144 PREGNANCY. cially examined with reference to the point. Dr. Hntton, of New York, 1 was also correct in 7 cases he fixed on for trial. Devilliers fonnd the difference in the sexes to be the same as Steinbach ; he attributes it, however, to the size and weight, rather than to the sex of the child, and believes the pulsations to be least numerous in large and well-developed children. As male children are usually larger than female, he thus explains the relatively less frequent pul- sations of their hearts. Dr. dimming, of Edinburgh, also believes that the weight of the child has considerable influeDce on the fre- quency of its cardiac pulsations, so that a large female child may have a slower pulse than a small male. 2 The point, however, is more curious than practical, and the rapidity of the pulsations certainly would not justify any positive prediction on the subject. Circum- stances influencing the maternal circulation seem to have no influence on that of the foetus. Site at which the Sounds are heard. — The foetal heart-sounds are generally propagated best by the back of the child, and are, there- fore, most easily audible when this is in contact with the anterior wall of the uterus, as is the case in the large majority of pregnancies. When the child is placed in the dorso-posterior position, the sounds have to traverse a larger amount of the liquor amnii, and are further modified by the interposition of the foetal limbs. They are, there- fore, less easily heard in such cases, but even in them they can almost always be made out. As the foetus most frequently lies with the occiput over the brim of the pelvis, and the back of the child towards the left side of the mother, the heart-sounds are usually most dis- tinctly audible at a point midway between the umbilicus and the left anterior-superior spine of the ilium. In the next most common posi- tion, in which the back of the child lies to the right lumbar region of the mother, they are generally heard at a corresponding point at the right side, but in this case they are frequently more readily made out in the right flank, being then transmitted through the thorax of the child, which is in contact with the side of the uterus. In breech cases, on the other hand, the heart-sounds are generally heard most distinctly above the umbilicus, and either to the right or left, accord- ing to the side towards which the back of the child is placed. It will thus be seen that the place at which the foetal heart-sounds are heard varies with the position of the foetus ; and this, when combined with the information derived from palpation, affords a ready means of ascertaining the presentation of the child before labor. The sounds are only audible over a limited space, about two to three inches in diameter ; therefore, if we fail to detect them in one place, a careful exploration of the whole uterine tumor is necessary before we are satisfied that they cannot be heard. Sources of Fallacy.— The ou\j mistake that is likely to be made is taking the maternal pulsations, transmitted through the uterine tumor, for those of the foetal heart. A little care will easily prevent this error, and the frequency of the mother's pulse should always be 2 Edin. Med. Journ., 1875. SIGNS AND SYMPTOMS OF PREGNANCY. 145 ascertained before counting the supposed foetal pulsations. If these are found to be 120 or more, while the mother's pulse is only 70 or 80, no mistake is possible. If the latter is abnormally quickened greater care may be necessary, but even then the rate of pulsation of each will be dissimilar. Braxton Hicks 1 has pointed out that in tedious labor, when the muscular powers of the mother are exhausted, the muscular subsurrus may produce a sound closely resembling the foetal pulsation ; but error from this source is obviously very im- probable. Mode of practising Auscultation. — In listening for the foetal heart- sounds the patient should be placed on her back, with the shoulders elevated and the knees flexed. The surface of the abdomen should be uncovered, and an ordinary stethoscope employed, the end of which must be pressed firmly on the tumor, so as to depress the ab- dominal walls. The most absolute stillness is necessary, as it is often far from easy to hear the sounds. Sometimes, after failing with the ordinary stethoscope, I have succeeded with the bin-aural, which remarkably intensifies them. [Dr. Camman's double instrument answers a good purpose. — Ed.] When once heard they are most easily counted during a space of five seconds, as, on account of their frequency, it is not always possible to follow them over a longer period. Value of this Sign of Pregnancy. — When the foetal heart-sounds are heard distinctly, pregnancy may be absolutely and certainly diag- nosed. The fact that we do not hear them does not, however, pre- clude the possibility of gestation, for the foetus may be dead, or the sounds temporarily inaudible. Umbilical Souffle. — There are some other sounds heard in ausculta- tion which are of very secondary diagnostic value. One of these is the so-called umbilical or funic souffle, which was first pointed out by Evory Kennedy. It consists of a single blowing murmur, synchro- nous with the foetal heart sounds, and most distinctly heard in the immediate vicinity of the point where these are most audible. Most authors believe it to be produced by pressure on the cord, cither when it is placed between a hard part of the foetus and the uterine walls, or is twisted round the child's neck. Schroeder and Hecker detected it in fourteen or fifteen per cent, of all cases, and the latter believed it to be caused by flexure of the first portion of the cord near the umbilicus. For practical purposes it is quite valueless, and need only be mentioned as ;i phenomenon which an experienced aus- cultator may occasionally detect. Uterine Souffle, — The uterine souffle is a peculiar single whizzing murmur which is almost always audible on auscultation. Ii varies very remarkably in character and position. Sometimes it is a gentle blowingor even musical murmur ; al others it is loud, harsh, and scrap- ping; sometimes continuous, sometimes intermittent. It may also be heard at any point of the uterus, but mosl frequently l<>w down, and to one or other side ; more rarely above the umbilicus, or towards the fun- 1 ( )l)st. Trans., vol. xv. 146 PREGNANCY. dus; and it often changes its position so as to be heard at a subsequent auscultation at a point where it was previously inaudible. It may be heard over a space of an inch or two only, or, in some cases, over the whole uterine tumor; or again, it may sometimes be detected simultaneously over two entirely distinct portions of the uterus. It is generally to be heard earlier than the foetal heart-sounds, often as soon as the uterus rises above the brim of the pelvis, and it can almost always be detected after the commencement of the fourth month. The sound becomes curiously modified by the uterine contractions during labor, becoming louder and more intense before the pain comes on, disappearing during its acme, and again being heard as it goes off. Hicks attributes to a similar cause, viz., the uterine contractions during pregnancy, the frequent variations in the sound which are characteristic of it. 1 The uterine souffle is also audible after the death of the foetus, and it is believed by some to be modified and to become more continuously harsh when that event has taken place. Theories as to its Cause. — Very various explanations have been given of the causes of this sound. For long it was supposed to be formed in the vessels of the placenta, and hence the name " placental souffle" by which it is often talked of; or if not in the placenta, in the uterine vessels in its immediate neighborhood. The non-placental origin of the sound is sufficiently demonstrated by the fact that it may be heard for a considerable time after the expulsion of the pla- centa. Some have supposed that it is not formed in the uterus at all, but in the maternal vessels, especially the aorta and the iliac arteries, owing to the pressure to which they are subjected by the gravid uterus. The extreme irregularity of the sound, its occasional disap- pearance, and its variable site, seem to be conclusive against this view. The theory which refers the sound to the uterine vessels is that which has received most adherents, and which best meets the facts of the case ; but it is by no means easy or even possible to account for the exact mode of its production in them. Each of the explanations which have been given is open to some objection. It is far from unlikely that the intermittent contractions of the uterine fibres, which are known to occur during the whole course of preg- nancy, may have much to do with it, by modifying, at intervals, the rapidity of the circulation in the vessels. Its production in this manner may also be favored by the chlorotic state of the blood, to which Cazeaux and Scanzoni are inclined to attribute an important influence, likening it to the anaemic murmur so frequently heard in the vessels in weakly women. Diagnostic Value. — From a diagnostic point of view the uterine souffle is of very secondary importance, because a similar sound is very generally audible in large fibroid tumors of the uterus, and even in some few ovarian tumors; it is, therefore, of little or no value in assisting us to decide the character of the abdominal enlarge- ment. The supposed dependence of the sound on the placental cir- culation has caused its site to be often identified with that of the 1 Op. cit. p. 233. SIGNS AND SYMPTOMS OF PREGNANCY. 147 placenta. It is, however, most frequently heard at the lower part of the uterus, while the placenta is generally attached near the fundus, so that its position cannot be taken as any safe guide in determining the situation of that viscus. Sounds produced hy the Movements of the Foetus. — Occasionally, in practising auscultation, irregular sounds of brief duration may be heard, which are not susceptible of accurate description, and which doubtless depend on the sudden movements of the foetus in the liquor amnii, or on the impact of its limbs on the uterine walls. When heard distinctly t\\Qj are characteristic of pregnancy; and they may be sometimes heard when the other sounds cannot be de- tected. They are, however, so irregular, and so often entirely absent, that they can hardly be looked upon in any other light than as occasional phenomena. Sounds referred to Decomposition of the Liguor Amnii and to sepa- ration of the Placenta. — Two other sounds have been described as being sometimes audible, which may be mentioned as matters of interest, but which are of no diagnostic value. One is a rustling sound, said by Stoltz to be audible in cases in which the foetus is dead, and Avhich he refers to gaseous decomposition of the liquor amnii; its existence is, however, extremely problematical. The other is a sound heard after the birth of the child, and referred by Caillant to the separation of the placental adhesions. He describes it as a series of rapid short scratching sounds, similar to those pro- duced by drawing the nails across the seat of a horse-hair sofa. Simp- son 1 admits the existence of the sound, but believed that it is produced by the mere physical crushing of the placenta, and artificially imitated it out of the body by forcing the placenta through an aperture the size of the os uteri. Relative Value of the Signs and Symptoms of Pregnancy. — It will be seen, then, that although there are numerous signs and symptoms accompanying pregnancy, many of them are unreliable by them- selves, and apt to mislead. Those which may be confidently de- pended on are the pulsations of the foetal heart, which, however, fail us in cases of dead children; the foetal movements when distinctly made out; ballottement; the intermittent contractions of the uterus; and to these we may safely add the presence of milk in the breasts, provided we have to do with a first pregnancy. The remainder are of importance in leading us to suspect preg- nancy, and in corroborating and strengthening other symptoms, but they do not, of themselves, justify a positive diagnosis. 1 Selected Obstet. Works, p. 151. 148 PREGNANCY. CHAPTEE V. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. SPURIOUS PREG- NANCY. THE DURATION OF PREGNANCY. SIGNS OF RECENT DELIVERY. Importance of the Subject. — The differential diagnosis of pregnancy has of late years assnmed much importance on account of the advance of abdominal surgery. The cases are so numerous in which even the most experienced practitioners have fallen into error, and in which the abdomen has been laid open in ignorance of the fact that pregnancy existed, that the subject becomes one of the greatest con- sequence. Fortunately it is less so from an obstetrical than from a gynaecological point of view, inasmuch as the converse error, of mis- taking some other condition for pregnancy, is of far less consequence, as it is one which time will always rectify. But even in this way carelessness may lead to very serious injury to the character, if not to the health of the patient ; and it will be well to refer briefly to some of the conditions most liable to be mistaken for pregnancy, and to the mode of distinguishing them. Adipose enlargement of the abdomen may obscure the diagnosis by preventing the detection of the uterus ; and if, as is not uncommon in women of great obesity, it is associated with irregular menstrua- tion, the increased size of the abdomen might be supposed to depend on pregnancy. The absence of corroborative signs, such as ausculta- tory phenomena, mammary changes, and the hardness of the cervix as felt per vaginam, make it easy to avoid this error. Distension of the uterus by retained menstrual fluid, or watery secretion, is an occurrence of rarity that could seldom give rise to error. Still it occasionally happens that the uterus becomes enlarged in this way, sometimes reaching even to the level of the umbilicus, and that the physical character of the tumor is not unlike that of the gravid uterus. The best safeguard against mistakes will be the previous history of the case, which will always be different from that of ordinary pregnancy. Retention of the menses almost always occurs from some physical obstruction to the exit of the fluid, such as imperforate hymen ; or if it occur in women who have already menstruated, we may usually trace a history of some cause, such as inflammation following an antecedent labor, which has produced occlusion of some part of the genital tract. The existence of a pelvic tumor in a girl who has never menstruated will of itself give rise to suspicion, as pregnancy under such circumstances is of extreme rarity. It will also be found that general symptoms have existed for a period of time considerably longer than the supposed duration of pregnancy, as judged of by the size of the tumor. The most DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 149 characteristic of them are periodic attacks of pain due to the addition, at each monthly period, to the quantity of retained menstrual fluid. Whenever, from any of these reasons, suspicion of the true character of the case has arisen, a careful vaginal examination will generally clear it up. Tn most cases the obstruction will be in the vagina, and is at once detected, the vaginal canal above it, as felt per rectum, being greatly distended by fluid ; and we may also find the bulging and imperforate hymen protruding through the vulva. The absence of mammary changes, and of ballottement, will materially aid us in forming a diagnosis. Congestive Hypertrophy of the Uterus. — The engorged and enlarged uterus, frequently met with in women suffering from uterine disease, might readily be mistaken for an early pregnancy, if it happened to be associated with amenorrhea. A little time would, of course, soon clear up the point, by showing that progressive increase in size, as in pregnancy, does not take place. This mistake could only be made at an early stage of pregnancy, when a positive diagnosis is never possible. The accompanying symptoms — pain, inability to walk, and tenderness of the uterus on pressure — would further prevent such an error. Ascitic Distension of the Abdomen. — Ascites, per se, could hardly be mistaken for pregnancy ; for the uniform distension and evident fluctuation, the absence of any definite tumor, the site of resonance on percussion changing in accordance with alteration of the position of the woman, and the unchanged cervix and uterus, should be suffi- cient to clear up any doubt, Pregnancy may, however, exist with ascites, and this combination may be difficult to detect, and might readily be mistaken for ovarian disease, associated with ascites. The existence of mammary changes, the presence of the softened cervix, ballottement, and auscultation — provided the sounds were not masked by the surrounding fluid — would afford the best means of diagnosing such a case. Uterine and Ovarian Tumors. — One of the most frequent sources of difficulty is the differential diagnosis of large abdominal tumors, either fibroid or ovarian, or of some enlargements due to malignant disease of the peritoneum or abdominal viscera. The most expe- rienced have been occasionally deceived under such circumstances. As a rule, the presence of menstruation will prevent error, as this generally continues in ovarian disease, while in fibroids it is often excessive. Tim character of the tumor — the fluctuation in ovarian disease, the hard nodular masses in fibroid — and the history of the case— especially the length of time the tumor has existed — will aid in diagnosis, while the absence of cervical softening, and of auscultatory phenomena will further beoi material value in forming a conclusion. Some of the mosl difficult cases to diagnose are those in which pr< nancy complicates ovarian or fibroid disease. Then the tumor may more or less completely obscure the physical signs of pregnancy. The usual shape of the abdomen will generally be altered consider- ably, and we may be able to distinguish the gravid uterus, separated from the ovarian tumor by a distinct sulcus, or with the fibroid 150 PREGNANCY. masses cropping out from its surface. Our chief reliance must then be placed in the alteration of the cervix, and in the auscultatory signs of pregnancy. Spurious Pregnancy. — .The condition most likely to give rise to errors is that very interesting and peculiar state, known as spurious pregnancy. In this most of the usual phenomena of pregnancy are so strangely simulated, that accurate diagnosis is often far from easy. There are hardly any of the more apparent symptoms of pregnancy which may not be present in marked cases of this kind. The abdo- men may become prominent, the areolae altered, menstruation arrested, and apparent foetal motions felt ; and, unless suspicion is aroused, and a careful physical examination made, both the patient and the prac- titioner may easily be deceived. Cases in which Spurious Pregnancy occurs. — There is no period of the child-bearing life in which spurious pregnancy may not be met with ; but it is most likely to occur in elderly women about the climacteric period, when it is generally associated with ovarian irrita- tion connected with the change of life ; or in younger women, who are either very desirous of finding themselves pregnant, or who, being unmarried, have subjected themselves to the chance of being so. In all cases the mental faculties have much to do with its production, and there is generally either very marked hysteria, or even a condi- tion closely allied to insanity. Spurious pregnancy is by no means confined to the human race. It is well known to occur in many of the lower animals. Harvey related instances in bitches, either after unsuccessful intercourse, or in connection with their being in heat, even when no intercourse had occurred. In such cases the abdomen swelled, and milk ajDpeared in the mammae. Similar phenomena are also occasionally met with in the cow. In these instances, as in the human female, there is probably some morbid irritation of the ova- rian system. Its Signs and Symptoms. — The physical phenomena are often very well marked. The apparent enlargement is sometimes very great, and it seems to be produced by a projection forward of the abdomi- nal contents due to depression of the diaphragm, together with rigidity of the abdominal muscles, and may even closely simulate the uterine tumor on palpation. After the climacteric it is frequently associated, as Gooch pointed out, with an undue deposit of fat in the abdominal walls and omentum, so that there may be even some dul- ness on percussion, instead of resonance of the intestines. The foetal movements are curiously and exactly simulated, either by involun- tary contractions of the abdominal walls, or by the movement of flatus in the intestines. The patient also generally fancies that she suffers from the usual sympathetic disorders of pregnancy, and thus her account of her symptoms will still further tend to mislead. Sometimes followed by Spurious Labor. — Not only may the supposed pregnancy continue, but, at what would be the natural term of de- livery, all the phenomena of labor may supervene. Many authentic cases are on record in which regular pains came on, and continued to increase in force and frequency until the actual condition was DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 151 diagnosed. Such mistakes, however, are onlj- likely to happen when the statements of the patient have been received without further inquiry. "When once an accurate examination has been made, error is no longer possible. Methods of Diagnosis. — We shall generally find that some of the phenomena of pregnancy are absent. Possibly menstruation, more or less irregular, may have continued. Examination per vaginam will at once clear up the case, by showing that the uterus is not enlarged, and that the cervix is unaltered. It may then be very difficult to convince the patient or her friends that her symptoms have misled her, and for this purpose the inhalation of chloroform is of great value. As consciousness is abolished, the semi -voluntary projection of the abdominal muscles is prevented, the large apparent tumor vanishes, and the bystanders can be readily convinced that none exists. As the patient recovers, the tumor again appears. Duration of Pregnancy. — The duration of pregnancy in the human female has always formed a fruitful theme for discussion amongst obstetricians. The reasons which render the point difficult of deci- sion are obvious. As the large majority of cases occur in married women, in whom intercourse occurs frequently, there is no means of knowing the precise period at which conception took place. The only datum which exists for the calculation of the probable date of delivery is the cessation of menstruation. It is quite possible, how- ever, and indeed probable, that conception occurred, in a considerable number of instances, not immediately after the last period, but im- mediately before the proper epoch for the occurrence of the next. Hence, as the interval between the end of one menstruation and the commencement of the next averages 25 days, an error to that extent is always possible. Another source of fallacy is the fact, which has generally been overlooked, that even a single coitus does not fix the date of conception, but only that of insemination. It is well known that in many of the lower animals the fertilization of the ovule does not take place until several days after copulation, the spermatozoa remaining in the interval in a state of active vitality within the genital tract. It has been shown by Marion Sims that living sper- matozoa exist in the cervical canal in the human female some days after intercourse. It is very probable, therefore, that in the human female, as in the lower animals, a considerable, but unknown interval, occurs between insemination and actual impregnation, which may render calculations as to the precise duration of pregnancy altogether unreliable. Average Time between Cessation of Menstruation and Delivery. — A large mass of statistical observations exist respecting the average duration of gestation, which have been drawn up and collated from numerous sources. It would serve no practical purpose to reprinl the voluminous tables on this subject that are contained in obstetrical works. They arc based on two principal methods of calculation. First, we have the length of time between the cessation oi' menstrua- tion and delivery. This is found to vary very considerably, bul the largest percentage of deliveries occurs between the 271th and 280th 152 PREGNANCY. day after the cessation of menstruation, the average day being the 278th ; but, in individual instances, very considerable variations both above and below these limits are found to exist. Next we have a series of cases, from various sources, in which only one coitus was believed to have taken place. These are naturally always open to some doubt, but, on the whole, they may be taken as affording tole- rably fair grounds for calculation. Here, as in the other mode of calculation, there are marked variations, the average length of time, as estimated from a considerable collection of cases, being 275 days after the single intercourse. It may, therefore, be taken as certain that there is no definite time which we can calculate on as being the proper duration of pregnancy, and, consequently, no method of esti- mating the probable date of delivery on which we can absolutely rel y- Methods of Predicting the probable Date. — The prediction of the time at which the confinement may be expected is, however, a point of considerable practical importance, and one on which the medical attendant is always consulted. Various methods of making the calculation have been recommended. It has been customary in this country, according to the recommendation of Montgomery, to fix upon ten lunar months, or 280 days, as the probable period of gesta- tion, and, as conception is supposed to occur shortly after the cessa- tion of menstruation, to add this number of days to any day within the first week after the last menstrual period as the most probable period of delivery. As, however, 278 days is found to be the average duration of gestation after the cessation of menstruation, and as this method makes the calculation vary from 281 to 287 days, it is evi- dently liable to fix too late a date. Naegele's method was to count 7 days from the first appearance of the last menstrual period, and then reckon backwards three months as the probable date. Thus, if a patient last commenced to menstruate on August 10, counting in this way from August 17 would give May 17 as the probable date of the delivery. Matthews Duncan has paid more attention than any one else to the prediction of the date of delivery. His method of calculating is based on the fact of 278 days being the average time between the cessation of menstruation and parturition ; and he claims to have had a greater average of success in his predictions than on any other plan. His rule is as follows : — " Find the day on which the female ceased to menstruate, or the first day of being what she calls ■" well." Take that day nine months forward as 275, unless February is included, in which case it is taken as 273 days. To this add three days in the former case, or five if February is in the count, to make up the 278. This 278th day should then be fixed on as the middle of the week, or, to make the prediction the more accurate, of the fortnight in which the confinement is likely to occur, by which mteans allowance is made for the average variation of either excess or deficiency." Various periodoscopes and tables for facilitating the calculation have been made. The periodoscope of Dr. Tyler Smith (sold by Messrs. John Smith, 52 Long Acre) is very useful for reference in DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 153 the consulting room, giving at a glance a variety of information, such as the probable period of quickening, the dates for the induc- tion of premature labor, etc. The following table, prepared by Dr. Protheroe Smith, is also easily read, and is very serviceable : — Table for Calculating the Period of Utero-Gestatiox. 1 Nine Calendar Months. Ten Lunar Months. From To Days. To Days. January 1 September 30 273 October 7 280 February 1 October 31 273 November 7 280 March 1 November 30 275 December 5 280 April 1 December 31 275 January 5 280 May 1 January 31 276 February 4 280 June 1 February 28 273 March 7 280 July 1 March 31 274 April 6 280 August 1 April 30 273 Mav 7 280 Septembei 1 Mav 31 273 June 7 280 October 1 June 30 273 July 7 280 November 1 July 31 273 August 7 280 December 1 August 31 274 September 6 280 Quickening a Fallacious Guide in estimating Date of Delivery. — The date at which the quickening has been perceived is relied on by many practitioners, and still more by patients, in calculating the probable date of delivery, as it is generally supposed to occur at the middle of pregnancy. The great variations, however, in the time at which this phenomenon is first perceived, and the difficulty which is so often experienced of ascertaining its presence with any certainty, render it a very fallacious guide. The only times at which the per- ception of quickening is likely to prove of any real value are when impregnation has occurred during lactation (when menstruation is normally absent), or when menstruation is so uncertain and irregular that the date of its last appearance cannot be ascertained. Asquicken- ing is most commonly felt during the fourth month, more frequently in its first than in its last fortnight, it may thus afford the only guide we can obtain, and that an uncertain one, for predicting the date of delivery. Is Protraction of Gestation Possible? — From a medico-legal point of view the question of the possible protraction of pregnancy beyond the average time, and of the limits within which such protraction can be admitted, is of very great importance. The law on this point 1 The above obstetric " Ready Reckoner" consists of two columns, one of calendar, the other of lunar months, and may be read a< follows: — A patient has ceased to menstruate on July l : her confinement may be expected at Boonest about .March ::i {the end of nine calendar months): or at latest <>n April <;. [th< end of ten lunar months). Another has ceased to menstruate on January 20 j her confinement may be expected on September SO, pins 20 days (the end of nint calendar months) at soonest; or on October 7, pins 20 davs (thr end of ten lunar months) at latest. 11 154 PREGNANCY. varies considerably in different countries. Thus in France it is laid down that legitimacy cannot be contested until 300 days have elapsed from the death of the husband, or the latest possible opportunity for sexual intercourse. This limit is also adopted by Austria, while in Prussia it is fixed at 302 days. In England and America no fixed date is admitted, but while 280 days is admitted as the "legitimum tempus pariendi," each case, in which legitimacy is questioned, is to be decided on its own merits. At the early part of the century the question was much discussed by the leading obstetricians in connec- tion with the celebrated Gardner peerage case, and a considerable difference of opinion existed among them. Since that time manj^ apparently perfectly reliable cases have been recorded, in which the duration of gestation was obviously much beyond the average, and in which all sources of fallacy were carefully excluded. Reliable Cases of Protraction. — Not to burden these pages with a number of cases, it may suffice to refer, as examples of protraction, to four well-known instances recorded by Simpson, 1 in which the pregnancy extended respectively to 336, 332, 319, and 324 days after the cessation of the last menstrual period. In these, as in all cases of protracted gestation, there is the possible source of error that im- pregnation may have occurred just before the expected advent of the next period. Making an allowance of 23 days in each instance for this, we even then have a number of days much above the average, viz., 313, 309, 296, and 301. Numerous instances as curious may be found scattered through obstetric literature. Indeed, the experience of most accoucheurs will parallel such cases, which may be more common than is generally supposed, inasmuch as they are only likely to attract attention when the husband has been separated from the wife beyond the average and expected duration of the pregnancy. Protraction common in the Lower Animals. — The evidence in favor of the possible prolongation of gestation is greatly strengthened by what is known to occur in the lower animals. In some of these, as in the cow and the mare, the precise period of insemination is known to a certainty, as only a single coitus is permitted. Many tables of this kind have been constructed, and it has been shown that there is in them a very considerable variation. In some cases in the cow it has been found that delivery took place 45 days, and in the mare 43 days after the calculated date. Analogy would go strongly to show, that what is known to a certainty to occur in the lower animals, may also take place in the human female. The fact, indeed, is now very generally admitted ; but we are still unable to fix, with any degree of precision, on the extreme limit to which protraction is possible. Some practitioners have given cases in which, on data which they believe to be satisfactory, pregnancy has been extremely protracted ; thus Meigs and Adler record instances which they believed to have been prolonged to over a year in one case, and over fourteen months in the other. These are, however, so problematical that little weight can be attached to them. On the whole it would hardly be safe to 1 Obstet. Memoirs, p. 84. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 155 conclude that pregnancy can go more than three or four weeks beyond the average time. This conclusion is justified by the cases we possess in which pregnancy followed a single coitus, the longest of which was 295 days. Evidence from Size of Child. — Dr. Duncan 1 is inclined to refuse credence to every case of supposed protraction unless the size and weight of the child are above the average, believing that lengthened gestation must of necessity cause increased growth of the child. The point requires further investigation, and it cannot be taken as proved that the foetus necessarily must be large because it has been retained longer than usual in utero ; or, even if this be admitted, it may have been originally small, and so, at the end of the protracted gestation, be little above the average weight. There are, however, many cases which certainly prove that a prolonged pregnancy is at least often associated with an unusually developed foetus. Dr. Duncan himself cites several, and a very interesting one is mentioned by Leishman, in which delivery took place 295 days after a single coitus, the child weighing 12 lbs. 3 ozs. In some Cases Labor may commence and be Arrested. — It seems possible that, in some cases of protracted pregnancy, labor actually came on at the average time, but, on account of faulty positions of the uterus, or other obstructing cause, the pains were ineffective and ultimately died away, not recurring for a considerable time. Joulin relates some instances of this kind. In one of them the labor was expected from the 20th to the 25th of October. He was summoned on the 23d, and found the pains regular and active, but ineffective ; after lasting the whole of the 21th and 25th they died away, and delivery did not take place until November 25th, after the lapse of a month. In this instance the apparent cause of difficulty was extreme anterior obliquity of the uterus. A precisely similar case came under my own observation. The lady ceased to menstruate on March 16, 1870. On December 12th, that is on the 273d day, strong labor pains came on, the os dilated to the size of a florin, and the membranes became tense and prominent with each pain. After lasting all night they gradually died away, and did not recur until January 12th, 301 days from the cessation of the last period. Here there was no assignable cause of obstruction, and the labor, when it did come on, was natural and easy. The curious fact that, in both these cases, as in others of the same kind that are recorded, labor came on exactly a month after the pre- vious ineffectual attempt at its establishment, affords, so far as it a, an argument in favor of the view maintained by many that labor is apt to come OH at what would have been a menstrual period. Signs of Recent Delivery. — From a forensic point of view it oft en becomes of importance to he able to give a reliable (.pinion as to the fact of delivery having occurred, and a few words may he here said as to the signs of recenl delivery. Our opinion is only likely to be sought in cases in which the Gael of delivery is denied, and in which 1 Fecundity and Fertility, p. 348. 356 PREGNANCY. we must, therefore, entirely rely on the results of a physical exami- nation. If this be undertaken within the first fortnight after labor, a positive conclusion can be readily arrived at. At this time the abdominal walls will still be found loose and flaccid, and bearing very evident marks of extreme distension in the cracks and fissures of the cutis vera. These remain permanent for the rest of the patient's life, and may be safely assumed to be signs of an antecedent pregnancy, provided we can be certain that no other cause of extreme abdominal distension has existed, such as ascites, or ovarian tumor. Within the first few days after delivery, the hard round ball formed by the contracted and empty uterus can easily be felt by abdominal palpation, and more certainly by combined external and internal examination. The process of involution, however, by which the uterus is reduced to its normal size, is so rapid, that after the first week it can no longer be made out above the brim of the pelvis. In cases in which an accurate diagnosis is of importance, the increased length of the uterus can be ascertained by the uterine sound, and its cavity will measure more than the normal 2 J- inches for at least a month after deliver}^. It should not be forgotten that the uterine parietes are now undergoing fatty degeneration, and that they are more than usually soft and friable, so that the sound should be used with great caution, and only when a positive opinion is essential. The state of the cervix and of the vagina may afford useful in- formation. Immediately after delivery the cervix hangs loose and patulous in the vagina, but it rapidly contracts, and the internal os is generally entirely closed after the eighth or tenth day. The re- mainder of the cervix is longer in returning to its normal shape and consistency. It is generally permanently altered after delivery, the external os remaining fissured and transverse, instead of circular with smooth margins, as in virgins. The vagina is at first lax, swollen, and dilated, but these signs rapidly disappear and cannot be satisfac- torily made out after the first few days. The absence of the fourchette may be recognized, and is a persistent sign. The presence of the lochia affords a valuable sign of recent deliv- ery. For the first few days they are sanguineous, and contain numer- ous blood-corpuscles, epithelial scales, and the ddbris of the decidua. After the fifth day they generally change in color, and become pale and greenish, and from the eighth or ninth day till about a month after delivery, they have the appearance of a thick opalescent mucus. They have, however, a peculiar, heavy, sickening odor, which should prevent their being mistaken for either menstruation or leucorrhoeal discharge. The appearance of the breasts will also aid the decision, for it is impossible for the patient to conceal the turgid swollen condition of the mammae, with the darkened areolae, and, above all, the presence of milk. If, on microscopic examination, the milk is found to con- tain colostrum corpuscles, the fact of very recent delivery is certain. In women who do not nurse it should be remembered that the secre- tion of milk often rapidly disappears, so that its absence cannot be ABNORMAL PREGNANCY. 157 taken as a sign that delivery has not taken place. On the whole, there should be no difficulty in deciding that a woman has been de- livered, as some of the signs are persistent for the rest of her life ; but it is not so easy, unless we see the case within the first eight or ten days, to say how long it is since labor took place. CHAPTER VI. ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER- Plural Births an abnormal variety of Pregnancy. — The occurrence of more than one foetus in utero is far from uncommon, but there are circumstances connected with it which, justify the conclusion that plural births must not be classified as natural forms of pregnancy. The reasons for this statement have been well collected by Dr. Arthur Mitchell, 1 who conclusively shows that not only is there a direct increase of risk both to the mother and her offspring, but that many abnormalities, such as idiocy, imbecility, and bodily deformity, occur with much greater frequency in twins than in single-born children. Pie concludes that "the whole history of twin births is exceptional, indicates imperfect development and feeble organization in the product, and leads us to regard twinning in the human species as a departure from the physiological rule, and therofore injurious to all concerned." Frequency of multiple Births. — The frequency of multiple births varies considerably under different circumstances. Taking the aver- age of a large number of cases collected by authors in various countries, we find that twin pregnancies occur about once in 87 labors; triplets once in 7679. A certain number of quadruple preg- nancies, and some cases of early abortion in which there were five foetuses, are recorded, so thai there can be no doubt of the possibility of such occurrences; but they arc bo extremely uncommon thai they may be looked upon as rare exceptions, the relative frequency of which can hardly be determined. Ilrhitirn fri'(jvnicy in different Countries. — The frequency of mul- tiple pregnancy varies remarkably in differenl races and countries. The following table 3 will show this at a glance: — 1 Med. Times and Gaz., Nov. 1862. J Puech, I >'■- Naissances Multiples. 158 PREGNANCY. Relative Fkequency of Mutiple Pkegnancies in Europe. Countries. Proportion of Twin to Single Births. Proportion of Triplets. Proportion of Quadruplets. E no-land . 1 : 116 1 : 94 1 : 89 1 : 95 1 : 99 1 : 64 1 : 68.9 1 : 81.62 1 : 89 1 : 50.05 1 : 79 1 : 102 1 : 862 1 : 6,720 Austria Grand Duchy of Baden Scotland . 1 : 6,575 France Ireland Mecklenburg- Scliwerin Norway . Prussia Russia 1 : 8,256 1 : 4,995 1 : 6,436 1 : 5,442 1 : 7,820 1 : 4,054 1 : 1,000 1 : 2,074,306 1 : 167,296 1 : 183,236 1 : 394,690 Saxony . Switzerland 1 : 400,000 Wurtemberg . 1 : 6,464 1 : 110,991 It will be seen that the largest proportion of multiple births occurs in Russia, and that the number of triple births is greatest where twin pregnancies are most frequent. Puech concludes that the number of multiple pregnancies is in direct proportion to the general fecundity of the inhabitants. Dr. Duncan has deduced some interesting laws, with regard to the production of twins, from a large number of statistical observations; 1 especially that the tendency to the production of twins increases as the age of the woman advances, and is greater in each succeeding pregnancy, exception being made for the first pregnancy, in which it is greater than in any other. Newly married women appear more likely to have twins the older they are. There can be no doubt that there is often a strong hereditary tendency in individual families to multiple births. A remarkable instance of this kind is recorded by Mr. Curgenven, 2 in which a woman had four twin pregnancies, her mother and aunt each one, and her grandmother two. Simpson mentions a case of quadruplets, consisting of three males and one female, who all survived, the female subsequently giving birth to triplets. 3 Sex of Children. — In the largest number of cases of twins the children are of opposite sexes, next most frequently there are two females, and twin males are the most uncommon. Thus out of 59,178 labors, Simpson calculates that twin male and female occurred once in 199 labors, twin females once in 226, and twin males once in 258. The proportion of male to female births is also notably less in twin than in single pregnancies. Size of Foetuses. — Twins, and a fortiori triplets, are almost always smaller and less perfectly developed than single children. Hence ' On Fecundity, Fertility, and Sterility, p. 99. 2 Obstet. Trans, vol. xi. 3 Obstet. Works, p. 830. ABNORMAL PREGNANCY. 159 the chances of their survival are much less, and Clarke calculates the mortality amongst twin children as one out of thirteen. Of triplets, indeed, it is comparatively rare that all survive ; while in quadruplets, premature labor and the death of the foetuses are almost certain. It is a common observation that twins are often unequally developed at birth. By some this difference is attributed to one of them being of a different age to the other. It is probable, however, that in most of these cases the full development of one foetus has been interfered with by pressure of the other. This is far from uncom- monly carried to the extent of destrojdng one of the twins, which is expelled at term, mummified and flattened between the living child and the uterine wall. In other cases when one foetus dies it may be expelled without terminating the pregnane}^, the other being retained in utero and born at term : and those who disbelieve in the possi- bility of superfoetation explain in this way the cases in which it is believed to have occurred. Causes. — Multiple pregnancies depend on various causes. The most common is probably the simultaneous, or nearly simultaneous, maturation and rupture of two Graafian follicles, the ovules becoming impregnated at or about the same time. It by no means necessarily follows, even if more than one follicle should rupture at once, that both ovules should be impregnated. This is proved by the occur- rence of cases in which there are two corpora lutea with only one foetus. There are numerous facts to prove that ovules thrown off within a short time of each other, may become separately impreg- nated, as in cases in which negro women have given birth to twins, one of which was pure negro, the other half caste. It may happen, however, that a single Graafian follicle contains more than one ovule, as has actually been observed before its rup- ture ; or, as is not uncommon in the egg of the fowl, an ovule may contain a double germ, each of which may give rise to a separate foetus. Arrangement of the Faital Membranes and Placentse. — The various modes in which twins may originate explain satisfactorily the varia- tions which are met with in the arrangement of the foetal membrane.-, and in the form and connections of the placenta3. In a large pro- portion of cases there are two distind bags of membranes, the septum between them being composed of four layers, viz., the chorion and amnion of each ovum. The placentae are also entirely separate. Eere it is obvious thai each twin is developed from a distind ovum, having its own chorion and amnion. On arriving in the uterus it is probable thai each ovum becomes fixed independently in the mucous membrane, and is surrounded by its own decidua reflexa. A.s growth advances, the decidua reflexa generally atro- phies from pressure, as it is no1 usual to find more than lour layers of membrane in the septum separating the ova. In other cases there is only «»ne chorion, within which an- two distind amnions, the sep- tum then consisting of two layers only. Then the placentse are generally in close apposition, and become fused Into a single ma--: the cords, separately attached to each foetus, no1 infrequently uniting 160 PREGNANCY. shortly before reaching the placental mass, their vessels anastomosing freely. In other more rare instances both foetuses are contained in a common amniotic sac ; but, as the amnion is a purely foetal mem- brane, it is probable that, when this arrangement is met with, the originally existing septum between the amniotic sacs has been destroyed. In both these latter cases the twins must have been de- veloped from a single ovule containing a double germ, and Schroeder states that they are then always of the same sex. Dr. Brunton 1 has started a precisely opposite theory, and has tried to prove that twins of the same sex are contained in separate bags of membrane, while twins of opposite sexes have a common sac. He says that out of twenty -five cases coming under his observation, in fifteen the children contained in different sacs were of the same sex, but in the remaining ten, in which there was only one sac, they were of opposite sexes. It is difficult to believe that there is not an error in these observations, since twins contained in a single amniotic sac do not occur nearly as often as ten times out of twenty-five cases, and no distinction is made between a common chorion with two amnions and a single chorion and amnion. The facts of double monstrosity also disprove this view, since conjoined twins must of necessity arise from a single ovule with a double germ, and there is no instance on record in which they were of opposite sexes. Membranes and Placentae in Triplets. — In triplets the membranes and placentae may be all separate, or, as is commonly the case, there is one complete bag of membranes, and a second having a common chorion, with a double amnion. It is probable, therefore, that trip- lets are generally developed from two ovules, one of which contained a double germ. Diagnosis of Multiple Pregna,ncy . — It is comparatively seldom that twin pregnancy can be diagnosed before the birth of the first child, and even when suspicion has arisen, its indications are very defective. There is generally an unusual size and an irregularity of shape of the uterus, sometimes even a distinct depression or suicus between the two foetuses. When such a sulcus exists it may be possible to make out parts of each foetus b}^ palpation on either side of the uterus. The only sign, however, on which the least reliance can be placed is the detection of two foetal hearts. If two distinct pulsations are heard at different parts of the uterus ; if, on carrying the stetho- scope from one point to another, there is an interspace where the pulsations are no longer audible, or when they become feeble, and again increase in clearness as the second point is reached ; and, above all, if we are able to make out a difference in frequency between them, the diagnosis is tolerably safe. It must be remembered, how- ever, that the sounds of a single heart may be heard over a larger space than usual, and hence a possible source of error. Twin preg- nancy, moreover, nuvy readily exist without the most careful auscul- tation enabling us to detect a double pulsation, especially if one child lie in the dorso-posterior position, when the body of the other may 1 Obst. Trans, vol. x. ABNORMAL PREGNANCY. 161 prevent the transmission of its heart's beat. The so-called placental souffle is generally too diffuse and irregular to be of any use in diagnosis, even when it is distinctly heard at separate parts of the uterus. Superfoetation and Superfecundation. — Closely connected with the subject of multiple pregnancies are the conditions known as super- fecundation and superfoetation, regarding which there has been much controversy and difference of opinion. By the former is meant the fecundation, at or near the same period of time, of two separate ovules before the decidua lining the uterus has been formed, which by many is supposed to form an insuperable obstacle to subsequent impregnation. The possibility of this occur- rence has been incontestably proved by the class of cases already referred to, in which the same woman has given birth to twins bear- ing evident traces of being the offspring of fathers of different races. By superfoetation is meant the impregnation of a second ovule, when the uterus already contains an ovum which has arrived at a considerable degree of development. The cases which are supposed to prove the possibility of this occurrence are very numerous. They are those in which a woman is delivered simultaneously of foetuses of very different ages, one bearing ail the marks of having arrived at term, the other of prematurity ; or of those in which a woman is delivered of an apparently mature child, and, after the lapse of a few months, of another equally mature. The possibility of superfoetation is strongly denied by many practitioners of eminence, and explana- tions are given, which doubtless seem to account satisfactorily for a large proportion of the supposed examples. In the former class of cases it is supposed, with much probability, that there is an ordinary twin pregnancy, the development of one foetus being retarded by the presence in utero of another. That this is not an uncommon occur- rence is certain, and the fact has already been alluded to in treating of twin pregnancy. In cases of the latter kind it is possible that some of them may be due to separate impregnation in a bilobed uterus, the contents of one division being thrown off a considerable time before those of the other. Numerous authentic exam] ties of tli is occurrence are recorded, but by far the most remarkable is that related by Dr. Ross, of Brighton, which has been already referred to (p. 58). In this <-asc the patient had previously given birth to many children without any suspicion of her abnormal formation having arisen, and, had it not been detected by Dr. Ross, the case might fairly enough have been claimed as an indubitable example of Buper- foetation. Making every allowance for these explanations, there remain a considerable number of eases which it is very difficult to accounl for, except on the supposition that th<- Becond child has been conceived a considerable time after the first. Those interested in the subjeel will find a large number of examples collected in a valuable paper by Dr. Bonnar, of Cupar. 1 lie has adopted the ingenious plan of 1 Edin. Med. Jour., L864-65. 162 PREGNANCY. consulting the records of the British peerage, where the exact date of the birth of successive children of peers is given, without, of course, any reasonable possibility of error, and he has collected numerous examples of births rapidly succeeding each other, which are apparently inexplicable on any other theory. In one case he cites, a child was born September 12, 1849, and the mother gave birth to another on January 24, 1850, after an interval of only 127 days. Subtracting from that 14 days, which Dr. Bonnar assumes to be the earliest possible period at which a fresh impregnation can occur after delivery, we reduce the gestation to 113 days, that is to less than four calendar months. As both these children survived, the second child could not possibly have been the result of a fresh impregnation after the birth of the first; nor could the first child have been a twin prematurely delivered, for if so it must have only reached rather more than the fifth month, at which time its survival would have been impossible. Besides the numerous examples of cases of this kind recorded in most obstetric works, there are one or two of miscarriage in the early months, in which, in addition to a foetus of four or five months' growth, a perfectly fresh ovum of not more than a month's develop- ment was thrown off. One such case was shown at the Obstetrical Society in 1862, which was reported on by Drs. Harley and Tanner, who stated that in their opinion it was an example of superfcetation. A still more conclusive case is recorded by Tyler Smith. 1 "A young married woman, pregnant for the first time, miscarried at the end of the fifth month, and some hours afterwards a small clot was dis- charged, inclosing a perfectly healthy ovum of about one month. There were no signs of a double uterus in this case. The patient had menstruated regularly during the time she had been pregnant." This case is of special interest from the fact of the patient having men- struated during pregnancy — a circumstance only explicable on the same anatomical grounds which, render superfcetation possible. So far as I know, it is the only instance in which the coincidence of superfcetation and menstruation during early pregnancy has been observed. Objections. — The objections to the possibility of superfcetation are based on the assumptions that the decidua so completely fills up the uterine cavity that the passage of the spermatozoa is impossible ; that their passage is prevented by the mucous plug which blocks up the cervix ; and that when impregnation has taken place ovulation is suspended. It is, koivever, certain that none of these are insupera- ble obstacles to a second impregnation. The first was originally based on the older and erroneous view which considered the decidua to be an exudation lining the entire uterine cavity, and sealing up the mouths of the Fallopian tubes and the aperture of the internal os uteri. The decidua reflexa, however, does not come into apposition with the decidua vera until about the eighth week of pregnancy, and, therefore, until that time there is a free space between the two mem- 1 Manual of Obstetrics, p. 112. ABNORMAL PREGNANCY. 163 branes through which the spermatozoa might pass to the open mouths of the Fallopian tube, and in which a newly -impregnated ovule might graft itself. A reference to the accompanying figure of a pregnancy in the third month, copied from Coste's work, will readily show that, as far as the decidua is concerned, there is no mechanical obstacle to the descent and lodgment of another impreg- nated ovule (Fig. 75). Then, as regards the plug of mucus, it is Fig. 75. Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa during the early months of Pregnancy. (After Coste.) pretty certain that this is in no way different from the mucus filling the cervix in the non-pregnant state, which offers no obstacle at all to the passage of the spermatozoa. Lastly, respecting the cessation of ovulation during pregnancy, this, no doubt, is the rule, and proba- bly satisfactorily explains the rarity of superfcetation. There are, however, a sufficient number of authenticated cases of menstruation during pregnancy to prove that ovulation is not always absolutely in abeyance; and, as long as it occurs, there is unquestionably no positive mechanical obstruction, at least in the early months of preg- nancy, in the way of the impregnation and lodgment of the ovules that are thrown off. The reasonable conclusion, therefore, seems to be that, although a large; majority of tin; supposed eases are explica- ble in other ways, it cannot be admitted that superfcetation is either physiologically or mechanically impossible. Extra-uterine Pregnancy. — The mosl importanl of the abnorma] varieties of pregnancy, if we consider the serious and very generally fatal results attending it, is the so-called extrauterine fcetation, which consists in the arrest and development of the ovum outside I be cavity 164 PREGNANCY. of the uterus. Of late years this subject lias received much well- merited attention, which, it is to be hoped, may lead to the establish- ment of some definite rules for the management of this most anxious and dangerous class of cases. Site of Extra-uterine Pregnancy. — The ovum may be arrested and developed in various situations on its way to the uterus, most com- monly in some part of the Fallopian tube, or it may be in the cavity of the abdomen, or even quite beyond it, as in a few rare cases in which the ovum has found its way into a hernial sac. Classification. — Extra-uterine gestation may be subdivided into the following classes : 1st, and most common of all, tubal gestation, and as varieties of this, although by some made into distinct classes, (a) interstitial and (b) tubo- ovarian gestation. In the former of these subdivisions the ovum is arrested in the part of the Fallopian tube that is situated in the substance of the uterine parietes ; in the latter, at or near the fimbriated extremity of the tube — so that part of its cyst is formed by the tube and part by the ovary. 2d. Abdominal gestation, in which an ovum, instead of finding its way into the tube, falls into the peritoneal cavity and there becomes attached and de- veloped ; or the so-called secondary abdominal gestation, in which an extra-uterine pregnancy, originally tubal, becomes ventral, through rupture of its cyst and escape of its contents into the abdominal cavity. 3d. Ovarian gestation, the existence of which is denied by many writers of eminence, such as Velpeau and Arthur Farre, while it is maintained by others of equal celebrity, such as Kiwisch, Coste, and Hecker. It must be admitted that it is extremely difficult to under- stand how an ovarian pregnancy, in the strict sense of the word, can occur, for it implies that the ovule has become impregnated before the laceration of the Graafian follicle, through the coats of which the spermatozoa must have passed. Coste, indeed, believes that this frequently occurs ; but, while spermatozoa have been detected on the surface of the ovary, their penetration into the Graafian follicle has never been demonstrated. Farre has also clearly shown that in many cases of supposed ovarian pregnancy the surrounding structures were so altered that it was impossible to trace their exact origin, and to say, to a certainty, that the foetus was really within the substance of the ovary. Kiwisch gives a reasonable explanation of these cases by supposing that sometimes the Graafian follicle may rupture, but that the ovule may remain within it without being discharged. Through the rent in the walls of the follicle the spermatozoa may reach and impregnate the ovule, which may develop in the situation in which it has been detained. While, therefore, it is impossible, in the face of many instances recorded by reliable authorities, to deny the existence of ovarian pregnancy, it must be considered to be a very rare and exceptional variety, which, as far as treatment and results are concerned, does not differ from tubal gestation. 4th. There are two rare varieties in which an ovum is developed either in the supplementary horn of a bi-lobecl uterus, or in a hernial sac. For the sake of clearness, we may place these varieties of extra- uterine gestation in the following tabular form : — ABNORMAL PREGXAXCY. 1G5 1st. Tubal— (a) Interstitial, (b) Tabo- ovarian. 2d. Abdominal — (a) Primary, (b) Secondary. 3d. Ovarian. 4th. In bi-hbed uterus, hernial, etc. Causes. — The etiology of extra-uterine fbetation in any individual case must necessarily be almost always obscure. Broadly speaking, it may be said that extra-uterine foetation may be produced by any condition which prevents, or renders difficult, the passage of the ovule to the uterus, while it does not prevent the access of the spermatozoa to the ovule. Thus inflammatory thickening of the coats of the Fallopian tubes by lessening their calibre, but not suffi- ciently so to prevent the passage of the spermatozoa, may interfere with the movements of the tube which propel the ovum forward, and so cause its arrest. A similar effect may be produced by various morbid conditions, such as inflammatory adhesions, from old-stand- ing peritonitis, pressing on the tube ; obstruction of its calibre by inspissated mucus or small polypoid growths ; the pressure of uterine or other tumors, and the like. The fact that extra-uterine preg- nancies occur most frequently in multiparas, and comparatively rarely in women under thirty years of age, tends to show that these con- ditions, which are clearly more likely to be met with in such women than in young primiparae, have considerable influence in its causation. A curiously large proportion of cases occur in women who have either been previously altogether sterile, or in whom a long interval of time has elapsed since their last pregnancy. The disturbing- effects of fright, either during coition or a few days afterwards, have been insisted on by many authors as a possible cause. Numerous cases of this kind are recorded ; and, although the influence of emotion in the production of this condition is not susceptible of proof, it is not difficult to imagine that spasms of the Fallopian tubes might be produced in this way, which would either interfere with the passage of the ovum, or direct it into the abdominal cavity. The oc- currence of abdominal pregnancy is probably less difficult to account for if we admit, with Coste, that the ovule becomes Impregnated on the surface of the ovary itself, for there must be very many conditions which prevent the proper adaptation of the fimbriated extremity of the tube to the surface of the ovary, and failing this, the ovum must of necessity drop into the abdominal cavity. Kiwisch has pointed out that this is particularly apl to occur when the Graafian follicle de- velops on the posterior surface of the ovary ; and, indeed, it is proba- ble that it may be of common occurrence, and thai the comparative rarity of abdominal pregnancy is due to the difficulty with which the impregnated ovule engrafts itself on the surrounding viscera. Im- pregnation may actually occur in the abdominal cavity itself, of which Keller 1 relates a remarkable instance. In this ease E£oeberl£had re- moved the body of the uterus and pari of the the cervix, leaving the 1 Dee Grossenes Extra-uterines, Paris, 1872. 166 PREGNANCY. ovaries. In the portion of the cervix that remained there was a fistu- lous aperture opening into the abdominal cavity, through which semen passed and produced an abdominal gestation. Several curious cases are also recorded, which have given rise to a good deal of discussion, in which a tubal pregnancy existed while the corpus luteum was on the opposite side (Fig. 76). The most probable explanation, however, is Fig. 76. Tubal Pregnancy, with the Corpus Luteum in the Ovary of the opposite side. The Decidua is represented in the process of detachment from the Uterine Cavity. that the fimbriated extremity of the tube in which the ovum was found had twisted across the abdominal cavity and grasped the opposite ovary, in this way, perhaps, producing a flexion which impeded the progress of the ovum it had received into its canal. Tyler Smith suggested that such cases might be explained by supposing that the ovum, after reaching the uterus, failed to graft itself in the mucous membrane, but found its way into the opposite Fallopian tube. Kussrnaul 1 thinks that such a passage of the ovum across the uterine cavity may be caused by muscular contraction of the uterus, occurring shortly after conception, squeezing the yet free ovum upwards towards the opening of the opposite tube, and possibly into the tube itself. The history and progress of cases of extra-uterine pregnancy are materially different according to their site, and, for practical pur- poses, we may consider them as forming two great classes: the tubal (with its varieties), and the abdominal. Tubal Pregnancies. — When the ovum is arrested in any part of the Fallopian tube the chorion soon commences to develop villi, just as in ordinary pregnancy, which engraft themselves into the mucous lining of the tube, and fix the ovum in its new position. The mucous membrane becomes hypertrophied, much in the same way as that of the uterus under similar circumstances; so that it becomes developed into a sort of pseudo-decidua. Inasmuch, however, as the mucous coat of the tubes is not furnished with tubular glands, a true decidua can scarcely be said to exist, nor is there any growth of 1 Mon. f. Geburt, Oct. 1862. ABNORMAL PREGNANCY 16" membrane around the ovum analogous to the decidua reflexa. The ovum is, therefore, comparatively speaking, loosely attached to its abnormal situation, and hence hemorrhage from laceration of the chorion villi can very readily take place. It is seldom that any development of the chorion villi into distinct placental structure is observed ; this is probably owing to the fact, that laceration and death generally occur before the period at which the placenta is normally formed. The muscular coat of the tube soon becomes hypertrophied, and, as the size of the ovum increases, the fibres are separated from each other, so that the ovum protrudes at certain points through them, and at these it is only covered by the stretched and attenuated mucous and peritoneal coats of the tube. At this time the tubal pregnancy forms a smooth oval tumor, which, as a rule, has not formed any adhesions to the surrounding structures Fig. Tulial Pregnancy. (From a Specimen in the Museum of King's College.) (Fig. 77). The pari of the tube unoccupied by the ovum may be round unaltered, and permeable in both directions; or, more fre- quently, it becomes bo Btretched and altered thai its canal cannol be detected. Most frequently it is that part of the tube nearest the uterus which cannot be made out. The condition of* the uterus in this, as in other forms of extra-uterine pregnancy, has been the Bub- ject of considerable discussion. It is now universally admitted thai the uterus undergoes a certain amounl of sympathetic engorgement, the cervix becomes softened, as in natural pregnancy, and the mucous membrane develops into a true decidua. In many cases the decidua is found on post-mortem examination, in others it is not; and hence the doubts that some have expressed as to it.- existence. 168 PREGNANCY. The most reasonable explanation of its absence is that given by Duguet, 1 who has shown that it is far from uncommon for the uterine decidua to be thrown off en masse during the hemorrhagic dis- charges which so frequently precede the fatal issue of extra- uterine gestation. Interstitial and False Ovarian Pregnancy. — When the ovum is arrested in that portion of the tube passing through the uterus, in so-called interstitial pregnancy, the muscular fibres of the uterus become stretched and distended, and form the outer covering of the ovum. When, on the other hand, the site of arrest is in the fimbri- ated extremity of the tube, the containing cysts is formed partly of the fimbrise of the tube, partly of ovarian tissue ; hence it is much more distensible, and the pregnancy may continue without laceration to a more advanced period, or even to term, so that when the ovum is placed in this situation, the case much more nearly resembles one of abdominal pregnancy. Period at which Rupture Occurs. — The termination of tubal preg- nancy, in the immense majority of cases, is death, produced by lace- ration giving rise either to internal hemorrhage, or to subsequent intense peritonitis. Eupture usually occurs at an early period of pregnancy, most generally from the fourth to the twelfth week, rarely later. However, a few instances are recorded in which it did not take place until the fourth or fifth month, and Saxtorph and Spiegel- berg have recorded apparently authentic cases in which the preg- nancy advanced to term without laceration. It is generally effected by distension of the tube, which at last yields at the point which is most stretched ; and sometimes it seems to be hastened or deter- mined by accidental circumstances, such as a blow or fall, or the excitement of sexual intercourse. Symptoms of Rupture. — The symptoms accompanying rupture are those of intense collapse, often associated with severe abdominal pain, produced by the laceration of the cyst. The patient will be found deadly pale, with a small, thready, and almost imperceptible pulse, perhaps vomiting, but with mental faculties clear. If the hemorrhage be considerable, she may die without any attempt at re- action. Sometimes, however — and this generally occurs in cases in which the tube tears, the ovum remaining intact — the hemorrhage may cease on account of the ovum protruding through the aperture, and acting as a plug. The patient may then imperfectly rally, to be again prostrated by a second escape of blood, which proves fatal. If the loss of blood is not of itself sufficient to cause death from shock and anosmia, the fatal issue is generally only postponed, for the effused blood soon sets up a violent general peritonitis, which rapidly carries off the patient. If she should survive the second danger, the case is transformed into one of abdominal pregnancy, the foetus becoming surrounded by a capsule produced by inflammatory exuda- tion (Fig. 78). The case is then subject to the rules of treatment 1 Armales de Gynecologie, May, 1874. ABNORMAL PREGNANCY. 169 presently to be discussed when considering that variety of extra- FlG. 78. uterine gestation Extra-uterine Pregnancy at terra of the Tubo-Ovarian variety. (After a Case of Dr. A. Sibley Campbell's.) Diagnosis. — The possibility of diagnosing tubal gestation before- rupture occurs is a question of great and increasing interest, from the fact that, could its existence be ascertained, we might very fairly hope to avert the almost certainly fatal issue which is awaiting the patient. Unfortunately, the symptoms of tubal pregnancy are always obscure, and too often death occurs without the slightest suspicion as to the nature of the ease having arisen. In the first place, it is to be observed that all the usual sympathetic disturbances of pregnancy exist : the breasts enlarge, the areolae darken, and morning Bickness is present. There is also an arresl of menstruation; but. after the absence of one or more periods, there is often an irregular hemor- rhagic discharge. This is an Important Bymptom, this value of which in indicating the existence of tubal pregnancy has of late years been much dwelt upon by various authors, both iii this country and abroad. Barnes attributes it to partial detachment of the chorion villi, produced by the ovum growing out of proportion to the tube in which it is contained. Whether this is the correcl explanation or not, it is a fact that irregular hemorrhage very generally precedes 12 170 PKEGNANCY. the laceration for several days or more. Accompanying this hemor- rhage there is almost always more or less abdominal pain, produced by the stretching of the tissues in which the ovum is placed, and this is sometimes described as being of a very intense and crampy char- acter. If, then, we meet with a case in which the symptoms of early pregnancy exist, in which there are irregular losses of blood, possibly discharge of membranous shreds, and abdominal pain, a careful ex- amination should be insisted on, and then the true nature of the case may possibly be ascertained. Should extra-uterine foetation exist, we should expect to find the uterus somewhat enlarged, and the cer- vix softened, as in early pregnancy, but both these changes are doubt- less generally less marked than in normal pregnancy. This fact of itself, however, is of little diagnostic value, for slight difference of this kind must always be too indefinite to justify a positive opinion. Presence of a Peri-uterine Tumor. — The existence of a peri-uterine tumor, rounded or oval in outline, and producing more or less dis- placement of the uterus, in -the direction opposite to that in which the tumor is situated, may point to the existence of tubular foetation. By bimanual examination, one hand depressing the abdominal wall, while the examining finger of the other acts in concert with it either through the vagina or rectum, the size and relations of the growth may be made out. There are various conditions, which give rise to very similar physical signs, such as small ovarian or fibroid growths, or the effusion of blood around the uterus ; and the differential diag- nosis must always be very difficult, and often impossible. A curious example of the difficulties of diagnosis is recorded by Joulin, in which Huguier, and six or seven of the most skilled obstetricians of Paris, agreed on the existence of extra-uterine pregnancy, and had, in con- sultation, sanctioned an operation, when the case terminated by abortion, and proved to be a natural pregnane}^. The use of the uterine sound, which might aid in clearing up the case, is necessarily contra-indicated unless uterine gestation is certainly disproved. Hence it must be admitted that positive diagnosis must almost always be very difficult. So that the most Ave can say is, that when the gen- eral signs of early pregnancy are present, associated with the other symptoms and signs alluded to, the suspicion of tubal pregnancy may be sufficiently strong to justify us in taking such action as may possibly spare the patient the necessarily fatal consequence of rupture. Treatment. — If the diagnosis were quite certain, the removal of the entire Fallopian tube and its contents by abdominal section would be quite justifiable, and probably would neither be more difficult, nor more dangerous, than ovariotomy; for, at this stage of extra-uterine foetation, there are no adhesions to complicate the operation. As yet, however, the uncertainty of the diagnosis has prevented the adoption of the practice. [In 1816, Dr. John King, 1 of Edisto Island, South Carolina, ope- rated upon a case of extra- uterine pregnancy by the vaginal section, and saved both mother and child. The placenta was removed, but there does not appear to have been any hemorrhage. — Ed.] [ ] New York Med. Repos., 1817, p. 388.] ABNORMAL PREGNANCY. 171 Opening of the Sac by the Galvano-caustic Knife. — Dr. Thomas, of New York, 1 has recently recorded a most instructive case, in which he saved the life of the patient by a bold and judicious operation. The nature of the case was rendered pretty evident by the signs above described, and Thomas opened the cyst from the vagina by a platinum knife, rendered incandescent by a galvano-caustic battery, by which means he hoped to prevent hemorrhage. Through the opening thus made he removed the foetus. In subsequently attempt- ing to remove the placenta very violent hemorrhage took place, which was only arrested by injecting the cyst with a solution of persulphate of iron. The remains of the placenta subsequently came away piecemeal, after an attack of septicaemia, which was kept within bounds by freely -washing out the cyst with antiseptic lotion, the patient eventually recovering. If I might venture to make a criticism on a case followed by so brilliant a success, it would be that, in another instance of this kind, it would be safer to follow the rule so strictly laid down with regard to gastrotomy in abdominal preg- nancies, and leave the placenta untouched, trusting to the injection of antiseptics, and the thorough drainage of the cyst, to prevent mischief. [In a second operation, performed on May 10, 1876, in a case of secondary abdominal pregnancy, Dr. Thomas 2 operated through the linea alba, and removed a female foetus weighing six pounds, fifteen ounces. The funis was traced to the left iliac fossa, where it was apparently inserted into the peritoneum, and no placenta was dis- cernible. The cord was cut off at its origin, and the wound closed, except at its lower part, which was kept open by a glass tube. The woman's pulse before the operation was 120, and fell to 107 at the end of the first week; temperature was always 100° and upwards, but in the middle of the fourth week it rose to 103°-101°, and the pulse to 130. The placenta was found presenting at the opening in the abdomen, and was removed with dressing forceps. It was of the ordinary diameter, and had a shrivelled appearance. The removal afforded a decided relief, and the temperature fell within three hours. Antiseptic injections were freely used in the treatment of the case, and the patient made a good recovery. The advice given by the author in regard to the non-removal of the placenta, was first urged upon the medical profession, so far as we can learn, in 1795, in a 3 letter from the late Dr. James Mease, of Philadelphia, to Dr. Lettsom, of London, in which he reported an operation by Dr. Charles McKnight, of New York, very similar to this of Dr. Thomas, and ending favorably to the woman. 4 The remarks of Dr. Mease on the impropriety of removing the placenta were read before the Medical Society of London, and concurred in by some of the members present. It is a little remarkable, that the opinion of Dr. Mease originated 1 New York Med Journ., June. 1875. [ 2 Am. Journ. of Obstetrics, vol. ix. p. 655, is:o.] f a Memoirs of Med. Soc. London, vol. i, p. 842, I7:i.">.] [» More recently I have learned, that Mr. William Trumbull made the Bame re- commendation, before the said Society, in 1791.] 172 PEEGNANCY. in an accident which occurred in the operation of Dr. McKnight, by which the funis was ruptured, and in consequence of which, the placenta, which was outside of the cyst, could not be found for removal. The value of this discovery appears to have been lost to the profession for a long term of years, as many authors have ob- jected to the operation because of the danger of removing the pla- centa. — Ed.] Means of Destroying the Vitality of the Foetus. — Another mode of managing these cases is to destroy the foetus, so as to check its further growth, in the hope that it may remain inert and passive within its sac. Various operations have been suggested and prac- tised for this purpose. Thus needles have been introduced into the tumor, through which currents of electricity have been passed, either the continuous current, or, as has been suggested hj Duchenne, a spark of Franklinic electricity. Hicks, Allen, and others have endeavored to destroy the foetus by passing an electro-magnetic current through it by means of a needle. In a case reported by Dr. Bachetti, in which the continuous current was used, the growth of the ovum was arrested, and the patient recovered. The same result, however, would probably have followed the simple puncture of the cyst. This has been successfully practised on several occasions, either with a small trocar and canula, or with a simple needle. A very interesting case, in which the development of a two months' tubal gestation was arrested in this way, is recorded by Greenhalgh, 1 and another by Martin, of Berlin. 2 Joulin suggested that not only should the cyst be punctured, but that a solution of morphia should be injected into it, which, by its toxic influence, would insure the destruction of the foetus. Other means proposed for effecting the same object, such as pressure, or the administration of toxic remedies by the mouth, are far too uncertain to be relied on. The simplest and most effectual plan would be to introduce the needle of an aspirator, by which the liquor amnii would be drawn off, and the further growth of the foetus effectually prevented. Parry, 3 indeed, is opposed to this practice, and has collected several cases in which the puncture of the cyst was followed by fatal results, either from hemorrhage or septicaemia. In these, however, an ordinary trocar and canula were probably employed, which would necessarily admit air into the sac. It is difficult to imagine that a fine hair-like aspi- rating needle, rendered properly antiseptic by carbolic acid, could have any injurious results; and it could do no harm, even if an error of diagnosis had been made, and the suspected extra-uterine foetation turned out to be some other sort of growth. If the aspirator proves that an extra-uterine foetation exists, then, if the cyst be of any considerable size, and the pregnancy advanced beyond the second month, we might, if deemed advisable, resort to a more radi- cal operation, such as that so successfully practised by Thomas. Treatment when Rupture has Occurred. — When the chance of arrest- ing the growth of a tubular foetation has never arisen, and we first : Lancet, 1867. 2 Monat. f. Geburt, 1868. 3 Parry on Extra-Uterine Pregnancy, p. 204. ABNORMAL PREGNANCY. 173 recognize its existence after laceration has occurred, and the patient is collapsed from hemorrhage, what course are we to pursue ? Hith- erto all that ever has been done is to attempt to rally the patient by stimulants, and, in the unlikely event of her surviving the imme- diate effects of laceration, endeavoring to control the subsequent peritonitis, in the hope that the effused blood may become absorbed, as in pelvic hematocele. This is, indeed, a frail reed to rest upon, and when laceration of a tubal gestation, advanced beyond a month, has occurred, death has been the almost certain result. It is supposed by Bernutz, and his opinion is shared by Barnes, that rupture which does not prove fatal, is probably not very rare in the first few days of extra-uterine gestation, and that it is not an uncommon cause of certain forms of pelvic haematocele. It has more than once been sug- gested that it would be perfectly justifiable when laceration has oc- curred to perform gastrectomy, to sponge away the effused blood, and to place a ligature round the lacerated tube and remove it, with its contents. This would no doubt be a bold and heroic procedure, but no one who is acquainted with the triumphs of modern abdominal surgery can say that it would be either impossible or hopeless. The sponging out of effused blood from the abdominal cavity is an every- day procedure in ovariotomy, nor is there any apparent difficulty in ligaturing and removing the sac of the extra-uterine pregnancy, for, as a rule, there are no adhesions formed to the surrounding parts. The history of these cases shows that death does not generally follow rupture for some hours, so that there would be usually time for the operation, and the extreme prostration might be, perhaps, tempo- rarily counteracted by transfusion. Pressure on the abdominal aorta, resorted to when the patient is first seen, might possibly be employed with advantage to check further hemorrhage, until the question of operation is decided. \Ve must remember that the alternative is death and hence any operation which would afford the slightest hope of success would be perfectly justifiable. I cannot, therefore, agree with those who hold that because the chances of success are so small, the operation should not be tried ; and I do not doubt that it will y«-t fall to the lot of some one, by this means, to snatch a patient from the jaws of death, and still further to extend the successes of abdominal surgery. 1 Abdominal Pregnancy. — In the second of the two classes int.) which, for practical convenience, we have divided extra-uterine gestation the ovum is developed in the abdominal cavity. It is as yet an open question whether in Borne cases the pregnancy is primarily abdominal or not. Barnes believes that it probably uever Is so, on accounl of the difficulty of admitting that so minute a body as the ovum should he able to lix itself on the smooth peritonea] surface. lie therefore thinks that all abdominal pregnancies are primarily either tubal or ovarian, the sac in which they were contained having given way, and the ovum having retained LtS vitality through partial attach- [' But for a difference of views in consultation, as t<> diagnosis and treatment, this operation would have been performed recently by Dr. I . i 1a 1 ly the foetus has been retained for a Length of time, even until the end of a long life, with- out producing any serious discomfort, and in many eases of this kind several normal pregnancies and deliveries have subsequently taken place. Even when the extra -uterine gestation appears to be tolerated, and has remained for long without producing any had effects, serious symptoms maybe suddenly developed ; so that no woman, under such circumstances, can be considered sale. The condition of these 176 PREGNANCY retained foetuses varies much. Most commonly the liquor amnii is absorbed, the foetus shrinks and dies, all its soft structures are changed into adipocere, and the bones only remain unaltered. Sometimes this change occurs with great rapidity. I have elsewhere 1 recorded a case of extra-uterine foetation in which at the full term of pregnancy the foetus was alive, and the woman died in less than a year after- wards. On post-mortem the foetus was found entirely transformed into a greasy mass of adipocere, studded with foetal bones, in which not a trace of any of the soft parts could be detected. On the other hand the foetus may remain unchanged ; in the Museum of the College of Surgeons there is one which was retained in the abdomen for fifty -two years, and which was found to be as fresh and unaltered as a new-born child. In other cases the sac and its contents atrophy and shrink, and calcareous matter is deposited in them, so that the whole becomes converted into a solid mass known as a lithopsedion Fig. (Fig. 80). The cases, however, in which gives rise to tiie retention of the foetus no mischief are quite exceptional. Gene- rally the foetus putrefies, and this may either immediately cause fatal peritonitis or septicaemia ; or, as more commonly happens, secondary inflammation and suppuration of the sac. Under the in- fluence of the latter the sac opens ex- ternally, either directly at some point of the abdominal walls, or indirectly through the vagina, the bowels, or even the bladder. Through the aperture or apertures thus formed (for there are often several fistulous openings), pus, and the bones and other parts of the broken-down foetus, are discharged ; and this may go on for months, and even years, until at last, if the patient's strength does not give way, the whole contents of the cyst are expelled, and recovery takes place. From various statistical observations it ap- pears, that the chances of recovery are best when the cyst opens through the abdominal walls, next through the vagina or bladder, and that the foetus is discharged with most difficulty and danger when the aperture is formed into the bowel. At the best, however, the process is long, tedious, and full of dangers ; and the patient too often sinks, during the attempt at expulsion, through the irritation and exhaustion produced by the abundant and long-continued discharge. Diagnosis. — The diagnosis of abdominal gestation is by no means so easy as might be thought, and the most experienced practitioners have been mistaken with regard to it. Lithopsedion. (From a preparation in the Museum of the College of Surgeons.) The most characteristic symptom, although this is not so common 1 Obst. Trans ABNORMAL PREGNANCY. 177 as in tubal gestation, is metrorrhagia, combined with the general signs of pregnancy. Yery severe and frequently repeated attacks of abdominal pain are rarely absent, and should at once cause sus- picion, especially if associated with hemorrhage. They are supposed by some to depend on intercurrent attacks of peritonitis, by which the foetal cyst is formed. Parrj^ doubts this explanation, and attrib- utes them partly to the distension of the cyst by the growing foetus, and partly to pressure on the surrounding structures. On palpation the form of the abdomen will be observed to differ from that of nor- mal pregnancy, being generally more developed in the transverse direction, and the rounded outline of the gravid uterus cannot be detected. When development has advanced nearly to term, the ex- treme distinctness with which the foetal limbs can be felt will arouse suspicion. Per vaginam the os and cervix will be felt softened as in ordinary pregnancy, but often displaced by the pressure of the cyst, and sometimes fixed by peri-metritic adhesions ; either of these signs is of great diagnostic value. By bimanual examination it may be possible to make out that the uterus is not greatly enlarged, and that it is distinctly separate from the bulk of the tumor ; these facts, if recognized, would of them- selves disprove the existence of uterine gestation. The diagnosis, if the foetal limbs or heart-sounds could be detected, would be cleared up in any case by the uterine sound, which would show that the uterus was empty and only slightly elongated. But we must be care- ful not to resort to this test unless the existence of uterine gestation is positively disproved by other means. As, however, it places the diagnosis beyond a doubt, it should always be employed whenever operative procedure is in contemplation. Treatment. — The treatment of abdominal gestation will always be a subject of anxious consideration, and there is much difference of opinion as to the proper course to pursue. It is pretty generally admitted that it is not advisable to adopt any active measures until the full term of development is reached. Puncturing the cyst, with the view of destroying the foetus and arresting its further growth, has been practised, but there are good grounds for rejecting it, for there is not the same imminent risk of death from rupture of the cyst as in tubal foetation ; and even if the destruction of the foetus could be brought about, there would still be formidable dangers from subsequent attempts at elimination, or from internal hemorrhage. Primary Gastrotomy. — When the full period has arrived, the child being still alive, as proved by auscultation, we have to consider whether it may not be advisable to perform gastrotomy before the foetus perishes, and so at least save the life of the child. There are few questions of greater importance, and more difficull to settle. The tendency of medical opinion is rather in Favor of immediate opera- tion, which is recommended by Velpeau, Kiwisch, Koeberle", Scnroe- der, and mnny other writers, whose opinion aecessarily carries greal weight. The arguments used in favor of immediate operations are that, while it affords a probability of saving the child, the risks bo the mother, great though they undoubtedly are, are qoI greaterthan 178 PREGNANCY. those which may be anticipated by delay. If we put off interference the cyst may rupture during the ineffectual efforts at labor, and death at once ensue ; or, if this does not take place, other risks, which can never be foreseen, are always in store for the patient. She may sink from peritonitis, or from exhaustion, consequent on the efforts at elimination, which in the majority of cases are sooner or later set up, so that, as Barnes properly says, " the patient's life may be said to be at the mercy of accidents, of which we have no sufficient warn- ing." On the other hand, if we delay, while we sacrifice all hope of saving the child, we at least give the mother the chance of the foeta- tion remaining quiescent for a length of time, as certainly not infre- quently occurs. Thus, Campbell collected 62 cases of ultimate re- covery after abdominal gestation, in 21 of which the foetus was retained without injury for a number of years. Then there is the question of secondary gastrotomy, which consists in operating after the death of the foetus when urgent symptoms have arisen, a course which is advocated by Mr. Hutchinson. In favor of this procedure it is urged, that by delay the inflammation taking place about the cyst will have greatly increased the chance of adhesions having formed between it and the abdominal parietes. so as to shut off its contents from the cavity of the peritoneum. The more effectually this has been accomplished, the greater are the patient's chances of recovery. When the foetus has been dead for some time the vascu- larity of the cyst will also be lessened, and the placental circulation will have ceased, so that the danger of hemorrhage will be much diminished. It will be seen, therefore, that there are arguments in favor of each of these views. The results of the primary operation are far less favorable than we should have, a priori, supposed. Since the first edition of this work appeared the subject has been carefully studied by Dr. Parry in his exhaustive treatise on Extra-Uterine Foetation. He has there shown that when the case is left until nature has shown the channel through which elimination is to be effected, the mortality is 17.35 less than in the cases in which the primary operation was performed. His conclusion is, that " the pri- mary operation cannot be too forcibly condemned. It is not too much to say that this operation adds only another danger to a life already trembling in the balance, which the delusive hope of saving the un- certain life of a child does not warrant us in assuming." It is only just to remember, as is forcibly pointed out by Keller, that in these clays of advanced abdominal surgery a better result might be antici- pated than when gastrotomy was performed in the haphazard way which was usual before we had gained experience from ovariotomy. No doubt minute care in the performance of the operation, a due attention to its details, studiously avoiding, as much as possible, the passage of blood and the contents of the cyst into the peritoneal cavity, would materially lessen its peril. Mode of performing the Operation. — The operation, then, should be performed with all the precautions with which we surround ovari- otomy. The incision, best made in the linea alba, should not be ABNORMAL PEEGNANCY. 179 greater than is necessary to extract the foetus, and may be lengthened as occasion requires. If there are no adhesions the walls of the cyst should be stitched to the margin of the incision, so as to shut it off as completely as possible from the peritoneal cavity. This has been specially insisted on by Braxton Hicks, and should never be omitted. The special risk is not so much the wounding of the peritoneum, as the subsequent entrance of septic matter from the cyst into its cavity. Another cardinal rule, both in primary and secondary gastrotomy, is to make no attempt to remove the placenta. Its attachments are generally so deep-seated and diffused, that any endeavor to separate it is likely to be attended with profuse and uncontrollable hemorrhage, or with serious injury to the structures to which it is attached. Many of the failures after operating can be traced to a neglect of this rule. The best subsequent course to pursue, after removing the foetus, and arresting all hemorrhage, either by ligature or the actual cautery, is to sponge out the cyst as gently as possible, and then to bring the upper part of the wound into apposition with sutures, leaving the lower open, with the cord protruding, so as to insure an outlet for the escape of the placenta as it slips down. The subsequent treat- ment must be specially directed to favor the escape of the discharge, and to prevent the risk of septicaemia. These objects may be much aided by injections of antiseptic fluids, such as a solution of carbolic acid, or diluted Condy's fluid ; and it would perhaps be advisable to place a drainage tube in the lower angle of the wound. It may be well to point 'out that there is no operation in which a scrupulous following of the antiseptic method, on Mr. Lister's principles, is so likely to be useful. Treatment when the Foetus is Dead. — As long as the placenta is re- tained the danger is necessarily great, and it may be many days or even weeks before it is discharged. When once this is effected the sac may be expected to contract, and eventually to close entirely. When the foetus is dead, or when we have determined not to attempt primary gastrotomy, it is advisable to wait, very carefully watching the patient, until either the gravity of her general symptoms, or some positive indication of the channel through which nature is about to attempt to eliminate the foetus, shows us that the time for action has arrived. If there be distinct bulging of the cyst in the vagina, or in the petro-vaginal cul-de-sac, especially if an opening has formed there, we may properly content ourselves with aiding the passage of the foetus through the channel thus indicated, and removing the parts that present piecemeal as they come within reach, cautiously enlarg- ing the aperture if necessary. If the sac have opened into the intes- tines, the expulsion of the foetus through this channel is so tedious and difficult, the exhaustion attending it so likely t<> prove fatal, and the danger from decomposition of* the foetus through passage of in- testinal gas so great, that it would probably he best to attempt to remove it by gastrotomy, especially if it is only recently dead, and the greater portion is still retained. Mode of performing Secondary Gastrotomy. [fan opening forms at the abdominal parietes, or if the symptoms determine us to resorl 180 PREGNANCY. to secondary gastrotomy before this occurs, the operation must be performed in the same way, and with the same precautions, as primary gastrotomy. Here, as before, the safety of the operation must greatly depend on the amount and firmness of the adhesions; for if the cyst be not completely shut off from the peritoneal cavity, the risks of the operation will be little less than those of primary gastrotomy. It would obviously materially influence our decision and prognosis if we could determine this point before operating. Unfortunately it is impossible, as the experience of ovariotomists proves, to ascertain the existence of adhesions with any certainty. If, however, we find that the abdominal parietes do not move freely over the cyst, and if the umbilicus be depressed and immovable, the presumption is that considerable adhesions exist. If they are found not to be present, the cyst walls should be stitched to the margin of the incision, in the manner already indicated, before the contents are removed. If the foetus has been long dead, and its tissues greatly altered, its removal may be a matter of difficulty. In the case under my own care, already alluded to, the foetal structures formed a sticky mass of such a nature, that I believe it would have been impossible to empty the cyst had an operation been attempted. This possibility would be, to some extent, a further argument in favor of the primary operation. Opening of Cyst by Caustics. — The importance of adhesion has led some practitioners to recommend the opening of the cyst by potassa fusa or some other caustic, in the hope that it would set up adhesive inflammation around the apertures thus formed. Several successful operations by this method are recorded, and it would be worth trying, should the extreme mobility of the cyst lead us to suspect that no adhesions existed. If we have to deal with a case in which fistulous openings leading to the cyst have already formed, it may, perhaps, be advisable to dilate the apertures already existing, rather than make a fresh incision ; but, in determining this point, the sur- geon will naturally be guided by the nature of the case, and the character and direction of the fistulous openings. General Treatment. — It is almost needless to say anything of general treatment in these trying cases ; but the administration of opiates to allay the sufferings of the patient, and the endeavor to support the severely taxed vital energies by appropriate food and medication, will form a most important part of the management. Gestation in a Bi-lohed Uterus. — A few words may be said as to gestation in the rudimentary horn of a bi-lobed uterus, to which considerable attention has of late years been directed by the writings of Kussmaul and others. It appears certain that many cases of supposed tubal gestation are really to be referred to this category. Although such cases are of interest pathologically, they scarcety re- quire much discussion from a practical point of view, inasmuch as their history is pretty nearly identical with that of tubal pregnancy. The rudimentary horn is distended by the enlarging ovum, and after a time, when further distension is impossible, laceration takes place. As a matter of fact, all the 13 cases collected bv Kussmaul termi- ABNORMAL PREGNANCY. 181 nated in this way ; and even on post-mortem examination it is often extremely difficult to distinguish them from tubal pregnancies. The best way of doing so is probable by observing the relations of the round ligaments to the tumor, for, if the gestation be tubal, they will be found attached to the uterus on the inner or uterine side of the cyst ; whereas, if the pregnancy be in a rudimentary horn of the uterus, they will be pushed outwards and be external to the sac. In the latter case, moreover, the sac will be probably found to contain a true decidua, w r hich is not the case in tubal pregnancy. The only point in which they differ is that in cornual pregnancy rupture may be delayed to a somewhat later period than in tubal, on account of the greater distensibility of the supplementary horn. Missed Labor. — The term " missed labor 11 is applied to an exceed- ingly rare class of cases in which, at the full period of pregnancy, labor has either not come on at all, or, having commenced, the pains have subsequently passed off, and the foetus is retained in utero for a very considerable length of time. Under such circumstances it has usually happened that the membranes have ruptured at or about the proper term, and the access of air to the foetus in utero has been followed by decomposition. A putrid and offensive discharge has then com- menced, and eventually portions of the disintegrating foetus have been expelled per vaginam. This discharge may go on until the entire foetus is gradually thrown off; or, more frequently, the patient dies from septicaemia, or other secondary result of the presence of the decomposing mass in utero. Thus McClintock relates one case, 1 in which symptoms of labor came on in a woman, 45 years of age, at the expected period of de- livery, but passed off without the expulsion of the foetus. For a period of sixty-seven weeks a highly offensive discharge came away, with some few bones, and she eventually died with symptoms of pyaemia. He also cites another case in which the patient died in the same way, after the foetus had been retained for eleven years. Ulceration of the Uterine Walls. — Sometimes, when the foetus lias been retained for a length of time, a further source of danger has been added by ulceration or destruction of the uterine walls, proba- bly in consequent' of an ineffectual attempt at its elimination. This occurred in Dr. Oldham's case i Fig. 81), in which the contained mass is said to have nearly worn through the anterior wall of the uterus; and also in one reported by Sir James Simpson, 2 in which a patient died three months after term, i he foel as having undergone (ail v meta- morphosis, an opening the size of half-a-erown having formed between the transverse colon and the uterine cavity. It is also stated that "the uterine walls were as thin as parchment." In some few eases, however, probably when the entrance of air has been prevented, the foetus has been retained for a length of time without decomposing, and without giving rise to any troublesome symptoms. Such a case is reported by Dr. Cheston, 8 in which the foetus remained in utero for fifty-two years. 1 Doublin Quart. Journ., Feb. and May, 1864. 2 Edin. Med. Journ., 1865. ' Med.Chir. Trans., isi \. 182 PREGNANCY. Its Causes. — The causes of this strange occurrence are altogether unknown. Generally the foetus seems to have died sometime before the proper term for labor, and this may have influenced the character of the pains. It is probably also most apt to occur in women of Fig. 81. Contents of the Cyst in Dr. Oldham's case of Missed Labor. feeble and inert habit of body, possibly where there was some obstacle to the dilatation of the cervix, which the pains were unable to over- come. Barnes suggests 1 that some presumed examples of missed labor "were really cases of interstitial gestation, or. gestation in one horn of a two-horned uterus." In several of the cases, however, the details of the post-mortem examination are too minute to admit of the possibility of this mistake having been made. From what has been said, it will be seen that the dangers arising from this state are very considerable, and when once the full term has passed beyond doubt, especially if the presence of an offensive discharge shows that decomposition of the foetus has commenced, it would be proper practice to empty the uterus as soon as possible, The necessary precaution, however, is not to decide too quickly that the term has really passed; and, therefore, we must either allow sufficient time to elapse to make it quite certain that the case really falls under this category, or have unequivocal signs of the death of the foetus, and injury to the mother's health. If we had to deal with the case before any extensive decomposition of the foetus 1 Diseases of Women, p. 445. DISEASES OF PREGNANCY. 183 had occurred, we probably should find little difficulty in its manage- ment, for the proper course then would be to dilate the cervix with the fluid dilators, and remove the foetus by turning; or, before doing so, we might endeavor to excite uterine action by pressure and ergot. If the case did not come under observation until disintegration of the foetus had begun, it would be more difficult to deal with. If the foetus had become so much broken up that it was being discharged in pieces, Dr. McClintock says that "in regard to treatment, our measures should consist mainly of palliatives, viz., rest and hip-baths to subdue uterine irritation; vaginal injections to secure cleanliness and prevent ex- coriation; occasional digital examination, so as to detect any frag- ments of bone that might be presenting at the os, and to assist in removing them. These are plain rational measures, and beyond them we shall scarcely, perhaps, be justified in venturing. Never- theless, under certain circumstances, I would not hesitate to dilate the cervical canal so as to permit of examining the interior of the womb, and of extracting any fragments of bone that may be easily accessible ; but unless they could thus be easily reached and removed, the safer course would be to defer, for the present, interfering with them. 1 It may be doubted, I think, whether, considering the serious results which are known to have followed so many cases, it would not, on the whole, be safer to make at least one decided effort, under chloroform, to remove as much as possible of the putrefying uterine contents, after the os has been fully dilated. Such a procedure would be less irritating than frequently repeated endeavors to pick away detached portions of the foetus, as they present at the os uteri. "When once the os is dilated, antiseptic intra -uterine injections, as of diluted Condy's fluid, might safely and advantageously be used. Unquestionably, it would be better practice to interfere and empty the uterus as soon as we are quite satisfied of the nature of the case, rather than to delay, until the foetus has been disintegrated. CIIAPTEK VII. DISEASES OF PRECxXAXCY. The diseases of pregnancy form a subject so extensive that they might well of themselves furnish ample material for a separate treatise. The pregnant woman is, of course, liable to the same diseases as the non-pregnant; but it is only necessary to allude to those whose course and effects are essentially modified by the exist- 1 Dublin Quart. Journ., vol. xxxvii. p. ,314. 184. PREGNANCY. ence of pregnancy, or which have some peculiar effect on the patient in consequence of her condition. There are, moreover, many dis orders which can be distinctly traced to the existence of pregnancy. Some of them are the direct results of the sympathetic irritations which are then so commonly observed; and, of these, several are only exaggerations of irritations which may be said to be normal accompaniments of gestation. These functional derangements may be classed under the head of neuroses, and they are sometimes so slight as merely to cause temporary inconvenience, at others so grave as seriously to imperil the life of the patient. Another class of disorders are to be traced to local causes in connection with the gravid uterus, and are either the mechanical results of pressure, or of some displacement, or morbid state of the uterus. While the origin of others may be said to be complex, being partly due to sympathetic irritation, partly to pressure, and partly to obscure nutritive changes produced by the pregnant state. Derangements of (he Digestive System-. — Among the sympathetic derangements there are none which are more common, and none which more frequently produce distress, and even danger, than those which affect the digestive system. Under the heading of u The Signs of Pregnancy," the frequent occurrence of nausea and vomiting has already been discussed, and its most probable causes considered (p. 135). A certain amount of nausea is, indeed, so common an accom- paniment of pregnancy, that its consideration as one of the normal symptoms of that state is fully justified. We need here only discuss those cases in which the nausea is excessive and long-continued, and leads to serious results from inanition, and from the constant distress it occasions. Fortunately a pregnant woman may bear a surprising amount of nausea and sickness without constitutional injury, so that apparently almost all aliments may be rejected, without the nutrition of the body very materially suffering. At times the vomiting is limited to the early part of the day, when all food is rejected, and when there is a frequent retching of glairy transparent fluid, in severe cases mixed with bile, while at the latter part of the day the stomach may be able to retain a sufficient quantity of food, and the nausea disappears. In other cases the nausea and vomiting are almost incessant. The patient feels constantly sick, and the mere taste or sight of food may bring on excessive and painful vomiting. The duration of this distressing accompaniment of pregnancy is also variable. Generally it commences between the second and third months, and disappears after the woman has quickened. Sometimes, however, it begins with conception, and continues unabated until the pregnancy is over. /SymjJtoms of the Graver Cases. — In the worst class of cases, when all nourishment is rejected, and when the retching is continuous and painful, symptoms of very great gravity, which may even prove fatal, develope themselves. The countenance becomes haggard from suffering, the tongue dry and coated, the epigastrium tender on pres- sure, and a state of extreme nervous irritability, attended with rest- lessness and loss of sleep, becomes established. In a still more aggra- DISEASES OF PREGNANCY. 185 vated degree, there is general feverishness, with a rapid, small, and thready pulse. Extreme emaciation supervenes, the result of wast- ing from lack of nourishment. The breath is intensely fetid, and the tongue dry and black. The vomited matters are sometimes mixed with blood. The patient becomes profoundly exhausted, a low form of delirium ensues, and death may follow if relief is not obtained. Prognosis. — Symptoms of such gravity are fortunately of extreme rarity, but they do from time to time arise, and cause much anxiety. Gueniot collected 118 cases of this form of the disease, out of which 46 died ; and out of the 72 that recovered, in 42 the symptoms only ceased when abortion, either spontaneous, or artificially produced, had occurred. When pregnancy is over the symptoms occasionally cease with marvellous rapidity. The power of retaining and assimi- lating food is rapidly regained, and all the threatening symptoms disappear. Treatment. — In the milder forms of obstinate vomiting, one of the first indications will be to remedy any morbid state of the primse vise. The bowels will not infrequently be found to be obstinately constipated, the tongue loaded, and the breath offensive ; and when attention has been paid to the general state of the digestive organs by gentle aperient medicines, and antacid remedies, such as bismuth and soda, and pepsine after meals, the tendency to vomiting may abate without further treatment. Regulation of Diet. — The careful regulation of the diet is very im- portant. Great benefit is often derived from recommending the patient not to rise from the recumbent position in the morning until she has taken something. Half a cup of milk and lime-water, or a cup of strong coffee, or a little rum and milk, or cocoa and milk, or even a morsel of biscuit, taken on waking, often has a remarkable effect in diminishing the nausea. When any attempt at swallowing solid food brings on vomiting, it is better to give up all pretence at keeping to regular meals, and to order such light and easily assimi- lated food, at short intervals, as can be retained. Iced milk with lime or soda-water, given frequently, and not more than a mouthful at a time, will frequently be retained when nothing else will. Cold beef jelly, a spoonful at a time, will also be often kept down. Spark- ling koumiss lias been strongly recommended as very useful in such . and is worthy of trial. It is well, however, to bear in mind, in regulating the diet, thai the stomach is fanciful and capricious, and that the patienl may l>c able to retain strange and apparently unlikely article- of food; and that, if she express a desire for such, tic experiment of Letting her have them should certainly be tried. .!/. dicinal Treatment.- —The medicines that have been recommended are innumerable, and the practitioner will often have to try one after the other unsuccessfully ; or may find, in an individual case, thai a lemedy will prove valuable which, in another, iiiav be altogether powerless. Amongsl those most generally useful arc effervescing iraughts, containing from three to five minims of dilute hydrocyanic acid; the creasote mixture of the Pharmacopoeia; tincture of mix 13 186 PREGNANCY. vomica, in doses of five to ten minims ; single minim doses of vinum ipecacuanhas, every hour in severe cases, three or four times daily in those which are less urgent ; salicine, in doses of three to five grains three times a day, recommended by Tyler Smith ; oxalate of cerium, in the form of pill, of which three to five grains may be given three times a day — a remedy strongly advocated by Sir James Simpson, and which occasionally is of undoubted service, but more often fails ; the compound pyroxylic spirit of the London Pharmacopoeia in doses of rive minims every four hours, with a little compound tincture of cardamoms, a drug which is comparatively little known, but which occasionally has a very marked and beneficial effect in checking vomiting ; opiates in various forms — which sometimes prove useful, more often not — may be administered either by the mouth or in pills containing from half a grain to a grain of opium, or in small doses of the solution of the bimeconate of morphia or of Battley's sedative solution, or subcutaneously, a mode of administration which is much more often successful. If there is much tenderness about the epigas- trium, one or two leeches may be advantageously applied, or one- third of a grain of morphia may be sprinkled on the surface of a small blister, or cloths saturated in laudanum may be kept over the pit of the stomach. In many cases I have found that the applica- tion of a spinal ice-bag to the cervical vertebrae, in the manner re- commended by Dr. Chapman, has checked the vomiting when all drugs have failed. The ice may be placed in one of Chapman's spinal ice-bags, and applied for ten minutes or a quarter of an hour, twice or three times a day. It invariably produces a comforting sensation of warmth, which is always agreeable to the patient. Ice may be given to suck ad libitum, and is very useful ; while, if there be much exhaustion, small quantities of iced champagne may also be given from time to time. Local Treatment.— Inasmuch as the vomiting unquestionably has its origin, in the uterus, it is only natural that practitioners should endeavor to check it by remedies calculated to relieve the irritability of that organ. Thus morphia in the form of pessaries per vaginam, or belladonna applied to the cervix, has been recommended, and — the former especially — are often of undoubted service. A pessary containing one-third to half a grain of morphia may be introduced night and morning, without interfering with other methods of treat- ment. Dr. Hemy Bennet directs especial attention to the cervix, which, he says, is almost always congested and inflamed, and covered with granular erosions. This condition he recommends to be treated by the application of nitrate of silver through the speculum. Dr. Clay, of Manchester, corroborates this view, and strongly advocates, especially when vomiting continues in the latter months, that one or two leeches should be applied to the cervix. Exception may fairly be taken to both these methods of treatment as being somewhat hazardous, unless other means have been tried and failed. I have little doubt, however, that, in many cases, a state of uterine con- gestion is an important factor in keeping up the unduly irritable condition of the uterine fibres, and an endeavor should always be DISEASES OF PREGNANCY. 187 made to lessen it by insisting on absolute rest in the recumbent pos- ture. Of the importance of this precaution in obstinate cases there can be no question. Dr. Chapman, of Norwich, strongly recommends dilation of the cervix by the finger, and states that he has found it very serviceable in checking nausea. It is obvious that this treat- ment must be adopted with great caution, as, roughly performed, it might lead to the production of abortion. Dr. Hewitt's views as to the dependence of sickness on flexions of the uterus have already been adverted to, and reasons have been given for doubting the general correctness of his theory. It is quite likely, however, that well-marked displacements of the uterus, either forwards or back- wards, may serve to intensify the irritability of the organ. Cazeaux mentions an obstinate case immediately cured by replacing a retro- verted uterus. A careful vaginal examination should, therefore, be instituted in all intractable cases, and if distinct displacement be de- tected, an endeavor should be made to support the uterus in its normal axis. If retroverted, a Hodge's pessary may be safely em- ployed ; if anteverted, a small air-ball pessary, as recommended by Hewitt, should be inserted. I believe, however, that such displace- ments are the exception rather than the rule in cases of severe sickness. The importance of promoting nutrition by every means in our power should always be borne in mind. The exhaustion produced by want of food soon increases the irritable state of the nervous system, and, if the stomach will not retain anything, we can only combat it by occasional nutrient enemata of strong beef tea, yolk of egg, and the like. The Production of Artificial Abortion. — Finally, in the worst class of cases, when all treatment has failed, and when the patient has fallen into the condition of extreme prostration already described, we may be driven to consider the necessity of producing abortion. For- tunately cases justifying this extreme resource are of great rarity, but nevertheless there is abundant evidence that, every now and then, women do die from uncontrollable vomiting, whose lives might have been saved had the pregnancy been brought to an end. The value of artificial abortion has been abundantly proved. Indeed, it is re- markable how rapidly the serious symptoms disappear when the uterus is emptied, and the tension of the uterine fibres lessened. It has fortunately but rarely fallen to my lot to have to perforin this operation for intractable vomiting. In one such case tin-, patient was reduced t<>a state of the utmost prostration, having kept hardly any food on her stomach for many weeks, and when I first saw her she was lying in a state of l'»w muttering delirium. Within a lew hours after abortion was Induced all the threatening symptoms had disap- peared, the vomiting had entirely ceased, and she was next day able to retain and absorb all that was given to her. The value of the operation, therefore, I believe to be undoubted. Where it has failed, it seems to have been on account of undue delay. Owing to the natural repugnance which all must feel towards this plan, it has gene- rally been postponed until the patient has been too exhausted to rally. 188 PREGNANCY. If, therefore, it is done at all, it should be before prostration has ad- vanced so far as to render the operation useless. In these cases the obvious indication is to lessen the tension of the uterus at once, and therefore the membranes should be punctured by the uterine sound, so as to let the liquor amnii drain away, and this may of itself be sufficient to accomplish the desired effect. It is almost needless to add, that no one would be justified in resorting to this expedient without having his opinion fortified by consultation with a fellow- practitioner. Other disorders of the digestive system may give rise to considerable discomfort, but not to the serious peril attending obstinate vomiting. Amongst them are loss of appetite, acidity and heartburn, flatulent distension, and sometimes a capricious appetite, which assumes the form of longing for strange and even disgusting articles of diet. As- sociated with these conditions there is generally derangement of the whole intestinal tract, indicated by furred tongue and sluggish bowels, and they are best treated by remedies calculated to restore a healthy condition of the digestive organs, such as a light easily digested diet, mineral acids, vegetable bitters, occasional aperients, bismuth and soda, and pepsine. The indications for treatment are not different from those which accompany the same symptoms in the non-pregnant state. Diarrhoea is an occasional accompaniment of pregnancy, often de- pending on errors of diet. When excessive and continuous it has a decided tendency to induce uterine contractions, and I have frequently observed premature labor to follow a sharp attack of diarrhoea. It should, therefore, not be neglected ; and, if at all excessive, should be checked by the usual means, such as chalk mixture with aromatic confection, and small doses of laudanum or chlorodyne. The possi- bility of apparent diarrhoea being associated with actual constipation, the fluid matter finding its way past the solid materials blocking up the intestines, should be borne in mind. Constipation is much more common, and is indeed a very general accompaniment of pregnancy, even in women who do not suffer from it at other times. It partly depends on the mechanical interference of the gravid uterus with the proper movements of the intestines, and partly on defective innervation of the bowels resulting from the altered state of the blood. The first indication will be to remedy this defect by appropriate diet, such as fresh fruits, brown bread, oat- meal porridge, etc. Some medicinal treatment will also be necessary, and, in selecting the drugs to be used, care should be taken to choose such as are mild and unirritating in their action, and tend to improve the tone of the muscular coats of the intestine. A small quantity of aperient mineral water in the early morning, such as the Hunyadi, Freclerickshalle, or Pullna water, often answers very well ; or an oc- casional dose of the confection of sulphur; or a pill containing three or four grains of the extract of colocynth, with a quarter of a grain of the extract of nux vomica, and a grain of extract of hyoscyamus at bed time ; or a teaspoonful of the compound liquorice powder in milk at bed time. Constipation is also sometimes effectually combated DISEASES OF PREGNANCY. 189 by administering, twice daily, a pill containing a couple of grains of the inspissated ox-gall, with a quarter of a grain of extract of bella- donna. Enemata of soap and water are often very useful, and have the advantage of not disturbing the digestion. In the latter months of pregnancy, especially in the few weeks preceding delivery, the irritation produced by the collection of hardened feces in the bowel is a not infrequent cause of the annoying false pains which then so commonly trouble the patient. In order to relieve them, it will be necessary to empty the bowels thoroughly by an aperient, such as a good dose of castor-oil, to which fifteen or twenty minims of laudanum may be advantageously added. Should the rectum become loaded with scybalous masses, it may be necessary to break clown and re- move them by mechanical means, provided we are unable to effect this by copious enemata. Hemorrhoids. — The loaded state of the rectum so common in preg- nancy, combined with the mechanical effect of the pressure of the gravid uterus on the hemorrhoidal veins, often produces very trou- blesome symptoms from piles. In such cases a regular and gentle evacuation of the bowels should be secured daily, so as to lessen as much as possible the congestion of the veins. Any of the aperients already mentioned, especially the sulphur electuary, may be used. Dr. Fordj^ce Barker 1 insists that, contrary to the usual impression, one of the best remedies for this purpose is a pill containing a grain or a grain and a half of powdered aloes, with a quarter of a grain of extract of nux vomica, and that castor oil is distinctly prejudicial, and apt to increase the symptoms. I have certainly found it answer well in several cases. When the piles are tender and swollen, they should be freely covered with an ointment consisting of four grains of muriate of morphia to an ounce of simple ointment, or with the Ung. Gallae c. opio [an addition of 5j of ext. of stramonium to 3j of this ointment, will be found valuable. — Ed.] of the Pharmacopoeia; and, if protruded, an attempt should be made to push them gently above the sphincter, by which they are often unduly constricted. Eelief may also be obtained by frequent hot fomentations, and some- times, when the piles are much swollen, it will be found useful to puncture them, so as to lessen the congestion, before any attempt at reduction is made. Ptyalisrn. — A profuse discharge from the salivary glands is an occasional distressing accompaniment of pregnancy. It is generally confined to the early months, but it occasionally continues during the whole period of gestation, and resists all treatment, only ceasing when delivery is over. Under such circumstances the discharge of saliva is sometimes enormous, amounting to several quarts a day, and the distress and annoyance to the patient are very great. In one case under my care the saliva pomed Prom the mouth all day long, and for several months the patient sal with a basin constantly by her side, incessantly emptying her mouth, until she was reduced to a condition giving rise to really serious anxiety. This profuse saliva- 1 The Puerperal Diseases, p 33. 190 PREGNANCY. tion is, no doubt, a purely nervous disorder, and not readily con- trolled by remedies. Astringent gargles, containing tannin and chlorate of potass, frequent sucking of ice, or of tannin lozenges, in- halation of turpentine and creasote, counter-irritation over the sali- vary glands by blisters or iodine, the bromides, opium internally, may all be tried in turn, but none of them can be depended on with any degree of confidence. Toothache and Caries of the Teeth. — Severe dental neuralgia is also a frequent accompaniment of pregnancy, especially in the early months. When purely neuralgic, quinine in tolerably large doses is the best remedy at our disposal ; but not infrequently, it depends on actual caries of the teeth, and attention should always be paid to the condition of the teeth when facial neuralgia exists. There is no doubt that pregnancy predisposes to caries, and the observation of this fact has given rise to the old proverb, " for every child a tooth." Mr. Oakley Coles, in an interesting paper 1 on the condition of the mouth and teeth during pregnancy, refers the prevalence of caries to the co-existence of acid dyspepsia, causing acidity of the oral secre- tions. There is much unreasonable dread amongst practitioners as to interfering with the teeth during pregnancy, and some recommend that all operations, even stopping, should be postponed until after delivery. It seems to me certain that the suffering of severe tooth- ache is likely to give rise to far more severe irritation than the opera- tion required for its relief, and I have frequently seen badly decayed teeth extracted during pregnancy, and with only a beneficial result. [We have had nitrous oxide administered and teeth extracted with- out difficulty, or any apparent risk. — Ed.] Affections of the Respiratory Organs. — Amongst the derangements of the respiratory organs, one of the most common is spasmodic cough, which is often excessively troublesome. Like many other of the sympathetic derangements accompanying gestation, it is purely nervous in character, and is unaccompanied by elevated temperature, quickened pulse, or any distinct auscultatory phenomena. In char- acter it is not unlike whooping-cough. The treatment must obviously be guided by the character of the cough. Expectorants are not likely to be of service, while benefit may be derived from some of the anti- spasmodic class of drugs, such as belladonna, hydrocyanic acid, opi- ates, or bromide of potassium. Such remedies may be tried in suc- cession, but will often be found to be of little value in arresting the cough. Dyspnoea may also be nervous in character, and sometimes symptoms, not unlike those of spasmodic asthma, are produced. Like the other sympathetic disorders, it, as well as nervous cough, is most frequently observed during the early months. There is an- other form of dyspnoea, not uncommonly met with, which is the me- chanical result of the interference with the action of the diaphragm and lungs by the pressure of the enlarged uterus. Hence this is most generally troublesome in the latter months, and continues unre- lieved until delivery, or until the sinking of the uterine tumor which 1 Trans, of the Odontologieal Society. DISEASES OF PREGNANCY. 191 immediately precedes it. Beyond taking care that the pressure is not increased by tight lacing, or injudicious arrangement of the clothes, there is little that can be done to relieve this form of breath- lessness. [Anoint the abdomen of the patient, and let her sleep on an inclined plane with a pillow under her thighs and knees. — Ed.] Palpitation, like dyspnoea, may be due either to sympathetic dis- turbance, or to mechanical interference with, the proper action of the heart. When occurring in weakly women it may be referred to the functional derangements which accompany the chlorotic condition of the blood often associated with pregnancy, and is then best reme- died by a general tonic regimen, and the administration of ferruginous preparations. At other times anti-spasmodic remedies may be indi- cated, but it is seldom sufficiently serious to call for much special treatment. Syncope. — Attacks of fainting are not rare, especially in delicate women of highly -developed nervous temperament, and are perhaps most common at or about the period of quickening, although some- times lasting through the whole pregnancy. In most cases these attacks cannot be classed as cardiac, but are more probably nervous in character, and they are rarely associated with complete abolition of consciousness. They rather, therefore, resemble the condition described by the older authors as lypothemia. The patient lies in a semi-unconscious condition with a feeble pulse and widely-dilated pupils, and this state lasts for varying periods, from a few minutes to half an hour or more. In one very troublesome case under my care they often recurred as frequently as three or four times a day. I have observed that they rarely occur when the more common sym- pathetic phenomena of pregnancy, especially vomiting, are present. Sometimes they terminate with the ordinary symptoms of hysteria such as sobbing. The treatment should consist during the attack in the administration of diffusible stimulants, such as ether, sal- volatile, and valerian, the patient being placed in the recumbent position with the head low. If frequently repeated it is unadvisable to attempt to rally the patient by the too free administration of stimulants. In the intervals a generally tonic regimen, and the administration of ferru- ginous remedies, are indicated. If they recur with great frequency the daily application of the spinal ice-bag has proved of much service. Extreme Anoemia and Chlorosis. — In connection with disorders of the circulatory system may be noticed those which depend on the state of the blood. The altered condition of the blood, which lias already been described as a physiological accompaniment of pregnancy (p. 130), is sometimes carried to an extent which may fairly be called morbid ; and, either on account of the deficiency of blood-corpnseles, or from the increase in its watery constituents, a state of extreme anaemia and chlorosis maybe developed. This maybe b etimes carried to a very serious extent. Thus Gusserow 1 records five cases in which nothing but excessive anaemia could be detected, all of which ended fatally. Generally when such symptoms have been carried to 1 Arch. f. Gyn. ii. 2, 1*71. 192 PREGNANCY. an extreme extent, the patient has been in a state of chlorosis before pregnancy. The treatment must, of course, be calculated to improve the general nutrition, and enrich the impoverished blood ; a light and easily assimilated diet, milk, eggs, beef-tea, and animal food — if it can be taken — attention to the proper action of the bowels, a due amount of stimulants, and abundance of fresh air, will be the chief indications in the general management of the case. Medicinally, fer- ruginous preparations will be required. Some practitioners object, apparently without sufficient reason, to the administration of iron during pregnancy, as liable to promote abortion. This unfounded prejudice may probably be traced to the supposed emmenagogue prop- erties of the preparations of iron ; but, if the general condition of the patient indicate such medication, they may be administered without any fear Preparations of phosphorous, such as the phosphide of zinc, or free phosphorous in capsules, also promise favorably, and are well worthy of trial. (Edema associated with Hydrsemia. — Some of the more aggravated cases are associated with a considerable amount of serous effusion into the cellular tissue, generally limited to the lower extremities, but occasionally extending to the arms, face, and neck, and even producing ascites and pleuritic effusion. Under the latter circum- stances this complication is, of course, of great gravity, and it is said that after delivery the disappearance of the serous effusion may be accompanied by metastasis of a fatal character to the lungs or the nervous centres. This form of oedema must be distinguished from the slight oedematous swelling of the feet and legs so commonly ob- served as a mechanical result of the pressure of the gravid uterus, and also from those cases of oedema associated with albuminuria. The treatment must be directed to the cause, while the disappearance of the effusion may be promoted by the administration of diuretic drinks, the occasional use of saline aperients, and rest in the horizon- tal position. Albuminuria. — The existence of albumen in the urine of pregnant women has for many years attracted the attention of obstetricians, and it is now well known to be associated, in ways still imperfectly understood, with many important puerperal diseases. Its presence in most cases of puerperal eclampsia was long ago pointed out by Lever in this country and Rayer in France, and its association with this disease gave rise to the theory of the dependence of the convul- sion on uraemia, which is still generally entertained. It has been shown of late years, especially by Braxton Hicks, that this associa- tion is by no means so universal as was supposed ; or rather that, in some cases, the albuminuria follows and does not precede the convul- sions, of which it might therefore be supposed to be the consequence rather than the cause ; so that further investigations as to these par- ticular points are still required. Modern researches have shown that there is an intimate connection between many other affections and albuminuria ; as, for example, certain forms of paralysis, either of special nerves, as puerperal amaurosis, or of the spinal system ; cephalalgia and dizziness ; puerperal mania ; and possibly hemor- DISEASES OF PREGNANCY. 193 rhage. It cannot, therefore, be doubted that albuminuria in the pregnant woman is liable, at any rate, to be associated with grave disease, although the present state of our knowledge does not enable us to define very distinctly its precise mode of action. Causes of Puerperal Albuminuria. — As the presence of albumen in the urine of pregnant women is far from a rare phenomenon — being met with, according to the researches of Blot and Litzman, in 20 per cent, of pregnant women — and as, in the large majority of these cases, it rapidly disappears after delivery, it is obvious that its presence must, in a large proportion of cases, depend on temporary causes, and has not always the same serious importance as in the non-pregnant state. This is further proved by the undoubted fact that albumen, rapidly disappearing after delivery, is often found in urine of pregnant women who go to term, and pass through labor without any unfavorable symptoms. Pressure by the Gravid Uterus. — The obvious fact that in pregnancy the vessels supplying the kidneys are subjected to mechanical pres- sure from the gravid uterus, and that congestion of the venous circu- lation of those viscera must necessarily exist to a greater or less degree, suggests that here we may find an explanation of the frequent occurrence of albuminuria. This view is further strengthened by the fact that the albumen rarely appears until after the fifth month, and, therefore, not until the uterus has attained a considerable size; and also that it is comparatively more frequently met with in primiparae, in whom the resistance of the abdominal parietes, and consequent pressure, must be greater than in women who have already borne children. It is, indeed, probable that pressure and consequent venous congestion of the kidneys have an important influence in its produc- tion; but there must be, as a rule, some other factor in operation, since an equal or even greater amount of pressure is often exerted by ovarian and fibroid tumors, without any such consequences. Altered State of the Blood. — This is probably to be found in the altered condition of the blood, which, on account of the unusual call for nutritive supply on the part of the foetus, contains an excess of albuminous material. Hence we have two factors always at work in the pregnant woman, both predisposing to the escape of albumen, viz., a turgid state of the renal venous system, and a super-albumi- nous condition of the blood. But in the large majority of cases, although these conditions are present, no albuminuria exists, and they must, therefore, be looked upon as predisposing causes, to which some other is added before the albumen escapes from the vessels. What this is generally escapes our observation, but probably any condition producing sudden hyperemia of the kidneys, and giving rise to a state analogous to the firsi stage of Bright's disease — such, for ex- ample, as sudden exposure to cold and Impeded cutaneous action — may be sumcienl to set a lighl to the match already prepared by the existence of pregnancy. In addition to these temporary causes it must not be forgotten that pregnancy may supervene in a patient already sutVering from Blight's disease, when of course the albumen will exist in the urine from the com met ment of gestation. 194 PREGNANCY. The Effects of Puerperal Albuminuria. — The various diseases asso- ciated with the presence of albumen in the urine will require sepa- rate consideration. Some of these, especially puerperal eclampsia, are amongst the most dangerous complications of pregnancy. Others, such as paralysis, cephalalgia, dizziness, may also be of considerable gravity. The precise mode of their production, and whether they can be traced, as is generally believed, to the retention of urinary elements in the blood, either urea or free carbonate of ammonia produced by its de- composition, or whether the two are only common results of some undetermined cause, will be considered when we come to discuss puerperal convulsions. Whatever view may ultimately be taken on these points, it is sufficiently obvious that albuminuria in a pregnant woman must constantly be a source of much anxiety, and must induce us to look forward with considerable apprehension to the termination of the case. Prognosis. — -We are scarcely in possession of a sufficiently large number of observations to justify any very accurate conclusions as to the risk attending albuminuria during pregnancy, but it is certainly by no means slight. One source of danger is that the morbid state of the kidneys may become permanent, and may lead to the estab- lishment of Bright's disease after the pregnancy is over. Goubeyre estimated that 49 per cent, of primiparse who have albuminuria, and who escape eclampsia, die from morbid conditions traceable to the albuminuria. This conclusion is probably much exaggerated, but if it even approximates to the truth, the danger must be very great. Tendency to produce Ahortion. — Besides the ultimate risk to the mother, albuminuria strongly predisposes to abortion, no doubt on account of the imperfect nutrition of the foetus by blood impoverished by the drain of albuminous materials through the kidneys. This fact has been observed by many writers. A good illustration of it is given by Tanner, 1 who states that four out of seven women he at- tended suffering from Bright's disease during pregnancy, aborted, one of them three times in succession. Symptoms. — The symptoms accompanying albuminuria in preg- nancy are by no means uniform or constantly present. That which most frequently causes suspicion is the anasarca — not only the cede- matous swelling of the lower limbs which is so common a consequence of the pressure of the gravid uterus, but also of the face and upper extremities. Any puffiness or infiltration about the face, or any oedema about the hands or arms, should always give rise to suspicion, and lead to a careful examination of the urine. Sometimes this is carried to an exaggerated degree, so that there is anasarca of the whole body. Anomalous nervous symptoms — such as headache, transient dizzi- ness, dimness of vision, spots before the eyes, inability to see objects distinctly, sickness in women not at other times suffering from nausea, sleeplessness, irritability of temper — are also often met with, sometimes to a slight degree, at others very strongly developed, and 1 Signs and Diseases of Pregnancy, p. 428. DISEASES OF PREGNANCY. 195 should always arouse suspicion. Indeed, knowing as we do that many morbid states may be associated with albuminuria, we should make a point of carefully examining the urine of all patients in whom any unusual morbid phenomena show themselves during pregnancy. Character of the Urine. — The condition of the urine varies con- siderably, but it is generally scanty and highly colored, and, in addition to the albumen, especially in cases in which the albuminuria has existed for some time, we may find epithelium cells, tube casts, and occasionally blood corpuscles. Treatment. — The treatment must be based on what has been said as to the causes of the albuminuria. Of course it is out of our power to remove the pressure of the gravid uterus, except by inducing labor ; but its effects may at least be lessened by remedies tending to promote an increased secretion of urine, and thus diminishing the congestion of the renal vessels. The administration of saline diure- tics, such as the acetate of potash, or bitartrate of potash, the latter being given in the form of the well-known imperial drink, will best answer this indication. The action of the bowels may be solicited by purgatives producing watery motions, such as occasional doses of the compound jalap powder. Dry cupping over the loins, frequently repeated, has a beneficial effect in lessening the renal hyperemia, The action of the skin should also be promoted by the use of the vapor bath, and with this view the Turkish bath may be employed with great benefit and perfect safety. The next indication is to improve the condition of the blood by appropriate diet and medica- tion. A very light and easily assimilated diet should be ordered, of which milk should form the staple. Tarnier 1 has recorded several cases in which a purely milk diet was very successful in removing albuminuria. With the milk we may allow white of egg, or a little white fish. The tincture of the perchloride of iron is the best medi- cine we can give, and it may be advantageously combined with small doses of tincture of digitalis, which acts as an excellent diuretic. Question of Inducing Labor. — Finally, in obstinate cases we shall have to consider the advisability of inducing premature labor. The propriety of this procedure in the albuminuria of pregnancy has of late years been much discussed, and I believe that, having in view the undoubted risks which attend this complication, the operation is unquestionably indicated, and is perfectly justifiable, in all cases at- tended with symptoms of gravity. It is not easy to lay down any definite rules to guide our decision; but I should not hesitate to adopl this resource in all cases in which the quantity <>!' albumen is considerable and progressively increasing, and in which treatmenl has failed to lessen the amount; and, above all, in ever)- case attended with threatening symptoms, such as Bevere headache, dizzine* loss of sight. The risks of tic operation are infinitesimal compared to those which tin.' patient would run in the event of puerperal con- vulsions supervening, of chronic Bright's disease becoming estab- 1 Annal. de Gynec., Jan. 1876. 196 PREGNANCY. listed. As the operation is seldom likely to be indicated until the child has reached a viable age, and as the albuminuria places the child's life in danger, we are quite justified in considering the mother's safety alone in determining on its performance. CHAPTEE VIII. DISEASES OF PREGNANCY (CONTINUED). Disorders of the Nervous System. — There are many disorders of the nervous system met with during the course of pregnancy. Among the most common are morbid irritability of temper, or a state of mental despondency and dread of the results of the labor, sometimes almost amounting to insanity, or even progressing to actual mania. These are but exaggerations of the highly susceptible state of the nervous system generally associated with gestation. Want of sleep is not uncommon, and, if carried to any great extent, may produce serious trouble from the irritability and exhaustion it produces. In such cases we should endeavor to lessen the excitable state of the nerves, by insisting on the avoidance of late hours, over-much society, exciting amusements, and the like ; while it may be essential to pro- mote sleep by the administration of sedatives, none answering so well as the chloral hydrate, in combination with large doses of the bro- mide of potassium, which greatly intensifies its hypnotic effects. [Bromide of sodium, since its reduction in price, being more soluble, more purely saline, more active, and more grateful to the stomach, is gradually supplanting in a measure the salt of potash. — Ed.] Headaches and Neuralgia. — Severe headaches and various intense neuralgias are common. Amongst the latter the most frequently met with are pain in the breasts, due to the intimate sympathetic connection of the mammas with the gravid uterus ; and intense inter- costal neuralgia, which a careless observer might mistake for pleu- ritic or inflammatory pain. The thermometer, by showing that there is no elevation of temperature, would prevent such a mistake. Neu- ralgia of the uterus itself, or severe pains in the groins or thighs — the latter being probably the mechanical results of dragging on the attachments of the abdominal muscles — are also far from uncommon. In the treatment of such neuralgic affections attention to the state of the general health, and large doses of quinine and ferruginous pre- parations whenever there is much debility, will be indicated. Locally sedative applications, such as belladonna and chloroform liniments ; friction with aconite ointment when the pain is limited to a small space ; and, in the worst cases, the subcutaneous injection of mor- phia, will be called for. Those pains which apparently depend on DISEASES OF PREGNANCY. 197 mechanical causes may often be best relieved by lessening the trac- tion on the muscles, by wearing a well-made elastic belt to support the uterus. Paralysis depending on Pregnancy. — Among the most interesting of the nervous diseases are various paralytic affections. Almost all varieties of paralysis have been observed, such as paraplegia, hemi- plegia (complete or incomplete), facial paralysis, and paralysis of the nerves of special sense, giving rise to amaurosis, deafness, and loss of taste. Churchill records 22 cases of paralysis during pregnancy, collected by him from various sources. A large number have also been brought together by Imbert Goubeyre, 1 in an interesting memoir on the subject, and others are recorded by Ford} r ce Barker, Joulin, and other authors ; so that there can be no doubt of the fact that paralytic affections are common during gestation. In the large pro- portion of the cases recorded the paralyses have been associated with albuminuria, and are doubtless uraemic in origin. Thus in 19 cases, related by Goubeyre, albuminuria was present in all. The dependency of the paralysis on a transient cause, explains the fact that in the large majority of these cases the paralysis was not per- manent, but disappeared shortly after labor. In every case of par- lysis, whatever be its nature, special attention should be directed to the state of the urine, and, should it be found to be albuminous, labor should be at once induced. This is clearly the proper course to pursue, and we should certainly not be justified in running the risk that must attend the progress of a case in which so formidable a symptom has already developed itself. When the cause has been removed, the effect will also generally rapidly disappear, and the prognosis is therefore, on the whole, favorable. Should the paralysis continue after delivery, the treatment must be such as we would adopt in the non-pregnant state ; and small doses of strj^chnia, along with faradization of the affected limbs, would be the best remedy at our disposal. Paralyses which are not Urvemic in their Origin. — There are, how- ever, unquestionably some cases of puerperal paralysis which are not uraemic in their origin, and the nature of which is somewhat obscure. Hemiplegia may doubtless be occasioned by cerebral hemorrhage, as in the non-pregnant state Other organic causes of paralysis, such as cerebral congestion, or embolism, may, now and again, be met with during pregnancy, but cases of this kind must be of compara- tive rarity. Other cases are functional in their origin. Tarnier relates a case of hemiplegia which he could only refer to extreme anaemia. Some, again, may be hysterical. Paraplegia is apparently more frequently unconnected with albuminuria than the other forms of paralysis ; and it may cither depend on pressure of the gravid uterus on the nerves as they pass through the pelvis, or on reflex action, as is sometimes observed in connection with uterine disease When, in Buch cases, the absence of albuminuria is ascertained by frequent examination of the urine, there is obviously no1 the same 1 M6m. de I' Acad, de M£d., 1801. 198 PREGNANCY. risk to the patient as in cases depending on uraemia, and therefore it may be justifiable to allow pregnancy to go on to term, trusting to subsequent general treatment to remove the paralytic symptoms. As the loss of power here depends on a transient cause, a favorable prognosis is quite justifiable. [Partial paralysis of one lower ex- tremity, generally the left, sometimes occurs, from pressure of the foetal occiput, and may continue for some days or weeks, with a gradual improvement, after parturition. — Ed.] Chorea is not infrequently observed, and forms a serious complica- tion. It is generally met with in young women of delicate health, and in the first pregnancy. In a large proportion of the cases the patient has already suffered from the disease before marriage. On the occurrence of pregnancy, the disposition to the disease again becomes evoked, and choreic movements are re-established. This fact may be explained partly by the susceptible state of the nervous system, partly by the impoverished condition of the blood. Prognosis. — That chorea is a dangerous complication of pregnancy is apparent by the fact that out of 56 cases collected by Dr. Barnes, 1 in an excellent paper on the subject, no less than 17, or 1 in 3, proved fatal. Nor is it danger to life alone that is to be feared, for it ap- pears certain that chorea is more apt to leave permanent mental dis- turbance when it occurs during pregnancy, than at other times. It has also an unquestionable tendency to bring on abortion or prema- ture labor, and in most cases the life of the child is sacrificed. Treatment. — The treatment of chorea during pregnancy does not differ from that of the disease under more ordinary circumstances ; and our chief reliance will be placed on such drugs as the liquor arsenicalis, bromide of potassium, and iron. In the severe form of the disease, the incessant movements, and the weariness and loss of sleep, may very seriously imperil the life of the patient, and more prompt and radical measures will be indicated. . If, in spite of our remedies, the paroxysms go on increasing in severity, and the patient's strength appears to be exhausted, our only resource is to remove the most evident cause by inducing labor. Generally the symptoms lessen and disappear soon after this is done. There can be no question that the operation is perfectly j astiflable, and may even be essential under such circumstances. It should be borne in mind that the chorea often recurs in a subsequent pregnancy, and extra care should then always be taken to prevent its development. Disorders of the urinary organs are of frequent occurrence. Be- tention of urine may be met with, and this is often the result of a retroverted uterus. The treatment, therefore, must then be directed to the removal of the cause. This subject will be more particularly considered when we come to discuss that form of displacement (p. 203) ; but we may here point out that retention of urine, if long con- tinued, may not only lead to much distress, but to actual disease of the coats of the bladder. Several cases have been recorded in which cystitis, resulting from urinary retention in pregnancy, eventually 1 Obst. Trans., vol. x. DISEASES OF PREGNANCY. 199 caused the exfoliation of the entire mucous membrane of the blad- der, 1 which was cast off, sometimes entire, sometimes in shreds, and occasionally with portions of the muscular coat attached to it. The possibility of this formidable accident should teach us to be careful not to allow any undue retention of urine, but, by a timely use of the catheter, to relieve the symptoms, while we, at the same time, endeavor to remove the cause. Irritability of the bladder is of frequent occurrence. In the early months it seems to be the consequence of sympathetic irritation of the neck of the bladder, combined with pressure, while in the later months it is, probably, solely produced by mechanical causes. When severe it leads to much distress, the patient's rest being broken and disturbed by incessant calls to micturate, and the suffering induced may produce serious constitutional disturbances. I have elsewhere pointed out, 2 that irritability of the bladder in the latter months of pregnancy is frequently associated with an abnormal position of the foetus, which is placed transversely or obliquely. The result is either that undue pressure is applied to the bladder, or that it is drawn out of its proper position. [Where the foetus is anencephalus, with the defective head presenting, the calls to urinate are in some cases a very serious annoyance, as the foetus makes an unusual pressure directly on the bladder. — Ed.] The abnormal position of the foetus can readily be detected by palpation, and as readily altered by external manipulation. In some of the cases I have recorded, altering the position of the foetus was immediately folloAved by relief; the symp- toms recurring after a time, when the foetus had again assumed an oblique position. Should the foetus frequently become displaced, an endeavor may be made to retain it in the longitudinal axis of the uterus by a proper adaptation of bandages or pads. In cases not referable to this cause we should attempt to relieve the bladder symp- toms by appropriate medication, such as small doses of liquor potassre, if the urine be very acid ; tincture of belladonna ; the decoction of triticum repens, an old but very serviceable remedy; and vaginal sedative ]>■ -varies containing morphia or atropine. Incontinence of Urine. — Women who have borne many children are often troubled with incontinence of urine during pregnancy, the water dribbling away on the slightest movement. Through this much irritation of the skin surrounding the genitals is produced, at- tended with troublesome excoriations and eruptions. Relief may be partially obtained by lessening the pressure on the bladder by an abdominal belt, while the skin is protected by applications of Bimple ointment or glycerine. Phosphatic Deposit.-— Dr. Tyler Smith has directed attention to a phosphatic condition of the urine occurring in delicate women, whose constitutions are severely tried by gestation. This condition can easily be altered by rest, nutritious diet, and a course of restorative medicines, such as steel, mineral acids, and the like. 1 Obst. Trans., vol. XL 2 Obst. Trans, vol. x iii. 200 PREGNANCY, Leucorrhoea. — A profuse whitish, leucorrhoeal discharge is very common during pregnancy, especially in its latter half. The discharge frequently alarms the patient, but, unless it is attended with disa- greeable symptoms, it does not call for special treatment. When at all excessive, it may lead to much irritation of the vagina and ex- ternal generative organs. The labia may become excoriated and covered with small aphthous patches, and the whole vulva may be hot, swollen, and tender. Warty growths, similar in appearance to syphilitic condylomata, are occasionally developed in pregnant women, unconnected with any specific taint, and associated with the presence of an irritating leucorrhoeal discharge. According to Thibierge, 1 these resist local applications, such as sulphate of copper or nitrate of silver, but spontaneously disappear after delivery. Inasmuch as the leucorrhoeal discharge is dependent on the congested condition of the generative organs accompanying pregnancy, we can hope to do little more than alleviate it. In the severer forms, as has been pointed out by Henry Bennet, the cervix will be found to be abraded or covered with granular erosion, and it may be, from time to time, cautiously touched with the nitrate of silver, or a solution of carbolic acid. Generally speaking, we must content ourselves with recom- mending the patient to wash the vagina out gently with diluted Condy's fluid; or with a solution of the sulpho-carbolate of zinc, of the strength of four grains to the ounce of water ; or with plain tepid water. For obvious reasons frequent and strong vaginal douches are to be avoided, but a daily gentle injection, for the purpose of ablution, can do no harm. Pruritus. — A very distressing pruritus of the vulva is frequently met with along with leucorrhoea, especially when the discharge is of an acrid character, which in some cases leads to intense and protracted suffering, forcing the patient to resort to incessant friction of the parts. Pruritus, however, may exist without leucorrhoea, being apparently sometimes of a neuralgic character, at others associated with apthous patches on the mucous membrane, ascarides in the rectum, or pediculi in the hairs of the mons veneris and labia. Cases are even recorded in which the pruritic irritation extended over the whole body. The treatment is difficult and unsatisfactory. Yarious sedative applica- tions may be tried, such as weak solutions of Goulard's lotion; or a lotion composed of an ounce of the solution of the muriate of morphia, with a drachm and a half of hydrocyanic acid, in six ounces of water; or one formed by mixing one part of chloroform with six of almond oil. A very useful form of medication consists in the insertion into the vagina of a pledget of cotton-wool, soaked in equal parts of the glycerine of borax and sulphurous acid. This may be inserted at bed time, and withdrawn in the morning by means of a string attached to it. In the more obstinate cases, the solid nitrate of silver may be lightly brushed over the vulva; or, as recommended by Tarnier, a solution of bichloride of mercury, of about the strength of two grs. to the ounce, may be applied night and morning. The state of the 1 Arch. G6n, de M6d., 1856. DISEASES OF PREGNANCY. 201 digestive organs should always be attended to, and aperient mineral water may be usefully administered. When the pruritus extends beyond the vulva, or even in severe local cases, large doses of bromide of potassium may perhaps be useful in lessening the general hyper - aesthetic state of the nerves. Effects of Pressure. — Some of the disorders of pregnancy are the direct results of the mechanical pressure of the gravid uterus. The most common of these are oedema and a varicose state of the veins of the lower extremities, or even of the vulva. The former is of little consequence, provided we have assured ourselves that it is really the result of pressure, and not of albuminuria, and it can generally be relieved by rest in the horizontal position. A varicose state of the veins of the lower limbs is very common, especially in multipara?, in whom it is apt to continue after delivery. Occasionally the veins of the vulva, and even of the vagina, are also enlarged and varicose, producing considerable swelling of the external genitals. Eest in the recumbent position, and the use of an abdominal belt, so as to take the pressure off the veins as much as possible, are all that can be done to relieve this troublesome complication. If the veins of the legs are much swollen, some benefit may be derived from an elastic stocking or a carefully applied bandage. Occasional serious results from Laceration of the Veins. — Serious and even fatal consequences have followed the accidental laceration of the swollen veins. When laceration occurs during or immediately after delivery — a not uncommon result of the pressure of the head — it gives rise to the formation of a vaginal thrombus. It has occa- sionally happened from an accidental injury during pregnanc} r , as in the cases recorded by Simpson, in which death followed a kick on the pudenda, producing laceration of a varicose vein, or in one men- tioned by Tarnier, where the patient fell on the edge of a chair. Severe hemorrhage has followed the accidental rupture of a vein in the leg. The only satisfactory treatment is pressure, applied directly to the bleeding parts by means of the finger, or by compresses satu- rated in a solution of the perchloride of iron. The treatment of vaginal thrombus following labor must be considered elsewhere. Occasionally the varicose veins inflame, become very tender and painful, and coagula form in their canals. In such cases absolute rest should be insisted on, while sedative lotions, such as the chloro- form and belladonna Liniments, should be applied to relieve the pain. Displacements of the Gravid Uterus. — Certain displacements of the gravid uterus an- tnel with, which may give rise to Bymptoms of great gravity. Prolapse, which Is pare, is almosl always the resull of pregnancy occurring in a uterus which had been previously more or less proci- dent. Under such circumstances the increasing weighl of the uterus will at first necessarily augmenl the previously existing tendency to protrusion of the \v<>ml>. which may come t<> protrude partially or entirely bej'ond the vulva. In the great majority of cases, a- preg- nancy advances, the prolapsus cures itself, for a1 aboul tin- fourth or fifth month the uterus will rise above the pelvic brim. It has been 14 202 PREGNANCY. said, that, in some cases of complete procidentia, pregnancy lias gone on even to term, with the uterus lying entirely outside the vulva. Most probably these cases were imperfectly observed, the greater part of the uterus being in reality above the pelvic brim, a portion only of its lower segment protruding externally; or, as has some- times been the case, the protruding portion has been an old standing hypertrophic elongation of the cervix, the internal os uteri and fundus being normally situated. Should a prolapsed uterus not rise into the abdominal cavity as pregnancy advances, serious symptoms will be apt to develop themselves ; for, unless the pelvis be unusually capacious, the enlarging uterus will get jammed within its bony walls, the rectum and urethra will be pressed upon, defecation and micturition will be consequently impeded, and severe pain and much irritation will result. In all probability such a state of things would lead to abortion. The possibility of these consequences should, there- fore, teach us to be careful in the management of every case of prolap- sus, however slight, in which pregnancy occurs. Absolute rest, in the horizontal position, should be insisted on ; while the uterus should be supported in the pelvis by a full-sized Hodge's pessary, which should be worn until at least the sixth month, when the uterus would be fully within the abdominal cavity. After delivery, prolonged rest should be recommended, in the hope that the process of involu- tion may be accompanied by a cure of the prolapse. There can be no doubt that pregnancy carried to term affords an opportunity of curing even old-standing displacements, which should not be neg- lected. Anteversion of the gravid uterus seldom produces symptoms of consequence. In all probability it is common enough when preg- nancy occurs in a uterus which is more than usually anteverted, or is anteflexed. Under such circumstances, there is not the same risk of incarceration in the pelvic cavity as in cases in which pregnancy exists in a retroflexed uterus, for, as the uterus increases in size, it rises without difficulty into the abdominal cavity. In the early months the pressure of the fundus on the bladder may account for the irritability of that viscus then so commonly observed. It will be remembered that (xraily Hewitt attributes great importance to this condition as explaining the sickness of pregnancy — a theory, however, which has not met with general acceptation. Extreme anteversion of the uterus ) at an advanced period of preg- nancy, is sometimes observed in multiparas with very lax abdominal walls, occasionally to such an. extent that the uterus falls completely forwards and downwards, so that the fundus is almost on a level with the patient's knees. This form of pendulous belly may be associated with a separation of the recti muscles, between which the womb forms a ventral hernia, covered only by the cutaneous textures. When labor comes on this variety of displacement may give rise to trouble by destroying the proper relation of the uterine and pelvic axes. The treatment is purely mechanical, keeping the patient lying on her back as much as possible, and supporting the pendulous abdo- men by a properly adjusted bandage. A similar forward displace- DISEASES OF PREGNANCY. 203 ment is observed in cases of pelvic deformity, and in the worst forms, in rachitic and dwarfed women, it exists to a very exaggerated de- gree. [This uterine hernia may even be such an obstacle to parturi- tion as to require the Cesarean section, as in the case reported by Dr. Harvey, 1 of Eichmond, Mississippi, in 1849. — Ed.] Retroversion. — The most important of the displacements, in conse- quence of its occasional very serious results, is retroversion of the gravid uterus. It was formerly generally believed that this was most commonly produced by some accident, such as a fall, which dislocated a uterus previously in a normal position. Undue dis- tension of the bladder was also considered to have an important influence in its production, by pressing the uterus backwards and downwards. Its Causes. — It is now almost universally admitted that, although the above-named causes may possibly sometimes produce it, in the very large proportion of cases it depends on pregnancy having occurred in a uterus previously retroverted or retroflexed. The- merit of pointing out this fact unquestionably belongs to the late Dr. Tyler Smith, and further observations have fully corroborated the correctness of his views. In the large majority of cases in which pregnancy occurs in a uterus so displaced, as the womb enlarges, it straightens itself, and rises into the abdominal cavity, without giving any particular trouble; or, as not infrequently happens, the abnormal position of the organ interferes so much with its enlargement as to produce abortion. Sometimes, however, the uterus increases without leaving the pelvis until the third or fourth month, when it can no longer be retained in the pelvic cavity without inconvenience. It then presses on the urethra and rectum, and eventually becomes completely in- carcerated within the rigid walls of the bony pelvis, giving rise to characteristic symptoms. Symptoms. — The first sign which attracts attention is generally some trouble connected with micturition, in consequence of pressure on the urethra. On examination, the bladder will often be found to be enormously distended, forming a large, fluctuating abdominal tumor, which the patient has lost all power of emptying. Fre- quently small quantities of urine dribble away, leading the woman to believe that she has passed water, and thus the distension is often overlooked. Sometimes the obstruction to the discharge of urine is so greal as to lead to dropsical effusion into the cellular tissue of the arms and legs. This was very well marked in one of my cases, and disappeared rapidly after the bladder had been emptied. Difficulty in defecation, tenesmus, obstinate constipation, and inability to empty the bowels, becomes established aboul the same time. These symp- toms increase, accompanied by some pelvic pain and a sense of weight and bearing down, until at last the patienl applies for advice, and the true nature of the ease is detected. When the retroversion, [' New Orleans Med. and Surg. Journal, vol. Ex. p. 772, is;,::.] 204 PEEGNANCY. occurs suddenly, all these symptoms develop with, great rapidity, and are sometimes very serious from the first. Progress and Termination. — The further progress is various. Sometimes, after the uterus has been incarcerated in the pelvis for more or less time, it may spontaneously rise into the abdominal cavity, when all threatening symptoms will disappear. So happy a termination is quite exceptional, and if the practitioner should not interfere and effect reposition of the organ, serious and even fatal consequences may ensue, unless abortion occurs. Termination if Reduction is not Effected. — The extreme distension of the bladder, and the impossibility of relieving it, may lead to lacerations of its coats, and fatal peritonitis ; or the retention of urine may produce cystitis, with exfoliation of the coats of the bladder ; or, as more commonly happens, retention of urinary elements may take place, and death occur with all the symptoms of uraemic poison- ing. At other times the impacted uterus becomes congested and inflamed, and eventually sloughs, its contents, if the patient survive, being discharged by fistulous communications into the rectum and vagina. It need hardly be said that such terminations are only possi- ble in cases which have been grossly mismanaged, or the nature of which has not been detected till a late period. Diagnosis. — The diagnosis is not difficult. On making a vaginal examination, the finger impinges on a smooth rounded elastic swell- ing, filling up the lower part of the pelvis, and stretching and de- pressing the posterior vaginal wall, which occasionally protrudes beyond the vulva. On passing the finger forwards and upwards we shall generally be able to reach the cervix, high up behind the pubes, and pressing on the urethral canal. In very complete retroversion it may be difficult or impossible to reach the cervix at all. On ab- dominal examination the fundus uteri cannot be felt above the pelvic brim ; this, as the retroversion does not give rise to serious symp- toms until between the third and fourth months, should, under natural circumstances, always be possible. By bi-manual examina- tion we can make out, with due care, the alternate relaxation and contraction of the uterine parietes characteristic of the gravid uterus, and so differentiate the swelling from any other in the same situa- tion. The accompanying phenomena of pregnancy will also prevent any mistake of this kind. Retroversion going on to Term. — In some few cases retroversion has been supposed to go on to term. Strictly speaking, this is impossi- ble ; but in the supposed examples, such as in the well-known case recorded by Oldham, part of a retroflexed uterus remained in the pelvic cavity, while the greater part developed in the abdominal cavity. The uterus is, therefore, divided, as it were, into two por- tions ; one, which is the flexed fundus, remaining in the pelvis, the other, containing the greater part of the foetus, rising above it. Under these circumstances, a tumor in the vagina would exist in combination with an abdominal tumor, and pregnancy might go on to term. Considerable difficulty may even arise in labor, but the DISEASES OF PREGNANCY. 205 malposition generally rectifies itself before it gives rise to any serious results. Treatment. — The treatment of retroversion of the gravid uterus should be taken in hand as soon as possible, for every day's delay involves an increase in the size of the uterus, and, therefore, greater difficulty in reposition. Our object is to restore the natural direc- tion of the uterus, by lifting the fundus above the promontory of the sacrum. The first thing to be done is to relieve the patient by emptying the bladder, the retention of urine having probably origi- nally called attention to the case. For this purpose it is essential to use a long elastic male catheter of small size, as the urethra is too elongated and compressed to admit of the passage of the ordinary silver instrument. Even then it may be extremely difficult to intro- duce the catheter, and sometimes it has been found to be quite im- possible. Under such circumstances, provided reposition cannot be effected without it, the bladder may be punctured an inch or two above the pubes by means of the fine needle of an aspirator, and the urine drawn off. Dieulafoy's work on aspiration proves conclusively that this may be done without risk, and the operation has been suc- cessfully performed by Schatz and others. It very rarely happens, however, and in long-neglected cases only, that the withdrawal of the urine is found to be impossible. Mode of Effecting Reduction. — The bladder being emptied, and the bowels being also opened, if possible, by copious enemata, we pro- ceed to attempt reduction. For this purpose various procedures are adopted. If the case is not of very long standing, I am inclined to think that the gentlest and safest plan is the continuous pressure of a caoutchouc bag, filled with water, placed in the vagina. The good effects of steady and long-continued pressure of this kind were proved by Tyler Smith, who effected in this way the reduction of an inverted uterus of long standing, and it is not difficult to understand that it may succeed when a more sudden and violent effort fails. I have tried this plan successfully in two cases, a pyriform India-rub- ber bag being inserted into the vagina, and distended as far as the patient could bear by means of a syriuge. The water must be let out occasionally to allow the patient to empty the bladder, and the bag immediately refilled. In both my cases reposition occurred within twenty-four hours. Barnes has failed with this method ; but it suc- ceeded so well in my cases, and is so obviously less likely to prove hurtful than forcible reposition with the hand, that I am inclined to consider it the preferable procedure, and one that should be tried first. Failing with the fluid pressure, we should endeavor to replace the uterus in the following way. The patient should be placed at the edge of the bed, in the ordinary obstetric position, and thoroughly anaesthetized. This is of importance, as it relaxes all the parts, and admits of much freer manipulation than is otherwise possible. One or more fingers of the left hand are then inserted into the rectum ; if the patient be deeply chloroformed, it is quite possible, with due care, even to pass the whole hand, and an attempt is then made to lift or push the fundus above the promonotory of the sacrum. At 206 PREGNANCY. the same time reposition is aided by drawing down the cervix with, the ringers of the right hand per vaginam. It has been insisted that the pressure should be made in the direction of one or other sacro-iliac synchondrosis rather than directly upwards, so that the uterus may not be jammed against the projection of the promontory of the sacrum. Failing reposition through the rectum, an attempt may be made per vaginam, and for this some have advised the up- ward pressure of the closed fist passed into the canal. Others recom- mend the hand and position as facilitating reposition, but this pre- vents the administration of chloroform, which is of more assistance than any change of position can possibly be. Various complex in- struments have been invented to facilitate the operation, but they are all more or less dangerous, and are unlikely to succeed when manual pressure has failed. As soon as the reduction is accomplished, subsequent descent of the uterus should be prevented by a large-sized Hodge's pessary, and the patient should be kept at rest for some days, the state of the bladder and bowels being particularly attended to. When reposition has been fairly effected, a relapse is unlikely to occur. Treatment when Reduction is found Impossible. — In cases in which reduction is found to be impossible, our only resource is the artificial induction of abortion. Under such circumstances this is imperatively called for. It is best effected by puncturing the membranes, the dis- charge of the liquor amnii of itself lessening the size of the uterus, and thus diminishing the pressure to which the neighboring parts are subjected. After this reposition may be possible, or we may wait until the foetus is spontaneously expelled. It is not always easy to reach the os uteri, although we can generally do so with a curved uterine sound. If we cannot puncture the membranes, the liquor amnii may be drawn off through the uterine walls by means of the aspirator, inserted through either the rectum or vagina. The injury to the uterine walls thus inflicted is not likely to be hurtful, and the risk is certainly far less than leaving the case alone. Naturally so extreme a measure would not be adopted until all the simpler means indicated have been tried and failed. Diseases coexisting with Pregnancy. — The pregnant woman is, of course, liable to contract the same diseases as in the non-pregnant state, and pregnancy may occur in women already the subject of some constitutional disease. There is no doubt yet much to be learned as to the influence of coexisting disease on pregnancy. It is certain that some diseases are but little modified by pregnancy, and that others are so to a considerable extent ; and that the influence of the disease on the foetus varies much. The subject is too extensive to be entered into at any length, but a few words may be said as to some of the more important affections that are likety to be met with. Eruptive Fevers. Smallpox. — The eruptive fevers have often very serious consequences, proportionate to the intensity of the attack. Of these variola has the most disastrous results, which are related in the writings of the older authors, but which are, fortunately, rarely seen in these daj^s of vaccination. The severe and confluent forms DISEASES OF PREGNANCY. 207 of the disease are almost certainly fatal to both the mother and child. In the discrete form, and in modified smallpox after vaccina- tion, the patient generally has the disease favorably, and, although abortion frequently results, it does not necessarily do so. Scarlet Fever. — If scarlet fever of an intense character attacks a pregnant woman, abortion is likely to occur, and the risks to the mother are very great. The milder cases run their course without the production of any untoward symptoms. Should abortion occur, the well-known dangerous effect of this zymotic disease after delivery will gravely influence the prognosis. Cazeaux was of opinion that pregnant women are not apt to contract the disease; while Mont- gomery thought that the poison when absorbed during pregnancy might remain latent until delivery, when its characteristic effects were produced. Measles, unless very severe, often runs its course without seriously affecting the mother or child. I have myself seen several examples of this. De Tourcoing, however, states that out of 15 cases the mothers aborted in 7, these being all very severe attacks. Some cases are recorded in which the child was born with the rubeolous eruption upon it. Continued Fevers. — The pregnant woman may be attacked with any of the continued fevers, and, if they are at all severe, they are apt to produce abortion. Out of 22 cases of typhoid, 16 aborted, and the remaining 6, who had slight attacks, went on to term ; out of 63 cases of relapsing fever, abortion or premature labor occurred in 23. According to Schweden the main cause of danger to the foetus in continued fevers is the hyperpyrexia, especially when the maternal temperature reaches 104° or upwards. The fevers do not appear to be aggravated as regards the mother, and the same ob- servation has been made by Cazeaux with regard to this class of disease occurring after delivery. Pneumonia seems to be specially dangerous, for of 15 cases collected by Grisolle 1 11 died — a mortality immensely greater than that of the disease in general. The larger proportion also aborted, the children being generally dead, and the fatal result is probably due, as in the severe continued fevers, to hyperpyrexia. The cause of the maternal mortality does not seem quite apparent, since the same danger does not appear to exist in severe bronchitis, or other inflammatory affections. Phthisis. — Contrary to the usually received opinion it appears certain that pregnancy has no retarding influence on coexisting phthisis, nor does the disease necessarily advance with greater rapidity after delivery. Out of 27 cases of phthisis, collected by Grisolle, 2 24 showed the first symptoms of the disease after pregnancy had commenced. Phthisical women are not apt to conceive ; a fact which may probabty be explained by the frequent coexistence, in such cases, of uterine disease, especially severe leucorrhoea. The entire duration of the phthisis seems to be shortened, as it averaged 1 Arch. Gen. de Med. vol. xiii. p. 298. 2 Ibid. vol. xxii. 208 PREGNANCY. only nine and a half months in the 27 cases collected — a fact which proves, at least, that pregnancy has no material influence in arresting its progress. If we consider the tax on the vital powers which pregnancy naturally involves, we must admit that this view is more physiologically probable than the one generally received, and appa- rently adopted without any due grounds. Heart-disease. — The evil effects of pregnancy and parturition on chronic heart-disease have of late received much attention from Spiegelberg, Fritsch, Peter, and other writers. The subject has been ably discussed 1 in a series of elaborate papers by Dr. Angus Mac- Donald, which are well worthy of study. Out of 28 cases collected by him, 17, or 60 per cent., proved fatal. This, no doubt, is not altogether a reliable estimate of the probable risk of the complica- tion; but, at any rate, it shows the serious anxiety which the occur- rence of pregnancy in a patient suffering from chronic heart-disease must cause. Dr. MacDonald refers the evils resulting from pregnancy in connection with cardiac lesions to two causes: First, destruction of that equilibrium of the circulation, which has been established by compensatory arrangements; secondly, the occurrence of fresh inflammatory lesions upon the valves of the heart already diseased. The dangerous symptoms do not usually appear until after the first half of the pregnancy has passed, and the pregnancy seldom advances to term. The pathological phenomena generally met with in fatal cases are pulmonary congestion, especially of the bronchial mucous membrane, and pulmonary oedema, with occasional pneu- monia and pleurisy. Mitral stenosis seems to be the form of cardiac lesion most likely to prove serious, and next to this aortic incompe- tency. The obvious deduction from these facts is that heart-disease, especially when associated with serious symptoms, such as dyspnoea, palpitation, and the like, should be considered a strong contra-indica- tion of marriage. When pregnancy has actually occurred, all that can be done is to enjoin the careful regulation of the life of the patient, so as to avoid exposure to cold, and all forms of severe exertion . Syphilis. — The important influence of syphilis on the ovum is fully considered elsewhere. As regards the mother, its effects are not different from those at other times. It need only, therefore, be said that, whenever indications of syphilis in a pregnant woman exist, the appropriate treatment should be at once instituted and carried on during her gestation, not only with the view of checking the pro- gress of the disease, but in the hope of preventing or lessening the risk of abortion, or of the birth of an infected infant. So far from pregnancy contra-indicating mercurial treatment, there rather is a reason for insisting on it more strongly. As to the precise medica- tion, it is advisable to choose a form that can be exhibited continu- ously for a length of time without producing serious constitutional results. Small doses of the bichloride of mercury, such as one-six- teenth of a grain, thrice daily, or of the iodide of mercury, answer this 1 Obstet. Journ. 1877. DISEASES OF PREGNANCY. 209 purpose well ; or, in the early stages of pregnancy, the mercurial vapor bath, or cutaneous inunction, may be employed. Dr. Weber, of St. Petersburg, 1 has made some observations show- ing the superiority of the latter methods, which he found did not interfere with the course of pregnancy ; the contrary was the case when the mercury was administered by the mouth, probably, as he supposes, from disturbance of the digestive system. It must be borne in mind, that in married women it may sometimes be expedient to prescribe an anti-syphilitic course without their knowledge of its nature, so that inunction is not always feasible. Epilepsy. — The influence of pregnancy on epilepsy does not appear to be as uniform as might perhaps be expected. In some cases the number and intensity of the fits have been lessened, in others the disease becomes aggravated. Some cases are even recorded in which epilepsy appeared for the first time during gestation. On account of the resemblance between epilepsy and eclampsia there is a natural apprehension that a pregnant epileptic may suffer from convulsions during delivery. Fortunately, this is by no means necessarily the case, and labor often goes on satisfactorily without any attack. Jaundice, the result of acute yellow atrophy of the liver, is occa- sionally observed, and is said to have been sometimes epidemic. Independently of the grave risks to the mother, it is most likely to produce abortion or the death of the foetus. According to Davidson, it originates in catarrhal icterus, the excretion of the bile-products being impeded in consequence of pregnancy, and their retention giving rise to the foetal blood-poisoning which accompanies the severer forms of the disease. Slight and transient attacks of jaun- dice may occur, without being accompanied by any bad consequences. Their production is probably favored by the mechanical pressure of the gravid uterus on the intestines and the bile-ducts. Carcinoma. — The occurrence of pregnancy in a woman suffering from malignant disease of the uterus is by no means so rare as might be supposed, and must naturally give rise to much anxiety as to the result. The obstetrical treatment of these cases will be dis- cussed elsewhere. Should we be aware of the existence of the dis- ease during gestation, the question will arise whether we should not attempt to lessen the risks of delivery hj bringing on abortion or premature labor. The question is one which is by no means easy to settle. We have to deal with a disease which is certain to prove fatal to the mother before long, and the progress of which is proba- bly accelerated after labor, while the manipulations necessary to in- duce delivery may very unfavorably influence the diseased structures. Again, by such a measure we necessarily sacrifice the child, while we are by no means certain that we materially lessen the clanger to the mother. The question cannot be settled except on a considera- tion of each particular case. If we see the patient early in pregnancy, by inducing abortion we may save her the dangers of labor at term - — possibly of the Caesarean section — if the obstruction be great. 1 Allo-em. Med. Cent. Zeit. Feb. 1875. 210 PREGNANCY. Under such circumstances, the operation would be j ustifiable. If the pregnancy have advanced beyond the sixth or seventh month, unless the amount of malignant deposit be very small indeed, it is probable that the risks of labor would be as great to the mother as a term, and it would then be advisable to give her the advantage of the few months' delay. Ovarian Tumor. — Cases are occasionally met with in which preg- nancy occurs in women who are suffering from ovarian tumor, and their proper management has given rise to considerable discussion. There can be no doubt that such cases are attended with very danger- ous and often fatal consequences, for the abdomen cannot well ac- commodate the gravid uterus and the ovarian tumor, both increasing simultaneously. The result is that the tumor is subject to much contusion and pressure, which have sometimes led to the rupture of the cyst, and the escape of its contents into the peritoneal cavity ; at others to a low form of inflammation, attended with much exhaustion, the death of the patient supervening either before or shortly after delivery. The danger during delivery from the same cause, in the cases which go on to term, is also very great. Of 13 cases of delivery by the natural powers, which I collected in a paper on "Labor Com- plicated with Ovarian Tumor," 1 far more than one-half proved fatal. [A lady of Philadelphia gave birth to three living children during the existence of an ovarian tumor : all of the children grew up ; and the mother fell a victim to the disease at the age of 77, after numerous tappings, during fifty years. — Ed.] Another source of danger is twisting of the pedicle, and consequent strangulation of the cyst, of which several instances are recorded. It is obvious, then, that the risks are so manifold that in every case it is advisable to consider whether they can be lessened by surgical treatment. Methods of Treatment. — The means at our disposal are either to induce labor prematurely, to treat the tumor by tapping, or to per- form ovariotomy. The question has been particularly discussed by Spencer Wells in his works on " Ovariotomy," and by Barnes in his "Obstetric Operations." The former holds that the proper course to pursue is to tap the tumor when there is any chance of its being materially lessened in size by that procedure, but that when it is multilocular, or when its contents are solid, ovariotomy should be performed at as early a period of pregnancy as possible. Barnes, on the other hand, maintains that the safer course is to imitate the means by which nature often meets this complication, and bring on premature labor without interfering with the tumor. He thinks that ovariotomy is out of the question, and that tapping may be insuffi- cient and leave enough of the tumor to interfere seriously with labor. So far as recorded cases go, they unquestionably seem to show that tapping is not more dangerous than at other times, and that ovario- tomy may be practised during pregnancy with a fair amount of suc- cess. Wells records 10 cases which were surgically interfered with. In 1 tapping was performed, and in 9 ovariotomy ; and of these 8 recovered, the pregnancy going on to term in 5. On the other hand, 1 Obst. Trans., vol. ix. DISEASES OF PREGNANCY. 211 5 cases were left alone, and either went to term, or spontaneous pre- mature labor supervened ; and of these 3 died. The cases are not sufficiently numerous to settle the question, but they certainly favor the view taken by Wells rather than that by Barnes. It is to be observed that, unless we give up all hope of saving the child, and induce abortion, the risk of induced premature labor, when the preg- nancy is sufficiently advanced to hope for a viable child, would almost be as great as that of labor at term ; for the question of interference will only have to be considered with regard to large tumors, which would be nearly as much affected by the pressure of a gravid uterus at seven or eight months, as by one at term. Small tumors gene- rally escape attention, and are more apt to be impacted before the presenting part in delivery. The success of ovariotomy during pregnancy has certainly been great, and we have to bear in mind that the woman must necessarily be subjected to the risk of the operation sooner or later, so that we cannot judge of the case as one in which abortion terminates the risk. Even if the operation should put an end to the pregnancy — and there is at least a fair chance that it will not do so — there is no certainty that that would increase the risk of the operation to the mother, while as regards the child we should only have the same result as if we intentionally produced abortion. On the whole, then, it seems that the best chance to the mother, and certainly the best to the child, is to resort to the appa- rently heroic practice recommended by Wells. The determination must, however, be to some extent influenced by the skill and ex- perience of the operator. If the medical attendant has not gained that experience which is so essential for a successful ovariotomist, the interests of the mother would be best consulted by the induction of abortion at as early a period as possible. One or other procedure, is essential ; for, in spite of a few cases in ivhich several successive pregnancies have occurred in women who have had ovarian tumors, the risks are such as not to justify an expectant practice. Should rupture of the cyst occur, there can be no doubt that ovariotomy should at once be resorted to, with the view of removing the lacerated cyst and its extravasated contents. Fibroid Tumors. — Pregnancy may occur in a uterus in which there are one or more fibroid tumors. If these are situated low down and in a position likely to obstruct the passage of the foetus, they may very seriously complicate delivery. When they are situated in the fundus or body of the uterus they may give rise to risk from hemor- rhage, or from inflammation of their own structure. Inasmuch as they are structurally similar to the uterine walls they partake of the growth of the uterus during pregnancy, and frequently increase re- markably in size. Cazeaux saj^s — " I have known them in several in- stances to acquire a size in three or four months which the}?" would not have done in several years in the non -pregnant condition." Con- versely, they share in the involution of the uterus after delivery, and often lessen greatly in size, or even entirely disappear. Of this fact I have elsewhere recorded several curious examples ; 1 and many other 1 Obst. Trans., vols. v. xiii. and xix. 212 PREGNANCY. instances of the complete disappearance of even large tumors have been described by authors whose accuracy of observation cannot be questioned. Treatment. — The treatment will vary with the position of the tumor. If it is such as to be certain to obstruct the passage of the child, abortion should be induced as soon as possible. If the tumor is well out of the way, this is not so urgently called for. The princi- pal danger then is that the tumor will impede the post-mortem con- traction of the uterus, and favor hemorrhage. Even if this should happen, the flooding could be controlled by the usual means, espe- cially by the injection of the perchloride of iron. I have seen several cases in which delivery has taken place under such circumstances without any untoward accident. The danger from inflammation and subsequent extrusion of the fibroid masses would probably be as great after abortion or premature labor, as after delivery at term. It seems, therefore, to be the proper rule to interfere when the tumors are likely to impede delivery, and in other cases to allow the preg- nancy to go on, and be prepared to cope with any complications as they arise. The risks of pregnancy should be avoided in every case in which uterine fibroids of any size exist, the patients being advised to lead a celibate life. CHAPTEE IX. PATHOLOGY OF THE DECIDUA AND OVUM. Comparatively little is, unfortunately, known of the pathological changes which occur in the mucous membrane of the uterus during pregnancy. It is probable that they are of much more consequence than is generally believed to be the case ; and it is certain that they are a frequent cause of abortion. Endometritis. — One of the most generally observed probably de- pends on endometritis antecedent to conception. When the impreg- nated ovule reached the uterus, it engrafted itself on the inflamed mucous membrane, which was in an unfit condition for its reception and growth. A not uncommon result, under such circumstances, is the laceration of some of the decidual vessels, extravasation of blood be- tween the decidua and the uterine walls, and consequent abortion at an early stage of pregnancy. As this morbid state of the uterine mucous membrane is likely to continue after abortion is completed, the same history repeats itself on each impregnation, and thus we may have constant early miscarriages produced. It does not neces- sarily follow, however, that the pregnancy is immediatedly terminated when this state of things is present. Sometimes a condition of PATHOLOGY OF THE DECIDUA AND OVUM 213 hyperplasia of the decidua is produced, the membrane becomes much thickened and hypertrophied, and the decidual cells are greatly in- creased in size (Fig. 82). In other instances the internal surface of the decidua becomes studded with rough polypoid growths, 1 depend- Fig. 82. Hypertrophied Decidua laid open, with the Ovum attached to its Fundal Portion. (After Duncan.) ing on proliferation of its interstitial tissue. Duncan has found that the hypertrophied decidua is always in a state of fatty degeneration, more advanced in some places than in others. 2 The result of these alterations is frequently to produce dwindling or death of the ovum, which, however, retains its connection with the decidua, until, after a lapse of time, the decidua is expelled in the form of a thick tri- angular fleshy substance, with the atrophied ovum attached to some part of its inner surface. In other cases, in which the hyperplasia has advanced to a less extent, the nutrition of the foetus is not inter- fered with, and pregnancy may continue to term, the changes in the decidua being recognizable after delivery. Other diseases besides endometritis may give rise to similar alterations in the decidua, one of these being, as Yirchow maintains, syphilis. The converse con- Vireliow's Archiv fur Path. 1868. Researches in Obstetrics, p. 293. 214 PREGNANCY, Imperfectly developed Decidua Yera, with the Ovum. (After Duncan.) Fig. 83. dition, and imperfect develop- ment of the decidua, especially of the decidua reflexa, has also been noted as a cause of abor- tion. The ovum will then hang loosely in the uterine cavity, without the support which the growth of the decidua reflexa around it ought to afford, and its premature expulsion readily follows (Fig. 83). Hydrorrhea Gravidarum. — The peculiar condition known as hydrorrhea gravidarum most probably depends on some ob- scure morbid state of the uterine mucous membrane. By this is meant a discharge of clear watery fluid at intervals during preg- nancy. It may happen at any period of gestation, but it is most commonly met with in the latter months. It may commence with a mere dribbling, or there may be a sudden and copious discharge of fluid. Afterwards the watery fluid, which is generally of a pale yellowish color, and transparent, like the liquor amnii, may continue to escape at intervals for many weeks, and sometimes in very great abundance, so as to saturate the patient's clothes. Yery frequently it is expelled in gushes, and at night, when the patient is lying quietly in bed ; its escape is then probably due to uterine contraction. Many theories have been held as to its cause. By some it is attributed to the rupture of a cyst placed between the ovum and the uterine walls ; Baudelocque referred it to a transudation of the liquor amnii through the membranes ; while Burgess and Dubois believed it to depend on a laceration of the membranes at a distance from the os uteri. Mattei more recently has attributed it to the existence of a sac between the chorion and the amnion. It may be that in some instances a single discharge of fluid may come from one of the two last-mentioned causes. But if it be continuous or repeated, another source must be sought for. Hegar 1 maintains that it is the result of abundant secretion from the glands of the mucous membrane, which accumulates between the decidua and chorion, and escapes through the os uteri. If this occur the decidua is probably in an hypertro- phied and otherwise morbid state. Hydrorrhoea is chiefly of interest from the error of diagnosis it is likely to give rise to ; for, on being- summoned to a case in which watery discharge has occurred for the first time, we are naturally apt to suppose that the membranes have ruptured, and that labor is imminent. Nor is there any very certain means of deciding if this be so. In hydrorrhoea, we find that pains 1 Monat. f. Geburt., 1863. PATHOLOGY OF THE DECIDUA AND OVUM. 215 Fig. 84. are absent, the os uteri unopened, and ballottement may be made out. Even if the membranes be ruptured, there will be no indica- tion for interference unless labor has actually commenced ; and the repetition of the discharge, and the continuance of the pregnane}^, will soon clear up the diagnosis. Hydrorrhcea, although apt to alarm the patient, need not give rise to any anxiety. The pregnancy generally progresses favorably to the full period ; although, in excep- tional cases, premature labor may supervene JSTo treatment is neces- sary, nor is there any that could have the least effect in controlling the discharge. Pathology of the Chorion. — The only important disease of the chorion, with which we are acquainted, is the well-known condition which is variously described as uterine hydatids, cystic disease of the ovum, hydatiform degeneration of the chorion, or vesicular mole. The name of uterine hydatids was long given to it on the supposition that the grapelike vesicles, which characterize the disease, were true hyda- tids, similar to those which develop in the liver and other structures. This idea has long been exploded, and it is now known as a certainty that the disease originates in the villi of the chorion. The precise mode and the causes of its production, are, however, not yet satisfac- torily settled. The disease is character- ized by the existence in the cavity of the uterus of a large number of translucent vesicles,, containing a clear limpid fluid, which has been found on analysis to bear close resemblance to the liquor amnii. These small bladder-like bodies, which vary in size from that of a millet-seed to an acorn, are often described as resem- bling a bunch of grapes or currants. On more minute examination, they are found not to be each attached to independent pedicles, as is the case in a bunch of grapes, bat some of them grow from other vesicles, while others have distinct pedicles attached to the chorion, the pedi- cles themselves sometimes being dis- tended by fluid (Fig. 84). This peculiar arrangement of the vesicles is explained by their mode of growth. Causes of Cystic Degeneration. — There has been considerable discussion as to the etiology of this disease. By some it is supposed always to follow death of the foetus ; and the whole developmental energy being expended on the chorion, which retains its attachment to the decidua, the result is its abnormal growth and cystic degenera- tion. This is the view maintained by Gierse and Graily Hewitt, and it is favored by the undoubted fact that in almost all cases the foetus has entirely disappeared ; and by the occasional occurrence of cases Hydatiform Degeneration of tht Chorion. 216 PREGNANCY. of twin conceptions in which one chorion has degenerated, the other remaining healthy until term. On the other hand, it is maintained that the starting-point is connected with the maternal organism. Virchow thinks it originates in a morbid state of the decidua ; while others have attributed it to some blood dyscrasia on the part of the mother, such as syphilis. There are many reasons for believing that canses of this nature may originate the affection. Th us it is often found to occur more than once in the same person ; and alterations of a simi- lar kind, although limited in extent, are not unfrequentiy found in connection with the placenta and membranes of living children. On this theory the death of the foetus is secondary, the consequence of impaired nutrition from the morbid state of the chorion. The prob- ability is that both views may be right, the disease sometim.es fol- lowing the death of the embryo, and at others being the result of obscure maternal causes. Pathology. — The degeneration of the chorion villi generally com- mences at an early period of pregnancy, before the placenta has com- menced to form. In that case the entire superficies of the chorion becomes affected. The disease, however, may not begin until after the greater part of the chorion villi has atrophied, and then it is lim- ited to the placenta. The epithelium of the villi appears to be the part first affected, and the whole interior of the diseased villus becomes filled with cells. The connective tissue of the villus under- goes a remarkable proliferation, and collects in masses at individual spots, the remainder of the villus being unaffected. By the growth of these elements the villus becomes distended, and many of the cells liquefy, the intercellular fluid, thus produced, widely separating the connective tissue, so as to form a network in the interior of the vil- lus. 1 Thus are formed the peculiar grapelike bodies which charac- terize the disease. When once the degeneration has commenced, the diseased tissue has a remarkable power of increase, so that it some- times forms a mass as large as a child's head, and several pounds in weight. The nutrition of the altered chorion is maintained by its connec- tion with the decidua, which is also generally diseased and hypertro- phied. Sometimes the adhesion of the mass to the uterine walls is very firm, and may interfere with its expulsion ; while, in a few rare cases, it has been found that the villi have forced their way into the substance of the uterus, chiefly through the uterine sinuses, and thus caused atrophy and thinning of its muscular structure. Cases of this kind are related by Volkmann, Waldeyer, 2 and Barnes, and it is obvious that the intimate adhesion thus effected must seriously add to the gravity of the prognosis. Medico-legal Questions. — Taking this view of the etiology of this disease, it is obvious that it is essentially connected with pregnancy, and that there is no valid ground for maintaining, as has sometimes been done, that it may occur independently of conception. It is just 1 Braxton Hicks, Guy's Hospital Reports, vol. ii. Third Series, p. 183. 2 Virchow's Archiv, vol. xliv. p. 88. PATHOLOGY OF THE DECIDTJA AND OVUM. 217 possible, however, that true entozoa may form in the substance of the uterus, which being expelled per vaginam, might be taken for the results of cystic disease, and thus give rise to groundless suspi- cions as to the patient's chastity. Hewitt has related one case in which true hydatids, originally formed in the liver, had extended to the peritoneum, and were about to burst through the vagina at the time of death. This occurred in an unmarried woman. One or two other examples of true hydatids forming in the substance of the ute- rus are also recorded. A very interesting case is also related by Hewitt, 1 in which undoubted acephalocysts were expelled from the uterus of a patient who ultimately recovered. A careful examina- tion of the cyst and its contents would show their true nature, as the echinococci heads, with their characteristic hooklets, would be dis- coverable by the microscope. It is also possible that unfounded suspicions might arise from the fact of a patient expelling a mass of hydatids long after impregnation. In the case of a widow, or woman living apart from her husband, serious mistakes might thus be made. This has been specially pointed out by McClintock, 2 who says, "Hydatids maybe retained in utero for many months or years, or a portion only may be expelled, and the residue may throw out a fresh crop of vesicles, to be dis- charged on a future occasion." Symptoms and Progress of the Disease. — The symptoms of cystic disease of the ovum are by no means well marked. At first there is nothing to point to the existence of any morbid condition, but as pregnancy advances its ordinary course is interfered with. There is more general disturbance of the health than there ought to be, and the reflex irritations, such as vomiting, may be unusually developed. The first physical sign remarked is rapid increase of the uterine tumor, which soon does not correspond in size to the supposed period of pregnancy. Thus, at the third month, the uterus may be found to reach up to, or beyond, the umbilicus. About this time there generally are more or less profuse watery and sanguineous dis- charges, which have been described as resembling currant juice. They no doubt depend on the breaking down and expulsion of the cysts, caused by painless uterine contractions. They are sometimes excessive in amount, recur with great frequency, and often reduce the patient extremely. Portions of cysts may now generally be found mingled with the discharge, and sometimes large masses of them are expelled from time to time. Indeed, the discovery of portions of cysts is the only certain diagnostic sign. Vaginal examination, before the os has dilated, will give no information, except the absence of ballottement. An unusual hardness or density of the uterus- described by Leishman, who attributes much importance to it, as "a peculiar doughy, boggy feeling"— has been pointed out by several writers. The contour of the uterine tumor, moreover, is often irregu- lar. In addition, we, of course, fail to discover the usual ausculta- tory signs of pregnancy. All this may aid in diagnosis, but nothing, 1 Obstet. Trans., vol. xii. 2 McClintoek's Diseases of Women, p. 398. 15 218 PREGNANCY. except the presence of cysts in the watery bloody discharge, will enable ns to pronounce with certainty as to the nature of the disease. Treatment. — As soon as the diagnosis is established, the indications for treatment are obvious. The sooner the uterus is cleared of its contents the better. Ergot may be given with advantage to favor uterine contraction, and the expulsion of the diseased ovum. Should this fail, more especially if the hemorrhage be great, the fingers, or the Avhole hand, must be introduced into the uterus, and as much as possible of the mass removed. As the os is likely to be closed, its preliminary dilatation by sponge or laminaria tents, or by a Barnes's bag, if it be already opened to some extent, will in most cases be required. If chloroform be then administered, the remaining steps of the operation will be easy. On account of the occasional firm adhesion of the cystic mass to the uterus, too energetic attempts at complete separation should be avoided. Any severe hemorrhage after the operation can be controlled by swabbing out the uterine cavity with the per chloride of iron solution. Under the name of Myxoma fibrosum, a more rare degeneration of the chorion has been described by Yirchow and Hildebrandt, 1 char- acterized, not by vesicular, but fibroid degeneration of the connective tissue of the chorion. This is, however, too little understood to require further observation. Pathology of the Placenta. — The pathology of the placenta has of late years attracted much attention, and it has an important practical bearing in consequence of its effects on the child. Placentas vary considerably in shape. They may be crescentic, or spread over a considerable surface, in consequence of the chorion villi entering into communication with a larger portion of the de- cidua than usual [Placenta membranacea). Such forms, however, are merely of scientific interest. The only anomaly of shape of any practical importance is the formation of what have been called pla- centae succenturise. These consist of one or more separate masses of placental tissue, produced by the development of isolated patches of chorion villi. Hohl believes that they always form exactly at the junction of the anterior and posterior walls of the uterus, which in early pregnancy is a mere line. As the uterus expands, the portions of placenta, on each side of this, become separated from each other. They are only of consequence from the possibility of their remain- ing unnoticed in the uterus after delivery, and giving rise to second- ary post-partum Hemorrhage. The rare form of double placenta with a single cord, figured in the accompanying woodcut (Fig. 85), was probably formed in this way, and the supplementary portion, in such a case, might readily escape notice. The placenta may also vary in dimensions. Sometimes it is of excessive size, generally when the child is unusually big ; but not infrequently in connection with hydramnios, the child being dead and shrivelled. In other cases it is remarkably small, or at least appears to be so. If the child be healthy, this is probably of no 1 Monat. f. Geburt, May, 1865. PATHOLOGY OF THE DECIDUA AND OVUM 219 pathological importance, as its smallness may be more apparent than real, depending on its vessels not being distended with blood. When true atrophy of the placenta exists, the vitality of the foetus may be seriously interfered with. This condition may depend either on a diseased state of the chorion villi, or of the decidua in which they are implanted. 1 The latter is the more common of the two ; and it generally consists in hyperplasia of the connective tissue of the de- cidua, which presses on the villi and vessels, and gives rise to gen- eral or local atrophy. This change is similar in its nature to that observed in cirrhosis of the liver, and certain forms of Bright's dis- ease. It has generally been ascribed to inflammatory changes, and, under the name of placentitis, has been described by many authors, Fig. Double Placenta, with single cord and has been considered to be a common disease. To it are attributed many of the morbid alterations which are commonly observed in placentae, such as hepatization, circumscribed purulent deposits, and adhesions to the uterine walls. Many modern pathologists have doubted whether these changes are in any proper sense inflammatory. Whittaker observes on this point : " The disposition to reject pla- centitis altogether increases in modern times. Indeed, it is impos- sible to conceive of inflammation on the modern theory (Cohnheim) of that process, since there are no capillaries, in the maternal portion 1 Whittaker, Amer. Journ. of Obst.. vol. iii., p. 229. 220 PREGNANCY at least, through whose walls a 'migration' might occur, and there are no nerves to regulate the contractility of the vessel- walls in the entire structure." Kobin thus explains the various pathological changes above alluded to: "What has been taken for inflammation of the placenta is nothing else than a condition of transformation of blood clots at various periods. What has been regarded as pus is only fibrine in the course of disorganization, and in those cases where true pus has been found the pus did not come from the pla- Fig. 86. fee/ Fatty Degeneration of the Placenta. centa, but from an inflammation of the tissue of the uterine vessels and an accidental deposition in the tissue of the placenta." The extravasations of blood here alluded to are of very common occur- rence, and they are found in all parts of the organ ; in its substance, on its decidual surface, or immediately below the amnion, where they serve as points of origin for the cysts that are there often observed. The fibrine thus deposited undergoes retrograde meta- morphosis as iii other parts of the body ; it becomes decolorized, it undergoes fatty degeneration or becomes changed into calcareous masses ; and in this way, it is supposed, may be explained the vari- ous pathological changes which are so commonly observed. The amount of retrograde metamorphosis, and the precise appearance presented will, of course, depend on the time that has elapsed since the blood extravasations took place. Fatty degeneration of the placenta, and its influence on the nutri- PATHOLOGY OF THE DECIDUA AND OVUM 221 tion of the foetus, have been specially studied iu this country by Barnes and Druitt. Yellowish masses of varying size are very commonly met with in placentae, and these are found to consist, in great part, of molecular • fat, mixed with a fine network of fibrous tissue. The true fatty degeneration, however, specially affects the chorion villi (Fig. 86). On microscopic examination they are found to be altered and misshaped in their contour, and to be loaded with fine granular fat-globules. Similar changes are observed in the cells of the decidua. The influence on the foetus will, of course, depend on the extent to which the functions of the villi are interfered with. The probable cause of this degeneration is, no doubt, some obscure alteration in the nutrition of the tissue, depending on the state of the mother's health. Barnes believes that syphilis has much influence in its production. Druitt has pointed out that some amount of fatty degeneration is always present in a mature placenta, and is probably connected with the physiological separation of the organ ; and Groodell has more recently suggested that an unusual amount of this change may be merely an anticipation of the natural termination of the life of the placenta. 1 Other morbid states of the placenta, of greater rarity, are occasionally met with, as an oedematous infiltration of its tissue, always occurring, according to Lange, in cases of hydramnios ; pigmentary and calca- reous deposits; and tumors of various kinds : but these require only a passing mention. Pathology of the Umbilical Cord. — The umbilical cord may be of excessive length, varying from 18 to 20 inches, which is its average measurement, up to 50 or 60 inches, and a case is recorded in which it even reached the extraordinary length of 9 feet. If unusually long it may be twisted round the limbs or neck of the child, and the latter position may, in exceptional in- stances, prove injurious during labor. Some authors refer cases of spontane- ous amputation of foetal limbs in utero to constrictions by the umbilical cord, but this accident is more probably pro- duced by filamentous adnexa of the amnion. Knots in the cord are not un- common, and they result from the foetus, in its movements, passing through a loop of the cord (Fig. 87). If there is an average amount of Wharton's jelly in the cord the vessels are protected from pressure, and no bad effects follow. Grery, in a recent paper on this subject, 2 at- tempts to show that such knots are more Fig Knots of the Umbilical Cord. 1 American Journal of Obstetrics, vol. ii. p. 535. 2 L' Union Medicale, Oct., 1876. 222 PREGNANCY. important than is generally believed, and relates two cases in which he believes them to have caused the death of the foetus. Extreme torsion of the cord, an exaggeration of the spiral twists generally observed, may prove injurious, and even fatal, to the child by obstructing the circulation in the vessels. Spaeth mentions three cases in which this caused the death of the foetus, the cord being twisted until it was reduced to the thickness of a thread. Anomalies in the distribution of the vessels of the cord are of common occurrence. The cord may be attached to the edge, instead of to the centre, of the placenta {battledore placenta). It may break up into its component parts before reaching the placenta, the vessels running through the membranes ; and if, in such a case, traction on the cord be made, the separate vessels may lacerate, and the cord become detached. There may be two veins and one artery, or only one vein and oue artery, or there may be two separate cords to one placenta. These, and other anomalies that might be mentioned, are of little practical importance. The principal pathological condition of the amnion with which we are acquainted is that which is associated Avith excessive secretion of liquor amnii, and is generally known under the name of hydr amnios. Its precise cause is still a matter of doubt. By some it is referred to inflammation of the amnion itself; at other times it is apparently connected with some morbid state of the decidua, which may be found diseased and hypertrophied. The foetus is very often dead and shrivelled, and the placenta enlarged and ©edematous. It does not necessarily follow, however, that hydramnios causes the death of the child. Out of 33 cases McClintock found that 9 children were born dead ; x and of the 19 born alive, 10 died within a few hours, the remainder survived. There does not appear to be any marked rela- tion between the state of the mother's health and the occurrence of this disease ; and it is certainly not necessarily present when the mother is suffering from dropsical effusions in other parts of the body. The theory that the disease is of purely local origin is favored by the fact, that when hydramnios occurs in twin pregnancy, one ovum only is generally affected. Its effects, as regards the mother, are chiefly mechanical. It rarely begins to show itself before the fifth or sixth month of pregnancy, but, when once it has commenced, it rapidly produces a feeling of discomfort and enlargement, alto- gether beyond that which should exist at the period of pregnancy which has been reached. In advanced stages the distress produced is often very great, the enlarged uterus pressing upon the diaphragm, and producing much embarrassment of respiration. Premature expulsion of the foetus very often supervenes. Four out of McClin- tock's patients died after labor, showing that the maternal mortality is high, a result which he refers to the debilitated state of the women who were the subjects of the disease. Diagnosis. — The diagnosis is not, as a rule, difficult. It has to be distinguished from ascitic distension of the abdomen, and from en- 1 Diseases of Women, p. 383. PATHOLOGY OF THE DECIDUA AND OVUM. 223 largement of the uterus from twin pregnancy. The former will be recognized by the superficial position of the fluid ; the difficulty of feeling the contour of the uterus, which is obscured by the surround- ing fluid ; and by the coexistence of dropsical effusions in other parts of the body. The latter may be difficult, and even impossible, to diagnose from it : generally, however, in hydramnois the uterine tumor is more distinctly tense or fluctuating; the foetal limbs cannot be felt on palpation ; and the lower segment of the uterus, as felt per vaginam, is unusually distended, the presenting part not being ap- preciable. Its effect on Labor. — During labor an excessive amount of liquor amnii is often a cause of deficient uterine action and delay, the pains being feeble and ineffective. This, of course, tells chiefly in the first stage, which is often much prolonged, unless the membranes are punctured early, and the superabundant fluid allowed to escape. Treatment. — Xo treatment is known to have any effect on the disease. If the discomfort and distension are verj T great, it may be absolutely necessary to puncture the membranes, and allow the water to escape. This inevitably brings on labor. If the pregnancy be not sufficiently advanced to give hope for the birth of a living child, we would not, of course, resort to this expedient unless the mother's health was seriously imperilled. It is possible that in such cases the patient might be relieved by inserting the minute needle of an aspi- rator through the os, and removing a certain quantity of the liquor amnii by aspiration, without inducing the labor. I have never had an opportunity of trying this expedient, but it seems a possibility. Deficiency of Liquor Amnii. — A defective amount of liquor amnii is said to favor certain malformations, by allowing the uterus to compress the foetus unduly. It certainly occasionally gives rise to adhesion between the foetus and the membranes, and to the formation of amniotic bands which are capable of producing certain foetal de- formities (p. 227). Appearance of the Liquor Amnii. — The liquor amnii itself varies much in appearance. It is sometimes thick and treacly, instead of limpid, and it may be offensive in odor. The cause of these varia- tions is not well understood. Pathology of the Foetus. — There is abundant evidence that the foetus in utero is subject to many diseases, some of which cause its death, and others leave distinct traces of their existence, although not proving fatal. The subject is of great importance, and is well worthy of study. There is still much to be done in this direction, which may yet lead to important practical results. I can, however, do little more than enumerate some of the principal affections which have been observed. Blood Diseases transmitted through the Mother. Smallpox. — It is a well-established fact that the various eruptive fevers, from which the mother may suffer, may be communicated to the foetus in utero. When the mother is attacked with confluent smallpox, she almost always aborts, but not necessarily so when it is discrete or modified. In such cases it has often happened that the foetus has been born 224 PKEGNANCY. with evident marks of smallpox. Cases are on record which, prove that the foetus was attacked subsequently to the mother. Thus a mother attacked with smallpox has miscarried, and has given birth to a living child showing no trace of the disease, which, however, showed itself in two or three days; proving that it had been con- tracted, and had ran through its usual period of incubation, when the foetus was still in utero. It does not follow, however, that the foetus is aifected, as Serres has collected 22 cases in which women, suffering from smallpox, gave birth to children who had not con- tracted the disease. It has been supposed that, in such cases, the child is protected from small-pox, though it has shown no symptom of having had the disease. Tarnier, however, cites two instances in which such children had smallpox two years after birth. Madge and Simpson record cases in which vaccination performed on the mother daring pregnancy protected the foetus, on whom all subse- quent attempts at vaccination failed. There is evidence also to prove that the disease may be transmitted to the foetus through a mother, who is herself unsusceptible of contagion; the child having been covered with smallpox eruption, the mother being quite free from it. It is probable, that the same facts which have been ob- served with regard to smallpox, hold true with reference to other zymotic diseases, such as scarlet fever and measles, although there is not sufficient evidence to justify a positive assertion to that effect. Measles and Scarlet Fever. — 'Amongst other maternal diseases, mala- rious and lead poisoning are known to affect the foetus in utero. Dr. Stokes relates cases in which the mother suffered from tertian ague, the child having also attacks, as evidenced by its convulsive move- ments, appreciable by the mother, which took place at the regular intervals, but at a different time from the mother's paroxysms. In other cases the febrile paroxysm comes on at the same time in the foetas as in the mother; and the fact has been verified by the observa- tion that the paroxysms continued to recur simultaneously after delivery. The foetus has also been born with distinct malarious enlargement of the spleen. From the frequency with which largely hypertrophied spleens are seen in mere infants in malarious districts, I imagine that the intra-uterine disease must be common. I have frequently observed this fact in India, although, of course, without any possibility of ascertaining if the mothers had suffered from inter- mittent fever during pregnancy. Lead-poisoning is also known to have a most prejudicial effect on the foetus, and frequently to lead to abortion. M. Paul has collected 81 cases, 1 in which it caused the death of the foetus, in some not until after birth; and occasionally it seems to have affected the foetus even when the mother escaped. Syphilis. — Of all blood dyscrasias transmitted to the foetus, the most important is sj^pliilis. Its influence in producing repeated abortion has been elsewhere described. It may unquestionably be transmitted to the foetus without producing abortion, and at term the mother may be either delivered of a living child, bearing evi- 1 Arch. Gen. tie Med., I860. PATHOLOGY OF THE DECIDUA AND OVUM. 225 dent traces of the disease ; of a dead child similarly affected ; or of an apparently healthy child in whom the disease develops itself after a lapse of a month or two. These varying effects probabl} r de- pend on the intensity of the poison. The disease is, no doubt, gen- erally transmitted through the mother, and if she be affected at the time of conception, the infection of the feet us seems certain. If, however, she contracts the disease at an advanced period of preg- nancy the child may entirely escape. Kicord even believes that syphilis, contracted after the six months of pregnancy, never affects the child. The father alone may transmit the disease to the ovum ; and Hutchinson has recorded cases to show that the mother may be- come secondarily affected through the diseased foetus. The evi- dences of syphilitic taint in a living or dead child are sufficiently characteristic. The child is generally puny and ill-developed. An eruption of pemphigus is common, either fully developed bullae, or their early stage, when they form circular copper-colored patches. This eruption is always most marked on the hands and feet, and a child born with such an eruption may be certainly considered sphi- litic. On post-mortem examination the most usual signs are small patches of suppuration in the thymus, similar localized suppurations in the tissues of the lungs, indurated yellowish patches in the liver, and peritonitis, the importance of which in causing the death of syphilitic children has been specially dwelt on by Simpson. 1 Inflammatory Diseases. — The most important of the inflammatory diseases affecting the foetus is peritonitis. Simpson has shown that traces of it are very frequently met with, and that it is not always syphilitic. Sometimes it has been observed when the mother has been in bad health during pregnancy, and at others it seems to have resulted from some morbid condition of the foetal viscera. Pleurisy, with effusion, is another inflammatory affection which has been noticed. Dropsies. — The dropsical affections most generally met with are ascites and hydrocephalus, which may both have the effect of im- peding delivery. Of these hydrocephalus is the more common, and may give rise to much difficulty in labor. Its causes are uncertain but it probably depends on some altered state of the mother's health, as it is apt to recur in several successive pregnancies, and is not in- frequently associated with an imperfectly developed vertebral column and spina bifida. The fluid collects in the ventricles, which it greatly distends, and these then produce expansion and thinning of the crauium, the bones of which are widely separated from each other at the sutures, which are prominent and fluctuating. In a few cases internal hydrocephalus may be complicated, and the diag- nosis in labor consequently obscured, by the coexistence of what has been called " external hydrocephalus." This consists of a collec- tion of fluid between the skull and the scalp, which may be either formed there originally, or may collect from a rupture of one of the sutures or fontanelles during labor, through which the intra-cranial fluid escapes. 1 Obst. Works, vol. i. p. 117. 226 PREGNANCY. Ascites is generally associated with hydramnios, and sometimes with hydro-thorax, or other dropsical effusions. Tt is a rare affec- tion, and, according to Depaul, 1 extreme distension of the bladder is noj; infrequently mistaken for it. Tumors of different kinds may be met with in various parts of the child's body, which sometimes grow to a great size and impede de- livery. Tarnier records cases of meningocele larger than a child's head, and large cj^stic growths have been observed attached to the nates, pectoral region, or other parts of the body. Cancerous tumors of considerable size, either external, or of the viscera, have also been met with. Other foetal tumors may be produced by congenital de- formities, such as projection of the liver or other abdominal viscera through a deficiency of the abdominal wall ; or spina bifida, from imperfectly developed vertebrae. The amount of dystocia produced by such causes will, of course, vary much in proportion to the size, consistency, and accessibility of the tumor. Wounds and Injuries of the Foetus. — Accidents of serious gravity to the foetus may happen from violence, to which the mother has been subjected, such as falls or blows, without necessarily interfering with gestation. Many curious examples of this kind are on record. Thus a child has been born presenting a severe lacerated wound, ex- tending the whole length of the spine, Avhere both the skin and the muscles had been torn, and which seems to have resulted from the mother having fallen in the last month of pregnancy. Similar lacerations and contusions have been observed in other parts of the body, the wounds being in various stages of cicatrization, corre- sponding to the lapse of time since the acci- dent had occurred. Intra-uterine fractures are not rare, apparently arising from similar causes. In some of these cases the broken ends of the bones had united, but, from want of accurate apposition, at an acute angle, so as to give rise to much subsequent de- formity. Chaussier records two cases in which there were many fractures in the same child, in one 113, and in another 42, which were in different stages of repair. He attributes this curious occurrence to some congenital defect in the nutrition of the bones, possibly allied to mollities ossium. 2 Intra-uterine amputations of foetal limbs have not infrequently been observed. Children are occasionally born with one ex- tremity more or less completely absent, and cases are known in which the whole four extremities were wanting (Fig. 88.) The mode in which these malformations are produced has given rise to much discussion. At one time it was supposed that the deficiency Fig Intra-uterine Amputation of both Arms and Leeither the history of previous labor, or a careful examination, con- vinces us that there is no obstacle due to pelvic deformity, in which Gazette Medicale, 1864. DYSTOCIA FROM F(ETUS. 363 the pains are strong and forcing, but in which the head persistently refuses to engage in the brim, we may fairly surmise the existence of hydrocephalus. Nothing, however, short of a careful examination under anaesthesia, the whole hand being passed into the vagina so as to explore the presenting part thoroughly, will enable us to be quite sure of the existence of this complication. Under these circum- stances such a complete examination is not only justified but impera- tive ; and, when it has been made, the difficulties of diagnosis are lessened, for then we may readily make out the large round mass, softer and more compressible than the healthy head, the widely sepa- rated sutures, and the fluctuating fontanelles. Pelvic Presentations are frequently met vjith. — In a considerable proportion of cases — as many, it is said, as 1 out of 5 — the foetus presents by the breech. The diagnosis is then still more difficult ; for the labor progresses easily until the shoulders are born, when the head is completely arrested, and refuses to pass with any amount of traction that is brought to bear on it. Even the most careful exami- nation may not now enable us to make out the cause of the delay, for the finger will impinge on the comparatively firm base of the skull, and may be unable to reach the distended portion of the cranium. At this time abdominal palpation might throw some light on the case, for the uterus being tightly contracted round the head, we might be able to make out its unusual dimensions. The wasted and shrivelled appearance of the child's body, which so often accom- panies hydrocephalus, would also arouse suspicion as to the cause of delay. On the whole such cases may be fairly assumed to be less dangerous to the mother than when the head presents ; for, in the latter, the soft parts are apt to be subjected to prolonged pressure and contusion ; while in the former, delay does not commence till after the shoulders are born, and then the character of the obstacle would be sooner discovered, and appropriate means earlier taken to overcome it. Treatment. — 'The treatment is simple, and consists in tapping the head, so as to allow the cranial bones to collapse. There is the less objection to this course, since the disease almost necessarily precludes the hope of the child's surviving. The aspirator would draw off the fluid effectually, and would at least give the child a chance of life ; and, under certain circumstances, the birth of a child, who lives for a short time only, may be of extreme legal importance. More gene- rally the perforator will be used, and as soon as it has penetrated, a gush of fluid will at once verify the diagnosis. Schroeder recom- mends that, after perforation, turning should be performed, on account of the difficulty with which the flaccid head is propelled through the pelvis. This seems a very unnecessary complication of an already sufficiently troublesome case. As a rule, when once the fluid has been evacuated, the pains being strong, as they generally are, no delay need be apprehended. Should the head not come down, the cephalotribe may be applied, which takes a firmer grasp than the forceps, and enables the head to be crushed to a very small size and readily extracted. 364 LABOR. Treatment when the Breech Presents. — When the breech presents, the head mnst be perforated through the occipital bone, and gene- rally this may be accomplished behind the ear without much diffi- culty. It has been said that opening of the vertebral canal might allow the intra- cranial fluid to escape, but I am not aware that the suggestion has ever been carried into practice. Other forms of dropsical effusion may give rise to some difficulty, but by no means so serious. In a few rare cases the thorax has been so distended with fluid as to obstruct the passage of the child. Ascites is somewhat more common; and, occasionally, the child's bladder is so distended with urine as to prevent the birth of the body. The existence of any of these conditions is easily ascertained ; for the head or breech, whichever happens to present, is delivered without difficulty, and then the rest of the body is arrested. This will naturally cause the practitioner to make a careful exploration, when the cause of the delay will be detected. The treatment consists in the evacuation of the fluid by puncture. In the case of ascites, this should always be done, if possible, by a fine trocar or aspirator, so as not to injure the child. This is all the more important since it is impossible to distinguish a distended bladder from ascites, and an opening of any size into that viscus might prove fatal, whereas aspiration would do little or no harm, and would prove quite as efficacious. Foetal Tumors Obstructing Delivery. — Certain foetal tumors may occasion dystocia, such as malignant growths, or tumors of the kidney, liver, or spleen. Cases of this kind are recorded in most obstetric works. Hydro-encephacele, or hydro-rachitis, depending on defective formation of the cranial or spinal bones, with the for- mation of a large protruding bag of fluid, is not very rare. The diagnosis of all such cases is somewhat obscure, nor is it possible to lay down any definite rules for their management, which must vary according to the particular exigencies. The tumors are rarely of sufficient size to prove formidable obstacles to delivery, and many of them are very compressible. This is especially the case with spina bifida and similar cystic growths. Puncture, and in the more solid growths of the abdomen or thorax, evisceration, may be required. Other Congenital Deformities. — Other deformities, such as the anen- cephalous foetus, or defective development of the thorax or abdominal parietes with protrusion of the viscera, are not likely to cause any difficulty; but they may much embarrass the diagnosis by the strange and unusual presentation that is felt. If, in any case of doubt, a full and careful examination be undertaken, introducing; the whole hand if necessary, no serious mistake is likely to be made. Dystocia from Excessive Development of the Foetus. — In addition to dystocia from morbid conditions of the foetus, difficulties may arise from its undue development, and especially from excessive size and advanced ossification of the skull. This last is especially likely to cause delay. Even the slight difference in size between the male and female head was found by Simpson to have an appreciable effect in increasing the difficulty of labor, when the statistics of a large DYSTOCIA FROM FCETUS. 365 number of cases were taken into account; for he proved beyond doubt that the difficulties and casualties of labor occurred in de- cidedly larger proportion in male than in female births. Other cir- cumstances, besides sex, have an important effect on the size of the child. Thus Duncan and Hecker have shown that it increases in proportion to the age of the mother and the frequency of the labors, while the size of the parents has no doubt also an important bearing on the subject. Although these influences modify the results of labor en masse, they have little or no practical bearing on any particular case, since it is impossible to estimate either the size of the head, or the degree of its ossification, until labor is advanced. Its Treatment. — When labor is retarded by undue ossification or large size of the head, the case must be treated on the same general principles which guide us when the want of proportion is caused by pelvic contraction. Hence, if delay arise, which the natural powers are insufficient to overcome, it will seldom happen that the dispro- portion is too great for the forceps to overcome. If we fail to de- liver by it, no resource is left but perforation. Large Size of the Body rarely causes Delay. — Large size of the body of the child is still more rarely a cause of difficulty, for, if the head be born, the compressible trunk will almost always follow. Still, a few authentic cases are on record, in which it was found im- possible to extract the foetus on account of the unusual bulk of its shoulders and thorax. Should the body remain firmly impacted after the birth of the head, it is easy to assist its delivery by traction on the axillse, by gently aiding the rotation of the shoulders into the antero- posterior diameter of the pelvic cavity, and, if necessary, by extracting the arms, so as to lessen the bulk of the part of the body contained in the pelvis. Hicks relates a case in which evisceration was required for no other apparent reason than the enormous size of the body. The necessity for any such extreme measure must, of course, be of the greatest possible rarity ; and it is quite exceptional for difficulty from this source to be beyond the powers of nature to overcome. 366 LABOR. CHAPTER XII. DEFORMITIES OF THE PELVIS. Deformities of the pelvis form one of the most important sub- jects of obstetric study, for from them arise some of the gravest difficulties and dangers connected with parturition. A knowledge, therefore, of their causes and effects, and of the best mode of de- tecting them, either during or before labor, is of paramount necessity ; but the subject is far from easy, and it has been rendered more dim- cult than it need be, from over-anxiety on the part of obstetricians to force all varieties of pelvic deformities within the limits of their favorite classification. Difficulties of Classification. — Many attempts in this direction have been made, some of which are based on the causes on which the deformities depend, others on the particular kind of deformity pro- duced. The changes of form, however, are so various and irregular, and similar, or apparently similar, causes so constantly produce dif- ferent effects, that all such endeavors have been more or less unsuc- cessful. For example, we find that rickets (of all causes of pelvic deformity the most important) generally produces a narrowing of the conjugate diameter of the brim; while the analogous disease, osteo-malacia, occurring in adult life, generally produces contraction of the transverse diameter, with approximation of the pubic bones, and relative or actual elongation of the conjugate diameter. We might, therefore, be tempted to classify the results of these two diseases under separate heads, did we not find that, when rickets affects children who are running about, and subject to mechanical influences similar to those acting upon patients suffering from osteo- malacia, a form of pelvis is produced hardly distinguishable from that met with in the latter disease. Most Simple Classification. — On the whole, therefore, the most simple, as well as the most scientific, classification is that which takes as its basis the particular seat and nature of the deformity. Let us first glance at the most common causes. Causes of Pelvic Deformity. — The key to the particular shape as- sumed by a deformed pelvis will be found in a knowledge of the cir- cumstances which lead to its regular development and normal shape in a state of health. The changes produced may, almost invariably, be traced to the action of the same causes which produce a normal pelvis, but which, under certain diseased conditions of the bones or articulations, induce a more or less serious alteration inform. These have been already described in discussing the normal anatomy of the pelvis, and it will be remembered that they are chiefly the weight of the body, transmitted to the iliac bones through the sacro-iliac joints, DEFORMITIES OF THE PELVIS. 867 and counter-pressure on these, acting through the acetabula. Some- times they act in excess on bones which are healthy, but possibly smaller than usual, and the result may be the formation of certain abnormalities in the size of the various pelvic diameters. At other times they operate on bones which are softened and altered in texture by disease, and which, therefore, yield to the pressure far more than healthy bones. The two diseases which chiefly operate in causing deformity are rickets and osteo-malacia. Into the essential nature and symptoma- tology of these complaints it would be out of place to enter here ; it may suffice to remind the reader that they are believed to be patho- logically similar diseases, with the important practical distinction that the former occurs in early life before the bones are completely ossified, and that the latter is a disease of adults producing softening in bones that have been hardened and developed. This difference affords a ready explanation of the generally resulting A^arieties of pelvic deformity. Effects of Rickets. — Rickets commences very early in life, some- times, it is believed, even in utero. It rarely produces softening of the entire bones, and only in cases of very great severity of those parts of the bones that have been already ossified. The effects of the disease are principally apparent in the cartilaginous portions of the bones, in which osseous deposit has not yet taken place. The bones, therefore, are not subject to uniform change, and this fact has an important influence in determining their shape. Rickety children also have imperfect muscular development ; they do not run about in the same way as other children, they are often continuously in the recumbent or sitting postures, and thus the weight of the trunk is brought to bear, more than in a state of health, on the softened bones. For the same reason counter-pressure through the acetabula is absent or comparatively slight. When, however, the disease occurs for the first time in children who are able to run about, the latter comes into operation, and modifies the amount and nature of the deformity. It is to be observed that in rickety children the bones are not only altered in form from pressure, but are also imperfectly developed, and this materially modifies the deformity. When ossific matter is deposited, the bones become hard and cease to bend under external influences, and retain forever the altered shape they have assumed. Effects of Osteo-malacia. — In osteo-malacia, on the contrary, the already hardened bones become softened uniformly through all their textures, and thus the changes which are impressed upon them are much more regular, and more easily predicated. It is, however, an infinitely less common cause of pelvic deformity than rickets, as is evidenced by the fact that in the Paris Maternity in a period of sixteen years, 402 cases of deformity due to rickets occurred to 1 due to osteo-malacia. 1 Their varying Frequency. — The frequency of both diseases varies greatly in different countries, and under different circumstances. 1 Stanesco, Recherches Cliniques sur les R6tr6cissements du Bassin. 368 LABOR. Eickets is much more common amongst the poor of large cities, whose children are ill-fed, badly clothed, kept in a vitiated atmo- sphere, and subjected to unfavorable hygienic conditions. Deformi- ties are, therefore, more common in them than in the more healthy children of the upper classes, or of the rural population. 1 The higher degrees of deformity, necessitating the Cesarean section, or crani- otomy, are in this country of extreme rarity ; while, in certain districts on the Continent, they seem to be so frequent that these ultimate resources of the obstetric art have to be constantly employed. Effects of Ossification of Pelvic Articulations. — In another class of cases the ordinary shape is modified by weight and counter-pressure operating on a pelvis in which one or more of the articulations is ossified. In this way we have produced the obliquely ovate pelvis of Naegele, or the still more uncommon transversely contracted pelvis of Eobert. Other Causes of Pelvic Deformity. — A certain number of deformed pelves cannot be referred to a modification of the ordinary develop- mental changes of the bones. Amongst these are the deformities resulting from spondylolithesis, or downward dislocation of the lower lumbar vertebras ; from displacements of the sacrum, produced by curvatures of the spinal column ; or from diseases of the pelvic bones themselves, such as tumors, malignant growths, and the like. Equally Enlarged Pelvis. — The first class of deformed pelves to be considered is that in which the diameters are altered from the usual standard, without any definite distortion of the bones ; and such are often mere congenital variations in size, for which no definite expla- nation can be given. Of this class is the pelvis which is equally enlarged in all its diameters {pelvis sequabiliter justo major), which is of no obstetric consequence, except insomuch as it may lead to pre- cipitate labor, and is not likely to be diagnosed during life. Equally Contracted Pelvis. — The corresponding diminution of all the pelvic diameters (pelvis sequabiliter justo minor) may be met with in women who are apparently well formed in every respect, and whose external conformation and previous history give no indica- tion of the abnormality. Sometimes the diminution amounts to half an inch or more, and it can readily be understood that such a lessening in the capacity of the pelvis would give rise to serious difficulty in labor. Thus, in 3 cases recorded by Naegele a fatal re- sult followed ; in 2 after difficult instrumental delivery, and in the third after rupture of the uterus. The equally lessened pelvis, how- ever, is of great rarity. An unusually small pelvis may be met with in connection with general small size, as in dwarfs. It does not necessarily follow, because a woman is a dwarf, that the pelvis is too small for parturition. On the contrary, many such women have borne children without difficulty. The Undeveloped Pelvis. — In some cases a pelvis retains its in- fantile characteristics after puberty (Fig. 125). The normal develop- 1 [These appear to be more common among the blacks of Alabama and Louisiana, than any other part of our population ; and in these States the Ca?sarean operation has been the most frequently performed of any in the Union. — Ed.] DEFORMITIES OF THE PELVIS. 369 merit of trie pelvis has been interfered with, possibly from premature ossification of the different portions of the innominate bones, or from arrest of their growth by a weakly or rachitic constitution. The measurements of these pelves are not always below the normal standard, they may continue to grow, although they have not de- veloped. The proportionate measurements of the various diameters Fig. 125. Adult Pelvis Retaining its Infantile Type. will then be as in the infant ; and the antero-posterior diameter may be longer, or as long, as the transverse, the ischia comparatively near each other, and the pubic arch narrow. Such a form of pelvis will interfere with the mechanism of delivery, and unusual difficulty in labor will be experienced. Difficulties from a similar cause may be expected in very young girls. Here, however, there is reason to hope that, as age advances, the pelvis will develop, and subsequent labors be more easy. Masculine or Funnel-shaped Pelvis. — The masculine, or funnel- shaped pelvis owes its name to its approximation to the type of the male pelvis. The bones are thicker and stouter than usual, the con- jugate diameter of the brim longer, and the whole cavity rendered deeper and narrower at its lower part by the nearness of the ischial tuberosities. It is generally met with in strong muscular women following laborious occupations, and Dr. Barnes, from his experience in the Eoyal Maternity Charity, says that it chiefly occurs in weavers in the neighborhood of Bethnal Green, who spend most of their time in the sitting posture. " The cause of this form of pelvis seems to be an advanced condition of ossification in a pelvis which would otherwise have been infantile, brought about by the development of unusual muscularity, corresponding to the laborious employment of the individual." The difficulties in labor will naturally be met with towards the outlet, where the funnel shape of the cavity is most apparent. 370 LABOR. Contraction of Conjugate Diameter of Brim. — Diminution of the antero-posterior diameter is most frequently limited to the brim, and is by far the most common variety of pelvic deformity. In its slighter degrees it is not necessarily dependent on rickets, although when more marked it almost invariably is so. When unconnected with rickets, it probably can be traced to some injurious influence before the bones have ossified, such as increased pressure of the trunk from carrying weights in early childhood, and the like. By this means the sacrum is unduly depressed, and projects forwards, so as to slightly narrow the conjugate diameter. Mode of production in Rickets. — When caused by rickets the amount of the contraction varies greatly, sometimes being very slight, some- times sufficient to prevent the passage of the child altogether, and necessitate craniotomy of the Cesarean section. The sacrum, softened by the disease, is pressed vertically downwards by the weight of the body, its descent being partially resisted by the already ossified por- tions of the bone, so that the result is a downward and forward movement of the promontory. The upper portion of the sacral con- cavity is thus directed more backwards ; but, as the apex of the bone is drawn forwards by the attachment of the perineal muscles to the coccyx, and by the sacro-ischiatic ligaments, a sharp curve of its lower part in a forward direction is established. Occasional Increase of Transverse Diameter. — The depression of the sacral promontory would tend to produce strong traction, through the sacro-iliac ligaments, on the posterior ends of the sacro-cotyloid beams, and thus induce expansion of the iliac bones, and consequent increase of the transverse diameter of the brim. So an unusual length of the transverse diameter is very often described as accom- panying this deformity, but probably it is not so often apparent as might otherwise be expected, on account of the imperfect develop- ment of the bones generally accompanying rickets ; and Barnes 1 says that in the parts of London where deformities are most rife, any enlargement of the transverse diameter is -exceedingly rare. Fre- quently the sacrum is not only depressed, but displaced more or less to one side, most generally to the left, thus interfering with the regular shape of the deformed brim. This is often the result of a lateral flexion of the spinal column, depending on the rachitic dia- thesis. Cavity of Pelvis is generally not Affected. — In most cases of this kind the cavity of the pelvis is not diminished in size, and is often even more than usually wide. The constant pressure on the ischia, which the sitting posture of the child entails, tends to force them apart, and also to widen the pubic arch. Considerable advantage results from this in cases in which we have to perform obstetric ope- rations, as it gives plenty of room for manipulation. Figure-of-eight Deformity. — In a few exceptional cases the narrow- ing of the conjugate diameter is increased by a backward depression of the symphysis pubis, which gives the pelvic brim a sort of figure- 1 Lectures on Obst. Operations, p. 280 DEFORMITIES OF THE PELVIS. 371 of-eight shape (Fig. 126). The most reasonable explanation of this peculiarity seems to be, that it is the result of the muscular contrac- tion of the recti muscles, at their point of attachment, when the centre of gravity of the body is thrown backwards, on account of Fig. 126. Rickety Pelvis, with backward depression of the Symphysis Pubis. the projection of the sacral promontory. Sometimes also the antero- posterior diameter of the cavity is unusually lessened by the disap- pearance of the vertical curvature of the sacrum, which, instead of forming a distinct cavity, is nearly flat (Fig. 127). Fig. 127. Flatness of Sacrum with Narrowing of Pelvic Cavity. Pelvis Deformed by Spondylolithe-is. (After Kilian.) Spondylolithesis. — In a few rare cases, to which attention was first called in 1853 by Kilian of Bonn, a very formidable narrowing of the conjugate diameter of the pelvic brim is produced by a down- ward displacement of the fourth and fifth lumbar vertebraB, which become dislocated forward, or if not actually dislocated, at least separated from their several articulations to a sufficient extent to encroach very seriously on the dimensions of the pelvic inlet. This condition is known as spondylolithesis, (Fig. 128.) 372 LABOR. The effect of this is sufficiently obvious, for the projection of the lumbar vertebrae prevents the passage of the child. To such an extent is obstruction thus produced, that, in the majority of the recorded cases, the Cesarean section was necessary. The true conjugate diam- eter, that between the promontory of the sacrum and the symphysis pubis, is increased rather than diminished ; but, for all practical pur- poses, the condition is similar to extreme narrowing of the conjugate from rickets, for the bodies of the displaced vertebras project into and obstruct the pelvic brim. The cause of this deformity seems to be different in different cases. In some it seems to have been congenital, and in others to have de- pended on some antecedent disease of the bones, such as tuberculosis or scrofula, producing inflammation and softening of the connection between the last lumbar vertebra and the sacrum, thus permitting downward displacement of the bones. Lambl believed that it gene- rally followed spina bifida, which had become partially cured, but which had produced deformity of the vertebrae, and favored their dislocation. Brodhurst, 1 on the other hand, thinks that it most prob- ably depends on rachitic inflammation and softening of the osseous and ligamentous structures, and that it is not a dislocation in the strict sense of the word. Narrowing of the Oblique Diameter. — [This disease is so rare in the United States, that it is not recorded in a single instance, as a cause for gastro-hysterotomy. — Ed.] The most marked examples of nar- rowing of both oblique diameters depend on osteo-malacia. In this disease, as has already been remarked, the bones are uniformly soft- ened; and the alterations in form are further influenced by the fact that the disease commences after union of the separate portions of the os innominatum has been completely effected. The amount of deformity in the worst cases is very great, and frequently renders delivery impossible without the Caesarean section. Sometimes the softening of the bones proves of service in delivery, by admitting of the dilatation of the contracted pelvic diameter by the pressure of the presenting part, or even by the hand. Some curious cases are on record in which the deformity was so great as to apparently require the Caesarean section, but in which the softened bones eventually yielded sufficiently to render this unnecessary. Mode of Production in Osteo-malacia. — The weight of the body de- presses the sacrum in a vertical direction, and at the same time compresses its component parts together, so as to approximate the base and apex of the bone, and narrow the conjugate diameter of the brim, by causing the promontory to encroach upon it. The most characteristic changes are produced by the pushing inwards of the walls of the pelvis at the cotyloid cavities, in consequence of pressure exerted at these points through the femurs. The effect of this is to diminish both oblique diameters, giving the brim somewhat the shape of a trefoil, or an ace of clubs. The sides of the pubis are at the same time approximated, and may become almost parallel, and 1 Obst. Trans., vol. vi. p. 97. DEFORMITIES OF THE PELVIS 373 the true conjugate may be even lengthened (Fig. 129). The tuberosities of the ischia are also compressed together, with the rest of the lateral Fig. 129. Osteo-malttcic Pelvis. pelvic wall, so that the outlet is greatly deformed as well as the brim (Fig. 130). Fig. 130. Extreme Degree of Osteo-malacic Deformity. Ohliquely Contracted Pelvis. — That form of deformity in which one oblique diameter only is lessened, has received considerable attention, from having been made the subject of special study by Kaegele, and is generally known as the ohliquely contracted pelvis (Fig. 131). It is a condition that is very rarely met with, although it is interesting from an obstetric point of view, as throwing considerable light on the mode in which the natural development of the pelvis is effected. It is difficult to diagnose, inasmuch as there is no apparent external deformity, and probably it has never, in fact, been detected before delivery. It has a very serious influence on labor ; Litzmann found that out of 28 cases of this deformity, 22 died in their first labors, 374 LABOR Fig. 131. Obliquely Contracted Pelvis. (After Duncan.) and 5 more in subsequent deliveries. The prognosis, therefore, is very formidable, and renders a knowledge of this distortion, rare though it be, of much importance. Its essential characteristic is flattening and want of development of one side of the pelvis, associated with anchylosis of the corre- sponding sacro-iliac synchondrosis. The latter is probably always present, and it seems to be most generally a congenital malformation. The lateral half of the sacrum on the same side, and the entire innominate bone are much atrophied. The promontory of the sacrum is directed towards the diseased side, and the symphysis pubis is pushed over towards the healthy side. The main agent in the production of this deformity is the absence of the sacro-iliac joint, which prevents the proper lateral expansion of the pelvic brim on that side, and allows the counter-pressure, through the femur, to push in the atrophied os innominatum to a much greater extent than usual. The chief dimi- nution in the length of the pelvic diameter is between the ilio-pec- tineal eminence of the affected side and the healthy sacro-iliac joint; while the oblique diameter between the anchylosed joint and the healthy os innominatum is of normal length. Narrowing of the Transverse Diameter. — Transverse contraction ol the pelvic brim is very much less common than narrowing of the conjugate diameter. It most frequently depends on backward cur- vature of the lower parts of the spinal column, in consequence of disease of the vertebras. This form of deformed pelvis is generally known as the kyphotic. The effect of the spinal curvature is to drag the promontory of the sacrum backwards, so that it is high up and out of reach. By this means the antero-posterior diameter of the brim is increased, while the transverse is lessened ; the relative pro- portion between the two is thus reversed. While the upper propor- tion of the sacrum is displaced backwards, its lower end is projected forward, so that the antero-posterior diameters of the cavity and outlet are considerably diminished. The ischial tuberosities are also nearer to each other, and the pubic arch is narrowed. Obstruction to delivery wiil be chiefly met with at the lower parts and outlet of the pelvic cavity ; for, although the transverse diameter of the brim is narrowed, there is generally sufficient space for the passage of the head. Robertas Pelvis. — Another form of transversely contracted pelvis is known as Robert's pelvis (Fig. 132), having been first described by Robert, of Coblentz. It is in fact a doable obliquely contracted pelvis, depending on anchylosis of both sacro-iliac joints, and conse- quent defective development of the innominate bones. The shape DEFORMITIES OF THE PELVIS. 375 Fig. 132. Robert's or Double Obliquely Contracted Pelvis. (After Duncan.) of the pelvic brim is markedly oblong, and the sides of the pelvis are more or less parallel with each other. The outlet is also much contracted transversely. The amount of obstruction is very great, so that, according to Schroeder, out of 7 well- authenticated cases the Cesarean section was required in 6. Deformity from Old- standing Hip- joint Disease. — Another cause of transverse deformity, occasionally met with, is luxation of the head of the femur, depending on old-standing joint disease. The head of the femur, in this case, presses on the innominate bone at the site of dislocation, and the result is that the iliac fossa on the affected side, or both if the acci- dent happens on both sides, is pushed inwards, the transverse diam- eter of the brim being lessened. The tuberosity of the ischium is, however, projected outwards, so that the outlet of the pelvis is increased rather than diminished. Deformity from Tumors, Fractures, etc. — Obstruction of the pelvic cavity from exostosis or other forms of tumors growing from the bones is of great rarity (Fig. 133). It may, however, produce very serious dystocia, Several curious examples are collected in Mr. "Wood's article on the pelvis, in some of which the obstruction was so great as to necessitate the Ceesarean section. 1 Some of these growths were true exostoses; others osteo-sarcomatous tumors attached to the pelvic bones, most generally the upper part of the sacrum; and others were malignant. In some cases spiculae of bone have developed about the linea ilio-pec- tinea or other parts of the pelvis, which may not be sufficient to pro- duce obstruction, but which may injure the uterus, or even the foetal head, when they are pressed upon them. Irregular projections may also arise from the callus of old fractures of the pelvic bones. All such cases defy classification, and differ so greatly in their extent, and in their effect on labor, that no Fig. 133. Bony Growth from Sacrum obstructing the Pelvic Cavity. \} Eight women having pelvic exostoses have been operated upon by Csesarean section in the United States, with four recoveries. — Ed.] 376 LABOR. rules can be laid down for them, and each must be treated on its own merits. Effects of Contracted Pelvis in Labor. — The effects of pelvic con- tractions on labor vary, of course, greatly with the amount and nature of the deformity; but they must always give rise to anxiety, and, in the graver degrees, they produce the most serious difficulties we have to contend with in the whole range of obstetrics. Nature of Uterine Action in Pelvic Deformity. — In the lesser degrees, in which the proportion between the presenting part and the pelvis is only slightly altered, we may observe little abnormal beyond a greater intensity of the pains, and some protraction of the labor. It is generally observed that the uterine contractions are strong and forcible in cases of this kind, probably because of the increased resistance they have to contend against; and this is obviously a desirable and conservative occurrence, which may, of itself, suffice to overcome the difficulty. The first stage, however, is not infre- quently prolonged, and the pains are ineffective, for the head does not readily engage in the brim, the uterus is more mobile than in ordinary labors, and it probably acts at a disadvantage. Pish to the Mother. — In the more serious cases, the mother is sub- jected to many risks, directly proportionate to the amount of obstruc- tion and the length of the labor. The long- continued and excessive uterine action, produced by the vain endeavors to push the child through the contracted pelvic canal, the more or less prolonged con- tusion and injury to which the maternal soft parts are necessarily subjected (not unfrequently ending in inflammation and sloughing with all its attendant dangers), and the direct injury which may be inflicted by the measures we are compelled to adopt for aiding de- livery (such as the forceps, turning, craniotomy, or Caesarean section), all tend to make the prognosis a matter of grave anxiety. Pish to the Child. — Nor are the dangers less to the child; and a very large proportion of still-births will always be met with. The infantile mortality may be traced to a variety of causes, the most important being the protraction of the labor, and the continuous pressure to which the presenting part is subjected. For this reason, even in cases in which the contraction is so slight that the labor is terminated by the natural powers, it has been estimated that 1 out of every 5 children is still-born ; and as the deformity increases in amount, so, of course, does the prognosis to the child become more unfavorable. Frequent Occurrence of Prolapse of the Cord. — Prolapse of the umbilical cord is of very frequent occurrence in cases of pelvic de- formity, the tendency to this accident being traceable to the fact of the head not entering and occupying the upper strait of the pelvis as in ordinary labors, and thus leaving a space through which the cord may descend. So frequently is this complication met with in pelvic deformity that Stanesco 1 found it had happened as often as 59 times in 414 labors ; and when the dangers of prolapsed funis are 1 Op. cit. p. 94. DEFORMITIES OF THE PELVIS. 377 added to those of protracted labors, it is hardly a matter of surprise that the occurrence should, under such circumstances, almost always prove fatal to the child. Injury to Child's Head. — The head of the child is also liable to injury of a more or less grave character from the compression to which it is subjected, especially by the promontory of the sacrum. Independently of the transient effects of undue pressure (temporary alteration of the shape of the bones and bruising of the scalp), there is often met with a more serious depression of the bones of the skull, produced by the sacral promontory. This is most marked in cases in which the head has been forcibly dragged past the projecting bone by the forceps, or after turning. The amount of depression varies with the degree of contraction ; but sometimes, were it not for the yielding of the bones of the foetal skull in this way, delivery, Avith- out lessening the size of the head by perforation, would be impossi- ble. Such depressions are found at the spot immediately opposite the promontory, generally at the side of the skull near the junction of the frontal and parietal bones. Sometimes there is a slight per- manent mark, but more often the depression disappears in a few days. The prognosis to the child is, however, grave, when the con- traction has been sufficient to indent the skull ; for it has been found that 50 per cent, of the children thus marked died either immediately or shortly after labor. 1 Course of Labor. — The means which nature takes to overcome these difficulties are well worthy of study, and there are certain peculiari- ties in the mechanism of delivery when pelvic deformities exist, which it is of importance to understand, as they guide us in deter- mining the proper treatment to adopt. Frequency of MaJpresentation. — Malpresentations of the foetus are of much more frequent occurrence than in ordinary labors ; partly because the head does not engage readily in the brim, but, remaining free above it, is apt to be pushed away by the uterine contractions ; and partly because of the frequent alteration of the axis of the uterine tumor. The pendulous condition of the abdomen in cases of pelvic deformity is often very obvious, so that the fundus is sometimes almost in a line with the cervix, and thus transverse or other abnormal positions are very frequently met with. It is to be noted, however, that we cannot regard breech presentations as so unfavorable as in ordinary labors, for the pressure from the con- tracted pelvis is less likely to be injurious Avhen applied to the body than to the head of the child ; and indeed, as we shall presently see, the artificial production of these presentations is often advisable as a matter of choice. Mechanism of Delivery in Head Presentations. — The mode in which the head passes naturally through a contracted pelvis is in some re- spects different from the ordinary mechanism of delivery in bead presentations, and has been carefully worked out by Spiegelberg, and other German obstetricians. 1 Schroeder, op. cit. p. 256. 25 378 LABOR. The means which nature adopts to overcome the difficulty are dif- ferent in cases in which there is a marked narrowing of the conju- gate diameter of the brim, and in those in which there is a generally contracted pelvis. In Contracted Brim. — In the former, and more common deformity, when the head enters the brim, in consequence of the resistance it meets with, the expelling power of the uterus acts more on the ante- rior part of the head than in ordinary cases, the chin becomes in some degree separated from the sternum, and the anterior fontanelle descends somewhat lower than the posterior. At this stage, on ex- amination, it will be found — supposing we have to do with a case in which the occiput points to the left side of the pelvis — that the inte- rior fontanelle is lower than the posterior, and to the right, the bi- temporal diameter of the head is engaged in the conjugate diameter of the brim (as the smallest diameter of the skull, there is manifest advantage in this), the bi-parietal diameter and the largest portion of the head points to the left side. The sagittal suture will be felt running across in the transverse diameter of the brim, but nearer to the sacrum, the head being placed obliquely. As the head is forced down by the uterine contractions, the parietal bone, which is resting on the promontory, is pushed against it, so that the sagittal suture is forced more into the true transverse diameter of the pelvic brim, and approaches nearer to the pubis. The next step is the depression of the head, the occiput undergoing a sort of rotation on its trans- verse axis, so that it reaches a plane below the brim. When this is accomplished, the rest of the head readily passes the obstruction. The forehead now meets with the resistance of the pelvic walls, the posterior fontanelle descends to a lower level, and, as the cavity of the pelvis in cases of antero-posterior contraction of the brim is generally of normal dimensions, the rest of the labor is terminated in the usual way. In generally Contracted Pelvis. — In the generally contracted pelvis the head enters the brim with the posterior fontanelle lowest, and it is after it has engaged in it that the resistance to its progress becomes manifest. The result is, therefore, an exaggeration of what is met with in ordinary cases. The resistance to the anterior or longer arm of the lever is greater than that to the occipital or shorter ; and, therefore, the flexion of the head becomes very marked. The pos- terior fontanelle is consequently unusually depressed, and the ante- rior quite out of reach. So the head is forced down as a wedge, and its further progress must depend upon the amount of contraction. If this be not too great the anterior fontanelle eventually descends, and delivery is completed in the usual way. Should the contraction be too much to permit of this, the head becomes jammed in the pelvis, and diminution of its size may be essential. In cases of deformity of the conjugate diameter, combined with general contraction of the pelvis, the mechanism partakes of the pe- culiarities of both these classes, to a greater or less extent, in pro- portion to the preponderance of one or other species of deformity. DEFORMITIES OF THE PELVIS. 379 Diagnosis. — It rarely happens that deformities of the pelvis, ex- cept of the gravest kind, are suspected before labor has actually commenced ; and, therefore, we are not often called upon to give an opinion as to the condition of the pelvis before delivery. Should we be so, there are various circumstances which may aid us in ar- riving at a correct conclusion. Prominent among them is the history of the patient in childhood. If she is known to have suffered from rickets in early life, more especially if the disease has left evident traces in deformities of the limbs, or in a dwarfed and stunted growth, or in curvature of the spine, there will be strong presumptive evi- dence of pelvic deformity ; a markedly pendulous state of the abdo- men may also tend to confirm the suspicion. Nothing short of a careful examination of the pelvis itself will, however, clear up the point with certainty ; and, even by this means, to estimate the pre- cise degree of deformity with accuracy requires considerable skill and practice. The ingenuity of practitioners has been much exer- cised, it might perhaps be justly said, wasted, in the invention of various more or less complicated pelvimeters for aiding us in obtain- ing the desired object. It is, however, pretty generally admitted by all accoucheurs, that the hand forms the best and most reliable in- strument for this purpose, at any rate as regards the interior of the pelvis ; although a pair of callipers, such as Baudelocque's well-known instrument, is essential for accurately determining the external meas- urements. The objections to all internal pelvimeters, even those most simple in their construction, are their cost and complexity, and the impossibility of using them without pain or injury to the patient. External Measurements. — It was formerly thought that by measur- ing the distance between the spinous processes of the sacrum and the symphysis pubis, and subtracting from it what we judge to be the thickness of the bones and soft parts, we might arrive at an approxi- mate estimate of the measurement of the conjugate diameter of the pelvic brim. It is now admitted that this method can never be de- pended on, and that it is practically useless. [In a case of rachitic deformity where the conjugate diameter measured 2 J inches, the ex- ternal sacro-pubic measurement was an inch over the normal. — Ed.] A change in the relative length of other external measurements of the pelvis is, however, often of great value in showing the existence of deformity internally, although not in judging of its amount. The measurements which are used for this purpose are between the anterior superior spines of the ilia, and between the centres of their crests, averaging respectively 9J and 10J inches. According to Spiegelberg these measurements may give one of three results. 1. Both may be less than they ought to be, but the relation of the one to the other remains unchanged. 2. That between the crests is not, or is at most very little, dimin- ished, but that between the spines is increased. 3. Both are diminished, but at the same time their mutual relation is not normal, the distance between the spines being as long, if not longer, than that between the crests. 380 LABOR. No. 1 denotes a uniformly contracted pelvis. No. 2, a pelvis simply contracted in the conjugate diameter of the brim, and not otherwise deformed. No. 3, a pelvis with narrowed conjugate and also uniformly contracted, as in the severe type of rachitic de- formity. Besides the above some information may be obtained by the measurement of the external conjugate diameter, which averages 7f inches. This may be taken by placing one point of the callipers in the depression below the spine of the last lumbar vertebra, the other at the centre of the upper edge of the symphysis pubis. If the measurement be distinctly below the average, we may conclude that there is a narrowing of the antero-posterior diameter of the brim, the extent of which we must endeavor to ascertain by other means. For the purpose of making these measurements Baudelocque's compas d'epaisseur can be used, or Dr. Lazarewitch's elegant universal pelvimeter, which can be adopted also for internal pelvimetry; but, in the absence of these special contrivances, an ordinary pair of calli- pers, such as are used by carpenters, can be made to answer the desired object. Internal Measurements. — -These external measurements must be corroborated by internal, chiefly of the antero-posterior diameter, by which alone we can estimate the F IG - 134. amount of the deformity. We en- deavor to find, in the first place, the length of the diagonal conjugate, between the lower edge of the sym- physis pubis and the promontory of the sacrum, which averages about half an inch more than the true conjugate. The patient lying- in the usual obstetric position, or still better lying transversely across the bed, with her hips raised, an attempt is made to reach the pro- montory of the sacrum with the tip of the index finger. In a health}- pelvis this is impossible, so that the mere fact of our being able to do so proves the existence of contraction. A mark is made with the nail of the index of the left hand on that part of the ex- amining finger which rests under the symphysis, and then the dis- tance from this to the tip of the finger, less half an inch, may be taken to indicate the measurement of the true conjugate of the brim. Various pelvimeters are meant to make the same measure- ments, such as Lumley Earle's, Lazarewitch's, which is similar in principle, and Van Huevel's; the best and simplest, I think, is that invented by Dr. Greenhalgh (Fig. 134). It consists of a mov- Greenhalgh's Pelvimeter DEFORMITIES OF THE PELVIS. 381 able rod, attached to a flexible band of metal which passes around the palm of the examining hand. At the distal end of the rod is a curved portion, which passes over the radial edge of the index finger. The examination is made in the usual way, and when the point of the finger is resting on the promontory of the sacrum, the rod is withdrawn until it is arrested by the posterior surface of the symphysis, the exact measurement of the diagonal conjugate being then read off on the scale. It is to be remembered that this procedure is useless in the slighter j degrees of contraction, in which the promontory of the sacrum cannot be reached. Dr. Eamsbotham proposed to measure the conjugate by spreading out the index and middle fingers internally, the tip of one resting on the promontory, the other behind the symphysis pubis; and then withdrawing them, in the same position, and measuring the distance between them. This manoeuvre I believe to be impracticable. Whenever, in actual labor, we wish to ascertain the condition of the pelvis accurately, . the patient should be anaesthetized, and the ! whole hand introduced into the vagina (which could not otherwise be done without causing great pain), and the proportions of the pelvis, and the relations of the head to it, thoroughly explored; and, if what has been said as to the mechanism of delivery in these cases be borne in mind, this may aid us in determining the kind of de- formity existing. In this way contractions about the outlet of the pelvis can also be pretty generally made out. Mode of Diagnosing the Oblique Pelvis. — The obliquely contracted pelvis cannot be determined by any of these methods, but certain external measurements, as Naegele has pointed out, will readily enable us to recognize its existence. It will be found that measure- ments, which in the healthy pelvis ought to be equal, are unequal in the obliquely distorted pelvis. The points of measurement are chiefly : 1. From the tuberosity of the ischium on one side to the posterior superior spine of the ilium on the other; 2. From the anterior superior iliac spine on the one side to the posterior superior on the opposite; 3. From the trochanter major of one side to the posterior superior iliac spine on the other; 4. From the lower edge of the symph}^sis pubis to the posterior superior iliac spine; 5. From the spinous process of the last lumbar vertebra to the anterior superior spine of the ilium on either side. If these measurements differ from each other by half an inch to an inch, the existence of an obliquely deformed pelvis may be safely diagnosed. The diagnosis can be corroborated by placing the patient 1 in the erect position, and letting fall two plumb lines, one from the spines of the sacrum, the other from the symphysis pubis. In a .healthy pelvis these will fall in the same plane, but in the oblique i pelvis the anterior line will deviate considerably towards the un- affected side. Treatment. — The proper management of labor in contracted pelvis i is, even up to this time, one of the most vexed questions in midwifery, notwithstanding the immense amount of discussion to which it has given rise; and the varying opinions of accoucheurs of equal expe- 382 LABOK. rience afford a strong proof of the difficulties surrounding the subject This remark applies, of course, only to the lesser degrees of deformity, in which the birth of a living child is not hopeless. When the antero- posterior diameter of the brim measures from 2} to 3 inches, it is universally admitted that the destruction of the child is inevitable, unless the pelvis be so small as to necessitate the performance of the Cesarean section. But when it is between 3 inches and the normal measurement, the comparative merits of the forceps, turning, and the induction of premature labor, form a fruitful theme for discus- sion. With one class of accoucheurs the forceps is chiefly advocated, and turning admitted as an occasional resource when it has failed ; and this indeed, speaking broadly, may be said to have been the general view held in this country. More recently we find German authorities of eminence, such as Schroeder and Spiegelberg, giving turning the chief place, and condemning the forceps altogether in contracted pelvis, or, at least, restricting its use within very narrow limits. More strangely still we find, of late, that the induction of premature labor, on the origination and extension of which British accoucheurs have always prided themselves, is placed without the pale, and spoken of as injurious and useless in reference to pelvic deformities. To see our way clearly amongst so many conflicting opinions is by no means an easy task, and perhaps we may best aid in its accomplishment by considering separately the three operations in so far as they bear on this subject, and pointing out briefly what can be said for and against each of them. The Forceps. — In England and in France it is pretty generally admitted that in the slighter degrees of contraction the most reliable means of aiding the patient is by the forceps. It should be remem- bered that the operation, under such circumstances, is always much more serious than in ordinary labors simply delayed from uterine inertia, when there is ample room, and the head is in the cavity of the pelvis ; for the blades have to be passed up very high, often when the head is more or less movable above the brim, and much more traction is likely to be required. For these reasons artificial assist- ance, when pelvic deformity is suspected, is not to be lightly or hurriedly resorted to. Nor fortunately is it always necessary ; for if the pains be sufficiently strong, and the contraction not too great to prevent the head engaging at all, after a lapse of time it will be- come so moulded in the brim as to pass even a considerable obstruc- tion. In all cases, therefore, sufficient time must be given for this ; and if no suspicious symptoms exist on the part of the mother — no elevation of temperature, dryness of the vagina, rapid pulse, and the like, and the foetal heart-sounds continue to be normal — labor may be allowed to go on for some hours after the rupture of the mem- branes, so as to give nature a chance of completing the delivery. When this seems hopeless, the intervention of art is called for. Cases Suitable for the Forceps. — The forceps is generally considered to be applicable in all degrees of contraction, from the standard measurement, down to about 3 J inches in the conjugate of the brim. DEFORMITIES OF THE PELVIS. 383 There can be no doubt that, in such cases, traction with the forceps often enables us to effect delivery, when the natural efforts have proved insufficient, and holds out a very fair hope of saving the child. Out of 17 cases in which the high forceps operation was re- sorted to for pelvic deformity, reported by Stanesco, in 13 living children were born. If the length of the labor, and the long-con- tinued compression to which the child has been subjected, be borne in mind, this result must be considered very favorable. Objections that have been raised to the Forceps. — What are the ob- jections which have been brought against the operation ? These have been principally made by Schroeder and other German writers. They are, chiefly the difficulty in passing the instrument ; the risk of injuring the maternal structures ; and the supposition that, as the blades must seize the head by the forehead and occiput, their com- pressive action will diminish its longitudinal and increase its trans- verse diameter (which is opposed to the contracted part of the brim), and so enlarge the head just where it ought to be smallest. There is little doubt that these writers much exaggerate the compressive power of the forceps. Certainly with those generally used in this country, any disadvantage likely to accrue from this is more than counterbalanced by the traction on the head ; and the fact, that minor degrees of obstruction can be thus overcome, with safety both to the mother and child, is abundantly proved by the numberless cases in which the forceps have been used. It is not equally Suitable in all hinds of Deformity. — It is very likely that the forceps do not act equally well in all cases. When the head is loose above the brim ; when the contraction is chiefly limited to the antero-posterior diameter, and there is abundance of room at the sides of the pelvis for the occiput to occupy after version; and when, as is usual in these cases, the anterior fontanelle is depressed and the head lies transversely across the brim, it is probable that turning may be the safer operation for the mother, and the easier performed. When, on the other hand, the head has engaged in the brim, and has become more or less impacted, it is obvious that version could not be performed without pushing it back, which may neither be easy nor safe. In the generally contracted pelvis, in which the head enters in an exaggerated state of flexion and lies obliquely, the posterior fon- tanelle being much depressed, the forceps are more suitable. Mechanical Advantage of Turning in certain Cases. — The special reasons why version sometimes succeeds when the forceps fails, or why it may be elected from the first as a matter of choice, have been by no one better pointed out than by Sir James Simpson. Although the operation was performed by many of the older obstetricians, its revival in modern times, and the clear enunciation of its principles, can undoubtedly be traced to his writings. He points out that the head of the child is shaped like a cone, its narrowest portion the base of the cranium (Fig. 135, bb), measuring, on an average, from J to f of an inch less than the broadest portion (Fig. 135, aa), viz., the bi-parietal diameter. In ordinary head presentations the latter :84 LABOR Fig. 135. Section of Foetal Cranium, show ing its Conical Form. Fig. 136. part of the head has to pass first; but if the feet are brought down, the narrow apex of the cranial cone is brought first into apposition with the contracted brim, and can be more easily drawn through than the broader base can be pushed through by the uterine con- tractions. Nor is this the only advantage, for after turning the narrower bi- temporal diameter (Fig. 136, bb) — which measures, on an average, half an inch less than the bi- parietal (Fig. 136, aa) — is brought into con- tact with the contracted conjugate, while the broader bi-parietal lies in the comparatively wide space at the side of the pelvis (Fig. 137). These mechanical considerations are suffici- ently obvious, and fully explain the success which has often attended the performance of the operation. Limits of the Operation. — It is generally admitted that it may be possible, for the rea- sons just mentioned, to deliver a living child by turning, through a pelvis contracted be- yond the point which would permit of a living child being extracted by the forceps. Many obstetricians believe that it is possible to de- liver a living child by turning in a pelvis contracted even to the extent of 2f inches in the conjugate diameter. Barnes maintains that, although an unusually compressible head may be drawn through a pelvis con- tracted to 3 inches, the chance of the child being born alive under such circumstances must necessarily be small, and that from 3J inches to the normal size must be taken as the proper limits of the operation. Showing the greater breadth of the Bi-parietal Diameter of the Foetal Cranium. (After Simpson.) Fig. 137. Showing the greater space for the Bi-parietal Diameter at the side of the Pelvis in certain cases of Deformity. (After Simpson.) That delivery is often possible by turning, after the forceps and the natural powers have failed, and when no other resource is left but the destruction of the child, must, I think, be admitted by all ; DEFORMITIES OF THE PELVIS. 385 for the records of obstetrics are full of such cases. To take one ex- ample only, Dr. Braxton Hicks 1 records four cases in which the for- ceps were tried unsuccessfully, in all of which version was used, three of the children being born alive. Here are the lives of three children rescued from destruction, within a short period, in the practice of one man ; and a fact like this would, of itself, be ample justification of the attempt to deliver by turning, when the child was known to be alive, and other means had failed. The possibility that craniotomy may still be required is no argument against the opera- tion ; for, although perforation of the after- coming head is certainly not so easy as perforation of a presenting head, it is not so much more difficult as to justify the neglect of an expedient by which it may possibly be altogether avoided. Comparative Estimate of the Two Operations. — The original choice of turning is a more difficult question to decide. My own impression is that the use of the forceps will generally be found to be preferable. An exception should, I think, be made for those cases in which the head refuses to enter the brim, and cannot be sufficiently steadied by external pressure to admit of an easy application of the instru- ment. Under these circumstances increasing experience leads me to prefer turning as decidedly the simpler and safer operation, and the passage of the head through the contracted brim can be very mate- rially facilitated by strong pressure from above, as has been so well pointed out by Groodell. 2 An argument used by Martin, of Berlin, 3 in reference to the two operations, should not be lost sight of, as it seems to be a valid reason for giving a preference to the forceps. He points out that moulding- may safely be applied for hours to the vertex ; but that when pres- sure is applied to the important structures about the base of the brain, as after turning, moulding cannot be continued beyond five minutes without proving fatal. This, however, is no reason why turning should not be used after the forceps and the natural efforts have proved ineffectual. Craniotomy or the Csesarean Section is required. — -When the con- traction is below 3 inches in the conjugate, or when the forceps and turning have failed, no resource is left but the destruction of the foetus, or the Caesarean section. The induction of premature labor as a means of avoiding the risks of delivery at term, and of possibly saving the life of the child, must now be studied. The established rule, in this country, is, that in all cases of pelvic deformity, the existence of which has been ascertained either by the experience of former labors, or by accurate examina- tion of the pelvis, labor should be induced previous to the full period, so that the smaller and more compressible head of the premature foetus may pass, where that of the foetus at term could not. The gain is a double one, partly the lessened risk to the mother, and partly the chance of saving the child's life. 1 Guy's Hosp. Rep. 1870. 2 Amer. Journ. of Obst., vol. viii. 3 Mon. f. Gebert. 1867. 386 LABOR. The practice is so thoroughly recognized as a conservative and judicious one, that it might be deemed unnecessary to argue in its favor, were it not that some most eminent authorities have of late years tried to show, that it is better and safer to the mother to leave the labor to come on at term ; and that the risk to the child is so great in artificially induced labor as to lead to the conclusion that the operation should be altogether abandoned, except, perhaps, in the extreme distortion in which the Csesarean section might other- wise be necessary. Prominent amongst those who hold these views are Spiegelberg and Litzmann, and they have been supported, in a modified form, by Matthews Duncan. Spiegelberg 1 tries to show, by a collection of cases from various sources, that the results of in- duced labor in contracted pelvis are much more unfavorable than when the cases are left to nature ; that in the latter the mortality of the mothers is 6.Q per cent., and of the children 28.7 per cent., whereas in the former the maternal deaths are 15 per cent., and the infantile 66.9 per cent. Litzmann 2 arrives at not very dissimilar results, namely, 6.9 per cent, of the mothers and 20.3 per cent, of the children in contracted pelvis at term, and 14.7 per cent, of the mothers and 55.8 per cent, of the children, in artificially induced premature labor. If these statistics were reliable, inasmuch as they show a very decided risk to the mother, there might be great force in the argu- ment that it would be better to leave the cases to run the chance of delivery at term. It is, however, very questionable whether they can be taken, in themselves, as being sufficient to settle the question. The fallacy of determining such points by a mass of heterogeneous cases, collected together without a careful sifting of their histories, has over and over again been pointed out ; and it would be easy enough to meet them by an equal catalogue of cases in which the maternal mortality is almost nil. The results of the practice of many authorities are given in Churchill's work, where Ave find, for example, that out of 46 cases of Merriman's, not one proved fatal. The same fortunate result happened in 62 cases of Rambotham's. His conclusion is, that " there is undoubtedly some risk incurred by the mother, but not more than by accidental premature labor," and this conclusion, as regards the mother, is that which has long ago been arrived at by the majority of British obstetricians, who un- doubtedly have more experience of the operation than those of any other nation. With regard to the child, even if the German statis- tics be taken as reliable, they would hardly be accepted as contra- indicating the operation, inasmuch as it is intended to save the mother from the dangers of the more serious labor at term, and, in many cases, to give at least a chance to the child, whose life would other- wise be certainly sacrificed. The result, moreover, must depend to a great extent on the method of operation adopted, for many of the plans of inducing labor recommended are certainly, in themselves, not devoid of danger both to the mother and the child. It may, I 1 Arch. f. Gyn. b. i. s. 1. 2 lb. b. ii. s. 169. DEFORMITIES OF THE PELVIS. 387 think, be admitted, as Duncan contends, 1 that the operation has been more often performed than is absolutely necessary, and that the higher degrees of pelvic contraction are much more uncommon than has been supposed to be the case. That is a very valid reason for insisting on a careful and accurate diagnosis, but not for rejecting an operation which has so long been an established and favorite re- source. Determination of Period for Inducing Labor. — When the induc- tion of labor has been determined on, the precise period at which it should be resorted to becomes a question for anxious consideration, for the longer it is delayed the greater, of course, are the dangers for the child. Many tables have been constructed to guide us on this point, which, are not, on the whole, of so much service as they might appear to be, on account of the difficulty of determining with minute accuracy the amount of contraction. The following, however, which is drawn up by Kiwisch, may serve for a guide in settling this ques- tion : — ■ Inches. Lines. When the sacro-pubic diameter is 2 2 md 6 or 7 8 " 9 induce labo u it r at 30th week. 31st " (C It 2 it 10 " 11 " ' 32d " (( IC 3 It — it I 33d ' ; u It 3 a 1 U i 33d " u u 3 a 2 " 3 It I 34th " C( u 3 a 4 " 5 11 i 35th " (( u 3 tt 5 " 6 11 I 36th " In cases of moderate deformity, when labor pains have been in- duced, the further progress of the case may be left to nature ; but, in the more marked cases, as in those below 3 inches, it will often be found necessary to assist delivery by turning or by the forceps, the former being here specially useful, on account of the extreme pliability of the head, and the facility with which it may be drawn through the contracted brim. By thus combining the two operations it may be quite possible to secure the birth of a living child even in pelves very considerably deformed. Production of Abortion in extreme Deformity . — 'When the contraction is so great as to necessitate the induction of the labor before the sixth month, or, in other words, before the child has reached a viable age, it would be preferable to resort to a very early production of abor- tion. The operation is then indicated, not for the sake of the child, but to save the mother from the deadly risk to which she would otherwise be subjected. As, in these cases, the mother alone is con- cerned, the operation should be performed as soon as we have posi- tively determined the existence of pregnancy. No object can be gained by waiting until the development of the child is advanced to any extent, and the less the foetus is developed, the less will be the pain and risks the mother has to undergo. There is no amount of deformity, however great, in which we could not succeed in bringing 1 Edin. Med. Journ., July, 1873, p. 339. 388 LABOR. on miscarriage by some of the numerous means at our disposal ; and, in spite of Dr. Eadford's objections, who maintains that the obstetri- cian is not justified in sacrificing the life of a human being more than once, when the mother knows that she cannot give birth to a viable child, there are few practitioners who would not deem it their duty to spare the mother the terrible dangers of the Cesarean section. CHAPTER XIII. HEMORRHAGE BEFORE DELIVERY: PLACENTA PREVIA. The hemorrhages which are the result of an abnormal situation of the placenta, partially or entirely, over the internal os uteri, have formed a most fruitful theme for discussion. The causes producing the abnormal placental site, the sources of the blood, and the causes of its escape, the means adopted by nature for its arrest, and the proper treatment, have, each and all of them, been the subject of endless controversies, which are not yet by any means settled. It must be admitted, too, that the extreme importance of the subject amply justifies the attention which has been paid to it; for there is no obstetric complication more apt to produce sudden and alarming effects, and none requiring more prompt and scientific treatment. By placenta prvevia we mean the insertion of the placenta at the lower segment of the uterine cavity, so that part of it is situated, wholly or partially, over the internal os uteri. In the former case there is complete or central placental presentation, in the latter an incomplete or marginal presentation. Causes. — The causes of this abnormal placental site are not fully understood. It was supposed by Tyler Smith to depend on the ovule not having been impregnated until it had reached the lower part of the uterine cavity. Cazeau suggests that the uterine mucous mem- brane is less swollen and turgid than when impregnation occurs at the more ordinary place, and that, therefore, it offers less obstruction to the descent of the ovule to the lower part of the uterine cavity. An abnormal size, or unusual shape, of the uterine cavity may also favor the descent of the impregnated ovule; the former probably explains the fact, that placenta previa more generally occur in women who have borne several children. These are merely interesting specu- lations having no practical value, the fact being undoubted that, in a not inconsiderable number of cases — estimated hj Johnson and Sinclair as 1 out of 573 — the placenta is grafted partially or entirely over the uterine orifice. History. — Placenta prawia was not unknown to the older writers, who believed that the placenta had original^ been situated at the HEMORRHAGE BEFORE DELIVERY. 389 fundus, from which it had accidentally fallen to the lower part of the uterus. Portal, Levret, Eoederer, and especially our own country- man Rigby, were among those whose observations tended to improve the state of obstetrical knowledge as to its real nature. To Rigby we owe the term "unavoidable hemorrhage" as a synonym for placenta praevia, and as distinguishing hemorrhage from this source from that resulting from separation of the placenta at its more usual position, termed by him, in contra-distinction, " accidental hemorrhage." These names, adopted by most writers on the subject, are obviously mis- leading, as they assume an essential distinction in the etiology of the hemorrhage in the two classes of cases, which is not always warranted It is of the utmost importance to a right understanding of the nature and treatment of placenta praevia that we should fully under- stand the source of the hemorrhage, and the manner of its produc- tion; but we shall be able to discuss this subject better after a description of the symptoms. Symptoms. — Although the placenta must occupy its unusual site from the earliest period of its formation, it rarely gives rise to appre- ciable symptoms before the last three months of utero-gestation. It is far from unlikely, however, that such an abnormal situation of the placenta may produce abortion in the earlier months, the site of its attachment passing unobserved. Sudden Flow of Blood. — The earliest symptom which causes suspi- cion is the sudden occurrence of hemorrhage, without any appreciable cause. The amount of blood lost varies considerably. In some cases the first hemorrhage is comparatively slight, and is soon spontaneously arrested; but, if the case be left to itself, the flow after a lapse of time — it may be a few days, or it may be weeks — again commences in the same unexpected way, and each successive hemorrhage is more profuse. The losses show themselves at different periods. They rarely begin before the end of the sixth month, more often nearer the full period, and sometimes not until labor has actually com- menced. The hemorrhage verv often coincides with what would have been a menstrual period; doubtless on account of the physio- logical congestion of the uterine organs then present. Should the first loss not show itself until at or near the full time, it may be tremendous, and a few moments may suffice to place the patient's life in jeopardy. Indeed it may be safely accepted as an axiom, that once hemorrhage has occurred, the patient is never safe; for excessive losses may occur at any moment without warning, and when assist- ance is not at hand. It often happens that premature labor comes on after one or more hemorrhages. In any case of placenta praevia, when labor has commenced, whether premature or at the full time, the hemorrhage may become excessive, and with each pain fresh portions of placenta may be de- tached, and fresh vessels torn and left open. Under these circum- stances the blood often escapes in greater quantity with each suc- cessive pain, and diminishes in the intervals. This has long been looked upon as a diagnostic mark by which we can distinguish be- tween the so-called "unavoidable '•' and "accidental " hemorrhage ; 390 LABOR. in the latter the flow being arrested during the pains. The distinc- tion, however, is altogether fallacious. The tendency of uterine contraction in placenta prsevia, as in all other forms of uterine hemorrhage, is to constrict the vessels from which the blood escapes, and so to lessen the flow. The apparently increased flow during the pains depends on the pains forcing out blood which has already escaped from the vessels. In one way, up to a certain point, the pains do favor hemorrhage, by detaching fresh portions of placenta ; but the actual loss takes place chiefly during the intervals, and not during the continuance of contraction. Results of Vaginal Examination. — On vaginal examination, if the os be sufficiently open to admit the finger, which it generally is on account of the relaxation produced by the loss of blood, we shall almost always be able to feel some portion of presenting placenta. If it be a central implantation, we shall find the upper aperture of the cervix entirely covered by a thick, boggy mass, which is to be distinguished from a coagulum by its consistence, and by its not breaking down under the pressure of the finger. Through the pla- cental mass we may feel the presenting part of the foetus ; but not as distinctly as when there is no intervening substance. In partial placental presentations the bag of membranes, and above it the head or other presentation, will be found to occupy a part of the circle of the os, the rest being covered by the edge of the placenta. In mar- ginal presentations we may only be able to make out the thickened edge of the after-birth, projecting at the rim of the os. If the cer- vix be high, and the gestation not advanced to term, these points may not be easy to make out, on account of the difficulty of reaching the cervix ; and, as accurate diagnosis is of the utmost importance, it is proper to introduce two fingers, or even the whole hand, so as thoroughly to explore the condition of the parts. The lower portion of the uterine ovoid may be observed to be more than usually thick and fleshy ; and Gendrin has pointed out that ballottement cannot be made out. The accuracy of our diagnosis may be confirmed, in doubtful cases, by finding that the placental bruit is heard over the lower part of the uterine tumor. Dr. Wallace 1 has suggested that vaginal auscultation may be ser- viceable in diagnosis, and states that, by means of a curved wooden stethoscope, the placental bruit may be heard with startling distinct- ness. This is, however, a manoeuvre that can hardly be generally carried out in actual practice. The Source of Hemorrhage. — It is now generally admitted by au- thorities that the immediate source of the hemorrhage is the lacerated utero-placental vessels. Only a few years ago Sir James Simpson advocated, with his usual energy, the theory, sustained by his pre- decessor, Dr Hamilton, that the chief, if not the only, source of hemorrhage was the detached portion of the placenta itself. He argued that the blood flowed from the portion of the placenta which was still adherent into that which was separated, and escaped from 1 Edin. Med. Journ., Nov. 1872. HEMORRHAGE BEFORE DELIVERY. 391 the surface of the latter ; and on this supposition he based his practice of entirely separating the placenta, having observed that, in many cases in which the after-birth had been expelled before the child, the hemorrhage had ceased. The fact of the cessation of the hemorrhage, when this occurs, is not doubted; but Simpson's expla- nation is contested by most modern writers, prominent among whom is Barnes, who has devoted much study to the elucidation of the sub- ject. He points out that the stoppage of the hemorrhage is not due to the separation of the placenta, but to the preceding or accompany- ing contraction of the uterus, which seals up the bleeding vessels, just as it does in other forms of hemorrhage. The site of the loss was actually demonstrated by the late Dr. Mackenzie in a series of experiments, in which he partially detached the placenta in pregnant bitches, and found that the blood flowed from the walls of the uterus, and not from the detached surface of the placenta. The arrange- ment of the large venous sinuses, opening as they do on the uterine mucous membrane, favors the escape of blood when they are torn across ; and it is from them, possibly to some extent also from the uterine arteries, that the blood comes, just as in post-partum hemor- rhage, when the whole, instead of a part, of the placental side is bared. Causes of Hemorrhage. — Various explanations have been given of the causes of the hemorrhage. For long it was supposed to depend on the gradual expansion of the cervix during the latter months of pregnancy, which separated the abnormally placed placenta. It has been seen, however, that this shortening of the cervix is apparent only, and that the cervical canal is not taken up into the uterine cavity during gestation, or, at all events, only during the last week or so. This, therefore, cannot be admitted as an explanation of pla- cental separation. Jacquemier proposed another theory which has been adopted by Cazeaux. He maintains that during the first six months of utero-gestation the superior portion of the uterus is more especially developed, as shown by the pyriform shape of the fundus during the time; and that, as the placenta is usually attached in that situation, and then attains its maximum of development, its relations to its attachments are undisturbed. During the last three months of pregnancy, on the contrary, the lower segment of the uterus develops more than the upper, while the placenta remains nearly stationary in size ; the inevitable result being a loss of proportion between the cervix and the placenta, and the detachment of the latter. There are various objections which can be brought against this theory ; the most important being that there is no evidence at all to show that the lower segment of the uterus does expand more in proportion than the upper during the latter months of pregnancy. Barnes's theory is based on the supposition that the loss of relation between the uterus and placenta is caused by excess of growth on the part of the placenta itself over that of the cervix, which is not adapted for its attachment. The placenta, on this hypothesis, grows away from the site of its attachment, and hemorrhage results. It will be observed that neither this theory, nor that propounded by Jacque- mier, are readily reconcilable with the fact that hemorrhage fre- 392 LABOR. quently does not begin until labor has commenced at term. Inasmuch as the loss of relation between the placenta and its attachments, which they both presuppose, must exist in every case of placenta prasvia, hemorrhage should always occur during some part of the last three months of pregnancy. Matthews Duncan 1 has recently in- vestigated the whole subject at length, and maintains that the hemor- rhages are accidental, not unavoidable, being due to precisely similar causes as those which give rise to the occasional hemorrhages when the placenta is normally placed. The abnormal situation of the pla- centa, of course, renders these causes more apt to operate ; but in their action he believes them to be precisely similar to those of acci- dental hemorrhage, properly so called. Separation of the placenta from expansion of the cervix, he believes to be the cause of hemor- rhage after labor has begun, and then it may strictly be called una- voidable ; but hemorrhage is comparatively seldom so produced during the continuance of pregnancy. " There are," says Duncan, " four ways in which this kind of hemorrhage may occur : — "1. By the rupture of a utero-placental vessel at or about the in- ternal os uteri. " 2. By the rupture of a marginal utero-placental sinus within the area of spontaneous premature detachment, when the placenta is in- serted not centrally or covering the internal os, but with a margin at or near the central os. "3. By partial separation of the placenta from accidental causes, such as a jerk or fall. " 4. By a partial separation of the placenta, the consequence of uterine pains producing a small amount of dilatation of the internal' os. Such cases may be otherwise described as instances of miscar- riage commencing, but arrested at a very early stage." I see no reason to doubt the possibility of hemorrhage being due, in many cases, to the first three causes, and in its production it would strictly resemble accidental hemorrhage. The fourth heading refers the hemorrhage to partial separation, in consequence of commencing dilatation of the cervix, but it explains the dilatation by the suppo- sition of commencing miscarriage. This latter hypothesis seems to be as needless as those which presuppose a want of relation between the placenta and its attachments. We know that, quite independ- ently of commencing miscarriage, uterine contractions are constantly occurring during the continuance of pregnancy. There is reason to suppose that these contractions do not affect the cervical, as well as the funclal portions of the uterus; and in cases in which the placenta is situated partial^ or entirely over the os, one or more stronger contractions than usual may, at any moment, produce laceration of the placental attachments in that neighborhood. Pathological Changes in the Placenta. — A careful examination of the placenta may show pathological changes at the site of separation, such as have been described by Gendrin, Simpson, and other writers. They probably consist of thrombosis in the placental cotyledons, and 1 Edin. Med. Journ., Nov. 1873, and Brit. Med. Journ., Nov. 1873. HEMORRHAGE BEFORE DELIVERY. 393 effused blood-clots, variously altered and discolorized, according to the lapse of time since separation took place. Changes occur in the portion of the placenta overlying the os uteri, whether separation has occurred or not. There may be atrophy of the placental struc- ture in this situation, as well as changes of form, such as complete or partial separation into two lobes, the junction of which overlies the os uteri. 1 Natural Termination when Placenta presents. — The history of de- livery, if left to nature, is specially worthy of study, as guiding to proper rules of treatment. It sometimes happens, when the pains are very strong and the delivery rapid, that labor is completed with- out any hemorrhage of consequence. "Although," says Cazeaux, " hemorrhage is usually considered to be inevitable under such cir- cumstances, yet it may not appear even during the labor ; and the dilatation of the os uteri may be effected without the loss of a drop of blood." Again, Simpson conclusively showed, that when the placenta was expelled before the birth of the child, all hemorrhage ceased. Barnes's theory of placenta previa, which has been pretty gene- rally adopted, explains satisfactorily both these classes of cases. He describes the uterine cavity as divisible into three zones or regions. When the placenta is situated in the upper or middle of these zones, no separation or hemorrhage need occur during labor. When, however, it is situated partially or entirely in the lower or cervical zone, the expansion of the cervix during labor must produce more or less separation, and consequent loss of blood. As soon as the previous portion of the placenta is sufficiently separated, provided contraction of the uterine tissue be present to seal up the mouths of the vessels, hemorrhage no longer takes place. The placenta may not be entirely detached, but no further hemorrhage occurs, in con- sequence of the remaining portion being engrafted on the uterus beyond the region of unsafe attachment. In the former, then, of these classes of cases, the absence of hemor- rhage is explained, on this theory, by the pains being sufficiently rapid and strong to complete the separation of the placental attach- ment from the lower cervical zone before flooding had taken place ; in the latter, it ceases, not necessarily because the entire placenta is expelled, but because of its detachment from the area of dangerous implantation. The amount of cervical expansion required for this purpose varies in different cases. Dr. Duncan 2 estimates the limit of the spontaneous detaching area to be a circle of 4J inches diameter, and that, after the cervix has expanded to that extent, no further separation or hemorrhage takes place. To admit of the passage of a full-sized head, Barnes estimates that expansion to about a circle of 6 inches diameter is necessary ; on the other hand he has sometimes observed ' " that the hemorrhage has completely stopped when the os uteri had ' opened to the size of the rim of a wineglass, or even less." I 1 Sinelius, Arch. Gen. de Med., vol. ii. 1861. 2 Obst. Trans., vol. xv. 26 394 LABOR. It will be seen then that in this, as in every other form of peur- peral hemorrhage, the tendency of uterine contraction is to check the hemorrhage ; and that, provided the pains are sufficiently ener- getic, nature may be capable of stopping the flooding without artifi- cial aid. It is but rarely, however, that she can be trusted for the purpose; and we shall presently see that these theoretical views have an important practical bearing on the subject of treatment. Prognosis. — The prognosis to both the mother and child is cer- tainly grave in all cases of placenta proevia. Eead, in his treatise on placenta prasvia, estimates the maternal mortality, from the statis- tics of a large number of cases, as 1 in 4J cases, and Churchill as 1 in 3. This is unquestionably too high an estimate, and based on statistics the accuracy of which cannot be relied on. The mortality will, of course, greatly depend on the treatment adopted. Doubtless, if cases were left to nature, the result would be quite as unfavorable as Eead supposes. But if properly managed, much more successful results may safely be anticipated. Out of 64 cases, recorded by Barnes, the deaths were 6, or 1 in 10J. Under any circumstances the risks to the mother are very great. Churchill estimates that more than half the children are lost. The reasons for the great danger to the child are very obvious, subjected as it is to the risk of asphyxia from the loss of the maternal blood, and from its respira- tion being carried on during labor by a placenta which is only par- tially attached ; many children also perish from prematurity, or from mal- presentation. Treatment. — Whenever, in the latter months of pregnancy, a sudden hemorrhage occurs, the possibility of placenta prasvia will naturally suggest itself; and, by a careful vaginal examination, which under such circumstances should always be insisted on, the existence of this complication will generally be readily ascertained. It is seldom that the os is not sufficiently dilated to enable us to satisfy ourselves whether the placenta is presenting. Is it justifiable to allow the Pregnancy to Continue? — The first ques- tion that will arise is, are we justified in temporizing, using means to check the hemorrhage, and allowing the pregnancy to continue? This is the course which has generally been recommended in works on midwifery. We are told to place the patient on a hard mattress, not to heat or overburden her with clothes, to keep her absolutely at rest, to have the room cool and well-aired, to apply cold cloths to the vulva and lower part of the abdomen, to administer cold and acidu- lated drinks, in abundance, and to prescribe acetate of lead and opium, or gallic acid, on account of their supposed hasmostatic effect. Of late years the judiciousness of these recommendations has been strongly contested. Not long ago an interesting discussion took place at the Obstetrical Society of London, 1 on a paper in which Dr. Grecnhalgh advised the immediate induction of labor in all cases of placenta praavia. No less than six metropolitan teachers of mid- wifery took part in it; and, although they differed in details, they 1 Obst. Trans., vol. vi. p. 188. HEMORRHAGE BEFORE DELIVERY. 395 all agreed as to the unadvisab'ility of allowing pregnancy to pro- gress when the existence of placenta previa had been distinctly ascertained. The reasons for this course are obvions and unanswer- able. The labor, indeed, very often comes on of its own accord; but should it not do so, the patient's life must be considered to be always in jeopardy until the case is terminated, for no one can be sure that most dangerous, or even fatal, flooding may not at any moment come on ; and the nearer to term the patient is, the greater the risk to which she is subjected. Xor is the safety of the child likely to be increased by delay. Provided it has arrived at a viable age, the chances of its being born alive may be said to be greater if preg- nancy be terminated at once, than if repeated floodings occur. I think, therefore, that it may be safely laid down as an axiom, that no attempt should be made to prevent the termination of pregnancy, but that our treatment should rather contemplate its conclusion as soon as possible. An exception may, however, be made to this rule when the hemorrhage occurs for the first time before the seventh month of utero-gestation. ' The chances of the child surviving would then be very small, and if the hemorrhage be not alarming, as at that early period is likely to be the case, the measures indicated above may be employed, in the hope of carrying on the pregnancy until there is a prospect of the patient being delivered of a living- child. But little benefit is likely to accrue from astringent drugs. Perfect rest in bed is more likely to be beneficial than anything else ; and astringent vaginal pessaries, of matico or perchloride of iron, might be used with advantage as local haemostatics. Various Methods of Treatment. — When the period of pregnancy, or the urgency of the case, determines us to forego any attempt at tem- porizing, there are various plans of treatment to be considered. These are chiefly — 1. Puncture of the membranes. 2. Plugging the vagina. 3. Turning. 4. Partial or complete separation of the placenta. It will be well to consider in detail the relative advantages of, and indications for, each of these. It is seldom, however, that we can trust to any one per se ; in most cases two or more are required to be used in combination. 1. Puncture of the membranes is recommended by Barnes as the first measure to be adopted in all cases of placenta praevia, sufficient to cause anxiety. "It is," he says, l 'the most generally efficacious remedy, and it can always be applied." The primary object gained is the increase of uterine contraction, by the evacuation of the liquor amnii. Although the first effect of this may be to increase the flow of blood by further separation of the placenta, the flooding can generally be commanded by plugging, until the os is sufficiently dilated to permit the passage of the child. As a rule, there is no great difficulty in effecting the puncture, especially if the placental presentation be only partial. A quill, or other suitable contrivance, guided by the examining finger, is passed through the cervix, and pushed through the membranes. In complete placenta praevia it may not be so easy to effect the evacuation of the liquor amnii ; and, al- though many authorities advise the penetration of the substance of 396 LABOR. the placenta itself, I am inclined to think that it would be better to abandon the attempt, in such cases, and trust to other methods of treatment. The objections which have been raised to puncture of the mem- branes are chiefly, that it interferes with the gradual dilatation of the os, and renders the operation of turning much more difficult. The os is not, however, so regularly dilated by the bag of membranes in cases of placenta praevia, as it is in ordinary labors. Moreover, the cervical tissues are generally relaxed by the hemorrhage, and dilatation is easily effected. Should we desire to dilate the os, pre- paratory to turning, we can readily do so by means of Barnes's bags, which act, at the same time, as an efficient plug. The objections, therefore, are not so weighty as they might have been before these artificial dilators were used. I am inclined, for these reasons, to agree with the recommendation that puncture of the membranes should be resorted to in all cases of placenta previa. 2. Plugging of the vagina, or, still better., of the cavity of the cer- vix itself, is specially serviceable in cases in which the os is not suffi- ciently dilated to admit of turning, or of separation of the placenta, and in which the hemorrhage still continues after the evacuation of the liquor amnii. By means of this contrivance the escape of blood is effectually controlled. The best way of plugging is to introduce a sponge tent of sufficient size into the cervical canal, and to keep it in situ by a vaginal phig; the best material for the latter, and the method of introduction, are described under the head of abortion. The sponge tent not only controls the hemorrhage more effectually than any other means, but is, at the same time, effecting dilatation of the cervix. It cannot be left in many hours on account of the irritation produced, and of the fetor from accumulating vaginal discharges. As long as it is in position, we should carefully examine, from time to time, to see that no blood is oozing past it. If preferred, a Barnes's bag may be used for the same purpose. While the plug is in situ, other modes of exciting uterine action may be very advantageously employed, such as a firm, abdominal bandage, occasional friction over the uterus, and repeated doses of ergot. The last is specially recommended by Dr. Greenhalgh, who uses, at the same time, a plug formed of an oblong India-rubber ball, inflated with air, and covered with spongio-piline. On the removal of the plug we may find that considerable dila- tation has taken place, perhaps to a sufficient extent to admit of labor being safely concluded by the natural efforts. In that case we shall find that, although the pains continue, no fresh hemorrhage occurs. Should it do so, it will be necessary to adopt further measures. 3. Turning has long been considered the remedy par excellence in placenta praevia ; and it is of unquestionable value in suitable cases. Much harm, however, has been done when it has been practised be- fore the os was sufficiently dilated to admit of the passage of the hand, or when the patient was so exhausted by previous hemorrhage HEMORRHAGE BEFORE DELIVERY. 397 as to be unable to bear the shock of the operation. The records of many fatal cases in the practice of those who taught, as did the large majority of the older writers, that turning at all risks was essential, conclusively prove this assertion. It is most likely to prove serviceable when, either at first, or after the use of the tampon, the os is sufficiently dilated to admit the hand, and when the strength of the patient is not much enfeebled. If she have a small, feeble, and thready pulse, it is certainly inapplicable, unless all other methods of arresting the hemorrhage have failed. And, even then, it would be well to attempt to rally the patient from her exhausted state by stimulants, etc., before the operation is com- menced. Provided the placental presentation be partial, the operation can be performed without difficulty in the usual way. In central implan- tation the passage of the hand may give rise to some difficulty. Dr. Eigby recommends that it should be pushed through the substance of the placenta, until it reaches the uterine cavity. It is hardly possible to conceive how this could be done without completely detaching the placenta, and still less to understand how the foetus could be dragged through the aperture thus made. It will be far better to pass the hand by the border of the placenta, separating it as we do so ; and, if we can ascertain to which side of the cervix it is least attached, that should be chosen for the purpose. In all cases in which it is possible, turning by the bi-polar method should be preferred. In cases of placenta praevia especially it offers many ad- vantages. The operation can be soon performed; complete dilatation of the os is not so necessary; and it involves less bruising of the cervix, which is likely to be specially dangerous. When once a foot has been brought within the os, the delivery need not be hurried. The foot forms a plug, which effectually prevents all further loss; and we may then safely wait until we can excite uterine contraction, and terminate the labor with safety. Fortunately, the relaxation of the uterus, which is so often present, facilitates this manner of per- forming version, and it can generally be successfully accomplished. Should the case be one which is otherwise suitable for turning, and the requisite amount of dilatation of the cervix not be present, the latter can generally be effected in the space of an hour or more (while at the same time a farther loss of blood is effectually pre- vented) by the use of Barnes's bags. 4. Separation of the Placenta. — Entire separation of the placenta was orignally recommended by Simpson in his well-known paper on the subject. The reasons which induced him to recommend it have already been stated. It is a mistake to suppose, however, as is so often done, that he intended to recommend it in all cases alike. This supposition he always was careful to deny. He advised it especially : — ■ 1. When the child is dead. 2. When the child is not yet viable. 3. When the hemorrhage is great and the os uteri is not yet suffi- ciently dilated for safe turning. This was the state in 11 out of 39 cases (Lee). 398 LABOR. 4. When the pelvic passages are too small for safe and easy turning. 5. When the mother is too exhausted to bear turning. 6. When the evacuation of the liquor amnii fails. 7. When the uterus is too firmly contracted for turning. 1 These are very much the cases in which all modern accoucheurs would exclude the operation of turning ; and it was especially when that was unsuitable that Simpson advised extraction of the placenta. As his theory of the source of hemorrhage is now almost universally disbelieved, so has the practice based on it fallen into disuse, and it need not be discussed at length. It is very doubtful whether the complete separation and extraction of the placenta was a feasible operation ; unquestionably it can be by no means so easy as Simp- son's writings would lead us to suppose. The introduction of the hand far enough to remove the placenta in an exhausted patient would probably cause as much shock as the operation of turning itself; and another very formidable objection to the procedure is the almost certain death of the child, if any time elapse between the separation of the placenta and the completion of delivery. The modification of this method, so strongly advocated by Barnes, is certainly much easier of application, and would appear to answer every purpose that Simpson's operation effected. It is impossible to describe it better than in Barnes's own words: 2 " The operation is this : Pass one or two fingers as far as they will go through the os uteri, the hand being passed into the vagina if necessary ; feeling the placenta, insinuate the finger between it and the uterine wall ; sweep the finger round in a circle so as to separate the placenta as far as the finger can reach ; if you feel the edge of the placenta, where the membranes begin, tear open the membranes carefully, especially if these have not been previously ruptured; ascertain, if you can, what is the presentation of the child before withdrawing your hand. Commonly, some amount of retraction of the cervix takes place after the operation, and often the hemorrhage ceases. 11 It will be seen from what has been said that no one rule of prac- tice can be definitely laid down for all cases of placenta prgevia. Our treatment in each individual case must be guided by the particular conditions that are present ; and, if only we bear in mind the natural history of the hemorrhage, we may confidently look to a favorable termination. It may be useful, in conclusion, to recapitulate the rules which have been laid down for treatment in the form of a series of pro- positions: — I. Before the child has reached a viable age, temporize, provided the hemorrhage be not excessive, until pregnancy has advanced suffi- ciently to afford a reasonable hope of saving the child. For this purpose the chief indication is absolute rest in bed, to which other 1 Selected Obst. Works, p. G8. 2 Obstet. Operations, 2d ed., p. 417. HEMORRHAGE BEFORE DELIVERY. 399 accessory means of preventing hemorrhage, such as cold, astringent pessaries, etc., may be added. II. In hemorrhage occurring after the seventh month of utero- gestation, no attempt should be made to prolong the pregnancy. III. In all cases in which it can be easily effected, the membranes should be ruptured. By this means uterine contractions are favored, and the bleeding vessels compressed. IV. If the hemorrhage be stopped, the case may be left to nature. If flooding continue, and the os be not sufficiently dilated to admit of the labor being readily terminated by turning, the os and the vagina should be carefully plugged, while uterine contractions are promoted by abdominal bandages, uterine compression, and ergot. The plug must not be left in beyond a few hours. V. If, on removal of the plug, the os be sufficiently expanded, and the general condition of the patient be good, the labor may be ter- minated by turning, the bi-polar method being used if possible. If the os be not open enough, it may be advantageously dilated by a Barnes's bag, which also acts as a plug. VI. Instead of, or before resorting to, turning, the placenta may be separated around the site of its attachment to the cervix. This practice is specially to be preferred when the patient is much ex- hausted, and in a condition unfavorable for bearing the shock of turning. CHAPTEE XIV. HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED PLACENTA. This is the form of hemorrhage which is generally described in obstetric works as "accidental" in contra-clistinction to the " unavoid- able" hemorrhage of placenta praevia. In discussing the latter, we have seen that the term "accidental" is one that is apt to mislead, and that the causation of the hemorrhage in placenta praevia is, in some cases at least, closely allied to that of the variety of hemorrhage we are now considering. When, from any cause, separation of a normally situated placenta occurs before delivery, more or less blood is necessarily effused from the ruptured utero-placental vessels, and the subsequent course of the case may be twofold. 1. The blood, or at least some part of it, may find its way between the membranes and the decidua, and escape from the os uteri. This constitutes the typical "accidental" hemorrhage of authors. 2. The blood may fail to find a passage externaLV, and may collect internally, giving rise to very serious 400 LABOR. symptoms, and even proving fatal, before the true nature of the case is recognized. Cases of this kind are by no means so rare as the small amount of attention paid to them by authors might lead us to suppose; and, from the obscurity of the symptoms and difficulty of diagnosis, they merit special study. Dr. Groodell 1 has collected together no less than 106 instances in which this complication occurred. Causes and Pathology. — The causes of placental separation may be very various. In a large number of cases it has followed an accident or exertion (such as slipping down stairs, stretching, lifting heavy weights, and the like), which has probably had the effect of lacerating some of the placental attachments. At other times it has occurred without such appreciable cause, and then it has been referred to some change in the uterus, such as a more than usually strong contraction producing separation, or some accidental determination of blood causing a slight extravasation between the placenta and the uterine wall, the irritation of which leads to contraction and further detach- ment. Causes such as these, which are of frequent occurrence, will not produce detachment except in women otherwise predisposed to it. It generally is met with in women who have borne many child- ren, more especially in those of weakly constitution and impaired health, and rarely in primiparse. Certain constitutional states proba- bly predispose to it, such as albuminuria, or exaggerated anaemia; and, still more so, degenerations and diseases of the placenta itself. This form of hemorrhage rarely occurs to an alarming extent until the latter months of pregnancy, often not until labor has commenced. The great size of the placental vessels in advanced pregnancy affords a reasonable explanation of this fact. Symptoms and Diagnosis. — If, after separation of a portion of the placenta, the blood finds its way between the membranes and the decidua, its escape per vaginam, even although in small amount, at once attracts attention, and reveals the nature of the accident. It is otherwise when we have to do with a case of concealed hemorrhage, the diagnosis of which is often a matter of difficulty. Then the blood probably at first collects between the uterus and the placenta. Some- times marginal separation does not occur, and large blood-clots are formed in this situation, and retained there. More often, the margin of the placenta separates, and the blood collects between the mem- branes and the uterine wall, either towards the cervix, where the presenting part of the child may prevent its escape, or near the fundus. In the latter case especially, the coagula are apt to cause very painful stretching and distension of the uterus. The blood may also find its way into the amniotic cavity, but more frequently it does not do so; probably, as Goodell has pointed out, because "should the os uteri be closed, the membranes, however delicate, cannot, other things being equal, rupture any sooner from the uterine walls, for the sum of the resistance of the inclosed liquor amnii being equally distributed exactly counterbalances the sum of 1 Amer. Journ. of Obstet., vol. ii. HEMORRHAGE BEFORE DELIVERY. 401 the pressure exerted by the effusion." This point is of some practical importance because, after rupture of the membranes, the liquor amnii is frequently found untinged with blood, and this might lead us to suppose ourselves mistaken in our diagnosis, if this fact were not borne in mind. Symptoms of Concealed Accidental Hemorrhage. — The most promi- nent symptoms in concealed internal hemorrhage are extreme col- lapse and exhaustion, for which no adequate cause can be assigned. These differ from those of ordinary syncope, with which they might be confounded, chiefly in their persistence and severity, and in the presence of the symptoms attending severe loss of blood, such as coldness and pallor of the surface, great restlessness and anxiety, rapid and sighing respiration, yawning, feeble, quick, and compres- sible pulse. When there is severe internal, with slight external hemorrhage, we may be led to a proper diagnosis by observing that the constitutional symptoms are much more severe than the amount of external hemorrhage would account for. Uterine pain is gene- rally present, of a tearing and stretching character, sometimes mode- rate in amount, more often severe, and occasionally amounting to intolerable anguish. It is often localized, and it, doubtless, depends on the distension of the uterus by the retained coagula. If the dis- tension be marked, there may be an irregularity in the form of the uterus at the site of sanguineous effusion ; but this will be difficult to make out, except in women with thin and unusually lax abdomi- nal parietes. A rapid increase in the size of the uterus has been described as a sign by Cazeaux and others. It is not very likely that this will be appreciable towards the end of utero-gestation, as a very large amount of effusion would be necessary to produce it. At an earlier period of pregnancy, at or about the fifth month, I made it out very distinctly in a case in my own practice. It obviously must have occurred to an enormous extent in a case related by Chevalier, in which post-mortem Cesarean section was performed under the im- pression that the pregnancy had advanced to term, but only a three months' foetus was found, imbedded in coagula which distended the uterus to the size of a nine months' gestation. 1 Labor pains may be entirely absent. If present, they are generally feeble, irregular, and inefficient. Differential Diagnosis. — The only condition, besides ordinary syn- cope, likely to be confounded with this form of hemorrhage, is rup- ture of the uterus, to which the intense pain and profound collapse induce considerable resemblance. The latter rarety occurs until after labor has been some time in progress, and after the escape of the liquor amnii ; whereas hemorrhage usually occurs either before labor has commenced, or at an early stage. The recession of the presenta- tion, and the escape of the foetus into the abdominal cavity, in cases of rupture, will farther aid in establishing the diagnosis. Prognosis. — The prognosis, when blood escapes externally, is, on the whole, not unfavorable. The nature of the case is apparent, and J Journ. de Med. Clin, et Pharraac, vol. xxi. p. 363. 402 LABOR. remedial measures are generally adopted sufficiently early to prevent serious mischief. It is different with the concealed form, in which the mortality is very great. Out of Goodell's 106 cases, no less than 54 mothers died. This excessive death-rate is, no doubt, partly due to the fact that extreme prostration so often occurs before the existence of hemorrhage is suspected, and partly to the accident generally hap- pening in women of weakly and diseased constitution. The prog- nosis to the child is still more grave. Out of 107 children, only 6 were born alive. The almost certain death of the child may be ex- plained by the fact that, when blood collects between the uterus and the placenta, the foetal portion of the latter is probably lacerated, and the child then also dies from hemorrhage. Treatment. — In this, as in all other forms of puerperal hemorrhage, the great hemostatic is uterine contraction, and that we must try to encourage by all possible means. The first thing to be done, whether the hemorrhage be apparent Or concealed, is to rupture the mem- branes. If the loss of blood be only slight, this may suffice to con- trol it, and the case may then be left to nature. A firm abdominal binder should, however, be applied to prevent any risk of blood col- lecting internally, as there is nothing to prevent its filling the uterine cavity after the membranes are ruptured. Contraction may be further advantageously solicited by uterine compression, and by the administration of full doses of ergot. If hemorrhage continue, or if we have any reason to suspect concealed hemorrhage, the sooner the uterus is emptied the better. If the os be sufficiently dilated, the best practice will be to turn without further delay, using the bi-polar method if possible. If the os be not open enough, a Barnes's bag should be introduced, while firm pressure is kept up to prevent uterine accumulation. Should the collapsed condition of the patient be very marked, the mere shock of the operation might turn the scale against her. Under such circumstances it may be better prac- tice to delay further procedure until, by the administration of stimu- lants, warmth, etc., we have succeeded in producing some amount of reaction, keeping up, in the meanwhile, firm pressure on the uterus. Should the head be low down in the pelvis, it may be easier to com- plete labor by means of the forceps. CHAPTER XV. HEMORRHAGE AFTER DELIVERY. Hemorrhage during, or shortly after, the third stage of labor is one of the most trjnng and dangerous accidents connected with partu- rition. Its sudden and unexpected occurrence just after the labor appears to be happily terminated, and its alarming effect on the HEMORRHAGE AFTER DELIVERY. -103 patient, who is often placed in the utmost danger in a few moments, tax the presence of mind and the resources of the practitioner to the utmost, and render it an imperative duty on every one who practises midwifery to make himself thoroughly acquainted with its causes, and preventive and curative treatment. There is no emergency in obstetrics which leaves less time for reflection and consultation, and the life of the patient will often depend on the prompt and imme- diate action of the medical attendant. Frequency of Post-partum Hemorrhage. — Post-partum hemorrhage is one of the most frequent complications of delivery. I do not know of any statistics which enable us to judge with accuracy of its frequency, but I believe it to be an unquestionable fact that, espe- cially in the upper ranks of society, it is very common indeed. This is probably due to the effects of civilization, and to the mode of life of patients of that class, whose whole surroundings tend to produce a lax habit of body which favors uterine inertia, the principal cause of post-partum hemorrhage. Generally a Preventable Accident. — Fortunately, it is, to a great extent, a preventable accident. I believe this fact canno t be too strongly impressed on the practitioner. If the third stage of labor be properly conducted, if every case be treated, as every case ought to be, as if hemorrhage were impending, it would be much more in- frequent than it is. It is a curious fact that post-partum hemorrhage is much more common in the practice of some medical men than in that of others ; the reason being, that those who meet with it often are careless in their management of their patients immediately after the birth of the child. That is just the time when the assistance of a properly qualified practitioner is of value, much more so than before the second stage of labor is concluded ; hence when I hear that a medical man is constantly meeting with severe post-partum hemorrhage, I hold myself justified ipso facto in inferring that he does not know, or does not practise, the proper mode of managing the third stage of labor. Causes and Nature^s Method of Controlling Hemorrhage after De- livery. — The placenta, as we have seen, is separated hj the last pains, and the blood, which in greater or less quantity accompanies the foetus, probably comes from the utero-placental vessels which are then lacerated. Almost immediately afterwards the uterus contracts firmly, and, in a typical labor, assumes the hard cricket-ball form which is so comforting to the accoucheur to feel. The result is the compression of all the vascular trunks which ramify in its walls, both arteries and veins, and thus the flow of blood through them is pre- vented. By referring to what has been said as to the anatomy of the muscular fibres of the gravid uterus, especially at the placental site (p. 52), it will be seen how admirably they are adapted for this purpose. The arrangement of the vessels themselves favors the j haemostatic action of uterine contraction. The large venous sinuses are placed in layers, one above the other, in the thickness of the uterine walls, and they anastomose freely. When the superimposed layers communicate with those immediately below them, the junc- 404 LABOR. tion is by a falciform or semilunar opening in the floor of the vessel nearest the external surface of the uterus. Within the margins of this aperture there are muscular fibres, the contraction of which probably tends to prevent retrogression of blood from one layer of vessels into the other. The venous sinuses themselves are of a flat- tened form, and they are intimately attached to the muscular tissues. It is obvious, then, that these anatomical arrangements are emi- nently adapted to facilitate the closure of the vessels. They are, however, large, and are destitute of valves ; and, if contraction be absent, or if it be partial and irregular, it is equally easy to under- stand why blood should pour forth in the appalling amount which is sometimes observed. Importance of Tonic Uterine Contraction. — If uterine action be firm, regular, and continuous, the vessels must be sealed up, and hemor- rhage effectually prevented. This fact has been doubted by many authorities. Grooch was the first to describe what he called " a pecu- liar form of hemorrhage" accompanying a contracted womb, and similar observations have been made by other writers, such as Velpeau, Bigby, and Grendrin. Simpson says, on this point, that strong uterine contractions " are not probably so essential a part in the mechanism of the prevention of hemorrhage from the open ori- fices of the uterine veins as we might a priori suppose." 1 With re- gard to Gooch's cases, it has been pointed out that his own description proves that, however firmly the uterus may have contracted imme- diately after the expulsion of the child, it must have subsequently relaxed, for he passed his hand into it to remove retained clots, a manoeuvre which he could not have practised had tonic contraction been present. Barnes suggests that in some of these cases the hemorrhage came from a laceration of the cervix. Of course, blood may readily escape from a mechanical injury of this kind, although the uterus itself be in a satisfactory state of contraction, and the possibility of this occurrence should always be borne in mind. Although, then, Ave may admit that post-partum hemorrhage is incompatible with persistent contraction of the uterus, it by no means follows that the converse is true. On the contrary, it is not uncom- mon to meet with cases in which the uterus is large and apparently quite flaccid, and in which there is no loss of blood. Alternate re- laxation and contraction of the uterus after delivery are also of con- stant occurrence, and yet hemorrhage, during the relaxation, does not take place. The explanation no doubt is that, immediately after the birth of the child, there was sufficient contraction to pre- vent hemorrhage, and that, during its continuance, coagula formed in the mouths of the uterine sinuses, by which they were suffi- ciently occluded to prevent any loss when subsequent relaxation occurred. In all probability both uterine contraction and thrombosis are in operation in ordinary cases ; and we shall presently see that all the 1 Selected Obstetric Works, p. 234. HEMORRHAGE AFTER DELIVERY. 405 means employed in the treatment of post-partum hemorrhage act by producing one or other of them. Secondary Causes of Hemorrhage. — Uterine inertia after labor, then, may be regarded as the one great primary cause of post-partum. hemorrhage; but there are various secondary causes which tend to produce it, one of the most frequent of which is exhaustion follow- ing a protracted labor. The uterus gets worn out by its efforts, and when the foetus is expelled, it remains in a relaxed state, and hemor- rhage results. Over-distension of the uterus acts in the same way. Hence hemorrhage is very frequently met with when there has been an excessive amount of liquor amnii, or in multiple pregnancies. One of the worst cases I ever met with was after the birth of triplets, the uterus having been of an enormous size. Rapid emptying of the uterus, during which there has not been sufficient time for complete separation of the placenta, often tends to the same result. This is the reason why hemorrhage so frequently follows forceps delivery, especially if the operation have been unduly hurried ; and it is one of the chief dangers in what are termed " precipitate labors." The general condition of the patient may also strongly predispose to it. Thus it is more often met with in women who have borne families, especially if they be weakly in constitution, comparatively seldom in primiparse ; and for the same reason that after-pains are most common in the former, namely that the uterus, weakened by frequent child-bearing, contracts inefficiently. The experience of practitioners in the tropics shows that European women, debilitated by the relax- ing effects of warm climates, are peculiarly prone to it, and it forms one of the chief dangers of childbirth amongst the English ladies in India. Irregular Uterine Contraction. — Another important cause of post- partum hemorrhage is partial and irregular contraction of the uterus. Part of the muscular tissue is firmly contracted, while another part is relaxed, and the latter very often the placental site. This has been especially dwelt on by Simpson. He says, "the morbid con- dition which is most frequently and earliest seen in connection with post-partum hemorrhage, is a state of irregularity and want of equa- bility in the contractile action of different parts of the uterus — and, it may be in different planes of the muscular fibres — as marked by one or more points in the organ feeling hard and contracted, at the same time that other portions of the parietes are soft and relaxed." Hour-glass Contraction. — One peculiar variety, which has been much dwelt on by writers, and is a prominent bugbear to obstetri- cians, is the so-called " hour-glass contraction." This in reality seems to depend on spasmodic contraction of the internal os uteri, by means of which the placenta becomes encysted in the upper portion of the uterus, which is relaxed. On introducing the hand, it first passes through the lax cervical canal, until it comes to the closed internal os, with the umbilical cord passing through it, which has generally been supposed to be a circular contraction of a portion of the body of the uterus. [The late Prof. Meigs was of the opinion that an encysted placenta 406 LABOR. was always an adherent one, and that the local inertia was the forced effect of the adhesion, preventing mechanically the contraction of the uterus over the utero-placental space. This was also the opinion of Kamsbotham, from whose work the following plates are taken. He had never seen a true hour-glass constriction, such as the right hand drawing. Miller claims to have met with the condition on several oc- casions. — Ed.] Encystment of the placenta, however, although more rarely, unquestionably takes place in a portion only of the body of the uterus (Fig. 138). Then apparently the placental site remains Fig. 138. Irregular Contraction of the Uterus, with Encystment of the Placenta. more or less paralyzed, with the placenta still attached, while the remainder of the body of the uterus contracts firmly, and thus encyst- ment is produced. Causes of Irregular Contractions. — These irregular contractions of the uterus are by no means so common as our older authors supposed. "When they do occur I believe them almost invariably to depend on defective management of the third stage of labor. " The most fre- quent cause," says Rigby, 1 "is from over anxiety to remove the placenta ; the cord is frequently pulled at, and at length the os uteri is excited to contract." While this is being done, no attempts are probably being made to excite the fundus to proper action, and, therefore, the hour-glass contraction is established. Duncan says of this condition : " Hour-glass contraction cannot exist unless the parts above the contraction are in a state of inertia ; were the higher parts of the uterus even in moderate action, the hour-glass contrac- tion would soon be overcome." 2 If placental expression were always employed, if it were the rule to effect the expulsion of the placenta by a vis a teryo, instead of extracting by a vis d fronte, I feel con- fident that these irregular and spasmodic contractions — of the influ- ence of which in producing hemorrhage there can be no question — would rarely, if ever, be met with. Tt is to be observed that even 1 Rigby' s Midwifery, p. 225. Researches in Obstetrics, p. 389. HEMORRHAGE AFTER DELIVERY. 407 in these cases, it is not because the uterus is in a state of partial con- traction, but because it is in a state of partial relaxation, that hemor- rhage ensues. Placental Adhesions. — Adhesions of the placenta to the uterine parietes may cause hemorrhage, especially if they be partial, and the remainder of the placentae be detached. The frequency of these has been over-estimated. Many cases believed to be examples of adherent placentas are, in reality, only cases of placentae retained from uterine inertia. The experience of all who see much midwifery will probably corroborate the observation of Brann, that "abnormal adhesion and hour-glass contraction are more frequently encountered in the experience of the young practitioner, and they diminish in frequency in direct ratio to increasing years." 1 The cause of adhe- sion is often obscure, but it most probably results from a morbid state of the decidua, which is produced by antecedent disease of the uterine mucous membrane; then the adhesion is apt to recur in sub- sequent pregnancies. The decidua is altered and thickened, and patches of calcareous and fibrous degeneration may be often found on the attached surface of the placenta. Most frequently the placenta is only partially adherent ; patches of it remain firmly attached to the uterus, while the rest is separated ; hence the uterine walls re- main relaxed, and hemorrhage frequently follows. The diagnosis and management of these very troublesome cases will be found de- scribed under the head of treatment (p. 411). Constitutional Predisposition to Flooding. — Finally I think it must be admitted that there are some women who really merit the appel- lation of "Flooclers," which has been applied to them, and who, clo what we may, have the most extraordinary tendency to hemorrhage after delivery. I do not think that these cases, however, are by any means so common as some have supposed. 2 I have attended several patients who have nearly lost their lives from post-partum hemor- rhage in former labors, some who have suffered from it in every pre- ceding confinement, and I have only met with two cases in which the assiduous use of preventive treatment failed to avert it. In these (one of which I have elsewhere published in detail 3 ), in spite of all my efforts, I could not succeed in keeping up uterine contraction, and the patients would certainly have lost their lives were it not for the means which modern improvements have fortunately placed at our disposal for producing thrombosis in the mouths of the bleeding vessels. The nature of these rare cases requires further investiga- tion ; possibly they may, to some extent, be the subjects of the so- called hemorrhagic diathes Signs and Symptoms. — The loss of blood may commence immedi- ately after the birth of the child, before the expulsion of the placenta, or not until some time afterwards, when the contracted uterus has again relaxed. It may commence gradually, or suddenly; in the latter case, it may begin with a gush, and in the worst form the bed- 1 Braun's Lectures, 1869. [ 2 See remarks on quinia, p, 330. — Ed.] 3 Obst. Journ., vol. i. 408 LABOR. clothes, the bed, and even the floor, are deluged with the blood which, it is no exaggeration to say, is pouring from the patient. If now the hand be placed on the abdomen, we shall miss the hard round ball of the contracted uterus, which will be found soft and flabby, or we may even be unable to make out its contour at all. If the hemor- rhage be slight, or if we succeed in controlling it at once, no serious consequences follow ; but if it be excessive, or if we fail to check it, the gravest results ensue. Exhaustion in Extreme Cases. — There are few sights more appal- ling to witness than one of the worst cases of post-partum hemorrhage. The pulse becomes rapidly affected, and may be reduced to a mere thread, or it may become entirely imperceptible. Syncope often comes on, not in itself always an unfavorable occurrence, as it tends to promote thrombosis in the venous sinuses. Or, short of actual syncope, there may be a feeling of intense debility and faintness. Extreme restlessness soon supervenes, the patient throws herself about the bed, tossing her arms wildly above her head ; respiration becomes gasping and sighing, the "besoin de respirer" is acutely felt, and the patient cries out for more air ; the skin becomes deadly cold, and covered with profuse perspiration ; if the hemorrhage continue unchecked, we next may have complete loss of vision, jactitation, convulsions, and death. Formidable as such symptoms are, it is satisfactory to know that recovery often takes place, even when the powers of life seem reduced to the lowest ebb. If we can check the hemorrhage while there is still some power of reaction left, however slight, we may not unrea- sonably hope for eventual recovery. The constitution, however, may have received a severe shock, and it may be months, or even years, before the patient recovers from the effects of only a few minutes' hemorrhage. A death-like pallor frequently follows these excessive losses, and the patient often remains blanched and exsanguine for a long time. Preventive Treatment. — The preventive treatment of post-partum hemorrhage should be carefully practised in every case of labor, however normal. If the practitioner make a habit of never remov- ing his hand from the uterus after the birth of the child until the placenta is expelled, and of keeping up continuous uterine contrac- tion for at least half an hour after delivery is completed, not neces- sarily by friction on the fundus, but by simply grasping the contracted womb with the palm of the hand and preventing its undue relaxation, cases of post-partum flooding will seldom be met with. As a rule we should, I think, not apply the binder until at least that time has elapsed. The binder is an effective means of keeping up, but not of producing, contraction, and it should never be trusted to for the latter purpose. If it be put on too soon, the uterus may relax under it, and become filled with clots without the practitioner knowing any- thing about it; whereas this cannot possibly take place as long as the uterine globe is held in the hollow of the hand. I have seen more than one serious case of concealed hemorrhage result from the too common habit of putting on the binder immediately after the HEMORRHAGE AFTER DELIVERY. 409 removal of the placenta. I believe also, as I have formerly said, that it is thoroughly good practice to administer a full dose of the liquid extract of ergot in all cases after the placenta has been ex- pelled, to insure persistent contraction, and to lessen the chance of blood-clots being retained in utero. These are the precautions which should be used in all cases alike; but when we have reason to fear the occurrence of hemorrhage, from the history of previous labors or other cause, special care should be taken. The ergot should be given, and preferably in the form of the subcutaneous injection of ergotine, before the birth of the child, when the presentation is so far advanced that we estimate that labor will be concluded in from ten to twenty minutes, as we can hardly expect the drug to produce any effect in less time. Particular atten- tion, moreover, should then be paid to the state of the uterus. Every means should be taken to insure regular and strong contraction, and it is advisable to rupture the membranes early, as soon as the os is dilated or dilatable, to insure stronger uterine action. If any tend- ency to relaxation occur after delivery, a piece of ice should be passed into the vagina, or into the uterus. Should coagula collect in the uterus, they may be readily expelled by firm pressure on the fundus, and the finger should be passed occasionally up to the cervix, and any which are felt there should be gently picked away. We should be specially on our guard in all cases in which the pulse does not fall after delivery. If it beat at 100 or more some ten minutes or a quarter of an hour after the birth of the child, hemorrhage not unfrequently follows; and, hence, it is a good prac- tical rule, which may save much trouble, that a patient should never be left unless the pulse has fallen to its natural standard. Curative Treatment. — As there are only two means which nature adopts in the prevention of post-partum hemorrhage, so the remedial measures also may be divided into two classes. 1. Those which act by the production of uterine contraction. 2. Those which act by producing thrombosis in the vessels. Of these the first are the most commonly used ; and it is only in the worst cases, in which they have been assiduously tried and have failed, that we resort to those coming under the second heading. Uterine Pressure. — The patient should be placed on her back, in which position we can more readily command the uterus, as well as attend to her general state. If the uterus be found relaxed and fall of clots, by firmly grasping it in the hand contraction may be evoked, its contents expelled, and further hemorrhage at once arrested. Should I this fortunately be the case, we must keep up contraction by gently kneading the uterus, until we are satisfied that undue relaxation will , not recur. The powerful influence of friction in promoting contrac- tion cannot be doubted, and nothing will replace it; no doubt it is fatiguing, but as long as it is effectual it must be kept up. No \ roughness should be used, as we might produce subsequent injury, but it is quite possible to use considerable pressure without any ' violence. Another method of applying uterine pressure has been strongly 27 410 LABOR. advocated by Dr. Hamilton, of Falkirk, and it may be serviceable where there is a constant draining from the uterus, and a capacious pelvis. It consists in passing the fingers of the right hand high up in the posterior cul de sac of the vagina, so as to reach the posterior surface of the uterus, while counter-pressure is exercised by the left hand through the abdomen. The anterior and posterior walls of the uterus are thus closely pressed together. Administration of Ergot. — During the time that pressure is being applied, attention can be paid to general treatment ; and in giving his directions to the bystanders the practitioner should be calm and collected, avoiding all hurry and excitement. A full dose of ergot should be administered, and if one have already been given, it should be repeated. We cannot, however, look upon ergot as anything but a useful accessory, and it is one which requires considerable time to operate. The hypodermic use of ergotine offers the double advan- tage, in severe cases, of acting with greater power, and much more rapidly than the usual method of administration. It should, there- fore, always be used in preference. Stimulants. — The sudden flow will probably have produced ex- haustion and a tendency to syncope, and the administration of stimu- lants will be necessary. The amount must be regulated by the state of the pulse, and the degree of exhaustion. There is no more ab- surd mistake, however, than implicitly relying on the brandy bottle to check post-partum hemorrhage. In the worst cases absorption is in abeyance, and brandy may be poured down in abundance, the prac- titioner believing that he is rousing his patient, while he is, in fact, merely filling the stomach with a quantity of fluid, which is eventu- ally thrown up unaltered. I have more than once seen symptoms, produced from the over-free use of brandy in slight floodings, which were certainly not those of hemorrhage. I remember on one occa- sion being summoned by a practitioner, with a view to transfusion, to a patient who was said to be insensible and collapsed from hemor- rhage. I found her, indeed, unconscious; but with a flushed face, a bounding pulse, a firmly contracted uterus, and deep stertorous breathing. On inquiry I ascertained that she had taken an enor- mous quantity of brandy, which had brought on the coma of pro- found intoxication, while the hemorrhage had obviously never been excessive. Hypodermic Injection of Ether. — The hypodermic injection of sul- phuric ether has been recommended as a powerful stimulant in cases in which exhaustion is very great. A fluidrachm may be in- jected, and the remedy is Avorthy of trial, when the tendency to syn- cope is extreme. Fresh Air, etc. — The windows should be thrown widely open, to allow a current of fresh cold air to circulate freely through the room. The pillows should be removed, the head kept low, and the patient should be assiduously fanned. Emptying of Uterus. — If bleeding continue, or if it commence be- fore the placenta is expelled, the hand should be carefully and gently passed into the uterus, and its cavity cleared of its contents. The HEMORRHAGE AFTER DELIVERY. 411 mere presence of the hand within the uterus is a powerful incitor of uterine action. When the placenta is retained it is the more essen- tial, as the hemorrhage cannot possibly be checked as long as the uterus is distended by it. During the operation the uterus should be supported by the left hand externally, and, by using the two hands in concert, the chances of injuring the textures are greatly lessened. Treatment of Hour-glass Contraction. — If the so-called "hour glass contraction " be present, or if the placenta be morbidly adherent, the operation will be more difficult, and will require much judgment and care. The spasmodic contraction of the inner os in the former case may generally be overcome by gentle and continuous pressure of the fingers passed within the contraction, while the uterus is supported from without. By this means, too, further hemorrhage can in most cases be controlled, until the spasm is sufficiently relaxed to admit of the passage of the hand. Signs of Adherent Placenta. — There are no very reliable signs to indicate morbid adhesion of the placenta, previous to the introduc- tion of the hand. The following are the symptoms as laid down by Barnes, any of which might, however, accompany non-detachment of the placenta, unaccompanied by adhesion : " You may suspect mor- bid adhesion, if there have been unusual difficulty in removing the placenta in previous labors ; if, during the third stage, the uterus contracts at intervals firmly, each contraction being accompanied by blood, and yet, on following up the cord, you feel the placenta in utero ; if on pulling on the cord, two fingers being pressed into the placenta at the root, you feel the placenta and uterus descend in one mass, a sense of dragging pain being elicited ; if, during a pain the uterine tumor does not present a globular form, but be more promi- nent than usual at the place of placental attachment." 1 Treatment of Adherent Placenta. — The artificial removal of an ad- herent placenta is always a delicate and anxious operation, which, however carefully performed, must of necessity expose the patient to the risk of injury to the uterine structures, and of leaving behind portions of placental tissue, which may give rise to secondary hemor- rhage, or septicaemia. The cord will guide the hand to the site of attachment, and the fingers must be very gently insinuated between the lower edge of the placenta and the uterine wall ; or, if a portion be already detached, we may commence to peel off the remainder at that spot. Supporting the uterus externally, we carefully pick off as much as possible, proceeding with the greatest caution, as it is by no means easy to distinguish between the placenta and the uterus. At the best it is far from easy to remove all, and it is wiser to separate only what we readily can, than to make too protracted efforts at com- plete detachment. When it is found to be impossible to detach and remove the whole, or a great part of the placenta, we cannot but look upon the further progress of the case with considerable anxiety. The retained portions may be, ere long, spontaneously detached and 1 Obstetric Operations, p. 440. 412 LABOR. expelled, or they may decompose and give rise to fetid discharge and septic infection. Such cases must be treated by antiseptic intra- uterine injections, so as to lessen the risk of absorption as much as possible ; but until the retained masses have been expelled, and the discharge has ceased, the patient must be considered to be in consider- able danger. In a few rare cases, there is reason to believe that considerable masses of retained placental tissue have been entirely absorbed. It is difficult to understand so strange a phenomenon, but several well-authenticated cases are recorded, in which there seems no reason to doubt that the retained placenta was removed in this way. 1 Excitement of Reflex Action by Cold, etc. — Various means are used for exciting uterine contraction by reflex stimulation. Amongst the most important of these is cold. In patients who are not too ex- hausted to respond to the stimulus applied, it is of extreme value. But, to be of use, it should be used intermittently, and not continu- ously. Pouring a stream of cold water from a height on the abdomen is a not uncommon, but bad, practice, as it deluges the patient and the bedding in water, which may afterwards act injuriously. Flap- ping the lower part of the abdomen with a wet towel is less objec- tionable. Ice can generally be obtained, and a piece should be in- troduced into the uterus. This is a very powerful haemostatic, and often excites strong action when other means fail. I constantly em- ploy it, and have never seen any bad results follow. A large piece of ice may also be held over the fundus, and removed, and re-applied from time to time. Iced water may be injected into the rectum. A very powerful remedy is washing out the uterine cavity with a stream of cold water, by means of the vaginal pipe of a Higginson's syringe carried up to the fundus. Another means of applying cold, said to be very effectual, is the application of the ether spray, such as is used for producing local anaesthesia, over the lower part of the abdomen. 2 All these remedies, however, depend for their good re- sults on the fact of the patient being in a condition to respond to stimulus ; and their prolonged use, if they fail to excite contraction rapidly, will certainly prove injurious. Rigby used to look upon the application of the child to the breast as one of the most certain in- citors of uterine action. It may be of service, after the hemor- rhage has been checked, in keeping up tonic contraction, and should therefore not be omitted; but we certainly cannot waste time in in- ducing the child to suck in the face of the actual emergency. Intra-uterine Injections of Warm. Water. — Of late, intra- uterine in- jections of warm water, at a temperature of from 110° to 120°, have been highly recommended as a powerful means of arresting post- partum hemorrhage, often proving effectual when all other treatment has failed. The number of published cases in which it has proved of great value is now considerable. The present master of the 1 See an interesting paper by Dr. Thrush on " Retention of the Placenta in Labor at Term." Am. Journ. of Obstet., July, 1877. 2 Griffiths, Practitioner, March, 1877. HEMORRHAGE AFTER DELIVERY. 413 Rotunda, Dr. Lombe Atthill, lias recorded 16 cases 1 in which it checked hemorrhage at once, in many of which ergot, ice, and other means had failed. He speaks of it as especially useful in those troublesome cases in which the uterus alternately relaxes and hardens, and resists all our efforts to produce permanent contraction. My own experience of this treatment is too limited to justify my giving a decided opinion on its merits; but I have tried it in two or three cases, and in them the result certainly exceeded my expecta- tions. I think it cannot be doubted that we have in these warm irrigations a valuable addition to our methods of treating uterine hemorrhage. State of the Bladder. — The late Dr. Earle pointed out 2 that a dis- tended bladder often prevents contraction, and to avoid the possi- bility of this the catheter should be passed. Plugging the Vagina. — Plugging of the vagina has often been used. It is only necessary to mention it for the purpose of insisting on its absolute inapplicability in all cases of post-partum hemorrhage ; the only effect it could have would be to prevent the escape of blood externally, which might then collect to any extent in the cavity of the uterus. Compression of the abdominal aorta is highly thought of by many continental authorities, but is little known or practised in this country. It has been objected to by some on the theoretical ground that the hemorrhage is chiefly venous, and not arterial, and that it would only favor the reflux of venous blood into the vena cava. Cazeaux points out that, on account of the close anatomical relations between the aorta and the vena cava, it is hardly possible to compress one vessel without the other. The backward flow of blood, therefore, through the vena cava may also be thus arrested. There is strong evidence in favor of the occasional utility of compression. Its chief recommendation is, that it can be practised immediately, and by an assistant who can be shown how to apply the pressure. It is most likely to prove useful in sudden and severe hemorrhage, and, if it only control the loss for a few moments, it gives us time to applv other methods of treatment. As a temporary expedient, therefore, it should be borne in mind, and adopted when necessary. It has the great advantage of supplementing, without superseding, other and more radical plans of treatment. The pressure is very easily applied, on account of the lax state of the abdominal walls. The artery can readily be felt pulsating above the fundus uteri, and can be compressed against the vertebrae by three or four fingers applied lengthways. Baudelocque, who was a strong advocate of this pro- cedure, states that he has, on several occasions, controlled an other- wise intractable hemorrhage in this way, and that he, on one occasion, kept up compression for four consecutive hours. Cazeaux believes that compression of the aorta may have a further advantageous effect in retaining the mass of the blood in the upper part of the body, and thus lessening the tendency to syncope and collapse. If an aortic 1 Lancet, February 9, 1878. 2 Earle' s Flooding after Delivery, p. 1G3. 414 LABOR. tourniquet, such as is used for compressing the vessel in cases of aneurism, could be obtained, it might be used with advantage in serious cases. Bandaging of the Extremities. — When the hemorrhage has been excessive, and there is profound exhaustion, firm bandaging of the extremities, by preference with Esmarch's elastic bandages if they can be obtained, may be advantageously adopted, with the view of retaining the blood as much as possible in the trunk, and thus lessen- ing the tendency to syncope. As a temporary expedient in the worst class of cases it may occasionally prove of service. Injection of Styptics. — Supposing these means fail, and the uterus obstinately refuses to contract in spite of all our efforts — and, do what we may, cases of this kind will occur — the only other agent at our command is the application of a powerful styptic to the bleeding surface to produce thrombosis in the vessels. "The latter," says Dr. Ferguson, 1 alluding to this means of arresting hemorrhage, "appears to be the sole means of safety in those cases of intense flooding in which the uterus flaps about the hand like a wet towel. Incapable of contraction for hours, yet ceasing to ooze out a drop of blood, there is nothing apparently between life and death but a few soft coagula plugging up the sinuses." These form but a frail barrier indeed, but the experience of all who have used the injection of a solution of perchloride of iron in such cases, proves that they are thoroughly effectual, and its introduction into practice is one of the greatest improvements in modern midwifery. Although this method of treating these obstinate cases is not new, since it was practised long ago in Germany, its adoption in this country is unquestionably due to the energetic recommendation of Dr. Barnes. Although the dangers of the practice have been strongly insisted on, and with a degree of acrimony that is to be regretted, I know of only one pub- lished case in which its use has been followed by any evil effects. Its extraordinary power, however, of instantly checking the most formidable hemorrhage, has been demonstrated by the unanimous testimony of all who have tried it. As it is not proposed by any one that this means of treatment should be employed until all ordinary methods of evoking contraction have failed, and as, in cases of this kind, the lives of the patients are of necessity imperilled, we should be fully justified in adopting it, even if its possible injurious effects had been much more certainly proved. It is surely at any time justifiable to avoid a great and pressing peril by running a possible chance of a less one. Whenever, therefore, we have tried the plans above indicated in vain, no time should be lost in resorting to this expedient. No practitioner should attend a case of midwifery with- out having the necessary styptic with him. The best and most easily obtainable form of using the remedy is the " liquor ferri per- chloricli fortior" of the London Pharmacopoeia, which should be diluted for use with six times its bulk of water. This is certainly better than a weaker solution. The vaginal pipe of a Higginson's 1 Preface to Gooch On Diseases of Women, p. xlii. HEMORRHAGE AFTER DELIVERY. 415 svringe, through which the solution has once or twice been pumped to exclude the air, is guided by the hand to the fundus uteri, and the fluid injected gently over the uterine surface. The loose and flabby mucous membrane is instantaneously felt to pucker up, all the blood with which the fluid comes in contact is coagulated, and the hemorrhage is immediately arrested. I think it is of importance to make sure that the uterus and vagina are emptied of clots before injection. In the only case in which I have seen any bad symptoms follow, this precaution had been neglected. The iron hardened all the coagula, which remained in utero, and septicaemia supervened ; which, however, disappeared after the clots had been broken up and washed away by intra-uterine antiseptic injections. After we have resorted to this treatment, all further pressure on the uterus should be stopped. \Ye must remember that we have now abandoned con- traction as an haemostatic, and are trusting to thrombosis, and that pressure might detach and lessen the coagula which are preventing the escape of blood. Other local astringents may be eventually found to be of use. Tincture of matico possibly might be serviceable, although I am not aware that it has beeu tried. Dupierris has advocated tincture of iodine, and has recorded 24 cases in which he employed it, in all without accident and with a successful issue. But nothing seems likely to act so immediately, or so effectually, as the perchloride of iron. Hemorrhage from Laceration of Maternal Structures. — A word mav here be said as to the occasional dependence of hemorrhage after delivery on laceration of the cervix, or other injury to the maternal soft parts. Duncan has narrated a case in which the bleed- ing came from a ruptured perineum. If hemorrhage continue after the uterus is permanently contracted, a careful examination should be made to ascertain if any such injury exist. Most generally the source of bleeding is the cervix, and the flow can be readily arrested by swabbing the injured textures with a sponge saturated in a solu- tion of the perchloride. Secondary Treatment. — The secondary treatment of post-partum hemorrhage is of importance. When reaction commences, a train of distressing symptoms often show themselves, such as intense and throbbing headache, great intolerance of light and sound, and general nervous prostration ; and, when these have passed away, we have to deal with the more chronic effects of profuse loss of blood. ISTothing is so valuable in relieving these symptoms as opium. It is the best restorative that can be employed, but it must be administered in larger doses than usual. Thirty to forty drops of Battley's solution should be given by the mouth, or in an enema. At the same time the patient should be kept perfectly still and quiet, in a darkened room, and the visits of anxious friends strictly forbidden. Strong- beef essence, or gravy soup, milk, or eggs beat up with milk, and similar easily absorbed articles of diet, should be given frequently, and in small quanties at a time. Stimulants will be required accord- ing to the state of the patient, such as warm brandy and water, port 416 LABOR. wine, etc. Rest in bed should be insisted on, and continued much. beyond the usual time. Eventually the remedies which act by pro- moting the formation of blood, such as the various preparations of iron, will be found useful, and may be required for a length of time. Transfusion. — Under the head of transfusion I have separately treated the application of that last resource in those desperate cases in which the loss of blood has been so excessive as to leave no other hope. Secondary Post-partum Hemorrhage. — In the majority of cases, if a few hours have elapsed after delivery without hemorrhage, we may consider the patient safe from the accident. It is by no means very rare, however, to meet with even profuse losses of blood coming on in the course of convalescence, at a time varying from a few hours, or days, up to several weeks after delivery. These cases are described as examples of " secondary hemorrhage" and they have not received at all an adequate amount of attention from obstetric writers, inas- much as they often give rise to very serious, and even fatal, results, and are always somewhat obscure in their etiology, and difficult to treat. We owe almost all our knowledge of this condition to an excellent paper by Dr. McClintock, of Dublin, who has collected characteristic examples from the writings of various authors, and accurately described the causes which are most apt to produce it. Profuse Lochial Discharge. — We must, in the first place, distin- guish between true secondary hemorrhage and profuse lochial dis- charge, continued for a longer time than usual. The latter is not a very uncommon occurrence, and is generally met with in cases in which involution of the uterus has been checked; as by too early exertion, general debility, and the like. The amount of the lochial discharge varies in different women. In some patients it habitually continues during the whole puerperal month, and even longer, but not to an extent which justifies us in including it under the head of hemorrhage. In such cases prolonged rest, avoidance of the erect posture, occasional small doses of ergot, and, it may be, after the lapse of some weeks, astringent injections of oak bark, or alum, will be all that is necessary in the way of treatment. True secondary hemorrhage is often sudden in its appearance and serious in its effects. McClintock mentions 6 fatal cases, and Mr. Bassett, of Birmingham, 1 has recorded 13 examples which came under his own observation, 2 of which ended fatally. The Causes are either Constitutional or Local. — The causes may be either constitutional, or some local condition of the uterus itself. Among the former are such as produce a disturbance of the vas- cular system of the body generally, or of the uterine vessels in particular. The state of the uterine sinuses, and the slight barrier which the thrombi formed in them offer to the escape of blood, readily explain the fact of any sudden vascular congestion producing hemor- rhage. Thus mental emotions, the sudden assumption of the erect posture, any undue exertion, the incautious use of stimulants, a 1 Brit. Med. Jour., 1872. HEMORRHAGE AFTER DELIVERY. 417 loaded condition of the bowels, or sexual intercourse shortly after delivery, may act in this way. McClintock records the case of a lady in whom very profuse hemorrhage occurred on the twelfth day after labor, when sitting up for the first time. Feeling faint after suckling, the nurse gave her some brandy, whereupon a gush of blood ensued, "deluging all the bed-clothes and penetrating through the mattress so as to form a pool on the floor." Here the erect posi- tion, the exquisite pain caused by nursing, and the stimulating drink, all concurred to excite the hemorrhage. In another instance the flooding was traced to excitement produced by the sudden return of an old lover on the eighth day after labor. Moreau especially dwells on the influence of local congestion produced by a loaded condition of the rectum. Constitutional affections producing general debility, and an impoverished state of the blood, probably also may have the same effect. Blot specially mentions albuminuria as one of these, and Saboia states that in Brazil secondary hemorrhage is a common symptom of miasmatic poisoning, and can only be cured by change of air and the free use of quinine. 1 Local Causes. — Local conditions seem, however, to be more fre- quent factors in the production of secondary hemorrhage. These may be generally classed under the following heads: — 1. Irregular and inefficient contraction of the uterus. 2. Clots in the uterine cavity. 3. Portions of retained placenta or membranes. 4. Retroflexion of the uterus. 5. Laceration or inflammatory state of the cervix. 6. Thrombosis or hematocele of the cervix or vulva. 7. Inversion of the uterus. 8. Fibroid tumors or polypus of the uterus. The first four of these need only now be considered, the others being described elsewhere. Relaxation of, and Clots in, the Uterus. — Relaxation of the uterus and distension of its cavity by coagula may give rise to hemorrhage, although not so readily as immediately after delivery, for coagula of considerable size are often retained in utero for many days after labor. The uterus will be found larger than it ought to be, and tender on pressure. Usually the coagula are expelled with severe after-pains; but this may not take place, and hemorrhage may ensue several days after delivery. Or there may be only a relaxed state of the uterus without retained coagula. Bassett relates 4 cases traced to these causes, and several illustrations will be found in McCIin- tock's paper. Portions of retained placenta or membranes are more frequent causes. The retention may be due to carelessness on the part of the practitioner, especially if he have removed the placenta by traction, and failed to satisfy himself of its integrity. It may, however, often be due to circumstances entirely beyond his control; such as adherent placenta, which it is impossible to remove without 1 Saboia, Traits des Accouchements, p. 819. 418 LABOR. leaving portions in utero, or more rarely placenta succenturia. In the latter case there is a small supplementary portion of placental tissue developed entirely separate from the general mass, and it may remain in utero without the practitioner having the least suspicion of its existence. Portions of the membranes are very apt to be left in utero. It is to prevent this that they should be twisted into a rope, and extracted very gently after expression of the placenta. Hemorrhage from these causes generally does not occur until at least a week after delivery, and it may not do so until a much longer time has elapsed. In 4 cases, recorded by Mr. Bassett, it commenced on the twelfth, tenth, fourteenth, and thirty-second day. It may come on suddenly and continue ; or it may stop, and recur frequently at short intervals. In my experience retention of portions of the pla- centa is very common after abortion, when adhesions are more gene- rally met with than at term. In addition to the hemorrhage there is often a fetid discharge, due to decomposition of the retained por- tion, and possibly more or less marked septicemic symptoms, which may aid in the diagnosis. The placenta or membranes may simply be lying loose as foreign bodies in the uterine cavity ; or they may be organically attached to the uterine walls, when their removal will not be so easily effected. Retroflexion. — Barnes has especially pointed out the influence of retroflexion of the uterus in producing secondary hemorrhage, 1 which seems to act by impeding the circulation at the point of flexion, and thus arresting the process of involution. In every case in which secondary hemorrhage occurs to any extent, careful investigation into the possible causes of the attack, and an accurate vaginal examination, are imperatively required. If it be due to general and constitutional causes only, we must insist on the most absolute rest on a hard bed in a cool room, and on the absence of all causes of excitement. The liquid extract of ergot will be very generally useful in 3j doses repeated every six hours. McClintock strongly recommends the tincture of Indian hemp, which may be ad- vantageously combined with the ergot, in doses of 10 or 15 minims, suspended in mucilage. Astringent vaginal pessaries of matico or perchloride of iron may be used. Special attention should be paid to the state of the bowels, and, if the rectum be loaded, it should be emptied by enemata. In more chronic cases a mixture of ergot, sulphate of iron, and small doses of sulphate of magnesia, will prove very serviceable. This is more likely to be effectual when the bleed- ing is of an atonic and passive character. McClintock speaks strongly in favor of the application of a blister over the sacrum. "When the hemorrhage is excessive, more effectual local treatmentVill be re- quired. Cazeaux advises plugging of the vagina. Although this cannot be considered so dangerous as immediately after delivery, inasmuch as the uterus is not so likely to dilate above the plug, still it is certainly not entirely without risk of favoring concealed internal hemorrhage. If it be used at all, a firm abdominal pad 1 Obstetric Operations, p. 492. RUPTURE OF THE UTERUS. 419 should be applied, so as to compress the uterus ; and the abdomen should be examined, from time to time, to insure against the possi- bility of uterine dilatation. With these precautions the plug may prove of real value. In any case of really alarming hemorrhage I should be disposed rather to trust to the application of styptics to the uterine cavity. The injection of fluid in bulk, as after delivery, could not be safely practised, on account of the closure of the os and the contraction of the uterus. But there can be no objection to swabbing out the uterine cavity with a small piece of sponge attached to a handle, and saturated in a solution of the perchloride of iron. There are few cases which will resist this treatment. If we have reason to suspect retained placenta or membranes, or if the hemorrhage continue or recur after treatment, a careful ex- ploration of the interior of the womb will be essential. On vaginal examination, we may possibly feel a portion of the placenta protrud- ing through the os, which can then be removed without difficulty. If the os be closed, it must be dilated with sponge or laminaria tents, or by a small -sized Barnes' bag, and the uterus can then be thoroughly explored. This ought to be done under chloroform, as it cannot be effectually accomplished without introducing the whole hand into the vagina, which necessarily causes much pain. If the placenta or membranes be loose in the uterine cavity, they may be removed at once ; or, if they be organically attached, they may be carefully picked off. The uterus should at the same time, and as long as the os remains patulous, be thoroughly washed out with Condy's fluid and water, to diminish the risk of septicaemia. Retroflexion can readily be detected by vaginal examination, and the treatment consists in careful reposition with the hand, and the application of a large-sized Hodges' pessary. [In managing the convalescence after excessive hemorrhage it is of great importance to replace the loss as rapidly as possible, in order to avoid serious diseases resulting from exhaustion. To accomplish this, we are usually in the habit of giving the essence of from three to seven pounds of beef per diem, for the first two weeks, and have given as high as eleven. It is remarkable how soon this restores the health and strength of the woman. — Ed.] CHAPTER XYI. RUPTURE OF THE UTERUS, ETC. Bupture of the uterus is one of the most dangerous accidents of labor, and until of late years it has been considered almost necessarily fatal, and beyond the reach of treatment. Fortunately it is not of 420 LABOR. very frequent occurrence, although the published statistics vary so much that it is by no means easy to arrive at any conclusion on this point. The explanation is, no doubt, that many of the tables con- found partial and comparatively unimportant lacerations of the cer- vix and vagina, with rupture of the body and fundus. It is only in large lying-in institutions, where the results of cases are accurately recorded, that anything like reliable statistics can be gathered, for in private practice the occurrence of so lamentable an accident is likely to remain unpublished. . To show the difference between the figures given by authorities, it may be stated that, while Burns cal- culates the proportion to be 1 in 940 labors, Ingleby fixes it as 1 in 1300 or 1400, Churchill as 1 in 1331, and Lehmann as 1 in 2433. Dr. Jolly, of Paris, has published an excellent thesis containing much valuable informatioii. 1 He finds that out of 782,741 labors, 230 rup- tures, excluding those of the vagina or cervix, occurred, that is 1 in 3403. Seat of Rupture. — Lacerations may occur in any part of the uterus — the fundus, the body, or the cervix. Those of the cervix are comparatively of small consequence, and occur, to a slight ex- tent, in almost all first labors. Only those which involve the supra- vaginal portion are of realiy serious import. Euptures of the upper part of the uterus are much less frequent than of the portion near the cervix ; partly, no doubt, because the fundus is beyond the reach of the mechanical causes to which the accident can, not unfrequently, be traced, and partly because the lower third of the organ is apt to be compressed between the presenting part and the bony pelvis. The site of placental insertion is said by Madame La Chapelle to be rarely involved in the rupture, but it does not always escape, as numerous recorded cases prove. The most frequent seat of rupture is near the junction of the body and neck, either anteriorly or posteriorly, op- posite the sacrum, or behind the symphysis pubis, but it may occur at the sides of the lower segment of the uterus. In some cases the entire cervix has been torn away, and separated in the form of a ring. Rupture may be Partial or Complete. — The laceration may be partial or complete ; the latter being the more common. The mus- cular tissue alone may be torn, the peritoneal coat remaining intact; or the converse majr occur, and then the peritoneum is often fissured in various directions, the muscular coat being unimplicated. The extent of the injury is very variable ; in some cases being only a slight tear, in others forming a large aperture, sufficiently extensive to allow the foetus to pass into the abdominal cavity. The direction of the laceration is as variable as the size, but it is more frequently vertical than transverse or oblique. The edges of the tear are irregu- lar and jagged ; probably on account of the contraction of the mus- cular fibres, which are frequently softened, infiltrated with blood, and even gangrenous. Large quantities of extravasated blood will 1 Rupture uterine pendant le Travail, Paris, 1873. RUPTURE OF THE UTERUS. 421 be found in the peritoneal cavity ; such hemorrhage, indeed, being one of the most important sources of danger. Causes are either Predisposing or Exciting. — The causes are divided into predisposing and exciting / and the progress of modern research tends more and more to the conclusion that the cause which leads to the laceration could only have operated because the tissue of the uterus was in a state predisposed to rupture, and that it would have had no such effect on a perfectly healthy organ. What these pre- disposing changes are, and how they operate, is yet far from being known, and the subject offers a fruitful field for pathological investi- gation. Said to be more Common in Multiparse. — It is generally believed that lacerations are more common in multipara than in primiparse. Tyler Smith contended that ruptures are relatively as common in first as in subsequent labors. Statistics are not sufficiently accurate or extensive to justify a positive conclusion, but it is reasonable to suppose that the pathological changes, presently to be mentioned as predisposing to laceration, are more likely to be met with in women whose uteri have frequently undergone the alteration attendant on repeated pregnancies. Age seems to have considerable influence, as a large proportion of cases have occurred in women between thirty and forty years of age. Alterations in the tissues of the uterus are probably of very great importance in predisposing to the accident, although our information on this point is far from accurate. Among these are morbid states of the muscular fibres, the result of blows or contusions during preg- nancy; premature fatty degeneration of the muscular tissues, an anticipation, as it were, of the normal involution after delivery ; fibroid tumors, or malignant infiltration of the uterine walls, which either produce a morbid state of the tissues, or act as an impediment to the expulsion of the foetus. The importance of such changes has been specially dwelt on by Murphy in this country, and by Lehmann in Germany, and it is impossible not to concede their probable influ- ence in favoring laceration. However, as yet these views are founded more on reasonable hypothesis than on accurately observed patho- logical facts. Another and very important class of predisposing causes are those which lead to a want of proper proportion between the pelvis and the foetus. Deformity in Pelvis is a Frequent Cause. — Deformity of the pelvis has been very frequently met with in cases in which the uterus has ruptured. Thus out of 19 cases, carefully recorded by Eadford, 1 the pelvis was contracted in 11, or more than one-half. Eadford makes the curious observation that ruptures seem more likely to occur when the deformity is only slight ; and he explains this by supposing that in slight deformities the lower segment of the uterus engages in the brim, and is, therefore, much subjected to compression, while in extreme deformity the os and cervix uteri remain above the brim, 1 Obst. Trans., vol. viii. 422 LABOR. the body and fundus of the uterus hanging down between the thighs of the mother. This explanation is reasonable ; but the rarity with which ruptured uterus is associated with extreme pelvic deformity may rather depend on the infrequency of advanced degrees of con- traction. Malpresentation. — Amongst causes of disproportion depending on the foetus are either malpresentation, in which the pains cannot effect expulsion, or undue size of the presenting part. In the latter way may be explained the observation that rupture is much more fre- quently met with male than with female children, on account, no doubt, of the larger size of the head in the former. The influence of intra-uterine hydrocephalus was first prominently pointed out by Sir James Simpson, 1 who states that out of 7-i cases of intra-uterine hydrocephalus the uterus ruptured in 16. In all such cases of dis- proportion, whether referable to the pelvis or foetus, rupture is pro- duced in a twofold manner, either by the excessive and fruitless uterine contractions, which are induced by the efforts of the organ to overcome the obstacle ; or by the compression of the uterine tissue between the presenting part and the bony pelvis, leading to inflam- mation, softening, and even gangrene. Mechanical Injury of JRupture. — The proximate cause of rupture may be classed under two heads — mechanical injury, and excessive uterine contraction. Under the former are placed those uncommon cases in which the uterus lacerates as the result of some injury in the latter months of pregnancy, such as blows, falls, and the like. Not so rare, unfortunately, are lacerations produced by unskilled attempts at delivery on the part of the medical attendant, such as by the hand during turning, or by the blades of the forceps. Many such cases are on record, in which the accoucheur has used force and violence, rather than skill, in his attempts to overcome an obstacle. That such unhappy results of ignorance are not so uncommon as they ought to be is proved by the figures of Jolly, who has collected 71 cases of rupture during podalic version, 37 caused by the forceps, 10 by the cephalotribe, and 30 during other operations, the precise nature of which is not stated. 2 The modus operandi of protracted and in- effectual uterine contractions, as a proximate cause of rupture, is sufficiently evident, and need not be dwelt on. It is necessary to allude, however to the effect of ergot, incautiously administered, as a producing cause. There is abundant evidence that the injudicious exhibition of this drug has often been followed by laceration of the unduly stimulated uterine fibres. Thus Trask, talking of the sub- ject, says that Meigs had seen three cases, and Bedford four, distinctly traceable to this cause. Jolly found that ergot had been administered largely in 33 cases in which rupture occurred. Premonitory Symptoms. — Some have believed that the impending occurrence of rupture could frequently be ascertained by peculiar premonitory symptoms, such as excessive and acute crampy pains about the lower part of the abdomen, due to the compression of part 1 Selected Obst. Works, p. 385. 2 Op. cit., p. 38. RUPTURE OF THE UTERUS. 423 of the uterine walls. These are far too indefinite to be relied on, and it is certain that the rupture generally takes place without any symptoms that would have afforded reasonable grounds for suspicion. General Symptoms. — The symptoms are often so distinct and alarm- ing as to leave no doubt as to the nature of the case ; not unfrequently, however, especially if the laceration be partial, they are by no means so well marked, and the practitioner may be uncertain as to what has taken place. In the former class of cases a sudden excruciating pain is experienced in the abdomen, generally during the uterine contrac- tions, accompanied by a feeling, on the part of the patient, of some- thing having given way. In some cases this has been accompanied by an audible sound, which has been noticed by the bystanders. At the same time there is generally a considerable escape of blood from the vagina, and a prominent symptom is the sudden cessation of the previously strong pains. Alarming general symptoms soon develop, partly due to shock, partly to loss of blood, both external and internal. The face exhibits the greatest suffering, the skin becomes deadly cold and covered with a clammy sweat, and fainting, collapse, rapid feeble pulse, hurried breathing, vomiting, and all the usual signs of extreme exhaustion quickly follow. Results of Abdom ina I a nd Vaginal Exa m in ations. — Abdominal pal- pation and vaginal examination both afford characteristic indications in well-marked cases. If the child, as often happens, have escaped entirely, or in great part, into the abdominal cavity, it may be readily felt through the abdominal walls; while, in the former case, the par- tially contracted uterus may be found separate from it in the form of a globular tumor, resembling the uterus after delivery. Per vaginam it may generally be ascertained that the presenting part has suddenly receded, and can no longer be made out: or some other part of the foetus may be found in its place. If the rupture be ex- tensive, it may be appreciable on vaginal examination, and, some- times, a loop of intestine may be found protruding through the tear. Other occasional signs have been recorded, such as an emphysema- tous state of the lower part of the abdomen, resulting from the entrance of air into the cellular tissue ; or the formation of a san- guineous tumor in the hypogastrium, or vagina. These are too uncommon, and too vague, to be of much diagnostic value. Symptoms are sometimes Obscure. — Unfortunately the symptoms are by no means always so distinct, and cases occur in which most of the reliable indications, such as the sudden cessation of the pains, the external hemorrhage, and the retrocession of the presenting part. may be absent. In some cases, indeed, the symptoms have been so obscure that the real nature of the case has only been detected after death. It is rarely, however, that the occurrence of shock and pros- tration is not sufficiently distinct to arouse suspicion, even in the absence of the usual marked signs. In not a few cases distinct and regular contractions have gone on after laceration, and the child has even been born in the usual way. Of course, in such a case, mistake is very possible. So curious a circumstance is difficult of explana- tion. The most probable way of accounting for it is, that the lacera- 424 LABOR. tion has not implicated the fundus of the uterus, which contracted sufficiently energetically to expel the foetus. Hence it will be seen that the symptoms are occasionally obscure, and the practitioner must be careful not to overlook the occurrence of so serious an accident, because of the absence of the usual and characteristic symptoms. Prognosis. — The prognosis is necessarily of the gravest possible character, but modern views as to treatment perhaps justify us in saying that it is not so absolutely hopeless as has been generally taught in our obstetric works. When we reflect on what has oc- curred — the profound nervous shock ; the profuse hemorrhage, both external, and especially into the peritoneal cavity, where the blood coagulates and forms a foreign body ; the passage of the uterine contents into the abdomen, with the inevitable result of inflamma- tion and its consequences, if the patient survive the primary shock ; — the enormous fatality need cause no surprise. Jolly has found that out of 580 cases 100 recovered, that is in the proportion of 1 out of 6. This is a far more favorable result than we are generally led to anticipate ; and as many of the recoveries happened in apparently the most desperate and unfavorable cases, we should learn the lesson that we need not abandon all hope, and should at least en- deavor to rescue the patient from the terrible dangers to which she is exposed. As regards the child the prognosis is almost necessarily fatal ; and indeed, the cessation of the foetal heart- sounds has been pointed out by McClintock as a sign of rupture in doubtful cases. The shock, the profuse hemorrhage, and the time that must necessarily elapse before the delivery of the child, are of themselves quite sufficient to explain the fact that the foetus is almost always dead. Treatment. — From what has been said of the impossibility of fore- telling the occurrence of rupture, it must follow that no reliable pro- phylactic treatment can be adopted, beyond that which is a matter of general obstetric principle, viz., timely interference when the uterine contractions seem incapable of overcoming an obstacle to de- livery, either on the part of the pelvis or foetus. Indications after Rupture has taken place. — After rupture the main indications are to effect the removal of the child and the placenta, to rally the patient from the effects of the shock, and, if she survives so long, to combat the subsequent inflammation and its consequences. By far the most important point to decide is the best means to be adopted for the removal of the child ; for it is admitted by all that the hopeless expectancy that was recommended by the older accou- cheurs, or, in other words, allowing the patient to die without making any effort to save her, is quite inadmissible. If the foetus be entirely within the uterine cavity, no doubt the proper course to pursue is to deliver at once per vias naturales 1 either by turning, by forceps, or by cephalotripsy. If any part other than the head present, turning will be best, great care being taken to avoid further increase of the laceration. If the head be in the cavity or at the brim of the pelvis, and within easy reach of the forceps, it may be cautiously applied, RUPTURE OF THE UTERUS. 425 the child being steadied by abdominal pressure, so as to facilitate its application. If there be, as is so often the case, some slight amount of pelvic contraction, it may be preferable to perforate and apply the cephalotribe, so as to avoid any forcible attempts at extraction, which might unduly exhaust the already prostrate patient, and turn the scale against her. This will be the more allowable since the child is, as we have seen, almost always dead, and we might readily ascer- tain if it be so by auscultation. Removal of the Placenta. — After delivery extreme care must be taken in removing the placenta, and for this it will be necessary to introduce the hand. The placenta will generally be in the uterus, for if the rent be not large enough for the child to pass through, it may be inferred that the placenta will not have clone so either. If it has escaped from the uterus, very gentle traction on the cord may bring it within reach of the hand, and so the passage of the hand through the tear to search for it will be avoided. Treatment when the Foetus has Escaped out of the Uterus. — There can be but little doubt that, in the cases indicated, such is the proper treatment, and that which affords the mother the best chance. Un- fortunately, the cases in which the child remains entirely in utero are comparatively uncommon, and generally it will have escaped into the abdomen, along with much extravasated blood. The usual plan of treatment recommended, under such circumstances, is to pass the hand through the fissure (some have even recommended that it should be enlarged by incision if necessary), to seize the feet of the foetus, to drag it back through the torn uterus, and then to reintro- duce the hand to search for and remove the placenta. Imagine what occurs during the process. The hand gropes blindly among the ab- dominal viscera, the forcible dragging back of the foetus necessarily tears the uterus more and more, and, above all, the extravasated blood remains as a foreign body in the peritoneal cavity, and neces- sarily gives rise to the most serious consequences. It is surely hardly a matter of surprise that there is scarcely a single case on record of recovery after this procedure. Reasons favoring Gastrotomy. — Of late years a strong feeling has existed that, whenever the child has entirely, or in great part, escaped into the abdominal cavity, the operation of gastrotomy affords the mother a far better chance of recovery ; and it has now been per- formed in many cases with the most encouraging results. It is easy to see why the prospects of success are greater. The uterus being already torn, and the peritoneum opened, the only additional danger is the incision of the abdominal parietes, which gives us the oppor- tunity of sponging out the peritoneal cavity, as in ovariotomy, and of removing all the extravasated blood, the retention of which so seriously adds to the dangers of the case. Another advantage is that, if the patient be excessively prostrate, the operation may be delayed until she has somewhat rallied from the effects of the shock, whereas delivery by the feet is generally resorted to as soon as the rupture is recognized, and when the patient is in the worst possible condition for interference of any kind. 28 426 LABOR. Comparative Results of Various Methods of Treatment. — Jolly has carefully tabulated the results of the various methods of treatment, and, making every allowance for the unavoidable errors of statistics, it seems beyond all question that the results of gastrotomy are so greatly superior to those of other plans, that I think its adoption may fairly be laid down as a rule whenever the foetus is no longer within the uterine cavity. Comparative Eesults of Various Methods of Treatment after Rupture of Uterus. Treatment. No. of cases. Deaths. Recoveries. Per cent, of recoveries. Expectation .... Extraction per vias naturales Gastrotomy 144 382 38 142 310 12 2 72 26 1.45 19 68.4 Of course this table will not justify the conclusion that 68 per cent, of the cases of ruptured uterus in which gastrotomy is per- formed will recover ; but it may fairly be taken as proving that the chances of recovery are at least three or four times as great as when the more usual practice is adopted. [According to Dr. Trask's reports, 1 27 recovered, out of 115 that were undelivered, and 77 out of 207, delivered : 29 operations by laparotomy saved 22 women. "We have been at considerable pains to find out what has been the result of this operation in the United States, and thus far have collected 30 cases, with a saving of 21 women and 1 child. The child saved resulted from an immediate operation with a pocket-knife, performed by Dr. Tupper, of Bay City, Michigan, in 1869 : the woman recovered. We are disposed to believe that a general record of cases, published and unpublished, would show a saving of from 60 to 65 per cent, of the women, which is lower than that claimed by Trask and Jolly, collected from pub- lished reports. We, however, believe that care and promptness ought to save 75 per cent, of the women, and more than the percentage of children on record. — Ed.] Necessity of Care in Performing the Operation. — It is perhaps need- less to say that the operation must be performed with the same minute care that has raised ovariotomy to its present pitch of per- fection, and that especial attention should be paid to the sponging out of the peritoneum, and the removal of foreign matters. Recapitulation. — To recapitulate, I think what has been said jus- tifies the following rules of treatment after rupture: — 1. If the head or presenting part be above the brim, and the foetus still in utero — forceps, turning, or omphalotripsy, according to circum- stances. 2. If the head be in the pelvic cavity — forceps or cephalotripsy. [' Am. Journ. Med. Sci., vol. xv. N. S. 1848, pp. 104, 383 ; vol. xxxii. p. 81.] RUPTURE OF THE UTERUS. 427 3. If the foetus have wholly, or in great part, escaped into the abdominal cavity — gastrotomy. Subsequent Treatment. — As to the subsequent treatment little need be said, since in this we must be guided by general principles. The chief indication will be to remove shock and rally the patient by stimulants, etc., and to combat secondary results by opiates and other appropriate remedies. Lacerations of the vagina occasionally take place, and in the great majority of cases, they are produced by instruments, either from a want of care in their introduction, or from nndue stretching of the vaginal walls during extraction with the forceps. Slight vaginal lacerations are probably much more common after forceps delivery than is generally believed to be the case. As a rule they are pro- ductive of no permanent injury, although it must not be forgotten that every breach of continuity increases the risk of subsequent septic absorption. When the laceration is sufficiently deep to tear through the recto- vaginal septum, or the anterior vaginal wall, the passage of the urine or feces is apt to prevent its edges uniting; then that most distressing condition, recto- vaginal, or vesico- vaginal fistula is established. It must not be supposed that fistulas are often the result of injury during operative interference. That is a common but very erroneous opinion both among the profession and the public. In the vast majority of cases the fistulous opening is the consequence of a slough resulting from inflammation, produced by long-continued pressure of the vaginal walls between the child's head and the bony pelvis, in cases in which the second stage has been allowed to go on too long. In most of these cases instruments were doubtless eventually used, and they get the blame of the accident; whereas the fault lay, not in their being employed, but rather in their not having been used soon enough to prevent the contusion and inflammation which ended in sloughing. When vesico-vaginal fistulae are the result of lacerations during labor, the urine must escape at once, but this is rarely the case. In the large majority of cases the urine does not pass per vaginam until more than a week after delivery, showing that a lapse of time is necessary for inflammatory action to lead to sloughing. In order to throw some light on these points, on which very erroneous views have been held, I have carefully examined the histories, from various sources, of 63 cases of vesico-vaginal fistula. 1st. In 20 no instruments were employed. Of these, there were in labor under 24 hours from 24 to 48 hours " 48 to 70 " 70 to 80 " 80 hours and upwards 2 8 1 2 7 1 20 1 But of these in 7 no precise time is stated. 6 of them are marked very tedious* therefore they probably exceeded the limit. 428 LABOR. Therefore out of these 20 cases one-half were certainly more than 48 hours in labor, and 6 of the remaining 10 were probably so also. In only 1 of them is the urine stated to have escaped per vaginam immediately after delivery. In 7 it is said to have done so within a week, and in the remainder after the seventh day. 2d. In 34 cases instruments were used, but there is no evidence of their having produced the accident. Of these, there were in labor under 24 hours ...... 2 from 24 to 48 hours ... 8 " 48 to 72 " . . . 10 " 72 hours and upwards . 14 34 The urine escaped within 24 hours in 2 cases only, within a week in 16, and after the seventh day in 15. So that here again we have the history of unduly protracted delivery, 24 out of the 34 having been certainly more than 48 hours in labor.. 3d. In 9 cases the histories show that the production of the fistula may fairly be ascribed to the unskilled use of instruments. Of these, there were in labor under 24 hours ... 7 from 24 to 48 hours ... 1 " 48 to 72 " . . . 1 The urine escaped at once in 7 cases, and in the remaining 2 after the seventh day. These statistics seem to me to prove, in the clearest manner, that, in the large majority of cases, this unhappy accident may be directly traced to the bad practice of allowing labor to drag on many hours in the second stage without assistance, and not to premature instru- mental interference. Treatment. — As to the treatment of vaginal laceration little can be said. In the slighter cases vaginal injections of diluted Condy's fluid will be useful to lessen the risk of septic absorption ; and the graver, when vesico-vaginal or recto- vaginal fistulas have actually formed, are not within the domain of the obstetrician, but must be treated surgically at some future date. INVERSION OF THE UTERUS. 429 CHAPTEE XVII. INVERSION" OF THE UTERUS. Inversion of the uterus shortly after the birth of the child is one of the most formidable accidents of parturition, leading to symptoms of the greatest urgency, not rarely proving fatal, and requiring prompt and skilful treatment. Hence it has obtained an unusual amount of attention, and there are few obstetric subjects which have been more carefully studied. An Accident of Great Rarity. — Fortunately, the accident is of great rarity. It was only observed once in upwards of 190,800 deliveries at the Eotunda Hospital since its foundation in 1745 ; and many practitioners have conducted large midwifery practices for a lifetime without ever having witnessed a case. It is none the less needful, however, that we should be thoroughly acquainted with its natural history, and with the best means of dealing with the emergency when it arises. Division into Acute and Chronic Forms. — Inversion of the uterus may be met with in the acute or chronic form; that is to say, it may come under observation either immediately or shortly after its occur- rence, or not until after a considerable lapse of time, when the invo- lution following pregnancy has been completed. The latter falls more properly under the province of the gynaecologist, and involves the consideration of many points that would be out of place in a work on obstetrics. Here, therefore, the acute form alone is con- sidered. Description of Inversion. — Inversion consists essentially in the en- larged and empty uterus being turned inside out, either partially or entirely ; and this may occur in various degrees, three of which are 1 usually described, and are practically useful to bear in mind. In the first and slightest degree there is merely a cup-shaped depression of the fundus (Fig. 139); in the second the depression is greater, so that the inverted portion forms an introsusception, as it were, and projects downwards through the os in the form of a round ball, not unlike the body of a polypus, for which, indeed, a careless observer might mistake it; and, thirdly, there is the complete variety, in which the whole organ is turned inside out and maj even project beyond the vulva. Its Symptoms. — The sj^mptoms are generally very characteristic, although, when the amount of inversion is small, they may entirely escape observation. They are chiefly those of profound nervous shock, viz., fainting, small, rapid, and feeble pulse, possibly convul- sions and vomiting, and a cold, clammy skin. Occasionally severe abdominal pain, and cramp and bearing down are felt. Hemorrhage 430 LABOR. Partial Inversion of the Fundus. (From a preparation in the museum of Guy's Hospital.) and tender swelling, Fig. 139. is a frequent accompaniment, some- times to a very alarming extent, espe- cially if the placenta be partially or entirely detached. The loss of blood depends to a great extent on the con- dition of the uterine parietes. If there be much contraction of the part that is not inverted, the introsuscepted part may be sufficiently compressed to pre- vent any great loss. If the entire organ be in a state of relaxation, the loss may be excessive. Results of Physical Examination. — The occurrence of such symptoms shortly after delivery would of neces- sity lead to an accurate examination, when the nature of the case may be at once ascertained. On passing the finger into the vagina, we either find the entire uterus forming a globular mass, to which the placenta is often attached ; or, if the inversion be incomplete, the vagina is occupied by a firm, round, which can be traced upwards through the os uteri. The hand placed on the abdomen will detect the absence of the round ball of the contracted uterus, and bi-manual examina- tion may even enable us to feel the cup-shaped depression at the site of inversion. Differential Diagnosis. — -When such signs are observed immedi- ately after delivery, mistake is hardly possible. Numerous instances, however, are recorded in which the existence of inversion was not immediately detected, and the tumor formed by it only observed after the lapse of several days, or even longer, when the general symptoms led to vaginal examination. It is probable that, in such cases, a partial inversion had taken place shortly after delivery, which, as time elapsed, became gradually converted into the more complete variety. In a case of this kind, as in a chronic inversion, some care is necessary to distinguish the inversion from a uterine polypus, which it closely resembles. The cautious insertion of the sound will render the diagnosis certain, since its passage is soon ar- rested in inversion, while, if the tumor be polypoid, it readily passes in as far as the fundus. Manner in which Inversion is Produced. — The mechanism by which inversion is produced is well worthy of study, and has given rise to much difference of opinion. Occasionally produced by Accidental Mechanical Causes. — A very general theory is, that it is caused, in many cases, by mismanage- ment of the third stage of labor, either by traction on the cord, the placenta being still adherent, or by improperly applied pressure on the fundus ; the result of both these errors being a cup-shaped cle- INVERSION OF THE UTERUS. 431 pression of the fundus, which is subsequently converted into a more complete variety of inversion. That such causes may suffice to start the inversion cannot be doubted, but it is probable that their fre- quency has been much exaggerated. Still there are numerous re- corded cases in which the commencement of the inversion can be traced to them. Improperly applied pressure (as when the whole body of the uterus is not grasped in the hollow of the hand, but when a monthly nurse, or other un instructed person, presses on the lower part of the abdomen, so as simply to push down the uterus en masse) is often mentioned in histories of the accident. Thus in the ''Edinburgh Medical Journal 1 ' for June, 1848, a case is related in which the patient would not have a medical man, but was attended by a midwife, who, after the birth of the child, pulled on the cord, while the patient herself clasped her hands and pushed down her abdomen, at the same time straining forcibly, when the uterus be- came inverted, and the patient died of hemorrhage before assistance could be procured. Here both the mechanical causes mentioned were in operation. In several cases it is mentioned that the accident occurred while the nurse was compressing the abdomen. That the accident is practically impossible when firm and equable contraction has taken place, cannot be questioned. Hence ib is of paramount importance that the practitioner should himself carefully attend to the conduct of the third stage of labor. Often Occurs Spontaneously. — In a large proportion of cases no mechanical causes can be traced, and the occurrence of spontaneous inversion must be admitted. There are various theories held as to how this occurs. Partial and irregular contraction of the uterus is generally admitted to be an important factor in its production: but it is still a matter of dispute whether the inversion is produced mainly by an active contraction of the fundus and body of the uterus, the lower portion and cervix being in a state of relaxation ; or whether the precise reverse of this exists, the fundus being relaxed and in a state of quasi-paralysis, while the cervix and lower portion of the uterus are irregularly contracted. The former is the view main- tained by Eadford and Tyler Smith, while the latter is upheld by Matthews Duncan. Evidence in Favor of Duncan's Theory. — There are good clinical reasons for believing that Duncan's view more nearly corresponds with the true facts of the case ; for, if the fundus and body of the uterus be really in a state of active contraction, while the cervix is relaxed, we have, as Duncan points out, the very condition which is normal and desirable after delivery, and that which we do our best to produce. If, however, the opposite condition exist, and the fundus be relaxed, while the lower portion is spasmodically contracted, a state exists closely allied to the so-called hour-glass contraction. Supposing now any cause produces a partial depression of the fundus, it is easy to understand how it may be grasped by the contracted portion, and carried more and more down, in the manner of an intro- susception, until complete inversion results. That such partial paraly- sis of the uterine walls often exists, especially about the placental 432 LABOR. Fig. 140. site, was long ago pointed out by Kokitansky, and other pathologists. This theory supposes the original partial depression and relaxation of the fundus. How this is often produced by mismanagement of the third stage has already been pointed out ; but, even in the absence of such causes, it may result from strong bearing-down efforts on the part of the patient, or, as Duncan holds, from the absence of the retentive power of the abdomen. Indeed the incompatibility of an actively contracted state of the fundus with the partial depression which is essential, according to both views, for the production of inversion, is the strongest argument in favor of Duncan's theory. Taylor's Theory. — A totally different view has more recently been sustained by Dr. Taylor, of New York, who maintains that "spon- taneous active inversion of the uterus rests upon prolonged natural and energetic ac- tion of the body and fundus; the cervix, the lower part, yielding first, is thus rolled out, or everted, or doubled up, as there is no obstruction from the contractility of the cervix, which is at rest or functionally paralyzed ; the body is gradually, some- times instantaneously, forced lower and lower, or inverted." 1 That partial inver- sion may commence at the cervix was pointed out by Duncan in his paper, who depicts it in the accompanying diagram (Fig. 140), and states it to be of not unfre- quent occurrence. It is not impossible that occasionally such a state of things should be carried on to complete inversion. But there are serious objections to the accep- tance of Dr. Taylor's view that such is the principal cause of inversion, since the pro- cess above described would be of necessity a slow and long-continued one, whereas nothing is more certain than that inversion is generally sudden and accompanied by acute symp- toms of shock, and is often attended by severe hemorrhage, which could not occur when such excessive contraction was taking place. Treatment. — The treatment of inversion consists in restoring the organ to its natural condition as soon as possible. Every moment's delay only serves to render restoration more difficult, as the inverted portion becomes swollen and strangulated ; Avhereas if the attempt at reposition be made immediately, there is generally comparatively little difficulty in effecting it. Therefore it is of the utmost import- ance that no time should be lost, and that we should not overlook a partial or incomplete inversion. Hence the occurrence of any unu : sual shock, pain, or hemorrhage after delivery, without an}^ readily ascertained cause, should always lead to a careful vaginal examina- tion. A want of attention to this rule has too often resulted in the Illustrating the Commencement of Inversion at the Cervix. (After Duncan). New York Med. Journ., 1872. INVERSION OF THE UTERUS. 483 existence of partial inversion being overlooked, until its reduction was found to be difficult or impossible. Mode of Attempting Reduction. — In attempting to reduce a recent inversion, the inverted portion of the uterus should be grasped in the hollow of the hand and pushed gently and firmly upwards into its natural position, great care being taken to apply the pressure in the proper axis of the pelvis, and to use counter-pressure, by the left hand, on the abdominal walls. Barnes lays stress on the import- ance of directing the pressure towards one side, so as to avoid the promontory of the sacrum. The common plan of endeavoring to push back the fundus first has been well shown by McClintock 1 to have the disadvantage of increasing the bulk of the mass that has to be reduced, and he advises that, while the fundus is lessened in size by compression, we should, at the same time, endeavor to push up first the part that was less inverted, that is to say, the portion nearest the os uteri. Should this be found impossible, some assist- ance may be derived from the manoeuvre, recommended by Merriman and others, of first endeavoring to push up one side or wall of the uterus, and then the other, alternating the upward pressure from one side to the other as we advance. It often happens as the hand is thus applied, that the uterus somewhat suddenly rein verts itself, sometimes with an audible noise, much as an India-rubber bottle would do under similar circumstances. When reposition has taken place the hand should be kept for some time in the uterine cavit}^ to excite tonic contraction; or Barnes's suggestion of injecting a weak solution of perchloride of iron may be adopted, so as to constrict the uterine walls, and prevent a recurrence of the accident. It is hardly necessary to point out how much these manoeuvres will be facilitated by placing the patient fully under the influence of an anaesthetic. Management of the Placenta. — There has been much difference of opinion as to the management of the placenta in cases in which it is still attached when inversion occurs. Should we remove it before attempting reposition, or should we first endeavor to rein vert the organ, and subsequently remove the placenta? The removal of the placenta certainly much diminishes the bulk of the inverted portion, and, therefore, renders reposition easier. On the other hand, if there be much hemorrhage, as is so frequently the case, the removal of the placenta may materially increase the loss of blood. For this reason, most authorities recommend that an endeavor should be made at reduction before peeling off the after birth. But if any delay or difficulty be experienced from the increased bulk, no time should be lost, and it is in every way better to remove the placenta and en- deavor to reinvert the organ as soon as possible. Management of Cases detected some time after Delivery. — Supposing we meet with a case in which the existence of inversion has been overlooked for daj^s, or even for a week or two, the same procedure must be adopted ; but the difficulties are much greater, and the 1 Diseases of W omen, p. 79. 434 LABOR. longer the delay, the greater they are likely to be. Even now, however, a well-conducted attempt at taxis is likely to succeed. Should it fail, we must endeavor to overcome the difficulty by con- tinuous pressure applied by means of caoutchouc bags, distended with water, and left in the vagina. It is rarely that this will fail in a comparatively recent case, and such only are now under considera- tion. It is likely that by pressure, applied in this way for twenty- four or forty-eight hours, and then followed by taxis, any case detected before the involution of the uterus is completed may be successfully treated. PART IV. OBSTETRIC OPERATIONS. CHAPTEE I. INDUCTION OF PEEMATUEE LABOE. The first of the obstetric operations we have to consider is the induction of premature labor, an operation which, like the use of for- ceps, was first suggested and practised in this country, and the recog- nition of which, as a legitimate procedure, we also chiefly owe to the labor of our fellow-countrymen, in spite of much opposition both at home and abroad. It is not known with certainty to whom we owe the original suggestion; but we are told by Denman that in the year 1756 there was a consultation of the most eminent physicians at that time in London, to consider the advantages which might be expected from the operation. The proposal met with formal approval, and was shortly after carried into practice by Dr. Macaulay, the patient being the wife of a linendraper in the Strand. From that time it has flourished in Great Britain, the sphere of its application has been largely increased, and it has been the means of saving many mothers and children, who would otherwise, in all probability, have perished. On the Continent, it w r as long before the operation was sanctioned or practised. Although recommended by some of the most eminent German practitioners, it was not actually performed until the year 1804. In France the opposition was long-continued and bitter. Many of the leading teachers strongly denounced it, and the Academy of Medicine formally discountenanced it so late as the year 1827. The objections were chiefly based on religious grounds, but partly, no doubt, on mistaken notions as to the object proposed to be gained. Although frequently discussed, the operation was never actually car- ried into practice until the year 1831, when Stoltz performed it with success. Since that time opposition has greatly ceased, and it is now employed and highly recommended by the most distinguished ob- stetricians of the French schools. Objects of the Operation. — In inducing premature labor, we propose to avoid or lessen the risk to which, in certain cases, the mother is exposed by delivery at term, or to save the life of the child which might otherwise be endangered. Hence the operation may be indi- cated either on account of the mother alone, or of the child alone, or, as not unfrequently happens, of both together. 436 OBSTETRIC OPERATIONS. Defective Proportion hetween the Child and Pelvis is the most Fre- quent Indication. — In by far the largest number of cases the operation is performed on account of defective proportion between the child and the maternal passages, due to some abnormal condition on the part of the mother. This want of proportion may depend on the presence of tumors either of the uterus or growing from the pelvis. But most frequently it arises from deformity of the pelvis (p. 383), and it is needless to repeat what has been said on that point. I shall, therefore, only briefly refer to a few more uncommon causes, which occasionally necessitate its performance. Habitually Large Size of the Foetal Head. — One of these is an habit- ually large, or over-flrmly ossified, foetal head. Should we meet with a case in which the labors are always extremely difficult, and the head apparently of unusual size, although there is no apparent want of space in the pelvis, the induction of labor would be perfectly justifiable, and in all probability would accomplish the desired ob- ject. In such cases the full period of delivery would require to be anticipated by a very short time. A week or a fortnight might make all the difference between a labor of extreme severity, and one of comparative ease. Condition of the Mother's Health calling for the Operation. — There is a large class of cases in which the condition of the mother indi- cates the operation. Many of these have already been considered when treating of the diseases of pregnancy. Amongst them may be mentioned vomiting which has resisted all treatment, and which has produced a state of exhaustion threatening to prove fatal; chorea, albuminuria, convulsions, or mania ; excessive anasarca, ascites, or dyspnoea connected with disease of the heart, lungs, or liver, may be, in a great measure, caused by the pressure of the enlarged uterus ; in fact, any condition or disease affecting the mother, provided only we are convinced that the termination of pregnancy would give the patient relief, and that its continuance would involve serious danger. It need hardly be pointed out that the induction of labor for any such causes involves grave responsibility, and is decidedly open to abuse; no practitioner would, therefore, be justified in resorting to it, especially if the child have not reached a viable age, without the most anxious consideration. No general rules can be laid down. Each case must be treated on its own merits. It is obvious that t he- nearer the patient is to the full period, the greater will be the chance of the child surviving, and the less hesitation need then be felt in consulting the interests of the mother. Conditions affecting the Safety of the Child alone. — In another class of cases the operation is indicated by circumstances affecting the life of the child alone. Of these the most common are those in which the child dies, in several successive pregnancies, before the termina- tion of utero-gestation. This is generally the result of fatty, calcare- ous, or syphilitic degeneration of the placenta, which is thus rendered incapable of performing its functions. These changes in the placenta seldom commence until a comparatively advanced period of preg- nancy; so that if labor be somewhat hastened, we may hope to INDUCTION OF PREMATURE LABOR. 437 enable the patient to give birth to a living and healthy child. The experience of the mother will indicate the period at which the death of the foetus has formerly taken place, as she would then have appre- ciated a difference in her sensations, a diminution in the vigor of the foetal movements, a sense of weight and coldness, and similar signs. For some weeks before the time at which this change has been expe- rienced, we should carefully auscultate the foetal heart from day to day, and, in most cases, the approach of danger will be indicated sufficiently soon to enable us to interfere with success, by tumultuous and irregular pulsations, or a failure in their strength and frequency. On the detection of these, or on the mother feeling that the move- ments of the child are becoming less strong, the operation should at once be performed. Simpson also induced premature labor with success in a patient who twice gave birth to hydrocephalic children. In the third pregnancy, which he terminated before the natural period, the child was well-formed and healthy. Induction of Labor when the Mother is mortally 111. — Some obstetri- cians have proposed to induce labor, with the view of saving the child, when the mother was suffering from mortal disease. This indication is, however, so extremely doubtful, from a moral point of view, that it can hardly be considered as ever justifiable. Various Methods of Inducing Labor ; their mode of Action. — The means adopted for the induction of labor are very numerous. Some of them act through the maternal circulation, as the administration of ergot, and other oxytocics; others by their power of exciting reflex action, or by interfering with the integrity of the ovum, or by a com- bination of both, as the vaginal douche separation of the membranes from the uterine walls, puncture of the ovum, dilatation of the os, stimulating enemata, or irritation of the breasts. The former class are never employed in modern obstetric practice. Of the latter, some offer special advantages in particular cases, but none are equally adapted for all emergencies. Often a combination of more methods than one will be found most useful. I shall mention the various methods in use, and discuss brief! v the relative advantages and dis- advantages of each. Puncture of Membranes. — The evacuation of the liquor amnii, by the puncture of the membranes, was the first method practised, and was that recommended by Denman and all the earlier writers. It is the most certain which can be employed, as it never fails, sooner or later, to induce uterine contractions. There are, however, several disadvantages connected with it, which are sufficient to contra-indi- cate its use in the majority of cases. It is uncertain as regards the time taken in producing the desired effect, pains sometimes coming on within a few hours, but occasionally not until several days have elapsed. The contracting walls of the uterus press directly on the body of the child, which, being frail and immature, is less able to bear the pressure than at the full period of pregnancy. Hence it involves great risk to the foetus. Besides, the escape of the water does away with the fluid wedge so useful in dilating the os, and should version be necessary from mal-presentation — a complication 438 OBSTETRIC OPERATIONS. more likely to occur than in natural labor — the operation would have to be performed under very unfavorable conditions. These objections are sufficient to justify the ordinary opinion that this pro- cedure should not be adopted, unless other means had been tried and failed. Every now and then cases are met with in which it is ex- tremely difficult to arouse the uterus to action, and, under such circumstances, in spite of its drawbacks, this method will be found to be very valuable. When the operation has to be performed before the child is viable, that is, before the seventh month, these objections do not hold, and then it is the simplest and readiest procedure we can adopt. Indeed, in producing early abortion, no other is prac- ticable. The operation itself is most simple, requiring only a quill, stiletted catheter, or other suitable instrument, to be passed up to the os, carefully guarded by the fingers of the left hand previously introduced, and to be pressed against the membranes until perfora- tion is accomplished. Meissner, of Leipsic, has proposed, as a modi- fication of this plan, that the membranes should be punctured obliquely, three or four inches above the os, so as to admit of a gradual and partial escape of the amniotic fluid, thus lessening the risk to the child from pressure by the uterus. For this purpose he employed a curved silver canuia, containing a small trocar, which can be projected after introduction. The risk of injuring the uterus by such an instrument would be considerable, and we have other and better means at our command which render it unnecessary. When we require to produce early abortion, it would be well not to attempt to puncture the membranes with a sharp-pointed instrument. The object can be effected with equal certainty, and greater safety, by passing an ordinary uterine sound through the os, and turning it round once or twice. Administration of Oxytocics. — The administration of ergot of rj r e, either alone, or combined with borax and cinnamon, has been some- times resorted to. . This practice has been principally advocated by Eamsbotham, who was in the habit of exhibiting scruple doses of the powdered ergot every fourth hour, until delivery took place. Sometimes he found that as many as thirty or forty doses were re- quired to effect the object ; occasionally labor commenced after a single dose. Finding that the infantile mortality was very great when this method was followed, he modified it, and administered two or three doses only, and, if these proved insufficient, he punc- tured the membranes. There can be no doubt that ergot possesses the power of inducing uterine contractions. The risk to the child is, however, quite as great as when the membranes are punctured ; for not only is it subject to injurious pressure from the tumultuous and irregular contractions which the ergot produces, but the drug itself, when given in large doses, seems to exert a poisonous influence on the foetus. For these reasons ergot may properly be excluded from the available means of inducing labor. Methods acting Indirectly on the Uterus. — Various methods have been recommended which act indirectly on the uterus, the source of irritation being at a distance. Thus D'Outrepont used frequently INDUCTION OF PREMATURE LABOR 439 repeated abdominal frictions and tight bandages. Scanzoni, remem- bering the intimate connection between the mammas and uterus, and the tendency which irritation of the former has to induce contraction- of the latter, recommended the frequent application of cupping- glasses to the breasts. Eadforcl and others have employed galvanism. Stimulating enemata have been employed. All these methods have occasionally proved successful, and, unlike the former plans we have mentioned, they are not attended by any special risk to the child. They are, however, much too uncertain to be relied on, besides being- irksome both to the patient and practitioner. The artificial dilatation of the os uteri, in imitation of its natural opening in labor, was first practised by Kliige. He was in the habit of passing within the os a tent made of compressed sponge, and allowing it to dilate by imbibition of fluid. If labor were not pro- voked within twenty-four hours he removed it, and introduced one of larger dimensions, changing it as often as was necessary until his object was accomplished. Although this operation seldom failed to induce labor, it had the disadvantage of occupying an indefinite time, and the irritation produced was often painful and annoying. Dr. Keiller, of Edinburgh, was the first to suggest the Use of caoutchouc bags, distended by air, as a means of dilating the os. This plan has been perfected by Dr. Barnes in his well-known dilators, which are of great use in many cases in which artificial dilatation of the cervix is necessary. They consist of a series of india-rubber bags of various sizes, with a tube attached (Fig. 141), through which water can be injected by an ordinary Higginson's syringe. They have a small pouch fixed externally, in which a sound can be placed, so as to facilitate their introduction. When distended with water the bags assume somewhat of a fiddle shape, bulging at both extremities, which insures their being retained within the os. When first introduced into practice as a means of inducing labor, it was thought that this method gave a complete control over the pro- cess, so that it could be concluded within a definite time at the will of the operator. The experience of those who have used it much has certainly not justi- fied this anticipation. It is true that, occasionally, contractions supervene within a few hours after dila- tation has been commenced; but, on the other hand, the uterus often responds very imperfectly to this kind of stimulus, and the bags may be inserted for many consecutive hours without the desired result supervening ; the puncture of the membranes being eventually necessary in order to hasten the process. Indeed, my own experience would lead me to the conclusion that, as a means of evoking uterine contraction, cervi- cal dilatation is very unsatisfactory. Dr. Barnes himself has evi- dently seen reason to modify his original views, for, while he at first talked of the bags as enabling us to induce labor with certainty at a given time, he has since recommended that uterine action should be Fig. 141. Barnes's Bag for Dilating the Cervix. 440 OBSTETRIC OPERATIONS. first provoked by other means, the dilators being subsequently used to accelerate the labor thus brought on. The bags thus employed find, as I believe, their most useful and a verj r valuable application; but when used in this way they cannot be considered a means of originating uterine action. A subsidiary objection to the bags is the risk of displacing the presenting part. I have, for example, intro- duced them when the head was presenting, and, on their removal, found the shoulder lying over the os. It is not difficult to understand how the continuous pressure of a distended bag in the internal os might easily push away the head, which is so readily movable as long as the membranes are unruptured. Still, if labor be in progress, and the os insufficiently dilated, the possibilit}^ of this occurrence is not a sufficient reason for not availing ourselves of the undoubtedly valuable assistance which the dilators are capable of giving. Separation of the Membranes. — Some processes for inducing labor act directly on the ovum, by separating the membranes, to a greater or less extent, from the uterine Avails. The first procedure of the kind was recommended by Dr. Hamilton, of Edinburgh, and con- sisted in the gradual separation of the membranes for one or two inches all round the lower segment of the uterus. To reach them, the finger had to be gently insinuated into the interior of the os, which was gradually dilated to a sufficient extent by a series of suc- cessive operations, repeated at intervals of three or four hours. When this had been accomplished, the fore-finger was inserted and swept round between the membranes and the uterus, but it was fre- quently found necessary to introduce the greater part of the hand to effect the object, and, sometimes, even this was not sufficient, and a female catheter or other instrument had to be used for the purpose. The method was generally successful in bringing on labor, but it now and then failed, even in Dr. Hamilton's hands. It is certainly based on correct principles, but it is tedious and painful both to the prac- titioner and the patient, and very uncertain in its time of action. For these reasons it has never been much practised. Vaginal and Uterine Douches. — In the year 1836 Kiwisch suggested a plan which, from its simplicity, has met with much approval. It consists in projecting, at intervals, a stream of warm or cold water against the os uteri. Its action is doubtless complex. Kiwisch him- self believed that relaxation of the soft parts, through the imbibition of water, was the determining cause of labor. Simpson found that the method failed, unless the water mechanically separated the mem- branes from the uterine Avails. Besides this effect, it probably di- rectly induces reflex action, by distending the vagina and dilating the os. In using it, it has been customary to administer a douche tAvice daily, and more frequently if rapid effects be desired. The number required varies in different cases. The largest number KiAvisch found it necessary to use was 17, the smallest 4. The average time that elapses before labor sets in is four days. Hence the method is obviously useless when rapid delivery is required. Dr. Cohen, of Hamburgh, introduced an important modification of the process, which has been considerably practised. It consists in INDUCTION OF PREMATURE LABOR. 441 passing a silver or gum-elastic catheter some inches within the os, between the membranes and the uterine walls, and injecting the fluid through it directly into the cavity of the uterus. He used creosote, or tar- water, and injected, without stopping, until the patient com- plained of a feeling of distension. Others have found the plan equally efficacious when they only employed a small quantity of plain water, such as 7 or 8 ounces. Professor Lazarewitch, of Char- koff, is a strong advocate of this method. He believes that uterine action is evoked much more rapidly and certainly if the water be injected near the fundus, and he has contrived an instrument for the purpose, with a long metallic nozzle. Dangers of these Plans. — So many fatal cases have followed these methods, that it cannot be doubted that, in spite of their certainty and simplicity, there is an element of risk in them which should not be overlooked. Many of these are recorded in Barnes's work, and he comes to the conclusion, which the facts unquestionably justify, that " the douche, whether vaginal or intra-uterine, ought to be ab- solutely condemned as a means of inducing labor." The precise rea- son of the clanger is not yqtj obvious. Sudden stretching of the uterine walls, producing shock, has been supposed to have caused it; but in many of the fatal cases the symptoms have been rather those attending the passage of air into the veins, and it is easy to under- stand how air may have been introduced, in this way, into the large uterine sinuses. Injection of Carbonic Acid Gas. — Simpson and Scanzoni have both tried with success the injection of carbonic acid gas into the vagina. Fatal results have, however, followed its employment, and Simpson has expressed an opinion that the experiment should not be re- peated. Simpson's Method of Operating. — Simpson originally induced labor bv passing the uterine sound within the os, and up towards the fun- dus, and, when it had been inserted to a sufficient extent, moving it slightly from side to side. He was led to adopt this procedure m the belief that we might thus closely imitate the separation of the deciclua, which occurs previous to labor at term. Uterine contrac- tions were induced with certainty and ease, but it was found impossi- ble to foretell what time might elapse between the commencement of j labor and the operation, which had frequently to be performed more than once. He subsequently modified this procedure by introducing ) a flexible male catheter, without a stilette, which he allowed to re- main in the uterus until contractions were excited. This plan is 1 much used in Germany, and is now that which is also most fre- quently adopted in this country. It is simple and very efficacious,, pains coming on, almost invariably, within 24 hours after the cathe- ter or bougie is introduced. A theoretical objection is the possi- \ bility of the catheter separating a portion of the placenta and giving I rise to hemorrhage ; but in practice this has not been found to occur, and the risk might generally be avoided by introducing the catheter at a distance from the placenta, the probable situation of which has been ascertained by auscultation. The more deeply the catheter is 29 442 OBSTETRIC OPERATIONS. introduced, the more certain and rapid is its effect, and not less than 7 inches should be pushed up within the os. It is not always easy to insert it so far, especially if a flexible catheter be used, which is apt to be too pliable to pass upwards with ease. A solid bougie — male urethral bougie — should, therefore, be employed, and I have found its introduction greatly facilitated by anaesthetising the patient, and passing the greater part of the hand into the vagina. In this way it can be pushed in very gently, and without any risk of injury to the uterus. There is some chance of rupturing the membranes while pushing it upwards. This accident, indeed, cannot always be avoided, even when the greatest care is taken ; but, when it occurs, the puncture will be at a distance from the os, so that a small portion only of the liquor amnii will escape, and this can scarcely be con- sidered a serious objection. It is always an advantage to allow the pains to come on gradually, and in imitation of natural labor. There- fore, if, after the bougie has been inserted for a sufficient time, uterine contractions come on sufficiently strongly, we may leave the case to be terminated naturally ; or, if they be comparatively feeble, we may resort to accelerative procedures, viz., dilatation of the cervix by the fluid bags, and subsequently the puncture of the membranes. In this way we have the labor completely under control ; and I believe this method will commend itself to those who have experience of it, as the simplest and most certain mode of inducing labor yet known, and the one most closely imitating the natural process. The Child is Immature and Difficult to Rear. — It should not be for- gotten that the child is immature, and that unusual care is likely to be required to rear it successfully. We should, therefore, be careful to have at hand all the usual means of resuscitation; and, as the mother may not be able to nurse at once, it would be a good pre- caution to have a healthy wet nurse in readiness. CHAPTEE II. TURNING. Turning, by which we mean the alteration of the position of the foetus, and the substitution of some other portion of the body for that originally presenting, is one of the most important of obstetric operations, and merits careful study. It is also one of the most ancient, and was evidently known to the Greek and Eoman physi- cians. Up to the fifteenth century, cephalic version — that in which the head of the foetus is brought over the os uteri — was almost exclusively practised, when Pare and his pupil Guillemeau taught the propriety of bringing the feet down first. It was by the latter TURNING. 443 physician especially that the steps of the operation were clearty defined; and the French have undoubtedly the merit both of per- fecting its performance, and of establishing the indications which should lead to its use. Indeed, it was then much more frequently performed than in later times, since no other means of effecting arti- ficial delivery were known, which did not involve the death of the child; and practitioners, doubtless, acquired great skill in its per- formance, and were inclined to overrate its importance, and extend its use to unsuitable cases. An opposite error was fallen into after the invention of the forceps, which for a time led to the abandonment of turning in certain conditions for which it was well adapted, and in which it has only of late years been again practised. Cephalic version has, since Pare wrote, been recommended and practised from time to time, but the difficulty of performing it satis- factorily was so great that it never became an established operation. Dr. Braxton Hicks has perfected a method by which it can be ac- complished with greater ease and certainty, and which renders it a legitimate and satisfactory resort in suitable cases. To him we are also indebted for introducing a method of turning without passing the entire hand into the cavity of the uterus, which, under favorable circumstances, is not only easy of performance, but deprives the operation of one of its greatest dangers. Turning by External and Internal Manipulation. — The possibility of effecting version by external manipulation has been long known, and was distinctly referred to and recommended by Dr. John Pechey, 1 so far back as the year 1698. Since that time it has been strongly advocated by Wigand and his followers ; and various authors in this country, notably Sir James Simpson, have referred to the advantage to be derived from external manipulation assisting the hand in the interior of the uterus. To Dr. Hicks, however, incontestably belongs the merit of having been the first distinctly to show the possibility of effecting complete version by combined external and internal mani- pulation, of laying down definite rules for its practice, and of thus popularizing one of the greatest improvements in modern midwifery. Object and Nature of the Operation.— -The operation is entirely dependent for success on the fact that the child in utero is freely movable, and that its position may be artificially altered with facility. As long as the membranes are unruptured, and the foetus is floating in the surrounding fluid medium, it is liable to constant changes in position, as may be readily demonstrated in the latter months of pregnancy ; and the operation, under these circumstances, may be performed with the greatest facility. Shortly after the liquor amnii has escaped there is still, as a rule, no great difficulty in effect- ing version ; but, as the body is no longer floating in the surround- ing liquid, its rotation must necessarily be attended with some increased risk of injury to the uterus. If the liquor amnii have been long evacuated, and the muscular structure of the uterus be strongly contracted, the foetus may be so firmly fixed, that any 1 The Complete Midwife's Practice, p. 142. 444 OBSTETRIC OPERATIONS. attempt to move it is surrounded with, the greatest difficulties, and may even fail entirely, or be attended with such risks to the maternal structures as to be quite unjustifiable. Cases Suitable for the Operation. — Version may be required either on account of the mother or child alone ; or it may be indicated by some condition imperilling both, and rendering immediate delivery necessary. The chief cases in which it is resorted to are those of transverse presentation, where it is absolutely essential ; accidental or unavoidable hemorrhage ; certain cases of contracted pelvis; and some complications, especially prolapse of the funis. The special indications for the operation have been separately discussed under these subjects. Statistics and Dangers of the Operation. — The ordinary statistical tables cannot be depended on as giving any reliable results as to the risks of the operation. Taking all cases together, Dr. Churchill esti- mates the maternal mortality as 1 in 16, and the infantile as 1 in 3. Like all similar statistics, they are open to the objection of not dis- tinguishing between the results of the operation itself, and of the cause which necessitated interference. Still they are sufficient to show that the operation is not free from grave hazards, and that it must not be undertaken without due reflection. The principal dangers will be discussed as we proceed. It may suffice to mention here that those to the mother must vary with the period at which the operation is undertaken. If version be performed early, before the rupture of the membranes, or, in favorable cases, without the introduction of the hand into the interior of the uterus, the risk must of course be infinitely less than in those more formidable cases in which the waters have long escaped, and the hand and arm have to be passed into an irritable and contracted uterus. But even in the most unfavorable cases accidents may be avoided, if the operator bear constantly in mind that the principal danger consists in lace- ration of the uterus or vagina from undue force being employed, or from the hand and arm not being introduced in the axis of the pas- sages. There is no operation in which gentleness, absence of all hurry, and complete presence of mind are so essential. A certain number of cases end fatally from shock or exhaustion, or from sub- sequent complications. As regards the child, the mortality is little, if at all, greater than in original breech and footliug presentations. Nor is there any good reason why it should be so, seeing that cases of turning, after the feet are brought through the os, are virtually reduced to those of feet presentation, and that the mere version, if effected sufficiently soon, is not likely to add materially to the risk to which the child is exposed. Version by External Manipulation. — The possibility of effecting version by external manipulation has been recognized by various authors, and was made the subject of an excellent thesis by Wigand, who clearly described the manner of performing the operation. In spite of the manifest advantages of the procedure, and the extreme facility with which it can be accomplished in suitable cases, it has by no means become the established custom to trust to it, and prob- TURNING. 445 ably most practitioners have never attempted it, even under the most favorable conditions. The possibility of operation is based on the extreme mobility of the foetus before the membranes are ruptured. After the waters have escaped, the uterine walls embrace the foetus more or less closely, and version can no longer be readily performed in this manner. Cases suitable for the Operation. — It may, therefore, be laid down as a rule that it should only be attempted when the abnormal posi- tion of the foetus is detected before labor has commenced, or in the early stage of labor, when the membranes are unruptured. It is also unsuitable for any but transverse presentations, for it is not meant to effect complete evolution of the foetus, but only to substi- tute the head for the upper extremity. It is useless whenever rapid delivery is indicated, for, after the head is brought over the brim, the conclusion of the case must be left to the natural powers. Method of Performance. — The manner of detecting the presentation by palpation has been already described (p. 114), and the success of the operation depends on our being able to ascertain the positions of the head and breech through the uterine walls. Should labor have commenced, and the os be dilated, the transverse presentation may be also made out by vaginal examination. Should the abnormal pre- sentation be detected before labor has actually begun, it is, in most cases, easy enough to alter it, and to bring the foetus into the longi- tudinal axis of the uterine cavity. It is seldom, however, discovered until labor has commenced, and, even if it be altered, the child is ex- tremely apt to reassume, in a short time, the faulty position in which it was formerly lying- Still there can be no harm in making the attempt, since the operation itself is in no way painful, and is abso- lutely without risk either to the mother or child. When the trans- verse presentation is detected early in labor, I believe it is good practice to endeavor to remedy it by external manipulation, and, if it fail, we may at once proceed to other and more certain methods of operating. The procedure itself is abundantly simple. The pa- tient is placed on her back, and the position of the foetus ascertained by palpation as accurately as possible, in the manner already indi- cated. The palms of the hands being then placed over the opposite poles of the foetus, by a series of gentle gliding movements, the head is pushed towards the pelvic brim, while the breech is moved in the opposite direction. The facility with which the foetus may some- times be moved in this way can hardly be appreciated by those who have never attempted the operation. As soon as the change is effected, the long diameters of the foetus and of the uterus will cor- respond, and vaginal examination will show that the shoulder is no longer presenting, and that the head is over the pelvic brim. If the os be sufficiently dilated, and labor in progress, the membranes should now be punctured, and the position of the foetus maintained for a short time by external pressure, until we are certain that the cephalic presentation is permanently established. If labor be not in progress, an attempt may at least be made to effect the same object by pads and a binder; one pad being placed on the side of the uterus 446 OBSTETRIC OPERATIONS. in the situation of the breech, and another on the opposite side in the situation of the head. Cephalic Version. — On account of the difficulty of performing cepha- lic version in the manner usually recommended, it has practically scarcely been attempted, and, with the exception of some more recent authors, it is generally condemned by writers on systematic mid- wifery. Still the operation offers unquestionable advantages in those transverse presentations in which rapid delivery is not necessary, and in which the only object of interference is the rectification of malposition; for, if successful, the child is spared the risk of being drawn footling through the pelvis. The objections to cephalic ver- sion are based entirely on the difficulty of performance; and, un- doubtedly, to introduce the hand within the uterus, search for, seize, and afterwards place the slippery head in the brim of the pelvis, could not be an easy process, even under the most favorable circum- stances, and must always be attended by considerable risk to the mother. Yelpeau, who strongly advocated the operation, w T as of opinion that it might be more easily accomplished by pushing up the presenting part, than by seizing and bringing down the head. Wi- gand more distinctly pointed out that the head could be brought to a proper position by external manipulation, aided by the fingers of one hand within the vagina. Braxton Hicks has laid down clear rules for its performance, which render cephalic version easy to ac- complish under favorable conditions, and will doubtless cause it to become a recognized mode of treating malpositions. The number of cases, however, in which it can be performed must always be .limited, since, as in turning by external manipulation alone, it is necessary that the liquor amnii should be still retained, or at least have only recently escaped ; that the presentation be freely movable above the pelvic brim ; and that there be no necessity for rapid delivery. Dr. Hicks does not believe protrusion of the arm to be a contra-indica- tion, and advises that it should be carefully replaced within the uterus. When, however, protrusion of the arm has occurred, the thorax is so constantly pushed down into the pelvis that replacement can neither be safe nor practicable, except under unusually favorable conditions, and podalic version will be necessary. Method of Performance. — It is impossible to describe the method of performing cephalic version more concisely and clearly than in Dr. Hicks's own words. "Introduce," he says, "the left hand into the vagina, as in podalic version; place the right hand on the out- side of the abdomen, in order to make out the position of the foetus, and the direction of its head and feet. Should the shoulder, for instance, present, then push it with one or two fingers in the direc- tion of the feet. At the same time pressure with the other hand should be exerted on the cephalic end of the child. This will bring the head clown to the os; then let the head be received on the tips of the inside lingers. The head will play like a ball between the two hands; it will be under their command, and can be placed in almost any part at will. Let the head then be placed over the os, taking care to rectify any tendency to face presentation. It is as TUBNING. 417 well, if the breech, will not rise to the fundus readily after the head is fairly in the os, to withdraw the hand from the vagina, and with it press up the breech from the exterior. The hand which is re- taining gently the head from the outside should continue there for some little time, till the pains have insured the retention of the child in its new position and the adaptation of the uterine walls to its new form. Should the membranes be perfect, it is advisable to rupture them as soon as the head is at the os uteri; during their flow and after the head will move easily into its proper position." The procedure thus described is so simple, and would occupy so short a time, that there can be no objection to trying it. Should we fail in our endeavors, we shall not be in a worse position for effecting delivery by podalic version, which can be proceeded with without withdrawing the hand from the vagina, or in any way altering the position of the patient. Podalic Version. — The method of performing podalic version varies with the nature of each particular case. In describing the operation, it has been usual to divide the cases into those in which the circum- stances are favorable, and the necessary manoeuvres easily accom- plished; and those in which there are likely to be considerable diffi- culties, and increased risk to the mother. This division is eminently practicable, since nothing can be more variable than the circum- stances under which version may be required. Before describing the steps of the operation, it may be well to consider some general conditions applicable to all cases alike. Position of the Patient. — In this country the ordinary position on the left side is usually employed. On the Continent and in America the patient is placed on her back, with the legs supported by assist- ants, as in lithotomy. The former position is preferable, not only as a matter of custom, and as involving much less fuss and exposure of the person, but because it admits of both the operator's hands being more easily used in concert. In certain difficult cases, when the liquor amnii has escaped, and the back of the child is turned towards the spine of the mother, the dorsal decubitis presents some advantages in enabling the hand to pass more readily over the body of the child ; but such cases are comparatively rare. The patient should be brought to the side of the bed, across which she should be laid, with the hips projecting over, and parallel to, the edge, the knees being flexed towards the abdomen, and separated from each other by a pillow, or by an assistant. Assistants should also be placed so as to restrain the patient if necessary, and prevent her involuntarily starting from the operator, as this might not only embarrass his movements, but be the cause of serious injury. Administration of Anaesthetics. — The exhibition of anaesthetics is peculiarly advantageous. There is nothing which tends to facilitate the steps of the process so much as stillness on the part of the patient, and the absence of strong uterine contraction. YThen the vagina is very irritable and the uterus firmly contracted round the body of the child, complete amesthesia may enable us to effect ver- sion, when without it we should certainly fail. 448 OBSTETRIC OPERATIONS. Period when the Operation should he Undertaken. — The most favor- able time for operating is when the os is fully dilated, before, or im- mediately after, the rupture of the membranes and the discharge of the liquor amnii. The advantage gained by operating before the waters have escaped cannot be overstated, since we can then make the child rotate with great facility in the fluid medium in which it floats. In the ordinary operation, in which the hand is passed into the uterus, it is essential to wait until the os is of sufficient size to admit its being introduced with safety. This may generally be done when the os is the size of a crown-piece, especially if it be soft and yielding. Choice of Hand to he used. — The practice followed with regard to the hand to be used in turning varies considerably. Some accoucheurs always employ the right hand, others the left, and some one or other, according to the position of the child. In favor of the right hand, it is said that most practitioners have more power with it, and are able to use it with greater gentleness and delicacy. In transverse presentations, if the abdomen of the child be placed anteriorly, the right hand is said to be the proper one to use, on account of the greater facility with which it can be passed over the front of the child ; and in difficult cases of this kind, when we are operating with the patient on her back, it certainly can be employed with more pre- cision than the left. In all ordinary cases, however, the left hand can be introduced much more easily in the axis of the passages, the back of the hand adapts itself readily to the curve of the sacrum, and, even when the child's abdomen lies anteriorly, it can be passed forwards without difficulty so as to seize the feet. These advantages are sufficient to recommend its use, and very little practice is re- quired to enable the practitioner to manipulate with it as freely as with the right. If, in addition, we remember that the right hand is required to operate on the foetus through the abdominal walls — and this is a point which should never be forgotten — we shall have abundant reasons for laying it down as a rule that the left hand should generally be employed. Before passing the hand and arm they should be freely lubricated, with the exception of the palm, which is left untouched to admit of a firm grasp being taken of the foetal limbs. It is also advisable to remove the coat, and bare the arm as high as the elbow. As it should be a cardinal rule to resort to the simplest procedure when practicable, it will be well to consider first the method by com- bined external and internal manipulation, without passing the hand into the uterus, and subsequently that which involves the introduc- tion of the hand. Turning by Combined External and Internal Manipulation. — To effect podalic version by the combined method it is an essential pre- liminary to ascertain the situation of the foetus as accurately as pos- sible. It will generally be easy, in transverse presentation, to make out the breech and the head by palpation ; while, in head presenta- tions, the fontanel! es will show to which side of the pelvis the face is turned. The left hand is then to be passed carefully into the TURNING 449 vagina, in the axis of the canal, to a sufficient extent to admit of the fingers passing freely into the cervix. To effect this, it is not always necessary to insert the whole hand, three or four fingers being gen- erally sufficient. If the head lie in the first or fourth position, push it upwards and to the left ; while the other hand, placed externally on the abdomen, Fig. 142. First Stage of Bi-polar Version. — Elevation of the Head and Depression of the Breech. (After Barnes.) depresses the breech towards the right (Fig. 143). By this means we act simultaneously on both extremities of the child's body, and easily alter its position. The breech is pushed down gently but firmly, by gliding the hand over the abdominal wall. The head will now pass oat of reach, and the shoulder will arrive at the os, and will lie on the tips of the fingers. This is similarly pushed upwards in the same direction as the head (Fig. 143), the breech at the same time being still further depressed, until the knee comes within reach of the fingers, when (the membranes being now ruptured, if still unbroken) it is seized and pulled down through the os (Fig. 144). Occasionally the foot comes immediately over the os, when it can be seized instead of the knee. Version may be facilitated by changing the position of the external hand, and pushing the head upwards from the iliac fossa, instead of continuing the attempt to depress the breech (Figs. 144 and 145). These manipulations should always be carried on in the intervals, and desisted from when the pains come 450 OBSTETRIC OPERATIONS. on ; and when the pains recur with great force and frequency, the advantage of chloroform will be particularly apparent. In the | Fig. 143. Second Stage of Bi-polar Version. — Elevation of the shoulders and depression of the breech. (After Barnes.) second and third positions, the steps of the operation should be re- versed; the head is pushed upwards and to the right, the breech Fig. 144. Third Stage of Bi-polar Version. — Seizure of the knee and partial elevation of the head. (After Barnes.) downwards and to the left. When the position cannot be made out with certainty, it is well to assume that it is the first, since that is TURNING. 451 the one most frequently met with ; and even if it be not, no great inconvenience is likely to occur. If the os be not sufficiently open to admit of delivery being concluded, the lower extremity can be retained in its new position with one finger, until dilatation is suffi- Fig. 145. Fourth Stage of Bi-polar Version. •Drawing down of leg and completion of version. Barnes.) (After ciently advanced, or until the uterus has permanently adapted itself to the altered position of the child, either of which results will gene- rally be effected in a short space of time. In transverse presentations the same means are to be adopted, the shoulder being pushed upwards in the direction of the head, while the breech is depressed from without. This is frequently sufficient to bring the knees within reach, especially if the membranes are entire, but version is much facilitated by pressing the head upwards from without, alternately with depression of the breech. If the liquor amnii has escaped, and the uterus is firmly contracted round the body of the child, it will be found impossible to effect an altera- tion in its position without the introduction of the hand, and the ordinary method of turning must be employed. The peculiar advan- tage of the combined process is, that it in no way interferes with the latter, for, should it not succeed, the hand can be passed on into the uterus without Avithdrawal from the vagina (provided the os be sufficiently dilated), and the feet or knees seized and brought down. Podalic Version v;hen the Hand is Introduced into theUterus. — Turn- ing, with the hand introduced into the uterus, provided" the waters 452 OBSTETRIC OPERATIONS. have not or have only recently escaped, and the os be sufficiently dilated, is an operation generally performed with ease. Introduction of the Hand. — The first step, and one of the most important, is the introduction of the hand and arm. The fingers having been pressed together in the form of a cone, the thnmb tying between the rest of the fingers, the hand, thus reduced to the smallest possible dimensions, is slowly and carefully passed into the vagina, in the axis of the outlet, in an interval between the pains, and passed onwards in the same cautious manner, and with a semi-rotatory motion, until it lies entirely within the vagina, the direction of intro- duction being gradually changed from the axis of the outlet to that of the brim. If uterine contractions come on, the hand should remain passive until they are over. It should ever be borne in mind, as one of the fundamental rules in performing version, that we should act only in the absence of pains, and then with the utmost gentleness — all force and violent pushing being avoided. The hand, still in the form of a cone, having arrived at the os, if this be suffi- ciently dilated, may be passed through at once. If the os be not quite open, but dilatable, the points of the fingers may be gently insinuated, and occasionally expanded, so as to press it open suffi- ciently to permit the rest of the hand to pass. While this is being done, the uterus should be steadied by the other hand placed exter- nally, or by an assistant. If the presentation should not previously have been made out with accuracy, we can now ascertain how to pass the hand onwards, so that its palmar surface may correspond with the abdomen of the child. Rupture of the Membranes. — The membranes should now be rup- tured — if possible during the absence of pain — so as to prevent the waters being forced out. The hand and arm form a most efficient plug, and the liquor amnii cannot escape in any quantity. Some practitioners recommend that, before rupturing the membranes, the hand should be passed onwards between them and the uterine walls, until we reach the feet. By so doing we run the risk of separating the placenta ; besides we have to introduce the hand much further than may be necessary, since the knees are often found lying quite close to the os. As soon as the membranes are perforated, the hand can be passed on in search of the feet (Fig. 146). At this stage of the operation increased care is necessary to avoid anything like force ; and should a pain come on, the hand must be kept perfectly flat and still, and rather pressed on the body of the child than on the uterus. If the pains be strong, much inconvenience may be felt from the compression; and, were the onward movement continued, or the hand even kept bent in the conical form in which it was introduced, rupture of the uterine Avails might easily be caused. This is not likely to occur in the class of cases now under consideration, for it is chiefly when the waters have long escaped that the progress of the hand is a matter of difficulty. Valuable assistance may now be given by pressing the breech downwards from without, so as to bring the knees or feet more easily within the reach of the internal hand. Having arrived at the knees or feet, they may be seized between the TURNING 453 fingers, and drawn downwards in the absence of a pain (Fig. 147). This will cause the foetus to revolve on its axis, the breech will de- scend, and, at the same time, the ascent of the head may be assisted bv the right hand from without. It is a question with many ac- Fio. 146. Seizure of the Feet when the Hand is Introduced into the Uterus. coucheurs which part of the inferior extremities should be seized and brought down. Some recommend us to seize both feet, others prefer one only, while some advise the seizure of one or both knees. In a simple case of turning, before the escape of the waters, it does not much matter which of these plans is followed, since version is accomplished with the greatest ease by any one of them. The seizure of the knee, however, instead of the feet, offers certain advantages which should not be overlooked. It is generally more accessible, affords a better hold (the fingers being inserted in the flexure of the ham), and, being nearer the spine, traction acts more directly on the body of the child. Any danger of mistaking the knee for the elbow may be obviated by remembering the simple rule that the salient angle of the former looks towards the head of the child, of the latter towards its feet. Certain advantages may also be gained by bring- ing down one foot or knee only, instead of both. When one inferior extremity remains flexed on the body of the child, the part which has to pass through the os is larger than when both legs are drawn down, and consequently the os is more perfectly dilated, and less 454 OBSTETRIC OPERATIONS difficulty is likely to be experienced in the delivery of the rest of the body, so that the risk to the child is materially diminished. Fig. 147. Drawing down of the Feet and Completion of Version. Choice of Leg to he brought down in Transverse Presentations. — Simpson, whose views have been adopted by Barnes and other writers, recommend the seizing, if possible, in arm presentations, of the knee farthest from and opposite to the presenting arm, as by this means the body is turned round on its longitudinal axis, and the presenting arm and shoulder more easily withdrawn from the os. Dr. Galabin has carefully investigated this point in a recent paper, 1 and contends that there is a greater mechanical advantage in seizing the leg which is nearest to, and on the same side as, the presenting arm, and this, moreover, is generally more readily done. Management of the Case after Version. — As soon as the head has reached the fundus, and the lower extremity is brought through the os, the case is converted into a foot or knee presentation, and it comes to be a question whether delivery should now be left to nature or terminated by art. This must depend to a certain extent on the case itself, and on the cause which necessitated version, but generally, it Obst. Trans., vol. xix. 187 7. TURNING 455 will be advisable to finish delivery without unnecessary delay. To accomplish this, downward traction is made during the pains, and desisted from in the intervals (Fig. 148). As the umbilical cord Fig. 148. Showing the Completion of Version. (After Bcarnes.) appears, a loop should be drawn down ; and if the hands be above the head, they must be disengaged and brought over the face, in the same manner as in an ordinary footling presentation. The manage- ment of the head, after it descends into the cavity of the pelvis, must also be conducted as in labors of that description. Turning in Placenta Prsevia. — In cases of placenta prsevia the os will, as a rule, be more easily dilatable than in transverse presenta- tions. Hicks's method offers the great advantage of enabling us to perform version much sooner than was formerly possible, since it only requires the introduction of one or two fingers into the os uteri. Should we not succeed by it, and the state of the patient indicates that delivery is necessary, we have at our command, in the fluid dilators, a means of artificially dilating the os uteri which can be employed with ease and safety. If we have to do with a case of ■entire placental presentation, the hand should be passed at that point where the placenta seems to be least attached. This will alwaj^s be better than attempting to perforate its substance, a measure some- times recommended, but more easily performed in theory than in practice. If the placenta only partially present, the hand should, of 456 OBSTETRIC OPERATIONS. course be inserted at its free border. It will frequently be advisable not to hasten delivery after the feet have been brought through the os, for they form of themselves a very efficient plug, and effectually prevent further loss of blood ; while, if the patient be much ex- hausted, she may have her strength recruited by stimulants, etc., before the completion of delivery. Turning in Ab domino -anterior Positions. — In abdomino-anterior positions, in which the waters have escaped, and in which, therefore, some difficulty may be reasonably anticipated, the operation is gener- ally more easily performed with the patient on her back ; the right hand is then introduced in the uterus, and the left employed exter- nally (Fig. 149). In this way the internal hand has to be passed a Fig. 149. Showing the Use of the Eight Hand in Abdomino-anterior Position. shorter distance, and in a less constrained position. The operator then sits in front of the patient, who is supported at the edge of the bed in the lithotomy position with the thighs separated, and the right hand is passed up behind the pubis, and over the abdomen of the child. Difficult Gases of Arm Presentation. — The difficulties of turning culminate in those unfavorable cases of arm presentation in which the membranes have been long ruptured, the shoulder and arm pressed down into the pelvis, and the uterus contracted round the body of the child. The uterus being firmly and spasmodically con- tracted, the attempt to introduce the hand often only makes matters worse, by inducing more frequent and stronger pains. Even if the hand and arm be successfully passed, much difficulty is often ex- perienced in causing the body of the child to rotate ; for we have no longer the fluid medium present in which it floated and moved with TURNING. 457 ease, and the arm of the operator may be so cramped and pained, by the pressure of the uterine walls, as to be rendered almost power- less. The risk of laceration is also greatly increased, and the care necessary to avoid so serious an accident adds much to the difficulty of the operation. Value of Anaesthesia in Relaxing the Uterus. — In these perplexing cases various expedients have been tried to cause relaxation of the spasmodically contracted uterine fibres, such as copious venesection in the erect attitude until fainting is induced, warm baths, tartar emetic, and similar depressing agents. None of these, however, are so useful as the free administration of chloroform, which has practi- cally superseded them all, and often answers most effectually when given to its full surgical extent. Mode of Procedure. — The hand must be introduced with the pre- cautions already described. If the arm be completely protruded into the vagina, we should pass the hand along it as a guide, and its palmar surface will at once indicate the position of the child's abdo- men. No advantage is gained by amputation, as is sometimes recom- mended. When the os is reached, the real difficulties of the operation commence, and, if the shoulder be firmly pressed down into the brim of the pelvis, it may not be easy to insinuate the hand past it. It is allowable to repress the presenting part a little, but with extreme caution, for fear of injuring the contracted uterine parietes. It is better to insinuate the hand past the obstruction, which can generally be done by patient and cautious endeavors. Having succeeded in passing the shoulder, the hand is to be pressed forward in the intervals, being kept perfectly flat and still on the body of the foetus when the pains come on. It is much safer to press on it than on the uterine walls, which might readily be lacerated by the projecting knuckles. When the hand has advanced sufficiently far, it will be better, for the reasons already mentioned, to seize and bring down one knee only. Management of Cases in which the Foot is brought down but the Foetus will not Revolve. — Even when the foot has been seized and brought through the os, it is by no means always easy to make the child ! revolve on its axis, as the shoulder is often so firmly fixed in the pelvic brim as not to rise towards the fundus. Some assistance may be derived from pushing the head upwards from without, which, of course, would raise the shoulder along with it. If this should fail, we may effect our object by passing a noose of tape or wire ribbon round the limb, by which traction is made downwards and back- wards; at the same time, the other hand is passed into the vagina to displace the shoulder and push it out of the brim. It is evident that this cannot be done as long as the limb is held by the left hand, as there is no room for both hands to pass into the vagina at the same time. By this manoeuvre version may be often completed, when the foetus cannot be turned in the ordinary way. Various instruments have been invented, both for passing a lac round the child's limb, and for repressing the shoulder, but none of them can compete, either in facility of use or safety, with the hand of the accoucheur. 458 OBSTETRIC OPERATIONS. Should all attempts at version fail, no resource is left but the mutilation of the child, either by evisceration or decapitation. This extreme measure is, fortunately, seldom necessary, as with due care version may generally be effected, even under the most unfavorable circumstances. CHAPTEE III. THE FORCEPS. Of all obstetric operations the most important, because the most truly conservative both to the mother and child, is the application of the forceps. In modern midwifery the use of the instrument is much extended, and it is now applied by some of our most expe- rienced accoucheurs with a frequency which older practitioners would have strongly reprobated. That the injudicious and unskilful use of the forceps is capable of doing much harm, no one will for a moment deny. This, however, is not a reason for rejecting the recommenda- tion of those who advise a more frequent resort to the operation, but rather for urging on the practitioner the necessity of carefully study- ing the manner of performing it, and of making himself familiar with the cases in which it is easy or the reverse. Nothing but practice — at first on the dummy, and afterwards in actual cases — can impart the operative dexterity which it should be the aim of every obstetri- cian to acquire, and without which there can be no assurance of his doing his duty to his patient efficiently. Description of the Instrument. — The forceps may best be described as a pair of artificial hands, by which the foetal head may be grasped and drawn through the maternal passages by a vis a fronte, when the vis a tergo is deficient. This description will impress on the mind the important action of the instrument as a tractor, to which all its other powers are subservient. The forceps consists of two separate blades of a curved form, adapted to fit the child's head ; a lock by which the blades are united after introduction ; and handles which are grasped by the operator, and by means of which traction is made. It would be a wearisome and unsatisfactory task to dwell on all the modifications of the instrument which have been made, which are so numerous as to make it almost appear as if no one could practise midwifery with the least pretension to eminence, unless he has attached his name to a new variety of forceps. The Short Forceps. — The original instrument, invented by the Cliamberlens, may be looked upon as the type of the short straight forceps, which has been more employed than any other, and which, perhaps, finds its best representative in the short forceps of Denman THE FORCEPS 459 Fig. 150. (Fig. 150). Indeed the only essential difference between the two is the lock of the latter, originally invented by Smellie, which is so excellent that it has been adopted in all British forceps; and which, for facility of juncture, is much superior to either the French pivot, or the German lock, while for firmness it is, for all practical purposes, as good as either. In this instrument the blades are 7, the handles -if inches in length; the extremities of the blades are exactly 1 inch apart, and the space between them, at their widest part, is 2| inches. The blades measure If inches at their greatest breadth, and spring with a regular sweep directly from the lock, there being no shank. The blades are formed of the best and most highly tempered steel, to resist the strain to which they are occasionally subjected, and they are smooth and rounded on their inner surface, to obviate the risk of injury to the scalp of the child. Advantages claimed for this Form of Instrument. — The special advantage claimed for this form of instrument is, that, the two halves being precisely similar, no care or forethought is re- quired on the part of the practitioner as to which blade should be introduced uppermost — an advantage of no great value, since no one should undertake a case of forceps delivery who has not sufficient knowledge of the operation, and presence of mind enough, to obviate any risk from the introduction of the wrong blade first. On account of its shortness, and the want of the second or pelvic curve, it is only adapted for cases in which the head is low clown in the pelvis, or actually resting on the perineum. The Pelvic Curve, its Advantages. — The question of the second or pelvic curve is one on which there is much difference of opinion. 1 The forceps we are now considering, and the many modifications formed on the same plan, is constructed solely with reference to its grasp on the child's head, and without regard to the axes of the maternal passages. Consequently were Ave to introduce it when the head was at the upper part of the pelvis, we could not fail to expose the soft parts to the risk of contusion, and (in consequence of the necessity of drawing more directly backwards) unduly stretch and even lacerate the perineum. Hence it is now admitted by obstetri- [ : The credit of devising the pelvic curve is now given to Dr. Benjamin Pugh, of Chelmsford, Essex, England, 1736. Levret, in 1747, and Smellie, in 1751, both used it. They are thought to have acted independently in the invention. — Ed.} Denman's Short Forceps. 460 OBSTETRIC OPERATIONS, Fig. 151. cians, with few exceptions, that the second curve is essential before the complete descent of the head, although it is not absolutely so after this has taken place. The only circumstances under which a straight blade can possess any superiority are in certain cases of occipito-posterior position, in which it is found necessary to rotate the head round a large extent of the pelvis, when the circular sweep of a strongly-curved instrument might prove injurious. Such cases, however, are of rare occurrence, and need in no way influence the general employment of the pelvic curve. Zeigler's Forceps. — The short forceps, usually employed in Scot- land, is the invention of the late Zeigler (Fig. 151), 1 and is useful from the facility with which the blades may be introduced in accurate apposition to each other, a point which in practice is of no little value. In general size and appearance it closely resembles Denman's forceps, but the fenestrum of the lower blade is continued down to the handle. In intro- ducing, the lower blade is slipped over the handle of the other blade already in situ, and thus it is guided with great certainty into a proper position, locking itself as it passes on. This instrument has the disadvantage of not having the second curve, but the facility of introduction has rendered it a great favorite with many who have been in the habit of employing it. The Long Forceps. — For cases in which the head is not on the perineum, or at least not quite low in the pelvis, a longer instrument is essential. To meet this indication Smellie invented the long forceps, which, like the shorter instrument, has been very variously modified. The most perfect instrument of the kind employed in this country is that known as Simpson's forceps (Fig. 152), which combines many excellent points selected from the forceps of various obstetricians, as well as some original additions, and which, as a whole, has never been surpassed. The curved portions of the blades are 6J inches long, the fenestrum measuring \\ at its widest part. The extremities of the blades are 1 inch asunder when the handles are closed, and 3 inches at their widest part. The object of this somewhat unusual width is to lessen the compressing power of the instrument, without in any way interfering with, its action as a tractor. The pelvic curve is less than in most long forceps, so as to admit of the rotation of the head when necessary, without the risk of injuring the maternal structures. Between the curve of the blade and the lock is a straight portion or shank, measuring 2f inches, which, before joining the handle, is bent at right angles into a knee. This shank is a useful addition to all forceps, and is essential in the long forceps to insure the junction of the blades beyond the parts of the mother, which might otherwise be caught in the lock and injured. Zeigler's Forceps. [' It Las been made here, but is not regarded with any favor. — En.] THE FORCEPS. 461 The knees serve the purpose of preventing the blades from slipping from each other after they have been united. They also admit of one finger being introduced above the lock, and used as an aid in traction ; a provision which is made in some other varieties of long- forceps by a semicircular bend in each shank. The handles which Fig. 152. in most British forceps are too small and smooth to afford a firm grasp, are serrated at the edge, and flattened from before backwards, so as to fit the closed fist more accurately. At their extremities, near the lock, there are a pair of projecting rests, over which the fore and middle fingers may be passed in traction, and which greatly increase our power over the instrument. Although this, and other varieties of the long forceps, are specially constructed for application when the head is high in the pelvis, it answers quite as well as the short forceps — in- deed, in most respects better — ■ when the head has descended low down. It is a decided advantage for the practitioner to habituate himself to the use of one instru- ment, with the application and power of which he becomes thoroughly familiar. It is a mere waste of space and money for him Simpson's Forceps. to incumber himself with a num- ber of instruments of various shapes and sizes, and he may be sure that a good pair of long forceps, such as Simpson's, will be suitable for every emergency, and in any position of the head. Disadvantages of a Weak Instrument. — The chief argument against the use of such an instrument in simple cases is its great power. This, however, is entirely based on a misconception. The existence of power does not involve its use, and the stronger instrument can be employed with quite as much delicacy and gentleness as the weaker. The remarks of Dr. Hodge 1 on this point are extremely apposite, and are well worthy of quotation. He says, " Certainly no man ought to apply the forceps who has not sufficient discretion, to use no more force than is absolutely requisite for safe delivery ; if, therefore, there is more power at command, he is not obliged to use it; while, on the contrary, if much power be demanded, he can, within the bounds of prudence, exercise it by the long forceps, but with the e System of Obstetrics, p. 242. 462 OBSTETRIC OPERATIONS. Fig. 153. short forceps his efforts might be unavailing; moreover, in cases of difficulty, the short forceps being used, the practitioner would be forced to make great muscular efforts ; while with the long forceps, owing to the great leverage, such effort will be comparatively trifling, and, of course the whole force demanded can be much more deli- cately, and at the same time efficiently, applied, and with more safety to the tissues of the child and its parent." Continental Forceps. — The forceps usually employed on the Con- tinent, and in America, differ considerably, both in appearance and construction, from those in use in this country. As a rule it is a larger and more powerful instrument, joined by a pivot or button joint, and it always possesses the second or pelvic curve. Of late years Simpson's forceps has been much employed in some parts of Germany. The chief objection to the Continental instruments is their cumbrousness. This is chiefly in the handles, which in many of them are forged in a piece with the blades, the part introduced within the maternal structures not being materially differ- ent from the corresponding part of the English instrument. The forceps invented by Professor Tarnier (Fig, 153) have recently at- tracted considerable attention. In this instrument traction is not made on the handles by which the blades are intro- duced, as in ordinary forceps, but on a supplementary handle (a) subsequently attached to the blades near the lower opening of their fenestras (b). The object claimed for this arrangement is that less force is required in traction, which can always be made in the proper axis of the pelvis ; that the blades are not likely to slip ; and that rotation of the head is not interfered with. The instrument, however, is much more complex than that usually employed in this country, and does not seem to possess sufficient advantages to coun- terbalance this defect. [Professor Tarnier has adopted, in this in- strument, the blades of Davis. It has been much simplified recently, by Dr. Kichard A. Cleemann, of Philadelphia, by taking away the long curve of the handles, dispensing with the tongue, and bending forward the shanks. — Ed.] Action of the Instrument. — The forceps is generally said to act in three different ways : — 1st. As a tractor. 2d. As a lever. 3d. As a compressor. The Chief Use of the Forceps as a Tractor. — It is more especially as a tractor that the instrument is of value, and it is used with the great- Tarnier's Forcep THE FORCEPS. 463 est advantage when it is employed merely to supplement the action of the uterus, which is insufficient of itself to effect delivery, or when, from some complication, it is necessary to complete labor with greater rapidity than can be accomplished by the unaided powers of nature. In most cases traction alone is sufficient ; but, in order that it may act satisfactorily, and that the instrument may not slip, a proper con- struction of the forceps, and a sufficient curvature of the blades, are essential. The want of these is the radical fault of many of the short, straight instruments in common use, which have a tendency to slip during our efforts at extraction. As a Lever. — The forceps acts also as a lever, but this action has been greatly exaggerated. It is generally described as a lever of the first class, the power being at the handles, the fulcrum at the lock, and the weight at the extremities. There may possibly be some leverage power of this kind when the instrument is first introduced, and the handles held so loosely that one blade is able to work on the other. But, as ordinarily used, the handles are held with a suffi- ciently firm grasp to prevent this movement, and then the two blades practically form a single instrument. Galabin, who has studied this subject in detail, points out 1 that : "1. The lever is formed by both blades of the forceps and the foetal head united in one immovable mass. As soon as the blades begin to slip over the head, the lever is decomposed, and the swaying move- ment ceases to have any mechanical advantage. 2. The power is applied to the handles in a slanting direction. The resistance or weight does not act at a point either between the former and the fulcrum, or beyond the fulcrum, but at a point in a plane nearly at right angles to the line joining these two points ; and its direction is a line perpendicular to that plane of the pelvis in which the greatest section of the head is engaged, that is to say, in the case of straight forceps, nearly parallel to the handles. The lever formed does not, therefore, strictly speaking, belong to any one of the three orders into which levers are commonly divided. 3. The fulcrum is fixed partly by friction, partly by the combination of traction with oscil- latory movement — in other words, by the power being directed in great measure downwards, and only slightly to one side." He further shows that the pendulum motion of the forceps is super- fluous in all ordinary forceps operations, in which traction alone is amply sufficient for delivery ; but that when the head is impacted, and great force is required for its extraction, a mechanical advantage may be gained from having recourse to an oscillatory movement, which should, however, be very limited, and only continued if found to effect distinct advance of the head. As a Compressor. — Eegarding the compressive power of the instru- ment there has been much difference of opinion. There is no doubt that the forceps, especially some of the foreign instruments in which the points nearly approach each other, is capable of exerting con- 1 Galabin, "Action of Midwifery Forceps as a Lever," Obstetrical Journal, November, 1876. 464 OBSTETRIC OPERATIONS. siderable compression on the head. It is, however, extremely prob- lematical if this action be of real value. It is to be borne in mind that in cases of protracted labor the head has been already moulded and compressed, and the bones have been made to overlap each other to their utmost extent, by the sides of the pelvis ; we can scarcely, therefore, expect to diminish the head much more by the forceps, without employing an amount of force that will seriously endanger the life of the child. It is in cases of disproportion between the head and the pelvis, depending on slight antero-posterior contraction of the pelvic brim, that diminution of the child's head by compres- sion would be most useful. Then, however, the pressure of the forceps is exerted on that portion of the head which lies in the most roomy diameter of the pelvis, where there is no want of space. If this pressure do not increase the opposite diameter, which is in appo- sition to the narrower portion of the pelvis, it can at least do nothing towards lessening it ; and diminution of any other part of the child's head is not required. Dynamical Action of the Forceps. — The mere introduction of the forceps sometimes excites increased uterine action, through the reflex irritation induced by the presence of a foreign body in the vagina. This has been called the dynamical action of the forceps ; but it can- not be looked upon in any other light than that of an occasional accidental result. The circumstances indicating the use of the forceps have been separately considered elsewhere, and to recapitulate them here would only lead to needless repetition. I shall therefore now merely de- scribe the mode of using the instrument. Difference between the High and Loiv Operations. — Before doing so it is well to repeat what has already been said as to the difference between what may be termed the high and low forceps operations. The application of the instrument, when the head is low in the pelvis, is extremely simple ; and when there is no disproportion between the head and the pelvis, and some slight traction is alone required to supplement deficient expulsive power, the operation, in the hands of any ordinarily well-instructed practitioner, ought to be perfectly safe both to the mother and child. It is very different when the head is arrested at the brim, or high in the pelvis. Then the application of the forceps is an operation requiring much dexterity for its proper performance, and must never be undertaken without anxious con- sideration. It is because these two classes of operations have been confused that the use of the instrument is regarded by many with such unreasonable dread. Preliminary Considerations. — Before attempting to introduce the forceps, there are several points to which attention should be di- rected: — 1st. The membranes must, of course, be ruptured. 2dly. For the safe and easy application of the instrument, it is also advisable that the os should be fully dilated, and the cervix re- tracted over the head. Still, these two points cannot be regarded, as many have laid down, as being sine qua non. Indeed we are often THE FORCEPS. 465 compelled to use the instrument when, although the os is fully dilated, the rim of the cervix can be felt at some point of the contour of the head, especially in cases in which the anterior lip is jammed between the head and the pubis. Provided due care be taken to guard the cervical rim with the fingers of one hand, as the instrument is slipped past it, there need be no fear of injury from this cause. If the os be not fully dilated, but is sufficiently open to admit of the passage of the forceps, the operation, under urgent circumstances, may be quite justifiable, but it must necessarily be a somewhat anxious one. 3dly. The position of the head should be accurately ascertained by means of the sutures and fontanelles. Unless this be done, the operation will always be hap-hazard and unsatisfactory, as the prac- titioner can never be in possession of accurate knowledge of the pro- gress of the case. It maybe that the occiput is directed backwards; and, although that does not contra-indicate the application of the forceps, it involves special precautions being taken. 4thly. The bladder and bowels should be emptied. Question of Administering Anaesthetics. — Before proceeding to ope- rate, the question of anaesthesia will arise. In any case likely to be difficult it is of the greatest assistance to have the patient completely under the influence of an anaesthetic to. the surgical degree, so as to have her as still as possible; but, whenever this is deemed necessary, another practitioner should undertake the responsibility of the admin- istration. In simple cases I believe it is better to dispense with anaes- thetics altogether, partly because they are apt to stop what pains there are, which is in itself a disadvantage, but chiefly because, under partial anaesthesia, the patient loses her self-control, is restless, and twists herself into awkward positions, which give rise to the utmost difficulty and inconvenience in the use of the instrument. Moreover, if no anaesthetic be given, the patient can assist the operator by placing herself in the most convenient attitude. Description of the Operation. — In describing the method of apply- ing the forceps, I shall assume that we have to do with the simpler variety of the operation, when the head is low in the pelvis. Sub- sequently I shall point out the peculiarities of the high operation. Position of the Patient. — As to the position of the patient, I believe there can be no doubt of the superiority of that which is usually adopted in this country. On the Continent and in America the for- ceps is always employed with the patient lying on her back, a posi- tion involving much needless exposure of the person, and requiring more assistance from others. In certain cases of unusual difficulty the position on the back is of unquestionable utility, but we may, at least, commence the operation in the usual way, and subsequently turn the patient on her back if desirable. Importance of a Suitable Position. — Much of the facility with which the blades are introduced depends on the patient's being properly placed. Hence, although it gives rise to a little more trouble at first, I believe that it is always best to pay particular attention to this point, whether the high or low forceps operation be about to be per- 466 OBSTETRIC OPERATIONS. formed. The patient should be brought quite to the side of the bed, with her nates parallel to, and projecting somewhat over its edge. The body should lie almost directly across the bed, and nearly at right angles to the hips, with the knees raised towards the abdomen Fig. 154. Position of Patient for Forceps Delivery and Mode of Introducing Lower Blade. (Fig. 154). In this way there is no risk of the handle of the upper blade, when depressed in introduction, coming in contact with the bed. The blades should be warmed in tepid water, lubricated with cold cream or carbolic oil, and placed ready to hand. These preliminaries having been attended to, we proceed to the in- troduction of the blades, sitting by the side of the bed, opposite the nates of the patient. Direction in which the Blades are to be Introduced. — The important question now arises, in what direction are the blades to be passed? The almost universal rule in our standard works is, that they mast be passed as nearly as possible over the child's ears, without any re- ference to the pelvic diameters. Hence, if the head have not made its turn, but is lying in one oblique diameter, the blades would re- quire to be passed in the opposite oblique diameter ; in short, the position of the forceps, as regards the pelvis, must vary according to the position of the head. Some have even laid down the rule, that the forceps is contra-indicated unless an ear can be felt; a rule that would very seriously limit its application, as in many cases in which it is urgently required it is a matter of great difficulty, and even impossibility, to feel the ear at all. [This is not the practice in this country with those who use the forceps of Hodge, Wallace, or Davis, which are designed to be applied over the parietal protuber- ances whenever practicable. — Ed.] It is admitted that in the high THE FORCEPS. 467 forceps operation the blades must be introduced in the transverse diameter of the pelvis, without relation to the position of the head. On the Continent it is generally recommended that this rule should be applied to all cases of forceps delivery alike, whether the head be high or low, and I have now for many years adopted this plan, and passed the blades in all cases, whatever be the position of the head, in the transverse diameter of the pelvis, without any attempt to pass them over the bi-parietal diameter of the child's head. Dr. Barnes points out with great force that, do what we will, and attempt as we may, to pass the blades in relation to the child's head, they find their way to the sides of the pelvis, and that the marks of the fenestra on the head always show that it has been grasped by the brow and side of the occiput. [That is because the variety of forceps used does not conform to the contour of the head. — -Ed.] Of the perfect cor- rectness of this observation I have no doubt ; hence it is a needless element of complexity to endeavor to vary the position of the blades in each case, and one which only confuses the inexperienced practi- tioner, and renders more difficult an operation which should be sim- plified as much as possible. While, therefore, it is of importance that the precise position of the head should be ascertained in order that we may have an intelligent notion of its progress, I do not think that it is essential as a guide to the introduction of the forceps. Method of Introducing the Lower Blade. — As a rule the lower blade, lightly grasped between the tips of the index and middle fingers and thumb, should be introduced first. Poised in this way, we have per- fect command over it, and can appreciate in a moment any obstacle to its passage. Two or more fingers of the left hand are introduced into the vagina, and by the side of the head, as a guide ; the greatest care must be taken, if the cervix be within reach, that they are passed within it, so as to avoid the possibility of injury. Necessity of Gentleness in Passing the Instrument. — The handle of the instrument has to be elevated, and its point slid gently along the palmar surface of the guiding fingers, until it touches the head (Fig. 154). At first the blade should be inserted in the axis of the outlet, but, as it progresses, the handle must be depressed and carried back- wards. As it is pushed onwards it is made to progress by a slight side-to-side motion, and it is of the utmost importance to bear in mind that the greatest gentleness must always be used. If any ob- struction be felt, we are bound to withdraw the instrument, partially or entirely, and attempt to manoeuvre, not force, the point past it. As the blade is guided on in this way, it is made to pass over the con- vexity of the head, the point being always kept lightly in contact with it, until it finally gains its proper position. When fully inserted the handle is drawn back towards the perineum, and given in charge to an assistant. The insertion must be carried on only in the inter- vals between the pains, and desisted from during their occurrence ; otherwise there would be a serious risk of injuring the soft parts of the mother. 468 OBSTETRIC OPERATIONS Introduction of the Upper Blade. — The second blade is passed di- rectly opposite to the first, and is generally somewhat more difficult to introduce, in consequence of the space occupied by the latter. It is passed along two fingers directly opposite the first blade, and with exactly the same precautions as to direction and introduction, except that at first its handle has to be depressed instead of elevated (Fig. 155). Fig. 155. Introduction of the Upper Blade. Locking of the Handles. — The handle which was in charge of the assistant is now laid hold of by the operator, and the two handles are drawn together. If the blades have been properly introduced, there should be no difficulty in locking ; but, should we be unable to join them easily, we must withdraw one or other, either partially or entirely, and reintroduce it with the same precautions as before. We must also assure ourselves that no hairs, nor any of the maternal structures are caught in the lock. Method of Traction. — When once the blades are locked we may commence our efforts at traction. To do this we lay hold of the handles with the right hand, using only sufficient compression to give a firm grasp of the head, and to keep the blades from slipping. The left hand may be advantageously used in assisting and support- ing the right during our efforts at extraction, and, at a late stage of the operation, may be employed in relaxing the perineum when stretched by the head of the child. Traction must always be made in reference to the pelvic axes; being at first backwards towards the perineum (Fig. 156), in the direction of the axis of the brim, and as the head descends and the vertex protrudes through the vulva, it must be changed to that of the outlet. We must extract only during the pains; and, if these should be absent, we must imitate them by THE FORCEPS. 469 acting at intervals. This is a point which deserves special attention, for there is no more common error than undne hurry in delivery. The only valid objection I know of against a more frequent resort to the forceps in lingering labors is, that the sudden emptying of the Fig. 156. Forceps in Position. Traction in the Axis of the Brim, downwards and backwards. uterus, in the absence of pains, may predispose to hemorrhage; and it cannot be denied that it is one of some weight. However, if due care be taken to operate slowly, and to allow several minutes to elapse between each tractive effort, while, at the same time, uterine contractions be stimulated by pressure and support, this need not be considered a contra-indication. Besides direct traction we may im- part to the instrument a gentle waving motion from handle to handle, which brings into operation its power as a lever; but this must not be done to any great extent, and must always be subservient to direct traction. Descent of the Head. — Proceeding thus in a slow and cautious manner, carefully regulating the force employed according to the exigencies of the case, we shall perceive that the head begins to descend ; and its progress should be determined, from time to time, by the fingers of the unemployed hand. The Rotation from the Oblique Diameter. — When the head lies in the oblique diameter, as it descends, in consequence of its perfect adaptation to the pelvic cavity, it will turn into the antero-posterior diameter without any effort on the part of the operator, provided only that the traction be sufficiently slow and gradual. As the head is about to emerge, it is necessary to raise the handles towards the mother's abdomen. More than usual care is required to prevent 470 OBSTETRIC OPERATIONS. laceration of the perineum, which is always much stretched (Fig. 157). If, as often happens, the pains have now increased, and the perineum be very thin and tense, it may even be desirable to remove the blades gently, and leave the case to be terminated by the natural powers ; but if due precautions are used this need not be necessary. Fig. 157. Last Stage of Extraction. The Handles of the Forceps turned upwards towards the Mother's Abdomen. The peculiarities of forceps delivery in occipito-posterior positions have already been discussed (p. 307), and need not be repeated. High Forceps Operations. — When the high forceps operation has been decided on, the passage of the blades will be found to be much more difficult from the height of the presenting part, the distance which they must pass, and, in some cases, from the mobility of the head interfering with their accurate adaptation. The general prin- ciples of introduction and of traction are, however, identical. If the operation be attempted before the head has entered the pelvic brim, it must be fixed, as much as possible, by abdominal pressure. In guiding the blades to the head special care must be taken to avoid any injury of the soft parts, especially if the cervix be not com- pletely out of reach. For this purpose it may even be advisable to introduce the entire left hand as a guide, so as to avoid any possi- bility of injuring the cervix, from not passing the instrument under its edge. Peculiar Method of Introducing the Blades. — Some authors advise that, in such cases, the blade should be introduced at first opposite THE FORCEPS. 471 the sacrum, until the point approaches its promontory. It is then made to sweep round the pelvis, under the protecting fingers, till it reaches its proper position on the head. This plan is advocated by Eamsbotham, Hall Davis, and other eminent practical accoucheurs, and it is certainly of service in some cases of difficulty ; especially when, from any reason, it is not possible to draw the nates over the edge of the bed, when the necessary depression of the handle of the I upper blade is difficult to effect. It involves, however, a somewhat complicated manoeuvre, and it is seldom that the blades cannot be j readily introduced in the usual w T ay. Necessity of Care in Locking. — In locking the slightest approach to roughness must be carefully avoided, for the extremities of the blades are now within the cavity of the uterus, and serious injury might easily be inflicted. If difficulty be met with, rather than em- ploy any force, one of the blades should be withdrawn, and reintro- • duced in a more favorable direction. If the blades have shanks of sufficient length, there should be no risk of including the soft parts of the mother in the lock, which, in a badly constructed instrument, is an accident not unlikely to occur. Method of Traction. — After junction traction must at first be alto- I gether in the axis of the brim, and to effect this the handles must be 1 pressed well backwards towards the perineum. As the head descends it will probably take the usual turn of itself, without effort on the part of the operator, and the direction of the tractive force may be gradually altered to that of the axis of the outlet. If the pains be strong and regular, and there be no indication for immediate delivery, we may remove the forceps after the head has descended upon the perineum, and leave the conclusion of the case to nature. This course may be especially advisable if the perineum and soft parts be ud usually rigid ; but generally it is better to termi- nate labor without removing the instrument. Possible Dangers of Forceps Delivery. — Before concluding this sub- ject, reference may be made to the possible dangers of the operation. I would here again insist on the importance of distinguishing be- tween the high and low forceps operations, which have been so unfor- tunately and unfairly confounded. Seasons have already been given for rejecting the statistics of the risks attending forceps delivery in the latter class of cases (p. 335). A formidable catalogue of dangers, both to the mother and child, might easily be gathered from our standard works on obstetrics. Among the former the principal are lacerations of the uterus, vagina, and perineum ; rupture of varicose veins, giving rise to thrombus ; pelvic abscess, from contusion of the soft parts; subsequent inflammation of the uterus or peritoneum; tearing asunder of the joints and symphyses; and even fracture of the pelvic bones. A careful analysis of these, such as has been so well made by Drs. Hicks and Philips, 1 proves beyond doubt that the application of the instrument is not so much concerned in their pro- duction, as the protraction of the labor, and the neglect of the practi- 1 Obst. Trans., vol. xiii. 472 OBSTETRIC OPERATIONS. tioner in not interfering sufficiently soon to prevent the occurrence of the evil consequences afterwards attributed to the operation itself. Many of these will be found to arise from the prolonged pressure on the soft parts within the pelvis, and the subsequent inflammation or sloughing. To these causes may be referred with propriety most cases of vesico- vaginal fistula (p. 427), peritonitis, and metritis fol- lowing instrumental labor. Lacerations and similar accidents may, however, result from an incautious use of the instrument. Slight lacerations of the mucous membrane of the vagina are probably far from uncommon. But if these cases were closely examined, it would be found that the fault lay not in the instrument, but in the hand that used it. Either the blades were introduced without due regard to the axes of the pelvis, or they were pushed forwards with force and violence, or an instru- ment was employed unsuitable to the case (such as a short straight forceps when the head was high in the pelvis), or undue haste and force in delivery were used. It would be manifestly unfair to lay the blame of such results upon the forceps, which, in the hands of a more judicious and experienced practitioner, would have effected the desired object with perfect safety. The instrument is doubtless unsafe in the hands of any one who does not understand its use, just as the scalpel or amputating knife would be in the hands of a rash and inexperienced surgeon. The lesson to be learnt seems to be clearly, not that the dangers should deter us from the use of the forceps, but that they should induce us to stud}?- more carefully the cases in which it is applicable, and the method of using it with safety. Possible Risks to the Child. — The dangers to the child are princi- pally, lacerations of the integuments of the scalp and forehead ; con- tusion of the face ; partial, but temporary, paralysis of the face from pressure of a blade on the facial nerve ; depression or fracture of the cranial bones ; injury to the brain from undue pressure of the blades. These evils are of rare occurrence, and when they do happen, gene- rally result from improper management of the operation — such as undue compression, the use of improper instruments, or excessive and ill- directed efforts at traction — and cannot, therefore, be con- sidered as in any way contra-indicating the use of the instrument. Many of the more common results, such as slight abrasions of the scalp, or paralysis of the face, are transitory in their nature and of no real consequence. [Although obstetrical forceps were first used in England, other countries in the march of improvement have made great changes, not only in the original forms, but in their manner of use ; and diffe- rent shapes, as well as different positions of the woman in application, have become in a measure almost national. With the exception of having adopted almost exclusively the French and German dorsal decubitus in making use of the instruments, we have become in a measure eclectic in the selection of the latter ; medical schools, accou- cheurs, and local obstetrical societies, influencing students and the THE FORCEPS. 473 junior members of the profession, to adopt the French, German, English, or American styles, as the case may be, the forceps them- selves bearing the names of their several inventors, or compilers ; for some are a trne compilation, the blade, from one contriver ; fenes- tra! openings, another ; pelvic curve, a third ; width, a fourth ; shanks, a fifth; method of locking, a sixth; etc. etc. For this reason the late Prof. Hodge named his forceps the eclectic, although in some re- spects entirely original, particularly in the long superimposed shanks, a great improvement for operating at the superior strait, and avoid- ing the painful stretching of the posterior commissure. Dr. Hodge expended a great deal of thought and money in perfecting his forceps, and the various steps in the process were marked bj r a new form, until, from a heavy, clumsy instrument, he gradually evolved what was at one time regarded as a wonderful improvement upon the forceps of France and England, A contemporary of Prof. Hodge, the late Prof. David D. Davis, ot London, was equally anxious to perfect the instrument, and turned his attention especially to making the blades light, open, and to so fit the sides of the foetal head as to enable traction to be made with- out much pressure, or leaving any mark on the child's scalp. There is a principal of mechanics involved in his instrument, which he studied to perfect, by moulding the blades so as to obtain conside- rable coaptating surface, and thus by increase of friction avoid undue and dangerous pressure. The Davis blade soon began to effect changes in the form of American forceps, and by the addition ot long handles, and some alterations of shape, weight, and curve, be- came a leading feature in those bearing the names of AYilliam Harris, Prof. TVallace, of the Jefferson Medical College, Dr. Bethel, and Albert H. Smith, all of this city. The short Davis instrument was a great favorite of the late Prof. Meigs, and Dr. William Harris, both largely engaged in obstetrical practice, as well as teaching, and many a delicate woman, with wasting forces, was aided in her delivery at their hands, and surprised to find no mark on the baby's head, and that her own sufferings could be so gently and safely relieved. Although such was the estimation of the Davis blade, and still is in many parts our country, it does not appear to have retained its ' popularity, or been adopted, as its mechanical perfection would lead one who appreciates it to suppose it would have been. In Great ; Britain, the favorite forms now in use are but a very slight improve- ment upon the forceps of a hundred years ago, except in finish and , material, the open fenestra? and bevelled blades of Davis being de- 'dined in favor of the looped fenestra? and flat-edged blades in use when he made his experiments and changes. This appears to have igrown out of a practice which has been largely adopted in Germany, i Great Britain, and many parts of the United States, in applying the forceps to the foetal head, the blades being introduced at the sides of die pelvis, without much reference to the position which the head 'occupies. As compression is objected to, the blades are made long and widely separated (3 J to 3 J), and the handles short, so as not to allow of much leverage. As the blades do not fit the head, the 31 474 OBSTETRIC OPERATION! mechanism of labor as' taught by Hodge has been much simplified, as it is not necessary to learn all the oblique fittings of the fenestras over the parietal protuberances or ears. Dr. Meigs used to tell the students that the forceps was the " child's instrument" and should be used as a tractor ; and it was, as a well applied mechanical tractor that he advocated the use of the Davis blades, against those of Sie- bold, Levret, Baudelocque, and Haighton, employed generally in our country forty years ago. His language is not very complimentary to what he denominates by distinction " the mother's instrument" the form being better adapted for saving the woman than the foetus. (" Obstetrics," p. 540.) At the present day we have two general varieties of forceps in use in the United States ; under each of which may be placed a vast number of special forms, which are simply changes upon one or the other general type, according to the fancy of the inventor. At the head of one type, may be placed the long forceps of Prof. Hodge, designed to be adapted to the sides of the child's head Fig. 158. in all possible cases : and of the other, those of Prof. Simpson, of Edinburgh, or their modification by Profs. Elliot and Bedford, of New York, intended to be used as tractors, and applied in reference to the sides of the mother's pelvis, rather than to those of the in- fant's head. Taking the long forceps of Levret and Baudelocque as improved and modified by Hodge ; with the blades of Prof. Davis as a substitute, and handles of less curve than those of Hodge; and we have the long forceps of Prof. Ellerslie Wallace, of the Jefferson College, the favorite instrument with, those who pur- chase forceps of the manufacturers in this city. Next in popularity are the instruments of Hodge, Davis, and Simpson, Elliot, Bedford, and a few others, in all about a dozen forms that are kept in stock. The improvement of the late Prof. Elliot upon the instru- ment of Simpson, consists in narrowing and length- ening the shanks; widening somewhat the fenestra^; elongating the blades; giving greater security against slipping in the handles; and gauging the distance between the blades by a milled-head screw-stop in the end of the handles: the shanks and blades are an exact counterpart of the Miller forceps of England, which appeared about the same time, 1858. The Hodge forceps were based in their contrivance upon the following points: 1. The instrument should be shaped to the contour of the foetal head, and have sufficient play to allow of compression, where the pelvis is too narrow for the head to pass in its normal condition. 2. The blades should be so arranged in reference to the shanks and handles as to enable them to seize the head of the foetus in its bi-parietal diameter at the superior straight, THE FORCEPS. 475 and be drawn upon in the direction of the curve of the pelvic canal until the deliver}- is complete. 3. The long forceps ought to be competent to act either at the superior strait of the pelvis, in its cavity, or at its outlet, so as to avoid a multiplicity of instruments and their attendant expense. And 4. The instrument should not cut the scalp of the child if properly adjusted, or injure the soft parts of the mother. It would be folly to claim that all this could or has been accom- plished ; as there must necessarily be exceptional cases in all the points given ; hence the contrivance of the forceps of Tarnier and Cleemann for certain presentations above the superior strait; and the long and short convertible instruments of a few inventors. There are many cases of labor in the higher walks of life where, although there is no obstruction, still the women require manual or instrumental assistance, as the}- cannot deliver themselves for want of sufficient contractile muscular force. Such women require that the forceps used should be easily introduced; should act simply as tractors; control the movement of the foetal head by being well fitted to its shape, and leave no effect upon the scalp or vulva. Although these requisites mRj be filled by the Hodge instrument, it is this class of cases that has demanded a lighter and more roomy pair of forceps, such as that devised by Davis. As the teaching of the Jefferson Fig. 159. Fig. 160. Medical College under Dr. Meigs, favored as we have stated the for- ceps of Davis, so his successor in carrying out in a measure the same views, has combined the blades of the Davis pattern, with the long handles of Hodge, in con- triving the Wallace forceps, now so much in use by the large number of graduates of this school. As compared with the Hodge instru- ment, it is one inch shorter (15 inches against 16); the blades are of the same length (6 inches) the fenestra are more open ; the shanks are only half the length, giving a much greater compressing power; and the handles are of the same measurement from pivot to hooks. Both have the Siebold lock, over which we believe the broad-topped button and notch to possess some advantages; and the Wallace is somewhat heavier than the Hodge which should weigh 17 ounces. The short Davis instrument made for Prof. Meigs under direc- tion Of the inventor Weighed 10J Wallace Forceps. 476 OBSTETKIC OPERATIONS ounces, and measured 12 inches in length; fenestra 5 inches long, 2 inches wide; blades separated 2£ inches. Handles 4J inches to lock, which was of the Smellie or English pattern. A recently purchased pair in possession of the editor is 13 J inches long, with 5 inch handles, a button lock, 2 inch close set shanks, and 6J inch Fig. 161. blades. We believe the changes are decided im- provements, especially the lock and elongated handles. It has answered admirably in adynamic cases, requiring only a few pounds of tractile assist- ance. The Davis blades have been added to long handles, and the whole made of steel and marvel- lously light, at the special request of a few accouch- eurs, who wished them to aid in some cases of arrest at the perineum. The late Prof. George T. Elliot, of New York, who received much of his practical obstetrical train- ing in the Dublin Lying-in Hospital, imbibed the teachings of the English school, and became im- pressed with the value of the system as taught by Simpson ; after the principle of whose forceps, modelled somewhat after that of the late Prof. Gun- ning G. Bedford, of New York, he in 1858, presented to the medical profession the instrument that bears his name. The forceps of Prof. Bedford has a trac- tion ring on each side, where the Elliot has a corn a, has a button joint, instead of a Smellie, has no screw stop, and has diverging, instead of superim- posed shanks. These points have generally been considered as improvements, and hence the Elliot has taken precedence in large measure over the Bedford instrument in • New York sales, the two being the leading forceps in demand. The instru- Eiiiot Forceps. ment of White, of Buffalo, is perhaps next, and then Hodge's. But few of Prof. Wallace's forceps, the leading instrument in the Philadelphia trade, are ordered. The White is a long forceps, a compound of the Elliot blade, long super- imposed shanks of Plodge, Siebold lock, and short corrugated steel handles bowed out like dental forceps, and ending in thin blunt hooks. The Sawyer and Simpson short forceps are about equally in de- mand in New York. The former is unknown to the trade here ; and but comparatively few of the Simpson are sold, although the system of their application has several advocates in Philadelphia. We have here a representation of one of the lightest of all the varieties of the short forceps, weighing but 5 ounces, and measuring 9 1 inches in length ; the handle being 3 inches, shank 1}, and chord of blade-curve 5 J. The blades are 1 J inches wide, with oval fenes- tra J inch wide, and are separated 2f inches at their widest part, and f inch at the tips. This instrument was invented about two years and a half ago, by Prof. Edw. Warren Sawyer, of Push Medical College, Chicago, and THE FORCEPS. 477 Fig. 162. has been highly commended by Prof. Byford and others. The for- ceps have the blades of Davis, superimposed shanks of Hodge, and lock of Smellie, with hard-rubber plates moulded hot upon the handles. The several parts have been somewhat modified ; the ob- ject being to secure a tractor for cases of defi- cient expulsive force, where the foetal head is low in the pelvis. Professor Sawyer says : " In the labors to which my forceps are applicable it is not ne- cessary for the operator's body to be in line with the pelvic axis. My mode of procedure is the following : The woman is placed upon her back and drawn to the edge of the bed, the outside leg is now flexed ; beneath, this flexed extremity and the bed covering, I apply the forceps — often using but one hand in the operation. When the instrument is locked, I grasp the handle in such a manner that the palm of the hand looks upward ; one hook then rests naturally upon the extensor surface of the first phalanx of the index finger, while the other hook rests upon a corresponding part of the thumb. When thus adjusted, I lift the head from the pelvic outlet, at the same time invoking the pendulum movement if de- sired. At this moment the advantage of the hooked handle is very apparent to the opera- tor." ..." All practitioners must have often felt, during the last moments of labor, when the uterus and the mother seemed fatigued, the need of a little help to the expulsive powers. The or- dinary instruments are too formidable to be used at the last moment, and it is then that this little forceps is useful." We have given the names and characters of the various forceps most in use in New York and Philadelphia ; and by the large num- ber of graduates of their respective schools, as shown by their pre- ferences in making purchases of the leading instrument makers of the two cities. The mechanism of instrumental delivery is much simplified by applying the forceps to whatever parts of the foetal head may be opposite the sides of the pelvis ; but it is very ques- tionable whether it is the scientific method, or the safer for the child. With one blade over the side of the occiput, and the other over that of the forehead, which is the manner of seizure in oblique positions of the vertex, we certainly have not a very secure hold, and run some risk of injury to the foetus. The advocates of this system claim that they use no compression, only a simple traction ; which, may be true in one sense, but amounts to the same in effect, else how could Dr. Elliot, by traction with great force, straighten out one of the blades of his Simpson forceps, as related in the " N. Y. Journ. of Med." for September, 1858, page 161, in the paper which he pre- Sawyer Forceps. 478 OBSTETRIC OPERATIONS sented, describing his new forceps and a number of cases in which, he had tested them. It makes but little difference whether we com- press the head before we begin to pull, or pull so as to wedge the head between the blades and thus compress it, except as to the differ- ence of fit in the two instances; the adjusted and even pressure, being the less likely to injure the foetus. We have always believed that the forceps should fit the head, and that the student should be taught how to accomplish it correctly in the various positions of the foetus. If the student has a mechanical turn of mind, a delicate sense of touch, and a clear head, he will soon learn : if he is not a mechanic, he will be forced to adopt a more simple method of de- livery. In a large city, there are but few first class obstetrical manipulators as a general rule, and they are usually well known as Fig. 163. Application of the Forceps at the Inferior Strait. such, for the reason that but few have all the requisites to enable them to achieve notoriety ; and yet there are hundreds who can de- liver a woman with forceps moderately well. To one, the mechan- ism of Hodge is a simple matter, and soon mastered; to another, it is THE FORCEPS. 479 a useless complication, and he prefers the more simple system. Hence the great differences between obstetricians, as to the best in- strument, and the best method of application. Some of the vast array of patterns have decided merit, and display much mechanical skill ; while others serve only to amuse the educated examiner. One obstetrician, like Elliot, uses a variety of forceps one after another in the same case, and palls with great force ; while another confines his work almost to one instrument, adjusts it easily, pulls moderately, and seldom fails. There are no doubt exceptions, but certainly the most delicate manipulators we have seen, believed in and practised the teachings of Hodge and Meigs. There may be cases where it might be well to practise the method of Simpson, as is done occa- sionally by some of our leading practitioners ; but we cannot see why his plan of delivery should be exclusively used on any mode of scientific reasoning. We present a series of plates in illustration of the American method of delivery with, the forceps ; the position, as will be seen, being that of France and Germany — on the back. When it is de- cided to use the forceps, in almost all cases in the United States, the patient is brought to the edge of the bed on her back, with her nates close to the edge, her feet on two chairs, and her knees widely sepa- rated, as in the plate above. The patient is covered with a sheet, or heavier covering if in winter, and there is no necessity of exposure, as the whole manipulation may be done by the sense of touch. The position is by far the most convenient for the obstetrician, and enables him much more easily to keep in his mind all the anatomical rela- tions of the foetus and pelvis, than when in the English decubitus. We study the anatomy, with the subject on the back, and the mechanism of labor in front of the pelvis, or mannikin, then why complicate matters by a change of position, which, to say the least, is a very awkward one, particularly in introducing the long forceps, setting them according to the instructions of Hodge, and carrying them forward between the thighs as the head emerges ? We have used the short forceps in an exhausted case, with the woman on her side, but found it much less convenient for the various movements, al- though we soon delivered the foetus. As to the question of exposure, there is less in appearance than in fact, in the English position, in many cases. If the patient and nurse are fastidious and careful during the use of the forceps, the accoucheur can manage without his eyes in a large proportion of cases; but the fault of exposure lies more frequently in the temporary reckless indifference begotten of pain and suffering in the woman, than in any act of the accou- cheur, if inclined to spare the feelings of his patient as much as possible. The long forceps, with its pelvic curve, was specially designed for use at the superior strait of the pelvis, the curve of the blades, as in the Davis instrument modified by Wallace, being intended to cor- respond with the direction of the occipito- mental diameter of the foetal head. The long superimposed shanks of several varieties of the long forceps will here be found valuable, as the lock is not intro- 480 OBSTETRIC OPERATIONS. duced, or the posterior commissure of the vulva widely stretched. If the head is entirely above the strait, the line of the blades must be changed correspondingly, in order to apply them properly, and keep the line of traction within the coccyx; and even then, to draw Fig. 164. Application of the Forceps with the Head at the Superior Strait ; the left blade held in place by an Assistant. in the proper direction, the left hand must act at first in a backward direction from the lock; while the right brings the handles down- ward, forward, and then upward; both hands describing a curve, but that of the right being much the greater. The peculiar forceps of Tarnier, or of Cleemann, being designed to meet this form of exi- gency, may be brought into requisition. In latter years it has become much more common than formerly to introduce the forceps into the uterus, before it is fully dilated, in THE FORCEPS 481 consequence of the success claimed for the plan as carried out in the Dublin Lying-in Hospital. As this should never be done where the os is not readily dilatable, and requires much skill in execution, it is not safe to recommend its general adoption in cases of delay in pri- vate practice. The forceps should not be introduced with any force, but the left blade should be slid in gently, and with a spiral motion, and then the right; care being taken that they should also lock without force, which they will do if properly adjusted. Traction is to be exerted slowly, and during a pain, the whole movement being made to cor- respond with the natural as closely as possible. Fig. 165. Direction of the Forceps as the Head is being Delivered. As the foetal head comes under the arch of the pubes, the handles of the forceps must rise more and more from the bed, until at last they are over the abdomen, as the head emerges from the perineum. This last movement of instrumental delivery should be a very slow one, for fear of rupture. It has been proposed to remove the blades before delivery is complete ; but there is no occasion for this, if the forceps are applied to the sides of the head over the parietal protru- berances ; as where these protrude, and the blades are flat and thin, there is very little additional space required. With such instruments as the old Levret, Baudelocque, and Rohrer forceps, with looped or 482 OBSTETRIC OPERATIONS. kite-shaped fenestra, and thick edges, this was a much more impera- tive direction, than with the better instruments of the present day. With a Sawyer forceps the perineum ought to be safer, and under better control than without. When the perineum is thought to be in danger, the process of distension should be retarded through two or three pains, or even more if required, instead of drawing the head through at once. After the head is delivered, if the cord is not around the neck, and, therefore, in danger from pressure, the body should be allowed to remain until the uterus has well contracted upon it, for fear of hemorrhage after delivery from uterine inertia. — Ed.] CHAPTEE IY. THE VECTIS — THE FILLET. In connection with the subject of instrumental delivery it is essen- tial to say something of the use of the vectis, on account of the value which was formerly ascribed to it, which was at one time so great in this country that it became the favorite instrument in the metropolis ; Denman saying of it that even those who employed the forceps were " very willing to admit the equal, if not superior, utility and conve- nience of the vectis." Even at the present day, there are practi- tioners of no small experience who believe it to be of occasional great utility, and use it in preference to the forceps in cases in which slight assistance only is required. In spite, however, of occasional attempts to recommend its use, the instrument has fallen into dis- favor, and may be said to be practically obsolete. Nature of the Instrument. — The vectis, in its most approved form, consists of a single blade, not unlike that of a short straight forceps, attached to a wooden handle. A variety of modifications exist in its shape and size. The handle has been occasionally manufactured, for the convenience of carriage, with a hinge close to the commencement of the blade (Fig. 166), or with a screw at the point where the handle and blade join. The power of the instrument, and the facility of introduction, depend very much on the amount of curvature of the blade. If this be decided, a firmer hold of the head is taken and greater tractive force is obtained, but the difficulty of introduction is increased. The vectis is used either as a lever or a tractor. When employed in the former way, the fulcrum is intended to be the hand of the ope- rator; but the risk of using the maternal structures as a point oVappui, and the inevitable danger of contusion and laceration which must follow, constitute one of the chief objections to the operation. Its THE VECTIS — THE FILLET. 483 Fig. 166. value as a tractor must always be limited, and quite inferior to that of the forceps, while it is as difficult to introduce and manipulate. Cases in which it is Applicable. — The vectis has been recommended in cases in which the low forceps operation is suitable, provided the pains have not entirely ceased. There is no doubt that it may be quite capable of overcoming a slight impediment to the passage of the head. It is applied over various parts of the head, most commonly over the occiput, in the same manner, and with the same precautions, as one blade of the forceps. Dr. Kamsbotham saj^s "we shall find it necessary to apply it to different parts of the cranium, and perhaps the face also, successively, in order to re- lieve the head from its fixed condition, and favor its descent." Such an operation obviously requires quite as much dexterity as the application of the forceps; while, if we bear in mind its comparatively slight power, and the risk of injury to the maternal struc- tures, we must admit that the disuse of the instrument in modern practice is amply justified. The vectis may, however, find a useful application when employed to rectify malpositions, especially in certain occipito-posterior presentations. This action of the instrument has already been considered (p. 308), and, under such circumstances, it may prove of. ser- vice where the forceps is inapplicable. When so em- ployed it is passed carefully over the occiput, and, while the maternal structures are guarded from injury, downward traction is made during the continuance of a pain. So used, its application is perfectly simple and free from clanger, and for this purpose it may be retained as a part of the obstetric armamentarium. The fillet is the oldest of obstetric instruments, having been fre- quently employed before the invention of the forceps, and even in the time of Smellie it was much used in the metropolis. It has since completely fallen out of favor as a scientific instrument, although its use is every now and again advocated, and it is certainly a favorite instrument with some practitioners. This is to be explained by the apparent simplicity of the operation, and the fact that it can gene- rally be performed without the knowledge of the patient; the latter, however, is one strong reason why it should not be used. Nature of the Instrument. — The fillet consists, in its most improved form (that which is recommended by Dr. Eardley Wilniot 1 (Fig. 167), of a slip of whalebone fixed into a handle, composed of two separate halves, which join into one. The whalebone loop is slipped over either the occiput or face, and traction used at the handle. Objections to its Use. — When applied over the face, after the head has rotated, it would probably do no harm ; but if it were so placed when the head was high in the pelvis, traction would necessarily produce extension of the chin before the proper time, and would Vectis -with. Hinged Handle. Obst. Trans., vol. xv. 484 OBSTETKIC OPERATIONS. Fig. 167 thus interfere with the natural mechanism of delivery. If placed over the occiput, it is impossible to make traction in the direc- tion of the pelvic axes, as the instrument will then infallibly slip. If traction be made in any other direction, there must be a risk of injuring the maternal struc- tures, or of changing the position of the head. Hence there is every reason for dis- carding the fillet as a tractor, or as a sub- stitute for the forceps, even in the simplest cases. It is quite possible that it may find a useful application in certain cases in which the vectis maj also be used, viz., as a rec- tifier of malposition, and, from the com- parative facility of its introduction, it would probably be the preferable instru- ment of the two. [The whalebone fillet was the great weapon of delivery in old Japanese ob- stetrics, and according to their obstetrical plates must have done fearful execution, especially when placed over the body of the foetus, and operated upon by a windlass. Fortunately for the native women, science is introducing a more rational method. — Ed.] Wilmot's CHAPTEE V. OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. Operations involving the destruction and mutilation of the child were among the first practised in midwifery. Craniotomy was evi- dently known in the time of Hippocrates, as he mentions a mode of extracting the head by means of hooks. Celsus describes a similar operation, and was acquainted with the manner of extracting the foetus in transverse presentations by decapitation; similar procedures were also practised and described by Aetius and others among the ancient writers. The physicians of the Arabian school not only employed perforators for opening the head, but were acquainted with instruments for compressing and extracting it. Religious Objections to Craniotomy. — Until the end of the seven- teenth century this class of operation was not considered justifiable OPERATIONS INVOLVING DESTRUCTION OF F(ETUS. 485 in the case of living children; it then came to be cliscnssed whether the life of the child might not be sacrificed to save that of the mother. It was authoritatively ruled by the Theological Faculty of Paris, that the destruction of the child in any case was mortal sin. "Si l'on ne peut tirer l'enfant sans le tuer, on ne pent sans peche mortel le tirer." This dictum of the Roman Church had great influence on Continental midwifery, more especially in France, where, up to a recent elate, the leading obstetricians considered craniotomy to be only justifiable when the death of the foetus had been positively ascertained. Even at the present day there are not wanting practitioners who, in their praise- worthy objection to the destruction of a living child, counsel delay until the child has died; a practice thoroughly illogical, and only sparing the operator's feelings at the cost of greatly increased risk to the mother. In England, the safety of the child has always been considered subservient to that of the mother; and it has been ad- mitted that, in every case in which the extraction of a living foetus by any of the ordinary means is impossible, its mutilation is perfectly justifiable. Unjustifiable Frequency. — It must be admitted that the frequency with which craniotomy has been performed in this country constitutes a great blot on British midwifery. During the mastership of Dr. Labbat, at the Rotunda Hospital, the forceps was never once applied in 21,867 labors. Even in the time of Clarke and Collins, when its frequency was much diminished, craniotomy was performed three or four times as often as forceps delivery. These figures indicate a destruction of foetal life which we cannot look back to without a shudder, and which, it is to be feared, justify the reproaches which our Continental brethren have cast upon our practice. Fortunately, professional opinion has now completely recognized the sacred duty of saving the infant's life, whenever it is practicable to do so; and British obstetricians now teach, as carefully as those of any other nation, the imperative necessity of using every endeavor to avoid the destruction of the foetus. Division of the Subject. — The operation now under consideration may be necessary: 1st, when the head requires either to be simply perforated, or afterwards more completely broken up and extracted ; an operation which has received various names, but is generally known in this country as craniotomy, and which may or may not require to be followed by further diminution of the trunk. 2dly, when the arm presents, and turning is impossible; this necessitates one of two procedures, decapitation with the separate extraction of the body and head, or evisceration. In both classes of cases similar instruments are employed, and those generally in use at the present time may be first briefly described. Description of Instruments Employed. — 1. The object of the perfo- rator is to pierce the skull of the child, so as to admit of the brain being broken up, and the consequent collapse and diminution in size of the cranium. The perforator invented by Den man, or some modi- fication of it, has been principally employed. It requires the handles to be separated in order to open the blades, and this cannot be done 486 OBSTETRIC OPERATIONS. by the operator himself. This difficulty is overcome in the modifi- cation of Naegele's perforator used in Edinburgh, in which the handles are so constructed that they open the points when pressed together, and are separated by a steel rod, with a joint at its centre, to prevent their opening too soon. By this arrangement the instru- ment can be manipulated by one hand only. The sharp-pointed portion has an external cutting edge, with projecting shoulders at its base, to prevent its penetrating too far into the cranium. Many modifications of these arrangements have since been contrived (Figs. 168, 169, 170). l In some parts of the Continent and America a Fig. 168. Fig. 169. Fig. 170. Various forms of Perforators. perforator is used constructed on the principle of the trephine; but this is vastly more difficult to work, and has the great disadvantage of simply boring a hole in the skull, instead of splitting it up, as is done by the sharp-pointed instrument. The instruments for extraction are the crotchet and craniotomy forceps. Crotchets and Craniotomy Forceps. — The crotchet is a sharp-pointed hook of highly-tempered steel, which can be fixed on some portion of the skull, either internal or external, traction being made by the handle. The shank of the instrument is either straight or curved (Figs. 171 and 172), the latter being preferable, and it is either at- tached to a wooden handle or forged in a single piece of metal. [The [ l The perforator of Meigs is simply the ordinary tapping trocar with a long handle. The trepan-perforator appears to have been first used by Assalini, of Italy, who was soon followed by Jorg, of Nnrnberg. Braun, of Vienna, invented an instrument with a curved tube and crank handle, which has been introduced here as a curiosity. E. Martin, of Berlin, has contrived a straight stemmed trephine of small size. Weiss and Son, of London, have improved the Braun perforator, and we have seen it hce but it is a mistake to suppose that these instruments have been adopted in our country .\ What is most sold is the perforating scissors (Fig. 170). — Ed.] OPERATIONS INVOLVING DESTRUCTION OF F(ETUS. 487 crotchet should be guarded, to save the mother from risk of lacera- tion in case it should slip. — Ed.] A modification of this instrument is known as Oldham's vertebral hook. It consists of a slender hook, measuring, with its handle, 13 inches in length, which is passed through the foramen magnum, and fixed in the vertebral canal, so as to secure a firm hold for traction. All forms of crotchets are open to the serious objection of being liable to slip, or break through the bone to which they are fixed, so wounding either the soft parts of the mother, or the fingers of the operator placed as a guard. Hence they are discountenanced by most recent writers, and may with propriety be regarded as obsolete Figs. 171, 172. instruments. Craniotomy Forceps are preferable for Extraction. — Their place as tractors is well supplied by the more modern craniotomy forceps (Fig. 173). These are intended to lay hold of the skull, one blade being introduced within the cranium, the other externally, and, when a firm grasp has been obtained, down- ward traction is made. A second object it fulfils is, to break away and remove portions of the skull, when perforation and traction alone are insufficient to effect delivery. Many forms of craniotomy for- ceps are in use ; some armed with formidable teeth, others, of simpler construction, depending on their roughened and serrated internal surfaces for firm- ness of grasp. For general use, there is no better instrument than the cranioclast of Sir James Simp- son (Fig. 174), which admirably fulfils both these indications. It consists of two separate blades, fastened by a button joint. The extremities of the blades are of a duck-billed shape, and are sufficiently curved to allow of a firm grasp of the skull being- taken ; the upper blade is deeply grooved to allow the lower to sink into it, and this gives the instru- ment great power in fracturing the cranial bones, when that is found to be necessary. It need not, however, be em- ployed for the latter purpose, and, the blades being serrated on their under surface, form as perfect a pair of craniotomy forceps as any in ordinary use. Provided with it, we are spared the necessity of pro- curing a number of instruments for extraction. Cephalotribe. — Amongst modern improvements in midwifery there are few which have led to more discussion than the use of the cephalotribe. 1 The instrument, originally invented by Baucleloccjue, was long employed on the Continent before it was used in this country, the prejudice against it being no doubt due to its formidable size and appearance. Of late years many of our leading obstetricians have used it in preference either to the crotchet or craniotomy forceps, and %J Crochets. 1 [Assalini's "Forcipe Comjiressore,' Cephalotribe. — Ed.] was in use twenty years before Baudelocque's 488 OBSTETRIC OPERATIONS. have materially modified and improved its construction, so that the most objectionable features of the older instruments are not entirely removed. Object of the Instrument. — The omphalotribe consists of two power- ful solid blades, which are applied to the head after perforation, and approximated by means of a screw so as to crush the cranial bones, and after this it may be also used for extraction. The peculiar value of the instrument is, that, when properly applied, it crushes the firm basis of the skull, which is left untouched by craniotomy, or, if it does not, it at least causes the base to turn edgeways within the Fig. 173. Fig. 174. Craniotomy Forceps, Simpson's Cranioclast. blades, so as to be in a more favorable position for extraction. An- other and specially valuable property is, that it crushes the bones within the scalp, which forms a most efficient protective covering to their sharp edges; in this way one of the principal dangers of crani- otomy — the wounding of the maternal passages by spicuhe of bone — ■ is entirely avoided. The cephalotribe, therefore, acts in two ways ; as a crusher, and as a tractor. Some obstetricians believe the former to be its more important use, and even maintain that the cephalotribe is unsuited for traction. This view is specially maintained by Pajot, who teaches that, after the size of the skull has been diminished by repeated crushings, its expulsion should be left to the natural powers. There are some grounds for believing that in the greater degrees of obstruc- tion the tractile power of the instrument should not be called into use; but, in the large majority of cases, the facility with which the crushed head may be withdrawn by it constitutes one of its chief claims to the attention of the obstetrician. No one who has used it in this way, and experienced the rapid and easy manner in which it accomplishes delivery, can have any doubt on this point. OPERATIONS INVOLVING DESTRUCTION OF ECETUS. 489 Fig Its Value. — There is every reason to believe that cephalotripsy will be much extended in this country, and that it will be considered, as I believe it unquestionably deserves to be, the ordinary operation in cases requiring destruction of the foetus. The comparative merits of cephalotripsy and craniotomy will be subsequently considered. Description of the Instrument. — The most perfect cephalotribe is probably that known as Braxton Hicks's (Fig. 175), which is a modi- fication of Simpson's. It is not of unwieldy size, but sufficiently power- ful for any case, and not extravagant iu price. The blades have a slight pelvic curve, which materially facili- tates their introduction, yet not suffi- ciently marked to interfere with their being slightly rotated after applica- tion. Dr. Kidd, of Dublin, prefers a straight blade ; while Dr. Matthews Duncan thinks it better to use a some- what bulkier instrument, modelled on the t} T pe of the Continental cephalo- tribes. The principle of action of all these is identical, and their differences are not of very material importance. Section r of the Skull by the Forceps- saw, or Ecraseur. — Another mode of diminishing- the foetal skull is bv re- moving it in sections. This object is aimed at in the forceps-saw of Van Huevel, which consists of two large blades, not unlike those of the cepha- lotribe in appearance. Within these there is a complicated mechanism, working a chain saw from below up- wards, which cuts through the foetal skull; the separated portions are sub- sequently withdrawn piecemeal. This instrument is highly spoken of by the Belgian obstetricians,who believe that it affords by far the safest and most effectual wa} r of reducing the bulk of the foetal skull. In this country it is practically unknown : and, although it must be admitted to be theoretically excellent, the complexity and cost of the apparatus have always stood in the way of its being used. Dr. Barnes has suggested that the same results may be obtained by dividing the head with a strong wire ecraseur. So far as I know, this suggestion has never yet been carried out in practice, not even by himself, and, therefore, it is not possible to say much about it. I should imagine, however, that there would be considerable difficulty in satisfactorily passing the loop of wire over the skull, in a pelvis in which there is any well-marked deformity. 32 Hicks's Cephalotribe. 490 OBSTETRIC OPERATIONS. Cases requiring Craniotomy. — The most common cause for which craniotomy or cephalotripsy is performed, is a want of proper pro- portion between the head and the maternal passages. This may arise from a variety of causes. The most important, and that most often necessitating the operation, is osseous deformity. This may exist either in the brim, cavity, or outlet, and it is most often met with in the antero-posterior diameter of the brim. Obstetric au- thorities differ considerably as to the precise amount of contraction which will prevent the passage of a living child at term. Thus Clarke and Barns believe that a living child cannot pass through a pelvis in which the antero-posterior diameter at the brim is less than 3 \ inches. Eamsbotham fixes the limit at 3 inches, and Osborne and Hamilton at 2f inches. The latter is the extreme limit at which the birth of a living child is possible ; but there can be no doubt that, under favorable circumstances, it may be possible to draw the foetus, after turning, through a pelvis of that size. The opposite limit of the operation is still more open to discussion. Various authorities have considered it quite possible to draw a mutilated foetus through a pelvis in which the antero-posterior diameter does not exceed 1J inches, and, indeed, have succeeded in doing so. But then there must be a fair amount of space in the transverse diameter of the pelvis to admit of the necessary manipulations. If there be a clear space here of 3 inches and upwards, it is no doubt possible to deliver per vias naturales ; but in such extreme deformities, the difficulties are so great, and the bruising of the maternal structures so extensive, that it becomes an operation of the greatest possible severity, with results nearly as unfavorable to the mother as the Cesarean section. Hence some Continental authorities have not scrupled to prefer the latter operation in the worst forms of pelvic deformity. The rule in English practice always has been that craniotomy must be performed whenever it is practicable ; and there can be no doubt that it is the right one. [The operation may be practicable, and still be more dangerous than the Cesarean section. Where experience shows this to be the case, we should in the United States elect the latter and perform it early. — Ed.] Limits of the Operation. — Between from 2f to 3 inches antero-pos- terior diameter in the one direction, and If inches in the other, may be said to be the limits of craniotomy, provided, in the latter case, there be a fair amount of space in the transverse diameter. The same limits may be laid down with regard to tumors or other sources of obstruction. Other Causes justifying Craniotomy. — There are a few other con- ditions in which craniotomy is justifiable, independently of pelvic contraction, such as certain conditions of the soft parts which are supposed to render the passage of the head peculiarly dangerous to the mother. Among them may be mentioned swelling and inflam- mation of the vagina from the length of the previous labor, bands and cicatrices in the vagina, and occlusion and rigidity of the os. It is hardly too much to say that with a proper use of the resources of midwifery, the destruction of a living foetus for any of these condi- OPERATIONS INVOLVING DESTRUCTION OF FOETUS. 491 tious might be obviated. The most common of them is undoubtedly swelling of the soft parts causing impaction of the head ; an occur- rence which ought to be invariably prevented by a timely use of the forceps. Should interference unfortunately be delayed until impac- tion has actually taken place, doubtless no other resource but crani- otomy would be left ; but such cases, it is to be hoped, are now of rare occurrence in British practice. Undue rigidity of the os can be overcome by dilatation with the caoutchouc bags, or, in more serious cases, by incision, which would certainly be less perilous to the mother than dragging even a mutilated foetus through the small and rigid aperture. In the case of bands and cicatrices in the vagina, dilatation or incision will generally suffice to remove the obstruction; but even were this not so, here, as in excessive rigidity of the peri- neum, it would be better that slight lacerations should take place, than that the child should be killed. Complications of Labor justifying Craniotomy. — Certain complica- tions of labor are held to justify craniotomy, such as rupture of the uterus, convulsions, and hemorrhage. The application of the forceps or turning will generally answer our purpose equally well, especially as we have the means of dilating the os sufficiently to admit of one or other of them being performed, when the natural dilatation is not sufficient. Craniotomy in rupture of the uterus will also be rarely indicated, as we have seen that gastrotomy appears to afford a better chance to the mother in those cases in which the foetus has partially or entirely escaped from the uterine cavity. Excessive Size of the Foetus. — Want of proportion between the foetus and the pelvis, depending on undue size of the head, either natural, or the result of disease, may render the operation essential. In the former of these cases we shall generally have first attempted delivery with the forceps, and, if it has failed, there can be no doubt as to the propriety of lessening the bulk of the head by perforation. Craniotomy when the Child is believed to be Dead. — In most obstetric works we are recommended to perforate, rather than apply the for- ceps, when we are convinced that the child has ceased to live. This advice is based on the greater facility with which craniotomy can be performed, and its supposed greater safety to the mother. There can be no doubt of the ease with which the child can be extracted after perforation, when the pelvis is not contracted; and, if Ave could always be sure of our diagnosis, the rule might be a good one. Be- fore acting on it, however, we must bear in mind the extreme diffi- culty of positively ascertaining the death of the foetus. Of the signs usually relied on for this purpose, there are scarcely any which are not open to fallacy, except peeling of the scalp, and disintegration of the cranial bones (which do not take place unless the child has been dead for a length of time), and they are, therefore, useless, in most instances. Discharge of the meconium constantly takes place when the child is alive; a cold and pulseless prolapsed cord may belong to a twin; and the foetal heart may become temporarily inaudible, although the child is not dead. If, indeed, we have carefully watched the foetal heart all through the labor, and heard it become more and 492 OBSTETRIC OPERATIONS Fig. 176. more feeble, and finally stop altogether, we might be certain that the child has died; but surely such observations would rather indicate an early recourse to the forceps or version, so as to obviate the fatal result we know to be impending. In certain breech presentations, or after turning, it may be found impossible to extract the head, without diminishing its size by per- forating behind the ear. In such cases we know to a certainty whether the child be alive or dead, before resorting to the operation. The first step, whether we resort to cephalotripsy or craniotomy, is perforation, which will, therefore, be first described. In the former the desirability of first perforating the head is not always recognized. To endeavor to crush the head without perforating is needlessly to increase the difficulties of the case, and it should be remembered, as a cardinal rule, that perforation is an essential preliminary to the proper use of the cephalotribe. Method of Perforation. — Before perforating we must carefully ascer- tain the exact relation of the os to the presenting part, since, in many cases, the operation is performed before the os is fully dilated, when there is a risk of wounding the cervix. Two or more fingers of the left hand should be passed up to the head, and placed against the most prominent part of the parietal bone. Under these, used as a guard (Fig. 176), the perforator should be cautiously introduced until the scalp is reached. It is important to fix on a bony part of the skull, and not on a suture or fontanelle, for puncture, because our object is to break up the vault of the cranium as much as possible, so as to allow the skull to collapse. When the instrument has reached the point we have selected, it should be made to penetrate the scalp and skull with a semi-rotatory boring motion, and advanced until it has sunk up to the rests, which will oppose its further progress. Occa- sionally considerable force will be necessary to effect penetration, more especially if the scalp be swollen by long-continued pres- sure; and this stage of the opera- tion will be facilitated by causing an assistant to steady the head by pressure on the foetus through the abdomen, more especially if it be still free above the pelvic brim. We must then press together the handles of the instrument, which will have the effect of widely Perforation of the Skull. OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 493 separating the cutting portion, and making an incision through the bones. After this the point should be turned round, and again opened at right angles to the former incision, so as to make a free crucial opening. During this process care must be taken to burj the perforator in the skull up to the rests, so as to avoid the possi- bility of injuring the maternal soft parts. The instrument should now be introduced within the skull and moved freely about, so as to thoroughly and completely break up the brain. Especial care must be taken to reach the medulla oblongata and base of the brain, for, if these were not destroyed, we might subject ourselves to the distress of extracting a child in whom life was not extinct. If this part of the operation be thoroughly performed, there will be no necessity for washing out the brain by the injection of warm water, as is sometimes recommended, for the broken-up tissue will escape freely through the opening made by the perforator. Perforation of the After-coming Head. — The perforation of the after-coming head does not generally offer any particular difficulty. It is accomplished in the same manner, the child's body being well drawn out of the way by an assistant. The point of the perforator, carefully guarded by the finger, is guided up to the occiput, or behind the ear, where it is inserted. It is sometimes useful to Postpone Extraction. — If there be no neces- sity for yqtj rapid delivery, and the pains be still present, it is often advisable to wait ten minutes or a quarter of an hour before pro- ceeding to extract. This delay will allow the skull to collapse and become moulded to the cavity of the pelvis, when forced down by the pains, and possibly the natural efforts may suffice to finish the labor in that time ; or, at least, the head will have descended further, and will be in a better' position for extraction. Should perforation be required after having failed to deliver with the forceps — and this is only likely to be the case when the obstruction is comparatively slight — it is certainly a good plan to perforate without removing the forceps, which may then be used as tractors. We have now to decide on the method of extraction, and our choice lies between the cephalotribe and the craniotomy forceps. Comparative merits of Omphalotripsy and Craniotomy. — Those who have used both must, I think, admit that in any ordinary case, in which the obstruction is not great, and only a comparatively slight diminution in the size of the head is required, cephalotripsy is infi- nitely the easier operation. The facility with which the skull can be crushed is sometimes remarkable, and those who will take the trouble to read the reports of the operation published by Braxton Hicks, Kidd, and others, cannot fail to be struck with the rapidity with which the broken-down head may often be extracted. This is far from being the case with the craniotomy forceps, even when the obstruction is moderate only; for it may be necessary to use conside- rable traction, or the blades may take a proper grasp with difficulty, or it may be essential to break down and remove a considerable portion of the vault of the cranium before the head is lessened suffi- ciently to pass. During the latter process, however carefully per- 494 OBSTETRIC OPERATIONS. formed, there is a certain risk of injuring the maternal structures, and, in the hands of a nervous or inexperienced operator, this dan- ger, which is entirely avoided in cephalotripsy, is far from slight. The passage of the blades of the cephalotribe is by no means difficult, and I think it must be admitted that the possible risks attending it are comparatively small. On account, therefore, of its simplicity and safety to the maternal structures, I believe cephalotripsy to be de- cidedly the preferable operation in all cases of moderate obstruction. When we approach the lower limit, and have to do with a very marked amount of pelvic deformity, the two operations stand on a more equal footing. Then the deformity may be so great as to render it difficult to pass the blades of even the smallest cephalotribe suffi- ciently deep to grasp the head firmly, and, even when they are passed, the space is often so limited as to impede the easy workiug of the instrument. Besides this, repeated crushings may be required to diminish the skull sufficiently. I attach but little importance to the argument that the diminution of the skull in one diameter increases its bulk in another. The necessity of removing and replacing the blades on another part of the skull, and of repeating this perhaps several times, in the manner recommended by Pajot, is a far more serious objection. To do this in a contracted pelvis involves, of necessity, the risk of much contusion. Fortunately cases of this kind are of extreme rarity, much more so than is generally believed, but when they do occur they tax the resources of the practitioner to the utmost. On the whole, the conclusion I would be inclined to arrive at with regard to the two operations is, that in all ordinary cases, cephalo- tripsy is safer and easier, whereas in cases with cousiderable pelvic deformity, the advantages of cephalotripsy are not so well marked, and craniotomy may even prove to be preferable. Description of the Operation. — The first step in using the cephalo- tribe is the passage of the blades. These are to be inserted in pre- cisely the same manner, and with the same precautions, as in the high forceps operation. In many cases the os is not fully dilated, and it is absolutely essential to pass the instrument within it. Special care should, therefore, be taken to avoid any injury to its edges, and, for this purpose, two or three fingers of the left hand, or even the whole hand, should be passed high up, so as thoroughly to protect the maternal structures. In order that the base of the skull may be reached and effectually crushed, the blades must be deeply inserted, and, in doing this, great care and gentleness must be used. As the projecting promontory of the sacrum generally tilts the head for- wards, the handles of the instrument, after locking, must be well pressed back towards the perineum. If the blades do not lock easily, or if any obstruction to their passage be experienced, one of them must be withdrawn and re-introduced, just as in forceps operations. Care mast be taken, as the instrument is being inserted, to fix and steady the head by abdominal pressure, since it is generally far above the brim, and would readily recede if this precaution were neglected. "When the blades are in situ, we proceed to crush by turning the screw slowly, and, as the blades are approximated, the bones yield, OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 495 Fig. 17 and the cephalotribe sinks into the cranium. The crushed portion then measures, of course, no more than the thickness of the blades, that is about 1J inches. This is necessarily accompanied by some bulging of the part of the cranium that is not within the grasp of the instrument (Fig. 177), but in slight deformity this is of no consequence, and we may proceed to extraction, waiting, if possible, for a pain, and drawing down- wards in the axis of the pelvic outlet, as in forceps delivery. The site of perfora- tion should be examined to see that no spiculae of bone are projecting from it, and if so they should be carefully removed. In such cases the head often descends at once, and with the greatest ease. Should it not do so, or should the obstruction be considerable, a quarter turn should be given to the handles of the instrument, so as to bring the crushed portion into the narrowed diameter, and the uncrushed portion into the wider transverse diameter. It may now be advisable to remove the blades carefully, and to reintroduce them with the same precautions, so as to crush the unbroken portion of the skull. This adds materially to the difficulties of the case, since the blades have a tendency to fall into the deep channel already made in the cranium, and so it is by no means always easy to seize the skull in a new direction. Before reapplying them, if the condition of the patient be good and pains be present, it may be well to wait an hour or more, in the hope of the head being moulded and pushed down into the pelvic cavity. This was the plan adopted by Dubois, and, according to Tarnier, was the secret of his great success in the operation. Pajot's method of repeated crushings, in the greater degrees of contraction, is based on the same idea, and he recommends that the instrument should be reintroduced at intervals of two, three, or four hours, according to the state of the patient, until the head is thoroughly crushed ; no attempts at traction being used, and expulsion being left to the natural powers. This, he says, should always be done when the contraction is below 2J inches, and he maintains that it is quite possible to effect delivery by this means when there is only 1J inches in the antero-posterior diameter. The repeated introduction of the blades in this fashion must necessarily be hazardous, except in the hands of a very skilful operator ; and I believe that if a second application fail to overcome the difficulty, which will only be very exceptionally the case, that it would be better to resort to the measures presently to be described. Foetal Head crushed by the Cephalotribe. 496 OBSTETRIC OPERATIONS. Fig Fig. 179. Should we elect to trust to the craniotomy forceps for extraction, one blade is to be introduced through the perforation, and the other, in apposition to it, on the outside of the scalp. In moderate deformi- ties, traction applied during the pains may of itself suffice to bring down the head. Should the obstruction be too great to admit of this, it is necessary to break clown and remove the vault of the cranium. For this purpose Simpson's cranioclast answers better than any other instrument. One of the blades is passed within the cranium, the other, if possible, between the scalp and the skull, and the portion of bone grasped between them is then broken off; this can generally be accomplished by a twisting motion of the wrist, without using much force. The separated portion of bone is then extracted, the greatest care being taken to guard the maternal struc- tures, during its removal, by the fingers of the left hand. The in- strument is then applied to a fresh part of the skull, and the same process repeated, until as mnch of the vault of the cranium as may be necessary is broken up and removed. [The craniotomy forceps chiefly in use with us were devised by the late Prof. Charles D. Meigs, for his second operation upon Mrs. Eeybold, of Philadelphia, in 1833, and have been used repeatedly since, either as tractors, or for reducing the size of the foetal head, in cases of deformity of the pelvis. 2 Some obste- tricians prefer the less curved, and broader- bladed instrument of Great Britain, as a trac- tor ; but for the general purposes of picking away the cranial bones, and drawing down the base of the skull, in cases of extreme pelvic deformity, there is no more simple appliance than that of Dr. Meigs. To act upon an oval body like the foetal head, Dr. M. was obliged to prepare two forms of forceps — straight and curved — to be used as might be required, according to the part of the skull to be broken clown, or drawn upon. These are lightly made, serrated, and 12} inches in length. — Ed.] Advantages of bringing down the Face in Difficult Cases. — Dr. Braxton Hicks 1 has con- clusively shown that in difficult cases, after the removal of the cranial vault, the proper procedure is to bring down the face; since the smallest measurement of the skull, after the removal of the upper part of the cranium, is from the orbital ridge to the alveolar edge of the superior maxillary bone. This alteration in the presentation he proposes to effect by a small blunt hook, made Straight Curved Craniotomy Craniotomy Forceps. Forceps. 1 Obst. Trans., vol. vii. [ 2 The illustration given is taken from the instruments devised by Dr. Meigs as an improvement upon his original pattern, and will be seen to differ from that heretofore given in American obstetrical publications. — Ed.] OPERATIONS INVOLVING DESTRUCTION OF FGSTUS. 497 for the purpose, which, is forced into the orbit, by means of which the face is made to descend. Barnes recommends that this should be done by fixing the craniotomy forceps over the forehead and face, and making traction in a backward direction, so as to get the face past the projecting promontory of the sacrum. The importance of bringing down the face was long ago pointed out by Burns, but it had been lost sight of, until Hicks again drew attention to it in the paper referred to. In the class of cases in which this procedure is valuable, the risk to the maternal passages, from the removal of fractured portions of bone, must always be considerable, and it is of great importance not only to preserve the scalp as entire as possible, so as to protect them, but to use the utmost possible care in removing the broken pieces of bone. Extraction of the Body. — When the extraction of the head has been effected, either by the cephalotribe or the craniotomy forceps, there is seldom much difficulty with the body. By traction on the head one of the axillae can easily be brought within reach, and if the body do not readily pass, the blunt hook should be introduced, and traction made until the shoulder is delivered. The same can then be done with the other arm. If there be still difficulty, the cephalotribe may be used to crushed the thorax. The body is, however, so com- pressible that this is rarely required. Embryotomy where Turning is Impossible. — There only remains for us to consider the second class of destructive operations. These may be necessary in long-neglected cases of arm presentation, in which turning is found to be impracticable. Here fortunately the question of killing the foetus does not arise, since it will, almost necessarily, have already perished from the continuous pressure. We have two operations to select from, decapitation and evisceration. Decapitation. — The former of these is an operation of great an- tiquity, having been fully described by Celsus. It consists in sever- ing the neck, so as to separate the head from the body ; the body is then withdrawn by means of the protruded arm, leaving the head in utero to be subsequently dealt with. If the neck can be reached without great difficulty — and, in the majority of cases, the shoulder is sufficiently pressed down into the pelvis to render this quite possi- ble — there can be no doubt, that it is much the simpler and safer operation. Methods of Dividing the Neck. — The whole question rests on the possibility of dividing the neck. For this purpose many instruments have been invented. The one generally recommended in this country is known as Eamsbotham's hook, and consists of a sharply curved hook, with an internal cutting edge. This is guided over the neck, which is divided by a sawing motion. There is often considerable difficulty in placing the instrument over the neck, although, if this were done, it would doubtless answer well. Others have invented instruments, based on the principle of the apparatus for plugging the nostrils, by means of which a spring is passed round the neck, and to the extremity of the spring a short cord, or the chain of an e*craseur, is attached ; the spring is then withdrawn and brings the 498 OBSTETRIC OPERATIONS. chain or cord into position. The objection to any of these appa- ratuses is, that they are unlikely to be at hand when required, for few practitioners provide themselves with costly instruments which they may never require. It is of importance, therefore, that we should have at our command some means of dividing the neck, which is available in the absence of any of these contrivances. Dubois re- commends for this purpose a strong pair of blunt scissors. The neck is brought as low as possible by traction on the prolapsed arm, and the blades of the scissors guided carefully up to it. By a series of cautious snipping movements it is then completely divided from below upwards. This, if the neck be readily within reach, can gen- erally be effected without any particuiar difficulty. Dr. Kidd, of Dublin, 1 who strongly advocates this operation, recommends that an ordinary male elastic catheter, strongly curved and mounted on a firm stilet, or, still better, on a uterine sound, should be passed round the neck. Previous to introduction a cord should be attached to the ex- tremity of the catheter, which is left round the neck when it is with- drawn. By means of this cord a strong piece of whipcord, or the wire of an ecraseur, can easily be drawn round the neck and used for dividing it. The former, to protect the maternal structures, may be worked through a speculum, and by a series of lateral movements the neck is easily severed. The ecraseur, however, offers special advantages, since it entirely does away with any risk of in- juring the mother. Withdrawal of the Body and Delivery of the Head. — After the neck is divided the remainder of the operation is easy. The body is withdrawn without difficulty by the arm, and we then proceed to deliver the head. By abdominal pressure this, in most cases, can be pushed down into the pelvis, so as to come easily within reach of the cephalotribe, which is by far the best instrument for extraction. Preliminary perforation is not necessary, since the brain can escape through the severed vertebral canal. The secret of doing this easily is to fix and press down the head sufficiently from above, otherwise it would slip away from the grasp of the instrument. The perfora- tor and craniotomy forceps may be used, if the cephalotribe be not at hand. Perforation is, however, by no means always easy, on ac- count of the mobility of the head. After it is accomplished one blade of the craniotomy forceps is passed within the skull, the other externally, and the head slowly drawn down. Evisceration. — The alternative operation of evisceration is a much more troublesome and tedious procedure, and should only be used when the neck is inaccessible. The first step is to perforate the thorax at its most depending part, and to make as wide an opening into it as possible, in order to gain access to its contents. Through this the thoracic viscera are removed piecemeal, being first broken up as much as possible by the perforator, and then, the diaphragm being penetrated, those in the abdomen. The object is to allow the body to collapse, and the pelvic extremities to descend, as in sponta- 1 Dublin Quart. Journ., May, 1871. CESAREAN SECTION. 499 neous evolution. This can be much facilitated by dividing the spinal column with a strong pair of scissors, introduced into the opening made in the thorax, so that the body may be doubled up as on a hinge. Here the crotchet may find a useful application, for it can be passed through the abdominal cavity, and fixed on some point in the interior of the child's pelvis ; and thus strong traction can be made without any risk of injury to the mother. It can be readily understood that this process is so lengthy and difficult as to render it probably the most trying of obstetric operations • it is certainly inferior in every respect to decapitation, and is only to be resorted to when that is impracticable. [In seven instances of impaction of the foetus in a transverse posi- tion, in the United States, the Cesarean operation has been per- formed, owing to great difficulty in accomplishing either decapitation or evisceration, and five of the women were saved. The two deaths were from exhaustion. — Ed.] CHAPTEE VI. THE (CESAREAN SECTION — SYMPHYSEOTOMY — AND LAPARO- ELYTROTOMY. History. — The Csesarean section has perhaps given rise to more discussion than any other subject connected with midwifery, and there is yet much difference of opinion as to the limits of, and indica- tions for, the operation. The period at which the Caesarean section was first resorted to is not known with accuracy. It seems to have been practised by the Greeks, after the death of the mother; and Pliny mentions that Scipio Africanus and Manlius were born in this way. The name of Caesar is said to have been given to children so extracted, and afterwards to have been assumed as a family patro- nymic. These children were dedicated to Apollo; whence arose the practice of things sacred to that god being taken under the special protection of the family of the Caesars. Many celebrities have been supposed to owe their lives to the operation ; among the rest ^Escula- pius, Julius Caesar, and our own Edward VI. Eegarding the two latter, there is conclusive proof that the tradition is without founda- tion. There is no doubt that the operation was constantly practised on women who had died at an advanced period of pregnancy, and indeed it has, at various times, been enforced by law. Thus among the Romans it was decreed by Nurna, that no pregnant woman should be buried until the foetus had been removed by abdominal section. The Italian laws also made it necessary, and the operation has 500 OBSTETRIC OPERATIONS. always received the strong support of the Eoman Church. So lately as the middle of the eighteenth century, the King of Sicily sentenced to death a physician who had neglected to practise it. The first authentic case in which the operation was performed on a living woman occurred in 1491. It was afterwards practised by Nufer in 1500 ; and in 1581 Eousset published a work on the subject, in which a number of successful cases were related. In English works of that time it is not alluded to, although it was undoubtedly performed on the Continent, and to such an extent that its abuse became almost proverbial. We have evidence in Shakespeare, however, that the operation was familiarly known in this country, since he tells us that — . Macduff was from liis mother's womb 1 Untimely ripped. Pare and Guillemeau, amongst the writers of the period, were noted for their hostility to the operation , while others equally strongly upheld it. In this country it has scarcely ever been performed in a manner which offers even the faintest hope of success. It has been looked upon as almost necessarily fatal to the mother, and it has, therefore, been delayed until the patient has arrived at the utmost stage of exhaustion. For example, in looking over the records of British cases, it is no uncommon thing to find that the Cesarean section was resorted to, two, three, or even six days after labor had begun, 2 and when the patient was almost moribund. With rare exceptions within the last few years, the operation has been performed in what may be called a hap-hazard way. In many cases long and fruitless attempts at delivery by craniotomy had already been made, so that the pas- sages had been subjected to much contusion and violence. Little or no attempt has been made to obviate the well-known risks of ab- dominal operations ; no care has been taken to prevent blood and other fluids finding their way into the peritoneal cavity, and no means have been adopted subsequently to remove them. It is, therefore, not so much a matter of surprise that the mortality has been so great, but rather that any cases have recovered. Mortality. — From what we know of the history of ovariotomy, its early fatality, and the extreme and even apparently exaggerated precautions which are essential to its success, it is fair to conclude that, if the Cesarean section were performed, as it is to be hoped it always will be in future, with the same careful attention to minute details as ovariotomy, the results would not be so disastrous. Making every allowance for these facts, it must be admitted that the Cesa- rean section is necessarily almost a forlorn hope ; and in making these observations I have no intention of contesting the well-estab- lished rule of British practice, that it is not admissible as an opera- [' The word "untimely" we have always regarded as proof that it did not refer to the Caesarean section, which is performed during labor. It more likely refers to the goring of a bull or cow, instances of which are upon record. — Ed.] 2 See Radford on Ciesarean Section, p. 15. CESAREAN SECTION. 501 tion of election, and must only be resorted to when delivery per vias naturales is impossible. Statistical Returns are not Reliable. — The mortality, as given in statistical returns from various sources, differs so greatly as to make them but little reliable. Radford tabulates 77 operations performed in this countn^, of which 66, or 85.71 per cent., proved fatal, and 11 or 14.28 per cent., recovered. Michaelis and Kayser found that out of 258 and 338 operations, 54 and 64 per cent, respectively were fatal. These include operations performed under all sorts of condi- tions, even when the patient was almost moribund ; and until we are in possession of a sufficient number of cases performed under con- ditions showing that the result is obviously due to the operation — • in which it was undertaken at an early period of labor, and performed with a reasonable amount of care — it is obviously impossible to arrive I at any reliable conclusions as to the mortality of the operation. That it is necessarily hopeless is certainly not the case, and we know that , on the Continent, where it is resorted to much oftener and earlier in [ labor than in this country, there are authentic cases in which it has been performed twice, thrice, and even, in one instance, four times on the same patient. Kayser thinks that a second operation on the same patient affords a better prognosis than a first, probably because peritoneal adhesions, resulting from the first operation, have shut off the general abdominal cavity from the uterine wound ; and he believes that in second operations the mortality is not more than 29 per cent. Results to the Child. — The mortality of the children likewise cannot be ascertained from statistical returns, since, in the large majority of cases in which dead children were extracted, the result had nothing to do with the operation. Indeed, there is nothing in the operation itself which can reasonably be supposed to affect the child. If, there- fore, the child be alive when the operation is commenced, there is every probability of its being extracted alive; and Radford's conclu- sion that, " the risk to infants in Cassarean births is not much greater than that which is contingent on natural labor, provided correct prin- ciples of practice are adopted," probably very nearly represents the I truth. Causes requiring the Operation. — The Cesarean section is required I when there is such defective proportion between the child and the I maternal passages, that even a mutilated foetus cannot be extracted. j This in by far the greatest number of cases is due to deformity of | the pelvis arising from rickets or mollities ossium. The latter may j occur in a patient who has been previously healthy, and who has given birth to living children. It is a more common cause of the extreme varieties of deformity than rickets, and out of 77 2 British cases, tabulated by Radford, in 43 the deformity was produced by osteomalacia, and in 14 only by rickets. In certain cases the pelvis itself may be of normal size, but has its cavity obstructed by a solid [' 98 operations —82 fatal, 16 recovered. 1868.— Ed.] [ 2 Out of 98, there were 46 deformed by osteomalacia against 16 by rickets. — Ed.] 502 OBSTETRIC OPERATIONS. tumor of the ovary, of the uterus itself, or one growing from the pelvic wall. The obstruction may also depend on morbid conditions of the maternal soft parts, of which the most common is advanced malignant disease of the cervix. Other conditions may, however, render it essential. Thus Dr. Newman 1 records a case in which he performed the operation for insurmountable resistance and obstruc- tion of the cervix, which was believed at the time to be malignant. The patient recovered, and was subsequently delivered naturally, and without anything abnormal being made out. This renders it probable that the disease was not malignant, and it may possibly have been an extensive inflammatory exudation into the tissues of the cervix, subsequently absorbed. I myself was present at a Cesa- rean section performed in Calcutta in the year 1857, when the pelvis was so uniformly blocked up with exudation, probably due to exten- sive pelvic cellulitis or hsematocele, that the operation was essential. Limits of Obstruction justifying the Operation. — Different accou- cheurs have fixed on various limits for the operation. Most British authorities are of opinion that it need not be resorted to, if the smallest diameter of the pelvis exceed 1J inch. This question has already been considered in discussing craniotomy, and it has been shown that a mutilated foetus may be drawn through a pelvis of 1J inch antero-posterior diameter, provided there be a space of 3 inches in the transverse diameter. If sufficient space for using the neces- sary instruments do not exist, the Csesarean section may be required, even when there is a larger antero-posterior diameter than 1J inch. This is especially likely to occur when we have to do with deformity arising from mollities ossium, in which the obstruction is* in the sides and outlet of the pelvis, the true conjugate being sometimes even elongated. On the Continent the Cesarean section is constantly practised, as an operation of election, when the smallest diameter measures from 2 to 2 J inches ; and when the child is known to be alive, some foreign authors recommend it when there are as much as 3 inches in the antero-posterior diameter. In this country, where the life of the child is most properly considered of secondary import ■ ance to the safety of the mother, we cannot fix one limit for the ope- ration when the child is living, and another when it is dead. Nor, I think, can we admit the desire of the mother to run the risk, rather than sacrifice the child, as a justification of the operation, although this is laid down as an indication by Schroeder. 2 Great as are the dangers attending craniotomy in extreme deformity, there can be no doubt that we must perform it whenever it is practicable, and only resort to the Caesarian section when no other means of delivery are possible. For this reason. I think it unnecessary to discuss the question, whether we are justified in destroying the foetus in several successive pregnancies, when the mother knows that it is impossible for her to give birth to a living child. Dennian was the first to question the 1 Obst. Trans., vol. iii. p. 343. 2 Manual of Midwifery, p. 202. CESAREAN SECTION. 503 advisability of repeating craniotomy on the same patient. Amongst modern authors Radford takes the most decided view on this point, and distinctly teaches that even when delivery by craniotomy is pos- sible, it " can be justified on no principle, and is only sanctioned by the dogma of the schools, or by usage," and that, therefore, the Cesarean section should be performed with the view of saving the child. Doubtless much can be said from this point of view; but, nevertheless, he would be a bold man who would deliberately elect to perform the Cesarean section on such grounds. 1 It is to be hoped, however, that in these days the induction of premature labor or abortion would always spare us the necessity of deciding so delicate a point. Post-mortem Csesarean Operation. — The Cesarean section may also be required in cases in which death has occurred during pregnancy or labor. This was the indication for which it was first employed, and it has constantly been performed when a pregnant woman has died at an advanced period of utero-gestation. There is no doubt that a prompt extraction of the child under these circumstances has frequently been the means of saving its life, but by no means so often as is generally supposed. Thus Schwartz 2 showed that out of 107 cases not one living child was extracted. Villeneuve, 3 however, re- ports several successful cases, in 4 of which the operation was per- formed immediately after the mother's death, in 5 others at periods varying from ten minutes to half an hour. Want of Success in Post-mortem Operation. — The reason that the want of success has been so great, is doubtless the delay that must necessarily occur before the operation is resorted to; for, inde- pendently of the fact that the practitioner is seldom at hand at the moment of death, the very time necessary to assure ourselves that life is actually extinct will generally be sufficient to cause the death of the foetus. Considering the intimate relations between the mother and child, we can scarcely expect vitality to remain in the latter more than a quarter, or at the outside, half an hour, after it has ceased in the former. The recorded instances in which a living child were extracted ten, twelve, and even forty hours after death, were most probably cases in which the mother fell into a prolonged trance or swoon, during the continuance of which the child must have been removed. A few authentic cases, however, are known in which there can be no reasonable doubt that the operation was performed successfully several hours after the mother was actually dead. An often -quoted and interesting example is that of the Princess of Schwartzenburgh, who perished one evening in a fire at Paris, and from whose body a living infant is said to have been removed on the morning of the following day ; the authenticity of this case, however, is open to grave doubt. [} This was done twice in the case of Mrs. Reybold, of Philadelphia, after she had twice been delivered by craniotomy under Dr. Meigs, who declined destroying any more children for her. — Ed.] 2 Monat. f. Geburt, suppl. vol., 1861, p. 121. 3 Operat. Csesar. Apres la Mort, Paris. 1862. 504 OBSTETRIC OPERATIONS. Since, then, there is a chance, however slight, of saving the child's life, we are bound to perform the operation, even when so much time has elapsed as to render the chances of success extremely small. It might be considered almost superfluous to iDsist on the necessity of assuring ourselves of the mother's death before commencing the neces- sary incisions ; but, unfortunately, numerous instances are known in which mistakes in diagnosis have been made, and in which the first steps of the operation have shown that the mother was still alive. The operation should, therefore, always be performed with the same care and caution as if the mother were living. If death have occurred during labor, some have advised version as a preferable alternative. This can only be resorted to, with any hope of success, if the passages be in a condition to admit of delivery with rapidity ; otherwise the delay required for dilatation, even when forcibly accomplished, and the drawing of the child through the pelvis, will be almost necessarily fatal. The only argument in favor of version is, that it is less painful to the friends ; and, if they manifest a decided objection to the Cesarean section, there can be no reason why an attempt to save the child in this way should not be made. Causes of Death after Csesarean Section. — The causes of death after the Csesarean section may, speaking generally, be classed under four principal heads ; hemorrhage, peritonitis and metritis, shock, and septicaemia. [And exhaustion from long delay. — Ed.] These are pretty much the same as those following ovariotomy, and the resem- blance between the two operations is so great that modern experience as to the best mode of performing ovariotomy, as well as regards the after treatment, may be taken as a guide in the management of cases of Csesarean section. Hemorrhage is Frequent, although Seldom Fatal. — Hemorrhage to an alarming extent is a frequent complication, although seldom the cause of death. Thus out of 88 operations, the particulars of which have been carefully noted, severe hemorrhage occurred in 14, 6 of which terminated successfully, and in 4 only could the fatal result be ascribed to the loss of blood. In 1 of these the source of the hemor- rhage is not mentioned, in another it came from the wound in the abdominal wall, and in the other 2 from the uterine incision being made directly over the placenta. In neither of the 2 latter was the loss of blood immediately fatal ; for it was checked by uterine con- traction, and only recurred after many hours had elapsed. The divided uterine sinuses, and the open mouths of the vessels at the placental site, are the most common sources of hemorrhage. Means of avoiding the Risk. — Much may be done to diminish the risk of bleeding, but even with every precaution, it must be a source of danger. Hemorrhage from the abdominal wall may be best prevented by making the incision as nearly as possible in the line of the linea alba, so as not to Avound the epigastric arteries, and by tying anjr bleeding vessels as we proceed. The principal loss of blood will be met with in dividing the uterus; and this will be greatest when the incision is near or over the placental site, where the largest vessels are met with. We are recommended to ascertain CESAREAN SECTION. 505 the position of the placenta by auscultation, and thus, if possible, to avoid opening the uterus near its insertion. But even if we admit the placental souffle to be a guide to its situation, if the placenta be attached to the anterior walls of the uterus, a knowledge of its posi- tion would not always enable us to avoid opening the uterus in its immediate vicinity. We must, in the event of its lying under the incision, rather hope to control the hemorrhage by removing it at once from its attachments, and rapidly emptying the uterus. When the child has been removed there may be a large escape of blood; but this will generally be stopped by the contraction of the uterus, in the same manner as after natural labor. Should contraction not take place, the uterus may be firmly grasped for the purpose of exciting it. This plan is advocated by Winckel, who had a large experience in the operation; and by using free compression in this way, and making a point of not closing the wound until the uterus is firmly contracted, he has never met with any inconvenience from hemorrhage. If bleeding continue, styptic applications may be used, as in a case reported by Hicks, who was obliged to swab out the uterine cavity with a solution of perchloride of iron. Peritonitis and Metritis are frequent Causes of Death. — Among the most frequent causes of death are peritonitis and metritis. Kayser attributes the fatal result to them in 77 out of 123 unsuccessful cases. The mere division of the peritoneum will not account for the fre- quency of this complication, since its occurrence is considerably more frequent than after ovariotomy, in which the injury to the peritoneum is quite as great, and indeed greater, if we take into account the adhesions which have to be divided or torn in that operation. The division of the uterus must be regarded as one source of this danger. Dr. West lays great stress on its unfavorable condition after delivery for reparative action. He believes that the process of involution or fatty degeneration which commences in the muscular fibres previous to delivery, renders them peculiarly unfitted to cica- trize ; and he points out that, on post-mortem examination, the edges. of the incision have been found dry, of unhealthy color, gaping, and showing no tendency to heal. On this account Hicks and others have operated ten days or more before the full period of labor, in the hope that the risk from this source might be avoided. It is by no means certain, however, that the change in the uterine fibres is the cause of the wound not healing, and involution will commence at once when the uterus is emptied, even if the full period of preg- nancy have not arrived. As a point of ethics, moreover, it is question- able if we are justified in anticipating the date of so dangerous an operation, even by a few weeks, unless the benefit to be derived is very decided indeed. Escape of Lochia and other Fluids into the Peritoneal Cavity. — One important cause of peritonitis is the escape of the lochia through the uterine incision into the cavity of the peritoneum, which there de compose and act as an unfailing source of irritation. This may be prevented, to a great extent, by seeing that the os uteri is patulous, so as to afford a channel for the escape of discharges, and by closing 33 506 OBSTETRIC OPERATIONS. the uterine wound by sutures. In addition there is the danger arising from blood and liquor amnii escaping into the peritoneum, and subsequently decomposing. There is little evidence that "la toilette du peritoine," on which ovariotomists now lay so much stress, has ever been particularly attended to in Cesarean operations. The Unhealthy Condition of the Patient is the Chief Source of Danger. — The chief predisposing cause of these inflammations, however, must be looked for in the condition of the patient, just as asthenic inflam- mation in ovariotomy is most frequently met with in those whose general health is broken down by the long continuance of the disease. We are fully justified, therefore, in assuming that peritonitis and metritis will be more likely to occur after the Cesarean section when that operation has been unnecessarily delayed, and when the patient is exhaused by a protracted labor. In proof of this we find that, in the large proportion of the cases above mentioned, peritonitis oc- curred when the operation was performed under unfavorable con- ditions. Septicemia. — The sources of septicaemia are abundantly evident, not the least, probably, being absorption by the open vessels in the uterine incision. Nervous Shock. — The last great danger is general shock to the ner- vous system. In Kayser's 123 cases, 30 of the deaths are referred to this cause. In the large majority of these the patient was pro- foundly exhausted before the operation was begun. It is in predis- posing to these nervous complications, that we should, d priori, expect that vacillation and delay would be most hurtful ; and in operating when the patient's strength is still unimpaired, we afford her the best chance of bearing the inevitable shock of an operation of such mag- nitude. Secondary Dangers. — In addition a few cases have been lost from accidental complications, which are liable to occur after any serious operation, and which do not necessarily depend on the nature of the procedure. Danger to Child from Portions of its Body being caught by the Con- tracting Uterus. — There is only one source of danger, special to the child, which is worthy of attention. As the infant is being removed from the cavity of the uterus, the muscular parietes sometimes con- tract with great rapidity and force, so as to seize and retain some part of its body. [A rapid delivery by the feet, will usually prevent this, but a pair of forceps should be at hand for the emergency. — Ed.] This occurred in 2 of Dr. Kadford's cases, and in 1 of them it is stated that " the child was vigorously alive when first taken hold of, but, from the length of time occupied in extracting the head, it be- came so enfeebled as to show only slight signs of life," and subse- quently all attempts at resuscitation failed. I have myself seen the head caught in this way, and so forcibly retained that a second in- cision was required to release it. In Dr. Kadford's cases the placenta happened to be immediately under the incision, and he attributes the inordinate and rapid contraction of the uterus to its premature sepa- ration. It is difficult to believe that this was more than a coinci- CESAREAN SECTION. 507 cleace, because the contraction does not take place until the greater part of the child's body has been withdrawn, and because numerous cases are recorded in which the uterus was opened directly over the placenta, or in which, it was lying loose and detached, in none of which this accident occurred. The true explanation may, I think, be found in the varying irritability of the uterus in different cases. Irrespective of the risk of portions of the child being caught and detained, rapid contraction is a distinct advantage, since the danger of hemorrhage is thereby much diminished. Serious consequences may be best avoided by removing, when practicable, the head and shoulders of the child first, or by employing both hands in extrac- tion, one being placed near the head, the other seizing the feet. Either of these methods is preferable to the common practice of lay- ing hold of the part that may chance to lie most conveniently near the line of incision. If this point were properly attended to, al- though the detention of the lower extremities might occasionally occur, the life of the child would not be imperilled. The preparation of the patient for the operation should seriously oc- cupy the attention of the practitioner, and this is the more essential, since almost all patients requiring the Cesarean section are in a wretchedly debilitated condition. [This is the case in England, where osteomalacia prevails, but it is exceptional in most cases in our own land, in the early period of labor. — Ed.]. If the patient be not seen until she is actually in labor, of course this is out of the question. But this will rarely be the case, since the deformed condition of the patient must generally have attracted attention. Every possible means should be taken, therefore, when practicable, to improve the general health by abundance of simple and nourishing diet, plenty | of fresh air, and suitable tonics (amongst which preparations of iron I should occupy a prominent place), while the state of the secretions, 1 the bowels, skin, and kidneys, should be specially attended to. I Whenever it is possible a large, airy apartment should be selected for the operation, which should never be done in a hospital, if other arrangements be practicable. These details may seem trivial and unnecessary ; but to insure success in so hazardous an under- taking, no care can be considered superfluous, and probably the want of attention to such points has had much to do with increasing the mortality. Question of Time to he Selected for the Operation. — The question arises whether we should operate before labor has commenced. By selecting our own time, as some have advised, we certainly have the advantage of operating under the most favorable conditions, instead of possibly hurriedly. There are, however, numerous advantages in I waiting until spontaneous uterine action has commenced, which I seem to me to more than counterbalance the advantages of choosing I our own time. Prominent among these is the partial opening of the ; os uteri, so as to afford a channel for the escape of the lochia, and I the certainty of active contraction of the uterus, to arrest hemor- ( rhage. Barnes recommends that premature labor should be first in- \ duced, and then the operation performed. This seems to me to 508 OBSTETRIC OPERATIONS. ■ introduce a needless element of complexity ; and besides, in cases of great deformity, it is by no means always easy to reach the cervix with the view of bringing on labor. All needful arrangements should be made, so as to avoid hurry and excitement when the operation is commenced, and we may then wait patiently until labor has fairly set in. The Administration of Anaesthetics. — The operation itself is simple. The patient should be placed on a table, in a good light, and with the temperature of the room raised to about 65 °. 1 Chloroform has so frequently been followed by severe vomiting, that it is probably better not to administer it. For the same reason Mr. Spencer Wells. has long given up using it in ovariotomy, and finds that chloro- methyl answers admirably. In one or two cases local anaesthesia has been used, by means of two spray producers acting simulta- neously; and this plan, if the patient have sufficient fortitude to dispense with general anaesthesia, has the further advantage of stimulating the uterus to powerful contraction. Description of the Operation. — The incision should be made as much as possible in the line of the linea alba, so as to avoid wounding the epigastric arteries. On account of the deformity, the configuration of the abdomen is often much altered, and some have advised that the incision should be made oblique or transverse, and on the most prominent part of the abdomen. The risk of hemorrhage being thus much increased, the practice is not to be recommended. The incision, commencing a little above the umbilicus, is carried down for about three inches below it. The skin and muscular fibres are carefully divided, layer by layer, until the shining surface of the peritoneum is reached, and any bleeding vessels should be secured as we proceed. A small opening is now made in the peritoneum, which should be laid open along the whole length of the incision, upon two fingers of the left hand introduced as a guide. Before incising the uterus an assistant should carefully support it in a proper position, and push it forward by the hands placed on either side of the incision, so as to bring its surface into apposition with the external wound, and pre- vent the escape of the intestines. If we have reason to believe that the placenta is situated anteriorly, we may incise the uterus on one or other side; otherwise the line of incision should be as nearly as possible central. The substance of the uterus is next divided until the membranes are reached, which are punctured, and divided in the same way as the peritoneum. The uterine incision should be of the same length as that in the abdomen, and it should not be made too near the fundus; for not only is that part more vascular than the body of the uterus, but wounds in that situation are more apt to gape, and do not cicatrize so favorably. After the uterus is opened, Dr. Winckel recommends that the fingers of an assistant should be placed in the two terminal angles of the wound, so that the ends of the incision may be hooked up, and brought into close apposition with the abdominal opening. By this means he prevents not only [' The temperature usually recommended in this country is 75° to 80°. — Ei>«] CESAREAN SECTION. 509 the escape of blood and liquor amnii into the cavity of the perito- neum, but also the protrusion of the abdominal viscera. Removal of the Child. — The child should now be carefully removed, the head and shoulders being taken out (if possible) at first; the placenta and membranes are afterwards extracted. Should the pla- centa be unfortunately found immediately under the incision, a con- siderable loss of blood is likely to take place, which can only be checked by removing it from its attachments, and concluding the operation as rapidly as possible. Importance of securing Uterine Contraction. — As soon as the child and the secundines have been extracted, the sooner the uterus con- tracts the better. It will usually do so of itself, but should it remain lax and flabby, it should be pressed and stimulated by the hand. "We are specially warned against handling the uterus by Eamsbotham and others; but there seems no valid reason why we should not restrain hemorrhage in this way, as after a natural labor. The intervention of the abdominal parietes, in their lax condition after delivery, can make very little difference between the two cases. Closure of the Uterine and Abdominal Wounds? — The advisability of closing the uterine wound by sutures is a mooted point. The balance of evidence is certainly in favor of this practice, as tending to prevent the escape of the lochia into the peritoneal cavity. Inter- rupted sutures of silver wire or carbolized gut 2 may be used, and cut short ; or, as successfully practised by Spencer Wells, a continuous silk suture may be applied, one end being passed through the os into the vagina, by which it is subsequently withdrawn. Before closing the uterine wound one or two fingers should be passed through the cervix, to insure its being patulous. A free escape of the lochia in this direction is of great consequence, and Winckel even advises the placing of a strip of lint, soaked in oil, in the os, so as to keep up a free exit for the discharge. A point of great importance, and not sufficiently insisted on, is the advisability of not closing the abdominal wound until we are thoroughly satisfied that hemorrhage is completely stopped, since any escape of blood into the peritoneum would very materially lessen the chances of recovery. In a successful case reported by Dr. New- man, 3 the wound was not closed for nearly an hour. Before doing so all blood and discharges should be carefully removed from the peritoneal cavity, by clean soft sponges dipped in warm water. The abdominal wound should be closed from above downwards, by harelip pins, wire or silk sutures, which should be inserted at a distance of an inch from each other, and passed entirely through the abdominal walls and the peritoneum, at some little distance from the edges of \} Sutures, mostly of silver, have been used in fifteen operations out of one hundred and one, in the United States. We regard their use as invaluable, where the wound gapes from uterine inertia. — Ed.] [ 2 Carbolized catgut has been used in the United States but once, and then failed. Even when treble-knotted, the suture is apt to become untied. The experience of the last ten years in Europe has caused it to be almost universally abandoned. — Ed.] 3 Obst. Trans., vol. viii. 510 OBSTETRIC OPERATIONS. the incision, so as to bring the two surfaces of the peritoneum into contact. By this means we insure the closure of the peritoneal cavity, the opposed surfaces adhering with great rapidity. The sur- face of the wound is then covered with pads of folded lint, kept in position by long strips of adhesive plaster, and the whole covered with a soft flannel belt. Subsequent Management. — Into the subsequent treatment it is un- necessary to enter at any length, since it must be regulated by general principles, each symptom being met as it arises. It has been cus- tomary to administer opiates freely after the operation ; but they seem to have a tendency to produce sickness and vomiting, and ought not to be exhibited unless pain or peritonitis indicate that they are required. In fact, the treatment should in no way differ from that usual after ovariotomy, and the principles that should guide us will be best shown by the following quotation from Mr. Spencer Wells's description of that operation : " The principles of after-treatment are — to obtain extreme quiet, comfortable "warmth, and perfectly clean linen to the patient; to relieve pain by warm applications to the abdomen, and by opiate enemas; to give stimulants when they are called for by failing pulse or other signs of exhaustion; to relieve sickness by ice, or iced drinks; and to allow plain, simple, but nourishing food. The catheter must be used every six or eight hours, until the patient can move without pain. The sutures are re- moved on the third day, unless tympanitic distension of the stomach or intestines endanger re-opening of the wound. In such circum- stances they may be left for some days longer. The superficial sutures may remain until union seems quite firm." Substitutes for the Csesarean Section; Symphyseotomy . — Bearing in mind the great mortality attending the Cesarean section, it is not surprising that obstetricians should have anxiously considered the possibility of devising a substitute, which should afford the mother a better chance of recovery. The first proposal of the kind was one from which great results were at first anticipated. In 1768 Sigault, then a student of medicine in Paris, suggested symphyseotomy , which consists in the division of the symphysis pubis, with the view of allowing the pubic bones to separate sufficiently to admit of the passage of the child. Although at first strongly opposed, it was sub- sequently ardently advocated by many obstetricians, and was often performed on the Continent, and in a few cases in this country. The Operation is Admitted to be Useless. — It is generally admitted that it is quite impossible to make this a substitute for the C cesarean section, since the utmost gain which even a wide separation of the symphysis pubis would give would be altogether insufficient to admit of the passage of even a mutilated foetus. Dr. Churchill concludes that, even if were possible to separate it to the extent of four inches, we should only have an increase of from four lines to half an inch in the antero-posterior diameter, in which the obstruction is generally most marked. In the lesser degrees of deformity this might possibly be sufficient to allow the foetus to pass ; but the risk of the operation CESAREAN SECTION. 511 itself, and the subsequent ill effects, altogether contra-indicate it in cases of this description. Laparo-Elytrotomy. — A far more promising operation is one which was originally suggested by Jdrg and Eitgen, in 1820, under the name of Gastro-Elytrotomy, but which, in the then defective state of abdominal surgery, scarcely received attention, and has not even been alluded to in any of our standard obstetric works. It has re- cently been reconsidered by Professor Thomas, of New York, 1 who suggests for it the name of Laparo-Elytrotomy, and it has now been performed five times in America. In two out of these cases the mother was in articulo mortis, but the remaining three mothers re- covered ; and, out of ten, five children were born alive. This is a remarkable result, and, at the least, entitles this operation to the most earnest attention of the profession. Should future cases show anything like the same success it will be the duty of accoucheurs to adopt this procedure instead of the almost inevitably fatal Cesarean section. 2 Object of the Operation and its Advantages. — In this operation it is proposed to divide the vagina at its juncture with the cervix, this being reached by an incision extending from the symphysis pubis to the anterior superior spine of the ilium. The loosely-attached peri- toneum is then raised up, and the child removed through the os uteri by turning, and extracted through the opening in the abdomen. It must be at once apparent that the chief dangers of the Cesarean section are obviated ; for the peritoneal cavity is not opened (and, therefore the risk of peritonitis is much lessened), there is no escape of blood into the peritoneum, and the uterus itself is not incised. The operation, as described and performed by Thomas, is as follows : — 1st. An incision is made extending from the symphysis pubis to the anterior superior spine of the ilium, dividing the thickness of the abdominal walls until the peritoneum is reached.- 2d. The peritoneum is lifted up by means of the fingers, or by metal retractors, so as to admit of the juncture of the vagina and uterus being reached. So far the operation is precisely that which is practised by surgeons for the ligature of the iliac arteries, and offers no particular difficulties. 3d. The vagina is made to protrude in the wound by means of a metal sound, introduced through the vulva, and is divided to a suffi- cient extent. 4th. This will allow the cervix to be reached, and it is drawn into the iliac fossa by a blunt hook passed into it, while the fundus uteri is depressed by an assistant in an opposite direction. If the os uteri be sufficiently open (and if possible it should have been previously dilated with caoutchouc bags), the hand is passed into the uterus, and the child removed by turning. 1 Laparo-Elvtrotomy, a substitute for the Cesarean Section: read before the New York Academy of Medicine, March 6, 1878. 2 [A very careful canvass of the State of Louisiana, carried on for some years, shows 18 Csesarean operations with 14 women saved. — Ed.] 512 OBSTETRIC OPERATIONS. In the American cases no special difficulty was met with in the performance of the operation, although in some of them the perito- neum was thickened and united to the neighboring parts by antece- dent inflammation. It is worthy of notice that in none of them was there any hemorrhage of consequence, although the iarge vascular supply to the vagina naturally renders that one of the most serious risks which we have to apprehend. No one who has seen much of ovariotomy could reasonably hold that there is anything in this procedure incompatible with success. Whether subsequent experience will justify the hopes that Dr. Thomas holds out, remains to be seen. Of course, all that can now be said of it is, that the operation is theoretically sufficiently simple, and that it offers a possible way of removing the child, without some of the gravest risks of the Csesarean section. Should hemorrhage occur, it would probably be quite within control, either by ligatures, or, as Thomas suggests, by passing a metallic speculum either through the abdominal wound or the vagina, and applying through it the actual cautery or the perchloride of iron. No difficulty need be anticipated in retracting the peritoneum to a sufficient extent, for in pregnancy that membrane is unusually ample, and much more loose in its attachments than in the non-pregnant state. [This operation, devised by Eitgen and Physick, and put into suc- cessful practice by Thomas and Skene, may possibly prove much less fatal than gastro-hysterotomy has in England, but we have grave doubts as to its adaptation to the rostrate pelvis of malacos- teon, which must materially interfere with delivery through the vagi- nal incision. — Ed.] [The Cesarean operation in our own country, with all its disad- vantages in a newly settled and sparsely inhabited land, has been so much more successful than in Great Britain, that we are inclined to regard it with much less dread of consequences than is done by English obstetricians. We are very apt in the United States to be influenced by the medical experiences of the Old World, and to cal- culate risks in operations by their collected statistics, when a careful collation at home, would show very different results. In no one operation perhaps, is there a more marked difference, than is to be found in the records of gastro-hysterotomy in England and America. This is due to several causes, which are greatly in our favor. 1. We have the advantages of a dry climate. 2. Osteomalacia, the adult bone-softening, so prevalent among child-bearing women of the Old World, and so fruitful a cause of pelvic deformity, does not prevail here, and has in no instance in America been the cause of difficulty, which has made the Cesarean section a necessity. 3. To the exist- ence of this disease we attribute much of the want of success in Great Britain. 4. We have no beer-drinking peasant women to operate upon, than whom worse subjects for surgery can scarcely be found. 5. We do not operate upon a woman with the feeling, that in all human probability she is much more likely to die than recover, and on this account, make her case almost hopeless by long delay, or by various fruitless and exhausting expedients to avoid the resort to CESAREAN SECTION. 513 what has been denominated "the forlorn hope" We have in many instances failed through delay; but a comparison made between timely English and American operations is very largely in our favor. 1 By means of a long-continued research, and an extensive correspond- ence, we have collected the records of 108 American Cesarean cases, 101 of them being in the United States. Fifty one of the 108 women were saved alive, and 45 out of the 101 ; the proportionate mortality in the second instance, being increased by the fact, that 38 of the 101 cases had never been published, such operations having been fatal in the proportion of two to one saved. Published cases, as a rule, show much the most favorable side of the question, our own giving a mortality of only 36 per cent, against one of 68 per cent., in those ob- tained by direct correspondence. We believe that our statistics more fully represent the truth with regard to gastro-hysterotomy in our country than those of any other land yet published; although after nine years 1 search we feel that the work is still imperfect. What most concerns us, is to determine the true clanger of the operation in the United States, when performed with due regard to time and condition. This we can approach in a measure by noting the result in 24 cases where the section was made early in labor; there were 18 women and 21 children saved. Seventeen operations performed npon eight women resulted favor- ably in fourteen instances ; one died from the third operation and two from the second. We are inclined to believe, that if timely performed, and with due skill and care, the Cassarean operation in our country is not as dangerous as craniotomy in pelves having a conjugate diameter of 2J inches or less. This was the opinion of the late Dr. Parry, 2 and our own observations have fully confirmed his views. In this city the Cesarean operation has been performed four times with a loss of two women, all the children being alive at the last accounts. There is no reason why our obstetricians should stand in awe of this operation if they are prompt in deciding and acting, so as to give both mother and child the best possible prospect of life. It should always be remembered, that the danger does not lie so much in incising the uterus per se, as in making the incision, when this organ has been rendered susceptible to inflammatory action by its prolonged efforts at expulsion and by exhaustion on the part of the patient. Ovariotomists by their repeated successes, have prepared the way for a more hopeful view of gastro-hysterotomy and of laparotomy for the purpose of delivery in rupture of the uterus and abdominal pregnancy; and there is reason to believe that in time all these operations will be performed with an encouraging hope of success. — ■ Ed.] 1 See Harris on Gastro-hysterotomy, Am. Jour. Med. Sei., April, 1878, p. 324. 514 OBSTETRIC OPERATIONS. CHAPTEE VII. THE TRANSFUSION OF BLOOD. The transfusion of blood in desperate and apparently hopeless cases of hemorrhage, offers a possible means of rescuing the patient which merits careful consideration. It has again and again attracted the attention of the profession, but has never become popularized in obstetric practice. The reason of this is not so much the inherent defects of the operation itself — for quite a sufficient number of suc- cessful cases are recorded to make it certain that it is occasionally a most valuable remedy — but the fact that the operation has been con- sidered a delicate and difficult one, and that it has been deemed necessary to employ complicated and expensive apparatus, which is never at hand when a sudden emergency arises. Whatever may be the difference of opinion about the value of transfusion, I think it must be admitted that it is of the utmost consequence to simplify the process in every possible way, and it is above all things neces- sary to show that the steps of the operation are such as can be readily performed by any ordinarily-qualified practitioner, and that the ap- paratus is so simple and portable as to make it easy for any obstetri- cian to have it at hand. There are comparatively few who would consider it worth while to carry about with them, in ordinary every- day work, cumbrous and expensive instruments which may never be required in a life-long practice ; and hence it is not unlikely that, in many cases in which transfusion might have proved useful, the op- portunity of using it has been allowed to slip. Of late years the operation has attracted much attention, the method of performing it has been greatly simplified, and I think it will be easy to prove that all the essential apparatus may be purchased for a few shillings, and in so portable a form as to take up little or no room ; so that it may be always carried in the obstetric bag ready for any possible emergency. The history of the operation is of considerable interest. In Villari's " Life of Savonarola " it is said to have been employed in the case of Pope Innocent VIII., in the year 1492, but I am not aware on what authority the statement is made. The first serious proposals for its performance do not seem to have been made until the latter half of the seventeenth century. It was first actually performed in France, by Denis, of Montpellier, although Lower, of Oxford, had previously made experiments on animals which satisfied him that it might be undertaken with success. In November, 1667, some months after Denis's case, he made a public experiment at Arundel House, in which twelve ounces of sheep's blood were injected into the veins ot a healthy man, who is stated to have been very well after the opera- THE TRANSFUSION OF BLOOD. 515 tion, which must, therefore, have proved successful. These u early simultaneous cases gave rise to a controversy as to priority of inven- tion, which was long carried on with much bitterness. The idea of resorting to transfusion after severe hemorrhage does not seem to have been then entertained. It was recommended as a means of treatment in various diseased states, or with the extrava- gant hope of imparting new life and vigor to the old and decrepit. The blood of the lower animals only was used ; and, under these cir- cumstances, it is not surprising that the operation, although practised on several occasions, was never established as it might have been had its indications been better understood. From that time it fell almost entirely into oblivion, although ex- periments and suggestions as to its applicability were occasionally made, especially by Dr. Harwood, Professor of Anatomy at Cam- bridge, who published a thesis on the subject in the year 1785. He, however, never carried his suggestions into practice, and, like his pre- decessors, only proposed to employ blood taken from the lower animals. In the year 1824 Dr. Blundell published his well-known work, entitled "Kesearches, Physiological and Pathological," which detailed a large number of experiments ; and to that distinguished physician belongs the undoubted merit of having brought the subject prominently before the profession, and of pointing out the cases in which the operation might be performed with hopes of success. Since the publication of this work, transfusion has been regarded as a legitimate operation under special circumstances ; but, although it has frequently been performed with success, and in spite of many in- teresting monographs on the subject, it has never become so estab- lished, as a general resource in suitable cases, as its advantages would seem to warrant. Within the last few years more attention has been paid to the subject, and the writings of Panum, Martin, and de Belina, abroad, and of Higginson, McDonnell Hicks, and Aveling at home, amongst many others, have thrown much light on many points con- nected with the operation, and it is to be hoped that the committee appointed by the Obstetrical Society, in their forthcoming report, may still more increase our knowledge. Nature and Object of the Operation. — Transfusion is practically only employed in cases of profuse hemorrhage connected with labor, al- though it has been suggested as possibly of value in certain other puerperal conditions, such as eclampsia, or puerperal fever. Theo- retically it may be expected to be useful in such diseases ; but, inas- much as little or nothing is known of its practical effects in these diseased states, it is only possible here to discuss its use in cases of excessive hemorrhage. Its action is probably twofold. 1st, the actual restitution of blood which has been lost. 2d, the supply of a sufficient quantity of blood to stimulate the heart to contraction, and thus to enable the circulation to be carried on until fresh blood is formed. The influence of transfusion as a means of restoring lost blood must be trivial, since the quantity required to produce an effect is generally very small indeed, and never sufficient to counter- balance that which has been lost. Its stimulant action is no doubt 516 OBSTETRIC OPERATIONS. of far more importance ; and if the operation be performed before the vital energies are entirely exhausted, the effect is often most marked. Use of Blood taken from the Lower Animals. — In the earliest opera- tions the blood used was always that of the lower animals, generally of the sheep. Dr. Blundell believed that such blood could not be employed with success. Eecent cases, such as those published by Keene, who used lamb's blood in 12 cases, 1 have conclusively proved this idea to be erroneous. Brown-Sequard has shown that Blundell's experiments with animal blood failed, partly because he used too large a quantity and injected too quickly, and partly because he used blood too rich in carbonic acid and too poor in oxygen. He has shown that the success of the operation must depend to a great ex- tent on these points, and that blood, containing sufficient carbonic acid to be black, proves directly poisonous, unless it is injected in very small quantity, and with great slowness. Although, then, it is certain that the blood of some of the lower animals, especially of those in which the corpuscles are of less size than in man, as in sheep, can be employed with safety, still the operation, of late years, has been almost always performed with human blood alone, and, for many obvious reasons, is always likely to be so. Difficulties from Coagulation of Fibrine — The great practical diffi- culty in transfusion has always been the coagulation of the blood very shortly after it has been removed from the body. When fresh drawn blood is exposed to the atmosphere, the fibrine commences to solidify rapidly, generally in from three to four minutes, sometimes much sooner. It is obvious that the moment fibrination has com- menced the blood is, ijjso facto, unfitted for transfusion, not' only be- cause it can be no longer passed readily through the injecting appa- ratus, but because of the great danger of propelling small masses of fibrine into the circulation, and thus causing embolism. Hence, if no attempt be made to prevent this difficulty, it is essential, no matter what apparatus is used, to hurry on the operation so as to inject be- fore fibrination has begun. This is a fatal objection, for there is no operation in the whole range of surgery in which calmness and de- liberation are so essential, the more so as the surroundings of the patient in these unfortunate cases are such as to tax the presence of mind and coolness of the practitioner and his assistants to the utmost. Methods of Obviating Coagulation. — All the recent improvements have had for their object the avoidance of coagulation, and practi- cally this has been effected in one of three ways. 1st, hj immediate transfusion from arm to arm, without allowing the blood to be ex- posed to the atmosphere, according to the methods proposed by Aveling and Koussel. [Direct tubular transfusion from arm to arm, is pictured in Heister's Surgery, London, 1768, p. 336. — Ed.] 2d, by adding to the blood certain chemical reagents which have the pro- perty of preventing coagulation. 3d, removal of the fibrine entirely, 1 London Med. Record, Dec. 31, 1873. THE TRANSFUSION OF BLOOD. 517 by promoting its coagulation and straining the blood, so that the liquor sanguinis and blood corpuscles alone are injected. Inasmuch as the success of the operation altogether depends on the method adopted, it will be well, before going further, to consider briefly the advantages and disadvantages of each of these plans. Immediate Transfusion. — 1. The method of immediate transfusion has been brought prominently before the profession by Dr. Aveling, who has invented an ingenious apparatus for performing it. The apparatus consists essentially of a miniature Higginson's syringe, without valves, and with a small silver canula at either end. One canula is inserted into the vein of the person supplying blood, the other into a vein of the patient, and by a peculiar manipulation of the syringe, subsequently to be described, the blood is carried from one vein into the other. It must be admitted that, if there were no practical difficulties, this instrument would be admirable, and it is therefore not surprising that it should have met with so much favor from the profession. I cannot but think, however, that the opera- tion is not so simple as it at first sight appears, and that therefore it wants one of the essential elements required in any procedure for performing transfusion. One of my objections is, that it is by no means easy to work the apparatus without considerable practice. Of this I have satisfied myself by asking members of my class to work it after reading the printed directions, and finding that they are not always able to do so at once. Of course it may be said that it is easy to acquire the necessary manipulative skill ; but, when the necessity for transfusion arises, there is no time left for practising with the instrument, and it is essential that an apparatus, to be uni- versally applicable, should be capable of being used immediately, and without previous experience. Other objections are the necessity of several assistants, the uncertainty of there being a sufficient circu- lation of blood in the veins of the donor to afford a constant supply, and the possibility of the whole apparatus being disturbed by rest- lessness or jactitation on the part of the patient. For these reasons, it seems to me that this plan of immediate transfusion is not so simple, nor so generally applicable, as defibrination. Still, it is im- possible not to recognize its merits, and it is certainly well worthy of further study and investigation. Another method of immediate transfusion is that recommended by Eoussel, 1 whose apparatus has recently attracted considerable attention. It possesses many undoubted advantages, and is, beyond doubt, a valuable addition to our means of performing the opera- tion. It has, however, the great disadvantage of being costly and complicated, and hence I do not believe that it is likely to come into general use. Addition of Chemical Agents to Prevent Coagulation. — 2. The second plan for obviating the bad effects of clotting is the addition of some substance to the blood which shall prevent coagulation. It is well known that several salts have this propert}^, and the experiments 1 Obstetrical Transactions, vol. xviii. 518 OBSTETRIC OPERATIONS. made in the case of cholera patients prove that solutions of some of them may be injected into the venous system without injury. This method has been specially advocated by Dr. Braxton Hicks, who uses a solution of three ounces of fresh phosphate of soda in a pint of water, about six ounces of which are added to the quantity of blood to be injected. He has narrated 4 cases 1 in which this plan was adopted successfully, so far as the prevention of coagulation was concerned. It certainly enables the operation to be performed with deliberation and care, but it is somewhat complicated; and it may often happen that the necessary chemicals are not at hand. A further objection is the bulk of fluid which must be injected, and there is reason to believe that this has, in some cases, seriously embarrassed the heart's action, and interfered with the success of the operation. In many of the successful cases of transfusion the amount of blood injected has been very small, not more than two ounces. Dr. Eichardson proposes to prevent coagulation by the addition of liquor ammonise to the blood, in the proportion of two minims, diluted with twenty minims of water, to each ounce of blood. Defibrination of the Blood. — 3. The last method, and the one which, on the whole, I believe to be the simplest and most effectual, is defi- brination. It has been chiefly practised in this country by Dr. McDonnell, of Dublin, who has published several very interesting cases in which he employed it, and abroad by Martin, of Berlin ; de Belina, of Paris [and James G. Allen, of Philadelphia. — Ed.]. The process of removing the fibrine is simple in the extreme, and occu- pies a few minutes only. Another advantage is that the blood to be transfused may be prepared quietly in an adjoining apartment, so that the operation may be performed with the greatest calmness and deliberation, and the donor is spared the excitement and distress which the sight of the apparently moribund patient is apt to cause, and which, as Dr. Hicks has truly pointed out, may interfere with the free flow of blood. The researches of Panum, Brown-Sequard, and others, have proved that the blood corpuscles are the true vivi- fying element, and that defibrinated blood acts as well, in every respect, as that containing fibrine. It has been proved that the fibrine is reproduced within a short time, 2 and the whole tendency of modern research is to regard it, not as an essential element of the blood, but as an excrementitious product, resulting from the degra- dation of tissue, which may, therefore, be advantageously removed. Another advantage derived from defibrination is, that the corpuscles are freely exposed to the atmosphere, oxygen is taken up, and car- bonic acid given off, and the dangers which Brown-Sequard has shown to arise from the use of blood containing too much carbonic acid are thereby avoided. There can be, therefore, no physiological objection to the removal of the fibrine, which, moreover, takes away all practical difficulty from the operation. The straining to which the defibrinated blood is subjected entirely prevents the possibility 1 Guy's Hosp. Reports, vol. xiv. 2 Panum, Virchow's Arch., vol. xxvii THE TRANSFUSION OF BLOOD. 519 of even the most minute particle of fibrine being contained in the injected fluid; the risk from embolism is, therefore, less than in any of the other processes already referred to. My own experience of this plan is limited to 3 cases, but in 2 it answered so well that I can conceive no reasonable objection to it. I should be inclined to say that transfusion, thus performed, is amongst the simplest of surgical operations — an opinion which the experience of McDonnell and others fully confirms. Statistical Results. — The number of cases of transfusion are perhaps not sufficient to admit of completely reliable conclusions. It is cer- tain, however, that transfusion has often been the means of rescuing the patient when apparently at the point of death, and after all other means of treatment had failed. Professor Martin records 57 cases, in 43 of which transfusion was completely successful, and in 7 tem- porarily so; while in the remaining 7 no reaction took place. Dr. Higginson, of Liverpool, has had 15 cases, 10 of which were success- ful. Figures such as these are encouraging, and they are sufficient to prove that the operation is one which at least offers a fair hope of success, and which no obstetrician would be justified in neglecting, when the patient is sinking from the exhaustion of profuse hemor- rhage. It is to be hoped also that further experience may prove it to be of value in other cases, in which its use has been suggested, but not, as yet, put to the test of experiment. Possible Dangers of the Operation. — The possible risks of the opera- tion would seem to be the danger of injecting minute particles of fibrine which form emboli, or bubbles of air, or of overwhelming the action of the heart by injecting too rapidly, or in too great quantity. These may be, to a great extent, prevented by careful attention to the proper performance of the operation, and it does not clearly appear, from the recorded cases, they have ever proved fatal. We must also bear in mind that transfusion is seldom or ever likely to be attempted until the patient is in a state which would otherwise almost certainly preclude the hope of recovery, and in which, there- fore, much more hazardous proceedings would be fully justified. Cases Suitable for Transfusion. — The cases suitable for transfusion are those in which the patient is reduced to an extreme state of exhaustion from hemorrhage during or after labor or miscarriage, whether by the repeated losses of placenta prsevia, or the more sudden and profuse flooding of post-partum hemorrhage. The opera- tion will not be contemplated until other and simpler means have been tried and failed, or until the symptoms indicate that life is on the verge of extinction. If the patient should be deadly pale and cold, with no pulse at the wrist, or one that is scarcely perceptible ; if she be unable to swallow, or vomits incessantly; if she lie in an unconscious state; if jactitation, or convulsions, or repeated fainting should occur; if the respiration be laborious, or very rapid and sighing; if the pupil do not act under the influence of light; it is evident that she is in a condition of extreme danger, and it is, under such circumstances, that transfusion, performed sufficiently soon, offers a fair prospect of success. It does not necessarily follow be- 520 OBSTETRIC OPERATIONS. cause one or other of these symptoms is present, that there is no chance of recovery under ordinary treatment, and indeed it is within the experience of all, that patients have rallied under apparently the most hopeless conditions. But when several of them occur together, the prospect of recovery is much diminished, and transfusion would then be fully justified, especially as there is no reason to think that a fatal result has ever been directly traced to its employment. In- deed, like most other obstetric operations, it is more likely to be postponed until too late to be of service, than to be emploj^ed too early; and in some of the cases reported as unsuccessful, it was not performed until respiration had ceased, and death had actually taken place. It has been sometimes said that transfusion can never be employed if the uterus be not firmly contracted, so as to prevent the injected blood again escaping through the uterine sinuses. The cases in which this is likely to occur are few; and if one were met w r ith, the escape of blood could be prevented by the injection into the uterus of the perchloride of iron. Description of the Operation. — In describing the operation I shall limit myself to an account of Aveling's method of immediate trans- fusion, and to that of injecting defibrinated blood. I consider myself justified in omitting any account of the numerous apparatuses which have been invented for the purpose of injecting pure blood, since I believe the practical difficulties are too great ever to render this form of operation serviceable. The great objection to most of the instru- ments used is their cost and complexity : and as long as any special apparatus is considered essential, the full benefits to be derived from transfusion are not likely to be realized. The necessity for employ- ing it arises suddenly ; it may be in a locality in which it is impossi- ble to procure a special instrument; and it would be well if it were understood that transfusion may be safely and effectually performed by the simplest means. In many of the successful cases an ordinary syringe was used ; in one, in the absence of other instruments, a child's toy syringe was employed. I have nryself performed it with a simple syringe purchased at the nearest chemist's shop, when a special transfusion apparatus failed to act satisfactorily. Method of performing Immediate Transfusion. — In immediate trans- fusion (Fig. 180), the donor is seated close to the patient, and the veins in the arms of each having been opened, the silver canula at either end of the instrument is introduced into them (a b). The tube between the bulb and the patient is now pinched (d), so as to form a vacuum, and the bulb becomes filled with blood from the donor. The finger is now removed so as to compress the distal tube (d'), and the bulb being compressed (c), its contents are injected into the patient's vein. The bulb is calculated to hold about two drachms, so that the amount injected can be estimated by the number of times it is emptied. The risk of injecting air is prevented by filling the syringe with Avater, which is injected before the blood. Injection of Defibrinated Blood. — For injecting defibrinated blood various contrivances have been used. McDonnell's instrument is a simple cylinder with a nozzle attached, from which the blood is pro- THE TRANSFUSION OF BLOOD 521 pelled by gravitation. When the propulsive power is insufficient, increased pressure is applied by breathing forcibly into the open end of the receiver. De Belina's instrument is on the same principle, only atmospheric pressure is supplied by a contrivance similar to Fig. 180. i D Method of Transfusion by Aveling's Apparatus. Kichardson's spray-producer, attached to one end. The idea is simple, but there is some doubt of a gravitation instrument being sufficiently powerful, and it certainly' failed in my hands. I have had valves applied to Aveling's instrument, so that it works by compression of the bulb, like an ordinary Higginson's syringe. This, with a single silver canula at one end, for introduction into the vein, forms a per- fect and inexpensive transfusion apparatus, taking up scarcely any space. If it be not at hand, any small syringe, with a tolerably fine nozzle, may be used. Mode of Preparing the Blood. — The first step of the operation is defibrination of the blood, which should, if possible, be prepared in an apartment adjoining the patient's. The blood should be taken from the arm of a strong and healthy man. The quality cannot be unimportant, and, in some recorded cases, the failure of the operation, has been attributed to the fact of the donor having been a weakly female. The supply from a woman might also prove insufficient ; and, although it has been shown that blood from two or more per- sons may be used with safety, yet such a change necessarily causes delay, and should, if possible, be avoided. A vein having been opened, eight or ten ounces of blood are withdrawn, and received into some perfectly clean vessel, such as a dessert finger-glass. As it flows it should be briskly agitated with a clean silver fork, or a glass rod, and, very shortly, strings of fibrine begin to form. It is now strained through a piece of fine muslin, previously dipped in hot water, into a second vessel which is floating in water at a tempera- ture of about 105°. By this straining the fibrine and air-bubbles resulting from the agitation are removed, and, if there be no exces- sive hurry, it might be well to repeat the straining a second time. It the vessel be kept floating in warm water, the blood is prevented 34 522 OBSTETRIC OPERATIONS. from getting cool, and we can now proceed to prepare the arm of the patient for injection. Mode of Exposing the Veins selected for Transfusion. — This is the most delicate and difficult part of the operation, since the veins are generally collapsed and empty, and by no means easy to find. The best way of exposing them is that practised by McDonnell, who pinches up a fold of the skin at the bend of the elbow, and transfixes it with a fine tenotomy knife or scalpel, so making a gaping wound in the integument, at the bottom of which they are seen lying. A probe should now be passed underneath the vein selected for opening, so as to avoid the chance of its being lost at any subsequent stage of the operation. This is a point of some importance, and from the neglect of this precaution I have been obliged to open another vein than that originally fixed on. A small portion of the vein being raised with the forceps, a nick is made into it for the passage of the canula. Injection of the Blood. — The prepared blood is now brought to the bedside, and, the apparatus having been previously filled with blood to avoid the risk of injecting any bubbles of air, the canula is in- serted into the opening made in the vein, and transfusion commenced. It should be constantly borne in mind that this part of the operation should be conducted with the greatest caution, the blood introduced very slowly, and the effect on the patient carefully watched. The injection may be proceeded with until some perceptible effect is pro- duced, which will generally be a return of the pulsation, first at the heart, and subsequently at the wrist, an increase in the temperature of the body, greater depth and frequency of the respirations, and a general appearance of returning animation about the countenance. Sometimes the arms have been thrown about, or spasmodic twitch - ings of the face have taken place. The quantity of blood required to produce these effects varies greatly, but in the majority of cases has been very small. Occasionally 2 ounces have proved sufficient, and the average may be taken as ranging between 4 and 6 : although in a few cases between 10 and 20 have been used. The practical rule is to proceed very slowly with the injection until some per- ceptible result is observed. Should embarrassed or frequent respira- tion supervene, Ave may suspect that we have been injecting either too great a quantity of blood, or with too much force and rapidity, and the operation should at once be suspended, and not resumed until the suspicious symptoms have passed away. It may happen that the effects of the transfusion have been highly satisfactory, but that in the course of time there is evidence of returning syncope. This may possibly be prevented by the administration of stimulants ; but if these fail there is no reason why a fresh supply of blood should not again be injected, but this should be done before the effects of the first transfusion have entirely passed away. Secondary Effects of Transfusion. — The subsequent effects in suc- cessful cases of transfusion merit careful study. In some few cases death is said to have happened within a few weeks, with symptoms resembling pyemia. Too little is known on this point, however, to justify any positive conclusions with regard to it. [For an account of the intra- venous injection of milk, see Appen- dix.— Ed.] PART V. THE PUERPERAL STATE CHAPTER I. THE PUERPEKAL STATE AND ITS MANAGEMENT. Importance of Studying the Puerperal State. — The key to the man- agement of women after labor, and to the proper understanding of the many important diseases which may then occur, is to be found in a study of the phenomena following delivery, and of the changes going on in the mother's system during the puerperal period. ISFo doubt natural labor is a physiological and healthy function, and during recovery from its effects disease should not occur. It must not be forgotten, however, that none of our patients are under phy- siologically healthy conditions. The surroundings of the lying-in woman, the effects of civilization, of errors of diet, of defective clean- liness, of exposure to contagion, and of a hundred other conditions, which it is impossible to appreciate, have most important influences on the results of childbirth. Hence it follows that labor, even under the most favorable conditions, is attended with considerable risk. The Mortality of Childbirth. — It is not easy to say with accuracy what is the precise mortality accompanying childbirth in ordinary domestic practice, since the returns derived from the reports of the Registrar-General, or from private sources, are manifestly open to serious error. The nearest approach to a reliable estimate is that made by Dr. Matthews Duncan, 1 who calculates from figures derived from various sources, that not fewer than 1 out of every 120 women, delivered at or near the fall time, dies within four weeks of child- birth. This indicates a mortality far above that which has been generally believed to accompany child-bearing under favorable cir- cumstances. It, however, closely approximates to a similar estimate made by McClintock, 2 who calculates the mortality in England and Wales as 1 in 126 ; and in the upper and middle classes alone, where the conditions may naturally be supposed to be more favorable, as 1 in 146. In these calculations there are some obvious sources of error, since they include deaths from all causes within four weeks of delivery, some of which must have been independent of the puerperal state. 1 "The Mortality of Childbed," Edin. Med. Journ., Nov. 1869. 2 Dublin Quarterly Journ., Aug. 1869. 524 THE PUERPERAL STATE. But it is not the deaths alone which should be considered. All practitioners know how large a number of their patients suffer from morbid states which may be directly traced to the effects of child- bearing. It is impossible to arrive at any statistical conclusion on this point, but it must have a very sensible and important influence on the health of child-bearing women. Alterations in the Blood after Delivery. — The state of the blood during pregnancy, already referred to, has an important bearing on the puerperal state. There is hyperinosis, which is largely increased by the changes going on immediately after the birth of the child ; for then the large supply of blood, which has been going to the uterus, is suddenly stopped, and the system must also get rid of a quantity of effete matter thrown into the circulation, in consequence of the degenerative changes occurring in the muscular fibres of the uterus. Hence all the depurative channels, by which this can be eliminated, are called on to act with great activity. If, in addition, the peculiar con- dition of the generative tract be borne in mind — viz., the large open vessels on its inner surface — the partially bared inner surface of the uterus, and the channels for absorption existing in consequence of slight lacerations in the cervix or vagina — it is not a matter of sur- prise that septic diseases should be so common. Condition after Delivery. — It will be well to consider successively the various changes going on after delivery, and then we shall be in a better position for studying the rational management of the puerperal state. Nervous Shock. — Some degree of nervous shock or exhaustion is observable after most labors. In many cases it is entirely absent ; in others it is well marked. Its amount is in proportion to the severity of the labor, and the susceptibility of the patient ; and it is, therefore, most likely to be excessive in women who have suffered greatly from pain, who have undergone much muscular exertion, or who have been weakened from undue loss of blood. It is evidenced by a feeling of exhaustion and fatigue, and not uncommonly there is some shivering, which soon passes off, and is generally followed by refreshing sleep. The extreme nervous susceptibility continues for a considerable time after delivery, and indicates the necessity of keeping the lying-in patient as free from all sources of excitement as possible. Fall of the Pulse. — Immediately after deliver}?- the pulse falls, and the importance of this, as indicating a favorable state of the patient, has already been alluded to. The condition of the pulse "has been carefully studied by Blot, 1 avIio has shown that this diminution, Avhich he believes to be connected with an increased tension in the arteries, due to the sudden arrest of the uterine circulation, continues, in a large proportion of cases, for a considerable number of days after delivery ; and, as a matter of clinical import, as long as it does, the patient may be considered to be in a favorable state. In many instances the slowness of the pulse is remarkable, often sinking to 1 Arch. G6n. de M6d., 1864. THE PUERPERAL STATE AND ITS MANAGEMENT. 525 50 or even 40 beats per minute. Any increase above the normal rate, especially if at all continuous, should always be carefully noted, and looked on with suspicion. In connection with this subject, however, it must be remembered that in puerperal women the most trivial circumstances may cause a sudden rise of the pulse. This must be familiar to every practical obstetrician, who has constant opportunities of observing this effect after any transient excitement or fatigue. In lying-in hospitals it has generally been observed that the occurrence of any particularly bad case will send up the pulse of all the other patients who may have heard of it. Temperature in the Puerperal State. — The temperature in the lying- in state affords much valuable information. Daring, and for a short time after labor, there is a slight elevation. It soon falls to, or even somewhat below, the normal level. Squire found that the fall oc- curred within twenty-four hours, sometimes within twelve hours, after the termination of labor. 1 For a few days there is often a slight increase of temperature, which is probably caused by the rapid oxidation of tissue in connection with the involution of the uterus. In about forty-eight hours there is a rise connected with the estab- lishment of lactation, amounting to one or two degrees over the normal level; but this again subsides as soon as the milk is freely secreted. Crede" has also shown 2 that rapid, but transient, rises of temperature may occur at any period, connected with trivial causes, such as constipation, errors of diet, or mental disturbances. But, if there be any rise of temperature which is at all continuous, especially to over 100° Fahr., and associated with rapidity of the pulse, there is reason to fear the existence of some complication. The Secretions and Excretions. — The various secretions and excre- tions are carried on with increased activity after labor. The skin especially acts freely, the patient often sweating profusely. There is also an abundant secretion of urine, but not uncommonly a diffi- culty of voiding it, either on aocount of temporary paralysis of the neck of the bladder, resulting from the pressure to which it has been subjected, or from swelling and occlusion of the urethra. For the same reason the rectum is sluggish for a time, and constipation is not infrequent. The appetite is generally indifferent, and the patient is often thirsty. Secretion of Milk. — Generally in about forty-eight hours the secre- tion of milk becomes established, and this is occasionally accompanied by a certain amount of constitutional irritation. The breasts often become turgid, hot, and painful. There may, or may not, be some general disturbance, quickening of pulse, elevation of temperature, possibly slight shivering, and a general sense of oppression, Avhich are quickly relieved as the milk is formed, and the breasts emptied by suckling. Squire says that the most constant phenomenon con- nected with the temperature is a slight elevation as the milk is secreted, rapidly falling when lactation is established. Barker noted i (< Puerperal Temperatures," Obstetrical Transactions, vol. ix. 2 Monat. f. Geburt, Dec. 1868. 526 THE PUERPERAL STATE. elevation, either of temperature or pulse, in only 4 out of 52 cases which were carefully watched. There can be little doubt that the importance of the so-called "milk fever" has been immensely ex- aggerated, and its existence, as a normal accompaniment of the puerperal state, is more than doubtful. It is certain, however, that, in a small minority of cases, there is an appreciable amount of dis- turbance about the time that the milk is formed. Many modern writers, such as Winckel, Griinewaldt, and d'Espine, entirely deny the connection of this disturbance with lactation, and refer it to a slight and transient septicaemia. Grraily Hewitt remarks that it is most commonly met with when the patient is kept low and on defi- cient diet after delivery, especially when the system is below par from hemorrhage, or any other cause. This observation will, no doubt, account for the comparative rarity of febrile disturbance in connection with lactation in these days, in which the starving of puerperal patients is not considered necessary. It is certain that anything deserving the name of milk fever is now altogether excep- tional, and such feverishness as exists is generally quite transient. It is also a fact, that it is most apt to occur in delicate and weakly women, especially in those who do not, or are unable to, nurse. There does not, however, seem to be any sufficient reason for refer- ring it, even when tolerably well marked, to septicaemia. The relief which attends the emptying of the breasts seems sufficient to prove its connection with lactation, and the discomfort which is necessarily associated with the swollen and turgid mammae, is, of itself, quite sufficient to explain it. Contraction of the Uterus after Delivery. — Immediately after de- livery the uterus contracts firmly, and can be felt at the lower part of the abdomen as a hard, firm mass, about the size of a cricket ball. After a time it again relaxes somewhat, and alternate relaxations and contractions go on, at intervals, for a considerable time after the expulsion of the placenta. The more complete and permanent the contraction, the greater the safety and comfort of the patient ; for when the organ remains in a state of partial relaxation, coagula are apt to be retained in its cavity, while, for the same reason, air enters more readily into it. Hence decomposition is favored, and the chances of septic absorption are much increased ; while, even when this does not occur, the muscular fibres are excited to contract, and severe after-pains are produced. Subsequent Diminution in the Size of the Uterus. — After the first few days the diminution in the size of the uterus progresses with great rapidity. By about the sixth day it is so much lessened as to project not more than 1 J or 2 inches above the pelvic brim, while by the eleventh day it is no longer to be made out by abdominal palpa- tion. Its increased size is, however, still apparent per vaginam, and, should occasion arise for making an internal examination, the mass of the lower segment of the uterus, with its flabby and patulous cervix, can be felt for some weeks after delivery. This may some- times be of practical value in cases in which it is necessary to ascer- tain the fact of recent delivery, and, under these circumstances, as THE PUERPERAL STATE AXD ITS MANAGEMENT. 527 pointed out by Simpson, the uterine sound would also enable us to prove that the cavity of the uterus is considerably elongated. Indeed the normal condition of the uterus and cervix is not regained until six weeks or two months after labor. These observations are corro- borated by investigations on the weight of the organ at different periods after labor. Thus Heschl 1 has shown that the uterus, imme- diately after delivery, weighs about 22 to 24 ozs. ; within a week, it weighs 19 to 21 ozs.; and at the end of the second week, 10 to 11 ozs. only. At the end of the third week, it weighs 5 to 7 ozs. ; but it is not until the end of the second month that it reaches its normal weight. Hence it appears that the most rapid diminution occurs during the second week after delivery. Fatty Transformation of the Muscular Fibres. — The mode in which this diminution in size is effected is by the transformation of the muscular fibres into molecular fat, which is absorbed into the mater- nal vascular system, which, therefore, becomes loaded with a large amount of effete material. Heschl has shown that the entire mass of the enlarged uterine muscles are removed, and replaced by newly- formed fibres, which commence to be developed about the fourth week after delivery, the change being complete about the end of the second month. Generally speaking, involution goes on without inter- ruption. It is, however, apt to be interfered with by a variety of causes, such as premature exertion, intercurrent disease, and, very probably, by neglect of lactation. Hence the uterus often remains large and bulky, and the foundation for many subsequent uterine ailments is laid. Changes in the Uterine Vessels. — Williams has drawn attention to changes occurring in the vessels of the uterus, some of which seem to be permanent, and may, should further observations corroborate his investigations, prove of value in enabling us to ascertain whether a uterus is nulliparous or the reverse ; a question which may be of medico-legal importance. After pregnancy he found all the vessels enlarged in calibre. The coats of the arteries are thickened and hypertrophied, and this he has observed even in the uteri of aged women who have not borne children for may years. The venous sinuses, especially at the placental site, have their walls greatly thickened and convoluted, and contain in their centre a small clot of blood (Fig. 181). This thickening attains its greatest dimensions in the third month after gestation, but traces of it may be detected as late as ten or twelve weeks after labor. Changes in the Uterine Mucous Membrane. — The changes going on in the lining membrane of the uterus immediately after delivery are of great importance in leading to a knowledge of the puerperal state, and have already been discussed when describing the decidua (p. 94). Its cavity is covered with a reddish-gray film, formed of blood and fibrine. The open mouths of the uterine sinuses are still visible, more especially over the site of the placenta, and thrombi may be 1 Researches on the Conduct of the Human Uterus after Delivery. 528 THE PUERPERAL STATE. seen projecting from them. The placental site can be distinctly made out, in the form of an irregularly oval patch, where the lining mem- brane is thicker than elsewhere. Section of a Uterine Sinus from the Placental Site nine weeks after Delivery. (After William-;.) Contraction of the Vagina, etc. — The vagina soon contracts, and, by the time the puerperal month is over, it has returned to its normal dimensions, but after child-bearing it always remains more lax, and less rugous, than in nullipara}. The vulva, at first very lax and much distended, soon regains its former state. The abdominal pari- etes remain loose and flabby for a considerable time, and the white streaks, produced by the distension of the cutis, very generally be- come permanent. In some women, especially when proper support by bandaging has not been given, the abdomen remains permanently loose and pendulous. The Lochial Discharge. — From the time of delivery, up to about three weeks afterwards, a discharge escapes from the interior of the nterus, known as the lochia. At first this consists almost entirely of pure blood, mixed with a variable amount of coagula. If efficient uterine contraction have not been secured after the expulsion of the placenta, coagula of considerable size are frequently expelled with the lochia for one or two days after delivery. In three or four days the distinctly bloody character of the lochia is altered. They have a reddish watery appearance, and are known as the lochia rubra or cruenta. According to the researches of ATertheimer, 1 they are at Yiivhow's Arch., 1861. THE PUERPERAL STATE AND ITS MANAGEMENT. 529 this time composed chiefly of blood corpuscles, mixed with epithelium scales, mucous corpuscles, and the debris of the decidua. The change in the appearance of the discharge progresses gradually, and about the seventh or eighth day it has no longer a red color, but is a pale greenish fluid, Avith a peculiar sickening and disagreeable odor, and is familiarly described as the " green waters." It now contains a l smaller quantity of blood corpuscles, which lessen in amount from day to day, but a considerable number of pus corpuscles, which re- main the principal constituent of the discharge until it ceases. Besides I these, epithelial scales, fatty granules, and crystals of cholesterine, are observed. Occasionally a small infusorium, which has been named the "trichomena vaginalis," has been detected; but it is into of constant occurrence. Variation in its Amount and Duration. — The amount of the lochia varies much, and in some women it is habitually more abundant than in others. Under ordinary circumstances it is very scanty after the first fortnight, but occasionally it continues somewhat abundant for a month or more, without any bad results. It is apt again to become of a red color, and to increase in quantity, in consequence of airy slight excitement or disturbance. If this red discharge con- ! tinue for any undue length of time, there is reason to suspect some abnormality, and it may not unfrequently be traced to slight lacera- tions about the cervix, which have not healed properly. This result may also follow premature exertion, interfering with the proper in- volution of the uterus ; and the patient should certainly not be alloAved to move about as long as much colored discharge is going on. Occasional Fetor of the Discharge. — Occasionally the lochia have an intense^ fetid odor. This must always give rise to some anxiety, since it often indicates the retention and putrefaction of coagula, and involves the risk of septic absorption. It is not very rare, however, to observe a most disagreeable odor persist in the lochia without any bad results. The fetor always deserves careful attention, and an endeavor should be made to obviate it by directing the nurse to syringe out the vagina freely night and morning with Condy's fluid and water; while, if it be associated with quickened pulse and elevated temperature, other measures, to be subsequently described, will be necessary. The after-pains, which many child-bearing women dread even more than the labor-pains, are irregular contractions, occurring for a varying time after delivery, and resulting from the efforts of the uterus to expel coagula which have formed in its interior. If, there- fore, special care be taken to secure complete and permanent con- traction after labor, they rarely occur, or to a very slight extent. Their dependence on uterine inertia is evidenced by the common observation that they are seldom met with in primiparaB, in whom uterine contraction may be supposed to be more efficient, and are most frequent in women who have borne many children. They are a preventible complication, and one which need not give rise to any anxiety; they are, indeed, rather salutary than the reverse, for if 1 coagula be retained in utero, the sooner they are expelled the better. 530 THE PUERPERAL STATE. The after-pains generally begin a few hours after delivery, and con- tinue in bad cases, for three or four days, but seldom longer. [These pains are frequently increased immediately upon giving the child the breast, the drawing of the milk acting sympathetically upon the uterus and causing much annoyance. — Ed.] When at their height they are often relieved by the expulsion of the coagula. They may be readily distinguished from pains due to more serious causes, by feeling the enlarged uterus harden under their influence, by the uterus not being tender on pressure, and by the absence of any con- stitutional symptoms. Management of Women after Delivery. — The management of women after child-birth has varied much at different times, according to fashion or theory. The dread of inflammation long influenced the professional mind, and caused the adoption of a strictly antiphlo- gistic diet, which led to a tardy convalescence. The recognition of the essentially physiological character of labor has resulted in more sound views, with manifest advantage to our patients. The main facts to bear in mind with regard to the puerperal woman are, her nervous susceptibility, which necessitates quiet and absence of all excitement ; the importance of favoring involution by prolonged rest ; and the risk of septicaemia, which calls for perfect cleanliness and attention to hygienic precautions. The Administration of Opiates is generally Unadvisahle. — As soon as we are satisfied that the uterus is perfectly contracted, and that all risk of hemorrhage is over, the patient should be left to sleep. Many practitioners administer an opiate; but, as a matter of routine, this is certainly not good practice, since it checks the contractions of the uterus, and often produces unpleasant effects. Still, if the labor have been long and tedious, and the patient be much exhausted, 15 or 20 drops of Battley's solution may be administered with advantage. Attention to the State of the Pulse, Bladder, and Uterus. — Within a few hours the patient should be seen, and at the first visit particular attention should be paid to the state of the pulse, the uterus, and the bladder. The pulse during the whole period of convalescence should be carefully watched, and, if it be at all elevated, the tem- perature should at once be taken. If the pulse and temperature remain normal, we may be satisfied that things are going on well ; but if the one be quickened and the other elevated, some disturbance or complication may be apprehended. The abdomen should be felt to see that the uterus is not unduly distended, and that there is no tenderness. After the first day or two this is no longer necessary. Treatment of Retention of Urine. — Sometimes the patient cannot at first void the urine, and the application of a hot sponge over the pubis may enable her to do so. If the retention of urine be due to temporary paralysis of the bladder, three or four 20-minim doses of the liquid extract of ergot, at intervals of half an hour, may prove successful. Many hours should not be allowed to elapse without re- lieving the patient by the catheter, since prolonged retention is only likely to make matters worse. Subsequently, it may be necessary to empty the bladder night and morning, until the patient regain her THE PUERPERAL STATE A 2s D ITS MANAGEMENT. 531 power over it, or until the swelling of the urethra subsides, and this will generally be the case in a few days. Occasionally the bladder becomes largely distended, and is relieved to some degree by drib- bling of urine from the urethra, Such a state of things may deceive the patient and nurse, and may produce serious consequences by causing cystitis. Attention to the condition of the abdomen will prevent the practitioner from being deceived, for in addition to some constitutional disturbance, a large, tender, and fluctuating swelling will be found in the hypogastric region, distinct from the uterus, which it displaces to one or other side. The catheter will at once prove that this is produced by distension of the bladder. Treatment of Severe After-pains. — If the after-pains be very severe, an opiate may be administered, or, if the lochia be not over-abund- ant, a linseed-meal poultice, sprinkled with, laudanum, or with the ■ chloroform and belladonna liniment, may be applied. If proper care have been taken to induce uterine contraction, they will seldom be sufficiently severe to require treatment. In America, quinine in ; doses of 10 grains twice daily, has been strongly recommended, espe- cially when opiates fail, and when the pains are neuralgic in character, and I have found this remedy answer extremely well. Diet and Regimen. — The diet of the puerperal patient claims care- ful attention, the more so as old prejudices in this respect are as yet far from exploded, and as it is by no means rare to find mothers and nurses who still cling tenaciously to the idea that it is essential to prescribe a low regimen for many days after labor. The erroneous- ness of this plan is now so thoroughly recognized, that it is hardly necessary to argue the point. There is, however, a tendency in some to err in the opposite direction, which leads them to insist on the patient's consuming solid food too soon after delivery, before she has regained her appetite, thereby producing nausea and intestinal de- rangement, Our best guide in this matter is the feelings of the pa- tient herself. If, as is often the case, she be disinclined to eat, there is no reason why she should be urged to do so. A good cup of beef- tea, some bread and milk, or an egg beat up with milk, may gener- ally be given with advantage shortly after delivery, and many patients are not inclined to take more for the first day or so. If the patient be hungry there is no reason why she should not have some more solid, but easily digested food, such as white fish, chicken, or sweet- bread; and, after a day or two, she may resume her ordinary diet, bearing in mind that, being confined to bed, she cannot with advan- tage consume the same amount of solid food as when she is up and about. Dr. Oldham, in his presidential address to the Obstetrical Society, 1 has some apposite remarks on this point, which are worthy of quotation. "A puerperal month under the guidance of a monthly nurse is easily drawn out, and it is well if a love of the comforts of illness and the persuasion of being delicate, which are the infirmities of many women, do not induce a feeble life, which long survives after the occasion of it is forgotten. I know no reason why, if a 1 Obstet. Trans, vol. vi. 532 THE PUERPERAL STATE. woman is confined early in the morning, she should not have her breakfast of tea and toast at nine, her luncheon of some digestible meat at one, her cup of tea at five, her dinner with chicken at seven, and her tea again at nine, or the equivalent, according to the varia- tion of her habits of living. [With our ideas in the United States, we do not think American women would stand this sort of substan- tial diet so soon after deliver}^. In fact few in the higher walks of life would care to try the experiment, or have the appetite to enjoy it — Ed.] Of course, there is the common sense selection of articles of food, guarding against excess, and avoiding stimulants. But gruel and slops, and all intermediate feeding, are to be avoided." No one who has seen both methods adopted can fail to have been struck with the more rapid and satisfactory convalescence which takes place when the patient's strength is not weakened by an unnecessarily low diet. Stimulants, as a rule, are not required ; but, if the patient, be weakly and exhausted, or if she be accustomed to their use, there can be no reasonable objection to their judicious administra- tion. Attention to Cleanliness, &c, — Immediately after delivery a warm napkin is applied to the vulva, and, after the patient has rested a little, the nurse removes the soiled linen from the bed, and washes the external genitals. It is impossible to pay too much attention during the subsequent progress of the case to the maintenance of perfect cleanliness. The linen should be frequently changed, and all dirty linen and discharges immediately removed from the apartment. The vulva should be washed daily with Condy's fluid and water, and the patient will derive great comfort from having the vagina syringed gently out once a day with the same solution. The re- markable diminution of mortality which has followed such antisep- tic precautions in certain Lying-in Hospitals in Germany, well shows the importance of these measures. The room should be kept toler- ably cool, and fresh air freely admitted. Action of the Bowels. — It is customary, on the morning of the second or third day, to secure an action of the bowels; and there is no better way of doing this than by a large enema of soap and ivater. If the patient object to this, and the bowels have not acted, some mild aperient may be administered, such as a small dose of castor oil, a few grains of colocynth and henbane pill, or the popular French aperient, the "Tamar Indien." Lactation. — The management of suckling and of the breasts forms an important part of the duties of the monthly nurse, which the prac- titioner should himself superintend. This will be more conveniently discussed under the head of lactation. Importance of Prolonged Rest. — The most important part of the management of the puerperal state is the securing to the patient pro- longed rest in the horizontal position, in order to favor proper invo- lution of the uterus. For the first few days she should be kept as quiet and still as possible, not receiving the visits of any but her nearest relatives, thus avoiding all chance of undue excitement. It is customary among the better classes for the patient to remain in ^ MANAGEMENT OF THE INFANT, LACTATION, ETC bed for eight or ten days ; but, provided she be doing well, there can be no objection to her lying on the outside of the bed, or slipping on to a sofa, somewhat sooner. After ten days or a fortnight she may be permitted to sit on a chair for a little ; but I am convinced that the longer she can be persuaded to retain the recumbent position, the more complete and satisfactory will be the progress of involution, and she should not be allowed to walk about until the third week, about which time she may also be permitted to take a drive. 1 If it be borne in mind that it takes from six weeks to two months for the uterus to regain its natural size, the reason for prolonged rest will be obvious. The judicious practitioner, however, while insisting on this point, will take measures, at the same time, not to allow the patient to lapse into the habits of an invalid, or to give the necessary rest the semblance of disease. Subsequent Treatment. — Towards the termination of the puerperal month some slight tonic, such as small doses of quinine with phos- phoric acid, may be often given with advantage, especially if conva- lescence be tardy. Nothing is so beneficial in restoring the patient to her usual health as change of air, and in the upper classes a short visit to the seaside may generally be recommended, with the certainty of much benefit. CHAPTEK II. STATION, ETC. Commencement of Respiration. — Almost immediately after its ex- pulsion, a healthy child cries aloud, thereb}^ showing that respiration is established, and this may be taken as a signal of its safety. The first respiratory movements are excited, partly by reflex action result- ing from the contact of the cold external air on the cutaneous nerves, and partly by the direct irritation of the medulla oblongata, in conse- quence of the circulation through it of blood no longer oxygenated in the placenta. Apparent Death of the New-born Child. — Not infrequently the child is born in an apparently lifeless state. This is especially likely to be the case when the second stage of labor has been unduly pro- longed, so that the head has been subjected to long-continued pres- sure. The uteroplacental circulation is also apt to be injuriously interfered with before the birth of the child when a tardy labor has [' In Paris, among patients of the higher walks of life, the time for remaining in bed is usually twenty-one days, even after very easy labors : the accoucheurs claiming that this length of rest is required, if we expect to avoid uterine displacements. — Ed.] 534 THE PUERPERAL STATE. produced tonic contraction of the uterus, and consequent closure of the uterine sinuses; or, more rarely, from such causes as the injudi- cious administration of ergot, premature separation of the placenta, or compression of the umbilical cord. In any of these cases it is probable that the arrest of the uteroplacental circulation induces attempts at inspiration, which are necessarily fruitless, since air cannot reach the lungs, and the foetus may die asphyxiated; the existence of the respiratory movement being proved on post-mortem examination by the presence in the lungs of liquor amnii, mucus, and meconium, and by the extravasation of blood from the rupture of their engorged vessels. Appearance of the Child in such Cases. — In most cases, when the child is born in a state of apparent asphyxia, its face is swollen and of a dark livid color. It not infrequently makes one or two feeble and gasping efforts at respiration, without any definite cry; on aus- cultation the heart may be heard to beat weakly and slowly. Under such circumstances there is a fair hope of its recovery. In other cases the child, instead of being turgid and livid in the face, is pale, with flaccid limbs, and no appreciable cardiac action, then the prog- nosis is much more unfavorable. Treatment of Apparent Death. — No time should be lost in endeavor- ing to excite respiration, and, at first, this must be done by applying suitable stimulants to th° cutaneous nerves, in the hope of exciting reflex action. The cord should be at once tied, and the child re- moved from the mother; for the final uterine contractions have so completely arrested the utero-placental circulation, as to render it no longer of any value. If the face be yerv livid, a few drops of blood may with advantage be allowed to flow from the cord before it is tied, with the view of relieving the embarrassed circulation. Yery often some slight stimulus, such as one or two sharp slaps on the thorax, or rapidly rubbing the body with brand}?- poured into the palms of the hands, will suffice to induce respiration. Failing this, nothing acts so well as the sudden and instantaneous application of heat and cold. For this purpose extremely hot water is placed in one basin, and quite cold water in another. Taking the child by the shoulders and legs, it should be dipped for a single moment into the hot water, and then into the cold; and these alternate applica- tions may be repeated once or twice, as occasion requires. The effect of this measure is often very marked, and I have frequently seen it succeed when prolonged efforts at artificial respiration had been made in vain. Artificial Respiration. — If these means fail, an endeavor must be at once made to carry on respiration artificially. The Sylvester method is, on the whole, that which is most easily applied, and, on account of the compressibility of the thorax, it is peculiarly suitable for infants. The child being laid on its back, with the shoulders slightly elevated, the elbows are grasped by the operator, and alter- nately raised above the head, and slowly depressed against the sides of the thorax, so as to produce the effect of inspiration and expiration. If this do not succeed, the Marshall Hall method may be substituted ; MANAGEMENT OF THE INFANT, LACTATION, ETC. 535 and one or more of the plans of exciting reflex action through the cutaneous nerves may be alternated with it. Insufflation of the Lungs. — Other means of exciting respiration have been recommended. One of them, much used abroad, is the artificial insufflation of the lungs by means of a flexible catheter guided into the glottis. It is not difficult to pass the end of a catheter into the glottis, using the little finger as a guide ; and once in position, it may be used to blow air gently into the lungs, which is expelled by com- pression on the thorax, the insufflation being repeated at short inter- vals of about ten seconds. One advantage of this plan is, that it allows the liquor aranii and other fluids, which may have been drawn into the lungs in the premature efforts at respiration before birth, to be sucked up into the catheter, and so removed from the lungs. The same effect may be produced, but less perfectly, by placing the hand over the nostrils of the child, blowing into its mouth, and immediately afterwards compressing the thorax. 1 One of these methods should certainly be tried, if all other means have failed. Faradization along the course of the phrenic nerves is a promising means of inducing respiration, which should be used if the proper apparatus can be procured. Encouragement to persevere in oar endeavors to resuscitate the child may be derived from the numerous authenticated instances of success after the lapse of a considerable time, even of an hour or more. As long as the cardiac pulsations continue, however feebly, there is no reason to despair. Washing and Dressing of the Child. — When the child cries lustily from the first, it is customary for the nurse to wash and dress it as soon as her immediate attendance on the mother is no longer required. i For this purpose it is placed in a bath of warm water, and carefully soaped and sponged from head to foot. With the view of facilitating the removal of the unctuous material with which it is covered, it is usual to anoint it with cold cream or olive-oil, which is washed off in the bath. Nurses are apt to use undue roughness in endeavoring to remove every particle of the vernix caseosa, small portions of which are often firmly adherent. This mistake should be avoided, as these particles will soon dry up and become spontaneously detached. The cord is generally wrapped in a small piece of charred linen, which is supposed to have some slight antiseptic property, and this is renewed from day to day until the cord has withered and separated. This generally occurs within a week ; and a small pad of soft linen is then placed over the umbilicus, and supported by a flannel belly- band, placed round the abdomen, which should not be too tight, for fear of embarrassing the respiration. By this means the tendency to umbilical hernia is prevented. [Many obstetricians have adopted the plan in our country of cleaning the child at the first dressing without water. Grease is well applied, and the body carefully wiped [ ! When this is done the oesophagus must be closed by placing the thumb and fingers on opposite sides of the larynx, and pressing it backward, just before blowing in the mouth. When this is accomplished so as to fill the lungs, the thorax should be pressed, and the inflation repeated. — Ed.] 536 THE PUERPERAL STATE. from head to foot with soft rags, until the skin is cleansed of every- thing but a slight oily trace, not sufficient to soil the clothing. This makes the skin soft, and the child is in less danger of taking cold than when soap and water are used. — Ed.] Clothing, etc. — The clothing of the infant varies according to fashion and the circumstances of the parents. The important points to bear in mind are that it should be warm (since newly-born children are extremely susceptible to cold), and at the same time light, and suffi- ciently loose to allow free play to the limbs and thorax. All tight bandaging and swaddling, such as is so common in some parts of the Continent, should be avoided, and the clothes should be fastened by strings or by sewing, and no pins used. At the present day it is customary not to use caps, so that the head may be kept cool. The utmost possible attention should be paid to cleanliness, and the child should be regularly bathed in tepid water, at first once daily, and, after the first few weeks, both night and morning. After drjdng, the flexures of the thighs and arms, and the nates, should be dusted with violet powder or Fuller's earth, to prevent chafing of the skin. The excrements should be received in napkins wrapped round the hips, and great care is required to change the napkins as often as they are wet or soiled, otherwise troublesome irritation will arise. A neglect of this precaution, and the washing of the napkins with coarse soap or soda, are among the principal causes of the eruptions and excoriations so common in badly cared for children. When washed and dressed the child may be placed in its cradle, and covered with soft blankets or an eider-brown quilt. Application of the Child to the Breast. — As soon as the mother has rested a little, it is advisable to place the child to the breast. This is useful to the mother by favoring uterine contraction. Even now there is in the breasts a variable quantity of the peculiar fluid known as colostrum. This is a viscid yellowish secretion, different in appear- ance from the thin bluish milk which is subsequently formed. Ex- amined under the microscope it is found to contain some milk globules, a number of large granular and small fat corpuscles. It has a purgative property, and soon produces, with less irritation than any of the laxatives so generally used, a discharge of the meco- nium with which the bowels are loaded. Hence the accoucheur should prohibit the common practice of administering castor oil, or other aperient, within the first few days after birth, although there can be no objection to it, in special cases, if the bowels appear to act inefficiently and with difficulty. Over-frequent Suckling should be Avoided. — For the first few daj^s, and until the secretion of milk is thoroughly established, the child should be put to the breast at long intervals only. Constant attempts at suckling an empty breast lead to nothing but disappointment, both to the mother and child, and, by unduly irritating the mammae, some- times to positive harm. Therefore, for the first day or two, it is sufficient if the child be applied to the breast twice, or at most three times, in the twenty -four hours. Nor is it necessary to be apprehen- sive, as many mothers naturally are, that the child will suffer from MANAGEMENT OF THE INFANT, LACTATION, ETC. 537 want of food. A few spoonfuls of milk and water being given from time to time, the child may generally wait without injury until the milk is secreted. This is generally about the third day, when the secretion is found to be a whitish fluid, more watery in appearance than cow's milk, and showing under the microscope an abundance of minute spherical globules, refracting light strongly, which are abundant in proportion to the quality of the milk. A certain number of granular corpuscles may also be observed shortly after the birth of the child, but, after the first month, these should have almost altogether disappeared. The reaction of human milk is decidedly alkaline, and the taste much sweeter than that of cow's milk. Importance of Nursing ivhen Practicable. — The importance to the mother of nursing her own child, whenever her health permits, on account of the favorable influence of lactation in promoting a proper involution of the uterus, has already been insisted on. Unless there be some positive contra-indication, such as a marked strumous cachexia, an hereditary phthisical tendency, or great general debil- ity, it is the duty of the accoucheur to urge the mother to attempt lactation, even if it be not carried on more than a month or two. It is, however, the fact that in the upper classes of society a large number of patients are unable to nurse, even though willing and anxious to do so. In some there is hardly any lacteal secretion at all, in others there is at first an over-abundance of watery and innu- tritious milk, which floods the breasts, and soon dies away altogether. [Milk Diet for the Mother. — Many can be enabled to nurse well by being largely fed with milk, the allowance gradually increased with the age of the child. One of our patients of 86 pounds weight, took 2 quarts daily, and gained 19 pounds. She had failed on three former occasions in a month, but on this one nursed 18 months. — Ed.] When the Mother cannot Nurse a Wet Nurse should be Procured. — Whenever the mother cannot or will not nurse, the question will arise as to the method of bringing up the child. From many causes there is an increasing tendency to resort to bottle-feeding, instead of procuring the services of a wet nurse, even when the question of expense does not come into consideration. No long experience is required to prove that hand-feeding is a bad and imperfect substitute for nature's mode, and one which the practitioner should discourage whenever it lies in his power to do so. 1 It is true that, in many cases, bottle-fed children do well ; but there is good reason to believe that, even when apparently most successful, the children are not so strong in after-life as they would have been had they been brought up at the breast. When, in addition, it is borne in mind how much of the success of hand feeding depends on intelligent care on the part of the nurse, what evils are apt to accrue from injurious selec- tion of food, and from ignorance of the commonest laws of dietetics, there is abundant reason for urging the substitution of a wet nurse, whenever the mother is unable to undertake the suckling of her [ l There is no country in which this is more realized than our own, where cholera infantum is so prevalent. — Ed.] 35 538 THE PUERPERAL STATE. child. It must be admitted that good hand-feeding is better than bad wet nursing, and the success of the latter hinges on the proper selection of a wet nurse. As this falls within the duties of the prac- titioner, it will be well to point out the qualities which should be sought for in a wet nurse, before proceeding to discuss the mode of rearing the child at the breast. Selection of a Wet Nurse. — In selecting a wet nurse we should en- deavor to choose a strong, healthy woman, who should not be over 30, or 35 years of age at the outside, since the quality of the milk deteriorates in women who are more advanced in life. For a similar reason a very young woman of 16 or 17 should be rejected ; It is needless to say that care must be taken to ascertain the absence of all traces of constitutional disease, especially marks of scrofula, or enlarged cervical or inguinal glands, which may possibly be due to antecedent syphilitic taint. If the nurse be of good muscular de- velopment, healthy-looking, with a clear complexion, and sound teeth (indicating a generally good state of health), the color of the hair and eyes are of secondary importance. It is commonly stated that brunettes make better nurses than blondes, but this is by no means necessarily the case ; and, provided all the other points be favor- able, fairness of skin and hair need be no bar to the selection of a nurse. The breasts should be pear-shaped, rather firm, as indicating an abundance of gland-tissue, and with the superficial veins well marked. Large, flabby breasts owe much of their size to an undue deposit of fat, and are generally unfavorable. The nipple should be prominent, not too large, and free from cracks and erosions, which, if existing, might lead to subsequent difficulties in nursing. On pressing the breast the milk should flow from it easily in a number of small jets, and some of it should be preserved for examination. It should be of a bluish-white color, and when placed under the microscope, the field should be covered with an abundance of milk corpuscles, and the large granular corpuscles of the colostrum should have entirely disappeared. If the latter be observed in any quantity in a woman who has been confined five or six weeks, the inference is that the milk is inferior in quality. It is not often that the prac- titioner has an opportunity of inquiring into the moral qualities of the nurse, although much valuable information might be derived from a knowledge of her previous character. An irascible, excit- able, or highly nervous woman will certainly make a bad nurse, and the most trivial causes might afterwards interfere with the quality of her milk. Particular attention should be paid to the nurse's own child, since its condition affords the best criterion of the quality of her milk. It should be plump, well nourished, and free from all blemishes. If it be at all thin and wizened, especially if there be any snuffling at the nose, or should any eruption exist affording the slightest suspicion of a syphilitic taint, the nurse should be unhesi- tatingly rejected. Management of Suckling. — The management of suckling is much the same whether the child is nursed by the mother or by a wet nurse. As soon as the supply of milk is sufficiently established, MANAGEMENT OF THE INFANT, LACTATION, ETC. 539 the child must be put to the breast at short iutervals, at first of about two hours, and, in about a month or six weeks, of three hours. From the first few days it is a matter of the greatest importance, both to the mother and child, to acquire regular habits in this respect. If the mother get into the w T ay of allowing the infant to take the breast whenever it cries, as a means of keeping it quiet, her own health must soon suffer, to say nothing of the discomfort of being incessantly tied to the child's side ; while the child itself has not sufficient rest to digest its food, and, very shortly, diarrhoea, or other symptoms of dyspepsia, are pretty sure to follow. After a month or two the infant should be trained to require the breast less often at night, so as to enable the mother to have an undisturbed sleep of six or seven hours. For this purpose she should arrange the times of nursing so as to give the breast just before she goes to bed, and not again until the early morning. If the child should require food in the interval, a little milk and water, from the bottle, may be advan- tageously given. Diet of Nursing Women. — The diet of the nursing woman should be arranged on ordinary principles of hygiene. It should be abundant, simple, and nutritious, and all rich and stimulating articles of food should be avoided. A common error in the diet of wet nurses is over-feeding, which constantly leads to deterioration of the milk. Many of these women, before entering on their functions, have been living on the simplest and even sparest diet, and not uncommonly, in the better class of houses, they are suddenly given heavy meat meals three and even four times a day, and often three or four glasses of stout. It is hardly a matter of astonishment that, under such cir- cumstances, their milk should be found to disagree. For a nursing woman in good health tivo good meat meals a day, with two glasses of beer or porter, and as much milk and bread and butter as she likes to take in the interval, should be amply sufficient. 1 Plenty of moderate exercise should be taken, and the more nurse and child are out in the open air, provided the weather be reasonably fine, the better it is for both. Signs of Successful Lactation. — Carried on methodically in this manner, wet nursing should give but little trouble. In the intervals between its meals the child sleeps most of its time, and wakes with regularity to feed ; but if the child be wakeful and restless, cry after feeding, have disordered bowels, and, above all, if it do not gain, week by week, in weight (a point which should be, from time to time, ascertained by the scales), w r e may conclude that there is either some grave defect in the management of suckling, or that the milk is not agreeing. Should this unsatisfactory progress continue, in spite of our endeavors to remedy it, there is no resource left but the alter- ation of the diet, either by changing the nurse, or by bringing up the child by hand. The former should be preferred whenever it is [* A wet nurse should with us have three regular meals, no stimulants at all; milk to drink if needed; moderate exercise, and be taught to nurse at regular iutervals. — Ed.] 540 THE PUERPERAL STATE. practicable, aud, in the upper ranks of life, it is by no means rare to have to change the wet nurse two or three times, before one is met with whose milk agrees perfectly. If the child have reached six or seven months of age, it may be preferable to wean it altogether, especially if the mother have nursed it, as hand-feeding is much less objectionable if the infant have had the breast for even a few months. Period of Weaning. — As a rule, weaning should not be attempted until dentition is fairly established, that being the sign that nature has prepared the child for an alteration of food ; and it is better that the main portion of the diet should be breast milk until at least six or seven teeth have appeared. This is a safer guide than any arbi- trary rule taken from the age of the child, since the commencement of dentition varies much in different cases. About the sixth or seventh month it is a good plan to commence the use of some suita- ble artificial food once a day, so as to relieve the strain on the mother or nurse, and prepare the child for weaning, which should always be a very gradual process. In this way a meal of rusks, of the entire wheat flour, or of beef- or chicken- tea, with bread crumb in it, may be given with advantage ; and, as the period for weaning arrives, a second meal may be added, and so eventually the child may be weaned without distress to itself, or trouble to the nurse. The Disorders of Lactation. — The disorders of lactation are nume- rous, and, as they frequently come under the notice of the practitioner, it is necessary to allude to some of the most common and important. Means of Arresting the Secretion of Milk. — The advice of the accou- cheur is often required in cases in which it has been determined that the patient is not to nurse, when we desire to get rid of the milk as soon as possible, or when, at the time of weaning, the same object is sought. The extreme heat and distension of the breasts, in the former class of cases, often give rise to much distress. A smart saline ape- rient will aid in removing the milk, and for this purpose a double Seidlitz powder, or frequent small doses of sulphate of magnesia, act well; while, at the same time, the patient should be advised to take as small a quantity of fluid as possible. Iodide of potassium in large doses, of 20 or 25 grains, repeated twice or thrice, has a remarkable effect in arresting the secretion of milk. This observation was first •empirically made by observing that the secretion of milk was arrested when this drug was administered for some other cause, and I have frequently found it answer remarkably well. The distension of the breasts is best relieved by covering them with a layer of lint or cotton wool, soaked in a spirit lotion, or eau de cologne and water, over which oiled silk is placed, and by directing the nurse to rub them gently with warm oil, whenever they get hard and lumpy. Breast- pumps and similar contrivances only irritate the breasts, and do more harm than good. The local application of belladonna has been strongly recommended as a means for preventing lacteal secretion. As usually applied, in the form of belladonna plaster, it is likely to prove hurtful, since the breast often enlarges after the plasters are applied, and the pressure of the unyielding leather on which they are spread ETC. 541 produces intense suffering. A better way of using it is by rubbing down a drachm of the extract of belladonna with an ounce of glyce- rine, and applying this on lint. In some cases it answers extremely well ; bat it is very uncertain in its action, and frequently is quite useless. Defective Secretion of Milk. — A deficiency of milk in nursing mothers is a very common course of difficulty. In a wet nurse this drawback is, of cause, an indication for changing the nurse ; but to the mother the importance of nursing is so great, that an endeavor must be made either to increase the flow of milk, or to supplement it by other food. Unfortunately, little reliance can be placed on any of the so-called galactagogues. The only one which in recent times has attracted attention is the leaves of the castor oil plant, which, made into poultices and applied to the breast, are said to have a beneficial effect in increasing the flow of milk. 1 More reliance must be placed in a sufficiency of nutritious food, especially such as contains phos- phatic elements ; stewed eels, oysters, and other kinds of shell-fish, and the Eevalenta Arabica, are recommended by Dr. Routh, who has paid some attention to this point, 2 as peculiarly appropriate. If the amount of milk be decidedly deficient, the child should be less often applied to the breast, so as to allow milk to collect, and pro- perly prepared cow's milk from a bottle should be given alternately with the breast. This mixed diet generally answers well, and is far preferable to pure hand-feeding. De-pressed Nipples. — A not uncommon source of difficulty is a de- pressed condition of the nipples, which is generally produced by the constant pressure of the stays. The result is, that the. child, unable to grasp the nipple, and wearied with ineffectual efforts, may at last refuse the breast altogether. An endeavor should be made to elon- gate the nipple before putting it into the child's mouth, either by the fingers, or by some form of breast-pump, which here finds a useful indication. In the worst class of cases, when the nipple is perma- nently depressed, it may be necessary to let the child suck through a glass nipple-shield, to which is attached an india-rubber tube, similar to that of a sucking-bottle ; this it is generally well able to do. Fissures and excoriations of the nipples are common causes of suf- fering, in some cases leading to mammary abscess. Whenever the practitioner has the opportunity, he should advise his patient to prepare the nipple for nursing in the latter months of pregnancy; and this may best be done by daily bathing it with a spirituous or astringent lotion, such as eau de cologne and water, or a weak solu- tion of tannin. After nursing has begun, great care should be taken to wash and dry the nipple after the child has been applied to it, and, as long as the mother is in the recumbent position, she may, if the 1 [Where milk agrees with the mother, it exceeds in virtue all other forms of diet. See article entitled " Milk as a Diet during Lactation," in Amer. Journ. of Obstet- rics, Feb. 1870, p. 675, by Ed.] 2 Routh, On Infant- feeding. 542 THE PUERPERAL STATE. nipples be at all tender, use zinc nipple-shields with advantage, when she is not nursing. In this way these troublesome complications may generally be prevented. The most common forms are either an abra- sion on the surface of the nipple, which, if neglected, may form a small ulcer, or a crack at some part of the nipple, most generally at its base. In either case, the suffering when the child is put to the breast is intense, sometimes indeed amounting to intolerable anguish, causing the mother to look forward with dread to the application of the child. Whenever such pain is complained of, the nipple should be carefully examined, since the fissure or sore is often so minute as to escape superficial examination. The remedies recommended are very numerous, and not always successful. Amongst those most commonly used are astringent applications, such as tannin, or weak solutions of nitrate of silver, or cauterizing the edges of the fissure with the solid nitrate of silver, or applying the flexible collodion of the Pharmacopoeia. Dr. Wilson, of Glasgow, speaks highly of a lotion composed of ten grains of nitrate of lead in an ounce of gly- cerine, which is to be applied after suckling, the nipple being care- fully washed before the child is again put to the breast. I have myself found nothing answer so well as a lotion composed of half an ounce of sulphurous acid, half an ounce of the glycerine of tannin, and an ounce of water, the beneficial effects of which are sometimes quite remarkable. Eelief may occasionally be obtained by inducing the child to suck through a nipple-shield, especially when there is only an excoriation ; but this will not always answer, on account of the extreme pain which it produces. Excessive Flow of Milk. — An excessive flow of milk, known as galactorrhea, often interferes with successful lactation. It is by no means rare in the first weeks after delivery for women of delicate constitution, who are really unfit to nurse, to be flooded with a super- abundance of watery and innutritious milk, which soon produces disordered digestion in the child. Under such circumstances, the only thing to be done is to give up an attempt which is injurious both to the mother and child. At a later stage the milk, secreted in large quantities, is sufficiently nourishing to the child, but the drain on the mother's constitution soon begins to tell on her. Palpitation, giddiness, emaciation, headache, loss of sleep, spots before the eyes, and even amaurosis, indicate the serious effects which are being pro- duced, and the absolute necessity of at once stopping lactation. When- ever, therefore, a nursing woman suffers from such symptoms, it is far better at once to remove the cause, otherwise a very serious and permanent deterioration of health might result. Mammary Abscess. — There is no more troublesome complication of lactation than the formation of abscess in the breast ; an occurrence by no means rare, and which, if improperly treated, may, by long- continued suppuration and the formation of numerous sinuses in and about the breast, produce very serious effects on the general health. The causes of breast abscess are numerous, and very trivial circum- stances may occasionally set up inflammation, ending in suppuration. Thus it may follow exposure to cold ; a blow, or other injury to the MANAGEMENT OF THE INFANT, LACTATION, ETC. 543 breast; some temporary engorgement of the lacteal tubes; or even sudden or depressing mental emotions. The most frequent cause is irritation from fissures or erosions of the nipples, which must, there- fore, always be regarded with suspicion, and cured as soon as possible. Signs and Symptoms. — The abscess may form in any part of the breast, or in the areolar tissue below it ; in the latter case, the in- flammation very generally extends to the gland structure. Abscess is usually ushered in by constitutional symptoms, varying in severity with the amount of the inflammation. Pyrexia is always present ; elevated temperature, rapid pulse, and much malaise and sense of feverishness, followed, in many cases, by distinct rigor, when deep- seated suppuration is taking place. On examining the breast it will be found to be generally enlarged and very tender, while, at the site of the abscess, an indurated and painful swelling may be felt. If the inflammation be chiefly limited to the subglandular areolar tissue, there may be no localized swelling felt, but the whole breast will be acutely sensitive, and the slightest movement will cause much pain. As the case progresses, the abscess becomes more and more super- ficial, the skin covering it is red and glazed, and, if left to itself, it bursts. In the more serious cases, it is by no means rare for multiple abscesses to form. These opening, one after the other, lead to the formation of numerous fistulous tracts, by which the breast may be- come completely riddled. Sloughing of portions of the gland-tissue may take place, and even considerable hemorrhage, from the de- struction of bloodvessels. The general health soon suffers to a marked degree, and, as the sinuses continue to suppurate for many successive months, it is by no means uncommon for the patient to be reduced to a state of profound and even dangerous debility. Treatment. — Much may be done by proper care to prevent the formation of abscess, especially by removing engorgement of the lacteal ducts, when threatened, by gentle hand friction in the manner already indicated. AYhen the general symptoms, and the local ten- derness, indicate that inflammation has commenced, we should at once endeavor to moderate it, in the hope that resolution may occur without the formation of pus. Here general principles must be attended to, especially giving the affected part as much rest as possi- ble. Feverishness may be combated by gentle saline, minute doses of aconite, and large doses of quinine ; while pain should be relieved by opiates. The patient should be strictly confined to bed, and the affected breast supported by a suspensory bandage. Warmth and moisture are the best means of relieving the local pain, either in the form of hot fomentations, or of light poultices of linseed-meal or bread and milk, and the breast may be smeared with extract of bella- donna rubbed down with glycerine, or the belladonna liniment sprinkled over the surface of the poultices. Generally the pain and irritation produced by putting the child to the breast are so great as to contra-indicate nursing from the affected side altogether, and we must trust to relieving the tension by poultices ; suckling being, in the mean time, carried on by the other breast alone. In favorable cases this is quite possible for a time, and it may be that, if the in- 544 THE PUERPERAL STATE. flammation do not end in suppuration, or if the abscess be small and localized, the affected breast is again able to resume its functions. Often this is not possible, and it may be advisable, in severe cases, to give up nursing altogether. Pus should be Removed as soon as Possible. — The subsequent man- agement of the case consists in the opening of the abscess as soon as the existence of pns is ascertained, either by fluctuation, or, if the site of the abscess be deep-seated, by the exploring needle. It may be laid down as a principle, that the sooner the pus is evacuated the better, and nothing is to be gained by waiting until it is superficial. On the contrary, such delay only leads to more extensive disorgani- zation of tissue and the further spread of inflammation. Antiseptic Treatment. — The method of opening the abscess is of primary importance. It has always been customary simply to open the abscess at its most depending part, without using any precaution against the admission of air, and afterwards to treat secondary ab- scesses in the same way. The results are well known to all practical accoucheurs, and the records of surgery fully show how many weeks or months generally elapse in bad cases before recovery is complete. The antiseptic treatment of mammary abscess, in the way first pointed out by Lister, afford results which are of the most remark- able and satisfactory kind. Instead of being weeks and months in healing, I believe that the practitioner who fairly and minutely car- ries out Mr. Lister's directions may confidently look for complete closure of the abscess in a few days ; and I know nothing, in the whole range of my professional experience, that has given me more satisfaction than the application of this method to abscesses of the breast. The plan I first used is that recommended by Lister in the "Lancet" for 1867, but which is now superseded by his improved methods, which, of course, will be used in preference by all w r ho have made themselves familiar with the details of antiseptic surgery. The former, however, is easily within the reach of every one, and is so simple that no special skill or practice is required in its applica- tion ; whereas the more perfected antiseptic appliances will probably not be so readily obtained, and are much more difficult to use. I, therefore, insert Mr. Lister's original directions, which he assures me are perfectly aseptic, for the guidance of those who may not be able to obtain the more elaborate dressings: — "A solution of one part of crystallized carbolic acid in four parts of boiled linseed-oil having been prepared, a piece of rag from four to six inches square is dipped into the oily mixture, and laid upon the skin where the incision is to be made. The lower edge of the rag being then raised, while the upper edge is kept from slipping by an assistant, a common scalpel or bistoury dipped in the oil is plunged into the cavity of the ab- scess, and an opening about three-quarters of an inch in length is made, and the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic curtain, beneath which the pus flows out into a vessel placed to receive it. The cavity of the abscess is firmly pressed, so as to force out all existing pus as nearly as may be (the old fear of doing mischief by rough treatment of the pyogenic MANAGEMENT OF THE INFANT, LACTATION, ETC. 545 membrane being quite ill-founded); and if there be much, oozing of blood, or if there be considerable thickness of parts between the abscess and the surface, a piece of lint dipped in the antiseptic oil is introduced into the incision to check bleeding and prevent primary adhesion, which is otherwise very apt to occur. The introduction of the lint is effected as rapidly as may be, and under the protection of the antiseptic rag. Thus the evacuation of the original contents is accomplished with perfect security against the introduction of living germs. This, however, would be of no avail unless an anti- septic dressing could be applied that would effectually prevent the decomposition of the stream of pus constantly flowing out beneath it. After numerous disappointments, I have succeeded w T ith the follow- ing, which may be relied upon as absolutely trustworthy: About six teaspoonfuls of the above-mentioned solution of carbolic acid in linseed oil are mixed up with common whiting (carbonate of lime) to the consistence of a firm paste, which is, in fact, glazier's putty with the addition of a little carbolic acid. This is spread upon a piece of common tin-foil about six inches square, so as to form a layer about a quarter of an inch thick. The tin-foil, thus spread with putty, is placed upon the skin, so that the middle of it corre- sponds to the position of the incision, the antiseptic rag used in opening the abscess being removed the instant before. The tin is then fixed securely by adhesive plaster, the lowest edge being left free for the escape of the discharge into a folded towel placed over it and secured by a bandage. The dressing is changed, as a general rule, once in 24 hours, but, if the abscess be a very large one, it is prudent to see the patient 12 hours after it has been opened, when, if the towel should be much stained with discharge, the dressing should be changed, to avoid subjecting its antiseptic virtues to too severe a test. But after the first 24 hours a single daily dressing is sufficient. The changing of the dressing must be methodically done, as follows: A second similar piece of tin-foil having been spread with the putty, a piece of rag is dipped in the oily solution and placed on the incision the moment the first tin is removed. This guards against the possibility of mischief occurring during the cleans- ing of the skin with a dry cloth, and pressing out any discharge w r hich may exist in the cavity. If a plug of lint was introduced when the abscess was opened, it is removed under cover of the anti- septic rag, which is taken off at the moment when the new tin is to be applied. The same process is continued daily until the sinus closes." Treatment of Long -continued Suppuration and Fever. — If the case come under our care when the abscess has been long discharging, or when sinuses have formed, the treatment is directed mainly to pro- curing a cessation of suppuration and closure of the sinuses. For this purpose methodical strapping of the breast with adhesive plaster, so as to afford steady support and compress the opposing pyogenic surfaces, w r ill give the best results. It may be necessary to lay open some of the sinuses, or to inject tinct. iodi or other stimulating lotions, so as to moderate the discharge, the subsequent surgical treatment 546 THE PUERPERAL STATE. varying according to the requirements of each case. As the drain on the system is great, and the constitutional debility generally pro- nounced, much attention must be paid to general treatment; and abundance of nourishing food, appropriate stimulants, and such medicines as iron and quinine, will be indicated. Hand-feeding. — In a considerable number of cases the inability of the mother to nurse the child, her invincible repugnance to a wet nurse, or inability to bear the expense, renders hand-feeding essen- tial. It is, therefore, of importance that the accoucheur should be thoroughly familiar with the best method of bringing up the child by hand, so as to be able to direct the process in the way that is most likely to be successful. Causes of Mortality hi Hand fed Children. — Much of the mortality following hand-feeding may be traced to unsuitable food. Among the poorer classes especially there is a prevalent notion that milk alone is insufficient; and hence the almost universal custom of ad- ministering various farinaceous foods such as corn-flour or arrow- root, even from the earliest period. Many of these consist of starch alone, and are therefore absolutely unsuited for forming the staple of diet, on account of the total absence of nitrogenous elements. Independently of this, it has been shown that the saliva of infants has not the same digestive property on starch that it subsequently acquires, and this affords a further explanation of its so constantly producing intestinal derangement. Eeason, as well as experience, abundantly prove that the object to be aimed at in hand-feeding is to imitate as nearly as possible the food which nature supplies for the new-born child, and therefore the obvious course is to use milk from some animal, so treated as to make it resemble human milk as nearly as may be. Ass's Milk. — Of the various milks used, that of the ass, on the whole, most closely resembles human milk, containing less casein and butter, and more saline ingredients. It is not always easy to obtain, and in towns is excessively expensive. Moreover, it does not always agree with the child, being apt to produce diarrhoea. We can, however, be more certain of its being unadulterated, which in large cities is in itself no small advantage, and it may be given with- out the addition of water or sugar. Goafs milk in this country is still more difficult to obtain, but it often succeeds admirably. In many places the infant sucks the teat directly, and certainly thrives well on the plan. Cow's Milk and its Preparation. — In a large majority of cases we have to rely on cow's milk alone. It differs from human milk in containing less water, a larger amount of casein and solid matters, and less sugar. Therefore, before being given, it requires to be diluted and sweetened. A common mistake is over- dilution, and it is far from rare for nurses to administer one-third cow's milk to two- thirds water. The result of this excessive dilution is, that the child becomes pale and puny, and has none of the firm and plump appear- ance of a well-fed infant. The practitioner should, therefore, ascer- tain that this mistake is not being made; and the necessary dilution MANAGEMENT OF THE INFANT, LACTATION, ETC. 547 will be best obtained by adding to pure fresh, cow's milk, one- third hot water, so as to warm the mixture to about 96°, the whole being slightly sweetened with sugar of milk, or ordinary crystallized sugar. After the first two or three months the amount of water may be lessened, and pure milk, warmed and sweetened, given instead. 1 Whenever it is possible, the milk should be obtained from the same cow, and in towns some care is requisite to see that the animal is properly fed and stabled. Of late years it has been customary to obviate the difficulties of obtaining good fresh milk by using some of the tinned milks now so easily to be had. These are already sweetened, and sometimes answer well, if not given in too weak a dilution. One great drawback in bottle-feeding is the tendency of the milk to become acid, and hence to produce diarrhoea. This may be obviated to a great extent by adding a tablespoonful of lime-water to each bottle, instead of an equal quantity of water. Artificial Human Milk. — An admirable plan of treating cow's milk, so as to reduce it to almost absolute chemical identity with human milk, has been devised by Professor Frankland, to whom I am in- debted for permission to insert the receipt. I have followed this method in many cases, and find it far superior to the usual one, as it produces an exact and uniform compound. With a little practice nurses can employ it with no more trouble than the ordinary mixing of cow's milk with water and sugar. The following extract from Dr. Frankland's work 2 will explain the principles on which the pre- paration of the artificial human milk is founded: "The rearing of infants who cannot be supplied with their natural food is notoriously difficult and uncertain, owing chiefly to the great difference in the chemical composition of human milk and cow's milk. The latter is much richer in casein and poorer in milk-sugar than the former, whilst asses' milk, which is sometimes used for feeding infants, is too poor in casein and butter, although the proportion of sugar is nearly the same as in human milk. The relations of the three kinds of milk to each other are clearly seen from the following analytical numbers, which express the percentage amounts of the different constituents : — Casein ...... Butter ...... Milk-sugar ..... Salts These numbers show that by the removal of one-third of the casein from cow's milk and the addition of about one -third more milk-sugar, a liquid is obtained which closely approaches human milk in compo- sition, the percentage amounts of the four chief constituents being as follows: — L 1 The milk of the Alderney cow is too rich in butter for a young infant. Milk from one cow is often a trick of the vendor. A selected animal should be neither young nor old, and of common stock, having had two or three calves, and healthy. — Ed.] 2 Frankland's Experimental Researches in Chemistry, p. 843. oman. Ass. Cow. 2.7 1.7 4.2 3.5 1.3 3.8 5.0 4.5 3.8 .2 .5 .7 548 THE PUERPERAL STATE. Casein 2.8 Butter 3.8 Milk-sugar .......... 5.0 Salts 7 The following is the mode of preparing the milk : Allow one-third of a pint of new milk to stand for about twelve hours, remove the cream, and add to it two-thirds of a pint of new milk, as fresh from the cow as possible. Into the one- third of a pint of blue milk left after the abstraction of the cream put a piece of rennet about one inch square. Set the vessel in warm water until the milk is fully curdled, an operation requiring from five to fifteen minutes, accord- ing to the activity of the rennet, which should be removed as soon as the curdling commences, and put into an egg-cup for use on sub- sequent occasions, as it may be employed daily for a month or two. Break up the curd repeatedly, and carefully separate the whole of the whey, which should then be rapidly heated to boiling in a small tin pan placed over a spirit or gas lamp. During the heating a further quantity of casein technically called "fleetings" separates, and must be removed by straining through muslin. Now dissolve 110 grains of powdered sugar of milk in the hot whey, and mix it with the two-thirds of a pint of new milk to which the cream from the other third of a pint was added as already described. The arti- ficial milk should be used within twelve hours of its preparation, and it is almost needless to add that all the vessels employed in its manufacture and administration should be kept scrupulously clean. Method of Hand-feeding. — Much of the success of bottle-feeding must depend on minute care and scrupulous cleanliness, points which cannot be too strongly insisted on. Particular attention should be paid to preparing the food fresh for every meal, and to keeping the feeding-bottle and tubes constantly in water when not in use, so that minute particles of milk may not remain about them and become sour. A neglect of this is one of the most fertile sources of the thrush from which bottle-fed infants often suffer. The particular form of bottle used is not of much consequence. Those now com- monly employed, with a long india-rubber tube attached, are prefer- able to the older forms of flat bottle, as thej^ necessitate strong suction on the part of the infant, thus forcing it to swallow the food more slowly. Care must be taken to give the meals at stated periods, as in breast-feeding, and these should be at first about two hours apart, the intervals being gradually extended. The nurse should be strictly cautioned against the common practice of placing the bottle beside the infant in its cradle, and allowing it to suck to repletion, a practice which leads to over-distension of the stomach, and conse- quent dyspepsia. The child should be raised in the arms at the proper time, have its food administered, and then be replaced in the cradle to sleep. In the first few weeks of bottle-feeding constipation is very common, and may be effectually remedied by placing as much phosphate of soda as will lie on a threepenny-piece in the bottle, two or three times in the twenty-four hours. MANAGEMENT OF THE INFANT, LACTATION, ETC. 549 Other hinds of Food. — If this system succeed, no other food should be given until the child is six or seven months old, and then some of the various infant's foods may be cautiously commenced. Of these there are an immense number in common use ; some of which are good articles of diet, others are unfitted for infants. In selecting them we have to see that they contain the essential elements of nutri- tion in proper combination. All those, therefore, that are purely i starchy in character, such as arrowroot, corn-flour, and the like, I should be avoided ; while those that contain nitrogenous as well as I starchy elements, may be safely given. Of the latter the entire wheat flour, which contains the husks ground down with the wheat, generally answers admirably ; and of the same character are rusks, tops and bottoms, JSTestle's or Liebig's infant's food, and many others. If the child be pale and flabby, some more purely animal food may often be given twice a day, and great benefit may be derived from a single meal of beef, chicken, or veal tea, with a little bread crumb in it, especially after the sixth or seventh month. Milk, however, should still form the main article of diet, and should continue to do so for many months. Management -when Milk disagrees. — If the child be pale, flabby, and do not gain flesh, more especially if diarrhoea or other intestinal dis- turbance be present, we may be certain that hand- feeding is not an- swering satisfactorily, and that some change is required. If the child be not too old, and will still take the breast, that is certainly the best remedy, but, if that be not possible, it is necessary to alter the I diet. When milk disagrees, cream, in the proportion of one table- ! spoonful to three of water, sometimes answers well. Occasionally I also Liebig's infant's food, when carefully prepared, renders good service. Too often, however, when once diarrhoea or other intesti- nal disturbance has set in, all our efforts may prove unavailing, and the health, if not the life, of the infant becomes seriously imperilled. It is not, however, within the scope of this work to treat of the dis- orders of infants at the breast, the proper consideration of which re- quires a large amount of space, and I, therefore, refrain from making any further remarks on the subject. [As a general rule, children in this country are better kept exclu- j sively on a milk diet for at least 10 months, especially if it is in the summer season. The best addition then, is exsiccated wheat flour prepared by the process of Hards, and known as Hards' farinaceous food, prepared wheat, imperial granum, etc. Ohio groats made of the oat kernel, and prepared barley flour, are sometimes useful where the habit of the child is constipated. — Ed.] 550 THE PUERPERAL STATE CHAPTEE III. PUERPERAL ECLAMPSIA. By the term puerperal eclampsia is meant a peculiar kind of epi- leptiform convulsions, which may occur in the latter months of preg- nancy, or during, or after parturition, and it constitutes one of the most formidable diseases with which the obstetrician has to cope. The attack is often so sudden and unexpected, so terrible in its nature, and attended with such serious danger both to the mother and child, that the disease has attracted much attention. Its Doubtful Etiology. — The researches of Lever, Braun, Frerichs, and many other writers who have shown the frequent association of eclampsia with albuminuria, have, of late years, been supposed to clear up to a great extent the etiology of the disease, and to prove its dependence on the retention of urinary elements in the blood. While the urinary origin of eclampsia has been pretty generally accepted, more recent observations have tended to throw doubt on its essential dependence on this cause; so that it can hardly be said that we are yet in a position to explain its true pathology with cer- tainty. These points will require separate discussion, but it is first necessary to describe the character and history of the attack. Considerable confusion exists in the description of puerperal con- vulsions from the confounding of several essentially distinct diseases under the same name. Thus, in most obstetric works, it has been customarv to describe three distinct classes of convulsion ; the epi- leptic, the hysterical, and the apoplectic. The two latter, however, come under a totally different category. A pregnant woman may suffer from hysterical paroxysms, or she may be attacked with apo- plexy, accompanied with coma, and followed by paralysis. But these conditions in the pregnant or parturient woman are identical with the same diseases in the non-pregnant, and are in no way special in their nature. True eclampsia, however, is different in its clinical history from epilepsy; although the paroxysms, while they last, are essentially the same as those of an ordinary epileptic fit. Premonitory Symptoms. — An attack of eclampsia seldom occurs without having been preceded by certain more or less well-marked precursory symptoms. It is true that, in a considerable number of cases, these are so slight as not to attract attention, and suspicion is not aroused until the patient is seized with convulsions. Still, sub- sequent investigations will very generally show that some symptoms did exist, which, if observed and properly interpreted, might have put the practitioner on his guard, and possibly enabled him to ward off the attack. Hence a knowledge of them is of real practical value. The most common are associated with the cerebrum, such as severe PUERPERAL ECLAMPSIA. 551 headache, which is the one most generally observed, and is sometimes limited to one side of the head. Transient attacks of dizziness, spots before the eyes, loss of sight, or impairment of the intellectual facul- ties, are also not uncommon. These signs in a pregnant woman are of the gravest import, and should at once call for investigation into the nature of the case. Less marked indications sometimes exist in the form of irritability, slight headache or stupor, and a general feel- ing of indisposition. Another important premonitory sign is oedema of the subcutaneous cellular tissue, especially of the face or upper extremities, which should at once lead to an examination of the urine. Symptoms of the Attack. — Whether such indications have preceded an attack or not, as soon as the convulsion comes on there can no longer be any doubt as to the nature of the case. The attack is gene- rally sudden in its onset, and in its character is precisely that of a • severe epileptic fit, or of the convulsions in children. Close observa- tion shows that there is at first a short period of tonic spasm, affecting the entire muscular system. This is almost immediately succeeded ;by violent clonic contractions, generally commencing in the muscles of the face, which twitch violently; the expression is horribly altered; I the globes of the eyes are turned up under the eyelids, so as to leave only the white sclerotics visible, and the angles of the mouth are retracted and fixed in a convulsive grin. The tongue is at the same time protruded forcibly, and, if care be not taken, is apt to be lacerated by the violent grinding of the teeth. The face, at first pale, soon becomes livid and cyanosed, while the veins of the neck are distended, and the carotids beat vigorously. Frothy saliva collects about the mouth, and the whole appearance is so changed as to render the patient quite unrecognizable. The convulsive movements soon attack the muscles of the body. The hands and arms, at first rigidly fixed, with the thumbs clenched into the palms, begin to jerk, and the whole muscular system is thrown into rapidly-recurring convul- sive spasms. It is evident that the involuntary muscles are impli- cated in the convulsive action, as well as the voluntary. This is shown by a temporary arrest of respiration at the commencement of {the attack, followed by irregular and hurried respiratory movements, J producing a peculiar hissing sound. The occasional involuntary ex- I pulsion of urine and feces indicates the same fact. During the attack the patient is absolutely unconscious, sensibility is totally suspended, and she has afterwards no recollection of what has taken place. For- tunately the convulsion is not of long duration, and, at the outside, does not last more than three or four minutes, generally not so long. In most cases, after an interval, there is a recurrence of the convul- sion, characterized by the same phenomena, and the paroxysms are repeated with more or less force and frequency according to the severity of the attack. Sometimes several hours may elapse before a second convulsion comes on ; at others the attacks may recur very often, with only a few minutes between them. In the slighter forms J of eclampsia there may not be more than 2 or 3 paroxysms in all; 1 in the more serious as many as 50 or 60 have been recorded. 552 THE PUERPERAL STATE. Condition between the Attacks. — After the first attack the patient generally soon recovers her consciousness, being somewhat dazed and somnolent, with no clear perception of what has occurred. If the paroxysms be frequently repeated, more or less profound coma con- tinues in the intervals between them, which, no doubt, depends upon intense cerebral congestion, resulting from the interference with the circulation in the great veins of the neck, produced by spasmodic contraction of the muscles. The coma is rarely complete, the patient showing signs of sensibility when irritated, and groaning during the uterine contractions. In the worst class of cases, the torpor may become intense and continuous, and in this state the patient may die. When the convulsions have entirely stopped, and the patient has completely regained her consciousness, and is apparently conva- lescent, recollection of what has taken place during, and some time before, the attack, may be entirely lost, and this condition may last for a considerable time. A curious instance of this once came under my notice in a lady who had lost a brother, to whom she was greatly attached, in the week immediately preceding her confinement, and in whom the mental distress seemed to have had a good deal to do in determining the attack. It was many weeks before she recovered her memory, and during that time she recollected nothing about the circumstances connected with her brother's death, the whole of that week being, as it were, blotted out of her recollection. Relation of the Attacks to Labor. — If the convulsions come on during pregnancy, we may look upon the advent of labor as almost a certainty ; and if we consider the severe nervous shock and general disturbance, this is the result we might reasonably anticipate. If they occur, as is not uncommon, for the first time during labor, the pains generally continue with increased force and frequency, since the uterus partakes of the convulsive action. It has not rarely happened that the pains have gone on with such intensity that the child has been born quite unexpectedly, the attention of the practi- tioner being taken up with the patient. In many cases the advent of fresh paroxysms is associated with the commencement of a pain, the irritation of which seems sufficient to bring on the convulsion. Results to the Mother and Child. — The results of eclampsia vary according to the severity of the paroxysms. It is generally said that about 1 in 3 or 4 cases dies. The mortality has certainly lessened of late years, probably in consequence of improved knowledge of the nature of the disease, and more rational modes of treatment. This is well shown by Barker, 1 who found in 1855 a mortality of 32 per cent, in cases occurring before and daring labor, and 22 per cent, in those after labor ; while since that date the mortality has fallen to 14 per cent. The same conclusion is arrived at by Dr. Phillips, 2 who has shown that the mortality has greatly lessened since the practice of repeated and indiscriminate bleeding, long considered the sheet anchor in the disease, has been discontinued, and the adminis- tration of chloroform substituted. 1 The Puerperal Disease, p. 125. 2 Guy's Hosp. Reps., 1870. PUERPERAL ECLAMPSIA. 553 Cause of Death. — Death may occur during the paroxysm, and then it may be due to the long continuance of the tonic spasm producing asphyxia. It is certain that, as long as the tonic spasm lasts, the respiration is suspended, just as in the convulsive disease of children known as laryngismus stridulus; and it is possible also that the heart may share in the convulsive contraction which is known to affect other involuntary muscles. More frequently, death happens at a later period, from the combined effects of exhaustion and asphyxia. The records of post-mortem examinations are not numerous; in those we possess the principal changes have been an anaemic condition of the brain, with some ©edematous infiltration. In a few rare cases the convulsions have resulted in effusion of blood into the ventricles, or on the base of the brain. The prognosis as regards the child is also serious. Out of 36 children, Hall Davis found 26 born alive, 10 being still-born. There is good reason to believe that the con- vulsion may attack the child in utero ; of this several examples are mentioned by Cazeaux; or it may be subsequently attacked with convulsions, even when apparently healthy at birth. Pathology of the Disease. — -The precise pathology of eclampsia cannot be considered by any means satisfactorily settled. When, in the year 1843, Lever first showed that the urine in patients suffering from puerperal convulsions was generally highly charged with albu- men — a fact which subsequent experience has amply confirmed — it was thought that a key to the etiology of the disease had been found. It was known that chronic forms of Wright's disease were frequently associated with retention of urinary elements in the blood, and not rarely accompanied by convulsions. The natural inference was drawn, that the convulsions of eclampsia were also due to toxaemia resulting from the retention of urea in the blood, just as in the uraemia of chronic Bright's disease; and this view was adopted and supported by the authority of Braun, Frerichs, and many other writers of eminence, and was pretty generally received as a satisfac- tory explanation of the facts. Frerichs modified it so far, that he held that the true toxic element was not urea as such, but carbonate of ammonia, resulting from its decomposition; and experiments were made to prove that the injection of this substance into the veins of the lower animals produced convulsions of precisely the same cha- racter as eclampsia. Dr. Hammond, 1 of Maryland, subsequently made a series of counter experiments, which were held as proving that there was no reason to believe that urea ever did become de- composed in the blood in the way that Frerichs supposed, or that the symptoms of uraemia were ever produced in this way. Spiegel- berg 2 has, more recently, again examined the question both clinically, in a patient suffering from convulsions, in whose blood an excess of ammonia and urea was found, and by experiments on dogs, and maintains the accuracy of Frerichs's views. Others have believed that the poisonous elements retained in the blood are not urea or the products of its decomposition, but other extractive matters which 1 Auier. Journ., 1861. 2 Arch. f. Gyn., 1870. 36 554 THE PUERPERAL STATE. have escaped detection. As time elapsed, evidence accumulated to show that the relation between albuminuria and eclampsia was not so universal as was supposed, or at least that some other factors were necessary to explain many of the cases. Numerous cases were observed in which albumen was detected in large quantities, without any convulsion following, and that, not only in women who had been the subject of Bright's disease before conception, but also when the albuminuria was known to have developed during pregnancy. Thus Imbert Goubeyre found that out of 164 cases of the latter kind, 95 had no eclampsia; and Blot, out of 41 cases, found that 34 were delivered without untoward symptoms. It may be taken as proved, therefore, that albuminuria is by no means necessarily accompanied by eclampsia. Cases were also observed in which the albumen only appeared after the convulsion; and in these it was evident that the retention of urinary elements could not have been the cause of the attack ; and it is highly probable that in them the albuminuria was produced by the same cause which induced the convulsion. Special attention has been called to this class of cases by Braxton Hicks, 1 who has recorded a considerable number of them. He says that the nearly simultaneous appearance of albuminuria and convulsion — and it is admitted that the two are almost invariably combined — must then be explained in one of three ways. 1st. That the convulsions are the cause of the nephritis. 2dly. That the convulsions and the nephritis 1 are producedj by the same cause, e. g., some detrimental ingredient circulating in the blood, irritating both the cerebro-spinal system and other organs at the same time. 3dly. That the highly congested state of the venous system, in- duced by the spasm of the glottis in eclampsia, is able to produce the kidney complication. Theory of Traube and Rosenstein. — More recently Traube and Ko- senstein have advanced a theory of eclampsia, purporting to explain these anomalies. They refer the occurrence of eclampsia to acute cerebral anemia, resulting from changes in the blood incident to preg- nancy. The primary factor is the hydremic condition of the blood, which is an ordinary concomitant of the pregnant state, and, of course when there is also albuminuria, the watery condition of the blood is greatly intensified ; hence the frequent association of the two states. Accompanying this condition of the blood, there is increased tension of the arterial system, which is favored by the hypertrophy of the heart which is known to be a normal occurrence in pregnancy. The result of these combined states is a temporary hyperemia of the brain, which is rapidly succeeded by serous effusion into the cerebral tissues, resulting in pressure on its minute vessels, and consequent anaemia. There is much in this theory that accords with the most recent views as to the etiology of convulsive disease ; as, for example, the re- searches of Kussmaul and Tenner, who have experimentally proved the dependence of convulsion on cerebral anaBmia, and of Brown- 1 Obstet. Trans., vol. viii. PUERPERAL ECLAMPSIA. 555 Sequard, who showed that an asemic condition of the nerve-centres preceded an epileptic attack. It explains also very satisfactorily how the occurrence of labor should intensify the convulsions, since, during the acme of the pains, the tension of the cerebral arterial system is necessarily greatly increased. There are, however, obvious difficul- ties against its general acceptance. For example, it does not satis- factorily account for those cases which are preceded by well-marked precursory symptoms, and in which an abundance of albumen is present in the urine. Here the premonitory signs are precisely those which precede the development of uraemia in chronic Bright's disease, the dependence of which on the retention in the blood of urinary elements can hardly be doubted. Excitability of Nervous System. — The key to the liability of the puerperal woman to convulsive attacks is, do doubt, to be found in the peculiar excitable condition of the nervous system in pregnancy — a fact which was clearly pointed out by the late Dr. Tyler Smith, and by many other writers. Her nervous system is, in this respect, not unlike that of children, in whom the predominant influence and great excitability of the nervous system are well-established facts, and in whom precisely similar convulsive seizures are of common occur- rence on the application of a sufficiently exciting cause. Exciting Causes. — Admitting this, we require some cause to set the predisposed nervous system into morbid action ; and this we mav have either in a toxaemic, or in an extremely watery, condition of the blood, associated with albuminuria ; or along with these, or some- times independently of them, in some excitement, such as strong emo- tional disturbance. It is highly probable, however, that the theory of Traube affords a true insight into the actual condition of the nerve- centres — a fact of much practical importance in reference to treat- ment. Treatment. — The management of cases in which the occurrence of suspicious symptoms has led to the detection of albuminuria, has al- ready been fully discussed (p. 194.) We shall, therefore, here only consider the treatment of cases in which convulsions have actually I occurred. Venesection. — Until quite recently venesection was regarded as the j sheet anchor in the treatment, and blood was always removed copi- ously, and, there is sufficient reason to believe, with occasional re- I markable benefit. Many cases are recorded in which a patient, in apparently profound coma, rapidly regained her consciousness when blood was extracted in sufficient quantity. The improvement, how- ever, was often transient, the convulsions subsequently recurring with increased vigor. There are good theoretical grounds for believing I that blood-letting can only be of merely temporary use, aud may even increase the tendency to convulsion. These are so well put by Schroeder, that I cannot do better than quote his observations on J this point: — "If," he says, "the theory of Traube and Rosenstein be j correct, a sudden depletion of the vascular system, by which the pressure is diminished, must stop the attacks. From experience it is known that after venesection the quantity of blood soon becomes the 556 THE PUERPERAL STATE. same through the serum taken from all the tissues, while the quality is greatly deteriorated by the abstraction of blood. A short time after venesection we shall expect to find the former blood-pressure in the arterial system, but the blood far more watery than previously. From this theoretical consideration it follows that abstraction of blood, if the above-mentioned conditions really cause convulsions, must be attended by an immediate favorable result, and, under cer- tain circumstances, the whole disease may surely be cut short by it. But, if all other conditions remain the same, the blood-pressure will after some time again reach its former height. The quantity of blood has, in the mean time, been greatly deteriorated, and consequently the danger of the disease will be increased." In Properly -selected Cases Venesection is a Valuable Remedy. — These views sufficiently well explain the varying opinions held with regard to this remedy, and enable us to understand why, while the effects of venesection have been so lauded by certain authors, the mortality has admittedly been much lessened since its indiscriminate use has been abandoned. It does not follow because a remedy, when carried to excess, is apt to be hurtful, that it should be discarded altogether; and I have no doubt that, in properly-selected cases, and judiciously employed, venesection is a valuable aid in the treatment of eclampsia, and that it is specially likely to be useful in mitigating the first violence of the attack, and in giving time for other remedies to come into action. Care should, however, be taken to select the cases properly, and it will be specially indicated when there is marked evidence of great cerebral congestion and vascular tension, such as a livid face, a full bounding pulse, and strong pulsation in the caro- tids. The general constitution of the patient may also serve as a guide in determining its use, and we shall be the more disposed to resort to it if the patient be a strong and healthy woman ; while, on the other hand, if she be feeble and weak, we may wisely discard it, and trust entirely to other means. In any case, it must be looked upon as a temporary expedient only ; useful in warding off immediate danger to the cerebral tissues, but never as the main agent in treat- ment. Nor can it be permissible to bleed in the heroic manner fre- quently recommended. A single bleeding, the amount regulated by the effect produced, is all that is ever likely to be of service. Compression of the Carotids. — As a temporary expedient, having the same object in view, compression of the carotids during the par- oxysms is worthy of trial. This was proposed by Trousseau in the eclampsia of infants, but I am not aware that it has been tried in puerperal convulsions. It is a simple measure, and it offers the ad- vantage of not leading to any permanent deterioration of the blood, as in venesection. Administration of Purgatives. — As a subsidiary means of diminish- ing vascular tension the administration of a strong purgative is de- sirable, and has the further effect of removing any irritant matter that may be lodged in the intestinal tract. If the patient be con- scious a full dose of the compound jalap powder may be given, or a PUERPERAL ECLAMPSIA. 557 few grains of calomel combined with jalap; and if she be comatose, and unable to swallow, a drop of croton oil, or a quarter of a grain of elaterium, may be placed on the back of the tongue. Administration of Sedatives and Narcotics. — The great indication in the management of eclampsia is the controlling of convulsive action by means of sedatives. Foremost amongst them must be placed the inhalation of chloroform, a remedy which is frequently remarkably useful, and which has the advantage of being applicable at all stages of the disease, and whether the patient be comatose or not. Theo- retical objections have been raised against its employment, as being likely to increase cerebral congestion; of this there is no satisfactory proof; on the contrary, there is reason to think that chloroform inhalation has rather the effect of lessening arterial tension, while it certainly controls the violent muscular action by which the hyper- emia is so much increased. Practically no one who has used it can doubt its great value in diminishing the force and frequency of the convulsive paroxysms. Statistically its usefulness is shown by Char- pentier, in his thesis on the effects of various methods of treatment in eclampsia, since out of 63 cases in which it was used, in 48 it had the effect of diminishing or arresting the attacks, 1 only proving fatal. The mode of administration has varied. Some have given it almost continuously, keeping the patient in a more or less profound state of anaesthesia. Others have contented themselves with care- fully watching the patient, and exhibiting the chloroform as soon as there were any indications of a recurring paroxysm, with the view of controlling its intensity. The latter is the plan I have myself adopted, and of the value of which, in most cases, I have no doubt. Every now and again, cases will occur in which chloroform inhala- tion is insufficient to control the paroxysm, or in which, from the very cyanosed state of the patient, its administration seems contra- indicated. Moreover, it is advisable to have, if possible, some remedy more continuous in its action, and requiring less constant personal supervision. Latterly the internal administration of chloral has been recommended for this purpose. My own experience is decidedly in its favor, and I have used, as I believe, with marked advantage a combination of chloral with bromide of potassium, in the proportion of twenty grains of the former to half a drachm of the latter,' repeated at intervals of from four to six hours. 1 If the patient be unable to swallow, the chloral may be given in an enema. The remarkable influence of bromide of potassium in controlling the eclampsia of infants would seem to be an indication for its use in puerperal cases. Fordyce Barker is opposed to the use of chloral, which he thinks excites instead of lessening reflex irritability. 2 Another remedy, not entirely free from theoretical objections, but strongly recom- mended, is the subcutaneous injection of morphia, which has the [' We have used bromide of sodium and chloral with good effect ; but as the latter is an intoxicant, have used doses of 10 to 15 grains, and at shorter intervals. — Ed.] 2 The Puerperal Diseases, p. 120. 558 THE PUERPERAL STATE. advantage of being applicable when the patient is quite unable to swallow. It may be given in doses of one-third of a grain, repeated in a few hours, so as to keep the patient well under its influence. It is to be remembered that the object is to control muscular action, so as to prevent, as much as possible, the violent convulsive paroxysm, and, therefore, it is necessary that the narcosis, however produced, should be continuous. It is rational, therefore, to combine the inter- mittent action of chloroform with the more continuous action of other remedies, so that the former should supplement the latter when in- sufficient. Other remedies, supposed to act in the way of antidotes to urasmic poisoning, have been advised, such as acetic or benzoic acid, but they are far too uncertain to have any reliance placed on them, and they distract attention from more useful measures. Precautions during the Paroxysm. — Precautions are necessary during the fits to prevent the patient injuring herself, especially to obviate, laceration of the tongue ; the latter can be best done by placing something between the teeth as the paroxysm comes on, such as the handle of a teaspoon enveloped in several folds of flannel. Obstetric Management. — The obstetric management of eclampsia will naturally give rise to much anxiety, and on this point there has been considerable difference of opinion. On the one hand, we have practitioners who advise the immediate emptying of the uterus, even when labor has commenced ; on the other, those who would leave the labor entirely alone. Thus Gooch said, " attend to the convul- sions, and leave the labor to take care of itself ;" and Schroeder says, " especially no kind of obstetric manipulation is required for the safety of the mother," but he admits, however, that it is sometimes advisable to hasten the labor to insure the safety of the child. In cases in which the convulsions come on during labor, the pains are often strong and regular, the labor progresses satisfactorily, and no interference is needful. In others we cannot but feel that empty- ing the uterus would be decidedly beneficial. We have to reflect, however, that any active interference might, of itself, prove very irri- tating, and excite fresh attacks. The influence of uterine irritation is apparent, by the frequency with which the paroxysms recur with the pains. If, therefore, the os be undilated, and labor have not begun, no active means to induce it should be adopted, although the membranes may be ruptured with advantage, since that procedure tends to no irritation. Forcible dilatation of the os, and especially turning are strongly contra-indicated. The rule laid down by Tyler Smith seems that which is most ad- visable to follow — that we should adopt the course which seems least likely to prove a souce of irritation to the mother. Thus if the fits seems evidently induced and kept up by the pressure of the foetus, and the head be within reach, the forceps or even craniotomy may be resorted to. But if, on the other hand, there be reason to think that the operation necessary to complete delivery is likely per se to prove a greater source of irritation than leaving the case to nature, then we should not interfere. PUERPERAL INSANITY. 559 [In one case of eclampsia in a primipara, the attacks were inter- mittent and lasted during the pains. As the labor progressed, the convulsions became more marked until the head of the foetus began to dilate the vulva, when they diminished and finally ceased. The forceps were ready for application, but were not required. — Ed.] CHAPTER IV. PUERPERAL INSANITY. Classification. — Under the head of u Puerperal Mania" writers on obstetrics have indiscriminately classed all cases of mental disease connected with pregnancy and parturition. The result has been unfortunate, for the distinction between the various types of mental disorder has, in consequence, been very generally lost sight of. But little study of the subject suffices to show that the term Puerperal Mania is wrong in more ways than one, for we find that a large number of cases are not cases of " mania" at all, but of melancholia; while a considerable number are not, strictly speaking, "puerperal," as they either come on during pregnancy, or long after the immediate risks of the puerperal period are over, being in the latter case asso- ciated with anaemia produced by over-lactation. For the sake of brevity, the generic term "Puerperal Insanity" may be employed to cover all cases of mental disorders connected with gestation, which may be further conveniently subdivided into three classes, each having its special characteristics, viz. : — I. The Insanity of Pregnancy. II. Puerperal Insanity, properly so called, that is insanity coming on within a limited period after delivery. III. The Insanity of lactation. This division is a strictly natural one, and includes all the cases likely to come under observation. The relative proportion these classes bear to each other can only be determined by accurate statis- tical observations on a large scale, but these materials we do not possess. The returns from large asylums are obviously open to objection, for only the worst and most confirmed cases find their way into these institutions, while by far the greater proportion, both before and after labor, are treated in their own homes. Taking such returns as only approximative, we find from Dr. Batty Tuke 1 that in the Edinburgh Asylum out of 105 cases of puer- peral insanity, 28 occurred before delivery, 13 during the puerperal 1 Edin. Med. Journ., vol. x. 560 THE PUERPERAL STATE. period, and 54 daring lactation. The relative proportions of each per hundred are as follows : — Insanity of Pregnancy, 8.06 per cent. Puerperal Insanity, 47.09 " Insanity of Lactation, 34. 8 " Marce 1 collects together several series of cases from various authori- ties, amounting to 310 in all, and the results are not very different from those of the Edinburgh Asylum, except in the relatively smal- ler number of cases occurring before delivery. The percentage is calculated from his figures — ■ Insanity of Pregnancy, 8.06 per cent. Puerperal Insanity, 58.06 " Insanity of Lactation, 30.30 " As each of these classes differs in various important respects from the others, it will be better to consider each separately. Insanity of Pregnancy. — The Insanity of Pregnancy is, without doubt, the least common of the three forms. The intense mental depression which in many women accompanies pregnancy, and causes the patient to take a desponding view of her condition, and to look forward to the result of her labor with the most gloomy apprehen- sion, seems to be often only a lesser degree of the actual mental derangement which is occasionally met with. The relation between the two states is further borne out by the fact that a large majority of cases of insanity during pregnancy are well-marked types of melancholia; out of 28 cases, reported by Tuke, 15 were examples of pure melancholia, 5 of dementia with melancholia. In many of these the attack could be traced as developing itself out of the ordi- nary hypochondriasis of pregnancy. In others the symptoms came on at a later period of pregnancy, the earlier months of which had not been marked by any unusual lowness of spirits. The age of the patient seems to have some influence, the proportion of cases between 30 and 40 years of age being much larger than in younger women. A larger proportion of cases occur in primiparae than in multipara, a fact that, no doubt, depends on the greater dread and apprehension experienced by women who are pregnant for the first time, especially if not very young. Hereditary disposition plays an important part, as in all forms of puerperal insanity. It is not always easy to ascer- tain the fact of an hereditary taint, since it is often studiously con- cealed by the friends. Tuke, however, found distinct evidence of it in no less than 12 out of 28 cases. Fiirstner 2 believes that other neuroses have an important influence in the causation of the disease. Out of 32 cases he found direct hereditary taint in 9, but in 11 more there was a family history of epilepsy, drunkenness, or hysteria. Period of Pregnancy at which it Occurs. — The period of pregnancy, at which mental derangement most commonly shows itself, varies. Most generally, perhaps, it is at the end of the third, or the beginning 1 Traite dc la Folic des Femmes enceintes. 2 Arelriv fur Psychiatric, Band v. Heft 2. PUERPERAL INSANITY. 561 of the fourth month. It may, however, begin with conception, and even return with every impregnation. Montgomery relates an in- stance in which it recurred in three successive pregnancies. Marce distinguishes between true insanity coming on during pregnancy, and aggravated hypochondriasis, by the fact that the latter usually lessens after the third month, while the former most commonly only begins after that date. It is unquestionable that in many cases no such distinction can be made, and that the two are often very inti- mately associated. Form of Insanity. — The form of insanity does not differ from ordi- nary melancholia. The suicidal tendency is generally very strongly developed. Should the mental disorder continue after delivery, the patient may very probably experience a strong impulse to kill her child. Moral perversions have been not uncommonly observed. Tuke especially mentions a tendency to dipsomania in the early months, even in women who have not shown any disposition to excess at other times. He suggests that this may be an exaggeration of the depraved appetite, or morbid craving, so commonly observed in pregnant women, just as melancholia may be a further develop- ment of lowness of spirits. Laycock mentions a disposition to "klep- tomania" as very characteristic of the disease. Casper 1 relates a curious case where this occurred in a pregnant lady of rank, and the influence of pregnancy, in developing an irresistible tendency, was pleaded in a criminal trial in which one of her petty thefts had involved her. Prognosis — The prognosis may be said to be, on the whole, favor- able. Out of Dr. Tuke's 28 cases, 19 recovered within six months. There is little hope of a cure until after the termination of the preg- nancy, as out of 19 cases recorded by Marce* only in 2 did the insanity disappear before delivery. Transient Mania during Delivery. — There is a peculiar form of mental derangement sometimes observed during labor, which is by some talked of as a temporary insanity. It may, perhaps, be more accurately described as a kind of acute delirium, produced, in the latter stage of labor, by the intensity of the suffering caused by the pains. According to Montgomery, it is most apt to occur as the head is passing through the os uteri, or, at a later period, during the ex- pulsion of the child. It may consist of merely a loss of control over the mind, during which the patient, unless carefully watched, might, in her agony, seriously injure herself or her child. Sometimes it produces actual hallucination, as in the case described by Tarnier, in which the patient fancied she saw a spectre standing at the foot of her bed, which she made violent efforts to drive away. This kind of mania, if it may be so called, is merely transitory in its character, and disappears as soon as the labor is over. From a rnedico-legal point of view it may be of importance, as it has been held by some that in certain cases of infanticide the mother has destroyed the child when in this state of transient frenzy, and when she was irrespon- 1 Casper's Forensic Medicine, vol. iv. 562 THE PUERPERAL STATE. sible for her acts. In the treatment of this variety of delirium we must, of course, try to lessen the intensity of the suffering, and it is in such cases that chloroform will find one of its most valuable applications. Puerperal Insanity [proper). — True puerperal insanity has always attracted much attention from obstetricians, often to the exclusion of other forms of mental disturbance connected with the puerperal state. We may define it to be, that form of insanity which comes on within a limited period after delivery, and which is probably in- timately connected with that process. Out of 73 examples of the disease tabulated by Dr. Tuke, only 2 came on later than a month after delivery, and in these there were other causes present, which might possibly remove them from this class. Although a large number of these cases assume the character of acute mania, that is by no means the only kind of insanity which is observed, a not inconsiderable number being well-marked examples of melancholia. The distinction between them was long ago pointed out by Gooch, whose admirable monograph on the disease contains one of the most graphic and accurate accounts of puerperal insanity that has yet been written. There are also some peculiarities as to the period at which these varieties of insanity show themselves, which, taken in connection with certain facts in their etiology, may eventually justify us in drawing a stronger line of demarcation between them than has been usual. It appears that cases of acute mania are apt to come on at a period much nearer delivery than melancholia. Thus Tuke found that all the cases of mania came on within sixteen days after delivery, and that all cases of melancholia developed themselves after that period. We shall presently see that one of the most recent theories as to the causation of the disease attributes it to some morbid condi- tion of the blood. Should further investigation confirm this supposi- tion, inasmuch as septic conditions of the blood are most likely to occur a short time after labor, it would not be an improbable hy- pothesis that cases of acute mania, occurring within a short time after labor, may depend on such septic causes, while melancholia is more likely to arise from general conditions favoring the develop- ment of mental disease. This must, however, be regarded as a mere speculation requiring further investigation. Causes. — Hereditary predisposition is very frequently met with, and a careful inquiry into the patient's history will generally show that other members of the family have suffered from mental derange- ment. Eeid found that out of 111 cases in Bethlehem Hospital there was clear evidence of hereditary taint in 45. Tuke made the same observation in 22 out of his 73 cases ; and, indeed, it is pretty gene- rally admitted by all alienist physicians that hereditary tendencies form one of the strongest predisposing causes of mental disturbance in the puerperal state. In a large proportion of cases circumstances producing debility and exhaustion, or mental depression, have pre- ceded the attack. Thus it is often found that patients attacked with it have have had post-partum hemorrhage, or have suffered from PUERPERAL INSANITY. 563 some other conditions producing exhaustion, such as severe and com- plicated labor ; or they may have been weakened by over-frequent pregnancies, or by lactation during the early months of pregnancy. Indeed anaemia is always well marked in this disease. Mental condi- tions also are frequently traceable in connection with its production. Morbid dread during pregnancy, insufficient to produce insanity be- fore delivery, may develop into mental derangement after it. Shame and fear of exposure in unmarried women not unfrequentfy lead to it, as is evidenced by the fact that out of 2281 cases, gathered from the reports of various asylums, above 64 per cent, were unmarried. 1 Sudden moral shocks or vivid mental impressions may be the deter- mining cause in predisposed persons. Gooch narratives an example of this in a lady who was attacked immediately after a fright pro- duced by a fire close to her house, the hallucinations in this case being all connected with light; and Tyler Smith that of another whose illness dated from the sudden death of a relative. The age of the patient has some influence, and there seems to be a decidedly greater liability at advanced ages, especially when such women are pregnant for the first time. Theory of its Dependence on Morbid State of the Blood. — The possi- bility of the acute form of puerperal insanity, coming on shortly after delivery, being dependent on some form of septicaemia is one which deserves careful consideration. The idea originated with Sir James Simpson, who found albumen in the urine of 4 patients. He suggested that this might probably indicate the presence in the blood of certain urinary constituents, which might have determined the attack, much in the same way as in eclampsia. Dr. Donkin subse- quently wrote an important paper, 2 in which he warmly supported this theory, and arrived at the conclusion, "that the accute danger- ous class of cases are examples of uraemic blood-poisoning, of which the mania, rapid pulse, and other constitutional symptoms are merely the phenomena ; and that the affection, therefore, ought to be termed uraemic or renal puerperal mania, in contradistiction to the other form of the disease." He also suggests that the immediate poison may be carbonate of ammonia, resulting from the decomposition of urea retained in the blood. It will be observed, therefore, that the pathological condition producing puerperal mania would, supposing this theory to be correct, be precisely the same as that which, at other times, is supposed to give rise to puerperal eclampsia. There can be no doubt that the patient, immediately after deliver}', is in a condition rendering her peculiarly liable to various forms of septic disease ; and it must be admitted that there is no inherent improba- bility in the supposition that some morbid material circulating in the blood may be the effective cause of the attack, in a person otherwise predisposed to it. It is also certain, as I have already pointed out, that there are two distinct classes of cases, differing according to the period after delivery at which the attack comes on. Whether this difference depends on the presence in the blood of some septic mat- 1 Journ. of Mental Science, 1870-1, p. 159. 2 Edin. Med. Journ., vol. vii. 56± THE PUERPERAL STATE. ter — especially urinary excreta — is a question which, our knowledge by no means justifies us in answering ; it is, however, one which well merits further careful study. Objections to this Theory. — It is only fair to point to some difficul- ties which appear to militate against the view which Dr. Donkin maintains. In the first place, the albuminuria is merely transient, while its supposed effects last for weeks or months. Sir James Simpson says, with regard to his cases : " I have seen all traces of albuminuria in puerperal insanity disappear from the urine within fifty hours of the access of the malady. The general rapidity of its disappearance is, perhaps, the principal, or, indeed, the only reason why this complication has escaped the notice of those physicians among us who devote themselves with such ardor and zeal to the treatment of insanity in our public asylums." This apparent anomaly Simpson attempts to explain by the hypothesis that, when once the ursemic poisoning has done its work, and set the disease in progress, the mania progresses of itself. This, however, is pure speculation ; and, in the supposed analogous case of eclampsia, the albuminuria certainly lasts as long as its effects. It is not easy to understand, also, why urasmic poisoning should in one case give rise to insanity, and in another to convulsions. For all we know to the contrary, transient albuminuria may be much more common after delivery than has been generally supposed, and further investigation on this point is required. Albumen is by no means unfrequently observed in the urine, for a short time, in various conditions of the body, without any serious consequences, as, for example, after bathing ; and we may too readily draw an unjustifiable conclusion from its detection in a few cases of mania. There are, however, many other kinds of blood- poisoning, besides uraemia, which may have an influence in the pro- duction of the disease, and it is to be hoped that future observations may enable us to speak with more certainty on this point. Prognosis. — The prognosis of puerperal insanity is a point which will always deeply interest those who have to deal with so distress- ing a malady. It may resolve itself into a consideration of the im- mediate risk to life, and of the chances of ultimate restoration of the mental faculties. It is an old aphorism of Goock's, and one the correctness of which is justified by modern experience, that "mania is more dangerous to life, melancholia to reason." It -has very gene- rally been supposed that the immediate risk to life in puerperal mania is not great, and, on the whole, this may be taken as correct. Tuke found that death took place, from all causes, in 10.9 of the cases under observation ; these, however, were all women who had been admitted into asylums, and in whom the attack may be assumed to have been exceptionally severe. Great stress was laid by Hunter and Gooch on extreme rapidity of the pulse, as indicating a fatal tendency. There can be no doubt that it is a symptom of great gravity, but by no means one which need lead us to despair of our patient's recovery. The most dangerous class of cases are those at- tended with some inflammatory complication ; and if there be marked elevation of temperature, indicating the presence of some such con- PUERPERAL INSANITY. 565 comitant state, our prognosis must be more grave than when there is mere excitement of the circulation. Post-mortem Signs. — There are no marked post-mortem signs found in fatal cases to guide us in forming an opinion as to the nature of the disease. "No constant morbid changes," says Tyler Smith, " are found within the head, and most frequently the only condition found in the brain is that of unusual paleness and exsanguinity Many pathologists have also remarked upon the extremely empty condition of the bloodvessels, particularly the veins. Duration of the Disease. — -The duration of the disease varies con- siderably. Generally speaking, cases of mania do not last so long as melancholia, and recovery takes place within a period of three months, often earlier. Very few of the cases admitted into the Edinburgh Asylum remained there more than six months, and after that time the chances of ultimate recovery greatly lessened. When the patient gets well, it often happens that her recollection of the events occurring during her illness is lost ; at other times, the delu- sions from which she suffered remain, as, for example, in a case which was under my care, in which the personal antipathies which the patient formed when insane became permanently established. Insanity of Lactation. — 54 out of the 155 cases collected by Dr. Tuke were examples of the insanity of lactation, which would appear, therefore, to be nearly twice as common as that of pregnancy, but considerably less so than the true puerperal form. Its dependence on causes producing anaemia and exhaustion is obvious and well marked. In the large majority of cases it occurs in multipara who have been debilitated by frequent pregnancies, and by length of nursing. When occurring in primiparse, it is generally in women who have suffered from post-partum hemorrhage, or other causes of exhaustion, or whose constitution was such as should have contra - indicated any attempt at lactation. The bruit-de-diable is almost invariably present in the veins of the neck, indicating the im- poverished condition of the blood. The type is far more frequently melancholic than maniacal, and when the latter form occurs, the attack is much more transient than in true puerperal insanity. The danger to life is not great, especially if the cause producing debility be recognized and at once removed. There seems, however, to be more risk of the insanity becoming permanent than in the other forms. In 12 out of Dr. Tuke's cases the melancholia degenerated into dementia, and the patient became hopelessly insane. Symptoms. — The symptoms of these various forms of insanity are practically the same as in the non-pregnant state. Generally in cases of mania there is more or less premonitory in- dication of mental disturbance, which may pass unperceived. The attack is often preceded by restlessness and loss of sleep, the latter being a very common and well-marked symptom ; or, if the patient do sleep, her rest is broken and disturbed by dreams. Causeless dislikes to those around her are often observed ; the nurse, the hus- band, the doctor, or the child, becomes the object of suspicion, and, 56Q THE PUERPERAL STATE. unless proper care be taken, the child may be seriously injured. As the disease advances, the patient becomes incoherent and rambling in her talk, and, in a fully -developed case, she is incessantly pouring forth an unconnected jumble of sentences, out of which no meaning can be made. Often some prevalent idea which is dwelling in the patient's mind can be traced running through her ravings, and it has been noticed that this is frequently of a sexual character, causing women of unblemished reputation to use obscene and disgusting lan- guage, which it is difficult to understand their even having heard. The tendency of such patients to make accusations impugning their own chastity was specially insisted on by many eminent authorities in a recent celebrated trial, when Sir James Simpson stated that in his experience "the organ diseased gave a type to the insanity, so that with women suffering from affections of the genital organs the de- lusions would be more likely to be connected with sexual matters." Eeligious delusions, as a fear of eternal damnation, or of having committed some unpardonable sin, are of frequent occurrence, but perhaps more often in cases which are tending to the melancholic type. There is generally intolerable restlessness, and the patient's whole manner and appearance are those of excessive excitement. She may refuse to remain in bed, may tear off her clothes, or attempt to injure herself. The suicidal tendency is often very marked. In one case under my care, the patient made incessant efforts to destroy herself, which were only frustrated by the most careful watching ; she endeavored to strangle herself with the bedclothes, to swallow any article she could lay hold of, and even to gouge out her own eyes. Food is generally persistently refused, and the utmost coaxing may fail in inducing the patient to take nourishment. The pulse is rapid and small, and the more violent the excitement and furious the de- lirum, the more excited is the circulation. The tongue is coated and furred, the bowels constipated and disordered, and the feces, as well as the urine, are frequently passed involuntarily. The urine is scanty and high-colored, and, after the disease has lasted for some time, it becomes loaded with phosphates. The lochia, and the se- cretion of milk, generally become arrested at the commencement of the disease. The waste of tissue, from the incessant restlessness and movement of the patient, is very great; and, if the disease continue for some time, she falls into a condition of marasmus, which may be so excessive, that she becomes wasted to a shadow of her former size. Symptoms of Melancholia — When the insanity assumes the form of melancholia, its advent is more gradual. It may commence with depression of spirits, without any adequate cause, associated with in- somnia, disturbed digestion, headache, and other indications of bodily derangement. Such symptoms, showing themselves in women who have been nursing for a length of time, or in whom any other evident cause of exhaustion exists, should never pass unnoticed. Soon the signs of mental depression increase, and positive delusions show them- selves. These may vary much in their amount, but they are all more or less of the same type, and very often of a religious character. The PUERPERAL INSANITY. 567 amount of constitutional disturbance varies much. In some cases which approach in character those of mania, there is considerable excitement, rapid pulse, furred tongue, and restlessness. Probably cases of acute melancholia, coming on during the puerperal state, most often assume this form. In others again there is less of these general symptoms, the patients are profoundly dejected, sit for hours without speaking or moving ; but there is not much excitement, and this is the form most generally characterizing the insanity of lacta- tion. In all cases there is a marked disinclination to food. There is also, almost invariably, a disposition to suicide ; and it should never be forgotten in melancholic cases that this may develop itself in an instant, and that a moment's carelessness on the part of the at- tendants may lead to disastrous results. Treatment. — Bearing in mind what has been said of the essential character of puerperal insanity, it is obvious that the course of treat- ment must be mainly directed to maintain the strength of the patient, so as to enable her to pass through the disease without fatal exhaus- tion of the vital powers, while we endeavor, at the same time, to calm the excitement, and give rest to the disturbed brain. Any over- active measures — for example, bleeding, blistering the shaven scalp, and the like — are distinctly contra-indicated. There is a general agreement on the part of the alienist physicians that in cases of acute mania the two things most needful are a suffi- cient quantity of suitable food and sleep. Importance of Adminstering Nourishment. — Every endeavor should be made to induce the patient to take abundance of nourishment, to remedy the effects of the excessive waste of tissue, and support her strength until the disease abates. Dr. Blandford, who has especially insisted on the importance of this, says, 1 "Now, with regard to the food, skilful attendants will coax a patient into taking a large quan- tity, and we can hardly give too much. Messes of minced meat with potato and greens, diluted with beef-tea, bread and milk, rum and milk, arrowroot, and so on, may be got down. Never give mere liquids so long as you can get down solids. As the malady pro- gresses, the tongue and mouth may become so dry and foul that nothing but liquids can be swallowed; but, reserving our beef- tea and brandy, let us give plenty of solid food while we can." Forcible Administration of Food. — The patient may in mania, as well as in. melancholia, perhaps even more in the latter, obstinately refuse to take nourishment at all, and we may be compelled to use force. Various contrivances have been employed for this purpose. One of the simplest is introducing a dessert-spoon forcibly between the teeth, the patient being controlled by an adequate number of attendants, and slowly injecting into the mouth suitable nourishment, by an india-rubber bottle with an ivory nozzle, such as is sold by all chemists. Care must be taken not to inject more than an ounce at a time, and to allow the patient to breathe between each deglutition. So extreme a measure will seldom be required, if the patient have 1 Blandford, Insanity and its Treatment. 568 THE PUERPERAL STATE. experienced attendants, who can overcome her resistance to food by gentler means; but it may be essential, and it is far better to employ it than to allow the patient to become exhausted from want of nour- ishment. In one case I had to feed a patient in this way three times a day for several weeks, and used for the purpose a contrivance known in asylums as Paley's feeding-bottle, which reduced the diffi- culty of the process to a minimum. Beef-tea, or strong soup, mixed with some farinaceous material, such as Revalenta Arabica, or wheaten flour, or milk, forms the best mess for this purpose. Stimulants. — In the early stages the patient is probably better without stimulants, which seem only to increase the excitement. As the disease progresses, and exhaustion becomes marked, it may be necessary to have recourse to them. In melancholia they seem to be more useful, and may be administered with greater freedom. State of the Bowels. — The state of the bowels requires especial attention. They are almost always disordered, the evacuations being dark and offensive in odor. In the early stages of the disease the prompt clearing of the bowels, by a suitable purgative, some- times has the effect of cutting short an impending attack. A curious example of this is recorded by Gooch, in which the patient's re- covery seemed to date from the free evacuation of the bowels. A few grains of calomel, or a dose of compound jalap powder, or of castor oil, may generally be readily given. During the continuance of the illness the state of the primae vise should be attended to, and occasional aperients will be useful, but strong and repeated purga- tion is hurtful from the debility it produces. The procuring sleep will necessarily form one of the most import- ant points of treatment. For this purpose there is no drug so valu- able as the hydrate of chloral, either alone, or in combination with bromide of potassium, which has a distinct effect in increasing its hypnotic action. Given in a full dose at bedtime, say 15 grs. to 3ss, it rarely fails in procuring at least some sleep, and, in an early stage of acute mania, this may be followed by the best effects. It may be necessary to repeat this draught night after night, during the acute stage of the malady. If we cannot induce the patient to swallow the medicine, it may be given in the form of enema. Question of Administering Opiates. — It is generally admitted that in mania preparations of opium, formerly much relied on in the treatment of the disease, are apt to do more harm than good. Dr. Blandford gives a strong opinion on this point. He says: "In pro- longed delirous mania I believe opium never does good, and may do great harm. We shall see the effects of narcotic poisoning if it be pushed, but none that are beneficial. This applies equally to opium given by the mouth and by subcutaneous injection. The latter, as it is more certain and effectual in producing good results, is also more deadly when it acts as a narcotic poison. After the administration of a dose of morphia by the subcutaneous method, the patient will probablv at once fall asleep, and we congratulate ourselves that our long wished-for object is attained. But after half an hour or so the sleep suddenly terminates, and the mania and excitement are worse PUERPERAL INSANITY. 569 than before. Here yon may possibly think that had the dose been larger, instead of half an hour's sleep you would have obtained one of longer duration, and you may administer more, but with a like result. Large closes of morphia not merely fail to produce refreshing- sleep; they poison the patient, and produce, if not the symptoms of actual narcotic poisoning, at any rate that typhoid condition which indicates prostration and approaching collapse. I believe there is no drug, the use of which more often becomes abused, than that of opium." It is otherwise in cases of melancholia, especially in the more chronic forms. In these opiates, in moderate doses, not pushed to excess, may be given with great advantage. The subcutaneous injection of morphia is by far the best means of exhibiting the drug, from its rapidity of action, and facility of administration. Other Calmatives. — There are other methods of calming the excite- ment of the patient besides the use of medicines. The prolonged use of the warm bath, the patient being immersed in water at a temperature of 90° or 92° for at least half an hour, is highly recom- mended by some as a sedative. The wet pack serves the same pur- pose, and is more readily applied in refractory subjects. Importance of Judicious Nursing. — Judicious nursing is of primary importance. The patient should be kept in a cool, well ventilated, and somewhat darkened room. If possible she should remain in bed, or, at least, endeavors should be made to restrain the excessive rest- less motion, which has so much effect in promoting exhaustion. The presence of relatives and friends, especially the husband, has gene- rally a prejudicial and exciting effect; and it is advisable to place the patient under the care of nurses experienced in the management of the insane, who, as strangers, are likely to have more control over her. It is not too much to say that much of the success in treatment must depend on the manner in which this indication is met. Rough, unskilled nurses, who do not know how to use gentleness combined with firmness, will certainly aggravate and prolong the disorder. Inasmuch as no patient should be left unwatched by day or night, more than one nurse is essential. Question of Removal to an Asylum. — The question of the removal of the patient to an asylum is one which will give rise to anxious consideration. As the fact of having been under such restraint of necessity fixes a certain lasting stigma upon a patient, this is a step which every one would wish to avoid if possible. In cases of acute mania, which will probably last a comparatively short time, home treatment can generally be efficiently carried out. Much must depend on the circumstances of the patient. If these be of a nature which preclude the possibility of her obtaining thoroughly efficient nursing and treatment in her own home, it is advisable to remove her to a place where these essentials can be obtained, even at the cost of some subsequent annoyance. In cases of chronic melancholia, the mange- ment of which is on the whole more difficult, the necessity for such a measure is more likely to arise, and should not be postponed too late. Many examples of incurable dementia, arising out of puerperal 37 5T0 THE PUERPERAL STATE. melancholia, can be traced to unnecessary delay in placing the patients under the most favorable conditions for recovery. Treatment during Convalescence. — When convalescence is com- mencing, change of air and scene will often be found of great value. Removal to some quiet country place, where the patient can enjoy abundance of air and exercise, in the company of her nurses, with- out the excitement of seeing many people is especially to be recom- mended. Great caution must be used in admitting the visits of relatives and friends. In two cases under my own care the patients relapsed, when apparently progressing favorably, because the hus- bands insisted, contrary to advice, on seeing them. On the other hand, Grooch has pointed out that, when the patient is not recovering, when month after month has been passed in seclusion without any improvement, the visit of a friend or relative may produce a favor- able moral impression, and inaugurate a change for the better. It is probably in cases of melancholia, rather than in mania, that this is likely to happen. The experiment may, under such circumstances, be worth trying ; but it is one the result of which we must contem- plate with some anxiety. CHAPTER V. PUERPERAL SEPTICEMIA. There is no subject in the whole range of obstetrics which has caused so much discussion and difference of opinion as that to which this chapter is devoted. Under the name of " Puerperal Fever" the disease we have to consider has given rise to endless controversy. One writer after another has stated his view of the nature of the affection with dogmatic precision, often on no other grounds than his own preconceived notions, and an erroneous interpretation of some of the post-mortem appearances. Thus, one states that puerperal fever is only a local inflammation, such as peritonitis; others declare it to be phlebitis, metritis, metro-peritonitis, or an essential zymotic disease sui generis, which affects lying-in women only. The result has been a hopeless confusion ; and the student rises from the study of the subject with little more useful knowledge than when he began. Fortunately, modern research is beginning to throw a little light upon this chaos. Modern View of the Disease. — The whole tendency of recent inves- tigation is daily rendering it more and more certain that obstetri- cians have been led into error by the special virulence and intensity of the disease, and that they have erroneously considered it to be something special to the puerperal state, instead of recognizing in it PUERPERAL SEPTICEMIA. 571 a form of septic disease practically inclentical with, that which is familiar to surgeons under the name of pyaemia or septicaemia. Objection to the Name. — If this view be correct, the term "puer- peral fever," conveying the idea of a fever such as typhus or typhoid, must be acknowledged to be misleading, and one that should be dis- carded, as only tending to confusion. Before discussing at length the reasons which render it probable that the disease is in no way specific, or peculiar to the puerperal state, it will be well to relate briefly some of the leading facts connected with it. History of the Disease. — More or less distinct references to the existence of the so-called puerperal fever are met with in the classical authors, proving, beyond doubt, that the disease was well known to them ; and Hippocrates, besides relating several cases the nature of which is unquestionable, clearly recognizes the possibility of* its originating in the retention and decomposition of portions of the placenta. Although Harvey and other writers showed that they were more or less familiar with it, and even made most creditable observations on its etiology, it was not until the latter half of the last century that it came prominently into notice. At that time the frightful mortality occurring in some of the principal lying-in hos- pitals, especially in the Hotel Dieu at Paris, attracted attention ; and ever since the disease has been familiar to obstetricians. Mortality resulting from it in Lying-in Hospitals. — Its prevalence in hospitals in which lying-in women are congregated has been con- stantly observed both in this country and abroad, occasionally pro- ducing an appalling death-rate ; the disease, when once it has appeared, frequently spreading from one patient to another, in spite of all that could be done to arrest it. It would be easy to give many startling instances of this. Thus it prevailed in London in the years 1760, 1768, and 1770, to such an extent that in some lying-in insti- tutions nearly all the patients died. Of the Edinburgh Infirmary in 1773, it is stated that " almost every woman, as soon as she was de- livered, or perhaps about twenty -four hours after, was seized with it, and all of them died, though every method was used to cure the dis- order." On the Continent, where the lying-in institutions are on a much larger scale, the mortality was equally great. Thus in the Maison d'Accouchements of Paris, in a number of different years, sometimes as many as 1 and 3 of the women delivered died ; on one occasion 10 women dying out of 15 delivered. Similar results were observed in other great Continental hospitals, as in Yienna, where, in 1823, 19 per cent, of the cases died, and, in 1812, 16 per cent. ; and in Berlin, in 1862, hardly a single patient escaped, the hospital being eventually closed. Such facts, the correctness of which is beyond any question, prove to demonstration the great risk which may accompany the aggrega- tion of lying-in women. Whether they justify the conclusion that all lying-in hospitals should be abolished, is another and a very wide question, which can scarcely be satisfactorily discussed in a practical work. It is to be observed, however, that most of the cases in which the disease produced such disastrous results, occurred before our more 572 PUERPERAL STATE. recent knowledge of its mode of propagation was acquired, when no sufficient hygienic precautions were adopted, when ventilation was little thought of, and when, in a word, every condition prevailed that would tend to favor the spread of a contagious disease from one patient to another. More recent experience proves that when the contrary is the case (as for example in such an institution as the Kotunda Hospital in Dublin), the occurrence of epidemics of this kind may be entirely prevented, and the mortality approximated to that of home practice. The Assumption of a Puerperal Miasm is Unnecessary. — The more closely the history of these outbreaks in hospitals is studied, the more apparent does it become that they are not dependent on any miasm necessarily produced by the aggregation of puerperal patients, but on the direct conveyance of septic matter from one patient to another. In numerous instances the disease has been said to be generally epidemic in domiciliary practice, much in the same way as scarlet fever, or any other zymotic complaint, might be. Such epidemics are described as having occurred in London in 1827-28, in Leeds in 1809-12, in Edinburgh in 1825, and many others might be cited. There is, however, no sufficient ground for believing that the disease has ever been epidemic in the strict sense of the word. That nume- rous cases have often occurred in the same place, and at the same time, is beyond question; but this can easily be explained without admitting an epidemic influence, knowing, as we do, how readily septic matter may be conveyed from one patient to another. In many of the so-called epidemics the disease has been limited to the patients of certain midwives or practitioners, while those of others have entirely escaped; a fact easily understood on the assumption of the disease being produced by septic matter conveyed to the patient, but irreconcilable with the view of general epidemic influ- ence. Numerous Theories advanced regarding its Nature. — It would be a useless task to detail at length the theories that have been advanced to explain the disease. Indeed it may safely be held that the sup- posed necessity of providing a theory which would explain all the facts of the disease has done more to surround it with obscurity than even the difficulties of the subject itself. If any real advance is to be made, it can only be by adopting an humble attitude, by admitting that we are only on the threshold of the inquiry, and by a careful observation of clinical facts, without drawing from them too positive deductions. Theory of its Local Origin. — Many have taught that the disease is essentially a local inflammation, producing secondary constitutional effects. This view doubtless originated from too exclusive attention to the morbid changes found on post-mortem examination. Exten- sive peritonitis, phlebitis, inflammation of the lymphatics, or of the tissues of the uterus, are very commonly found after death ; and each of these has, in its turn, been believed to be the real source of the disease. This view finds but little favor with modern pathologists, PUERPERAL SEPTICEMIA. 573 and is in so many ways inconsistent with clinical facts, that it may be considered to be obsolete. No one of the conditions above men- tioned is universally found, and in the worst cases, definite signs of local inflammation may be entirely absent. Nor will this theory explain the conveyance of the disease from one patient to another, or the peculiar severity of the constitutional symptoms. Theory of an Essential Zymotic Fever. — A more admissible theory, and one which has been extensively entertained, is, that there is an essential zymotic fever peculiar to, and only attacking, puerperal women, which is as specific in its nature as typhus or typhoid, and to which the local phenomena observed after death bear the same relation that the pustules on the skin do to smallpox, or the ulcers in the intestinal glands to typhoid. This fever is supposed to spread by contagion and infection, and to prevail epidemically, both in private and in hospital practice. The most recent exponent of this view is Fordyce Barker, who, in his excellent work on the ''Puer- peral Diseases," has entered at length into all the theories of the disease. He, like others who hold his opinions, has, I cannot but think, entirely failed to bring forward any conclusive evidence of the existence of such a specific fever. It is no doubt true that in typhus and typhoid, and other undoubted examples of this class of disease, there are well-marked local secondary phenomena; but then they are distinct and constant. He makes no attempt to prove that anything 'of the kind occurs in puerperal fever. On the contrary, probably there are no two cases in which similar local phenomena occur; nor is there any case in which the most practised obstetrician could foretell, either the course and duration of the illness, or the local phenomena. Again, this theory altogether fails to explain the very important class of cases which can be distinctly traced to sources originating in the patient herself, viz., the absorption of septic matter from decomposing coagula, and the like. Barker meets this difficulty by placing such cases of auto-infection under a separate category, admitting that they are examples of septicaemia. But he fails to show that there is any difference in symptomatology or post-mortem signs between them and the cases he believes to depend on an essen- tial fever ; nor would it be possible to distinguish the one from the other by either their clinical or pathological history. Theory of Identity with Surgical Septicemia. — The modern view, which holds that the disease is, in fact, identical with the condition known as pyaemia or septicaemia, is by no means free from objections, and much patient clinical investigation is required to give a satisfac- tory explanation of certain peculiarities which the disease presents ; but, in spite of these difficulties, which time may serve to remove, it offers a far better explanation of the phenomena observed than any other that has yet been advanced. Nature of this View. — According to this theory the so-called puer- peral fever is produced by the absorption of septic matter into the system, through solutions of continuity in the generative tract, such as always exist after labor. It is not essential that the poison should be peculiar or specific; for, just as in surgical pyaemia, any decom- 574 PUERPERAL STATE. posing organic matter, either originating within the generative organs of the patient herself, or coming from without, may set up the morbid action. In describing the disease under discussion, I shall assume that, so far as our present knowledge goes, this view is the one most conso- nant with facts ; but, bearing in mind that very little is yet known of surgical septicaemia, it must not be expected that obstetricians can satisfactorily explain all the phenomena they observe. Basis of Description. — The best basis of description I know of, is that given by Burdon Sanderson, when he says, "in every pyaemic process you may trace a focus, a centre of origin, lines of diffusion or distribution, and secondary results from the distribution. In every case an initial process from which infection commences, from which the infection spreads, and secondary processes which come out of this primary one." 1 Adopting this division, I shall first treat of the mode in which the infection may commence in obstetric cases, and point out the special difficulties which this part of the subject presents. Channels through which Septic Matter may be Absorbed. — The fact that all recently delivered women present lesions of continuity in the generative tract, through which septic matter, brought into contact with them, may be readily absorbed, has long been recognized. The analogy between the interior of the uterus after delivery and the surface of a stump after operation, was particularly insisted on by Cruvelhier, Simpson, and others ; an analogy which was, to a great extent, based on erroneous conceptions of what took place, since they conceived that the whole interior of the uterus was bared. It is now well known that that is not the case ; but the fact remains that at the placental site, at any rate, there are open vessels through which ab- sorption may readily take place. That absorption of septic material occurs through this channel is probable in certain cases in which decomposing materials exist in the interior of the uterus, especially when, from defective uterine contraction, the venous sinuses are ab- normally patulous, and are not occluded by thrombi. It is difficult to understand how septic matter, introduced from without, can reach the placental site. Other sites of absorption are, however, always available. These exist in every case in the form of slight abrasions or lacerations about the cervix, or in the vagina, or especially in primiparae, about the fourchette and perineum. There is even some reason to think that absorption of septic matter may take place through the mucous membrane of the vagina or cervix without any breach of surface. This might serve to account for the occasional, although rare, cases, in which symptoms of the disease develop them- selves before delivery, or so soon after it as to show that the infection must have preceded labor ; nor is ther ; any inherent improbability in the supposition that septic material may be occasionally absorbed through the unbroken mucous membrane, as is certainly the case with some poisons, for example that of syphilis. Hence there is no 1 Clinical Transactions, vol. viii. p. cviii. PUERPERAL SEPTICEMIA. 575 difficulty in recognizing the similarity of a lying-in woman to a pa- tient suffering from a recent surgical lesion, or in understanding how septic matter conveyed to her, during or shortly after labor, may be absorbed. It is necessary, however, to suppose that absorption takes place immediately or very shortly after these lesions of continuity are formed, for it is well known that the power of absorption is arrested after they have commenced to heal. This fact may explain the cases in which sloughing about the perineum or vagina exists without any septicaemia resulting, or the far from uncommon cases, in which an intensely fetid lochia! discharge may be present a few days after delivery, without any infection taking place. The character and sources of the septic matter constitute one of the most obscure questions in connection with septicaemia, and that which is most open to discussion. The most practical division of the subject is into cases in which the septic matter originates within the patient, so that she infects herself, the disease then being properly autogenetic ; and into those in which the septic matter is conveyed from without, and brought into contact with absorptive surfaces in the generative tract, the dis- ease then being hetero genetic. Sources of Self-infection. — The sources of auto-infection may be various, but they are not difficult to understand. Any condition giving rise to decomposition, either of the tissues of the mother herself, of matters retained in the uterus or vagina that ought to have been expelled, or decomposing matter derived from a putrid foetus, may start the septicaemic process. Thus it may happen that, from continuous pressure on the maternal soft parts during labor, sloughing has set in; or there may be already decomposing material present from some previous morbid state of the genital tracts, as in carcinoma. A more common origin is the retention of coagula, or of small portions of membrane, or of placenta, in the interior of the uterus, which have putrefied from access of air; or in the decompo- sition of the lochia. That the retention of portions of the placental tissue has at all times been the cause of septicaemia may be illustrated by the case of the Duchesse d'Orleans, in the time of Louis XIII., who had an easy labor, but died of child-bed fever. An examination was made by the leading physicians of Paris, in their report of which it was stated, " On the right side of the womb was found a small portion of after-birth, so firmly adherent that it could hardly be torn off' by the finger nails." 1 The reason why self-infection does not more often occur from sucli sources, since more or less decomposition is of necessity so often present, has already been referred to in the fact that absorption of such matters is not apt to occur when the lesions of continuity, always existing after parturition, have com- menced to heal. This observation may also serve to explain how previous bad states of health, by interfering with the healthy repa- rative process occurring after delivery, may predispose to self-infec- tion. It is interesting to note that puerperal septicaemia, arising 1 Louise Bourgeois, by Goodell. 576 PUERPERAL STATE. from such, sources, is not limited to the human race. In the debate on pysemia at the Clinical Society Mr. Hutchinson recorded several well-marked examples occurring in ewes, in whose uteri portions of retained placenta were found. Source of Heterogenetic Infection. — The sources of sceptic matter conveyed from without are much more difficult to trace, and there are many facts connected with heterogenetic infection which are very difficult to reconcile with theory, and of which, it must be admitted, we are not yet able to give a satisfactory explanation. It is probable that any decomposing organic matter may infect, but that some forms operate with more certainty and greater viru- lence than others. Influence of Cadaveric Poisoning. — One of these, which has attracted special attention, is what may be termed cadaveric poison, derived from dissection of the dead subject in the anatomical and post-mortem theatre, and conveyed to the genital tract by the hands of the accou- cheur. Attention was particularly directed to this source of infec- tion by the observations of Semmelweiss, who showed that in the division of the Vienna Lying-in Hospital attended by medical men and students who frequented the dissecting rooms, the mortality was seldom less than 1 in 10, while in the division solely attended by women, the mortality never exceeded 1 in 34 ; the number of deaths in the former division at once falling to that of the latter, as soon as proper precautions and means of disinfection were used. Many other facts of a like nature have since been recorded, which render this origin of puerperal septicaemia a matter of certainty. An interesting example is related by Simpson with characteristic candor: — "In 1836 or 1337 Mr. Sidey of this city had a rapid succession of "five or six cases of puerperal fever in his practice, at a time when the dis- ease was not known to exist in the practice of any other practitioners in the locality. Dr. Simpson, who had then no firm or proper belief in the contagious propagation of puerperal fever, attended the dis- section of Mr. Sidey's patients, and freely handled the diseased parts. The next four cases of midwifery which Dr. Simpson attended were all affected with puerperal fever, and it w r as the first time he had seen it in practice. Dr. Patterson, of Leith, examined the ovaries, etc. The three next cases which Dr. Patterson attended in that town were attacked with the disease. 1 Negative examples are of course brought forward of those who have attended post-mortem examina- tions without injury to their obstetric patients, which merely prove that the cadaveric poison does not, of necessity, attach itself to the hands of the dissector ; and no amount of such testimony can invali- date such positive evidence as that just narrated. Barnes believes that there is not so much danger attending the dissection of patients who have died of any ordinary disease, but that the risk attending the dissection of those who have died of infectious or contagious complaints is very great indeed. 2 I presume there is no doubt that 1 Selected Obst. Works, p. 508. 2 "Lectures on Puerperal Fever," Lancet, vol. ii. 18G5. PUERPERAL SEPTICEMIA. 577 the risk is greater when the subject has died from zymotic disease ; but the distinction is too delicate to rely on, and the attendant on midwifery will certainly err on the safe side by avoiding, as much as possible, having anything to do with the conduct of dissections or post-mortem examinations. Infection from Erysipelas. — Another possible source of infection is erysipelatous disease in all its forms. The intimate connection be- tween erysipelas and surgical pyaemia has long been recognized by surgeons, and the influence of erysipelas in producing puerperal septicaemia has been especially observed in surgical hospitals in which lying-in patients were also admitted. Trousseau relates in- stances of this kind occurring in Paris. The only instance that I know of in London was in the lying-in ward of King's College Hospital, where, in spite of every hygienic precaution, the mortality was so great as to necessitate the closure of the ward. Here the association of erysipelas with puerperal septicaemia was again "and again observed; the latter proving fatal in direct proportion to the prevalence of the former in the surgical wards. The dependence of the two on the same poison was in one instance curiously shown by the fact of the child of a patient wmo died of puerperal septicaemia, 1 dying from erysipelas which started from a slight abrasion produced by the forceps. A more recent and very remarkable example is related by Dr. Lombe Atthill. 1 A patient suffering from erysipelas was admitted into the Eotunda Hospital on February 15, 1877. The sanitary condition of the hospital was at the time excellent. The I patient was removed next day; but of the next 10 patients confined in adjoining wards, 9 were attacked with puerperal peritonitis, the I only one who escaped being a case of abortion. But the connection between erysipelas and puerperal septicaemia is not limited to hospi- tals, having been often observed in domiciliary practice. Some interesting facts have been collected by Dr. Minor, 2 who has shown that the two diseases have frequently prevailed together in various parts of the United States, and that during a recent outbreak of puerperal fever in Cincinnati, it occurred chiefly in the practice of those physicians who attended cases of erysipelas. Many children also died from erysipelas, whose mothers had died from puerperal fever. Infection from other Zymotic Diseases. — There is good reason to believe that the contagium of other zymotic diseases may produce a form of disease indistinguishable from ordinary puerperal septicaemia, and presenting none of the characteristic features of the specific complaint from which the contagium was derived. This is admitted to be a fact by the majority of our most eminent British obstetri- cians, although it does not seem to be allowed by Continental authori- ties, and it is strongly controverted by some writers in this country. It is certainly difficult to reconcile this with the theory of septicae- mia, and we are not in a position to give a satisfactory explanation 1 Medical Press and Circular, April, 187 7. 2 Erysipelas and Childbed Fever. Cincinnati, 1874. 578 PUERPERAL STATE. of it. I believe, however, that the evidence in favor of the possi- bility of puerperal septicemia originating in this way is too strong to be assailable. The scarlatinal poison is that regarding which the greatest number of observations have been made. Numerous cases of this kind are to be found scattered through our obstetric literature, but the largest number are to be met with in a paper by Dr. Braxton Hicks in the 12th volume of the "Obstetrical Transactions," and they are especi- ally valuable from that gentleman's well-known accuracy as a clinical observer. Out of 68 cases of puerperal disease seen in consultation, no less than 37 were distinctly traced to the scarlatinal poison. Of these 20 had the characteristic rash of the disease ; but the remain- ing 17, although the history clearly proved exposure to the conta- gium of scarlet fever, showed none of its usual symptoms, and were not to be distinguished from ordinary typical cases of the so-called puerperal fever. On the theory that it is impossible for the specific contagious diseases to be modified by the puerperal state, we have to admit that one physician met with 17 cases of puerperal septicaemia in which, by a mere coincidence, the contagion of scarlet fever had been traced, and that the disease nevertheless originated from some other source; an hypothesis so improbable, that its mere mention carries its own refutation. With regard to the other zymotic diseases the evidence is not so strong ; probably from the comparative rarity of the diseases. Hicks mentions one case in which the diphtheritic poison was traced, al- though none of the usual phenomena of the disease were present. I lately saw a case in which a lady, a few days after delivery, had a very serious attack of septicemia, without any diphtheritic symp- toms, her husband being at the same time attacked with diphtheria of a most marked type. Here it would be difficult not to admit the dependence of the two diseases on the same poison. It is, however, certain that all the zymotic diseases may attack a newly delivered woman, and run their characteristic course without any peculiar intensity. Probably most practitioners have seen cases of this kind ; and this is precisely one of the points of difficulty which we cannot at present explain, but on which future research may be expected to throw some light. It seems to me not improba- ble, that the explanation of the fact that zymotic poison may in one puerperal patient run its ordinary course, and in another produce symptoms of intense septicemia, may be found in the channel of absorption. It is at any rate comprehensible that if the conta'gium be absorbed through the skin or the ordinary channels, it may pro- duce its characteristic symptoms, and run its usual course ; while if brought into contact with lesions of continuity in the generative tract, it may act more in the way of septic poison, or with such in- tensity that its specific symptoms are not developed. It may reasonably be objected that if puerperal and surgical sep- ticemia be identical, the zymotic poisons ought to be similarly modi- fied when they infect patients after surgical operations. The subject of specific contagium as a cause of surgical pyemia has been so little PUERPERAL SEPTICEMIA. 579 studied, that I do not think any one would be justified in asserting that such an occurrence is not possible. Fritsch, of Halle, and other German physicians, have recently shown how elaborate antiseptic precautions in lying-in hospitals may prevent the origin of the dis- ease from such sources. Sir James Paget, in his " Clinical Lectures," seems to believe in the possibility of such modification. He says, " I think it not improbable that, in some cases, results occurring with obscure symptoms, within two or three days after operations, have been due to the scarlet-fever poison, hindered in some way from its usual progress." Mr. Spencer Wells informs me that he has seen cases of surgical pyaemia, which he had reason to believe originated in the scarlatinal poison ; and his well-known success as an ovario- tomist is, no doubt, in a great measure to be attributed to his extreme care in seeing that no one, likely to come in contact with his patients, has been exposed to any such source of infection. Septicaemia from Contagion convey eel from other Puerperal Patients. — The last source from which septic matter may be conveyed is from a patient suffering from puerperal septicaemia, a mode of origin which has, of late, attracted special attention. That this is the explanation of the occasional endemic prevalence of the disease in lying-in hos- pitals can scarcely be doubted. The theory of a special puerperal miasm pervading the hospital is not required to account for the facts, for there are a hundred ways, impossible to detect or avoid — on the hands of nurses or attendants, in sponges, bed-pans, sheets, or even suspended in the atmosphere — in which septic material, derived from one patient, may be carried to another. The poison may be conveyed, in the same manner, from one pri- vate patient to another. Of this there are many lamentable instances recorded. Thus it was mentioned by a gentleman at the recent dis- cussion at the Obstetrical Society, that 5 out of 14 women he attended died, no other practitioner in the neighborhood having a case. This origin of the disease was clearly pointed out by Gordon 1 towards the end of last century, who stated that he himself "was the means of carrying the infection to a great number of women," and he also traced the spread of the disease in the same way in the practice of certain midwives. In some remarkable instances the unhappy pro- perty of carrying contagion has clung to individuals in a way which is most mysterious, and which has led to the supposition that the whole system becomes saturated with the poison. One of the strangest cases of this kind was that of Dr. Rutter, of Philadelphia, which caused much discussion. He had 45 cases of puerperal septi- caemia in his own practice in one year, while none of his neighbors' patients were attacked. Of him it is related, "Dr. Rutter, to rid himself of the mysterious influence which seemed to attend upon his practice, left the city for ten days, and before waiting on the next parturient case had his hair shaved off, and put on a wig, took a hot bath, and changed every article of his apparel, taking nothing with him that he had worn or carried to his knowledge on any 1 See Lectures on Puerperal Fever. By Robert J. Lee, M.D. 580 PUERPERAL STATE. former occasion: and mark the result. The lady, notwithstanding that she had an easy parturition, was seized the next day with child- bed fever, and died on the eleventh day after the birth of the child. Two years later he made another attempt at self- purification, and the next case attended fell a victim to the same disease." No wonder that Meigs, in commenting on such a history, refused to believe that the doctor carried the poison, and rather thought that he was "merely unhappy in meeting with such accidents through God's providence." It appears, however, that Dr. Eutter was the subject of a form of ozoena, and it is quite obvious that, under such circumstances, his hands could never have been free from septic matter. 1 [The Author quotes from the Editor. Dr. Eutter had an ozoena which in time much disfigured him from its effect upon the contour of his nose. He was unfortunately inoculated in his index finger from a patient, and neglected the pustule. He had 95 cases of puerperal septicemia in 4 years and 9 months, with 18 deaths. — Ed.] This observation is of peculiar interest as showing that the sources of infection may exist in conditions difficult to suspect and impossible to obviate, and it affords a satisfactory explanation of a case which was for years considered puzzling in the extreme. It is quite possible that other similar cases, of which many are on record, although none so re- markable, may possibly have depended on some similar cause per- sonal to the medical attendant. The sources of septic poison being thus multifarious, a few words may be said as to the mode in which it may be conveyed to the patient. Mode in which the Poison may be Conveyed to the Patient. — As on the view of puerperal septicaemia which seems most to agree with recorded facts, the poison, from whatever source it may be derived, must come into actual contact with lesions of continuity in the gene- rative tract, it is obvious that one method of conveyance may be on the hands of the accoucheur. That this is a possibility, and that the disease has often been unhappily conveyed in this way, no one can doubt. Still it would be unfair in the extreme to conclude that this is the only way in which infection may arise. In town practice, especially, there are many other ways in which septic matter may reach the patient. The nurse may be the means of communication, and, if she have been in contact with septic matter, she is even more likely than the medical attendant to convey it when washing the genitals during the first few days after delivery, the time that ab- sorption is most apt to occur. Barnes relates a whole series of cases occurring in a suburb of London, in the practice of different practi- tioners, every one of which was attended by the same nurse. Again septic matter may be carried in sponges, linen, and other articles. What is more likely, for example, than that a careless nurse might use an imperfectly washed sponge, on which discharge has been allowed to remain and decompose ? Nor do I see any reason to question the 1 This is stated on the authority of an obstetrical contemporary of Dr. Rutter. See Amer. Journ. of Med. Sciences, April, 1875, p. 471. PUERPERAL SEPTICEMIA. 581 possibility of infection from septic matter suspended in the atmos- phere; and in lying-in hospitals, where maiw women are congre- gated together, there can be little doubt that this is a common origin of the disease. It is certain, whatever view we may take of the character of the septic material, that it must be in a state of very minute subdivision, and there is no theoretical difficulty in the assumption of its being conveyed by the atmosphere. Conduct of the Practitioner in relation to the Disease. — This ques- tion naturally involves a reference to the duty of those who are unfortunately brought into contact with septic matter in any form, either in a patient suffering from puerperal septicaemia, zymotic dis- ease, or offensive discharges. The practitioner cannot always avoid such contact, and it is practically impossible, as Dr. Duncan has in- sisted, to relinquish obstetric work every time that he is in attendance on a case from which contagion may be carried. Nor do I believe, especially in these days when the use of antiseptics is so well under- stood, that it is essential. It was otherwise when antiseptics were not employed ; but I can scarcely conceive any case in which the risk of infection cannot be prevented by proper care. The danger I believe to be chiefly in not recognizing the possible risk, and in ne- glecting the use of proper precautions. It is impossible, therefore, to urge too strongly the necessity of extreme and even exaggerated care in this direction. The practitioner should accustom himself, as much as possible, to use the left hand Only in touching patients suf- fering from infectious diseases, as that which is not used, under ordi- nary circumstances, in obstetric manipulations. He should be most careful in the frequent employment of antiseptics in washing his hands, such as Condy's fluid, carbolic acid, or tincture of iodine. Clothing should be changed on leaving an infectious case. Much more care than is usually practised should be taken by nurses, espe- cially in securing perfect cleanliness in every thing brought into contact with the patient. When, however, a practitioner is in actual and constant attendance on a case of puerperal septicaemia, when he is visiting his patient many times a day, especially if he be himself washing out the uterus with antiseptic lotions, it is certain that be cannot deliver other patients with safety, and he should secure the assistance of a brother practitioner, although there seems no reason why he should not visit women already confined, in whom he has not to make vaginal examinations. Nature of the Septic Poison. — As to the precise character of the septic poison — although of late much has been said about it, and there is good reason to believe that further research may throw light on this obscure subject — too little is known to justify any positive statement. With regard to the influence of the minute organisms known as bacteria, and their supposed connection with the produc- tion of the disease, this is especially the case. Heiberg has proved that they may be traced, in most cases of puerperal septicaemia, pass- ing through the veins and lymphatics, and that they are found in various organs and pathological products. But what their relation is to the disease, whether they themselves form the septic matter, or 582 PUERPERAL STATE. carry it, or whether they are mere accidental concomitants of the pysemie process, it is impossible, in the present state of our know- ledge, to state ; and I, therefore, prefer to dwell on that part of the subject which is of clinical importance, rather than enter into specu- lative theories, which may to-morrow prove to be valueless. Channels of Diffusion. — Passing on to the channels of diffusion through which the septic matter may act, we have to consider its effects on the structures with which it is brought into contact, and the mode in which it may infect the system at large ; and this will include a consideration of the pathological phenomena. Local changes consequent on the absorption of the poison are pretty constant, and of these we may form an intelligible idea of thinking of them as similar in character and causation to those which we have the opportunity of studying when septic matter is applied to a wound open to observation, as, for example, in cases of blood-poisoning fol- lowing a dissection wound. Distinct traces of local action are not of invariable occurrence, and in some of the worst class of cases, when the amount of septic matter is great, and its absorption rapid, death may occur after an illness of short duration bat great intensity, and before appreciable local changes, either at the site of absorption or in the system at large, have had time to develop themselves. The fact that puerperal fever may prove fatal, without leaving any tan- gible post-mortem signs, has often been pointed out, such cases most frequently occurring during the endemic prevalence of the disease in lying-in hospitals. There can be little doubt, however, that in such cases of intense septicaemia marked pathological changes exist, in the form of alterations of the blood and degenerations of tissue, but not of a character which can be detected by an ordinary post-mortem examination. In the great majority of cases, indications of the dis- ease exist at the site of absorption. These are described by patholo- gists as identical in their character with the inflammatory oedema which occurs in connection with phlegmonous erysipelas. If lacera- tions exist in the cervix or vagina they take on unhealthy action, their edges swell, and their surfaces become covered with a yellowish coat, similar in appearance to diphtheritic membrane. The mucous membrane of the uterus is also generally found to be affected, and in a degree varying with the intensity of the local septic process. There is evidence of severe endometritis ; and, very frequently, the whole lining of the uterus is profoundly altered, softened, covered with patches of diphtheritic deposit, and it may be in a state of general necrosis. In the severer cases these changes affect the mus- cular tissue of the uterus, which is found to be swollen, soft, imper- fectly contracted, and even partially necrosed, a condition which is likened by Heiberg to hospital gangrene. The connective tissue surrounding the generative tract is also swollen and cedematous, and the inflammation may in this w r ay reach the peritoneum, although peritonitis, so often observed in puerperal septicaemia, does not ne- cessarily depend on the direct transmission of inflammation from the pelvic connective tissue, but is more often a secondary phenomenon. The channels through which general systemic infection may super- PUERPERAL SEPTICEMIA. 583 vene are the lymphatics and the venous sinuses, the former being by far the most important. Eecent researches have shown the great number and complexity of the lymphatics in connection with the pelvic viscera, and marked traces of the absorption of septic matter are almost always to be found, except in those very intense cases alreadj^ alluded to, in which no appreciable post-mortem signs are discoverable. The septic matter is probably absorbed from the lymph spaces abounding in the connective tissue, and carried along the lymphatic canals to the nearest glands. The result is inflamma- tion of their coats, and thrombosis of their contents, which may be seen on section as a creamy purulent substance. The absorption of septic material may, as Virchow has shown, be delayed by the local changes produced in the lymphatics and in the glands with which they communicate, which are, therefore, conservative in their action ; and the further progress of the case may in this way be stopped, and local inflammation alone result, such cases being believed by Heiberg to be examples of abortive pyaemia. On the other hand the free septic material may be too abundant and intense to be so arrested, it may pass on through the lymph canals and glands, until it reaches the blood current through the thoracic duct, and so produces a gene- ral blood-infection. This mode of absorption of septic matter, and the tendency of the glands to arrest its further progress, serve to explain the progressive character of many cases, in which fresh exacerbations seem to occur from time to time; since fresh quantities of poison, generated at its source of origin, may be absorbed as the case progresses. The uterine veins are supposed by D'Espinne to be the channel of absorption in the intense form of disease which proves fatal very shortly after delivery, too soon for the more gradual pro- cess of lymphatic absorption to have become established. It is evi- dent that the veins are not likely to act in this way, since they must, under ordinary circumstances, be completely occluded by thrombi, otherwise hemorrhage would occur. If, however, uterine contraction be incomplete, the occlusion of the venous sinuses may be imperfect, and absorption of septic material through them may then take place. Some writers have laid great stress on imperfect uterine contraction in predisposing to septicaemia, and its influence may thus be well explained. The veins may bear an important part in the production of septicaemia, independent of the direct absorption of septic matter through them, by means of the detachment of minute portions of their occluding thrombi, in the form of emboli. If phlegmonous inflammation occur in the immediate vicinity of the veins, the thrombi they contain may become infected. When once blood infection has occurred, by any of these channels, general septicaemia, the so-called puerperal fever, is developed. Pathological Phenomena observed after general Blood-infection. — The variety of pathological phenomena found on post-mortem ex- amination has had much to do with the prevalent confusion as to the nature of the disease. This has resulted in the description of many distinct forms of puerperal fever; the most marked pathological alte- ration having been taken to be the essential element of the disease. 584 PUERPERAL STATE. As a matter of fact there is no doubt that various types of pathologi- cal change are met with. Heiberg describes four chief classes which are by no means distinctly separated from one another, are often found simultaneously in the same subject, and are certainly not to be distinguished by the symptoms during life. Intense Cases without marked Post-mortem Signs. — Of these, the first is the class of cases in which no appreciable morbid phenomena are found after death. This formidable and fatal form of the disease has long been well known, and is that described by some of our authors as adynamic, or malignant puerperal fever. It is the variety which was so prevalent in our lying-in hospitals, and which Eams- botham talks of as being second only to cholera in the severity and suddenness of its onset, and in the rapidity with which it carried off its victims. It is quite erroneous to suppose that the existence of pathological changes in this form of disease has never been recog- nized. Even with the coarse methods of examination formerly used, the occurrence of a fluid and altered state of the blood, and ecchy- moses in connection with various organs — especially the lungs, spleen, and kidneys — were noticed and specially described by Copland in his dictionary of medicine. More recently it has been clearly proved by the microscope that there exist, in addition, the commencement of inflammation in most of the tissues, as shown by cloudy swellings, and granular infiltration and disintegration of the cell elements; proving that the blood, heavily charged with septic matter, had set up morbid action wherever it circulated, the patient succumbing before this had time to develop. Cases Characterized by Inflammation of the Serous Membranes. — In the second type, and that perhaps most commonly met with, the morbid changes are most frequently found in the serous membranes, in the pleura, the pericardium, but, above all, in the peritoneum, the alterations in which have long attracted notice, and have been taken by many writers as proving peritonitis to be the main element of the disease. Evidences of more or less peritonitis are very general. In the more severe cases there is little or no exudation of plastic lymph, such as is found in peritonitis unassociated with septicaemia. There is a greater or less quantity of brownish serum only, the coils of intestine, distended with flatus, and highly congested, being sur- rounded by it. More often there are patchy deposits of fibrinous exudation over many of the viscera, the fundus uteri, the under sur- face of the liver, and the distended intestines. There is then also a considerable quantity of sero- purulent fluid in the abdominal cavity. The pleural cavities may also exhibit similar traces of inflammatory action, containing imperfectly organized lymph, and sero-purulent fluid. Schrceder states that pleurisy is more often the direct result of transmission of inflammation through the substance of the dia- phragm or lung, than a secondary consequence of the septicaemia. In like manner evidences of pericarditis may exist, the surface of the pericardium being highly injected, and its cavity containing serous fluid. Inflammation of the synovial membranes of the larger joints, PUERPERAL SEPTICEMIA. 585 occasionally ending in suppuration, is not uncommon, and may pro- bably be best included under this class of cases. Cases Characterized by changes in the Mucous Membrane. — In the third type the mucous membranes appear to bear the brunt of the disease. The pathological changes are most marked in the mucous membrane lining the intestines, which is highly congested and even ulcerated in patches, with numerous small spots of blood extra vasat^d in the sub-mucous tissue. Similar small apoplectic effusions have been observed in the substance of the kidneys, and under the mucous membrane of the bladder. Pneumonia is of common occurrence. In most cases it is probably secondary to the impaction of minute emboli in the smaller branches of the pulmonary artery ; but it may doubtless arise from independent inflammation of the lung tissue, and will then be included in the class of cases now under considera- j tion. Cases Characterized by the Impaction of Infected Emboli and Second- ary Inflammation and Abscess. — -The fourth ciass of pathological phenomena are those which are produced chiefly by the impaction of minute infected emboli in small vessels in various parts of the ibody. These are the cases which most closely resemble surgical (pyaemia, both in their symptoms and post-mortem signs, and which by many writers are described under the name of puerperal pyaemia. | The dependence of puerperal fever on phlebitis of the uterine veins i was a favorite theory, and in a large proportion of cases the coats of the veins show signs of inflammation, their canals being occupied with thrombi in a more or less advanced state of disintegration. The mode in which these thrombi may become infected has been shown by Babnoff, who has proved that leucocytes may penetrate the coats of the vein, and entering its contained coagulum, may set up disin- tegration and suppuration. This observation brings these pyaemic forms of disease into close relation with septicaemia, such as we have been studying, and justifies the conclusion of Yerneuil that purulent infection is not a distinct disease, but only a termination of septi- caemia, with which it ought to be studied. We have, moreover; to differentiate these results of embolism from those considered in a subsequent chapter ; the characteristic of these cases being the in- fected nature of the minute emboli. Localized inflammations and .abscesses, from the impaction of minute capillary emboli, are found in many parts of the body ; most frequently in the lungs, then in the kidneys, spleen, and liver, and also in the muscles and connective I tissues. Pathologists are by no means agreed as to the invariable ' dependence of these on embolism, nor is it possible to prove their origin from this source by post-mortem examination. Some attri- bute all such cases to embolism, others think that they may be the results of primary septicaemic inflammation. It has been proved by Weber that minute infected emboli may pass through the lung- capillaries ; and this disposes of one argument against the embolic theory, based on the supposed impossibility of their passage. It is probable that both causes may operate, and that localized inflamma- tions occurring a short time after delivery are directly produced by 38 586 PUERPERAL STATE. the infected blood, while those occurring after the lapse of some time, as in the second or third week, depend upon embolism. Description of the Disease. — From what has been said as to the mode of infection in puerperal septicaemia, and as to the very various pathological changes which accompany it, it will not be a matter of surprise to find that the symptoms are also very various in different cases. This can readily be explained by the amount and virulence of the poison absorbed, the channels of infection, and the organs which are chiefly implicated; but it renders it very difficult to describe the disease satisfactorily. The symptoms generally show themselves within two or three days after delivery. As infection most often occurs during labor, or, in cases which are autogenetic, within a short time afterwards, and before the lesions of continuity in the generative tract have commenced to cicatrize, it can be understood why septicaemia rarely commences later than the fourth or fifth day. In the great majority of cases the disease begins insidiously. There are, generally, some chilliness and rigor, but by no means always, and even when present they frequently escape observation, or are referred to some transient cause. The first symptom which excites attention is a rise in the pulse, which may vary from 100 to 140 or more, according to the severity of the attack ; and the thermometer will also show that the temperature is raised to 102°, or, in bad cases, even to 104° or 106°. Still, it must be borne in mind that both the pulse and temperature may be increased in the puerperal state from transient causes, and do not, of themselves, justify the diagnosis of septicaemia. Symptoms of Intense Septicaemia. — In the more intense class of cases, in which the whole system seems overwhelmed with the severity of the attack, the disease progresses with great rapidity, and often without any appreciable indication of local complication. The pulse is very rapid, small, and feeble, varying from 120 to 1-10, and there is generally a temperature of 108° or 10-i°. There may be little or no pain, or there may be slight tenderness on pressure over the abdomen or uterus; and, as the disease progresses, the intestines get largely distended with flatus, so that intense tympanites often form a most distressing symptom. The countenance is sallow, sunken, and has a very anxious expression. As a rule, intelligence is unimpaired, and this ma}?- be the case even in the worst forms of the disease, and up to the period of death. At other times, there is a good deal of low muttering delirium, which often occurs at night alone, and alternates with intervals of complete consciousness, but is occasionally intensified, for a short time, into a more acute form. Diarrhoea and vomiting are of very frequent occurrence; by the latter dark, grumous, coffee- ground substances are ejected. The diarrhoea is occasionally very profuse and uncontrollable; in mild cases it seems to relieve the severity of the symptoms. The tongue is moist and loaded with sordes ; but sometimes it gets dark and dry, especially towards the termination of the disease. The lochia are generally suppressed, or altered in character, and sometimes they have a highly-offensive odor, especially when the disease is auto- PUERPERAL SEPTICEMIA. 587 genetic. The breathing is hurried and panting, and the breath itself has a very characteristic, heavy, sweetish odor. The secretion of milk is often, but not always, arrested. Duration of the Disease. — \Tith more or less of these symptoms the case goes on; and when it ends fatally it generally does so within a week, the fatal termination being indicated by more weak- ness, rapid, threadlike, or intermittent pulse, marked delirium, great tympanites, and sometimes a sudden fall of temperature, until at last the patient sinks with all the symptoms of profound exhaustion. Variety of Symptoms in Different Cases. — In milder cases similar symptoms, variously modified and combined, are present. It is seldom that two precisely similar cases are met with ; in some, the rapid, weak pulse is most marked ; in others, abdominal distension, vomiting, diarrhoea, or delirium. Symptoms of Peritonitis. — Local complications variously modify the symptoms and course of the disease. The most common is peri- tonitis, so much so that with some authors puerperal fever and puer- peral peritonitis are sjmonymous terms. Here the first symptom is severe abdominal pain, commencing at the lower part of the abdomen, where the uterus is felt enlarged and tender. As the abdominal pain and tenderness spread, the sufferings of the patient greatly increase, the intestines become enormously distended with flatus, and the breathing is entirely thoracic, in consequence of the upward dis- placement of the diaphragm and the fact that the abdominal muscles are instinctively kept as much in repose as possible. The patient lies on her back, with her knees drawn up, and sometimes cannot bear the slightest pressure of the bed clothes. There is generally much vomiting, and often severe diarrhoea. The temperature gener- ally ranges from 102° to 104°, or eA^en 106°, and is subject to occa- sional exacerbations and remissions^ possibly depending on fresh absorption of septic matter. The case generally lasts for a week or more, the symptoms going on from bad to worse, and the patient dying exhausted. D'Espinne points out that rigors, with exacerba- tions of the general symptoms, not unfrequentty occur about the sixth or seventh day, which he attributes to fresh systemic infection, from foetid pus in the peritoneal cavity. It must not be supposed that all these symptoms are necessarily present when the peritonic I complication exists. Pain especially is often entirely absent, and I ] have seen cases in which post-mortem examination proved the exist- ence of peritonitis in a very marked degree, in which pain was entirely absent. Sometimes the pain is only slight, and amounts to little more than tenderness over the uterus. Other local complications are characterized by their own special symptoms ; thus pneumonia by dyspnoea, cough, dulness, etc. ; peri- carditis by the characteristic rub ; pleurisy by dulness on percussion ; kidney affection by albuminuria and the presence of casts; liver ; complication by jaundice ; and so on. Pysemic Forms of the Disease. — The course of the disease is not always so intense and rapid, being, in some cases, of a more chronic character. The symptoms in the early stage are often indistinguish- able from those already described ; and it is generally only after the 588 PUERPERAL STATE. second week, that indications of purulent infection develop them- selves. Then we often have recurrent and very severe rigors, with marked elevations and remissions of temperature. At the same time there is generally an exacerbation of the general symptoms, a pecu- liar yellowish discoloration of the skin, and occasionally well- developed jaundice. Transient patches of erythema are not uncom- monly observed on various parts of the skin, and such eruptions have often been mistaken for those of scarlet fever or other zymotic disease. Localized inflammations and suppuration may rapidly follow. Amongst the most common are inflammation or even sup- puration of the joints — the knees, shoulders, or hips — which is pre- ceded by difficulty of movement, swelling, and very acute pain. Large collections of pus in various parts of the muscles and connec- tive tissues are not rare. Suppurative inflammation may also be found in connection with many organs, as in the eye, in the pleura, pericardium, or lungs ; each of which will, of course, give rise to characteristic symptoms, more or less modified by the type of the disease and the intensity of the inflammation. Treatment. — In considering the all-important subject of treatment, the views of the practitioner are naturally biased by the theory he has adopted of the nature of the disease. If that here inculcated be correct, the indications we have to bear in mind are : 1st, to discover, if possible, the source of the poison, in the hope of arresting further septic absorption ; 2d, to keep the patient alive until the effects of the poison are worn off; and 3d, to treat any local complications that may arise. The Use of Antiseptic Injections. — The first is likely to be of great importance in cases of self-infection as fresh quantities of septic mat- ter may be, from time to time, absorbed. We, fortunately, are in possession of a powerful means of preventing further absorption by the application of antiseptics to the interior of the uterus, and to the canal of the vagina. This is especially valuable when the existence of decomposing coagula, or other sources of septic matter, is sus- pected in the uterine cavity, or when offensive discharges are present. Disinfection is readily accomplished by washing out the uterine cavity, at least twice daily, by means of a Higginson's syringe with a long vaginal pipe attached. 1 The results are sometimes very re- 1 My colleague, Dr. Hayes, has invented a silver tube for the purpose of adminis- tering such intra-uterine injections (Fig. 182), which answers its purpose admirably. Fig. 182. Hayes's Tube for Intra-uterine Injections. The numerous apertures at its extremity allow of a number of minute streams of fluid being thrown out in the form of a spray over the interior of the uterus, the complete PUERPERAL SEPTICEMIA 589 107" « • t m - £ ra eh ■ t Jj: il i A 1 U I a ■ t M I M • £ ; ; 1 ; l i ■ i M [ 106' : \ : N l°5" u o : : |: j : I u ,01 * < loo' 90' ? : \ '• j i M\\\ \\\\\ ill" i" 2" 3' J •V 1 5' u l<> , . l"« ■markable, the threatening symptoms rapidly disappearing, and the ^temperature and pulse falling so soon after the use of the antiseptic ■injections as to leave no doubt of the beneficial effects of the treatment. I cannot better illustrate the advan- tages of this treatment than by the ^accompanying temperature chart, •which is from a case which came junder my observation in the out-door Ipractice of King's College Hospital, lit was that of a healthy woman, thirty-six years of age, who had an easy and natural labor. Nothing re- markable was observed until the 3d day after delivery, when the temper- ature was found to be slightly in- creased. On the morning of the 8th day the temperature had risen to 105.4°. She was delirious, with a rapid, thready pulse, clammy perspiration, tympanitic abdomen, and her general condition indicated the most urgent clanger. On vaginal examination a piece of com- pressed and putrid placenta was found in the os. This was removed by my colleague, Dr. Hayes, and the uterus thoroughly washed out with Condy's fluid and water. The same evening the temperature had sunk to 99°, and the general symptoms were much improved. The next day there was a slight return of offensive discharge, and an aggravation of the symptoms. After again washing out the uterus the temperature fell, and from that elate the patient convalesced without a single bad symptom. This is a very well-marked example of the value of local anti- septic treatment, and I have seen many cases of the same kind. It should, therefore, never be omitted in all cases in which self-infection is possible; and, indeed, even when there is no reason to suspect the presence of a local focus of infection, the use of antiseptic lotions is advisable, as a matter of precaution, since it can do no harm, and is generally comforting to the patient. Any antiseptic may be used, such as a weak solution of carbolic acid, or of tincture of iodine, or Condy's fluid largely diluted. I generally use the two latter alter nately, the one in the morning, the other in the evening. The nozzle of the syringe should be guided well through the cervix, and the cavity of the uterus thoroughly washed out, until the fluid that issues from the vagina is no longer discolored. As the os is always patulous, there is no risk of producing the troublesome symptoms of uterine colic which occasionally follow the use of intra-uterine injections in the unimpregnated state. It is quite useless to entrust the injection to the nurse, and it should be performed at least twice daily by the practitioner himself, in all cases in which the discharges are offensive. bathing of its surface and washing out of its cavity being thus insured. It is, more- over, introduced more easily than the ordinary vaginal pipe, and can be attached to a Higginson syringe. 590 THE PUERPERAL STATE. Administration of Food and Stimulants. — In a disease characterized by so marked a tendency to prostration, the importance of sustaining the vital powers by an abundance of easily assimilated nourishment cannot be overrated. Strong beef-tea, or other forms of animal soup, milk, alone or mixed either with lime or soda water, and the yolk of eggs, beat up with milk and brandy, should be given at short inter- vals, and in as large quantities as the patient can be induced to take; and the value of thoroughly efficient nursing will be specially ap- parent in the management of this important part of the treatment. As there is frequently a tendency to nausea, the patient may resist the administration of food, and the resources of the practitioner will be taxed in administering it in such form and variety as will prove least distasteful. Generally speaking, not more than one or two hours should be allowed to elapse without some nutriment being given. The amount of stimulant required will vary with the inten- sity of the symptoms, and the indications of debility. Generally, stimulants are well borne, prove decidedly beneficial, and require to be given pretty freely. In cases of moderate severity a tablespoonful of good old brandy or whiskey every four hours may suffice; but when the pulse is very rapid and thready, when there is much low delirium, tympanites, or sweating (indicating profound exhaustion), it may be advisable to give them in much larger quantities and at shorter intervals. The careful practitioner will closely watch the effects produced, and regulate the amount by the state of the patient, rather than by any fixed rule ; but in severe cases, eight or twelve ounces of brandy, or even more, in the twenty-four hours may be given with decided benefit. Venesection not Admissible. — Venesection, both general and local, was long considered a sheet anchor in this disease. Modern views are, however, entirely opposed to its use; and in a disease character- ized by so profound an alteration of the blood, and so much prostra- tion, it is too dangerous a remedy to employ, although it is possible that it might alleviate temporarily the severity of some of the symptoms, especially in cases in which peritonitis is well marked, and much local pain and tenderness are present. Medicinal Treatment. — The rational indications in medicinal treat- ment are to lessen the force of the circulation as much as is possible without favoring exhaustion; and to diminish the temperature. Use of Arterial Sedatives. — For the former purpose, Barker strongly advocates the use of veratrum viride, in doses of five drops of the tincture every hour, until the pulse falls to below 100, when its effects are subsequently kept up by two or three drops every second hour. Of this drug I have no personal experience; but I have ex- tensively used minute doses of tincture of aconite for the same pur- pose, and, when carefully given, I believe it to be a most valuable remedy. The way I have administered it is to give a single drop of the tincture, at first every half-hour, increasing the interval of ad- ministration according to the effect produced. Generally, after giving four or five doses at intervals of half an hour, the pulse begins to fall, and afterwards a few doses, at intervals of one or two hours, PUERPERAL SEPTICEMIA. 591 Will suffice to prevent the heart's action rising to its former rapidity. The advantage of thus modifying cardiac action, with the view of preventing excessive waste of tissue, cannot be questioned. It is evident that so powerful a remedy must not be used without the most careful supervision, for, if continued too long, or given at too frequent intervals, it may undnly depress the circulation, and do more harm than good. It is necessary, therefore, that the practi- tioner should constantly watch the effect of the drug, and stop it if the pulse become very weak, or if it intermit. It is most likely to be useful at an early stage of the disease before much exhaustion is present, and then only when the pulse is of a certain force and volume. Barker says of the veratrum viride, what is also true of aconite, that "it should not be given in those cases in which rapid prostration is manifested by a feeble, thread-like irregular pulse, I profuse sweats, and cold extremities." Reduction of Temperature. — The reduction of temperature must , form an important part of our treatment, and for this purpose many agents are at our disposal. Quinine in large doses, of from 10 to 20 grains, has been much j used for this purpose, especially in Germany. After its exhibition I the temperature frequently falls one or two degrees. It may be given morning and evening. Unpleasant head-symptoms, deafness, and ringing in the ears, often render its continuance for a length of time impossible; these may, however, be much lessened by the addition of 10 to 15 minims of hydrobromic acid to each dose. Salicylic acid, in doses of from 10 to 20 grains, or the salicylate of soda in the same doses, is a valuable antipyretic, which I have found on the whole more manageable than quinine. Under its use the temperature often falls considerably in a short space of time. It is, however, apt to depress the circulation, and thus requires to be care- fully watched while it is being administered, and should the pulse become very small and feeble, it should be discontinued. Warburg's Tincture. — In some cases, especially when the fever has assumed a remittent type, I have administered with marked benefit, a drug which is of high repute in India, in the worst class of mala- rious remittent fevers, and the almost marvellous effects of which in such cases I had myself witnessed in India many years ago. This is the so-called Warburg's tincture, the value of which has been testified to by many high authorities ; among whom I may mention Dr. Mac- lean of Ketley, Dr. Broadbent, and Sir Alexander Armstrong, the Director-General of the Medical Department of the Navy, who informs me that it is now supplied to all Her Majesty's ships in the tropics, because it is found to be of the utmost value in cases in which quinine has little or no effect. Eecently its composition has been made public by Dr. Maclean. The basis is quinine, in combination with various aromatics and bit- ters, some of which probably intensify its action. Be this as it may, the testimony in favor of the anti-pyretic action of the remedy is very strong. I have found its exhibition followed by a profuse dia- phoresis (this being its almost invariable effect), and sometimes a 592 THE PUERPERAL STATE. rapid amelioration of the symptoms. In other cases in which I have tried it, like every thing else, it has proved of no avail. Application of Cold. — Cold may be advantageously tried in suitable cases. The simplest mode of using it is by Thornton's ice-cap, by which a current of cold water is kept continuously running round the head. This has been found of great value in pyrexia after ova- riotomy, and I have also found it useful as a means of reducing tem- perature in puerperal cases. It is a comforting application, and gives great relief to the throbbing headache, which often causes much suf- fering. Under its use the temperature often falls two or more de- grees, and it is easily continued day or night. In very serious cases, when the temperature reaches 105° and up- wards, the external application of cold to the rest of the body may be tried. I have elsewhere related a case of puerperal septicaemia with hyper-pyrexia, the temperature continuously ranging over 105°, in which I kept the patient for eleven days 1 nearly continuously covered with cloths soaked in iced water, by which means only was the temperature kept within moderate bounds, and life preserved. But this method of treatment is excessively troublesome, and is in no way curative. It is only of use in moderating the temperature when it has reached a point at which it could not continue long with- out destroying the patient. I should, therefore, never think of em- ploying it unless the temperature was over 105°, and then only as a temporary expedient, requiring incessant watching, to be desisted from as soon as the temperature had reached a more moderate height. It is clearly impossible to place a puerperal patient in a bath, as is practised in hyper-pyrexia associated with acute rheumatism. The same effect may, however, be obtained by placing her on Mackintosh sheeting, and covering the body with towels soaked in iced water, which are frequently renewed by the attendant nurses. During the application the temperature should be constantly taken, and as soon as it has fallen to 101°, the cold applications should be discontinued. Administration of Turpentine. — Amongst other remedies which have been used is turpentine, which was highly thought of by the Dublin school. In cases with much tympanitic distension, and a small weak pulse, it is sometimes of unquestionable value, and it probably acts as a strong nervine stimulant. Given in doses of 15 to 20 minims, rubbed up with mucilage, it can generally be taken in spite of its nauseous taste. Evacuant Remedies. — Purgatives, diaphoretics, or even emetics, have often been employed as eliminants of the poison. The former are strongly recommended by Schroeder and other German authori- ties, and in this country they were formerly amongst the most favorite remedies. In the first volume of the " Obstetrical Journal," there is a paper by Mr. Morton, in which this practice is strongly advocated, and some interesting cases are recorded in which it appa- rently acted well. He administers calomel in doses of 3 or 4 grains 1 A Lecture on a case of Puerperal Septicemia, with Hyper-pyrexia, treated by the continuous application of Cold. — Brit. Med. Journ., Nov. 17, 1877. PUERPERAL SEPTICEMIA. 593 with compound extract of colocynth, so as to keep up a free action of the bowels. It seems quite reasonable, when there is constipation, to promote a gentle action of the bowels by some mild aperient ; but, bearing in mind that severe and exhausting diarrhoea is a common accompaniment of the disease, I should myself hesitate to run the risk of inducing it artificially, especially as there is no proof whatever that septic matter can really be eliminated in this way. At the commence- ment of the disease, however, I have often given one or two aperient doses of calomel with decided benefit. Internal Antiseptic Remedies. — It is possible that further research will give us some means of counteracting the septic state of the blood, and the sulphites and carbolates have been given for this purpose, but as yet with no reliable results. Tincture of Perchloride of Iron. — The tincture of the perchloride of iron naturally suggests itself, from its well-known effects in surgi- cal pyaemia. In the less intense forms of the disease, especially when ; local suppurations exist, it is certainly useful, and may be given in doses of 10 to 20 minims every 3 or i hours. In very acute cases other remedies are more reliable, and the iron has the disadvantage I of not unfrequently causing nausea or vomiting. Opiates. — When restlessness, irritation, and want of sleep are prominent symptoms, sedatives may be required. Under such cir- cumstances opiates may be given at night, and Battley's solution, nepenthe, or the hypodermic injection of morphia, are the forms which answer best. Treatment of Local Complications. — Pain and tenderness, and local complications, must be treated on general principles. The distress from them is most experienced when peritonitis is well marked. Then warm and moist applications, in the form of poultices or fomen- tations, are very useful. Eelief is also sometimes obtained from turpentine stupes, and, when the tympanites is distressing, turpentine enemata are very serviceable. I have found the free application over the abdomen of the flexible collodium of the pharmacopoea decidedly useful in alleviating the suffering from peritonitis. Such are the remedies most used in the treatment of this disease. It is needless to say that it is quite impossible to lay down fixed rules for the management of any individual case ; and it is obvious that, if puerperal septicaemia be not a special and distinct disease, its judi- cious management must depend on the general knowledge of the attendant, and on a careful study of the symptoms each separate case presents. 594 THE PUERPERAL STATE, CHAPTEK VI. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. Under the head of thrombosis we may class several important diseases connected with the puerperal state, which have received far less attention than they deserve. It is only of late years that some, we may probably safely say the majority, of those terribly sudden deaths which from time to time occur after delivery, have been traced to their true cause, viz., obstruction of the right side of the heart and pulmonary arteries from a blood- clot, either carried from a distance, or, as I shall hope to show, formed in situ. Although the result, and, to a great extent, the symptoms, are identical in both, still a careful consideration of the history of these two classes of cases tends to show that in their causation they are distinct, and that they ought not to be confounded. In the former, we have primarily a clotting of blood in some part of the peripheral venous system, and the sepa- ration of a portion of such a thrombus due to changes undergone during retrograde metamorphosis tending to its eventual absorption. In the latter we have a local deposition of fi brine, the result of blood changes consequent on pregnancy and the puerperal state. The formation of such a coagulum in vessels, the complete obstruction of which is incompatible with life, explains the fatal results. "When, however, a coagulum chances to be formed in more distant parts of the circulation, the vital functions are not immediately interfered with, and we have other phenomena occurring, due to the obstruction. The disease known as phlegmasia dolens, I shall presently attempt to show, is one result of blood-clot forming in peripheral vessels. But from the evident and tangible symptoms it produces it has long been considered an essential and special disease, and the general blood dyscrasia which produces it, as well as other allied states, has not been studied separately. I shall hope to show that all these various, conditions, dissimilar as they at first sight appear, are very closely connected, and that they are in fact due to a common cause; and thus, I think, we shall arrive at a clearer and more correct idea of their true nature, than if we looked upon them as distinct and separate affections, as has been commonly clone. I am aware that in phlegmasia dolens, the pathology of which, has received perhaps more study than that of almost any other puerperal affection, some- thing beyond simple obstruction of the venous system of the affected limb is probably required to account for the peculiar tense and shining swelling which is so characteristic. Whether this be an obstruction of the lymphatics, as Dr. Tilbury Fox and others have maintained with much show of reason, or whether it is some as yet undiscovered state, further investigation is required to show. But PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 595 it is beyond any doubt that the important and essential part of the disease is the presence of a thrombus in the vessels; and I think it will not be difficult to prove that in its causation and history it is precisely similar to the more serious cases in which the pulmonary arteries are involved. It will be well to commence the study of the subject by a considera- tion of the conditions which, in the puerperal state, render the blood so peculiarly liable to coagulation, and we may then proceed to discuss the symptoms and results of the formation of coagula in various parts of the circulatory system. Conditions which favor Thrombosis. — The researches of Yirchow, Benj. Ball, Humphrey, Eichardson, and others, have rendered us tolerably familiar with the conditions which favor the coagulation of the blood in the vessels. These are chiefly: 1. A stagnant or arrested circulation; as, for example, when the blood coagulates in the veins which draw blood from the gluteal region in old and bed- ridden people, or as in some forms of pulmonary thrombosis, in which the clots in the arteries are probably the result of obstruction in the circulation through the lung- capillaries, as in certain cases of emphysema, pneumonia, or pulmonary apoplexy. 2. A mechanical obstruction around which coagula form, as in certain morbid states of the vessels, or, a better example still, secondary coagula which form around a travelled embolus impacted in the pulmonary arteries. 3. And most important of all, in which the coagulation is the result of some morbid state of the blood itself. Examples of this last con- dition are frequently met with in the course of various diseases, such as rheumatism or fever, in which the quantity of flbrine is increased, and the blood itself is loaded with morbid material. Thrombosis from this cause is of by no means infrequent occurrence after severe surgical operations, especially such as have been attended with much hemorrhage, or when the patient is in a weak and anaemic condition. This has been specially dwelt upon as a not infrequent source of death after operation by Fayrer and other surgeons. 1 Conditions which favor Coagulation in the Puerperal State. — But little consideration is required to show why thrombosis plays so im- portant a part in the puerperal state, for there most of the causes favoring its occurrence are present. Probably there is no other con- dition in which they exist in so marked a degree, or are so frequently combined. The blood contains an excess of fiorine, which largely increases in the latter months of utero- gestation, until, as has been pointed out by Andral and Gavarret, it not ^infrequently contains a third more than the average amount present in the non-pregnant state. As soon as delivery is completed, other causes of blood dys- crasia come into operation. Involution of the largely hypertrophied uterus commences, and the blood is charged with a quantity of effete material, which must be present, in greater or less amount, until that process is completed. It is an old observation that phlegmasia dolens is of very common occurrence in patients who have lost much 1 Edin. Med. Journ., March, 1861; Indian Annals of Med., July, 1867. 596 THE PUERPEKAL STATE. blood during labor ; thus Dr. Leishman says: "In no class of cases has it been so frequently observed as in women whose strength has been reduced to a low ebb by hemorrhage either during or after labor; and this, no doubt, accounts for the observation made by Merriman, that it is relatively a common occurrence after placenta prsevia. 1 An examination of the cases in which death results from pulmonary thrombosis shows the same facts, as in a large proportion of them severe post-partum hemorrhage has occurred. The exhaus- tion following the excessive losses so common after labor must of itself strongly predispose to thrombosis, and, indeed, loss of blood has been distinctly pointed out by Richardson to be one of its most common antecedents. "There is," he observes, "a condition which has been long known to favor coagulation and fibrinous deposition. I mean loss of blood, and syncope or exhaustion during impoverished states of the body." Since then so many of the predisposing causes of thrombosis are present in the puerperal state, it is hardly a matter of astonishment that it should be of frequent occurrence, or that it should lead to conditions of serious gravity. And yet the attention of the profession has been for the most part limited to a study of one only of the results of this tendency to blood-clotting after delivery, no doubt because of its comparative frequency and evident symptoms. True the balance of professional opinion has lately held that phlegmasia dolens is chiefly the result of some morbid condition of the blood producing plugging of the veins ; but the wider view which I am attempting to maintain, which would bring this disease into close relation with the more rarely observed, but infinitely important, obstructions of the pulmonary arteries, has scarcely, if at ail, been insisted on. Doubtless further investigation will show that it is not in these parts of the venous system alone that puerperal thrombosis occurs ; but the symptoms and effects of venous obstruction else- where, important though they may be, are unknown. I propose then to describe the symptoms and pathology of blood- clot in the right side of the heart and pulmonary artery. It may be useful here to repeat that this is essentially distinct from embo- lism of the same parts. The latter is obstruction due to the impac- tion of a separated portion of a thrombus formed elsewhere, and for its production it is essential that thrombosis should have preceded it. Embolism is in fact an accident of thrombosis, not a primary affec- tion. The condition we are now discussing I hold to be primary, precisely similar in its causation to the venous obstruction which, in other situations, gives rise to phlegmasia dolens. At the threshold of this inquiry we have to meet the objection, started by several who have written on this subject, 2 that sponta- neous coagulation of the blood, in the right side of the heart and pulmonary arteries, is a mechanical and physiological impossibility. This was the view of Virchow, who, with his followers, maintained 1 Leishman, System of Obstetrics, p. 710. 2 See especially Bertin, Des Embolics, p. 46 et seq. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 597 that whenever death from pulmonary obstruction occurred, an em- bolus was of necessity the starting-point of the malady, and the nucleus round which secondary deposition of fibrine took place. Yirchow holds that the primary factor in thrombosis is a stagnant state of the blood, and that the impulse imparted to the blood by the right ventricle is of itself sufficient to prevent coagulation. It is to be observed that these objections are purely theoretical. Without denying that there is considerable force in the arguments adduced, I think that the clinical history of these cases strongly favors the view of spontaneous coagulation ; and I would apply to the theoretical objections advanced the argument used by one of their strongest upholders, with regard to another disputed point, " Je prefere laisser la parole aux faits, car devant eux la theurie s'incline." 1 The anatomical arrangement of the pulmonary arteries shows how spontaneous coagulation may be favored in them ; for, as Dr. Hum- phrey has pointed out, 2 "the artery breaks up at once into a number of branches, which radiate from it, at different angles, to the several parts of the lungs. Consequently, a large extent of surface is pre- sented to the blood, and there are numerous angular projections into the currents ; both which conditions are calculated to induce the spontaneous coagulation of the fibrine." We know also, that throm- bosis generally occurs in patients of feeble constitution, often debili- tated by hemorrhage, in whom the action of the heart is much weak- ened. These facts, of themselves, go far to meet the objections of those who deny the possibility of spontaneous coagulation at the roots of the pulmonary arteries. Results of Post-mortem Examinations. — The records of post-mortem examinations show also, that in many of the cases the right side of the heart, as well as the larger branches of the pulmonary arteries, contained firm, leathery, decolorized, and laminated coagula, which could not have been recently formed. The advocates of the purely embolic theory maintain that these are secondary coagula, formed around an embolus. But surely the mechanical causes which are sufficient to prevent spontaneous deposition of fibrine, would also suffice to prevent its gathering round an embolus; unless, indeed, the obstruction was sufficient to arrest the circulation altogether, when death would occur before there was any time for secondary deposit. Before we can admit the possibility of embolism we must have at least one factor, that is, thrombosis in a peripheral vessel, from which an embolus can come. In many of the recorded cases nothing of the kind was found, and although, as is argued, this may have been overlooked, yet such an oversight can hardly always have been made. The strongest argument, however, in favor of the spontaneous origin of pulmonary thrombosis is one which I originally pointed out in a series of papers " On thrombosis and embolism of the pul- monary artery as a cause of death in the puerperal state." 3 I there 1 Bcrtin, Des Embolies, p. 149. 2 Humphrey, On the Coagulation of the Blood in the Venous System during Life. 3 Lancet, 1867. 598 THE PUERPERAL STATE. showed, from a careful analysis of 25 cases of sudden death after delivery in which accurate post-mortem examination had been made, that cases of spontaneous thrombosis and embolism may be divided from each other by a clear line of demarcation, depending on the period after delivery at which the fatal result occurs. In 7 out of these cases there was distinct evidence of embolism, and in them death occurred at a remote period after delivery ; in none before the nineteenth day. This contrasts remarkably with the cases in which the post-mortem examination afforded no evidence of embolism. These amounted to 15 out of the 25, and in all of them, with one exception, death occurred before the fourteenth day, often on the second or third. The reason of this seems to be that in the former, time is required to admit of degenerative changes taking place in the deposited fibrine leading to separation of an embolus ; while in the latter, the thrombosis corresponds in time, and to a great extent no doubt also in cause, to the original peripheral thrombosis from which, in the former, the embolus was derived. Many cases I have since collected illustrate the same rule in a very curious and instructive way. Another clinical fact I have observed points to the same conclusion. In one or two cases distinct signs of pulmonary obstruction have shown themselves without proving immediately fatal, and shortly afterwards, peripheral thrombosis, as evidenced by phlegmasia dolens of one extremity, has commenced. Here the peripheral thrombosis obviously followed the central, both being produced by identical causes, and the order of events, necessary to uphold the purely em- bolic theory, was reversed. I hold, then, that those who deny the possibility of spontaneous coagulation in the heart and pulmonary arteries do so on insufficient grounds, and that we may consider it to be an occurrence, rare no doubt, but still sufficiently often met with, and certainly of sufficient importance, to merit very careful study. History, — Dr. Chas. D. Meigs, of Philadelphia, was one of the first to direct attention to spontaneous coagulation of the blood in the right side of the heart and pulmonary arteries, as a cause of sudden death in the puerperal state. The occurrence itself, however, has been carefully studied by Paget, whose paper was published in 1845, four years before Meigs wrote on the subject. 1 It is true that none of Paget's cases happened after delivery, but he none the less clearly apprehended the nature of the obstruction. In 1865, Hecker 2 at- tributed the majority of these cases to embolism proper; and since that date most authors have taken the same view, believing that spontaneous coagulation only occurs in exceptional cases, such as those in which, on account of some obstruction in the lung or in the debility of the last few hours before death, coagula form in the smaller ramifications of the pulmonary arteries, and gradually creep backwards towards the heart. 1 Medico-Chir. Trans., vol. xxvii. p. 162, and vol. xxviii. p. 352; Philadelphia Medical Examiner, 1849. 2 Deutsche Klinicke, 1855. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 599 Symptoms of Pulmonary Obstruction. — The symptoms can hardly be mistaken, and there seems to be no essential difference between the symptomatology of spontaneous and embolic obstruction, so that the same description will suffice for both. In a large proportion of cases the attack comes on with an appalling suddenness which forms one of its most striking characteristics. Nothing in the condition of the patient need have given rise to the least suspicion of impending mischief, when, all at once, an intense and horrible dyspnoea comes on ; she gasps and struggles for breath ; tears off the coverings from her chest in a vain endeavor to get more air ; and, often, dies in a few minutes, long before medical aid can be had, with all the symp- toms of asphyxia. The muscles of the face and thorax are violently agitated in the attempt to oxygenate the blood, and an appearance closely resembling an epileptic convulsion may be presented. The face may be either pale or deeply cyanosed. Thus in one case I have elsewhere recorded, which was an undoubted example of true em- bolism, Mr. Pedler, the resident accoucheur at King's College Hos- pital, who was present during the attack, writes of the patient, 1 "She was suffering from extreme dyspnoea, the countenance was excessively pale, her lips white, the face generally expressing deep 1 anxiety." In another, which was probably an example of sponta- neous thrombosis, 2 occurring on the twelfth day after delivery, it is stated " the face had assumed a livid purple hue, which was so re- markable as to attract the attention both of the nurse and of her mother, who was with her." The extreme embarrassment of the cir- ' culation is shown by the tumultuous and irregular action of the heart, in its endeavor to send the venous blood through the obstructed arteries. Soon it gets exhausted, as shown by its feeble and flutter-. ing beat. The pulse is thread-like, and nearly imperceptible, the respirations short and hurried, but air may be heard entering the lungs freely. The intelligence during the struggle is unimpaired ; and the dreadful consciousness of impending death adds not a little to the patient's sufferings, and to the terror of the scene. Such is an imperfect account of the symptoms, gathered from a record of what has been observed in fatal cases. It will be readily understood why, in the presence of so sudden and awful an attack, symptoms have not been recorded with the accuracy of ordinary clinical observation. A question of great practical interest, which has been entirely overlooked by writers on the subject is — Have we any ground for supposing that there is a possibility of recovery after svmptoms of pulmonary obstruction have developed themselves? That such a result must be of extreme rarity is beyond question ; but I have little doubt that in some few cases, entirely inexplicable on any other hypothesis, life is prolonged until the coagulum is absorbed, and the pulmonary circulation restored. In order to admit of this it is, of course, essential that the obstruction be not sufficient to prevent the passage of a certain quantity of blood to the lungs, to carry on the vital functions. The history of many cases tends to show that the 1 Brit. Med. Journ., March 27, 1869. 2 Obst. Trans., vol. xii. p. 194. 600 THE PUERPERAL STATE. obstructing clot was present for a considerable time before death, and that it was only when some sudden exertion was made, such as rising from bed or the like, calling for an increased supply of blood which could not pass through the occluded arteries, that fatal symptoms manifested themselves. This was long ago pointed out by Paget, 1 who says, " The case proves that, in certain circumstances, a great part of the pulmonary circulation may be arrested in the course of a week (or a few days more or less), without immediate danger to life, or any indication of what had happened." And, after referring to some illustrative cases, " Yet in all these cases the characters of the clots by which the pulmonary arteries were obstructed, showed plainly that they had been a week or more in the process of forma- tion." If we admit the possibility of the continuance of life for a certain time, we must, I think, also admit the possibility, in a few rare cases, of eventful complete recovery. What is required is time for the absorption of the clot. In the peripheral venous system coagula are constantly removed by absorption. So strong, indeed, is the tendency to this, that Humphrey observes with regard to it, " It appears that the blood is almost sure to revert to its natural channel in process of time." 2 If then the obstruction be only par- tial, if sufficient blood pass to keep the patient alive, and a sudden supply of oxygenated blood is not demanded by any exertion which the embarrassed circulation is unable to meet, it is not inconceivable that the patient may live until the obstruction is removed. Illustrative Cases. — Such, I believe, to be the only explanation of certain cases, some of which, on any other hypothesis, it is impossible to understand. The symptoms are precisely those of pulmonary obstruction, and the description I have given above may be applied to them in every particular; and, after repeated paroxysms, each of which seems to threaten immediate dissolution, an eventual recovery takes place. "What then, I am entitled to ask, can the condition be, if not that which I suggest? As the question I am considering has never, so far as I am aware, been treated of by any other writer, I may be permitted to state, very briefly, the facts of one or two of the cases on which I found my argument, some of which I have already published in detail elsewhere. K. H., delicate young lady. Labor easy. First child. Profuse postpartum hemorrhage. Did well until the 7th day, during the whole of which she felt weak. Same day an alarming attack of dyspnoea came on. For several days she remained in a very critical condition, the slightest exertion bringing on the attacks. A slight blowing murmur heard for a few days at the base of the heart, and then disappeared. For two months patient remained in the same state. As long as she was in the recumbent position she felt pretty comfortable; but any attempt at sitting up in bed, or any unusual exertion, immediately brought on the embarrassed respiration. During all this time it was found necessary to administer stimulants profusely to ward off the attacks. Eventually the patient recovered completely. Q. F., a3t. 44. Mother of twelve children. Confined on July 6. On the 11th day she went to bed feeling well. There was no swelling or discomfort of any kind about the lower extremities at this time. About half-past 3 A.M. she was sitting up in bed, when she was suddenly attacked with an indescribable sense of oppression in Op. cit., p. 358. 2 Med. Chir. Trans., vol. xxvii, p. 14. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 601 the chest, and fell back in a semi-unconscious state, gasping for breath. She re- mained in a very critical condition, with the same symptoms of embarrassed respira- tion, for three days, when they gradually passed away. Two days after the attack, phlegmasia dolens came on, the leg swelled, and remained so for several months. This case is an example of the fact I have already referred to, of phlegmasia dolens coming on after the symptoms of pulmonary obstruction had manifested themselves ; the inference being that both depended on similar causes operating on two distinct parts of the circulatory sj^stem. C. H., aet. 24. Confined of her first child on August 20, 1867. Thirty hours after delivery she complained of great weakness and dyspnoea. This was alleviated by the treatment employed, but on the ninth day, after making a sudden exertion, the dyspnoea returned with increased violence, and continued unabated until I saw the patient on September 4, fourteen days after her confinement. The following are the notes of her condition made at the time of the visit : "I found her sitting on the sofa, propped up with pillows, as she said she could not breathe in the recumbent position. The least excitement or talking brought on the most aggravated dyspnoea, which was so bad as to threaten almost instant death. Her sufferings during these paroxysms were terrible to witness. She panted and struggled for breath, and her chest heaved with short gasping respirations. She could not even bear any one to stand in front of her, waving them away with her hand, and calling for more air. These attacks were very frequent, and were brought on by the most trivial causes. She talked in a low suppressed voice, as if she could not spare breath for articulation. On auscultation air was found to enter the lungs freely in every direction, both in front and behind. Immediately over the site of the pulmonary arteries there was a distinct harsh, rasping murmur, confined to a very limited space, and not propagated either upwards or downwards. The heart-sounds were feeble and tumultuous." These symptoms led me to diagnose pulmonary obstruction, and I, of course, gave a most unfavorable prognosis, but to my great surprise the patient slowly recovered. I saw her again six weeks later, when her heart-sounds were regular and distinct, and the murmur had completely disappeared. E. E., a3t. 42, was confined for the first time on November 5, 1873, in the sixth month of utero-gestation. She had severe post-partum hemorrhage, depending on partially adherent placenta, which was removed artificially. She did perfectly well until the 14th day after delivery, when she was suddenly attacked with intense dyspnoea, aggravated in paroxysms. Pulse pretty full, 130, but distinctly inter- mittent. Air entered lungs freely. The heart's action was fluttering and irregular, and, at the juncture of the fourth and fifth ribs with the sternum, there was a loud blowing systolic murmur. This was certainly non-existent before, as the heart had been carefully auscultated before administering chloroform during labor. For two days the patient remained in the same state, her death being almost momentarily expected. On the 21st, that is two days after the appearance of the chest symptoms, phlegmasia dolens of a severe kind developed itself in the right thigh and leg. She continued in the same state for many days, lying more or less tranquilly, but having paroxysms of the most intense apnoea, varying from two to six or eight in the twenty- four hours. No one who saw her in one of these could have expected her to live through it. Shortly after the first appearance of the paroxysms it was observed that the cellular tissue of the neck and part of the face became swollen and (Edematous, giving an appearance not unlike that of phlegmasia dolens. The attacks were always relieved by stimulants. These she incessantly called for, declaring that she felt they kept her alive. During all this time the mind was clear and collected. The pulse varied from 110 to 130. Respirations about GO, temperature 101° to 102.5°. By slow degrees the patient seemed to be rallying. The paroxysms diminished in num- ber, and after December 1 she never had another, and the breathing became free and easy. The pulse fell to 80, and the cardiac murmur entirely disappeared. The patient remained, however, very weak and feeble, and the debility seemed to increase. Towards the second week in December she became delirious, and died, apparently exhausted, without any fresh chest symptoms, on the 19th of that month. No post- mortem examination was allowed. 39 602 THE PUERPERAL STATE. I have narrated this case, although it terminated fatally, because I hold it to be one of the class I am considering. The death was certainly not' due to the obstruction, all symptoms of which had disappeared, but apparently to exhaustion from the severity of the former illness. It illustrates too the simultaneous appearance of symptoms of pulmonary obstruction and peripheral thrombosis. The swelling of the neck was a curious symptom, which has not been recorded in any other cases, and may possibly be a further proof of the analogy between this condition and phlegmasia dolens. Now, it may, of course, be argued that these cases do not prove my thesis, inasmuch as I only assume the presence of a coagulum. But I may fairly ask in return what other condition could possibly explain the symptoms? They are precisely those which are noticed in death from undoubted pulmonary obstruction. No one seeing one of them, or even reading an account of the symptoms, while ignorant of the result, could hesitate a single instant in the diagnosis. Surely, then, the inference is fair that they depended on the same cause? In the very nature of things my hypothesis cannot be veri- fied by post-mortem examination; but there is at least one case on record, in which, after similar symptoms, a clot was actually found. The case is related by Dr. Eichardson. 1 It was that of a man who for weeks had symptoms precisely similar to those observed in the cases I have narrated. In one of his agonizing struggles for breath he died, and after death it was found "that a fibrinous band, having its hold in the ventricle, extended into the pulmonary artery." This observation proves to a certainty that life may continue for weeks after the deposition of a coagulum ; and, moreover, this condition was precisely what we should anticipate, since, of course, the ob- structing coagulum must necessarily be small, otherwise the vital functions would be immediately arrested. Cardiac Murmurs in Pulmonary Obstruction. — There is a symptom noted in two of the above cases, and to less extent in a third, which has not been mentioned in any account of fatal cases occurring after delivery, viz., a murmur over the site of the pulmonary arteries. It is a sign we should naturally expect, and very possibly it would be met with in fatal cases if attention were particularly directed to the point. In both these instances it was exceedingly well marked, and in both it entirely disappeared when the symptoms abated. The probability of such a murmur being audible in cases of thrombosis of the pulmonary artery, has been recognized by one of our highest authorities in cardiac disease, who actually observed it in a non- puerperal case. In the last edition of his work on diseases of the heart, Dr. Walshe 2 says: "The only physical condition connected with the vessel itself would probably be systolic basic murmur fol- lowing the course of the pulmonary main trunk and of its immediate divisions to the left and right of the sternum. This sign I most certainly heard in an old gentleman whose life was brought to a 1 Clinical Essays, p. 224 et sen. 2 Walshe, On 'Diseases of the Heart, 4th ed. 1873. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 603 sudden close, in the course of an acute affection, by coagulation in the pulmonary artery, and to a moderate extent in the right ven- tricle." Similar cases have, probably, been overlooked or misinterpreted. Many seem to have been attributed to shock, in the absence of a better explanation, a condition to which they bear no kind of re- semblance. Causes of Death. — The precise mode of death in pulmonary ob- struction, whether dependent on thrombosis or embolism, has given rise to considerable difference of opinion. Yirchow attributes it to syncope, 1 depending on stoppage of the cardiac contraction. Panum, 2 on the other hand, contests this view, maintaining that the heart con- tinues to beat even after all signs of life have ceased. Certainly tumultuous and irregular pulsations of the heart are prominent ) symptoms in most of the recorded cases, and are not reconcilable ! with the idea of syncope. Panum's own theory is, that death is the | result of cerebral anaemia. Paget seems to think that the mode of death is altogether peculiar, in some respects resembling syncope, in others anaemia. Bertin, who has discussed the subject at great length, attributes the fatal result purely to asphyxia. The condition, ! indeed, is in all respects similar to that state; the oxygenation of the blood being prevented, not because air cannot get to the blood, but because blood cannot get to the air. The symptoms also seem best explained by this theory ; the intense dyspnoea, the terrible struggle 1 for air, the preservation of intelligence, the tumultuous action of the heart, are certainly not characteristic either of syncope or anaemia. Post-mortem Appearances of Clots. — The anatomical character of the clots seems to vary considerably. Ball, by whom they have been most carefully described, believes that they generally commence in the smaller ramifications of the arteries, extending backwards towards the heart, and filling the vessels more or less completely. Towards its cardiac extremity the coagulum terminates in a rounded head, in which respect it resembles those spontaneously formed in the peripheral veins. It is non-adherent to the coats of the vessels, and the blood circulates, when it can do so at all, between it and the vascular walls. Such clots are white, dense, and of a homogeneous structure, consisting of layers of decolorized fibrine, firm at the peri- phery, where the fibrine has been most recently deposited, and soft- ened in the centre, where amylaceous or fatty degeneration has commenced. Ball maintains that if the coagulum have commenced in the larger branches of the arteries, it must have first begun in the ventricle, and extended into them. According to Humphrey, the same changes take place in pulmonary as in peripheral thrombi, and they may become adherent to the walls of the vessels, or con- verted into threads or bands. When the obstruction is due to em- bolism, provided. the case is a well-marked one, and the embolus of some size, the appearances presented are different. We have no longer a laminated and decolorized coagulum, with a rounded head, 1 Gesamm. Abhandl , 1862, p. 316. 2 Virchow's Arcliiv, 1863. 604 THE PUERPERAL STATE. similar to a peripheral thrombus. The obstruction in this case generally takes place at the point of bifurcation of the artery, and we there meet with a grayish -white mass, contrasting remarkably with the more recently deposited fibrine before and behind it. It may be that the form of the embolus shows that it has recently been separated from a clot elsewhere; and in many cases it has been pos- sible to fit the travelled portion to the extremity of the clot from which it has been broken. We may also, perhaps, find that the embolus has undergone an amount of retrograde metamorphosis corresponding with that of the peripheral thrombus from which we suppose it to have come, but differing from that of the more recently deposited fibrine around it. It must be admitted, however, that the anatomical peculiarities of the coagula will by no means always enable us to trace them to their true origin. In many cases emboli may escape detection from their smallness, or from the quantity of fibrine surrounding them. Treatment. — But few words need be said as to the treatment of pulmonary obstruction. In a large majority of cases the fatal result so rapidly follows the appearance of the symptoms, that no time is given us even to make an attempt to alleviate the patient's suffer- ings. Should we meet with a case not immediately fatal, it seems that there are but two indications of treatment affording the slightest rational ground of hope : — 1. To keep the patient alive by the administration of stimulants — brandy, ether, ammonia, and the like — to be repeated at intervals corresponding to the intensity of the paroxysms, and the results pro- duced. In the cases I have above narrated, in which recovery ensued, this took the place of all other medication. Possibly leeches, or dry cupping to the chest, might prove of some service in relieving the circulation. 2. To enjoin the most absolute and complete repose. The object of this is evident. The only chance for the patient seems to be, that the vital functions should be carried on until the coagulum has been absorbed, or, at least, until it has been so much lessened in size as to admit of blood passing it to the lungs. The slightest movements may give rise to a fatal paroxysm of dyspnoea, from the increased supply of oxj^genated blood required. It must not be forgotten that in a large proportion of cases death immediately followed some exer- tion in itself trivial, such as rising out of bed. Too much attention, then, cannot be given to this point. The patient should be absolutely still; she should be fed with abundance of fluid food, such as milk, strong soups, and the like ; and should on no account be permitted to raise herself in bed, or attempt the slightest muscular exertion. If we are fortunate enough to meet with a case apparently tending to recovery, these precautions must be carried on long after the severity of the symptoms has lessened, for a moment's imprudence may suffice to bring them back in all their original intensity. Bertin, 1 indeed, recommends a system of treatment very different 1 Op. cit. p. 393. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 605 i from this. In the vain hope that the violent effort induced may : cause the displacement of the impacted embolus (to which alone he attributes pulmonary obstruction), he recommends the administra- tion of emetics. Few, I fancy, will be found bold enough to attempt so hazardous a plan of treatment. Various drugs have been suggested in these cases. Richardson recommended ammonia, a deficiency of which he at that time believed to be the chief cause of coagulation. He has since advised that liquor ammonias should be given in large doses, 20 minims every hour, in the hope of causing solution of the deposited fibrine ; and he has stated that he has seen good results from the practice. Others advise the administration of alkalies, in the hope that they may favor absorption. The best that can be said for them is, that they are not likely to do much harm. CHAPTER VII. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. The same condition of the blood which so strongly predisposes to coagulation in the vessels through which venous blood circulates, tends to similar results in the arterial system. These, however, are by no means so common, and do not, as a rule, lead to such important consequences. The subject has been but little studied, and almost all our knowledge of it is derived from a very interesting essay by Sir James Simpson. 1 As I have devoted so much space to the con- sideration of venous thrombosis and embolism, I shall but briefly consider the effects of arterial obstruction. Causes. — In a considerable number of recorded cases the obstruc- tion has resulted from the detachment of vegetations deposited on |the cardiac valves, the result of endocarditis, either produced by (antecedent rheumatism, or as a complication of the puerperal state. (Sometimes the obstruction seems to depend on some general blood 'dyscrasia, similar to that producing venous thrombosis, or on some j local change in the artery itself. Thus Simpson records a case ap- parently produced by local arteritis, which caused acute gangrene of both lower extremities, ending fatally in the third week after de- livery. In other cases it has been attributed to coagulation follow- I ing spontaneous laceration and corrugation of the internal coat of the artery. Symptoms. — The symptoms of puerperal arterial obstruction must, of course, vary with the particular arteries affected. Those, with 1 Selected Obst. Works, vol. i. p. 523. 606 THE PUERPERAL STATE. the obstruction of which we are most familiar, are the cerebral, the humeral, and the femoral. The effects produced must also be modi- fied by the size of the embolus, and the more or less complete ob- struction it produces. Thus, for example, if the middle cerebral artery be blocked up entirely, the functions of those portions of the brain supplied by it will be more or less completely arrested, and hemiplegia of the opposite side of the body, followed by softening of the brain-texture, will probably result. If the nervous symptoms be developed gradually, or increase in intensity after their first ap- pearance, it may be that an obstruction, at first incomplete, has in- creased by the deposition of fibrine around it. So the occasional sudden supervention of blindness, with destruction of the eyeball — cases of which are recorded by Simpson — not improbably depend on occlusion of the ophthalmic artery, the function of the organ de- pending on its supply through the single artery. The effects of ob- struction of the visceral arteries in the puerperal state are entirely unknown ; but it is far from unlikely that further investigation may prove them to be of great importance. In the extremities arterial obstruction produces effects which are well marked. They are classi- fied by Simpson under the following heads: 1. Arrest of pulse beloiu the site of obstruction. — This has been observed to come on either suddenly or gradually, and if the occlusion be in one of the large arterial trunks, it is a symptom which a careful examination will readily enable us to detect. 2. Increased force of pulsation in the ar- teries above the seat of obstruction. 3. Fall in the temperature of the limb. — This is a symptom which is easily appreciable by the ther- mometer, and, when the main artery of the limb is occluded, the coldness of the extremity is well marked. 4. Lesions of motor and sensory functions, paralysis, neuralgia, etc. etc. — Loss of power in the affected limb is often a prominent symptom, and when it comes on suddenly, and is complete, the main artery will probably be occluded. It may be diagnosed from paralysis depending on cerebral or spinal causes by the absence of head symptoms, by the history of the attack, and by the presence of other indications of arterial obstruction, such as loss of pulsation in the artery, fall of temperature, etc. The sen- sory functions in these cases are generally also seriously disturbed, not so much by loss of sensation, as by severe pain and neuralgia. Sometimes the pain has been excessive, and occasionally it has been the first symptom which directed attention to the state of the limb. 5. Gangrene below or beyond the seat of arterial obstruction. — Several interesting cases are recorded, in which gangrene has followed arte- rial obstruction. Generally speaking gangrene will not follow occlusion of the main arterial trunk of an extremity, as the collateral circulation becomes soon sufficiently developed to maintain its vitality. In many of the cases either thrombi have obstructed the channels of collateral circulation as well, or the veins of the limb have also been blocked up. When such extensive obstructions occur they obviously cannot be embolic, but must depend on a local thrombosis, traceable to some general blood d} r scrasia depending on the puerperal state. CAUSES OF SUDDEX DEATH DURING LABOR. 607 Treatment. — Little can be said as to the treatment of such cases, ■which, must vary with the gravity and nature of the symptoms in each. Beyond absolute rest (in the hope of eventual absorption of the thrombus or embolus), generous diet, attention to the general health of the patient, and sedative applications to relieve the local pain, there is little in our power. Should gangrene of an extremity supervene in a puerperal patient, the case must necessarily be well- nigh hopeless. Simpson, however, records one instance in which amputation was performed above the line of demarcation, the patient eventually recovering. CHAPTEE VIII. OTHER CAUSES OF SUDDEN TDEATH DURING LABOR AND THE PUERPERAL STATE. A large number of the cases in which sudden death occurs during or after delivery find their explanation, as I have already pointed oat, in thrombosis or embolism of the heart and pulmonary arteries. Probably, many cases of the so-called idiopathic asphyxia were in fact examples of this accident, the true nature of which had been misunderstood. Besides these there are, no doubt, many other con- ditions which may lead to a suddenly fatal result in connection with parturition. Some of these are of an organic, others of a functional nature. Organic Causes. — Among the former may be mentioned cases in which the straining efforts of the second stage of labor have pro- duced death in patients suffering from some pre-existent disease of the heart. Euptare of that organ has probably occurred from fatty degeneration of its walls. Dehous 1 narrates an instance in which the efforts of labor caused the rapture of an aneurism. Another case, from interference with the action of the heart in a patient who had pericardial effusion, is narrated by Eamsbotham. Dr. Devilliers re- lates an instance occurring in a young woman during the second stage of labor. The heart was found to be healthy, bat the lungs were intensely congested, and blood was extensively extravasated all through their texture. This was probably caused by pulmonary congestion and apoplexy, produced by the severe straining efforts. Many cases from effusion of blood into the brain-substance, or on its surface, are on record, no doubt in patients who, from arterial de- generation or other causes, were predisposed to apoplectic effusions. The so-called apoj:>lectic convulsions, formerly described in most 1 Dehous, Sur les Alorts subites. 6C8 THE PUERPERAL STATE. works on obstetrics as a variety of puerperal convulsions, are evi- dently nothing more than apoplexy coming on during or after labor. As regards their pathology they do not seem to differ from ordinary cases of apoplexy in the non-pregnant condition. One example is recorded of death which was attributed to rupture of the diaphragm from excessive action in the second stage. Functional Causes. — Among the causes of death which cannot be traced to some distinct organic lesion, may be classed cases of syncope, shock, and exhaustion. Many instances of this kind are recorded. Thus in some women of susceptible nervous organization, the severity of the suffering appears to bring on a condition, similar to that pro- duced by excessive shock or exhaustion, which has not unfrequently proved fatal. Several examples of this kind have been cited by McClintock. 1 It is also not unlikely that sudden syncope sometimes produces a fatal result, during or after labor. Most cases of death, otherwise inexplicable, used to be referred to this cause ; but accu- rate autopsies were seldom made, and even when they were — -the important effects of pulmonary coagula being unknown — it is more than probable that the true cause of death was overlooked. It has been supposed that the sudden removal of pressure from the veins of the abdomen, by the emptying of the gravid uterus after delivery, may favor an increased afflux of blood into the lower parts of the body, and thus tend to an anaemic condition of the brain, and the production of syncope. However this may be, the possibility of its occurrence, and its manifest danger in a recently delivered woman, are sufficient reasons for enforcing the recumbent position after labor is over. In some of the cases the syncope was evidently produced by the patient's suddenly sitting upright. Death from Air in the Veins. — Some cases of sudden death imme- diately after labor seem to be due to the entrance of air into the veins. Six examples are cited by McClintock which were probably due to this cause. La Chapelle relates two. An interesting case is related by M. Lionet. 2 In this the patient died five and a half hours after an easy and natural labor, the chief symptoms being extreme pallor, efforts at vomiting, and dyspnoea. Air was found in the heart and in the arachnoid veins. There can be no question that the ute- rine sinuses after delivery are nearly as well adapted as the veins of the neck for allowing the entrance of air. They are firmly attached to the muscular walls of the uterus, so that they gape open when that organ is relaxed, and it is easy to understand how air might enter. Indeed, in the post-mortem examination in one of the cases occurring in the practice of Mme. La Chapelle, it is stated that "the uterine sinuses opened in the interior of the uterus by large orifices (one line and a half in diameter), through which air could readily be blown as far as the iliac veins, and vice versa. 11 The condition of the uterus after delivery also enables the air to have ready access to the mouths of the sinuses, for the alternate relaxation and contrac- tion of the uterus, occurring after the placenta is expelled, would 1 Union Medic, 1853. 2 Delious, op. cit. p. 58. PERIPHERAL VENOUS THROMBOSIS, ETC. 609 tend to draw in the air as by a suction pump. Hence, an additional reason for insisting on firm contraction of the uterus, as this will lessen the risk of this accident. Cause of Death in such Cases. — The precise mechanism of death from air in the veins has been a subject of dispute among patholo- gists. By Bichat, ' it was referred to anaemia and syncope from want of blood in the vessels of the brain, which are occupied by air ; Nysten 2 attributed it to distension of the cavities of the heart by rarefied air, producing paralysis of its walls ; Greroy to a stoppage of the pulmonary circulation, and consequent want of proper blood- supply to the left heart ; while Leroy d'Etoilles thought it might depend on any of these causes, or a combination of all of them. These, and many other hypotheses on the subject, have been ad- vanced, to all of which serious objection could be raised. The most recent theory is one maintained by Yirchow and Oppolzer, 3 and more recently by Feltz, which attributes the fatal results to impaction of the air-globules in the lesser divisions of the pulmonary arteries, where they form gaseous emboli, and cause death exactly in the same way as when the obstruction depends on a fibrinous embolus. The symptoms observed in fatal cases closely correspond to those of pul- monary obstruction, and it is not unlikely that some cases, attributed to other causes, may really depend on the entrance of air through the uterine sinuses. Such, for example, was most probably the explanation of a case referred to by Dr. Graily Hewitt in a discussion at the Obstetrical Society. 4 Death occurred shortly after the removal of an adherent placenta, during which, no doubt, air could readily enter the uterine cavity. The symptoms, viz., "severe pain in the cardiac region, distress as regards respiration, and pulselessness," are identical with those of pulmonary obstruction. Dr. Hewitt refers the death to shock, which certainly does not generally produce such phenomena. CHAPTER IX. PERIPHERAL VENOUS THROMBOSIS — (SYN. : CRURAL PHLEBITIS — PHLEGMASIA DOLEXS — ANASARCA SEROSA — OEDEMA LACTEUM — ■ WHITE LEG, ETC.). We now come to discuss the symptoms and pathology of the con- ditions associated with the formation of thrombi in the peripheral venous system, or rather in the veins of the lower extremities, since 1 Recherches sur la Vie et la Mort, 1853. 2 Nysten, Recherches de Phys. et Chem. Path., 1811. 3 Casuistics des Embolie ; Wiener Med. "Woch , 1863. Des Embolics Capillaires, 1868. Op. cit., p. 115. 4 Obstet. Trans., vol. x. p. 28. 610 THE PUERPERAL STATE. too little is known of their occurrence in other parts to enable us to say anything on the subject. The most important of these is the well-known disease which, under the name of phlegmasia dolens, has attracted much attention, and given rise to numerous theories as to its nature and pathology. In describing it as a local manifestation of a general blood-dyscrasia, and not as an essential local disease, I am making an assumption as to its pathology, that many eminent authorities would not consider justifiable. I have, however, already stated some of the reasons for so doing, and I shall shortly hope to show that this view is not incompatible with the most probable explanation of the peculiar state of the affected limb. Symptoms. — The first symptom which usually attracts attention is severe pain in some part of the limb that is about to be affected. The character of the pain varies in different -cases. In some it is extremely acute, and is most felt in the neighborhood of, and along the course of the chief venous trunks. It may begin in the groin or hip, and extend downwards ; or it may commence in the calf, and proceed upwards towards the pelvis. The pain abates somewhat after swelling of the limb (which generally begins within twenty - four hours), but it is always a distressing symptom, and continues as long as the acute stage of the disease lasts. The restlessness, want of sleep, and suffering which it produces are sometimes excessive. Coincident with the pain, and sometimes preceding it, more or less malaise is experienced. The patient may for a day or two be rest- less, irritable, and out of sorts, without any very definite cause; or the disease may be ushered in by a distinct rigor. Generally there is constitutional disturbance, varying with the intensity of the case. The pulse is rapid and weak, 120 or thereabouts; the temperature elevated from 101° to 102°, with an evening exacerbation. The pa- tient is thirsty; the tongue glazed, or white and loaded; the bowels constipated. In some few cases, when the local affection is slight, none of these constitutional symptoms are observed. Condition of the Affected Limb. — The characteristic swelling rapidly follows the commencement of the symptoms. It generally begins in the groin, from whence it extends downwards. It may be limited to the thigh ; or the whole limb, even to the feet, may be implicated. More rarely it commences in the calf of the leg, extending upwards to the thigh, and downwards to the feet. The affected parts have a peculiar appearance, which is pathognomonic of the disease. They are hard, tense, and brawny ; of a shiny, white color ; and not yield- ing on pressure, except towards the beginning and end of the illness. The appearances presented are quite different from those of ordinary oedema. When the whole thigh is affected the limb is enormously increased in size. Frequently the venous trunks, especially the femoral and popliteal veins, are felt obstructed with coagula, and rolling under the finger. They are painful when handled, and in their course more or less redness is occasionally observed. Either leg may be attacked, but the left more frequently than the right. There is a marked tendency for the disease to spread, and we often 611 find, in a case which is progressing apparently well, a rise of tem- perature and an accession of febrile symptoms, followed by the swell- ing of the other limb. Progress of the Disease. — After the acute stage has lasted from a week to a fortnight, the constitutional disturbance becomes less marked, the pulse and temperature fall, the pain abates, and the sleeplessness and restlessness are less, The swelling and tension of the limb now begin to diminish, and absorption commences. This is invariably a slow process. It is always many weeks before the effu- sion has disappeared, and it may be many months. The limb re- tains for a length of time the peculiar wooden feeling, as Dr. Churchill terms it. Any imprudence, such as a too early attempt at walking, may bring on a relapse and fresh swelling of the limb. This gradual recovery is by far the most common termination of the disease. In some rare cases suppuration may take place, either in the subcuta- neous cellular tissue, the lymphatic glands, or even in the joints, and death may result from exhaustion. The possibility of pulmonary obstruction and sudden death from separation of an embolus have already been pointed out, and the fact that this lamentable occurrence has generally followed some undue exertion should be borne in mind, as a guide in the management of our patient. Period of Commencement. — The disease usually begins within a short time after delivery, rarely after the second week. In 22 cases tabulated by Dr. Robert Lee, 7 were attacked between the fourth and twelfth days, and 14 after the second week, Some cases have been described as commencing even months after delivery. It is question- able if these can be classed as puerperal, for it must not be forgotten that phlegmasia dolens is by no means necessarily a puerperal disease. There are many other conditions which may give rise to it, all of them, however, such as produce a septic and hyperinosed state of the blood, such as malignant disease, dysentery, phthisis, and the like. My own experience would lead me to think that cases of this kind are much more common than is generally believed. History and Pathology. — The disease has long attracted the atten- tion of the profession. Passing over more or less obscure notices by Hippocrates, De Castro, and others, we find the first clear account in the writings of Mauriceau, who not only gave a very accurate de- scription of its symptoms, but made a guess at its pathology, which was certainly more happy than the speculations of his successors ; it is, he says, caused, " by a reflux on the parts of certain humors which ought to have been evacuated by the lochia." Puzos ascribed it to the arrest of the secretion of milk, and its extravasation in the affected limb. This theory, adopted by Levret and many subsequent writers, took a strong hold on both professional and public opinion, and to it we owe many of the names by which the disease is known to this day, such as oedema lacteum, milk leg, etc. In 1784 Mr. White, of Manchester, attributed it to some morbid condition of the lymphatic glands and vessels of the affected parts ; and this, or some analogous theory, such as that of rupture of the lymphatics crossing the pelvic brim, as maintained by Tyre, of Gloucester, or 612 THE PUERPERAL STATE. general inflammation of the absorbents as held by Dr. Ferriar, was generally adopted. Phlebitic Theory. — It was not until the year 1823 that attention was drawn to the condition of the veins. To Bouillaud belongs the un- doubted merit of first pointing out that the veins of the affected limb were blocked up by coagula, although the fact had been previously observed by Dr. Davis, of University College. Dr. Davis made dissec- tions of the veins in a fatal case, and found, as Bouillaud had done, that they were filled with coagula, which he assumed to be the results of inflammation of their coats ; hence the name of " crural phlebitis" which has been extensively adopted instead of phlegmasia dolens. Dr. Kobert Lee did much to favor this view, and finding that thrombi were present in the iliac and uterine, as well as in the femoral, veins, he concluded that the phlebitis commenced in the uterine branches of the hypogastric veins, and extended downwards to the femorals. He pointed out that phlegmasia dolens was not limited to the puerperal state ; but that when it did occur independ- ently of it, other causes of uterine phlebitis were present, such as cancer of the os and cervix uteri. The inflammatory theory was pretty generally received, and even now is considered by many to be a sufficient explanation of the disease. Indeed the fact that more or less thrombus was always present could not be denied, and on the supposition that thrombus could only be caused by phlebitis, as was long supposed to be the case, the inflammatory theory was the natural one. Before long, however, pathologists pointed out that thrombosis was by no means necessarily, or even generally, the result of inflam- mation of the vessels in which the clot was contained, but that the inflammation was more generally the result of the coagulum. Theory of its Dependence on Septic Causes. — The late Dr. Mackenzie took a prominent part in opposing the phlebitic theory; He proved, by numerous experiments in the lower animals, that inflammation is not sufficient of itself to produce the extensive thrombi which are found to exist, and that inflammation originating in one part of a vein is not apt to spread along its canal, as the phlebitic theory assumes. His conclusion is, that the origin of the disease is rather to be sought in some septic or altered condition of the blood, pro- ducing coagulation in the veins. Dr. Tyler Smith 1 pointed out an occasional analogy between the causes of phlegmasia dolens and puer- peral fever, evidently recognizing the dependence of the former on blood dyscrasia. " I believe," he says, " that contagion and infection play a very important part in the production of the disease. I look on a woman attacked with phlegmasia dolens as having made a fortunate escape from the greater dangers of diffuse phlebitis or puerperal fever." In illustration of this he narrates the following instructive history : "A short time ago a friend of mine had been in close attendance on a patient dying of erysipelatous sore-throat with sloughing, and was himself affected with sore-throat. Under these circumstances, he attended, within the space of twenty-four hours, 1 Tyler Smith, Manual of Obstetrics, p. 538. PUERPERAL VENOUS THROMBOSIS, ETC. 613 three ladies in their confinements, all of whom were attacked with phlegmasia dolens." View of Tilbury Fox. — The latest important contribution to the pathology of the disease is contained in two papers by Dr. Tilbury Fox, published in the second volume of the " Obstetrical Transac- tions." He maintains that something beyond the mere presence of coagula in the veins is required to produce the phenomena of the disease, although he admits that to be an important, and even an essential, part of pathological changes present. The thrombi he be- lieves to be produced either by extrinsic or intrinsic causes : the former comprising all cases of pressure by tumor or the like ; the latter, and the most important, being divisible into the heads of — 1. True inflammatory changes in the vessels, as seen in the epi- demic form of the disease. 2. Simple thrombus, produced by rapid absorption of morbid fluid. 3. Virus action and thrombus conjoined, the plegmasia dolens itself being the result of simple thrombus, and not produced by dis- eased (inflamed) coats of vessels ; the general symptoms the result of the general blood-state ; the virus present. He further points out that the peculiar swelling of the limbs can- not be explained by the mere presence of oedema, from which it is essentially different. The white appearance of the skin, the severe neuralgic pain, and the persistent numbness indicating that the whole of the cutaneous textures, the cutis vera and even the epithelial layer, are infiltrated with fibrinous deposit. He concludes, there- fore, that the swelling is the result of oedema plus something else ; that something being obstruction of the lymphatics, by which the absorption of effused serum is prevented. The efficient cause which produces these changes he believes to be, in the majority of cases, a septic action originating in the uterus, producing a condition similar to that in which phlegmasia dolens arises in the non -puerperal state. There is no doubt much force in Dr. Fox's arguments, and it may, I think, be conceded that obstruction of the veins per se is not suffi- cient to produce the peculiar appearance of the limb. It is, more- over, certain that phlebitis alone is also an insufficient explanation not only of the symptoms, but even of the presence of thrombi so extensive as those that are found. The view which traces the disease solely to inflammation or obstruction of lymphatics is purely theoretical, has no basis of facts to support it, and finds, nowadays, no supporters. The experiments of Mackenzie and Lee, as well as the vastly increased knowledge of the causes of thrombosis which the researches of modern pathologists have given us, seem to point strongly to the view already stated, that the disease can only be explained by a general blood dyscrasia, depending on the puerperal state. It by no means follows that we are to consider Dr. Fox's speculations as incorrect. It is far from improbable that the lym- phatic vessels are implicated in the production of the peculiar swell- ing, only we are not as yet in a position to prove it. There is no inherent improbability in the supposition that the same morbid 614 THE PUERPERAL STATE. state of the blood which produces thrombosis in the veins, may also give rise to such an amount of irritation in the lymphatics as may interfere with their functions, and even obstruct them altogether. The essential and all-important point in the pathology of the disease, however, seems undoubtedly to be thrombosis in the veins; and the probability of there being some as yet undetermined pathological changes in addition to this, by no means militates against the view I have taken of the intimate connection of the disease with other results of thrombosis in more distant vessels. Changes Occurring in the Thrombi. — The changes which take place in the thrombi all tend to their ultimate absorption. These have been described by various authors as leading to organization or suppuration. It is probable, however, that the appearances which have led to such a supposition are fallacious, and that they are really due to retrograde metamorphosis of the flbrine, generally of an amy- laceous or fatty character. Detachment of Emboli. — The peculiarities of a clot that most favor detachment of an embolus are such a shape as admits of a portion floating freely in the blood current, by the force of which it is detached and carried to its ultimate destination. When the accident has occurred, it is often possible to recognize the peripheral thrombus from which the embolus has separated, by the fact of its terminal extremity presenting a freshly fractured end, instead of the rounded head natural to it. Such detachment is unlikely to occur, even when favored by the shape of the clot, unless sufficient time have elapsed after its formation to admit of its softening and becoming brittle. The curious fact I have before mentioned, of true puerperal embolism occurring, in the large majority of cases, only after the nineteenth day from delivery, finds a ready explanation in this theory, which it remarkably corroborates. Treatment. — On the supposition that phlegmasia dolens was the result of inflammation of the veins of the affected limb, an antiphlo- gistic course of treatment was naturally adopted. Accordingly, most writers on the subject recommend depletion, generally by the application of leeches, along the course of the affected vessels. We are told that if the pain continue the leeches should be applied a second, or even a third time. If we admit the septic origin of the disease we must, I think, see the impropriety of such a practice. The fact that it occurs, in a large majority of cases, in patients of a weakly and debilitated constitution, often in women who have already suffered from hemorrhage, is a further reason for not adopt- ing this routine custom. If local loss of blood be used at all, it should be strictly limited to cases in which there is much tenderness and redness along the course of the veins, and then only in patients of plethoric habit and strong constitution ; cases of this kind will form a very small minority of those coming under our observation. Over-active Treatment Unadvisable. — What has been said of the pathology of the affection tends to the conclusion that active treat- ment of any kind, in the hope of curing the disease, is likely to be useless. Our chief reliance must be on time and perfect rest, in PUERPERAL VENOUS THROMBOSIS, ETC. 615 order to admit of the thrombi and the secondary effusion being absorbed; while we relieve the pain and other prominent symptoms, and support the strength and improve the constitution of the patient. Relief of Pain, etc. — The constant application of heat and moisture to the affected limb will do much to lessen the tension and pain. Wrapping the entire limb in linseed-meal poultices, frequently changed, is one of the best means of meeting this indication. If, as is sometimes the case, the weight of the poultices be too great to be readily borne, we may substitute warm flannel stupes, covered with oiled silk. Local anodyne applications afford much relief, and may be advantageously used along with the poultices and stupes, either by sprinkling their surface freely with laudanum, or chloroform and belladonna liniment, or by soaking the flannels in poppy-head fomen- tation. It is needless to say that the most absolute rest in bed should I be enjoined, even in slight cases, and that the limb should be effectu- 1 ally guarded from undue pressure b}^ a cradle or some similar con- trivance. Local counter-irritation has been strongly recommended, and frequent blisters have been considered by some to be almost specific. I should myself hesitate to use blisters, as they would certainly not be soothing applications, and one hardly sees how they can be of much service in hastening the absorption of the effusion. Constitutional Treatment. — During the acute stage of the disease the constitutional treatment must be regulated by the condition of the patient. Light, but nutritious diet, must be administered in abundance, such as milk, beef-tea, and soups. Should there be much debility, stimulants in moderation may prove of service. With regard to medicines, we shall probably find benefit from such as are calculated to improve the condition of the blood and the general health of the patient. Chlorate of potash, with dilute hydrochloric acid, quinine, either alone or in combination with sesquicarbonate of ammonia, the tincture of the perchloride of iron, are the drugs that are most likely to prove of service. Alkalies and other medicines, which have been recommended in the hope of hastening the absorp- tion of coagula, must be considered as altogether useless. Pain must be relieved and sleep produced by the judicious use of anodynes, such as Dover's powder, the subcutaneous injection of morphia, or chloral. Generally no form answers so well as the hypodermic in- jection of morphia. Subsequent Local Treatment. — When the acute symptoms have abated, and the temperature has fallen, the poultices and stupes may be discontinued, and the limb swathed in a flannel roller from the toes upwards. The equable pressure and support thus afforded ma- terially aid the absorption of the effusion, and tend to diminish the size of the limb. At a still later stage very gentle inunctions of weak iodine ointment may be used with advantage once a day before the roller is applied. Shampooing and friction of the limb, generally recommended for the purpose of hastening absorption, should be carefully avoided, on account of the possible risk of detaching a portion of the coagulum, and producing embolism. This is no merely imaginary danger, as the following fact narrated by Trousseau 616 THE PUERPERAL STATE. proves. "A phlegmasia alba dolens had appeared on the left side in a young woman suffering from peri-uterine phlegmon. The pain having ceased, a thickened venous trunk was felt on the upper and internal part of the thigh. Rather strong pressure was being made, when M. Demarquay felt something yield under his fingers. A few minutes afterwards the patient was attacked with dreadful palpita- tion, tumultuous cardiac action, and extreme pallor, and death was believed to be imminent. After some hours, however, the oppression ceased, and the patient eventually recovered. A slightly attached coagulum must have become separated, and conveyed to the heart or pulmonary artery." 1 Warm douches of water, of salt water if it can be obtained, may be advantageously used in the later stages of the disease, and they may be applied night and morning, the limb being bandaged in the interval. The occasional use of the electric current is said to promote absorption, and would seem likely to be a serviceable remedy. Change of Air, etc. — When the patient is well enough to be moved, a change of air to the seaside will be of value. Great caution, how- ever, should be recommended in using the limb, and it is far better not to run the risk of a relapse by any undue haste in this respect. It is well to warn the patient and her friends, that a considerable time must of necessity elapse, before the local signs of the disease have completely disappeared. CHAPTER X. PELVIC CELLULITIS AND PELVIC PERITONITIS. From the earliest time the occurrence after parturition of severe forms of inflammatory disease in and about the pelvis, frequently ending in suppuration, has been well known. It is only of late years, however, that these diseases have been made the subject of accurate clinical and pathological investigation, and that their true nature has begun to be understood. Nor is our knowledge of them as yet by any means complete. They merit careful study on the part of the accoucheur, for they give rise to some of the most severe and pro- tracted illnesses from which puerperal patients suffer. They are often obscure in their origin and apt to be overlooked, and they not rarely leave behind them lasting mischief. These diseases are not limited to the puerperal state. On the con- trary, many of the severest cases arise from causes altogether uncon- nected with child-bearing. These will not be now considered, and 1 Trousseau, Clinique do l'Hotel-Dieu in Gaz. des Hop., 1860, p. 577. PELVIC CELLULITIS AXD PELVIC PERITONITIS. 617 this chapter deals solely with such forms as may be directly traced to child-birth. Two Distinct Forms. — Eecent researches have demonstrated that there are two distinct varieties of inflammatory disease met with after labor, which differ materially from each other in many respects. In one of these, the inflammation effects chiefly the connective tissue surrounding the generative organs contained within the pelvis, or i extends up from it beneath the peritoneum, and into the iliac fossae. In the other, it attacks that portion of the peritoneum which covers the pelvic viscera, and is limited to it. So much is admitted by all writers, but great obscurity in descrip- tion, and consequent difficulty in understanding satisfactorily the nature of these affections, have resulted from the variety of nomen- clature which different authors have adopted. Thus the former disease has been variously described as pelvic cellulitis, peri-uterine phlegmon, para-metritis, or pelvic abscess, while the latter is not unfrequently called peri-metritis, as contra- distinguished from para-metritis. The use of the prefix para ov peri, to distinguish the cellular or peritoneal variety of inflammation, originally suggested by Virchow, has been pretty generally adopted in Germany, and has been strongly advocated in this country by Matthews Duncan. It has never, however, found much favor with English writers, and the similarity of the two names is so great as to lead to confusion. I have, therefore, selected the terms " pelvic peri- tonitis" and "pelvic cellulitis" as conveying in themselves a fairly accurate notion of the tissues mainly involved. Importance of Distinguishing the Two Classes of Cases. — The im- portant fact to remember is that there exist two distinct varieties of inflammatory disease, presenting many similarities in their course, symptoms, and results, often occurring simultaneously, but in the main distinct in their pathology, and capable of being differentiated. Thomas compares them — and, as serving to fix the facts on the memory, the illustration is a good one — to pleurisy and pneumonia. "Like them," he says, "they are separate and distinct, like them affect different kinds of structure, and like them they generally com- plicate each other." It might, therefore, be advisable, as most writers on the disease occurring in the non-puerperal state have done, to treat of them in two separate chapters. There is, however, more difficulty in distinguishing them as puerperal than as non-puer- peral affections, for which reason, as well as for the sake of brevity, I think it better to consider them together, pointing out, as I pro- ceed, the distinctive peculiarities of each. Seat of Disease. — When attention was first directed to this class of diseases, the pelvic cellular tissue was believed to be the only struc- ture affected. This was the vieAV maintained by Nonat, Simpson, and many modern writers. Attention was first prominently directed to the importance of localized inflammation of the peritoneum, and to the fact that many of the supposed cases of cellulitis were really peritonitic, by Bernutz. There can be no doubt that he here made an enormous step in advance. Like many authors, however, he rode 40 618 THE PUERPERAL STATE. his hobby a little too hard, and he erred in denying the occurrence of cellulitis in many cases in which it undoubtedly exists. Etiology. — The great influence of child-birth in producing these diseases has loug been fully recognized. Courty estimates that about two-thirds of all the cases met with occur in connection with de- livery or abortion, and Duncan found that out of 40 carefully observed cases, 25 were associated with the puerperal state. The Inflammation is Secondary and never Idiopathic. — It is pretty generally admitted by most modern writers that both varieties of the disease are produced by the extension of inflammation from either the uterus, the Fallopian tubes, or the ovaries. This point has been especially insisted on by Duncan, who maintains that the disease is never idiopathic, and is "invariably secondary either to mechanical injury, or to the extension of inflammation of some of the pelvic vis- cera, or to the irritation of the noxious discharges through or from the tubes or ovaries." Often intimately connected ivith Septicaemia. — Their intimate con- nection with puerperal septicaemia is also a prominent fact in the natural history of the diseases. Barker mentions a curious observa- tion illustrative of this, that when puerperal fever is endemic in the Bellevue Hospital in New York, cases of pelvic peritonitis and cel- lulitis are also invariably met with. Olshausen has also remarked that in the Lying-in Hospital at Halle, during the autumn vacation, when the patients are not attended by practitioners, and when, there- fore, the chance of septic infection being conveyed to them is less, these inflammations are almost always absent. As inflammation of the lining membrane of the uterus, of the vaginal mucous membrane, and of the pelvic connective tissue, are of very constant occurrence as local phenomena of septic absorption, the connection between the two classes of cases is readily susceptible of explanation. Schroeder, indeed, goes further, and includes his description of these dis- eases under the head of puerperal fever. They do not, however, necessarily depend upon it ; for, although it must be admitted that cases of this kind form a large proportion of those met with, others unquestionably occur which cannot be traced to such sources, but are the direct result of causes altogether unconnected with the inflam- mation attending on septic absorption, such as undue exertion shortly after delivery, or premature coition. Mechanical causes may be- yond doubt excite the disease in a woman predisposed by the puer- peral process, but they cannot fairly be included under the head of puerperal fever. Seat of the Inflammation in Pelvic Cellulitis. — Abundance of areolar tissue exists in connection with the pelvic viscera, which may be the seat of cellulitis. It forms a loose padding between the organs con- tained in the pelvis proper, surrounds the vagina, the rectum, and the bladder, and is found in considerable quantity between the folds of the broad ligaments. From these parts it extends upwards to the iliac fossae, and the inner surface of the abdominal parietes. In any of these positions it may be the seat of the kind of inflammation we are discussing. The essential character of the inflammation is similar PELVIC CELLULITIS AND PELVIC PERITONITIS. 619 to that which accompanies areolar inflammation in other parts of the body. There is first an acute inflammatory oedema, followed by the infiltration of the areolae of the connective tissue with exudation, and the consequent formation of appreciable swellings. These may form in any part of the pelvis. Thus we may meet with them, and this is a very common situation, between the folds of the broad ligaments, forming distinct hard tumors, connected with the uterus, and extending to the pelvic walls, their rounded outlines being readily made out by bi-rnanual examination. If the cellulitis be limited in extent, such a swelling may exist on one side of the uterus only, forming a rounded mass of varying size, and apparently attached to it. At other times the exudation is more extensive, and may com- pletely or partially surround the uterus, extending to the cellular tissue between the vagina and rectum, or between the uterus and the bladder. In such cases the uterus is imbedded and firmly fixed in dense, hard exudation. At other times, the inflammation chiefly affects the cellular tissue covering the muscles lining the iliac fossae. There it forms a mass, easily made out by palpation, but on vaginal examination little or no trace of the exudation can be felt, or only a sense of thickness at the roof of the vagina on the same side as the swelling. Seat of the Inflammation in Pelvic Peritonitis. — In pelvic peritonitis the inflammation is limited to that portion of the peritoneum which invests the pelvic viscera. Its extent necessarily varies with the intensity and duration of the attack. In some cases there may be little more than irritation, while more often it runs on to exudation of plastic material. The result is generally complete fixation of the uterus, and hardening and swelling in the roof of the vagina; and the lymph poured out may mat together the surrounding viscera, so as to form swellings, difficult, in some cases, to differentiate from those resulting from cellulitis. On post-mortem examination the pelvic viscera are found extensively adherent, and the agglutination may involve the coils of the intestine in the vicinity, so as sometimes to form tumors of considerable size. Relative Frequency of the Two Forms of Disease. — The relative fre- quency of these two forms of inflammation as puerperal affections is not easy to ascertain. In the non-puerperal state the peritonitic variety is much the more common, but in the puerperal state they very generally complicate each other, and it is rare for cellulitis to exist to any great extent without more or less peritonitis. Symptomatology . — The earliest symptom is pain in the lower part of the abdomen, which is generally preceded by rigor or chilliness. The amount of pain varies much. Sometimes it is comparatively slight, and it is by no means rare to meet with patients, who are the subjects of very considerable exudations, who suffer little more than a certain sense of weight and discomfort at the lower part of the abdomen. On the other hand the suffering may be excessive, and is characterized by paroxysmal exacerbations, the patient being com- paratively free from pain for several successive hours, and then having attacks of the most acute agony. Schroeder says that pain 620 THE PUERPERAL STATE. is always a symptom of peritonitis, and that it does not exist in uncomplicated cellulitis. The swellings of cellulitis are certainly sometimes remarkably free from tenderness, and I have often seen masses of exudation in the iliac fossae, which could bear even rough handling. On the other hand, although this is certainly more often met with in non-puerperal cases, the tenderness over the abdomen is sometimes excessive, the patient shrinking from the slightest touch. The pulse is raised, generally from 100 to 120, and the thermometer shows the presence of pyrexia. During the entire course of the disease both these symptoms continue. The temperature is often very high, but more frequently it varies from 100° to 104°, and it generally shows more or less marked remissions. In some cases the temperature is said not to be elevated at all, or even to be sub-nor- mal, but this is certainly quite exceptional. Other signs of local and general irritation often exist. Among them, and most distinctly in cases of peritonitis, are nausea and vomiting, and an anxious pinched expression of the countenance, while the local mischief often causes distressing dysuria and tenesmus. The latter is especially apt to occur when there is exudation between the rectum and vagina, which presses on the bowel. The passage of feces, unless in a very liquid form, may then cause intolerable suffering. Such symptoms may show themselves within a few days after delivery, and then they can harely fail to attract attention. On the other hand, they may not commence for some weeks after labor, and then they are often insidious in their onset, and apt to be overlooked. It is far from rare to meet with cases six weeks or more after con- finement, in which the patient complains of little beyond a feeling of malaise and discomfort, and in which, on investigation, a conside- rable amount of exudation is detected, which had previously entirely escaped observation. Results of Physical Examination. — On introducing the finger into the vagina it will be found to be hot and swollen, in some cases dis- tinctly oedematous, and on reaching the vaginal cul-de-sac the exist- ence of exudation may generally be made out. The amount of this varies much. Sometimes, especially in the early stage of the disease, there is little more than a diffuse sense of thickness and induration at either side of, or behind, the uterus. More generally careful bi-manual examination enables us to detect a distinct hardening and swelling, . possibly a tumor of considerable size, which may appa- rently be attached to the sides of the uterus, and rise above the pelvic brim, or may extend quite to the pelvic walls. The examina- tion should be very carefully and systematically conducted with both hands, so as to explore the whole contour of the uterus before, behind, and on either side, as well as the iliac fossos ; otherwise a considerable exudation might readily escape detection. When the exudation is at all great, more or less fixity of the uterus is sure to exist, and is a very characteristic symptom. The womb, instead of being freely movable by the examining finger, is firmly fixed by the surrounding exudation, and in severe forms of the disease is quite encased in it. More or less displacement of the organ is also of PELVIC CELLULITIS AND PELVIC PERITONITIS. 621 common occurrence. If the swelling be limited to one side of the pelvis or to Douglas's space, the uterus is displaced in the opposite direction, so that it is no longer in its usual central position. The Two Forms of Disease cannot always be Distinguished. — The differential diagnosis of pelvic cellulitis and pelvic peritonitis cannot always be made, and, indeed, in many cases it is impossible, since both varieties of disease coexist. The elements of differentiation generally insisted on are, the greater general disturbance, nausea, etc., in pelvic peritonitis, with an earlier commencement of the symp- toms after labor. The swellings of pelvic peritonitis are also more tender, with less clearly-defined outline than those of cellulitis. When the cellulitis involves the iliac fossa the diagnosis is, of course, easy, and then a continuous retraction of the thigh on the affected side (an involuntary position assumed with the view of keeping the muscles lining the iliac fossa at rest), is often observed. When the inflammation is chiefly limited to the cavity of the pelvis, the dis- tinction between the two classes of cases cannot be made with any degree of certainty. Terminations. — Both forms of disease may end either in resolution or in suppuration. In the former case, after the acute symptoms have existed for a variable time, it may be for a few daj^s only, it m&y be for many weeks, their severity abates, the swellings become less tender and commence to contract, become harder and are gradu- ally absorbed ; until, at last, the fixity of the uterus disappears, and it again resumes its central position in the pelvic cavity. This pro- cess is often very gradual. If is by no means rare to find a patient, even some months after the attack, when all acute symptoms have long disappeared, who is even able to move about without incon- venience, in whom the uterus is still immovably fixed in a mass of deposit, or is, at least, adherent in some part of its contour. More or less permanent adhesions are of common occurrence, and give rise to symptoms of considerable obscurity, which are often not traced to their proper source. Symptoms of Suppuration. — When the inflammation is about to terminate in suppuration, the pyrexial symptoms continue, and eventually well-marked hectic is developed, the temperature gene- rally showing a distinct exacerbation at night, At the same time rigors, loss of appetite, a peculiar yellowish discoloration of the face, and other signs of suppuration, show themselves. The relative fre- quency of this termination is variously estimated by authors. Duncan quotes Simpson as calculating it as occurring in half the cases of pelvic cellulitis, but states his own belief that it is much more frequent. West observed it in 23 out of 43 cases following delivery or abor- tion, and McClintock in 37 out of 70. Schroeder says that he has only once seen suppuration in 92 cases of distinctly demonstrable exudation, a result which is certainly totally opposed to common experience. Barker also states that in his experience suppuration in either pelvic peritonitis or cellulitis " is very rare, except when they are associated with pyaemia or puerperal fever." It is certain that suppuration is more likely to occur in pelvic cellulitis than in 622 THE PUERPERAL STATE. pelvic peritonitis, but it unquestionably occurs, in this country at least, much more frequently than the statements of either of these authors would lead us to suppose. Channels through which Pus may Escape. — The pus may find an exit through various channels. In pelvic cellulitis, more especially when the areolar tissue of the iliac fossa is implicated, the most common site of exit is through the abdominal wall. It may, how- ever, open at other positions, and the pus may find its way through the cellular tissue and point at the side of the anus, or in the vagina, or it may take even a more tortuous course and reach the inner sur- face of the thigh. Pelvic abscesses not uncommonly open into the rectum or bladder, causing very considerable distress from tenesmus or dysuria. According to Hervieux, it is chiefly the peritoneal varieties which open in this way. Not unfrequently more than one opening is formed; and when the pus has burrowed for any dis- tance, long fistulous tracts result, which secrete pus for a length of time, and are very slow to heal. Eupture of an abscess into the peritoneal cavity, especially of a peritonitic abscess, is a possible (but fortunately a very rare) termination, and will generally prove fatal by producing general peritonitis. In one case which I have recorded in the fifteenth volume of the ''Obstetrical Transactions," suppuration was followed by extensive necrosis of the pelvic bones. Two similar cases are related by Trousseau in his " Clinical Medi- cine," but I have not been able to meet with any other examples of this rare complication, which was probably rather the result of some obscure septicemic condition than of extension of the inflammation. Prognosis. — The prognosis is favorable as regards ultimate re- covery, but there is greak risk of a protracted illness which may seriously impair the health of the patient, especially if suppuration result. Hence it is necessary to be guarded in an expression of opinion as to the consequences of the disease. Secondary mischief is also far from unlikely to follow, from the physical changes pro- duced by the exudation, such as permanent adhesions or malpositions of the uterus, or organic alterations in the ovaries or Fallopian tubes. Treatment. — In the treatment of both forms of disease the import- ant points to bear in mind are the relief of pain, and the necessity of absolute rest ; and to these objects all our measures must be sub- ordinate, since it is quite hopeless to attempt to cut short the inflam- mation by any active medication. If the disease be recognized at a very early stage, the local abstrac- tion of blood, by the application of a few leeches to the groin or to the hemorrhoidal veins, may give relief; but the influence of this remedy has been greatly exaggerated, and when the disease is of any standing it is quite useless. Leeches to the uterus, often recommended, are, I believe, likely to do more harm than good (unless in very skilful hands), from the irritation produced by passing the speculum. Opi- ates in large closes may be said to be our sheet anchor in treatment whenever the pain is at all severe, either by the mouth, in the form of morphia suppositories, or injected subcutaneousfy. In the not uncommon cases in which pain comes on severely in paroxysms, the PELVIC CELLULITIS AND PELVIC PERITONITIS. 623 opiates should be administered in sufficient quantity to lull the pain, and it is a good plan to give the nurse a supply of morphia supposi- tories (which often act better than any other form of administering the drug), with directions to use them immediately the pain threatens to come on. When there is much pyrexia large doses of quinine may be given with great advantage, along with the opiates. The state of the bowels requires careful attention. The opiates are apt to produce constipation, and the passage of hardened feces causes much suffering. Hence it is desirable to keep the bowels freely open. Nothing answers this purpose so well as small doses of castor oil, such as half a teaspoonful given every morning. Warmth and moisture, constantly applied to the lower part of the abdomen, give great relief either in the form of large poultices of linseed meal, or, if these prove too heavy, of spongio-piline soaked in boiling water. The poultices may be advantageously sprinkled with laudanum or belladonna liniment. I say nothing of the use of mercurials, iodide of potassium, and other so-called absorbent remedies, since I believe them to be quite valueless, and apt to divert attention from more useful plans of treatment. Importance of Rest. — The most absolute rest in the recumbent posi- tion is essential, and it should be persevered in for some time after the intensity of the symptoms is lessened. The beneficial effect of rest in alleviating pain is often seen in neglected cases, the nature of which has been overlooked, instant relief following the laying up of the patient. Counter- Irritation. — When the acute symptoms have lessened, ab- sorption of the exudation may be favored, and considerable relief obtained, from counter-irritation, which should be gentle and long- continued. The daily use of tincture of iodine until the skin peels, perhaps best meets this indication ; but frequently repeated blisters are often very serviceable. This I believe to be a better plan than keeping up an open sore with savine ointment, or similar irritating applications. Opening of Pelvic Abscesses. — When suppuration is established the question of opening the abscess arises. When this points in the groin, and the matter is superficial, a free incision may be made, and here, as in mammary abscess, the antiseptic treatment is likely to prove very serviceable. The abscess should, however, not be opened too soon, and it is better to wait until the pus is near the surface. The importance of not being in too great a hurry to open pelvic abscesses has been insisted on by West, Duncan, and other writers, and I have no doubt the rule is a good one. It is more especially applicable when the abscess is pointing in the vagina or rectum, where exploratory incisions are apt to be dangerous, and when the presence of pus should be positively ascertained before operating. We have in the aspirator a most useful instrument in the treatment of such cases, which enables us to remove the greater part of the pus without any risk, and the use of which is not attended with danger, even if employed prematurely. If it do not sufficiently evacuate the abscess, a free opening can afterwards be safely made with the bis- bZi THE PUERPERAL STATE. toury. The surgical treatment of pelvic abscess is, however, too wide a subject to admit of being satisfactorily treated here. Diet and Regimen. — The diet should be abundant, but simple and nutritious. In the early stages of the disease, milk, beef-tea, eggs, and the like, will be sufficient. After suppuration a large quantity of animal food is required, and a sufficient amount of stimulants. The drain on the system is then often very great, and the amount of nourishment patients will require and assimilate, when a copious purulent discharge is going on, is often quite remarkable. A general tonic plan of medication will also be required, and such drugs as iron, quinine, and cod-liver oil, will prove useful. [APPENDIX. THE INTRA- VENOUS INJECTION OF FRESH MILK, AS AN IMPROVED SUBSTITUTE FOR THE TRANSFUSION OF BLOOD. The introduction of freshly drawn, blood- warm milk, of the cow and goat, into the veins of an exhausted patient, whether the condi- tion is the result of hemorrhage or disease, is not altogether new as a means of physical restoration, but has been recently revived with improvements, both as to method and application, by several Ame- rican physicians, most prominent among whom is Dr. T. Gaillard Thomas, of New York. The credit of the initiative revival is due to Dr. Edward M. Hodder, of Toronto, Canada, who made use of it in the collapse of Asiatic cholera, with the saving of two patients, in the epidemic of 1850, when warm water, artificial serum, etc., were being injected experimentally but ineffectually into the bloodvessels of patients. Dr. Joseph W. Howe, of New York, instituted a series of experi- ments upon dogs ; but, using milk brought from the country, all of his animals promptly died. Dr. Depuy repeated the same, with immediately drawn milk, and found the fluid perfectly harmless in this form. Dr. Howe injected, also, f 3yj of goat's milk into the cephalic vein of a patient affected with phthisis, with success, so far as the immediate effect was concerned. Dr. Thomas presented an account of his cases in a paper read before the New York Academy of Medicine last spring, an abridg- ment of which appeared in the Medical Record of April 27th, 1878. His first trial was made in October, 1875, in a case of uterine hemor- rhage following ovariotomy, with f Jviiiss of warm and freshly drawn cow's milk, the medium of introduction being a glass funnel, India- rubber tube, and nozzle. A rigor resulted, followed by a rise of temperature to 101°, but these symptoms soon disappeared. The patient made a good recovery, being clown stairs on the twenty -first day. In a second ovarian case, Dr. Thomas injected on five occasions, from f |vj up to f 3xv, in a period of ten clays ; and although the patient died of intestinal gangrene, the impression was that the milk had prolonged her life about six days. As far as we have ascertained, there have been fifteen patients under treatment by this method, viz., Dr. Hodder, three cases ; Dr. 626 APPENDIX. Howe, two ; Dr. Thomas, seven ; and Dr. Charles T. Hunter, of Phila- delphia, three. Dr. Hunter greatly prefers this method to that of the transfusion of blood, over which it has many advantages, both in introduction and result. He has the milk drawn into a double vessel, with warm water in the interspace, and regulates the temperature to about 99° Fahr. The fluid is strained through fine wire gauze, to exclude any foreign matters that might be injurious. Attached to the funnel and tube, Dr. Hunter has a perforating canula, with a small stopcock to shut off the flow of milk. After the vein is fully exposed, the milk is ran through the tube, the cock closed, which keeps the canula full by capillary attraction, and the vessel perforated by the cutter on the end of the canula ; the cock is then opened, funnel elevated, and milk carried in by its own weight. He has used cows' milk in two cases, and goats' milk in the third and last. He objects to the use of the syringe as much more troublesome and less safe than the simple fountain apparatus described. The milk used should not only be just drawn, but perfectly free from any acidity, as shown by test-paper. In hot weather, the passage of milk through the air from the udder to the vessel will develop a slight formation of lactic acid, which should be neutralized by the addition of bicarbonate of soda. Dr. A. Jacobi, in the discussion of Dr. Thomas's paper, stated that the milk of some cows was acid while still in the uclder. The cow, or goat, should be fed upon grass or fine hay, and be milked as near to the patient as possible, into the double vessel already described, or, what will answer, a clean farina- boiler or glue-pot, both of which are double-cased. In the country this can be readily managed so far as the cow is concerned, as she can be driven to the door to be milked ; but in cities there is much more difficulty, where this animal is rarely kept, and we are obliged to use the goat as a substitute, feeding her in the yard or cellar for the time wanted. No doubt the milk of the ass or mare, when at hand, would answer equally well. Both Dr. Thomas and Dr. Hunter believe that a measure of f Jviij is sufficient for ordinary use, although the former has used as high as fifteen, and the latter ten. We be- lieve that the size of the patient should make a difference in the number of ounces to be employed, just as it does in the volume of blood naturally in the body, the range in the extremes being con- siderable. As chyle varies in color and analysis according to the food consumed, being most nearly allied to milk when the animal has been fed with it, there must be in the blood a capability of con- version, of a variable character, which enables it to alter, not only the extremes of the chylous fluid, but milk also, with its butter and casein, which are not found in chyle. Pure milk has been satisfac- torily proved to be innocent in the blood when properly collected and introduced ; and not only this, but also a valuable means of saving life in cases of extreme prostration. How it acts, we do not understand ; or why it will answer as well as, or better than, blood ; we are satisfied that it does, and are prepared to recommend it to our readers. APPENDIX. 627 "We have -a patient, almost in articulo- mortis, pale, prostrate, per- haps emaciated and anasmic, lying in a semi-comatose sleep, into whose veins we inject a half pint of pure, warm, new milk. She has a chill, then a considerable rise of temperature, and finally opens her eyes and appears for the time as one almost awakened from the sleep of death. If the condition of the patient is not necessarily fatal, by reason of its destructive progress, we may bridge over the period of danger until convalescence is established, and thus save the case. Milk has done this when food and stimulants appeared to be unavail- able ; and we have faith to believe, that it has a future of much use- fulness in a great variety of cases. To make known its value, is to largely increase its sphere of usefulness in general practice. — Ed.] INDEX ABDOMEN, adipose enlargement of, 148 enlargement of, as a sign of preg- nancy, 139 state of, after delivery, 526 ■Abdominal pregnancy. (See Extra-uterine | pregnancy.) Abortion, 229 causes of, 231 difficulty in procuring artificial, 230 liability to recurrence of, 230 retention of secundines in, 235, 240 symptoms of, 235 treatment of, 235 production of, in vomiting of preg- nancy, 187 [value of opium in prevention of, 236] Abscess of mammae. (See Mammary ab- scess.) 'Abscess, pelvic. (See Pelvic cellulitus.) After-pains, 529 treatment of, 531 Age, influence of, in labor, 328 Albuminuria in pregnancy, 192 relation of, to eclampsia, 550 relation of, to puerperal insanity, 563 Allantois, 96 Amnion, formation of, 95 pathology of, 223 structure of, 98 Amputations (intra-uterine), 226 Anaemia in pregnancy, 191 Anaesthesia in labor, 282 in forceps operations, 465 value of, in difficult cases of turning, 457 Anasarca in pregnancy, 194 Ante-version of the gravid uterus, 202 Apoplexy during or after labor, 550, 606 Arbor vitas, 51 Area germinativa, 94 Area pellucida, 95 Areola, 70 changes of, during pregnancy, 136 Arm, presentation of. (See Shoulder pre- sentation.) dorsal displacement of, 318 Artificial human milk, 547 Artificial respiration in cases of apparent I still-birth, 534 Ascites as a cause of dystocia; 364 Asphyxia (idiopathic), 607 [Atmosphere, advantages of a pure, in preventing abortion, 237] Auscultatory signs of pregnancy, 142 BAGS (Barnes's). (See Dilators.) Ballottement, 141 Bi-lobed uterus, gestation in, 180 Binder, uses of, 281 Bladder, distension of, as a cause of pro- tracted labor, 328 state of, after delivery, 530 Blastodermic membrane, 88 division and layers of, 94 Blood, alteration in, after delivery, 524 Blood-diseases transmitted to foetus, 223 Blunt-hook in breech presentation, 297 Bowels, action of, after delivery, 532 Breech presentations. (See Pelvic pre- sentations.) Broad ligaments of uterus, 59 [Bromide of sodium preferred to bromide of potassium, 196] Bronchitis as a cause of protracted labor, 328 Brow presentations, 306 p^SAREAN section, 203, 317, 345, 375, 499 causes of mortality after, 504 causes requiring the operation, 501 description of, 508 history of, 499 post-mortem operation, 503 results to child in, 501 statistics of, 501 substitutes for, 510 [Caesarean operation in the United States, 512] [carbolized catgut sutures in, 509] [transverse position of foetus, 499] Calculus of bladder obstructing labor, 347 Caput succedaneum, 266 Carcinoma in pregnancy, 209 obstructing labor, 314 Caries of teeth in pregnancy, 190 Carunculae myrtiformes, 44 630 INDEX [Catheter introduced in dorsal decubitus, 43] introduction of, 43 Caul, 251 Cellulitis, pelvic. (See Pelvic cellulitis.) Cephalotribe, 487 Cephalotripsy. (See Craniotomy.) Cervix uteri, 51 alterations of, after childbirth, 50 cavity of, 50 dilatation of, in labor, 246 impaction of, before foetal head, 274 incision of, for rigidity, 342 modification of, by pregnancy, 126 mucous membrane of, 55 organic causes of rigidity of, 341 rigidity of, as a cause of pro- tracted labor, 339 treatment of rigidity, 340 villi of, 55 Charlotte, Princess of Wales, death of, 336 Child (the new born). (See Infant.) Child, risks to, in forceps operations, 472 Childbirth, mortality of, 523 Chloral in labor, 283 in rigidity of cervix, 340 Chloroform in labor, 283 in difficult cases of turning, 457 in rigidity of cervix, 340 Chorea in pregnancy, 198 Chorion, 99 vesicular degeneration of, 215 Circulation of foetus, 119 Cleavage of yelk, 88 Clitoris, 42 Coccyx, 27 ligaments of, 28 ossification of, 28 mobility of, 28 Cold in the treatment of puerperal hyper- pyrexia, 592 Colostrum, 536 Complex presentations, 317 Conception, signs of, 133 Constipation in pregnancy, 188 [Constriction of uterus, tetanoid, 350] Continued fever in pregnancy, 207 Convulsions (puerperal). (See Eclamp- sia.) Corps reticule, 97 Corpus luteum, 74 Cranioclast, 487 Craniotomy, 484 cases requiring, 490 comparative merits of, and cephalo- tripsy, 493 description of cejmalotripsy, 494 extraction of head by craniotomy for- ceps, 496 method of perforating, 492 perforators, 486 perforation of after-coming head, 493 religious objections to, 484 Craniotomy forceps, 488 Crotchets, 486 Cystocele, obstructing labor, 347 DEATH, apparent, of new-born child. (See Infant.) Death, sudden, during labor and the puer peral state, 607 from air in the veins, 608 functional causes of, 608 organic causes of, 607 Decapitation of foetus, 497 Decidua, 89 at end of pregnancy, and after de- livery, 93 cavity between d. vera and reflexa, 93 divisions of, 89 fatty degeneration of, as the cause of labor, 243 formation of d. reflexa, 91 structure of, 90 Delivery, state of patient after, 524 contraction of uterus after, 526 management of patient after, 530 nervous shock after, 524 prediction of date of, 152 signs of recent, 155 state of pulse after, 524 weight of uterus after, 526 Diameters of foetal skull, 111 of pelvis, 33 Diarrhoea in pregnancy, 188 [Diet, milk, in nursing mothers, 537] of lying-in women, 531 Dilators (caoutchouc) in the induction of premature labor, 439 in rigidity of cervix, 341 Diphtheria in the puerperal state, 571 Diseases of pregnancy, 183 albuminuria, 192 anaemia and chlorosis, 191 carcinoma, 209 cardiac diseases, 208 chorea, 198 constipation, 188 diarrhoea, 188 disorders of the nervous system, 196 respiratory organs, 190 teeth, 190 urinary system, 198 displacements of the gravid ute- rus, 201 epilepsy, 209 eruptive fevers, 206 fibroid tumors, 211 hremorrhoids, 189 icterus, 209 leucorrhoea, 200 ovarian tumor, 210 palpitation, 191 paralysis, 197 pneumonia, 207 pruritus, 200 INDEX 631 Diseases of pregnancy — ptyalism, 189 syncope, 191 syphilis, 208 varicose veins, 201 vomiting (excessive), 184 Dropsies affecting the foetus, 225 Ductus arteriosus, 119 venosus, 119 j Dystocia from foetus, 353 ECLAMPSIA, 550 cause of death in, 553 condition of patient between the at- tacks, 552 confusion from defective nomencla- ture, 550 exciting causes of, 555 [intermittent, 559] obstetric management in, 558 pathology of, 553 premonitory symptoms of, 550 relation of, to labor, 552 results to mother and child in, 552 symptoms of, 551 transfusion in, 515 Traube and Rosenstein's theory of, 554 treatment of, 555 uraemic theory of, 550 Ecraseur, use of, as a substitute for crani- otomy, 489 Embolism. (See Thrombosis.) Embryotomy, 497 Emotion, mental, as a cause of protracted labor, 328 Epiblast, 94 Epilepsy, in pregnancy, 209 Epileptic convulsions, 550 Ergot of rye, 331 as a means of inducing labor, 438 objections to use of, 331 mode of administration, 331 value of, after delivery, 281 Eruptive fevers in pregnancy, 206 Erysipelas, as a cause of puerperal septi- caemia, 577 Ether in labor, 285 [in the United States, 285] Exhaustion, importance of distinguishing between temporary and permanent in labor, 331 Expression, uterine. (See Pressure.) of the placenta, 280 Extra-uterine pregnancy, 163 abdominal variety of, 173 causes of, 165 changes of the foetus in, 175 classification of, 164 diagnosis of abdominal variety, 176 diagnosis of tubal variety, 169 gastrotomy in, 172, 177 pseudo-labor in, 175 Extra-uterine pregnancy — symptoms of rupture in, 168 treatment after rupture, 172 treatment of abdominal variety, 178 tubal variety, 166 treatment of tubal variety, 170 Evisceration, 498 FACE presentation, 297 causes of, 298 diagnosis of, 299 difficulties connected with, 305 erroneous views formerly enter- tained of, 297 mechanism of delivery in, 299 mento-posterior positions in, 304 prognosis in, 304 treatment of, 304 Fallopian tubes, 61 False pains, character and treatment of, 270 Faradization, in apparent still birth, 535 Fibroid tumor in pregnancy, 211 obstructing labor, 344 Fillet, 482 in breech presentations, 296 [Japanese, 484] nature of the instrument, 482 objections to its use, 483 Foetal head, anatomy of, 110 induction of premature labor, for large size of, 435 Foetal heart, sounds of, in pregnancy, 142 Foetus, anatomy and physiology of, 107 [anencephalous, causing eneuresis, 199] appearance of a putrid, 228 appearance of, at various stages of de- velopment, 108 at term, 109 circulation of, 119 changes in circulation of, as cause of labor, 242 changes in position of, during preg- nancy, 113 death of, 228 detection of position in utero by pal- pation, 113 early viability of, 229 excessive development of, as a cause of difficult labor, 364 explanation of its position in utero, 114 functions of, 116 nutrition of, 116 pathology of, 222 position of, in utero, 112 respiration of, 118 signs and diagnosis of death of, 228, 493 Fontanelles, 110 Foot, diagnosis of, 289 632 INDEX Foot presentations. (See Pelvic presenta- tions.) Foramen ovale, 119 Forceps, 458 action of, 462 advantages of pelvic curve in, 459 [application at inferior strait, 478] [at superior strait, 480] application of, to after-coming head in breech presentations, 295 application of, within the cervix, 343 [carried over abdomen, to complete delivery of head, 481] cases in which a straight instrument should be used, 459 dangers of, 335, 471 dangers of, to child, 472 description of, 458 description of the operation, 465 difference between high and low ope- rations, 464 disadvantages of a weak instrument, 461 frequent use of, in modern practice, 333, 458 high operations, 470 long, 460 preliminary considerations before using, 464 short, 458 use of anaesthetics in forceps delivery, 465 use of in deformed pelvis, 382 use of in difficult occipito-posterior positions, 308 use of in protracted labor, 333 [Forceps, Bedford's, 476] [Clemann's, 462] [Davis's, 475] [Elliot's, 476] [Hodge's, 474] [Meigs's Craniotomy, 496] [Sawyer's, 477] [Wallace's, 475] [White's, 476] Forceps-saw, 489 [Forcipe compressore, Assalini's, 487] Fossa navicularis, 44 Funis. (See Umbilical cord.) GALACTAGOGUES, 541 Galactorrhcea, 542 Galvanism as a means of inducing labor, 438 Gangrene of limbs from arterial obstruc- tion, 594 Gastrotomy, after rupture of uterus, 425 in extra-uterine pregnancy, 171, 179 Gastro-elytrotomy. (See Laparo-elytrot- omy.) Generative organs, in the female, 41 division according to function, 41 Germinal vesicle, disappearance of, after impregnation, 87 Gestation. (See Pregnancy.) Graafian follicle, 65 structure of, 67 HEMATOCELE, obstructing labor, 348 Haemorrhoids, in pregnancy, 189 [Hand, introduction of, in occipito-poste- rior positions, 308] Hand-feeding of infants, 546 ass's milk in, 546 artificial human milk in, 547 causes of mortality in, 546 cow's milk in, and its prepara- tion, 546 goat's milk in, 546 method of, 548 [Harris on early puberty, 76] Head presentations, 255 description of cranial positions in, 256 division of, 256 explanation of frequency of 1st position, 257 frequency of, 256 mechanism of 1st position, 359 2d position, 264 3d position, 265 4th position, 266 relative frequency of various po- sitions, 257 Heart, diseases of, in pregnancy, 208 hypertrophy of, in pregnancy, 130 Hemorrhage, accidental, 399 causes and pathology of, 400 concealed internal, 401 diagnosis, prognosis, and treatment of concealed internal, 400 prognosis of, 401 symptoms and diagnosis of, 400 treatment of, 402 Hemorrhage after delivery, 402 causes of, 403 constitutional predisposition to, 407 curative treatment of, 409 from laceration of maternal struc- tures, 415 nature's mode of preventing, 253, 403 preventive treatment of, 408 secondary causes of, 405 secondary treatment of, 415 symptoms of, 407 transfusion of blood in, 416 Hemorrhage after delivery (secondary), 416 distinction between, and pro- fuse lochial discharge, 416 local causes of, 417 treatment of, 418 Hemorrhage, unavoidable. (See Placenta previa.) Hernia, in labor, 347 Hour-glass contraction of uterus, 405, [406] INDEX. 633 Hydatids of uterus, 215 Hydramnios, 222 Hydrocephalus of foetus, as a cause of dif- ficult labor, 361 Hydrorrhea gravidarum, 214 Hymen, 43 [an obstacle to delivery, 44] Hypoblast, 94 Hysteria during labor, 550 INDUCTION of premature labor. (See Premature labor.) Inertia of the uterus, frequent child-bear- ing as a cause of, 327 Infant, apparent death of, 533 appearance of, in cases of apparent death, 534 clothing of, 536 evils of over-suckling, 536 management of, 538 management of, when food disagrees, 549 treatment of apparent death of, 534 various kinds of food of, 549 •washing and dressing of, 535 Infantile mortality, diminution of, as a reason for more frequent use of forceps, 335 Inflammatory diseases affecting the foetus, 225 Insanity (puerperal), 559 classification of, 559 of lactation, 565 of pregnancy, 560 predisposing causes of, 560 puerperal (proper), 562 causes of, 562 form of, 561 prognosis of, 564 post-mortem signs of, 565 symptoms of, 565 transient mania during delivery, 561 treatment of, 567 treatment during convalescence, 570 question of removal to an asylum, 569 Insomnia in pregnancy, 196 Intermittent fever affecting the foetus, 224 Intestines, disorders of, as influencing labor, 328 Inversion of uterus. (See Uterus.) Irregular uterine contractions after labor, 405 as a cause of lingering labor, 329 Irritable bladder in pregnancy, 199 Ischium, planes of the, 38 "JAUNDICE in pregnancy, 209 41 KIESTEIN, 132, [133] Knots on the umbilical cord, 221 Knee presentation, 288 Kyphotic deformity of pelvis, 373 LABIA major a, 41 Labia minora, 42 Labor, 242 age, influence of, on, 328 anaesthesia in, 282 arrest of, 155 causes of, 242 causes of precipitate, 338 causes of protracted, 326 character and source of pain in, 248 character of false pains, 270 dilatation of cervix in, 246 duration of, 254 effect of uterine contractions in, 244 evil effects of protracted, 324 induction of. (See Premature labor.) influence of stage of, in protracted, 325 management of, in deformed pelvis, 381 management of natural, 268 management of third stage of, 278 mechanism of, in head presentation, 256 obstructed by faulty condition of the soft parts, 339 period of day at which labor com- mences, 255 phenomena of, 242 position of patient during, 272 preparatory treatment, 268 precipitate, 338 prolonged and precipitate, 324 rupture of membranes in, 246 stages of, 249 symptoms of protracted, 326 treatment of protracted, 329 Lactation, defective secretion of milk in, 541 diet of nursing women during, 539 excessive flow of milk in, 542 importance of to mother, 537 importance of wet-nursing to child, 537 insanity of, 565 management of, 538 means of arresting secretion of milk in, 540 period of weaning in, 540 Lamina? dorsales, 95 Laparo-elytrotomy, 511 Lead-poisoning, affecting the foetus, 224 as a cause of abortion, 234 Leucorrhoea, in pregnancy, 200 Lever. (See Vectis.) [Line, dark abdominal, in negro, 138] Liquor amnii, 98 uses of, 99 634 INDEX. Liquor amnii — source of, 99 deficiency of, 223 Lochia, 528 variation in amount and duration of, 529 occasional fetor of, 529 Lying-in hospitals, mortality in, 571 Lypothemia, 191 MALPRESENTATIONS, peculiar form of bag of membranes in, 288 Mammary abscess, 542 antiseptic treatment of, 544 signs and symptoms of, 543 treatment of, 543 changes during pregnancy, 136 their diagnostic value, 138 glands, 69 their sympathetic relations with the uterus, 71 [McKnight's operation, 171] Measles, affecting the foetus, 224 in pregnancy, 207 Meconium, 122 Membranes, artificial rupture of, 273 puncture of, as a means of inducing labor, 437 Menstruation, 71 cessation of, 82 during pregnancy, 134 changes in Graafian follicle after, 72 [increased by change of residence to a hot climate, 78] period of, duration, and recurrence, 77 purpose of, 82 sources of blood in, 79 theory of, 80 quantity of blood lost in, 78 vicarious, 82 Mesoblast, 94 [Milk, Alderney, too rich for young in- fants, 547] artificial human, 547 ass's, 546 cow's, and its preparation, 546 defective secretion of, 541 excessive secretion of, 542 goat's, 546 means of arresting the secretion of, 540 secretion of, after delivery, 536 Milk-fever, 525 Miscarriage. (See Abortion.) Missed labor, 181 Moles, 232 Monstrosity (double), 357 classification of, 358 mechanism of delivery in, 358 Mons veneris, 41 Montgomery's cups, 90 Morning sickness, 135 Mortality of childbirth, 523 Mucous membrane of uterus. Uterus.) (See NERVOUS shock after delivery, 524 Nervous system, changes in, during pregnancy, 131 disorders of, in pregnancy, 196 excitability of, in puerperal wo- men, 555 Neuralgia in pregnancy, 196 Nipple, 70 Nipples, depressed, 541 fissures and excoriations of, 541 Nursing. (See Lactation.) Nutrition of foetus, 116 Nymphae. (See Labia minora.) OBLIQUELY contracted pelvis, 373 Obstetric bag, 269 Occipito-posterior positions, difficult cases of, 307 causes of face-to-pubis delivery in, 307 forceps in, 308 treatment of, 308 vectis or fillet in, 308 Omphalo-mesenteric artery and vein, 96 Opiates, use of, after delivery, 530 Os innominatum, 25 Osteomalacia, as a cause of deformity, 367 Osteophytes, formation of, during preg- nancy, 131 Os uteri, dilatation of, as a means of in- ducing labor, 439 occlusion of, in labor, 342 Ovarian pregnancy. (See Extra-uterine pregnancy.) tumor in pregnancy, 210 Ovariotomy in pregnancy, 210 Ovary-; -63 functions of, 71 structure of, 63 vascular arrangements of, 68 Ovule, 68 changes in, after impregnation, 87 changes in, when retained in utero after its death, 232 formation of, 66 Oxytocic remedies, 330 PAINS, after-, 529 false, 250 irregular and spasmodic as a cause of protracted labor, 329 labor, 245 Palpitation, in pregnancy, 191 Pampiniform plexus, 56 Paralysis in pregnancy, 197 from embolism of the cerebral arteries, 600 from embolism of the main arteries of the limb, 600 INDEX 635 Parovarium, 59 Parturient canal, axis of, 37 Pathology of decidua and ovum, 212 Pelvis, alterations in, articulations of, during pregnancy, 31 anatomy of, 25 articulations of, 28 axes of, 37 Caesarean section in deformities of, 385 causes of deformity of, 366 comparative estimate of turning and forceps in deformity of, 383 craniotomy in deformity of, 385 diagnosis of deformity, 379 deformities of, 366 development of, 39, 40 difference according to race, 40 difference in the two sexes, 32 division into true and false, 32 equally contracted, 368 equally enlarged, 368 forceps in deformity of, 382 induction of premature labor in de- formity of, 385 infantile, 39 kyphotic, 374 ligaments of, 28 masculine, 369 mechanism of delivery in deformed, 377 movements of the articulations of, 30 obliquely contracted, 373 planes of, 37 Robert's, 374 soft parts connected with, 40 tumors of, 375 turning in deformity of, 383 undeveloped, 369 Pelvic cellulitis and peritonitis, 616 etiology of, 617 importance of distinguishing the two forms of disease, 617 connection with septicaemia, 618 opening of abscess in, 623 prognosis of, 622 relative frequency of the two forms of disease, 619 results of physical examina- tion, 620 seat of inflammation in cellu- litis, 618 seat of inflammation in peri- tonitis, 619 suppuration in, 621 symptomatology, 619 terminations of, 621 treatment of, 622 two distinct forms of disease, 617 presentations, 286 application of forceps to the after- coming head in, 295 Pelvic presentations — causes of, 286 danger to child in, 294 diagnosis of, 287 frequency of, 286 management of impacted breech in, 296 mechanism of, 289 prognosis in, 287 treatment of, 293 Pelvimeters, various forms of, 379 Perchloride of iron, injection of, in post- partum hemorrhage, 414 [Perforator, Meigs's, 486] [rotary, 486] Perforators, 485 Perineum, 411 distension of, in labor, 252, 275 incision of, 276 laceration of, 277 relaxation of, 275 rigidity of, as a cause of protracted labor, 343 Peritonitis, pelvic. (See Pelvic cellulitis.) Peritonitis, puerperal. (See Septicaemia.) Phlegmasia dolens. (See Thrombosis, peripheral venous.) Placenta, 100 adhesion of, after delivery, 407 degeneration of, 106 detachment of, in labor, 253 expression of, 280 foetal portion of, 101 form of, in man and animals, 100 functions of, 106 maternal portion of, 104 minute structure of, 101 pathology of, 218 sinus system of, 103 sounds produced during separation of, 147 treatment of adherent, 411 Placenta membranacea, 218 Placenta praevia, 388 causes of, 388 causes of hemorrhage in, 391 natural termination of labor in, 393 pathological changes of placenta in, 392 prognosis in, 384 sources of hemorrhage in, 390 summary of rules of treatment in, 398 symptoms of, 389 treatment of, 394 turning in, 455 Placenta succenturia, 218 Placentitis, 219 Plugging of vagina, 239 Plural births, 157, 353 arrangement of placentae and membranes in, 159 causes of, 159 diagnosis of, 160 636 INDEX. Plural "births — relative frequency of, in different countries, 158 sex of children in, 158 treatment of, 354 Pneumonia in pregnancy, 207 " Polar globule," 87 [Polypus, an obstacle to delivery, 346] Position of cranium in head-presentation. (See Head presentation.) Post-partum hemorrhage. (See Hemor- rhage.) ' Pregnancy, 123 abnormal, 157 alteration of color of vaginal mucous membrane as a sign of, 142 ballottement as a sign of, 141 changes in the blood during, 129 changes in the liver, lymphatics, and spleen during, 131 in the urine during, 132 [complicated with ovarian tumor, 210] deposits of pigmentary matter during, 138 differential diagnosis of, 148 dress of patient in, 268 duration of, 151 enlargement of abdomen as a sign of, 139 extra-uterine. (See Extra-uterine Pregnancy.) foetal movements in, 139 formation of osteophytes during, 131 hypertrophy of the heart during, 130 in cases of double uterus, 57 in the absence of menstruation, 135 intermittent uterine contractions as a sign of, 140 [nitrous oxide safely given in, 190] ptyalism in, 189 prolapse of the uterus in, 201 protraction of, 153 pruritus in, 200 quickening, 139 sickness of, 135 signs and diagnosis of, 133 sounds produced by the foetal move- ments in, 147 spurious, 150 sympathetic disturbances of, 135 uterine fluctuation in, 142 vaginal signs of, 141 pulsation in, 141 Premature labor, 224 history of the operation of induc- tion of, 435 induction of, 435 in deformed pelvis, 388 injection of carbonic acid gas as a means of inducing, 441 insertion of flexible bougie as a means of inducing, 441 objects of the operation of induc- tion of, 435 Premature labor — oxytocics as a means of inducing, 438 period for the induction of, in de- formed pelvis, 387 precautions as regards the child in the induction of, 442 puncture of the membranes as a means of inducing, 437 separation of the membranes as a i means of inducing, 440 vaginal and uterine douches as a means of inducing, 440 Pressure as a means of inducing uterine contractions, 332 mode of applying, 333 Prolapse of umbilical cord. (See Umbili- cal cord.) Ptyalism in pregnancy, 189 Puerperal convulsions. (See Eclampsia.) fever. (See Septicaemia.) mania. (See Insanity.) state, 523 after-treatment in, 533 diet and regimen in, 531 diminution of uterus in, 526 importance of prolonged rest in, 532 secretions and excretions in, 525 temperature in, 525 Pulmonary arteries, anatomical arrange- ment of, as favoring thrombosis, 597 Pulse, state of, after delivery, 524 QUICKENING, 151 [Quinine as an oxytocic, 330] RACE as influencing the size of the foetal skull, 112 Recto-vaginal fistula, 427 Respiration of foetus, 118 Respiratory chamber, 86 Retroversion of the gravid uterus, 203 Rickets as a cause of pelvic deformity, 367 Rosenmuller, organ of. (See Parovarium.) Round ligaments of the uterus, 60 Rupture of uterus. (See Uterus.) SACRUM, anatomy of, 27 mechanical relations of, 27 Salivation in pregnancy, 189 Scarlet fever affecting the foetus, 224 in pregnancy, 207 in the puerperal state, 578 Scybalse in the rectum obstructing labor, 347 Septicemia (puerperal), 570 bacteria in, 581 channels of diffusion in, 582 through Avhich septic matter may be absorbed, 574 cold in treatment of, 592 INDEX 637 Septicaemia — conduct of practitioner in regard to, 581 contagion from other puerperal pa- tients as a cause of, 579 description of, 586 division into auto-genetic and hetero- genetic forms, 575 epidemics of, 572 history of, 571 importance of antiseptic precautions in, 581 influence of cadaveric poison as a cause of, 576 influence of zymotic diseases in caus- ing, 577 its connection with pelvic cellulitis and peritonitis, 618 local changes in, 582 mode in which the poison may be con- veyed to patients in, 580 nature of septic poison, 581 pathological phenomena in, 583 pysemic forms of, 585 sources of auto-infection in, 575 of hetero-infection, 575 symptoms of the intense forms, 586 theory of an essential zymotic fever, 573 of identity with surgical septi- caemia, 573 of local origin, 572 transfusion of blood in, 514 treatment of a, 588 Warburg's tincture in the treatment of, 591 Sex, discovery of, of foetus during preg- nancy, 143 of foetus as influencing the size of the skull, 112 Shoulder presentations, 309 diagnosis of, 312 division of, 310 mechanism of, 314 prognosis and frequency of, 312 spontaneous version in, 314 treatment of, 321 [Siamese Twins, how born, 358] Sickness of pregnancy, 135 [Silver uterine sutures, 509] [Sleep on inclined plane, for relief of dys- pnoea of pregnancy, 191] Smallpox affecting the foetus, 223 in pregnancy, 207 Smith's, Tyler, theory of labor, 243 Spondylolithesis, 371 Spontaneous evolution, 315 version, 313 Spurious pregnancy, 150 diagnosis of, 151 symptoms of, 150 Symphyseotomy, 510 Syncope during or after labor, 607 in pregnancy, 191 Syphilis affecting the foetus, 224 Syphilis — as a cause of abortion, 233 in pregnancy, 208 Super-fecundation and super-fcetation, 161 Sutures of foetal head, 110 TEMPERATURE after delivery, 524 [Thomas's operation, 171] Thrombosis (peripheral venous), 609 changes in thrombi in, 618 condition of the affected limb, 610 detachment of emboli in, 614 history and pathology of, 611 progress of the disease, 611 symptoms of, 610 treatment of, 614 (puerperal), 594 arterial thrombosis and embolism, 605 cardiac murmur in pulmonary, 602 cases illustrating recovery from pulmonary, 600 causes of death in pulmonary, 603 clinical facts in favor of pulmo- nary, 597 conditions which favor throm- bosis in the puerperal state, 595 distinction between thrombosis and embolism, 596 phlegmasia dolens a consequence of, 594 post-mortem appearance of clots in pulmonary, 603 question of primary thrombosis in the pulmonary arteries, 611 question of recovery from pulmo- nary, 596 symptoms of arterial, 605 of pulmonary obstruction in, 599 treatment of arterial, 607 of pulmonary, 604 Thrombus. (See Hematocele.) Toothache in pregnancy, 190 Transfusion of blood, 514 addition of chemical reagents to prevent coagulation of fibrine, 517 cases suitable for the operation, 519 dangers of the operation, 519 defibrination of blood in, 518 difficulties of the operation, 516 effects of successful transfusion, 522 history of the operation, 514 immediate transfusion, 517 method of injecting defibrinated blood, 522 method of performing immediate transfusion, 520 638 INDEX Transfusion of blood — method of preparing defibrinated blood, 521 mature and object of the opera- tion, 515 secondary effects of, 522 statistical results of, 519 Tropics, influence of residence in, on labor, 327 Trunk, presentation of. (See Shoulder presentations.) Tumors, diagnosis of uterine and ovarian, 149 foetal, 226 obstructing labor, 364 Tunica albuginea, 64 Turning, 442 anaesthesia in, 446 by combined method, 446 by external manipulation only, 444 cases suitable for the operation, 444 for operating by combined method, 445 cephalic, 446 choice of hand to be used, 448 history of the operation, 442 in abdomino-anterior positions, 456 in deformed pelvis, 383 in placenta preevia, 396, 455 method of cephalic, 443 of performing by external manip- ulation, 445 of podalic, 447 object and nature of the operation, 443 period when the operation should be performed, 448 podalic, 447, 451 position of patient in, 447 statistics and dangers of, 44 value of anassthetics in difficult cases of, 457 Twins. (See Plural births.) conjoined, 356 locked, 355 UMBILICAL cord, 106 knots of, 107, 227 ligature of, 277 pathology of, 221 prolapse of, 319 causes of, 321 diagnosis of, 321 frequency of, 319 prognosis of, 420 postural treatment of, 322 reposition of, 323 Umbilical souffle, 145 vesicle, 95 [" Untimely ripped" in Shakespeare, 500] Urachus, 97 Uraemia, in connection with eclampsia, 522 in connection with puerperal insanity, 563 Urethra, 43 Urine, changes in, during pregnancy, 132 retention of, after delivery, 530 Uterine fluctuation, as a sign of preg- nancy, 142 souffle, 145 Utero-sacral ligaments, 61 Uterus, 47 analogy of interior of, after delivery, and stump of an amputated limb, 93 anomalies of, 57 arrangement of muscular fibres of, 52 axis of, during pregnancy, 125 changes in cervix during pregnancy, 126, 141 changes in form and dimensions of, during pregnancy, 123 changes in mucous membranes of, after delivery, 527 changes in mucous membranes of, after impregnation, 89 changes in tissues of, during preg- nancy, 128 changes in the vessels of, after de- livery, 527 congestive hypertrophy of, 149 contractions of, in labor, 245 dimensions of, 49 diminution in size of, after delivery, 526 distension of, as a cause of labor, 243 distension of, by retained menses, 148 fatty transformation of, after delivery, 527 intermittent contractions of, during pregnancy, 140 internal surface of, 50 inversion of, 429 differential diagnosis of, 430 production of, 430 results of physical examination in, 430 symptoms of, 429 treatment of, 432 ligaments of, 59 lymphatics of, 56 malposition of, as a cause of protracted labor, 328 mode of action in labor, 245 mucous membrane of, 53 muscular fibres of, 52 nerves of, 57 [persistent intermittent contraction of, 141] regional division of, 50 relations of, 48 retroversion of gravid, 204 [rupture of, gastrotomy, 426] size of, at various periods of preg- nancy, 124 state of, in protracted labor, 327 structures composing, 51 rupture of, 419 alterations of tissues in, 421 ft INDEX 639 Jterus, rupture of — causes of, 421 comparative result of various methods of treatment in, 426 prognosis of, 424 seat of laceration in, 420 symptoms of, 423 treatment of, 424, 427 utricular glands of, 53 vessels of, 56 weight of, after delivery, 527 ilTAGINA, 45 f bands and cicatrices of, obstructing delivery, 343 contraction of, after delivery, 526 lacerations of, 427 orifice of, 43 structure of, 46 [Vaginismus, with double vagina, 58] Varicose veins in pregnancy, 201 iVectis, 482 action of, 482 cases in which it is applicable, 483 Veins, entrance of air into, as a cause of sudden death after delivery, 608 Venesection for rigidity of cervix, 340 Version. (.See Turning.) Vesico-uterine ligaments, 61 Vesico-vaginal fistula, 427 Vestibule, 42 Vicarious menstruation, 82 Vomiting in pregnancy, 184 Vulva, 41 condition of, after delivery, 528 oedema of, obstructing labor, 348 vascular supply of, 45 Vulvo-vaginal glands, 44 WARBURG'S tincture, 591 "Weaning. (See Lactation.) Wet-nurse, selection of, 537 Wolffian bodies, 57, 108 Wounds of the foetus, 226 ZONA pellucida, 68 Zymotic disease, affecting the foetus, 223 as a cause of septicaemia, 577 Cv X ^. ^ <^ ^ ■>-• ,,\ h >. %$ £ *+*. 4 aV -V W ^ v* '%. <^ -*> LIBRARY OF CONGRESS 022 216 254 3