J^i^' 
 
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 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT 
 
 Marion D. Harris
 
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 J^^^l^r^c^rt^uiU-^^ ty / JX/uyiyy^%y^iL <Q-Mi2^
 
 THE SCIENCE AND ART 
 
 OF 
 
 MIDAYIFEEY 
 
 BY 
 
 WILLIAM THOMPSON LUSK, M. D., LL. D. (Yale) 
 
 PROFESSOR OF OBSTETRU'S ANI) THE DISEASES OF WOMEN AND CHILDREN 
 
 IN THE BELLEVTE HOSPITAL MEDICAL COLLEGE 
 
 CONSULTING PHYSICIAN TO THE MATERNITY HOSPITAL AND TO THE FOUNDLING ASYLtJM 
 
 VISITING PHYSICIAN Tl > THE EMERGENCY HOSPITAL 
 
 GYN.ECOLOGIST TO THE BELLEVIE AND TO THE ST. VINCENT HOSPITALS 
 
 HONORARY FELLOW OF THE EDINBURGH AND THE LONDON OBSTETRICAL SOCIETIES 
 
 CORRESPONDING FELLOW OF THE OBSTETRICAL SOCIETIES OF PARIS AND LEIPSIC 
 
 CORRESPONDING FELLOW OF THE PARIS ACADEMY OF MEDICINE, ETC. 
 
 AEW EDITION, REVISED AXD ENLARGED 
 WITH NUMEROUS ILLUSTRATIONS 
 
 NEW YORK 
 D. APPLETON AND COMPANY 
 
 1899
 
 COPYRIGHT. 1881, 1885, 1892, 1P9C, 
 By D. APPLETON AND COMPANY. 
 
 Electrotvped and Printed 
 at the appleton press. u. s. a.
 
 AUSTIN FLINT, M.D., LL. D. 
 
 IN MEMORY OF MANY YEARS OF FRIENDSHIP 
 
 THIS BOOK IS DEDICATED 
 
 BY THE AUTHOR 
 
 I b 
 L.'?75'£
 
 PREFACE TO THE FOURTH EDITION. 
 
 The third edition of this work, pubhshed in 1885, Avas intended 
 to present to the reader a picture of the most advanced obstetrical 
 teachings of that date. In the brief interval, liowever, that has 
 elapsed since then the changes that have taken place in both the 
 theory and practice of obstetrics have made it necessary for me to 
 present to the profession what is essentially a new book. Thus 
 many modifications in the theory have resulted from more careful 
 observations in anatomy and pathology, and from fruitful physio- 
 logical investigations. It has been my endeavor to interweave 
 aseptic precautions with all branches of obstetric art without, how- 
 ever, insisting upon pedantic measures which experience has 
 shown to be needless. But the noblest conquests of the past years 
 have been the result of the employment of modern surgery for the 
 relief or removal of a host of complications formerly regarded as 
 beyond the pale of human help. 
 
 In making needed alterations I have not felt it obligatoi-y when 
 new discoveries have destroyed the value of former deductions to 
 retain these in order to maintain a reputation for consistency. 
 
 I thank the medical press and the medical profession of this 
 countr}^ and Great Britain for the flattering welcome they have 
 hitherto extended to this treatise, and trust that in its new form it 
 may connnand a like degree of favor. 
 
 For the preparation of the index special thanks are once more 
 due to my friend Dr. W. H. Flint, whose painstaking accuracy 
 will be evident to those who have occasion to consult these pages. 
 
 April 13, 1892,
 
 CONTENTS. 
 
 PHYSIOLOGICAL ANATOMY. 
 CHAPTER I. 
 
 PAGE 
 
 Female Organs of Generation . . , . , i 
 
 The pudendum. — Labia niajora. — Clitoris. — Labia minora. — Vestibule. — 
 The bulbs of the vestibule. — Meatus urethrje. — Sebaceous glands. — Mu- 
 cous glands. — Vaginal orifice. — Hymen. — Vagina. — Vessels of vagina. — 
 Uterus. — Fallopian tubes. — Ovaries. — Vessels of uterus and its append- 
 ages. — Nerves of uterus. — Lymphatics. — Development of the female or- 
 gans of generation. — Arrests of development. 
 
 PHYSIOLOGY OF THE OVUM. 
 
 CHAPTER II. 
 Development of the Ovum . . . . . .35 
 
 The Graafian follicles and the ovum. — Discharge of the ova from the ovary, 
 and the formation of the corpus luteum.^ — The migration of the ovum.— 
 Fecundation. — Changes taking place in the ovums ubsequent to fecunda- 
 tion. — Nourishment of the embryo. — The allantois and chorion. — The 
 decidu^. — The placenta ; its development and structure. — Formation of 
 the umbilical cord. — The amniotic fluid. 
 
 CHAPTER III. 
 Development of the Fcetus . . . . , .62 
 
 Development of the foetus in the successive months of pregnancy. — Fetal 
 circulation. — Fcetus at term. — Fetal ci'anium. — Attitude, presentation 
 and position of foetus. 
 
 PHYSIOLOGY OF PREGNANCY. 
 CHAPTER IV. 
 
 Changes Effected in the Maternal Organism by Pregnancy . 77 
 Changes in the sexual apparatus and neighboring organs. — Changes in the 
 uterus. — Explanation of apparent shortening of cervix. — Changes in the 
 vagina, vulva, abdomen, navel, breasts, nipple. — Functional disturbances 
 of bladder. — Constipation. — CICdema. — Changes effected in the entire or- 
 ganism. 
 
 CHAPTER V. 
 The Diagnosis of Pregnancy . . . . . .91 
 
 Signs of pregnancy. — Suppression of menses. — Nausea. — Salivation. — Breasts. 
 — Increase of abdomen. — Changes of the os and cervix. — Quickening. — 
 Ballottement. — Fetal heart-beat. — Uterine bruit. — Funic souffle. — Inter- 
 rogation of the patient. — Methods of physical examination. — Inspection 
 of abdomen. — Palpation. — Auscultation. — The vaginal touch. — Distinc- 
 tion between first and subsequent pregnancies. — Diagnosis of death of 
 foetus. — Duration of pregnancy. — Prediction of day of confinement from 
 date of last mensti'uation. — Date of quickening. — Size of uterus.
 
 viii CONTENTS. 
 
 PREGNANCY. 
 
 CHAPTER VI. p^g^ 
 
 The Management op Pregnancy . . . . .112 
 
 Hygiene of pregiiaiiey. — The disorders of pregnancy. — The blood-changes of 
 liregnatiey. — Pernicious anaemia. — Hydneinic oedema. — Varicose veins. 
 — Nausea and vomiting. — Keart-burn. — Insalivation. — Pruritus. — Face- 
 ache. — Cephalalgia. — insomnia. 
 
 LABOR. 
 
 CHAPTER Vn. 
 
 The Physiology op Labor and its Clinical Phenomena . . 123 
 
 Causes of labor. — Uterine contractions. — Action of labor-pains upon the 
 uterine walls. — Contraction of ligaments. — Action of abdominal muscles. 
 — Action of vagina. — The pain of labor. — General influence of labor- 
 pains upon the organism. — Precursory symptoms of labor. — First, second, 
 and third stages of labor. — Duration. — Action of the expellent forces. 
 
 CHAPTER Vin. 
 
 Mechanism op Labor . . . . . . .140 
 
 Anatomical factors. — Anatomy of pelvis. — Sacrum.- — Coccyx. — Ossa innomi- 
 nata — The ilia. — The pubes. — The ischia. — Articulations of the pelvis. — 
 Sacro-iliac articulations. — Symphysis pubis. — The pelvic ligaments. — Ob- 
 turator membrane. — Sacro-sciatic ligaments. — Inclination of the pelvis. 
 — The pelvis as a whole. — The pelvic planes. — Plane of the brim. — Plane 
 of the outlet. — Planes of the cavity. — Ischial planes. — Pelvic axis. — 
 Differences between male and female pelvis. — Differences between the in- 
 fantile and adult pelvis. — The soft parts of the pelvis. — The perineal 
 floor. — The head of the fa'tus at term.^Sutures and fontanelles. — The 
 diameters of the fetal head. — The articulation of the head with the 
 spinal column. 
 
 CHAPTER IX. 
 
 Mechanism of IuABOR.— {Continued.) . . . . .168 
 
 Presentations: natural, unnatural, normal.— Vertex presentations: frequency, 
 positions. — Manner in which head enters pelvis. — Positions, normal 
 mechanism of labor. — Descent and flexion. — Rotation. — Extension. — Ex- 
 ternal rotation. — Expulsion of the trunk. — Abnormal mechanism (vertex 
 presentations). — Mechanism of occipito-posterior positions. — Configura- 
 tion of the head in vertex presentations. — Molding. — Scal])-tumor. — Di- 
 agnosis of vertex presentations. 
 
 CHAPTER X. 
 
 Mechanism op Labor— (Conifmned.) ..... 184 
 Face presentations. — Frequency. — Causes. — Mechanism. — Descent and exten- 
 sion. — Rotation. — Flexion. — External Rotation. — Abnormal mechanism. 
 — Configuration of head. — Diagnosis. — Prognosis. — Treatment. — Brow 
 presentations. — Breech presentations. — Causes. — Diagnosis. — Mechan- 
 ism. — Irregular mechanism. — Configuration. — Prognosis. — Treatment. 
 
 CHAPTER XI. 
 
 Conduct op Normal Labor . . . . . .205 
 
 Preliminary preparations. — Examination of the patient. — Management of 
 the first stage. — Management of the second stage. — Preservation of the 
 perina?um. — Delivery of the shoulders. — Tying the cord. — Third or pla- 
 cental stage. — Care of patient after delivery. — Treatment of perineal 
 laeractions. — Amc-thetics in inidwiferv.
 
 CONTENTS. 
 
 IX 
 
 CHAPTER XII. 
 
 PAGE 
 
 Multiple Pregnancies and their Management . . . 228 
 
 Frequency. — Origin. — Varieties. — Acardia. — Weight. — Unequal development. 
 Superfetation. — Diagnosis. — Labor. — Presentations. — Simultaneous en- 
 trance of both children into the pelvis. — Locking. — Prognosis. — Conduct 
 of labor. 
 
 THE PUERPERAL STATE. 
 
 CHAPTER XIII. 
 
 The Physiology and Management of Childbed . . . 238 
 
 The puerperal state borders closely upon pathological conditions. — Post-par- 
 tum chill. — Temperature. — The pulse. — General functions. — Retention of 
 urine. — Loss of weight. — Involution. — Separation of the decidua. — Clos- 
 ure of the sinuses.— The cervix. — The vagina. — Position of uterus. 
 After-pains. — The lochia. — The secretion of milk. — Anatomical consider- 
 ations. — Milk-fever. — Composition of milk. — Diagnosis of the puerjieral 
 state. — The new-born infant. — Changes in circulation. — The navel. 
 Tumor upon the presenting part. — Digestion. — Skin. — Icterus. — Loss of 
 weight. — Management of puerperal state. — Sleep. — Passing nrine. — 
 Visits of physician. — Washing the vagina. — Diet. — Laxatives. — Nursing. 
 — Duration of lying-in period. — Care of new-born infant. — Bath. — Cord. 
 — Nursing. — Wet-nurses. — Artificial feeding. 
 
 THE PATHOLOGY OF PREGNANCY. 
 CHAPTER XIV. 
 
 Accidental Complications. — Abnormities of the Uterus. . 260 
 
 Variola. — • R-iiljeohi. -7- Scarlatina. — Scarlatina puerperalis. — Cholera. — Ty- 
 phus, typhoid, and relapsing fever. — Malarial fever. — Icterus. — Cai'diae 
 diseases. — Pneumonia. — Emphysema, chronic pleurisy, and empyema. — 
 Phthisis. — Syphilis. — Chorea. — Surgical operations during pregnancy. — 
 Double uterus. — Anteversion and anteflexion. — Retroversion. — Retroflex- 
 ion. — Prolapse of uterus and vagina. — Hernias. 
 
 CHAPTER XV. 
 Diseases of the Decidua. — Diseases of the Ovum . . . 284 
 
 Endometritis decidua: I. Chronica; 3. Tubersoa ; 3. Catarrhalis.— Anoma- 
 lies of the placenta. — Anomalies of form ; of position ; of development; 
 of circulation.— Placentitis. — Degenerations. — Syphilis. — Anomalies of 
 the amnion and of the amniotic fluid. — Hydramnion. — Deficiency of am- 
 niotic fluid. — Anomalies of the umbilical cord : torsion; knots; liernias; 
 coiling of the cord ; cysts ; stenoses of vessels ; marginal implantations. 
 — Hydatidiforra mole. 
 
 CHAPTER XVI. 
 The Premature Expulsion of the Ovum . . . .307 
 
 Causes of abortion. — Disposition to abortion. — Immediate causes. — Svmp- 
 toms. — Moles. — Incomplete abortions. — Diagnosis. — Prognosis. — Treat- 
 ment. — Prophylaxis. — Arrest of threatened abortion. — Treatment of in- 
 evitable abortion. — Treatment of neglected abortion. — Removal of fibri- 
 nous polypi. — Treatment of miscarriage. 
 
 CHAPTER XVII. 
 Extra-uterine Pregnancy ...... 327 
 
 Definition. — Tubal pregnnncy. — Pregnancy in rudimentary cornu. — Inter- 
 stitial pregnancy. — Tubo-abdominal and tubo-ovarian pregnancy.— 
 Ovarian pregnancy. — ALdominul pregnancy. — Symptoms. — Termina-
 
 X CONTENTS. 
 
 PAGE 
 
 tions. — Diagnosis. — Treatment in cases of early gestation. — Cases of ad- 
 vanced gestation (foetus living). — Cases of gestation prolonged after the 
 death of the foetus. 
 
 OBSTETRIC SURGERY. 
 CHAPTER XVIII. 
 
 The Induction of Premature Labor ..... 349 
 
 Induction of premature labor. — Indications. — Contracted pelvis. — Habitual 
 death of foetus. — Diseases which imperil the life of the mother. — Opera- 
 tion. — Catheterisatio uteri. — Intra-uterine injections.— Rupture of mem- 
 branes. — Mechanical dilatation of cervix. — Vaginal douches. — Tampon. 
 — Choice of methods. — Care of the child. — Artificial abortion. 
 
 CHAPTER XIX. 
 Forceps , . . . . . . . .361 
 
 History. — Vai'ieties of forceps; short forceps ; long forceps. — Action of for- 
 ceps. — Indications. — Preparations. — Forceps at outlet. — Operation ; in- 
 troduction ; locking ; tractions ; removal. — Forceps at brim ; operation. 
 — Axis-traction forceps. — Forceps in occipito-posterior positions ; in face 
 presentations. 
 
 CHAPTER XX. 
 
 Extraction in Foot and Breech Presentations . . . 382 
 
 Extraction in pelvic presentations. — Attitude of the physician. — Prognosis. 
 — Position. — Extraction of trunk.^Extraction by the feet ; by the breech. 
 — Management of the cord. — Liberation of "the arms. — Exceptional 
 cases. — Extraction of the head. — Smellie's method. — Veit's method. 
 Head at brim. — Prague method. — Forceps to the after-coming head. 
 
 CHAPTER XXI. 
 Version . . . . . . . . .400 
 
 Cephalic version. — External method. — Combined method. — Busch. — D'Ou- 
 trepont. — Wright. — Ilohl. — Braxton Hicks. — Podalic version. — Bipolar 
 method. — Internal version. — Neglected version. — Use of the fillet. 
 
 CHAPTER XXII. 
 Craniotomy and Embryotomy ...... 413 
 
 Craniotomy.— Indications. — Operation. — Perforators. — Method of perforating. 
 — Extraction after perforation. — Forceps.— Cephalotribe. — Action of the 
 cephalotribe. — Objections. — Application of the cephalotribe. — Crani- 
 oclast. — Crotchet and blunt hook. — Cephalotomy. — Embryotomy. — Ex- 
 enteration. — Decapitation. 
 
 CHAPTER XXIII 
 
 Cesarean Section.— Operations of Thomas and Porro . . 436 
 
 CsBsarean section. — History. — Indications. — Operation. — After-treatment. — 
 Prognosis. — Operation of Porro. — Operation of Thomas. 
 
 THE PATHOLOGY OF LABOR. 
 CHAPTER XXIV. 
 
 Anomalies of the Expellent Forces . . . .452 
 
 Precipitate labors. — Tardy labors. — Irregular pains in the first stage of labor. 
 — Treatment of protracted first stage. — Irregular pains in the second stage. 
 — Treatment of protracted second stage. — On the use of ergot in labor. — 
 Irregular pains in the third stage ; treatment. — Painful labors : from 
 
 i
 
 CONTENTS. xi 
 
 PAQB 
 
 hysteria; from rheumatism; from intestinal irritation; from inflamma- 
 tory changes. 
 
 CHAPTER XXV. 
 Contracted Pelves ....... 466 
 
 Varieties. — Frequency. — Diagnosis. — Pelvic measurements. — Forms of the 
 contracted pelvis. — Justo-rainor pelves. — Flattened non-rachitic pelves. — 
 Rachitic flattened pelves. — Generally contracted, flattened pelves. — Ir- 
 reg'jlar forms. — Pseudo-osteomalacia. — Scoliosis. — Kyphosis. — Influ- 
 ence of contracted pelves during pregnancy and labor. — Influence upon 
 tlie uterus. — Influence upon the presentation. — Influence upon the pains. 
 — Influence upon the first stage of labor. — Influence upon the mechan- 
 ism of labor. — Effects of pressure upon the maternal tissues. — Influence 
 upon the fetal head. — Effects of pressure upon the integuments ; upon 
 the cranium. — Prognosis. 
 
 CHAPTER XXVI. 
 
 Treatment of Contracted Pelves ..... 493 
 
 Cases of extreme pelvic contraction, rendering delivery per vias natnrales 
 impossible. — Cases indicating craniotomy or premature labor. — Cases 
 where extraction of a living child at term is possible. — Premature labor. 
 — Version. — Forceps. — Expectant treatment. 
 
 CHAPTER XXVn. 
 Rare Forms of Pelvic Distortion . . . . .514 
 
 The Naegele oblique pelvis : morbid anatomy, etiology, diagnosis, mechan- 
 ism of labor in, prognosis, treatment. — The kyphotic pelvis : morbid 
 anatomy, etiology, diagnosis, prognosis. — Scolio-rachitic pelvis: anatomi- 
 cal characters. — Robert's pelvis: anatomy, etiology, diagnosis, prognosis. 
 — Spondylolisthetic pelvis : anatomical characters, diagnosis, prognosis. 
 — Funnel-shaped pelvis. — Osteomalacia. — Pelvis narrowed by exostoses. 
 — Divided symphysis. 
 
 CHAPTER XXVIII. 
 Abnormities of the Sexual Organs ..... 535 
 
 Atresia of the genital canal. — Vulvar atresia. — Vaginal atresia. — Cystocele. — 
 Rectocele. — Retention of urine. — Impacted calculi. — Vaginal hernias. — 
 Cystic degeneration of the vaginal wall. — Vaginismus. — Echinococci. — 
 IJterine atresia. — Conglutinatio orificii externi. — Cicatrical atresia. — 
 Rigidity. — Thrombus of the cervix. — Symptoms of atresia. — Note on 
 treatment. — Tumors. — Fibroids. — Cancer.— Ovarian tumors. 
 
 CHAPTER XXIX. 
 
 Abnormities of the Fcetus which Offer an Obstruction to 
 
 Delivery ........ 5.^1 
 
 Premature ossification of the cranium. — Hydrocephalus. — Encephalocele. — 
 Ilydrothorax. — Ascites. — Other causes of abdominal distention. — Tumors 
 of the trunk. — Monstrosities. — Double monsters. — Acardiaci. — Anen- 
 cephalous monsters. — Abnormal positions. — Spontaneous version. — 
 Spontaneous evolution. 
 
 CHAPTER XXX. 
 Eclampsia . . . . . . . . .567 
 
 Definition. — Clinical history. — Prognosis, pathology, and etiology. — Treat- 
 ment. 
 
 CHAPTER XXXI. 
 
 Post-partum hemorrhage and Retained Placenta . . 581 
 
 Normal agencies for checking haemorrhage. — Disturbances of contractility, of 
 retractility, of thrombus formation. — Treatment. — Method of securing
 
 xii CONTENTS. 
 
 PAGE 
 
 contraction and retraction. — Treatment of cerebral anasmia. — Retained 
 placenta. 
 
 CHAPTER XXXII. 
 
 Placenta Previa.— Accidental, Hemorrhage.— Inversion of the 
 
 Uterus ........ 594 
 
 Situation. — Varieties. — Frequency. — Causes of hfemorrhage. — Clinical feat- 
 ures. — Prognosis. — Diagnosis. — Treatment. — Accidental haemorrhage. — 
 Inversion of the uterus. 
 
 CHAPTER XXXIII. 
 
 Ruptures of the Genital Canal ..... 610 
 
 Rupture of tlie uterus. — Etiology.— Pathological anatomy. — Symptoms and 
 diagnosis. — Treatment. — Prophylaxis. — Treatment after ru{)ture. — Rupt- 
 ure limited to the peritoneal covering of the uterus. — Perforation from 
 pressure. — Lacerations of the vaginal portion. — Laceration of the vagina. 
 — Laceration of the vulva. — Thrombus of the vulva and vagina. — 
 Rupture of the pelvic articulations. 
 
 CHAPTER XXXIV 
 
 Prolapse of the Funis, etc. . . . . . .629 
 
 Prolapsed funis. — Asphyxia neonatorum. — Collapse and sudden death during 
 labor and childbed from thrombosis, from embolism, and from entrance 
 of air into the circulation. — On the extraction of the child in case of 
 death of the mother in pregnancy or labor. — Tympanites uteri. 
 
 DISEASES OF CHILDBED. 
 
 CHAPTER XXXV. 
 Puerperal Fever . . . . . . .653 
 
 Definition. — Frequency. — Morbid anatomy. — Endometritis and endocolpitis. 
 — Metritis and parametritis. — Pelvic and diffused peritonitis. — Plilebitis 
 and phlebothrombosis. — Septicaemia. — Earlier views concerning the 
 nature of puerperal fever. — The nature of puerperal fever as regarded 
 from the standpoint of modern investigation. — General symptoms. — 
 The symptoms of endometritis and endocolpitis ; of parametritis and 
 perimetritis; of general peritonitis; of septicaemia lymphatica; of se])- 
 tica^mia venosa ; of pure septicajmia. 
 
 CHAPTER XXXVI. 
 
 Puerperal Fkykr.— (Continued.) . . . . .681 
 
 Causes. — The atmosphere. — Inoculation. — Season of the year. — Social state. 
 — Relations to zymotic diseases. — The prevention of puerperal fever. — 
 Treatment. — Vaginal and uterine injections. — Iodoform bacilli ; opium ; 
 leeches; stapes; laxatives; quinine; salicylate of sodium; Warburg's 
 tincture; veratrum viride; digitalis; antipyrine ; alcohol ; cold. — Treat- 
 ment of peritoneal effusions and inflammatoi'v exudations. 
 
 CHAPTER XXXVII. 
 
 Puerperal Insanity. — Phlegmasia Alba Dolens. — Diseases of 
 
 the Breasts . . . . . . .701 
 
 The insanity of pregnancy, of childbed, of lactation. — Phlegmasia allja 
 dolens. — Defective milk secretion. — Galactorrlioea. — Sore nipples. — Sub- 
 cutaneous inflammation of the breast. — Submammary abscess. — Paren- 
 chymatous mastitis. — Galactocele. — Prophylaxis of ophthalmia neona- 
 torum. 
 
 APPENDIX. 
 
 Symphysiotomy ........ 713
 
 LIST OF ILLUSTRATIONS. 
 
 FIOrRE PAGE 
 
 1. The external parts of generation (in the virgin). (Sappey.) .... 2 
 
 2. Lateral view of the erectile structures of the external organs of the female 
 
 (from Kobelt), two thirds 3 
 
 3. Front view of the erectile structures of the external organs of the female 
 
 (Kobelt.) 4 
 
 4. Vulva of a woman who has borne children. (Sappey.) .... 6 
 
 5. Section through the female pelvis. (Kohlrausch, modified by Spiegeiberg.) 8 
 
 6. Complete genital organs of the female. (Beigel.) 11 
 
 7. Virgin uterus. (Sappey.) 12 
 
 8. Multiparous uterus. (Sappey.) 13 
 
 9. Virgin uterus opened posteriorly. (Bandl.) 14 
 
 10. Uterus of a woman who has borne children. (Bandl.) 15 
 
 11. Section through the mucous membrane of a normal virgin uterus, magni- 
 
 fied about forty diameters. (Kundrat and Engelmanu.) . . . .17 
 
 12. Section through uterus, showing cavity. (Wel)er.) 18 
 
 13. Posterior lateral view of the uterus, with portion of lig. latum, oviduct, and 
 
 ovary. (Henle.) 20 
 
 14. Section thi'ough Fallopian tube. (Richard.) 20 
 
 15. Section through ampulla (thirty diameters). (Luschka.) . . . .21 
 
 16. Longitudinal section of ovary from a person aged eighteen (eight diame- 
 
 ters). (Henle.) 22 
 
 17. Arterial vessels in a uterus ten days after delivery. (Luschka.) . . .24 
 
 18. Uterine and utcro-ovarian veins (plexus pampiniformis). (Sappey.) . . 25 
 
 19. Nerves of the uterus. (Frankenhaeuser.) 28 
 
 20. Rudimentary sexual organs. (Luschka.) 29 
 
 21. Uterus and its appendages in the foetus at the end of the fourth month (nat- 
 
 ural size). (Courty.) 29 
 
 22. (Jterus unicornis from a young child, posterior aspect. (Pole.) . . .30 
 
 23. Double uterus and vagina from a girl aged nineteen. (Eiseumann.) . . 31 
 
 24. Uterus oicornis, double cavity and double vagina, from a girl seventeen 
 
 years of age. (Schroeder.) 32 
 
 25. Uterus cordiformis, double natural size. (Kussmaul.) 33 
 
 26. Uterus septus bilocularis. (Cruveilhier.) 33 
 
 27. Uterus semi-partitus. (Gravel.) 34 
 
 28. Section of Wolffian body, with rudimentary ovary (embryo of chick, fourth 
 
 day of incubation). (VValdeyer.) 35 
 
 29. Section through portion of the ovary of mammal. (Wiedersheim.) . . 36 
 
 30. Sagittal section of the ovary of an adult bitch (after Waldeyei'). . . .37 
 
 31. Spermatozoa from the human subject (magnified eight hundred diameters). 
 
 (Luschka.) 43
 
 xjy LIST OF ILLUSTRATIONS. 
 
 FIGURE 
 
 PACK 
 
 32. Ovum of the nephelis vulgaris, showing retraction of vitellus and the pene- 
 tration of the spermatozoa through the vitelline membrane (magnified 
 
 three hundred diameters). (Robin.) 44 
 
 38. Fertilization of ovum of a moUusk (Elysia viridis) 45 
 
 34. Formation of the blastodermic vesicle. (Van Beneden.) . . . .46 
 
 35. Diagrammatic section (Iladdon) of mammalian blastoderm. . . . 47 
 
 36. Surface view of area pellucida of hen's egg, after eighteen hours of incuba- 
 
 tion. (Balfour.) 47 
 
 37. Dorsal view of embryonic area of blastoderm of chick 48 
 
 38. Transverse section through the embryo of the chick, a few hours after the 
 
 conmiencement of incubation 48 
 
 39. Diagram representing transverse section through the embryo of a chick, at 
 
 the end of the first day of incubation 48 
 
 40. Transverse section through the embryo of a chick, on the second day of in- 
 
 cubation (magnified one hundred diameters). . . , . 49 
 
 41. Section through the ovum of chick, after the development of umbilical 
 
 vesicle 49 
 
 42. Diagram showing early stage in development of amnion 51 
 
 43. Diagram showing completion of the amnion and formation of the chorion . 51 
 
 44. Human embryo at the third week, showing villi covering the entire cho- 
 
 rion. (Haeckel.) , 52 
 
 45. Diagram showing the exochorion ; endochorion; umbilical vesicle ; amnion 
 
 and pedicle of allantois 52 
 
 46. Diagram showing the formation of the decidua, first stage . . . .53 
 
 47. Diagram showing the formation of the decidua completed . . . .54 
 
 48. Diagram showing the branching of the villi and the connection of the 
 
 larger trunks with the placenta 56 
 
 49. Diagram oi uterus and placenta in the fifth month 58 
 
 50. Diagram of the umbilical arteries and vein. (Tarnier and Chantreuil.) . 60 
 
 51. Human germs or embryos from the second to the fifteenth week (natural 
 
 size). (Principally after Ecker.) 63 
 
 52. Diagram of the fetal circulation. (Flint.) 67 
 
 53. Fetal skull, seen from the side. (J. Veit.) 71 
 
 54. Fetal skull, seen from above. (J. Veit.) 71 
 
 55. Attitude of foetus in utero. (Tarnier and Chantreuil.) .... 73 
 
 56. Lower segment of uterus, sixth month of pregnancy. ^Hofmeier.) . . 79 
 
 57. Diagram showing apparent shortening of cervical cannl . . . .83 
 
 58. Uterus from a multipara who died in the last montii of pregnancy, showing 
 
 cervix of normal length, with membranes adherent to the os internum. 
 
 (Bellevue Hospital.) 86 
 
 59. Diagram for computing pregnancy. (Schultze.) 109 
 
 60. Schultze diagram 110 
 
 61. Diagram showing the mucous membrane of the uterus 125 
 
 62. Diagram showing shape of uterus during a 7)ain. (Lahs.) .... 128 
 
 63. Diagram showing elevation of fundus during a pain. (Lahs.) . . . 128 
 
 64. Diagram showing the changes in the thickness of the uterine walls during 
 
 labor. (Lahs.) 129 
 
 65. Section through a frozen corpse. Stage of expulsion. (Braune.) . , 132 
 
 66. The uterus and parturient canal. Foetus removed. (Braune.) . . . 133 
 
 67. Longitudinal section through walls of uterus in eighth month of pregnancy. 
 
 (Bandl.) 137 
 
 68. Sacrum and coccyx (anterior surface.) 141
 
 LIST OF ILLUSTRATIONS. 
 
 XV 
 
 FIGURE PAGE 
 
 69. Section of sacrum and coccyx 142 
 
 70. Os innominatum, before consolidation 143 
 
 71. Outer surface of os innominatum 143 
 
 72. Inner surface of OS innominatum . . . 144 
 
 73. Section through the left sacro-iliac articulation (natural size). (Luschka.) 145 
 
 74. Section of symphysis. (Luschka.) 14(5 
 
 75. Front view of pelvis, with ligaments. (Quain.) 146 
 
 76. Transverse section through pelvis, to show the sacro-seiatic ligaments. 
 
 (Tarnier and C'hantreuil.) . 147 
 
 77. Section showing the inclination of the pelvis according to Naegele. (Tar- 
 
 nier and Chantreuil.) 148 
 
 78. Diagram showing oscillatory movements of sacrum. (Duncan.) . . 149 
 
 79. Anterior half of the pelvis 149 
 
 80. Posterior half of the pelvis 150 
 
 81. Diameters of the brim 151 
 
 82. Diameters of the outlet 151 
 
 83. Section showing the inclination of the pelvis according to Naegele. (Tar- 
 
 nier and Chantreuil ) 152 
 
 84. Axis represented upon a vertical section through a plaster cast of the pel- 
 
 vic cavity. (Hodge.) 153 
 
 85. Vertical section of a female infantile pelvis. (Fehling.) .... 154 
 
 86. 87. Diagrammatic representations of sections through the infantile and 
 
 adult pelves. (Schroeder.) 155 
 
 88. Pelvis covered with the soft parts, with removal of bladder, uterus, and 
 
 rectum 157 
 
 89. Section of pelvis, showing the pyriform muscles. (Tarnier and Chan- 
 
 treuil.) . . . • 158 
 
 90. Section of pelvis, showing the internal obturator muscle. (Tarnier and 
 
 Chantreuil.) 159 
 
 91. The levator-ani muscle, as seen from above. (Dickinson.) .... 160 
 
 92. The levator, seen from the side, when the ischium is removed. (Redrawn 
 
 from Luschka by Dickinson.) 161 
 
 93. Antero-posterior section of the perineal floor. (Tarnier and Chantreuil.) 162 
 
 94. Muscles of the perinaeum. (Henle.) 163 
 
 95. The parturient canal. (Hodge.) 164 
 
 96. Lateral view of fetal skull. (Hodge.) 165 
 
 97. Fetal head, as seen from above. (Hodge.) 165 
 
 98. Antero-posterior and vertical dia:neters of the fetal head. (Tarnier and 
 
 Chantreuil.) 167 
 
 99. Vertex presentation ; child surrounded by amniotic fluid. (Pinard.) . 172 
 
 100. Figure illustrating the mechanism of labor in occipito-anterior deliveries. 
 
 (After Schultze.) 174 
 
 101. Attitude of fcetus. (Tarnier and Chantreuil.) 176 
 
 102. Figure illustrating the mechanism of labor in oecipito-posterior positions. 
 
 (After Schultze.) 179 
 
 103. Outlines showing diflference between head of child at birth and four days 
 
 subsequent to delivery. (Budin.) 180 
 
 104. Figure showing shape of head in oecipito-posterior deliveries. (Tarnier 
 
 and Chantreuil.) 181 
 
 105. Method of performing external palpation. (Pinard.) 182 
 
 106. Attitude of head in face presentations. (Ribemont.) 186 
 
 107. Engagement of the head in face presentations. (Tarnier and Chantreuil.) 187
 
 j^^j LIST OF ILLUSTRATIONS. 
 
 FIGURE 
 
 PAGB 
 
 108. Mechanism of face presentations. (Schultze.) 188 
 
 109. Face presentation, chin to the rear. (Hodge.) 189 
 
 110. Outline of head born with face presenting 190 
 
 111. Same head five days later. (Builin.) 190 
 
 112-114. Diagrams showing Schatz's method of converting face presentations 
 
 into vertex presentations 193 
 
 115. Outline of head after delivery, the brow presenting. (Budin.). . .194 
 
 116. Brow presentation, subsequently converted into that of the face. (Mater- 
 
 nity Hospital.) 195 
 
 117. Presentation of the breech. Left dorso-anterior position. (Pinard.) . 198 
 
 118. Showing lateral inflexion of the trunk during delivery of the breech. . 200 
 
 119. Exit of head in breech presentations. Face covered by perinjeum. (Fara- 
 
 boeuf and Varnier.) 201 
 
 120. Exit of head in breech presentations 203 
 
 121. Showing shape of head in breech presentations. (Budin.) .... 203 
 
 122. Expression of the placenta. (Crede.) 220 
 
 123. Descent of the placenta according to Schultze 222 
 
 124. Showing normal descent of placenta. (Duncan.) 223 
 
 125. Twin placenta, showing arterial anastomosis 229 
 
 126. Author's case of acardia 230 
 
 127. Twin pregnancy, both heads presenting. (Tarnier and Chantreuil.) . 233 
 
 128. Twin pregnancy, head and breech presenting. (Tarnier and Chantreuil.) 235 
 
 129. Mammary gland. (Liegeois.) 246 
 
 130. Section through acinus from breast of a nursing woman. (Billroth.) . 248 
 
 131. Torsion of the cord. (Schauta.) 294 
 
 132. Knot of umbilical cord. (Leyman.) 295 
 
 133. Insertio velamentosa. (Lobstein.) 297 
 
 134. Specimen from hydatidiform mole, in the Wood Museum .... 299 
 lb5. Ovum, with imperfectly developed decidua; outer surface of vera. (Dun- 
 can.) 309 
 
 136. Uterus with basis of a fibi'inous polypus, after an abortion. (Frankel.) 314 
 
 137. Intraperitoneal rupture of tube 329 
 
 138. Rupture of tube between the folds of the broad ligament .... 330 
 
 139. Pregnancy in rudimentary cornu. (Kiissmaul, observed by Heyfelder.) 332 
 
 140. Interstitial pregnancy. (Hennig.) 333 
 
 141. Bifurcation of tubal canal. (Hennig.) 334 
 
 142. Crede's apparatus for the maintenance of the body-heat of premature and 
 
 feeble infants 357 
 
 143. Section of hospital incubator. (Tarnier.) 358 
 
 144. Forceps of Chamberlen 362 
 
 145. Forceps of Smellie 3fi2 
 
 146. Levret's forceps 3(j3 
 
 147. Naegele's forceps 364 
 
 148. Simpson's forceps 365 
 
 149. Hodge's forceps 365 
 
 150. Introduction of blades 37O 
 
 151. Blades of the Tarnier forceps adjusted to the sides of the head at outlet. 
 
 (Faraboeuf and Varnier.) 37I 
 
 152. IMethod of making tractions 373 
 
 153. Position of operator when head is on perinaeum 374 
 
 154. Forceps applied to head at brim 375 
 
 155. Taylor's narrow-bladed forceps 376
 
 LIST OF ILLUSTRATIONS. 
 
 xvii 
 
 FIGURE PAGE 
 
 150. Author's modification of Tarnier's forceps 378 
 
 157. Occipito-posterior position. Traction in a downward direction, to secure 
 
 the descent of the head beneath the pubic arch. (Farabceuf and Var- 
 nier.) 380 
 
 158. Occipito-post«rior position. Elevation of handle of forceps, to aid the ro- 
 
 tation of the occiput over the perina'uin. (Farabanif and Yarnier.) . 380 
 
 159. Taylor's method in mento-posterior positions of the face .... 383 
 
 160. Method of seizing the breech 385 
 
 161. Method of seizing both extremities 387 
 
 162. Tarnier forceps applied to the thighs. (Ollivier.) 389 
 
 163. The fillet, in dorso-anterior position. (Ollivier.) 390 
 
 164. The fillet in dorso-posterior position. (Ollivier.) 391 
 
 165. Porte-fillet. (Ollivier.) 393 
 
 166. Combined traction upon mouth and shoulders. (Farabceuf and Varnier.) 397 
 
 167. The method of extraction by the Prague method 398 
 
 168. The Prague method of extracting the head 399 
 
 169. Chin arrested at symphysis. (Chailly-Honore.) 400 
 
 170. D'Outrepont's method, modified by Scanzoni 402 
 
 171. Version in head presentations. (Chailly-Honore.) 406 
 
 172. Version in dorso-anterior position, first stage. (Farabceuf and Varnier.) 408 
 
 173. Version in dorso-anterior position, second stage. (Farabceuf and Var- 
 
 nier.) 409 
 
 174. Version in dorso-posterior [tosition. (FarabciMif and Varnier.) . . . 410 
 
 175. Method of seizing the foot, in lireccli cases. (Farabceuf and Varnier.) . 411 
 
 176. Braun's repositor 412 
 
 177. Catheter used as a re])ositor 412 
 
 178. Scissors of Smellie 415 
 
 179. Simpson's perforator 415 
 
 180. Blot's perforator 415 
 
 181. Hodge's craniotomy scissors 415 
 
 182. Thomas's perforator 416 
 
 183. Simpson's basylist ' . 416 
 
 184. Trephine perforator 416 
 
 185. Operation for perforating the child's head 417 
 
 186. Cephalotribe of Blot 421 
 
 187. Cephalotribe of Scanzoni 421 
 
 188. The author's cephalotril)e 422 
 
 189. Simpson's cranioclast 426 
 
 190. Braun's cranioclast 427 
 
 191. Head of child after delivery with the cranioclast. (Simpson.) . . . 427 
 
 192. ;Meigs's craniotomy forceps (modified by Professor I. E. Taylor.) . . 429 
 
 193. Crotchet ' 429 
 
 194. Dr. Taylor's right-angled blunt hook 430 
 
 195. Segment removed by the Tarnier forceps-saw. (P. Thomas.) . . .431 
 
 196. Braun's decapitating hook 432 
 
 197. Braun's method of decapitation 433 
 
 198. Embryotome of P. Thomas 434 
 
 199. Embryotome adjusted around the neck of the child 435 
 
 200. Baudelocque's pelvimeter 467 
 
 201. Schultze's pelvimeter 468 
 
 202. Normal inclination of the symphysis pubis. (Spiegelberg.) . . . 470 
 20.3. Diminution of angle between symphysis and pelvic brim .... 470
 
 LIST OF ILLUSTRATIONS. 
 XVlll 
 
 PAGK 
 FIGURE . 
 
 204. Increase of angle between symphysis ami pelvic bnm 4<U 
 
 205. Specitnens from the Wood Museum (Bellevue Hospital). No. 1, Normal 
 
 pelvis. No. 2. Justo-minor pelvis 473 
 
 206. Flattened rachitic pelvis. (Wood's Museum.) 475 
 
 207. Small symmetrical I'achitic pelvis. (Wood's Museum.) . . . .478 
 
 208. Pseudo-osteomalacia. (Naegele.) 478 
 
 209. Scoliosis, (Litzmann.) 479 
 
 210. Pressure-mark upon skull. (Dohrn.) 490 
 
 211. Base of skull ^ •'•04 
 
 212. Method of applying suprapubic pressure. (Munde.) G05 
 
 213. Naegele oblique pelvis. (From specimen in the Wood Museum.) . . 515 
 
 214. Specimen of kyphotic pelvis. (Litzmann.) 519 
 
 215. Specimen of scolio-rachitic pelvis. (Litzmann.) 522 
 
 21G. Kobert's pelvis. (Lambl.) 523 
 
 217. Spondylolisthetic pelvis. (Kilian.) 525 
 
 •218. Osteomalacia. (Specimen from Wood's Museum.) 530 
 
 219. Osseous tumors filling pelvic cavity. (Naegele.) 533 
 
 230. Autiior's case of acardia 558 
 
 231. Neglected shoulder presentation. (Chiara.) 565 
 
 222. Birth with doubled body. (Kleinwachter.) 566 
 
 233. Diagram showing a relaxed and a contracted uterus 583 
 
 224. Bimanual compression of uterus. (Breisky.) 586 
 
 225. Diagram showing unavoidable placental separation as a consequence of 
 
 cervical dilatation 597 
 
 226. Inversion of uterus 608 
 
 237. First stage of replacement 609 
 
 237a. Second stage of replacement 609 
 
 228. Diagram showing dangerous thinning of lower segment, owing to the non- 
 
 descent of the head in contracted pelvis. (Bandl.) 611 
 
 229. Case of ruptured uterus 613 
 
 230. Retraction in a case of shoulder presentation. (Bandl.) .... 617 
 
 231. Robertson's repositor 634 
 
 232. Specimens of micrococci 665 
 
 233. Diagram showing that the sacrum forms the key to the pelvic arch. 
 
 (Faraboeuf.) " 719 
 
 234. Ijateral view of sacrum. (Faraboeuf.) 720 
 
 235. Tiie sacral articular surface. (Faraboeuf.) , 731 
 
 236. Diagram showing the axis of rotation for the ilium after symphysiotomy. 
 
 (Faraboeuf.) 723 
 
 237. Illustration showing the detachment of the periosteum from the ilium 
 
 due to separation of the pubip bones. (Faraboeuf.) .... 733 
 
 238. Farabceuf's method of fixing the ilium to the sacrum 734 
 
 239. Diagram showing gain to pelvic space due to symphysiotomy. (Fara- 
 
 boeuf.) ' 727 
 
 240. Frontal section through symphysis in early life. (Faraboeuf.) . . . 727 
 
 241. Transverse section thi'ough symphysis near puberty. (Faraboeuf.) . . 727 
 
 242. Transverse and sagittal sections through symphysis in a young woman. 
 
 (Faraboeuf.) 727 
 
 243. The anterior aspect of the symphysis. (Faraboeuf.) 728 
 
 244. Median section through the fibro-cartilaginous plug between the pubic 
 
 bones. (Faraboeuf.) 729 
 
 245. The symphysis, and deep portions of the vulvar region. (Faraboeuf.) . 730
 
 LIST OF ILLUSTRATIONS. xix 
 
 PIGITRE PAOE 
 
 24G. The vessels upon the inner surface of the pubes. (Faraboeui.) , . . 733 
 
 247. Anterior surface of inflated bladder. (^Farabccuf.) 733 
 
 248. Veins behind the synipiiysis and veins of the bladder. (Faraboeuf.) . . 784 
 
 249. Division of suspensory lijjainent of clitoris. (Faraboeuf.) .... 737 
 
 250. The pubic arch after division of the suspensory ligauient. (FarabcEuf.) . 738 
 
 251. Incision of the perichondrium with scalpel. (Farabanit.) .... 739 
 253. Extension of incision with scissors. (Fai'aboeuf.) 739 
 
 253. Introduction of finger and grooved guard by the supra-pubic route. (F'ara- 
 
 boeuf.) 740 
 
 254. Knife of Faraboeuf 740 
 
 255. The grooved guard introduced from below behind the pubis. (Faraboeuf.) 741 
 250. Division of the syinpiiysis. (Faraboeuf.) 743 
 
 257. Introduction of sutures. (Faraboeuf.) 744 
 
 258. Tying the sutures while the bones are held in place by Faraboeuf's fixation 
 
 forceps 745 
 
 PLATE PACING PAGE 
 
 I. Section through pelvic organs of multipara, ad nafuram. (Freund.) . . 8 
 II. Fig. 1. Deutoplasm-fonning ovum from a Graafian follicle ^ 
 of a woman twenty-seven years old. I 
 
 Fig. 3. Fresh ovum from Graafian follicle of a woman j (^^S^^-f • ^^ 
 thirty years old. J 
 
 III. Fig. 1. Human embryo at the ninth week. [ (Erdl ) . . 53 
 Fig. 3. Human embryo at the twelfth week. J 
 
 IV. Microscopic sections in puerperal endometritis. (Bumra.) .... 667
 
 THE 
 
 SCIEiNCE AND ART OF MIDWIFERY. 
 
 PHYSIOLOGICAL AXATOMY. 
 
 CHAPTER I. 
 
 FE3IALE ORGANS OF OENERATION. 
 
 The pudendum. — Labia majora. — Clitoris. — Labia minora. — Vestibule. — The bulbs 
 of the vestibule. — Meatus urethra). — Sebaceous glands. — Mucous glands. — 
 Vaginal orifice. — Hymen. — Vagina. — Vessels of vagina. — Uterus. — Fallopian 
 tubes. — Ovaries. — Vessels of uterus and its appendages. — Nerves of uterus. — 
 Lymphatics. — Development of the female organs of generation. — Arrests of 
 development. 
 
 The female organs of generation may be properly divided as fol- 
 lows: 1. The external parts, or pudendum, and the vagina. 2. The 
 uterus, Fallopian tubes, and ovaries. 
 
 The external parts and vagina are chiefly concerned in the act of 
 copulation. As they likewise constitute the channel through which 
 the child passes during parturition, a knowledge of their anatomical 
 structure becomes of importance to those who would practice the ob- 
 stetric branch of medicine. 
 
 The internal organs, i. e., the uterus. Fallopian tubes, and ovaries, 
 assume obstetrical importance in connection with the parts they play 
 in gestation. Thus, the ovary furnishes the germ from which the 
 new being is developed. The Fallopian tube receives the germ, and 
 conveys it to the uterus. In the uterus, the fecundated germ obtains 
 the nutritive materials necessary for its subsequent growth and devel- 
 opment. 
 
 1. The ExTERisTAL Parts of GrE]s^EEATioN' and Vagina. 
 
 The Pudendum. — The pudendum comprises all those parts which 
 are perceptible externally. It includes the mons Veneris, the labia, 
 the clitoris, the nymphge, and the hymen. It is situated at the lower
 
 PHYSIOLOGICAL ANATOMY. 
 
 opening of the pelvis, and has a wedge-shape, whence the term cunmis, 
 i. e., cunens. Its base is formed by the mons Veneris, a fatty cushion, 
 abundantly supplied with hair, which covers the symphysis pubis. As 
 it follows the curvature of the lower portion of the trunk, in extreme 
 inclination of the pelvis it is sometimes directed so far backward as to 
 render difficult the introduction of the speculum and tlie accomplish- 
 ment of tlie sexual act. It is di- 
 
 hf 4-^^ 
 
 ^.- A- 
 
 
 y^^ 
 
 -i 
 
 vided in the median line by the 
 rima piidendi, which extends from 
 the mons Veneris to the peri- 
 na^um. Upon each side of the 
 rima there are two longitudinal, 
 slightly curved, and rounded folds 
 of integument, which rest upon 
 cushions of adipose areolar tissue. 
 These folds constitute the so-called 
 lahia majora, which, like the mons 
 Veneris, are covered, though to a 
 less extent, with hair. In healthy 
 young women they are firm and 
 full, while in deteriorated consti- 
 tutions, and in advanced life, they 
 become wrinkled and jiendulous, 
 from diminution of the adipose 
 tissue. 
 
 The labia majora act as a sort 
 of valve, Avhich closes the orifice 
 of the vagina, whence the term 
 vulva — i. e., valva, the folding- 
 door of the ancients. When the 
 labia are full and well rounded, 
 they are approximated closely to- 
 gether, and form the vulva coji- 
 nivens. With the loss of adipose 
 tissue, a gaping of the flaccid labia 
 ensues, and forms the vulva Jiiaus. 
 The labia offer an external and internal surface. The outer surface 
 presents the usual characteristics of tegumentary tissue, and is abun- 
 dantly supplied with large sebaceous glands. The inner surface is in 
 all respects like a mucous membrane, except that it possesses seba- 
 ceous glands in place of mucous follicles. The subcutaneous tissue 
 is composed of connective tissue, rich in elastic elements, and con- 
 taining fatty lobules continuous with the underlying adipose structure. 
 It furnishes support to an abundant venous jilexus, to which the 
 turgescence of the labia in pruritu, and under sexual excitement, is 
 
 Fig. 1.— The external parts of generation (in 
 the virgin). 1, labium majus ; 2, four- 
 chette ; 3, the nynipha ; 4, glans clitoridis ; 
 5, meatus urethrae ; 6, vestibule ; 7, orifice 
 of vagina ; 8, hynaen ; 9, orifice of the 
 glands of Duverney ; 10, anal orifice. 
 (Sappey.)
 
 FKMALK ORGANS OF (FENERATION. 
 
 mainly duo. Tlu- existence of contractile elements has never been 
 demonstrated. 
 
 The two extremities of the vidva have been designated, res])ect- 
 iveh', the (interior and 2^of<terior commiissures of the labia ; but tliese 
 terms, so far as they convey the idea of connecting bands between the 
 labia, are incorrect, for Luschka* 
 has shown that the labia are directly 
 continnous with the jnons Veneris 
 in front and the })erin(eum behind. 
 
 The ditoris is a small, elongated 
 body, situated beneath the so-called 
 anterior commissnre. It resembles 
 the i^enis in form and structure, but 
 differs in possessing neither corpus 
 spongiosum nor urethra. The cli- 
 toris is divided into the crura, the 
 corpus, and the glans. The crura 
 are long, spindle-shaped processes, 
 attached to the borders of the as- 
 cending rami of the ischia and the 
 descending rami of the pubis. The 
 corpus is formed by the junction of 
 tlie crura in the median line, just 
 beneath the pubic arch. Even in a 
 state of extreme erection, it does not 
 normally exceed an inch in length. 
 The glans is the rounded, imper- 
 forate extremity. During erection 
 
 it attains the dimensions of a small pea. The cuticular covering of 
 the glans is of a pale-red color, and is covered with papillae, part of 
 which contain vessels, and part, nerA-e-endings similar to those found 
 in the nipple, and termed by Krause "terminal bulbs" [End-Kolhen). 
 The nerves of the clitoris are more fully develoi^ed than the cor- 
 responding nerves in the penis. The clitoris is regarded as the seat 
 of the voluptuous sensations experienced by the female during copu- 
 lation. 
 
 The labia^ minora are twoiuirrow, reddish, moist folds of mucous 
 membrane, situated between the labia majora, Avith which they are 
 continuous by their outer surface. The inner surface is continuous 
 Avith the mucous membrane of the vestibulum. The\' are, sometimes, 
 termed likewise the nyniphm. XymphcB vocantur vd quod sint casti- 
 tatis prmsides, vd (juod xponsum, prima internLittant, vd quod aquis 
 prosilientihus prcBsint (P]azzonus),f or, as Sir Charles Bell words it 
 
 * LcscHKA, Die Anatoinie des menschliclieii Beckens, p. 407. 
 f Und., Tiibingen, 18G4, p. 408. 
 
 Fir:. •,'. Lateral view of tlie erectile struct- 
 ures of the external organs of the fe- 
 male (from Kobelt), two thirds. The 
 l)loo(l-vessels have i)eeii injected, , and 
 the skin and mucous membrane have 
 been removed, n, bulbus vestibuli ; c, 
 Iilexiis of veins, named the pars inter- 
 media ; e, glans clitoridis ; /, corpus 
 clitoridis ; h, ilorsal vein ; I, right crus 
 clitoridis ; j/i, v'estil)ulum ; »i, rightgland 
 of Barthohn or Duvernev.
 
 4 PHYSIOLOGICAL ANATOMY. 
 
 in his Anatomy, " The most modest of the uses ascribed to them is 
 that of directing the stream of urine." Wlien the rima pudendi is 
 narrow, as in virgins, the labia minora are concealed and protected by 
 the labia majora. In the vulva hians, the labia minora acquire, from 
 exposure to the atmosphere, a dirty-bluish color, and take on the prop- 
 erties of the cutis. In Hottentot and Bushman women, they some- 
 times reach the length of eight inches, and constitute the so-called 
 " Hottentot apron." 
 
 Each labium minus splits anteriorly into two folds, of which the 
 outer joins the corresponding one of the opposite side to form a cover 
 for the clitoris, the prcBinitimn clitor'idis. The lower folds converge 
 to meet beneath the lower border of the glans clitoridis, and form the 
 frenuluDi of the clitoris. This attachment serves to bring the clitoris 
 forward into contact with the penis, as the labia minora are pressed 
 inward during copulation. 
 
 The labia minora meet posteriorly, in most instances, and form a 
 thin circular band, the frenulnm vulvce ox fourchette. The fourchette 
 has usually been regarded as the posterior commissure of the labia 
 majora ; but this view Luschka has shown to be incorrect.* 
 
 
 V .^^^ 
 
 /!i% 
 
 Fig. 3.— Front view of the erectile structures of the external organs of the female iKolielf^ 
 A pubis ; B, B ischium : C, clitoris ; D, gland of the chtoris ; E. bulb : F, constrictor muscle 
 of the vulva ; G, left pillar of the clitoris : H, dorsal vein of the clitoris ; I. intern edarv 
 plexus ; J, vein of communication with the obturator vein ; K, obturator vein • JI labia 
 minora. ' ' "'^"* 
 
 The vestihulum is the angular space bounded by the labia minora 
 and the vaginal orifice. 
 
 The hulhi vestihuU vagince, the bulbs of the vaginal estibule, are 
 two curved, leech-shaped masses of reticulated veins, situated between 
 * Luschka, Die Anatomie des menschlichen Beckens, Tubingen, 1864, p. 404,
 
 FEMALE ORGANS OF GENERATION. 5 
 
 the vestibulum and pubic arch of each side. Kobelt has shown that 
 they correspond to the two separated halves of the male bulbus ure- 
 thra. They are composed of erectile tissue, and measure, when dis- 
 tended with blood, a little over an inch in length. As the head of the 
 child passes through the vulva during parturition, these bodies are 
 2)ressed forward to prevent their being compressed between the head 
 and the pubic arch. Still, rupture does sometimes occur, and then 
 the haemorrhage leads to the formation of thrombus of the labia ma- 
 jora. The upper ends of the vaginal bulbs are rather pointed, and 
 communicate, by means of a small plexus, the pars intermedia of 
 Kobelt, with the vessels of the glans clitoridis. Through this connec- 
 tion the blood is pressed, during venereal excitement, by the reflex 
 contractions of the musculus constrictor cunni, from the turgid bulbs 
 into the glans of the clitoris. 
 
 The meatus uretlircB is situated in the median line, at the lower 
 portion of the vestibular space, about three quarters., of an inch from 
 the glans of the clitpris. It is surrounded by a ring of muscular fibers, 
 which keep it closed under ordinary circumstances. These fibers cause 
 a puckering of the mucous membrane, which is easily recognized by 
 the experienced finger, and serves as a guide for the introduction of 
 the catheter. 
 
 Sebaceous glands are found in great abundance in the tissues of 
 the nymphffi, where ' tlK'y furnish a fatty, yellowish-white material, 
 possessing a peculiar odor. This material, when accumulated beneath 
 the prepuce of the clitoris, constitutes the smegma prmputii, so com- 
 mon in women who neglect the niceties of the toilet. 
 
 The mucous glands of the vulva are divided into the glandulfe 
 vestibulares majores and the glandule vestibulares minores. 
 ., The glandidce vestibulares minores are from five to seven in num- 
 ber, and are irregularly distributed in the neighborhood of the meatus 
 urethra?. They are of the compound racemose variety, of about the 
 size of poppy-seed, and j)ossess short, wide ducts with large orifices. 
 T\'ler Smith says that one of these lacunae may be enlarged suffi- 
 ciently to admit a small-sized catheter, leading the operator to suppose 
 that he has reached the bladder, while the instrument is really in a 
 cul-de-sac* 
 
 Professor Skene,f of Brooklyn, has drawn attention to the exist- 
 ence of two glandular structures, from three eighths to three quarters 
 of an inch in length, situated in the muscular walls of the urethra. 
 The orifices of these glands are found about an eighth of an inch 
 above (within) the outer border of the meatus. The correctness of 
 this observation I have had frequent opportunity to verify. 
 
 * W. TvLER Smith. Manual of Obstetrics, p. 22. 
 
 t Skene, The Anatomy and Physiology of Two Important Glands of the Female 
 Urethra, American Journal of Obstetrics, April, 1880. p. 265.
 
 r, 
 
 PHYSIOLOGICAL ANATOMY. 
 
 The ylanthdiB vesiihulares majores were first discovered iu the 
 human subject bv Bartlioliu, and bear sometimes his name and some- 
 times that of Duvernev. They are two in number, of the size of a 
 pea, and of a reddish-vellow color. They are situated behind the pos- 
 terior extremities of the bulbi vestibuli, which, however, they partially 
 overlap. They are of the compound racemose variety, and their acini 
 open into a duct a little over a half-inch in length, wide at its begin- 
 ning, but which narrows toward its orifice. The duct takes an oblique 
 course along the inner side of the vaginal bulbs, and terminates m 
 front of the^hymen, at the angle whicli the hymen or its remains (the 
 
 carunculai myrtiformes) makes 
 with the Avails of the vestibule. 
 The glands of Bartliolin secrete 
 a yellowish, adhesive fluid, which 
 is poured out freely during coit- 
 us, and preparatory to the pas- 
 sage of the child at the time of 
 labor. This secretion, by render- 
 ing the parts moist and slippery, 
 serves to protect the mucous 
 surfaces from mechanical injury. 
 An abundant secretion may like- 
 wise be caused by erotic dreams, 
 or, in fact, by any form of sexual 
 excitement. They are more de- 
 veloped in young persons than 
 in those of middle life, and in 
 old age they seem in some cases 
 to disappear altogether. 
 
 The urifichim rar/incp differs 
 greatly, both as to size and ap- 
 pearance, in virgins, in women 
 accustomed to sexual intercourse, 
 and in those who have borne 
 children. 
 
 In virgins {vide Fig. 1) the 
 
 anterior extremity of the vagina 
 
 terminates in a thin membranf , 
 
 termed the hymen, which pio- 
 
 jects between tlie labia minora. 
 
 The mucous membrane of the 
 
 inner surface of the hymen is 
 
 continuous with that of the vagina ; the outer surface is covered by 
 
 an extension of the mucous covering of the vulva. The space between 
 
 the two mucous surfaces contains blood-ve.ssels, connective tissue, and 
 
 'ii^fl; 
 
 Fig. 4.— Vulva of a ^\ ninan wlio has borue chil- 
 dren. 1, labium uiajus ; 2, fourehette ; 3. la- 
 bium minus; 4. interior layei- passing beneath 
 the clitoris ; 5, upper laj-er forming the pre- 
 puce ; 6, clitoris ; 7, prepuce ; 8, meatus ure- 
 thra ; 9, vestibule ; 10. oriflce of the vagiua, 
 showing lower portion of the vaginal canal ; 
 11, orifice of the gland of Duverney ; 13, mons 
 Veneris. (Sappey.)
 
 FEMALE OKGANS OF GENERATION. 7 
 
 a few muscular fibers derived from tlie vaginal walls.* The vaginal 
 orifice, which is therefore in virgins identical with that of the hymen, 
 has usually a crescentic shape, with its concave border looking toward 
 the urethral orifice, so that a small opening is left anteriorly for the 
 escape of the menstrual fluid. There are, however, a number of other 
 less common varieties, of which the following are the most important : 
 1. The hymen annularis, with a small central opening. 2. The hymen 
 cribriformis, with a number of small openings. 3. The hymen imper- 
 foratus, which completely occludes the vagina, and occasions retention 
 of the menses. 4. The hymen fijn briatus , from its resemblance to the 
 fringed extremity of a Fallopian tubei Tliis variety possesses medico- 
 legal importance, from the possibility of its being mistaken for a nor- 
 mal ruptured hymen. 
 
 The thin tissues which constitute the hymen are usually lacerated 
 by the first complete coitus. Laceration, however, is not, in all eases, 
 the necessary result of sexual intercourse. A young girl, nineteen 
 years of age, at one time under treatment for amenorrhcea in the uter- 
 ine wards of the Bellevue Hospital, i)ossessed a perfect hymen, the 
 opening of which was of the ordinary size, yet so distensible was its 
 tissue that a medium-sized (one inch) Fergusson speculum was repeat- 
 edly introduced, for purposes of exploration, without in the slightest 
 degree affecting its integrity. Hyrtl mentions a specimen of the 
 female genitalia preserved in ^leckel's museum, at Halle, where the 
 hymen is perfect, though the woman had given birth to a seven- 
 months child, f 
 
 We are indebted to Schroeder for having pointed out that the 
 fleshy eminences, known as the carunculffi myrtiformes, are the result 
 of child-bearing, and not, in the rule at least, of sexual intercourse. 
 Coitus simply causes a solution in the continuity, at one or more 
 points, of the free border of the hymen. The pressure of the child's 
 head, however, during labor causes necrosis and sloughing of the 
 heretofore persistent though lacerated hymen, of which, subsecpiently, 
 the familiar, isolated elevations of mucous tissue about the vaginal 
 orifice furnish the only visible traces. J My own experience is entirely 
 confirmatory upon this point. In the examination of young nulliixx- 
 rous prostitutes, who enter the Bellevue Hospital for uterine disor- 
 ders, I have always found a torn hymen, but, in no case, caruncula? 
 myrtiformes. 
 
 AVith the destruction of tli« hymen the orificiiim vaginm is bounded 
 by the labia minora and the vestibule. 
 
 * Vide BuDix. Recherches sur Thymen et I'orifice vaginale. Publication du 
 progres raedicale, 1879. 
 
 t Hyrtl, Handbuch der topographischen Anatomie, Wien, 5te Auflage, Bd. ii, 
 p. 162. 
 
 X Schroeder, Schwangerschaft, Geburt, und Wochenbett, Bonn, 1867, p. 6.
 
 8 
 
 PHYSIOLOGICAL ANATOMY. 
 
 The Vagina.— Tlie vagina is a membranous canal, connecting the 
 nterus with the external parts of generation. It runs in an oblique 
 direction forward from its attachment at the cervix to its orifice at the 
 vulva When not artificially dilated, its anterior and posterior walls 
 are in contact with each other. The length of the vagina, owing to its 
 extraordinary distensibility, is usually greatly over-estimated. Admit- 
 
 Fig. 5. — Section through the female pelvis (diagrammatic). 1, rectum ; 2, uterus ; 3, excavatio 
 recto-uterina (eul-cle-sac of Douglas) ; 4, excavatio vesico-uterina ; a, bladder ; 6, clitoris ; 
 7, urethra ; 8, symphysis ; 9, sphincter ani ; 10, vagina ; 11. connective-tissue layer. (Kohl- 
 rausch modifleil by Spiegelberg.) 
 
 ting considerable variations, dependent upon weight, position, etc., of 
 the uterus, two and a half inches for the anterior, and a little over 
 three inches for the posterior Avail may be accepted as fair average 
 measurements.* The vagina is placed between the rectum and blad- 
 der, and is more or less intimately connected with both those organs. 
 In its upper fifth, the vagina is separated from the rectum by the cul- 
 
 * LuscHKA, Die Anatoraie des menschlichen Beckens, Tiibingen, 1864, p. 383.
 
 PLATE I, 
 
 Section through pelvic organs of multipara, ad naturam. (Freund.) 1, Uterus ; 2, vagina; 
 3, bladder : 4. excavatio recto-uterina ; 5, excavatio-vesico-uterina ; 6, fornix vaginae ; 
 r, external os ; 8, internal os ; 9, uterine cavity, with raucous lining ; 10, septum urethro- 
 vaginale.
 
 FEMALE ORGANS OF GENERATION. 9 
 
 de-S(w of Dougliis. From thence downward, the rectum and vao-ina 
 form a common partition, the !<ejjtuni recio-vaginule. Above the pel- 
 vic floor a layer of connective tissue continuous with the pelvic fascia 
 unites the rectum and vagina together. Below the pelvic floor the 
 union of the two organs is immediate. Luschka limits the term 
 " septum recto-vaginale " to this lower half of the common wall.* 
 
 The upper half of tiie anterior vaginal wall is attached to the blad- 
 der by means of loose connective tissue, while the lower half is insepa- 
 rable from the tissues about the urethra. The partition thus formed 
 between the urethra and vagina is termed the .septum urethro-vaginale. 
 
 The for7iix, as the upper part of the vagina is termed, encircles the 
 vaginal portion of the cervix in such a way as to extend at least twice 
 as liigh upon its jiosterior as upon its anterior aspect. The vaginal 
 walls, when not distended artificially, are directly applied to the vaginal 
 portion of the cervix. 
 
 The structure of the vaginal walls is not identical in all parts of 
 the canal. In the upper portion the internal surface is nearly smooth, 
 and the walls measure from a half a line to a line in thickness. They 
 are composed of a mucous membrane, a muscular coat, and an external 
 connective-tissue sheath, or layer. The latter is highly elastic, and 
 aft'ords support to the vaginal blood-vessels. The muscular fibers, Avhich 
 are of the invpluntary variety, run in both a longitudinal and trans- 
 verse direction, and are so interwoven together that a dissection into 
 distinct strata is imjiossible. 
 
 The connective-tissue and muscular layers gradually increase in 
 thickness as they approach the vaginal orifice. A circular bundle of 
 voluntary fibers, the sphincter vagi nee of Luschka, surrounds the lower 
 extremity of the vagina and urethra. The contraction of this sphincter 
 not only acts upon the vaginal orifice, but likewise serves to close the 
 urethra by compressing it against the septum urethro-vaginale.f 
 /' The vaginal columns are two thickened ridges, which occur in the 
 median line, upon the anterior and posterior walls, at the lower jDortion 
 of the vagina. The anterior column is more prominent, in the rule, 
 than the posterior. It is often divided into two portions by a longi- 
 tudinal furrow. In these thickened ridges the muscular' fibers possess 
 a trabecular arrangement and inclose offshoots from the venous plexus. 
 The columns thus present a cavernous structure. They are not, how- 
 ever, endowed with erectility. When turgid with blood, they serve 
 to close the vagina, but the resistance they offer, like that afforded by 
 a filled sponge, is easily overcome. J The mucous membrane covering 
 the columns is greatly thickened, and abundantly supplied with vessels. 
 
 * Luschka, Die Anatomie des menschliehen Beckens, Tiibingen, 1864, p. 384. 
 t Ibid., p. 387. 
 
 j Hexle, Handbuch der Eingeweidelehre des Menschen, Braunschweig, 1866, 
 p. 450.
 
 ^^ PHYSIOLOGICAL ANATOMY. 
 
 The vao-ina is likewise furnislied with transverse ridges (cristce, not 
 -^ruQ^-thev are not wrinkles), which are more fully developed upon 
 the anterior than upon the posterior wall. In virgins these ridges 
 possess a nearlv cartilaginous consistence. Any relaxing agency, sucli 
 US chronic cat"arrh, child-bearing, and the like, serves to efface them, 
 and render the vagina smooth. 
 
 y The mucous membrane of the vagina is covered with numerous. 
 Kascular papilh^, which, under certain conditions, especially those per- 
 taining to pregnancy, may reach such a degree of development as to 
 communicate to the finger a distinctly granular sensation. 
 
 Though the secreting glands of the vagina * are few in number, it 
 is covered, even in periods of repose, with a thin layer of acid mucus. 
 Under sexual excitement, and during menstruation or pregnancy, the 
 amount of this secretion is largely increased. 
 
 The hypogastric, the uterine, the vesical, and the pudendal arteries 
 nil send branches to the vagina. The pulsations of the uterine artery 
 may sometimes be felt through the upper part of the vaginal walls. 
 During pregnancy these pulsations are always so distinctly marked as 
 to constitute a good inferential sign of that condition. 
 
 The veins form a close plexus around the vagina. Like all the 
 pelvic veins, they are without valves, and are therefore peculiarly sub- 
 ject to stasis from anything that interferes with the return circulation. 
 Blood-stasis, with enlargement of the vaginal veins, communicates a 
 deep-purple color to the vagina. As the requisite conditions are ful- 
 filled during gestation, Jacquemin and Kluge include this coloration of 
 the vagina, which they compared to wine-lees, among- the signs of preg- 
 nancy. It occurs, however, though perhaps to a less intense degree, in 
 prolapsus uteri, in cases of pelvic tumors, and the like. As free inter- 
 communication exists between the vaginal plexus and the plexuses dis- 
 tributed to the pudendum, the rectum, the bladder, and the uterus, a 
 disturbance in the circulation of any one of these organs is necessarily 
 attended with some degree of circulatory disturbance in all the con- 
 tiguous organs. 
 
 The general relations of the external and internal organs of genera- 
 tion are admirably given in Fig. 6, Avhich we have borrowed from 
 Beigel.f It represents the complete generative system of a virgin 
 (natural size). 
 
 II. The Uterus, Fallopian Tubes, and Ovaries. 
 
 The Uterus. — The uterus in the virgin differs somewhat in shape 
 and size from that of a woman who has borne children. The follow- 
 
 * The occasional presence of glands in the vagina has been demonstrated by 
 Preiischen. Vide Virchow's Archiv, 1877, vol. Ixx. p. 111. 
 
 \ Beigel, Die Krankheiten des weiblichen Geschlechtes, Erlangen, 1874. Bd. i, 
 p. 23, Pig. 2.
 
 FEMALE ORGANS OF GENERATION. 
 
 11
 
 12 
 
 PHYSIOLOGICAL ANATOMY, 
 
 ing description is intended to apply to the nulliparous uterus only : In 
 outward form the uterus has been compared to an inverted, wide- 
 necked flask. It is flattened antero-posteriorly. Its average length is 
 in the neighborhood of two and a half inches, though its dimensions 
 vary to a verv considerable extent. It is divided by a tolerably well- 
 
 V... I . - \ irg-in utt-ius. A. amen n \ n « I nuciiiii -Neitioii (\ lati i »1 st'itioii ihapjjev ; 
 A, 1, body ; 2, 2, angles : 3, oei \ i\ 1 site of tlie os iiit< i nnm , "), \<i}riticil poi tioii of the cer- 
 vix ; 6, external os ; 7, 7, vagina B 1, 1, piofile ot the anteiior stii face 2, vesico uterine 
 . cul-de-sac ; 3, 3, profile of the posterior Siufaue , 4, body . 5, neck , 6. istlmius , 'i, ^avity of 
 the body ; 8, cavity of the cervix ; 9, os internum : 10. anterior Up of the os externum ; 11. 
 posterior lip ; 12, 12, vagina. C, 1, cavity of the botly ; 2, lateral wall ; 3, superior wall ; 
 4. 4, cornna ; 5, os internum : 6. cavity of the cervix ; 7, arbor vitae of the cervix : 8, os ex- 
 ternum ; 9, 9, vagina. 
 
 defined constriction into two parts of nearly equal length. The upper, 
 larger portion possesses an anterior, flattened, and a posterior, convex 
 surface. It is limited by three borders The upper border is moder- 
 ately convex. The lateral borders are convex above and concave below. 
 The Fallopian tubes pass into the uterus at the junction of the upper 
 and lateral borders. The width of the uterus at this point is about one 
 inch and a half. The lower portion has a spindle shape, and measures 
 about a half-inch in its widest diameter. 
 
 All the lower, spindle-shaped portion of the uterus is termed the 
 cervix, or neck. The portion of the uterus comprised between the 
 neck and the Fallopian tubes is called the coi'pus, or body. The seg- 
 ment situated above the Fallopian tubes is distinguished as t\ve fundus. 
 
 The lower extremity of the cervix projects freely into the vagina, 
 and forms the portio vaginalis, the vaginal portion. It possesses a 
 transverse aperture, measuring from a half a line to two lines in width, 
 termed the external orifice, or sometimes the os tincm, from a fancy of 
 the anatomists that it resembled the mouth of a tench. The external 
 orifice is bounded by two thick lips, of which the anterior is absolutely
 
 FEMALE ORGANS OF GENERATION. 
 
 13 
 
 longer than tlie posterior. As, however, the distuuce from the external 
 orifice to the vaginal insertion is about half as great anteriorly as pos- 
 teriorly, a sensation is communicated to the finger, when an examina- 
 tion is made j>ey vaginam, as though the anterior lip were really the 
 shorter of the two. This absolute superior length of the anterior lip, 
 combined with the natural oblique direction of the uterus, causes the 
 external orifice to look nearly directly backward, a fact which is readily 
 recognized when the organs are examined in situ by means of a Sims's 
 .■speculum. 
 
 Upon lateral section, the uterus is found to be provided with a 
 cavity, in which the upper portion or cavity of the body is to be dis- 
 tinguished from the lower portion or canal of the cervix. The cavity 
 of fJte body presents a triangular shape with convex borders. The two 
 upper angles communicate by a small opening, hardly large enough to 
 admit a fine bristle, with the canal of the Fallopian tubes. At the 
 lower angle is situated the os internum, a circular orifice, large enough 
 to admit a uterine sound, which forms the internal anatomical limit 
 between the body and the cervix. The canal of the cervix has a fusi- 
 form slia])e, and is included between the internal and external orifices 
 ah-eady described. Its inner surface is characterized by two longitu- 
 dinal ridges, occupying the anterior and posterior walls, from which 
 
 Fig. 8.— a, muciparous uterus, anterior surface ; B, uterine cavity. (Sappey.) 
 
 branching processes extend obliquely upward, giving rise to an appear- 
 ance which justifies the title — arbor vitce uterina. 
 
 In women who have borne children, the uterus measures three inches 
 in length, of which nearly two inches belong to the body and one to 
 the cervix. There is increased convexity of the fundus. The distance
 
 u 
 
 PHYSIOLOGICAL ANATOMY. 
 
 between the insertions of tlie Fallopian tubes measures over two inches. 
 The width of the cervix, at its Junction with the body, measures one 
 inch. The uterus thus assumes a pyriform shape. The cavity of the 
 uterus loses its triangular character, and assumes a more ovoid ap- 
 pearance. The external orifice no longer forms a smooth transverse 
 depression, but its edges, lacerated by childbirth, communicate the 
 impression of a rounded, puckered surface. 
 
 When a profile section is made through a perfectly healthy unim- 
 /^^pregnated uterus, its walls are found in actual contact. A cavity does 
 not, therefore, naturally exist. 
 
 The uterus is so situated in the pelvic cavity as to possess a large 
 degree of mobility. Its lower extremity projects, as we have seen, into 
 
 Fig. 9. — Virgin uterus opeuecl posteriorly, showing at A, A', the os internum ; at O, e, os exter- 
 num ; P, peritoneal folds. (Bandl.) 
 
 the vagina. The supra- vaginal portion of the cervix is attached anteri- 
 orly to the walls of the bladder. That portion of the uterus which ex- 
 tends freely into the pelvic cavity is covered by a reflection of the pe'ri- 
 tonseum, precisely as though the uterus had been pushed from below 
 upward into the peritoneal sac. Thus the peritonaeum covers the 
 uterus anteriorly and posteriorly. Its two surfaces meet at the lateral 
 borders of the uterus, and thence spread outward to the ilia of the 
 respective sides. These peritoneal folds divide the pelvic cavity into 
 two nearly equal halves, and are termed the Ugametita lata, or broad 
 ligaments. 
 
 Two peritoneal folds, containing a few contractile fibers derived 
 from the muscular tissue of the uterus, pass forward from the uterus
 
 FEMALE OUGANS OF GENERATION. 
 
 15 
 
 to the bladder — the pUcce vesico-ntcrince. These folds form the sides 
 to a space, limited anteriorly and posteriorly by the bladder and uterus, 
 termed the excavatio vesico-uterina. 
 
 Upon the posterior surface, the peritoniBum descends down not 
 only over the entire supra- vaginal portion of the uterus, but over that 
 portion of the vagina which covers the posterior lip of the intra-vagi- 
 nal portion. Thence it curves upward, and becomes continuous with 
 the peritoneal investment of the rectum. Thus a deep cul-de-sac is 
 formed between the uterus and the rectum, known as the excavatio 
 recto-utevina^ or cul-de-sac of Douglas. Two lateral folds of peri- 
 tonaeum likewise pass from the uterus to the rectum, which form sides 
 to this space, the ^^//Vvp yerfo-uterina>. These folds inclose in their 
 
 Fig. 10. — Uterus of a woman wlio has borne children. A, A', the portion of the uterine cavity 
 corresponding to the peritoneal folds, P ; B, B', os internum ; O, e, os externum. (Bandl.) 
 
 free borders contractile muscular fibers, derived from the uterus and 
 vagina. The plicae recto-uteri nae pass backward, near the rectum, to 
 the neighborhood of the second sacral vertebra. As the muscular 
 fibers they contain were believed by Luschka to fulfill the function 
 of maintaining the uterus in a state of normal anteversion, he proposed 
 that they should be termed the retractores uteri. In Figs. 9 and 
 10, copied from Bandl, it will be noted that in the virgin uterus the 
 upper borders of the peritoneal folds which bound laterally the cul-de- 
 sac of Douglas leave the uterus at a point corresponding very nearly 
 to the site of the os internum ; whereas, in the uterus of women who 
 have borne children, the os internum is situated at a considerable
 
 jg PHYSIOLOGICAL ANATOMY. 
 
 distance below the folds, a difference whicb Baudl believes to be due 
 to an expansion of the upper portion of the cervical canal by the growth 
 of the ovum during pregnancy, the expanded portion thereafter form- 
 ing permanently an addition to the uterine cavity. 
 
 The peritonaeum covering the uterus is an exceedingly delicate 
 membrane. Over the body. and fundus of the uterus, both front and 
 rear, it adheres intimately to the muscular tissues, while below the 
 level of the recto-uterine folds, where the subperitoneal connective tis- 
 sue is more abundant, separation is easily effected. 
 
 Though it may be proper to speak, in a general way, of the uterus 
 as occupying a position coincident with the axis of the superior pelvic 
 strait, it must be borne in mind that, in reality, its position is largely 
 influenced by the neighboring organs. Thus, a full bladder pushes the 
 fundus backward. A full rectum shoves the cervix forward. When 
 bladder and rectum are both evacuated, the resiliency of the muscular 
 fibers in the recto-uterine folds produces a limited amount of ante- 
 version. Marked degrees of anteversion or anteflexion following the 
 evacuation of the bladder are abnormal, and are due either to fixation 
 of the cervix resulting from inflammatory changes in the parametrium, 
 to increased size of the uterus, or to the loss of the muscular tomis. 
 
 The uterus is composed of muscular fibers of the unstriped variety, 
 arranged in bundles and united together by delicate processes of con- 
 nective tissue. In the non-gravid, but more distinctly in pregnant and 
 puerperal, uteri the arrangement of the muscular fibers in three layers 
 is indicated, though the layers are not absolutely separable from one 
 another. 
 
 1, The superficial layer covers tlie anterior and posterior surfaces 
 of the uterus like a hood, while the sides are left free. It possesses a 
 membranous thinness, and is intimately adherent to the peritonanim. 
 Its fibers, a part of which are continuous with the longitudinal fibers 
 of the external muscular layer of the Fallopian tubes, pursue an appar- 
 ently circular course in the neighborhood of the tubes and a longitu- 
 dinal direction near the median line. 
 
 The continuity of the outer layer is, however, broken by the inser- 
 tions of the retractor muscles, and of the ovarian and round liga- 
 ments. The ovarian ligament is a broad band, measuring about an 
 inch in length and a fifth of an inch in width, which passes posteriorly 
 from the upper lateral portions of the uterus between the layers of the 
 broad ligament to the ovary. The round ligament, a muscular bundle 
 of rounded form, passes from the anterior uterine surface near the in- 
 sertions of the Fallopian tubes between the peritoneal folds of the 
 broad ligament and through the inguinal canal to the symphysis pubis, 
 where its fibers terminate in the connective tissue of the mons Veneris. 
 The round ligament is four to five inches in length, and in the unim- 
 pregnated condition, when the fundus is depressed below the pelvic
 
 FEMALE ORGANS OF GENERATION. 
 
 lY 
 
 brim, runs in a curved direction upward, outward, and forward, to gain 
 the inguinal ring. 
 
 2. The median layer constitutes the great bulk of the uterine walls. 
 It is composed of longitudinal and transverse fibers which form an in- 
 tricate interlacement, in the meshes of which are contained the vessels 
 of the organ. In pregnancy the arrangement of muscular bundles in 
 superimposed leaf-like plates or lamella3 is observable. These start in 
 the fundus and body of the uterus from the peritonaeum, to which they 
 are firmly attached, and at first the fibers are in close proximity. They 
 soon, however, split into bundles, which follow, in most cases, an oblique 
 course downward and inward to the uterine mucous membrane. In 
 the lower uterine segment, i. e., the inferior convex portion of the uter- 
 ine cavity, which in pregnancy and childbirth is subjected to the dis- 
 tending influence of the presenting part, th§ muscular lamellae — seven 
 to ten in number (J. Veit) — are attached to the peritonaeum by means 
 of loose connective tissue. They send fibers in part to the connective 
 tissue of the cervix, and in part to that which surrounds the upper 
 vaginal walls. 
 
 3. The inner layer is of extreme tenuity. Its fibers pursue a sjii- 
 roidal course around the orifices of the tubes. Between the latter and 
 the internal os the fibers of the inner layer form on the anterior and 
 posterior surfaces beneath the mucous membrane a triangular muscle, 
 and extend downward into the cervix. During j^regnancy the triangu- 
 lar muscles, owing to their fixation at the internal os, do not follow the 
 expansion of the uterine cavity. The underlying transverse fibers are 
 therefore exposed upon the lateral walls, a con- 
 dition which persists, after involution is com- 
 plete (Bayer). 
 
 The cervical walls are composed mainly of 
 connective tissue. The muscular structures 
 of the cervix are derived from the lamella? of 
 the lower segment, from the inner layer of the 
 uterus, and from the fibers which accompany 
 the distribution of the vessels. 
 
 Upon the outer surface of the cervix, just 
 at the point of the vaginal attachment, there 
 is a well-developed layer of transverse muscular 
 fibers. Circular vessels, imbedded in a loose- 
 meshed connective tissue containing wide lym- 
 phatic spaces, surround the cervix at the same 
 point. Thus a ridge is formed, which is greatly augmented in size 
 during pregnancy. 
 
 In the cervix, the connective tissue exists in the form of well-differ- 
 entiated fibers of the ordinary variety. In the body of the uterus, a 
 similar loose-meshed, wavy connective tissue is found in the external 
 2 
 
 Fig. 11.— S<'ction tlirougli tlie 
 mucous membrane of a 
 normal virgin uterus, 
 magnified about forty di- 
 ameters (Kundrat and En- 
 gelmanni. S, mucous 
 membrane : D. glands : M. 
 muscular tissue belonging 
 to the internal layer.
 
 18 
 
 PHYSIOLOGICAL ANATOMY. 
 
 layer where it sends processes "between the muscular bundles, and 
 surrounds the vessels. In the median layer, rings of connective 
 tissue accompany the vessels, while fibers of the finest description 
 penetrate between the muscular bundles. Fine fibers, of a like char- 
 acter, but more abundant, are found in the inner muscular stratum, 
 whence they pass directly into the connective tissue of the mucous 
 
 membrane. 
 
 The mucous membrane of the uterus is divided into that lining the 
 body and that which lines the cervical portion, between which charac- 
 teristic differences of structure exist. 
 
 TJie mucous memhrane of the hodij is smooth and soft. ^ At the fun- 
 dus and upon the sides it measures about ^j of an inch in thickness, 
 but is thinner in the vicinity of the tubes and 
 the cervical portion. It is covered, under nor- 
 mal conditions, with a thin layer of transpar- 
 ent alkaline mucus. AVhen examined with a 
 magnifying-glass its surface presents a per- 
 forated appearance, due to the openings of 
 the uterine glands. These glands are of the 
 tubular variety, have a sinuous course, and are 
 oftentimes divided below into two or three 
 separate blind extremities. They extend, in 
 the rule, through the entire thickness of the 
 mucous membrane, and, in rare instances, 
 penetrate into the muscular tissue of the 
 uterus. They possess a delicate basement 
 membrane, composed of spindle-shai)ed cells, 
 which dovetail into one another like the endo- 
 thelium of the capillaries and lymphatics.* 
 They are lined by cylindrical cells which are 
 said to possess cilias. The mucous membrane 
 of the body of the uterus possesses an epi- 
 thelium of the ciliated variety, which produces 
 a current in the direction of the Falloi)ian 
 tubes, f 
 A very irregular capillary net-work, with delicate walls, extends 
 between the glands, and passes near the free surface into venous radi- 
 cles, which furnish during menstruation the source of venous haemor- 
 rhage. 
 
 The intermediate space is filled up by a connective-tissue mesh-work, 
 composed of fine processes and spindle-shaped cells, whose nuclei im- 
 
 * Leopold, Die Lymphgefasse des normalen nicht schwangeren Uterus, Arch. 
 I. Gynaek., Bd. vi, 1873, Heft 1, p. 33. 
 
 t V. Strickeb, Die Lehre der Geweben, Leipsic, 1871, art. Uterus, von Dr. II. 
 Chrobak, pp. 1173 e^ seq. 
 
 Fig. 12.— Section through ute- 
 rus showing cavity, a, and 
 glandular structures, d. 
 ^Weber.)
 
 PEMALK ORGANS OP GENKKATIOX. ;19 
 
 part to liardciied specimens a granular appearance. Leopold * claims 
 for this mesh-work the.signiticance of lympli-siniises. The close attach- 
 ment of the mucous membrane to the muscular tissue is explained by 
 the direct continuity of the connective tissues of the two structures. 
 
 The mucous memhrane of the cervix is of a yellowish-red color, of ai 
 firm consistence, and possesses the penniform ridges already described. 
 It is therefore readily distinguished, both by the eye and the touch, 
 from the red, smooth, velvety structure of the mucous membrane lin- 
 ing the body. At the time of puberty it possesses a ciliated, cylindri- 
 cal epithelium, which extends down to within from two to three lines 
 of the OS externum. f Simple gland-tubes, and glands with multiple 
 cuJx-dc-sac, are found upon the crests and sides of the ridges and upon 
 those portions of the cervical canal in which ridges do not exist. These 
 glands are, genetically considered, simple inversions of the mucous mem- 
 brane, and are lined by ciliated epithelium. When the neck of one of 
 these glands becomes obstructed, the secretion accumulates, and forms 
 the straw-colored vesicles which have been termed the ovula of Nabotli. 
 Papillary structures, of clavate shape, are very numerous in the lower 
 half or third of the canal. According to Lott,J a section through one 
 of these papilla3 is not to be distinguished from a section through one 
 of the smaller folds of the arbor vitai uterina. The cervical mucous 
 membrane affords thus an extensive secretory surface, furnishing an 
 alkaline mucus, Avhich" possesses important physiological functions in 
 connection with conception, pregnancy, and labor. 
 
 The Fallopian Tubes. — The Fallopian tubes, as the history of their 
 develo^iments goes to demonstrate, are, strictly speaking, integral por- 
 tions of the uterus. A glance at Fig. 14 will serve to make apparent 
 the continuity between the tissues of the uterus and those of the Fal- 
 lopian tubes. It will be noticed, too, that the canal of the latter com- 
 mi;nicates directly with the uterine cavity. The Fallopian tubes meas- 
 ure from three to four inches in length. They are included between 
 the folds of the broad ligament at its upper border. As they pass out- 
 Avard from the uterus they follow a somewhat sinuous course, and gradu- 
 ally increase in width and thickness. The free extremity possesses an 
 opening communicating with the abdominal cavity, the ostiinn abdomi- 
 nale, which is large enough to admit a small goose-quill {2"), whereas 
 the uterine opening does not exceed ^ of an inch in diameter. Henle 
 designated the inner, narrower half, which runs a comparatively straight 
 course, the isfhmus, and the outer, sinuous, dilated portion the amjmlla 
 of the tube. A number of ragged, fringe-like processes surround the 
 ostium abdominale, whence the name fimhriated extremity of the ttibe. 
 These fringes received likewise from the mediaeval anatomists the name 
 
 * Op. cit., p. 47. 
 
 t LoTT. Zur Anatomie und Physiologic der Cervix Uteri, Erlangen, 1872, p. 17, 
 
 X LoTT, I. c, p. 20.
 
 20 
 
 PHYSIOLOGICAL ANATOMY 
 
 onorsui! diahoU, from a supposed resemblance to the root of the seabiosa 
 puccissa, the peculiar appearance of which was ascribed by the super- 
 
 O.a. 
 
 L-i.p. 
 
 L.i.Q. 
 
 X 
 
 L.I. 
 
 Fig. 13.— Posterior lateral view of the aterus (D".f.). with portion of lig. latum (L.I.), oviduct, 
 and ovary. Od, isthmus ; Od', ampulla ; Js infundibulum ; O.a., ostium abdQminale ; F.o., 
 fimbria ovarica ; O. ovarium ; L.o., lis- ovarii ; L.i.o., lig. infundibulo-ovaricum ; L.i.jp., lig. 
 infundibulo-pelvicum ; Po., parovarium. (Henle.) 
 
 stitious to a bite the devil gave it in a lit of anger at its beneficent 
 action in the maladies that affect the human race.* One of the fim- 
 
 ■gyofo^^ 
 
 Fig. 14.— Section through Fallopian tube. (Richard.) 
 
 briffi {F.o.) is rather longer than the rest, and is attached to the outer 
 angle of the ovary. 
 
 The muscular avails of the tubes are composed of unstriped fibers, 
 * Hyrtl, Topographische Anatomic, Wien, 1865, Bd. xi, p. 210,
 
 FEMALE OIKIANS OF CIENERATIUX. 
 
 21 
 
 similar to those described as existing in the uterus. They are arranged 
 in three layers : two, longitudinal, continuous respectively with the 
 external and internal layers of the uterus ; and one, circular, continuous 
 with the circular fibers of the inner uterine layer. Galvanization of the 
 tubes causes contractions of a vermicular character. 
 
 Between the muscular walls and the peritoneal covering there is a 
 connective-tissue layer, which gives support to a rich plexus of blood- 
 vessels. 
 
 Fig. 15.— Section througrh ampulla (thirty diameters), o. submucous tissue ; 6, muscular layer ; 
 c, serous coating ; d, mucous membrane ; e, e. vessels : 1,1, little folds, resembling villosi- 
 ties when seen in profile ; 2, 2, longitudinal folds of larger size, with numerous accessory 
 folds : 3, 3, little folds, united together so as to form a sort of canalicular net-work. 
 (Luschka.) 
 
 The mucous membrane of the tubes is extremely vascular, and has 
 a ciliated epithelium, which produces a current in the direction of the 
 uterus. It presents numerous longitudinal folds, which are much more 
 complicated in the ampulla than in the isthmus. In the ampulla these 
 folds possess an arborescent character, as may be seen in Fig. 15. 
 
 The Ovaries. — The ovaries are two flattened, nearly ovoid bodies, 
 situated between the layers of the broad ligament. They measure 
 from one to one and a half inch in length, from three fourths of an 
 inch to an inch in breadth, and from a third to a half inch in thick- 
 ness. Each' ovary is connected with the uterus by a muscular band 
 about an inch in length and a fifth of an inch in width, termed the 
 ligamcnium ovarii.
 
 90 
 
 PHYSIOLOGICAL ANATO Jl Y. 
 
 Previous to pxTbortv tlie ovaries present a siiiootli surface, but after 
 maturity tliey become' uneven and corrugated from the enlargement, 
 rupture^ and'cicatrization of the Graafian follicles. 
 
 Although the ovaries are said to be of ovoid shape, in reality one 
 border is much more convex than the other. The comparatively 
 straight border is attached to the posterior surface of the anterior 
 layei^of the broad ligament. The posterior layer of the broad liga- 
 ment is reflected over the entire ovar^j, Avith the exception of the at- 
 tached l)()rder, at which point tlie hilum, or opening, is situated. 
 
 through which the sper- 
 matic vessels, which are in- 
 cluded between the folds 
 of the broad ligament, find 
 entrance into the sub- 
 stance of tlie organ. Wal- 
 deyer * has shown that an 
 abrupt change in the chai-- 
 acter of the epithelium 
 from the pavement to the 
 cylindrical variety takes 
 place where the perito- 
 naeum reaches the hilum 
 of the ovary. At this 
 point, too, the connective 
 tissue of the serous mem- 
 brane ceases to form an 
 independent layer, easily 
 separable from the under- 
 lying tissues, but becomes 
 lost in the stroma of the 
 ovary. 
 
 When the broad liga- 
 ments are removed from 
 the body, and held as 
 nearly as possible in the 
 natural position, the con- 
 vex border of the ovary 
 looks downward. If the 
 broad and ovarian liga- 
 ments are, however, put upon the stretch, the convex border rises and 
 looks directly backward. 
 
 The ovary is found, upon section, to contain a fibrous stroma, the 
 
 * "Waldeyer, Eierstock uud Nebeneierstock, Strieker's Handbuch der Lehre 
 der Geweben, p. 545. And for modification of Waldej'er's earlier views, vide Arehi- 
 blast and Parablast, Bonn, 1883, p. 68. 
 
 Fig. 16.— Longitudiual section of ovary from a i)frsou 
 aged eighteen (eight diameters). 1, albuginea ; 2, 
 fibrous layer of cortical portion ; 3. cellular layer of 
 cortical portion ; 4, medullarj' substance ; 5, loose 
 connective tissue between the firm layers of the me- 
 dullary substance. (Henle.)
 
 FEMALE ORGAXS OF GENERATION. 23 
 
 arrangement of which can be best understood by reference to the ac- 
 companying excellent illustration from Henle. 
 
 Externally, the ovary is surrounded by a fibrous coating, the so- 
 called tunica albuginea. In the first three years of existence, how- 
 ever, the albuginea is wanting. Even in a state of complete develop- 
 ment, it can never be stripped off as a separate layer, but is always 
 intimately adherent to the subjacent tissues. 
 
 Beneath the albuginea the parenchyma of the gland is further 
 divided into an outer cortical and an inner medullary substance. 
 
 The medullary substance has a spongy texture, and is of a reddish 
 color. It contains an abundance of blood-vessels, the branches of which 
 pursue a spiral course. The cortical subi^tance is of a grayish color. 
 In it a multitude of small follicles, of the utmost functional impor- 
 tance, lie imbedded. The precise description of these follicles will be 
 given in connection with the subject of ovulation. The stroma of the 
 cortical substance is nowhere sharply distinguished from that of the 
 medullary portion. The fibers of the stroma, for the most part, radi- 
 ate from the center toward the circumference. Just underneath the 
 albuginea, however, the connective tissue of the cortical substance pre- 
 sents a felted arrangement. This portion is termed in the illustration 
 (Fig. 16) the fibrous layer, in contradistinction to the more central 
 portion, which is largely composed, in the neighborhood of the vessels 
 and the follicles, of round and spindle-shaped cells. 
 
 The Vessels of the Uterus and its Appendages. — The uterus receives 
 its arterial supplies from the following sources: 1. The arferia nter- 
 ina liypofiasfrira. This artery, as its name implies, is derived from 
 the hypogastric. It first pursues a downward course to reach the vagi- 
 nal fornix, where its pulsations may be felt during pregnancy. Thence 
 it curves upward between the folds of the broad ligament, and follows 
 a tortuous course along the lateral borders of the cervix and corpus 
 uteri. It distributes small branches to the fornix vaginae, and large 
 ones to the uterus. Tlie uterine branches are, in part, distributed to 
 the surface of the uterus, and, in part, penetrate the muscular tissue, 
 to form a thick capillary net-work immediately under the uterine mu- 
 cous membrane. Of surgical interest is a circumflex branch, which 
 unites the arteries of each side with one another. The situation of 
 this branch is just at the junction of the cervix and body. During 
 pregnancy other anastomotic branches are developed.* As the preg- 
 nant uterus is situated directly under the abdominal Avails, the arterial 
 murmurs are at certain points distinctly appreciable, and furnish the 
 auscultatory sign of pregnancy improperly termed the "placental 
 
 * Hyrtl disputes the formation of anastomoses during pregnancy, and states 
 that in the pregnant as well as in the non-pregnant uterus none but capillary com- 
 munication exists between the arteries. Topographische Anatomic, Wien, 1865, Bd. 
 ii, p. 194
 
 24 
 
 PHYSIOLOGICAL ANATOMY. 
 
 bruit." 2. The arteria uterina aortica, or internal spermatic artery. 
 The origin of this artery is situated about two and a half inches above 
 the bifurcation of the aorta. It pursues a serpentine course, and, in 
 places, makes spiral turns, which are specially marked during preg- 
 nancy. It descends obliquely downward under the peritonaeum to the 
 cavity of the pelvis, and then ascends between the folds of the broad 
 ligaments to reach, by its branches, the ovary, the Fallopian tube, and, 
 
 by its main trunk, the side of the 
 uterus, where it forms a direct 
 communication with the art. uter- 
 ina hypogastrica. 
 
 This communication between 
 the aortic and hypogastric uterine 
 arteries serves to maintain a con- 
 tinuous blood current during ges- 
 tation. The situation of the uter- 
 ine artery within the pelvic cavity, 
 and its exposure to pressure, would 
 render it, were it the sole source of 
 blood-supply, an extremely unsafe 
 dependence. It is well to note 
 here, that when pressure is made 
 upon the aorta, after childbirth, 
 with a view to checking posf-par- 
 tum haemorrhage, the manipulation 
 fails to affect in any way the blood- 
 stream which pours into the uterus 
 from the aortic uterine branches. 
 
 The beautiful injections of 
 Rouget* have demonstrated a pe- 
 culiar disposition of the aortic uter- 
 ine branches, as they penetrate the 
 body of the uterus. Instead of di- 
 viding, as they branch, dichoto- 
 mously, they break up, on reaching the vicinity of the Fallopian tubes, 
 into from twelve to eighteen arterial tufts, of which each branch is 
 twisted in spiral form. These tufts of vessels are so aggregated to- 
 gether as frequently to cover the angles of the uterus. 
 
 The veins of the uterus form a net-work, which traverses the uter- 
 ine tissues in all directions. As their walls are intimately adherent to 
 the muscular tissues of the uterus, they remain ]iatulous upon section, 
 and, when enlarged by pregnancy, are termed " sinuses.-" Rouget like- 
 wise describes twisted, tangled venous tufts, which often form spirals 
 
 * Rouget, Eecherches sur les Organes firectiles de la Femrne, Jour, de la 
 Physiol., 1858, t. i, jip. 320 et seq. 
 
 Fia. 17.— Arterial vessels in a uterus ten days 
 after delivery ; the uterus is turned for- 
 ward, so as to present the posterior as- 
 pect. 1, fundus uteri ; 2, vaginal portion , 
 3, 3, lig. teres ; 4, 4, Fallopian tubes ; 5, 
 right ovary ; 6, abdominal aorta ; 7, art. 
 mesenterica inf. ; 8, 8, art. uterina aortica 
 (spermatic arteries) ; 9, 9, art. iliaca com- 
 munis ; 10, art. iliaca ext. ; 11, art. hypo- 
 gastrica ; 12, art. uterina hypogastrica. 
 (Lusehka.)
 
 FEMALE ORGANS OF GENERATION. 
 
 25 
 
 like those described in the arteries. Tlie same authority claims that 
 the ultimate divisions of the arteries communicate with the venous 
 sinuses by very line vessels, measuring from ^o^th to -^^th of an inch, 
 instead of by capillary net- works. 
 
 The return-currents of the uterus empty into two venous plexuses : 
 
 1. The plexus uterinus. This plexus receives its blood from the 
 uterus alone. It extends between the folds of the broad ligament, and 
 empties into the hypogastric vein. 
 
 2. The plexus pci'iipi'iifonuis. The plexus pampiniformis derives 
 its blood from the uterus, the Fallopian tubes, and ovaries. Its vessels 
 combine to form a single trunk, the vena spermatica interna, which 
 follows the course of the artery of the same name, and empties, on the 
 left side, into the vena renalis, on the right into the vena cava. 
 
 Fia. 18. — Uterine ami ntero-ovarian veins (plexus painpinifonnis*. 1, utenisiseen from the 
 front ; its right half is covered bj- the peritonaeum ; upon the left half may be seen the 
 plexus of utero-ovarian veins (internal spermatic) ; 6. utero-ovarian vessels covered by peri- 
 tonaeum : 7, the same vessels exposed ; 8, 8, 8, veins from the Fallopian tube ; 9, venous 
 plexus of the hilum ovarii : 10, uterine vein ; 11, uterine artery ; 12, venous plexus, cover 
 ing tile borders of the uterus ; 13, anastomoses of the uterine with the utero-ovarian vein 
 (int. spermatic). (Sappey.) 
 
 The m'teries of the ovary are derived, as we have had occasion to 
 notice, from the internal spermatic, penetrate the medullary substance, 
 at the hilum ovarii, and describe a spiral course. The arterial branches 
 anastomose within the ovary, and form an interlacement, including 
 spaces, which become smaller and smaller as the surface of the gland 
 is approached. The veins start as radicles from the capillaries, then 
 rapidly enlarge, and present a varicose appearance. By their anasto- 
 moses they form a plexus, which includes spaces of very irregular size. 
 The blood is then taken up by venous trunks, which run parallel to 
 the arterial branches, and terminate finally in the internal spermatic 
 vein (termed by Sappey, Fig. 18, the utero-ovarian vein). 
 
 Upon the basis of the foregoing description * Rouget draws a par- 
 allel between the structures of the penis and those of the corpus uteri, 
 
 and claims identity between the two organs. One feature, however, of 
 « 
 * Rouget, Recherches sur les Organes ^firectiles de la Pemrae, Jour, de la Physiol., 
 t. 1, pp. 338 et seq.
 
 2g PHYSIOLOGICAL ANATOMY. 
 
 the erectile tissue, as generally understood, is wanting in the uterus, 
 viz a dense, fibrous sheath, a tunica albuginea, inclosing the erectile 
 or^rln limiting the degree of its distention and enhancing its turgidity 
 "as experimental proof that the uterus possesses erectile properties, 
 Eou-et has shown that, when an injection is forced by the spermatic 
 arter^y, in the dead subject, so as completely to distend the vessels of 
 the body of the uterus, the latter becomes elevated in the pelvis, and 
 makes a movement similar to that performed by the penis during 
 venereal excitement. 
 
 It is, however, obvious that the forcible distention of the vessels of 
 a flaccid uterus, in which the muscular walls are deprived of their 
 normal tonus by death, does not necessarily represent the phenomena 
 produced during life by the turgescence resulting from either ovula- 
 tion or the sexual orgasm. Unfortunately, so far as the body of the 
 uterus is concerned, the difficultiss in the way of direct observation 
 upon the living subject have hitherto rendered the settlement of this 
 point impossible. 
 
 With regard to the cervix uteri, we have physiological as well as 
 anatomical reasons for admitting a certain kind of erectility. To be 
 sure, a tunica albuginea is wanting. It is, therefore, not an ideal erect- 
 tile oro-an. But it is among the occasional unpleasant exijeriences 
 of gynecological practice that a simple digital examination, made for 
 the purpose of a diagnosis, may evoke the venereal orgasm. Precise 
 observations as to the phenomena presented by the accessible portion 
 of the uterus during the orgasm have been furnished by Wernich,* 
 Litzmann,f and in one remarkable case by Beck, \ which leave very 
 little doubt that strong erotic excitement is attended by a rigidity of 
 the cervix, which produces an impression upon the fingers similar to 
 that imparted by the glans of the male organ during erection. 
 
 The following anatomical peculiarities of the cervix uteri are fur- 
 nished by Henle : The walls of the vessels (arteries, capillary branches, 
 and veins) are characterized by an extraordinary development of the 
 circular layer of muscular fibers. For instance, in vessels measuring 
 from -gxro" ^^ To7 of an inch, the diameter of the bore is scarcely one 
 third the diameter of the entire vessel. The arrangement of the ves- 
 sels is likewise peculiar. In the labia uterina, especially within the 
 muscular tissues, small branches pass directly down to the mucous sur- 
 face. These branches pursue an undulatory course, are parallel-, and 
 run at nearly equal distances from one another. Just beneath the 
 mucous surface in like manner the veins arise and make their way up- 
 ward parallel to the arteries, and with the same orderly arrangement. 
 
 * Werxich, Die Erectionsfahigkeit des unteren Uterus- Abschnittes, Beitr. zur 
 Geburtsh. und Gynaek., Bd. i, p. 296. 
 
 f Wagner s Handworterbuch der Physiologie, Bd. iii, p. .53. 
 
 X Beck, How do the Spermatozoa enter the Uterus? Am. Jour. Obst., Nov., 1874.
 
 FEMALE ORGANS OF GENERATION. 27 
 
 The capillary connections between these veins and arteries are situated 
 just beneath the epithelium, where they form looped projections into 
 the papilhv. In the pliciv palinata^ the general direction of the vessels 
 is likewise perpendicular to the surface. In commenting upon these 
 facts, Ilenle remarks that there is nothing in the situation of- the 
 arterial walls that would call for their special development, as they are 
 not ])articularly exposed to external pressure. " Where, liowever," he 
 says, " extraordinary means are employed in maintaining contraction, 
 extraordinary relaxation and dilatation are possible." He therefore 
 premises, as at least probable, " that the changing degrees of contrac- 
 tility in the finer vessels may serve to impart a sort of capacity for 
 erection, or, at least, turgescence, to the cervical and vaginal portion " 
 — an anatomical deduction sustained, as we have seen, by physiological 
 observation. 
 
 A similar atteiii])t on the part of M. Rouget to constitute an erect- 
 ile organ out of the ovai-y is disposed of by Sappey as follows : 
 " Erectile tissue is formed by large, short, anastomosing capillaries, 
 supporting muscular trabecula?, and into which open the ultimate 
 divisions of the arteries; but in the bulb (the vascular portion of the 
 ovary) there are neither dilated capillaries, nor areolae, nor trabeculse. 
 The analogy signalized l)y M. Rouget is thei-efore much more apparent 
 than real."' ^ 
 
 The Nerves. — The nerves of the uterus are derived from the gan- 
 gliated cords of the sympathetic system, through which important 
 connections are formed with all the abdominal viscera. Just at the 
 bifurcation of the aorta there is a broad band of nerve tissue termed 
 the plexus uferinvs magnus, formed by the coalescence of filaments 
 from the spermatic ganglia (two i^airs of ganglia, situated upon each 
 side of the inferior mesenteric artery) and filaments derived from that 
 ]iortion of the aortic plexus which is distributed mainly to the supe- 
 rior mesenteric artery (plexus mesentericus superior, Frankenhaeuser).f 
 About an inch and a half below the bifurcation of the aorta it divides 
 into two strands, the plexnf< Jn/pof/asfrici, which pass right and left 
 around the rectum to the uterus and upper portion of the vagina. 
 The hypogastric plexuses receive nerve branches from the lower lum- 
 bar and three upper sacral ganglia. Upon the sides of the rectum 
 they divide each into two jiortions, of which the smaller passes directly 
 to the posterior and lateral w^alls of the uterus, while the larger con- 
 tributes to the formation of the cervical ganglion. 
 
 The cervical ganglion (Frankenhaeuser) is not, according to Jastre- 
 botf,;|: a separate organ, but a large plexus comi:>osed of many ganglia, 
 
 * Traite d'Anatomie. Paris, 1874, vol. iv, p. 691. 
 + Frankexhaeuser, Die Nerven der Gebarmutter, Jena, 1867. 
 X Jastreboff. Anatomy of the Gangjion Cervicale Uteri, London Obst. Trans., 
 vol. xxiii, p. 266.
 
 28 
 
 PHYSIOLOGICAL ANATOMY 
 
 which measures during pregnancy two inches in length by one and a 
 half inch in breadth. It is formed by the concurrence of filaments 
 from the hypogastric plexus, the three upper sacral ganglia, and the 
 
 Fia. 19.— Nerves of the uterus. A, plexus uterinus niagnus ; B, plexus liypogastricus ; C, cer- 
 vical ganglion. 1, sacrum ; 2, rectum : 3. bladder ; 4. uterus ; 5, ovary ; 6, extremity of 
 Fallopian tube. (Frankenhaeuser.) 
 
 first, second, and third sacral nerves. The cervical ganglion supplies 
 the entire uterus, and especially the cervical portion, with nerves. 
 Examined with the naked eye, these nerves are soon lost sight of as 
 they penetrate the walls of the uterus, but their ultimate filaments have 
 been traced by Frankenhaeuser, in microscopic preparations, to the 
 muscular element, where they apparently terminate in the nucleus of 
 the fiber- cell. 
 
 The Lymphatics.— We have already had occasion to notice the prob-
 
 FEMALE ORGANS OF GENEKATIUX. 
 
 29 
 
 Fk;. 20.— Rudimentary sexual organs. 
 The internal cirgans represented at 
 the seventh week of fetal Ufe ; the 
 external organs belong to a later 
 period. 1, spinal column ; 3, 3. 
 AVolffian bodies ; 5, glands destined 
 to become the ovaries in the female, 
 the testicles in the male ; 6, Wolff- 
 ian duct ; 7, filaments of Jliiller ; 
 8, bladder ; 9, tubercle, forming the 
 rudiment of either the clitoris or 
 penis : 10, folds destined to form 
 the labia majora (in the male the 
 scrotum); 11, sinus uro-genitalis ; 
 12, anus. (Luschka.) 
 
 able existence of lymph-spaces in the uterine mucous membrane. In 
 the niusenlar tissue of the uterus, lymph-spaces are found in the deli- 
 cate connective tissue which unites the 
 muscular bundles together. Regular 
 lymphatic veissels are found in the con- 
 nective tissue which accompanies the 
 arterial trunks into the uterine paren- 
 chyma. A net-work of lymphatic ves- 
 .sels, with dilated and constricted por- 
 tions, and provided with valves, exists 
 beneath the serous coat. The lymph- 
 .-paces of the uterine mucous mem- 
 l)rane communicate, by funnel-shaped 
 depressions, with the lymph-spaces and 
 lymphatics of the muscular strata. Just 
 beneath the external muscular layer, 
 upon the lateral borders of the uterus, 
 are large receiving vessels, into which 
 empty the lymphatics from both the 
 subserous and uterine vessels. The 
 lymphatics of the cervix pass to the 
 glands of the pelvic cavity, while those 
 of the border and fundus follow the 
 course of the plexus pampiniformis to form connections with the 
 lymphatics of the lumbar region.* 
 
 Deyelopmext of the Female 
 Generative Organs. — Three con- 
 nected structures make their ap- 
 pearance on either side of the spinal 
 column, at an early period of fetal 
 existence, which need to be under- 
 stood by those who would gain a 
 clear idea of the developed organs 
 of generation in the female. These 
 structures are the Wolffian bodies, 
 the ducts of j\[uller, and the rudi- 
 mentary organs Avhich are destined 
 at a more advanced period to be- 
 come the ovaries. 
 
 The Wolffian bodies are oblong 
 glandular structures, temporary in character, which are thought to 
 perform, in the embryo, the excretory function of the kidney. They 
 
 * Leopold, Die Lymphgefasse der normalen nicht schwangeren Uterus, Arch, 
 f. Gynaek., Bd., vi, Heft I, pp. 1 et seq. ; Luschka, Die Anatomie des menschliclien 
 Beckens, Tubingen, 1865, p. 378. 
 
 Fig. 21.— Uterus and its appendages in the 
 fcBtus at the end of the fourth month 
 (natm-al size). A. external view ; «, a, 
 ovaries, relatively large, nearly as long 
 as the oviducts ; h, 6, the Fallopian tubes 
 (oviducts); c, c, round ligaments; d, 
 uterus ; <-, vagina ; /, vaginal orifice. B, 
 interior view ; a. rami of the arbor vitae, 
 extending to the fundus of the uterus ; 
 6, vaginal portion of utei-us ; c, vagina. 
 (Courty.)
 
 8U 
 
 PHYSIOLOGICAL ANxVTO.MY. 
 
 possess ducts, situated at the sides, wliicli converge together below the 
 Wolffian bodies to empty into the sinus uro-genitalis. 
 
 Two organs, destined to become the orarics, make their appearance 
 upon the iliner side of the Wolffian bodies. They possess at first an 
 elongated, but subsequently assume a more oval appearance. 
 
 The ducts of Miiller are secondary formations, and are produced by 
 an inversion of the peritoneal epithelium, beginning near the anterior 
 end of the Wolffian body and thence extending downward parallel to 
 the Wolffian ducts. (Kolliker.) Below they pass spirally forward, 
 where they meet in the median line, to descend together to the sinus 
 
 Fig. 23.— Uterus unicornis from a young child, posterior asi>ect (Pole), o. uterus unicornis, left 
 half of uterus undeveloped ; 6, right Fallopian tube ; c, left Fallopian tube, exceptionally 
 present ; d, d, ovaries ; e, bladder. (Courty.) 
 
 uro-genitalis. By the eighth week the lower portions of the filaments, 
 which are in apposition with one another, fuse together, and furnish 
 the first rudiments of the uterus and vagina. The free portions of the 
 filaments become the Fallopian tubes. Both uterus and vagina are at 
 first divided into two parts by a common partition-wall, which disap- 
 pears subsequently from below upward. 
 
 Bayer (Freund's Gynakolische Klinik, Bd. i, p. 412 et seq.) regards the 
 uterus as derived not alone from the ducts of Mllller, but that tlie retractors, 
 the round ligaments, and the ovarian ligaments likewise contribute to the forma- 
 tion of its muscular structures. In the Fallopian tubes there are tlnee layers of 
 muscular tissue, viz., the external and internal longitudinal layers and the 
 median layer, whose fibers run in a transverse direction. The fusion of the 
 tubes forms, as it were, the frame upon which the uterus is built. From the 
 external and internal longitudinal fibers are derived the longitudinal fibers of 
 the outer and inner layers of the uterus. The spirals, which aae observable 
 at the uterine cornua, are formed from the longitudinal fibers by a semirotation 
 of the tubes from before backward at their point of union Avith the uterus. The 
 transverse fibers in the median layer oi the tubes persist as circular fibers in the 
 uterus. The retractor muscles pass to the lower portion of the cervix, are 
 thence reflected upward, and their fibers cross at the level of the internal os.
 
 FEMALE ORGANS OF GENERATION. 
 
 31 
 
 At each point in their course they give off fibers to the substance of the uterus 
 and contribute the principal share to the median layer of the lower uterine pole 
 and of the cervix, forming an interlacement with the other muscular bundles. 
 The chief mass of the posterior wall of the body, and of the layers surrounding 
 the cornua, are derived from the ovarian ligaments, while the outer layer of the 
 anterior wall of the corpus, of the lower portion of the cervix, and the entire 
 supravaginal portion are derivative from the round ligaments. The median 
 layer of the fundus is composed of fibers derived from both the round and ova- 
 rian ligaments. 
 
 The uterus, at the fourth month of fetal life, presents distinct traces 
 of the early origin from the ducts of Miiller. The fundus is undevel- 
 
 Fig. 23.— Double uterus and vagina from a girl aged nineteen (Eisenmann). a, double vaginal 
 orifice with double hymen ; 6, meatus urethras ; c. clitoris ; d, urethra ; e, e, the double 
 vagina : /, /, uterine orifices ; g, r/, cervical portions ; h, h, bodies and cornua ; i, i, ovaries ; 
 k, k. Fallopian tubes : I, I, round ligaments ; Hi, m, broad ligaments. (Courty.) 
 
 oped. The ridges of the arbor vitse uterina, which are confined at a 
 later period to the cervix, extend the entire length of the uterus. A
 
 38 
 
 PHYSIOLOGICAL ANATOMY. 
 
 Fio. 24.— Uterus bicornis, double cavity and double vagina, from a girl seventeen years of age. 
 c, cervical portions united together, presenting the appearance of a single cervix ; d, d, the 
 two cornua. (Schroeder.) 
 
 I 
 
 Fig. 26. —Uterus cordiformis, double natural size. (Kussmam.
 
 FEMALE ORGANS OF GENERATION. 
 
 33 
 
 depression at the fundus marks the point of union between the ducts 
 of MuUer. Two eornua, or horns, are thus distinguishable upon the 
 external surface of the uterus. About the eighth or ninth month the 
 convex fundus is developed, and the eornua disappear externally, though 
 all through life they are traceable upon the inner surface in lateral sec- 
 tions of the uterus (ride Fig. 15, p. 21). 
 
 Before the differentiation of sex has taken place, the external organs 
 of generation present the following appearances : Two ridges, or folds, 
 surround a central opening (sinus uro-genitalis), which either unite to 
 form the scrotum of the male, or develop into the labia majora in the 
 female. Where these folds join together above, there is a small pro- 
 jecting body, or tubercle, destined to become the penis or the clitoris. 
 In either case the lower surface of the tubercle is furnished with a 
 groove. The margins of the groove extend along the sides of the sinus 
 uro-genitalis, and, in the development of the female type, become the 
 
 FiQ. 26.— uterus septus bilocularis. Double uterus, with simple vagina, seen from the front. 
 Left walls more developed in consequence of pregnancy. (Cruveilhier.) 
 
 labia minora. The sinus uro-genitalis affords a common aperture for 
 the bladder and internal organs of generation. 
 
 Abnormalities of the Uterus. — An arrest of fetal development 
 gives rise to a number of deviations from the ordinary uterine type, of 
 3
 
 34 
 
 PHYSIOLOGICAL ANATOMY. 
 
 which we borrow from Courty the following as of direct obstetrical im- 
 portance : 
 
 1. Uterus Unicornis.— The one-horned uterus results from the atro- 
 phy or incomplete development of one of the filaments of Miiller, while 
 the other continues its evolution. We then have a uterus which is com- 
 posed of a single lateral half, possessing generally but one Fallopian tube. 
 
 2. Uterus Duplex, or Didelphys. — Both filaments of Miiller are de- 
 veloped, but do not become united together. Thus two distinct uteri are 
 produced, of which each represents in reality the half of a normal uterus. 
 
 3. Uterus Bicornis. — Partial union of the filaments of Miiller takes 
 place, but without reaching the ordinary level indicated by the inser- 
 tions of the round ligaments. The upper portion of the uterus is thus 
 divided into two horns, separated by a furrow from one another. 
 
 4. Uterus Cordiformis. — The uterus remains of the fetal type indi- 
 cated in Fig. 25. Instead of a complete development of the fundus, 
 the latter remains depressed, and presents an appearance remotely re- 
 sembling the heart of a playing-card. 
 
 5. Uterus Septus Bilocularis. — Complete union of the two filaments 
 of Miiller has taken place, but the common wall, formed by their co- 
 alescence, persists. We have thus two distinct uterine cavities. The 
 septum may extend the whole length of the vagina, and give rise to a 
 double vagina ; or absorption of the vaginal septum and a portion of 
 the uterine septum may have taken place, so that we may have a double 
 uterine cavity with a single cervix, vfrrns semi-partitus. 
 
 Fig. 27.— Uterus semi-partitus. (Gravel.)
 
 PHYSIOLOGY OF THE OVUM. 
 
 CHAPTER 11. 
 
 DEVELOPMENT OF THE OVUM. 
 
 The Graafian follicles and the ovum. — Discharge of the ova from the ovary, and the 
 formation of the corpus luteura. — The migration of the ovum. — Fecundation. — 
 Changes taking place in the ovum subsequent to fecundation. — Nourishment of 
 the embryo. — The allantois and chorion. — The deciduie. — The placenta; its de- 
 velopment and structure. — Formation of the umbilical cord. — The amniotic 
 fluid. 
 
 The physiology of the ovum comprises its genesis, development, 
 and discharge from the ovary, its fecundation, and the entire series 
 of subsequent changes by 
 which the simple structure 
 of the germ becomes con- 
 verted into a complex or- 
 ganism presenting the spe- 
 cific characteristic of the 
 parent. 
 
 The following account 
 of the history of the ovum 
 is derived in great measure 
 from Waldeyer.* 
 
 The GKAAFI.A.N" Fol- 
 licles AND THE Ovum. — 
 In the embryo of the chick, 
 by the fourth day of incu- 
 bation, the Wolffian body 
 is covered by cylindrical 
 epithelium, contrasting 
 sharply with the flattened 
 cells of the peritonaeum. 
 Soon after, a thickening 
 of the epithelium becomes 
 noticeable on the inner side, 
 and forms the earliest trace 
 
 Fig. 28.— Section of Wolffian body, with rudimentary 
 ovary (embryo of chick, fourth day of incubation). 
 WK, Wolffian body ; y, section of Wolffian duct ; 
 a, a, thickened epithelium ; 2, duct of Muller ; E, 
 early stage in development of ovary ; O, O, primor- 
 dial ova ; m, mesentery ; i, lateral wall of abdomen. 
 (Waldeyer.) 
 
 * Eierstock und Nebeneierstock, Strickeb's Handbuch der Lehre von den Gewe- 
 ben, Leipsic, 1871 ; Eierstock und Ei, Leipsic, 1870.
 
 36 
 
 PHYSIOLOGY OF THE OVUM. 
 
 of the ovary Next, a small rounded elevation, rich in cells, and derived 
 from the interstitial tissue of the Wolffian body, makes its appearance 
 underneath the thickened epithelium. The epithelium is destined to 
 form the Graafian follicles and ova; the proliferated connective tissue 
 furnishes the vascular stroma of the ovary. Between the fourth and 
 fifth day certain cells already indicate their destiny as future ova by 
 their size, their rounded shape, and large nuclei. The further develop- 
 ment of the ovary is the result 
 of the multiplication of the epi- 
 thelial cells and the continued 
 growth of the stroma. As the 
 connective-tissue processes grow 
 outward and penetrate between 
 the cells, the latter gradually be- 
 come imbedded in the stroma. 
 Thus, the connective-tissue pro- 
 cesses assume a trabecular ar- 
 rangement, the meshes of which 
 are filled with cell-masses of a 
 nearly cylindrical shape, which 
 hang together in the form of a 
 net-work. Among the imbedded 
 cells, the large ones already no- 
 ticed are termed "primordial 
 ova." The smaller cells remain 
 small, and arrange themselves 
 like epithelium around the larger 
 ones. In the course of develop- 
 ment, the interpenetration of the 
 connective tissue continues, until 
 each primordial ovum is con- 
 tained in its own separate par- 
 tition. These partitions, with 
 the included cells, are rudiment- 
 ary Graafian follicles. Two dis- 
 tinct ova within the same Graafian follicle are of rare occurrence. As 
 the ova enlarge and the epithelial cells multiply, an irritative action 
 is set up in the surrounding stroma. An increase in vascularity re- 
 sults, and young connective tissue is developed about each epithelial 
 collection. As the follicle grows, the outer layer becomes fibrillated. 
 Thus around each Graafian follicle a distinct .envelope is formed, 
 termed by Baer the tJieca folUcuU, consisting of an internal vascular 
 coat, the tunica propria, and an external fibrillated coat, the tunica 
 fibrosa. 
 
 Each primordial ovum is at first encircled by a single layer of cylin* 
 
 Fia. 
 
 . 29.— Section through portion of the ovary 
 of mammal, illustrating mode of develop- 
 ment of the Graafian follicles ( Wiedersheim). 
 D, discus proligerus ; Ei, ripe ovum ; G, fol- 
 licular cells of germinal epithelium; g, blood- 
 vessels ; K, germinal vesicle (nucleus) and 
 germinal spot (nucleolus) ; KE, germinal 
 epithelium ; L/, liquor folliculi ; Mg, mem- 
 brana or tunica granulosa, or follicular epi- 
 thelium ; Ml), zona pellucida ; PS, ingrowths 
 from the germinal epithelium, ovarian tubes, 
 by means of which some of the nests retain 
 their connection with the epithelium ; S, 
 cavity which appears within the Graafian 
 follicle ; So, stroma of ovary ; ly, theca fol- 
 liculi or capsule ; [7, primitive ova. When 
 an ovum with its surrounding cells has be- 
 come separated from the nest, it is known as 
 a Graafian follicle.
 
 DEVELOPMENT OP THE OVUM. 
 
 37 
 
 drical cells. Gradually new layers form, in which the ovum lies im- 
 bedded. Afterward, at a point remote from the ovum, a crescent- 
 shaped opening makes its appearance, which becomes filled with a clear 
 fluid derived from transuded serum, and in part from liquefied epithe- 
 lium. A heap of cells remains about the ovum and forms the discus 
 proligerus. With the increase of the follicular fluid the cylindrical 
 
 Fig. 30.— Sagittal section of the ovary of an adult bitch (after Waldeyer). o. e, ovarian epi- 
 thelium ; o. t, ovarian tubes ; y. f, younger follicles : o. /, older follicle : d. p, discus pro- 
 ligerus, with the ovum ; e. epithelium of a second ovum in the same follicle ; /. c, fibrous 
 coat of the follicle ; p. c, proper coat of the follicle ; e. /, epithelium of the follicle (niem- 
 brana granulosa) ; a./, collapsed atrophied follicle ; b. v, blood-vessels : c. t, cell-tubes of 
 the parovarium, divided longitudinally and transversely ; t. d, tubular depression of the 
 ovarian epithelium, in the tissue of the ovary ;.6. e, beginning of the ovarian epithelium, 
 close to the lower border of the ovary. 
 
 cells are pressed against the membrana propria, and form a third coat- 
 ing, or layer, termed the memhrana granulosa. 
 
 A glance at a transverse section through the ovary of a mature mam- 
 mal exhibits follicles of different ages. To recapitulate :
 
 3g PHYSIOLOGY OF THE OVUM, 
 
 The young follicles are composed of primordial ova, surrounded by 
 epithelium, and imbedded in the ovarian stroma. 
 
 The fully developed follicles possess a vesicular character. They 
 are surrounded by a connective-tissue wall (theca folliculi), which is 
 composed of two layers (tunica propria and tunica fibrosa). The tunica 
 propria is lined by cells (membrana granulosa), which are gathered in 
 heaps (discus proligerus) around the ova. The discus proligerus is 
 seated sometimes superficially, sometimes in the deepest portion of the 
 follicle. Each ovum is surrounded by a special layer of cylindrical 
 epithelium (epithelium of the ovum). 
 
 Henle estimates the entire number of Graafian follicles in each ovary 
 at thirty-six thousand. 
 
 The primordial ova, we have seen, consisted originally of epithelial 
 cells distinguished by their rounded shape and large nuclei. For a cer- 
 tain period these cells have a continuous growth, due probably to the 
 absorption of nutritive material furnished by the liquefaction of cells 
 in the discus proligerus. The nutrient material, according to Nagel,* 
 is derived from special cells containing nuclei and one or more nucleoli, 
 and of larger size than the ordinary follicular epithelium. The liquefied 
 product, Nagel maintains, enters the protoplasm of the primitive ova 
 by diffusion. 
 
 The fully developed ovum is no longer a simple cell composed of pro- 
 toplasm. It is of large size. In the human female the ovum measures 
 about yfg- of an inch in diameter. As it lies in the discus proligerus it 
 is surrounded by elongated cells with distinct nuclei and finely granu- 
 lar protoplasm. These cells are placed side by side, and are arranged 
 in two to three layers. By Waldeyer they have been termed the epithe- 
 lium of the ovary, and by Bischoff, owing to their characteristic appear- 
 ance, the zona radiata. 
 
 The mature ovum possesses a thick, transparent envelope, termed 
 the vitelline membrane or, from the manner in which it transmits light, 
 the zona pellucida. The zona pellucida was formerly thought to be 
 due to a thickening of the cell contour. It is now commonly regarded 
 as something superadded to the primordial ovum. Probably the at- 
 tached portions of the radiate cells contribute to its formation. It has 
 been noticed as a curious coincidence, that at the time of the appear- 
 ance of the zona pellucida a similar clear, structureless membrane de- 
 velops between the membrana granulosa and the internal layer of the 
 theca folliculi. When the zona has once formed around the ovum the 
 latter ceases to increase in size. 
 
 The ovum and the zona are not in immediate contact. Between 
 the two there exists a clear space, termed the perivitelline space, which 
 
 * W. Nagel, Das Menschliche Ei, Arch, fur Microscopische Anatomic, vol. xxxi, 
 pp. 380 and 381. The ovaries were examined in a perfectly fresh condition after 
 their removal from the body for surgical reasons. 

 
 2ona pelliicida 
 
 ^''otoplasmic 
 
 Zoncr' 
 
 Fhife II 
 
 Perivitclline Space. 
 
 A51 
 
 Cells of the discus 
 proligerus. 
 
 Corona radiata. 
 (terminal Vesicle, 
 
 ' ^e^toplasmic Zone. 
 
 -fc^. 
 
 J'rotoplasmic Zone 
 
 Cortma radiata 
 
 -^K: 
 
 Zona, pellucida. 
 
 Deutoplasmic Zone. 
 
 ( \ Q-erminal Vesicle, 
 ] vjifh an amceboid 
 "^germinal Spot. 
 
 Fig. 2. 
 
 J'erivitelline Space. 
 
 Clear Outer Zone. 
 
 Fig. l.-Deutoplaem-forming ovum from a Graafian follicle of a woman 27 years old (Nagel). 
 Pig. 2. -Fresh ovum from Graafian folUcle of a woman 30 years old; slightly reduced from 
 the original figure (Nagel).
 
 DEVELOPMENT OF THE OVUM. 
 
 39 
 
 permits amwboid movement and rotation of the egg protoplasm to take 
 place. The thickness of the zona is from one twentieth to one tenth 
 the diameter of the ovum. 
 
 The body of the cell, which constitutes the primordial ovum, be- 
 comes the vitellus of the ripe egg. It possesses contractility and other 
 properties of protoplasm. In the mature ovum it assumes an opaque 
 appearance, due to the development of granular matter and light-re- 
 fracting particles. The primitive cell matter of the vitellus is termed 
 the protoplasm of the ovum, or the formative yelk. From it are de- 
 rived the cells which furnish the basis of embryonic development. The 
 small particles consist of nutrient material, and are termed deutoplasm, 
 or the 7iutritive yelk, as they constitute at an early period the material 
 which contributes to the cell growth. The deutoplasm is supposed 
 to be derived from the liquefied cells of the discus proligerus, but in 
 the human ovum the penetration of particles from without is not 
 direct. They do not appear until after the zona is formed, when the 
 growth of the ovum ceases. They therefore are to be regarded as the 
 product of the vital activity of the cell. Upon the addition of eosin 
 the protoplasm is colored with a beautiful rose tint, while not a trace 
 of the coloring matter is taken up by the deutoplasm (Nagel). The 
 particles first make their appearance at the center of the vitellus. In 
 the perfectly fresii human ovum it is possible to distinguish a central 
 portion rendered opaque by deutoplasm, a finely granular ring in which 
 the protoplasm predominates, and a clear peripheral border in which 
 the protoplasm is free from deutoplasmic matter. 
 
 The nucleus of the cell becomes converted into a large, clear, color- 
 less vesicle, known as the germinative vesicle. It occupies an eccen- 
 tric position in the clear outer zone of the vitellus. The nucleolus per- 
 sists as a dark, probably solid body within the germinative vesicle. It 
 is characterized by amoeboid changes of shape, and is termed the germi- 
 native spot. 
 
 Discharge of the Ova from the Ovary, and the Formation 
 OF the Corpus Luteum. — We have already seen that the number of 
 Graafian follicles within a single ovary is estimated at many thousands. 
 The formation of these follicles is, in great degree at least, completed 
 during the antenatal period of existence. Previous to puberty, how- 
 ever, they remain in a quiescent condition. With the advent of 
 puberty the ovaries assume functional importance. The surface of the 
 ovary, if examined at this time, is no longer smooth, but studded with 
 small vesicles. These vesicles are nothing more than the enlarged 
 Graafian follicles, which, as they become distended by their fluid con- 
 tents, approach the periphery, thin the tunica albuginea, and form 
 rounded translucent prominences. By the additional disappearance of 
 the blood-vessels and the lymphatics, a weak point in the wall of the 
 follicle, the macula or stigma folUcuU, is left exposed.
 
 ^Q PHYSIOLOGY OF THE OVUM. 
 
 The discharge of the ovum is closely associated with the formation 
 of the corpus luteum. 
 
 The corpus luteum begins by an abundant cell proliferation, in which 
 both the follicular epithelium and the tunica propria participate. This 
 cell proliferation is most abundant at the bottom of the Graafian fol- 
 licle. Vascular arches push forth into the cavity, and still further en- 
 croach upon the already crowded space. Finally, a point is reached at 
 which the follicle ruptures, and its contents, including the ovum, are 
 discharged. When the Graafian follicle has reached maturity, the con- 
 gestion, occurring at the time of the menses, operates unquestionably 
 in a most effective manner to the accomplishment of this result. 
 
 Immediately following the rupture of the Graafian follicle, blood is 
 effused into its cavity. At the same time a process of cell disintegra- 
 tion ensues. But, in place of a degenerative product, the disintegra- 
 tion furnishes a granular, vitellus-like substance of a yellow color. Ex- 
 amined by the microscope, in addition to the granular mass, globules 
 may be recognized, which correspond to the light-refracting particles 
 contained in the vitellus of the ovum. 
 
 While the above-mentioned process is going on, an abundant trans- 
 migration of wandering cells (lutein cells, Nagel) from the vascular 
 network surrounding the follicle takes place, which lift up the granu- 
 losa cells, with the pseudo-yelk substance, and press them toward the 
 center of the follicle. Along with the young wandering cells, vascular 
 offshoots, like small papilla?, push out from every side into the epithe- 
 lial and vitellus-like masses. As the larger vessels form more marked 
 projections, they give to the corpus luteum a folded appearance. 
 
 In a state of complete development the corpus luteum consists of — 
 1. The pseudo-yelk substance, mingled Avith effused blood. 2. The 
 thickened layer of the granulosa and lutein cells, mingled with yelk- 
 substance. It is this layer which, to a great extent, forms the folded, 
 yellow portion of the corpus luteum. 3. The vessels which, 'with the 
 lutein cells, push from all directions into the epithelial masses. As 
 these vessels reach the center of the follicle, a complete interpenetra- 
 tion of the connective tissue and epithelial elements of the corpus 
 luteum results, and the foldings become indistinct. 
 
 Finally, absorption of the vitellus-like substance occurs; the last 
 vestiges of the effused blood are converted into blood-crystals ; the arte- 
 rial vessels degenerate ; the epithelial masses and the connective-tissue 
 mesh-works disappear gradually, until at the last only a white, stellate 
 cicatrix remains. 
 
 If the ovum is discharged without impregnation taking place, the 
 corpus luteum reaches its maximum size at the end of three weeks, and 
 then begins to decline, until, at the end of two months, it is reduced to 
 an insignificant cicatrix. But when conception occurs, the changes in 
 the corpus luteum take place more slowly. The corpus luteum reaches
 
 DEVELOPMENT OP THE OVUM. ^i 
 
 a higher state of development. Its increase in size continues for two 
 months. It then remains stationary up to the end of the sixth month. 
 During the hist three months of pregnancy it gradually loses its bright- 
 yellow color, grows smaller, but still measures one half of an inch in 
 diameter at the end of the period of gestation. 
 
 The corpus luteum of pregnancy is often termed the true corpus 
 luteum, to distinguish it from the more trivial variety which is pro- 
 duced by the rupture of a Graafian follicle at a menstrual period, or 
 between two menstrual epochs. The latter has been termed the false 
 corpus luteum, because it is found in virgins, and does not constitute 
 a sign of pre-existent pregnancy. 
 
 The Migration of the Ovum.— The number of ova in each ovary 
 amounts to many thousands. Only a small proportion of them, how- 
 ever, meet with the conditions requisite for fruition. It is probable 
 that many ova perish while still surrounded by the stroma of the ovary. 
 It becomes an interesting subject of inquiry as to the conditions which 
 ordinarily determine the passage of the ovum from the ovary into the 
 Fallopian tube of the corresponding side. It will not do to assume, as 
 is usual, a peculiar erectility of the Fallopian tube, which enables it to 
 apply its funnel-shaped extremity to the ovary just at the moment of 
 the rupture of the Graafian follicle. Setting aside the inherent im- 
 probability of the existence of such a degree of intelligence in the fim- 
 briae as would lead to the exact adaptation of the tube to the precise 
 point at which the ovum is to be discharged, it has been proved that 
 the Fallopian tube possesses none of the characteristics of erectile tis- 
 sue. Injections of its vessels after death do not communicate to it the 
 slightest change of form or place.* 
 
 Muscular action has also been often invoked to explain the assumed 
 manner in which the fimbriae seize the ovary, but galvanization of the 
 tubes, practiced upon criminals recently executed, produces only ver- 
 micular contractions, which do not affect the position of the fimbrije.f 
 Indeed, when we remember the position of the Fallopian tubes in the 
 pelvis, and bear in mind that they are at all times necessarily subjected 
 to the pressure of the intestines, it becomes difficult to understand how 
 they can execute any very extended movements. | 
 
 * RouGET, Les Organes ftrectiles de la Feinme, Jour, de la Physiol., t. i, 1858, 
 p. 337. 
 
 f Hyrtl, Handbuch der topographischen Anatomie, Wien, 1865, Bd. ii, p. 210. 
 
 i Henle, Handbuch der Eingeweidelehre, Braunschweig, 1866, p. 470. Rouget 
 (vide Organes firectiles. Jour, de la Physiol., 1858) has studied with great care the 
 arrangement of the muscular fibers situated between the peritoneal layers of the 
 broad ligament. These fibers are directly continuous with the delicate external 
 muscular layer of the uterus. Certain of them are so distributed, according to 
 Rouget, as to produce by their contraction a direct approximation of the fimbria; to 
 the ovary. Henle remarks, by way of criticism, that more stress might be laid upon 
 tbase fibers were they distributed to the Fallopian tubes alone. As, however, they
 
 ^2 PHYSIOLOGY OF THE OVUM. 
 
 In the absence of dii-ect experimental proof, the suggestion oi 
 Henle that the passage of the ovum into the Fallopian tube is due to 
 the currents produced in the serum by the ciliated epithelium, which 
 covers both the external and internal surfaces of the fimbriae, is, on 
 the score of probability, entitled to the most consideration. One of 
 the fimbriae (fimbria ovarica. Fig. 13) is, as we have already seen, per- 
 manently attached to the lower angle of the ovary. It is likely that 
 the ovum, discharged from a Graafian follicle, is floated down by the 
 peritoneal serum toward the lower and outer border of the ovary, where 
 a sufficient current is present to insure its being caught up and con- 
 veyed into the infundibulum tuba?. Failures on the part of the ovum 
 to reach its destination are, in all probability, not uncommon. Support 
 is given to the theory of the importance of the cili* in influencing the 
 migration of the ovum by the observation of Thiry,* that in batrachi- 
 ans, which have the oviducts fixed to the abdominal walls, and situated 
 at a distance from the ovary, during the rutting period little pathways 
 of ciliated epithelium form in the peritonaeum, which collectively con- 
 verge toward the openings of the tubes. 
 
 Cases of the complete migration of the ovum from the ovary of one 
 side to the Fallopian tube of the opposite side are not readily explained 
 by any hypothesis. 'Yet the occurrence of such cases is undoubted. 
 Pregnancy, for instance, may exist where there is complete absence or 
 closure of the Fallopian tube upon the same side with the corpus 
 luteum. Leopold tied the right Fallopian tube in rabbits in two places, 
 and exsected a portion of the tube between the ligatures ; the left ovary 
 was carefully removed and the abdominal wound was closed. After 
 recovery the rabbit was put to the male. In two such cases pregnancy 
 followed, f 
 
 The progression of the ovum through the Fallopian tube is effected 
 by the ciirrent produced by the ciliated epithelium and by the peristal- 
 tic action of the circular muscular fibers. 
 
 Fecundation. — The precise point at which fecundation takes place 
 has been variously assigned by authors to the tubes, the uterus, and the 
 ovary. The question, however, up to the present time is a purely 
 speculative one. The length of time required by the human ovum to 
 complete the passage from the ovary to the uterine cavity is unknown ; 
 nor has as yet the period of the extra-ovarian life of the ovum, when 
 not vivified by the contact of the male element of generation, been de- 
 termined. Single observations show that fecundation may take place 
 in any part of the course described. The ordinary site of fecundation 
 is a matter which remains to be decided by future investigations. 
 
 spread likewise over the ovary, their probable action would consist in drawing both 
 ovary and tube toward the median line. 
 
 * Thiry, Gottingen Nachrichten, 1862, p. 171. 
 
 f Arch. f. Gynaek., vol. xvi, p. 24.
 
 DEVELOPMENT OF THE OVUM. 
 
 43 
 
 Fig. 31. — Spermatozoa from the human 
 subject (magnified eight hundred 
 diameters). (Luschka.) 
 
 The seme}i, contact with which is essential to the fecundation of 
 the ovum, is a tliick, viscid, albuminous fluid, of a whitish color and 
 a peculiar odoi-, which has been compared to that of the raspings of 
 bone. When examined by the microscope, it is found to contain 
 numerous minute anatomical elements, 
 termed spermatozoa. Each spermato- 
 zoon consists of an oval head and a long 
 filiform extremity or tail. The head is 
 flattened, and measures about ^nsW of 
 an inch in width. When seen in pro- 
 file, it presents a pyriform appearance. 
 The entire spermatozoon measures from 
 ^oTT ^o T^ ^^ ^^ inch in length. 
 
 The spermatozoa do not simply float 
 in the seminal fluid, but possess the 
 capacity of moving from place to place, 
 as though endowed with volition. In- 
 deed, as the observer sees them advance, now singly and now in shoals, 
 now diving down and then rising again to the surface, now avoiding 
 some obstacle, or skillfully picking their way between masses of epi- 
 thelium, it is difficult to resist the conviction that they are really, what 
 they were long supposed to be, distinct organisms capable of a certain 
 degree of voluntary action. But there is little doubt, at the present 
 day, that the undulatory movements of the tail, which furnish the pro- 
 pelling force, are due to purely molecular tissue changes, similar to 
 those which give rise to the amoeboid movements of protoplasm or 
 the oscillations of the hair-like processes of ciliated epithelium. 
 
 Henle estimates that the spermatozoa travel at the rate of an inch 
 in seven and a half minutes. It is to these bodies that the semen owes 
 its fecundating power, but only so long as they retain the faculty of 
 motion — a faculty which has been found to exist in full force, within 
 the female genital organs, eight to ten days after ejaculation.* 
 
 In 1840 Martin Barry described a point in the zona pellucida (vitel- 
 line membrane) of the rabbit, which appeared to him to be an opening 
 designed for the passage of spermatozoa. At first embryologists pro- 
 nounced Barry's descriptions to be based upon an illusion, but since 
 then the existence of such an opening, termed later by Keber the mi- 
 cropyle, has been abundantly demonstrated in the ova of fishes, mol- 
 lusks, insects, etc.f 
 
 A very interesting series of observations connected with this sub- 
 ject have been made by M. Kobin upon the ova of the nephelis vul- 
 garis, or common leech. The earliest token of the maturity of the 
 
 * Luschka, Die Anatomie des menschlichen Beckens, Tubingen, 1864, p. 273. 
 t Vide Milne-Edwards, Legons de la Physiologie, t. viii, Paris, 1873, pp. 361 et 
 seq. ; Waldeyer, Eierstock und Nebeneierstock, Stricker's Handbuch, p. 354.
 
 4:4 
 
 PHYSIOLOGY OF THE OVUM. 
 
 ovum consisted in the disappearance of the germinative vesicle. At the 
 same time a retraction took place in the vitellus, which became thereby 
 reduced one sixth to one fourth in size. At first the removal of inter- 
 nal pressure, consequent upon this retraction, led to a wrinkling of the 
 vitelline membrane. Afterward, however, a clear, limpid fluid, proba- 
 bly in part exuded from the vitellus and in part derived by endosmosis 
 from external sources, filled up the intervening space, and caused the 
 wrinkles to disappear. The spermatozoa, in their movements around 
 the ovum, assumed a perpendicular or oblique direction to the vitelline 
 membrane. At one point in the membrane the penetration of these 
 
 bodies could be distinctly observed. 
 At the end of an hour the penetra- 
 tion had ceased, and then a little 
 bundle of spermatozoa could be seen 
 arrested, partly within and partly 
 without the ovum. In the clear, 
 limpid space surrounding the vitel- 
 lus, the spermatozoa continued to 
 move about actively for a time, but 
 in fifteen to twenty minutes their 
 movements began to grow slow, and 
 in a couple of hours had ended 
 altogether.* 
 
 In the human ovum nothing in 
 the nature of a micropyle has been 
 observed. The fine radiate lines which may be seen in the zona 
 pellucida when high magnifying powers are employed do indeed 
 suggest the idea of minute pores, but the view of Waldeyer f has 
 been generally accepted, that these are really unchanged filaments of 
 protoplasm derived from the cells to which the zona pellucida owes 
 its origin. 
 
 Fig. 32.— Ovum of the nephelis vulgaris, 
 showing retraction of vitellus and the 
 penetration of the spermatozoa through 
 the vitelline membrane (magnified three 
 Ijundred diameters). (Robin.) 
 
 Changes taking place in the Ovum subsequent to Fecun- 
 dation. 
 
 In describing its anatomy, we have noted that the ovum was orig- 
 inally a simple cell, possessing contractility and other properties of liv- 
 ing matter. The ova of certain of the sponges, which do not possess 
 a zona pellucida, move about under the field of the microscope by 
 pushing out finger-like processes, precisely like the ordinary amoeba.J 
 Contractile movements of the vitellus within the zona pellucida have 
 
 * Memoire sur les Phenoraenes qui se passent dans I'Ovule avant la Segmenta- 
 tion du Vitellus, Robin, Jour, de la Physiol., t. v, pp. 67 et seq. 
 
 \ Waldeyer, Eierstock und Nebeneierstock, Strickee's Handbuch der Lehre 
 von den Geweben, Leipsic, 1871, p. 354. 
 
 X Haeckel, Anthropogenie, Leipsic, 1874. p. 112.
 
 DEVELOPMENT OF THE OVUM. 45 
 
 been described by Robin in the ova of the leech and other low orders 
 of animal life.* 
 
 With the formation of the deutoplasm the germinative vesicle is 
 crowded to the periphery of the ovum. 
 
 The maturity of the ovum is signalized by the detachment from 
 the main mass of two small cells termed the polar globules. Formerly 
 this process was supposed to be associated with the disappearance of 
 the germinal vesicle. More recent investigations have demonstrated 
 that in the production of the polar globules the germinative vesicle 
 plays an active part. Thus observation shows that the latter elongates 
 in a radiate direction. Around the two extremities, or poles, nuclear 
 matter from the vitellus collects. A separation of the lines connectino- 
 the poles next takes place, and two new nuclei surrounded by radiate 
 masses of yelk matter result. These liave a star-like arrangement. 
 The upper pole is then extruded and the first polar globule is formed. 
 The process is then repeated, and the second polar globule is perfected. 
 Finally the persistent portion of the original nucleus recedes from the 
 surface. It resembles in appearance the original germinal vesicle with 
 its nucleolus, and is known as i\\& female pronucleus. 
 
 The formation of the polar globules is a sign that the ovum has 
 reached maturity, and occurs independently of fecundation. The latter 
 is effected by the penetration into the vitellus of a single spermatozoon, 
 the head of which is termed the )nale pronudeus. The male pro- 
 nucleus approaches the female pronucleus, and the two coalesce to 
 form the segmentation nucleus of the fecundated ovum. After this 
 union has taken place the ovum is turmed the oosperm. 
 
 F.PNr^ 
 
 '. ... \~M.PN. 
 
 F.PNr 
 
 Fig. 33 —Fertilization of ovum of a mollusk (Elysici viridis). A, ovum sending up a protuber- 
 ance to meet the spermatozoon. B. approach of male pronucleus to meet the female pro- 
 nucleus. F. PN, female pronucleus ; M. PN, male pronucleus ; S, spermatozoon. 
 
 Almost immediately after the production of the segmentation nucleus 
 it divides into two nuclei. By a similar process of cleavage the vitellus 
 likewise divides into two halves. The nuclei act as central points, 
 around which collect the molecular and viscid portions of the pro- 
 toplasm. In this manner the ovum is divided into two new cells, which 
 differ somewhat in size, and which lie near together within the zona 
 
 * Haeckel, Anthropogenie, Leipsic, 1874, pp. 100 et aeq.
 
 4:6 
 
 PHYSIOLOGY OP THE OVUM. 
 
 pellucida. The larger cell and tliose subsequently derived from it are 
 termed the epiblastic spheres, and the smaller one with its products 
 are termed hypoblastic spheres. To the cleavage process by which the 
 single cell has been converted into two, the term segmentation is 
 applied. By continued segmentation the two cells are divided into 
 four, the four into eight, and so in succession, until finally a great 
 
 
 Fig. 34.— Formation of the blastodermic vesicle (Van Beneden). A, B, C, D, sections of ova in 
 successive stages of development in the rabbit ; zp, zona pellucida ; ep, epiblastic cells ; 
 hyp, hypoblastic cells. 
 
 multitude are generated, all closely crowded together, and giving to 
 the ovum a mulberry appearance ; whence the term morula has been 
 applied to the ovum at this stage of its development. 
 
 "When the segmentation process is completed, the epiblast cells 
 occupy the outer circumference and line the inner surface of the zona 
 pellucida, except at one point, termed by Van Beneden the blastophore. 
 They are clear, and have an irregular cubical form. The hypoblast 
 cells form a solid mass in the center. They are granular, polygonal, 
 and are somewhat larger than the epiblast cells. 
 
 The epiblast cells next grow over the blastophore. A layer of fluid
 
 DEVELOPMENT OP THE OVUM. 
 
 47 
 
 Fio. 35. — Diagrammatic sec- 
 tion (Haddon) of mamma- 
 lian blastoderm after the 
 cover-cells have closed in 
 the blastoderm, and the 
 embryo proper has become 
 two-layered. ep\ non-em- 
 bryonic epiblast ; ep, em- 
 bryonic epiblast ; hy, hypo- 
 blast ; y. s, yelk .sac. 
 
 then forms within the morula, by means of wliich the epiblast and 
 hypoblast cells are separated from one another except at the point 
 where the blastophore had previously existed. 
 By an increase of the fluid the morula is 
 converted into a globular vesicle, termed the 
 blastodermic vesicle. The hypoblast cells are 
 pressed to the circumference, where they form 
 a lens-shaped mass attached to the epiblast 
 cells and projecting into the cavity of the 
 vesicle. The blastodermic vesicle continues 
 to enlarge rapidly. The hypoblast cells be- 
 come flattened and spread over the inner sur- 
 face of the epiblast. The central part thick- 
 ens and forms a dark spot, which constitutes 
 the commencement of the embryonic area; 
 
 upon sec- 
 tion, the 
 embryonic 
 
 area is found to consist of three lay- 
 ers, the outer layer composed of epi- 
 blast cells, and two inner layers com- 
 posed of hypoblast cells. The former 
 takes no active part in the formation 
 of the embryo, but disappears at an 
 early period. Beyond the embryonic 
 area the epiblast cells help to form the 
 amnion. The hypoblast cells alone 
 contribute to the formation of the 
 new being. The outer layer becomes 
 the epiblast, and the inner layer forms 
 the hypoblast of the embryo. Sub- 
 sequently a third intermediate cell 
 layer, termed the mesoblast, develops 
 between the embryonic epiblast and 
 hypoblast. At a later period the cells 
 of the mesoblast and of the hypoblast 
 spread by peripheral extension, and 
 finally line the inner surface of the 
 primitive epiblast.* 
 Without entering minutely into the subject, it may be well to state 
 that, according to present views, the three layers existing at the em- 
 
 * This description is taken from Van Beneden's Developperaent Embryonnaire 
 des Mamraiferes, Bull, de I'Acad. Belgique, 1874. Vide translation in article The 
 Physiology and Histology of Ovulation, Menstruation, and Fertilization, etc., by 
 Newell Martin, Hirst's System of Obstetrics, vol. i, p. 101. 
 
 Fig. 36.— Surface view of area pellucida of 
 hen's egg, after eighteen hours of incu- 
 bation (Balfour). A, medullary folds ; 
 m.c, medullary groove ; pr, primitive 
 groove.
 
 48 
 
 PHYSIOLOGY OF THE OVUM. 
 
 bryonic area are assumed to liave the following 
 relations to the ulterior development of the body : 
 
 The epiblast is concerned in the formation of 
 the epidermis, hair, nails, the epithelium of the 
 mouth, nose, and of the cloaca, the glandular 
 structures of the skin, the brain, the spinal cord, 
 and the organs of special sense. 
 
 The hypoblast furnishes the epithelium lining 
 the walls and glands of the intestines, and the epi- 
 thelium of the lungs and of the air passages. 
 
 The mesoblast gives rise to the corium, the 
 muscles of the trunk, the bony framework, the 
 connective tissues, the muscular structures of the 
 digestive tracts, the blood, the blood-vessels, and 
 the genito-urinary system.* 
 
 The first change observed in the embryonic 
 area consists in the appearance of a dark streak, 
 the primitive streak, due to a thickening of the 
 mesoblast. It becomes grooved, and is known as 
 the primitive groove. It has nothing to do with 
 the development of the embryo. The embryonic area, which was pre- 
 viously of a rounded form, now assumes an ovoid shape. In front of 
 
 d f m h 
 
 a.pr- 
 
 P.pr- 
 
 Fig. 37. — Dorsal view of 
 embryonic area of 
 blastoderm of chick 
 after the medullary 
 folds have arched 
 over and met for t 
 great part of their 
 extent but have not 
 j-et fused together, 
 a. pr, anterior part 
 of primitive groove ; 
 p. pr, remnant ol 
 posterior part of 
 primitive groove. 
 
 Fia. 38.— Transverse section through the eniliryo of the chick a few hours after the commence- 
 ment of incubation, h, epiblast ; ?/i, external stratum of mesoblast ; /, internal stratum of 
 mesoblast ; d, hypoblast ; n, medullary groove ; x, chorda doraalls. 
 
 the primitive trace two ridges are formed by a thickening of the epi- 
 blast. These ridges are known as the medullary folds. They bound 
 
 a furrow termed the medullary 
 groove. The folds at first diverge 
 behind, but soon converge and 
 meet so as to include between 
 them the front portion of the 
 primitive trace. 
 
 Upon microscopic examina- 
 tion of a t>ransverse section at 
 
 Fig. 39.— Diagram representing transverse sec- 
 tion through the embryo of a chick at the 
 end of the first day of incubation, m, me- 
 dullary plates ; c/i, chorda dorsalis ; v, ver- 
 tebral chords ; a p, abdominal plates. 
 
 * Haeckel, Anthropogenie, p. 218. According to His, the three primitive lay- 
 ers are concerned in the formation of the epithelial, the muscular, and the nerve 
 tissues only, whereas the blood and connective tissues, comprising the leucocytes, 
 the red blood-corpuscles, the blood-glands, the endothelia, and all the connective-
 
 DEVELOPMENT OP THE OVUM. 49 
 
 this time the three layers of the embryo are found in tlie vertebrata 
 to be united at the median line. The intermediate layer (mesoblast), 
 
 f'Tt\y 
 
 Fio. 40.— Transverse section through the enibiyo of a chick on the second day of incubation. 
 (Magnified one hundred diameters), t m. the dorsal plates have closed to form tubus medul- 
 lar is ; the connection with the outer or cutaneous layer (ci is broken off ; ch, chorda ; v, 
 vertebral chords ; (i /», the abdominal plates, have separated into an external and internal 
 stratum, united at in to form the mesenteric folds. 
 
 which possesses the greatest thickness, already presents the appearance 
 of two closely connected strata. The medullary groove may be recog- 
 nized in the middle of the upper 
 surface, and the dorsal plates are 
 seen rising up as low ridges. 
 At the same time, just beneath 
 the furrow, a cylindrical organ, 
 known as the chorda dorsali.'<, 
 becomes separated from the cell- 
 mass. The chorda dorsal is owes 
 its importance to the fact that 
 it is around this cylindrical body 
 that the vertebra subsequently 
 form. Tlie vertebrae themselves 
 are derived from two longitudi- 
 nal chords, separated by a cleav- 
 age from the portions of the in- 
 termediate layer next to either 
 side of the chorda dorsalis. The 
 peripheral portions of the inter- 
 mediate layer are now termed 
 the lateral or abdominal plates. 
 Meantime the medullary folds 
 continue to grow, and, by curv- 
 ing toward one another, finally 
 meet in the median line, so as to 
 
 Fio. 41.— Section through the ovum of chick 
 after development of umbilical vesicle, c /i, 
 chorda dorsalis ; t m, tuba meduUaris ; om, 
 outer layer of mesoblast, from which are 
 formed the bony skeleton, the blood-vessels, 
 and large muscles of the trunk ; ect, epi- 
 blast ; int. intestinal tube, formed from the 
 inner stratum of the mesoblast and the hy- 
 poblast (en() : u I', umbilical vesicle, con- 
 tinuous with intestine ; a p. abdominal 
 plates, formed from the outer stratum of 
 the mesoblast and the hypoblast. Event- 
 iiallj- the abdominal plates meet to inclose 
 the cavity of the trunk (.thorax and abdo- 
 men) ; am, amnion, formed from epiblast 
 and outer stratum of the mesoblast ; z. zona 
 pellucida ; ?, outer lamina of the amniotic 
 folds, derived from the primitive epiblast. 
 
 tissue forms, including cartilage, bone, and teeth, are derived from cell elements 
 outside the area germinativa into which they subsequently migrate and especially 
 invade the median layer. The three primary layers His terms the archiblast, and 
 the invading cells the parablast. The median layer is, to a great extent, a second- 
 ary formation. For an excellent discussion as to the origin of the parablast, the 
 curious reader is referred to Archiblast and Parablast, Waldeyer, Bonn, 1883.
 
 5Q PHYSIOLOGY OF THE OVUM. 
 
 form a closed tube, the tubus meduUaris, in which is developed the 
 central nervous system. Tims it Avill be noticed that the organ 
 through the agency of which the individual is brought into contact 
 with the external world is primitively derived from the epiblastic layer. 
 
 The intermediate layer (mesoblast) now separates into an internal 
 and external stratum, the existence of which, it has been noted, was 
 indicated at an earlier stage. These two strata remain united by their 
 inner borders, and form later, at the point of union, the mesenteric 
 folds. The outer extremities of the inner of these strata now curve 
 inward, and finally unite together to form the intestine. They inclose 
 at the same time the hypoblast. The closure, unlike that of the dorsal 
 plates, takes place from front to rear, as well as from the two sides. 
 The intestinal tube is thus formed from the inner stratum of the 
 mesoblast, which furnishes the fibro-muscular tissues, and from the 
 hypoblast, from which the glandular structures are derived. A por- 
 tion of the blastodermic vesicle is, however, not included in the in- 
 testinal tube, but hangs, during the early months of gestation, from 
 the body of the embryo, and is termed the umhilical vesicle {u v). 
 Finally, the epiblast and the- outer stratum of the mesoblast (the fibro- 
 muscular layer of the trunk) curve forward and inward so as tc 
 inclose a long cavity which surrounds the intestine. This cavity in 
 mammals subsequently becomes divided by the diaphragm into thorax 
 and abdomen. 
 
 The body of the embryo, seen in profile, at the time these changes 
 are going on, possesses a thickened anterior or cephalic portion and a 
 tapering posterior extremity. It manifests at an early 2)eriod a tend- 
 ency to elevate itself above the level of the area germinativa. The 
 back becomes arched, and the extremities approximate toward one 
 another. Fluid collects between the two strata of the mesoblast and 
 separates them from one another. Of these, the outer stratum forms a 
 union with the primitive epiblast so as to produce a single membrane, 
 folds of which rise at the same time from the extremities and sides 
 of the embryo, and encompass it with an outer wall or parapet. In 
 the process of growth these folds approach one another over the dor- 
 sum of the embryo, and finally unite together. Thus a sac, including 
 the embryo, is formed, termed the amnion, the cavity of which sub- 
 sequently fills with fluid. 
 
 Nourishment of the Embryo. 
 
 It now becomes a matter of importance for us to consider the 
 sources from which the embryo receives the nutritive materials requi- 
 site for its further growth and development. 
 
 The ovum, in its passage through the Fallopian tube, is increased 
 in size by absorption of albuminous materials from -^ of an inch to 
 from -^ to ^ of an inch.
 
 DEVELOPMENT OF THE OVUM. 
 
 51 
 
 a: a! 
 
 Fig. 42.— Diagram showing early 
 stage in development of amuion. 
 a, <(, epiblast, rising ujj over the 
 dorsum of enibrj-o to form the 
 amniotic folds ; p, allantois ; m, 
 umbilical vesicle. 
 
 In describing the formation of the intestinal tube, it was noted that 
 a portion only of the blastodermic vesicle was included by the curving 
 inward of the inner stratum of the mesoblast, while a portion, known 
 as the umbilical vesicle, hung from the abdomen. The umbilical vesicle 
 is lined, like the intestinal tube, by the hypoblast, and is covered by an 
 extension of the inner stratum of the 
 mesoblast. At first the cavity of the 
 vesicle communicates with the intestine. 
 Vessels from the intestinal tube are dis- 
 tributed over its surface, through the 
 medium of which it contributes to the 
 nourishment of the embryo. This ar- 
 rangement, however, is only temporary. 
 The passage very soon becomes obliter- 
 ated, and the remains of the uml)ilical 
 vesicle hang downward, attached by an 
 impervious pedicle to the intestine. 
 
 From the time the ovum has passed 
 into the uterus, however, it derives its 
 main nutritive supply from the mucous 
 
 membrane of that organ, at first by simple absorption, and afterward 
 by the formation of the placenta, an organ through which the blood of 
 the foetus circulates, separated from that of the mother by the thinnest 
 
 of partitions. Through the party- 
 wall there pass to the foetus all the 
 materials necessary for existence 
 and growth, and from the foetus 
 the excrementitious principles rep- 
 resenting the waste which is inci- 
 dent to vital action. 
 
 There is nothing in j^hysiology 
 more interesting than the process 
 by which the circulation of the 
 foetus is brought into close rela- 
 tion Avitli that of the mother. It 
 includes the consideration of the 
 allantois, the cliorion, the dccidita, 
 and finally the joint product of 
 them all, viz., the placenta. 
 
 The Allantois and Cliorion. — 
 The chorion is the external mem- 
 brane that invests the ovum. Before the formation of the amnion it con- 
 sists simply of the zona pellucida or vitelline membrane. As the ovum 
 is received into the uterus the vitelline membrane becomes covered with 
 amorphous villi, which help to fix the ovum in the uterine cavit}^ 
 
 Fig. 43.— Diagram showing completion of the 
 amnion and formation of the chorion. 
 A, amnion ; 1 zona pellucida ; 2, outer 
 lamina of the epiblast after closure of 
 amniotic folds ; P, allantois ; U, umbiUcal 
 vesicle.
 
 52 
 
 PHYSIOLOGY OF THE OVUM. 
 
 Fig. 44.— Human embryo at the third week, showing 
 villi covering the entire chorion. (Haeckel.) 
 
 After the completion of the amniou by the closure of the amniotic 
 folds it remains for a time attached to the outer lamina of the epiblast, 
 
 at the point where the folds 
 meet over the back of the 
 embryo. The outer lamina 
 meantime expands until it 
 comes in contact with the 
 vitelline membrane, which 
 then disappears. Thus the 
 outer lamina becomes in turn 
 the external covering or 
 chorion. The new chorion, 
 like the one it superseded, is 
 speedily covered by a growth 
 of non - vascular villosities. 
 These villosities are not 
 solid, but hollow, like the 
 finger of a glove. They soon 
 reach an extraordinary de- 
 velopment. New villi sprout 
 upward from the chorion, 
 the older ones push out buds and lateral ofEshoots, so that already in 
 the third week the entire surface of the ovum is covered with a dense 
 forest of villi, presenting the most delicate and graceful characters. 
 
 We have just noted that the um- 
 bilical vesicle was a temporary struct- 
 ure, and only for a brief period of 
 physiological importance. Mean- 
 time a new organ is developed, by 
 means of which a vascular connec- 
 tion is established between the em- 
 bryo and the villi of the chorion. 
 This organ is termed the allantois. 
 The allantois begins as a sac-like pro- 
 jection from the posterior extremity 
 of the intestine at the time when the 
 amniotic folds rise up in the form 
 of an embankment around the em- 
 bryo {vide Fig. 43). At this time 
 the umbilical vesicle is still very 
 large. The allantois, like the umbilical vesicle- and the intestine, is 
 composed of two layers derived respectively from the hypoblast and 
 the inner stratum of the mesoblast. It speedily becomes vascular, and 
 increases rapidly in size. The inner surfaces of the sac soon adhere 
 together, so as to form a single membrane. In the course of the third 
 
 FiQ. 45.— 1, exochorion ; 2, endochorion ; C7, 
 umbilical vesicle ; Ay amnion ; P, pedi- 
 cle of allantois.
 
 PlaU III 
 
 Fig. l.-Human embryon, at the ninth week, removed from the membranes; three thnes 
 
 the natural size (Erdl). . , 
 
 Fig. 2.-Human embryon, at the twelfth week, inclosed in the amnion; natural size (Lrdl).

 
 DEVELOPMENT OF THE OVUM. 53 
 
 week the allantois reaches the chorion, over which it spreads and forms 
 a complete vascular lining. According to the usual acceptation, the 
 vessels of the allantois everywhere penetrate into the villi of the 
 chorion. Then the chorion and allantois fuse together, and form by 
 their consolidation a compound membrane termed the permanent 
 cliurio)i.* At first the embryo is connected with the vascular chorion 
 by two arteries and two veins. The two arteries persist as the arteries 
 of the umbilical cord. One of the two veins disappears, while the 
 other becomes enlarged in proportion, and forms the umbilical vein. 
 
 With the growth of the ovum its surface diminishes in vascularity, 
 except in the neighborhood of the attachment of the allantoic vessels, 
 at which point the villi increase in size and profusion. Over the rest 
 of the ovum the villi atrophy and disappear. Thus the greater por- 
 tion of the chorion becomes smooth, while about one third of its sur- 
 face is covered with a thickened, shaggy portion, destined to contribute 
 to the formation of the placenta. 
 
 The DeciduSB. — When the ovum passes from the Fallopian tubes into 
 the uterus, it tinds the mucous membrane prepared, by certain changes, 
 for its reception. These changes, as shown in a specimen examined by 
 Dr. Engelmann,f in the first month consisted of a tenfold increase in 
 thickness (two fifths of an inch). The tissues were intensely vascular, 
 and the entire mucous membrane was thrown into convolutions. The 
 thickening was mainly due to an 
 increase in the elements compos- 
 ing the interglandular connective 
 tissue. This was more especially 
 the case in the upper layers, where 
 the cells were like those of young 
 
 connective tissue. A soft, pulpy Fig. 46.-Formatii>n of deoldua, first stage. 
 
 state of the mucous membrane 
 
 was occasioned by an augmented production of the amorphous inter- 
 cellular substance which characterizes connective tissue in the embry- 
 onic state. 
 
 It is this thickened, vascular, softened mucous membrane which 
 furnishes the decidua vera. 
 
 The ovum, soon after its entry into the uterus, finds a lodgment in 
 one of the folds of the decidua vera. This takes place usually in the 
 upper portion of the uterine cavity, upon the posterior wall, near one 
 of the tubal orifices. 
 
 The point of attachment between the ovum and the decidua is dis- 
 
 * The outer portion, derived from the epiblast, furnishes the epithelium, and is 
 called the exochorion, while the inner vascular surface furnished by the allantois is 
 entitled the endochorion. 
 
 f Engelmann, Mucous Membrane of the Uterus, Anier. Jour, of Obstet, May, 
 1875.
 
 54 
 
 PHYSIOLOGY OP THE OVUM. 
 
 Fig. 47 
 
 —Formation of decidua completed, a, decidua re- 
 flexa ; 6, decidua vera ; v, decidua serotina. 
 
 tinguished as the deciihia serotina. It is physiologically important as 
 the site of the placenta. 
 
 The ovum is not simply adherent. It lies, as it were, imbedded in 
 the tumefied membrane, folds of which grow up around it, and finally 
 
 meet so as to inclose 
 c it in a cavity of its 
 
 own, shut oft" from the 
 general cavity of the 
 uterus.* 
 
 The folds of mucous 
 membrane wliich inclose 
 tlie ovum are termed 
 the decidua rejiexa. 
 
 Tlie space between 
 the decidua vera and ru- 
 flexa is filled by opaque, 
 viscid mucus. 
 The Placenta, — The villi which cover the chorion become imbedded 
 in the soft tissues of the decidua, and derive, by absorption, nutritive 
 materials from the circulatory system of the mother. After the for- 
 mation of the permanent chorion, by the extension of the allantois to 
 the inner surface of tlie Q^g., the allantoic vessels convey the absorbed 
 materials directly to the embryo. At first, absorption takes place from 
 the entire circumference of the chorion, but with the enlargement of 
 the ovum there ensues a thinning of the reflexa, with obliteration of 
 its vessels. At the same time the villi cease to grow over that portion 
 of the chorion in contact with the reflexa, and the whole process of 
 exchange between foitus and mother becomes concentrated at the de- 
 cidua serotina. At this point the chorion, in place of becoming bare, 
 is covered with an infinite multitude of villi, which enlarge, lengthen, 
 and, by sending out lateral offshoots, assume an arborescent appear- 
 ance. The villi are arranged in tufts, sixteen to twenty in number, 
 which together form a soft, spongy mass, and constitute the fetal 
 portion of the placenta. 
 
 The uterine mucous membrane, in which the villi lie imbedded, 
 contributes likewise its share to the muke-up of the completed pla- 
 
 * Leopold, in his account of the uterine mucous membrane, adopts Reichert's 
 view of the formation of the reflexa. viz., that, owin^ to the less rapid increase in 
 the growth of the serotina, the ovum becomes buried in the thickening of the vera. 
 — {Vide Studien ilberdie Uterusschleimhaut. etc., Arch. f. Gynaek., Bd. xi, p. 455.) 
 In opposition to the accepted view that the decidua is the tumefied mucous mem- 
 brane, Ercolani (On the Utricular Glands of the Uterus, translated by Marcy) 
 insists that both the vera and reflexa are organs of new formation, the products of 
 exudations, the neo-formative process consisting in the production of new vessels 
 with single endothelial walls, from tbe surface of which the decidual cells are 
 elaborated.
 
 DEVELOPMENT OP THE OVUM. 55 
 
 centa. The structure of this so-called maternal portion of the organ 
 has been the subject of much difference of opinion. Indeed, an in- 
 telligible idea of its anatomy can hardly be conveyed without a pre- 
 liminary consideration of certain points connected with its develop- 
 ment. 
 
 Thus, the villi are often erroneously described as penetrating direct- 
 ly into the glandular structures of the adjacent uterine mucous mem- 
 brane. Professor Turner has, however, conclusively shown that, in all 
 the less complicated placental forms throughout the animal kingdom, 
 the depressions or cryjits into which the villi dip occupy the soft, 
 pulpy, interglandular tissues. Engelmann further draws attention to 
 the large size of the terminal sprouts of the villi in the human placenta, 
 which would render their entrance into the glandular tubules, unless 
 by a mere exceptional chance, a mechanical impossibility. Moreover, 
 Friedliinder * has demonstrated, as will be again noted hereafter, the 
 persistence of the enlarged flattened glands in the serotina even after 
 the separation of the i)lacenta at childbirth. It may be deemed, there- 
 fore, as fairly settled that the maternal portion of the placenta is de- 
 rived from the tissues occupying the spaces between the glands, and 
 not from the glands themselves. 
 
 In the mare, the relations of the villi to the uterine mucosa are of 
 the simplest character. With a little force it is possible to draw the 
 villi from the crypts, which, on vertical section, are seen to be cup- 
 like depressions between the glands. The crypts are surrounded by 
 a dense capillary plexus, and are lined by eiDithelial cells. The epi- 
 thelial cells are partly columnar, like those covering the mucous 
 membrane of the uterus in the unimpregnated state, while others are 
 so swollen out that their length but little exceeds their breadth, 
 while others are of irregular shape. Transitional forms prove the 
 derivation of the irregularly shaped cells from ordinary columnar 
 epithelium, f 
 
 In the arrangement just described, it will be seen that the villi 
 containing the vessels communicating with the foetus dip into crypts 
 in the uterine mucous membrane. The crypt-walls are highly vascu- 
 lar, and are lined with epithelium. There is, therefore, no direct com- 
 munication between the fetal and maternal blood-vessels. The crypts, 
 however, elaborate a secretion, termed by Haller uterine milk, which 
 contains fatty, saline, and albuminous matters dissolved in water. The 
 uterine milk is, therefore, well qualified to serve as a nutrient mate- 
 
 * Friedlander, Untersuchungen iiber den Uterus, 1870— Ueber die Innenflache 
 des Uterus post partura, Arch. f. Gynaek., Bd. ix, p. 22, 1876. Friedlander's ob- 
 servations have been confirmed by Kundrat and Engelmann, Langlians, and 
 Leopold. 
 
 t Professor Turner, The Structure of the Placenta, Jour, of Anat. and Physiol., 
 vol. X, p. 136.
 
 56 
 
 PHYSIOLOGY OF THE OVUM. 
 
 rial, and is without doubt absorbed by the villi for the benefit of the 
 
 foetus.* 
 
 In the cat, the villi of the chorion have the form of broad, sinuous 
 leaflets, which, about the completion of one half the period of gesta- 
 tion, are so interlocked with the crypts that the two surfaces can not 
 be diseno-aged from one another. Vertical sections show that the walls 
 of the crypts closely follow the sinuosities of the villi in such wise as 
 to form an intimate investment for them. Injections of the maternal 
 capillaries show them to be dilated to two or three times the size of 
 the capillaries in the fetal villi. f 
 
 In the human placenta the relations of the villi to the uterine mu- 
 cous membrane differ somewhat at different stages of development. 
 
 I 
 
 Fig. 48.— Diagram showing the branching of the vilH and the connection of the larger trunks 
 with the placenta. «, chorion ; b, primary trunk, with radiate branches (o; t/, tlie tertiary 
 branches, which either directly, or after previous division (rf'i, penetrate the placenta ma- 
 terna (/). The free terminal tufts (e) are indicated only at a few points. (Langbaus.) 
 
 Thus, at first, the empty cylindrical villi simply sink into the soft, 
 pulpy, interglandular spaces. Next, as the villi sprout and become vas- 
 cular and arborescent, projections formed from the proliferation of 
 the superficial portion of the serotina grow around the oft'shoots and 
 branching processes. At this time we distinguish in the placenta a 
 fetal portion, the placenta foetalis, composed of the villous tufts of the 
 
 * The uterine milk can not be obtained from the placenta of the mare unmixed 
 with the secretions from the uterine glands. The analyses of Professors Prevost. 
 Schlossberger, and Gamgee were made upon a fluid derived from polycotyledonous 
 placenta?.— ( Vide Structure of the Placenta, p. 176.) Hoffmann (Sicherer Xachweis 
 der Uterinmilch beim Menschen, Ztschr. f. Geburtsk. und Gynaek, Bd. vili, p. 258) 
 claims to have demonstrated the presence of uterine milk in the human placenta 
 likewise. This he obtained by the insertion of capillary tubes into the substance of 
 the placenta from its maternal surface. The fluid consisted of serum, of some of 
 the formed elements of the blood, and of a multitude of spherical bodies which he 
 regarded as analogous to m.ilk globules. Werth, however (Ueber die sogenannte 
 Uterinmilch des Menschen. Arch, f, Gynaek.. Bd. xxii. p. 233), has shown that this so- 
 called uterine milk is a post-mortem production, not present directly after delivery ; 
 that the serous portion is derived from the villi, and the formed elements from the 
 exochorial cells. 
 
 f Turner, op. cit., pp. 155, 156.
 
 DEVELOPMENT OP THE OVUM. 57 
 
 ovum, and a uterine portion, the placenta uterina, derived from the 
 tissues of the serotina. 
 
 In the third and fourth months the union of the fetal and maternal 
 tissues is very intimate. But subsequently the growth of the uterine 
 tissue does not keep pace with that of the villi, so that the mature 
 placenta is almost altogether a fetal organ. A layer of uterine mu- 
 cosa, not exceeding ^^ of an inch in thickness, covers the surface of 
 the placenta after delivery. Between the cotyledons, however, thin 
 partitions from the serotina extend downward for a considerable dis- 
 tance, thougli never, except near the borders, as far as the chorion. 
 
 Sections through the hardened placenta show that the main villous 
 trunks divide at a short distance from the chorion. The secondary 
 branches assume a radiate direction, from which proceed tertiary 
 branches, which terminate in club-shaped extremities and bury them- 
 selves in the serotina. From these tertiary branches fine lateral ones, 
 having a dendritic arrangement, are given off, and fill the spaces be- 
 tween tlie tertiary trunks. 
 
 Many of these lateral tufts are attached directly to the serotina, 
 and fill up in part the interval between the larger radiate branches ; 
 others, again, float freely in the blood-currents derived from the ma- 
 ternal vessels.* 
 
 The precise origin and nature of the vascular spaces between the 
 villi have been a prolific subject of discussion. In the early months, 
 we saw, the scrotinal projections extended deep down between the 
 villi, and contained largely dilated capillaries ; and yet afterward 
 every trace of these vessels is found to have disappeared throughout 
 the entire placenta, except in the thin layer of the placenta uterina, 
 where the endothelium, or inner lining, may still be detected. The 
 most probable supposition is, that the vessels have become eroded 
 and finally destroyed by the growth of the villi, leaving the blood to 
 flow unimpeded tlirough the intervillous spaces. A delicate layer of 
 epithelium may, indeed, be found upon the villous trunks and tufts ; 
 but these, it is sufficiently established, belong to the villi, and are de- 
 rived from the exochorion.f Whether these cells essentially modify 
 the interchange between the fetal and maternal circulations, can only 
 be a matter of conjecture. The fact that certain medicinal substances, 
 such as iodide of potassium and salicylic acid, when administered dur- 
 
 * Langhans, Zur Kenntniss der menschlichen Placenta, Arch. f. Gynaek., Bd. i, 
 1870, p. 317; vide also Kolliker, Entwickelungsgeschichte ; Leopold, Der Bau 
 der Placenta, Arch. f. Gynaek., Bd. xi, 1877, p. 443. 
 
 t Kolliker, Entwickelungsgeschichte, 2te Auflage, p. 333; Leopold, Der Bau 
 der Placenta, Arch. f. Gynaek., Bd. xi, p. 467. It is, however, proper to state here 
 that Ercolani maintains that the dilated endothelial walls of the maternal vessels 
 are simply bent inward by the proliferating villi, and that the epithelium observed 
 upon the villi are decidual, and are not derived from the exochorion. Vide Marcy,. 
 N. Y. Med. Journal, July 28 and Aug. 4, 1883.
 
 58 
 
 PHYSIOLOGY OF THE OVUM. 
 
 ing the latter days of pregnancy, may be found in the blood and 
 secretions of the fcetus, whereas others, as woorari and perhaps mer- 
 cury, have not been so found, renders some action on the part of the 
 cells, aside from simple osmosis, at least probable.* 
 
 The Structure of the Fully-developed Placenta.— The placenta, 
 after its removal from the body, is found to be a soft, si)ongy mass, of a 
 
 Ch f<7ti 
 
 V ^.R.LAtErt. 
 
 Fio. 49— Diagram of uterus and placenta in the fifth month. CVi, clioriou ; Am, amnion ; V, 
 villi ; L, lacunae; 6', serotina ; AH, areolar ; I", small arteries. (Leoiwld.) 
 
 somewhat oval shape. It measures upward of seven and a lialf inches 
 in its longest diameter, is from two thirds to an inch in thickness at 
 the point of insertion of the funis, and weighs about sixteen ounces. 
 Its internal surface is smooth, and is covered by the amnion, through 
 which the vessels communicating with those of tlie funis can be seen 
 
 * Vide Fehling, Zur Lehre der Stoffwechsel, Arch. f. Gebtirtsk.. Bd. ix. p. 313; 
 Beneke, Ztschr. f. Geb. und Frauenkrankheiten. Bd. i. i». 477: Gusserow, Arch. f. 
 Geburtsk., Bd. iii, p. 241 ; Schauesstei.v und Spaeth. Jahrb. dor Kinderhoilk., 2ter 
 'iJahrg., p. 18 ; R. Heinz, Arch. f. Gynaek.. Bd. .xxxiii, p. 413 ; Unter.'^uchungen iiber den 
 Bail und die Entwickehiiig der menschlichen Placenta. Heinz states that on the bor- 
 ders of the placenta a portion of decidual ti.'^sue is pushed under the placenta (2 to 3 
 cm.), and at this point septa may be found penetrating the placenta to the subchorial 
 layer of the decidua. Detached portions of decidual tissue sometimes are found in 
 placental tissue. At term the villi have no epithelial covering. In the early months 
 cell coverings may be seen here and' there, but are derived from the villi. The 
 remains of glandular structures described by Friedlander, after separation of 
 decidua, are not found in the serotina at the end of pregnancy. The separation 
 must therefore take place from the borders in the puerperal period, when the point 
 at which placental separation has taken place is of small .size. Heinz observed 
 specific instances where the villi penetrated directly into the lumina of the decidual 
 glands, but leaves open the question whether they likewise , penetrate into the 
 interglandular tissue. Heinz's view of placenta formation is as follows: Villi
 
 DEVELOPMENT OP THE OVUM. 5q 
 
 in their distribution over tlie surfuce of the organ previous to plung- 
 ing into the tissues beneath. The uterine surface has a peculiar, gran- 
 ular feel, and is divided into a number of lobes, corresponding to the 
 fetal tufts or cotyledons already described. It is covered with a soft, 
 thin membrane, which sends septa or partitions in between the cotyle- 
 dons. This membrane is simply the product of the surface layer of 
 the serotina. 
 
 Curled arteries from the uterus penetrate the cotyledons, and con- 
 vey the maternal blood into the spaces or lacuna? between the fetal 
 tufts. Through these spaces the blood flows in a sluggish current, 
 and is conveyed back to the uterus by the coronary vein upon the 
 margin of the i)lacenta, and by means of sinuses situated in the septa 
 between the cotyledons, and continuous with the venous sinuses of the 
 uterine walls.* The fetal tufts which thus bathe in the mother's 
 blood receive, through the umbilical arteries, the blood which comes 
 from the fcetus, darkened with carbonic acid. In the ultimate rami- 
 tications of the villi, the arteries communicate by an arch or loop with 
 a corresponding branch of the umbilical vein, which returns to the 
 cliild red, arterialized blood. f 
 
 liut the placenta is not simply a respiratory organ. The rapid de- 
 velopment of tlie ovum, from a simple cell of microscopic size to the 
 proportions of the infant at birth, argues as surely that the relations 
 of the blood-currents in tiie placenta enable the fcetus to derive from 
 the mother all the proximate principles required for the building 
 up of tissue, the diiferentiation of organs, and the performance of 
 function. 
 
 Then, too, the fa?tus has been shown to have a temperature of its 
 own, somewhat higher than tluit of the mother.]; This production of 
 heat is necessarily attended with destruction of tissue. Of this there 
 
 penetrate tlie deoidim and chiefly enter gland stnictnres, break through the gland 
 wallj:. and destroy maternal tissue, with the exception of small remnants, which per- 
 sist as islets. Villi grow into dilated vessels, and bathe freely in them. The opened 
 vessels pour the l)lood into the intervillous spaces. In the mature placenta there 
 remains of decidua only the serotina, one half to one millimetre thick. The septa 
 and the islets are evidence that serotinal tissue once existed near the chorion, but 
 was destroyed by growth of villi. 
 
 * For alTirmative evidence f)f the existence of placental lacunae, vide Professor 
 TcRXER, Structure of the Human Placenta, Jour, of Anat. and Physiol., vol. vii, p. 
 120. So, too. Professor Daltox's ingenious inflation of the intervillous spaces with 
 air, Treatise on Human Physiology, 1867, p. 615. For objections, the elaborate 
 paper of Braxtox Hicks, in the London Obstet. Trans., vol. xiv, deserves careful 
 perusal. 
 
 + Vide experiments of Zweifel, Die Respiration des Fojtus, Arch. f. Gynaek., 
 Bd. ix, p. 293. See also Berard, t. iii, p. 422, experiments of Legallois. 
 
 , X WuRSTER. Ueber die Eigenwarme der Neugebornen, Berl. klin. Woch., Nr. 87, 
 1869 ; Alexeef, Ueber die Temperatur d6s Kindes im Uterus, Arch. f. Gynaek., Bd. 
 X, p. 141.
 
 60 
 
 PHYSIOLOGY OF THE OVUM. 
 
 is evidence in the presence of urea in the bladder and the amniotic 
 fluid. There can be little question, however, but that the placenta 
 furnishes the chief channel through which the devitalized products are 
 discharged. 
 
 The Formation, of the Umbilical Cord. 
 
 To understand the structure of the cord, it is well to bear in mind 
 the various particulars connected with its development. At the time 
 when the allantois first appears as a sac-like projection from the intes- 
 tine, the embryo is hardly more than an appendage to the umbilical 
 vesicle. The larger size of the latter directs the allantois over the 
 posterior extremity of the foetus. By its growth and extension, the 
 
 Fig. 50.— a, umbilical arteries forming spirals (1 ]') around the vein ; constrictions indicating 
 the presence of folds (3, 3'); circular folds (.5, .5'); lateral openings showing the arterial walls. 
 B, vein opened upon the side, showing a constriction (2) correspondiiiK to an interior valve 
 (3"i; semi-lunar valves (3, 3', 3") C, section of vein and arteries showing valve of vein (1», 
 a semi-lunar arterial valve (2), and a circular arterial valve (3). (Tarnier et Chantreuil.) 
 
 allantois reaches the chorion, and forms a sort of pedicle, by means of 
 which a vascular communication is established between the embryo 
 and the periphery of the ovum. This pedicle is the first indication of 
 the umbilical cord. Its vessels become reduced to two arteries, the 
 umbilical arteries, and a single vein, the umbilical vein. Meantime, 
 the umbilical vesicle diminishes in size, and finally shrinks to a mere 
 thread. The amnion fills with fluid, exuded probably from the body 
 of the foetus, and continues to expand, so that often by the end of the
 
 DEVELOPMENT OF THE OVUM. 
 
 61 
 
 second month it comes in contact with the chorion.* In this way it 
 forms a reflection over the pedicle of the aUantois, which it invests 
 like the finger of a glove. Finally, the structure of the cord is com- 
 pleted by the formation of an elastic substance, termed the gelatine of 
 Wharton^ which consists of connective-tissue elements inclosing large 
 spaces containing amorphous matter. The gelatine of Wharton func- 
 tionally serves to protect the vessels of the cord from compression. 
 It is formed by hypergenesis from the outer layers of the amnion and 
 the allantois, both of which are derived from the intermediate layer, 
 described in the development of the foetus {vide p. 50). The interme- 
 diate layer furnishes, likewise, the connective tissue of the body. 
 
 The fully-developed cord consists, therefore, of a sheath from the 
 amnion, the gelatine of Wharton, the umbilical vein and arteries, and 
 traces of the umbilical vesicle,f and the pedicle of the allantois.J It 
 averages twenty inches in length, though it has been observed as long 
 as seventy inches, and as short as two and a half inches.* A long cord 
 predisposes to the formation of coils about the neck, body, and limbs 
 of the foetus. It is usually of about the size of the little finger, but is 
 very variable, its circumference depending chiefly upon the quantity 
 of the gelatine of Wharton. The arteries are so twisted as to form 
 spiral turns around the vein, and, owing to the superior length of the 
 right artery, in most cases in the direction from right to left. As an 
 anatomical peculiarity, may be mentioned the fact that the walls of 
 the arteries are only slightly thicker than those of the vein. The 
 arteries as well as the vein contain semi-lunar valves. 
 
 The Amniotic Fluid. — The origin of the amniotic fluid in the ear- 
 lier months of gestation is not known, the most probable suggestion 
 being that it is simply exuded from the tissues of the foetus. After 
 the formation of the placenta, a capillary network, connected with the 
 vessels of the umbilical cord, is developed just beneath the amnion in 
 that portion of the chorion which covers the placenta. From these 
 vessels a transudation of serum takes place into the cavity of the 
 amnion. II After the first half of pregnancy has been reached, the 
 capillary network disappears. The continued increase of fluid in the 
 amnion in the later months of gestation is possibly due to the accu- 
 mulation of urine, which the fcetus passes intermittently during intra- 
 uterine existence.^ The composition of the amniotic fluid corresponds 
 
 * Vide Hunter's Gravid Uterus, plate xxxiii, Fig. 2 ; Ecker, Icon. Physiolog., 
 plate xxxiii, Fig. 7. 
 
 f ScHULTZE, Das Nabelblaschen, ein constantes Gebilde, etc., Leipsic, 1861. 
 X Ahlfeld, Die Allantois des Menschen, Arch. f. Gynaek., vol. x, p. 81. 
 
 * Chantreuil, Des Dispositiens du Corden, Paris, 1875. 
 
 J JuNGBLUTH, Beitrag zur Lehre vom Fruchtwasser, Inaug. Dissert., Bonn, 1869. 
 
 ^ Gusserow, Zur Lehre vom Stoffwechsel des Foetus, Arch. f. Gynaek.. vol. iii, 
 pp. 268, 269. Prochownick, Beitrage zur Lehre vom Fruchtwasser und seiner Ent- 
 stehung, Arch. f. Gynaek., vol. xi. p. 304. Krukenberg, Kritische und experi-
 
 62 
 
 PHYSIOLOGY OF THE OVUM. 
 
 to its double origin. In addition to water it contains albumen, urea, 
 and the saline substances which are found in serum and urine. Its 
 quantity varies usually between one and two pints, of which nearly one 
 half is contributed during the last three lunar months.* 
 
 Ahlfeld concludes from the great quantities of lanugo found in the 
 meconium that the child of necessity during intra-uterine life swallows 
 a very considerable quantity of amniotic fluid. As no fluid is found 
 at birth in the intestinal canal, the fluid was of necessity absorbed. As 
 the amniotic fluid contains albumen, in certain cases the precipitate 
 amounting to from twenty-five to fifty per cent, he believes this al- 
 buminosus contributes something to the nourishment of the child. 
 Richard Schroeder, on the contrary, regards the quantity of albumen 
 in the amniotic fluid as too small to contribute appreciably to fetal 
 nutrition. 
 
 CHAPTER III. 
 
 DEVELOPMENT OF THE F(ETUS. 
 
 Development of the foetus in the successive months of pregnancy. — Fetal circula- 
 tion. — Fcetus at term. — Fetal cranium. — Attitude, presentation and position 
 of foetus. 
 
 Development of the Fcetus ix the Successive Months of 
 
 Pregnancy. 
 
 It is customary to reckon the duration of pregnancy at two hun- 
 dred and eighty days, and to divide that space into ten months of 
 twenty-eight days each. As it is often a matter of importance that an 
 accoucheur should be able to judge the age of a prematurely expelled 
 embryo or fcetus, the following particulars concerning the olianges in 
 each month are furnished as a guide to the formation of an ojnnion. 
 In the writer's experience all rules regarding the age of the ovum pos- 
 sess, however, nothing more than an approximative value, owing to the 
 very great normal variations in the rapidity of development in different 
 individual cases. 
 
 First Montli. — At the end of the second week, the embryo is repre- 
 sented by the embryonic spot, which has assumed a biscuit-shape. The 
 dorsal plates are developed. The entire ovum measures one fourth of 
 an inch, and the embryo one twefth of an inch. A week later the 
 embryo has doubled in length, and presents as special features a curv- 
 
 mentelle Untersuchungen ueber die Herkunft des Fruehtwassers, Arch f. Gvnaek., 
 vol. xxii, p. 1. 
 
 * OussEROw, /. c, p. 269. F. Ahlfeld, In Wie Weit das Fruchtwasser ein Nahr- 
 ungsmittel fur die Frucht ist, Zt. f. Geb. und Gynaek., vol. xiv, p. 405.
 
 DEVELOPMENT OF THE FCETUS. 
 
 63 
 
 mg of the back, an enlargement of the cephalic extremity, with rudi- 
 ments of the three higher organs of special sense, and the appearance 
 of the visceral arches. The amnion is fully developed. The embryo is 
 nourished by the umbilical vesicle. The allantois carries the vessels 
 from the embryo to the periphery of the ovum, but the vessels do not 
 penetrate the villi. An ovum described by Waldeyer, exactly four 
 weeks old, was of about the size of a pigeon-egg, and three fourths of 
 an inch long by two thirds of an inch broad. It weighed upward of 
 two scruples. The embryo measured nearly one third of an inch in 
 
 Fig. 51.— Human germs or embryos from the second to the fifteenth week (natural size), seen 
 from the left side, the arched back turned toward the right. (Principally after Ecker.) II, 
 human embryo of fourteen days ; III. of three weeks ; IV, of four weeks ; V, of five weeks ; 
 VI, of six weeks ; VII, of seven weeks ; VIII. of eight weeks ; XII, of twelve weeks ; XV, of 
 fifteen weeks. 
 
 length, or four fifths of an inch in length following the dorsal curva- 
 ture from the top of the cephalic extremity to the end of the coccyx. 
 The head of the embryo presented the primitive cerebral vesicles. 
 The eyes were in the sides of the head, and the ears posterior to the 
 eyes. Beneath, the visceral arches were well marked. Four bud- 
 like processes indicated the beginnings of the anterior and posterior 
 extremities. The intestine, with anal and oral openings, was formed. 
 The cord was short and thick, with a single vein and two arteries. 
 The amnion was only moderately distended, and space still existed
 
 64 
 
 PHYSIOLOGY OF THE OVUM. 
 
 between the amnion and cliorion The umbilical vesicle was tolerably 
 
 large. 
 
 Second Month.— An embryo described by Waldeyer from the sixth 
 to the seventh week measured about one inch in length, following the 
 dorsal curve. Another in the eighth week described by Ecker meas- 
 ured two thirds of an inch in a direct line from the head to the caudal 
 curve.* The ovum itself was of about the size of a hen's egg. The 
 amnion at the end of the second month is distended with fluid and in 
 contact with the chorion. f The villi become abundant near the im- 
 plantation of the umbilical cord. The umbilical vesicle is greatly re- 
 duced in size, and hangs from the embryo by a slender pedicle. The 
 umbilical cord is increased in length, but its vessels do not yet assume 
 a spiral direction. The umbilical ring is small, though still containing 
 loops of intestine. Ossification begins in the lower jaw and clavicle. 
 The three divisions of the extremities are clearly indicated. 
 
 Third Month. — Toward the end of the third month the ovum meas- 
 ures nearly four inches in length. The embryo is between three and 
 three and a half inches long, and weighs about an ounce. The chorion 
 has lost in great measure its villosities. The placenta is formed, though 
 of small size. The cord lengthens, and forms spiral turns. The neck 
 now separates the head from the trunk The development of the ribs 
 distinguishes the thorax from the abdomen. The mouth is closed by 
 the lips, and the nasal se2)arated from tiie oral cavity by the palate. 
 Points of ossification appear in most of the bones. Thin, membrane- 
 like nails appear upon the fingers and toes. The scrotum and labia 
 majora begin to form from cutaneous folds. The penis and clitoris do 
 not difl:er from one another in length. 
 
 Fourth Month. — Toward the end of the fourth month there is an 
 increase of size and thickness in the placenta. The cord is increased 
 to two or three times the length of the fatus, and has become thicker 
 from the formation of the gelatine of Wharton. The fwtus measures 
 four to six inches in length. The weight is estimated all the way be- 
 tween two and four ounces. The head of the ftetus is one fourth the 
 length of the entire body. The bones of the skull are partly ossified. 
 The sutures and fontanelles are widely separated. The mouth, eyes, 
 ears, and nose assume their proper shape. The sex is distinguishable, 
 the skin firmer, and hair begins to form upon the scalp. The foetus 
 makes slight movements with its limbs. 
 
 Fifth Month. — The foetus measures from seven to ten inches in 
 length, and weighs nearly ten ounces. The head is still relatively 
 large. The face, however, is wrinkled, and wears a senile aspect. Fine 
 hair (lanugo) appears over the whole surface of the body. The fetal 
 movements are now distinctly felt by the mother. 
 
 * Spiegelberg, Lehibuch der Geburtshiilfe, p. 84. 
 f Loc. ciL, p. 84.
 
 DEVELOPMENT OF THE FCETUS. 
 
 65 
 
 Sixth Month. — Near the end of the sixth month the foetus is eleven 
 to thirteen inches long and weighs about twenty-three ounces. The 
 deposition of fat in the subcutaneous cellular tissue begins. The eye- 
 lids separate. A foetus born at this time breathes feebly, but in the 
 course of a few hours dies. 
 
 Seventh Month. — The fa?tus measures fourteen to fifteen inches, and 
 weighs in the neighborhood of thirty-nine ounces. The skin is still 
 wrinkled, of a red color, and covered with vernix caseosa. Children 
 born between the twenty-fourth and the twenty-eighth week move 
 their limbs and cry feebly at birth, but in spite of every care they die 
 in the course of a few hours or days. 
 
 Note. — Ahlfeld has recently suggested the inquiry as to whether the assump- 
 tion that children born before the completion of tlie twenty-eighth week neces- 
 sarily perish is not too arbitrary. Many practitioners have observed instances of 
 the survival of a premature child which, both from the data obtained from the 
 parents and from all the indications presented by the child, they at the time of 
 birth had placed within tlie limit regarded as hopeless. Ahlfeld has culled a num- 
 ber of such cases from the published literature of the subject. Granting the many 
 sources of error which would lead us to accept such cases with caution, it none the 
 less seems incumbent upon us to regard Ahlfeld's advice, and look upon every child 
 which respires at birth as one whose life may possibly be preserved by suitable 
 care. It may be that the skepticism of medical men is in part the cause of the 
 unfavorable results.* 
 
 Eighth Month. — The foetus measures sixteen to seventeen inches, 
 and weighs upon the average about fifty-two ounces. The pupillary 
 membrane disappears ; the hair of the head increases in thickness ; the 
 lanugo begins to disappear from the face ; the nails are harder, but do 
 not yet reach the tips of the fingers. Usually, in boys, a testicle may 
 be felt in the scrotum ; the navel is situated nearly in the center of the 
 child's body. With care, the life of a child born within this period 
 may be preserved. 
 
 Ninth Month.— The length is between sixteen and a half and seven- 
 teen and a half inches ; the weight is about sixty-four ounces ; the body 
 becomes rounded and the face more comely, losing its wrinkled, anti- 
 quated aspect; the bones of the head bend easily, and the lanugo 
 begins to disappear from the body. Children at this period are less 
 energetic than at full term, sleep a great part of the time, and are prone 
 to die with lack of careful attention. 
 
 Tenth Month.— In the first two weeks the fa?tus measures eighteen 
 to nineteen inches, and weighs about seventy-seven ounces, f 
 
 * Ahlfeld, Ueber unzeitig und sehr fruhzeitig geborene Friichte die am Leben 
 blieben. Arch. f. Gynaek., Bd. viii, p. 194. 
 
 t The weights and measures are taken from Hecker's averages, based on 486 
 observations. ( Vide Monatssehr. f . Geburtsk., Bd. xxvii, 1866.) 
 
 Observations of Fesser showed similar results. (Lehrbuch der Geburtshiilfe, von 
 Otto Spiegelberg, 1877, p. 86.) 
 
 Ahlfeld obtained considerably larger averages from 250 observations in which 
 5
 
 g^ PHYSIOLOGY OP THE OVUM. 
 
 For convenience of reckoning from memory it is sufficiently accu- 
 rate to assume the length of the child in the third and fourth month 
 at respectively three and four inches. In the fifth, sixth, seventh, and 
 eighth months close approximations to the average length may be 
 obtained by doubling the number of months. In the ninth and tenth 
 months the length may be placed respectively at seventeen and eight- 
 een inches. 
 
 The Fetal Circulation. — The umbilical arteries at first take their 
 origin from the inferior vertebral arteries, and afterward from the 
 hypogastric or internal iliac arteries. 
 
 The umbilical vein enters the abdomen at the navel, and thence 
 passes to the lower surface of the liver; it gives off a number of 
 branches to the left lobe, the lobus quadratus, and the lobus Spigelii. 
 At the transverse fissure it divides into two branches, the larger of 
 which empties directly into the portal vein, and supplies the right lobe 
 with umbilical blood ; the other passes to the inferior vena cava, and 
 is termed the ductus venosus. Thus the greater portion of the regen- 
 erated blood, brought by the umbilical vein from the placenta, first 
 passes through the liver before entering the general circulation of the 
 foetus, while the lesser amount empties at once into the inferior vena 
 cava. As, however, with the advance of gestation, the relative dispro- 
 portion between the hepatic trunks and the ductus venosus is in- 
 creased, toward the end nearly all the blood from the placenta has to 
 make the circuit of the liver. 
 
 Thus the inferior vena cava carries to the right auricle, in part, 
 blood from the lower extremities charged with effete matters, and, in 
 part, placental blood, either received direct from the umbilical vein 
 through the ductus venosus, or after having previously traversed the 
 liver. 
 
 In the foetus the currents of blood through the heart are especially 
 adapted to the unexpanded condition of the pulmonary organs. Previ- 
 ous to the first respiratory act at birth, the lung is small, and, were 
 the entire contents of the right side of the heart, as in the adult, at 
 once discharged into the pulmonary vessels, intense engorgement with 
 rupture of the capillaries would ensue. This danger is, however, 
 averted by the anatomical peculiarities already stated. Thus, in the 
 early months the blood from the inferior cava, in place of emptying 
 from the right auricle into the right ventricle, passes directly across 
 the right auricle, guided by the Eustachian valve, through the foramen 
 ovale to the left auricle, and thence to the left ventricle. As the heart 
 contracts it enters the aorta, and is distributed by the large vessels 
 which spring from the latter to the head and upper extremities. The 
 blood returned from the upper portion of the body by the superior 
 
 the date of conception could be determined. (Bestimmungen der Grosse und des 
 Alters der Frucht vor der Geburt, Arch. f. Gynaek., ii, 1871, p. 361.)
 
 DEVELOPMENT OF THE FCBTUS. 
 
 67 
 
 vena cava enters the right auricle, where it passes in front of the 
 Eustachian valve into the right ventricle. A commingling of the 
 currents from the superior and inferior venae cavae in the right auricle 
 
 Pulmonary Art. 
 
 Foramen Ovale 
 
 Ji'ustachian Valve. 
 Right Aurtc. - Vent. Opening. 
 
 Hepatic Vein. 
 
 Branf/i(s of the 
 Umbilical Vetn, 
 to the Liver. 
 
 Bladder 
 
 Pulmonary Art. 
 Left Auricle. 
 ....Left Awic. ■ Vent. 
 Opening. 
 
 g Ductus VenotHS, 
 
 Internal Iliac Arteries. 
 Fig. 52.— Diagram of the fetal circulation. (Fjiii....
 
 68 
 
 PHYSIOLOGY OF THE OVUM. 
 
 is almost completely prevented in the earlier months by the Eustachian 
 valve. With the advance of gestation, however, a gradual disappear- 
 ance of the Eustachian valve takes place, so that a part of the blood 
 from the inferior cava enters with that of the superior cava into the 
 right ventricle. The contraction of the right ventricle forces the blood 
 into the pulmonary artery, which distributes an insignificant quantity 
 to the lungs, while the main current passes through the ductus arteri- 
 osus into the aorta, ly which it is distributed to the lower portion of 
 the body. 
 
 Thus it will be noted that at all times provision is made for sup- 
 plying the head and upper parts of the body with regenerated placen- 
 tal blood. On the other hand, the lower extremities are for a time 
 almost entirely supplied with blood which has already fed the tissues 
 and received the waste of the upper portion of the body. As preg- 
 nancy, however, advances with the disappearance of the Eustachian 
 valve, a small measure of placental blood is likewise distributed to the 
 lower portion of the body. This is in unison with the well-known 
 fact that the relative development of the lower extremities increases as 
 the end of gestation is approached. 
 
 With the cessation of the placental circulation at birth, the um- 
 bilical vessels close, with the exception of the umbilical arteries, which 
 remain pervious at their lower portion and constitute the vesical arte- 
 ries. After the establishment of respiration, the blood from the right 
 side of the heart makes the circuit of the lungs and returns to the left 
 side by the pulmonary veins. The ductus arteriosus then contracts 
 and disappears. As the left auricle fills with blood, the pressure closes 
 the valve of the foramen ovale. Occasionally, however, the foramen 
 ovale remains open after birth, and allows a portion of the venous 
 blood to pass from the right to the left auricle. We have then one 
 form of the condition known as cyanosis neonatorvm^ an affection 
 characterized by intermittent attacks of dyspnoea, blueness of the sur- 
 face of the body, and depression of the temperature. 
 
 The Foetus at Term.— In the child at birth the body is well rounded, 
 and the skin has lost its deep-red coloring ; the fine down (lanugo) 
 has, for the most part, disappeared ; the nails project beyond the fin- 
 ger-tips ; in the male the scrotum contains both testicles, and in the 
 female the labia majora are in "contact. In the fifth month the sur- 
 face of the fetal body is covered by the vernix caseom, a whitish sub- 
 stance composed of a commingling of surface epithelium, down, and 
 the products of the sebaceous glands. This coating probably protects 
 the skin during intra-uterine life from the penetration of the amniotic 
 fluid. The amount of this substance upon the body is very variable 
 at birth, when it is chiefly found upon the back and flexor surfaces of 
 the extremities. 
 
 Children at term cry lustily soon after birth, move their limbs
 
 DEVELOPMENT OF THE FCETUS. 
 
 69 
 
 freely, and nurse when put to the breast. In the first few hours they 
 pass urine and the so-called meconium^ a mixture of intestinal mucus 
 with epithelium, epidermis cells, lanugo, and bile, which gives to it a 
 black or brownish-green color.* 
 
 The average length at birth is from twenty to twenty-one inches. 
 The average weight seems to be, in some degree, dependent upon race 
 peculiarities. Scunzoni f found, in nearly 0,000 births, an average for 
 both sexes of nearly seven pounds. Ingerslev,J in Copenhagen, from 
 statistics based upon 3,-450 births, arrived at nearly the same results. 
 Hecker,* in Munich, out of something over 1,000 births, obtained six 
 and four fifths pounds as the average ; wliile Fesser, || in Breslau, found 
 it only six and a half pounds. Bailly ^ likewise reports the average 
 weight as something less than seven pounds. The weights of 200 
 infants born in the Bellevue Hospital gave to the writer an average of 
 seven and two thirds pounds for the two sexes. The boys averaged 
 seven and nine tenths pounds, and the girls seven and one third 
 pounds. Three fourths of the mothers were of Irish birth, one fifth 
 were born in America, while the remaining fraction was divided be- 
 tween English, Scotch, and Germans. The largest child weighed 
 eleven pounds. Ingerslev's largest child weighed ten and three eighths 
 pounds ; Hecker found two weighing between ten and eleven pounds ; 
 La Chapelle, out of 7,000 cases, found thirteen infants weighing ten 
 pounds, but none exceeded that limit. Credible histories I) of children 
 weighing from twelve to sixteen pounds are extant; such children 
 have often been still-born. Waller, however, J reports a case of a living 
 infant delivered by him with forceps, which weighed fifteen pounds 
 fifteen ounces. I have extracted with forceps a living child which 
 weighed over fifteen pounds. Dr. C. W. Gleavis, of Wytheville, Va., 
 writes me that a lady in that place gave birth to a living male child 
 which weighed eighteen pounds. The size of the child is influenced 
 in especial by — 1. The sex. Boys average a greater weight than girls. 
 2. The number of pregnancies. The children of primiparae average 
 less than those of multiparfe. The increase in weight of children in 
 each successive pregnancy is progressive, though this law is liable to in- 
 terruption where pregnancies follow one another too rapidly, or in cases 
 
 * ZwEiFEL, Untersuchungen iiber das Meconium, Arch. f. Gynaek., Bd. vii, 1875, 
 p. 474. 
 
 f ScANZONi, Lehrbuch der Geburtshiilfe, p. 96. 
 
 X Ingerslev's On the Weight of New-born Children, Obstet. Jour., iii, 1876, 
 p. 705. 
 
 * Klinik der Geburtskunde, ii, 1864. 
 
 II Spiegelberg, Lehrbuch der Geburtshiilfe, p. 86. 
 ^ Bailly, Nouveau Dictionnaire, t. xv, art. Foetus, p. 5. 
 
 Naegele's Lehrbuch der Geburtshiilfe, bearbeitet von Grenser, 8te Auflage, 
 p. 624. 
 
 X Waller, London Obstet. Trans., vol. i, p. 309.
 
 70 
 
 PHYSIOLOGY OF THE OVCJM- 
 
 in which there is a change of sex. In the latter instance the variation 
 is to the disadvantage of the female born in succession to a male.* 
 3. The age of the mother. Duncan found the greatest weight in 
 children born of mothers between the twenty-fifth and twenty-ninth 
 years ; f Wernich, between the thirtieth and thirty-fourth years. I 4. 
 The constitution and health of the parents. By some, too, the size 
 of the father is sup^josed to exercise an influence upon that of the 
 child. 
 
 The Fetal Cranium.— Except in children of exaggerated size, the 
 head is the most voluminous and unyielding part which has to traverse 
 the parturient canal.* The diameters of the head and the physical char- 
 acters of its bones are chiefly of importance in connection with the mech- 
 anism of labor. Their consideration may, therefore, be conveniently 
 postponed to the study of that subject. A knowledge, however, of the 
 general structure of the skull is essential to the diagnosis of pregnancy. 
 
 The face is very small in proportion to the cranium. The latter 
 consists of the two frontal bones, the two parietal bones, the occipital 
 bone, the temporal bones, and the alfe of the sphenoid bone. At birth 
 these various bones are not, as in the adult, directly articulated together, 
 but are united by means of fibrous bands, termed sutures, in which ossi- 
 fication subsequently takes place. It is important to become familiar 
 with the following sutures : 1. The fronfal xnture, between the frontal 
 bones. 2. The sagittal suture, between the two parietal bones. 3. Tlie 
 coronal siiture, between the frontal and parietal bones. 4. The lambda 
 suture, between the occipital and two parietal bones. 
 
 When three or more bones meet together, the rounded angles of the 
 bones offer at the point of concurrence a deficiency of osseous substance, 
 which is closed by fibrous membrano similar to that which forms the 
 sutures. These membranous interspaces are termdd foyitanelles. Two 
 of these, the large anterior and the small posterior fontanelle, are of 
 immediate obstetrical interest, as they, with the sutures, furnish the 
 guiding points which enable the examining finger to determine, in ad- 
 vanced pregnancy, the position of the child's head. 
 
 The large fontanelle, or bregmatic space (bregma, the sinciput), 
 occupies the gap between the parietal and frontal bones. It possesses 
 a lozenge-shape. Its anterior angle is continuous with the frontal 
 suture, its posterior angle with the sagittal suture, and its lateral 
 angles with the two halves which compose the coronal suture. Its an- 
 terior angle is much longer than the posterior angle. 
 
 The small fontanelle is situated at the junction of the occipital with 
 
 * Wernich, Ueber die Zunahme der weiblichen Zeugungsfahigkeit, Beitr. zur 
 Geburtsh., Bd. 1. p. 3. 
 
 t Duncan, Fecundity, Fertility, and Sterility, p. 53. 
 X hoc. cit., p. 10. 
 
 * In bulky children, the shoulders sometimes ofEer the greatest diflBculties in 
 delivery.
 
 DEVELOPMENT OF THE FCETUS. 
 
 71 
 
 Fio 
 
 53.— Fetal skull, seen from tlie side. T F, tuber parietale : L. lambda suture ; OM,oc- 
 cipito-iuental diameter ; C, coroual suture. (J. Veit.) 
 
 Fig. 54.— Fetal skull seen from above. 
 
 TT, bitemporal diameter ; FP, bi-parietal diameter. 
 (J. Veit.)
 
 Y2 PHYSIOLOGY OF THE OVUM. 
 
 the parietal bones. It is of a triangular shape, and, as its name indi- 
 cates, of small size. As a rule, it no longer exists at birth, owing to 
 the complete ossification of the angles which form it. 
 
 The anterior fontanelle may be recognized by the finger, during 
 labor, by its large size, its lozenge-shape, and by its four converging 
 sutures which cross one another at right angles. The posterior fon- 
 tanelle, on the contrary, is small and triangular ; the sagittal suture 
 forms, with the lambda suture, an obtuse angle on either side, and ter- 
 minates at the occipital bone. During the descent of the child's head 
 into the pelvis, the occipital bone is frequently depressed beneath the 
 parietal bones, which thus form a relief, along which the finger readily 
 passes to the site of the small fontanelle, even when the latter no longer 
 exists as an open gap or space. 
 
 The Attitude, Pkesentatiox, and Position of the Foetus. 
 
 The attitude of the foetus i/i ntero is as follows : The spinal col- 
 umn is bent forward, the chin is inclined toward the chest, the arms 
 are bent at the elbow and the forearms are crossed upon the breast, 
 the thighs are flexed upon the abdomen, and the feet extended so 
 as to come in contact with the legs, which, like the forearms, are 
 often crossed. By this arrangement the fci'tus assumes the smallest 
 bulk, and presents an ovoid form, of which the head furnishes the 
 smaller end. 
 
 By presentation we understand that portion of the foetus which oc- 
 cupies the lower segment of the uterus. By the determination of the 
 presentation, we are enabled to decide upon the relation of the axis of 
 the child to the long diameter of the uterus. When these two coin- 
 cide, either of the two extremities of the child, viz., the head or the 
 breech, becomes the presenting part. When the long diameter of the 
 child corresponds to the oblique or transverse diameter of the uterus, 
 the shoulder becomes the presenting part. 
 
 Though head-presentations form, during labor, by far the large 
 majority of all cases (ninety-six per cent.), changes of position are very 
 common during pregnancy. The frequency of these changes is in 
 inverse ratio to the advance of pregnancy, occurring with diminished 
 frequency in the later months. In multiparae they take place oftener 
 than in primiparae. In multiparse they occur not rarely shortly before 
 birth, while it is exceptional in primiparae for them to take place in 
 the last three weeks of pregnancy. Great ingenuity has been exercised 
 to account for the preponderating frequency, at the time of labor, of 
 head-presentations. Hippocrates taught that, during the early months 
 of pregnancy, the fojtus occupied a sitting posture, with the head 
 uppermost. In the seventh month, however, it made a complete 
 turn or somersault preparatory to its exit from the womb, an act
 
 DEVELOPMENT OP TUE FOETUS. 
 
 73 
 
 accomplished by the vohmtary efforts of the child. Aristotle referred 
 the head-presentations to the laws of gravity, a theory which has 
 always had many adherents and is still actively defended at the pres- 
 ent day.* 
 
 Dubois f made a serious breach in this doctrine by showing that if 
 he allowed a dead fa?tus, of any period between the fourth and ninth 
 months, to sink in a vessel filled with 
 water, it was not the head, but the 
 back or right shoulder which first 
 reached the bottom. Dubois there- 
 upon denied the influence of gravity, 
 and referred the head-presentations to 
 instinctive or voluntary movements on 
 the part of the foetus, designed to 
 bring it into a position best adapted 
 for intrauterine domicile, or for par- 
 turition. He likewise argued against 
 the gravitation theory, that in pre- 
 mature births, and in children who 
 die in utero, pelvic and transverse pre- 
 sentations are very common — a fact 
 that would be inexplicable were grav- 
 ity the sole or chief force in opera- 
 tion. Simpson J agreed with Dubois 
 in ascribing the cephalic presentations 
 to fetal movements, but, in place of 
 the instinctive or voluntary movements 
 of Dubois, substituted, in an argument 
 of extraordinary ingenuity, a theory 
 of reflex action. Thus, the frequency 
 of mal-positions in the first six months 
 of pregnancy was explained by the 
 
 spheroidal shape of the uterine cavity, which allows of unrestrained 
 fetal movements. In the later months, however, as the uterus assumed 
 a more ovoid shape, it was only when the child was situated in the 
 uterus with the head lowest that a physical adaptation between icetus 
 and uterus existed. In case from any cause, therefore, a deviation 
 from this, the normal position, took place, the pressure upon the cuta- 
 neous surface of the child, by the uterine wall, would give rise to excito- 
 
 * Vide historical part of Cohnstein's paper entitled Die Aetiologie der normalen 
 Kinderlage, Monatssch. f. Geburtsk., Bd. xxxi, p. 142. 
 
 t Dubois, Memoire sur la cause des presentations de la tete, Mem. de I'Acad. 
 Roy. de Med., tome ii, 1833, p. 265. 
 
 t Simpson, Attitude and Positions of the Foetus in Utero, Obstetric Works, 
 edited by Priestley and Storer, vol. ii, p. 81. 
 
 Fig. 55.— Attitude of foetus in ntero. 
 (Tarnier et Chantreuil.)
 
 ^^ PHYSIOLOGY OF THE OVUM. 
 
 motory movements of an adaptive kind, calculated to restore the dis- 
 turbed presentation. Duncan* and Yeit succeeded in partially re- 
 habilitating the gravitation theory by sliowing that, notwithstanding 
 Dubois's experiinents, the center of gravity lies much nearer the 
 cephalic than the pelvic extremity of the child. They found that a 
 fresh fa?tus immersed in a saline fluid possessing nearly the same spe- 
 cific gravity as the foetus, in place of sinking upon its back or side to 
 the bottom of the vessel, assumed an oblique direction in the fluid 
 with the right shoulder looking downward, f They therefore con- 
 cluded that the foetus, lying upon the inclined plane furnished by 
 the uterine walls, would naturally assume a similar position were no 
 other forces operative to interfere. Crede, Kristeller,| and Braxton 
 Hicks* maintain that the contractions of the pregnant uterus adapt 
 the position of the foetus to the form of the uterus. Veit believes 
 that the stability of the foetus is insured by the descent in advanced 
 pregnancy of the presenting part below the level of the pelvic brim. 
 
 Now, each one of these conflicting ideas undoubtedly represents a 
 portion of, but not all, the truth. It is certain that the influences 
 cited do exist, and it only remains for us clinically to assign to each its 
 relative value. In the early months of pregnancy, the spheroidal 
 shape of the uterine cavity, the small size of the fcrtus in comparison 
 with that of the uterus, and the large proportion of amniotic fluid, all 
 allow the foetus the greatest measure of mobility. At this time the 
 position of the child must be influenced by the active movements 
 which are felt by the mother subjectively often as early as the four- 
 teenth week. As usually, during the first half of pregnancy even, 
 the shoulder and head are turned downward, it is fair to ascribe tliis 
 position to the laws of gravity. The frequency of malpresentations in 
 premature labors is explained in part by the tardy dilatation of the 
 cervix and the mobility of the foetus, which render easy the displace- 
 ment of the head from its first position, under the influence of pressure 
 exerted upon the axis of the child's body. Malpresentations are more 
 frequent in the case of a dead foetus than in the living, but Duncan 
 has shown that in the dead foetus, owing to post-mortem changes, the 
 center of gravity often shifts toward the pelvic extremity. With the 
 advance of pregnancy, as the longitudinal exceeds the lateral growth 
 of the uterus, the child adapts itself to the long axis of the uterus, 
 and the furthei pregnancy advances the more complete the adaptation 
 becomes. When from any cause or condition the correspondence be- 
 tween the fetal and uterine axis is disturbed, compression of a portion 
 of the cutaneous surface of the foetus results. Reflex movements, 
 
 * Duncan, Researches in Obstetrics, p. 14. Yeit, Scanzoni's Beitrage, Bd. iv, p. 279. 
 f On account of the liver upon the right side. 
 
 X Vide Schroeder's Handbuch der Geburtshiilfe, 4te Auflage, p. 47. 
 
 * Hicks, Contractions of Pregnant Uterus, Obstet. Trans., p. 224. 
 
 I
 
 DEVELOPxMENT OF THE FCETUS. ^5 
 
 especially in the lower extremities, are excited, which restore the fcetus 
 to that position in which it enjoys the most complete freedom from 
 discomfort. Often, too, the uterine walls resent the pressure of the 
 foetus, and, by their contractions, serve to maintain the body of the 
 child in the uterine axis. 
 
 In cases of hydramnios the conditions more nearly resemble those 
 which exist in early pregnancy ; hence malpresentations occur with 
 greater frequency, favored by the mobility of the fcetus in the surplus- 
 age of amniotic fluid. Per contra, when, as is the case toward the 
 end of normal pregnancies, the fcetus nearly fills the intra-uterine 
 space, the movements are very restricted, and displacements rare. 
 
 In primiparous women, the pyriform shape of the uterus in the 
 later months is most marked, and as a consequence the head of the 
 child is usually held by the uterine walls in the pelvic cavity. In 
 multipara?, on the contrary, owing to the relaxation of the uterine 
 parietes, it) is usual for the child, in obedience to the laws of gravity, 
 to lie somewhat obliquely in the uterus, with its head resting upon one 
 of the iliac fossa?. As soon as labor begins, however, the uterine con- 
 tractions carry the head to the axis of the superior strait of the pelvis. 
 
 The changes in the fetal presentation are not, however, confined 
 to simple conversions from an oblique to an upright direction, or to 
 shiftings of position iy obedience to laws of gravity. But even in ad- 
 vanced pregnancy a breech-presentation may become a head-presenta- 
 tion, and vice versa* P. Miiller reported a case in which the foetus 
 made six such revolutions within five days.f Now, it can not be sup- 
 posed that the difficulties which the foetus must encounter from the 
 resistance of the short transverse diameter of the uterus could be over- 
 come by such comparatively feeble forces as gravity, or reflex adapt- 
 ive movements, or partial uterine contraction. In Miiller's case the 
 changes, if the mother's story be correct, must have taken ^place not 
 gradually but suddenly, and by the vigorous movements of the child's 
 limbs. Meeh | calls attention to the fact that the movements of the 
 child are produced chiefly by the extension of the lower extremities, 
 and argues that these movements aid to a greater extent in changing 
 the presentation of the child when the breech occupies the lower seg- 
 ment of the uterus, because of the solid resistance offered by the bony 
 pelvic ring, while in head-presentations the pressure of the extremities 
 against the elastic fundus is in the rule unavailing to effect any con- 
 siderable changes of position. 
 
 * ScHROEDER, Schwang., Geb. u. Wochenbett, Bonn, 1867, p. 31 ; Schultze, 
 Unters. uber den Wechsel der Lage, etc., Leipsic, 1868 : Fassbender, Berl. Beitrage 
 zur Geb. und Crvnaek., Bd. i, p. 41. 
 
 t ScAxzoNi's Handbueh der Geb., 4te Auflage, p. 123. 
 
 X Meeh. Warum komrat das Kind am haufigsten in der Kopfendlage zur Welt f 
 Arch. f. Gynaek., vol. xx, p. 185.
 
 Yg PHYSIOLOGY OF THE OVUM. 
 
 By position is designated the relation of a determinate point in the 
 body of the foetus to the uterine walls. In head or breech presenta- 
 tions, the back of the child is most commonly turned to the left, which, 
 hence, is termed the first position. The back turned to the right is 
 known as the second position, and occurs with much less frequency. 
 
 In the first position the back is usually directed somewhat ante- 
 riorly, while in the second position it is turned rather to the rear. 
 T.n shoulder-presentations the back is usually directed to the front. 
 Changes of position are frequent in pregnancy, and take place, Avhen 
 other influences do not prevent, in obedience to laws of gravity. When 
 the woman stands erect, the axis of the uterus is continuous with the 
 axis of the superior strait of the pelvis, and forms with the horizon an 
 angle of thirty-five degrees. The uterus does not occupy exactly the 
 median line, but lies more to the right. It is also twisted slightly upon 
 its axis, so that the left lateral portion is directed somewhat to the 
 front. In the upright position, therefore, the anterior wall of the 
 uterus not only forms an inclined plane, but one, too, with a down- 
 ward drop toward the left side. Now, if these relations be borne in 
 mind, it w\l be readily seen that the child, resting upon the inclined 
 plane furnished by the anterior wall, with its right shoulder directed 
 downward, must, if left to itself, turn with its back to the left side of 
 the uterus. In the recumbent posture, the axis of the uterus forms 
 with the horizon an angle of thirty degrees, and the downward slope is 
 to the right side. The child, now resting upon the inclined plane 
 furnished I^j;; the posterior wall, with its right shoulder directed down- 
 ward, would naturally turn with its back to the right side of the uterus. 
 These considerations are not purely theoretical, as, when the conditions 
 have been such as to allow the foetus latitude of movement, the changes 
 indicated in the fetal position followed changes in the attitude of the 
 mother.* 
 
 The position of the child has heretofore been determined by that 
 of the child's head when, after the advent of labor, the head has been 
 brought within reach of the examining fingers. Sutugin, however, 
 maintains that, during pregancy, if the patient be examined in the re- 
 cumbent position, the back is nearly always turned to the rear whether 
 it be situated to the right or the left of the spinal column. Changes of 
 position by posterior rotation he believes are not uncommon. f 
 
 * HiJxixG, Scanzoni's Beitrage, Bd. vii, p. 99. 
 
 t Sutugin, Beitrage zum Mechanismus der Geburt bri SchOdellagen. Klinische 
 
 Vortrage, No. 310.
 
 PHYSIOLOGY OF PREGiN'AE'OY. 
 
 CHAPTER IV. 
 
 CHANGES EFFECTED IN THE MATERNAL ORGANISM BY 
 PREGNANCY. 
 
 Changes in the sexual apparatus and neighboring organs. — Changes in the uterus. 
 — Explanation of apparent shortening of cervix. — Changes in the vagina, 
 vulva, abdomen, navel, breasts, nipple. — Functional disturbances of bladder. — 
 Constipation. — CEdema. — Changes effected in the entire organism. 
 
 Changes occuruixg ix the Sexual Apparatus axd 
 Neighboring Organs. 
 
 The pregnant state is signalized by the nutritive energy imparted 
 by the fecundated ovum to the generative organs and to the viscera in 
 their vicinity. 
 
 The uterus, from, the inception of pregnancy, increases in vascu- 
 larity. Its mucous membrane becomes soft and thickened. The mus- 
 cular fibers are increased seven to eleven times in length, and three 
 to five times in width. During the first five months new muscular 
 fibers are developed, especially upon the inner layer of the uterus. 
 The delicate connective-tissue processes between the muscular fibers 
 become more abundant, and toward the termination of pregnancy 
 display distinct fibrillar. The vessels increase in number, length, and 
 circumference. The arteries, as we have noticed, assume a spiral 
 course, and in places communicate directly with the veins. The veins 
 are dilated, and form, especially in the placental region, wide-meshed 
 networks. The walls of the veins are intimately united with the 
 muscitlar walls of the uterus, and form, when divided, open-mouthed 
 canals. The lymphatics, starting from the spongy tissues of the lin- 
 ing mucous membrane, traverse the muscular structures, and are 
 gathered up by abundant plexuses, which are distributed especially 
 over the fundus and sides of the womb. The nerves increase in length 
 and thickness, and grow inward toward the uterine cavity. Upon the 
 inner surface of the uterus ganglia may be observed.* The ganglion 
 cervicale, Avhich measures in the non-pregnant condition three fourths 
 of an inch in length and half an inch in width, is now an inch and a 
 half in breadth, and possesses a length of two inches. 
 
 * Spiegelberg, Handbuch der Geburtshiilfe, p. 50.
 
 ^^ PHYSIOLOGY OF PKEGNANCY. 
 
 These textural changes are accompanied by an enormous increase in 
 the vohime of the uterus. The weight of the latter in the virgin state 
 is about an ounce, while toward the end of pregnancy it weighs in the 
 neighborhood of two pounds. The increase in the bulk of the uterus 
 is progressive. The following table, by Arthur Farre,* furnishes ap- 
 proximate measurements for the different months of pregnancy : 
 
 Length. Width. 
 
 End of 3d month 4^-5 inches, 4 inclies. 
 
 4th " 
 
 5th 
 6th 
 7th 
 8th 
 9th 
 
 5i-6 ' 
 
 5 
 
 6 -7 " 
 
 5J 
 
 8 -9 " 
 
 6i 
 
 10 ' 
 
 7i 
 
 11 ' 
 
 8 
 
 12 ' 
 
 9 
 
 According to Levret, the surface of the virgin uterus msasures six- 
 teen square inches, while that of the pregnant uterus at term measures 
 three hundred and thirty-nine square inches. f The uterine cavity is 
 stated by Krause to be enlarged five hundred and nineteen times. | 
 
 The enlargement of the uterus is not due, in the beginning of 
 pregnancy at least, to the pressure of the expanding ovum, for the 
 same changes occur during the first four months in cases of extra- 
 uterine pregnancy. In the latter months, however, a mechanical 
 stretching is probable, as the walls become thinned and conform to 
 the size of the ovum. At term, the walls are not of uniform thickness, 
 but vary between one sixth and one fourth of an inch. 
 
 In pregnancy the muscular fibers of the uterus, as has been shown 
 by Ruge, Hofmeier, and others, are arranged in groups, which possess 
 a lamellar structure, the individual layers pursuing a general direction 
 from the peritoneal covering downward and inward toward the lining 
 mucous membrane. The principal layers are in turn united by com- 
 municating bundles, so that when separated from one another the spaces 
 between them have a rhomboidal shape. Very nearly the same ap- 
 pearances are obtained when the section is transverse or oblique as 
 when made in a longitudinal direction. Over the larger portion of 
 the uterine surface the peritonaeum is firmly adherent. Only at the 
 lower segment, for a space varying from three to six centimetres, 
 measured from the internal os, the peritoneal attachment is easily 
 separable. According to Hofmeier,* the muscular plates in this 
 division are loosely associated together, and the fibers of each lamella 
 are intimately interwoven, crossing one another in every direction. In 
 
 * Cyclopaedia of Anatomy and Physiology, article Uterus and its Appendages, 
 p. 645. 
 
 f Vide ScANZONi, Handbuch der Geburtshiilfe, p. 77. 
 
 X Vide Spiegelberg, Handbuch der Geburtshiilfe, p. 51. 
 
 » Hofmeier, Das Unterer Uterensegment in Schroeder's Schwagnere und Kreiss- 
 ende Uterus, p. 59.
 
 CHANGES IN THE MATERNAL ORGANISM BY PREGNANCY. Y9 
 
 the body proper of the uterus there 
 is a broad muscular layer, which ad- 
 heres firmly to the peritoneal covering, 
 the differentiation of the individual 
 lamellae is more pronounced, the mus- 
 cular fibers are arranged more in bun- 
 dles, and, in general, form layers which 
 correspond to a greater degree to the 
 longitudinal and transverse axes of the 
 uterus. 
 
 The uterine artery, after first sup- 
 plying a branch to the cervix, runs up 
 along the side of the uterus, and gives 
 off the first important branch to the 
 body of the uterus at the point where 
 the peritonaeum firmly adheres to the 
 muscular walls. The lower segment, 
 therefore, receives no important vessels, 
 and is characterized by a low degree 
 of vascularity.* 
 
 With the growth of the gravid 
 uterus, the peritoneal coat is put upon 
 the stretch, and, in places, a thicken- 
 ing of the serous membrane lakes place 
 by the formation of new tissue ele- 
 ments. At the same time the folds 
 of the broad lip:aments gradually sepa- 
 rate, so that toward the end of preg- 
 nancy the ovaries and Fallopian tubes 
 are in close contact with the uterus. 
 
 The growth of the uterus is con- 
 fined chiefly to the body, the cervix 
 participating only to a slight extent. 
 In the early months, the increase is 
 rather in the antero-posterior and lat- 
 eral diameters than in the longitudinal 
 diameter. As a consequence, in the 
 rule, it is not until the fourth month 
 that the fundus can be felt through 
 the abdominal walls above the sym- 
 physis pubis. In these earlier months 
 the normal anteflexion of the uterus 
 is increased by the weight of the cor- 
 
 * HoFMEiER, Beitrage zur Anatomie der Schwangeren und Kreissenden Uterus, 
 p. 33. 
 
 O.i. 
 
 O.e. 
 
 Fig. 56.— Lower segment of uterus, sixth 
 month pregnancy. iHofmeier.) B, 
 boundary of firm peritoneal attach- 
 ment ; O. I., internal orifice ; O. e., 
 external orifice.
 
 80 
 
 PHYSIOLOGY OP PREGNANCY. 
 
 pus uteri. In the fifth month the uterus fills the hypogastrium, and 
 in the ninth month reaches the epigastrium. During the last two 
 weeks, however, the uterus sinks somewhat into the pelvic cavity. At 
 the same time the fundus of the uterus sinks downward and forward, 
 so as to stand about three inches beneath the lower extremity of the 
 sternum. 
 
 In the upright posture the uterus, in advanced pregnancy, rests 
 upon the anterior abdominal walls. As, in the intervals of contrac- 
 tion, the uterus is a mere sac with fluid contents, it becomes flattened 
 from front to rear, and the width increases at the expense of the dis- 
 tance from the fundus to the symphysis pubis. In the horizontal 
 position, in which the uterus rests upon the vertebral column, its 
 length is, on the contrary, increased and its width diminisiied. In 
 the upright position, the intestines occupy the space posterior to the 
 uterus. In the dorsal position, the intestines lie chiefly upon the 
 sides, but partly, too, in front of the uterus. 
 
 During the first three months of pregnancy the pyriform shape of 
 the uterus is preserved. During the succeeding three months, owing 
 to the relative increase in the lateral and antero-posterior diameters, 
 the body gradually assumes the appearance of a flattened spheroid. 
 After the sixth month the longitudinal diameter again preponderates. 
 
 As the dilatation of the uterus takes place more rapidly in its upper 
 than in its lower segment, the cavity of the organ assumes, under 
 normal conditions, an oval shape, with the narrow end pointing down- 
 ward, corresponding to the ovoid shape of the foetus in head-presenta- 
 tions. It was long taught and believed that this change of shape, 
 occurring in the later months of pregnancy, was due to the gradual 
 unfolding of the cervix uteri from above downward, which thus con- 
 tributed to the enlargement of the uterine cavity. It is, however, 
 probable that, with rare exceptions, the cervix uteri maintains its com- 
 plete integrity up to the commencement of labor. The enlargement 
 of the uterus, necessitated by the development of the foetus, results 
 chiefly from the growth and distention of the fundus and posterior 
 uterine wall. 
 
 The cervix uteri participates in the hypertrophy of the entire 
 uterus. Its development, however, is completed by the fourth month, 
 and is the result not so much of increased growth or new formation of 
 tissue elements as of the loosening of its structure and swelling from 
 serous infiltration. This latter is the consequence of a hyperaemia of 
 the cervix, which results from the passive relaxation and dilatation of 
 the cervical vessels. It occasions a physiological softening of the 
 tissues, which first manifests itself in those portions of the cervix where 
 the least resistance is encountered, viz., beneath the mucous mem- 
 brane beginning at the os externum, extending outward through the 
 muscular structures of the vaginal portion, and afterward upward
 
 CHANGES IN THE MATERNAL ORGANISM BY PREGNANCY, si 
 
 toward the os iuteruuin.* The follicles of the cervical mucous mem- 
 brane furnish a thickened secretion, which fills the cervical canal, 
 and forms what is known as the " mucous plug." Frequently the 
 orifices of the follicles become occluded. The follicular sacs then fill 
 with their own secretion, and project from the mucous surface as the 
 ovules of Naboth. Erosions about the os externum are rarely absent 
 in advanced pregnancy. 
 
 With the advance of pregiumcy an apparent shortening of the cer- 
 vix takes place, at first confined to the vaginal portion, but afterward 
 involving the entire organ. The earlier explanation of this phenomenon, 
 and one which still nK?ets with very general acceptance, assumes that, 
 after the sixth month, a gradual unfolding of the cervix from above 
 downward takes place, which contributes to the enlargement of the 
 uterine cavity. In this manner space is provided in correspondence 
 with the rapidly increasing growth of the foetus. The strength of 
 this doctrine lay, in a great measure, in the seemingly confirmatory 
 evidence afforded by digital explorations. 
 
 In opposition to the current opinion, Stoltz, in his inaugural thesis, 
 published in 182(!,f maintained that the internal os remained closed up 
 to the last two weeks ])receding delivery, when, indeed, under the in- 
 fluence of painless contractions, the effacement of the cervix, described 
 by earlier writers, did in fact, at least in primipara?, take place. Stoltz 
 explained the ai)jiarent shortening of the cervix as the result of a 
 spindle-shaped dilatation of the cervical canal, causing an approxima- 
 tion of the external and internal orifices. In 1859 Duncan;]; furnished 
 corroborative evidence of the general correctness of Stoltz's view, by 
 means of two dissections of uteri derived from women who died re- 
 spectively in the seventh and eighth months of pregnancy. In these 
 cases the length of the cervix uteri had undergone little or no change 
 consequent upon pregnancy. Duncan, however, in common with 
 Stoltz, admitted that, during the later days of gestation, incipient 
 uterine contractions of a painless nature may lead to the opening of 
 the internal os. In 1803 he showed that Stoltz's discovery had been 
 anticipated by Weitbrecht in 1750.* In 1862 Professor I. E. Taylor, || 
 of New York, stated, what is without doubt true in the majority of 
 cases, that the cervix remained closed, and retained its entire length up 
 to the very beginning of active labor. In evidence he offered the re- 
 sults of four post-mortem examinations made upon women dying from 
 
 * LoTT, Zur Anatomie und Physiologic des Cervix Uteri, Erlangen, 1872, pp. 
 35, 36. 
 
 t Sur les dififerents etats du col de I'literus, niais principaleinent sur les change- 
 ments que la gestation et raccoucheinent lui font eprouver, Strasbourg, 183G. 
 
 t On the Cervix Uteri in Pregnancy, Edinburgh Med. Jour., vol. iv, 1859, p. 774. 
 
 * Vide Edinburgh Med. Jour., September. 1863. 
 
 1 Taylob, On the Cervix Uteri, Am. Med. Times, June 21, 1862. 
 6
 
 g2 PHYSIOLOGY OP PREGNANCY. 
 
 accidental causes during the first stage of labor.* In 1873 I found in 
 the dissecting-room a woman seven months pregnant, who had died 
 in the first stage of labor, but after dilatation of the cervix had well 
 advanced. The bag of waters, in the form of a cylindrical sac two 
 inches in diameter, protruded into the vagina. Both the cervical 
 orifices were distinctly defined; the cervix was equally expanded 
 tliroughout its entire extent ; and tlie head rested above the os inter- 
 num. The cervix clearly formed no part of the uterine cavity, but 
 served merely as a communicating passage between the uterus and 
 vao-ina. Dr. Taylor has made some very interesting observations upon 
 the action of tlie cervix during labor, using for the purpose a large 
 (three to three and a half inch) cylindrical speculum, by means of 
 which the entire process can be freely witnessed. In multiparous 
 women he has seen the head descend during a pain so as to produce 
 complete obliteration of the cervix, and then recede, leaving the latter 
 with the same appearances as existed previous to labor, f 
 
 While the non-shortening of the cervix has been fairly demon- 
 strated, it is not so clear tluit the os internum remains closed in all 
 cases up to the beginning of labor. Certainly there are rare excep- 
 tions to the rule, Litzmann J reported a case in which the mem- 
 branes were found, at the time of labor, attached to the cervical wall 
 around the periphery of the os externum. In a few instances I have 
 had an opportunity, during the last period of pregnancy, to deter- 
 mine by touch the dilatation of the os internum. The cervix, how- 
 ever, did not expand in such a way as to become continuous with the 
 uterine cavity, but remained distinct and apart, preserving its inde- 
 pendent existence. IIow far such a dilatation is due to painless labor 
 it is impossible to say. Miiller * regards it rather as the result of the 
 pressure of the head upon the softened cervix. I had once occasion 
 to examine a multipara toward the end of gestation, to determine the 
 question as to the safety of her making a railroad journey to a neigh- 
 boring city. I found the head low, the cervix soft, and the os inter- 
 num clearly dilated to the size of a dollar. Two weeks later I was 
 called to see her in the early stage of labor, and found that, under the 
 influence of the uterine contractions, the canal of the cervix had again 
 closed. 
 
 The apparent shortening of the cervix is unquestiona])ly due in 
 part to the swelling, incident to pregnancy, of the vaginal mucous 
 
 * Vide likewise the ease of Angus McDonald, in Edinburgh Med. Jour., April, 1877. 
 \ Med. Record, October 13, 1877. 
 
 X Das Verhalten des Cervix Uteri in der Schwangerschaft, Arch. f. Gynaek., Bd. 
 X, p. 130. 
 
 * Untersuchungen iiber die Verklirzung der Vaginalportion in den letzten 
 Monaten der Graviditat : Scanzoni's Beitrage, Bd. v, H. 2, 1869. pp. 306 et seq. 
 Muller does not, however, exclude the possible action of uterine contractions.
 
 CHANGES IN THE MATERNAL ORGANISM BY PREGNANCY. 
 
 83 
 
 membrane, and of the vascular, loose-meshed tissues surrounding the 
 cervix at the vaginal junction. But, in addition, a noticeable differ- 
 ence may be observed between cases in which the head occupies the 
 pelvis and tliose in which it rests upon an iliac fossa. In the latter the 
 cervix is found, both by the speculum and by the touch, to have pre- 
 served its entire length. In the former, on the contrary, the anterior 
 lip is often obliterated, while the length of the canal and the posterior 
 cervical wall remain unchanged. 
 
 In explanation of this phenomenon, it is to be borne in mind that 
 in the upright position the uterus forms with the horizon an angle of 
 thirty-five degrees. The weight of the ovum, resting upon the in- 
 clined plane of the ixterus, increases the convexity of the anterior wall, 
 and the head of the foetus, when it enters the pelvic cavity, does not 
 fall directly upon the os internum, but somewhat in front, producing, 
 
 Fig. 57.— B, borders of the cervical mucous membrane ; PI, placenta ; V, bladder : O.i., os in 
 ternum ; O.e., os externum ; A a', apparent length of cervical canal on digital examination 
 
 in accordance with the laws of gravity, a bulging of the anterior lower 
 segment. TTpon vaginal examination the head is felt, therefore, low 
 down, and covered by the uterine walls, while the cervix is drawn up- 
 ward and backward by the retractor muscles, and is often reached 
 with difficulty, because the finger, in passing to it, has first to make 
 the circuit of the child's head. The bulging produced by the latter 
 effaces the angle between the anterior lip and the vaginal wall, while 
 the posterior lip remains unchanged. The canal of the cervix assumes
 
 g^ PHYSIOLOGY OF PREGNANCY. 
 
 an oblique or nearly vertical direction, but when examined with care, 
 with due regard to the physiological softening of its tissues, is found 
 to have preserved its normal length. By pushing the head away from 
 the cervix, or by placing the patient in the knee-elbow position, so as 
 to allow the head to recede, the anterior lip resumes its normal dimen- 
 sions.* 
 
 Bandl (Ueber das Verhalten des Uterus und Cervix in der Schwangerschaft 
 und wahrend der Geburt, 1876) has sought to prove that whereas, in point of 
 fact, a portion of the cervix remains closed to the end of ])regnancv, a portion of 
 the same does, as Roederer tauglit, contribute to the formation of the uterine 
 cavity. 
 
 In presenting his views to the Naturforscher-Versammlung at Hamburg, in 
 1876, Bandl stated that, upon examination of the familiar Braune section, 
 made upon the cadaver of a parturient woman, he was struck with the impossi- 
 bility that the cervix therein depicted, measuring eleven centimetres in front and 
 ten centimetres posteriorly, could be the sliort narrow canal, from two to four 
 centimetres long, observed by Miiller toward the end of gestation. As a rule, 
 however, in case of the deep position of the ovum, or fetal head, above the 
 constriction designated by Mtiller as the os internum, may be felt a second and 
 much larger ring, which his subsequent investigations showed was the os 
 internum proper. The lower constriction he termed, therefore, the spurious os 
 internum, or the ring of Miiller. Owing to the fact that the walls of tlie canal 
 between the upper and lower rings are much thinner than those of the uterine 
 body, a well-defined ridge is felt, which has since been termed the.j u.ntr <jf 
 Bandl. 
 
 At first Bandl supposed that the new cervico- uterine canal was covered by 
 decidua, the mucous membrane jjioper having been crowded downward by the 
 pressure of the ovum. In this way, by the formation of overla])j)ing folds, the 
 ring of Muller is approximated to the os externum, and the apparent shortening 
 of the cervix is accomplished. At the same time, by the continued growth, 
 and by what he termed the vital action of the parts, a "new cervix " was 
 formed above the remains of the old canal, derived chiefly by a sort of migra- 
 tory movement from the nuiscular structure of the original cervix. The 
 decidua, meantime, unable to follow the expansion of the outer layers, was torn 
 in many places, forming scattered islets, between which the chorion came into 
 immediate contact with the muscular walls. 
 
 In September, 1877, at a meeting of the German gynaecologists at Munich, 
 Bandl abandoned his theory of a new cervix formed by a movement u])ward of 
 musculai- fibers and the crowding down of the cervical nmcous membiane, and 
 taught in its place that, in primiparai, a portion of the cervix really exjjands to 
 contribute to the uterine cavity. In the earlier months, he stated, the mucous 
 membrane of this portion retains its cervical characteristics, but in the latter 
 part of gestation it is converted into a kind of decidua. The flattened, ex- 
 panded portion in multiparae, he acknowledged, was often extremely small. 
 
 * P. MULLKR, op. pit., p. ,343. 
 
 LoTT, Verhalten des Cervix Uteri wahrend der Schwangerschaft, p. 71. 
 
 I. E. Taylor, Non-shortening of the Cervix during Gestation, Med. Record, 
 October 13, 1877, p. 646, with verbal statement of the author concerning the results 
 of his examinations of pregnant women in the genu-pectoral position.
 
 CHANGES IN THE MATERNAL ORGANISM BY PREGNANCY, 
 
 85 
 
 This, at first, he attributed to morbid conditions, such as slight inflamma- 
 tions, or defective invoUition, which interfered with the rolling out of the 
 ujjper portion of the canal. In 1879, before the Natur.-Versammlung at 
 Baden-Baden, he explains finally that, in first labors, the mucous membrane of 
 the dilated portion of the cervix becomes torn and stripped off. Subsequently 
 a new membrane is formed upon the denuded surface which is not distinguish- 
 able from that of the uterine body, and upon which, in future pregnancies, 
 the decidual formation may be traced to the persistent portion of the canal. 
 The OS internum, according to this view, is not marked by the cervical mucous 
 membrane, but is situated in the muscular walls, and usually corresponds to the 
 point at which the peritonaium leaves the uterus. 
 
 Kustner (Beitrage zur Anatomic der Cervix Uteri, Arch. f. Gynaek., vol. 
 xii, p. 383) and Marchand (Noch Einmal das Verhalten der Cervix Uteri in der 
 Schwangerschaft, Arch. f. Gynaek., vol. xv, p. 169) claimed in certain cases 
 to have found the \Aicx palmatse and cylindrical epithelial cells at the distance 
 of from two to two and a half centimetres from the internal os, showing that a 
 funnel-shaped expansion of the upper portion of the cervix does take place 
 during pregnancy. Further evidence in support of Ktistner's views has been 
 offered by Keilmana (Zur Klarung der Cervixfrage, Zeitschr. f. Geburtshlilfe 
 und Gynaek., vol. xxii, p. 106) derived from observations made upon the uteri 
 of gravid bats. 
 
 Bayer (Gynaekologische Klinik, von Freund, Art. Morphologic der Gebar- 
 mutter, 1885), in an extremely complicated account of the muscular structure 
 of the uterus, maintains, likewise, that the lower segment is produced by the 
 rolling out of the upper part of the cervix, and that the cervical mucous mem- 
 brane is converted into decidua. He regards the process as a temporary pro- 
 vision, which disappears with pregnancy. The constriction termed by Bandl 
 the ring of Mtiller, Bayer maintains, is not an accidental point in the cervix, 
 but is the result of the loop-like arrangement of fibers derived from the re- 
 tractor muscles, by which the continuance of the cervical eversion is arrested at 
 a definite point in the canal. 
 
 According to investigations made by Leopold, McDonald, Miiller, 
 Sanger, Schroeder, Hofmcier, Waldeyer, myself, and others, the lower 
 segment is derived from the body of the uterus, and not from the cer- 
 vix. In three autopsies made by me upon women who had died in the 
 last month of pregnancy — one primipara and two multiparae — the same 
 conditions prevailed in all, viz., the cervix exceeded four centimetres 
 in length and was increased in thickness, the mucous plug terminated 
 at the upper orifice, and the membranes adhered closely to the lower 
 segment and to the borders of the internal orifice. That the cervix 
 maintains its independence to the beginning of labor is therefore true 
 in very many instances. That there are no exceptions, it would be 
 hazardous to maintain in the face of the positive testimony of Bandl, 
 Marchand, and Bayer. 
 
 In the vagina changes take place corresponding to those in the 
 uterus, though, of course, less in degree. The smooth muscular fibers 
 hypertrophy ; the vessels of the venous plexus increase in size, and im- 
 part a blue color to the vaginal walls ; the mucous membrane becomes
 
 gg PHYSIOLOGY OF PREGNANCY. 
 
 thickened, and furnishes a more abundant secretion. The mucous 
 membrane likewise increases in length, so that, in spite of the fact that 
 it is lifted upward by the elevation of the uterus, the anterior vaginal 
 
 Fia. 58. — Utenis from a multipara who died in the last month of pretrnanoy, showing: cervix of 
 normal length with membranes adherent to the os internum. (Bellevue Hospital.) 
 
 wall not unfrequently protrudes from the vulva. The papillae swell, 
 and impart a granular feel to the finger. 
 
 The vulva becomes turgescent, the labia gape apart, to the mucous 
 surface the enlargement of the veins and venous plexuses gives a dusky 
 hue, and the follicles secrete abundantly. 
 
 The connective tissue between the layers of the broad ligaments and 
 around the uterus becomes succulent from serous infiltration. The 
 lymphatics, which convey away the waste engendered by the rapid tis- 
 sue-changes in the pelvic organs, enlarge in conformity with the in- 
 creased labor thrown upon them. The hii)s broaden from the deposit 
 of fat in the subcutaneous tissue of the entire pelvic region. 
 
 With the growth of the uterus the abdominal walls are put upon
 
 CHANGES IN THE MATERNAL ORGANISM BY PREGNANCY. §7 
 
 the stretch, and, in well-nourislied individuals, are increased in thick- 
 ness by the more abundant formation of adipose tissue. By the fifth 
 montJi the navel begins to diminish in depth, and about the seventh 
 month becomes level with the skin. During the last two months the 
 navel often is everted by the pressure of the uterine tumor, and forms 
 a rounded elevation. Another consequence of the stretchino- of the 
 abdominal walls is the formation of reddish, bluish, and at times of 
 white glistening streaks (stria^), which do not disappear after delivery, 
 though they lose their coloring. They rarely fail in the last third of 
 pregnancy. They are found most abundant upon the lower half of the 
 abdomen, especially upon the sides, where they form curved, sinuous 
 lines. They are due to an atrophic condition of all the skin-layers, 
 to partial obliteration of the lymph-spaces, and to a condensation of 
 the connective- tissue elements, which, in place of forming rhomboid 
 meshes, run parallel to one another.* Stria? are produced likewise in 
 pathological distentions of the abdomen, and are not peculiar to preg- 
 nancy. Similar streaks form upon the nates and upon the anterior 
 and posterior surfaces of the thighs. They may occur, too, independ- 
 ent of pregnancy, as in the ra])id development of the hips at puberty. 
 Painful sensations at the costal insertions of the abdominal muscles 
 are often experienced during pregnancy. They occur more commonly 
 in multiparse, and, owing to the preponderance of the right lateral 
 position of the uterus, with greater frequency upon the right side. 
 Sometimes the recti muscles are separated from one another. This is 
 specially liable to take place in contracted pelves, and in women of 
 small stature, in whom, on account of the insufficient longitudinal 
 diameter of the abdominal cavity, the uterus is forced to make for itself 
 the space requisite for its development to term at the expense of the 
 abdominal walls. 
 
 The mammary glands, previous to gestation, are firm and nearly 
 hemispherical. During pregnancy the breasts increase in volume, and 
 present characteristic changes in structure and consistence. These 
 changes are due to a swelling of the connective tissue of the organ, the 
 development of glandular acini along the course of the lactiferous ducts, 
 and the increased deposition of fat between the lobes. The enlarge- 
 ment of the breast often begins in the second month, and becomes no- 
 ticeable between the fourth and fifth months of gestation. With the 
 development of the glandular structure the breasts possess a knotty, 
 uneven feel, more marked at first about the periphery of the organ, and 
 thence proceeding gradually toward the nipple. The veins enlarge, 
 and form a tracery beneath the skin. Early in pregnancy, fullness of 
 the breasts, and pains, shooting toward the axilla, are often experienced. 
 As the breasts increase in size, the cutis yields in many women about 
 
 * BusEY, The Cicatrices of Pregnancy, Trans, of the Am. Gynicc. Soc, vol. iv, 
 p. 141.
 
 gg PHYSIOLOGY OF PREGNANCY. 
 
 the periphery, where the tension is greatest, whereby bhiish, white, or 
 reddish lines, like those remarked ui)on the abdomen and thighs, make 
 their appearance. 
 
 The nipple becomes elongated, is more sensitive, and enters readily 
 into an erectile condition. Changes in the areola are jnstly regarded 
 as among the most important evidences of the existence of pregnancy. 
 Often as early as the second month the areola has a soft, anlematous 
 feel, and is raised above the level of the surrounding skin. The seba- 
 ceous follicles, ten to twenty in number, enlarge, and bedew the surface 
 with moisture. By the middle of pregnancy a circle, due to pigment-, 
 ary deposit, is formed around the nipple, the coloration of which de- 
 pends in part, though not altogether, upon the complexion of the 
 individual, being usually more intense in brunettes than in women 
 with fair hair and delicate skins. In the negress the areola is jet- 
 black, while in the albino it is of a delicate rose-color (Montgomery). 
 The diameter of the pigmented circle averages from an inch to an inch 
 and a half, though it sometimes greatly exceeds the figures mentioned. 
 In the latter part of pregnancy there often forms around the outer part 
 of the areola a so-called secondary areola, consisting of scattered round 
 spots, presenting the appearance as though, to use the language of 
 Montgomery, the color had been discharged by a shower of drops. 
 This peculiarity is due, for the most part, to the presence of enlarged, 
 non-pigmented sebaceous follicles. 
 
 The pressure of the gravid uterus gives rise to functional disturb- 
 ances in the neighboring organs of the pelvic cavity. The capacity 
 of the bladder is diminished, and, as a consequence, increased fre- 
 quency of urination results. In some women, when the bladder is 
 moderately full, the mere act of coughing or sneezing, or the up- 
 right posture, produces involuntary discharges of water. Constipa- 
 tion is common, due not so much, however, to mechanical obstruction 
 as to diminished intestinal action. In the later months of })regnaiu;y, 
 pressure on the sacral nerves gives rise at times to numbness of the 
 extremities, neuralgic pains, cramps, and hindered locomotion. (Ede- 
 ma of the lower half of the body and varicose dilatation of the veins 
 of the legs, the rectum, and vulva, are referable partly to pressure and 
 partly to the increased vascular fullness of the pelvic vessels induced 
 by pregnancy. 
 
 Changes effected in the Entire Organism. 
 
 Corresponding to the enormous development of the vascular ap- 
 paratus in the gravid uterus, there is an increase in the total quantity 
 of blood in the circulation.* Andral and Gavarret, Regnault and 
 
 * This assertion, which is simply the formal statement of a physiological 
 necessity, has been experimentally proved to be correct in bitches by Spiegelberg and
 
 CHANGES IN THE MATERNAL ORGANISM BY PREGNANCY. 
 
 89 
 
 Becquerel and Kodier, maintained that in pregnancy the blood was 
 serous in character. This view was sustained apparently by the 
 later investigations of Nasse, Spiegelberg, Gscheidlin, Ingerslev, and 
 Meyer. It is unquestionable that in early pregnancy a hydrtemic 
 condition develops in many women, consequent upon the demands 
 made upon tlie maternal system by the growing foetus, and upon the 
 increased tissue waste when these conditions are associated with a 
 diminished capacity to take and assimilate food ; but with improved 
 methods of examination it has been demonstrated by Fehlinf, Rein, 
 and Richard Schroeder that, in advanced pregnancy, both the haemo- 
 globin and the total number of red blood-corpuscles, are in the rule, 
 augmented.* 
 
 As a necessary corollary to the increase of the total blood-supply in 
 pregnant women, the maintenance of the circulation would seem to 
 require either greater frequency in the contractions of the heart, or 
 that the entire quantity of blood entering the ventricles during the 
 diastole should be increased. Kehrer maintains that the frequency of 
 the pulsations of the heart exceeds eighty to the minute. Larcher f 
 and other French investigators assert that the interposition of the en- 
 larged and multiplied vascular channels in the pelvic organs increases 
 the labor thrown upon the heart, in response to which an eccentric 
 hypertrophy of the left ventricle takes place, but the evidence on this 
 point is conflicting. 
 
 Pregnancy increases the size of the thyroid gland. In districts 
 where goitre is endemic, and in women in whom a predisposition al- 
 ready exists, pregnancy may produce a temporary form of the disease, 
 or furnish the starting-point of the permanent affection. J 
 
 In rather more than half the cases of pregnancy, thin bone-like 
 lamellae, consisting chiefly of phosphate and carbonate of lime, meas- 
 uring from one sixth to one half a line in thickness, are found de- 
 posited upon the inner surface of the skull. These plates have been 
 termed osteophytes by Rokitansky. They occur after the third month, 
 and are found chiefly upon the frontal and parietal bones, especially 
 along the course of the sulcus falciformis and the arteria meningea 
 media* 
 
 We have already noticed the increase in the carbonic acid discharged 
 
 Gscheidlin. Vide Untersuchungen iiber die Blutraenge traehtiger Hiinde, Arch. £. 
 Gynaek., Bd. iv, p. 112. 
 
 * Vide Schroeder, Untersuchungen ueber die Beschaffenheit des Blutes von 
 Schwangeren und Wochnerinnen, etc., Arch. f. Gynaek., vol. xxxix, p. 306. 
 
 f Vide Joulin, Traite complet d'accouchement, p. 383. 
 
 X L. Tait, Enlargement of the Thyroid Body, Obstet. Jour, of Gr. Brit, and Ire., 
 June, 1875. 
 
 « F6RSTER, Handbuch der patholog. Anat., Bd. ii, p. 945. These osteophytes 
 are not peculiar to pregnancy ; they likewise occur commonly in consumptives. 
 Nouveau Diet, de Chir. et de Med., t. xvii. Art, Grossesse.
 
 90 
 
 PHYSIOLOGY OF PREGNANCY. 
 
 by the lungs during pregnancy. Andral and Gavarret found the mean 
 consumption of carbon hourly in pregnant women equaled 8 grammes 
 instead of 6-4 grammes, as in menstruating women. The thorax is 
 increased in breadth and diminished in depth, a condition which 
 becomes reversed after delivery. There is usually, toward the end at 
 least, a diminution in the vital capacitv of the lungs.* Subjectively, 
 there is of ten experienced, especially in primipara?, a sense of oppressed 
 respiration during the later months of pregnancy. This feeling is 
 relieved, however, to a considerable extent when the uterus, in the 
 last two to three weeks of pregnancy, sinks downward and forward. 
 
 Very few pregnant women escape altogether troubles of digestion ; 
 of these the most common are nausea and vomiting, due to spasmodic 
 contractions of the stomach and diaphragm. The nausea and vomit- 
 ing usually occur on waking in the morning, i. e., with an empty 
 stomach, more rarely after meals. In a few cases, these gastric dis- 
 turbances take place only three or four times in the beginning of 
 pregnancv, upon the first suppression of the menses. Usually, how- 
 ever, they recur daily during the first three months, and then gradu- 
 ally disappear. In the early period of pregnancy, the appetite is, as 
 a rule, capricious, like that of chlorotic women. Some are said to 
 crave unusual and even disgusting articles of food (longings). An 
 increased secretion of the salivary glands is often a noticeable symptom. 
 The bowels are more commonly constipated. In a few, however, diar- 
 rh(jea takes place, often about the time of the month when the woman 
 would, if not pregnant, have her menstrual flow. 
 
 It is not surprising that in the first three months of pregnancy 
 many women lose their flesh and color, have dark circles about their 
 eyes, and wear a drawn, haggard look ; but after the third month, or 
 later, after fetal movements have been felt, the appetite returns, the 
 digestion becomes more active, the nutrition is improved, and an in- 
 crease of weight in normal cases takes place, which can not be accounted 
 for simply by the growth of the ovum. According to Gassner's esti- 
 mates, the average gain in the eight months amounts to five and a half 
 pounds, in the ninth month to three and a half pounds, and in the tenth 
 month to about three and a quarter pounds. The total increase he 
 found not far from one thirteenth of the entire weight of the body.f 
 
 We have already noticed the pigmentation of the areola in speaking 
 of the changes produced in the breasts of pregnancy. The forehead 
 
 * Dohrn found that in sixty per cent there was a marked diminution in the vital 
 capacity of the kings of women in the latter part of pregnancy, as compared with 
 that of the same women tested twelve to fourteen days after delivery. Zur 
 Kenntniss des Einflusses von Schwangerschaft und Wochenbett auf die vitale 
 Capacitat der Lungen, Monatsschr. f. Geburtsk., Bd. xxviii, 1866, p. 457. Earlier 
 observations, not entirely in accord with those of Dohrn, were made by Fabius and 
 Wintrich. Vide Spiegelberg, Lehrbuch der Geburtshulfe, 1877, p. 63. 
 
 f Monatsschr. f. Geburtsk., Bd. xix, p. 1.
 
 THE DIAGNOSIS OF PREGNANCY. o^^ 
 
 likewise at times becomes covered with dirty-looking brownish patches 
 which may extend over tlie entire face, especially over the eyelids, the 
 root of the nose, and the upper lip. These sjiots, with the disfigure- 
 ment they occasion, rarely remain permanent, l)ut, as a rule, disap- 
 pear shortly after confinement. Similar discolorations are often ob- 
 served about the external organs of generation, upon the abdomen, 
 and, with considerable constancy, along the linea alba and around the 
 umbilicus. 
 
 Owing to the hydraemic condition which exists during pregnancy, 
 the urine is more abundant and watery. Albumen in the urine is not 
 an infrequent occurrence, due, probably, in the milder cases, to transi- 
 tory catarrhal affections of the bladder.* 
 
 The nervous system becomes more impressionable. The whole 
 character frequently undergoes a change. The most amiable of women 
 are liable to become fretful, peevish, and unreasonable. The spirits 
 are often depressed, esi)ecially in the earlier months, when the general 
 nutrition is most impaired. The melancholia in women already pre- 
 disposed to insanity may terminate in mania. The memory is gen- 
 erally weakened, especially in women who have borne a number of 
 children in rapid succession. On the other hand, nervous women 
 sometimes lose their nervousness, and, exceptionally, there are individ- 
 uals who ex])erience during pregnancy a peculiar sense of well-being. 
 Neuralgic affections are common (face-ache, toothache, etc.) ; local 
 anaesthesia and paresis occur at times; the senses are often disordered 
 (nyctalopia, amaurosis, amblyopia, deafness, perversions of taste and 
 smell) ; pruritus is sometimes troublesome ; and, finally, pregnant 
 women are subject to attacks of dizziness and syncope. 
 
 CHAPTER V. 
 
 THE DIAGNOSIS OF PREGNANCY. 
 
 Signs of pregnancy.— Suppression of menses. — Nausea. — Salivation.— Breasts. — In- 
 crease of abdomen.— Changes of the os and cervix.— Quickening.— Ballotte- 
 ment.— Fetal heart-beat.— Uterine bruit.— Funic souffle.— Interrogation of the 
 patient.— Methods of physical e.xamination.— Inspection of abdomen.— Palpa- 
 tion.— Auscultation.— The vaginal touch.— Distinction between first and sub- 
 sequent pregnancies.— Diagnosis of death of foetus.— Duration of pregnancy.— 
 Prediction of day of confinement from date of last menstruation.— Date of 
 quickening. — Size of uterus. 
 
 A THOROUGH familiarity with all the signs which lead us to the 
 recognition of pregnancy is an essential part of the outfit of every 
 
 * Kaltenbach, Ueber Albuminurie und Erkrankungen der Harnorgane in der 
 Fortpflanzungsperiode, Arch. f. Gynaek., Bd. iii, p. 1.
 
 92 
 
 PHYSIOLOGY OF PREGNANCY. 
 
 practicing physician. The reasons for this are obvious. Mistakes as 
 to the diagnosis of the pregnant state can never be covered up. They 
 therefore inevitably subject the author of them to criticism and ridi- 
 cule. But, apart from personal considerations, it is to be remembered 
 that, in the practice of both medicine and surgery, the coexistence of 
 pregnancy not infrequently modifies materially the prognosis and 
 treatment. Moreover, it is one of the most grateful functions the 
 physician is called upon to perform to be able to dissipate unjust sus- 
 picions of pregnancy, which sometimes cloud the reputations of per- 
 fectly pure women. On the other hand, the writer has known many 
 cases of grievous wrong and injustice done to the innocent by a care- 
 less, hasty, and incorrect decision on the part of the medical examiner. 
 The so-called " signs of pregnancy " are based upon the physiological 
 changes which take place in the ovum, and the changes wrought by 
 the growth of the ovum upon the maternal organism. Many of the 
 signs, therefore, possess little weight, and serve only to draw attention 
 to the possible existence of pregnancy. A number of the signs taken 
 together furnish cumulative evidence of the probability of pregnancy. 
 There are, however, single signs, which, taken individually, make 
 pregnancy probable ; only a few possess a positive significance. Hence 
 the rule that the physician keep ever in mind possible sources of error, 
 and, in cases of doubt, that he maintain a prudent reserve in the ex- 
 pression of his opinion. 
 
 The diagnosis of pregnancy depends upon an acquired facility in 
 the mental grouping of symptoms in the order of their respective 
 weight, and upon a familiarity with all the methods by which objective 
 symptoms can be determined. 
 
 We have, therefore, to consider : 
 
 1. The signs of pregnancy, with their limitations and possible 
 sources of error. 
 
 2. Methods of physical exploration. 
 
 3. The differential diagnosis of pregnancy. 
 
 The Signs of Pregnancy. 
 
 The suppression of the menses is, to most women who have been 
 exposed to impregnation, the first warning of the occurrence of con- 
 ception. Certainly, where they have been previously habitually regu- 
 lar, this sign rarely leads them into error. Still, it is by no means 
 reliable. To estimate it at its true value, it is necessary to bear in 
 mind the numerous aberrations to which the menstrual function is 
 subject. In married women a retardation of the menses for a few 
 days, or even two or three weeks, is not an uncommon occurrence. 
 These retardations are not unusual in newly-married women, in whom 
 the disturbance appears to follow the novelty of the matrimonial rela-
 
 THE DIAGNOSIS OF PREGNANCY. 
 
 93 
 
 tion. Again, they may be the result of colds, fatigue, and mental 
 emotions. In the unmarried, who, by reason of imprudent conduct, 
 have had occasion to fear pregnancy, a retardation sometimes occurs 
 as the result of pure apprehension. 
 
 The causes of amenorrhoni do not need to be specified here. They 
 are operative in the married as well as in the unmarried. The family 
 physician, howeyer, cognizant of the peculiarities and temperaments 
 of his patients, will easily recognize such conditions, and separate 
 them from the cessation of the menses induced by pregnancy. Should 
 any doubt exist, of course it would be proper to suspend judgment, 
 and await the advent of other symptoms before expressing an opinion. 
 
 Pregnancy, while it suspends ovulation, the usual concomitant of 
 menstruation, is not incompatible with a periodic flow, which may 
 obscure the diagnosis. When conception occurs immediately j)rior to 
 a menstrual period, it frequently does not arrest the discharge, though 
 it usually diminishes the amount. A few women have periodic dis- 
 charges during the first two or three months of pregnancy, and, in 
 very rare cases, throughout its entire duration. Authors have like- 
 wise recorded instances of women whose habit it was to menstruate (?) 
 only during pregnancy (Montgomery). In all such cases it is probable 
 that the haemorrhage is of cervical origin, and is a pathological phe- 
 nomenon. In one instance my friend Dr. L. M. Yale, of this city, 
 verified the presence in the cervical canal of a small mucous polypus, 
 with the removal of whicii the trouble disappeared. In mentioning 
 tlu'se deviations from the standard, it is necessary to invite the student 
 to view them in proper perspective. They are of extremely rare oc- 
 currence, and the physician will not often fall into error who main- 
 tains a skeptical attitude toward cases of supposed pregnancy in which 
 apparently normal menstruation is reported to continue. 
 
 In women who are Jiabitually irregular, or in Avhom the menstrual 
 periods are absent altogether, the question of the existence of preg- 
 nancy is often in the early months a very puzzling one. There are 
 now and then patients who menstruate only at long intervals. If they 
 once suspect pregnancy, they are apt to simulate other corroborative 
 signs ; or, on the other hand, they may proceed far in gestation with- 
 out the slightest misgivings of their true condition. In such instances 
 the physician, unless he bases his opinion on purely objective symp- 
 toms, is at times drawn into error, which places both himself and his 
 patient in a ludicrous position. 
 
 In the same category are to be placed cases of pregnancy occurring 
 in nursing women before the return of the menses, in young girls 
 before the appearance of menstruation, and in women who have aj)- 
 parently passed the climacteric. 
 
 Among the sympathetic disturbances, those of the stomach possess 
 the greatest diagnostic importance. Nausea and vomiting, occurring
 
 94 PHYSIOLOGY OF PREGNANCY. 
 
 especially in the morning, and following suppression. of the menses, are 
 signs to which the women themselves, and the laity in general, attach 
 great value. They are, however, sometimes absent in pregnancy, while 
 they are present in a variety of other conditions. They are notable 
 features of chlorosis, where they are likewise often associated with sus- 
 pension of menstruation. However, after eliminating other morbid 
 causes, they are always suspicious symptoms in women who, in their 
 sexual relations, have exposed themselves to conception, and who never 
 experienced similar sensations in the unimpregnated state. Abundant 
 salivation possesses a similar significance.* 
 
 Tingling sensations and swelling of the breasts, turgescence and 
 pigmentation of the areola, the development of the glandular follicles 
 around the nipple, enlargement of the superficial veins, and the secre- 
 tion of milk, are valuable though not infallible signs of pregnancy. 
 Thus, painful sensations and sympathetic swelling of the breasts may 
 depend upon pathological conditions of the sexual organs. To be of 
 importance, they should be persistent and progressive. The coloration 
 may be the relic of a previous ])regnancy. The other changes in the 
 areola rarely lead us into error when they are present, but I have 
 often noted their entire absence. I have likewise noted cases where 
 there was entire absence of milk in the breasts until after confinement. 
 Numerous and very curious instances of milk in the breasts of the 
 non-pregnant have been recorded. The importance of these excep- 
 tions is greatly lessened by the fact that milk rarely appears in preg- 
 nancy before the development of other signs which enable us to make 
 the diagnosis certain. 
 
 Iticrease in the size of the abdomen during the child-bearing period 
 always suggests the existence of pregnancy. But it is to be remem- 
 bered that it is not invariably of uterine origin. Thus, it may result 
 from ascites, from an excessive deposit of adipQse tissue in the abdom- 
 inal walls, from tympanitic distention, and from various abdominal 
 tumors having no connection with the uterus. If the enlargement 
 proves to be due to a uterine tumor, we have then to exclude fibroids 
 in the earlier months, subinvolution, and the increase of size often 
 associated with peri-uterine inflammations. The absence of uterine 
 enlargement in women supposed to be several months pregnant, pos- 
 sesses, of course, absolute value in the way of purely negative testi- 
 mony. 
 
 Hegar regards as a valuable early sign of pregnancy the softening 
 
 * A pellicle, formed upon the surface of the urine, twenty-four to forty-eight 
 hours after emission, was once regarded as of great diagnostic value. It received 
 the name of kiesteine, and has been found to consist of a proteine substance, triple 
 phosphates, fungi, and infusoria. It is not invariably present in the urine of 
 pregnant women. It may occur at other times, and has even been found in the 
 urine of the male.
 
 THE DIAGNOSIS OP PREGNANCY. 95 
 
 and compressibility of the lower uterine segment as contrasted with the 
 firm tissues of the cervix and the fundus. To determine its existence 
 the thumb should be introduced into the vagina, and tlie index-finger 
 into the rectum as far as the pocket of the third sphincter ani. The 
 fundus should then be pushed downward by pressure exerted through 
 the abdominal walls, when the fundus, the lower uterine segment, and 
 the cervix all are brought within the reach of the index-finger. The 
 sign, however, is not conclusive, as its absence has been observed in 
 early pregnancy, and a condition closely simulating it has been noticed 
 in certain morbid states of the non-pregnant uterus.* 
 
 The changes in the os and cervix uteri are of great value in decid- 
 ing the question of pregnajicy. They consist of softening and cedema- 
 tous swelling of the cervix, velvety character of the mucous mem- 
 brane, associated with increased cervical secretion. In primiparje the 
 external orifice, instead of offering the sensation of a transverse slit, 
 feels circular. In multipara? the tip of the finger penetrates to a 
 greater depth than in its former state. During the first two months 
 the changes are rarely sufficiently marked to distinguish them from 
 conditions that obtain at or near the menstrual period. 
 
 Quicketiimi is the term used to designate the earliest movements of 
 the foetus perceived by the mother. They are at first slight, and have 
 been compared " to the tremulous motion of a little bird held in the 
 hand " (Montgomery). Modern investigations place the time at which 
 the foetus first begins to employ its muscles at about the tenth week. 
 It is, however, somewhat rare for these movements to excite the at- 
 tention of the mother before the sixteenth to the eighteenth week, 
 though experienced matrons may recognize them at an earlier period. 
 Ilyperaesthetic women do so, I should say, as a rule. The clear state- 
 ments of intelligent women leave me no reason to doubt that they may 
 feel life as early as the twelfth week. At first the sensation is that of 
 a flutter or tap, but the intensity of the movements is increased as 
 pregnancy advances. They are rendered more active by a long fast, 
 and by certain positions in bed. For considerable periods during the 
 day they disappear altogether. Occasionally they may be suspended 
 for days or Aveeks at a time, without the life of the child having become 
 necessarily compromised. Cases have been cited in wdiich women have 
 never recognized the feeling of quickening throughout the entire 
 period of pregnancy. Dropsy of the amnion and ascites are said to 
 obscure the sensation of the fetal movements. 
 
 The subjective impressions of women as to quickening require, 
 however, to be received with reserve. Instances are not infrequent 
 where sterile women, misled by their eager longings for maternity, 
 have not only deceived themselves, but have succeeded in betraying 
 
 * Vide Compes, Berliner klinischer Wochenschrift, No. 38, 1885,
 
 96 
 
 PHYSIOLOGY OF PREGNANCY. 
 
 their medical advisers into error by their confident assurances of hav- 
 ing distinctly felt the movements of the child in the womb. 
 
 Fetal movements, on the other hand, when recognized by the 
 medical expert, furnish conclusive evidence of pregnancy. These 
 movements may be active or passive. Active movements may be de- 
 tected by the eye, or by immediate contact. They seldom assume 
 much distinctness before the sixth month, though this is not invari- 
 ably the rule. (Thus, a patient of mine, the mother of six children, 
 aborted at the fourth month. The ovum was expelled on the 27th 
 of March. She gave birth on the 35th of December following— i. e., 
 just nine months later— to a full-term child. In the latter part of 
 July the movements were clearly appreciable to both the sight and 
 touch.) At first the sensation is that of a simple pat or throb, but in 
 the sixth and seventh months tiie limbs may be felt to escape from 
 under the hand with a rolling or gliding movement. In the last two 
 months, in women with lax abdominal parietes, it is sometimes pos- 
 sible to seize with the fingers a limb of the foetus, especially when it 
 chances to form a projection recognizable through the intermediate 
 coverings. The fetal movements have been closely simulated by the 
 irregular and spasmodic action of certain of the abdominal muscles. 
 In the celebrated case of Joanna Southcote, who at the age of sixty- 
 four claimed to be with child by the Holy Ghost, Dr. Eeece says, " I 
 felt something move under my hand, possessing a kiiul of undulatory 
 motion, and appearing and disappearing in the same manner as a 
 foetus."* 
 
 Ballottement is the term applied to the passive movements commu- 
 nicated to the foetus by the physician. It may be performed either by 
 impressing the uterine contents with the two hands laid upon the 
 abdominal wall, so as to cau.se tiie intervening body to float between 
 them ; or by introducing two fingers into the vagina and pushing them 
 suddenly against the lower segment of the uterus just anterior to the 
 cervix. When this is done, the head, if the presenting part, is made 
 to bound away from the fingers, to drop down again in a few moments 
 upon them with a gentle tap. Vaginal ballottement can sometimes 
 be practiced successfully as early as the latter part of the fourth month. 
 Ballottement is to be regarded as positive proof of pregnancy, as there 
 is no other condition in which a solid body is found floating in the 
 uterine cavity. 
 
 The important auscidtatory signs consist of the uterine bruit and 
 the sounds of the fetal heart. The discovery of the latter was made 
 by M. Mayor, a surgeon of Geneva, as appears by the following note 
 contributed by the editor of the Bibliotheque Universelle, in speak- 
 ing of the co7npte rendu made by Percy, June 29, 1818, to the Academy 
 of Sciences, upon the memoir of Laennec relative to auscultation; 
 * Montgomery, Signs of Pregnancy, second edition, p. 144.
 
 THE DIAtJNOSIS OP PREGNANCY. 9^ 
 
 " This observation reminds us of one made by M. Mayor, which has 
 appeared very interesting to us in its connection with the art of mid- 
 wifery and legal medicine. He has discovered that it is possible to 
 recognize with certainty whether a child is living or no, by applying 
 the ear to the abdomen of the mother of the child ; if the child is liv- 
 ing, one can hear very well the beatings of its heart, and distinguish 
 them from those of the maternal pulse." * Time has served only to con- 
 firm in the most complete manner the accuracy of this statement. The 
 heart-sounds of the foetus, when once clearly heard, are now regarded 
 as the most valuable of the signs of pregnancy, and conclusive evidence 
 that the child is alive. They are, like those of the mother, distinctly 
 double, and have been aptly compared by Kergaradec to the tick-tack of 
 a watch. They are much more rapid than the corresponding sounds, 
 in the heart of the mother, oscillating between 120 and 160 per minute. 
 They may be temporarily increased in frequency by movements of the 
 mother, and by both the active and passive movements of the child. 
 At the beginning of a pain, especially after rupture of the membrane, 
 the heart-sounds often become more frequent ; on the other hand, they 
 become slowed during the height of the contraction, and may even for 
 the moment cease altogether, either in consequence of the compression 
 of the child's body, or as the result of the disturbance produced in the 
 placental circulation. In the interval between the pains, the average 
 frequency is usually restored. If at any time the frequency of the 
 heart-beat permanently either rises above or falls below the normal 
 average, the child's life is to be regarded as endangered. As the fetal 
 circulation is entirely independent of that of the mother, there is no 
 direct relation between the rapidity of the pulsations of the fetal and 
 maternal hearts. However, in the febrile affections of the mother, 
 the health of the child may become coincidently deranged, with re- 
 sulting increase in the frequency of its heart's sounds. In general, the 
 heart beats more frequently in girls than in boys — a circumstance prob- 
 ably owing to the average smaller size of the female at birth. In 
 fifty observations, Frankenhaeuser f found the average in the boys was 
 124, while that of the girls was 144. He believed, therefore, that it 
 would prove possible to predict the sex of the child m utero three 
 months previous to confinement. Subsequent experience has demon- 
 strated, however, that prophecies based upon the frequency of the 
 heart-beats are at best of only approximative value, and that it is 
 the part of wisdom to reserve a prognosis which may be falsified by 
 time. 
 
 The fetal heart may generally be made out by the eighteenth to 
 the twentieth week. Under favorable circumstances it has been de- 
 tected as early as the fifteenth to the sixteenth week. It is usually 
 
 * .JouLiN, Traite complet d'accouchement, 1867, p. 410. 
 f Monatsschr. f. Geburtsk., Bd. xiv, p. 161. 
 7
 
 98 PHYSIOLOGY OF PREGNANCY. 
 
 heard over the dorsum of the fa?tus ; in face-presentations, on the 
 contrary, it is heard most distinctly over the anterior surface of the 
 thorax. The sound is often obscured by the thickness of the abdomi- 
 nal walls in fat women, and by an excessive amount of amniotic fluid. 
 When the dorsum of the fcetus is turned posteriorly, it may be absent 
 altogether. It is customary, therefore, to make frequent examinations 
 at intervals before deciding, in consequence of its failure, upon the 
 death of the child. 
 
 The lUerine bruit is a blowing sound synchronous with the mater- 
 nal pulse. It resembles strongly the souffle heard in aneurismal 
 tumors, and varies greatly in quality and intensity. It is apt to be 
 louder in markedly anemic women. During the uterine contractiojis 
 it possesses more of a musical character ; at the height of a pain it may 
 disappear for the moment. It may be modified by the pressure of 
 the stethoscope or arrested altogether. When first discovered by 
 Kergaradec (1822), it was attributed to the utero-placental circula- 
 tion, and was therefore termed the placental bruit. As, however, it 
 was found to persist two or three days after delivery, it became evident 
 that the sound must be of uterine origin. It is now the generally 
 accepted belief that the sound is produced in the ascending branches 
 of the arteria uterina. Rotter* and Rapin have shown that, in press- 
 ure along the course of the artery, both when made through the ab- 
 dominal walls and through the vagina, a vibratory thrill may be ex- 
 perienced by the touch, which corresponds to the sounds heard in 
 auscultation. 
 
 It is seldom heard before the fourth month. Spiegelberg f states 
 that, in women with lax abdominal ])arietes, he has succeeded, by 
 pressing the stethoscope, placed above the symphysis jiubis, deep down- 
 ward so as to reach the sides of the lower portion of the uterus, in 
 detecting the murmur as early as the eighth to the ninth week. As a 
 sound similar to the uterine bruit may sometimes be detected in uter- 
 ine fibroids, its value as a distinctive sign of pregnancy is thereby 
 greatly impaired. 
 
 A hissing sound synchronous with those of the fetal heart is some- 
 times heard in auscultating the abdomen. This sound is referable to 
 the umbilical cord, and is termed the funic souffle. Its etiology is a 
 matter of conjecture. As it is only found in fourteen to fifteen per 
 cent of cases examined, it possesses moderate value as a sign of preg- 
 nancy. 
 
 It is sometimes possible to detect the sound of the fetal move- 
 ments as early as the fourteenth to the sixteenth week, i. e., a month 
 earlier than the sounds of the fetal heart. It possesses a rubbing, 
 crepitant character, resembling, according to Schulze, the sound pro- 
 
 * Rotter, Ueber fiihlbares Uteringerausch, Arch. f. Gynaek., p. 539. 
 f Lehrbuch der Geb., p. 104.
 
 THE DIAGNOSIS OF PREGNANCY. 99 
 
 duced when the thumb is placed over the ear aud the nail is scraped 
 by the nail of another finger.* 
 
 Interrogation of the Patient.— In all cases of presumed pregnancy 
 it is customary to commence an investigation by preliminary inquiries 
 as to the existence of tiie more important subjective symptoms. As 
 such are to be regarded the suppression of the menses,, the so-called 
 " morning-sickness," salivation, pricking sensations and lancinating 
 pains in the breasts, enlargement of the abdomen, and quickening. 
 As we have already seen, however, none of these symptoms are really 
 decisive. Patients, by their statements, may in perfect good faith lead 
 the physician into error ; or, where they have an interest in practicing 
 deception, may deny the existence of incriminating symptoms alto- 
 gether. It is, therefore, often necessary to supplement the testimony 
 of patients by the evidences to be obtained by a clinical examination. 
 Ordinarily the vaginal touch suffices. In a few cases of doubt it may 
 be necessary to possess one's self of all the objective signs before arriv- 
 ing at a conclusion. 
 
 Methods of Physical Exploration. 
 
 The patient may be examined in the upright or in the recumbent 
 position. In the upright position, the physician may first examine the 
 breasts, with reference to the existe^jce of the changes characteristic 
 of pregnancy. With the eye he takes note of the oedema and discolor- 
 ation of the areola, the development of the follicles^ the secondary 
 areola, aud the increased size of the organ. To distinguish from the 
 enlargement of the breast due to adipose tissue, he looks for the 
 presence of developed veins upon its surface, and with the touch 
 recognizes the knotty, uneven feel produced by the development 
 of the glandular tissue. By pressing the breast near the nipple 
 between the thumb and index-finger the presence of milk may be 
 determined. 
 
 An examination j)er cwjinam is sometimes made in the upright 
 position, in cases where the physician desires simply to rapidly ac- 
 quaint himself with the condition of the generative passages and the 
 lower portion of the uterus. The patient either stands with the feet 
 apart, or with one foot raised upon a stool, while the physician, kneel- 
 ing before her, encircles her hips with the left arm, and with the right 
 hand passed beneath the clothing makes the requisite exploration. ^ 
 This method furnishes incomplete results, and is apt to offend sensi- 
 tive patients. It possesses no advantages over that in the recumbent 
 position, and is rarely resorted to except in the hurry of office practice. 
 
 Although for certain purposes it may prove advantageous to choose 
 the lateral or knee-chest position, in all ordinary cases it is advisable 
 
 * J. Veit, Mtiller's Handbueh, vol. i, p. 311.
 
 ■^QQ PHYSIOLOGY OP PREGNANCY. 
 
 to examine the patient upon her back, as being most convenient for 
 both external, internal, and conjoined exploration. 
 
 In the dorsal position the body should be as nearly horizontal as 
 possible, with the head and shoulders resting upon a pillow, and the 
 thighs flexed at right angles to the body and separated from one 
 another. In this way the greatest possible relaxation of the abdominal 
 walls and of the perinaeum is attained. Corsets, or other articles of 
 apparel interfering with freedom of investigation, should be removed. 
 The woman should be covered with a sheet, and the clothes reflected 
 upward so as to expose the abdomen. Where actual inspection is not 
 necessary, it is well to draw the chemise smoothly over the abdominal 
 walls, to avoid offending the modesty of the patient. When it is of im- 
 portance to survey the external surface, care should be taken to so 
 arrange the sheet as to cover the pubic region. 
 
 Inspection of the abdomen enables us to recognize its form and 
 shape, the coloration of its surface, the striae due to distention, and 
 the condition of the navel. A flattening of the abdomen at the um- 
 bilical region, with bulging at the sides, would lead to the suspicion of 
 ascites. A depression of the navel is incompatible with advanced 
 pregnancy. Fetal movements are sometimes visible through the ab- 
 dominal prarietes. 
 
 Palpation of the abdomen enables us — 1, to recognize the size, 
 shape, and consistency of the uteYine tumor, and to distinguish it from 
 other intra-abdominal growths ; 2, to ascertain, in advanced preg- 
 nancy, the presence of the fwtus. In a very large number of cases 
 palpation alone serves to establish the existence of pregnancy. It is, 
 however, only after the third month of pregnancy, when the fundus 
 uteri can be felt above the symphysis pubis, that this method of ex- 
 ploration becomes available. 
 
 In its performance the physician stands by the side of the patient, 
 and with the tips of his fingers rapidly traverses the abdomen from the 
 pubes upward. In this way he takes note of the thickness of the ab- 
 dominal walls and of the general position of the uterus. The latter 
 may then be outlined by pressing the abdominal walls inward to the 
 sides of the uterus, with the ulnar borders of the two hands. The 
 uterus is then steadied with one hand, while, with the other, intermit- 
 tent pressure is made to determine the consistence of the tumor. In 
 pregnancy, after the second month, the uterus becomes soft and elas- 
 tic, a condition that increases with the growth of the ovum, so that, 
 toward the end, palpation often furnishes an obscure sense of fluctu- 
 ation. The physician should next turn his face toward the feet of his 
 patient, and make deep pressure above the symphysis pubis to the 
 lower borders of the uterus. He should here seek to discover the vi- 
 bratory thrill, which may sometimes be detected along the course of 
 the uterine arteries. At the same time, in head-presentations (after
 
 THE DIAGNOSIS OF PREGNANCY. 1q1 
 
 the sixth month), a hard, round body can generally be felt, and made 
 to float to and fro between the examining fingers of the two hands. 
 In thin persons, with relaxed abdominal and uterine parietes, it is pos- 
 sible, in the later months, to trace upward the Vjack, the breech, and 
 the extremities of the foetus. The dorsal surface may be rendered 
 more distinct by pressure on the breech, so as to augment the dorsal 
 curve (Budin). During the progress of the examination in advanced 
 pregnancy, the movements of tlie child are usually excited, and are 
 readily appreciated. 
 
 The Differential Diagnosis of Pregnancy. 
 
 The differential diagnosis between pregnancy and other sources of 
 abdominal enlargement is in most cases not difficult. In subperitoneal 
 myomata of the uterus, the unevenness of the surface and the hardness 
 of the tissues are distinctive. But it must be remembered that 
 myomata, though they commonly cause sterility, do not actually ex- 
 clude pregnancy. In the rare cases in which myomata and pregnancy 
 coexist, the diagnosis for a time may be doubtful. 
 
 Braxton Hicks* lays great stress on the fact that, from the third 
 month to the completion of labor, spontaneous contractions of the 
 uterus take place, lasting generally from one to two minutes, and oc- 
 curring at intervals of from five to twenty minutes. This enables us to 
 determine the fact of pregnancy, and that the pregnancy is intra- 
 uterine. It occurs likewise in degenerations of the ovum, and in 
 cases of a dead foetus. He found, too, that where pregnancy coexisted 
 with myomata the exact relations of the uterus were readily made out 
 by the alteration which occurred at short intervals in the density of 
 the uterus. 
 
 It is therefore important, where any uncertainty exists, to abstain 
 from the use of sounds and to await the result of a future examination. 
 In a few weeks' time the rapid growth of the pregnant uterus, quick- 
 ening, ballottement, and the fetal heart will furnish the necessary data 
 for establishing the distinction. 
 
 Ovarian cysts, in the early stages of their growth, occupy a position 
 to the side of the pelvis, and are hardly likely to be confounded with 
 the pregnant uterus. When, however, by their increase in size, they fill 
 the abdomen, the history of ovariotomy shows that, without a full and 
 complete examination, such a mistake is possible. Where ovarian 
 cysts are complicated by pregnancy, the latter has been at times over- 
 looked, simply because it was not so much as suspected. Thus, a 
 young servant-girl was sent to me some years ago to consult me rela- 
 tive to the nature of an abdominal tumor. The diagnosis of ovarian 
 cyst was readily established. A year later she sought the advice of a 
 * Trans. Internat. Med. Congress, 1887.
 
 -^Q2 PHYSIOLOGY OF PREGNANCY. 
 
 surgeon, formerly of this city, who counseled its removal. Having ob- 
 tained her consent, he made the usual incision in the median line, and 
 exposed, to his horror, the pregnant uterus. He afterward learned 
 that the girl, having been assured that conception was impossible on 
 account of the ovarian disease, had yielded to the solicitations of her 
 lover. Finding herself pregnant, she purposely concealed her con- 
 dition, and had sought the operation when seven months advanced, in 
 the hope that a fatal issue would cover her shame. The ovarian tumor 
 was left untouched, and the wound was quickly closed. The girl 
 died, however, a few days afterward. In this case, the undoubted 
 presence of an ovarian cyst and the reputable character of the girl 
 combined to disarm suspicion. 
 
 In ovarian cysts there is, on palpation, ordinarily greater distinct- 
 ness of fluctuation than in the gravid uterus. Tlie diagnosis is, how- 
 ever, mainly based upon the presence or absence of the usual signs of 
 pregnancy. 
 
 Thick layers of fat in the abdominal walls and ascites could hardly 
 be mistaken for pregnancy, though they may serve to obscure palpation. 
 
 Tympanitic distention is recognized in part by the character of 
 the percussion note, and in part by demonstrating the absence of the 
 uterine tumor. The latter is accomplished by directing the patient to 
 make alternate deep inspirations and prolonged expirations. The phy- 
 sician then places the left hand upon the abdomen. During the long 
 inspiration he remains passive; with the expiration, he presses with 
 the fingers of the right hand, placed obliquely against those of the 
 left, in the direction of the spinal column. With the recurrence of 
 inspiration, he holds steadily the ground previously gained. During 
 the following expiration further progress is made, and thus ])y succes- 
 sive advances, in case no intervening body prevents, the hand is made 
 to sink inward until the vertebra? are felt.* In cases of undue sensi- 
 tiveness of the abdominal walls, chloroform may be administered to 
 complete anaesthesia. Some patients, by means of contractions of the 
 abdominal muscles, succeed in producing the semblance of a tumor, 
 which may even be mapped out with the hands applied to the ab- 
 domen. These so-called " phantom tumors " occur most commonly 
 in liysterical women who are earnestly desirous of becoming mothers. 
 They are eminently calculated to entrap the unwary, if the examina- 
 tion be confined to the abdomen or to listening to the patient's sub- 
 jective symptoms. They flatten down and disappear under chloro- 
 form, or when the attention is distracted during the course of an in- 
 vestigation. 
 
 Auscultation furnishes the most certain evidences of the existence 
 of pregnancy. The stethoscope may be employed, or the ear may be 
 
 * This valuable method is borrowed from Professor Spiegelberg's Diagnose der 
 Eierstocktumoren, Volkmann's Samral. klin. Vortr., No. 55.
 
 THE DIAGNOSIS OF PREGNANCY. iq^ 
 
 applied directly to the abdomen. To hear the fetal heart requires a 
 certain amount of practice, but the art can be readily acquired. As 
 the sounds are, at best, of feeble intensity, the utmost stillness in the 
 neighborhood of the patient is necessary for this appreciation. Thev 
 are always heard with great difficulty before the end of the sixth 
 mouth. There is no special point at which they can be invariably dis- 
 tinguished. In head or breech presentations, with the back of the 
 iaitns curved and in contact with the uterine wall, the sounds are most 
 clearly to be made out over its dorsal aspect. In face-presentations, 
 on the contrary, the anterior surface of the child is pressed against the 
 uterine walls, and the sounds are heard with the greatest distinctness 
 over the chest. As in the last three months of pregnancy the cephalic 
 presentations, with the back to the left, preponderate, the heart-sounds 
 are oftenest heard in a line extending from the anterior superior spi- 
 nous process to the umbilicus. When the back of the child is turned 
 to the right, they are likewise directed somewhat posteriorly. The 
 heart-sounds are then less accessible, and therefore appear feebler. 
 Care must be taken not to confound with the fetal heart the con- 
 ducted heart-sounds of the mother, or the aortic pulse. Thick ab- 
 dominal walls, or abundant amniotic fluid, may interfere with the 
 recognition of the heart-sounds. When the back of the child is turned 
 to the rear, or during a uterine contraction, they may disappear alto- 
 gether. If the child be living, however, repeated examinations will not 
 fail to detect them. The uterine souffle is heard with maximum in- 
 tensity to the sides of the uterus. In the early months it is to be 
 sought for near the median line, just over the symphysis pubis. 
 
 T/ie vaginal touch enables one to effect an examination of the 
 genital canal and that portion of the uterus which is contained within 
 the pelvic cavit3^ The accoucheur should accustom himself to use 
 either hand Avith equal ease, and to conduct an examination upon 
 whichever side of the bed his patient chances to be lying. The index- 
 finger should be anointed with cold cream, lard, butter, vaseline, oil, 
 or simple soap and water, to make its introduction into the vagina less 
 painful. As the hand is passed under the clothes, it is a good plan 
 to cover the index with the thumb and remaining fingers, to prevent 
 its soiling the patient's wearing-apparel. The patient should now be 
 told to separate her knees widely, while the index-finger glides for- 
 ward over the perinaeum to the introitus vagina. Note should be 
 taken here of the size and direction of the orifice, and the degree of 
 resistance offered by the external parts. Where there is much hair 
 about the pubes, the introduction of the index-finger into the vagina 
 is greatly favored by separating the labia with the fingers of the other 
 hand. As the finger enters the vagina, it is well to notice the urethra, 
 the condition of the rectum (whether filled with fiBces), the length and 
 width of the vagina, and the amount of lubricating secretion furnished
 
 JQ4 PHYSIOLOGY OF PREGNANCY. 
 
 by the vaginal walls. To explore the anterior half of the pelvis, close 
 the unemployed fingers upon the palm of the hand, direct the palmar 
 surface of the index-finger to the front, and press upward to the pre- 
 senting part. In the early months, place the unemployed hand upon the 
 abdomen above the symphysis pubis, and, by conjoined manipulation, 
 make out the size, shape, and consistence of the uterus. If pregnancy 
 is sufficiently advanced, ballottement may be produced. To reach the 
 cervix, the finger should be next turned to the rear. Many practi- 
 tioners prefer to extond the previously closed fingers, and press them 
 opened against the perineum. Should the cervi x not be readily reached, 
 the examination should be made with both the index and middle 
 fingers. If the middle finger is introduced slowly and with care, it 
 gives no additional jiain, and increases the reach by nearly an inch. 
 The actual distance to the cervix may be diminished by placing the 
 closed hand under the extremity of the sacrum, so as to diminish the 
 degree of pelvic inclination. It is often necessary to resort to this meas- 
 ure when, toward the end of pregnancy, the cervix is situated un- 
 usually high up and is directed well to the rear. AVith the touch, we 
 recognize the size and thickness of the cervix, the length of both the 
 anterior and posterior walls, the shape of the os, and, if open, the 
 character of the cervical canal. 
 
 The rectal touch is only necessary where there is oV)literation of the 
 vagina — a condition which does not exclude ])regnancy, but it is some- 
 times usefully resorted to in other cases to complete information ob- 
 tained by vaginal exploration. 
 
 The bluish coloration of the vulvar and vaginal mucous membrane 
 is of considerable diagnostic importance. Chadwick * has recently 
 drawn attention to tlie value of simple inspection of the vaginal orifice, 
 without employment of the speculum. A faint diffused bluish tint he 
 regards as suggestive ; a faint bluish tint limited to the anterior 
 vaginal wall he regards as characteristic and diagnostic ; wliile a deep 
 blue tint is a nearly absolute proof of pregnancy. The sign is often 
 available as early as tlie end of the second month. Chadwick's tables 
 show that in the second half of pregnancy the color is of such a 
 character as to be in the rule diagnostic. My own experience is en- 
 tirely in accord with that of Dr. Chadwick. In many instances where 
 pregnancy had been concealed or not suspected, this sign has served 
 me as a warning against the performance of an operation contra-in- 
 dicated by the pregnant state. 
 
 Distinction between First and Subsequent Pregnancies. 
 
 In women who have once completed the full term of utero-gesta- 
 tion, the imprints left by the pregnant state are indelible and easy to 
 
 * Chadwick, Vaginal Coloration in Pregnancy, Trans. Am. Gyn. Soc, p. 399.
 
 THE DIAGNOSIS OF PREGNANCY. * ^qS 
 
 recognize. As it is sometimes a matter of forensic importance for a 
 physician to be able to distinguish between first and subsequent preg- 
 nancies, it is desirable for every practitioner to make himself familiar 
 with the characteristic differences between the two conditions. 
 
 In priinipane the abdominal integuments are firm and tense, so 
 that it is difficult to map out through them the underlying uterus, 
 or to feel the head, the breech, or the limbs of the child. The stri« 
 found upon the abdomen, the nates, and the thighs appear late in 
 pregnancy, and have a reddish-brown or slaty color. The breasts are 
 full, firm, and sensitive to pressure. The labia are in apposition, and 
 the fraenulum is intact. The hymen is torn, but each fragment re- 
 mains attached in its entirety to the introitus vaginas. The urethra 
 is hyj)ertroj)hied, and appears as a cylindrical body, of a reddish-blue 
 color, in the vaginal orifice. The vagina itself is narrow, with dis- 
 tinct transverse ridges, and oftentimes possesses a granular feel, from 
 the enlargement of the papillae. The vaginal portion of the cervix 
 is soft. When the head enters the pelvis, toward the end of preg- 
 nancy, shortening of the anterior lip takes place. The os externum 
 is closed, or, not infrequently toward the close of gestation, admits the 
 passage of the extremity of the examining finger. It then feels like 
 a round opening, with smooth borders, and a sharp inner edge at the 
 point where it joins the cervical mucous membrane. The cervical 
 canal has a spindle-shape. The head, in the latter months, as a rule, 
 sinks into the pelvis, and bulges the vagina. 
 
 In wouu'fi who have already home chUdren the skin of the abdo- 
 men is loose, wrinkled, and can be gathered into folds by the hands. 
 The uterus is likewise relaxed, and through its walls can be felt, in 
 many cases, the projecting parts of the ftetus. The uterus is easily 
 defined. In addition to the striae upon the abdomen, noted in primi- 
 par», many of older date, possessing a shining white or silvery ap- 
 pearance, can be made out. The breasts are flabby, pendulous, and 
 marked with silvery lines. The vulva gapes open, and wears a bluish 
 aspect from the development of the superfical veins. The fraenulum 
 is usually found to have been lacerated. The carunculae myrtiformes 
 alone remain as vestiges of the hymen.* The vagina is smooth, from 
 the obliteration of the transverse ridges. Swelling of the vaginal 
 papillae is exceptional. The cervix is swollen, and has a cylindrical 
 rather than a conical shape. At times it is like a cone, with the base 
 downward. The os is open, and admits the extremity of the finger. 
 This patulous condition is due to lacerations of the cervix, which are 
 the inseparable concomitants of child-bearing. The lacerations diSer 
 greatly in degree, but are rarely difficult of recognition. As they are 
 situated usually on the sides of the cervix, they convert the os into a 
 wide, transverse slit, bounded by a well-defined anterior and posterior 
 
 * Vide p. 6,
 
 106 
 
 PHYSIOLOGY OF PREGNANCY. 
 
 lip. The cervical canal lias a funnel-shape, narrowing above. In the 
 ninth month (in some cases earlier) the finger passes readily through 
 the OS internum to tlie child's head. The latter rarely descends into 
 the pelvis before the advent of labor, but either is situated at the 
 brim, or rests upon one of the iliac foss*. 
 
 It should be added, finally, by way of caution, that while the pres- 
 ence of the foregoing signs speaks plainly in favor of the existence of a 
 previous pregnancy, their absence is not absolutely incompatible with 
 the occurrence of a premature labor, or even, in rare cases, with the 
 delivery of a small foetus at full term. 
 
 The Diagnosis of thk Death of the Fcetus. 
 
 The presence of a dead child /;/ utero may be inferred where active 
 movements are not elicited by palpation, or where the heart-sounds, 
 after repeated trials, can not be made out. As we have seen, a number 
 of conditions sometimes combine to temporarily render it impossible, 
 even when the child is living, to obtain positive results by ausculta- 
 tion. A decision should not, therefore, be based upon the results of 
 an isolated examination. 
 
 In the earlier months, previous to the j)eriod wlu'n the fetal heart 
 can be heard, the death of the foetus is rendered probable by fial^biness 
 and diminution in size of the uterus, by a flaccid condition of the 
 breast, and certain subjective sensations experienced by the mother, 
 such as languor, chilliness, bad taste in the mouth, and the feeling 
 of a weight like a foreign body in the hyi)ogastrium. Certainty is 
 obtained when, through the open cervix, the cranial bones can be 
 made out, and are found loose and movable within the integuments. 
 
 The DiRATiON of Pregnancy. 
 
 There is no question in obstetrics ujwn the solution of which so 
 much ingenuity has been expended as the determining of the normal 
 duration of pregnancy. Inasmuch as it has i)roved imi)ossible to 
 ascertain the precise moment in.which conception (i. e., the fertilizing 
 of the ovum by the spermatozoa) takes place, it has been customary 
 to assume as the starting-point for the reckoning of gestation either 
 the date of the last menstruation or that of a single fruitful coitus. 
 It would seem at first as though the latter would lead us to more 
 nearly accurate results. But, aside from the fact that the distance 
 of time between insemination and conception is avowedly variable,* 
 it is only in rare cases that the particular coitus which has resulted 
 in pregnancy can be definitely ascertained. Duncan collected 46 cases 
 in which connection took place during a single day only, and found the 
 
 * Duncan, Fecundity, Fertility, and Sterility, second edition, pp. 433, 435.
 
 THE DIAGNOSIS OF PREGNANCY. ^q'j 
 
 average time to the date of parturition was 275 days. Ahlfeld, from 
 an analysis of 425 cases, obtained an average of 271 days.* In 108 
 cases furnished by Hecker the average was 273-52 days.f Yeit pub- 
 lished 43 cases, with an average of 270-42 days.J In 63 cases of Faye's 
 the average was 270-G(;.* Undoubtedly many of the cases included in 
 these tables are of questionable reliability; two of them, indeed, in 
 which confinement is reported to have followed coitus, respectively 
 in 320 and 330 days, evidently belong to the realm of fable. Assum- 
 ing, however, that the size of the tables serves to nearly neutralize 
 specific inaccuracies, the small value of the averages obtained, as a 
 means of predicting the date of confinement, is shown by the wide 
 differences between the terms of gestation in the individual cases of 
 which the tables are composed. Thus, in Ahlfeld's table there existed, 
 between the longest and shortest gestation, a difference of 99 days ; in 
 Keeker's, a difference of 63 days; and in Yeit's, a difference of 36 
 days. In the breeding of domestic animals, in which conception, as 
 a rule, follows a single act of sexual congress, similar variations are 
 common. In the now familiar observations of Tessier, Krahmer, and 
 Spencer, the average duration of gestation in rabbits is 31 days, the 
 variation 8 dayj ; in sheep, pregnancy averages 151 days, and the 
 variation amounts to 26 days ; in cows, the average time of gestation 
 is 283 days, but calving may occur between the 183d and the 356th 
 day ; in mares, the average time is 347 days, but foaling may occur be- 
 tween the 287th and the 419th day.|| 
 
 However, Ahlfeld's tables show that the bulk of confinements vary 
 within narrow limits. Of 653 women, in 15-93 per cent delivery oc- 
 curred in the thirty-eighth week ; in 27-56 per cent, in the thirty- 
 ninth week ; in 26-19 per cent, in the fortieth week ; and in 10-01 
 per cent, in the forty-first week. In other words, more than half the 
 cases occurred in the thirty-ninth and fortieth weeks, and 80 per cent 
 between the thirty-eighth and forty-first week inclusive. Of the re- 
 mainder, 14 per cent took place prior to the thirty-eighth week, and 
 were probably influenced by the many operative accidental causes 
 which favor prematurity. Of the 6 per cent reported as occun:ing 
 later than the forty-first week, a considerable number are of question- 
 
 * Beobachtungen iiber die Dauer der Schwangerschaf t, Monatsschr. f. Geburtsk., 
 Bd. xxxiv, p. 208. Ahlfeld's actual reckoning gave an average of 269-91 days, but 
 this was afterward corrected by Lowenhardt, who found Ahlfeld's tables really fur- 
 nished an average of 270-94. Vide Lowenhardt, Die Berechnung und Dauer der 
 Schwangerschaft, Arch. f. Gynaek., Bd. iii, p. 458. 
 
 f Ahlfeld, op. cit., p. 208. 
 
 X Ibid., p. 210. 
 
 ♦Other tables may be found in Montgomery, Signs of Pregnancy, second 
 edition, pp. 493 et seq. 
 
 \ Vide Ahlfeld, op. cit., p. 216 ; St. Cyr, Traite d'obstetrique veterinaire, pp. 107 
 
 et seq.
 
 j^Qg PHYSIOLOGY OP PREGNANCY. 
 
 able authenticity. Gestation protracted beyond the two hundred and 
 eighty-fifth day is certainly of very rare occurrence.* 
 
 Prediction of the Day of Confinement. 
 
 In all schemes for predicting the date of confinement, it is custom- 
 ary to throw out, as defying calculation, the exceptional cases, which 
 fall much below or greatly exceed the usual average. No scheme is 
 ever likely to be devised which will insure accuracy with regard to the 
 day upon which labor will occur. In every scheme it has been assumed 
 that errors of from four to five days are inevitable. Moral emotions, 
 fatigue, attacks of indigestion, mechanical causes, and the like, are 
 recognized as liable, toward the end of gestation, to precipitate labor 
 at any time. But a vast deal of ingenuity has been expended in the 
 endeavor to reduce ordinary errors within the narrowest limits. 
 
 The Last Menstruation. — Now, it has already been remarked that it 
 is only in rare cases that the day of conception (i. e., insemination) can 
 be utilized. In all calculations of the duration of pregnancy, it has 
 been customary, therefore, to select the menstrual period as the start- 
 ing-point. As the days immediately following menstruation are those 
 in which conception usually occurs, the end of menstruation has been 
 adopted by some as the most suitable point of departure. Ahlfeld 
 estimated tliat 35-55 per cent of married women conceived on the 
 last day of menstruation, and that 88-44 per cent conceived within 
 twelve days, counting from the first of menstruation. f Experience 
 has shown, however, that there is no single day in the intermen- 
 strual period in which conception may not occur. Jewish women, 
 indeed, who are forbidden sexual intercourse by the Mosaic law during 
 menstruation and the seven days following, are proverbially fruitful. 
 Lowenhardt has shown that, though in two women conception follows 
 in each a single act of coitus, occurring the same number of days after 
 menstruation, there is no necessary correspondence of the date of con- 
 finement in the two. J 
 
 As, therefore, there is little to be gained by estimating the day of 
 confinement from the probable day of conception, it lias become the 
 usual rule to reckon from the first rather than from the last day of 
 menstruation, especially as most women exercise more care in preserv- 
 ing the record of the former date. 
 
 From the days of Hippocrates, it has been customary to regard 
 
 * Many cases of apparent protracted gestation find their exfilanation in the fact 
 that conception may occur just prior to the menstruation jjeriod succeeding to that 
 from which the count is made. In one instance, in wliich a lady was confined three 
 hundred and six days after the last menstrual period, the statement was volunteered 
 that for twenty days following menstruation " precautions " against pregnancy had 
 been resorted to. 
 
 \ Ahlfeld, op. cit., p. 191. J Op. cif., pp. 461 et seq.
 
 THE DIAGNOSIS OF PREGNANCY. 
 
 109 
 
 pregnancy as extending over ten lunar months, or ten menstrual pe- 
 riods of twenty-eight days each. In accordance with this idea, Nae- 
 gele* proposed a ready method of computing two hundred and eighty 
 days from any given date, which has since his time been generally 
 adopted. This consisted in counting forward nine months, or, what 
 amounted to the same thing, counting backward three, months, and 
 then adding seven^ays (in leap-years, after February, six) to the date 
 chosen as the starting-point of the calculation. Naegele selected the 
 first day of the last menstruation. His method is, of course, equally 
 applicable, when the day 
 of cessation is preferred as 
 the point of departure. For 
 seven months in the year 
 Naegele's method is abso- 
 lutely correct. In Febru- 
 ary, however, four days, in 
 December and January 
 five days, and in April and 
 September six days only 
 are required to complete 
 two hundred and eighty 
 days. Tables may be found 
 in most physicians' visiting 
 lists, by means of which the 
 two hundred and eighty 
 days may be determined at 
 a glance. The following 
 circle of Schultze is based 
 
 upon N^aegele's method. The figures between the radii show the exact 
 number of days to be added for each of the months severally. The 
 figures in ])arenthese8 are to be employed in leap-year. 
 
 Unfortunately, the supposition that labor comes on after the ex- 
 piration of ten menstrual periods of twenty-eight days each is correct 
 for only a small number of cases, so that it has been found necessary 
 to shift the ground somewhat to the position that the normal duration 
 of pregnancy covers ten menstrual periods. The instability of the 
 reckoning would then find its explanation in tlie common experience 
 that ten consecutive periods of exactly twenty-eight days each are rare 
 even in the most regular of women. Although ovulation is suspended 
 during pregnancy, at the return of the menstrual epochs the existence 
 of an ovarian influence upon the generative organs may be clearly 
 traced in many individuals. At such times a sensation of fullness is 
 often experienced in the pelvic organs, associated in some women with 
 an awakening of the sexual appetite. At such times, too, there has 
 * Naegele, Lehfbuch der Geb., achter Auflage, p. 122. 
 
 -Diagram for computing pregnancy. 
 (Schultze.)
 
 110 
 
 PHYSIOLOGY OF PREGNANCY. 
 
 been observed a tendency to miscarry, so that it becomes incumbent 
 upon sensitive, impressionable females, predisposed to abort, to espe- 
 cially avoid either reflex or mechanical sources of disturbance during 
 the continuance of the state under notice. When the ovum reaches 
 maturity, the recurrence of the tenth menstrual epoch furnishes local 
 conditions in a peculiar degree favoring the production of labor. 
 
 Lowenhardt * found it 
 was possible to calculate 
 the duration of preg- 
 nancy in twenty-two in- 
 dividuals with tolerable 
 accuracy, by assuming 
 that ten menstrual peri- 
 ods represent not two 
 hundred and eighty days, 
 but ten times the length 
 of time between the last 
 menstrual period and the 
 one immediately preced- 
 ing it. In no case thus 
 calculated did the error 
 exceed five days, a de- 
 gree of exactitude un- 
 attainable by the motbod 
 of Nacgele. 
 
 The Date of Quicken- 
 ing. — Wben the date of 
 the last menstruation can 
 not be obtained, it is 
 customary to reckon the 
 time of labor approxi- 
 mately by adding twen- 
 ty-two weeks to the date 
 of quickening, which is 
 assumed to occur in the 
 eighteenth week of pregnancy. The extreme variation, however, in 
 the time at which quickening occurs in different individuals renders 
 this method of calculation a very uncertain one. 
 
 The Size of the Uterus. — As the increase of the uterus is progress- 
 ive, its size is sometimes used in determining approximatively the 
 
 * Die Berechnung und die Dauer der Schwangerschaft, Arch. f. Gynaek., Bd. iii, 
 p. 476. In quite a number of instances I have had curious confirmation of Liiwen- 
 hardt's theory. Thus I can recall two cases where the menses recurred once in 
 twenty-six days, and the apparent length of gestation was two hundred and sixty 
 days. But the rule has many exceptions. 
 
 Fig. 60.— Schultze diagram.
 
 THE DIAGNOSIS OF PREGNANCY. -^^^-^ 
 
 period to which gestation has advanced. According to a rude for- 
 mida, commonly employed at the bedside, the uterus is, in the second 
 month, of the size of an orange ; in the third month, of the size of a 
 child's head. In the fourth month, it can be felt above the symphysis 
 pubis. In the fifth month, the fundus of the uterus rises to a point 
 midway between the symphysis and the navel. By the sixth month, 
 it reaches the level of the navel. In the seventh month, it should be 
 the breadth of two or three fingers above the navel. In the eighth 
 month, it rises half-way between the navel and the epigastrium. In 
 the ninth month, it reaches the epigastrium. In the tenth month, 
 two to three weeks before confinement, the uterus sinks downward and 
 somewhat forward, so that its upper level corresponds very nearly to 
 that of the uterus in the eighth month. 
 
 In the foregoing calculation most of the data are obtained from the 
 relation of the fundus to the navel. But the navel is not a fixed point. 
 Spiegelberg found the distance between the upper border of the sym- 
 physis and the navel varied in different women as much as six inches.* 
 The average distance from the symphysis pubis to the fundus of the 
 uterus in the different months of pregnancy he found was — 
 
 From the 22d to the 26th week 8^ inches.f 
 
 " " " 28th week lOi " 
 
 " " " 30th week 11 " 
 
 " " " 32(1 and 33d week Hi <' 
 
 " " " 34th week 12 " 
 
 " " " 35th and 36th week 12^ " 
 
 " " " 37th and 38th week 13 " 
 
 " " " 39th and 40th week 13i " 
 
 But the size of the uterus is subject to considerable variations, due 
 to the size of tlie child and the amount of the amniotic fluid. 
 
 * Lehrbuch der Geb., Bd. ii, p. 115. 
 
 f These measurements exceed considerably those furnished by Farre, p. 83. 
 The discrepancies are due in part to the extent of individual variation, and in part 
 to the fact that they were made with a tape-measure. Thus, Ahlfeld, employing 
 the cyrtometre of Baudelocque, found the distance from the symphysis pubis to 
 the fundus only ten and a half inches in the fortieth week. Ahlfeld found the 
 length of the child to be nearly double the distance between the head and breech 
 when the child assumed the attitude usual in the uterus. To determine the date of 
 pregnancy, he proposed to measure the axis of the foetus in utero, by means of a 
 cyrtometre, one extremity of which, passed into the vagina, rested upon the child's 
 head, while the other was extended to a mark upon the abdominal wall correspond- 
 ing to the breech. He then sought to establish the length of a child at each week 
 of pregnancy. His tables show, however, such variations in the size of children 
 born in the same week as to impair the practical value of the method. Vide 
 Ahlfeld, Bestimmung der Grosse und des Alters der Frucht vor der Geburt, Arch, 
 f. Gynaek., Bd. ii, p. 353.
 
 PREGNANCY. 
 
 CHAPTER VI. 
 
 THE MANAGEMENT OF PREGNANCY. 
 
 Hygiene of pregnancy. — The disorders of pregnancy. — The blood-changes of preg- 
 nancy. — Pernicious anajmia. — Hydrasmic oedema. — Varicose veins. — Nausea and 
 vomiting. — Heart-burn. — Insalivation. — Pruritus. — Face-ache. — Cephalalgia. — 
 Insomnia. 
 
 In studying the effects of pregnancy we saw that, besides the local 
 changes in the sexual apparatus and the disturbances produced by 
 pressure, the organism had to adapt itself to a variety of new condi- 
 tions, of which the most conspicuous were alterations in the quality of 
 the blood and increase of its quantity, with additional work thrown 
 upon the lungs and kidneys, and reflex derangements of the nervous 
 and digestive systems. The physiological condition of the pregnant 
 woman approximates so closely to what would be regarded as patholog- 
 ical at other times, that the necessity arises for the patient to carefully 
 observe hygienic rules, while the physician often finds himself called 
 upon to exercise his art in restraining distressing symptoms within 
 limits consistent with the healthy progress of gestation. 
 
 The Hygiene o! Pregnancy. — During the pregnant state, the in- 
 creased elimination of carbonic acid by the lungs is necessarily associ- 
 ated with increased consumption of oxygen. This respiratory activity 
 makes an abundance of fresh, pure air a matter of prime importance. 
 As a rule, therefore, a rural neighborliood is more conducive to nor- 
 mal pregnancy than large cities. To be avoided are small, close, heated 
 rooms, confinement indoors, and crowded assemblages. 
 
 The dietary should embrace all nutritious, easily digested articles 
 of food. The natural tendency to acidity, heart-burn, flatulence, and 
 colic is apt to be increased by indulgence in the products of the frying- 
 pan and the dainties of the pastry-cook and confectioner. The con- 
 suming desire for unwonted articles of food, which is customarily 
 termed "longings," I have never yet witnessed, and am tempted to 
 regard as in a great measure mythical. A good appetite is the best 
 safeguard against most of the discomforts of pregnancy. Owing, how-
 
 THE MANAGEMENT OF PREGNANCY. n^ 
 
 ever, to the activity of the assimilative processes, a very moderate ap- 
 petite is not incompatible with a considerable gain in weight. A very 
 large appetite is not normal during pregnancy, and requires to be 
 restrained. 
 
 The dress should be loose and easy. Garters and tight corsets 
 should be discarded. When the projection of the abdomen removes 
 the folds of the dress from the lower limbs, flannel drawers reaching 
 to the waist should be worn as a protection. 
 
 Gentle exercise, not pushed to the verge of fatigue, should be en- 
 couraged. Walks and drives in the fresh air are the best means of 
 fostering sleep and maintaining the appetite and general assimilative 
 processes. Violent exercise, on the other hand, is liable to produce 
 miscai'riage. It is stated that the predisposition to miscarriage is 
 greatest at the third and seventh months. Throughout pregnancy 
 special care should be observed at the recurrence of the menstrual 
 epochs. Long railway Journeys at such times are a frequent cause of 
 trouble. Marital relations, though not absolutely to be prohibited, 
 should be of infrequent occurrence. Excesses in the newly married 
 are a common source of abortion. 
 
 The skin should be kejit in good condition by frequent bathing, as 
 by its eliminative action it is capable of relieving the kidneys of a por- 
 tion of the work thrown upon them. The increased vaginal secretion 
 renders it important for the woman to frequently wash the external 
 genitals. Tlie vaginal douche is a source of comfort to many women, 
 but the quantity injected should not exceed a pint of water, and should 
 be introduced slowly, with every precaution in the way of allowing an 
 immediate reflux to take place. 
 
 The increased irritability often observable in pregnant women calls 
 for the greatest forbearance and gentleness on the part of those who 
 are brought into close contact with them. Their unreasonableness is 
 not to be cured by either impatience or stern treatment. It is the 
 product of nervous derangement, and is to be regarded as due rather to 
 physical than to moral fault. 
 
 The Disorders of Pregnancy.— Among women reared amid the 
 Tefinements of civilization the entire period of pregnancy is very fre- 
 quently attended with a great deal of discomfort. The attempt to 
 relieve the disorders of pregnancy seriatim, it should be stated in a 
 general way, is a vain undertaking, and is a good method to beget hys- 
 teria by fixing the female's attention upon minor ailments. The best 
 medicines, in a large proportion of cases, are amusements and occu- 
 pations calculated to produce a forgetfulness of self. When, how- 
 ever, the disorders of pregnancy advance beyond the stage of dis- 
 comfort to that of actual suffering or danger, every effort should bo 
 put forth for their relief or mitigation. 
 
 The Blood-Changes of Pregnancy.— Under ordinary physiological
 
 ^^^ PREGNANCY. 
 
 conditions, as we have noted, there is a natural increase of the red 
 corpuscles in the blood during pregnancy ; but as a consequence of 
 faulty food assimilation, or of penury and want, there may be a loss of 
 /red corpuscles and of albumen. The red blood-corpuscles, as the 
 ■^ oxygen-carriers to the tissues, are illy spared from the economy. "When 
 they have undergone destruction to any material extent, the cell-ele- 
 ments, whose vitality is intimately associated with the power to take 
 oxygen from the blood, suffer from inanition, and the starved cells 
 waste or fill with fatty molecules. These changes are of necessity fol- 
 lowed by loss of weight, muscular prostration, impaired functional 
 activity of the secretory organs, and increased nerve irritability. As a 
 consequence, the appetite fails, the digestion is weakened, neuralgic 
 pains develop, and even moderate muscular exertion is attended with 
 effort and followed by a sense of fatigue ; vertigo, loss of memory, and, 
 in severe cases, chorea, hysteria, and insanity, may result from the 
 deranged condition of the nerve-centers ; attacks of syncope, palpita- 
 tions, and precordial oppression point to feeble heart-action ; the arte- 
 rial tension is lowered and venous hyperemia results ; and, finally, the 
 stagnant blood, deprived of its albumen, in place of inviting endos- 
 motic currents, transudes through the walls of the vessels, giving rise 
 to oedema and dropsical effusions. Gusserow* (1871) called attention 
 to the fact that the anemia of pregnancy might progress to such an 
 extreme as to produce a fatal termination. 
 
 The treatment of anemia is largely prophylactic. Light, air, 
 moderate exercise, good food, regulation of the bowels, cheerful society, 
 and an occasional respite from household and family cares, will always 
 be the main checks to its extreme development. Iron, though of little 
 avail in repairing losses which have already taken place, is of the ut- 
 most value in limiting the progress of the malady. Iron reduced by 
 hydrogen, in three-grain doses, either alone or combined with a fiftieth 
 of a grain of arsenic, has rendered me most service in this affection. 
 It should, however, be continued without intermission for weeks at a 
 time in order to obtain the full advantage of its beneficent action. 
 The liquid forms of iron, so useful at other times, I have rarely found 
 tolerated for a lengthened period in the pregnant state. In weakened 
 states of the stomach, when the latter revolts at beefsteak and mutton, 
 easily assimilated albuminoid articles, such as milk, soft-boiled eggs, 
 and scraped raw or underdone meat, should be administered in small 
 but frequently repeated portions. Where the marasmus is extreme, 
 and the rectum tolerant, the stomach may be relieved of a part of its 
 duty by the use of nutritive enemata prepared in accordance with the 
 now familiar prescription of Leube. In the pernicious form of anaemia, 
 Gusserow tried transfusion, but without success. He recommended, 
 
 * Gusserow, Ueber hochgradigste Anaemie Schwangerer, Arch. f. Gynaek., Bd. 
 ii, p. 218.
 
 THE MANAGEMENT OP PREGNANCY. II5 
 
 therefore, the resort to premature labor. In a case wliich occurred to 
 me in hospital practice, before my attention was drawn to Gusserow's 
 essay, I employed tlie latter method after consultation with my col- 
 leagues. The patient made a slow but apparently sure progress to- 
 ward recovery, until, at the end of a month, she managed, in the tem- 
 porary absence of the ward nurse, to get out of bed and make a hearty 
 meal of corned beef and cabbage. Vomiting set in, followed by col- 
 lapse, which proved fatal in a few hours. This pernicious form of 
 ana?mia, though not confined to multiparte, develops most frequently in 
 Avomen who have borne many cliildren in rapid succession. 
 
 A not unusual result of hydraemia consists in a swelling of the 
 lower extremities, beginning at the ankles, and thence extending up- 
 ward and invading often the labia, the vagina, and the lower segment 
 of the uterus. When not associated with kidney comjilications, this 
 oedema is rarely dangerous, though often the source of extreme dis- 
 comfort. In some cases of oedema of the vulva, the labia may attain 
 to the size of a man's head, and become nearly diaphanous from the 
 serous infiltration. When the distention is extreme, gangrene may 
 threaten and make it necessary to resort to puncture. In lying-in 
 hospitals this should be done with every antiseptic precaution. With 
 free drainage established, the swelling rapidly subsides. In a half- 
 dozen cases which I have thus far treated in this manner, premature 
 labor has followed in the course of two or three days — a coincidence of 
 such frequent occurrence as to make it necessary to employ puncture 
 with circumspection. 
 
 (Edema of the lower extremities seldom disappears entirely before 
 confinement, though relief is sometimes experienced in the last month, 
 when the fundus of the uterus falls forward. Slight degrees, such as 
 swelling limited to the feet, making it necessary for the woman to go 
 around in old shoes or her husband's slippers, do not require treat- 
 ment. Where, however, the skin of the limbs becomes tense and 
 painful, warm cloths should be applied, diaphoresis if possible should 
 be induced, tonics should be administered, and the patient be kept in 
 a recumbent position, or with the extremities raised a VAmericaine. 
 Hydragogue cathartics, by still further impovishering the blood, tend 
 to aggravate the difficulty. 
 
 Varicose Veins. — Varicose veins occur with greater frequency in 
 multipara? than in primiparae. So long as the large veins are not 
 involved, they possess slight significance. The saphena is always first 
 affected, then the lateral branches upon the inner surface of the leg 
 and thigh, especially just above the knee,* and less commonly the 
 veins of the vulva. Dilatation of the haemorrhoidal veins is a very 
 frequent occurrence. 
 
 The treatment of varicose veins is limited to the adoption of meas- 
 
 * Spiegelberg, loc. cit., p. 250.
 
 ^-^Q PREGNANCY. 
 
 Tires to prevent their increase, and to i)rovide against the dangers of 
 rupture. The first indication is best fulfilled by regulation of the bow- 
 els and the wearing of elastic stockings. The subcutaneous injection of 
 one to two grains of ergotin in solution has been recommended, and is 
 reported not to awaken uterine contractions. As the danger of rupture 
 is not speculative (Spiegelberg * reports two cases of fatal haemorrhage 
 from this cause), the patient should always be provided with a com- 
 press and bandage, which she should be taught to apply herself in case 
 of a sudden emergency before professional aid can be obtained. 
 
 Nausea and Vomiting. — There are few known therapeutical agents 
 which have not at one time or another been essayed as remedies for 
 the nausea and vomiting of pregnancy. Some of them have even en- 
 joyed for a time high repute as specifics, but the sobering effect of 
 experience has invariably served to dispel illusive hopes, the most suc- 
 cessful of them proving uncertain, and of benefit to only a limited 
 class of patients. It is usually, therefore, the part of prudence to do 
 nothing for the minor degrees of the affection, such as the ordinary 
 morning-sickness, or even for continuous nausea, so long as the inges- 
 tion of food and the general nutrition of the patient are undisturbed. 
 For these cases Seyfert's advice, to let the wife go home on a visit to 
 her mother, implying the value of changed surroundings, furnishes a 
 serviceable hint in the way of practice. When, however, the distress- 
 ing symptoms continue after the first three months, and perceptibly 
 tend to exhaust the vital powers, every resource should be tried in 
 turn, in the hope that some one of the many in repute may prove of 
 service as a means of warding off impending disaster. 
 
 At the outset of any systematic jilan of treatment for pregnancy- 
 vomiting, it is essential that the physician should inspire his patient 
 with confidence in his ultimate success. Care should be taken to reg- 
 ulate the bowels, as constipation invariably aggravates existing gastric 
 disturbance. Coitus often increases the sickness. If, in the early 
 months, the uterus is found retroverted or retrofiexed, it should be re- 
 placed in the knee-chest position, and the recurrence of the displacement 
 should be prevented by a suitable pessary. Grailly Hewitt has likewise 
 called attention to the fact that pregnancy-sickness may coexist with 
 impaction of the uterus connected with marked anteflexion. In such 
 cases relief is sometimes afforded by elevating the patient's hips and 
 by pushing the fundus of the uterus upward with the finger. If 
 necessary, the replacement should be maintained by cotton pledgets, or 
 by Gariel's air pessary A speculum examination should be made of 
 the cervix, and, should it be found eroded, the raw surface should be 
 brushed at intervals of from two to three days with a ten-per-cent 
 solution of nitrate of silver. Collins (Lancet, Dec. 17, 1887) has 
 
 * Ibid,, p. 250. For a complete discussion of the subject, t%de Des varices chez 
 la femme enceinte, These d'Agregation, par le Dr. P. Budin.
 
 TPIE MANAGEMENT OF PREGNANCY. 217 
 
 caused the cessation of vomiting by a single application to the cervix 
 of a ten-per-cent cocaine salve by means of a cotton tampon. In quite 
 a number of cases a mitigation of the distress is obtained by applyino- 
 the faradaic current to the pit of the stomach ; in others, the ice-bao- 
 applied to the cervical vertebra? affords a considerable measure of 
 relief ; and again in still others the sickness is helped by spraying the 
 pit of the stomach with ether. In hysterical patients Doleris recom- 
 mends the shower-bath. The inhalation of oxygen has likewise been 
 tried by Pinard with success. To many, ice-cold effervescent drinks are 
 grateful. Dr. Fordyce Barker was wont to recommend carbonic-acid 
 water containing a drachm of bromide of potassium to the siphon. 
 Dry champagne is of assistance to a comparatively small class, but 
 more often I have found it revolting to a squeamish stomach. Of 
 medicinal agents, subnitrate of bismuth and the oxalate of cerium pos- 
 sess the widest application. Usually I order ten grains of the former, 
 combined with five to ten grains of the latter, to be taken ten minutes 
 before eating. In cases of gastric catarrh, my favorite is the tincture 
 of nux vomica given in ten-drop doses before meals. Drop doses of 
 Fowler's solution at meal-time are said to exert considerable influence 
 in allaying stomach irritability. A twelfth of a grain of morphia given 
 hypodermically or by the mouth will frequently aid the retention of 
 food by the stomach, but may lead to the formation of the opium habit. 
 Simmons, of Yokohama, advises the injection of thirty grains of chloral 
 per rectum morning and evening, a practice of which Richardson ad- 
 vises ftirther trial.* After eating, digestion may be promoted by ten 
 grains of pepsin, given alone or with either the dilute muriatic acid 
 or Horsford's acid phosphate. Gunther f states that he has caused 
 the cessation of vomiting by the use of galvanism as follows : He placed 
 the anode covered by a sponge to the cervix, and the cathode, by 
 means of a large plaque, 4x8 inches, over the spine, between the eighth 
 and twelfth vertebri^i. In no case did the vomiting persist more than 
 five days. The strength of the current was at first 2i to 3 milli- 
 amperes, and never exceeded 5 milliamperes. 
 
 If the foregoing measures prove of no avail, the patient should be 
 made to take small quantities of easily digested food, such as milk and 
 lime-water, koumyss, Valentine's beef-juice, or the pulp scraped from 
 raw or underdone beef, at hourly intervals, while rest in bed is maintained 
 for the purpose of avoiding the slightest unnecessary waste of tissue. 
 
 In very rare instances the vomiting becomes incessant, and resists 
 every remedy. If death from starvation threatens, it may become 
 necessary, as an ultimate resource, to terminate pregnancy by artifi- 
 cial means. The severest cases rarely are such at the beginning. 
 
 * Richardson, Hydrate of Chloral iu Obstetric Practice, Trans, of the Am. 
 Gynsec. Soe. vol. i, p. 347. 
 
 t Centralblatt, 1888, p. 465.
 
 ^1^ PREGNANCY. 
 
 Usually, at the outset, there is a period of nausea, followed by occa- 
 sional attacks of easy, painless vomiting. But in time everything 
 taken into the stomach is rejected. The patient experiences a disgust 
 for all food, or, rarely, a craving for indigestible articles of diet. With 
 this condition is often associated pains in the stomach and profuse 
 salivation; constipation is common; diarrhoea is the exception. Ac- 
 cording to Horwitz, patients sometimes complain of unpleasant odors 
 (hyperosmia). With the constant vomiting, they become wasted, pale, 
 and apathetic. As exhaustion becomes marked, the pulse grows weak 
 and rapid ; the respirations are more frequent ; the skin of the body 
 becomes dry and hard ; the extremities are cold and blue, and at times 
 are covered with sweat. Xow and then a slight elevation of tempera- 
 ture is observable. The vomited matter consists of mucus mingled 
 with bile, and is sometimes tinged with blood. Toward the end con- 
 stant thirst is felt, the mouth and throat are dry, the buccal mucous 
 membrane is reddened, the tongue is red at the tip and brown at the 
 root, sordes cover the gums and the teeth, and the breath has a most 
 disgusting odor. The quantity of the urine sinks to a few ounces daily, 
 is concentrated, and contains both albumen and casts, the latter ordi- 
 narily epithelial, but sometimes fibrinous. To the close of life extreme 
 emaciation and weakness ensue, the face is pinched, the eyes are dull 
 and sunken, fainting attacks are frequent, the sensorium is sometimes 
 unobscured, but often there are hallucinations and tlelirium. Before 
 life closes the vomiting ceases. 
 
 Remissions in the course of the disease are not uncommon. Some- 
 times the strength holds out to the end of pregnancy. The fatus in 
 these cases suffers but little from the exiiaustion of the mother. In 
 general, however, the prognosis is bad. Joulin has reported one hun- 
 dred and twenty-one cases, with forty-nine deaths. Without treat- 
 ment, of fifty-seven cases, twenty-eight were fatal ; with treatment 
 (abortion induced), of thirty-six patients, nine only died. 
 
 The treatment consists first in the careful removal of all compli- 
 cating conditions. In the early stages it may be sufficient to resort to 
 the measures already recommended. If the vomiting is literally un- 
 controllable, the patient should be placed at rest in bed. Every un- 
 necessary movement should be avoided. Horwitz recommends that 
 the room be darkened, and in advanced cases that warmth be applied 
 to the body. Rectal alimentation is often capable of rendering excel- 
 lent service.* Peptonized milk, defibrinated blood,t and the beef and 
 
 * Dr. BusEY, in an article published in the Am. Jour, of the Med. Sci. (1879, pp. 
 112-117), advises stomach-rest, nutritive eneraata, and the rectal administration of 
 bromide of potassium. Later experiences have fully confirmed the value of his 
 recommendations. 
 
 t We owe this excellent suggestion to Dr. A. H. Smith. The defibrinated blood 
 should be administered warmed, three to four ounces at a time, once in eight hours.
 
 THE MANAGEMENT OF PREGNANCY. ^^ 
 
 pancreas solution of Leube,* may be used for this purpose. The quan- 
 tity should not exceed four to six ounces, and should not be repeated 
 more frequently than three to four times in twenty-four hours. Some- 
 times it is necessary tliat the stomach-rest sliould be absolute. It is 
 however, permissible for the patient to ease her thirst with bits of ice 
 or small quantities of sparkling drinks when they are not immediately 
 ejected. If the latter is the case, I administer eight ounces of water 
 with the addition of two whites of eggs, per rectum three times daily, 
 in addition to the regular enemas. Usually it will be necessary to 
 quiet the nervous system by some anodyne agent. Dr. Busey recom- 
 mends the rectal administration of bromide of potassium. Horwitz 
 and Sutugin press the claims of chloral. Codeia by the mouth and 
 morphia hypodermically are of undoubted service in many cases. 
 But the choice will have to be determined by the idiosyncrasy of the 
 patient. 
 
 After the regular continuance for a few days of the rectal alimen- 
 tation, attempts should be made to test the capacity of the stomach to 
 retain solid food. Sutugin got good results from little balls of meat 
 which he had cooked over a spirit-lamp. Small quantities of pepto- 
 nized milk, or paucreatized solutions of meat, should be tried, though 
 sometimes indigestible articles of food are found to be those which are 
 really best tolerated. 
 
 Dr. Henry F. Campbell f relates a case where he nourished a pa- 
 tient fifty-two days by the rectum alone. Such cases are very rare, 
 owing to the fact that in time the rectum becomes intolerant of the 
 presence of injected materials. If, therefore, the rectal method of 
 nutrition fails to relieve the patient, the induction of abortion or pre- 
 mature labor should be resorted to before the stage of extreme inan- 
 ition is reached. But first in such a case it is well to recall the expe- 
 rience of Dr. Copeman, of Norwich, England. Desirous of exciting 
 abortion (patient at sixth month), he pushed his finger upward through 
 the cervix to the membranes. These he tried to rupture with a sound, 
 but without success. Two hours later he returned to his patient, and 
 found, to his astonishment, the vomiting had ceased. Later he tried 
 the plan of dilating the os externum and cervix with the index-finger 
 for the cure of persistent vomiting, and in four cases he succeeded by 
 this method in removing the distressing symptom. In three subse- 
 
 To prevent decomposition, Dr. Smith advises the addition of a grain and a iialf of 
 chloral to each fluidounce of the blood. 
 
 * Leube's formula consists of five to ten ounces of finely chopped beef, to which 
 should be added one third its weight of finely minced pancreas (pig or ox). The 
 mixture should be treated in a mortar with five ounces of lukewarm water, and re- 
 duced to a thick soup (Foster's Clinical Medicine, p. 24). Not more than four to 
 six ounces should be given at a time, nor more frequently than once in four hours. 
 
 t H. F. Campbell, Rectal Ahmentation in Pregnancy, Trans, of the Am. Gyn. 
 See., vol. iii, p. 273.
 
 ^20 PREGNANCY. 
 
 quent trials he found that it was not necessary to press up to the os in- 
 ternum, but that it sufficed to pass the index-finger to the first joint. 
 Rosenthal has since reported two favorable cases. Dr. AV. Gill Wylie * 
 believes that most cases of nausea may be cured by Copeman's method 
 combined with treatment of any discoverable cervical lesion. He has 
 devised a special steel dilator to take the place of the finger. His de- 
 scription of his plan of conduct is as follows : 
 
 " The vulva and vagina are carefully washed with a l-to-3,000 solu- 
 tion of mercuric bichloride. I then dip the blades of my dilator in pure 
 carbolic acid and shake off the free acid and introduce the points into 
 the cervix for about half an inch, a»d slowly dilate until the blades 
 separate from one third to one half an inch. If there is an eroded or 
 everted diseased tissue present, I touch it lightly with an applicator that 
 has been dipped in pure carbolic acid. I then, with a powder-blower, 
 cover the cervix with a thin layer of iodoform, and place against the 
 cervix a flat pledget of borated absorbent cotton soaked in pure glycer- 
 in, which is to be removed in twenty-four hours by means of a short 
 string attached to it. In some cases there is slight j^ain, but in most 
 cases no pain or real disturbance whatever is produced. As a rule, 
 this will relieve nausea ; but after four or five days, if there is still 
 nausea, I repeat the dilatation, and may pass the dilator three fourths 
 of an inch, and in some cases, where the cervix is long, even more. 
 Very rarely will more than two dilatations be needed. In some cases 
 the cervix is so patulous that dilatation may seem to be useless, but 
 well up in the cervix tight bands may be found, and, when stretched, 
 complete relief is effected. Even where the cervix is lacerated and 
 apparently open, bands may be found, and, when stretched, relief is 
 obtained. It is easy in such cases to recognize when the end of the 
 dilator comes against the os internum, for it is firmly closed, and by 
 passing the instrument until the os is felt, and then slightly withdraw- 
 ing it, dilatation can be done without much risk. In severe cases the 
 cervix may be of a very bluish-black color. The glycerin application 
 causes a free watery discharge, and relieves this congestion. Formerly 
 I used nitrate of silver for granular erosion, but I found that the car- 
 bolic acid and glycerin had an equally good effect." 
 
 Horwitz was less fortunate ; still, the trial of the measure is justi- 
 fiable, inasmuch as its failure does not aggravate the patient's discom- 
 fort, and does not measurably delay the resort to the artificial inter- 
 ruption of pregnancy. By the latter method, McClintock reports in 
 thirty-six cases the saving of twenty-seven lives. It is obvious that 
 the results are mainly determined by the condition of the patient at 
 the time the operation is undertaken. In the advanced stages of the 
 disease, after the tongue has become dry and brown, the urine scanty 
 and albuminous, and when the wasting and prostration have reached 
 * Wylie, Vomiting in Pregnancy, N. Y. Med. Record, Dec. 6, 1884.
 
 THE MANAGEMENT OF PREGNANCY. i^)-^ 
 
 an extreme degree, it is hardly to be expected that many lives are to 
 be rescued.* 
 
 For the induction of abortion in the early months I prefer the 
 tupelo tents, as, with the softening and dilatation caused by the tents, the 
 sickness usually ceases for a considerable period previous to expulsion 
 of the ovum. 
 
 In deciding the question of abortion, it is necessary not to forget the 
 neurotic character of the stomach sickness in many pregnant women. The 
 comj^lcte cessation of the vomiting, deemed uncontrollable as the result of 
 mental impressions, has been often noted by clinical observers. In one instance, 
 owing to extreme exhaustion of the patient due to continued vomiting, I de- 
 cided to induce abortion. As I was making preparations to that end, the 
 patient, somewhat unexpectedly to myself, announced' her determined opposi- 
 tion to the proposed plan of treatment. I endeavored to show her that it was 
 necessary, to save her life. She asked me to hand her a cup of bouillon. As 
 she swallowed it I told her there would be no occasion to induce abortion, if 
 she kept it on her stomach. This she did seemingly without difficulty, and 
 from tiiat moment to the end of the pregnancy there was no recurrence of 
 stomach sickness. A similar history is related by Kaltenbach.t In a paper on 
 the excessive vamiting of pregnancy, Kaltenbach urges that in all cases 
 especial stress should be laid upon the underlying disturbance of the nervous 
 system. With this object in view, he recommends that the physician should 
 seek to win the confidence of his patients in respect to methods of treatment 
 prescribed and the efficacy of remedies employed. Often, to secure favorable 
 results, it becomes necessary to isolate the sufferer from anxious and in- 
 judicious friends, and from the petty irritations of domestic life. "The more 
 authoritatively the 2)hysician carries out his plans of treatment," he says, "the 
 more rarely will he be driven to seek a cure in artificial abortion." 
 
 Heart-bum. — Heart-burn becomes distressing in the later months 
 of pregnancy. It can rarely be cured before delivery, but may, in 
 most cases, be palliated by carbonate of magnesia or half-teaspoonful 
 doses of aromatic spirits of ammonia. 
 
 Salivation. — Excessive flow of saliva to the extent of two to three 
 quarts in the course of the day has been observed. For this dis- 
 order small doses of atropia, the twelfth of a grain of pilocarpine, and 
 the fluid extract of viburnum prunifolium have been severally recom- 
 mended. 
 
 Pruritus.— Pruritus, without any visible affection of the skin, 
 Bometimes occasions in pregnant women an unendurable degree of 
 suffering. When general, temporary relief may be obtained by plac- 
 ing the patient in a prolonged soda-bath, and subsequently rubbing 
 the entire surface with vaseline. Very commonly the itching is con- 
 
 * For recent discussions of this subject, vide Horwitz. Ueber das unstillbare 
 Erbrechen der Schwangeren, Ztschr. f. Geburtsk. und Gynaek., vol. ix. p. 110. 
 SuTUGiN, Hyperemesis gravidarum, Berlin, 1883. 
 
 t Kaltenbach, Ueber Hyperemesis gravidarum, Ztschr. fur Geburtsk. und 
 Gynaek., Bd. xxi, p. 200.
 
 ^22 PREGNANCY. 
 
 fined to the distended abdominal walls. In such cases, cloths wet 
 with camphor liniments, with the addition of chloroform (lin. saponis 
 comp., 1 V ; chloroform, I j), or a solution of carbolic acid ( 3 j ad 
 Oj), applied to the itching surface will usually allay the irritation for 
 the time. In pruritus of the vulva, in addition to local external ap- 
 plications, great care should be taken to cleanse the vagina with so- 
 lutions of borax or carbolic acid. A half-pint slowly injected into the 
 vagina may be employed twice daily, without risk of provoking labor. 
 If the itching results from an acrid discharge proceeding from an 
 ulcerated cervix, the application of nitrate of silver, or the introduction 
 at night of a cotton plug soaked in a solution of tannin in glycerin 
 (ac. tannic, 3 J ; glycerinae, 3 j), will usually aiford relief. 
 
 Face-ache. — Neuralgia of the fifth nerve is a common affection in 
 pregnant women. It can often be quieted by the external application 
 of aconite, chloroform, or camphor liniment. Should these or kindred 
 remedies fail, it is best to resort at once to the hypodermic injection 
 of morphia. The recurrence of i)ain, as the effects of the morphia 
 pass away, can in most cases be prevented by giving to the patient 
 once in four hours from three- to five-drop doses of the fluid extract of 
 gelsemium, suspending its administration so soon as the slightest in- 
 dication of ptosis is produced. Croton-chloral, in from two- to five- 
 grain doses hourly, has likewise proved effective. Bartholow advises 
 not to push • the remedy beyond fifteen grains. Lindner (Arch. f. 
 Gynaek., Bd. xvi, p. 312) recommends ten grains at a dose given at 
 bedtime. 
 
 Cephalalgia. — Headache should be treated according to the cause. 
 Constipation should be removed, and iron should be given when the 
 headache is dependent upon anaemia. If of malarial origin, I have 
 never hesitated to give quinine in large doses, and have never yet ob- 
 served its acting as an oxytocic. When purely of reflex origin, the 
 guarana powder, the diffusible stimulants, and the entire range of 
 nerve sedatives are indicated. Unfortunately, there are no fixed rules 
 by which, in a given case, the ajjpropriate remedy can be invariably 
 selected. 
 
 Insomnia. — Troublesome sleeplessness may toward the end of preg- 
 nancy reduce a woman to an unfavorable condition for encountering 
 the perils of childbirth. The main reliance should be placed, where 
 possible, upon moderate exercise, upon bromide of potassium, chloral, 
 camplior and hyoscyamus, and codeine. The ordinary forms of opium 
 should be placed under the ban, on account of the fatal facility with 
 which the opium habit is acquired. Even in ordering the less ob- 
 jectionable hypnotics, care should be taken against their continued 
 employment. With proper caution, however, their occasional admin- 
 istration for the purpose of breaking a morbid habit is to be com- 
 mended.
 
 LABOR. 
 
 CHAPTER VII. 
 
 THE PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. 
 
 Causes of labor. — Uterine contractions. — Action of labor-pains upon the uterine 
 walls. — Contraction of ligaments. — Action of abdominal muscles. — Action of 
 vagina. — The pain of labor. — General influence of labor-pains upon the or- 
 ganism. — Precursory symptoms of labor. — First, second, and third stages of 
 labor. — Duration. — Action of the expellent forces. 
 
 Under the term labor are comprised all the physiological and me- 
 chanical processes by means of which the extrusion of the ovum from 
 the maternal organs of generation is effected. As the term implies 
 exertion, its application is restricted to the parturient efforts of vi- 
 viparous animals. The duration of pregnancy varies widely in the 
 different classes of the animal kingdom. The occurrence of normal 
 labor is coincident with the maturity of the foetus. This, in man, is 
 found to correspond very nearly to the interval between ten menstrual 
 periods. 
 
 Causes of Labor. 
 
 Speculation as to the proximate causes of labor has so far proved 
 profitless. The following particulars comprise the extent of our knowl- 
 edge of the conditions which prepare the way during pregnancy for 
 the final expulsive efforts : 
 
 1. During the first three months the growth of the uterus is more 
 rapid than that of the ovum, which is freely movable within the uter- 
 ine cavity, except at its placental attachment. In the fourth month 
 the reflexa becomes so far adherent to the chorion that it can only be 
 separated by the exertion of some slight degree of force, and the am- 
 nion is in contact with the chorion. After the fourth month the 
 chorion and amnion are agglutinated together, though even at the ter- 
 mination of pregnancy they may with care be separated from one 
 another. After the fifth month the agglutination of the decidua vera 
 and reflexa takes place. In the second half of pregnancy the rapid 
 development of the ovum causes a corresponding expansion of the 
 uterine cavity, the uterine walls becoming thinned, so that by the end 
 of gestation they do not exceed upon the average two to three lines in 
 thickness. The vast extension of the uterine surface is not, however.
 
 124 
 
 LABOR. 
 
 simply a consequence of over-stretching, a fact shown by the circum- 
 stance that the uterus toward the close of gestation is increased from 
 twenty- to thirty-fold in weight, and by the histories of extra-uterine 
 fetations, in which, up to a certain limit, the uterus enlarges progress- 
 ively, in spite of the non-presence of the ovum. The augmented 
 weio'ht of the uterus is the result of the increase in length and width 
 of the individual muscular fiber-cells, the extreme vascular develop- 
 ment, and the abundant formation of connective tissue. Ujj to the 
 sixth and a half month there has further been observed a genesis of 
 new fiber-cells, especially upon the inner uterine surface. According 
 to Ranvier, the smooth muscular fibers become striated as the end of 
 gestation is reached.* 
 
 The precise manner in which the distention of the uterus is accom- 
 plished has as yet not been demonstrated. A priori only two possibil- 
 ities are apparently admissible, viz., either the individual structure 
 elements are stretched after the manner of elastic bands, or a re- 
 arrangement of the muscular elements t ikes place in such wise that a 
 certain proportion of the fiber-cells, instead of lying, as in the begin- 
 ning of pregnancy, parallel to one another, gradually, with the ad- 
 vance of gestation, are displaced, so that the ends only are in juxta- 
 position. It is probable, though not proved, that toward the close 
 the thinning of the walls is the result of both conditions. Bearing 
 these premises in mind, it becomes a disputed question as to whether 
 one of the causes of labor is not to be found in the reaction of the 
 uterus, as a hollow muscular organ, from the extreme tension to Avhich 
 its fibers are ultimately subjected. Countenance to the affirmative 
 side is afforded by the tendency to premature labor in hydramnion and 
 multiple pregnancies, in which a high degree of tension is reached at 
 a period considerably antedating the complete development of the 
 foetus. 
 
 3. There is a perceptible increase of irritability in the uterus from 
 the very beginning of gestation. Indeed, the occurrence of spontane- 
 ous contractions has been put forward by Braxton Hicks as one of 
 the distinguishing signs of pregnancy. This irritability is especially 
 marked at the recurrence of the menstrual epochs ; it is very appar- 
 ent at the beginning of pregnancy, then diminishes in the middle pe- 
 riod, and becomes once more a prominent feature in the later months, 
 when spontaneous painless contractions are ordinary incidents of the 
 normal condition. 
 
 3. The researches of Friedlander, Kundrat, Engelmann, and Leo- 
 pold have demonstrated that the decidua vera of pregnancy is dis- 
 tinguishable into an outer, dense, membranous stratum, composed of 
 large cells resembling pavement epithelia, probably metamorphosed 
 cylindrical cells, and an — in appearance — underlying mesh-work, 
 
 * Vide Tarxier et Chantrkuil, Traite de I'art des accouchements, p. 203.
 
 THE PHYSIOLOGY OF LABOR. 
 
 125 
 
 formed from the walls of the enlarged decidual glands. It is in this 
 spongy layer that the separation of the decidua takes place, the fundi 
 of the glands persisting, even after the expulsion of the ovum. By 
 many, a fatty degeneration of the cells of the decidua has been 
 observed toward the end of pregnancy, but Leopold, Dohrn, and 
 I-anghans have shown that this is not of constant occurrence.* The 
 trabeculge which inclose the spaces of the network diminish in size 
 
 Fig. 61.— The mucous membrane of the uterus. A, amuion ; R, reflexa ; D, decidua vera; 
 D. R, glandular spaces of the lower stratum ; M, muscular structure of uterus. (Engel- 
 manu.) 
 
 with the advance of pregnancy. Thus, while they measure at the 
 fourth month about -g^ of an inch in thickness, they become gradu- 
 ally reduced in the subsequent months to -g-^Vo" ^^ ^^^ inch, a change 
 which materially facilitates the peeling off of the decidual surface. f 
 
 4. From the fifth month onward, large-sized cells make their 
 appearance in the serotina, especially in the neighborhood of thin- 
 walled vessels. The largest of the so-called giant-cells contain some- 
 times as many as forty nuclei Though a physiological product, they 
 resemble for the most part the so-called specific cancer-cells of the older 
 writers. They are of special obstetrical interest from the fact observed 
 by Friedltinder, and confirmed by Leopold, J that they penetrate the 
 uterine sinuses from the eighth month, and lead to coagulation of the 
 blood, and to the formation of young connective tissue, by means of 
 which a portion of the venous sinuses becomes obliterated before labor 
 begins. The subtraction of these vessels from the circulation tends to 
 increase the amount of the venous blood in the intervillous spaces of 
 the placenta. 
 
 * Leopold. Stiidien iiber die Sehleimhaut, etc., Arch. f. Gynaek., Bd xi, p. 49. 
 
 t Engelmann, The Mucous Membrane of the Uterus, p. 45. 
 
 i Op. cit., pp. 492 et seq. The migration of the giant-cells into the maternal 
 vessels described by Frankenhaeuser has been questioned by Palenko and Heinz, 
 who ascribe the thrombosis of the vessels to proliferation of the endothelial cells, 
 which subsequently become converted into giant-cells. Heinz, Arch. f. Gynaek, voL 
 xxxiii, p. 417.
 
 126 
 
 LABOR. 
 
 5. It is proper to recall here the fact that the nerve-filaments of the 
 uterus are derived in principal measure from the sympathetic system. 
 The large cervical ganglion, which in pregnancy measures about two 
 inches in length by one and a half inch in breadth, receives, however, 
 in addition to the sympathetic fibers, filaments from the second, third, 
 and fourth sacral nerves. 
 
 Physiology has as yet left unsettled the question as to the main 
 channels of the motor impulses which are conveyed to the uterus during 
 labor. One of my hospital patients, with paralysis of the lower ex- 
 tremities, retention of urine, and loss of power over the sphincter-ani 
 muscle, had a perfectly natural though painless labor. The cause of 
 the paralysis was obscure, the patient subsequently making a complete 
 recovery. Jacquemart * reports a similar case, in which the paralysis 
 was due to partial compression of the cord at the level of the first 
 dorsal vertebra. On the other hand, Schlesinger f has shown that the 
 sympathetic is not the only motor nerve, as reflex movements of the 
 uterus follow stimulation of the organ when all the branches of the 
 aortic plexus have been carefully divided. 
 
 A motor center for uterine contractions has been proved to exist in 
 the medulla oblongata. This center is excited directly to action by 
 anaemic conditions, and by the presence of carbonic acid in the blood 
 conveyed to it. Vivid mental emotions may either awaken or suspend 
 uterine contractility. 
 
 Reflex movements of the uterus may be provoked by stimulating 
 the central end of any of the spinal nerves — a fact which serves to ex- 
 plain the consensus long recognized as existing between the breasts 
 and the organs of generation. When the spinal cord is divided below 
 the medulla oblongata, this phenomenon is no longer observed. Direct 
 stimuli to the uterus, however, determine contractions independently 
 of the medulla oblongata, the spinal cord then acting as a reflex center. 
 The presence of asphyxiated blood in the arterial trunks acts as a 
 physiological stimulus to labor. | By the separation of the decidua 
 from its organic connection with the uterus, the ovum acts as a 
 foreign body, and, as is well known, speedily awakens uterine move- 
 ments. Finally, Kehrer* has shown that, when a cornu is removed 
 from the uterus during labor, rhythmic contractions of the mus- 
 cular fibers will continue from a half-hour to an hour after separa- 
 tion, provided only the tissues be kept moist and at a suitable tem- 
 perature. || 
 
 * Tarnier et Chantreuil, Traite de I'art des accouchements, p. 229. 
 t Ober und Schlesinger, Strieker's Wiener med. .Jahrbuch. 1872. 
 
 I Vide Schlesinger, Strieker's Wiener med. Jahrbuch, 1873. 
 
 * Kehrer, Beitrage zur vergleichende und experimentellen Geburtskunde, 2tes 
 Heft, p. 48. 
 
 H CoHNSTEiN (Zur Innervation der Gebarmutter, Arch. f. Gynaek., vol. xviii.
 
 THE PHYSIOLOGY OF LABOR. 
 
 12Y 
 
 The following theory of the causes of labor is offered, not because 
 of its completeness, but merely as a means of grouping the foregoing 
 facts together in the order of their relative importance. The advance 
 of pregnancy is associated with increase in the irritability of the uterus, 
 a property most pronounced at the recurrence of the menstrual epochs. 
 By thinning of the partitions between the glandular structures the 
 way is prepared, as the time for labor approaches, for the easy separa- 
 tion of the dense inner stratum of the decidua. The ready response 
 of the uterus to stimuli reflected from the peripheral extremities of 
 the spinal nerves, to direct local irritation, and to the presence of blood 
 surcharged with carbonic acid in the uterine vessels, explains the fre- 
 quency of painless contractions for days, or even weeks, in some cases, 
 previous to labor. To these means of exciting uterine motility there 
 should be added, in all probability, the reaction of the uterine muscle, 
 from the tension to which it is subjected by the growth of the ovum, 
 and to circulatory disturbances in the cerebral centers sometimes 
 effected by vivid emotions. Frequently repeated uterine contractions, 
 without partial separation of the decidua, are hardly comprehensible 
 after the decidua vera and reflexa are brought into close contact with 
 one another. Such a physiological separation would of necessity, 
 when of sufficient extent, by converting the ovum into a foreign body, 
 furnish an active cause for the advent of labor, in the same way that 
 labor is prematurely excited by a similar separation when artificially 
 induced. Thus, by the time the development of the foetus is com- 
 pleted, all things are in train for its expulsion. When other causes 
 do not early operate as determining forces, the increase of uterine 
 irritability at the recurrence of the menstrual epochs probably accounts 
 for the ordinary coincidence of labor with the tenth catamenial date. 
 
 Physiological Phenomena of Labor. 
 
 The Uterine Contractions. — The uterine contractions are entirely 
 independent of volition. As in other organs composed of smooth 
 muscular fibers, each contraction at the beginning is slow and weak ; 
 gradually it reaches the point of greatest intensity ; the acme con- 
 tinues for a brief period, and then, finally, is followed by complete 
 relaxation. Each complete excursion is termed a labor-pain. Peri- 
 staltic movements have been observed in animals with two-horned 
 uteri. A similar action, proceeding from the fundus to the cervix, 
 has been sometimes assumed for the human subject. The peristaltic 
 wave, however, if indeed it exists, extends so rapidly that it is best 
 to consider the uterus as a hollow muscle, which contracts simulta- 
 
 p. 394), from his own experiments and those of others, concludes that the determin- 
 ing cause of the uterine contractions is contained in the intra-muscular ganglionic 
 cells : that the central nerve-organs regulate the uterine activity, and that the sym- 
 pathetic acts simply as a vaso-motor nerve.
 
 128 
 
 LABOR. 
 
 neously in all its parts. As labor advances, an increase in the length 
 and the force of the contractions is developed. The stronger the 
 pains, the shorter is the interval between them. The average normal 
 duration of a labor-pain is about one minute. 
 
 The Action of Labor-Pains upon the Uterine Walls.— During the 
 intervals between the pains, it is well known that the uterus possesses 
 
 Fig. 63.— Transverse section, dotted line 
 representingr shape of uterus during 
 a pain. (Lahs.) 
 
 Fig. fi3.— Longitudinal section, dotted 
 line representing elevation of fun- 
 dus during a pain. (Lahs.) 
 
 an ovoid shape, and is flattened antero-posteriorly by the pressure of 
 the abdominal walls. During the pains, however, the uterus, as it 
 closes upon the fluid contents of the ovum, assumes a more nearly 
 globular outline. As a consequence, the transverse diameter is dimin- 
 ished, and the antero-posterior increased in corresponding proportion. 
 By this change, the uterus, which had previously rested by its poste- 
 rior surface upon the spinal column, rises upward so that its fundus 
 produces a bulging of the anterior abdominal walls. 
 
 Owing to the loose connection of the muscular strata with the peri- 
 tongeum in the lower uterine segment, the walls of the latter offer less 
 resistance to the pressure of the ovum, and thus are stretched downward 
 during each pain. While, in contractions of the uterus, the lower seg- 
 ment is thinned, the diminished bulk of the contracted organ leads to 
 an increase in the thickness of the walls of the body and fundus.* 
 
 The Contractions of the Uterine Ligaments. — Structurally the mus- 
 cular fibers of the round and broad ligaments are in direct continuity 
 with the external muscular layer of the uterus. As would be antici- 
 pated, they contract simultaneously with that organ. In contracting, 
 they help to fix the uterus at the pelvic brim. 
 
 * For most of the following deductions the writer is indebted to Dr. Lahs'9 
 ingenious work entitled Die Theorie der Geburt. For modifications in details in 
 the present edition, vide inter alios Werth, Die Physiologie der Geburt, MCller's 
 Handbuch der Geburtshiilfe, vol, i, p. 330.
 
 THE PHYSIOLOGY OF LABOR. 
 
 129 
 
 v^ / 
 
 O 
 
 Fig. 64. — Diagram 
 changes in the 
 
 representing 
 thicl^ness fif 
 
 uterine walls during labor. (Lahs.^ 
 
 the 
 the 
 
 The Action of the Abdominal Muscles.— The contraction of the 
 abdominal walls is a powerful auxiliary to the expulsive action of the 
 uterus. At the beginning of labor the contractions are voluntary, 
 but as labor advances they become more and more reflex in charac- 
 ter, until, in many women, the dis- 
 position to press during each pain as- 
 sumes the form of an uncontrollable 
 impulse. The mechanism by which 
 these auxiliary forces are called into 
 play is as follows : As, toward the 
 acme of the pain, the fundus uteri is 
 elevated and lifts up the abdominal 
 walls, the woman takes a deep ins^jira- 
 tion, the glottis closes, and the dia- 
 phragm contracts. The latter pushes 
 the intestines downward, and thus 
 aids in raising the uterus to a position 
 nearly perpendicular to the pelvic 
 brim. All the expiratory muscles then 
 enter into active contraction. Mean- 
 time, the laboring woman secures fixa- 
 tion of the trunk by finding points of support for the upper and lower 
 extremities. By these means the capacity of the abdominal cavity is 
 greatly diminished, and the uterus is compressed not only by the ad- 
 jacent muscular coverings, but by the entire mass of inclosed viscera. 
 The effect is twofold : 
 
 1. There results an augmentation of the intra-uterine pressure. 
 
 2. A portion of the contents of the large vessels of the trunk is 
 forced to the extremities. To this cause is attributable the flushed, 
 congested appearance of the face during labor-pains. As the intra- 
 abdominal pressure is not brought to bear upon the organs within the 
 pelvic cavity, hypersemia of the vagina and the contiguous tissues 
 follows. As a consequence, the channel through which the head has 
 to pass, as labor advances, becomes infiltrated with serum, and offers 
 less resistance to the presenting part. At the same time the glandu- 
 lar structures are excited to increased action, and the lining mucous 
 membrane becomes lubricated by the secretion which is freely poured 
 out. 
 
 The Influence of the Vagina in Parturition.— As the head advances 
 through the cervix, the vagina at first opposes an obstacle to its fur- 
 ther progress. After, however, the largest circumference of the child 
 has passed through the genital canal, the contractions of the vagina 
 aid somewhat in the expulsion of the after-coming extremities and of 
 the placenta. 
 
 The Pains of Labor.— The painful sensations which are the accom-
 
 130 
 
 LABOR. 
 
 paniment of the uterine contractions begin in the lower uterine seg- 
 ment. They are at first especially felt over the sacrum, Avhence they 
 radiate to the rectum and the bladder, across the abdomen, and down 
 the thighs. In the beginning of labor the sensations are dull, and of 
 a bearing-down character. As labor advances, however, the pains 
 increase in acuteness, and in many persons reach an unendurable de- 
 gree of severity. They are mainly induced through the compression 
 of the uterine nerves by the contractions of the muscular fibers. They 
 are probably likewise in part the result, as Werth suggests, of hyperaemia 
 of the lower extremity of the sjiinul cord and of its envelopes. The 
 severity of the pains is proportioned to the resistance to be overcome. 
 At first, as has been stated, confined to the lower segment of the 
 uterus, the pains subsequently invade the body and the fundus. The 
 sufferings of the female increase with the mechanical distention of 
 the cervix, especially with that of the external orifice, and finally 
 reach the point of supreme agony as the head jjasses through the 
 vagina and vulva, which are abundantly supplied witli sensitive spinal 
 nerves. 
 
 The pains are often greater in very young or in elderly primipar* 
 than in women at the prime of physical life. Though labor is rarely 
 absolutely painless, where the first stage is slow and the resistance of 
 the soft parts slight the suffering may become comparatively insignifi- 
 cant. 
 
 Influence of the Pains upon the Organism. — During each pain the 
 arterial pressure is increased ; the rrecpiency of the pulse rises until 
 the acme is reached, when it slowly declines to the normal jioint ; the 
 respirations are slowed during the pains, owing to the contraction of 
 the abdominal walls, but are more rapid in the pauses as a consequence 
 of the general muscular exertion ; the temperature rises progressively 
 during labor, but, as a rule, within narrow limits; and tlie urinary ex- 
 cretion, in consequence of the increased arterial pressure, is augmented.* 
 
 The Clixical Course of Labor. 
 
 Precursory S3nnptoms.— About the thirty-ninth week of pregnancy 
 it is usual for the entire uterus to sink somewhat downward into the 
 pelvis, while the fundus falls forward. This change of position is 
 followed by considerable relief to the respiration, and to previously 
 existing gastric disturbances. At the same time there is experienced 
 an increased difficulty in locomotion ; the oedema of the lower extremi- 
 ties is aggravated ; the intra-pelvic pressure causes a frequent desire 
 to urinate, and predisposes to the development of haemorrhoids, espe- 
 cially where, as is the rule in primiparae, the head likewise descends 
 deep into the pelvic cavity. Indeed, in primiparse the changes of 
 
 * Naegele, Lehrbuch der Geb., p. 163. .
 
 THE PHYSIOLOGY OF LABOR. 131 
 
 position are more pronounced than in women who have passed throucrh 
 re2)eated pregnancies. As gestation drjiws to a close, a copious glairy 
 secretion is poured out from the cervix, the vagina relaxes, the labia 
 majora become swollen, and the vulva gapes open. For a variable 
 period preceding the advent of labor, painless contractions occur at 
 irregular intervals. These so-called dolores presagientes are the ordi- 
 nary prelude to labor in multipar^e, thougTi~HTeyare^teTi inappreciable 
 in primiparjB. They very commonly begin in the evening hours and 
 continue till toward the middle of the night. Very often they are as- 
 sociated with a dragging sensation between the sacrum and symphysis 
 and a feeling of tension in the abdominal region. Sometimes they 
 expand the os internum to a considerable extent, but never in such a 
 way that any portion of the cervical canal contributes to the enlarge- 
 ment of the uterine cavity. 
 
 Actual labor has been divided, as a matter of clinical convenience, 
 into three stages, as follows : 
 
 First stage, or stage of dilatation of the cervical canal. 
 
 Second stage, or the stage of expulsion, comprising the laeriod from 
 the dilatation of the cervix to the expulsion of the child. 
 
 Third stage, or stage of the placental delivery. 
 
 1. The First Stage — Dilatation of the Cervix. — The advent of true 
 labor is characterized by painful contractions, which render the patient 
 restless, and dispose her either to bend forward with clinched hands, 
 or to seek some firm support for the sacrum to ease her sufferings. 
 Usually, in the beginning of labor, women prefer the sitting posture, 
 which enables them to press with the forearm against the sacrum dur- 
 ing the pains. The pain of labor begins with the dilatation of the 
 internal os. In true labor the dilatation progresses gradually. As the 
 OS internum opens, the contractions cause the membranes to descend 
 and press upon the cervical canal. With the advance of labor the 
 pains increase in intensity and frequency. During their persistence 
 the external os is put upon the stretch, so that the border becomes 
 thin and sharply defined.* As the pain subsides, the os relaxes and 
 the membranes retreat. Each new pain increases the dilatation, and 
 forces the membranes somewhat deeper. The softening, the relaxa- 
 tion, and the hypersecretion of the soft parts become more and more 
 decided. As the borders of the os yield to pressure, lacerations occur, 
 which tinge the mucous discharges with blood. When the dilatation 
 has reached a certain limit (usually by the time the diameter of the 
 external os is three to three and a half inches), the protruding mem- 
 branes remain tense in the intervals between the pains, and are then 
 ready for rupture. After rupture, which usually occurs spontaneously, 
 the water in front of the child's head escapes, though the greater part 
 
 * In multiparjc this resistance of the external os may be entirely lacking.
 
 132 
 
 LABOR. 
 
 of the amniotic fluid is retained within the uteru^ by the valve-like 
 pressure of the presenting part.. After a short pause the head descends 
 into the cervix, the walls of which are stretched to the pelvic borders, 
 
 liq. amnios. 
 
 Fig. 65. — Section through a frozen corpse. Stage of expulsion. (Braune.) 
 
 and finally become so dilated that cervix and vagina form one con- 
 tinuous canal. 
 
 In case the presenting part does not thoroughly tampon the lower 
 segment of the uterus, a more or less complete escape of the entire 
 amniotic fluid may follow the rupture of the membranes. As a rule, 
 the tear in the membranes takes place in the most dependent point 
 of the convex portion which constitutes the bag of waters in the cer- 
 vical canal. Sometimes, however, the rupture takes place above the 
 cervix, where there can be a gradual escape of fluid in spite of the per- 
 sistence of the bag of waters. 
 
 If the membranes rupture before the dilatation of the cervix is 
 complete, the head descends and acts as a dilating wedge. In rare
 
 THE PHYSIOLOGY OF LABOR. 
 
 133 
 
 cases the rupture of the membranes, if left to nature, does not occur 
 and the ovum may descend in its integrity to the vulva. In such in- 
 stances the membranes sometimes rupture in the neighborhood of the 
 
 ! I IT /'■'''' ^ 
 
 placent 
 
 orif. tub 
 
 vagina, 
 rectum. 
 
 ureth 
 
 Fig. 66.— The uterus and parturient canal. Ftetus' removed. (Braune.) 
 
 child's neck, and the head is born covered with the so-called "caul," 
 i. e., with the detached portion of the membranes, which old nurses 
 regard as significant of good luck. In still rarer cases, where the fretus 
 is small and the amount of amniotic fluid limited, the entire ovum 
 may be expelled without rupture of its coverings. 
 
 2. The Second Stage— The Stage of Expulsion.— After the short 
 pause which follow^s the rapture of the membranes, the pains become 
 stronger and more frequent, and are now powerfully re-enforced by the 
 involuntary contractions of the abdominal muscles, which, though pre- 
 viously not entirely inactive, have played only a sixbordinate part. With 
 each pain the head now makes perceptible progress, retreating, however,
 
 j^y^ LABOR. 
 
 as the Tjains decline. After the head has passed the pelvic outlet, and is 
 covered only by the soft parts, the perinaeum bulges outward, the labia 
 ffape, and a portion of the head makes its appearance at the vulva. 
 As within the pelvic canal, with each pain the head advances, and puts 
 the perinreum upon the stretch, receding somewhat in turn as the 
 pains subside. The pressure upon the rectum leads to the evacuation 
 of fecal contents. Finally, the thinning of the perineum reaches a 
 point at which the sutures can be readily felt through its structure ; 
 the recession of the head ceases ; the anus assumes an oval shape ; the 
 orifice of the vulva looks forward and upward ; the urethra is pushed 
 against the symphysis pubis ; while, as the circumference of the head 
 in the neighborhood of the parietal bosses engages in the vulva, the 
 labia and frenulum form a thin circular band, through which, during 
 a pain or the contraction of the abdominal walls, the head makes its 
 way, usually leaving behind moderate lacerations of the fraenulum or 
 anterior portion of the perinjeum. The same, or the succeeding pain, 
 leads to the expulsion of the trunk. The birth of the child is fol- 
 lowed by the outpouring of the amniotic fluid, which, as a rule, escapes 
 colored with blood from the site of the wholly or partially detached 
 placenta. 
 
 3. The Third Stage— The Stage of the Placenta.— The placental 
 period embraces tlie time from the birtii of tlic child to the delivery 
 of the placenta and membranes. 
 
 After the birtli of the child, the recession of the blood from the 
 brain, which follows the diminution of the intra-abdominal pressure, 
 often produces a sense of faintness, and sometimes temporary syncope. 
 The rapid evacuation of the uterus is at times, too, succeeded by a 
 chill, which, however, does not betoken the onset of fever, but is the 
 result of vaso-motor disturbance, and the loss, through the expulsion 
 of the child, of a source of heat-supply. Most women, however, ex- 
 perience a restful feeling of comfort and repose. This sense of qui- 
 etude lasts anywhere from a few minutes to a quarter of an hour, when 
 the contractions return, which detach the placenta, and force it into 
 the vagina. The separation of the placenta takes place in the meshy, 
 lamellated layer which is formed in th,e serotina by the thinned, elon- 
 gated walls of the gland-tubules, the dense cell-layer of the maternal 
 portion remaining adherent to the placenta. As the maternal vessels 
 are necessarily torn across, some haemorrhage follows the detachment. 
 The haemorrhage is, however, speedily arrested by the contractions of 
 the uterus, which both compress the vessels and furnish the conditions 
 favorable to the formation of fibrinous clots in their distal extremities. 
 When the mechanism of expulsion is left to nature, the placenta de- 
 scends by its edge into the vagina, while premature tractions upon the 
 cord cause it to present by its fetal surface at the cervical orifice. 
 When once in the vagina, the expulsion is completed by the action of
 
 THE PHYSIOLOGY OF LABOR. ^^^ 
 
 the abdominal muscles, sustained by the retraction of the muscles which 
 form the floor of the pelvis. 
 
 According to Gassner,* after confinement the female experiences 
 as a consequence of the expulsion of the ovum, of the exhalations from 
 the lungs and skin, from the discharge of excrements, and from hsem- 
 orrhage, a loss of weight equivalent to one ninth of that of the entire 
 body. 
 
 Duration of Labor. — Spiegelberg found, in 506 labors, the average 
 for primipara? was KJiours, for multipara 12 hours. In primipar* 
 past the thirtieth year Hecker found the average 21-1 hours, while 
 Ahlfeld, in 82 women over thirty-two years of age, obtained an average 
 of 27.6 hours. f 
 
 In ordinary normal labor the second stage lasts about two hours in 
 primiparfe, and about' half as long in multiparae, though in the latter 
 the resistance is frequently so slight that a few pains suffice to com- 
 plete the delivery. 
 
 According to Kleinwachter,J the time at which labor-pains begin 
 occurs most frequently between ten and twelve o'clock in the evening. 
 Spiegelberg * states that the maximum frequency of births takes place 
 between twelve and three o'clock in the morning. 
 
 The Actiox of the Expellext Forces. 
 
 Having considered separately the action of the uterus, the uterine 
 appendages, and the abdominal muscles during labor, there remams 
 for us to combine these factors together, and to show in what manner 
 they contribute to the end of all parturient effort, viz., the expulsion 
 of the ovum. 
 
 In the first place, the contractions of the uterus are intermittent. 
 "When they lose their rhythmical quality and become continuous, they 
 cease to belong to the domain of physiology. It is only during the 
 act of contraction that work is performed. Whenever the alternating 
 relaxation ceases, and the uterus passes into a condition of tonic con- 
 traction, no work is accomplished, and the pains are ineffective. 
 
 The uterus is a hollow muscle, which during a pain closes down 
 upon its contents. If all parts of the uterine walls offered an equal 
 resistance, the force of the contractions would be expended upon the 
 periphery of the ovum, and, as the contents of the latter are practically 
 incompressible, the effort would be resultless. If, however, the walls 
 were so constructed that the distensibility varied in different regions, 
 
 * Gassner, Ueber d. Veranderungen des Korpergewichtes b. Schwang., Gebar. 
 und Wochner, Monatsschr. f. Geburtsk., xix, p. 18. 
 
 f Spiegelberg, Lehrbuch, pp. 134, 135. 
 
 i Kleinwachter, Die Zeit des Geburtsbeginnes, Ztschr. f. Geburtsh., Bd. i, 
 p. 230. 
 
 * Spiegelberg, Lehrbuch, etc., p. 135.
 
 136 ^^20^- 
 
 the peripheral compression exerted during a pain would be followed by 
 a bulging at the points of least resistance, provided the tissue acted 
 upon possessed the property of elasticity. Now it is an anatomical 
 fact, that during a labor-pain a stretching of the fundus and of the 
 lower uterine segment actually takes place. Indeed, after continued 
 labor we often find the intermediate portion of the uterus two to 
 three times as thick as the lower segment. As a result of these 
 conditions, concentric pressure of the fluid contents of the ovum is 
 followed by an increase in the longitudinal diameter of the uterus. 
 While the convexity of the fundus is unquestionably increased during 
 a pain, the effect of the latter is chiefly manifested in the distention of 
 the lower segment. Various causes combine to produce this result. 
 Thus, the muscular structures of the lower segment are loosely as- 
 sociated together, and are easily separable from the peritonseum. They 
 therefore offer a less resistance than that afforded by the close inter- 
 lacement of both circular and longitudinal fibers which prevails in the 
 fundal and upper uterine zones. Then, too, as was pointed out by 
 Lahs,* the lower segment sustains, in the ordinary positions assumed 
 by the female, the entire weiglit of the superimposed ovum with its 
 fluid and solid contents ; and, finally, the pressure transmitted from 
 the abdominal muscles takes a direction from above downward. 
 
 In 1876 Bandl f called attention to the thinned condition of the 
 lower uterine segment, extending from what had been previously re- 
 garded as the OS internum from four to six inches upward, and ter- 
 minating abruptly in a muscular ridge upon the inner surface. This 
 ridge he regarded as the upper limit of the cervical canal, which had 
 been opened up by the growth of the ovum. Lahs J however, places 
 this ring at the level of the pelvic brim. Above the pelvic brim, he 
 says, the convexity of the uterus is nearly uniform, while the portion 
 of the uterus below forms, as it were, a segment of a sphere with a 
 short radius attached to tlie abdominal division. In this way, upon 
 longitudinal section, a projection of the wall toward the uterine cavity 
 is observable at the pelvic brim where the two segments meet. He 
 therefore proposes that the ridge thus produced be called the " pelvic- 
 brim stricture." My own observations, which correspond to those of 
 Schroeder, show that in many instances this ridge is but slightly indi- 
 cated before the beginning of labor. During and as a consequence of 
 the labor-pains, the ridge becomes well marked, and clearly defines the 
 limits between the thinned, stretched lower portion and the thickened, 
 retracted upper portion of the uterus. Both from a physiological and 
 a pathological point of view this limiting ring possesses great import- 
 
 * Lahs, Die Theorie der Geburt. p. 116. 
 
 \ Bandl, Ueber das Verhalten des Uterus und Cervix in der Schwangerschaft 
 uud wahrend der Geburt. 
 
 I Lahs, Was heisst Unteres Uterinsegment, Arch. f. Gynaek., vol. xxiii, p. 215.
 
 THE PHYSIOLOGY OF LABOR. 
 
 137 
 
 ance. It is desirable, therefore, that it receive a designation definitive 
 of its character. The term " ring of Bandl," which has received some 
 currency, is objectionable, because that term has already beconue asso- 
 ciated with Bandl's views as to the true position of the internal os. 
 The " pelvic-brim stricture " of Lalis has an awkward sound in Eng- 
 lish, and expresses a theory not yet absolutely established. Ebell pro- 
 posed the name " mechanical or clinical os," but it requires a complete 
 familiarity with the discussion which the subject has occasioned not to 
 confound the structure with the orifices of the cervical canal. My own 
 choice would be to term it the 
 " retraction ring," as indicative 
 of what I believe to be its ori- 
 gin. As, however, Schroeder 
 has already introduced the term 
 " contraction ring," and as that 
 term has become somewhat fa- 
 miliar, I have thought it best 
 to accept that designation in 
 these pages in spite of criti- 
 cisms which have been made as 
 regards its propriety. 
 
 So far, for the sake of sim- 
 plicity, we have regarded the 
 uterus as a closed sac, possess- 
 ing walls of unequal thickness. 
 In reality the lower segment ter- 
 minates in an opening, the canal 
 of the cervix, which, though at 
 the beginning gf labor of small 
 size, and offering considerable 
 resistance to the pressure of the 
 ovum, is capable of sufficient 
 distention to permit the exit of 
 the foetus. 
 
 The dilatation of the cervix is partly mechanical, and partly the 
 effect of certain organic changes which have already received cursory 
 mention. 
 
 The mechanical dilatation is the result of— 1. The pressure of the 
 ovum upon the lower uterine segment, which forces open the os inter- 
 num, and unfolds the cervix from above downward. 
 
 2. The retraction of the uterus is an important property, which 
 requires brief description. While each contraction of the uterus is 
 followed by relaxation and a period of repose, a gradual change is con- 
 tinually going on in the length and arrangement of the muscular 
 fibers. In the thinned lower segment the fibers are stretched, and 
 
 FiQ. 67.— Longitudinal section tlirougli walls of 
 uterus in eighth month of prt gnancy ( Bandl). 
 a, contraction ring, or ring of Bandl ; 6, os in- 
 ternum ; cl, OS externum.
 
 138 
 
 LABOR. 
 
 separated from one another. lu the upper portion, on the contrary, 
 they shorten, and change their position in such a way that those which 
 previo^isly had only their extremities in contact assume a more nearly 
 parallel arrangement. The walls, therefore, in the upper zones thicken 
 and shorten, especially in the longitudinal direction. The limit be- 
 tween the thinned lower segment and the upper thickened zones is 
 marked, as we have seen, by a distinct ridge termed by Schroeder the 
 contraction ring. It is to the changes in the uterus which take place 
 above the contraction ring that the term retraction is apijlicable. As 
 the retraction is progressive, it leads to a gradual withdrawal upward 
 of the uterine walls, in consequence of which the lower segment is not 
 only put upon the stretch during the pains, but toward the end of the 
 period of dilatation is subjected to a greater or less degree of perma- 
 nent tension. Then, too, as the contraction ring moves upward, a 
 phenomenon observable where the descent of the head is hindered, the 
 longitudinal fibers of the lower segment, by reason of their insertion in 
 part at least into the vaginal portion, exert a direct influence in dilat- 
 ing the cervical canal. 
 
 3. When the abdominal muscles contract, the uterus is pressed down- 
 ward into the pelvic cavity. The descent is, however, limited by the 
 attachment of the uterine ligaments and the adjacent organs. But the 
 resistance afforded by the uterine attachments exercises a peripheral 
 traction upon the cervix, and thus tends to draw its walls asunder. 
 
 The normal dilatation of the cervix is, however, by no means a 
 matter of pure mechanical distention. If the canal which forms the 
 communication between the vagina and the uterus were simply an elas- 
 tic tube, it would of necessity retract down upon the neck of the foetus 
 after the passage of the head, and thus a new distention would be 
 required to permit the passage of the shoulders. Indeed, the condi- 
 tions of an elastic tube are not unfrequently realized in versions, where 
 an attempt is made to extract the foetus through an imperfectly dilated 
 os; in which case, after the disengagement of the shoulders, the 
 cervix is apt to close upon the neck and arrest the delivery of the 
 after-coming head. That this complication does not happen as a rule, 
 is due to the fact that in natural labors the mechanical expansion is 
 associated with certain organic changes, which render the cervix soft 
 and distensible and at the same time diminish its retractility. The 
 basis of the organic changes consists in the serous infiltration of the 
 lymphatic interspaces, which separates the tissue-elements, and de- 
 prives them of the resistance afforded by the force of cohesion. The 
 main factor in the production of the softening of the cervix is an 
 active hyperaemia, which the cervix shares during pregnancy with all 
 the pelvic organs, and which during labor is greatly enhanced by the 
 diminished pressure to which the parts below the pelvic brim are 
 subjected. We have already noticed how, during the acme of a pain,
 
 THE PHYSIOLOGY OF LABOR. ;^39 
 
 the contents of the uterine vessels are forced into the vessels of the 
 intra-pelvic viscera. 
 
 In normal head presentations the organic changes are in a special 
 degree furthered by the formation of what is known as the bag of 
 waters. As the head descends into the lower uterine segment, the 
 contraction of the muscular fibers around its largest circumference 
 separates a layer of fluid from the contents of the uterine cavity. At 
 first this layer becomes tense only during a pain. With the descent 
 of the head the tension increases, and the '^ bag of waters " is formed. 
 As the abdominal pressure is not operative below the pelvic line, and 
 as the intra-uterine pressure is arrested in a measure by the child's 
 head, in that portion of the uterus which lies below the circle of 
 cephalic compression, hyperemia, serous infiltration, and softening fol- 
 low as necessary corollaries of the anatomical conditions. The value 
 of the bag of waters in dilating the cervix is due, therefore, not only 
 to the hydrostatic pressure it exerts, but to the manner in which it 
 favors the development of the organic j^rocesses described. 
 
 Thus far we have considered the expellent forces as acting upon 
 the ovum as a whole. Many authorities accept in addition a direct 
 pressure of the fundus upon the breech of the child, which is transmit- 
 ted through the spinal column to the cephalic pole. A little reflec- 
 tion, however, will show, as Lahs* has pointed out, that so long as the 
 ovum contains any measurable quantity of fluid, or at least more than 
 enough to fill the fetal interspaces, the immediate contact of the 
 breech with the fundus is hardly possible. To be sure, Ahlfeld f de- 
 termined, by direct measurements, that there was an actual increase of 
 about one and a half inch in the distance between the two poles of 
 the child in head-presentation^s during the height of a pain. Schroe- 
 der I attributes this extension to the lateral compression of the foetus, 
 which results from the diminution of the transverse diameter of the 
 uterus during contraction ; but it is evident that lateral pressure would 
 equally produce an elevation of the fluid contents of the ovum, and 
 thus, as the fundus assumes a spherical shape, prevent the impinge- 
 ment of the breech. Moreover, it is not easy to see how, so long as 
 the fwtus is surrounded by a fluid medium, any effective propulsive 
 force can be transmitted through a flexible column like the- spine. It 
 is certain that, in the intervals of the pains, manual pressure upon the 
 breech through the fundus simply bends the fetal body, and deflects it 
 from the vertical direction. Even if, during a pain, the lessening of the 
 uterus in the transverse diameter hinders this movement to some 
 extent, the increase antero-posteriorly would still leave ample space for 
 lateral incurvation. 
 
 * Lahs, Studien zuriGeburtskunde, Arch. f. Gynaek., Bd. iii, p. 195. 
 
 •f- Ahlfeld, Arch. f. Gynaek., Bd. ii, p. 367. 
 
 I ScHROEDER, Lehrbuch der Geburtshiilfe, 6te Aufl., p. 15G.
 
 ^^Q LABOR. 
 
 The descent of the ovum is followed necessarily by increased ten- 
 sion of the bag of waters. Under a pressure, estimated by Duncan * 
 as varying, according to the resistance of the membranes, between 
 four f and thirty-seven and a half pounds, rupture occurs. The cervix 
 then usually closes, but remains dilatable ; i. e., it yields readily to 
 pressure, and offers no resistance to the advancing head. 
 
 The pressure exerted by the united action of the uterine and ab- 
 dominal walls requisite to accomiilish delivery, according to the esti- 
 mates of Schatz,! based upon manometric observations, varies between 
 seventeen and fifty-five pounds.* Although the methods by which 
 both the results of Schatz and Duncan have been obtained possess 
 defects, which the authors themselves make no attempts to conceal, 
 they are quoted as furnishing approximations to the truth. 
 
 CHAPTER VIII. 
 
 MECHANISM OF LABOR. 
 
 Anatomical factors. — Anatomy of pelvis. — Sacrum. — Coccyx. — Ossa innominata.— 
 The ilia. — The pubes. — The ischia. — Articulations of the pelvis. — Sacro-iliac 
 articulations. — Symphysis pubis. — The pelvic ligaments. — Obturator membrane. 
 — Sacro-sciatic ligaments. — Inclination of the pelvis. — The pelvis as a whole. — 
 The pelvic planes. — Plane of the brim. — Plane of the outlet. — Planes of the 
 cavity. — Ischial planes. — Pelvic axis. — Differences between male and female 
 pelvis. — Differences between the infantile and adult pelvis. — The soft parts of 
 the pelvis. — The perineal floor. — The head of the fa?tus at term. — Sutures and 
 fontanelles. — The diameters of the fetal head. — The articulation of the head 
 with the spinal column. 
 
 The mechanism of labor comprehends the movements of adjust- 
 ment, by means of which the foetus accommodates itself to the dimen- 
 sions of the bony pelvis and to the variations in the direction of the 
 parturient canal. Its study is, therefore, properly prefaced by the 
 enumeration of a series of anatomical details relating to the pelvic 
 ring and the soft tissues which form the floor of the pelvic basin, 
 and to the structure, the diameters, and the reducibility of the fetal 
 head. 
 
 * Duncan, Researches in Obstetrics. 
 
 \ RiBEMONT, Recherches experimentales sur la resistance, etc., des membranes 
 de I'ceuf humain, p. 35, places the minimum resistance at fifteen and three fourths 
 pounds. 
 
 X Vide ScHROEDER, Lehrbuch, 6te Aufl., p. 158. 
 
 * PoLAiLLON, Recherches sur la physiologic de I'uterus gravide, p. 38, estimates 
 the minimum pressure at twenty-three pounds.
 
 MECHANISM OB^ LABOR. 
 
 lil 
 
 The Axatomy of the Pelvis. 
 
 The following description includes only such points as are of direct 
 obstetrical interest : 
 
 The bony pelvis is formed by the union of the sacrum and coccvx 
 and the two ossa innominata. 
 
 The Sacrum. — The sacrum is a curved quadrilateral bone, inserted 
 like a wedge between the ossa innominata. Like a wedge, it is broad 
 above and tapers toward its lower extremity. It is composed of a 
 central vertebral portion, and two outer masses termed the ala^ or wino-s. 
 The central portion, as its name implies, is really a continuation of 
 the spinal column. In early childhood it consists of five distinct ver- 
 tebrae with well-defined joint-surfaces and intermediate cartilaginous 
 
 RBONIONTORV, — ' 
 
 LINEA 
 TRANSVERSALIS. 
 
 Fig. 68.— Sacrum and coccyx (anterior surface). 
 
 disks ; but with the completion of the growth the whole becomes con- 
 solidated into a single' piece by the inter-articular deposition of bone. 
 The bony union is confined chiefly to the outer circumference, and is 
 marked by ridges termed the linece ti^ansverscB. The base of the 
 sacrum articulates with the last lumbar vertebra, with which it forms 
 a projecting angle. It possesses a convex anterior surface, termed the 
 promontor}^ which juts forward and encroaches upon the pelvic space. 
 From the sides of the central piece there extend two triangular 
 portions of bone, termed the alte or wings. Under normal conditions 
 they are symmetrical. They are developed upon each side from three 
 independent nuclei, which make their appearance near the bodies of 
 the three upper vertebrse. They are supposed to have the morphological 
 significance of ribs. In the course of this growth they fuse together, 
 except at the points of junction of the bodies of the vertebra?, where 
 they leave between them open spaces or foramina, for the passage of 
 the spinal nerves.
 
 142 
 
 LABOR. 
 
 The sacrum in the female is about four and a half inches wide, and 
 from four to four and a half inches long, when measured from the 
 promontory to the lower extremity. The sacrum possesses two curves : 
 one, less marked, from §ide to side, and the other extending from 
 above downward. The depth of the latter is greatest just below the 
 upper border of the third vertebra, where it measures a little over an 
 
 inch. 
 
 Upon the posterior surface we notice a canal, continuous with the 
 spinal canal, which runs the entire length of the sacrum, but is incom- 
 pletely closed at the fifth vertebra, giving rise to a slit-like opening, 
 termed the hiatus sacraUs. In the middle line the spinous processes 
 coalesce into a vertical crest for the attachment of the erector spinas 
 muscle. The posterior lateral masses are formed by the fusion of the 
 transverse processes and their consolidation with the anterior struct- 
 ures. Next to the vertebra?, however, spaces are 
 left between the processes for the passage of the 
 posterior sacral nerves. Opposite the three upper 
 vertebrae, the outer border is known as the tuber- 
 osity of the sacrum. It possesses a roughened 
 surface, to which are attached the sacro-iliac liga- 
 ments. 
 
 The upper portion of the side of the sacrum is 
 furnished witli an ear-shaped articulating surface 
 termed the superficies auricnlaris. 
 
 The Coccyx. — The coccyx is composed of four 
 rudimentary vertebrae, which progressively dimin- 
 ish in size from above downward. It possesses 
 as a whole, therefore, a triangular shape. It is 
 attached to the extremity of the sacrum by a hinge- 
 joint, and is pushed backward during defecation, 
 and in childbirth as the head passes the jielvic outlet. It is only when 
 anylchosed that the coccyx assumes obstetrical importance. 
 
 The Ossa Innominata. — Each os innominatum may be roughly com- 
 pared to a figure eight, of which the ujiper and larger portion slants 
 upward, outward, and backward, while the lower smaller division in- 
 clines downward and inward. Up to the age of puberty it consists 
 really of three bones, which are connected at the acetabulum by car- 
 tilage of a Y-shape. These three bones are termed respectively the 
 ilium, the ischium, and the pubes, names wdiich are subsequently re- 
 tained for convenience of description, in spite of the fact that in adult 
 life the separate parts become solidly united, by the deposition of bone- 
 tissue, into a single continuous piece. 
 
 The iliac portion has an external surface marked by a number of 
 roughened lines, to which are attached the three gluteal muscles. The 
 inner surface is excavated and forms the so-called iliac fossa, which 
 
 Fig. 69.— Section of sa 
 crum and coccyx.
 
 MECHANISM OF LABOR. 
 
 143 
 
 contains the internal iliac muscle. The fossa is bounded below by the 
 linea arcuata interna, a convex ridge which contributes to form the 
 
 Fig. 70.— Os innominatum, before consolidation. 1, ilium ; 2, ischium ; 3, pubes. 
 
 brim of the pelvis. The upper border or crest of the ilium possesses 
 an S-shaped curve, the anterior extremities of which are directed in- 
 
 CREST. 
 
 ANT. SOP 
 SPINOUS ER0CEG9. 
 
 LESSER 
 SCIATIC NOTCH 
 
 TUBEROSITY 
 OF ISCHINUM 
 
 OBTURATOR TORAMEN. 
 Fig. 71.— Outer surface of os innominatum. 
 
 ward. The crest of the ilium terminates, front and rear, in bony 
 prominences, termed respectively the anterior and posterior superior
 
 144 
 
 LABOR. 
 
 spinous processes. Beneath the upper spines, and separated from them 
 by curved indentations, are two lower, less sharply defined projections, 
 termed the anterior and posterior inferior spinous processes. Behind 
 the iliac fossa is situated an ear-shaped articular surface, the super- 
 ficies auricularis, which corresponds to the surface of similar name 
 described upon the sides of the sacrum. 
 
 The pubic portion consists of the body and two rami. The body 
 presents upon its inner border an oval surface, which articulates with 
 the pubic bone upon the opposite side. The superior border is fur- 
 nished with a rough crest, terminating in the projecting spine. The 
 upper, or, as it is usually designated, the horizontal ramus, possesses 
 a ridge, the pecten pubis, extending from the spine and becoming con- 
 
 CREST. 
 
 FOSS/l. 
 
 SUPERFICIES 
 AURICULARIS. 
 LINE. 
 
 NOTCH., 
 
 MNE OF ISCHIUM 
 LESSER SCIATiC NOTCH 
 
 rUBEROSITVOr ISCHIUM. 
 Fig. 72.— Inner surface of os innominatum. 
 
 tinuous with the linea arcuata of the ilium. The linea terminalis, or 
 boundary-line of the pelvic brim, is generally known as the ilio-pec- 
 tineal line, from its sources of origin. Near the junction of the ilium 
 and OS pubis is situated a slight elevation, the ilio-pectineal eminence, 
 which, however, according to Luschka,* belongs entirely to the pubic 
 bone. The descending ramus helps to bound the obturator foramen, 
 and to form the pubic arch. The ischium completes the lower portion 
 of the OS innominatum. It consists of two rami, which, with the rami 
 of the pubic bones, include the obturator foramen. It contributes about 
 two fifths to the formation of the acetabulum ; from this the descend- 
 
 * Luschka, Die Antoraie des raenschlichen Beckens, p. 86.
 
 MECHANISM OF LABOR. j^g 
 
 ing ramus drops vertically downward, and thence curves forward, and 
 forms the ascending ramus, which unites with the descending ramus 
 of the pubes. At the point where the descending ramus hooks forward 
 there is a thickened projection, termed the tuberosity of the ischium, 
 upon which the body rest in the sitting posture. Upon the posterior 
 border of the descending ramus there is a sharp spine, projecting 
 inward, which plays an important part in the mechanism of labor. 
 Between the posterior inferior spinous process and the spine of the 
 ischium there is a deep incurvation, termed the great sciatic notch; 
 while a smaller incurvation, between the spine and the tuberosity, is 
 known as the small sciatic notch. 
 
 The Pelvic Articulations. — The articulations of the ossa innominata 
 with the sacrum are usually termed the sacro-iliac synchondroses. The 
 
 L 
 
 Fig. 73.— Section through the left sacroiliac articulation (natural size). (Luschka.) 
 
 anterior articulation of the innominate bones with one another is known 
 as the symphysis pubis. 
 
 The term " synchondrosis," as applied to the sacro-iliac articulation, 
 is really a misnomer. Luschka has shown that, in place of an inter- 
 vening plate of cartilage, section demonstrates the existence of a true 
 synovial membrane, limiting a narrow but well-defined joint-cavity. 
 The middle third of the iliac surface is convex, and fits into a corre- 
 sponding concave depression on the sacral end. There is likewise a 
 . "bite" or ledge in front, formed by the ilium, which aids in prevent- 
 ing the sacrum from slijpping forward into the pelvic cavity. 
 10
 
 146 
 
 LABOR. 
 
 The office of maintaining the sacrum in position devolves chiefly 
 upon the ligaments distributed front and rear, and particularly upon 
 the very numerous and closely interwoven bundles extending from the 
 tuberosities of the sacrum to the roughened portions, or tuberosities, 
 of the ilia, which project posteriorly beyond the articulation. 
 
 The symphysis pubis is likewise supplied with a small cavity, only 
 the posterior portion of which possesses a synovial membrane. ' The 
 
 Fig. 74.— Section of symphysis. (Luschka.) 
 
 fibro-cartilage between the articulating surfaces of the bones is thicker 
 in front than behind. The anterior ligaments are more developed than 
 the posterior ones, and allow no movements of importance to take 
 place in the non-pregnant condition. 
 
 The Pelvic Ligaments. — In addition to the ligaments which have 
 already been noticed as contributing to the solidity of the joints, the 
 
 ILIO-FEMORAL 
 LIGAMENT. 
 
 —i^SACSOSCIATO 
 LIGAMENT 
 
 Fig. 75.— Front view of pelvis, with ligaments. (Qiiain.)
 
 MECHANISM OP LABOR. 
 
 147 
 
 following help to close in the pelvis. Across the obturator foramen is 
 stretched a fibrous septum, complete except where a small opening is 
 left for the passage of the nerve and vessels. 
 
 The great sacro-sciatic ligament extends partly from the lower bor- 
 der of the sacro-iliac articulation, and partly from the lower border of 
 
 GREAT SCIATIC 
 FORAMEN. 
 
 SMALL SCIATIC 
 LIGAMENT. 
 
 SMALL SCIATIC FORAMEN 
 
 GREAT SCIATIC LIGAMENT. 
 
 Fig. 76.— Transverse section through pelvis, to show the sacro-sciatic ligaments. 
 (Taruier et ChantreuiL) 
 
 the sacrum and coccyx, to the tuberosity of the ischium. The small 
 sacro-sciatic ligament lies in front of the preceding, and extends from 
 the side of the sacrum and coccyx to the spinous process of the 
 ischium. These two ligaments close the large and small sacro-sciatic 
 notches, and convert them into two foramina, which bear the same 
 name. » 
 
 The Inclination of the Pelvis. — The plane of the brim of the pelvis 
 was formerly supposed to run nearly parallel to the horizon, whence 
 the term "horizontal ramus," applied to the upper branch of the 
 pubes. As a fact, however, in the upright position, the inclination of 
 the brim to the horizon varies from 45° to 100°. According to Meyer, 
 the center of gravity, instead of passing directly througli the median 
 line of the acetabula, is situated somewhat posteriorly, so that a tilting 
 of the pelvis backward is only prevented by the strong ilio-femoral 
 ligaments (Fig. 75). Whatever, therefore, serves to relax the ligaments 
 in question diminishes the angle of inclination, while positions that 
 increase the natural tension cause the pelvis to assume a nearly vertical 
 attitude. Experimentally Meyer found that the pelvic inclination was 
 diminished to the greatest extent when the thighs were moderately 
 separated and rotated slightly inward, while its increase was due to four 
 conditions : closing the knees, stretching the legs widely apart, exter- 
 nal rotation, and exaggerated internal rotation. Naegele endeavored
 
 148 
 
 LABOR. 
 
 to ascertain the normal inclination upon the living subject, by detei- 
 mining the distance between the extremity of the coccyx and a hori- 
 zontal line drawn from the lower border of the symphysis, and then 
 placing the bony pelvis in a position conforming to the measurement 
 
 COCCYX V 
 
 PUSHED BACK 
 
 OBSTETRICAL CONJUGATE 
 
 HORIZON 
 
 PLANE OF OUTLET 
 
 clination of the pel 
 (Taruier et Chantreuil.) 
 
 Fig. 77.— Section showing the incUnation of the pelvis according to Xaegele. 
 - if.) 
 
 thus obtained. He found in this way that the mean inclination was 
 nearly 60°, a result explained by the fact that the method of measure- 
 ment rendered a separation of the knees, and consequently an increase 
 of tension of the ilio-femoral ligaments, a matter of necessity.* 
 
 Movements at the Pelvic Akticulations. 
 
 At the symphysis pubis during gestation the fibers which compose 
 its fibro-cartilage become infiltrated with serum, and the ligaments 
 elongate, so that at term the distance between.the articular surfaces of 
 the pubic bones is increased twofold. Budin has shown that if the 
 patient, when the finger is introduced into the vagina and pressed 
 upward against the lower border of the symphysis, be made to walk, 
 an elevation of the ramus upon the side of the extremity in motion 
 can be distinctly recognized. In the rule, this mobility is most 
 marked in women who have borne a number of children.f 
 
 Zaglass first pointed out that, in spite of the close union at the 
 
 * ScHROEDER, Lchrbuch der Geburtshiilfe, 6te Aufl., note, p. 7 : Xaegele, 8te 
 Aufl., p. 81. 
 
 f Tarnier et Chantreuil, Traite de I'art des accouchements, p. 239.
 
 MECHANISM OF LABOR. 
 
 149 
 
 Fig. 78. — Diagram showing oscillatory move- 
 rueuts of sacrum. (Duncan.) 
 
 sacro-iliac articulation, a certain degree of mobility between the sacrum 
 and iliac bones existed. Thus, in defecation, when the body is thrown 
 forward, the promontory is tilted toward the symphysis, and the in- 
 ferior extremity of the sacrum is thrown backward, thereby enlarging 
 the outlet of the pelvis. Matthews Duncan describes similar move- 
 ments, only exaggerated in extent, during pregnancy, and points out 
 how they practically contribute to facilitate labor. Thus, at the be- 
 ginning of labor, as the head enters the brim, the woman naturally 
 chooses to sit up, to walk about, 
 or, if in bed, to recline with the 
 lower extremities extended — posi- 
 tions which favor the rotation back- 
 ward of the upper portion of the 
 sacrum, and the consequent increase 
 of the antero-posterior diameter at 
 the superior strait. As the head, 
 however, descends to the floor of 
 the pelvis, the patient instinctively 
 draws up her knees, throws the 
 body forward, and during a pain 
 contracts the abdominal muscles. 
 In this way she succeeds in tilting 
 up the pubes, in pressing the promontory forward, and in rotating the 
 point of the sacrum backward, so as to perceptibly increase the conju- 
 gate diameter at the pelvic outlet. 
 
 The Pelvis as a Whole. — The pelvis is divided by the linea termi- 
 nalis into an upper and lower portion. 
 
 The upper, or, as it is usually termed, the large pelvis, is composed 
 of the lumbar vertebrae and the upper surfaces of the wings of the 
 
 sacrum behind, the spreading 
 portions of the ilia upon the 
 sides, while the anterior seg- 
 ment is closed in by the mus- 
 cles of the abdominal parietes. 
 In shape, the bony part of 
 the large pelvis has been com- 
 pared to the rim of a barber's 
 basin. Obstetrically the iliac 
 fossae are of interest, inasmuch 
 as they furnish shelves upon 
 whicli the head of the fwtus 
 in multipara? commonly rests 
 during the latter part of pregnancy. The inclination of the ilia to 
 the horizon, the shape of the crests, and the distance between the two 
 anterior superior spinous processes, are important points for study, 
 
 Fig. 79.— Anterior half of the pelvis.
 
 150 
 
 LABOR. 
 
 Fig. 80.— Posterior Jialt" of the pelvis. 
 
 because they furnish data upon which vahiable inferences are based, 
 in cases of pelvic deformity, relative to the shape and dimensions of 
 the pelvic canal. 
 
 It will be remembered that the crests of the ilia possess an S-shaped 
 curve. JSTormally, the widest distances between the crest measure ten 
 inches; the distance between the anterior superior spinous processes 
 measures nine inches.* The slope of the inner surfaces of the ilia is 
 
 such that an extension of the 
 lines drawn from the crest to 
 the linea terminalis would meet 
 in the neighborhood of the 
 fourth sacral vertebra. 
 
 The inferior or small pelvis 
 comprises the portion below 
 the linea terminalis. It is 
 formed by the sacrum, the 
 coccyx, the lower portion of 
 the ilia, the ischia and pubes, 
 the obturator membrane, and 
 the sacro - sciatic ligaments. 
 Together the foregoing inclose a basin-like cavity, which, though open 
 below in the skeleton, is closed in by soft parts in the living subject. 
 The posterior wall, formed by the sacrum and coccyx, measures five 
 inches in a direct line from the promontory to the a2)ex ; the anterior 
 wall at the Symphysis jjubis measures one and three quarters inch ; the 
 lateral walls, from the linea terminalis to the tuberosities of the ischia, 
 measure three and three quarters inches. The posterior wall is curved ; 
 the symphysis pubis slo^aes downward and inward, so as to run nearly 
 parallel with the two upper sacral vertebrae ; the rami of the pubes 
 approach one another at an angle of 95° to 100°, and unite beneath 
 the symphysis in the form of an arch, the arcus pubis ; the side walls 
 are solid in front where they are constituted by the ischia, while be- 
 hind the great sciatic notch is closed only by soft structures and the 
 sacro-sciatic ligaments. The transverse diameter, owing to the incline 
 of the side walls, narrows toward the outlet. 
 
 The Planes and Axes of the Pelvis.— The eccentric forms of the 
 pelvic bones render it extremely difficult to convey a clear impression 
 of the nature of the pelvic inclosure. As a means to this end, it is 
 
 * As no two pelves possess precisely the same dimensions, pelvic measurements 
 are given somewhat differently by authors. They are obtained either by taking 
 the mean of a large number of pelves (a method which furnishes fractions difficult 
 to remember, but offering no special advantages in the way of accuracy), or by 
 selecting as the normal standard either a whole number, or, where fractions are 
 necessary, the nearest half or quarter approximating to the mean average. The 
 latter plan recommends itself in practice equally on the score of utility and con-
 
 MECHANISM OF LABOR. 
 
 151 
 
 customary to study a series of planes drawn at different levels through 
 the pelvic walls, which serve to show the changes in the shape and 
 dimensions of the bony canal at selected points of observation. By a 
 plane is meant simply a mathematical surface, without reference to 
 depth or thickness. 
 
 The upper and lower openings are both somewhat contracted, and 
 hence are termed respectively the superior and inferior straits, while 
 the space between is denominated the cavity of the pelvis. 
 
 The first plane requiring our attention is that of the superior strait 
 or brim. It is bounded by the linea terminalis, and has an elliptical 
 
 OlSTANnE BETWEEN 
 THE CRESTS lOIN. 
 
 DISTANCE BETWEEN 
 ANIT.SUP.SP PR0C.9IH. 
 SACRD COTYLOID. 
 
 OBLIQUE DIAMETER SIN. 
 
 CONJUGATE 4 '/♦!»». 
 
 Fig. 8].— Diameters of the brim. 
 
 contour, with a depression posteriorly, produced by the projection of 
 
 the promontory of the sacrum. 
 
 The dimensions of each plane are determined by measuring the 
 
 an tero - posterior, the trans- 
 verse, and the two oblique 
 diameters. 
 
 The antero-posterior, or, 
 as it is generally termed, the 
 conjugate diameter, extends 
 from the upper border of the 
 symphysis pubis to the prom- 
 ontory. Its length is four 
 and a quarter inches. About 
 two fifths of an inch below 
 the upper border of the sym- 
 physis is situated the obstet- 
 rical, as distinguished from 
 
 the anatomical, conjugate. The length of the former, owing to the 
 
 thickening of the pubic bones, is reduced to four inches. 
 
 The transverse, sometimes termed the bis-iliac, diameter is the widest 
 
 distance between the ilia. It measures five and a quarter inches. 
 
 Fig. 82.— Diameters of the outlet.
 
 152 
 
 LABOR. 
 
 The oblique diameters extend from the ilio-pectineal eminences to 
 the opposite sacro-iliac articulations. The distance between the points 
 mentioned is five inches. The right oblique diameter is the one 
 directed to the right, and the left to the left sacro-iliac articulation. 
 
 The axis of the superior strait is represented by a line drawn per- 
 pendicular to the center of the plane. The extension of this line falls 
 below upon the extremity of the coccyx, and above strikes the abdo- 
 men near the umbilicus {vide Fig. 98). The circumference of the 
 brim is very nearly sixteen inches. 
 
 The inferior strait proper, or outlet of the pelvis, is bounded by 
 the sub-pubic ligament, the pubic rami, the rami and tuberosities of 
 the ischia, the sciatic ligaments, and the coccyx. Owing to the pro- 
 jection of the ischia, the surface of the pelvic outlet is rendered con- 
 vex, or, perhaps, is better described by supposing it to be composed 
 
 OBSTETRICAL CONJUGM"E. 
 
 HORIZON 
 
 aUSBED BACK 
 
 Fig. 83.— Section showing thb inclination of the pelvis according to Naegele. 
 (Tarnier et Chantreuil. ) 
 
 of two obtuse-angled triangles with apices at the symphysis and 
 coccyx, and witli a common base formed by a line drawn through the 
 ischia. 
 
 The antero-posterior diameter extends from the lower border of 
 the symphysis to the extremity of the coccyx. It measures three and 
 three quarters inches, though, when the coccyx is pushed backward, 
 the distance may be extended to four and a half inches. 
 
 The transverse diameter between the inner borders of the tuberoS' 
 ities measures four and a quarter inches.
 
 MECHANISM 01' LABOR. 
 
 153 
 
 Owing to the elasticity of the sciatic ligaments, the oblique diam- 
 eters are not regarded as of obstetrical importance. 
 
 The axis of the inferior strait, when the coccyx is not disturbed 
 strikes the promontory. When the coccyx is pushed backward, a per- 
 pendicular line drawn from the center impinges upon the lower bor- 
 der of the first sacral vertebra. 
 
 The circumference of the inferior strait measures thirteeen and a 
 half inches. 
 
 The pelvic cavity or canal possesses an irregular, cylindrical shape, 
 constricted somewhat above at the superior strait, and narrowing rap- 
 idly at the pelvic outlet. Below the brim the dimensions are in- 
 creased considerably by the concavity of the sacrum. Thus, a plane 
 passing through the lower portion of the symphysis pubis, and across 
 the upjjer margins of the acetabula, to the junction of the second and 
 third sacral vertebrse, gains three quarters of an inch in the conjugate, 
 while the transverse diameter is barely one fourth of an inch less than 
 the transverse diameter of the brim. The narrowing at the outlet is 
 most marked in a j)lane drawn so as to intersect the spines of the 
 iscliia and the extremity of the sacrum. At the level indicated, the 
 distance between the spines (transverse diameter) is but four inches, 
 and the antero-posterior diameter four and a half inches. 
 
 The sciatic spines divide the pelvic cavity into two unequal sec- 
 tions. In the larger, anterior section, the lateral walls slope toward 
 the symphysis and arch of the pubes, while 
 posteriorly the walls slope in the direction 
 of the sacrum and coccyx. The declivities 
 in front of the spines are termed the an- 
 terior inclined planes of the pelvis, over 
 which rotation of the occiput takes place in 
 the mechanism of normal labor. Behind 
 the spines the lateral slopes are known as 
 the posterior inclined planes. Meeting to- 
 gether in the median line of the sacrum, 
 they constitute a sort of vault, into which the 
 face is turned after rotation is completed. 
 
 The general direction of the pelvic cav- 
 itv is best shown by a line representing the 
 
 axis of tlie bony channel. It should, however, be stated in advance 
 that the so-called pelvic axis of obstetrical writers is not to be con- 
 strued as the median line of a cylinder in a strict mathematical sense, 
 but is really intended to indicate very nearly the course which a round 
 body like the fetal head would naturally pursue in its course through 
 the parturient canal. In practice it is convenient to follow the sugges- 
 tion of Hodge, and draw a plane from the supra-pubic ligament back- 
 ward to the sacrum, and parallel to the plane of the superior strait. 
 
 Fig. 84 
 
 Axis represented upon a 
 vertical section through a plas- 
 ter cast of ihe pelvic cavity. 
 (Hodge.)
 
 154 
 
 LABOR. 
 
 This second parallel would intersect the middle portion of the second 
 sacral vertebra. Inasmuch as the pubic walls run nearly parallel to 
 the upper portion of the sacrum, the axis of the cavity included be- 
 tween the two planes may be regarded as continuous with the axis of 
 the brim. Below the second plane, owing to the curvature of the 
 sacrum, the axis describes a nearly circular course, with intersecting 
 planes radiating from the lower border of the symphysis as a center. 
 Further on it will be shown that the axial curve is continued beyond 
 the bony canal by the distended tissues which form the floor of the 
 pelvic basin 
 
 Differences between the Male and Female Pelvis. — In the male, the 
 bones of the pelvis are thick and solid ; the brim is triangular in 
 
 shape ; the promontory projecting ; 
 the cavity deep, and sloping inward 
 like a funnel ; the sacrum long, 
 narrow, and moderately curved ; 
 and the arch of the pubes is formed 
 at an angle of from 75° to 80°. In 
 the female, on the contrary, the 
 bones are lighter and more delicate 
 in contour, therein corresi)onding 
 to the inferior muscular develop- 
 ment of the sex ; thc^brim, owing 
 to the less marked Jutting inward 
 of the i^romontory, has an ellipti- 
 cal outline ; the diameters, both 
 antero-posterior and transverse, are 
 increased ; the pelvic inclination 
 is more pronounced ; the sacrum 
 is wider and more concave ; the 
 tuberosities of the ischia are wider 
 apart ; the angle of the arch of the 
 pubes measures from 90° to 100° ; 
 and the, entire depth of the pelvis 
 is diminished. As a result of the 
 increased transverse diameter in 
 the female, the trodianters are at 
 a greater relative distance from one another, and are directed some- 
 what obliquely to the front. This peculiarity brings the knees in 
 close proximity, and accounts for the characteristic feminine gait. 
 
 The configuration of the female pelvis, though unfavorable to 
 rapid locomotion, is in a special degree adapted to render possible 
 the birth of the child. A female pelvis approximating in type to 
 that of the male gives rise to a variety of dystocia of a very formid- 
 able character. 
 
 Fig. 85. 
 
 -Vertical section of a female infantile 
 pelvis. (Fehling.)
 
 MECHA^^ISM OF LABOR. 
 
 155 
 
 Differences between the Infantile and Adult Pelvis.— In the in- 
 fantile pelvis the promontory occupies a relatively higher position 
 above the upper border of the symphysis ; the last lumbar and two 
 upper sacral vertebrse possess a moderate convexity — i. e., the prom- 
 ontory does not project forward, as in the adult ; the sacrum, after 
 running a straight course, begins to curve forward first at the fourth 
 vertebra; the alse are slightly developed; the inclination of the ilia 
 more nearly approaches the perpendicular ; the S-shaped curve of the 
 crests is barely indicated, there being but slight difference in the dis- 
 tances between the crests and anterior superior spines ; the conjugate 
 diameter in proportion to the transverse is increased; the side-walls 
 converge toward the outlet ; the pubic arch is formed at an acute 
 angle ; and the distance between the spines of the ischia is greater than 
 the transverse diameter of the outlet. 
 
 Distinctions pertaining to sex are but slightly accentuated. In the 
 female, the sacrum, owing to the smaller size of the vertebrae, is 
 narrower than in the male ; the side walls are higher ; the symphysis 
 
 Figs. 86, 87.— Diagrammatic representations of sections through the infantile and adult pelves. 
 
 (Schroeder.) 
 
 lower ; the iliac incline approaches more nearly a vertical line ; the 
 pubic arch is less acute ; and the transverse diameter is increased. 
 
 The most important agent in effecting the changes which char- 
 acterize the adult pelvis is unquestionably the weight of the trunk. 
 Owing "to the wedge-shape of the sacrum, and the shelf-like ledge 
 which projects from the lower surface of the iliac articulation, no dis- 
 placement can take place in the direction of the long axis of the au- 
 ricular surfaces. But, when we bear in mind the inclination of the 
 pelvis, it is obvious that pressure from above must act upon the sa- 
 crum likewise in a downward, forward, and inward direction. Now, if 
 the sacrum were, as it is sometimes represented, the key-stone of the 
 pelvic arch, its position would be fixed between the ilia. We owe to
 
 156 LABOR. 
 
 Duncan,* however, the demonstration that this view is incorrect, and 
 that in reality the sacral articulation slopes backward and inward in 
 the direction of the median line. The fact that the sacrum does not 
 under pressure drop from the arcli is due to the strong sacro-iliac 
 ligaments, which hold it in position as part of the bony ring. The 
 ligaments do not, however, prevent the sacrum from sinking forward 
 to*a limited extent into the pelvic cavity, as is shown in the projection 
 backward at maturity of the tuberosities of the ilia, whereas in the 
 infantile pelvis the dorsal surface of the sacrum is level with the pos- 
 terior superior spinous processes. 
 
 As the line of gravity of the trunk falls in front of the sacrum, 
 the weight from above presses the promontory forward and inward 
 toward the symphysis pubis. At the same time the rotation backward 
 of the sacral apex is restrained by the sciatic ligaments. The natural 
 effect of these two simultaneously operative forces, acting at a period 
 when ossification is still incomplete, is to increase the sacral curve, 
 and consequently to shorten the distance between the upper and lower 
 ends of the base. As a result, the height of the promontory is dimin- 
 ished, the pelvic brim and outlet become constricted, and the dimen- 
 sions of the pelvic cavity are increased. The upper portion of the 
 sacrum, in rotating forward, drags upon the posterior ligamentous at- 
 tachments of the ilia. This traction would, were it not for their union 
 at the symphyses and the pressure of the heads of the thigh-bones, 
 cause the ossa innominata to revolve around the sacral articular sur- 
 faces, like doors upon their hinges. As a result of the antagonistic 
 action of the symphysis and the sacro-iliac ligaments, however, the 
 ossa innominata bend at the point of least resistance in front of the 
 sacrum, and in this way an increase takes place in the transverse at the 
 expense of the antero posterior diameter. 
 
 The sexual differences are attributable to differences in the char- 
 acter of the pelvic contents and the external sexual organs, to differ- 
 ences in muscular development, and to certain distinctive peculiarities 
 of growth. Thus, in the female eunuchs of India, described by 
 Koberts,f there were absence of vagina and complete atrophy of cellular 
 tissue in the genital organs ; at the same time the pelvis approximated 
 to the male type, and, in place of the pubic arch, the rami of the 
 pubes and ischia appeared as though they were in contact at the site 
 usually occupied by the vagina. 
 
 In fetal life, the female sacrum, owing to the small size of the 
 vertebrae, is narrower than in the male. Subsequently the more rapid 
 growth of the alae becomes the cause of the increased width which 
 characterizes the sacrum of the female at maturity. The larger cir- 
 cumference of the brim in the female is due partly to this difference 
 
 * Duncan, Researches in Obstetrics. 
 
 f Vide Tilt, Uterine and Ovarian Inflammation, p. C3.
 
 MECHANISM OF LABOR. 
 
 157 
 
 in the width of the sacrum and partly to the greater length of the 
 linea innominata. 
 
 The Soft Parts of the Pelvis.— Prefatory to the history of the im- 
 pregnated ovum, we have already considered the more important pel- 
 vic viscera concerned in generation and parturition. In studying the 
 
 mechanism of labor, it is, however, necessary in addition to recall 
 
 1. The soft tissues which encroach upon the pelvic space; 2. The 
 
 AORTA. 
 
 VENA CAVA 
 
 PSOAS MUSCLE 
 
 PRIMUrVF ILIAC 
 
 VEIN, 
 
 EXTERNAL ILIAC VEIN 
 ILIAC MUSCLE 
 
 PRiMlTlVi 
 lUAO. 
 
 EXTERNAL 
 ILIAC. 
 
 INTERNAL ILIAC 
 
 Fig. 88.— Pelvis covered with the soft parts, with removal of bladder, uterus, and rectum. 
 
 structures which close in the openings of the pelvis, and convert it 
 into a basin-like cavity. 
 
 1. The diameters of the brim are diminished somewhat by the 
 ilio-psoae muscles. The iliac muscles proper occupy the entire surface 
 of the internal iliac fossa?. The fibers converge below, and, passing 
 beneath Poupart's ligament, become united to the borders of the psoas 
 muscle. The pelvic portion affords a soft cushion for the support of 
 the gravid uterus. The great psoje muscles fill out the spaces upon
 
 158 
 
 LABOR. 
 
 the sides of the promontory. They take their origin from the lateral 
 surfaces of the bodies and transverse processes of the four upper him- 
 bar and tlie last dorsal vertebrse. They cross the pelvis parallel to the 
 linea innominata, which, hovrever, they slightly overlap. They taper 
 below, and, passing beneath the femoral arch, terminate in a tendon, 
 which is inserted into the small trochanter. These two muscles flex 
 the thighs upon the abdomen. The iliac muscle likewise acts as an 
 abductor, and the psoas serves to flex the pelvis upon the spinal col- 
 umn. The ilio-psoa3 muscles diminish the transverse diameter nearly 
 a half-inch, so that the latter becomes very nearly equal in length to 
 the oblique diameters. When the limbs are extended and the muscles 
 are rendered tense, the influence they exert in lessening the pelvic 
 space is somewhat greater than when they are relaxed by flexing the 
 legs upon the thighs. 
 
 The large arteries and veins at the pelvic brim do not undergo com- 
 pression during labor under normal conditions. When, however, con- 
 
 SACRUM. 
 
 FORMIS M. 
 
 Fig. 89.— Section of pelvis, showing the pjTiform muscles. (Tarnier et Chantreuil.) 
 
 siderable disproportion exists between the pelvis and the child's head, 
 the effects of pressure are sometimes manifested in the swelling of all 
 the soft tissues within the pelvic cavity— a swelling which, in turn, 
 enhances the difficulties of delivery. 
 
 2. The open spaces of the pelvis, which are closed in by soft 
 parts, are the great sciatic notches, the obturator foramina, and the 
 pelvic outlet. 
 
 The closure of the sacro-sciatic notches is effected by the pyriformis 
 muscles. The pyriformis muscle has a triangular shape. Its base 
 presents a series of digitations which are inserted upon the lateral 
 portions of the anterior surface of the sacrum, along the outer borders 
 of the four lower sacral foramina and the upper portion of the sacro-
 
 MECHANISM OF LABOR. 
 
 159 
 
 SACRO-SCIATI 
 I.IG. 
 
 LARGE SAC RC -SCIATIC LIG. 
 
 PUBIS, 
 
 sciatic ligament. It then crosses the large sciatic foramen, and, 
 passing outward, terminates in a tendon, which is inserted into the 
 large trochanter. 
 
 The obturator foramen is covered by the internal obturator mus- 
 cle. The latter is attached to the quadrilateral surface which corre- 
 sponds to the cotyloid cavity, to the circumference of the foramen, and 
 to the inner surface of the obturator membrane. Its fibers converge 
 to form a tendon, which passes 
 through the lesser sciatic fora- 
 men, and thence is directed 
 downward and backward to 
 the digital cavity of the great 
 trochanter. 
 
 Owing to their tenuity, 
 and to the fact that they 
 fqrm distensible coverings to 
 spaces limited only by elastic 
 tissues, neither the pyriform 
 nor the obturator muscles ap- 
 preciably affect the dimen- 
 sions of the pelvic cavity. 
 
 The outlet of the pelvis 
 is closed by a succession of 
 layers, which together consti- 
 tute the perineal or pelvic 
 floor. These layers, passing 
 from Avithout inward, consist 
 respectively of the external cutaneous tissue, the muscular layers with 
 their associated aponeuroses, the subperitoneal cellular tissue, and the 
 peritonaeum. 
 
 The most important structure which enters into the formation of 
 the perineal floor is the levator-ani muscle. This muscle is attached 
 above partly to the horizontal rami of the pubes, about an inch and a 
 half below the upper border of the rami, and partly to the tendinous arch 
 of the pelvic fascia, which is situated about two inches below the ilio- 
 pectineal line, stretching from the inner border of the pubes to the 
 spines of the ischia. The pubic portion consists of separate bands, 
 about two fingers in width. These sweep nearly horizontally back- 
 ward, and are united behind the rectum, which they encircle like a 
 collar. The anterior insertions are about an inch apart from one 
 another. The fibers attached to the tendinous arch do not possess a 
 uniform arrangement. Passing from before backward, we have first a 
 band a few lines in width, which crosses the pubic bundles and 
 descends to the recto- vaginal septum ; next, large bundles descend from 
 the two sides and meet behind the rectum ; then follows a smaller 
 
 INTERNAL 
 OBTURATOR 
 
 Fig. 90.— Section of pelvis, showing the internal 
 obturator muscle. (Tarnier et Chantreuil.)
 
 160 
 
 LABOR. 
 
 median portion, whose fibers are united by a tendinous raphe in front 
 of the coccyx, while posteriorly a narrow bundle is fastened by a 
 tendon to the fourth coccygeal vertebra. The arrangement of the 
 muscular fibers is best seen from the side, as in Fig. 93, where the 
 ischium has been removed. 
 
 Tlie margins which border the rectum and vagina are thicker than 
 the rest of the levator. They are closely attached to those organs by 
 strong connective tissue. They cross the vagina beneath the bulbs of 
 
 Fig. 91.— The levator-ani muscle as seen from above, with the tendinous arch which spans the 
 obturator muscle. (Dickinson.) 
 
 the vestibules ; the rectal crossing is on a level with the upper fibers of 
 the external sphincter. The contraction of the muscle draws the 
 rectum and vagina toward the symphysis. The average power exerted 
 is estimated by Dickinson* at ten pounds, rising in certain cases to 
 twenty-seven pounds. 
 
 The levator measures from | to f of an inch in thickness. It be- 
 comes, however, hypertrophied during pregnancy. 
 
 The muscular floor of the pelvis is rendered complete by the coccy- 
 geus muscle, situated between the levator and the pyriformis, and in 
 front of the small sciatic ligament. The base is attached to the sides 
 
 * Dickinson, Studies of the Levator Ani Muscle, Am. Jour. Obstetrics, Sept., 
 1889, p. 909. To this article I am indebted for the changes made in the present 
 text.
 
 MECHANISM OF LABOR. 
 
 161 
 
 of the coccyx and the lower extremity of the sacrum ; the insertion of 
 the apex is at the spine of the ischium. In caudate animals the coccv- 
 geus is strongly developed, and enables them to move the tail laterally. 
 The upper surface of the levator-ani and coccygeal muscles is con- 
 cave. The muscles themselves are flattened, and alone are capable of 
 affording but feeble support to the superimposed viscera. They are, 
 
 Fig. 92.— The levator (L) seen from the side when the ischium is removed. The lower bundles 
 are the strong and heavy ones. The sphincter ani is shown surrounding the anus and the 
 coccygeus is faintly indicated. (Redrawn from Luschka by Dickinson.) 
 
 however, above closely attached to the strong tissues of the internal 
 pelvic fascia, which possess the qualities of elasticity and toughness. 
 
 The internal pelvic fascia is attached to the upper border of the 
 superior strait, where it meets the fascia which lines the iliac fossae 
 and the transverse fascia of the abdominal walls. It covers the pyri- 
 formis and the upper half of the obturator muscles. In front it de- 
 scends from the symphysis to the neck of the bladder, and forms the 
 pubo-vesical ligament. From the linea terminalis to the arcus ten- 
 11
 
 Hj2 
 
 LABOR. 
 
 dineus the fascia upon the side walls is firmly attached to the perios- 
 teum. The tendinous arch marks the line at which the fascia leaves 
 the pelvic walls to form the inner lining of the levator and coccygeal 
 
 muscles. 
 
 The upper surface of the internal pelvic fascia is covered by the 
 peritonfeiim, to which it is united by loose connective tissue. 
 
 The fascial coverings beneath the levator-ani muscle are divided 
 into a posterior and anterior portion by a line drawn between the two 
 ischia. 
 
 The posterior portion consists of a single layer. It starts from the 
 sacro-sciatic ligaments and the tuberosities of the ischia; thence it 
 
 mounts upward over 
 the inner surfaces of 
 the ischia and the ob- 
 turator internus muscle 
 to the tendinous arch, 
 which it contributes to 
 form, and from the 
 tendinous arch is re- 
 flected at an acute 
 angle over the inferior 
 surface of the levator- 
 ani muscle. The space 
 thus limited between 
 the side walls of the 
 pelvis and the levator 
 ani is termed the ischio- 
 rectal excavation. 
 
 The anterior por- 
 tion, or perineal fascia 
 proper, fills the space 
 between the bis-ischiatic line and the arch of the pubes. It is composed 
 of three layers, as follows : 1. The deep perineal fascia, which covers 
 the lower surface of the levator ani ; 2. The median perineal fascia, 
 separated from the former by a narrow interval, and inclosing the 
 pudic vessels and nerves; 3. The superficial perineal fascia which 
 forms, with the median layer, a shallow compartment in which are lodged 
 the superficial muscles of the perinaeum, the bulbs of the vagina, the 
 vulvo-vaginal glands, and the rami of the clitoris. Each one of these 
 organs, except the latter, is, moreover, enveloped in a special sheath, 
 derived from prolongations of the upper surface of the aponeurosis. 
 
 The superficial perineal muscles are of slight obstetrical importance. 
 They are the constrictor vaginse, the ischio-cavernosi, and the trans- 
 versi perin^ei. 
 
 The constrictor vagina consists of two small lateral muscles, situ- 
 
 THREE LAYERS OF 
 THE PERINEAL FASCIA 
 
 Fig. 93.— Antero-posterior section of the perineal floor. 
 (Tarnier et ChantreuH.)
 
 MECHANISM OF LABOR. 
 
 163 
 
 ated upon the outer sides of the vestibular bulbs, and surrounding the 
 vulvar orifice. Posteriorly the extremities of the main muscle start 
 from the perineal fascia at a point nearly midway between the sphinc- 
 ter ani and the ischia, while a small bundle only is connected with the 
 sphincter ani itself.* x\bove, the convergent ends separate into a 
 superficial and deep portion. The superficial portions terminate in a 
 tendon which unites them together above the dorsal vein of the clito- 
 ris ; the deep portions pass between the upper ends of the bulbs and 
 the clitoris, and are likewise united by an aponeurosis. 
 
 The action of the muscle consists chiefly in compressing the veins 
 crossed by its tendon, and in thus enhancing the turgidity of the erectile 
 
 CLITORIS. 
 
 .^V 
 
 URETHRA. 
 
 CONSTRICTOR 
 
 CUNNI M. 
 
 TRANSVERSUS ' PERINAEI 
 
 Fig. 94.— Muscles of the periuseuai. (Henle.) 
 
 apparatiis. It is in no sense a sphincter muscle, though, by pressing 
 the turgid bulbs inward, it may narrow the vestibule of the vagina. 
 
 The ischio-cavernosi muscles form a fibro-muscular sheath about the 
 crura of the clitoris. They are united together above by an aponeuro- 
 sis which crosses the posterior extremity of the body of the clitoris. 
 During sexual excitement these muscles are capable not only of com- 
 * LuscHKA, Anatomie des menschlichen Beckens, p. 399.
 
 164 
 
 LABOR. 
 
 I^ressing the crura, thereby forcing the blood toward the body of the 
 clitoris, but, through the pressure exerted by the ajjoneurosis upou the 
 dorsal vein, they help to retard the return of the blood from the turges- 
 cent organ. 
 
 The transversi perini»i muscles are small, triangular, flattened 
 muscles, which j^ass from the inner sides of the ischia, underneath the 
 constrictor muscle, to the sides of the vagina and rectum. AVhen the 
 perinajum is lacerated, these muscles tend to produce gaping of the 
 wound, and to interfere with union by first intention. 
 
 A mere enumeration, such as has been given, of the thin, flat, mus- 
 cular and aponeurotic structures of the pelvic floor affords, however, 
 a very incomplete idea of the true anatomy of the lower portion of the 
 
 Fir;. 95.— Tlif partiirietit canal. iHoilj;*' i 
 
 parturient canal. Both as regards form and function, the role of the 
 connective tissue which fills out all the available interstices between 
 the different organs, the different muscular groups and the bony walls, 
 is of the highest importance. It is to this tissue that the perineal 
 body occupying the space between the vagina and rectum owes its ex- 
 traordinary distensibility. In a sagittal section, the perineal body has 
 usually very nearly a quadrangular shape.* Laterally it spreads out 
 to the rami and the tuberosities of the ischia. In height it extends 
 upward nearly one half the length of the vagina. Between the border 
 of the anus and the posterior commissure of the vulva, the external 
 portion, which forms the base of the triangle, measures on the average 
 
 * Foster, P. P., Anatomy of the Uterus and its Surroundings, \m. Jour, of 
 Obstet., January, 1880.
 
 MECHANISM OF LABOR. 
 
 Un") 
 
 an inch in length. When the head of the child, during labor, de- 
 scends below the level of the bony walls, it bulges the perinfeum and 
 stretches it from four to five inches in the antero-posterior direction. 
 Both the length and degree of curvature of the pelvic canal are there- 
 by increased, the soft parts posterior to the vulva forming a gutter- 
 like extension, the axis of which is continuous with that of the pelvis. 
 
 The Head of the Fcetus at Term. 
 
 The head is the part which presents the greatest mechanical diffi- 
 culties in the passage of the foetus through the parturient canal. It 
 is therefore important to become familiar with its shape, its diameters, 
 and the modification it undergoes during labor. 
 
 In studying the fetal head we distinguish the face and the cranium. 
 
 The face is of little importance in normal labors. It may, how- 
 ever, be here incidentally noted, what is sometimes of consequence in 
 
 Fig. yii.— Lateral view of fetal 
 skull. (Hodge.) 
 
 Fi<i. 97. hetal head, as seen 
 trom above. (Hodge.) 
 
 extreme degrees of pelvic contraction, that the distance (two and a 
 half inches) between the malar bones possesses but a slight degree of 
 reducibility. 
 
 In the cranium Ave distinguish again between the upper compressi- 
 ble portion or vault and the lower incompressible portion or base of 
 the skull. The vault is composed of the frontal and parietal bones 
 and the squamous portions of the temporal and occipital bones. The 
 base is formed by the union of the ethmoid, the sphenoid, the petrous 
 portion of the temporal bones, and the basilar portion of the occipital 
 bone. 
 
 The Sutures and Fontanelles.— The flat bones which form the vault 
 are thin and imperfectly ossified, consisting, indeed, of little more than 
 the diploe. Instead of union by serrated osseous borders, they are 
 held in their relative positions by the periosteum and dura mater, 
 which come into contact with one another and form membranous com- 
 missures between the bones. Where more than two bones meet at a 
 given point, the ossification is apt to be incomplete, and spaces are left, 
 covered only by membranes termed fontanelles. 
 
 The sutures, to which it will be found necessary to make constant 
 reference, are the following : The frontal suture, situated between the
 
 IGG 
 
 LABOR. 
 
 ununited halves of the frontal bone ; tlie coronal suture, between the 
 frontal and parietal bones ; the sagittal suture, where the parietal 
 bones meet at the top of the cranium ; the lambda suture, so called 
 from its resemblance to the Greek letter of that name, between the 
 triano-ular portion of the occipital and the posterior borders of the 
 parietal bones. 
 
 At the point of intersection of the frontal, the sagittal, and the 
 coronal sutures the incomplete ossification of the frontal and parietal 
 bones leaves a large open space of a rhomboidal shape, termed the an- 
 terior or large fontanelle, or sometimes simply the bregma. Of the 
 four sides, the anterior are longer, often extending for some distance 
 between the bones of the os frontis. 
 
 The posterior or small fontanelle is situated at the junction of 
 the sagittal and lambda sutures. It is formed at the meeting of three 
 bones, viz., the two parietal and the occipital, and possesses a triangu- 
 lar shape. In very many cases the ossification of the bones is complete 
 at the time of delivery. Its site then is indicated by the angle formed 
 by the posterior borders of the parietal bones, beneath which, as a 
 consequence of labor, the occipital bone is usually found depressed. 
 
 Budin has recently demonstrated that the squamous or triangular 
 portion is attached to the basilar portion of the occipital bone by means 
 of a band of cartilaginous and fibrous tissue. A sort of hinge-joint is 
 thus formed, which permits veritable movements of flexion and exten- 
 sion to take place.* 
 
 The flexibility of the cranial bones, the sutures, the fontanelles, 
 and the fibro-cartilaginous bands of union, together enable very con- 
 siderable changes to take place in the diameters of the fetal head 
 during the progress of labor. 
 
 The Diameters of the Fetal Head.— The diameters of the child's 
 head are a series of imaginary lines extending between fixed points, 
 selected so as to indicate the dimensions of the largest segments which, 
 in the different positions and presentations, engage in the pelvic canal. 
 We distinguish diameters running in the antero-posterior, the trans- 
 verse, and the vertical directions.! 
 
 The antero-posterior diameters are : 1. The occipito-mental ; 2. The 
 occipito-frontal ; 3. The sub-occipito-bregmatic. 
 
 The occipito-mental diameter extends from the highest point of 
 the occiput to the chin ; J the occipito-frontal, from the occiput to 
 the root of the nose ; the sub-occipito-bregmatic, from the junction 
 
 * BuDiN^ De la Tete du Foetus, p. 73. 
 
 t The points of departure of the following diameters have been adopted from 
 Budm's excellent monograph, already quoted. 
 
 t The occipito-mental diameter is usually referred to as the longest one of the 
 head. According to Budin, the true maximum diameter is situated between the 
 chm and a variable point in the line of the sagittal suture above the occiput.
 
 MECHANISM OF LABOR. 
 
 167 
 
 oithe occiput with the neck to the point of intersection in the large 
 fontanelle of the coronal and sagittal sutures. 
 
 The transverse diameters are : 1. The bi-parietal ; 2. The hi-tem- 
 poral ; 3. The bi-mastoid. 
 
 The bi-parietal diameter stretches between the two bosses or pro- 
 tuberances of the parietal bones ; the hi- temporal, between the extremi- 
 
 OCCIPITO MENTAL "> 
 
 F RONTO MENTAL. 
 
 OCCIPITOFRONTAL. 
 
 SUB QCCIPITO BREGMATIC 
 
 '" JFrVICO BREGMATIC. 
 Fig. 98.— Antero-posterior ami vt-rtical diameters of the fetal head. (Tarnier et ChantreuiL) 
 
 ties of the coronal sutures ; the bi-mastoid, between the mastoid pro- 
 cesses at the base of the skull. 
 
 The vertical diameters are ; 1. The fronto-mental ; 2. The cervico- 
 bregmatic. 
 
 The fronto-mental diameter extends from the top of the forehead 
 to the point of the chin ; the cervico-bregmatic, from the middle of 
 the large fontanelle to the upper portion of the neck near the larynx. 
 
 In furnishing standard measurements of the foregoing diameters 
 it is of course understood that no two heads present precisely the same 
 dimensions. As a rule, as shown by Sir J. Y. Simpson, the heads of 
 boys are larger than those of girls. In selecting type-cases it will be re- 
 membered too, that, owing to the plasticity of the head, in none are 
 the diameters completely normal immediately after the transit through 
 the generative passages. Unless, therefore, the child is delivered by 
 Cesarean section, sufficient time should be allowed to elapse after de- 
 livery before the measurements are made, to permit the head to return 
 to its natural shape. Again, as in the measurements of the pelvis, the 
 figures selected to represent the normal average should be such as 
 admit of convenient recollection. 
 
 DIAMETERS OF FETAL HEAD.* 
 
 Occipito-mental diameter ^^ inches. 
 
 Occipito-f rental '* ** 
 
 * The diameters given are based upon the table in Tarnier and Chantreuil, which 
 were averaged from measurements taken with great precision in forty-four cases.
 
 ■|/>D LABOR. 
 
 Sub-occipito-bregmatic diameter 3| inches. 
 
 Bi-parietal " 3J 
 
 Bi-temporal " 3J 
 
 Bi-mastoid " 3 
 
 Fronto-raental " 3J 
 
 Cervico-bregmatic " 3 J 
 
 The circumference of the head, from the chin to the vertex, using 
 the latter term to express the highest part of the skull, without refer- 
 ence to any fixed anatomical point, is about fourteen and three quar- 
 ters inches. The circumference at the sub-occipito-bregmatic diameter 
 is but thirteen inches. 
 
 The Articulation of the Head with the Spinal Column.— The move- 
 ments of the occiput upon the atlas are extremely limited, those of 
 extension and flexion, which the head executes so readily, taking place 
 for the most part in the articulations of the cervical vertebrae. Move- 
 ments of rotation are performed at the articulation between the axis 
 and the atlas In practice, the head can not be turned with safety to 
 either side beyond a quarter of a circle, though, when rotation is per- 
 formed slowly after delivery, it may sometimes be carried to such an 
 extent as to enable the face to look directly backward. The insertion 
 of the spinal column at a point nearer to the occipital than the frontal 
 extremity of the child's head is of supreme importance in the further- 
 ance of the mechanical processes of labor. It converts the head into 
 a lever, consisting of two unequal portions. When the head, there- 
 fore, encounters circular resistance in passing thi'ough the obstetric 
 canal, pressure transmitted through the spinal column causes the de- 
 scent of the occipital short end of the lever ; while the pressure upon 
 the forehead from the side walls flexes the chin upon the thorax, the 
 degree of flexion depending upon the size of the canal through which 
 the transit is made. 
 
 CHAPTER IX. 
 
 MECHANISM OF LABOR.— (Continued.) 
 
 Presentations : natural, unnatural, normal.— Vertex presentations : frequency, posi- 
 tions.— Manner m which head enters pelvis.— Positions, normal mechanism of 
 labor.— Descent and flexion.— Rotation.— Extension.— External rotation.— Ex- 
 pulsion of the trunk. — Abnormal mechanism (vertex presentations). — Mechanism 
 of oecipito-posterior positions.— Configuration of the head in vertex presenta- 
 tions.— Molding.— Scalp-tumor. — Diagnosis of vertex presentations. 
 
 The mechanism of labor— -i. e., the manner in which the foetus 
 passes through the parturient canal— varies with the presentation. 
 The presentations are classified, in the first place, with reference
 
 MECHANISM OF LABOR. ^09 
 
 to the position of the fcetus in relation to the axis of the uterus. In 
 cases where the long diameter of the fretus coincides with that of the 
 uterus, we have further to distinguish presentations of the head and 
 presentations of the pelvic extremity. 
 
 Head or cephalic presentations comprise those of the vertex, i. e., 
 the portion lying between the two fontanelles, the brow, and the Jace^ 
 
 Pelvic presentations oifer two varieties, viz., breech presentations 
 and foot presentations. 
 
 When the long diameter of the foetus crosses the axis of the uterus, 
 there is produced a transverse, or, after the operation of uterine con- 
 tractions, a shoulder presentation. 
 
 Vei-tex, face, and pelvic presentations are included in the category 
 of natural labors. Brow and shoulder presentations are termed unnat- 
 ural, as, with few exceptions, they are not terminable except by the 
 resources of the obstetric art. 
 
 Vertex presentations alone are to be regarded as normal, as they 
 only realize the mechanical conditions compatible with the highest 
 degree of safety to both mother and child. 
 
 In the following pages it is purposed to associate with the descrip- 
 tions of the mechanism of labor, in the various presentations and posi- 
 tions, an account of the means of diagnosis and the treatment suited 
 to the special cases under consideration, instead of placing diagnosis, 
 mechanism, and treatment in chapters distinct from one another. 
 The writer believes, from long experience in teaching, that what is thus 
 sacrificed in the way of systematic completeness is more than compen- 
 sated by the clinical advantage of keeping in close proximity the prin- 
 ciples of obstetric art and the rules of practice directly deducible from 
 them. 
 
 Precedence of description is given to the vertex presentation as 
 representing the normal type of labor. 
 
 , A'ertex Presentations. 
 
 In 93,871 births, collected from private practice, Spiegelberg found 
 that in over ninety-seven per cent the cranial vault presented,* The 
 back of the child in utero is directed in about seventy per cent of 
 cases to the left, and in thirty per cent to the right, side of the mother. 
 The fronto-occipital diameter of the head measures four inches and 
 a half. The diameters of the pelvic brim, after deducting the soft 
 parts, are nearly as follows : 
 
 Transverse diameter of brim 4f to 5 inches. 
 
 Oblique " " 4f to 5 inches. 
 
 Antero-posterior diameter of brim (minimum diameter 
 
 about one third inch below the crista pubis) 4 inches. 
 
 * Spiegelberg, Lehrbuch der Geburtshiilfc, p. 148.
 
 170 
 
 LABOR. 
 
 Thus it will be seen that the fronto-occipital diameter of the head 
 may, at the brim, enter the pelvis without meeting with any special 
 resistance in either the transverse or oblique diameters. In the conju- 
 gate diameter, on the contrary, this is not possible. Transverse posi- 
 tions, where the conditions are normal, are of very exceptional occur- 
 rence, though they form the rule in flattened pelves. Tarnier * 
 suggests that this infrequency is jDartially explicable on mechanical 
 grounds. The long transverse diameter of the pelvis, he says, is, 
 owing to the projection of the promontory, situated in a line consid- 
 erably posterior to the point at which the sagittal suture normally 
 meets the conjugate. When the head, therefore, enters the pelvis in a 
 transverse direction with both parietal bones upon the same plane, the 
 fronto-occipital diameter corresponds to a shortened chord subtending 
 two points of the pelvic ring in front of the anatomical transverse 
 diameter ; in point of fact, therefore, the latter, at the site of engage- 
 ment, is less than either of the oblique diameters. In flattened j^elves 
 this difficulty does not exist, as, in place of both parietal bones entering 
 upon the same level, the posterior is turned toward the corresponding 
 shoulder, the anterior dipping obliquely into the brim (lateral obliquity 
 of Naegele), an arrangement by which the long diameter of the head 
 is brought into correspondence with the long diameter of the pelvis. 
 
 At the time when the sagittal suture is accessible, and it is possible 
 to observe with correctness, the antero-posterior diameter of the head 
 is found to approximate to one or the other of the pelvic oblique diam- 
 eters. 
 
 It is customary to classify the positions of the head with reference 
 to the direction of the occiput. Most English authorities admit four 
 varieties, viz. : 
 
 The right occipito-anterior (occii>ito-dextra anterior, 0. D. A.), 
 the right occipito-posterior (occipit*dextra posterior, 0. D. P.), the 
 left occipito-anterior (occipito-lfeva anterior, 0. L. A.), the left oc- 
 cipito-posterior (occipito-lgeva posterior, 0. L. P.). 
 
 Naegele first called attention to the fact that the head approximates, 
 in an overwhelming proportion of cases, to the right oblique diameter ; 
 that, therefore, when directed to the left, the occiput is turned to the 
 cotyloid cavity, and, when directed to the right, it looks toward the 
 sacro-iliac synchondrosis. This peculiarity probably results from the 
 fact that the uterus is usually rotated in such a way upon the spine 
 that the right side inclines obliquely backward, while the left side is 
 turned somewhat to the front. 
 
 Naegele's observation is undoubtedly correct as regards the position 
 of the head after labor has actually begun. Sutugin,f however, main- 
 
 * Tarnier et Chantreuil, Traite de I'art des accouchements, p. 465. 
 t SuTUGiN, Beitrage zum Mechanismus der Geburt bei Schadellagen, KHnischer 
 Vortrage, No 310.
 
 MECHANISM OF LABOR. 
 
 171 
 
 tains that when the patient is examined in the recumbent position during 
 pregnancy abdominal palpation sliovvs that, as a rule, the back, of the 
 child, whether situated to the right or the left of the vertebral column, 
 is turned somewhat posteriorly. 
 
 At the beginning of labor the head, surrounded by the lower seg- 
 ment of the uterus, is commonly found at the brim or resting upon 
 ;in iliac fossa in multiparae, and below the brim, Avithin the pelvic 
 cavity, in primiparae. The direction of the head, as regards its vertical 
 axis, depends upon the degi-ee of resistance afforded by the contigu- 
 ous uterine tissues. In the softened, relaxed condition often observ- 
 able in multipara toward the close of pregnancy, the two fonta- 
 nelles are not infrequently situated upon the same level. Where the 
 lower uterine walls are firm and slope toward the os internum, the 
 weight of the child's body, transmitted through the vertebral column, 
 depresses the occiput. At the same time the sloping uterine walls, 
 acting upon the frontal extremity of the child's head, direct the chin 
 toward the thorax, thus producing a state of semi-flexion. 
 
 The Nokmal Mechanism of Labor. 
 
 The mechanism of labor in vertex presentations is usually described 
 as consisting of a series of acts, termed respectively descent, flexion, 
 rotation, external restitution, and expulsion of the trunk. 
 
 A familiarity not with the names of the various acts, but the things 
 the names represent, is essential to the judicious prosecution of the 
 obstetric art. 
 
 Descent and Flexion. — Descent and flexion go hand in hand, and 
 should be associated in thought as they are in reality. It is evident, 
 whenever the head encounters the resistance of the obstetric canal, 
 the force transmitted through the spine to the foramen magnum will 
 cause the descent of the occiput, and thus flexion will result. The 
 degree of flexion, however, is proportioned to the extent of the action 
 of the walls upon the frontal extremity of the head, and therefore is 
 variable in different subjects and in different parts of the canal. 
 
 The head enters the pelvis in the axis of the brim with the bi- 
 parietal diameter very nearly parallel to the superior strait. This direc- 
 tion it maintains until arrested by the curvature of the sacrum and by 
 the floor of the pelvis. 
 
 The descent of the head through the cervix is effected by the 
 pressure of the uterus during contraction upon its entire contents. 
 Even admitting the possibility of a certain amount of propulsive 
 energy from the uterine walls through the trunk of the child to the 
 head, it is necessarily of feeble force, as the flexibility of the spine and 
 the smoothness of tlie breech prevent the latter from finding a proper 
 point (Vappui against the vaulted fundus.
 
 172 
 
 LABOR. 
 
 In the transit of the head through the cervix the degree of flexion 
 is governed by the amount of pressure exerted by the cervical ring 
 upon the frontal portion. In some instances this suffices to render 
 flexion complete — i. e., the chin sinks until arrested by contact with the 
 chest ; whereas, as is most often the case in multipara?, the cervix may 
 be so softened and dilatable as to aifect but slightly the direction of 
 the occipi to-frontal diameter. Most frequently the maximum degree 
 of flexion is occasioned by the convergence of the walls of the parturi- 
 ent canal at the pelvic outlet. It is well for the beginner to keep con- 
 stantly in mind that flexion is not in any sense an active movement. 
 It is always a movement of accommodation, the end of which is the 
 successive substitution of a shorter diameter for a previous longer one, 
 so soon as the latter has encountered sufficient resistance to arrest 
 its further progress. The mechaYiical advantages of flexion are obvious, 
 when we recall that the average length of the sub-occipito-bregmatio 
 
 Fig. 99.— Vertex presentation ; child surrounded by aiiuiiutic Huid. (Pinard.) 
 
 or maximum diameter of the flexed head (3f inches) is three quarteis 
 of an inch less than the occipito-frontal or maximum diameter of the 
 head when midway between extension and flexion. Again, the maxi- 
 mum circumference of the flexed head (thirteen inches) is 1| inch 
 less than one measured about the extremities of the occipito-frontal 
 diameter. These measurements, which are representative of the natural 
 state, are, however, far from expressing the full extent of the ditfer- 
 ences which exist after the plastic head has undergone the molding 
 processes incident to labor.
 
 MECHANISxM OP LABOR. -^h^ 
 
 A further advantage of flexion is thus described by Professor Pajot ; 
 « The foetus, in its entirety, is to be regarded as a broken, vacillating 
 rod, possessed of mobility at the articulation of the head and trunk • 
 but a solid thus disposed presents conditions unfavorable to the trans- 
 mission of a force acting principally upon one of its extremities; it 
 follows, therefore, that previous to flexion the uterine action, pressing 
 upon the pelvic extremity to promote the advance of the foetus, is lost 
 in great measure in its passage from the trunk to the head by reason 
 of the mobility of the latter ; but the cephalic extremity, once fixed 
 upon the thorax, is most advaiitageously disposed to participate in the 
 impulse communicated to the general mass of the foetus." * 
 
 After the head is once released from the environment of the cer- 
 vical canal, a slight movement of extension may follow, provided the 
 resistance offered by the vagina is less than that of the cervix. In 
 many cases, as has been stated, Avhere dilatation is complete at the time 
 of rupture of the membranes, the head may pass through the cervix 
 with scarcely any change in its direction, flexion taking place first 
 when the head encounters the resistance of the sloping pelvic walls and 
 the j^erineal floor. 
 
 Rotation. — The head, as we have seen, follows the axis of the su- 
 perior strait until arrested by the extremity of the sacrum and the 
 perineal floor. As it nears the latter, the curvature of the sacrum ap- 
 proximates the posterior Avail to the sagittal suture. Upon vaginal 
 examination, the finger comes in contact with the anterior half of the 
 heail as the presenting part. It is not, however, on that account to 
 be assumed that the head is inclined laterally toward the posterior 
 shoulder, though the sensation produced deceptively favors such a 
 theory, t 
 
 When the head has once reached the perineal floor, its further 
 progress is associated with the most interesting of the mechanical acts 
 of labor. The occiput, whether previously directed to the anterior or 
 posterior extremity of an oblique diameter, turns forward under the 
 arch of the pubes, until the sagittal suture occupies very nearly the 
 antero-posterior diameter of the outlet. The utility of this movement 
 is obvious. Owing to the inward slope of the side walls of the pelvis, 
 the distance between the ischia is but 4^ inches, and between the spines 
 4 inches. If, in forceps operations, the head is dragged through the 
 transverse diameter of the pelvis previous to rotation, it becomes flat- 
 tened and lengthened in the direction of the trachelo-bregmatic diam- 
 
 * Pajot, Dictionnaire encyclopedique des sciences medicales, t. i, p. 382, quoted 
 by Tarnier et Chantreuil, p. 639. 
 
 t With the apparent obliquity it is probable that a certain amount of real 
 obliquity coexists. As, even in extreme flexion, the lateral movements of the head 
 are not interfered with, it is hardly to be expected that the head, when arrested at 
 the perineal floor, would continue to maintain a right line with the spine.
 
 174 
 
 LABOR. 
 
 eter, and the child's life, and the soft parts of the mother, are jeop 
 ardized. When, however, rotation is completed, the bi-parietal diam- 
 eter (3f inches), which is capable of snstaining a considerable degree 
 of lateral compression, engages in the transverse diameter of the pel- 
 vis ; at the same time the sub-occipito-bregmatic engages in the con- 
 jugate diameter. The latter, though measuring but 3f inches, may be 
 extended to 4^ inches by the pressing backward of the tip of the coccyx. 
 The conditions for the forward rotation of the occiput are — 
 1. Flexion ; 2. Good labor-pains ; 3. A firm perinaeum. 
 • In either of the occipito-anterior positions rotation is not diffi- 
 cult to understand. The convergent anterior inclined planes furnish 
 smooth surfaces upon which the occiput glides downward and forward 
 
 Fig. 100.— Figure illustrating the mecliauisiu ut Ictbor in occipito-anterior deliveries. 
 (.After Sctiultze. ) 
 
 to the front. The rigid ischial spines direct the forehead to the sacro- 
 sciatic ligaments, which determine the backward movement corre- 
 sponding to that of the occiput in the front part of the pelvis.* 
 
 * Prof. Henry G. Landis, in a most ingenious essay entitled How to use the 
 Forceps, argues that, practically, the pelvis contains two canals, partially separate 
 at the beginning and identical at their termination. The right canal is the one in 
 which the right sacro-iliac articulation is found, and the left the one to which the 
 left sacro-iliac articulation belongs. These canals converge from above down- 
 ward, and are also mutually curved from before backward. Their direction is 
 therefore spiral. The caliber of each canal is that of the fetal head ; therefore, 
 the head may descend in either canal, and will follow a spiral course in so doing.
 
 MECHANISM OF LABOR. -^^^J^ 
 
 Professor Pajot expresses the law which governs the rotation move- 
 ments in the following terms: " When a solid body is contained within 
 another, if the receptacle (eontenant) is the seat of alternations of move- 
 ment and repose, and its surfaces are slippery and but slightly angular, 
 the contained body will tend increasingly to accommodate its form 
 and dimensions to the form and capacity of the receptacle." * 
 
 In occipito-posterior positions, the rotation of the occiput forward 
 is, at the first glance, a puzzling phenomenon, as the inclined planes 
 of the pelvis, the ischial spines, and the law of accommodation, pre- 
 viously invoked by way of explanation, should determine the rotation 
 of the occiput not to the front but to the sacral cavity. The follow- 
 ing experiment of Dubois, however, throws considerable light upon 
 the principal conditions of success : " In a woman who had died a 
 short time previous in child- bed, the uterus, which had remained 
 flaccid and of large size, was opened to the cervical orifice, and held 
 by aids in a suitable position above the superior strait ; the foetus of 
 the woman was then placed in the soft and dilated uterine orifice in 
 the right occipito-posterior position. Several pupil-midwives, pushing 
 the fretus from above, readily caused it to enter the cavity of tiie pelvis ; 
 much greater effort was needed to make the head travel over the peri- 
 na?um and clear the vulva ; but it was not without astonishment that 
 we saw, in three successive attempts, that when the head had traversed 
 the external genital organs, the occiput had turned to the right ante- 
 rior position, while the face had turned to the left and to tne rear ; in 
 a word, rotation had taken place as in natural labor. We repeated the 
 experiment a fourth time, but as the head cleared the vulva the occi- 
 put remained posterior. Then we took a dead-born foetus of the pre- 
 vious night, but of much larger size than the preceding ; we placed it 
 in the same conditions as the first, and twice in succession witnessed 
 the head clear the vulva after having executed the movement of rota- 
 tion. Upon the third and following essays, delivery was accomplished 
 without the occurrence of rotation ; thus the movement only ceased 
 after the perina?um and vulva had lost the resistance which had made 
 it necessary, or, at least, had been the provoking cause of its accom- 
 plishment." f 
 
 This interesting experiment shows that it is unnecessary to assume 
 a rotation force in the uterus itself. A certain amount of light is 
 thrown upon the action of the perineal floor by the clinical fact tbat it 
 is always the most dependent portion of the presenting part which ro- 
 tates to the front. A moment's reflection will show that rotation, 
 therefore, takes place in such a direction that the sloping surface of 
 the child's head is brought into correspondence with the downward 
 slope of the perinseum. Thus it sometimes happens, in occipito-pos- 
 
 * Martel, De raccommodation en obstetrique, vide introduction, 
 f Ibid., quotation, p. 93.
 
 176 
 
 LABOR. 
 
 terior positions, that moderate extension occurs, so that the large fon- 
 tanelle is felt below the plane of the small one. In this case, the head 
 rests with its entire length upon the perineal floor ; its movements 
 are of necessity restrained within narrow limits; and, if extension 
 persists, the pressure of the opposing ischio-pubic ramus directs the 
 forehead under the arch of the pubes. When, however, the head is 
 well flexed it no longer corresponds to the perineal plane. The oc- 
 ciput then glides downward, and is 
 projected forward by the elastic pelvic 
 floor until the anterior parietal boss is 
 forced between the ischio-pubic rami. 
 As the occipital end of the flexed 
 head descends downward and forward 
 toward the pubic arch, the frontal ex- 
 tremity encounters the resistance of 
 the pelvic wall near the ileo-pectineal 
 eminence. If the pressure upon the 
 head were in all parts equal, no further 
 progress would now be possible. But 
 it is not equal. The backward press- 
 ure applied to the frontal portion of 
 the head is exerted upon the long end 
 of a lever, and works, therefore, at a 
 greater mechanical advantage than 
 that directed against the occiput.* 
 At the same time, if the anterior wall 
 be divided by a line drawn on a level 
 with the lower margin of the sym- 
 physis, we find that in the superior 
 division the general pelvic pressure di- 
 minishes from before backward, while 
 below the line indicated, owing to 
 the open space afforded by the pubic 
 arch in front, pressure diminishes from behind forward. Now, in 
 accordance with the mechanical principle that when a body is sub- 
 jected to varying pressures the movement will take place in the direc- 
 tion of the least pressure,f we find that the frontal portion, which lies 
 above the sub-pubic plane, turns backward, while the occiput, which 
 lies below, turns under the arch of the pubis. 
 
 It must not be supposed, in imagining the results of rotation, that 
 the movement continues until exact coincidence of the sagittal suture 
 and the conjugate is reached. Leishman endeavored to measure the 
 
 * Tarnier et Chantreuil, Traite de I'art des accouchements, p. 644. 
 t Stephenson, On the Mechanism of Labor, Obstet. Jour, of Gr. Brit, and Ire., 
 October, 1878, p. 405. 
 
 Fig. 101— O, B, short end of the head 
 lever ; B, F, long end of head lever. 
 (Tarnier et Chantreuil.)
 
 MECHANISM OF LABOR. 
 
 irr 
 
 divergence between the two after the head had escaped from under the 
 pelvic arch, by stretching a cord over the surface of the head from the 
 lower border of the symphysis to the coccyx. He found that in left 
 occipital positions the cord crossed the lambdoidal suture about an inch 
 to the right of the small fontanelle, and thence extended forward to 
 the middle of the opposite orbit, intersecting the median line at or 
 near the anterior fontanelle.* 
 
 In emerging from the pelvis, the two tubera parietalia do not pass 
 out at the same time. In place of this, the head rolls upon its side, so 
 that in left occipital positions the presentation is formed by the upper 
 and posterior part of the right parietal bone, and in right occipital posi- 
 tions by the corresponding territory upon the left parietal bone. 
 
 Extension. — As the head clears the inferior strait it distends the 
 perina3um, and converts it into a groove, which directs the occiput 
 toward the vaginal orifice. With the descent of the head the peri- 
 ngeum lengthens ; between the pains the perina?um retracts, and the 
 head recedes. A gradual softening results from the continuance of 
 this play, and, with diminished resistance from the perinaeum, the oc- 
 ciput descends along the anterior pelvic wall, the trunk enters the 
 cavity, and the neck finds support against the os pubis. Flexion con- 
 tinues until the occiput engages between the pubic rami. When the 
 resistance of the anterior bony wall is no longer encountered, the sur- 
 face of the child's head glides forward upon the perinaeum, as upon an 
 inclined plane, and describes a circle beneath the pelvic arch, of which 
 the sub-occipito-bregmatic diameter forms the radius. 
 
 The extension of the head, which is an essential feature of the fore- 
 going movement, is the resultant of two forces, derived, first, from the 
 uterus, second, from the pelvic floor. 
 
 The uterine action is transmitted in the axis of the superior strait. 
 With the occiput fixed beneath the pubic arch and the neck resting 
 against the inner surface of the pubes, the propulsive force is exjjeuded 
 upon the frontal extremity of the head, and this causes the separation 
 of the chin from the thorax. So soon as the forehead passes the apex 
 of the sacrum, the recoil of the coccyx and the elastic perinaeum drives 
 the fronto-occipital diameter forward to the vulva, which now looks in 
 a nearly vertical direction. When the bi-parietal diameter has once 
 passed the vaginal orifice, the perinaeum rapidly retracts, and, as it 
 glides over the face, the occiput is thrown sharply and rapidly upward 
 against the pubes. 
 
 External Rotation.— After the birth of the head, the face, no longer 
 supported by the perinaeum, sinks toward the anal region. At the 
 same time, or w^ith the recurrence of a pain, the head makes a quartor- 
 
 * Leishman, The Mechanism of Parturition, p. 84. It will be readily under- 
 stood, that in right occipital positions the cord should pass from the left of the 
 small fontanelle forward to the right orbit. 
 12
 
 1 -c LABOR. 
 
 rotation, the occiput turning toward the thigh corresponding to the 
 side to which it was originally directed (right occipital position, right 
 thif^h ; left occipital position, left thigh), and the face to the internal 
 surface of the opposite thigh. This movement is partly a restitution 
 of the head to its normal direction, and partly is due to a corresponding 
 rotation of the shoulders in the pelvic cavity. To understand the 
 mechanism of external rotation it must be borne in mind that, in the 
 movement of rotation, performed by the head in its transit through the 
 pelvic canal, the trunk participates to a diminished extent only. Thus, 
 Schatz * found, in the frozen section made by Braune through the ca- 
 daver of a woman who died in the second stage of labor, where the head 
 had originally occupied the right occipito-posterior position, that the 
 deviation between the pelvic extremity and the head was measured by 
 an angle of thirty degrees, and between the head and trunk, on a line 
 with the shoulders, by an angle of thirteen degrees. After the release 
 of the head from the vulva the torsion ceases, and the fetal parts re- 
 sume their natural relations to one another. The head, therefore, turns 
 slightly to the side, as it accommodates itself to the direction of the 
 shoulders. This first movement is termed " restitution," and is much 
 less marked in occipito-anterior than in occipito-posterior positions. The 
 shoulders assume an obhque position, until, encountering the sloping 
 pelvic planes, the anterior shoulder rotates forward, and the bis-acromial 
 diameter approximates to the antero-jiosterior diameter of the outlet. 
 The internal rotation of the shoulders usually takes place suddenly, and 
 is accompanied by the corresponding movement of the child's head. 
 
 Excessive rotation is sometimes observed. Thus, the shoulders, in 
 place of turning to the antero-postorior diameter, may continue in 
 movement until they occupy the oblique diameter of the opposing 
 side, the posterior shoulder coming to the front. This necessarily 
 causes faulty external rotation of the head. It occurs most frequently 
 in occipito-posterior positions, f 
 
 Expulsion of the Trunk. — After rotation, the anterior shoulder 
 passes under the arch of the pubes ; the trunk, as it is driven down 
 from above, becomes bent laterally, and the posterior shoulder glides 
 forward upon the perineum to the commissure of the vulva; both 
 shoulders then make the exit from the vaginal canal simultaneously. 
 In the delivery of the shoulders the bis-acromial diameter is usually 
 somewhat oblique. The expulsion of the trunk, owing to the previous 
 dilatation of the passage, follows with rapidity ; the body executes a 
 spiral movement until the hips engage at the outlet; during the 
 birth of the pelvis, however, the bis-iliac diameter rotates so as to 
 approximate to the line extending from the coccyx to the pubes. 
 
 * Schatz, Arch. f. Gynaek., Bd. vi, p. 413. 
 
 t DoHRN, Ueber die Ursachen fehlerhaftes Drehung der Schultern, etc., Arch. f. 
 Gynaek., Bd. iv, p. 363.
 
 MECHANISM OF LABOR. 
 
 n9 
 
 Abnormal Mechanism of Labor. (Vertex Presentation.) 
 
 In the proper performance of the various mechanical acts of labor, 
 it is necessary that the diameters of the fetal head approximate to 
 those of the canal through which it has to pass. A very large pelvis, 
 or a very small head, may become disturbing factors by leading to 
 imperfect flexion and rotation. In either case, with a lax perinfpum 
 and gaping vulva, the head may be born in any of the diameters of the 
 pelvis. Head-births in either an oblique or transverse diameter are, 
 however, extremely rare. They are attended with unusual difficultv, as 
 the occiput has to traverse a longer course than when directed forward 
 under the pubic arch. 
 
 The most important of the irregular forms results from the rota- 
 tion of the occiput, in occipito-posterior positions, backward into the 
 hollow of the sacrum.* The chief condition of its production is a 
 partial extension of the head, the forehead then turning anteriorly, in 
 accordance with the law that the most dependent portion of the pre- 
 senting part is moved to the front. 
 
 Fig. 102.— Illustrating the mechanism of labor in occipito-posterior positions. 
 (After Schultze.l 
 
 The Mechanism of Occipito-posterior Positions.— When the occiput 
 turns backward, it rests upon the anterior surface of the sacrum and 
 
 * Playfair states that Dr. Uvedale West found the frequency of this back- 
 ward rotation was four times to the hundred in occipito-posterior positions. 
 American edition, p. 265.
 
 180 
 
 LABOR. 
 
 upon the 2)erina&um ; the forehead and the anterior fontanelle distend 
 the vulva. If the rotation is incomplete, the anterior parietal, or adja- 
 cent frontal bones, are seen at the rima pudendi ; and, as the frontal 
 portion is born, the occiput sweeps forward to the perineal commissure. 
 After the occiput makes its exit, the neck rests upon the perineum, 
 while the head swings backward, describing a circle, of which the sub- 
 occipito-bregmatic diameter forms the radius. 
 
 Delivery in these cases is apt to be tedious, and often demands the 
 aid of forceps. 
 
 Configuration of the Head in Vertex Presentations. 
 
 During labor the various head diameters of the foetus undergo ex- 
 tensive modification as they are subjected to the resistance of the par- 
 turient canal. Of these, the most important is the diminution of the 
 sub-occipito-bregmatic, the occipito-frontal, and the bi-temporal diam- 
 eters, with compensatory elongation taking place in a line running 
 from the chin to a point in the sagittal suture situated between the 
 apex of the occipital bone and the large fontanelle (maximum diame- 
 ter of Budin). The plastic changes mentioned are rendered possible 
 by the presence of the fontanelles, the width of the sutures, the plia- 
 
 FiG. 103.— Outlines showing difference between head of child at birth (1) and four days subse- 
 quent to delivery (2). (Budin.) 
 
 bility of the sagittal borders of the parietal bones, the depressibility of 
 the OS frontis, and the joint-like movement between the squamous and 
 basilar positions of the occipital bone. As a consequence of these ana- 
 tomical dispositions, pressure from above inclines the frontal bones 
 backward, while the resistance encountered below shoves the occipital 
 bone in a forward direction. These movements are rendered possible
 
 MECHANISM OF LABOR. 
 
 ISl 
 
 by the depression of both frontal and occipital bones beneath the 
 adjacent borders of the parietal bones; at the same time, the dragging 
 thus exerted upon the latter, front and rear, increases the curve of the 
 cranial vault along the line of the sagittal suture. The sharpness of 
 the bend at the summit of the curve is more or less pronounced, ac- 
 cording to the rigidity of the channel through which the head passes. 
 In cases of bii'th with the occiput to the rear, the head is often drawn 
 out to a great length, the occiput forming an almost vertical line with 
 the neck and shoulders, while in front the forehead and parietal bones 
 slope upward to the vertex in nearly the same plane. 
 
 The contour of the head is still further modified by the formation 
 of the caput succedaneura, or scalp-tumor, a swelling developing upon 
 the portion of the presenting part, which is 
 subjected to diminished pressure from the 
 obstetric canal, and which in consequence be- 
 comes the seat of venous hyperasmia, oedema, 
 and extravasation. The formation of the 
 tumor is usually preceded by wrinkling of 
 the scalp, indicative of the stronger compres- 
 sion above. It may be produced within the 
 cervical canal, but is then usually of insig- 
 nificant size and of small practical impor- 
 tance. Indeed, it may even form previous to 
 rupture of the membranes in cases where the 
 separation of the bag of waters from the con- 
 tents of the uterine cavity is complete, and 
 where, we have seen, the water-pressure below 
 the line of cervical contact with the head 
 is less than the intra-uterine pressure above. 
 Usually, however, it is developed after the head reaches the pelvic 
 floor, at the outlet of the vagina, the situation upon the scalp often 
 enabling one subsequent to delivery to diagnose the position the head 
 had occupied within the pelvic canal.* 
 
 A voluminous scalp-tumor is, as a rule, the result of compression 
 from the bony canal, and forms, therefore, in normal pelves, below 
 the narrowing of the inferior strait. In generally contracted pelves, 
 however, where the resistance of the bony canal is encountered at the 
 
 * The tumor forms, in left occipito-anterior positions, upon the superior posterior 
 angle of the right parietal bone, encroaching somewhat upon the small fonlanelle 
 and the occiput; in right occipito-anterior positions, upon the corresponding 
 point on the left side of the cranium. In occipito-posterior deliveries the tumor 
 develops upon the anterior superior angle of the parietal bone turned to the 
 pubic -arch, and encroaching upon the large fontanelle. and even upon the frontal 
 suture. If the head-rotation is complete, and the head is detained for a long 
 period at the vulva, the tumor may occupy the median line, and thus obscure the 
 diagnosis. 
 
 Showing shape of 
 head in occipito-posterior 
 deliveries. (Tarnier et Chan- 
 treiiil. )
 
 182 
 
 LABOR. 
 
 brim, the formation of an enormous scalp-tumor may precede the en- 
 trance of the head into the pelvis. 
 
 According to Dessaut,* the scalp-tumor is usually of larger size 
 when situated upon the anterior surface of the head, partly because of 
 the greater laxity of the tissues, and partly because of the longer dura- 
 tion of labor when the forehead is directed to the front. Its length 
 may vary from a half -inch to two inches or more. In extreme cases, 
 where the labor has been prolonged, there is sometimes found, asso- 
 ciated with the scalp-tumor, a separation of both the periosteum and 
 the dura mater from the underlying segment of the cranium. 
 
 Diagnosis. — The diagnosis of cranial presentations by external pal- 
 pation is usually not difficult. The head is recognized by its hardness, 
 
 Method of j)erforniinK external palpation. (Pinai d.) 
 
 its rounded form, its separation from the trunk by the neck, and the 
 ease with which ballottement is produced. Sometimes, by pressure 
 upon the cranial bones, a peculiar parchment-like crackle is elicited, 
 which is perceptible even through the abdominal parietes.f The 
 breech, on the contrary, is of uneven shape, of smaller size, and of 
 
 * Tarnier et Chantreuil, p. 686. 
 
 t Fasbender. Monatsschr. f. Geburtsk., Bd. xxxiii, p. 435. Dr. P. P. Muiide 
 has recently furnished an excellent resume of the subject of diagnosis by external 
 examination in an essay termed Obstetric Palpation.
 
 MECHAXISM OF LABOR. -^^^ 
 
 softer consistence. The feet are found in close jjroximity. Ballottemeut 
 is obscure on account of the broad connection between the breech and 
 the trunk. Under favorable conditions the back presents upon one side 
 of the uterus a broad, palpable surface without distinctive bony projec- 
 tions. The outline of the dorsal surface may be rendered more distinct 
 by downward pressure exerted over the fundus upon the breech of the 
 child. The position of the child is determined — 1. By the fetal heart, 
 which, except in face-presentations, is heard most distinctly over the 
 dorsal surface ; 2. By the direction of the feet, which are situated upon 
 the abdominal side of t'.ie child. 
 
 Upon examination made per vagiuam the head is felt as a hard, 
 round, smooth body, characterized by the sutures and fontanelles, and 
 sufficiently large to till the space of the pelvis. Before the rupture of 
 the membranes, investigations should be conducted in the intervals be- 
 tween the pains, i. e., vv^hile the membranes are lax and depressible. If 
 the head is high, and retreats before the examining finger, it should be 
 steadied by counter-pressure applied to the fundus uteri through the 
 abdominal walls. 
 
 The sutures and fontanelles are best made out after rupture of the 
 membranes. In passing the extremity of the index-finger backward 
 over the cranium toward the sacrum, the sagittal suture is usually en- 
 countered. At the extremities of the sagittal suture the two fonta- 
 nelles are perceived, distinguishable from one another by the differences 
 in size and shape. In exceptional cases the extreme compression of 
 the bones of the skull may render the large fontanelle scarcely recog- 
 nizable ; in others, again, the presence of membranous spaces in the 
 line of the sagittal suture, fissures at the apex of the occipital bone, or 
 the existence of ossa triquetra near the site of the small fontanelle, may 
 cause perplexity, and lead to errors in the diagnosis of head positions. 
 It is therefore well to bear in mind, as special marks of distinction, 
 that the small fontanelle furnishes the meeting-point of three sutures, 
 while four sutures meet at the large fontanelle. 
 
 The sagittal suture pursues a straight course, forming a right angle 
 with the coronal and an obtuse angle with the lambda suture. An- 
 teriorly it is continuous with the frontal suture; posteriorly it ends 
 abruptly at the occipital bone. The lambda suture, which is the only 
 one liable to be mistaken for the preceding, is distinguished by its 
 curvilinear direction, by the greater thickness of the parietal borders, 
 and by the depression of the occipital beneath the parietal bones. 
 
 When the sutures are masked by the presence of a large scalp- 
 tumor, it is still possible in most cases to diagnose the position by 
 pushing the finger up behind the symphysis pubis and feeling for 
 the ear.
 
 jg^ LABOR. 
 
 CHAPTER X. 
 
 MECHANISM OF LABOR.— (Continued.) 
 
 Pace presentations. — Frequency. — Causes. — Mechanism. — Descent and extension. — 
 Rotation. — Flexion. — External Rotation. — Abnormal mechanism. — Configura- 
 tion of head. — Diagnosis. — Prognosis. — Treatment. — Brow presentations. — 
 Breech presentations. — Causes. — Diagnosis. — Mechanism, — Irregular mechan- 
 ism, — Configuration. — Prognosis. — Treatment, 
 
 Face Presejsttatioxs, 
 
 Ix facial presentations, in place of the normal attitude of the foetus, 
 the chin is extended, the occiput is reflected against the neck, and the 
 face with the frontal portion of the skull occupies the entrance to the 
 pelvis. It is not a very common anomaly, having occurred, according 
 to Pinard, 320 times in 81,711 confinements at the Maternitc in Paris, 
 or, in round numbers, once in 250 cases.* 
 
 Causes. — The causes of face presentations are imperfectly known. 
 Clinical observation has, however, succeeded in connecting the exten- 
 sion of the head in the pelvic canal with a variety of predisposing con- 
 ditions. To Ahlfeld \ we are indebted for a collection of associated 
 events derived from a careful analysis of well-observed cases. From 
 these, the following are selected because of their more palpable con- 
 nection with the phenomenon in question : 
 
 Separation of the chin from the chest, resultiiig from congenital en- 
 largement of the thyroid gland ; from increased size of the chest in- 
 terfering with flexion ; from stricture of the cervix about the neck of 
 the child, the uterine walls adding to the circumference of the thorax ; 
 from the mobility of the foetus, either because of its small size or from 
 excess of amniotic fluid ; from oblique positions of the child and of the 
 uterus, especially in cases of rapid escape of the amniotic fluid ; and 
 from coiling of the cord around tlie head of the foetus, Ilecker J lays 
 great stress upon the shape of the child's head, and has endeavored 
 to establish a connection between face presentations and unusual length 
 of the occiput. To be sure, after birth in face presentations the hind- 
 head is often found to nearly equal in length the anterior portion, arid 
 it is easy to see that, were such the case at the beginning of labor, the 
 question of extension or flexion would always be in suspense ; but, in 
 most cases, the shape is the effect rather than the cause of the presen- 
 tation. Still, Hecker and others have reported instances where the 
 elongation, instead of proving temporary, persisted after delivery, and 
 therefore, it was fair to assume, had existed as a pre-natal condition. 
 
 * Charpentier, Contributions a I'etude des presentations de la face, p. 15. 
 t Ahlfeld, Die Entstehung der Stirn- und Gesichtslagen. 
 X Hecker, Ueber die Schadelform bei Gesichtslagen.
 
 MECHANISM OP LABOR. 
 
 18^ 
 
 The resistance encountered by the occiput, which converts partial 
 into complete extension of the head, may be furnished by either the 
 uterine or the pelvic walls. 
 
 Most writers ascribe great importance to oblique positions of the 
 foetus and of the uterus in the etiology of face presentations. In mul- 
 tiparas, the former are not uncommon during pregnancy, the head 
 then resting upon an iliac fossa. As a rule, however, the first pains 
 straighten the foetus, the narrowing of the uterus in its transverse 
 diameter serving to press the breech toward the fundus and the head 
 into the pelvis. So long as the back of the child is directed downward, 
 the rectification would inevitably be followed by head-flexion. When, 
 however, the back is turned toward the fundus, and the change to the 
 vertical attitude is not readily effected, the pressure of the adjacent 
 uterine wall may, during contraction, act in a special degree upon the 
 occiput, and direct it backward toward the neck, while the forehead 
 sinks forward into the brim of the j^elvis. This movement is often 
 temporary, and with the descent of the child the resistance encoun- 
 tered by the forehead may exceed that met with from the occiput, and 
 thus in the end flexion may follow in the ordinary manner. If, how- 
 ever, the extension continues, a point is finally reached at which the 
 propelling force is exerted specially in the direction of the chin, now 
 converted into the short end of the lever, and the face presentation 
 becomes complete. In the same way, extension may be produced when 
 the occiput is arrested at the linea iunominata, an accident most likely 
 to occur in transverse narrowing of the pelvis, and, again, in flattened 
 pelves when the bi-parietal diameter is arrested by the contracted con- 
 jugate. The mechanism of head- flexion may likewise be interfered 
 with by a prolapsed extremity encroaching upon the pelvic space. 
 
 In lateral obliquity of the uterus, the curvature of the uterine canal 
 favors the production of face presentations when the back of the child 
 conforms to the convexity of the lower surface, as the propelling force, 
 which is transmitted in the axis of the uterus, then passes along the 
 anterior aspect of the foetus, and increases the tendency of the fore- 
 head to descend. 
 
 While in vertex presentations the left dorsal positions are nearly 
 three times as frequent as the right, in face presentations the differ- 
 ence is very small.* Both Duncan f and Schroeder J ascribe this rela- 
 
 * Statistics are as yet not sufficiently numerous to determine the question as to 
 which position actually occurs most frequently. Dubois and Desormeaux (Diction- 
 naire, in thirty volumes, p. 364) reported eighty-five cases. Of these, in forty-five 
 the chin was turned to the right, while in thirty-eight it was directed to the left. 
 Dr. A. Walther (Winckel's Berichte, Bd. iii. p. 212) reported from the Dresden 
 Lying-in Institute thirty-one cases. Of these, the chin was turned to the left 
 twenty-one times, to the right ten times. 
 
 t Duncan, Edinburgh Obstet. Trans., vol. ii, p. 108. 
 
 X Schroeder, Lehrbuch der Geburtshiilfe. p. 182.
 
 186 
 
 LABOR. 
 
 tive preponderance of face presentations with the chin directed to the 
 left to the constancy of right lateral obliquity of the uterus. 
 
 Alilfeld * mentions further that it is not infrequent for extension 
 to take place within the pelvic cavity, the arrest of the occiput result- 
 ing from an unusual projection of the spines of the ischia. 
 
 The Mechanism of Face Presentations. 
 
 As in vertex presentations, the dorsum of the child may be turned 
 to the right or to the left side. The position of the face is usually 
 designated by the direction of the chin. We distinguish, therefore : 
 0'. <i {-^t Right mento-iliac positions (chin to right ilium) ; 
 
 ^ ^ Left mento-iliac positions (chin to left ilium). 
 '■ ' ■ Most frequently the face occupies the right oblique diameter of the 
 
 pelvis. The common positions are, therefore, the right mento^jliac 
 
 posterior and the left mentojriliac 
 anterior ; still, it is by no means 
 rare for the face to enter the 
 pelvis transversely, probably be- 
 cause of the frequent association 
 of face presentations with a nar- 
 rowing of the conjugate. 
 
 Descent and Extension. — 
 These two movements, like de- 
 scent and flexion in vertex pre- 
 sentations, are conjoined — not 
 distinct from one another. At 
 the brim, the large fontanelle is 
 easily reached, while the chin is 
 inaccessible. As the vertebral 
 column is situated, in face pres- 
 entations, nearer to the chin than 
 the occiput, extension is accom- 
 plished in obedience to the same 
 rules which produce flexion in 
 vertex cases. With the descent 
 of the head through the pelvic 
 channel, the chin sinks deeper 
 and deeper, while the occiput is 
 pushed backward and pressed 
 firmly against the dorsal surface 
 of the child. The degree of extension at the different stages of the 
 descent is measured by the relative positions of the chin and the large 
 fontanelle. 
 
 The engagement of the head is usually slow and accomplished with 
 * Ahlfeld, Ioc. cif., p. 62. 
 
 -Attitude of the head in face presenta- 
 tions. (Rib^mont.)
 
 MECHANISM OF LABOR. 
 
 187 
 
 difficulty, owing to the fact that the neck and posterior portion of the 
 head enter the excavation at the same time. The descent of the head 
 is normally limited by the length of the child's neck, as it is only in the 
 case of a very small child, or exceptionally roomy pelvis, that the head 
 and upjjer portion of the thorax can enter the pelvis simultaneously. 
 
 When the face reaches the pelvic floor, a slight degree of lateral 
 obliquity is produced, the cheek directed toward the pubes advancing 
 somewhat more rapidly than the one turned to the sacrum. 
 
 Rotation. — When the chin has descended along the lateral or pos- 
 terior wall of the pelvis until the thorax reaches the linea innominata, 
 further progress is only rendered possible when the chin rotates forward 
 and engages beneath the arch of the^pulSei] TfirTrrenhanism of ^Hm^^^ 
 
 Fig 
 
 Engagement of the head in face presentations. (Tarnier et Chantreuil.) 
 
 rotation is the same portrayed in vertex presentations. When extension 
 is complete, the chin, as the most dependent portion, glides downward 
 and forward upon the ]3eriaa^um, and the malar bone is pressed between 
 the pubic rami. We have seen already that the pressure above the 
 pubic arch diminishes from before backward, while below it diminishes 
 from behind forward. In accordance with the mechanical principle, 
 that a body subjected to varying pressures moves in the direction of 
 least pressure, the chin or deeper portion turns to the front, while the 
 cranial vault rotates into the hollow of the sacrum. To this movement 
 the unequal length of the two extremities of the lever, measuring from
 
 188 
 
 LABOR. 
 
 the malar bone to the top of the forehead on the one side, and from the 
 malar bone to the chin upon the other, contributes in an important 
 degree.* 
 
 Flexion. — After rotation, the chin emerges beneath the pubic arch, 
 the shoulders press upon the base of the skull, the perinseum becomes 
 rounded by the cranial vault, and, finally, as the head performs the 
 movement of flexion in obedience to the forward impulse imparted by 
 the perinaBum, the chin rounds the symphysis, while the mouth, the 
 nose, the brow, the vertex, and the occiput appear in succession at the 
 posterior commissure of the vulva. 
 
 External Rotation. — When the delivery of the head is complete, 
 the shoulders rotate Tnto the antero-posterior diameter of the pelvis, 
 the chin turning in correspondence, in right mento-iliac positions, to 
 the right thigh ; in left mento-iliac positions, to the left thigh. 
 
 Abnoemal Mechanism. 
 
 In a foetus of small size, the face may, when it meets with slight 
 resistance from the perinaeum, be borne in any of the pelvic diameters. 
 Instances of spontaneous delivery without anterior rotation of the chin 
 
 Fig. 108.— Mechanism of face presentations. (Scbultze.) 
 
 are, however, extremely rare. The egress of the face in the transverse 
 diameter is possible in a shallow, rachitic pelvis, flattened in the conju- 
 gate at the brim, and wide between the ischia at the outlet. The head 
 * Tarnier et Chantreuil, he. cit., p. 658.
 
 MECHANISM OF LABOR. 
 
 189 
 
 emerges with the chin resting upon one of the ischio-pubic rami, 
 around which the rotation of the mento-occipital diameter takes place. 
 As the movement is associated with excessive stretching of the neck it 
 is evident that its execution is favored by the tensile condition of the 
 tissues which follows death of the foetus. 
 
 At full terra, the face presenting, spontaneous^delivery in mento- 
 posterior positions is notj)racticable. ^TiTs becomes evident when we 
 reflect that, owing to the length of the sacral wall, the chin can not de- 
 scend to the fourchette without an incredible flattening of the cranial 
 
 Fig. 109.— Face presentation, chin to the rear. (Hodge.) 
 
 vault and the simultaneous entrance of the chest into the pelvic cavity. 
 It is claimed, however, that when the head is small and compressible it 
 may stretch either the sacro-sciatic ligaments when oblique, or the 
 perinaeum after passing the extremity of the sacrum, to an extent 
 sufficient to permit the descent of the occiput beneath the pubic arch, 
 and the conversion of the face into a vertex-presentation. 
 
 CONFIGUKATION OF THE HeAD IN FaCE PRESENTATIONS. 
 
 In face presentations the vault of the cranium is flattened, so that 
 the sagittal suture runs from fontanelle to fontanelle in nearly a hori- 
 zontal line ; the squamous portion of the occipital bone is pushed back- 
 ward, while in both the occipital and frontal bones the convexity is in- 
 creased. As a result, there is an augmentation of the transverse, the 
 occipito-frontal, and occipito-mental diameters, while the sub-occipito- 
 bregmatic is diminished. The maximum diameter either corresponds
 
 190 
 
 LABOR. 
 
 Fig. 110.— Outline of head born with face presenting. 
 
 to the occipito-mental, or terminates posteriorly at a point below the 
 
 apex of the occiput.* 
 
 The sero-sanguineous tumor, which forms upon the presenting part 
 
 as a consequence of the diminished pressure, occupies the lower portion 
 
 of the malar region, and 
 the corner of the mouth 
 (left mento-iliac position, 
 left cheek ; right mento- 
 iliac position, right cheek) 
 in mento-anterior positions, 
 and the upper portion of 
 the malar region, and even 
 the eye, in mento-posterior 
 positions. The integu- 
 ments of the cheek assume 
 a blackish-blue color ; the 
 tumefaction of the lids is 
 such that at birth the eyes 
 are closed, and sanguineous 
 
 effusions are found upon the ocular conjunctiva; and the inoutii, when 
 
 involved, becomes swollen and distorted, so that suction is sometimes 
 
 interfered with for several 
 
 days after birth. 
 
 Diagnosis. — At a time 
 
 when a portion of the head 
 
 still remains above the level 
 
 of the pelvic brim, it is 
 
 not infrequently possible to 
 
 form a diagnosis from ex- 
 ternal manipulations alone. 
 
 Thus, by making deep 
 
 pressure with the tips of 
 
 the fingers above the sym- 
 physis pubis, the cranium 
 
 may, under favorable cir- 
 cumstances, be recognized 
 
 upon one side of the pelvis, 
 
 together with the sharp 
 
 angle formed at the neck 
 
 between the occiput and 
 
 the dorsum of the foetus. 
 
 tinctness over the anterior 
 
 Fig. 111.— Same head five days later. (Budin.) 
 
 As the heart is heard with greatest dis- 
 portion of the chest in face presenta- 
 tions, confirmatory evidence of the latter is afforded by detecting 
 the presence of the fetal extremities, and the heart-sounds upon the 
 * Budin, loc. ciL, p. 77.
 
 MECHANISM OF LABOR. J9JL 
 
 same, instead of, as in vertex presentations, upon opposite sides of 
 the trunk. 
 
 Upon internal examination, the distinct peculiarities are a high 
 position of the presenting part, a flattening of the vaginal fornix, and, 
 through the intervening tissues, the recognition of the smooth forehead, 
 contrasting with the uneven surface of the face. Through the dilated 
 cervix the finger detects the forehead, the bridge of the nose, the 
 nostrils, the orbits, the malar bones, the alveolar processes of the jaw, 
 the mouth, and, when extension is complete, the pointed chin. In- 
 stances have, indeed, been recorded where, in advanced labor, the dis- 
 torted face has been confounded with the breech, the inexperienced 
 observer mistaking the swollen cheeks for the "nates, the malar bones 
 for the ischia, the nose for the tip of the coccyx, the oedematous eyelids 
 for the scrotum, and the mouth for the anus. Such an error is best 
 avoided by deliberation in exploring the presenting part. With proper 
 care the smooth forehead, the bridge of the nose, the hard orbital 
 borders, the chin, and especially the mouth, through which the jaws 
 can be felt, afford sufficient data for a correct diagnosis. 
 
 Prognosis. — According to the statistics of Winckel,* the mortality 
 of the children in face presentations amounted to thirteen per cent, 
 while that of the mothers reached as high as six per cent. Thus, 
 though spontaneous delivery is the rule in face presentations, the 
 dangers to both mother and child are considerably greater than in 
 vertex presentations. The causes of the less favorable prognosis are 
 to be looked for in the increased peripheral head measurements, which 
 engage successively in the different planes of the obstetric canal, and 
 consequently from the increased reciprocal pressure exerted between 
 the head and the soft parts, and partly from the compression of the 
 veins of the neck by the anterior wall of the pelvis. Though the 
 average length of labor does not much exceed that of normal presen- 
 tations,! the duration is more readily affected by minor disturbances, 
 such as weak pains, moderately contracted pelves, and rigidity of the 
 obstetric canal. At the same time, the prolongation of labor in these 
 cases is attended by more disastrous consequences, and calls more 
 frequently for the resources of art to complete the delivery. 
 
 Treatment— The first rule in the treatment of face presentations is 
 to carefully avoid prematurely rupturing the membranes. The face is 
 ill adapted to serve the purpose of a dilator to the cervical canal, and 
 early rupture is apt to be followed by complete escape of the amniotic 
 fluid— an accident always to be dreaded, but specially serious in face- 
 presentations, where the umbilical cord is exposed to pressure between 
 the anterior surface of the child and the uterine wall. Examinations 
 made with a view to diagnosis should therefore be conducted Avith 
 
 * Winckel, Pathologie der Geburtshiilfe, p. 89. 
 f Walther, Wingkel's Berichte, Bd. iii. p. 315.
 
 192 
 
 LABOR. 
 
 great care, during an interval between the pains, and their repetition 
 should be avoided when the requisite information has once been ob- 
 tained. During the progress of the first stage of labor, it is recom- 
 mended to place the mother upon the side toward which the chin of 
 the child is turned, with a view of favoring extension and rotation. 
 
 Because of the uncertainties of the prognosis in face presentations, 
 many manoeuvres have been proposed for the conversion of the latter 
 into normal presentations. The manipulations chiefly recommended 
 consist of either pushing up the face or drawing down the occiput, 
 with the fingers passed through the cervical canal. Though occasion- 
 ally successful, they have been discountenanced at least in mento-an- 
 t'erior positions by most obstetric writers, because experience has shown 
 the results to be by no means commensurate with the dangers incurred. 
 Schatz * has, however, suggested a rational plan for reducing the ex- 
 tended head by external manipulations only, which avoids the objec- 
 tions to the earlier methods. His manoeuvre consists in restoring the 
 normal attitude of the body by flexing the trunk, and leaving the head 
 to resume spontaneously its proper position as it sinks into the pelvis. 
 It is performed by seizing the shoulder and breast with the hand 
 through the abdominal walls ; then lifting the chest upward and press- 
 ing it backward, at the same time steadying or raising the breech with 
 the other hand applied near the fundus, so as to make the long axis of 
 
 
 Figs. 112-114.— Diagram showing Schatz's method of converting face presentations into vertex 
 
 presentations. 
 
 the child conform to that of the uterus, and, finally, pressing the breech 
 directly downward. As the child is raised, the occiput is allowed to 
 descend, and then, as the body is bent forward, head-flexion is pro- 
 duced by the resistance of the side walls of the pelvis. Schatz illus- 
 
 * Schatz, Die Umwandlung von Gesichtslage, etc., Arch. f. Gynaek.. Bd. v, 
 p. 313.
 
 MECHANISM OF LABOR. ^93 
 
 trates these movements by the accompanying diagrams. If, owing to 
 its elevation, the head tends to move to one side when backward press- 
 ure is made upon the chest, the place of the pelvic wall may be sup- 
 plied by external pressure exerted by an assistant. The time for at- 
 tempting this* manipulation is previous to the rupture of the mem- 
 branes. The requisites for success are experience in mapping out the 
 fetal outlines by external palpation, and the absence of abdominal and 
 uterine irritability. After rupture of the membranes, great care must 
 be exercised in vaginal explorations, to avoid injuring the eves or 
 exciting premature respiratory movements by allowing air to enter the 
 mouth. 
 
 If the chin remains persistently directed to the rear, rotation may 
 sometimes be promoted by either pressing forward with two fingers 
 upon the lower jaw, or by pushing the forehead backward and upward, 
 to produce a deep descent of the chin. To be effective, either manipu- 
 lation should be executed during a pain. Hodge advocates the vectis, 
 and others a blade of the forceps, as of use in correcting mento-poste- 
 rior positions. As a rule, however, good pains and complete extension 
 are the conditions most likely to effect the forward movement of the 
 chin. It is practically of importance to bear in mind that tardy rota- 
 tion is characteristic of face presentations. If, however, the face re- 
 mains persistently turned to the rear, before resorting to craniotomy, 
 an attempt to produce head flexion by Baudelocque's method is ad- 
 missible. This consists in making upward pressure with two fingers 
 — first upon the chin, and then in succession upon the fossae canin^e 
 and upon the brow. Ziegenspeck * has recently reported a case where 
 interference was dela3'ed until uterine rupture threatened, in Avhich 
 he succeeded in flexing the head by combining the method of Bau- 
 delocque with that of Schatz. By the latter, an assistant succeeded 
 in raising the brow to the level of the pelvic brim, while Ziegen- 
 speck used pressure through the abdominal walls upon the occiput, 
 and with the internal hand upon the face, until a vertex presenta- 
 tion was effected. The child was born living, and the mother made 
 a good recovery. The treatment, in cases where all measures prove 
 ineffective to secure a favorable change of position, and dangers ac- 
 crue from delay to either mother or child, belongs to the domain of 
 operative midwifery. 
 
 During head-expulsion caution must be used in supporting the 
 perineum, in order not to injure the neck by too strong forward press- 
 ure against the anterior wall of the pelvis. 
 
 It is safe to assure the bystanders that the distortion of the face and 
 the extension of the head after delivery will disappear spontaneously in 
 the course of from twenty-four to forty-eight hours. 
 
 * Ziegenspeck, Beitrag zur Behandlung der Gesichtslagen klinische Vortrage. 
 
 No. 284. 
 
 13
 
 194 
 
 LABOR. 
 
 Brow Presentations. 
 
 In brow presentatious the head occupies a position intermediate 
 between flexion and extension. Of necessity every face presentation 
 has become such after first passing through the frontal stage. A tem- 
 porary dip of the large fontanelle in the earlier period of labor is by no 
 means uncommon. With the advance of the head, however, the resist- 
 ance encountered usually causes the complete descent of either the chin 
 or the occiput. The causes of brow presentations are, in the main, the 
 same as those given for presentations of the face, viz., obliquity of the 
 uterus and foetus, enlargements of the neck and thorax, contracted 
 pelvis, excessive mobility of the foetus, and partial cervical stricture. 
 
 The diagnosis is made by recognizing the apex of the forehead in 
 the pelvic canal, with the orbits and the root of the nose upon one 
 side, and the large fontanelle and parietal bones upon the other. At 
 
 the brim the frontal suture 
 is usually transverse, but 
 becomes oblique in its prog- 
 ress toward the pelvic outlet. 
 A small head may pass 
 through a roomy pelvis, tlie 
 l)row ])resenting, without 
 injury to either mother or 
 child. In the mechanism 
 of delivery the forehead 
 turns to the front and ap- 
 pears at the vulva, the upper 
 maxilla resting against the 
 symphysis and the cranium 
 lying in the hollow of the 
 sacrum and upon the peri- 
 nfeum. The exit is accomplished by the cranial vault first sweeping 
 forward over the perinaeum ; the upper Jaw, the mouth, and the chin 
 afterward making their appearance beneath the symphysis pubis. 
 
 Sometimes, though usually only when the forceps is used, the 
 head may be delivered in the transverse diameter. In spontaneous 
 cases the superior maxilla finds a point of support against one ischio- 
 pubic ramus, while the cranium rotates transversely through the vulva. 
 When the face turns posteriorly, delivery of a living child is scarcely 
 possible. 
 
 The configuration of the head is very striking. The swelling of 
 the integuments extends from the root of the nose to the upper angle 
 of the large fontanelle. The forehead is nearly perpendicular, while 
 the parietal and occipital bones form a slope which inclines downward 
 and backward. The mento-frontal and sub-occipito-frontal diameters 
 
 Fig. 115.— Outline of head after delivery, the brow 
 presenting. (Budin.)
 
 MKCriANlSM OF LABOR. 
 
 195 
 
 are increased, while the distance between the chin and a point in the 
 sagittal snture anterior to the occiput is diminished. These changes 
 impart to the head a triangular 'shape. The peculiar formation is ex- 
 plained by the compression of the occiput between the pelvis and the 
 dorsal surface of the child, and the compensatory elongation which 
 takes place in the direction of the forehead. 
 
 The prognosis isjess favorable than in vertex presentations, but is 
 by no means so sinister as is popularly supposed. Many cases of origi- 
 
 PiG. 116.— Brow presentation, subsequently converted into that of the face.* (Maternity 
 
 Hospital.) 
 
 nal brow presentations become converted into face or vertex presenta- 
 tions during the progress of labor ; many are delivered spontaneously, 
 or by the aid of the forceps. Craniotomy is rarely called for. 
 
 Ahlfeld (Die Entstehung Steiss- und Gesichtslagen) furnishes twentj^-six 
 cases in which the result to both mother and child is given. Fritsch (Kliuik 
 der alltaglichen geburtshiilflichen Operationen, p. 46) gives the histories of 
 seven cases, and Budix (TMe du Foetus, p. 53) the history of one case. In the 
 thirty-four deliveries there were two maternal deaths ; in one of the fatal cases 
 coxalgic oblique pelvis existed as a complication. In the other the brow spon- 
 taneously changed into a face presentation. There were ten spontaneous deliv- 
 eries, the brow presenting, with four dead children, but one died previous to 
 labor. There were ten cases of spontaneous delivery in which the brow during 
 delivery became converted into either a face or vertex presentation. Of these, 
 one child died. Fourteen children were extracted with the forceps, nine with 
 the brow presenting, of which two were dead, one from prolapsed funis, and 
 
 * Recovery of both mother and child. (From drawing of A. II. Fridenberg).
 
 ll^,; LABOR. 
 
 one which had died before hibor; five, after conversion into face or vertex pres- 
 entations, with no deaths. Thus, of the thirty-four children there were seven 
 deaths, but of these four only could be attributed to the presentation. 
 
 From the foregoing, it is evident that the duties of the accoucheur, 
 in the presence of brow presentation, should be confined to efforts to 
 direct the hibor to a favorable termination by one of the paths indi- 
 cated by Nature. At the brint^^jrejviiiusto engagement, the dip of the 
 anterior fontanelle is often temporary, in many cases simply signifying 
 a narrowing in the upper conjugate. Version, therefore, so frequently 
 recommended with a view to the substitution of diameters more con- 
 formable to those of the pelvis, should be limited to cases where the 
 head is retained at the contracted conjugate, where the faulty position 
 is due to cervical stricture (Bayer), and where speedy delivery is de- 
 manded in the interest of either mother or child. 
 
 Manual attempts to convert a brow presentation into one of the 
 face or vertex possess more legitimate claims to favor. The method of 
 Baudelocque consists in seizing the head with the entire hand intro- 
 duced into the vagina, lifting it to the brim, and then drawing the oc- 
 ciput downward with the fingers until flexion becomes complete. The 
 procedure was bitterly opposed by Chailly,* who urged against it, in 
 addition to the frequency of failure, the dangers of uterine rupture, of 
 prolapse of the cord, and the inconveniences arising from the early 
 evacuation of the amniotic fluid. There is no question of success by 
 this measure, and, if care is exercised, the concurrent risks are hardly 
 sufficient to furnish contra-indications. At any rate, it would be 
 proper to make the attempt when brow presentations complicate de- 
 livery in justo-minor pelvis, or in persistent mento-posterior positions, 
 as in these cases craniotomy is the only alternative. Complete anaes- 
 thesia facilitates reduction. While elevating the head, firm counter- 
 pressure should be made at the fundus uteri. f 
 
 Occasionally the conversion of the brow into a vertex or face pres- 
 entation may be effected by pressure exerted during a pain upon re- 
 spectively the occipital or frontal extremity of the head. In bringing 
 down the vertex, the movement should be aided by external pressure 
 made with the disengaged hand above the brim of the pelvis. When 
 a face presentation is desired, the woman should be made to lie during 
 labor upon the side to which the child's abdomen is directed, and upon 
 the side to which the back is turned when the descent of the vertex is 
 aimed at. 
 
 SchatzJ recommends, with the view to the production of a face 
 
 * Chailly-Honork, Traite pratique des accouchements, p. 783. 
 
 f Vide Parry, On the Use of the Iland to correct Unfavorable Presentations, 
 etc., Am. Jour, of Obstet., vol. viii, p. 138. 
 
 X ScHATZ, Die Uinwandlung von Gesichtslage zu Hinterhauptslage, etc., A rch. 
 f. Gynaek., Bd. v, p. 338.
 
 MECHANISM OF LABOR. 1 9^ 
 
 presentation, the introdiiction of two fingers into the child's mouth, 
 and making traction on the superior maxilla. 
 
 When the head shows a disposition to revert to its original position 
 so soon as pressure or traction is suspended, the forceps should be 
 applied, and traction made in such a manner after reposition as to 
 hold the head in the direction sought for. 
 
 In case the brow presentation is irreducible, the labor should be 
 allowed to continue as long as compatible with the safety of the 
 mother. Owing to its plasticity, the head often adapts itself in the 
 most surprising manner to the unfavorable diameters of the pelvis, so 
 that, even when spontaneous delivery fails to take place, the forceps be- 
 come available. In mento-posterior positions, efforts should be made 
 with the fingers, or the vectis, to rotate the chin forward. In fixecl 
 mento-posterior positions, the use of the forceps is impossible, and the 
 conversion of the brow into a face presentation does not lessen the 
 mechanical difficulties of delivery. The only artifice by which the 
 life of the child can be saved consists in bringing down the occiput 
 and producing a vertex presentation. Failing in this manoeuvre, 
 craniotomy becomes inevitable. In all cases of brow jDreseutation, if 
 the child is dead, craniotomy is indicated in the interest of the mother. 
 
 Breech Presentations. 
 
 In breech presentations the attitude of the child is primarily the 
 same as in those of the vertex, though, owing to a variety of causes, such 
 as voluntary or reflex movements and the action of gravity, especially 
 after rupture of the membranes, the extremities may advance in front 
 of the breech, and give rise secondarily to presentations of the foot or 
 knee. Sometimes one extremity may become prolapsed, while the other 
 is retained in its normal position ; again, it may happen that, after the 
 rupture of the membranes, the feet, which had previously been in close 
 proximity to the breech, are pushed upward, so that the limbs become 
 extended parallel to the anterior surface of the child's body. None 
 of these changes, however, materially affect the mechanism of delivery. 
 
 Pinard * found, in 100,000 cases of confinement, 3,301 presentations 
 by the breech, or in the proportion of one to thirty ; but excluding 
 'premature births, the proportion was reduced to one in sixty-two. 
 
 Causes. — The causes of. breech .jpresentations are to be sought for 
 mainly in the absence of the conditions which ordinarily determine 
 the presentations of the head, or which interfere with the fixation of 
 the foetus. Thus, the production of breech presentations is favored by 
 an excess of amniotic fluid, by lax uterine walls, and by contractions of 
 the pelvis. They are more common in multipara? than in primiparae. 
 Of the 3,301 cases collected by Pinard, there wereT,347 prrmiparse and 
 * Tarxier et Chantretiil. Traito dv larl dos ac. p. 454.
 
 198 
 
 LABOR. 
 
 1,954 multipara?, though the entire number was nearly equally divided 
 between the two classes.* Finally, they occur with greatest frequency 
 of all in twin pregnancies, and during the expulsion of premature and 
 dead children. Of 32,264 children from the statistics of Hegar and 
 Spiegelberg,f 910 were the product of multiple pregnancies, and 659 
 
 P^G. 117.— Preseutatiou of the breech. Left dorso-anterior pu.sitiou. (Pinard.) 
 
 were premature Of the former, 227, or 25 per cent, and of the latter, 
 148, or 224 per cent, were delivered by the breech, though we have 
 seen that the ratio of breech presentations to the entire number of 
 births does not exceed the proportion of one to thirty. 
 
 Diagnosis. — By external palpation the recognition of the liead at 
 the fundus uteri furnishes the chief diagnostic sign. Upon vaginal 
 examination, the presenting part, as in face presentations, is usually 
 high up, and reached with difficulty. The bag of membranes is apt^ 
 to be of large size, owing to the imperfect closure of the lower uterine 
 segment by the small breech, often descending through the canal, 
 where the cervix is rigid, in the form of an elongated pouch. Through 
 the membranes, upon pressing the foetus downward during the inter- 
 val between the pains, the breech is felt as a soft, irregular body, and 
 with care it is possible to recognize the coccyx, the sacrum, the Jlia, 
 and sometimes to feel tapping movements from the feet. After 
 rupture, the nates, the cleft between the nates, in boys the scrotum, 
 
 * Vide Tarnier et Chaxtreuil. p. 4-5.5. f Spieoelbero, loc. fit., p. 171.
 
 MECHANISM OF LABOR. ;^(^C) 
 
 the anus,'the feet when accessible, the coccyx, the sacrum, aud the ilia, 
 furnish the necessary data for an exact diagnosis. The pressure of 
 the uterus upon the breech frequently occasions an evacuation of 
 meconium. The latter is thick and consistent, thereby differing from 
 the meconium passed in vertex cases by a dying foetus, which is 
 ordinarily thin from admixture of amniotic fluid. When the nates 
 are much swollen they may be confounded with the cheeks in a face 
 presentation — an error, however, easy to avoid, if the examination be 
 made with deliberation, and the principaTpoints of difference between 
 breecli and face already given {vide "Face Presentations," p. 191) are 
 borne in mind. 
 
 The foot, as compared with the hand, is longer and narrower ; tlie 
 toes are shorter, of nearly equal length, and continuous in a straight 
 line with the sole ; the ankle-joint is less flexible than the wrist, and is 
 distinguished by the malleoli aud the pointed heel. As the outer bor- 
 der of the foot is thin and rounded, while the inner edge is thick and 
 hollowed, it becomes possible to recognize which of the feet is under 
 examination. 
 
 The knee is distinguished from the elbow by its larger size, by the 
 patella, and by the spine of the tibia. 
 
 The Mechanism of Breech Presentations. — The position in breech 
 presentations is defined by the direction of the back. Thus, we have 
 right and left dorsal positions. Usually the hips occupy one of the 
 oblique diameters of the pelvis. According, therefore, as the back is 
 turned anteriorly or posteriorly, we distinguish right and left dorso- 
 anterior and dorso-posterior positions. 
 
 The cervix dilates slowly, especially when the feet are in close 
 proximity to the breech and increase the bulk of the presenting part. 
 The latter is pressed downward into the pelvis until the perineal floor 
 is reached. Here, owing to the shortness of the pubic wall, the ante- 
 rior hip is felt with great distinctness, while the cleft of the nates lies 
 near the curved sacrum. These anatomical relations give rise to the 
 impression of an exaggerated degree of lateral obliquity. At the peri- 
 ngeuni the breech glides forward and rotates upon its long axis, so that 
 the bis-iliac diameter nearly corresponds to the lower conjugate. In 
 the movement of rotation, it is always the anterior-lying hip, irrespect- 
 ive of the position of the trunk, which moves to the front. At the 
 outlet one hip engages beneath the arch of the pubes, the other rests 
 upon the coccyx and perinaeum, while the sacrum is directed toward 
 the tuber ischii. As thje_ shoulders enter the pelvis in an oblique 
 diameter, the trunk of the child becomes somewhat twisted by the 
 rotation of the breech. The anterior buttock makes its appearance at 
 the vulva, while the posterior distends the perinteum. As rotation is 
 rarely complete, the forward trochanter usually finds its point of sup- 
 port against the nearest iscKio-pubic ramus. During the advance of
 
 200 
 
 LABOR. 
 
 the breech the hmibar region undergoes a certain amount of lateral 
 flexion, owing to the forward movement imparted to the posterior hip 
 by the' coccyx and elastic perineum. The degree of flexion is, how- 
 ever, limited by the rigidity of the lumbar portion of the vertebral 
 
 Fig. 118.— Showing lateral inttexion of the trunk during delivery of the breech. 
 
 column. When the posterior trochanter reaches the commissure of the 
 vulva, the perinaeum retracts, and in gliding baciiward directs the 
 breech still farther to the front. 
 
 After delivery, the breech rotates into the oblique diameter it had 
 originally occupied, this external rotation bringing the transverse 
 diameter of the hips into correspondence with that of the shoulders. 
 The uterine contractions continuing, the abdomen and base of the 
 thorax slowly make their appearance ; the thighs are then delivered, 
 and the arms, folded upon the upper portion of the thorax, emerge 
 from the vulva. The shoulders, which enter the pelvis in an oblique 
 diameter, are delivered in the conjugate, the anterior shoulder resting 
 beneath the pubic arch, while the posterior shoulder sweeps over the 
 perinaeum. 
 
 The head enters the pelvis in an oblique diameter, with the chin 
 flexed upon the thorax. The expulsive efforts as the chin reaches the 
 perineum are followed by the rotation of the occiput to the pubes, and 
 of the face into the hollow of the sacrum. At the outlet the neck is 
 supported by the arch of the pubes, the face rests upon the perinteum, 
 and the large fontanelle is felt at the coccyx. Under the influence of 
 pressure from the abdomen, the brow sinks deeper and deeper, and is
 
 MECHANISM OF LABOR. 
 
 201 
 
 pushed by the soft parts of the pelvic floor still closer to the thorax. 
 The occiput then revolves beneath the pubic arch, and the chin, the 
 moutb, the nose, the brow, the large fontanelle, and finally the occiput, 
 appear in succession at the commissure of the vulva. 
 
 Irregularities in the Mechanism of Breech Presentations.— Though 
 it is by no means rare for the breech to enter the pelvis with the 
 sacrum turned to the sacro-iliac synchondrosis, the rotation, begun 
 with the passage of the hips through the vulva, usually continues in 
 the same direction until the back revolves to the front ; or, after a first 
 slight retrograde movement, the rotation forward takes place as the 
 shoulders engage at the outlet. Still, cases do sometimes occur in 
 which the back remains. posterior during the whole period occupied by 
 the expulsion of the trunk, and in which, consequently, the head enters 
 the pelvis with the face directed to the pubes. Even here, however, 
 it is viery common for the occiput to eventually rotate forward, and for 
 delivery to follow in the ordinary manner. Should, on the contrary. 
 
 Fig. 119.— Exit of head in breech presentations. Face covered by perinaeum. 
 iFarabceuf and Varnier.i 
 
 the occiput remain in the hollow of the sacrum, spontaneous delivery 
 may occur in either of two ways: 1. When no tractions have been 
 made upon the extremities, the head reaches the outlet with the chin 
 well flexed, the neck resting upon the commissure of the vulva, and the 
 brow braced against the arch of the pubes. The birth of the head is 
 then accomplished, as the neck pushes back the perinaeum, by the suc- 
 cessive descent of the face, the cranial vault, and the occiput. With a 
 rigid perineum, or an immovable coccyx, owing to the considerable 
 degree of flexion which this movement necessitates, unaided delivery
 
 202 
 
 LABOR. 
 
 may be rendered impossible. 2. If, during the tran.sit of the head 
 through the pelvis, extension occurs, the chin may be arrested at or 
 above the symphysis pubis. In this position pressure from above 
 pushes back the brow, so that the face looks upward, and the occiput 
 is turned to the bottom of the pelvic excavation. During delivery the 
 occiput glides over the perinteum to the fourchette, and the small fon- 
 
 FiG. 120.— Exit of head in breceli presentations. Face has emerged from the perinaeum. 
 
 tanelle, the cranial vault, and the face escajie in succession through the 
 vulva. It is only possible for this method of delivery to take place 
 spontaneously when either the head is small or the pelvis roomy, and 
 the soft parts are devoid of rigidity. In artificial extraction of the 
 head, it is proper to bear in mind and to imitate the natural order in 
 expulsion. 
 
 In presentations of the foot and knee, the breech, if of small size, 
 may pass the vulva in an oblique or transverse diameter, rotation fol- 
 lowing later during the passage of the trunk. 
 
 Excessive rotation is not imcommon, both head and trunk some- 
 times describing a half-circle. This occurrence is most frequently 
 observed in cases where the posterior extremity presents, while the 
 anterior buttock is caught above the pubic wall, the prolapsed limb 
 then rotating, as a rule, to the front.* 
 
 The Conflguration of the Foetus in Breech Deliveries.— During the 
 descent of the child through the genital canal, more or less swelling is 
 developed upon that portion of the presenting part which is subjected 
 to diminished pressure. This swelling varies, according to the dura- 
 
 * Vide KtisTXER. Die Steiss- uiul Fusslageii. p. 21.
 
 MECHANISM UK L.\liUK. 
 
 203 
 
 Idl. ^Showing shape of head iu brt 
 (Budin.) 
 
 ^(•\\ presentations. 
 
 tiou of labor, from a slight cedeina to a large, intensely discolored tumor, 
 it is usually seated upon the anterior buttock, but often invades the 
 genital organs, especially the scrotum, which at birth may present a 
 bluish-black color, and be 
 
 of double the usual size. ^ 
 
 The extremities, when 
 near the breech, may also 
 show signs of discolor- 
 ation. 
 
 The head has usually 
 a characteristic round 
 shape. This is due, ac- 
 cording to Spiegelberg,* 
 to the pressure exerted 
 by the genital canal upon 
 the circumference of the 
 head, while at the same 
 time, with the absence of 
 pressure from above, there 
 is produced an increase 
 in tlie convexity of the 
 
 cranial vault. Two cases reported by Hecker,f in which the length 
 of the occiput was comparable to that found in face presentations, 
 show, however, that the original shape of the head counts for some- 
 thing in the appearances presented after delivery. 
 
 Prognosis. — As rega rds the mother, the pro gnosis in uncomplicated 
 cases does not differ materially from that of vertex cases. Where 
 manual extraction becomes necessary, there is always, however, increased 
 danger of lacerating — 1, the cervix ; 2, the perineum. 
 
 Lacerations are apt to follow attempts to drag the after-coming 
 head through an imperfectly dilated cervix. The prognosis is more 
 favorable, therefore, in cases where the membranes do not rupture until 
 after dilatation is completed. It is also better in pelvic presentations, 
 where the bulk of the breech is increased by the addition of the ex- 
 tremities. In footling cases, when the membranes rupture prematurely, 
 the smaller size of the pelvis and its rapid descent through the cervix 
 imperfectly prepare the way for the subsequent passage of the head. 
 A stricture is therefore liable to form abont the neck of the child, 
 and, as the spasm does not yield to force, the result of violent tractions 
 *is to sacrifice the integrity of the cervix, the extent of the laceration 
 being proportioned to the power exerted. 
 
 Lacerations of the perinaeum occur where with rigidity of the 
 tissues it becomes necessary to introduce the hand to release the 
 
 necessary 
 
 * Spiegelbeko. foe. ri(., p. ITfi. 
 
 f Hecker. Ai-cli. f. (ivnaek.. Bd. .Ki. p. 
 
 348.
 
 20* 
 
 LABOR. 
 
 arms, or the interest of the child demands the speedy delivery of 
 
 the head. 
 
 The. prognosis for the child is, on the other hand, extremely un- 
 favorable. According to the statistics of Dubois,* the mortality in full- 
 term children is as one to eleven, while in vertex presentations the pro- 
 portion is as one to fifty. The chief cjluse of this large death-rate is 
 the pressure to which the cord is subjected between the child and the 
 surface of the utero-vaginal canal, especially after the navel appears at 
 the vulva. The pressure is exerted principally at the orifices of the 
 uterus and the vagina, and is raised to the point of greatest danger 
 after the head has become engaged in the pelvis. Other sources of peril 
 arise from prolapse of the funis and the coiling of the latter around 
 the body of the child, and from the complete escape of the aniniotie 
 fluid in premature rupture of the membranes. 
 
 Treatment. — Early in labor, with the membranes intact, it is desir- 
 able, in consideration of the unfavorable prognosis for the child, to try 
 and perform cephalic version by external manipulations. In case of 
 failure to bring down the head, care should be taken to preserve the 
 membranes until dilatation is completed. To this end unnecessary 
 examinations should be avoided ; the patient should be placed upon her 
 side, and cautioned not to strain ; and when the membranes tend to 
 form an elongated pouch, counter-pressure may be employed by means 
 of a moderately distended Barnes's dilator introduced into the vagina. 
 After rupture of the membranes it is best to remain passive. In the 
 interest of the child, it is desirable that the expulsion of the trunk 
 should take place slowly. Bringing down an extremity, as a prophy- 
 lactic measure in order to secure a good handle in case of subsequent 
 delay, is a questionable procedure. By this manceuvre a path is opened 
 for the descent of the cord, and the mechanism of delivery is disturbed. 
 When the hips appear at the vulva, the attending physician should be 
 ready to extract in case of emergency. The patient should, therefore, 
 if lying upon the left side, be brought near the edge of the bed; if 
 upon the back, she should be placed across the bed, with the hips well 
 over the edge. She should be instructed to bear down during the 
 pains. The lateral flexion of the lumbar portion of the trunk should 
 be sustained by the hand applied to the perineum. The trunk, as it 
 advances through the vulva, should be wrapped in a warm cloth and 
 raised upward. When the cord appears, it should be drawn gently 
 downward in the direction of one of the recesses to the side of the 
 promontory ; in case the cord passes between the thighs of the child, \\ 
 should be released by slipping it over one hip. From this time on the 
 pulsations of the cord should be carefully watched, and, in case of fail- 
 ing strength, extraction should be resorted to. 
 
 With one hand the physician now supports the body of the child, 
 * Dubois, Mem. de I'Acad. Roy de Med., vol. iii, p. 450.
 
 CONDUCT OF NORMAL LABOR. 2l)5 
 
 while with the other he should make sustained and gradually increas- 
 ing pressure upon the fundus uteri. The patient should be exhorted 
 to strain, and bring into play all the auxiliary muscles concerned in 
 expulsion. During the passage of the arms, the lateral flexion of the 
 body should be promoted by raising the hips and supporting the peri- 
 iin?um. After the engagement of the head, it is desirable, if possible, 
 to commit to the hands of a skilled assistant the maintenance of the 
 supra-pubic pressure. When the face reaches the coccyx, the physician 
 should raise the body of the child toward the abdomen of the mother. 
 By this manoeuvre the occiput is pushed upward by the pubic Avail, and 
 the chin brought forward to the vulva. The delivery of the head is 
 then speedily accomplished by pressing the forehead forward with two 
 lingers applied to the perinaeum in front of the coccyx, or introduced 
 into the rectum. By then keeping the head jflexed, lacerations of the 
 perinaeum are best avoided. 
 
 When the occiput is turned posteriorly, the body should be raised 
 if the chin is arrested at the symphysis, and depressed when flexion is 
 complete. 
 
 CHAPTER XI. 
 
 CONDUCT OF NORMAL LABOR. 
 
 Preliminary preparations. — Examination of the patient. — Management of the first 
 stage. — Management of the second stage. — Preservation of the perintBum. — 
 Delivery of the shoulders. — Tying the cord. — Third or placental stage. — Care 
 of patient after delivery. — Treatment of perineal lacerations. — AniBsthetics in 
 midwifery. 
 
 It is hardly an exaggeration to state that the greater proportion of 
 the sins of midwifery practice are committed in the management of 
 normal labors. It is equally easy to fall into errors of commission and 
 errors of omission. It is as necessary to know when to abstain as when 
 to interfere. It is an old but always good rule, not to meddle with the 
 physiological performance of a function ; but the rule, when applied to 
 obstetrics, presupposes a thorough familiarity with the physiological 
 processes of childbirth, and the contingencies to which women in par- 
 turition are exposed. There is no sense in reposing a blind, unreason- 
 ing confidence in the powers of Nature. Indeed, legitimate grounds 
 for interference are liable to arise in the simplest labors. The attitude 
 of the medical attendant should be one of watchful expectancy. He 
 should be ready, if needful, to assuage pain, to forestall dangers, and to 
 limit the duration of sufl'ering. 
 
 Preliminary Preparations.— When summoned to a patient, the phy- 
 sician should ao armed to meet the sudden emergencies of obstetrical
 
 ^,,„] LABOR. 
 
 practice. His armamentarium slioulcl include a silver catheter, an 
 English catheter of small size (No. 7) for use in asjihyxia of the new- 
 born child, a pair of forceps, needles and needle-holder, and silk or 
 wire for sutures, a Davidson syringe, a set of Barnes's dilators, and a 
 hypodermic syringe. He should go provided with chloroform, Ma- 
 gendie's solution of morphia, ergot, the perchloride or persulphate of 
 iron, carbolic acid, powders or tablets of corrosive sublimate, and a small 
 vial of sulphuric ether. At the house, ice, brandy or whisky, hot 
 and cold water, a new English gum catheter (No. 10), and a fountain 
 syringe, should be had in readiness. 
 
 As it is not uncommon for women, especially among the poorer 
 classes, to test the experience of young physicians by asking details 
 relative to the arrangement of the bed upon which the confinement is 
 to take place, it is trusted, that a few words upon the subject will not 
 be regarded as entirely superfluous. 
 
 The bedstead should not be too low. If against the wall, it 
 should be moved out, so as to allow easy access from both sides. 
 The bedding should consist of a hair mattress or of a straw i)aillasse. 
 Feather-beds are an abomination. Over that portion of the mat- 
 tress upon which the woman expects to lie, a rubber-cloth or other 
 impervious material should be sjiread. Next to the water-proof, 
 nurses usually lay a folded woolen comforter or blanket, to absorb 
 the fluid discharges. The whole is then covered smoothly w^ith a 
 sheet, and a second sheet, folded in several thicknesses, is laid beneath 
 the hips of the patient. All these preparations are designed to limit 
 the soiling of the bedding to a circumscribed space, and to facilitate 
 the removal of the discharges after the termination of the delivery. 
 The sheets and articles in contact with the patient should be freshly 
 washed. Soiled linen is incompatible with the requirements of aseptic 
 labor. 
 
 Examination of the Patient. — The first duty which devolves upon 
 the physician in the lying-in chamber is to examine his patient, and to 
 inform the family if " all is right " — i. e., whether the head presents, 
 and no unusual obstacle to delivery exists. It is a good plan at the 
 outset to map out the foetus through the abdominal and uterine walls, 
 as by palpation alone it is usually possible to determine the dorsum of 
 the child, the presentation at the pelvic brim, the direction of the 
 feet, and the presence or absence of fetal movements. So, too, by ex- 
 ternal methods we are enabled to make out the size and shape of the 
 uterus, the existence of hydramnion, the presence of twins, or of com- 
 plicating tumors. The strength and frequency of the fetal heart- 
 sounds should be ascertained by auscultation. Inspection and palpa- 
 tion of the pelvis suffice to make evident grosser varieties of deformity. 
 Nearly everything in the way of essential information is obtainable 
 without resorting to an internal examiuation — a fact of no mean im
 
 CONDUCT OF NORMAL LABOR. 207 
 
 portaiice wheu a physician fiuds liiiuself obliged to conduct a case of 
 labor when fresh from contact with materials capable of conveying 
 infection. 
 
 Before proceeding to a vaginal examination the physician should 
 scrupulously clean the nails, the hands, and forearms with soap and 
 water, then wash them with pure water, and afterward immerse them 
 for several minutes in a solution of corrosive sublimate in the propor- 
 tion of one to a thousand. Similar precautions should be taken by the 
 nurse ; and in the same way the external parts, the perinaium, the 
 mons veneris, the inner surface of the thighs, and the abdomen of the 
 patient, should be freed from impurities. Soap and water should be 
 preferred as a lubricant for the fingers. Under normal conditions the 
 vagina is to be regarded as aseptic. Douching, therefore, with strong 
 solutions of carbolic acid or corrosive sublimate is not indicated as a 
 prophylactic measure. 
 
 The internal examination should take cognizance of the condition 
 of the vulva and perineum, the state of the rectum and bladder, the 
 length of the vagina, the degree of dilatation and softening of the 
 cervix, the amount of cervical and vaginal secretion, the hardness of 
 the child's head, the dimensions of the pelvis, and, if the membranes 
 are not ruptured, the quantity of amniotic fluid. It is customary to 
 begin the examination during an interval between the pains, but it is 
 often convenient to continue the investigation during the pains, in or- 
 der to judge of their eflBcacy and character. 
 
 The history of the case should embrace the length of previous 
 labors, the health during pregnancy, the number of times the woman 
 has been pregnant, and Avhether in the present instance she has ad- 
 vanced to full time. Inquiries should be made as to when the labor- 
 pains commenced, as to their frequency and situation, and if the mem- 
 branes have ruj)tured. 
 
 After the examination of the patient is ended, the physician is ex- 
 pected to express an opinion as to the probable duration of the labor. 
 It is, however, necessary for the responses upon this point to be 
 guarded and Delphic. In general terms, when the pelvis is normal, 
 the head well flexed, the vagina short, and the cervix and perinai-um 
 are dilatable, an easy and rapid labor is to be anticipated ; while, ;jpr 
 contra, with a small pelvis, tardy flexion, a long vagina, and rigidity of 
 the uterine and perineal orifices, a tedious period of waiting is to be 
 assumed. Of course, too, labor is, as a rule, much longer in primi- 
 parae than in women who have previously borne children. Moreover, 
 with few exceptions, the result depends in a special degree upon the 
 energy and persistence of the pains. The latter, however, represent 
 always the uncertain element in the calculation. If the pains are 
 good, therefore, the reservation should be made that, for a short labor, 
 they must continue as at the beginning; while, if weak and powerless,
 
 208 
 
 LABOR. 
 
 it should be stated tliat better pains will be needed to bring the labor 
 to a speedy conclusion. 
 
 Management of the Fikst Stage of Labok. 
 
 The duties of the physician during the first stage of labor are, in 
 normal cases, extremely simple. He sliould from time to time, say at 
 hourly intervals, repeat the examination with the precautions already 
 indicated, with a view to inform himself of the progress of dilatation. 
 He should caution his patient to pass her urine frequently. In case of 
 retention, he should draw the water Avitli a catheter. When the head 
 is low down, the urethra often follows its convexity. The introduction 
 of the straight female catheter may then be extremely difficult. Many 
 recommend in such cases a silver male catheter to whicli a suitable 
 curve has been giveu. I use by preference the English flexible cathe- 
 ter, which is passed easily, provided the end is guided by the index- 
 finger, through the anterior vaginal wall, to the point of contact be- 
 tween the head and the symphysis pubis. A flattening of the tube by 
 pressure to an extent causing obliteration is not likely to take plaCe. 
 The catheter should be a new one, of about the No. 10 size. 
 
 In many instances certain hindrances to labor are remediable by postural 
 methods. Thus, in the half-sitting posture, with the shoulders raised, the axis 
 of the uterus assumes a direction vertical to the pelvic brim. This attitude 
 contributes to bring the weight of the ovum to bear directly upon the lower 
 segment, and tends to correct presentations of the posterior parietal bone. The 
 direction of the head to the sacrum in pendulous abdomen is to be remedied 
 by the complete dorsal decubitus. Marked lateral deviations of the cervix are 
 to be corrected by placing the patient upon the opposite side. 
 
 If at the time of exami)uition the rectum is found clogged with 
 faeces, an enema should be ordered. A disposition on the part of the 
 patient to bear down during the first stage of labor should be discour- 
 aged, as wasting her strengtli without possessing any counterbahmcing 
 utility. The patient sliould be encouraged not to take to bed at the 
 outset of labor. In the upright or sitting posture gravity aids the 
 fixation of the head and promotes passive hyperoeraia and dilatation of 
 the cervix. 
 
 As the end of the first stage approaches, however, the woman should 
 undress and lie down, as the pains after rupture usually follow one 
 another with rapidity, and make locomotion difficult. To avoid soil- 
 ing, the night-dress should be drawn well up under the arms. Tidy 
 nurses pin a folded sheet around the hips of their patients, to arrest 
 the soaking of fluids upward. 
 
 Euptare of the membranes is ordinarily a spontaneous act. Yet 
 often enough something may be done in the way of shortening labor 
 by puncturing the membranes so soon as cervical dilatation is complete
 
 CO.NDUCT OF NORMAL LABOR. 
 
 209 
 
 They have then fulfilled their i^hysiological mission, and their persist- 
 ence simply retards the advance of the child's head. Artificial rupt- 
 ure is easily effected by means of a straightened hairpin passed in the 
 groove between the index and middle fingers of the examining hand to 
 the amniotic pouch. The puncture should be made during a pain, at 
 a time Avlien the membranes are tense and separated from the scalp by 
 a deep layer of fluid. 
 
 f 
 
 Makagemeis^ of the Second Stage of Labor. 
 
 The management of the second stage of labor calls for considerable 
 tact on the part of the medical attendant. It is incumbent upon him 
 to make examinations from time to time to determine the degree of 
 rapidity with which the descent of the head takes place. So long as 
 the advance is regular, he should abstain from interference. Should 
 the pains slacken, however, he should not allow the duration of the 
 second stage to exceed the physiological limits. It is not easy to de- 
 fine exactly what is implied in the expression, "physiological limits." 
 As a rule, a very rapid second stage is not physiological, as it endangers 
 the integrity of the vagina and perinaeum, and predisposes to post- 
 partum ha3morrhage. Still, now and then labor is ended by a single 
 pain after rupture of the membranes, without detriment to the mother. 
 Of course, such cases are extremely uncommon in primiparaj. They 
 require an unusually distensible condition of the soft parts and an ex- 
 traordinary degree of resiliency in the uterus. On the other hand, 
 pressure of the head, after its descent into the pelvic cavity, leads, if 
 too long continued, to pathological changes in the tissues of the canal 
 and of the outlet. It is usual, therefore, unless the head is small or 
 the pelvis roomy, to use the resources of art to terminate labor when 
 the head remains stationary at the perineal floor after two hours of 
 effort. It is desirable, therefore, when the pains are weak and ineffect- 
 ive, to utilize all the simple adjuvants which experience has shown to 
 possess real efficacy in increasing the activity of labor. 
 
 Changes of posture increase the power of the pains temporarily. 
 When head-flexion is incomplete, it has been recommended to place 
 the patient upon the side toward which the occiput is turned. Others, 
 again, claim that the descent of the occiput is best effected by placing 
 the mother upon the side toward which the child's forehead is directed. 
 In point of fact, either posture frequently leads to the desired result, 
 simply because the change from the dorsal to the lateral position is apt 
 to be followed by a temporary addition to the uterine force.* 
 
 In many women, owing to defective innervation or to insufficient 
 development of the muscular structures of the uterus, it is of great 
 moment that the expulsion of the child be aided by the voluntary 
 
 * Lahs, Die Theorie der Geburt, Bonn, 1877, p. 237. 
 14
 
 21Q LABOR. 
 
 pressure of the abdominal walls. To be sure, in most cases the reflex 
 impulse to bear down is imperative ; but in otliers, where the impulse 
 is feeble or held in abeyance by the dread of the patient lest she in- 
 crease her sufferings, it becomes the duty of the physician, in tardy 
 labors, to see to it that all the auxiliary forces are brought into play. 
 To this end he should instruct his patient to fix her pelvis, either by 
 pressing her feet against the foot board of the bed, or by drawing up 
 her knees and resting them against an assistant, who assumes the 
 position best adapted to furnish the requisite support. Then the 
 nurse, or other suitable person, should grasp the woman's hands, so 
 as to enable her to fix her thorax and to bring all the expiratory 
 muscles into full exercise. Often, when the agony is intense the 
 patient can be induced to strain with her pains, if her sufferings 
 are first dulled by small doses of chloroform. When the head is on 
 the perinaium, the physician may further expulsion by rubbing the 
 abdomen to excite pains, and by pressing upon the breech through 
 the fundus. 
 
 During the second stage the patient's posture should be left in 
 general to her own volition. The physician should accustom himself 
 to conduct labor with equal facility, no matter whether the woman lies 
 upon her side or upon her back. The left lateral j)osition, affected 
 by English accoucheurs, is very convenient at the timi; of delivery, es- 
 pecially when there is occasion to support the perinajum, and where, 
 owing to the flatness of the nates, the vulya is scarcely raised in the 
 dorsal posture above the level of the bedding. 
 
 The Pkeservatiox of the Perin.eum. 
 
 By far the most delicate task which the physician has to fulfill 
 toward his patient in the expulsion stage consists in so regulating tlie 
 exit of the child's head as best to avoid perineal lacerations. It is 
 needless to state that such lacerations, unless of slight extent, entail 
 upon women a variable degree of subsequent discomfort and suffering. 
 When the perinaeum is examined with care after labor — a practice which 
 should be invariable with a conscientious attendant — the frequent oc- 
 currence of more or less extensive rupture of its tissues is a matter of 
 easy confirmation. Statistics of their frequency are of little value, 
 much depending upon individual skill in management. Olshausen * 
 reports, as the result of the preventive measures adopted at the clinic 
 in Halle, during a period of ten years, 21-1 per cent of perineal in- 
 juries in primiparse and 4-7 per cent in multiparas. These percent- 
 ages did not include slight tears confined to the fraenulum. He regards 
 15 per cent as not too high an estimate for the absolutely unavoidable 
 
 * Olshausen, Ueber Dammverletzung und Dammschutz, Volkmann's Saminl. 
 klin. Vortr., No. 41, p. 360.
 
 CONDUCT OF NORMAL LABOR. 211 
 
 lacerations, due to defective distensibility of the perinaeum, and to the 
 disproportionate size of the child's head. 
 
 The aim of prophylactic measures should be to develop the elas- 
 ticity of the soft parts to the fullest practicable extent, and to cause 
 the head to pass through the distended orifice of the vulva by its small- 
 est diameters. Preliminary softening of the perinaeum is best accom- 
 plished by the continuous but not too rapid descent of the presenting 
 part. The relaxation, as a rule, begins earlier and is more complete 
 in multiparas than in primipar*. In a few cases the soft parts will 
 already have ceased, by the end of the first stage of labor, to offer any 
 effective barrier to delivery. The distensibility of the soft parts may 
 be fairly inferred from the presence of a copious discharge of glairy 
 mucus. 
 
 When rupture takes place, the vaginal mucous membrane is the 
 first structure to give way. In the ordinary form the perineal body 
 tears from the commissure backward to the rectum. In rare cases a 
 central perforation may result, and the child be expelled through a 
 rent situated between the vulva and the anus. 
 
 When the head begins to make the perinaeum bulge the physician 
 should be on the alert, and inform himself during each contraction of 
 the strain to which the parts are subjected. At first it is only neces- 
 sary to rest the hand lightly upon the perinasum. Direct pressure is 
 to be avoided, except when the perinaeum is stretched to a membranous 
 thinness, and the danger of central perforation threatens. As the head 
 begins to distend the vulva, the tension at the fr^enulum should be 
 carefully gauged by a finger introduced between the labia. Measures 
 to avert ru2:>ture may be classified under three headings, viz. : 
 
 1. Those designed to check the exit of the head before the fullest 
 expansion has been secured, and to prevent expulsion during the acme 
 of a pain, when the borders of the orifice are most rigid. 
 
 2. Measures which impart an upward movement to the head, with 
 a view of making all unoccupied space beneath the arch of the pubes 
 available. 
 
 3. Measures which favor expulsion during the interval between the 
 pains, or at least after the acme has subsided. 
 
 In ordinary cases Hohl's method, recommended by Olshausen,* has 
 rendered me excellent service. It consists in applying the support 
 not to the perinasum but to the presenting part. To this end the 
 thumb should be applied anteriorly to the occiput, and the index and 
 middle fingers posteriorly upon that portion of the head which lies 
 nearest to the commissure. The unconstrained position of the hand 
 enables the operator to exercise effective pressure in the direction of 
 the vagina, while the posterior fingers favor the rotation of the head 
 under the pubic arch. The patient should at the same time be directed 
 * Olshausen, loc. cit., p. 366.
 
 212 
 
 LABOR. 
 
 not to hold her breath during the pains, except when they are weak 
 and powerless. Where the impulse to bear down is irresistible, chloro- 
 form should be given to annul the excessive reflex irritability. Under 
 the most skillful management laceration is liable to occur, unless the 
 physician is able to control the action of the auxiliary expulsive forces. 
 
 So soon as the bi-parietal diameter passes the tense border of the 
 vulva the perineum retracts rapidly over the face, and the expulsion 
 of the head is completed. It is during this period that laceration is 
 most apt to occur. This danger is, however, greatly lessened if the 
 head is made to issue through the orifice after the pain has subsided, 
 and when the soft parts are in a relaxed and dilatable condition. To 
 accomplish this, in many instances where the resistance to be overcome 
 is slight, it is sufficient for the woman to hold her breath during an 
 interval between the pains, and voluntarily call into play all the mus- 
 cles of expiration. In the larger proportion of cases, however, these 
 efforts are futile, because of the comparatively feeble motor force 
 brought into action. 
 
 An excellent method of manual delivery we owe to Eitgen,* which 
 consists in lifting the head upward and forward through the vulva, 
 between the pains, by pressure made with the tips of the fingers upon 
 the perinifium behind the anus close to the extremity of the coccyx. 
 Of course, the metliod is only available after the head has descended 
 sufficiently for the pressure to be exerted upon the frontal region. 
 
 Rectal expression has lately found warm advocates in Olshausen f 
 and Ahlfeld.J The manoeuvre consists in passing two fingers into the 
 rectum toward the close of the second stage of labor, and hooking 
 them into the mouth or under the chin of the child through the thin 
 recto-vaginal septum. By pressing the face forward and upward, the 
 normal rotation of the head beneath the pubic arch can be effected, 
 and delivery can be accomplished between the pains at the will of the 
 operator. 
 
 When rupture is felt to be imminent, mock-modesty should be dis- 
 carded, and the parts imperiled should be unhesitatingly exposed to 
 view. If, owing to its excessive elasticity, the occiput, in place of 
 being directed forward to the vulva by the perineum, distends the 
 latter so that central perforation threatens, the hand should be applied 
 in such a way as to give direct support to the stretched tissues and to 
 guide the head upward to the outlet. If, . on the other hand, the 
 danger arises from defective elasticity, the physician, standing to the 
 right of the patient, with his face toward the foot of the bed, should 
 
 * Olshausen, Ueber Daramverletzung und Daii^raschutz, Volkmann's Samm- 
 lung., No. 41, p. 369. 
 
 f See Ahlfeld, Das Dammschutz Verfahren nach Ritgen, Arch. f. Gynaek., vi, 
 p. 279. 
 
 X Loc. cit.
 
 CONDUCT OF NORMAL LABOR. 213 
 
 pass the left hand between lier thiglis and press the head upward and 
 inward, during each pain, Avith the thumb and two fingers, as previ- 
 ously described. At the same time, the movement of extension, should 
 it threaten danger to the parts, should be hindered by pressing back- 
 ward upon the frontal region, through the perineum, with the disen- 
 gaged hand. 
 
 Dr. Goodell* recommends hooking two fingers into the anus and 
 drawing the perina?um forward during a pain, to remove the strain 
 from the thinned border of the vulva, and to promote the elasticity of 
 the tissues. 
 
 Merkerttschiantz advocates the emplojTnent of bilateral pressure upon the 
 periuffum during the pains to diminish the tension in the median line where 
 rupture usually occurs. To accomplish this the patient lies upon her back 
 with her knees moderately separated. The physician sits to the right of the 
 patient. The right hand is then placed beneath the right thigh, with the 
 thumb and the fingers respectively applied to points on the right and left of the 
 perinaeum. The points selected should correspond as nearly as possible to the 
 region where the strain is the greatest. During a pain the thumb and fingers 
 should be employed to press the perineal tissues from the sides toward the cen- 
 ter. When the presenting part begins to distend the vulva, the left hand 
 should be placed with the ulnar border over the mons veneris, and with the 
 thumb and fingers resi^ectively applied to the right and left labia. As the 
 frfenulum is put upon the stretch, the middle finger and the thumb should guard 
 by lateral pressure a point in the perinseum about half an inch from the anterior 
 border. This point should likewise be sustained at the same time from below 
 by the thumb and fingers of the right hand. Merkerttschiantz f reports over 
 110 cases treated by this method without a single perineal laceration. More 
 recently a plan which is the same in principle has been recommended by Dr. 
 T. J. McGillicuddy, of this city.^ 
 
 Fasbender* places the patient upon the left side; then, standing 
 behind her, he seizes the head between the index and middle fingers of 
 the right hand, applied to the occiput, and the thumb thrust as far 
 into the rectum as possible. By this manoeuvre the head is held under 
 complete control, the rectal wall harrlly affecting the grip in any ap- 
 preciable manner. During a pain the progression and extension of 
 the head are readily prevented. During the interval between the 
 pains, by pressure with the thumb through the rectum and the poste- 
 rior portion of the perinaeum, the head can be pressed forward and out- 
 ward at the will of the operator. 
 
 Between pains, I have been in the habit, in cases of rigidity, of 
 alternately drawing the chin downward through the rectum until the 
 head distends the perinaeum, and then allowing it to recede. It is as- 
 
 * Goodell, Am. Jour, of the Med. Sci., January, 1871. 
 
 f Merkerttschiantz, Arch. f. Gynaek., vol. xxvl, p. 327, 1885. 
 X Vide Am. Jour. Obst., Dec., 1889, p. 1341. 
 
 * Fasbender, Ztschr. f. Geburtsh. und Gynaek., Bd. ii, H. 1, p. 58.
 
 214: 
 
 LABOR. 
 
 tonisliing how often apparently the most obstinate resistance can be 
 oyercome by the simple repetition of this to-and-fro movement, the 
 parts rapidly becoming soft and distensible. Of course it should be 
 discontinued the moment contraction begins, and care should be taken 
 to effect delivery after uterine action has subsided. 
 
 "With judicious management the number of unavoidable lacerations 
 can be restricted to a small proportion of cases. Still, there are indi- 
 vidual peculiarities which Avill now and then render abortive the best 
 prophylactic measures. In this. category I have already alluded to a 
 primitive lack of development of the maternal parts, to unusual size 
 of the child's head, and to the excessive rigidity of the perineum in 
 primiparffi, especially after the thirtieth year. -In addition, should be 
 mentioned cases where the pubic arch is diminished by the approxi- 
 mation of the pubic rami, or where the tissues have been rendered 
 friable from chronic oedema, from a varicose condition of the veins, 
 from condylomata, from syphilitic sores, or from inflammatory infil- 
 tration consequent ui)on undue jjrolougation of the second stage of 
 labor. Lacerations are more frequent in occipito-posterior positions, 
 and in the delivery of the after-coming head, where hasty extraction 
 is demanded in tlie interest of the child. 
 
 When, in the judgment of the physician, rupture of the perina^um 
 seems inevitable, he is justified in making lateral incisions through the 
 vulva to relieve the strain upon the recto-vaginal septum. To this 
 operation tlie term episiotomy is applied. By it not only is the danger 
 of deep laceration through the sphincter ani prevented, but, owing to 
 their eligible position, the wounds themselves are capable of closing spon- 
 taneously ; Avhereas, when laceration follows the raphe, the retraction of 
 the transversi perinaii muscles causes a gaping to take place which inter- 
 feres with immediate union. As, however, every wounded surface is a 
 source of danger in childbed, episiotomy should never be performed 
 so long as hope exists of otherwise preserving the perinaeum. It is 
 essentially the operation of young practitioners, the occasions for its 
 employment diminishing in frequency with increasing experience. 
 The chief resistance encountered by the head is not at the thin border 
 of the vulva, but is furnished by a narrow ring situated half an inch 
 above, and composed of the constrictor cunni, the transversi perina^i, 
 and sometimes of the levator ani muscles. Incisions should be made 
 during a pain, Avhen the ring becomes tense and rigid, and is easily 
 recognized with the finger. As it is not desirable that the head should 
 be driven suddenly through the vulva during the act of operating, the 
 time selected for performing episiotomy should be at the commence- 
 ment or close of a contraction. The division of the rigid fibers may 
 be accomplished by means of a blunt-pointed bistoury, or a pair of 
 angular scissors. So far as practicable, the incisions should be con- 
 fined to the vagina, and should not exceed three quarters of an inch
 
 CONDUCT OF NORMAL LABOR. 215 
 
 in length. In cases where the head is on the eve of expulsion, the 
 bistoury may be introduced flat between it and the vagina, half an inch 
 anterior to the commissure, and the section made from within outward. 
 Care, however, should be taken at the same time to avoid severino- the 
 external skin by drawing it us far back as possible.* In central per- 
 foration it is best to divide the band left attached to the vulva, as its 
 preservation is of no advantage. 
 
 The Delivery of the Shoulders.— After the expulsion of the head, 
 mucus should be wiped from the mouth and nose, and cleared from 
 the throat with the finger should laryngeal rales indicate an embar- 
 rassment of the respiration. If the cord is found coiled around the 
 neck, it should be loosened by drawing upon the placental end until 
 the shoulders can pass readily tlirough the loop. Should this be found 
 impossible, either because the cord is unusually short, or because it is 
 wound several times around the body, a ligature should be applied, 
 the cord should be cut between the ligature and the placenta, and de- 
 livery should be hastened by manual efforts, f 
 
 In the majority of cases the shoulders are expelled spontaneously. 
 Still, it is a good plan to expedite the descent by pressure made with 
 the left hand at the fundus of the uterus. Care must be taken lest 
 the lower shoulder convert a slight tear in the perinjeum into an ex- 
 tensive laceration. The right hand should therefore be applied to the 
 perineum in such a way as to lift the shoulder upward, and at the same 
 time furnish a bridge over which it can glide in its movement forward. 
 Sometimes after the j^assage of the head a deep vaginal laceration co- 
 exists with an intact condition of the external parts. The shoulder 
 then tears through the skin, and a complete rupture ensues. Olshau- 
 sen recommends, in cases where rupture is imminent, to turn the 
 shoulders so that they clear the vulva in an oblique or transverse 
 diameter. 
 
 If, after birth of the head, the child does not breath, and asphyxia 
 threatens, the j^hysician should rub the uterus with the hand through 
 the abdominal wall, to excite a pain, during which he should urge the 
 patient to press down, and thus aid expulsion. The most common 
 hindrance to delivery consists in an arrest of the upper shoulder be- 
 neath the pubes. Usually its release is readily effected by seizing the 
 sides of the head with the two hands and drawing directly downward. 
 It is rarely necessary to raise the head subsequently, or to hook the 
 finger into the armpit to extract the posterior shoulder. 
 
 Tying the Cord.— When the cord is torn across, as sometimes hap- 
 pens in street-births, no hemorrhage takes place from the lacerated 
 
 * Olshausen, loc. cit., pp. 372, 373. 
 
 t Tarnier recommends dividing^ the cord and then compressing the proximal 
 end between the thumb and the ind'ex^finger. The proximal end is uistinguisheC 
 by the spouting of the two umbilical arteries.
 
 216 
 
 LABOR. 
 
 vessels. Of course, this occurrence deprives the physician of the 
 power of choosing the point at which the division sliall be made. As 
 it is desirable, for the sake of convenience, to sever the cord about two 
 inches from the navel, it is the custom in all civilized countries to cut 
 it with scissors, and to prevent hemorrhage by the application of a 
 ligature. Almost any material may be employed for the latter purpose, 
 though nothing is so handy as the narrow flat bobbin which most 
 nurses keep in readiness. Dr. Craig, of Jersey City, recommends the 
 use of an clastic ligature as a security against haemorrhage. The 
 ligature should be applied tightly, and the cut surface should subse- 
 quently be examined once or twice by the physician before leaving, to 
 make sure that the arteries are sufficiently compressed to prevent oozing 
 from taking place. The cord should be held in the hollow of the hand 
 at the time of its division, to avoid the possibility of including ac- 
 cidentally any portion of the child between the blades of the scissors. 
 Commonly two ligatures are applied, and the cord is severed between 
 them, though the question of one or two ligatures is, excei^t in twin 
 pregnancies, of trifling importance. 
 
 In practice it is very desirable that the physician should understand 
 the physiological difference between the effects of the early and those 
 of the late application of the ligature. The custom as regards this 
 point has been by no means uniform. The ancients deferred the liga- 
 ture until after the expulsion of the placenta. Mauriceau, Clement, 
 and Deventer followed the same plan, but employed artificial expe- 
 dients to complete the third stage of labor rapidly.* The common 
 practice at the present day is to tie the cord immediately after the 
 birth of the child. Still, there have not been wanting in recent 
 times warning voices against precipitate action. Naegele advised wait- 
 ing until the pulsation of the cord had ceased ; Braun f first describes 
 the changes from the fetal to the post-natal circulation, and then says : 
 " This stupendous process should be taken into consideration in the 
 treatment of every case of labor, and because of it the cord should 
 never be severed or tied so long as pronounced pulsations can be felt 
 near the navel." Stoltz I noticed that " after the child has respired 
 
 * BuDiN, A. quel moment doit-on operer la ligature du cordon ombilical ? Publi- 
 cations (lu Progres Medical, 1876. 
 
 t Braun, Lehrbuch der Geburtshiilfe, p. 192. 
 
 X Stoltz, art. Accouchement naturel, Nouveau Dictionnaire, p. 283. So. too, 
 WurrE wrote, in 1773 : " The common method of tying and cutting the navel- 
 string the instant the child is born is likewise one of those errors in practice that 
 has nothing to plead in its favor but custom. Can it be supposed that this im- 
 portant event, this great change which takes place in the lungs, the heart, and the 
 liver, from the state of a foetus kept alive by the umbilical cord to that state when 
 life can not be carried on without respiration, whereby the lungs must be fully ex- 
 panded with air. and the whole mass of bloofl, instead of one fourth part, be cir- 
 culated through them, the ductus venosus, foramen ovale, ductus arteriosus, and the 
 
 I
 
 CONDUCT OF NORMAL LABOR. 9^^ 
 
 well division of the cord is followed by an insignificant loss of blood, 
 while after immediate section blood escapes in abundance." Winkler,* 
 from anatomical observation alone, recommended not to tie the cord 
 until the expulsion of the placenta, or at least until the cord had be- 
 come pale and had ceased to pulsate, giving as his reason that by 
 delay a certain quantity of blood would pass from the placenta to the 
 child, and tliat every plus is a gain to the child, which would increase 
 its powers of resistance. He finally expressed it as almost his belief 
 that the practice recommended would tend to diminish the familiar 
 loss of weight in the new-born during the first days of existence. 
 
 In 1875, Budin, at that time interne at the Maternite of Paris, 
 undertook the following experiments at the suggestion of Professor 
 Tarnier : In one series, the cord was tied immediately after tlie birth of 
 the child, and the blood which escaped from the placental extremity 
 was measured ; in the other, tlie quantity of blood was determined ia 
 cases where the cord was not tied until several minutes after delivery. 
 By a comparison of the results thus obtained, he found that the aver- 
 age amount of placental blood was three ounces greater in the first 
 than in the second series of experiments.! Welcker estimated the 
 entire quantity of the blood in the infant at one nineteenth the weight 
 of the body, which would amount, in a child of seven pounds, to six 
 ounces. To tie the cord immediately after birth would therefore be 
 equivalent to robbing the child of three ounces of blood which would 
 otherwise pass into its circulation. This startling result has in the 
 main been abundantly confirmed by subsequent observers. Two years 
 later (18TT), Schiicking, extending Budin's experiments by weighing 
 the cliild at birth and then observing the changes that took place up 
 to the time of the cessation of the placental circulation, found that the 
 child gained from one to three ounces in Aveight by delay. It is cer- 
 tain that these amounts do not represent the entire increase, as a portion 
 necessarily escapes observation in the interval that must elapse before 
 the weight can be ascertained. 
 
 There is a difference of opinion as to the mechanism by which the 
 
 umbilical arteries and veins must all be closed, and the mode of circulation in the 
 principal vessels entirely altered — is it possible that this wonderful alteration in 
 the human machine should be properly brought about in one instant of time, and 
 at the will of a bystander i Let us but leave the afifair to Nature and watch her 
 operations, and it will soon appear that she stands not in need of our feeble as- 
 sistance, but will do the work herself at a proper time and in a better manner. In 
 a few minutes the lungs will be gradually expanded, and the great alterations in 
 the heart and blood-vessels will take place. As soon as this is perfectly done the 
 circulation in the navel-string will cease of itself, and then if it be cut no hjpraoi- 
 rhage will ensue from either end. . . ." A Treatise on the ISIanagement of Pregnant 
 and Lying-in Women, by Charles White, London, 1873, p. 107. 
 
 * Winkler, Arch. f. Gynaek., vol. iv. p. 250 (1872). 
 
 f Budin, loc. cit.
 
 218 
 
 LABOR. 
 
 transfer of the blood from the placenta to the child takes place. Ac- 
 cording to Budin, the principal factor in the accomplishment of the 
 result is thoracic aspiration. With the first breath, the afflux of blood 
 to the lungs develops a " negative pressure " in the vessels of the larger 
 circulation, so that a suction force is exerted upon the placental blood, 
 which continues until the equilibrium is restored. To tie the cord 
 prematurely, therefore, is to cut off from the child a supply of blood 
 for which the establishment of the pulmonary circulation had created 
 a physiological need. 
 
 Schiickiug,* on the contrary, maintains that, after the first inspira- 
 tion, thoracic expansion ceases to operate as an active force, and that 
 the main agent which drives the blood from the placenta through the 
 umbilical vein is the compression exerted by the retraction, and, at 
 intervals, by the contractions of the uterus. 
 
 The difference in the theoretical standpoint of these two observers 
 is of practical importance, for, if the movement of blood to the child 
 results from thoracic aspiration, the quantity which enters its circula- 
 tion will not exceed its requirements ; while, if the movement is due 
 to uterine compression, the question arises as to whether the forcible 
 transfusion thus accomplished is compatible with the child's safety 
 and welfare. The ultimate decision will depend partly upon experi- 
 mental and partly upon clinical observations. Provisionally, the case 
 stands as follows : The manometric observations of Ribemont f show 
 that the pressure in the umbilical arteries is uniformly greater than 
 that in the umbilical vein ; during a series of deep inspirations and 
 expirations tlie blood in the umbilical vein is subject to marked oscil- 
 lations; after the pulsations of the cord have ceased, the uterine con- 
 tractions alone are insufficient to propel the placental blood through 
 the umbilical vein to the infant. Again, Budin (discussion upon 
 Ribemont's. paper), in a breech-delivery, compressed the cord at the 
 vulva as far as possible from the navel ; at birth, the vein was dis- 
 tended with blood, but with the first inspiration it was instantly 
 emptied. Thoracic aspiration does, therefore, exist as an operative 
 force. On the other hand, Schiicking found that when the placenta 
 was rapidly expelled by Crede's method, so as to remove it from the 
 influence of uterine retraction, the pressure in the vein was slightly 
 lessened, and the total amount of blood transferred to the infant was 
 greatly restricted. 
 
 According to the clinical observations of Budin, Ribemont, and 
 Schiicking, infants which have had the benefit of late ligation of the 
 cord are red, vigorous, and active, whereas those in which the cord 
 
 * ScHucKiNG, Zur Physiologie der Nachgeburtsperiode, Berl. klin. Woch., Nos. 
 1 and 2, 1877. 
 
 f Ribemont, Recherches sur la tension du sang dans les vaisseaux du foelus et 
 du nouveau-ne, Arch, de Toeol., October, 1879.
 
 OUNDUOT OF NORMAL LABO£. 211) 
 
 is tied early are apt to be pale and apathetic. Hofmeier,* Ribemont, 
 Badin, and Zweifel f have shown that the loss of weight wliich occurs 
 in the first few days following confinement is less in amount and of 
 shorter duration when the cord is not tied until after the pulsations 
 have ceased. 
 
 There appear to be no harmful results to the child growino- out of 
 the practice of late ligation. Porak, indeed, reports two cases of dai-k 
 vomiting, two of mel^ua, and two with sanguineous discharges from 
 the vagina, which he is convinced were the result of the practice; but 
 the extensive trial to which it has since been subjected in the principal 
 lying-in institutions of the Continent have sufficiently demonstrated 
 that it is exempt from danger. 
 
 In late ligation, the amount of blood retained in the placenta and 
 the increase in the weight of the child differ materially in different 
 eases I — a difference which seems to indicate that, so long as the placen- 
 tal circulation is left undisturbed, the amount of blood passing to the 
 child will be measured by its needs. In a case of Illing's,* on the 
 other hand, after the placenta had been expressed from the uterus, its 
 contents and that of the cord were forcibly squeezed into the circula- 
 tion of the child, and death followed from overdistention of the heart. 
 Porak and Georg Violet | claim that there is a special predisposition 
 to icterus in children when the cord is tied after the placental circula- 
 tion has ceased. Violet attributes the discoloration not to bile-pig- 
 ment but to a rapid disintegration of the excess of blood-corpuscles. 
 Helot, he says, found on the first day after the birth a difference of 
 nine hundred thousand corpuscles to the cubic millimetre between 
 cases of late and those of early ligation, while on the ninth day the 
 difference fell to three hundred thousand. Others have failed to 
 notice any characteristic icteric discoloration peculiar to late ligation. 
 Neither Porak nor Violet attaches any pathological significance to the 
 symptom. 
 
 The outcome of the foregoing observations may fairly be stated as 
 follows : 
 
 1. The cord should not be tied until the child has breathed vigor- 
 ously a few times. When there is no occasion for haste arising out of 
 the condition of the mother, it is safer to wait until the pulsations of 
 the cord have ceased altogether. 
 
 * Der Zeitpunkt der Abnabelung, etc., Ztschr. f. Geburtsh. u. Gyiiaek., iv, 1, 
 p. 114. 
 
 f Zweifel, Centralbl. f. Gyiiaek., No. 1. 
 
 i See Wiener, Ueber den Einfluss der Abnabelungszeit auf den Blutgehalt der 
 Placenta, Arch. f. Gynaek., xiv, 1, p. 34; also, Meyer, Centralbl. f. Gynaek., 1878, 
 No. 10. 
 
 * Inaug. Diss., Kiel, 1877. 
 
 II Georg Violet, Ueber die Gelbsucht der Neugeborenen und die Zoit der 
 Abnabelung, Virchow's Archiv, Ixxx, 3, p. 353.
 
 220 
 
 LABOR. 
 
 2. Late ligation is not dangerous to the child. From the excess of 
 blood contained in the fetal portion of the placenta, the child receives 
 into its system only the amount requisite to supply the needs created 
 by the opening up of the pulmonary circulation. 
 
 3. Until further observations have been made, the practice of 
 employing uterine expression previous to tying the cord is question- 
 able. 
 
 4. In children born pale and anaemic, suffering at birth from syn- 
 cope, late ligation furnishes an invaluable means of restoring the equi- 
 librium of the fetal circulation. 
 
 Management of the Third or Placextal Stage of Labor. 
 
 The duties of the physician in the third stage are to guard against 
 hfemorrhage, to promote uterine contractions, and to farther the ex- 
 pulsion of the placenta. These objects are best fulfilled by manipula- 
 tions through the abdominal walls. Tractions upon the cord should 
 not be resorted to before the placenta has accomplished its descent 
 into the vagina. The method of expressing the placenta by seizing 
 the uterus through the abdominal coverings is associated indissolubly 
 with the name of Crede, for, though the value of friction, of knead- 
 ing, and compression, was appreciated, as their writings show, by Mau- 
 riceau, Robert Wallace Johnson, Joseph Clarke, Busch, Mayer, and 
 
 others,* it was Crede who, by in- 
 dependent study, worked out the 
 practical details of the manoeu- 
 vre, and by his advocacy gained 
 for the principle of placental ex- 
 pression its present wide-spread 
 acceptance. 
 
 Crede's method consists es- 
 sentially in applying at first light 
 and afterward stronger friction 
 to the fundus of the uterus until 
 an energetic contraction is ob- 
 tained ; at its height the uterus 
 is grasped so that the fundus 
 rests in the palm of the hand, 
 compressed between the thumb 
 and fingers. The exercise of 
 circular compression forces the 
 placenta from the uterus, or in case of failure the process may be 
 repeated until the object is accomplished. Crede lays great stress 
 
 * For historical references, vide Riol, Delivrance par expression, G. Masson, 
 1880 ; MuNDE, Obstetric Palpation, p. 103. 
 
 Fig. 122.— Expression of the placenta. (Cred6.)
 
 CONDUCT OF NORMAL LABOR. 221 
 
 upon the avoidance of violence in the practice of his method. It is 
 true that the expulsion of the placenta will, as a rule, occur spontane- 
 ously. The unaided uterus is, however, liable to relax and become the 
 source of hajniorrhage ; or, where the delivery does not take place 
 speedily, it may, on the other hand, close down so as to imprison the 
 placenta within its cavity. The great merit of Crede's method is 
 that by maintaining retraction it prevents hasmorrhage, and by pro- 
 moting speedy expulsion it guards against the dangers of retention. 
 When systematically practiced, the bugbear known as adherent pla- 
 centa is the rarest of accidents. The method is not difficult, and is 
 devoid of danger. To be successful, however, expression should ])e 
 employed only during the acme of a contraction, and the propulsive 
 force should be directed from the fundus downward in the axis of the 
 uterus. 
 
 Crede in his earlier papers advocated the expression of the placenta 
 as soon after the birth of the child as possible. It appears, however, 
 from the observations of Schroeder and others, that in most cases the 
 placenta spontaneously leaves the uterine cavity, either in whole or in 
 part, within the first fifteen to twenty minutes after the birth of the 
 cliild, and that the delay observable in so many cases left to the un- 
 aided elforts of Nature occurs usually after the placenta has sunk into 
 the lower uterine segment. For this reason it is a good rule, accepted 
 of late by Crede, not to resort to external manipulations until at least 
 fifteen minutes have exjjired. 
 
 The evidence of the expulsion of the placenta is furnished to the 
 operator by his feeling the anterior and posterior walls in contact with 
 one another. By thei^ pressing the uterus downward in the axis of the 
 brim it is usually possible to drive the placenta through the vagina 
 and out of the valva. There is no objection, however, at this stage, in 
 case of delay, to expedite delivery by drawing upon the cord downward 
 and backward. When the placenta passes the vulva the uterus is often 
 firmly contracted, and a considerable portion of the membranes are 
 still within the uterine cavity. Hasty traction is then apt to tear off 
 the retained part of the membranes. It is well, therefore, at this point 
 to support the placenta until relaxation of the uterus has taken place, 
 when the complete separation of the membranes is effected without 
 endangering their integrity. 
 
 There has been considerable discussion of late as to the true physi- 
 ology of placental expulsion. Thus it has been maintained by Schultze 
 that after the birth of the child the diminution of the placental area 
 during a uterine contraction is followed by a central separation of the 
 placenta from the uterine walls and by a bulging of the separated 
 portion into the uterine cavity. The detachment takes place in the 
 decidual layer ; the mouths of uterine vessels are consequently opened 
 up, and blood is aspirated into the retro-placental cavity. As, in i)oint
 
 222 
 
 LABOR. 
 
 regular 
 
 Fig. 
 
 of fact, no uterine cavity exists during a contraction, Colm * modified 
 the Schultze theory by assuming that the central separation takes 
 place in fact as a consequence of uterine contraction, but that the 
 
 hematoma follows upon the occurrence of 
 uterine relaxation. The further separa- 
 tion of the placenta from the center to- 
 ward the periphery is either the result of 
 the increase in the amount of the effused 
 blood, or is effected during a contraction 
 by the peripheral pressure exerted by the 
 blood previously aspirated behind the pla- 
 centa. According to Schultze, therefore, 
 the placenta normally descends by its fetal 
 surface into the vagina, and a certain 
 amount of hnemorrhage is the 
 concomitant of placental expulsion 
 
 Dohrn,t accepting the views of Schultze, 
 objects to Cred6, that by his metliod " a proc- 
 ess which should develop naturally is disturbed 
 by a comparativelj' brusque manipulation." As 
 a result of hasty placental expression, he men- 
 tioned as especially to be deprecated the tend- 
 ency to retention of the membranes. Later, 
 Ahlfeld I urged against the Cred6 method that 
 it increased the cases of dangerous haemorrhage, that it favored retention of 
 the membranes, and that, as a consequence of the latter accident, it created a 
 disposition to puerperal fever. The evils depicted by Dohrn, and especially by 
 Ahlfeld, of the results of manual expression of the placenta, were so entirely 
 opposed to my own experience, that during the past ten years I have continued 
 to follow, with slight modifications, the counsels of CYede, and remain uncon- 
 vinced that they do not furnish the best practical solution of the safe manage- 
 ment of the stage of labor. When skillfully performed, I know of no other 
 obstetrical manoeuvre to which the terms cito tuto, etjucunde can be so properly 
 applied. 
 
 As to the alleged dangers of the method, my experience corresponds to that 
 of Roemer,* of Zinstag,|| of Fehling,^ and of Cred6,0 whose comparative sta- 
 
 * CoHX, Zur Physiologie und Diatetik der Naehgeburtsperiode, Ztschr. f. Ge- 
 burtshiilfe und Gynaek., vol. xii, p. .381. 
 
 ■f- DoHRN, Deutsche med. Wochenschr., 1880, No. 41. 
 
 X Ahlfeld, Berichte und Arbeiten aus Giessen, 1881 and 1882. 
 
 * RoEMEB, Klinische Beobachtungen ueber der Nachgeburtszeit, Arch. f. Gy- 
 naek., vol. xxviii, p. 283. 
 
 II ZiNSTAG, Beitrage zum Mechanismus der physiologischen Losung der Placenta, 
 Arch. f. Gynaek., vol. xliii, p. 255. 
 
 ^ Peeling, Zur Frage der Zweckmassigsten Behandlung der Nachgeburtszeit, 
 Centralblatt fur Gynaek., 1880, No. 25. 
 
 Crede, Die Behandlung der Naehgeburt bei regelmassigen Geburten, Arch, f. 
 Gynaek., vol. xxxii, p. 96. 
 
 12.3.— Descent of the placenta 
 according to Schultze.
 
 CONDUCT OP NORMAL LABOR. 
 
 223 
 
 tistics show that Credo's method does not increase the quantity of blood lost 
 either in the third stage or during the puerperium ; that, unless resorted to at too 
 early a period, it does not conduce to retention of the membranes; and that, 
 even if this accident should occur, it does not, with rigid antiseptic conduct of 
 labor, enhance the risks of puerperal infection. 
 
 In opposition to Schultze, Duucan maiutaius that when the mech- 
 anism of placental delivery is not interfered with by premature trac- 
 tions upon the cord, the placenta descends edgewise through the cervix, 
 and its expulsion is effected with the loss of 
 but a trifling amount of blood. Of course 
 it is understood that traction upon the cord 
 is of common occurrence during the birth 
 of the child, and that in consequence the 
 Schultze method of descent is frequently 
 enough met with. But Zinstag furnishes us 
 observations in one hundred and thirty cases 
 in which the cord was divided when coiled 
 around the neck of the child immediately 
 after the birth of the head, and in other cases 
 during the passage of the breech. When 
 this precaution was taken the mechanism of 
 Schultze occurred in nine cases only ; that 
 of Duncan * with the placenta folded on the 
 fetal surface in ninety-four cases; and in 
 twenty-seven cases with the edge presenting 
 but with the placenta folded upon the uterine 
 surface, and with a certain amount of blood 
 effused from the uterine sinuses between 
 the folds and behind the membranes. 
 
 As a matter of practical importance, it is well to remember that 
 when extraction is attempted previous to descent by pulling upon the 
 cord, the central portion of the placenta is dragged into the cervix, 
 while the borders are inverted in such a way as to form a cup-like 
 cavity. This disturbance of the normal mechanism not only increases 
 the difficulty of delivering the placenta, but causes the latter to exer- 
 cise a suction force which increases the haemorrhage, and at times even 
 is capable of partially inverting the lax uterine walls. Now and then, 
 where the occlusion of the cervix is complete, it may be found impos- 
 sible to effect delivery without first introducing two fingers and hook- 
 ing down the margin of the placenta, so as to allow air to pass above 
 into the uterine cavity. 
 
 * Matthews Duncan, Edinburgh Med. Jour., April, 1871. 
 
 Fig. 124.— Showing normal de- 
 scent of placenta. (Duncan.)
 
 224 LABOR. 
 
 Care of the Patient after Delivery. 
 
 As the danger of haemorrhage does not always end with placental 
 expulsion, the physician should be ready to sacrifice, even in simple 
 cases, at least a half-hour to close observation ©f the subsequent be- 
 havior of the uterus. The weight of the hand laid above the sym- 
 physis pubis is usually sufficient to maintain a safe degree of retrac- 
 tion. Should, however, the uterus become lax, and lose its outline, the 
 physician should grasp it in his hand and knead it firmly until a con- 
 traction is excited. In this way he not only guards against haemor- 
 rhage, but, by preventing the formation of clots, he diminishes in mul- 
 tiparae the severity of the after-pains. 
 
 Most physicians seek additional security against haemorrhage by 
 administering ergot, which, as is well known, favors tonic retraction 
 of the uterus. To this there is no objection, provided the ergot be 
 given subsequent to the expulsion of the placenta. When given, as 
 is commonly done," at the time of the passage of the child's head, it is 
 liable to produce its effect prematurely, and thus to give rise to hour- 
 glass contraction. The rarity of the accident is no argument in favor 
 of the popularity of the practice in the face of the serious complica- 
 tion to which it is capable of giving rise. When the physician judges 
 it is safe to suspend the prophylactic pressure upon the uterus, ho 
 should see that all the soiled clothing be removed from beneath his 
 patient, and that the nurse wash the genitalia gently but thoroughly. 
 Nothing does so much to cause speedy disappearance of the soreness of 
 the external parts as perfect cleanliness. In hospitals, a vaginal douche 
 of warm carbolized water should be combined with external ablutions. 
 The perinifium should then be carefully examined, and, if lacerations 
 are discovered, the physician should make himself acquainted with 
 their extent and importance. 
 
 Without entering into a discussion at this place of the methods 
 of repairing perineal tears, it is proper to state that, both as a means 
 of preventing infection and of promoting speedy convalescence, it is 
 wise, in all cases where the laceration extends to or nearly to the 
 sphincter ani, to bring the torn surfaces together by means of sut- 
 ures. The technique is simple, and immediate union is the rule, if 
 the same care is employed with regard to cleanliness that is usual in 
 gynaecological practice. Rarely, failures to obtain union may result 
 from syphilis, or from lowered vitality of the tissues due to extreme 
 prolongation of the second stage of labor. 
 
 The application of the binder is one of those points in practice 
 about which men of large experience entertain a difference of opinion. 
 In my student days in the Ilopital des Cliniques in Paris the binder 
 was dispensed with. A folded sheet was, however, laid across the 
 abdomen, it having been found that a certain amount of pressure was
 
 CONDUCT OF NORMAL LABOR. 225 
 
 necessary for the comfort of tlie patient. This plan compelled her to 
 lie upon her back, and thus had the disadvantage of restrictino- freedom 
 of movement. Careful observation has failed, however, to show me a 
 single good reason why the binder should be discarded. When properly 
 applied, it adds greatly to the woman's comfort, and enables her to turn 
 at will upon her side. My own preference is for a piece of unbleached 
 muslin wide enough to reach below the hips. 
 
 In adjusting the binder, the physician should place himself to the 
 right of the woman ; he should seize the near end between the thumb 
 and two fingers of the left hand, while with the right hand he draws 
 the further portion smoothly over it. The two ends should then be 
 held with the left hand, and the pins, which should preferably be of 
 large size, should be inserted with the right. The process should begin 
 below, and be followed upward at intervals of about two inches. These 
 details are given because the writer remembers his own embarrassment 
 arising from his inability to get information upon this trivial subject in 
 the early days of his practice. Moreover, as many women are somewhat 
 tenacious of having the binder first applied by the physician, to know 
 how to do it with address is not an indifferent accomplishment. Many 
 place a compress made of a folded towel above the symphysis pubis. 
 This addition usually serves no better purpose than to displace the 
 uterus to one side. The toilet of the patient is finally completed by 
 laying a warm folded napkin at the vulva to receive the lochial dis- 
 charge. 
 
 An aseptic dressing to the external parts is, however, warmly to 
 be recommended in private as well as in hospital practice. This con- 
 sists after washing the genitals thoroughly with a bichloride solution 
 (1 to 3,000), in powdering the parts with iodoform, and then applying 
 iodoform or bichloride gauze. The dressings should be held in place 
 by an oakum pad. A little attention to these details possesses the 
 immense advantage of preventing decomposition of the lochia and of 
 promoting the healing of external wounds. 
 
 Anesthetics ix Midwifery. 
 
 The value of anassthetics in certain irregularities of the labor- 
 pains, in eclampsia, and in most midwifery operations, is no longer a 
 matter of discussion. The benefits from their employment in such 
 cases are palpable and beyond dispute. As to the right, however, of a 
 woman to have her sufferings assuaged in ordinary normal labor, there 
 is by no means unanimity of opinion. To be sure, the old objections 
 raised in Sir James Simpson's day, that labor-pain is a salutary mani- 
 festation of life-force, that anaesthesia gives rise to paralysis, to peri- 
 tonitis, to puerperal mania, to haemorrhage, to pericardial adhesions, to 
 indecencies of language and behavior, and that it contravenes the Word 
 15
 
 226 LABOR. 
 
 of God, are now known to be unfounded or imaginary. Still, there is 
 no doubt that the vast majority of medical men refrain from the use 
 of anesthetics in ordinary labor, either from vain apprehensions or 
 because some incident in their practice has led them to suspect that, in 
 spite of statistics, they are not devoid of objectionable or dangerous 
 properties. In my own experience during the last sixteen years, there 
 have been comparatively few cases in which I have not used chloroform 
 or ether in some stage of labor. The result of my experience has been 
 to make me a warm advocate of their wider employment on the one 
 hand, while proclaiming the necessity of caution in their use upon the 
 other. It seems to me that the hesitancy manifested regarding their 
 general adoption is due, in large measure, to the fact that few practi- 
 tioners give themselves the trouble to master the necessary modus 
 operandi^ to study the limitations of their usefulness, or to learn the 
 conditions of their safe administration. It should be steadfastly borne 
 in mind that the giving of anaesthetics in labor is an art to be acquired 
 — a very simple one, perhaps, but the practice of which admits of 
 neither ignorance nor carelessness. 
 
 As in ordinary surgical practice, auEesthetics are contra-indicated by 
 organic affections of the heart and lungs. 
 
 Except in the prolonged insensibility required for difficult ob- 
 stetrical ojDerations, I think the preference should be accorded to 
 chloroform rather than to ether. The former possesses the advan- 
 tage of being more agreeable, more manageable, and more rapid in its 
 action. 
 
 Ansesthesia, not narcosis, is the object aimed at, and the dulling 
 of the sensibility is much more readily effected by chloroform than 
 by ether. 
 
 As a rule, chloroform should not be administered during the first 
 stage of labor, partly because of its tendency, when given at too early 
 a period, to weaken the contractions of the uterus, and partly because 
 protracted anesthesia has a tendency to impair the cardiac force. To 
 this rule there are, however, numerous exceptions, to which we shall 
 have occasion to revert in connection with the consideration of irregu- 
 lar labor-pains. 
 
 If the pains in the second stage are of feeble intensit)^ it is best to 
 withhold the anesthetic; if of normal strength, chloroform may be 
 given, but at first only in small doses and during the continuance of a 
 pain. The anaesthetic should not be pushed to the stage of complete 
 unconsciousness until the head begins to emerge at the vulva. 
 
 Chloroform can be conveniently given upon a folded handkerchief. 
 The latter should be held near to, but not in contact with, the respir- 
 atory passages. The best diluent for chloroform, as was long ago stated 
 by Sir James Simpson, is atmospheric air. If the handkerchief be laid 
 directly across the nose, instant suspension of respiration may result.
 
 CONDUCT OF NORMAL LABOR. 227 
 
 A minor evil is tlie cutaneous irritation produced by placing the chloro- 
 form in direct contact with the lips and mouth. 
 
 At the beginning of each pain the patient should be directed to 
 take a number of deep inspirations. During the acme of the pain the 
 expiratory efforts which arc then called into play prevent the inhala- 
 tion of any considerable amount of the anaesthetic. 
 
 When the head presses upon the perinaeum, the handkerchief should 
 be intrusted to the nurse, but the administration to the end should be 
 directed and strictly supervised by the physician. 
 
 When chloroform is first given, it is common for the pains to become 
 weakened ; but this suspensive influence upon the uterus is usually 
 temporary. Exceptionally, however, the weakness of the pains may 
 continue, and render it necessary to withhold the anesthetic. In still 
 rarer cases the pains remain inefficient after the antesthesia has subsided. 
 On this account it seems to me certain that those who use chloroform 
 habitually will find themselves compelled to resort to the forceps with 
 somewhat increased frequency. A tardy labor, due to uterine inertia, 
 will likewise call for additional vigilance during the stage of placental 
 expulsion to forestall the occurrence of hemorrhage. 
 
 The immunity enjoyed by women in childbirth against the accidents 
 which sometimes occur from anaesthesia in surgical practice is not abso- 
 lute, but dependent upon its cautious and intelligent administration. I 
 once narrowly escaped losing a patient in the Bellevue Hospital, upon 
 whom I designed to perform version, in consequence of my house phy- 
 sician suddenly crowding a paper funnel containing a towel wet with 
 chloroform over the respiratory passages. 
 
 Chloroform should not be given in the third stage of labor. The 
 relative safety of chloroform in parturition ceases with the birth of the 
 child. x\fter delivery it favors the relaxation of the uterus and predis- 
 poses to hEemorrhage. Moreover, after the uterus has been emptied 
 there is always an increase of blood in the large vessels of the abdomen, 
 and a corresponding recession of blood from the head. Xow, it is 
 known that the quantity of chloroform which one day is perfectly tol- 
 erated by an individual in health may prove fatal on the succeeding day, 
 in case of the intervention of any considerable loss of blood. Cerebral 
 anasmia, from any cause, increases the risk of anesthesia. 
 
 In lengthy operations requiring prolonged anesthesia, ether, as has 
 already been intimated, should be preferred to chloroform.
 
 223 LABOR. 
 
 CHAPTER XII. 
 
 MULTIPLE PREGNANCIES AND THEIR MANAGEMENT 
 
 Frequency.— Origin.— Varieties.— Auardia.— Weight.— Unequal develupment.— Su- 
 perfetation.— Diagnosis.— Labor.— Presentations.— .Simultaneous entrance of 
 both children into the pelvis.— Locking.— Prognosis.— Conduct of labor. 
 
 The term midtiple pregnancy is used when more than one germ 
 are simultaneously developed. Twins, the most common form, occur 
 in the proportion of one to between eighty and ninety births ; triplets 
 in about the proportion of one to seven thousand; quadruplets and 
 quintuplets are of extreme rarity. No authentic example of over five 
 children at a birth is on record. An instance of quintuplets I have 
 once witnessed. In the Prussian statistics of Von Hemsbach and Veit 
 based upon thirteen million births, the number of twin pregnancies 
 amounted to 150,000. Of these, in 50,000 both children were boys ; in 
 46,000 both were girls ; and in 54,000 the children consisted of a boy 
 and a girl. 
 
 Twins may develop either from two distinct ova, discharged from the 
 same or from distinct Graafian follicles, or may both originate from a 
 single ovum. If two Graafian follicles rupture, the ovaries will offer 
 two corpora lutea. In some instances a corpus luteum has been found 
 in each ovary ; in others both are situated in the same ovary. 
 
 In the case where twins develop from two ova, each foetus is con- 
 tained in its own chorion. If the ova are imbedded in the decidua at 
 sufficiently distant points, the placentae will be separate, and each ovum 
 will have its distinct reflexa. If near one another, the placentas are 
 often united at their borders, each, however, maintaining its independ- 
 ent circulation. In some cases the two ova lie so close together that 
 they are encircled by a common reflexa. 
 
 When twins are developed from two centers contained in the same 
 ovum, the placenta, the chorion, and reflexa are, of course, common to 
 both. In most instances each foetus is contained in its own amnion. 
 Occasionally, however, twins are furnished with but one amnion — a 
 peculiarity which, in some cases at least, is not primary, but the re- 
 sult of an absorption of the party-wall between two originally distinct 
 cavities.* 
 
 Twins from the same ovum are always of the same sex. Anasto- 
 moses of greater or less extent exist between the placental vessels of 
 the two embryos. The consequences of these communications are of 
 the utmost importance, for, when extensive, the heart's action in one 
 
 * Ahlfeld, Beitrage zur Lehre von den Zwillingen, Arch. f. Gynaek., Bd. vii, 
 p. 281.
 
 MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 229 
 
 foetus counterbalances that of the other ; the stronger blood-current in 
 the placenta pushes back the weaker one, at first impeding the circula- 
 tion of the less favored fcetus, then arresting it, and finally causing it 
 to reverse its direction. The heart atrophies, and an acardia is pro- 
 duced, which is simply an appendage to the healthy foetus. The cir- 
 culation in the acardia takes place as follows : Venous blood from the 
 healthy foetus is conveyed by the umbilical arteries to the placenta ; the 
 force of the fetal heart drives the stream through the communicating 
 
 Fig. 125. - Twin placenta, sliowin^ arterial anastomosis. 
 
 branches to the umbilical arteries of the less favored twin ; this force 
 is, however, insufficient to carry the current to the upper parts of the 
 body, which are, therefore, not developed. The favorable position of 
 the lower extremities for receiving the blood from the umbilical vessels 
 explains their continued though imperfect growth and development. 
 The blood carried to the foetus by the umbilical arteries is returned by 
 the umbilical vein. 
 
 According to Ahlfeld,* a division may take place in the formative 
 material contained within a single area germinativa. This division 
 
 * Ahlfelp, Die Entstehung der Doppelbildung und der liomologen Zwillinge, 
 Arch. f. Gynaek., Bd. ix, p. 196.
 
 230 
 
 LABOR. 
 
 may be complete, and thus produce separate twins inclosed in the 
 same amnion, which not only are of the same sex, but bear to one 
 another through life the most striking similarity as regards appear- 
 ance, physical peculiarities, and both mental and moral characteris- 
 
 I 
 
 Fig. 126.— Author's case of acardia. The monstrosity weighed tliree pounds nine ounces ; 
 there were no traces of heart, lungs, pancreas, liver, spleen, or sternum. 
 
 tics ; or it may be incomplete, and thus give rise to conjoined twins, 
 or one of the numerous forms of double monsters.* 
 
 In triplets, it is common to find one child derived from an inde- 
 pendent ovum and two from a single ovum. In a case of quadruplets 
 
 * Schultze, on the other hand, contends that the double monsters are derived 
 from the fusion of two embryos developed upon the blastodermic vesicle at points 
 close to one another. Schultze. Ueber Zwillingsschwangerschaft, Volkmann's 
 Samm. klin. Vortr., No. 34.
 
 MULTIPLE PREGNANCIES AND TIIKIK MANAGEMENT. 231 
 
 reported by P. i\Inller,* two ova were simple, while the third contained 
 two embryos. The children in the single ova were of the female 
 while those in the double ovum Avere of the male sex. 
 
 The average weight of the individual children in multiple preg- 
 nancies is less than that of children born single. This is partly due 
 to the frequency with v/hich the excessive distention of the uterus 
 becomes the exciting cause of premature delivery, and partly to the 
 obvious fact that the maternal organism is rarely capable of furnishing 
 the nutritive material requisite for the complete growth of more than 
 a single child. 
 
 Twins often exhibit at birth a remarkable disparity as regards both 
 size and development — a disparity unquestionably due to local condi- 
 tions. A striking example of this is shown in a case related by 
 Schultze.f One child, at the time of delivery, was nearly if not quite, 
 mature, while the other presented the appearances of a six weeks' 
 fcetus. As both ova were enveloped in the same reflexa, their develop- 
 ment mast have begun at nearly the same time. 
 
 Sometimes one foetus dies, and yields to the more fortunate brother 
 the space and the nutritive material which would otherwise have fallen 
 to his share. In such a case the ovum and the contained fa?tus may 
 be compressed by the surviving twin, and be flattened against the 
 uterine wall, giving rise to the so-called " foetus papyraceus " ; or it 
 may degenerate into a mole ; or the aborted ovum may be exjselled, 
 while the living foetus advances to the full term of gestation. 
 
 Very rarely, where the twins are both living but have undergone 
 unequal development, the stronger child may be delivered first, \\'hile 
 the other remains in the uterus, and is born after weeks of delay, dur- 
 ing which, under more favorable conditions, it makes good the defi- 
 ciencies due to its retarded evolution. The most remarkable cases of 
 this kind occur in the uterus duplex. Professor Fordyce Barker re- 
 lated an instance in his practice where, in a double uterus, a mature 
 living male child was born on the 10th of July, 1855, and on the 2.2d of 
 September following the mother gave birth to a full-term living girl. 
 
 Histories like the foregoing are often adduced in support of the 
 theory of what is known as superfetation — a theory which supposes 
 that, aftcx conception has once occurred, a second gestation may result 
 from a subsequent coitus. That this is possible, if two ova are de- 
 tached during the same menstrual period, seems to be established by 
 authentic accounts of negro women giving birth to twins, showing the 
 evidences of a paternity derived in one from the black and in the 
 other from the white race. That impregnation can take place at two 
 periods distant from one another must be regarded as an inadmissible 
 
 * P MiJLLER, Eine Vierling's Geburt, Ztschr. f. Geburtsh. uiul Gynack.. IM. iii, 
 p. 166. 
 
 f SCHULTZE, loc. cit., p. 308.
 
 232 LABOR. 
 
 hypothesis, until physiologists shall succeed in demonstrating in a sin- 
 gle instance, by the presence of corpora lutea of different ages, that 
 ovulation ever occurs during pregnancy. 
 
 Diagnosis. — The diagnosis of multii^le pregnancy is rarely to be 
 made out with absolute certainty. Unusual dze of the uterus, with 
 exaggeration of the syhiptoms which result from pressure, would nat- 
 urally lead to inquiry on the part of the physician, as it is certain to 
 excite uppreliensions in the mind of the pregnant female. (Size, how- 
 ever, furnishes but an uncertain criterion, as it may be equally due to 
 the presence of a very large child, or to an excess of amniotic fluid. 
 More trustworthy information is to be obtained from palpation and 
 auscultation. Thus the recognition of a number of distinct fetal parts 
 and the exclusion of hydramnion would render tlie diagnosis of twin 
 pregnancy probable. The outlining of two fetal heads at a distance 
 from one another would make the diagnosis certain. When the fetal 
 heart is heard at two remote points, and the sound is found to die 
 away in the intervening space, it is justifiable to conclude that the 
 sound at each point has a separate origin. If the two heart-beats 
 are counted at the same time by different observers, and are found 
 not to correspond in frequency, a twin pregnancy is established be- 
 yond dispute. After the birth of the first child, the presence of the 
 second is determined by the size and consistence of the uterus, and the 
 perception of fetal parts both through the abdominal walls and tlie 
 vagina. 
 
 The recognition of triplets and quadruplets is, of course, attended 
 with even greater difficulties than that of twins. 
 
 Labor in Multiple Pregnancies.— We have already noticed the fre- 
 quency of ])remature labor in multiple pregnancies. Of one hundred 
 and ninety-two twin births reported by Reuss* from the AViirzburg 
 clinic, fifty-one did not complete the full term of gestation. In one 
 of these abortion resulted from small-pox, in another from syphilis, in 
 two cases premature labor was induced artificially, in the others labor 
 occurred spontaneously — in one instance at the seventh month, in the 
 other in the ninth or tenth months. 
 
 Twin labors are usually easy. The first child is delivered as in 
 simple labors, and, except in faulty presentations, is followed shortly 
 by the second. The interval varied, in seventy-four of Reuss's cases 
 which terminated spontaneously, from five minutes to one and a half 
 hour. In seventy-nine per cent the interval was less than an hour. 
 As the stage of dilatation is completed at the time of the expulsion of 
 the first twin, a protracted interval is occasioned purely by weakness 
 and inefficiency of the pains. 
 
 The placenta? are usually expelled after the birth of the second 
 child ; now and then tlie placenta of the first child precedes the birth 
 * Reuss, Znr Lehre von den Zwillingen, Arch. f. Gynaek., Bd. iv, p. 123.
 
 I 
 
 MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 233 
 
 of the second ; again, the second child may not be born until after the 
 delivery of its placenta. When the placenta are united, a portion may 
 be torn off and expelled with the first child, while the remainder is not 
 thrown off until after the birth of the second.* The placental stage 
 is, owing to the relaxed state of the uterine walls, apt to be of longer 
 duration than in simple labors, and calls for the exercise of special 
 care to guard against the occurrence of hemorrhage. 
 
 Fig. 127.— Twin pregnancy, both heads presenting. (Tarnier et Chantreuil.) 
 
 Presentations in Twin Labors.— Spiegelberg f furnishes the follow- 
 ing table, derived from 1,138 deliveries, of which 899 were taken from 
 Kleinwiichter and 203 from Reuss : 
 
 Both heads presenting 558, 
 
 Head and breech presenting 361, 
 
 Both pelvic presentations 98, 
 
 Head and transver.se presentations. ... ... 71, 
 
 Breech and transverse 46, 
 
 Both transverse 4, 
 
 or 49 
 
 per cent. 
 
 " 31-7 
 
 
 " 8-6 
 
 
 " 618 
 
 
 " 4-14 
 
 
 " 0-35 
 
 
 Vide SpiEGELBERCi, Lehrbuch der Geburtshiilfe. Bd. i, p. 203. 
 
 t Ibid.
 
 234 
 
 LABOR. 
 
 The transverse presentations are mostly secondary, consequent 
 upon the roominess of the uterine cavity and the sudden escape 
 of the amniotic fluid. Version is, of course, in such cases easily per- 
 formed. 
 
 The Simultaneous Entrance of Both Children into the Pelvis.— The 
 consideration of the various complications to which this anomaly gives 
 rise belongs to the domain of pathology. To avoid, however, needless 
 repetitions, they may, for convenience' sake, be properly considered in 
 the present connection. 
 
 AVheu both children present at the brim previous to the rupture of 
 the membranes, it usually happens that, with the escape of the amni- 
 otic fluid, one of the twins descends into the pelvis, while the second 
 glides to one side. The result is identical, whether the twins are con- 
 tained in a single or in separate sacs. If interference is called for 
 because of delay, the amnion, or one amnion in case there are two, 
 should be ruptured, and the nearest presenting part brought into the 
 pelvis, while the other is at the same time pushed out of the way. 
 If -head and breech present, the head should preferably be allowed to 
 descend first. 
 
 It may happen, however, that after rupture both children may 
 descend into the pelvis so close to one another as to hinder each the 
 other in its further progression. This locking of the twins, as it is 
 termed, may take place in one of two ways, viz. : 
 
 1. In double vertex presentations, delivery may be impeded by the 
 pressing of the second head into the neck of the more advanced foetus, 
 or, after the birth of the first head, the second may enter the pelvis 
 and arrest the advance of the thorax. Obviously this difficulty could 
 only arise in a case where both heads were of unusually small size. 
 The diagnosis has rarely been made previous to the birth of the first 
 head. The treatment consists in the artificial extraction of one head 
 after the other, and then delivering the body of the first child. Cra- 
 niotomy is usually not necessary. The prognosis as regards the chil- 
 dren is extremely unfavorable. Eeimann * reports six cases in which 
 the fate of the children was known. Of the six first-born, one sur- 
 vived; of the six last-born, two survived. Reimann, in commenting 
 on these figures, remarks : " The child whose head first enters the pel- 
 vis is in great danger, because not only is its neck squeezed by the 
 head of the second child, thereby producing cerebral hyperaemia, but 
 its umbilical cord is exceedingly liable to be compressed by the body 
 of the second child." ■ 
 
 2. When one child presents by the breech, the other by the vertex, 
 the former, because of its smaller size, is apt to descend first into the 
 pelvis. No difficulty is then experienced until the neck is born. In 
 case, however, meantime the head of the second child has entered the 
 
 * Reimans. Am. .Jour, of Obstet., 1877, vol. i. p. .58.
 
 MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 235 
 
 pelvis, further progress may be rendered impossible, a lock resulting 
 either from the overlapping of the chins, or of the occipital portions 
 of the two heads, or from the pressure of the face of one child into 
 the neck beneath the occiput of the other. By lifting the body of the 
 child, and introducing the half-hand into the vagina, the diagnosis is 
 rendered easy. 
 
 In a large, roomy pelvis, if the pains are good and the children 
 small, spontaneous delivery may take place. In a number of cases of 
 
 Fig. 128.— Twill pregnancy, head and breech presenting. (Tarnier et Chantreuil.) 
 
 this kind which have been reported, the head of the second child was 
 born first. In a few instances it has been found possible to push up 
 the second head. Operative measures consist in applying the forceps 
 and extracting the second head, and afterward, if necessary, the first. 
 In case of failure, craniotomy remains as an ultimate resort. The first 
 child is rarely born living. Of twenty-six children, the fate of which 
 was ascertained by Reimann, only three survived. The prognosis of 
 the second child is more favorable. Of twenty-nine cases, Reimann 
 reports nineteen survivals. Xaturally, therefore, the perforation of
 
 236 
 
 LABOR. 
 
 the first head would be preferred, were the matter one purely of elec- 
 tion, but the operation is very difficult, and does not remove the ob- 
 stacle, for even the diminished head can not pass the one already 
 occupying the pelvis.* In the cases so far reported, where decapita- 
 tion of the first child has been performed, the operation has not proved 
 successful in saving the life of the second. 
 
 The possibility of one twin sitting astride the other, when trans- 
 verse, requires mention, because of the perplexity that may arise as to 
 the diagnosis, unless the hand is introduced into the lower segment 
 of the uterus to determine the exact relations of the twins to one 
 another. 
 
 Prognosis. — The prognosis, both as regards the children and the 
 mother, is much more unfavorable than in simple labors. Statistics 
 on this point are valueless, as much depends upon the conduct of the 
 physician. As regards the children, the increased mortality results 
 from prematurity, from unequal development, and from the frequency 
 of malpositions and malpresentations, requiring operative interference. 
 As regards the mother, the mortality and susceptibility to puerperal 
 diseases are augmented by the excessive distention of the uterus, the 
 extent of the placental wound, the feebleness in many cases of uterine 
 retraction after delivery, and by the operations which grow out of the 
 anomalies to which labor in multiple pregnancies is subjected. 
 
 Conduct of Labor in Multiple Pregnancies. — The management of 
 multiple pregnancies does not dift'er essentially from that of ordinary 
 labor. After the birth of the first child, the placental end of the cord 
 should in all cases be tied, on account of the frequency with which 
 anastomoses are found between the vessels of the placentae. A period 
 of repose should then be allowed, to enable the uterus to retract down 
 upon the remaining ovum. During the birth of the second child, 
 every care should be taken to follow the uterus with the hand, and 
 redoubled precautions should be observed against the occurrence of 
 haemorrhage, to which the woman is exposed both on account of the 
 large size of the placental wound and the disposition to relaxation. 
 In case the second child presents by the shoulder, version by external 
 manipulations alone is usually practicable. Expression should be em- 
 ployed to force the placentae into the vagina. When both descend at 
 once, if it is necessary to make tractions, both cords should be drawn 
 upon, simultaneously or in alternation, to find which placenta is most 
 easily removed. When one placenta follows the birth of the first child, 
 it should be left untouched until the advent of the second. Vigilance 
 after delivery should be long observed. 
 
 We have already noticed that the length of time between the ex- 
 pulsion of twins situated in separate membranes rarely exceeds an 
 hour. When, therefore, there is a longer delay in the delivery of the 
 
 * Reimann, ioc. cU.. p. 61.
 
 I 
 
 MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 2?>T 
 
 second child, measures should be employed to excite pains, and the 
 membranes should be ruptured. In case of a premature child deliv- 
 ered with its own placenta, cases of continued deVelopment, in utero, 
 of the remaining child, would point to the policy of abstention. In 
 instances where more than two children are contained in the uterus, 
 the anomalies of position are more frequent, and the danger of hsemor- 
 rhage is still further enhanced.* 
 
 * Spiegelberu, Lehrbuch. pp. 206, 307.
 
 THE PUERPERAL STATE. 
 
 CHAPTER XIII. 
 
 THE PHYSIOLOGY AND 3IANAGEMENT OF CHILDBED. 
 
 The puerperal state borders closely upon pathological conditions.— Post-parlum 
 chill.— Temperature.— The pulse.— General functions.— Retention of urine.— 
 Loss of weight.— Involution.— Separation of the decidua.— Closure of tlie 
 sinuses.— The cervix.— The vagina.— Position of uterus.— After-pains.— The 
 lochia.— The secretion of milk.— Anatomical considerations. — Milk-fever. — 
 Composition of milk.— Diagnosis of the puerperal state.— The new-born in- 
 fant.— Changes in circulation.— The navel.— Tumor upou the presenting part, 
 —Digestion.— Skin.— Icterus. — Loss of weight. — Management of puerperal 
 state.— Sleep.— Passing urine.— Visits of physician.— Washing the vagina.— 
 Diet.— Laxatives.— Nursing.— Duration of lying-in period.— Care of new-born 
 infant.— Bath.— Cord.— Nursing.— Wet-nurses.— Artificial feeding. 
 
 The puerperal state occupies the border-land between health and 
 disease. Though in a strict sense physiological, it otters a variety of 
 conditions, as Schroeder * has pointed out, whicli at other times, and 
 under other circumstances, would be regarded as pathological. Thus, 
 the exfoliation of the decidua, and the copious serous transudation, 
 with the abundant formation of young cells which accompanies the 
 development of the new mucous membrane, would elsewhere be re- 
 garded as characteristic features of catarrhal inflammation. The acute 
 degeneration of the uterus presents a phenomenon which, when re- 
 peated in any other organ of the body, would prove speedily fatal. 
 The thrombus formation in the open placental vessels possesses no 
 corresponding physiological analogue. Again, the torn vessels may 
 lead to haemorrhage, while the traumata which even in normal labor 
 result from parturition, the ease with which deleterious materials are 
 absorbed by the wide lymphatic interspaces, the serous infiltration of 
 the pelvic tissues, the exaggerated size of the lymphatics and veins, 
 create a predisposition to innumerable forms of disease. The nicety 
 of the balance between normal and morbid conditions renders it pecul- 
 iarly necessary for the practitioner to make himself familiar with the 
 physiological limits of the phenomena of childbed. 
 
 Post-partum Chill. — The exertion of labor is followed by a sense of 
 comfort and repose. Often, after the birth of the child, a chill sets in 
 
 * Schroeder, Handbuch der Geburtsliiilfe, 6te Aufl., p. 216.
 
 THE PHYSIOLOGY AND MANAGEMENT OP CHILDBED. 
 
 239 
 
 of greater or less intensity, but of short duration, and of no prof^nostic 
 importance. It is to be accounted for by the disturbance of the 
 equilibrium between the internal temperature and that of the external 
 surface. Thus, toward the end of labor, and for a short period sub- 
 sequent to delivery, the loss of heat is increased by the evaporation 
 from the lungs and skin and the cessation of muscular effort. This 
 cooling process is, however, speedly arrested by the contraction of the 
 cutaneous arterioles. During the period which intervenes until the 
 external and internal temperatures rise to relatively equal levels, the 
 l)atient experiences chilly sensations, or a distinct, well-defined chill* 
 This phenomenon is more frequent in hypera^sthetic women and in 
 those whose skins are bathed in profuse perspiration, especially where 
 there has been some necessary exposure of the person during the ex- 
 pulsion of the head or of the placenta. Under the influence of a 
 warm, dry bed, the chill at once subsides. 
 
 Temperature. — As a rule, it may be stated that the temperature 
 range in normal childbed does not differ materially from that which 
 prevails in non-puerperal conditions.f Still, a rise of temperature fol- 
 lowing the parturient act, averaging one and a half degree in primipara? 
 and one degree in multiparas, is not uncommon. This elevation may 
 continue during the first six days, with, however, morning remissions 
 and slight evening exacerbations. It is most pronounced in the first 
 twelve hours, especially when they coincide with the normal evening 
 increment. In the following days the highest point is usually reached 
 at five in the afternoon, while the lowest temperature is found in the 
 night hours between eleven and one. A sub-febrile temperature of 
 100^° has no prognostic significance. A temperature rise above 100^° 
 is by no means incomjsatible with a generally satisfactory condition 
 of the patient. Among the provoking causes of increased heat pro- 
 duction may be reckoned prolonged labor, fecal impaction, mental 
 excitement, the reaction of small wounds in the course of the geni- 
 tal canal, and the disturbances attendant upon the establisliment of 
 lactation. J 
 
 The Pulse.— In contrast to the increase in the temperature, the 
 pulse often exhibits a remarkable diminution in frequency, in perfectly 
 norjnal cases ranging between sixty and seventy beats, but not unfre- 
 quently dropping to a still lower level, and may even sink to less than 
 forty pulsations in the minute. This slowing of the pulse is of favor- 
 able prognostic import. It is known to be associated with diminished 
 
 ■"• Fehling, Klin. Beobachtungen Gberden Einfluss der todten Fruehto auf die 
 Miitter, Arch. f. Gynaek., Bd. vii, p. 15L 
 
 •f- Temesvary and Backer, Studien aus dem Gebiete des Woehenbettes, Arcii. f. 
 Gynaek., vol. xxxiii, p. 331. 
 
 t Vidp ScHROEDER, Schwangersohaft, Geburt und Wochcnbett, pp. 168-177; 
 SpiEGELBERG, Lelirbuch. p. 210.
 
 240 THE PUEttPERAL STATE. 
 
 arterial teusion,* and has beeu attributed to a variety of not very sat- 
 isfactory reasons, such as the sudden removal of the utero-placental 
 vessels from the circulation, entailing a less degree of labor upon the 
 heart, repose in bed, and disturbed action of the pneumogastric 
 nerves. It is usually most marked on the second or third day, and 
 does not appear to be specially influenced by the establishment of 
 lactation. 
 
 General Functions.— During the first week the skin is active and 
 moist ; the patient is, therefore, sensitive to temperature changes, and 
 is subject to profuse perspiration when warmly covered or during sleep. 
 The appetite is lessened, the thirst is increased, the bowels are slug- 
 gish, and the urine abundant. In spite of the light diet and repose 
 in bed, the amount of urea eliminated is but slightly diminished. 
 Sugar in the urine is observed at the time of the establishment of lac- 
 tation. It disappears soon afterward, to reappear, however, whenever 
 the milk production is in excess of its consumption.! The diabetes 
 is, therefore, due to absorption. J 
 
 Retention of Urine. — In the first day or two following confinement, 
 retention of urine is a common occurrence. It results, according to 
 Schroeder, from the increased capacity of the bladder following the re- 
 moval of pressure from the gravid uterus. !Many women who suffer 
 from retention when reclining are able to voluntarily urinate when 
 raised to a sitting posture, probably because of the greater facility with 
 which, in the latter case, the pressure of the lax abdominal parietes can 
 be exerted upon the bladder. 
 
 Loss of Weight. — Owing to the rapid retrograde changes in the 
 pelvic organs, the discharges from the genital passage, the increased 
 secretions of the skin and kidne3'S, combined with limited ingestion of 
 food, the loss of weight in the first week amounts to from nine to ten 
 pounds, or, roughly speaking, to about one twelfth the weight of the 
 body.* 
 
 Involution. — The processes by means of Avhich the uterus returns to 
 its non-puerperal condition are inaugurated at the commencement of 
 labor. During the rapidly following contractions of the uterus there 
 is, on the one hand, waste of tissue substance, engendered by the work 
 performed, while on the other, the compression of the nutrient vessels 
 diminishes the supply of reparative material. As a result of this dis- 
 turbed equilibrium, there ensues a fatty degeneration of the protoplasm 
 of the muscle cells. This process continues after the expulsion of tlie 
 ovum. At the same time, the individual muscular cells shorten and 
 
 * Meyberg, Ueber die Pulse der Wochnerinnen, Arch. f. Gynaek., Bd. xii, p. 114. 
 f JoHANN'ovsKY, Ueber den Zuckergehalt im Harne der Wochnerinnen, Arch. f. 
 Gynaek., Bd. vii, p. 448. 
 
 X Spiegelberg, loc. cit, p. 212. 
 
 « Gassner, Monatsschr. f. Geburtsk., Bd. xix, p. 47.
 
 THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 241 
 
 broaden, while transverse and longitudinal ridges form iipon them. 
 In this way, and by the absorption of the superfluous protoplasm, the 
 muscular cells are gradually reduced to normal dimensions. In from 
 six to eight weeks the process described reaches its completion. The 
 lochia then cease, and, in women who do not nurse, menstruation 
 returns. 
 
 Tlie view maintained by Hesclil, which long received the support of obstet- 
 rical writers, was in effect that subsequent to labor the entire muscular tissue of 
 the uterus underwent fatty degeneration, and that the oxidized products were 
 gradually absorbed. Meantime, a new formation of muscular cells, beginning 
 upon the periphery of the organ, about the fourth week, took the place of the 
 old elements. In accordance with this view, it has been customary to state 
 that witli the end of each pregnancy the old uterus was destroyed, and that a 
 new organ was built up upon its ashes. KoUiker admitted a partial destruction 
 and a partial new formation of muscle cells, but held that the greater number 
 of the enormously enlarged cells of pregnancy did not entirely disappear. 
 
 The view we have given is that defended originally by Luschka and Robin. 
 In studies preparatory to his work on Caesarean section, Sanger was perplexed 
 to see how union of cut surfaces could be secured by means of suture if the 
 theory of simultaneous acute fatty degeneration should be proved correct. 
 Careful observations made by him upon this point seem to settle the question 
 in favor of the more conservative natural process. * 
 
 Immediately after birth the uterus weighs upward of two pounds. 
 The peritoneal surface is covered with transverse, oblique, and longi- 
 tudinal ridges, and furrows corresponding to the direction of the un- 
 derlying muscular bundles. In two days the weight falls to a pound 
 and a half ; the uterus is seven to eight inches in length, and about 
 four and a lialf inches broad ; the walls are from an inch to an inch 
 and a half in thickness. At the end of a week the uterus weighs a 
 pound, and is five to six and a half inches long. At the end of two 
 weeks the weight is three fourths of a pound, the length five inches, 
 and the walls hardly a half-inch in thickness. Of course, the indi- 
 vidual variations from these averages are very great, f In six weeks 
 the process usually reaches the end, though the uterus remains ever 
 after somewhat larger and more rounded than in nulliparae— a change 
 due chiefly to an increase of connective tissue. 
 
 Repair of the Decidua.— With the expulsion of the ovum the outer 
 portion of the decidua vera for the most part adheres closely to the 
 reflexa, while the meshy portion, with the fundi of the glands, remains 
 attached to the uterus. The adherent portion consists of empty areolar 
 spaces, of gland septa, of lymphatic spaces and blood-vessels, while 
 
 * Vide The Involution of the Muscular Tissue of the Puerperal Uterus, by Dr. 
 M. Sanger, Annals of Gynjecology, Boston, July, 1888. 
 
 f BoRNER, Ueber deri puerperalen Uterus ; Sinclair, Measurements of the Uter- 
 ine Cavity, Trans, of the Am. Gynaec. Soc, vol. iv, p. 231. 
 Ifi
 
 242 THE PUERPERAL STATE. 
 
 only the fundal extremities are liued with glandular epithelium.* As, 
 however, the line of demarkation rarely takes place throughout the 
 entire decidua at any fixed level, fragments of the outer, more com- 
 pact layer may frequently be found here and there clinging to the 
 inner surface of the residual membrane.f 
 
 The uterine cavity is covered and in part filled with at first a bloody 
 and subsequently a muco-sanguinolent fluid containing blood and mu- 
 cus corpuscles, and decidua-cells in various stages of degeneration. 
 
 At the end of a week the mucous membrane measures at most from 
 a half to three quarters of a line in thickness ; the inner surface has 
 become smoother from the disintegration and exfoliation of adherent 
 shreds ; the glands, owing to diminished size of the uterus, are pressed 
 closer together, and assume a more nearly perpendicular direction ; the 
 gland-epithelium extends upward along the gland-walls to the surface 
 of the membrane ; the interglandular sjjaces are filled with lymphoid 
 cells, with blood-corpuscles, fat-granules, and epithelial cells, in a state 
 of fatty degeneration. As the regenerative process goes on, fine capil- 
 laries Avithout walls form in the interglandular substance, so that the 
 latter jn'esents the appearance of granulation -tissue. By the third week 
 these vessels of new formation stretch upward to the surface of the 
 mucous membrane, and by the sixth week the development of the vas- 
 cular network is complete. In the second week the lymphoid cells 
 begin to dissolve, and thus the glands are brought into near contact 
 with one another. Spindle-shaped cells of young connective tissue 
 are formed between the glands in the second week, and with continued 
 connective-tissue jjroliferation the flattened tubules arc drawn upward, 
 and assume a perpendicular direction. The epithelial cells at the 
 mouths of . the glands, which at first formed separate islets, approach 
 one another as the glands assume their normal positions, and by act- 
 ively multiplying spread from the circumference until they form a 
 continuous lining to the wounded surface. 
 
 As regards tlie principal features, the changes which take place at 
 the placental site are the same as those described elsewhere Avithin the 
 uterine cavity. Immediately after delivery, however, the surface pos- 
 sesses an uneven aspect, with elevations where the septa of the serotina 
 had penetrated between the placental cotyledons, and with intervening 
 depressions. The mouths of the torn vessels are closed by thrombi, 
 and large vessels are irregularly distributed beneath the attached resi- 
 due of the mucous membrane. The process of regeneration at the 
 placental site takes place somewhat more slowly than elsewhere within 
 the uterus. 
 
 * Leopold, Studien iiber die Uterusschleimhaut, etc., Arch. f. Gynaek., Bd. xii, 
 p. 180. 
 
 t KiJsTNER, Die LOsung der miitterlichen Eihaute, Arch. f. Gynaek., Bd. xiii 
 p. 422.
 
 THK PHYSIOLOGY A\I) MANAGEMENT OF CHILDBED. 9+3 
 
 Closure of the Sinuses.— Bv tlie eighth montli of pregnancy, as has 
 been mentioned, a portion of the sinuses beneatli the placenta are oblit- 
 erated by the emigration of giant-cells which cause coagulation of the 
 blood circulating through them. After delivery, the blood stagnates 
 in the intact vessels in such a way that at first the inner walls are 
 covered with fibrin, while the center contains fresh red blood. The 
 walls then thicken by proliferation of the endothelium, and lymph - 
 and blood -corpuscles penetrate into the coagulated layer. Finally, the 
 thrombus fills the entire vessel, spindle-shaped cells radiate from the 
 endothelium, and with the development of young connective tissue a 
 gradual shrinkage takes place, which, however, proceeds slowly, so that 
 four to five months after birth the placental site is still distinguishable.* 
 According to Eugehuann, pigmentary deposits in the tissue of the 
 mucous membrane are almost conclusive evidence of recent delivery, 
 as after menstruation they are not found, probably on account of the 
 superficial chai'acter of the haemorrhage. 
 
 The Cervix.— After delivery the cervix speedily resumes its normal 
 size. At first it has a soft and pulpy feel. The os internum forms a 
 resistant ring, which constitutes a well-defined boundary between the 
 corpus and cervix uteri. This ring varies in size in different subjects, 
 but is always sufficiently o])en to permit the introduction of two fingers. 
 Beneath, the walls are thrown into transverse and longitudinal folds. 
 The OS externum is usually torn, especially upon the sides, and the 
 thickened labia roll outward. The length of the canal measures tAvo 
 and three quarters inches and upward. At the end of twelve hours 
 the distinction between the cervix and vagina is clearly marked, and 
 the OS internum is so far closed that a certain amount of force is 
 requisite to pass two fingers into the uterine cavity. The contraction 
 of the OS internum renders the longitudinal folds more pronounced in 
 the upper portion of the canal. From this time on, the involution of 
 the cervix advances rapidly. At the end of twelve days the canal is 
 shortened to an inch in length. As the longitudinal muscles contract, 
 the plicas palmat* become distinct as transverse ridges. The longi- 
 tudinal folds, Avith the exception of the anterior and posterior ridge 
 which belong to the plic« palmate, disappear with the retrograde 
 changes which take place in the mucous membrane. The os exter- 
 num long remains patulous, and permits the finger to pass to the os 
 internum for a period varying between the seventh and fourteenth 
 days. The anterior lip is thicker than the posterior, and is frequently 
 the seat of erosions and granulations. The involution of the vaginal 
 
 * Leopold, Studien iiber die Uteriisschleimhaut. etc.. Arch. f. Gynaek.. Bd. xii. 
 p. 169 ; Engelmann, The Mucous Membrane of the Utenis, Am. Jour, of Obstel., 
 May, 1875 ; Spiegelberg. Lehrbuch, p. 214 ; Schroeder. Lehrbuch, p. 232 ; Ktsx- 
 NER, Die Losung der miitterlichen Eihiiute, etc., Arch. f. Gynaek.. Bd. xiii, p. 422 : 
 PbiedlXndkr, Arch. f. Gynaek., Bd. ix, p. 22.
 
 24-1: THE PUERPERAL STATE. 
 
 portion is not completed until after the expiration of five to six 
 weeks.* 
 
 The Vagina. — The vagina during the tlrst few days is soft, smooth, 
 and relaxed, and requires from three to four weeks to regain its nor- 
 mal dimensions. The contraction and involution proceed more rap- 
 idly at the introitus than above in the neighborhood of the fornix, 
 though, owing to the presence of lacerations, it remains, with few 
 exceptions, permanently wider than in women who have never borne 
 children. 
 
 Position of the Uterus.— Immediately after the expulsion of the 
 placenta the contracted uterus is felt through the abdominal walls as a 
 tirm, solid body, of a flattened, pyriform shape. When both hips are 
 on the same level, and both bladder and rectum are empty, the uterus 
 is found in the median line with the fundus between the symphysis 
 and the navel. At the same time the Aveight of the body and the 
 laxity of the abdominal walls lead to a moderate degree of anteflex- 
 ion. Urine in the bladder and fa»ces in the rectum give rise to a cer- 
 tain amount of lateral displacement, and now and then to a torsion 
 of the uterus upon its long axis. As in pregnancy, the fundus of the 
 uterus is thus generally, though not always, directed to the right, 
 and the left border looks to the front. The mean elevation of the 
 fundus above the symphysis is about four and one third inches, the 
 width of the fundus is upward of four and a half inches, and the 
 length of the entire uterine cavity, as measured by the sound, is in 
 the neighborhood of six inches. The dimensions of the uterus are 
 somewhat less in primiparae than in multiparae. A full bladder pushes 
 the fundus upward, and increases the longitudinal diameter of the 
 organ. Borner has observed an increase from this cause amounting 
 to three and a half inches. 
 
 A diminution in the size of the uterus is apparent in most cases in 
 the course of the first twenty-four hours. An actual increase is either 
 pathological, or due to the above-mentioned influence of the bladder. 
 The diminution is most marked in the first twenty days, but afterward 
 progresses at a slow rate. About tht tenth day the fundus sinks below 
 the level of the symphysis pubis, and the posterior surface of the ante- 
 fleeted uterus occupies the plane of the brim.f 
 
 After-Pains. — The reduction of the uterus in the first few days of 
 
 * LoTT, Zur Anatomie und Physiologie der Cervix Uteri, pp. 87 ei seq. BOrner, 
 Ueber den puerperalen Uterus, p. 47, states that at the end of the second week the 
 OS internum permits the passage of the finger in about half the cases, but is closed 
 in all by the end of the third week. 
 
 f BoRNER, loc, cit. ; Crede, Beitrage zur Bestimmung der normalen Lage der 
 gesunden Gebarmutter, Arch. f. Gynaek., Bd. i, 1870, p. 84; Pfannkuch. Ueber die 
 Eyifluss der Nachbar-Organe auf die Lage und Involution der puerperalen Uterus, 
 Arch. f. Gynaek., Bd. iii, 1872, p. 327.
 
 I 
 
 THE PHYSIOLOGY AND MANAGEMENT OF ( IlllJ)i;i;i). 245 
 
 tlie childbed period is in the main the result of contractions, termed 
 after-pains, resembling those of labor both as regards the hardenino- of 
 the uterine walls perceptible through the abdominal coverings, and the 
 nature of the dolorous sensations which they evoke. The after-pains 
 stretch over a period varying from one to four days. Their duration 
 and intensity are in inverse proportion to the duration and activity of 
 the preceding labor. On this account they are more pronounced in 
 multiparas, while they are often absent subsequent to a first delivery. 
 They are intimately associated with the permanent retraction of the 
 uterus, and are therefore to be regarded as a normal and favorable 
 phenomenon. T'hey are especially prominent in cases of overdisten- 
 tion of the uterus, as, for instance, in cases of twin pregnancies and 
 hydramnios. Suckling the infant produces reflex contractions of a 
 somewhat intense character. 
 
 The Lochia. — 'I'he discharges from the genital passage consequent 
 upon delivery are termed the lochia. At first the latter are composed 
 of pure blood with coagula of fibrin, but after a few hours the wounded 
 surface of the uterus furnishes an abundant exudation of a serous, alka- 
 line fluid, which washes away in its descent the secretion from the cer- 
 vix and the vaginal mucus. For the first two or three days the lochia 
 are of a red color {lochia ri(brn) from the commingling of blood, while 
 upon the third, fourth, and sometimes upon the fifth day, as the san- 
 guineous elements diminish, they present a pale-red color (lochia serosa). 
 As constituents, we find under the microscojie cervical and vaginal epi- 
 thelium, blood and mucus corpuscles, bits of decidua, and sometimes 
 shreds of membranes and of the placenta. The organic constituents 
 consist of albumen, mucine, the saponified fats, and a variety of saline 
 matters. From the fifth to the seventh or eighth day the discharge 
 continues thin, but the blood-corj)uscles become less abundant, while 
 there is an increase in leucocytes and fatty globules. In the second week 
 the discharge becomes of a grayish- white or greenish-3^ellow color (lochia 
 alba sen lactia), and of a creamy consistence. It contains chiefly leu- 
 cocytes, young epithelial cells, spindle-shaped connective-tissue cells, 
 fat-granules, free fat, and crystals of cholesterine. The reaction is 
 neutral or acid. Gradually the discharge diminishes, becomes trans- 
 parent, and finally assumes a normal appearance. The vaginal lochia 
 in the rule are found to contain a variety of micro-organisms, such as 
 the diplo- and strepto-cocci, rod bacteria, the trichomonas vaginalis, and 
 sometimes gonococci. They vary greatly in quantity, and increase in 
 abundance with the advance of the puerperal week. They are derived 
 in part from germs present in the vagina previous to confinement, and 
 in part obtain entrance through the vulva. In the vagina the condi- 
 tions for their development are peculiarly favorable. The number can 
 be greatly limited by hygienic measures. When they obtain access to 
 the uterine cavity their power for evil is grciitly .-uigmontod. Toward
 
 246 
 
 THE rUKUPHKAL STATE. 
 
 the end of the first week, and, espeeiall}' after leaving the bed, fresh 
 blood often makes its appearance.* 
 
 The quantity of the lochia varies with the peculiai'ities of the indi- 
 vidual. It is, as a rule, greater in nuiltipar;v, in women who do not 
 uurse their children, and in those of flabby fiber, who habitually men- 
 struate abundantly. The mean quantity, according to Gassner, of the 
 lochia omenta or rubra (to fourth day) amounts to nearly two and a 
 fourth pounds ; of the lochia serosa (to sixth day) to rather more than 
 nine ounces; and of the lochia alba (to ninth day) to six and two thirds 
 ounces; so that the entire amount lost during the first eight days 
 reached the total amount of nearly three and a quarter pounds. 
 
 The Secretion of Milk. 
 
 Anatomical Considerations. — The breasts, which furnish the secre- 
 tion of the milk, are two large glands of the compound racemose vari- 
 ety. They are covered by a fine, su]i]ile skin and a layer of adipose 
 
 I 
 
 Fig. 129.— Mammary gland, a. nipple, the central iwrtiou of which is retracted : b, areola : 
 c, c, c, c, c lobules of the gland ; 1, sinus, or dilated portion of one of the lactiferous ducts ; 
 A extremities of the lactiferous ducts. (.Liegeois.) 
 
 tissue, which increases in thickness toward the periphery of the organ. 
 The mass of the glandular substance is composed of from fifteen to 
 
 * Fide ScHBOEDER. Lehrbuch, etc., 6te Aufl.. p. 226; Spikoklberg LehrbTK'h 
 p. 218.
 
 THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. -f^- 
 
 twenty-four lobes, which in turn are subdivided into lobules made u]) 
 of a greater or less number of acini, or culs-de-sac. Fine canaliculi 
 start from the latter, and unite together to form the canals of the 
 lobules. These again anastomose, to form a principal canal for eacli 
 lobe, termed the lactiferous ducL The lactiferous ducts terminate at 
 the nipple by small openings measuring only from one sixtieth to one 
 fortieth of an inch. Each duct, as it passes downward, enlarges in the 
 nipple to one twenty-fifth or one twelfth of an inch in diameter, aud 
 beneath the areola it presents an elongated dilatation, from one sixth 
 to one third of an inch in diameter, called the sinus of the duct 
 (Flint). The spaces between the lobes are filled with adipose tissue, 
 and the various elements which constitute the mammary glands are 
 united into a single mass by a dense connective tissue continuous with 
 that of the subcutaneous layer. The acini, which are merely rudiment- 
 ary in the non-pregnant state, are lined with a single layer of small 
 polyhedral cells, assuming a more cylindrical character in the neighbor- 
 hood of the canalicular ducts. The main ducts are lined with low 
 cylindrical cells, and contain m their walls non-striated muscular fibers, 
 the contractions of which are the cause of the spurting of the milk in 
 lactation. 
 
 During pregnancy the breasts enlarge m consequence of the swell- 
 ing and increase of the connective tissue, the accumulation of fat 
 between the lobes, and the multiplication of the acini, which fill with 
 fatty globules resulting from the disintegration of the lining epithelial 
 cells. The changes in the secretory apparatus give rise to irregularly 
 distributed nodular cords, which, however, at first are most distinct 
 at the periphery, and thence advance toward the center of the organ. 
 With continued development a lactescent fluid is produced, which 
 either exudes spontaneously from the nipple or is discharged by 
 pressure. 
 
 Milk-Fever. — About the third or fourth day of the childbed period 
 the turgescence of the breasts is suddenly increased, and they become 
 full, tense, nodular, and sensitive to the touch. The axillary glands 
 enlarge, and radiating pains are experienced in the arm and shoulder. 
 The intensity of the mammary congestion varies in differejit individ- 
 uals. It is more pronounced in women who postpone nursing their 
 children until after the secretion of milk is fully established. In ex- 
 ceptional cases it may be absent altogether. Since the general intro- 
 duction of the thermometer into practice, and the better understanding 
 of the causes of febrile temperatures in the puerperal state, the exist- 
 ence of a distinct milk-fever referable to functional disturbances in 
 the breasts during the period in question has been found to be an en- 
 tirely exceptional occurrence. The temperature tables which have 
 been kept with great regularity for the past ten years in the Maternity 
 Hospital of this city prove that, under normal conditipns, the tempera-
 
 248 
 
 THE PUERPERAL STATE. 
 
 tares of tlio third day do not rise above 100^°. With tliis sub-febrile 
 increase there is, indeed, often conjoined considerable general dis- 
 turbance, indicated by slight chilly sensations, headache, anorexia, 
 and a quickened pulse, which, however, disappear in the course of 
 twenty-four hours, with profuse perspiration, and an abundant secre- 
 tion of milk. Most writers regard the higher temperatures which are 
 sometimes found associated with extreme turgescence, tenderness, and 
 
 Fifi. 180.- Section tliroujili iiL-iiiiis from breast of a nursing woman. iBiUroth.) 
 
 reddening of the mammae, and which subside when the latter are 
 partially unloaded, as dependent upon a non-suppurative form of 
 parenchymatous inflammation. 
 
 Composition of Milk. — Milk is composed of a fluid portion and of 
 formed constituents, the first derived from the blood, and the second, 
 termed the milk-globules, from the epithelial contents of the acini. 
 In the production of the milk-globules the gland-cells actively mul- 
 tiply^ and become filled with granular particles, which gradually co- 
 alesce to form drops of fat. Subsequently the nuclei and the contours 
 of the cells disappear, so that the latter consist of mulberry-shaped 
 aggregations of fat-drops held together by the remains of the cell-pro- 
 toplasm. The epithelial elements thus metamorphosed are termed 
 colostrum-corpuscles. They are found sparingly distributed in the 
 crude, imperfectly formed secretion known as colostrum, which is fur- 
 nished by the breasts of women who have been but recently confined. 
 Finally, the fat-globules of large and small size separate from one 
 another, and form an emulsion with the fluid transuded from the 
 blood, a process aided, according to Kehrer, by the diffusion through 
 the fluid of the residual protoplasm of the cells.* 
 
 * Kehrer. Zur Morphologie des Milch-Caseins, Arch. f. Gynaek., Bd. ii, p. 1.
 
 THE PHYSIOLOGY AND MANAGEMENT OP CHILDBED. v^i) 
 
 Colostrum is a watery, semi-opaque, mueiliagiuous fluid, containing' 
 yellowish streaks composed of fat-globules and fatty-degenerated cells 
 which hang together in stringy masses. It is distinguished from true 
 milk not only in the physical characteristics mentioned, but in the 
 greater proportion of sugar and inorganic salts it contains, and in the 
 . fact that it coagulates upon boiling. It possesses laxative qualities, 
 wliich render it of use to the infant in aiding the removal of the me- 
 conium. 
 
 Perfectly formed milk contains from 2-5 per cent to 7-6 per cent 
 butter in emulsion, and from 3-2 per cent to six per cent milk-sugar 
 in solution. Both of these substances are directly manufactured by 
 the gland-structures. It possesses likewise a protein substance termed 
 casein, which fluctuates in quantity between one, three, and four per 
 cent. Kehrer maintains that it is not held in the milk in solution, 
 but is composed of particles derived from cell-protoplasm which are 
 diffused through the fluid. The salts in the milk amount to 0*14 per 
 cent.* 
 
 The Diagnosis of the Puerperal State. — The diagnosis of recent de- 
 livery is based upon the physiological conditions which, we have seen, 
 characterize the puerperal state. Thus, the abdomen is flabby and 
 wrinkled, with pigmented linea alba, and is traversed by white and red 
 lines ; the breasts are full, tense, and nodular, and secrete milk or 
 colostrum ; the areola about the nipple is discolored ; the uterus is 
 enlarged, anteflexed, palpable through the abdominal wall, and is ex- 
 cited to contract by pressure ; the vulva is swollen, the labia gape 
 apart, the hymen is ragged, the perineum is distensible, and in recent 
 cases lacerations, in older ones ulcers or granulating wounds, are found 
 about the vaginal orifice ; in the smooth, lax vagina there is observable 
 the absence of the columns rugarum ; the cervix is soft, wide below 
 and narrowing above, with the labia often torn and contused ; when 
 the finger can be passed into the uterine cavity, thrombi may be 
 felt at the placental site; finally, the lochia are hardly likely to 
 be confounded with haemorrhages or discharges from non-puerperal 
 causes. 
 
 During the first two weeks an approximative estimate may be made 
 as to the date of confinement by bearing in mind that just after de- 
 livery colostrum is found in the breasts, the lochia are bloody, and the 
 lacerations about the vulva present a fresh appearance ; that during 
 the following days the lochial secretion changes first to a serous and 
 then to a purulent character ; that the uterus gradually diminishes in 
 size, the fundus at the tenth day sinking below the upper border of the 
 symphysis, while the os internum remains patulous to the tenth day, 
 and is usually impassable for the finger after the twelfth day. 
 * Spiegelberg, loc. cit., p. 221.
 
 250 
 
 THE PUERPERAL STATE. 
 
 The Xew-borx Ixfant. 
 
 With the first inspiration the thorax exjiands and air fills the 
 alveoli of the lungs ; at the same time the blood passes from the right 
 side of the heart to the capillaries of the pulmonary organs, and is 
 returned arterialized to the left side of the heart. As a consequence 
 of the establishment of the pulmonary circulation, the ductus arteri- 
 osus contracts, the foramen ovale closes, and the left ventricle under- 
 goes eccentric hypertrophy. With the diversion of a part of the blood- 
 currents to the lungs, the pressure in the aorta sinks, and the circula- 
 tion in that portion of the umbilical arteries which lies outside the 
 navel ceases, while thoracic aspiration empties the umbilical vein. The 
 cord dries from the cut surface toward the navel, and drops off on the 
 fourth or fifth day. The line of demarkation forms at the termina- 
 tion of a capillary network which extends upward upon the cord to a 
 distance of from three to four lines from the skin. When the cord 
 drops off, a wounded surface is left, which heals in a few days. 
 
 The swelling upon the presenting part subsides mostly in twenty- 
 four to forty-eight hours. The head slowly resumes its normal shape 
 — a process completed, probably, in the course of two to thi-ee weeks. 
 
 Soon after birth the meconium is discharged from the intestines, 
 and in a few days the evacuations assume a feculent character. The 
 production of pepsin in the stomach, and the secretion by the pancreas 
 of a fluid capable of emulsifying fats and digesting albuminoid sub- 
 stances, render the assimilation of milk practicable. The kidneys 
 excrete an abundance of urine of a low specific gravity. 
 
 About the third day an exfoliation of the epithelium begins, which 
 is maintained for a week, or even a longer period. During this time 
 the hyperaemia of the skin is very marked, and imparts to it a red 
 color, which as it fades passes into a yellowish tint. The breasts in 
 both sexes swell very commonly, become red and sensitive, and yield 
 upon pressure a serous, milky fluid. 
 
 Icterus of the new-born infant is a pretty common affection. Its 
 occurrence is, however, largely influenced by local conditions. Thus, 
 Porak placed the frequency at eighty per cent among the children 
 born in the Hopital Cochin in Paris ; Kehrer, in the vast maternities 
 of Vienna, at sixty-eight per cent ; Ebstein, in Prague, at forty-two 
 per cent ; while West declares it is a rare phenomenon at the Rotunda 
 Hospital in Dublin. It develops usually upon the second or third 
 day, and ends, as a rule, by the sixth to eighth day. Kehrer * has 
 shown statistically that it occurs more frequently in boys, in prema- 
 ture mfants, in the children of primiparae, and as a consequence of 
 malpresentations. It is likewise promoted by atelectasis, by intestinal 
 
 * Kehrer, Studien iiber den Icterus Neonatorum, Jahrbuch f. Paediatrik, Bd. 
 ii, p. 71, 1871.
 
 THE PHYSlULOGV AND MANAGEJMKNT OF CHILDBED. 251 
 
 affections, bv depressing the temperature of the child, by insufficient 
 feeding, and, in a word, by all the various patliological conditions and 
 unfavorable hygienic influences intensifying or giving an abnormal 
 direction to the ordinary changes which take place in the blood (Eb- 
 stein). Its frequency in lying-in hospitals is probablv connected with 
 a septic infection, for which the wounded surface at the navel furnishes 
 the point of entry. It is rarely dependent upon gastro-duodenal ca- 
 tarrh, npon a narrowing of the bile-duct, or upon retention of meconi- 
 um. The ffeces are stained with bile. In all the tissues of the body, 
 and most abundantly in the kidneys, pigment-crystals and yellowish- 
 red amorphous granules are fonnd deposited in greater or less quanti- 
 ties. It is as yet an unsettled question as to Avhether these pigment- 
 bodies are the products of the liver or result from the disintegration of 
 the blood-corpuscles. A very considerable destruction of the latter is 
 found in all cases of icterus of the new-born. The tissue-waste is like- 
 wise marked. Hofmeier * found the average loss of weight in icteric 
 children on the third day after birth was 9-3 per cent of the original 
 weight, whereas in non-icteric children it was but 5-69 per cent. The 
 urine contained an excess of nrea and uric acid, and pigment-bodies 
 proportioned to the intensity of the icterus. The pigment-bodies, he 
 claims, 'nirnished the characteristic color reaction with nitric acid of 
 the acids of the bile. An expectant treatment is the only rational one. 
 Laxatives are unnecessary, and perhaps harmful. f 
 
 Owing to the discharge of meconium and urine, and the limited 
 amount of sustenance at its disposal, the new-born infant experiences 
 a loss of weight in the first two or three days, estimated at from seven 
 to eight ounces. After the second or third day the loss is gradually 
 i-eeovered, so that between the fifth and eighth days the weight at birth 
 is reached. The loss of weight is greater in the children of primipara? 
 than in those of multipara?, in artificially nourished infants, and where 
 the immediate application of the ligature to the cord at birth has been 
 resorted to. 
 
 The Maxagemext of the Puerperal State. 
 
 Sleep.— After every precaution has been taken against haemorrhage, 
 after the i):itient has been washed carefully and i)laced upon clean, dry 
 l)edding, and after the baby has been bathed and dressed, it is very de- 
 sirable that the mother should enjoy a few hours of refreshing sleep. 
 To this end the room should be darkened and absolute stillness en- 
 forced. The crying of the baby, the affectionate salutation of friends, 
 or the tidying of the room by household Marthas, often becomes the 
 
 * Hofmeier, Die Gelbsucht der neugeborencn, Ztschr. fiir Geburtsli. iiml Gyiiaek., 
 vol. vii, p. 287. 
 
 t Ebstein, Ueber die Gelbsucht bei neugeboiviu'ii Kiiuloni. Volkiiiiiiurs Sanunl. 
 klin. Vortr., No. 180.
 
 252 
 
 THE PUERPERAL STATE. 
 
 starting-point of nervous restlessness, which is with difficulty over- 
 come by the aid of the strongest soporifics. Should the mother 
 feel faint and exhausted, she should be allowed a cup of hot tea or 
 bouillon. 
 
 In multipara it is well to leave with the nurse some form of ano- 
 dyne, to be administered in case sleep is interrupted by the frequent 
 recurrence and severity of the after-pains. Opiates, while they lull 
 the pain, do not, after labor, arrest those physiological changes in the 
 uterus with which the after-pains are associated. 
 
 Passing Urine. — As the natural impulse to urinate after delivery is 
 very feeble, even when the bladder is full, the nurse should be instructed 
 to solicit the patient to pass water in the course of eight or ten hours. 
 It is usually recommended that the act of urination should be performed 
 upon the back, which, of course, necessitates the use of the bed-pan. 
 It has been my own rule to enforce the dorsal position during the first 
 days of childbed, but there are a good many women who are able to 
 pass water without difficulty in the sitting posture, who fail in the 
 attempt. when recumbent. Goodell therefore advocates the practice of 
 raising the woman for purposes of urination from the beginning of 
 childbed. He believes that the occasional assumption of the ujjright 
 attitude for a brief period possesses the advantage of promoting drain- 
 age of the parturient canal, and of forestalling the evils incident to 
 lochial stagnation in the vagina. The belief tliat such a course in- 
 creases the risk of haemorrhage he regards as unfounded. The physician 
 should make it a rule to visit his patient within twelve hours from the 
 time of confinement. He should then inquire not only whether she 
 lias passed water, but ascertain the quantity voided. If the quantity 
 has not exceeded three to four ounces, he should introduce the catheter 
 and make sure that the bladder is completely emptied. In cases of re- 
 tention, the urine should be drawn at least four times in the twenty- 
 four hours. Before using the catheter, the lochia should be carefully 
 washed from the external parts with a warm carbolized fluid (two per 
 cent), as the lochial discharge after the first day is liable to excite 
 cystitis. Both the catheter and the operator's hand should be surgi- 
 cally clean. In passing the catheter beneath the bedclothes, the ure- 
 thral orifice can readily be detected by first feeling for the tumefied 
 urethra with the index-finger of the right hand through the anterior 
 vaginal wall, and then following it in a forward direction until the 
 meatus is reached. 
 
 Visits of the Physician. — The physician should see his patient at 
 least once daily during the first week following confinement. During 
 the first four days it is my custom to make both a morning and evening 
 visit, not only for the purpose of noting carefully the pulse and tem- 
 perature, but to be sure that my patient is not made a victim to ti-adi- 
 tional prejudices and siiperstitions. If tlie physician will take the
 
 THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 253 
 
 trouble to call occasionally upon his patient subsequent to the first 
 week, to insure the unretarded progress of puerperal convalescence, he 
 will do much to circumscribe the field of gynaecological practice. 
 
 General Directions. — Great care should be taken to keep the air of 
 the lying-in chamber fresh and pure. If the room is warm, the patient 
 sliould be lightly covered, owing to the tendency during childbed to 
 profuse perspirations. There is no foundation for the prevalent belief 
 that it is dangerous to comb the hair of a puerperal woman. Nothing 
 contributes so much to the removal of soreness, and the healing of 
 wounds in the genital canal, as cleanliness. 
 
 Where the antiseptic pad is employed this object is attained by 
 thoroughly washing the external parts with a bichloride (1 : 5,000) or a 
 carbolic solution (two per cent), whenever it becomes necessary to 
 change the pad either by reason of the evacuation of the bowels or 
 bladder, or because of the saturation of the pad with the lochial dis- 
 charge. From the latter cause alone a change once in four hours in 
 the early childbed period is to be advocated. The pad removed should 
 be destroyed. 
 
 When the ordinary napkin is used external ablutions should be em- 
 ployed several times daily. It is a question whether the present tend- 
 ency to prohibit the vaginal douche is warranted. Against its employ- 
 ment it may be urged, that in spite of the addition of carbolic acid or 
 corrosive sublimate there is statistical evidence that the vaginal douche 
 augments the chances of infection. In hospital practice it has invariably 
 increased the morbidity and mortality rate. In my own private prac- 
 tice, on the other hand, it has proved to many patients a source of 
 comfort. When carefully administered by nurses trained to aseptic 
 work it has given rise to no injurious symptoms, and I still occa- 
 sionally employ it — not, however, as a prophylactic, but because of 
 the property possessed by hot vaginal injections to assuage pelvic dis- 
 comfort. ^^.^ 
 
 Diet— The diet should be selected with reference to the physio- 
 logical requirements of the patient. Thus, during the first three days, 
 when, as a rule, the patient is thirsty and is indifferent to solid food, 
 the diet should consist of gruel, milk, milk-toast, and tea ; to which 
 may be added clear soups and bouillon, and soft-boiled eggs, should 
 more stimulating aliments be called for. It is equally desirable, on the 
 one hand, to avoid exciting colics and catarrhal affections of the stomach 
 by too early resorting to a substantial regimen, and, on the other, to 
 remember that the speedy establishment of an abundant milk secretion 
 is apt to be hindered by subjecting women to a process of semi-starva- 
 tion. After the bowels have moved on the third or fourth day, the 
 normal appetite usually returns. All easily digested articles of food, 
 such as eggs, chicken-broth, small birds, steak, chops, and the like, 
 according to the taste of the patient, should then be allowed. Cooked
 
 254 THE PUERPERAL STATE. 
 
 fruits are of service in overcoming the natural constipation of the 
 puerperal period. The popular prejudice against fish and vegetables 
 containing a large amount of nitrogenized substances seems to me well 
 founded. 
 
 Laxatives. — The canonical practice of administering a laxative on 
 the third day is of unquestionable utility. In most women there 
 occurs an accumulation of fecal matter during the last weeks of preg- 
 nancy — an accumulation which is often enormous in quantity, and 
 which creates a predisposition to puerperal affections. The remedies 
 selected should, however, be adapted to the peculiarities of the individual. 
 In some women an ordinary injection of soap and olive-oil in water 
 suffices to procure an adequate evacuation ; in others, the object is ful- 
 filled by the milder laxatives, such as the compound rhubarb pill, a 
 claret-glass of Huuyadi-Janos water, or the compound licorice jjowder 
 of the German pharmacopoeia ; while in obstinate cases a calomel purge, 
 or some such combination as the post-jjaritim pill of the late Prof. 
 Barker,* will be found requisite. Castor oil I give only in cases of 
 severe colic, either alone or combined with fifteen drops of laudanum. 
 In hemorrhoids complicating puerj^eral convalescence, I can add my 
 testimony to that already given by Prof. Barker as to the specific 
 curative effect of half-grain doses of aloes administered night and 
 morning. 
 
 Nursing. — Every healthy woman should nurse her child at least 
 through the puerperal period.f The advisability of continuing lacta- 
 tion subsequent to the resumption of household duties must depend 
 upon the question as to whether the mother is in a position to make 
 the necessary sacrifices to the interests of the child. When the do- 
 mestic and social demands upon her time and thoughts are numerous 
 and pressing, lactation is apt to be imperfect, and the child will not 
 thrive. Humanity, in such cases, requires that the child be surren- 
 dered to a wet-nurse. Nursing may be rendered impossible by a lack 
 of milk, by flattened, misshapen nipples, and by the health of the 
 mother. It should be prohibited in phthisis, in epilepsy, and in cases 
 of syphilis contracted shortly before the birth of the child. 
 
 The child should be applied to the breast after the mother has 
 rested, and within the first twelve hours following the end of labor. 
 Soon after birth the child seizes the nipple eagerly, and though the 
 quantity of nourishment obtained is small, it is infinitely better adapted 
 to the child's needs than the catnip-teas and sweet oil which monthly 
 
 * Ext. colocynth. comp., 3j ; ext. hyoscyami, gr. xv. ; pulv. aloes soc, gr. x.; 
 ext. nuc. vom., gr. v. : podophyllin, ipecacuanha, aa, gr. j. M. Ft. pil. (argent.) No. 
 xii. Of these, two usually act efficiently and without causing pain. 
 
 t The quantity of milk daily consumed by the infant during the first nine days 
 increases, according to Deneke, gradually from one ounce and a half on the first 
 day to about fourteen ounces on the ninth day. Ueber Ernahrung des Sauglings, 
 Arch. f. Gynaek., vol. xv, p. 340.
 
 THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 9 
 
 Z.)i> 
 
 nurses employ as substitutes. The early apjolication of the child to 
 the breast benefits the mother by promoting the contractions and the 
 involution of the uterus, and by lessening the painful distention of the 
 breasts which occurs at the time when the function of lactation is fully 
 established. 
 
 As the child sleeps for the most part during the first few days of 
 existence, no rule can be laid down with regard to the frequency with 
 which it should be placed to the breast. Afterward it should be ac- 
 customed to some regular routine. So long as the stomach is of small 
 capacity and regurgitates a portion of its food, the interval should not 
 exceed a couple of hours. From an early period, however, the child 
 should be accustomed to sleep six hours at night, which gives an op- 
 portunity for the mother to recuperate her strength. This discipline is 
 of course not practicable where the child sleeps in the same bed with 
 the mother. After six months the child should not nurse oftener than 
 five or six times in the twenty-four hours. 
 
 The breasts should be suckled in alternation. The nipples should 
 be carefully washed both before and after nursing. The addition of 
 boric acid to the water prevents the development of fungi. The ex- 
 treme sensitiveness of the nipples at the commencement of lactation 
 can be greatly relieved by applying constantly to them a rag wet with 
 the liquor plumM subacetat.j in the proportion of a teaspoonful to a 
 tumbler of water. For a few days a metallic shield over the nipples, 
 to prevent the rubbing of the night-dress or the bedclothes, is a source 
 of comfort. 
 
 Duration of Lying-in Period. — Most women expect permission to be 
 given them to sit vip ujjon the tenth day. There should, however, be 
 no fixed rule about leaving the bed which does not take into account 
 the individuality of the specific case. Not to leave the bed before the 
 tenth day is a safe rule in normal puerperal convalescence ; but, where 
 there are wounds to heal by granulation, a much longer period of time 
 may be necessary. Garrigues * expressed his conviction that " the up- 
 right and sitting postures ought to be carefully avoided until involu- 
 tion has proceeded so far that the uterus has receded from the anterior 
 wall of the abdomen and returned to the pelvic cavity " — a rule which 
 would allow one woman to sit up in a week, while another would be 
 kept in bed two weeks, or even longer. The continuance of the lochia 
 rubra should serve as a warning against a change to the upright posi- 
 tion. The first attempt at getting up should be tentative. The re- 
 sumption of household duties should be postponed until the patient 
 can walk about without fatigue or backache. When the abdominal 
 walls are greatly relaxed, a well-fitted bandage should be worn for 
 weeks subsequent to delivery. 
 
 * Garrigues, Rest after Delivery, Am. Jour, of Obstet., October, 1880, p. 861.
 
 256 THE PUERPERAL STATE. 
 
 The Cake of the JS^ew-bokn Infant. 
 
 As the new-born infant possesses feeble powers of resistance to 
 cold, the first bath should be ninety-eight degrees, or nearly that of 
 the body. The vernix caseosa should be softened by oil or fat-inunc- 
 tion, and gentleness employed in its removal. The child should then 
 be gently dried in soft, warm cloths, and carefully examined with 
 reference to any possible defect of formation or development. The 
 cord should be wrapped in absorbent cotton,* and held in place upon 
 the left side by a flannel bandage. After the cord has separated, the 
 wounded surface should be dressed with iodoform, or bismuth powder. f 
 The clothing of the child is the province of the nurse, and varies con- 
 siderably in the different social ranks. Cleanliness and fresh air are 
 essential to healthy development. To avoid sprue, the mouth of the 
 child should be washed with cool water each time after nursing. 
 
 Selecting a Wet-Nurse.— Should the mother be unable to nurse her 
 child, a wet-nurse should be urgently recommended. In selecting the 
 latter, an examination should be made with regard to her constitution 
 and health. The physician should, by inspecting the throat, the legs, 
 the glands of the neck, and, if possible, the genital organs, exclude 
 the existence of a syphilitic or strumous taint. A nurse should be 
 between twenty and thirty-five years of age, and should present all the 
 appearances of good health. The gums should be red and firm ; the 
 breasts should preferably possess a pyriform shape, and should be mar- 
 bled with blue veins ; it is not necessary that they should be large, but 
 they should be firm, elastic, and nodular from abundance of glandular 
 structure ; the nipples should be well formed, prominent, and free 
 from cracks and erosions ; the milk should flow easily, and not be too 
 bluish in color ; the age of the milk should bear some correspoTidence 
 to that of the child to be suckled. Aside from the question of adapta- 
 bility, it is obvious that, where a great discrepancy exists, the milk of 
 the nurse is liable to fail before the time of weaning is reached. One 
 of the best tests of a nurse's capacity is the appearance of her own 
 child. If the latter is plump, with well-rounded limbs, and with a 
 healthy skin and mucous membranes, the presumptions are in her 
 
 * This plan, which I first saw recommended by Dr. W. D. Babcock, of Evans- 
 ville, Indiana (Am. Jour, of Obstet., October, 1888, p. 1055), has since been warmly- 
 praised by Crede and Weber, Arch. f. Gynaek., vol. xxxiii, p. 73. 
 
 f Dr. Goodell seizes the cord, after it has been cut as usual, between the thumb 
 and forefinger of the left hand, near the navel, and then strips off the gelatin of 
 Wharton with the thumb and forefinger of the right hand. The pressure at the 
 navel is next temporarily suspended where the internal portions of the vessels 
 collapse. The cord is thereupon subjected to a second stripping, tied in the usual 
 manner, and left free without any dressing whatever. The result is that it separates 
 without any bad smell. ( Vide Parry's note, Leishman's Midwifery, third American 
 edition, p. 608.)
 
 THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 257 
 
 favor, even if she does not present in her own person, as Jacobi sport- 
 ively suggests, a "combination of Aphrodite, Athene, and Psyche." 
 When a choice has once been made, a change should not be recom- 
 mended without a fair trial. It is by no means uncommon for a nurse 
 but recently separated from her child, placed among strangers, and 
 introduced to a foreign mode of life, to temporarily puffer from a dimi- 
 nution of the lacteal secretion, the milk returning in a brief period 
 under the influence of kindness, habit, and a nourishing regimen. 
 Moderate exercise is necessary for the maintenance of health. The 
 nurse should be allow^ed to drink milk freely, but malt liquors should 
 be prohibited, at least until toward the close of lactation. 
 
 Artificial Feeding. — If it is impossible to procure the services of a 
 wet-nurse, or if the aversion of the parents to wet-nurses as a class 
 proves unconquerable, artificial alimentation must be tried. It is un- 
 questionable that many babies thrive fairly when brought up on the 
 bottle. For success, scrupulous cleanliness, punctuality, intelligence, 
 and experience are requisite. The beautiful roundness of outline, the 
 Men aise, and the easy dentition of infants at the breast are, however, 
 rarely attainable by those who are brought up by hand. Bottle-fed 
 infants are apt to be lean, to be subject to attacks of indigestion, and 
 to suffer from nervous disturbances when teething. If cow's milk is 
 used as a substitute for human milk, the experiment is more likely to 
 prove a success in the country, where the milk can be obtained fresh 
 morning and evening, than in the city, where milk is of necessity at 
 least twelve hours old at the time of delivery, and thirty-six hours 
 old before a fresh supply can be obtained. My own experience inclines 
 me to favor employing, where it is practicable, milk from one cow, 
 especially if the cow is selected with reference to the child's individu- 
 ality, precisely in the same manner as a wet-nurse would be selected. 
 The fitness of the milk to the child is to be determined rather by ex- 
 periment than by analysis. In a general way, however, it is well to 
 remember that the milk of a very young cow is deficient in fat-glob- 
 ules, while that of an old cow is apt to err on the side of excessive 
 richness, and that either extreme is equally liable to tax the infantile 
 organs of digestion. 
 
 The difference in the digestibility of human and cow's milk is de- 
 pendent upon a difference in the molecular arrangement of the casein 
 varieties they respectively contain. The acid of the stomach precipi- 
 tates human casein in the form of flocculent shreds, while that of the 
 cow's milk is converted into firm, solid masses. Now, of the two forms 
 it has been experimentally proved that the former is much more solu- 
 ble in the gastric juice than the latter. With many physicians the 
 favorite plan for neutralizing this objection consists in substituting 
 cream for milk (diluted at first with three and afterward with two 
 parts water [Biedert]), and thus to reduce the quantity of casein to 
 17
 
 258 THE PUERPERAL STATE. 
 
 minimum proportions; but this diet, by confining the child almost 
 entirely to the hydrocarbons, to the exclusion of the protein constit- 
 uents, has never seemed to me in practice, even when well borne, to 
 meet the full tissue requirements of a growing child. After many 
 trials of this mixture, which found a warm advocate in the late Pro- 
 fessor Childs, of this city, I have finally returned to milk of good 
 standard quality, stirring it before using to distribute the fat-globules 
 evenly between the different layers, and adding to it water propor- 
 tioned to the age of the child, beginning with eight tablespoonfuls of 
 milk to eight of water, increasing the one and diminishing the other 
 a tablespoonful at a time as rapidly as the digestive organs exhibit a 
 toleration of the change. The water does not, of course, alter the 
 chemical constitution of the casein, but aids digestion by provoking 
 an increased flow of the gastric juice, and incidentally contributes to 
 alleviate thirst (Jacobi). 
 
 City milk should be boiled to prevent fermentation,* an unnecessary 
 practice when milk can be obtained fresh night and morning. Instead 
 of plain water, Jacobi has pointed out the utility of using some sub- 
 stance " which by its physical consistence is able to hold the casein- 
 clots in suspension, thus protecting the stomach from irritation while 
 they are being prepared for dissolution." I have been in the habit of 
 following out to this end his earlier suggestion, to employ an indiffer- 
 ent substance, as gum-arabic or isinglass, for very young children, and 
 afterward a thin decoction of oatmeal or barley, according to the tend- 
 ency of the child to constipation or diarrhoea. The distress occasioned 
 in some cases by the casein is often relieved by subjecting the milk to 
 a peptonizing process. 
 
 Condensed milk is popular with many physicians, because children 
 with whom it agrees fatten upon it, and suffer but little from indiges- 
 tion and loose passages. The large amount of sugar it contains un- 
 fits it, however, for prolonged use. I have seen a number of children 
 exclusively fed upon it, after passing through apparently a blooming 
 infancy, develop symptoms of rickets at the end of their first year. 
 I have, however, been in the habit of allowing its habitual use during 
 the first three months of existence, and in the city during the hot 
 months of summer. 
 
 Whatever the preparation selected, it should be warmed to blood- 
 heat before it is given to the child. A small quantity of salt and a 
 grain or two of bicarbonate of soda, or a tablespoonful of lime-water, 
 
 * This object is best attained by means of the steam sterilizer. The bottles in 
 this apparatus, after being filled with milk, are immersed in boiling water until 
 freed from micro-organisms. They are then hermetically sealed. The milk when 
 thus treated will remain sweet for days. If the sterilization be complete, the milk 
 will keep indefinitely. The perfection of the method immensely reduces the risks 
 of bottle-feeding.
 
 THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 259 
 
 should be added to the infant's food, the former to promote assimila- 
 tion, and the latter to neutralize any free acid the milk may chance to 
 contain. When artificially reared, many children do not gain flesh 
 in spite of apparently healthy digestion. I have often derived great 
 benefit, after the third month, from the addition to each bottle of a 
 tablespoonful of Lofflund's Liebig's food for infants. Presumably the 
 various forms of malt extracts now so popular in this country would 
 serve the purpose equally well. 
 
 The bottle from which the child is fed should be scalded each time 
 that it is used, and should then be filled with cold water to which a 
 little soda has been added. The tube and mouth-piece should both 
 be washed, cleaned with a brush, and allowed to soak in cold water 
 in the intervals of feeding. Unless every precaution is taken to prevent 
 the development of fungi, a bottle-fed infant will never prosper.
 
 THE PATHOLOGY OF PREG:n:A]N^CT. 
 
 CHAPTER XIV. 
 
 ACCIDENTAL COMPLICATIONS.— ABNORMITIES OF THE 
 
 UTERUS. 
 
 Variola. — Rubeola. — Scarlatina.— Scarlatina puerperalis.— Cholera.— Typhus, ty- 
 phoid, and relapsing fever.— Malarial fever.— Icterus.— Cardiac diseases.— Pneu- 
 monia.— Emphysema, chronic pleurisy, and empyema.— Phthisis. — Syphilis. — 
 Chorea. — Surgical operations during pregnancy. — Double uterus. — Ante version 
 and anteflexion.— Retroversion. — Retroflexion. — Prolapse of uterus and vagina. 
 — Hernias. 
 
 The pathology of pregnancy includes the various morbid condi- 
 tions which exercise an unfavorable influence upon pregnancy, whether 
 of maternal or fetal origin. 
 
 The maternal diseases comprehended under this title may consist 
 of simple exaggerations of normal disturbances — a class which has, 
 however, already received attention in connection with the chapter 
 on the management of pregnancy ; accidental complications which 
 materially influence the circulation or the integrity of the pelvic 
 organs; and, finally, diseases of the uterus and the uterine append- 
 ages which endanger the health of the ovum, or pave the way to its 
 expulsion. 
 
 The pathological processes which affect the ovum may be primary, 
 or may result secondarily from maternal disturbances. 
 
 The haemorrhages of the first half of pregnancy and the prema- 
 ture expulsion of the ovum are ordinarily the result of fetal or mater- 
 nal disease. Their consideration, therefore, forms a fitting conclusion 
 to the subject-matter in hand. 
 
 The management of the haemorrhages occurring in the second half 
 of pregnancy requires a preliminary knowledge of the operative pro- 
 cedures of midwifery. Its consideration will therefore be postponed 
 until the principles governing the conduct of difficult labor have un- 
 dergone discussion. 
 
 Morbid states which exercise an unfavorable influence less during 
 pregnancy than after the development of labor will, to avoid double 
 mention, be considered in connection with the pathology of the latter 
 process.
 
 ACCIDENTAL COMPLICATIONS. 261 
 
 Accidental Complicatioxs of Pkegnaxcy. 
 
 Variola attacks pregnant women more frequently than any other 
 eruptive fever, and, although it manifests a preference for those in 
 whom pregnancy is not far advanced, its type is severer and its prog- 
 nosis graver when it affects women near their confinement. 
 
 Variola is, unless of a mild form, a peculiarly dangerous complica- 
 tion of pregnancy, greatly imperiling the life of both mother and 
 foetus,* through its tendency to metrorrhagia and abortion. 
 
 When the disease pursues its course without producing abortion, 
 the child may present characteristic variolous cicatrices, or the latter 
 may be absent. Occasionally the child remains unaffected by the dis- 
 ease until after birth, and may sometimes escape it altogether. 
 During epidemics of variola, women may, without manifesting other 
 symptoms of infection from the variolous poison, give birth to prema- 
 ture children, who remain unaffected with the disease. Children 
 sometimes suffer from variola either before or soon after birth, while 
 their mothers enjoy complete immunity from the disease.f 
 
 The healthy child of a mother affected with variola, or of one vac- 
 cinated during pregnancy, may be insusceptible to vaccinia for some 
 time after birth. J 
 
 It is advisable that all women becoming pregnant during an epi- 
 demic of variola should be immediately vaccinated. 
 
 Measles is an infrequent complication of pregnancy. In eleven 
 cases collected by Klotz, nine were attended by premature delivery. 
 This, according to Klotz,* is attributable not to excessive heat, nor to 
 haemorrhagic tendencies, but to an exanthematous form of endometritis. 
 
 Of the four cases occurring in his personal practice, all recovered. 
 Of sixteen cases collected by Underhill,|| in seven attacked during 
 pregnancy there were two deaths ; in seven cases in which the attack 
 occurred at the end of pregnancy, two died ; while in two cases at- 
 tacked in childbed, both died. Aside from a disposition to puerperal 
 haemorrhage, pneumonia is a frequent and dangerous complication. 
 
 In measles, premature delivery is apt to be followed by chronic en- 
 dometritis, which, in case of renewed pregnancy, becomes again a cause 
 of abortion. The poison is sometimes transferred from the mother to 
 the child during intrauterine existence. 
 
 * Meyer, Ueber Poeken, beim weiblichen Geschlecht, Berlin, Beitr. z. Geburtsh., 
 ii, 1873, p. 197. 
 
 t ScHROEDER, Lehrbuch d. Geburtsh., p. 364. 
 
 i Spiegelberg, Geburtsh.. p. 259 : jMax Runge, Die acute Iiifectionskrankheiten 
 in atiologische Beziehung zur Schwangerschaftsunterbrechung, Volkniann'sSaminl. 
 klin. Vortr., No. 174, p. 1376. 
 
 # Klotz, Beitrage zur Pathologie der Schwangerschaft, Arch. f. Gynaek., voL 
 xxix, p. 449. 
 
 I Underbill, Obstet. Jour. Great Britain and Ireland. 1880, p. 385.
 
 262 THE PATHOLOGY OF PREGNANCY. 
 
 Scarlatina is a less frequent complication of pregnancy than vari- 
 ola, attacks priniipara? by preference, although not exclusively, and 
 manifests a decided tendency to develop itself in the puerperal state, 
 even when infection has taken place in the earlier months of preg- 
 nancy. Olshausen * was able to collect from all the medical literature 
 at his disposal only seven cases of scarlatina occurring during preg- 
 nancy, while the number of cases taking place in the puerperal state 
 amounted to one hundred and thirty-four. 
 
 The theory that, in cases of exposure during pregnancy, the poison 
 may remain dormant in the system, and after weeks or months of in- 
 cubation may break out in childbed, is not inherently probable, f 
 
 The mortality of scarlatina occurring in pregnancy and in the 
 puerperal state varies notably in different epidemics.;}; Attacks oc- 
 curring immediately after confinement are more fatal than those de- 
 veloped later. 
 
 The stage of invasion may be entirely absent, or may exist for one 
 or two days before the appearance of the eruption. When present, it 
 is characterized by intense febrile movement, emesis, and notable con- 
 gestion of the face. Usually, however, the earliest announcement of 
 the attack consists in the sudden development of the eruption on all 
 parts of the body. In severe cases the eruption soon assumes a charac- 
 teristic livid color, which is usually retained until the fatal issue, 
 should the latter occur within a week 
 
 The pharyngitis and tonsillitis and the tongue changes are either 
 very mild or entirely absent. Diarrhoea is a frequent and dangerous 
 complication. Albuminuria is common. Aside from the above-men 
 tioned peculiarities, puerperal scarlatina presents no important vari- 
 ations from the clinical history of ordinary scarlet fever. The lochial 
 discharge, the lacteal secretion, and tlie uterine involution are un- 
 affected by the disease 
 
 Some authors have applied the designation " scarlatina puerperalis " 
 to an infectious disease which, although resembling scarlatina, is still 
 said to be identical with or closely related to puerperal fever. The 
 theory advocated by them is based upon the fact that, in the cases 
 upon which their deductions are founded, the angina was trivial in 
 character ; the attacks occurred usually within three days after con- 
 finement ; infection with scarlatinus jjoison could not, in the majority 
 of cases, be established ; the rate of mortality was very high, and peri- 
 
 * Olshausen, Untersueh. iiber d. Complic. des Puerp. rait Scarlat. und die 
 sogenannte S. puerperalis, Arch. f. Gynaek., ix, 1876, p. 169 ; Braxton Hicks, Trans, 
 of the Obstet. Soc. of London, vol. xvii. 
 
 t Vide BoxALL, Obstet. Trans, of London, vol. sxx ; L. Meyer, Zeitschr. fur 
 Geb. und Gynaeii., vol. xiv, p. 289. 
 
 X Denham saw only one recovery in eight and Hicks only four reeoveri^ in 
 eighteen cases ; MeClintock had ten fatal results in thirty-four cases ; Boxall, six- 
 teen cases with no deaths ; L. Meyer, eighteen cases with one death.
 
 ACCIDENTAL COMPLICATIONS. 263 
 
 tonitis and cellulitis were often revealed on autopsy. Olshausen* 
 concludes with apparent justice, after a careful review of the reasons 
 for and against the introduction of this new disease into obstetric nosol- 
 ogy, that the grounds for its establishment are insufficient, and that 
 the cases of so-called " scarlatina puerperalis " are nothing more than 
 ordinary cases of scarlet fever modified by the concomitant puerperal 
 condition, but in no way akin to puerperal pyaemia or septica?mia. It 
 is worthy of note, that scarlatina and puerperal fever may occur in 
 combina'tion without mutually affecting their respective signs and 
 symptoms. Braxton Hicks f advocates the extreme theory that a 
 puerperal woman when infected with scarlatina develops puerperal 
 fever, and that persons other than lying-in women contracting the dis- 
 ease through intercourse with the puerperal patients are attacked by 
 scarlatina of the usual form. 
 
 Antipyretic measures, particularly cool baths, are indicated in pro- 
 portion to the intensity of the febrile movement. Cathartics are to be 
 avoided, because of the inherent tendency to diarrhoea, alluded to 
 above. Special attention should be paid to the treatment of septic 
 symptoms where these coexist. 
 
 Cholera. — The predisposition on the part of ])regnant and puer- 
 peral women to cholera Asiatica is not usually decided, but varies 
 with different epidemics, and is more marked in cities than in the 
 country. Women are most liable to an attack of cholera in the latter 
 half of pregnancy, particularly in the seventh and eighth months, and 
 the prognosis is gravest for cases occurring at those periods. The 
 prognosis is almost necessarily fatal in the case of children born before 
 the ninth month.;); The intensity of the disease is somewhat mitigated 
 by the existence of the puerperal state. Slight attacks of cholera may 
 take their natural course without prejudicial effects upon mother or 
 foetus, but the disease frequently results in abortion or premature de- 
 livery, due in part to hasmorrhagic metritis. The pathological uterine 
 conditions observed in the cases recorded by Slavjansky ^ comprised 
 roughening of the inner surface of the uterus by dark-violet shreds of 
 the decidua vera, numerous extravasations permeating the mucous 
 membrane, which remained intact in some places and was ulcerated at 
 others, besides the presence in the uterine cavity of coagulated blood, 
 pus, and shreds of the uterine mucous membrane. 
 
 The placenta fetalis presented granular degeneration and almost 
 complete disintegration of the epithelium covering the villi. Both of 
 
 * R. Olshausen, Ioc. cit. 
 
 f BraxtOxV Hicks, Trans, of the Obstet. Soc. of London, 1871, pp. 44, 75. 
 i Ueber d. Einfluss d. C. auf Schw. u. Woehenbett, Monatsschr. f. Geburtsh., 1868, 
 xxxii, p. 60. 
 
 * Slavjansky, Endometrit. decidualis haem. bei Cholerakranken, Arch. f. Gy- 
 naek., iv, 1872, p. 293.
 
 264 
 
 THE PATHOLOGY OF PREGNANCY. 
 
 the pathological processes above described conspire to induce the death 
 of the foetus, which then, in common with coagula and inflammatory 
 products in the uterine cavity, acts as a foreign body and produces 
 abortion. Schroeder * refers the death of the foetus to asphyxia pro- 
 duced by changes in the maternal blood which interfere with the pla- 
 cental respiratory function. The clinical history of cholera is not 
 materially affected by coexisting pregnancy, except in so far as uterine 
 symptoms are concerned. Eclampsia sometimes occurs, and irregular 
 uterine pains may persist for several days without producing ab'ortion.f 
 Cholera does not specially predispose to puerperal diseases, nor does 
 it afford protection against them. Lactation, whether commencing or 
 already established, is not markedly affected by cholera, although the 
 lochia are often almost suppressed. 
 
 The treatment is conducted upon general principles. The artifi- 
 cial induction of premature delivery has had many advocates, on ac- 
 count of its supposed tendency to ameliorate the prognosis, but has 
 now fallen into disrepute, although Judicious measures to hasten par- 
 turition, already begun bv nature, are regarded as justifiable. 
 
 Typhus, Typhoid, and Relapsing Fevers. — These fevers more fre- 
 quently complicate the earlier than the later months of I3regnancy, 
 and affect the prognosis more seriously at the former epoch, owing to 
 the greater tendency then existing to protracted jjost-partiwi haimor- 
 rhage.J They may also, rarely, complicate the puerperal state. 
 
 Typhus fever manifests a less marked tendency to the induction of 
 abortion or of premature delivery than either typhoid or relapsing 
 fever, probably because it is less frequently accompanied by metrorrha- 
 gia.* It, however, occasionally produces these results, thereby essen- 
 tially increasing the danger of a lethal termination. || 
 
 Typhoid fever is frequently, and relapsing fever almost constantly, 
 accompanied by abortion or by premature delivery induced by profuse 
 uterine haemorrhages,"^ and thus greatly endanger life. The clinical 
 history and the treatment of the fevers in question are unaffected by 
 coexisting pregnancy except in so far as symptoms and indications 
 having reference to the occurrence of metrorrhagia, abortion, or pre- 
 mature delivery, are concerned. 
 
 Malarial Fever. — Malarial fever is not a very frequent complication 
 of pregnancy, perhaps because the latter secures a certain freedom 
 from exposure to the malarial poison. Women who have previously 
 experienced malarial fever, and who have been considered cured of the 
 disease for several years, often suffer a relapse during subsequent preg- 
 
 * Schroeder, Lehrb. d. Geburtsh., 1873, p. 365. -f- Hennig, loc. cit. 
 
 X Wallichs, Monatsschr. f. Geburtsk., xxx, H. iv, 1867, p. 353 ; Spiegelbbrg, 
 Handb. d. Geburtsh., p. 360. 
 
 * Zuelzer, Monatsschr. f. Geburtsk., xxxi, H. vi, 1868, p. 419. 
 
 U Wallichs, op. cit, p, 361. ^ Zuelzer, op. cif., p. 434.
 
 ACCIDENTAL COMPLICATIONS. 265 
 
 nancies.* Attacks occurring under these circumstances may be re- 
 garded as acute exacerbations of a chronic malarial disease which has 
 remained latent for a certain time. Malarial fever, according to 
 Runge,t Ritter,^ and most observers in this country, does not produce 
 abortion except iu rare instances, even when the febrile phenomena 
 persist up to the termination bf pregnancy ; though Goth * has re- 
 ported forty-six cases, in nineteen of which either abortion or premature 
 delivery took place. Parturition usually suspends the periodic parox- 
 ysms, supposing them to have continued up to confinement, possibly 
 owing to the loss of blood dependent on delivery, but the rule is not 
 without exceptions. During the puerperal state, however, particularly 
 in the second and third weeks, the paroxysms usually return, or a latent 
 malarial cachexia may manifest itself in the manner previously alluded 
 to. I The disease may be communicated to the foetus, as has been 
 proved by the detection of the characteristic pathological appearances 
 induced by malarial poisoning in the spleen, and by the discovery of 
 malarial pigment-granules in the blood and skin of children dying be- 
 fore or immediately after birth.^ 
 
 Hubbard^ reported an interesting case of intra-uterine malarial 
 fever of the tertian type, in which the fetal movements were entirely 
 suspended during the maternal paroxysms, and returned during the 
 intermissions. The woman was confined during an intermission. On 
 the following day the mother and child had a simultaneous paroxysm. 
 Quinia was now administered, with the result of curing both mother 
 and child — the latter obtaining the antiperiodic through the medium 
 of the mother's milk. 
 
 The usual course of malarial fever is altered by coexisting preg- 
 nancy. Intermissions are usually wanting, and the fever becomes 
 continued or remittent, the chills occurring irregularly. J Even those 
 cases which most nearly approximate the usual malarial course show 
 a tendency to anticipation or retardation of the paroxysms. The fever 
 may assume a pernicious character, its tendency in this direction being 
 accounted for by the nervous prostration and autemia attendant upon 
 the puerperal condition. Quinia best controls the febrile phenomena, 
 but must be given in large doses, since the powers of digestion and of 
 assimilation are seriously impaired by the puerperal state.|; 
 
 * Robert Barnes. Trans, of the Am. Gyn. Soc. 1876, p. 144. 
 
 t Max Runge. Volkmann's Samml. klin. Voi-tr.. No. 174, p. 10. 
 
 i RiTTER, Studien iiber Malaria-Infection, Virch. Arch., vol. xxxix, p. 14. 
 
 « Goth, Ueber tlen Einfluss der Malaria-Infection auf Schwangerschaft, Geb. 
 und Woehenbett, Ztschr. f. Gebh. und Gynaek., vol. ri, p. 17. 
 
 II Spiegelberg. Gebui-tsh., p. 261. ^ Max Runge, loc. cit. 
 
 {> Hubbard. Edinburgh Med. Jour., June, 1866. 
 
 i Mendel, Intermittens wahrend Schwangerschaft und Woehenbett, Monatsschr. 
 f. Geburtsk., Bd. xxxii, H. i, p. 10. 
 
 % Barker, in a paper termed Puerperal Malarial Fever (Am. Jour, of Obstet.,
 
 266 
 
 THE PATHOLOGY OP PREGNANCY. 
 
 Icterus.— Icterus, although a i3henomeuon of rare occurrence dur- 
 ing pregnancy, is interesting and important on account of its tendency 
 to precede or to accompany the fatal pathological changes and symp- 
 tomatic events connected with acute yellow atrophy of the liver. It 
 is ordinarily assumed that this grave general disease is developed from 
 a form of icterus which, when compRcating pregnancy, usually has 
 etiological relations identical with those of simple obstructive or so- 
 called'' hepatic jaundice, although the causative condition frequently 
 eludes observation. The development in pregnancy of icterus termi- 
 nating fatally is also sometimes due to the lesions of phosphorus- 
 poisoning. Davidson* attributes the fatal influence of pregnancy 
 upon the course of simple icterus to the three following causes: 
 
 1. The impairment of the renal excretory function, due to the passive 
 congestion produced by uterine pressure upon the renal veins. This 
 etiological factor operates by causing the retention in the blood of the 
 reabsorbed biliary acids, which, according to the investigations of 
 Traube and others, are of themselves capable, even when present in 
 the blood in moderate quantity, of producing acute yellow atrophy. 
 
 2. The hydraemia of pregnancy, which renders the system less capable 
 of resistance to toxic agencies. 3. The impairment of cardiac activ- 
 ity, due to the retention of the biliary acids, which still further com- 
 promises renal eliminative action. Icterus often produces abortion by 
 destroying the life of the foetus. The causative connection between 
 icteius and fetal death has been proved by the intense icterus of the 
 dead foetus, by the detection of biliary acids in its blood, and by the 
 exclusion of other causes. After abortion a previously benign icterus 
 may speedily develop all the characteristic lesions and symptoms of 
 acute yellow atrophy. f Under these circumstances the sudden advent 
 of the fatal symptoms may be accounted for by the anajmia and hy- 
 drsemia induced by the ha?morrhage accompanying parturition. As- 
 suming the correctness of the above-mentioned deductions with refer- 
 ence to the usual etiology of fatal icterus complicating pregnancy, 
 we must admit the urgent indication in these cases for measures cal- 
 culated to facilitate the elimination of the biliary acids from the blood 
 by restoring the normal excretory function of the kidneys. An early 
 resort to appropriate measures might, partially or entirely, prevent the 
 accumulation of the poison upon whose presence such baneful results 
 are believed to depend. 
 
 Cardiac Diseases. — The various effects produced upon pregnancy 
 by coexisting heart-disease depeiid entirely upon the seat and character 
 of the cardiac affection. While the results of myocarditis are serious, 
 
 April, 1880), furnishes a most valuable addition to our knowledge of the symptome 
 and treatment of this disease. 
 
 * Davidson, Monatsschr. f. Geburtsk., Bd. xxx, H. vi, 1867, p. 465. 
 
 t ScHROEDER, Lehrbuch der Geburtsh., p. 366.
 
 I 
 
 ACCIDENTAL COMPLICATIONS. 
 
 267 
 
 because of its interference with the development of cardiac hyper- 
 trophy adequate for the compensation of existing valvular lesions, and 
 acute endocarditis, occurring during pregnancy, shows a marked tend- 
 ency to assume the fatal ulcerative form,* pericarditis has no percep- 
 tible effect upon the normal course of utero-gestution.f Chronic en- 
 docarditis often produces disastrous results, which may, in general 
 terms, be accounted for by the fact that an amount of cardiac hyper- 
 trophy completely compensatory for pre-existing valvular lesions is no 
 longer able to overcome the increased arterial and venous pressure 
 prevailing during pregnancy, or to adapt itself to the sudden variations 
 in vascular tension due to the parturient act. The augmented arterial 
 pressure which calls for increased cardiac activity is referable, in part, 
 to the newly developed utero-placental circulation. It is also attrib- 
 uted by some authors to the actual pressure of the gravid uterus upon 
 the aorta ; while Spiegelberg J believes it to be measurably due to the 
 plethora of pregnancy, and to the limitation of the intra-thoracic space 
 by the encroachments of the diaphragm. An important source of 
 varying and perturbed heart-action is, moreover, found during labor in 
 the suddenly changing conditions of pressure produced by the alter- 
 nating uterine contractions and relaxations with the corresponding 
 violent respiratory efforts. 
 
 Spiegelberg* refers the symptoms of aortic insufficiency or stenosis, 
 which are usually most marked in the later months of pregnancy, 
 solely to cardiac disturbances due to increased arterial tension, and the 
 disappearance of these symptoms after birth to the restitution of the 
 normal pressure. McDonald || refers the improvement not so much to 
 the diminution of the arterial tension as to the absence of the extra 
 tension associated with the bearing-down effort. Spiegelberg considers 
 the grave symptoms of mitral disease often presenting themselves 
 soon after confinement as referable to excessive distention of the 
 right heart with blood forced into it from the contracted uterus. 
 Fritsch^ opposes this view,' and attributes the morbid phenomena of 
 mitral disease to the accumulation of blood in the abdominal vessels 
 recently released from the pressure of the gravid uterus, and to the 
 cardiac paralysis resulting from an insufficient blood-supply and con- 
 sequent defective nutrition of the heart. 
 
 The hydremia of the puerperal state may contribute to the impair- 
 
 * Lebert, Beitr. zur Casuistik der Herz- und Gefaf5skrankheiten im Puerperium, 
 Arch. f. Gynaek., Bd. iii, 1872, p. 39. 
 
 •(■ PoRAK. De Tinfl. recip. de la grossesse et des mal. de coeur, 1880. p. 92. 
 X Spiegelberg, Ueber d. Comp. des Puerp. m. chron. Herzkr., Arch. f. Gynaek., 
 ii, 1871, p. 236. 
 
 * Spiegelberg, ibid., p. 233. 
 
 II McDonald, Heart Disease during Pregnancy, Parturition, and Childbed, 
 p. 47. 
 
 ^ Fritsch, DieGefahren d. MitralLsfehler, ibid., viii. 1875. p. .-JSl.
 
 2fi8 
 
 THE PATHOLOGY OF PREGNANCY. 
 
 meut of nutrition, and thus co-operate with the abo^e causative agen- 
 cies in the production of cardiac paralysis. 
 
 Fresh inflammatory affections may attack the valves and endocar- 
 dium of a heart already weakened by disease. This occurs by prefer- 
 ence in cardiac cases of more recent origin. In all cases of heart 
 disease, and especially in those with acute symptoms, there is great 
 danger of embolism. Slight exposure to cold and exertion in preg- 
 nant patients with cardiac diseases is liable to occasion pulmonary dis- 
 turbances. These appear usually in the second half of pregnancy.* 
 
 The symptoms of aortic valvular disease are usually manifested 
 during the latter half of pregnancy. They consist in palpitations, 
 dyspnoea, and, in extreme cases, in abortion or premature delivery. 
 Should pregnancy proceed to a normal termination, the symptoms are 
 aggravated by parturition, and syncope is of common occurrence, but 
 the symptoms disappear speedily after labor is ended. Mitral valvular 
 lesions, if slight or completely compensated for, may not manifest 
 their existence by any rational symptoms. If, however, the compen- 
 sation bo inadequate, the patient's life may be greatly and sometimes 
 suddenly endangered by the occurrence, either before or after confine- 
 ment, of extreme pulmonary congestion and oedema, ascites, albumi- 
 nuria, or metrorrhagia. The foetus may die in utero, as the result of 
 metrorrhagia or of impaired nutrition due to deficient oxygenation of 
 the maternal blood. Children whose mothers are the victims of car- 
 diac disease are often imperfectly developed, and predisposed to un- 
 timely death. The prognosis is based upon the general conditions of 
 the patient. In seventeen of the thirty-one cases collected by McDon- 
 ald the patients died. The prognosis is impaired by coexisting pul- 
 monary lesions, tending to obstruct the circulation in the lungs, as 
 well as by diseases of other vital organs. Mitral lesions are of more 
 grave significance than those at the aortic orifice, and mitral stenosis 
 is particularly dangerous,! because of its tendency to produce dilata- 
 tion of the left auricle and the heart. 
 
 Women with cardiac disease of any considerable gravity should be 
 dissuaded, from marriage. The indications for medicinal treatment 
 are the same as for cardiac diseases uncomplicated by pregnancy. 
 Chloroform should be administered with special caution during partu- 
 rition. McDonald, however, believes that, cautiously administered in 
 the second stage, chloroform is useful by diminishing the down-bearing 
 efforts. In order to lessen the latter, the same author urges as of ex- 
 treme importance the timely application of the forceps, or the perform- 
 ance of version in suitable cases, should the second stage be in any way 
 prolonged. The artificial induction of abortion or of premature de- 
 livery is justified only, according to McDonald, in cases where, as in 
 hydramnion, the abdomen is unduly distended. 
 
 * McDonald, I. c, pp. 199, 200. f Porak, op. cit., p. 113 ; Fbitsch, op. cit, p. 383.
 
 ACCIDENTAL COMPLICATIONS. 269 
 
 Acute Lobar Pneumonia. — Pneumonia attacks women less fre- 
 quently thau men. Its rate of mortality is, however, much larger 
 among the former. These facts should be remembered by investi- 
 gators of the reciprocal relations between pneumonia and pregnancy, 
 in order that the influence exerted by the former upon the latter be 
 not exaggerated. Pneumonia is an infrequent comj^lication of the 
 pregnant state, but affects the course of the latter very prejudicially * 
 Although a pneumonia of large extent may terminate in complete 
 recovery without having endangered tlie life of mother or foetus,t it 
 often produces abortion or premature delivery, the frequency of these 
 results increasing in direct proportion to the duration of pregnancy. 
 The type of the pulmonary inflammation is also more severe in the 
 later stages of utero-gestation, and parturition exerts an unfavorable 
 effect upon women in proportion as their pregnancy is far advanced.| 
 
 It was formerly believed that pneumonia, occurring during preg- 
 nancy, owed its fatal character chiefly to the encroachments of the 
 gravid uterus upon the intra-thoracic space, and to the consequent 
 interference with the necessary compensatory increase of functional 
 activity on the part of the healthy lung-tissue. Later investigations 
 having not only shown the fallacy of this theory,* but even rendered 
 jirobable an actual increase in the intra-thoracic space during preg- 
 nancy,! the fatal character of intercurrent pneumonia is referred to 
 coexisting hydremia, and to the inability of the poorly nourished 
 heart to restore the balance of a pulmonary circulation disturbed by 
 the consolidation of lung-tissue and by the consequent impermeabil- 
 ity of large capillary areas. Pulmonary oedema, resulting trom pro- 
 gressive cardiac asthenia, directly induces the fatal issue. Parturition 
 itself, whether naturally or artificially produced, greatly imperils the 
 woman's life"^ by making exorbitant demands upon the already failing 
 heart-power and by aggravating existing hydraemia. Abortion, when 
 occurring under these circumstances, is referred to fetal death caused 
 by deficient oxygenation of the maternal blood, by placental anemia 
 produced through an inadequate supply of blood to the left heart, and 
 by the abnormally elevated maternal temperature.^ From the fatal 
 results of parturition in pneumonia we conclude that the induction 
 of abortion or of premature delivery in ordinary cases is unjustifi- 
 able.J Should labor, however, have already begun, Its termination 
 must be hastened by all available means. Our further treatment must 
 
 * Pasbexder, Ueber P. als Sehwangersch. Complicat., etc., Beitrag. z.Geburtsh.. 
 hi, 1874, Silzgsber., p. 54. 
 
 t GussEROw, Pn. b. Schwangeren, Moniitsschr. f. Gebiirtsk., xxxii, H. ii, 1868, p. 93. 
 t Werxich, Beitrag. z. Geburtsh., iii. 1874, Sitzgsb., p. 56. 
 
 * GussEROw, op. cit., p. 88. 
 
 II Wernich, Berlin. Beitrag. z. Geburtsh., ii, 1873. p. 249. 
 
 ^ Fasbexder. op. cit., p. 55. Spiegelberi;, Lehrb. d. Geburtsli., i>. 2G~u 
 
 J Werxich, op. cit., p. 2C1.
 
 270 THE PATHOLOGY OP PREGNANCY. 
 
 consist in efforts at strengthening the heart's action. Brandy and car 
 bonate of ammonia, digitalis and quinia, deserve the most confiden(;e 
 for the fulfillment of these indications. Wernich recommends cautious 
 venesection for tlie relief of extreme dyspnoea or cyanosis, and pro- 
 poses that the collapse to which bloodletting may lead be combated by 
 transfusion.* 
 
 Emphysema, Chronic Pleurisy, and Empyema.— These affections are 
 dangerous complications of pregnancy, in that they produce cardiac 
 dilatation and prevent the heart from successfully adapting its activity 
 to the varying conditions of vascular tension obtaining in parturition 
 and the puerperal state. The induction of abortion or of premature 
 delivery may be indicated by the existence of these diseases, provided 
 the mother's strength has become so impaired as to incapacitate her 
 for continued utero-gestation. 
 
 Phthisis. — It was formerly erroneously held that pregnancy afforded 
 immunity against pulmonary phtliisis. This view may have been 
 based upon the clinical fact that the progress of pre-existent phthisis 
 is sometimes retarded by the supervention of pregnancy. f This re- 
 sult is observed, according to Lebert,J in only a small proportion of 
 cases. In the majority of instances, pregnancy not only hastens the 
 progress of actually existing phthisis but precipitates its development. 
 The latter result is of especially frequent occurrence in those heredi- 
 tarily predisposed to the disease, or in such persons as may have re- 
 covered from a previous attack. These effects of pregnancy upon the 
 development and course of phthisis are most manifest between the 
 ages of twenty and thirty years, although they are not infrequent be- 
 tween the ages of thirty and forty. The advanced stages of phthisis 
 prevent conception, but the same is not true of its earlier periods. The 
 puerperal state often favors the development of phthisis, particularly 
 in those hereditarily predisposed to it, and usually hastens the fatal 
 issue of the disease if it has already manifested itself. In very excep- 
 tional instances, however, parturition and the post-partum state exert 
 a favorable influence upon the course of phthisis. It often happens 
 that women with inherited tendencies to phthisis may escape it during 
 their first pregnancy, only to become its victims in a later one.* Al- 
 though women with progressing phthisis may pass through the partu- 
 rient and puerperal states in safety, they are greatly prostrated thereby, 
 and rarely have sufficient milk to nurse their children. They, more- 
 over, often experience abortion or premature delivery. The children 
 of such women are usually puny and feeble. They are slowly and im- 
 
 * ScHROEDER, Lehrb. d. Geburtsh., p. 364. 
 
 t Wernich, Berlin. Beitrag. z. Geb., ii, 1873. p. 251. 
 
 X Lebebt, Ueber Tab. d. weiblich. Geschlechtsorgane, Arch. f. Gynaek., iv, 1872, 
 p. 469. 
 
 * Spiegelberg, Lehrb. d. Geburtsh., p. 266. 
 
 I
 
 ACCIDENTAL COMPLICATIONS. 271 
 
 perfectly developed, and are predisposed to pulmonary disease. Prophy- 
 lactic treatment affords the only encouraging prospects of success in 
 the cases under consideration. Girls with suspected hereditary predis- 
 position to phthisis should, accordingly, not marry, as they should not 
 become mothers. If they do bear children, they must never nurse 
 them. 
 
 SjrpMlis. — When syphilis, which is a frequent complication of preg- 
 nancy, is contracted at the beginning or during the course of the latter, 
 it is characterized by intense initial and by unusually mild consecutive 
 symptoms.* The duration of the incubation is ordinarily about two 
 weeks, but may be protracted to six weeks. The initial lesions, which 
 are more extensive than in women who are not pregnant, may involve 
 the vagina, cervix, labia, nates, and thighs. They embrace swelling, 
 reddening, and excoriation of the mucous membrane and skin, oedema, 
 eczema, follicular abscesses, and even necrosis of connective tissue. 
 These intense inflammatory processes may be referred to increased 
 nutrition of the parts, and to the mechanical results of friction between 
 them. The secondary symptoms are of a mild type, consisting chiefly 
 of general glandular induration, papules on and around the genitals, 
 and scales on the palms and soles. Mewis f states that the occurrence 
 of parturition has a favorable effect upon these lesions, usually result- 
 ing in their disappearance. Erythema, pharyngitis, alopecia, iritis, and 
 febrile movement are either absent or slightly marked. Pregnant 
 women owe the mildness of their secondary symptoms to amelioration 
 of their general nutrition. Syphilis exerts a very prejudicial influence 
 upon the product of conception. If either parent be affected with 
 general syphilis at the time of the coition resulting in impregnation, 
 syphilis is communicated to the foetus. It is almost equally impos- 
 sible for a foetus poisoned by the paternal reproductive element to 
 infect a healthy mother. Provided the mother were untainted at the 
 time of conception, syphilis contracted by her during pregnancy is 
 rarely communicated to the foetus. If the father be syphilitic, the 
 infection of the ovum is accomplished by the diseased spermatozoids. 
 If the mother be constitutionally tainted, the ovum is already poi- 
 soned. Should both parents be the victims of general syphilis, each 
 equally bequeaths the disease to the offspring. It is probable, too, that 
 the syphilitic poison can traverse the septa intervening between the 
 fetal and the maternal vascular systems. J 
 
 A progressive and continuous diminution in the intensity of fetal 
 
 * SiGMUND, Ueber d. Verlauf. d. S. bei Schwangerschaft, Wien. med. Presse. xiv, 
 1873, No. 1. 
 
 t Mewis, Syphilis congenita, Ztschr. f. Geburtsh. u. G>Tiaek., iv, 1879, I, p. 62. 
 
 X Professor McLane, of this city, has reported to me the history of a well- 
 observed case, where error was hardly possible, in which the mother, previously 
 healthy, was infected in the fourth month, and gave birth in the ninth month to a 
 dead child with well-marked syphilitic lesions.
 
 272 THE PATHOLOGY OF PREGNANCY 
 
 syphilis, directly proportionate to the length of time which has elapsed 
 since the contraction of the disease by the parent who communicated 
 it, is observed in cases unmodified by treatment. Parents whose 
 syphilis is allowed to pursue its natural course retain the capability 
 of transmitting the disease to their offspring for varying periods, 
 the average length of which is ten years. Latency of the parental 
 syphilis does not secure immunity of the foetus from the disease. 
 although it diminishes the probability of its transmission. Parents 
 with tertiary syphilitic symptoms may or may not communicate the 
 disease to their children, according as the poison whose original pres- 
 ence produced the gummata is still retained in the system or has 
 been eliminated by nature or by mercurials. In accordance with the 
 varying intensity of the hereditary influence, the foetus may either 
 perish in utero, its death resulting in abortion or premature delivery, 
 may be born alive but destined to die early, or may manifest the dis- 
 ease only at the expiration of periods varying from weeks to months. 
 Conception occurring during the first years after the parents' infec- 
 tion with syphilis almost invariably terminates in abortion or prema- 
 ture delivery, the causes of which are either the vitiated nutritive 
 processes of the foetus, the increased maternal temperature due to 
 syphilitic fever, or syphilitic degeneration of the fetal placenta, con- 
 sisting, according to Mewis,* of inflammatory changes in the tunica 
 intima of the blood-vessels. Similar pathological changes are said, by 
 the same author, to occur in the intima of the umbilical vessels. The 
 pathological conditions observed in syphilitic disease of the placenta 
 are either granular degeneration of the placental villi, with obliteration 
 of the blood-vessels, or the morbid changes designated by the names 
 endometritis placentaris gummosa and endometritis decidualis.f (For 
 a more detailed account of placental syphilis, vide chapter on placental 
 diseases.) 
 
 Every pregnant woman who at the time of conception is or has 
 been affected with constitutional sypliilis, should be promptly sub- 
 jected to a thorough mercurial treatment, preferably by the method 
 of inunction. This is' desirable even when no present symptoms are 
 detected, with reference to the prevention of the frequently disastrous 
 influences of latent syphilis. If, however, the disease be contracted 
 during the later months of pregnancy, the treatment may consist of 
 palliative measures until after parturition, since no harm will result 
 from the maternal syphilis to the fetal life. Local primary or second- 
 ary disease of the genitals should receive appropriate treatment, in 
 order that the child be not infected during delivery. 
 
 Chronic Nephritis. — There are few subjects about which so much 
 confusion of thought exists as that of albuminuria in pregnancy. 
 With most it is associated in the mind with eclampsia, and yet 
 * Mewis, loc. cit., p. 42. f Frankel, op. cit., p. 53.
 
 ACCIDENTAL COMPLICATIONS. 273 
 
 eclampsia in chronic nephritis is a comparatively rare event. (1 :40 ac- 
 cording to Fehling's statistics; 2:70 according to those of Seyfert). 
 
 It is desirable to differentiate, therefore, the various conditions in 
 which albuminuria develops during pregnancy. Fehling's * researches 
 in this direction have a special value. 
 
 - In the transitory form in which eclampsia is most apt to occur, 
 the albuminuria develops in the later months of pregnancy. It is as- 
 sociated with an abundance of hyaline and granular casts, and has a 
 tendency to disappear after labor. There is, moreover, no especial dis- 
 position for the albuminuria to return in later pregnancies. 
 
 In a second group, women who in the non- pregnant state are 
 apparently healthy, or who exhibit only slight traces of albumen in the 
 urine, develop albuminuria from the beginning of pregnancy. In these 
 cases the casts in the urine are scanty, the heart's action is increased in 
 force, there is sometimes oedema, and occasionally the condition is 
 associated with hemorrhages. In most cases death of the fwtus occurs 
 in consequence of placental changes. The amniotic fluid diminishes 
 in quantity, the uterus is arrested in its development, and the albu- 
 minuria disappears in part, or in its entirety. Characteristic of this 
 form is its tendency to recur with each consecutive pregnancy. 
 
 In still another group of cases the albuminuria is due to chronic 
 Interstitial or parenchymatous nephritis. With pregnancy there is 
 usually an acute exacerbation of the symptoms. Casts and albumen be- 
 come more abundant, oedema develops, albuminuric retinitis is a com- 
 mon complication, and nasal or intracranial haemorrhage may occur. 
 
 The causes of the increased trouble are attributed to reflex contrac- 
 tion of the arterioles and consecutive ansemia of the unaffected portions 
 of the kidney, and to associated venous congestion resulting from 
 cardiac insufficiency. As regards treatment, Fehling advises to ex- 
 amine the urine frequently, especially if oedema is present. Slight 
 traces should admonish to watchfulness. If the amount of urine 
 exceeds one per cent, woolen underwear should be worn ; the action of 
 the skin should be maintained by tepid baths ; the diet should consist 
 in large measure of milk, and alcohol should be avoided. In severer 
 cases rest in bed, hot baths (98° to 107°), and warm packs often give 
 relief. 
 
 If, however, there are headache, nose-bleed, heart disturbance, or 
 if no improvement in the number of casts or in quantity of albumen 
 results from treatment, abortion or premature labor is indicated. 
 
 In chronic nephritis, death of the child from ])lacental changes 
 (white infarctions, according to Fehling) is so common that considera- 
 tions for the life of the child must be always subsidiary to the interests 
 of the mother. 
 
 * Fehling, Weitere BeitrJige znr klinischon Bedeutung der Nephritis in der 
 Schwangerschaft, Arch. f. Gynaek.. vol., xxxix, ]>. 408. 
 18
 
 274 THE PATHOLOGY OF PREGNANCY. 
 
 In chronic nephritis it is not desirable that the kidneys should be 
 subjected to the hazards of a renewal of pregnancy. 
 
 Diabetes in Pregnancy. — Dr. Mathews Duncan * has called atten- 
 tion to the very serious consequences of diabetes complicating preg- 
 nancy and the puerperal state. But few cases have been recorded. 
 Diabetes may occur during pregnancy, and in some cases during 
 pregnancy only. It may cease after the termination of pregnancy, 
 and may not return in pregnancy after its cure. Pregnancy may occur 
 during diabetes, and in that case may be apparently unaffected in its 
 healthy progress by the disease. 
 
 In twenty-two pregnancies, occurring in fifteen mothers, four termi- 
 nated fatally. In several, death was by collapse rather than by coma. 
 Hydramnios was frequent, and in one case sugar was found in the 
 fluid. 
 
 In seven out of nineteen pregnancies, occurring in fifteen mothers, 
 the child died in pregnancy, having in all of them reached u viable 
 age. In two more the child was feeble at birth, and died a few hours 
 after. In one case the child was diabetic. 
 
 With one exception, all the mothers were multij^arae. 
 
 Chorea in Pregnancy. — Chorea, which is a rare complication of 
 pregnancy, affects primipars by preference, particularly those possess- 
 ing an hereditary predisposition. Barnes f was able to collect only 
 fifty-six and Fehling I only twelve additional cases from the whole do- 
 main of obstetrical literature. 
 
 Organic cerebral lesions are assumed by Spiegelberg* as established 
 causes of the disease. In regard to other etiological agencies wide di- 
 versities of opinion prevail. According to Goodell,|| the choreic move- 
 ments are of reflex nature, and are referable to im])aired nutrition of 
 the central nervous system, incident to the hydraemia of pregnancy. 
 The association of chorea and organic cardiac disease has been fre- 
 quently observed, and the discovery in certain cases of fibrous vege- 
 tations upon the mitral and aortic valves accounts for the assumption 
 by some authors of embolism as a cause of chorea. Barnes''' dis- 
 countenances this view, and calls attention to the probable causative 
 agency of myelitis. Terror and other intense emotions may act as 
 exciting causes of chorea. 
 
 Choreic movements occurring in pregnancy do not differ from 
 those attending the disease in the unimpregnated state. They are 
 usually bilateral. In most cases the muscular contractions manifest 
 themselves in the earlier months of pregnancy, and continue until 
 
 * Matthews Duncan, On Puerperal Diabetes, Obstet. Trans., vol. xxiv, p. 256. 
 t Barnes, Trans, of the Obstet. Soc. of London, x, 1869, p. 147. 
 
 X Fehling, Arch. f. Gynaek., vi. 1874, p. 137. 
 
 * Spiegelberg, Lehrb.. p. 2.5.5. 
 
 I GooDELL, Am. Jour, of Obstet., May, 1870, p. 149. 
 ^ Barnes, loc. cit., p. 179.
 
 ACCIDENTAL COMPLICATIONS. 375 
 
 delivery is accomplished. In rare instances they are arrested at the 
 beginning of parturition. In still more exceptional cases the contrac- 
 tions may either cease before delivery or persist during the ^0A^j!>a//7/?/i 
 state. Transitory albuminuria and diabetes mellitus are occasional 
 unexplained complications of chorea gravidarum, and the phosphates 
 and urates of the urine are present in abnormal abundance. Abortion 
 and premature delivery, due to the repeated succussion of the uterus, 
 are of very frequent occurrence. 
 
 Chorea exerts a prejudicial influence upon the course of pregnancy,* 
 having interrupted it in about one half the recorded cases. Death of 
 the mother resulted in seventeen of the fifty-six cases collected by 
 Barnes. f The lethal termination was usually referable to the ex- 
 haustion consequent upon protracted muscular exertion, or to hemi- 
 plegia secondary to grave cerebral or spinal lesions. The life of the 
 child is less frequently sacrificed, but it is itself often affected with 
 chorea. 
 
 The treatment consists in the administration of iron and quinine, 
 and the lowering of the reflex excitability by the prolonged use of the 
 bromide of potassium. During the attack, chloroform, chloral, and 
 the subcutaneous injection of morphia are often serviceable. When 
 palliative remedies prove fruitless, in view of the perilous nature of the 
 affection, artificial labor or even abortion is indicated. 
 
 Relaxation of the Pelvic Symphyses, t — This condition, which con- 
 sists in an excess of the ordinary physiological softening at the jielvic 
 articulations, may permit of such a degree of mobility between tlie 
 pelvic bones as to effectually hinder locomotion. This is usually ac- 
 companied by pains in the ligaments of the joints affected, in the 
 thighs, and in the lumbar region. Its existence is easily recognized. 
 Thus, motion at the symphysis pubis becomes apparent if, with the 
 patient in an upright position, she be made to throw the weight of the 
 body upon each leg in alternation, while the accoucheur holds the sym- 
 physis between the thumb and two fingers placed within the vagina. 
 Motion in the sacro-iliac joint is perceived by seizing the crests of the 
 ilium and getting the patient to move forward. In the recumbent 
 posture movements at either the pubic or sacro-iliac joints may be 
 recognized by means of the vaginal touch, upon extending or flexing 
 the femur. 
 
 The great relief afforded to all the symptoms in such cases by means 
 of a firm binder makes it most desirable that the possibility of its oc- 
 currence should be always borne in mind where the patient walks with 
 difficulty during the latter months of pregnancy, or subsequent to the 
 
 * GooDELL, Am. Jour, of Obstet., vol. viii, p. 168. 
 t Barnes, Trans, of the Obstet. Soc. of London, x, 1869. 
 
 i Snelling, On Relaxation of the Female Pelvic Symphyses, American Journal 
 of Obstetrics, February, 1870; Barker, Puerperal Diseases, p. 192.
 
 276 THE PATHOLOGY OP PREGNANCY. 
 
 childbed period. The first case I witnessed at the Bellevue Hos- 
 pital was altogether a mystery to me, until the nature of the disabil- 
 ity was pointed out by Professor Barker. The patient was in the 
 last month of pregnancy, had been six weeks in bed, unable to move, 
 though apparently otherwise in perfect health. A rude bandage, 
 constructed of canvas and made to lace in front, furnished a good 
 support, and enabled my patient to stand and move around with- 
 out inconvenience. She had, at the end of gestation, a good confine- 
 ment, and subsequently recovered without a trace of her previous diffi- 
 culty. 
 
 In childbed a towel-binder is capable of rendering good service. 
 During pregnancy, or during the period of puerperal convalescence, 
 where frequent changes of the bandage are not necessary, Martin's 
 girdle, consisting of a solid metal ring surrounding the whole pelvis, 
 has been strongly recommended. I employ a pair of strong breeches, 
 furnished me by Philip Schmidt, instrument-maker, of this city, which 
 are carefully fitted to the thighs and hips of the patient, and are made 
 to buckle in front and lace behind. The apparatus is light, comforta- 
 ble, and answers every requirement. 
 
 Surgical Operations during Pregnancy. — Massot* concludes, from 
 the observation of a considerable number of cases, that ordinary surgi- 
 cal operations do not interfere with pregnancy unless they materially 
 and permanently disturb the uterine circulation, or call into activity 
 the uterine muscular force by reflex irritation. Cohnstein f states as 
 the result of his researches, that after operations and injuries preg- 
 nancy reaches a normal termination in 54-5 per cent of all cases. In- 
 terruption of pregnancy was in his cases determined — {a) by the 
 period of pregnancy when the operation took place, occurring more 
 frequently as the result of surgical measures resorted to in the third, 
 fourth, and eighth months ; {b) upon the seat of the operation, result- 
 ing, in two thirds of all cases, from operations upon the genito-urinary 
 organs ; (c) upon the extent of the wound following amputations, ex- 
 articulations, and ovariotomies with great relative frequency ; (d) upon 
 the number of children, occurring in multiple pregnancy with uniform 
 regularity. Age seemed to exert no causative influence. Abortion di- 
 rectly results under these circumstances from reflex irritation, or from 
 fetal death referable to hasmorrhage or to septic poisoning on the 
 mother's part. The prognosis, so far as the mother is concerned, de- 
 pends upon the time when delivery occurs. The mortality ordinarily 
 attending delivery, if at term, is insignificant ; for abortions and pre- 
 mature deliveries it amounts, according to Cohnstein, to thirty-three 
 
 * Massot, Ueber d. Einfluss trauraat. Einwirk. auf d. Verlauf der Schwanger- 
 schaft, Schmidt's Jahrb., 1874, 164, p. 266. 
 
 t CoHNSTEix, Ueber chirurg. Op. bei Schwangeren, Volkmann's Samml. klin. 
 Vortr., No. 59, 1873, p. 493.
 
 ABNORMAL CONDITIONS OP THE UTERUS. 277 
 
 per cent. The most frequent causes of the mother's death are shock 
 peritonitis, septicemia, haemorrhage, and oedema pulraoualis. In 
 ninety cases of minor operations upon the pelvic organs collected by 
 Professor Mann,* of Buffalo, there were twenty abortions and four 
 deaths. They included the removal of a caruncle, of epitheliomata, of 
 condylomata, and of polypi, the opening of cysts and abscesses, the dil- 
 atation of the urethra for stone, the plastic operations upon the vulva, 
 cervix, and vagina, etc. He concludes that during pregnancy the 
 union of denuded surfaces is the rule, that the most risky operations 
 are those upon the rectum, and that vaginal operations are apt to be at- 
 tended by severe hemorrhage, though not otherwise dangerous. In 
 view of the manifest danger from operations of any magnitude, it may 
 be stated as a general law that surgical measures not absolutely indi- 
 cated by the existence of pathological conditions liable to aggravation 
 by delayed interference should be postponed until after confinement. 
 Those morbid conditions, however, whose development is hastened by 
 pregnancy, which threaten the existence of pregnancy, or whose exist- 
 ence offers mechanical obstacles to parturition, must be early subjected 
 to operative interference. This remark applies with special force to 
 carcinomatous growths in any part of the body and to intrapelvic 
 tumors. 
 
 The time of operation should not coincide with the menstrual 
 epoch of pregnant women, as abortion is more likely to occur at that 
 period.f For a similar reason it is recommended that the third, 
 fourth, and eighth months should be avoided. Massot is of the opin- 
 ion I that anaesthetics, when employed during operations on pregnant 
 women, exert rather a favorable than a prejudicial effect upon fetal 
 life by diminishing reflex irritation. 
 
 Abnormal Conditions of the Uterus. 
 
 Double Uterus. — Double uterus occurs under various forms. The 
 uterus and cervix may be double, the vagina remaining single. The 
 double uterus may have a single cervix opening into an undivided 
 vagina. The uterus, although double, may have a single cervix open- 
 ing into a double vagina, the septum beginning at the os internum ; 
 or uterus, cervix, and vagina nay be double throughout. 
 
 All these forms permit of normal utero-gestation on either side or 
 on both sides simultaneously, provided that each half of the genital 
 canal be sufficiently developed. If, however, the dividing septum ex- 
 tends quite to the vaginal entrance, simultaneous pregnancy in each 
 horn is exceedingly rare.* 
 
 * Manx, Surgical Operations on the Pelvic Organs of Pregnant Women, Gyna- 
 cological Trans., 1883. 
 
 f Spiegelberg, Lehrbuch d. Geburtsh., p. 268. 
 
 t Massot, loc. ciL, p. 267. * Schroeder. Lehrb. d. Geburtsh., p. 376.
 
 278 THE PATHOLOGY OF PREGNANCY. 
 
 If pregnancy occur in only one side of a double uterus, a decidua 
 vera is developed in the other side, and expelled at the end of preg- 
 nancy. Double uterus is less readily diagnosticated during pregnancy 
 than' after or before it, but is usually recognized with facility. A 
 double vagina is not necessarily indicative of double uterus, but if 
 two vaginae are found, each containing a cervix, the presence of double 
 uterus may be safely assumed. If a double cervix terminate in an un- 
 divided vagina, the uterus may or may not be double. When preg- 
 nancy exists in only one horn the uterine development is manifestly 
 unilateral, and the existence of an unimpregnated half may be de- 
 termined by combined manipulation or by the uterine sound. In 
 cases presenting a double uterus witli a single cervix and vagina, the 
 diagnosis rests chiefly upon unilateral uterine development and de- 
 pression of the fundus and body corresponding to the septum. The 
 form of a double uterus is most plainly manifest during the contrac- 
 tions accompanying and succeeding parturition.* It is still undecided 
 whether double uterus be a cause of abortion and of premature de- 
 livery. Ordinarily, however, the symptoms and course of pregnancy 
 are unaffected by this malformation. The complete functional inde- 
 pendence of the two segments is demonstrated by the fact that in 
 twin pregnancies parturition is frequently not simultaneously accom- 
 plished by them. In the case of unilateral pregnancy, the ratio of 
 head to breech presentations is, according to Schatz, as twenty-one to 
 two. Tedious labor may result in cases of double uterus from uterine 
 atony, referable either to imperfect muscular development of the preg- 
 nant horn, to its deviation from the normal pelvic axis, or to obstruc- 
 tion produced by the unimpregnated horn. Post-purtuni haemorrhage 
 may result from uterine atony or from attachment of the placenta to 
 the septum, whose imperfect development prevents its firm and thor- 
 ough contraction. 
 
 Anteversion and Anteflexion. — The normal anteversion of the un- 
 impregnated uterus is exaggerated by the increased weight of the 
 gravid uterine body, but this deviation is usually rectified by the grad- 
 ual development and upward movement of the uterus. In exceptional 
 cases the anteversion persists after the fourth mouth, and produces 
 vesical tenesmus, dysuria, or incontinence. No evidences of uterine 
 incarceration are, however, observed, and the comparatively trivial 
 symptoms are relieved by regulating defecation, replacing the fundus, 
 causing the patient to assume the dorsal decubitus, or by adjusting an 
 appropriate pessary. 
 
 In the later stages of utero-gestation anteversion combined with 
 anteflexion may again occur, and produce the deformity known as 
 pendulous abdomen. It is then chiefly due to the inadequate sup- 
 
 * Schatz, Mitth. aus d. Leipz. Geb.-Klinik u. Polyklinik. Arch. f. Gynaek., ii, 
 1871, p. 297.
 
 ABNORMAL CONDITIONS OF THE UTERUS. 2^9 
 
 port afforded to the uterus by the abdominal parietes. The failure of 
 their sustaining power is referable to their relaxation— which is most 
 marked in multiparae— to separation of the recti muscles, or to the 
 yielding of old cicatrices produced by operations or injuries. The dis- 
 placement is also favored by lordosis of the lumbar vertebrae and by 
 contracted pelvis, which prevent the normal descent of the uterus. In 
 extreme eases of pendulous abdomen, the uterus, having separated the 
 recti, descends, covered by fascia and skin, almost or quite to the 
 knees, and seriously interferes with locomotion. Its pressure also pro- 
 duces ffidema of the abdominal wall, vesical tenesmus, and pain in the 
 distended cutaneous tissues. These symptoms are relieved by repo- 
 sition of the uterus and by the application of a suitable abdominal 
 bandage. 
 
 Retroversion. — Retroversion, a comparatively infrequent form of 
 displacement in the unimpregnated uterus, usually rectifies itself dur- 
 ing the earlier months of pregnancy. Should spontaneous restitution 
 not occur, the fundus being detained below the promontory until after 
 the third month, the cervix bends upon itself at an acute angle, and 
 the retroversion is transformed into a retroflexion. 
 
 Retroflexion. — Retroflexion occurs infrequently in women who have 
 not borne children, but often renders sterile those who are thus affect- 
 ed. It is one of the most common uterine displacements in women 
 who have borne children, though it does not in their case, ordinarily 
 prevent conception. AA'hen conception occurs in a retroflexed uterus, 
 the latter usually rises from the pelvis, and assumes a position of ante- 
 version at the fourth month. In many cases, however, the displace- 
 ment produces congestion of the uterine mucous membrane, metritis, 
 and abortion. In still other cases the fundus does not ascend above 
 the promontory at the usual time, and either the sym})toms of retro- 
 flexion with incarceration are slowly developed, or that form of retro- 
 flexion known as partial retroflexion, or retroflexion in the second half 
 of pregnancy, occurs. This consists in the division of the uterine 
 cavity into an anterior and a posterior diverticulum or iiouch. The 
 anterior diverticulum is produced by the more rapid upward develop- 
 ment of the anterior uterine wall, Avhicli is subjected to comparatively 
 slight pressure and contains the larger part of the foetus. The pos- 
 terior uterine wall enters predominantly into the formation of the 
 posterior diverticulum, and usually contains the fetal head. This 
 peculiar form of uterine displacement may be spontaneously rectified 
 during pregnancy, or may persist until delivery, producing no impor- 
 tant symptoms except vesical and rectal tenesmus, with dysuriji and 
 painful defecation. In the latter case it materially interferes with par- 
 turition, inasmuch as the cervix, which is displaced upward and for- 
 ward behind the svmphvsis, is not situated in the pelvic axis, and the 
 posterior diverticulum ' is forced by the uterine contractions against
 
 280 * THE PATHOLOGY OF PREGNANCY. 
 
 the perinaeum and posterior vaginal wall. Even at this stage Nature 
 may restore the uterus to its normal position ; but, in default of spon- 
 taneous restitution, it must be replaced by forcing up the posterior 
 diverticulum with the hand introduced into the rectum, while the an- 
 terior pouch is displaced downward by pressure upon the abdomen and 
 by traction applied to the cervix ; or, where version is practicable, by 
 bringing down the breech, room may be made for the release of the 
 imprisoned head. 
 
 Retroflexion of the Gravid Uterus, with Incarceration.— Although 
 this form of retroflexion is usually developed in the gradual manner 
 above described, it may, in rare instances, be rapidly produced by sud- 
 den abdominal compression or concussion. 
 
 The symptoms, which are in either case essentially the same, differ 
 chiefly in the varying rapidity of their development, and result from 
 the pressure of the displaced uterus upon the intrapelvic viscera and 
 tissues, They embrace dysuria, eventuating sometimes in complete re- 
 tention of urine from urethral compression, vesical tenesmus, incon- 
 tinence of urine, painful defecation, constipation or obstipation, vio- 
 lent sacral and lumbar pains which radiate into the thighs, and in 
 grave cases emesis, with all the other symptoms of ileus Abortion, 
 followed by spontaneous restitution and recovery, may occur even at 
 this stage. Should incarceration, however, persist, violent metritis, 
 parametritis, and peritonitis may lead to a fatal issue. In rare cases, 
 gangrene of the uterus or vagina may be induced. A lethal termina- 
 tion may also indirectly result from pathological processes in the blad- 
 der occasioned by retained and decomposing urine. These morbid 
 processes consist in cystitis, sometimes complicated by diphtheritic and 
 gangrenous inflammation of the mucous membrane and of the deeper 
 vesical tissues, which may lead to septicaemia or to rupture of the blad- 
 der. Death may, moreover, result from passive renal congestion and 
 ursemia. 
 
 The diagnosis of uterine retroflexion with incarceration is based 
 upon the foregoing clinical history ; the fluctuating abdominal tumor, 
 from which large quantities of urine may be obtained by the catheter 
 or by puncture ; the oedema of the vulva ; the presence in Douglas's 
 cul-de-sac of a tumor presenting the characteristic consistence of uter- 
 ine tissue ; the position of the cervix and meatus urinarius behind the 
 symphysis ; and the distention of the perinaeum by the fundus uteri. 
 
 The distinction between an incarcerated uterus and an extra-uterine 
 pregnancy is sometimes difficult, necessitating a thorough bimanual 
 examination, aided, in cases of abdominal tenderness, by the employ- 
 ment of an anaesthetic. 
 
 The replacement of the uterus, which, of course, is the objective 
 point of treatment, should in all cases be preceded by the evacuation 
 of the bladder. This is usually accomplished without much trouble
 
 ABNORMAL CONDITIONS OF THE UTERUS. 281 
 
 by means of a sharply curved male catheter, and by remembering that 
 the urethra is ordinarily deflected somewhat to one side. Cohnstein 
 states that the introduction of the catheter is facilitated by seizing the 
 posterior lip or the vaginal portion with volsella forceps, and diminish- 
 ing the pressure on the urethra by tractions made in a backward di- 
 rection. Veit,* in an experience of from seventy to eighty cases, found 
 catheterization always practicable. Where intelligent effort is at- 
 tended by failure, puncture is allowable. To this end an aspirator 
 needle — which, however, should not be of too small caliber — should be 
 passed through the abdominal walls at a point about three inches above 
 the symphysis. In practice this operation has thus far proved devoid 
 of danger, though the possible risk from infiltration of urine should 
 act as a check to its rash employment. 
 
 After emptying the bladder spontaneous reposition may take 
 place. If this does not speedily occur, the patient should be put in the 
 knee-elbow position, and steady pressure should be made with two or 
 four fingers upon the fundus, through the vagina. With a little pa- 
 tience this method rarely fails. E. Martin f reports sixteen cases, in 
 four of which spontaneous reposition followed the evacuation of the 
 bladder, and in eleven reposition was accomplished in the knee elbow 
 position. In my own practice the latter method has so far invariably 
 proved successful. If anaesthesia is -required, the replacement of the 
 uterus should be attempted with the patient in the Sims latero-prone 
 position. Pressure upon the fundus should be exerted by four fingers 
 introduced into the vagina or rectum. Barnes J recommends tilting 
 the fundus to one side, so as to disengage it from the projection of the 
 promontory. It may happen that the first attempt may be only par- 
 tially successful, while a renewal of the manipulation after twelve to 
 twenty-four hours may lead to complete reduction (Veit). 
 
 In exceptional cases the replacement of the uterus may be prevent- 
 ed by inflammatory adhesions, or by the secondary swelling of the dis- 
 placed organ. The induction of abortion then becomes imperative, 
 either by the ordinary methods or by puncture of the uterine walls. 
 
 The introduction of a uterine sound or a flexible catheter is rarely 
 practicable. In a case reported by P. Miiller,* where the retroversion 
 was complete, with the fundus upon the perineum and the cervix 
 looking directly upward, Muller resorted to the following ingenious 
 expedient : He cut off the end of a male silver catheter, and then bent 
 the extremity into a hook. Having succeeded in passing the latter 
 
 * Veit, Ueber die Retroflexion der Gebarmutter in den spateren Scbwanger- 
 schaftsmonaten, Volkmann's Samml. klin. Vortr., No. 170, p, i;j()3. 
 
 t E. Martin, Riickwartsiieigung der schwangeren GebJirrautter, Ztschr. f. Ge- 
 burtsh. und Frauenkrankheiten. vol. i, p. 1. 
 
 I Barnes, Obstetric Operations, third American edition, p. 276. 
 
 » P. MuLLEB, Zur Therapie der Retroversio Uteri gravidi, Beitr. zur Geburtsh^ 
 Bd. iii, p. 67.
 
 282 THE PATHOLOGY OF PREGNANCY. 
 
 into the cervix, lie introduced a piece of catgut through the tube be- 
 tween the membranes and the uterus. After twelve hours, during 
 which the catgut was left in situ, the foetus was expelled. If catheter- 
 ization can not be accomplished by either of the foregoing methods, 
 puncture of the uterus with a fine trocar, and with antiseptic precau- 
 tions, has proved a tolerably safe procedure, and, by the withdrawal 
 of a portion of the amniotic fluid, a certain means of provoking abor- 
 tion. 
 
 Prolapse of the Pre^ant Uterus. — In rare instances the normal 
 pregnant uterus becomes prolapsed during the early months through 
 mechanical violence, and its sudden displacement may lead to abortion 
 through uterine congestion and haemorrhage. Ordinarily, however, 
 procidentia uteri is only observed during pregnancy when it has 
 antedated conception, and it is most frequent in multiparae. A slight 
 prolapse disappears temporarily with the ascent of the uterus. A well- 
 marked procidentia, however, as a result of which a part or the whole 
 of the uterus has been extruded from the vagina, is often attended by 
 symptoms of incarceration terminating in abortion. There is no 
 recorded instance of procidentia in which pregnancy persisted until 
 the time of normal delivery in a uterus lying Avholly without the 
 vagina. Procidentia uteri is simulated by hypertrophy either of the 
 supravaginal or of the infravaginal portion of the cervix. This patho- 
 logical condition is unattended by grave results, unless it lead to rigid- 
 ity of the OS uteri, tedious delivery, and uterine inertia. If excessively 
 developed, however, the portio vaginalis may be transformed into a 
 pulpy, polyp-like mass, which by its constant friction and irritation 
 produces abortion. It should not be mistaken for prolapse of the 
 uterus, as efforts at reposition may produce irritation sufficiently severe 
 to induce premature delivery. Amputation of the hypertrophied cer- 
 vix performed during the third month does not necessarily disturb 
 pregnancy, and is indicated in aggravated cases, because of the possi- 
 ble prejudicial influence of cervical hypertrophy, unmodified by treat- 
 ment, upon utero-gestation and parturition. 
 
 When prolapse, even of slight extent, exists in a pregnant uterus, 
 the normal ascent of the organ should be encouraged by the avoidance 
 of exertion and by careful regulation of defecation and micturition. 
 In more pronounced cases the uterus must be replaced, and sustained 
 by a suitable tampon Spiegelberg * advises the use of a cotton tampon 
 soaked in glycerin and held in position by a perineal bandage, aiui 
 renewed at short intervals. Caution is necessary in the reduction of 
 the uterus, lest the fundus be caught beneath the symphysis and the 
 procidentia converted into a retroflexion. When incarceration has oc- 
 curred and the parts are much swollen, their volume may be reduced 
 by scarification, after which reposition must be attempted. Should it 
 * Spiegelberg, Geburtshiilfe, p. 278.
 
 ABNOliMAL CONDITIONS OF TUE UTERUS. 2>(3 
 
 fail, abortion should be induced before the incarceration has irrepa- 
 rably compromised the vitality of the pelvic tissues. 
 
 Prolapse of the Vagina.— A slight degree of vaginal prolapse occurs 
 more frequently in pregnant women than does uterine prolapse. Cases 
 of more complete prolapse of the vagina are, however, almost invari- 
 ably attended with procidentia uteri. The anterior vaginal wall is 
 usually alone involved in the prolapse, although the posterior wall 
 may descend alone, or both walls become simultaneously prolapsed. 
 This displacement produces traction upon the bladder and rectum, 
 resulting in irritation of these organs and of the vulva. During i)ar- 
 turition, moreover, the prolapsed vagina offers an impediment to 
 delivery, and may therefore be subjected to an amount of pressure in- 
 compatible with the maintenance of its vitality. The treatment con- 
 sists in producing regular alvine evacuations, and in sustaining the 
 vagina with cotton tampons and a perineal band, or with the latter 
 alone. During labor, persistent efforts at reposition of the prolapsed 
 vagina must be made between the pains. Should these attempts prove 
 effectual, the vagina must be- sustained in proper position until the 
 descent of the head has occurred. If reposition be impossible, the 
 forceps must be resorted to in order to prevent the disastrous results 
 of excessive pressure on the vaginal tissues, and traction must be so 
 applied as to avoid injury of the anterior vaginal wall. 
 
 Hernias of the Pregnant Uterus.— Although hernias of the uniui- 
 pregnated uterus are very rare, they still occur much more frequently 
 than those of the gravid uterus. The most frequent forms under 
 which they present themselves are the umbilical and the ventral. 
 Femoral and inguinal uterine hernias, as well as hernias through the 
 foramen ovale and the great sacro-sciatic foramen, also occur. The sac 
 of a ventral hernia is often formed by the yielding and dilatation of 
 extensive cicatrices in the abdominal wall, such as result from ovari- 
 otomies and gastrotomies, or by the separation of the recti muscles. 
 
 Femoral and inguinal uterine hernias are either congenital or are 
 produced by ovarian or omental hernias, between which and the uterus 
 adhesions exist. Pregnancy has been observed to occur most frequently 
 in inguinal uterine hernias, next in umbilical, and least frequently in 
 femoral hernias.* It has never been discovered in a uterus which had 
 escaped through the foramen ovale or the greater sacro-sciatic foramen. 
 Pregnancy occurring in inguinal or femoral uterine hernias is uni- 
 formly terminated by abortion or by premature delivery. The diag- 
 nosis is readily made if due regard be paid to the absence of the uterus 
 from its natural situation, to the shape and consistence of the hernial 
 tumor, to the physical signs furnished by auscultation and percussion 
 over it, and to the displacement of the vagina toward the site of the 
 hernia. 
 
 * SPIE(!KLBKR(i. Cifburtsli.. p. '280.
 
 284 THE PATHOLOGY OF PREGNANCY. 
 
 When the hernia is recognized at an early date, the uterus must, if 
 possible, be restored to its normal position, and there retained by an 
 appropriate truss. Should attempts at reposition be unsuccessful, 
 artificial abortion should be induced, as it will otherwise occur spon- 
 taneously at a later date, and under less favorable conditions. When 
 the product of conception has already attained a large size, reposition 
 and delivery, whether spontaneous or artificial, are rarely accomplished 
 unless the constricting hernial ring be previously divided. Even the 
 latter procedure may prove ineffectual, in which case hysterotomy is 
 the last resort. 
 
 CHAPTER XV. 
 
 DISEASES OF THE DECIDUA.— DISEASES OF THE OVUM. 
 
 Endometritis decidua : 1. Chronica; 2. Tuberosa; 3. Catarrhalis. — Anomalies of 
 the placenta. — Anomalies of form ; of position ; of development ; of circula- 
 tion. — Placentitis. — Degenerations. — Syphilis. — Anomalies of the amnion and 
 of the amniotic fluid. — Hydramnion. — Deficiency of amniotic fluid. — Anomalies 
 of the umbilical cord : torsion ; knots ; hernias ; coiling of the cord ; cysts ; 
 stenoses of vessels ; marginal implantations. — Hydatidiform mole. 
 
 Endometritis decidua. — The normal congestion of the uterine mu- 
 cous membrane attendant upon conception, and resulting in the forma- 
 tion of the decidua, may, under the irritating influence of various 
 exciting causes, develop into endometritis. The inflammation may be 
 either acute in character, as is often tlie case in cholera Asiatica and 
 other infectious diseases,* or may pursue a chronic course, presenting 
 itself in the three distinct forms about to be considered : 
 
 L Endometritis decidua chronica diffusa. — The causes of this form 
 of endometritis are not usually readily discoverable. It is believed to 
 be sometimes developed from an endometritis antedating conception. 
 It is also referred to syphilitic infection,! to excessive physical exer- 
 tion, J and to secondary inflammation resulting from the death of the 
 foetus and its retention in the uterine cavity.** 
 
 The anatomical changes characteristic of this form of endometritis 
 consist essentially in thickening and induration of the decidua, due 
 to a more or less diffuse development of new connective tissue, and to 
 proliferation of the decidual cells. Cysts have been observed in the 
 hypertrophied decidua by Hegar and Maier.|| Kaschewarowa dis- 
 
 * Slavjanksy, Arch. f. Gynaek., iv, p. 285. 
 t Prankel, Arch. f. Gynaek., v, 1873, p. 53. 
 
 X Kaschewarowa, Virchow's Arch., 1868, vol. xliv, p. 113. 
 
 * ScHROEDER, Geburtsh., sixth edition, p. 392. 
 Ij Spiegelberg, Geburtsh., p. 301.
 
 DISEASES OP THE DECIDUA. 285 
 
 covered newly developed and liypertrophied involuntary muscular 
 fibers in the substance of the decidua.* Extravasations into the hyper- 
 trophied decidual tissue are of frequent occurrence.! The decidua 
 vera or the decidua reflexa may be separately or Jointly involved in 
 these pathological processes, and may be affected throughout a part 
 or the whole of their extent. When the hyperplasia of the mucous 
 membrane is developed in the later months of utero-gestation, pursues 
 a notably chronic course, is limited in extent, or does not .involve the 
 placental decidua, pregnancy may proceed to a normal termination. 
 When, however, the endometritis appears early, assumes an acute or 
 hjemorrhagic type, is attended by partial separation of the decidua, or 
 involves the placental decidua, it frequently induces abortion or i)re- 
 mature delivery, either by causing the deatla of the foetus through in- 
 terference with its nutrition J or by exciting reflex uterine contrac- 
 tions. Parturition may, in either case, be protracted by the slow 
 separation of the decidua, between which and the deeper uterine tis- 
 sues adhesions have been formed by the newly developed connective 
 tissue and muscular fibers. If the placental decidua be involved in 
 the morbid process, the placenta may be separated with difficulty, and 
 its slow expulsion be attended by copious haemorrhages. Another con- 
 sequence of the hyperplasia of the decidua in the later months of 
 pregnancy, according to Kaltenbach,* consists in the non-separation 
 of the decidua vera at the time of parturition. The thickened mem- 
 brane is either rapidly detached after childbirth, forming a sac to 
 which blood coagula adhere, and which in turn become the occasion 
 of haemorrhage, or it is slowly eliminated, giving rise to a putrid 
 discharge, and furnishing materials for auto-infection. He advises, 
 therefore, in cases of syphilis in either parent, that a careful examina- 
 tion be made of the membranes at childbirth, and, if no traces of the 
 decidua are to be found upon their surface, to introduce the hand into 
 the uterus, and to remove retained portions ; or, should this not be done, 
 to promote their expulsion by ergo tin, and to employ prophylactic 
 antiseptic injections. 
 
 II. Endometritis decidua tuberosa et polyposa.— The etiology of 
 this variety of decidual inflammation is involved in obscurity. Syph- 
 ilis was regarded as a causative agent by Virchow, who first described 
 the degenerative changes under consideration,! and pre-existent endo- 
 metritis is also supposed to occupy a causative relation to them. Gus- 
 serow^ suggests that conception occurring soon after delivery may 
 
 * Kaschewarowa, he. cit., p. 111. 
 
 f EiGENBROD und Hegab, Monatsschr. f. Geburtsk.. vol. xxii, 1863. {>. 161. 
 I Klebs. Monatsschr. f. Geburtsk., 1806, vol. xxvii. p. 402. 
 
 * Kaltexbach, Diffuse Flyperplasic der De<'idiia am Ende der GraviditaU 
 Zeitschr. fiir Gebiirtsh. und Gynnek., vol. ii, p. 225. 
 
 I Ahlfeld, Arch. f. Gynaek., vol, x, 1876, p. 173, 
 
 ^ GussEROw, Monatsschr, f. Gynaek., vol, xxvii. 1866, p. 383.
 
 286 THE PATHOLOGY OP PREGNANCY. 
 
 excite the recently formed vascular uterine nuieous membrane to ab- 
 normal proliferative processes. It is doubtful whether the latter are 
 ever secondary to irritation produced by the death of the foetus.* In 
 Ahlfeld's cases the inflammation was apparently idiopathic. 
 
 The pathological processes peculiar to this variety of endometritis 
 are usually observed in the decidua vera alone, and manifest a jirefer- 
 ence for those portions of the decidua corresponding to the anterior 
 and posterior uterine surfaces. In some cases, characterized by absence 
 of the decidua vera, the decidua reflexa is found involved in the mor- 
 bid changes. The latter consist in marked thickening of the entire 
 decidua referable to proliferation of the interstitial connective tissue 
 and to extensive hypertrophy of the decidual cells, which are provided 
 with nuclei of enormous size. Occasional free nuclei occur. f The 
 uterine surface of the decidua is rough and covered with coagulated 
 blood, while the entire mucous membrane is exceedingly vascular. 
 Upon that surface of the decidua which is directed toward the ovum 
 are situated large excrescences or elevations, the prevailing shape of 
 which is polypoid. They may, however, appear in the form of nod- 
 ules, of cones, or of boss-like projections provided with a broad, non- 
 pedunculated base. Their height is from one quarter to one half an 
 inch, and their surface is smooth, very vascular, and devoid of uterine 
 follicles. The latter are, however, plainly visible on the mucous mem- 
 brane intervening between the polypoid outgrowths, but they are com- 
 pressed and their orifices constricted or obliterated by the pressure 
 of Avhitish, contracting bands of newly developed connective tissue. 
 Similar fibrous bands surround the blood-vessels. On section, the 
 larger prominences sometimes appear permeated with coagulated blood, 
 and narrow, cord -like bands of hypertrophied decidual tissue occasion- 
 ally form bridge-like connections between neighboring polvpi. The 
 uterine follicles are in some cases filled with blood-clots. The epi- 
 thelium is often absent from the uterine surface of the decidua except 
 around the orifices of the follicular glands,J and the deeper decidual 
 tissues contain large numbers of lymphoid cells. The cells of the 
 decidua reflexa frequently undergo fatty degeneration. The placental 
 villi may show hypertrophy of their club-shaped ends, or be the seat 
 of myxomatous growths, in which case their cells are granular and 
 cloudy. The fa?tus is generally dead and partially disintegrated. 
 This form of endometritis decidua is consequently usually accom- 
 panied by abortion, which occurs predominantly at an early stage of 
 pregnancy. 
 
 III. Endometritis decidua catarrhalis.— Hydrorrlioea gravidarum.— 
 This form of uterine inflammation is less intense than the two varie- 
 
 * ScHROEDER, Geburtsh., sixth edition, p. 393. 
 
 f GussERow, loc. cU., p. 322. 
 
 X Hegar, Monatsschr. f. Geburtsk., vol. xxii, 1863, pp. 300, 429.
 
 DISEASES OF THE OVUM. 287 
 
 ties just described, affects pluriparae more frequently than primiparae, 
 and seems to stand in etiological relations with hydrsemia. The 
 pathological processes involved in the disease are vascularity, hyperse- 
 mia, and hypertrophy of the interstitial connective tissue and of the 
 glandular elements of the decidua. The inflammation involves the 
 decidua vera by preference, but may simultaneously affect the de- 
 cidua refiexa. The most striking symptomatic occurrence is due to 
 the glandular hypertrophy, and consists in the escape from the uterine 
 cavity of a thin, watery, muco-purulent or sero-sanguinolent liquid, 
 which resembles the amniotic fluid both in color and in odor. Pro- 
 vided that free exit be afforded to the secretion, its discharge is affected 
 gradually and in small quantities. Should, however, obstacles to its 
 continuous evacuation be encountered, either in the usual adhesions 
 between the decidua vera and reflexa or in impenetrability of the os 
 internum, the secretion, having accumulated between the decidua and 
 the chorion, forces a passage through the decidua reflexa and is dis- 
 charged in considerable quantities. In some cases even a pound or 
 more of the liquid is thus suddenly evacuated. Small quantities of 
 the secretion are often observed as early as the third month. The 
 more abundant discharges occur only in the later periods of pregnancy, 
 and are often attended by slight uterine contractions, which may, in 
 exceptional cases, become so severe as to induce abortion or premature 
 delivery. 
 
 The diagnosis involves differentiations between a discharge emanat- 
 ing from the hypertrophied decidual glands and the ante-'partwii es- 
 cape of a fluid which sometimes accumulates between the amnion and 
 chorion. The latter discharge, the quantity of which may be so large 
 as to stimulate hydramnion, differs from that of hydrorrhoea gravi- 
 darum in that it occurs only once.* The escape of the decidual secre- 
 tion might be mistaken for that of the amniotic fluid, which may be 
 easily distinguished by the fact that the latter immediately precedes 
 delivery. The treatment should embrace analeptic and tonic measures, 
 as well as the careful avoidance of vaginal douches and of all local 
 irritation tending to produce abortion. Should uterine contractions 
 accompany the escape of the decidual fluid, appropriate anodyne treat- 
 ment must be adopted. 
 
 Anomalies of the Placenta. 
 
 1. Anomalies of Form.— The usually round or oval placenta may be 
 of a horseshoe or other irregular shape. The superficies depends upon 
 the extent to which the villi form vascular connections with the de- 
 cidua. In general terms it may be stated that the thickness of the 
 placenta is in inverse proportion to its surface extension. PlacentaB 
 
 * Spiegelberg. Of. cit.. p. 303.
 
 288 THE PATHOLOGY OF PREGNANCY. 
 
 succenturiatae, small accessory placental developments, are due to the 
 persistence of isolated villous groups, which form vascular connections 
 with the decidua vera. Placentas spuria? consist of circumscribed de- 
 velopments of villi, the decidua not participating in the growth. A 
 placenta membranacea is a broad and thin vascular membrane pro- 
 duced by a diffuse proliferation of the villi over the entire ovum, form- 
 ing vascular connections with the reflexa, or, where the latter is absent, 
 with the vera. 
 
 3. Anomalies of Position. — The placenta may be attached over the 
 OS internum, thus constituting placenta praevia, over the orifice of the 
 Fallopian tube, or in connection with extra-uterine pregnancy, at vari- 
 ous points in the abdominal cavity. 
 
 3. Anomalies of Development.— A hypertrophied placenta is ab- 
 normally large in proportion to the size of the foetus, occurs chiefly 
 in connection with hydramnion, and consists of a genuine parenchym- 
 atous hyperplasia. A small placenta is referable either to defective 
 development, to premature involution, or to hyperplasia of the connect- 
 ive tissue, with subsequent contraction.* 
 
 4. Anomalies of Circulation. — Haemorrhage into the placenta is 
 sometimes produced by congestion of the utero-placental vessels, due 
 to disturbances in the motlier's vascular system, f The extravasation 
 may, rarely, be intraplacental, may occur into the serotina, thus con- 
 stituting utero-placental apoplexy, or may take place into the uterine 
 sinuses. In the last case, thrombosis of the placental sinuses is said 
 to have occurred. J Placental haematomata are the above-mentioned 
 collections of coagulated blood in various stages of disintegration. The 
 causes of the haemorrhage are chiefly morbid changes in the decidual 
 vessels^ often referable to placentitis. The extravasated blood usually 
 experiences the ordinary retrogressive metamorphoses. It sometimes 
 undergoes cystic, fatty, or calcareous degeneration. The pressure upon 
 the villi produced by the haematomata impairs the nutrition of the 
 foetus, and may cause the death of the latter. 
 
 (Edema of the placenta, a morbid condition usually attributed to 
 derangement of the fetal or umbilical circulation, is characterized by 
 abnormal pallor, with increased size', friability, and succulence of the 
 placenta, due to serous infiltration. The morbid anatomical changes 
 consist essentially in cystic dilatation in and between the villi, accom- 
 panied sometimes by extravasations. 
 
 5. White Infarctions of the Placenta. — This term is applied to 
 thickenings of the placental tissue, varying in color from a yellowish 
 red or yellow to a dirty or grayish white. They have a dense struct- 
 ure, are moderately firm in young infarctions, with more of a fibrous 
 
 * Whitaker, Am. Jour, of Obstet, August, 1870, p. 229. 
 
 t Nouv. Diet, de Med. et de Chirurg. Prat., vol. xxviii, Placenta, p. 63. 
 
 X Slavjassky, Arch. f. Gynaek.. v.. 1878,. p. 360.
 
 DISEASES OF THE OVUM. 28<) 
 
 character in older ones. In size they vary from that of a beau to that 
 of an English walnut. For the most part they are sharply circum- 
 scribed ; sometimes flattened, sometimes oval or rounded or wedge- 
 shaped. In some cases the infarctions send out radiate processes. 
 More frequently they are found upon the maternal surface of the pla- 
 centa. They do, however, form on the fetal side. They may extend 
 through from surface to surface, or may be imbedded in the placental 
 substance. 
 
 These so-called infarctions apparently are due primarily to a hyaline 
 degeneration of the decidua. The same process extends to the de- 
 cidual vessels, and thence to the intervillous spaces. In these a coagu- 
 lation of the blood takes place. The ensuing compression exerted 
 upon the fetal villi leads to their necrosis and obliteration.* Fehling 
 believes that rupture of the maternal vessels due to endarteritis may 
 likewise serve as the primary cause of the compression and necrosis of 
 the villi. 
 
 White infarctions are present in nearly every placenta. AVhen few 
 in number and of small size, they are innocuous. In syphilis, in endo- 
 metritis, in nephritis (Fehling), etc., they may lead to extensive 
 destruction of placental tissue, and are the most frequent cause of the 
 intra-uterine death of the foetus. 
 
 6. Degenerative Changes. — (a) Fatty degeneration of the placenta, 
 circumscribed or diffused, may result from retrograde changes in ex- 
 travasations. When developed early in pregnancy, it is sometimes re- 
 garded as a premature completion of the fatty degeneration normally 
 occurring at the end of pregnancy, and may be due to syphilis or 
 scrofula, (b) Amorphous calcareous deposits are frequent, and are 
 almost invariably found on the uterine placental surface, in the decidua 
 serotina. Thence the process may extend to the fetal portion of the 
 placenta. When the calcareous change begins in the fetal tissues it 
 is confined to these, and affects the small blood-vessels of the villi, be- 
 ginning in their terminal ramifications and gradually involving their 
 trunks, (c) Pigment deposits, resulting usually from alterations in the 
 hasmoglobin of extravasations, are found in both healthy and diseased 
 placentae within the blood-sinuses or villi. {(I) Cysts are of frequent 
 occurrence in the placenta. They are found near the center of its 
 concave surface, and vary from a few lines to several inches in diameter. 
 The cyst-wall is covered by the protruding surface of the amnion. The 
 fluid in the cysts contains albumen and mucin. Fenoinenow f regards 
 these cysts as the product of the placental villi. The latter, he sup- 
 poses, in consequence of irritative changes, swell and undergo a partial 
 
 * For resume of literature of the subject with recent observations, vide Jacob- 
 sohn, Untersuchungen uber die Weissen Infarcte der Placenta, Ztschr. fiir Geb. und 
 Gynaek., vol. xx, p. 237. 
 
 f Fenomenow; Zur Pathologie der Placenta. Arch. f. Gynaek., vol. xv, p. 343. 
 19
 
 290 THE PATHOLOGY OF PREGNANCY. 
 
 loss of epithelium. The denuded surfaces adhere, aud thus spaces are 
 formed. The fluid he regards as an excessive physiological secretion 
 from that portion of the epithelium which remains intact upon the 
 
 villi. 
 
 7. Syphilis of the Placenta.— In placental syphilis the placenta is 
 pale and heavy, often equaling one third of the weight of the fretus. It 
 only exists, according to Frankel,* in connection with congenital or 
 hereditary fetal syphilis. It involves the maternal portion of the pla- 
 centa, when the mother was infected either before or soon after con- 
 ception, and produces gummatous proliferation of the decidua, charac- 
 terized by the development of large-celled connective tissue, with occa- 
 sional accumulations of younger cells. 
 
 When the infection is conveyed by the father to the foetus alone, 
 or to both mother and foetus, pathological changes occur as the result 
 of a chronic inflammatory process, embracing proliferation of the cells 
 and connective tissue in the villi, with subsequent obliteration of the 
 vessels, often complicated by the marked proliferation and hardening 
 of their epithelial covering. 
 
 The affected villi become swollen, cloudy, aud thickened, while 
 their epithelium undergoes proliferation and cloudy swelling. The 
 parenchyma of the villi is filled Avith lymph-cells, and the vessels are 
 either compressed or obliterated. The blood-sinuses are gradually 
 encroached upon by the villi, the foetus dies from lack of adequate 
 nutrition, and the villi undergo fatty degeneration. Portions of the 
 healthy placental tissue, which often intervene between the diseased 
 parts, may be the seat of extravasations. 
 
 Anomalies of the Amniox and of the Amniotic Fluid. 
 
 I. Hydraxnnion. — Inasmuch as the amount of the liquor amnii va- 
 ries considerably within normal limits, the term hydramnion should 
 be restricted to those cases in which the amount of fluid is so large 
 as to produce morbid symptoms by its pressure upon the uterus, the 
 abdominal and thoracic viscera. When the quantity exceeds tAvo to 
 three pints, inconveniences are often experienced. It is, hoAvever, 
 usually only when the higher degrees — viz., five pints and upAvard — are 
 reached that the symptoms possess such an intensity as to constitute a 
 special malady. 
 
 It is customary to distinguish an acute and a chronic form — in the 
 former a rapid increase in the size of the abdomen taking place in a 
 few days, or even, as in a case reported by Sentex, in a single night; 
 whereas in the latter the progress is slow, extending over months, and 
 occasioning infinitely less disturbance of function. 
 
 Etiology. — The causes of hydramnion are hardly to be found in a 
 
 * FrXnkel, Arch. f. Gynaek., v, 1873, p. 52.
 
 DISEASP^S OF THE OVUM. 291 
 
 single morbid condition. In a limited number of cases— and this h 
 especially true of the rare acute form, though even in these not in all 
 reported instances— tlie excessive production of fluid was found to be 
 associated with inflammation of the amnion. In by far the largest 
 proportion of cases, however, the evidence is strong that the excess of 
 fluid is of fetal origin. Sallinger's * experiments show that when a 
 liquid is injected into the umbilical vein it transudes witli great 
 rapidity into the amniotic sac, and that the amount of transudation is 
 proportioned to the pressure exerted, and to the size of the cord. 
 Jungbluth described, during the first half of pregnancy, a capillary 
 network (vam propria), connected with the vessels of the umbilical 
 cord, developed just beneath the amnion, in that portion of the cho- 
 rion which covers the placenta. Levison f found that this capillary 
 network was persistent at term in hydramnion, but not in nornud 
 pregnancy. Between these vessels and the inner surface of the am- 
 nion, canalicular spaces furnished a series of communicating passages. 
 Lebedjew X concluded that in certain abnormal conditions of the fa'tus 
 found associated with hydramnion the capillary network of Jung- 
 bluth was persistent to the end of pregnancy. With these anatomical 
 conditions an increased secretion, due to stasis in the vasa j^ropria, 
 would result from any condition causing stenosis of the umbilical vein, 
 from obstructions to the hepatic circulation, and from diseases of the 
 fetal heart and lungs. In this connection it is proper to observe that 
 syjDhilis, and especially syi^hilitic affections of the liver, are frequently 
 associated with hydramnion. 
 
 Charpentier found that, in one hundred and twenty-three cases of 
 multiple pregnancy, fifty- two were cases of hydramnion. Kiistner,* 
 Schatz,|| and Werth^ have recently drawn attention to the occurrence 
 of hydramnion affecting one amniotic sac only in twins developed from 
 the same ovum — i. e., with a single chorion, the sac of the second foetus 
 containing less than the normal quantity of fluid. In all these cases^ 
 in the foetus contained in the hydramniotic sac both heart and kid- 
 neys were hypertrophied, and the amniotic fluid contained an unusual 
 amount of urea. The cardiac hypertrophy Kiistner ascribes to the 
 appropriation by the stronger fcetus of the placental territory, which 
 in twin pregnancies from a single ovum is primarily common to both 
 foetuses. The increased work thus entailed upon the heart leads to a 
 thickening of its Avails, which in turn is followed by increased growth 
 and activity of the kidneys. In Kiistner's cases there was likewise 
 
 * Sallinger, Dissert. Inaugural, Zurich, 1875. 
 
 f Levison, Summary in Arch. f. Gynaek., vol. ix, p. 517. 
 
 X Lebed.jew, vide Traite pratif^ue des accoucheraents, par Dr. A. Char[H'nticr, 
 p. 886. 
 
 * KfsTNER. Arch. f. Gynaek., vol. xxi, p. 1. 
 II ScHATZ, Arch. f. Gynaek., vol. xix. p. 329. 
 -^ Wertii, Arch. f. Gynaek., vol. xx, p. 353.
 
 292 THE PATHOLOGY OP PREGNANCY. 
 
 hepatic obstruction. AVertli suggests that the activity of the fetal cir- 
 culation leads to more active absorption on the part of the placental 
 villi, and that the insufficient action of the kidneys, in their attempt 
 to maintain the necessary equilibrium in the fetal circulation, explains 
 the outpouring of fluid not only into the amnion but into the serous 
 cavities of the fcetus, as is often observed in bydramnion. 
 
 The question as to how far the amniotic fluid may be of maternal 
 origin is still an undecided one. Ahlfeld and Leopold maintain that 
 serum may pass through the pores in the chorion and amnion from the 
 vessels of the decidua reflexa (and later from those of the ova) directly 
 into the amnion. Zuntz, Wiener, and Bar state that substances experi- 
 mentally injected into the maternal veins may be found in the amni- 
 otic fluid Avithout having first traversed the body of the foetus.* 
 
 Symptoms and Signs.— The distention of the uterus, and the conse- 
 quent abnormal expansion of the abdomen produced by hydramnion, 
 results in an impediment to locomotion, and causes discomfort or 
 actual pain by traction upon the abdominal parietes. The diaphragm 
 is forced upward, and, encroacliing upon the thoracic space, compresses 
 the lungs and displaces the heart, thus producing dyspncea and car- 
 diac palpitation. The urine may become scanty and albuminous from 
 impeded renal circulation. Neuralgic pains and redema of the abdomi- 
 nal walls, of the labia and lower extremities, are produced by com- 
 pression of the pelvic nerves and vessels. Vomiting and dyspeptic 
 aymptoriis result from direct compression of the digestive organs or 
 from reflex irritation of them. Ascites may be produced by obstruc- 
 tion of the portal circulation. Insomnia results from the patient's 
 general discomfort and the deterioration of her health. In the acute 
 form, vomiting is often incessant, the pain is intense, and febrile symp- 
 toms develop. Physical examination reveals in advanced cases an im- 
 mensely distended abdomen. The uterus, which can be easily mapped 
 out by palpation and percussion, is tense, elastic, and obscurely 
 fluctuating. The fetal cardiac sounds are faint or imperceptible. 
 The foetus changes its position with unusual rapidity and facility. 
 Combined manipulation shows the lower segment of the uterus to be 
 elastic and tense, while the foetus can not be readily felt by the finger 
 placed in contact with the cervix. Pregnancy accompanied by hy- 
 dramnion seldom reaches its normal termination, delivery being pre- 
 maturely induced by death of the foetus, by separation of the placenta, 
 or by overdistention of the uterus. The first stage of labor is abnor- 
 mally prolonged, because of the comparatively feeble contractions of 
 the expanded uterine walls. Labor may become precipitate in the 
 second stage, owing to the sudden escape of the amniotic fluid ; and 
 uterine inertia, in the third stage, frequently results in post-partum 
 liEemorrhage. Involution is apt to be protracted and incomplete. 
 * Vide Charpentier, Traite pratique des accouchements, p. 890.
 
 DISEASES OF THE OVUM, 293 
 
 Diagnosis.— Hydramnion may be mistaken for twin pregnancy, 
 but is easily excluded by the rational symptoms, by the tenseness of the 
 uterine walls, by the feebleness or absence of fetal heart-sounds, and 
 by the difficulty experienced in perceiving the foetus on palpation. 
 
 Prognosis.— The prognosis for the child is fatal in nearly one fourth 
 of the cases. For the mother it is favorable, although the risk of po-sf- 
 jmrtum haemorrhage is considerable. This high mortality is due to 
 malformations of the foetus, to dropsical affections, to prematurity, 
 and to the frequency of faulty presentations. Thus, of one hundred 
 and thirteen cases collected by Charpentier, twenty-one presented by 
 the breech, twenty by the shoulder, and two by the face. 
 
 Treatment. — The treatment embraces the application of an abdomi- 
 nal supporter and the injunction to refrain from active physical ex- 
 ertion. Grave disturbances of the mother's heart indicate the induc- 
 tion of premature delivery, which should, hoAvever, in the interest of 
 the child, be delayed as long as is consistent with maternal safety. In 
 parturition, the membranes should be punctured if the accumulated 
 liquor amnii retards the dilatation of the cervix. Puncture must be 
 performed in the interval of the jiains, in order that the waters may 
 escape gradually and leave the position of the child unchanged. After 
 the expulsion of the placenta, the usual prophylactic measures against 
 post-2)arf/nii hemorrhage must be promptly adopted. 
 
 II. Abnormally Small Amount of Amniotic Fluid. — The quantity 
 of amniotic fluid may, even in some cases of advanced pregnancy, be 
 so limited as to render the uterus unusually small and firm, and to 
 limit the freedom of the movements. Under these circumstances, 
 the movements are so plainly perceptible to the mother as to be the 
 source of positive discomfort. 
 
 An abnormally small quantity of liquor amnii is, however, only of 
 importance in the earlier stages of fetal development. If the amnion 
 be not then separated from the fatus by an adequate amount of fluid, 
 abnormal amniotic foldings and adhesions between the amnion and 
 the surface of the foetus may take place. 
 
 The so-called foeto-amniotic bands * thus formed may, by mechani- 
 cal compression, result in various fetal deformities, or in spontaneous 
 intra-uterine amputation. 
 
 AXOMALIES OF THE UMBILICAL CORD. 
 
 I. Torsion. — Torsion consists in such a rotation of the umbilical 
 cord upon its longitudinal axis that its vessels are thereby rendered 
 nearly or quite impermeable. It occurs most frequently in foetuses 
 which have advanced beyond the middle period of normal utero-gesta- 
 tion, particularly, according to Spiegelberg,t in those of the seventh 
 
 * PuRST. Arch. f. Gynaek., Bd. ii, 171. p. :U8. 
 ■f Spiegelberg, LehrV)uch, p. 'SHO.
 
 294: 
 
 THE PATHOLOGY OF PREGNANCY. 
 
 mouth. It is, however, often met with in fcetuses of an earlier age. 
 Until a comparatively recent period, authors have unreservedly attrib- 
 uted torsion to active movements on the part of the feftus, and re- 
 garded it as the cause of the latter's death. Martin * has shown that 
 this theorv is untenable for the majority of cases, because the patho- 
 
 FiG. 131.— Torsion of the cord. (Schauta."* 
 
 logical conditions which result from fetal death induced by torsion, 
 whether rapidly or slowly produced, are almost invariably absent. 
 These morbid anatomical processes embrace rupture of the umbilical 
 blood-vessels, and extravasations, for cases of sudden origin, and con- 
 gestion, with oedema, for those more gradually developed. Martin 
 
 * Martin, Ztschr. f. Gebnrtsh. ii. Gynaek.. Rd. ii. Heft 2, 1878, p. 346.
 
 DISEASES OF THE OVUM. 295 
 
 therefore concluded that torsion was o. post-mortem event, resulting 
 from rotation of the foetus produced by maternal movements. Ruo-e* 
 earnestly advocated the same view, and suggested the various morbid 
 changes due to syphilis, endometritis placentaris, and sub-placental 
 hemorrhage as the cause of fetal death in cases which subsequently 
 developed numerous torsions. Schauta \ appears as a recent champion 
 of the same theory, although he admits that loose torsions, incapable 
 of producing actual stenosis of the umbilical vessels, may often occur 
 during the life of the fcetus. He bases his belief in the post-mortem 
 occurrence of torsion — 1. Upon the large number of twists often pre- 
 senting themselves, any one of which would have involved the death 
 of the foetus. Even granting the original torsion to have been of ante- 
 mortem origin, the others must then have occurred after death. 2. 
 Upon the improbability of the formation of very numerous torsions in 
 a healthy cord, inasmuch as its elasticity would lead to comj^ensatory 
 reverse rotation. 3. Upon the fact that even twenty-five artificially 
 induced torsions resulted in rupture of the normal cord from excessive 
 tension. Schauta regards the cysts found in connection with some 
 torsions as insufficient proof of their ante-mortem occurrence. Tor- 
 sions are more frequently present in the umbilical cords of male than 
 in those of female foetuses, and are sometimes surprisingly numerous. 
 Schauta reports a case in which he observed three hundred aud eighty 
 rotations of the cord on its longitudinal axis. It occurs by preference 
 in multiparae, probably on account of the greater latitude afforded for 
 fetal movements. Unusual length of the cord favors its occurrence, 
 for a similar reason. The seat of the torsion is ordinarily in close 
 proximity to the umbilicus. It occurs but rarely at the placental end 
 or in the center of the cord. The umbilical vessels are usually nearly 
 occluded at -the seat of the torsion, but 
 still permeable. Thrombi of varying 
 consistency are often found in the ves- 
 sels. Sero-sanguinolent fluid in the ab- 
 dominal cavity of the foetus, oedema, and 
 cystic degeneration of the cord, are also 
 pathological conditions frequently at- 
 tending torsion. 
 
 II. Knots. — Knots in the umbilical 
 cord, which occur once in two hundred ^ , .,. , 
 
 Fig. 132.— Knot of umbilical conl. 
 
 cases, may result from the passage oi the iLeyman.i 
 
 foetus through a twisted loop of the cord, 
 
 whether the passage be effected during pregnancy by the spontaneous 
 
 fetal movements, or at term by the uterine expulsive efforts, or by the 
 
 manipulations of the accoucheur. Knots formed during parturition 
 
 * RuGE, ihid., Bd. iii, Heft 2, 1878, p. 417. 
 
 f Schauta, Arch. f. Gynaek., Bd. xvii, Heftl, 1881. p. 20.
 
 296 THE PATHOLOGY OF PREGNANCY. 
 
 are loose and easily untied. They are unattended by any diminution 
 in the gelatin of Wharton. Those occurring during pregnancy are 
 more closely and firmly drawn, and more difficult to loosen than the 
 former variety. The cord is partly or completely denuded of the 
 gelatin at the seat of the knot, and plainly shows the location of 
 the latter, after its solution, by well-marked indentations. Knots in 
 the cord, of either variety, are comparatively insignificant, although a 
 tightly contracted one, in a thin cord, may occasion grave or even 
 fatal disturbance of the ujnbilical circulation. 
 
 III. Hernia. — Hernia of the umbilical cord consists in the escape 
 from the abdomen, at the point of insertion of the cord, of some or all 
 of the fetal abdominal viscera. It is due either to arrested embryonic 
 development, which prevents the complete closure of the abdominal 
 cavity, or to the failure of the fetal intestines, originally situated out- 
 side the abdomen, to enter the same. Hernia of the cord may occur 
 alone, in otherwise normally developed foetuses, but is usually accom- 
 panied by other deformities, such as stricture of the rectum, imper- 
 forate anus, or distortions of the lower limbs and of the genitals, pro- 
 duced by traction of the displaced viscera upon adjoining parts. The 
 contents of the hernial sac, which is composed of the amnion and of 
 the peritouiBum, are usually convolutions of the intestine, or these 
 with a portion of the liver, although the kidneys, stomach, and sjDleen 
 are sometimes also extruded, leaving the fetal abdomen nearly empty. 
 
 IV. Coiling of the Cord. — Windings of the umbilical cord around 
 the foetus, occurring during pregnancy, vary in their results with the 
 rapidity of their formation. When rapidly developed, they may in 
 rare cases lead to sudden interruption of the umbilical circulation, 
 and to consequent death of the foetus. Should the coils be gradually 
 formed and firm, the extremity embraced by the cord increases, by its 
 own growth, the tightness of the constricting ligature. The latter 
 slowly lessens the caliber of the vessels supplying the extremity con- 
 cerned, and finally, occluding them, produces death of the limb. Ab- 
 sorption of the soft and hard parts of the extremity may result from 
 the cord's unyielding pressure, and the limb be thus completely 
 severed from the trunk by so-called spontaneous amputation. In cer- 
 tain cases the combined pressure of the cord and of the slowly grow- 
 ing member may suffice to completely arrest the umbilical circulation, 
 and thus produce the death of the foetus. Should the neck be encir- 
 cled by the cord, death may ensue from strangulation, and be followed 
 in some cases by almost complete amputation of the head. Coilings 
 of the cord around the foetus occurring at birth are of little impor- 
 tance unless they be numerous. In that case they lead to a shorten- 
 ing of the cord, and produce anomalous positions, premature separa- 
 tion of the placenta, retarded second stage of labor, and even death of 
 the foetus from interference of the umbilical circulation.
 
 DISEASES OF THE OVUxM. 
 
 297 
 
 V. Cysts.— Cysts of the umbilical cord within the amniotic sheath 
 are either produced by liquefaction of mucoid tissue, or by accumula- 
 tion of serum between the epithelial layers of the allantois. 
 
 VI. Stenosis of Umbilical Vessels.— Partial occlusion of the um- 
 bilical vein at the placental insertion, produced by new connective 
 tissue resulting from circumscribed periphlebitis, is sometimes ob- 
 served, but is not sufficiently marked to impede the umbilical circula- 
 tion. Stenosis of the umbilical arteries is occasionally produced by 
 atheroma and subsequent thrombosis. Stenosis of the umbilical vein, 
 
 Fig. 133.— Insertio velamentosa. (Lobstein.) 
 
 and, more rarely, of the arteries, may also result from chronic phlebitis 
 characterized pathologically by the growth in the intima of spindle- 
 shaped and round cells, which later develop into new connective
 
 298 THE PATHOLOGY OP PREGNANCY. 
 
 tissue. This process, whicli is usually referred to hereditary syphilis * 
 may extend into the muscularis, and even invade the adventitia. The 
 result of the stenosis of the uterine vessels is, of course, prejudicial to 
 the foetus in direct proportion to its grade of development. 
 
 VII. Calcareous Degeneration.— Calcareous deposits have been ob- 
 served in the cords of syphilitic foetuses. 
 
 VIII. Marginal Insertion of the Cord.— This anomaly is sometimes 
 called the battledoor placenta, while the term iiisertio velamentosa is 
 applied to cases where the vessels of the cord pursue their course for 
 some distance through the membranes before reaching the placenta. 
 To comprehend their origin, it is necessary to recall the main physio- 
 logical processes involved in the normal development of the placental 
 organ. The vessels of the allantois are not invariably carried at the 
 outset to the point in the periphery of the ovum which the placenta 
 will ultimately occupy. The vessels at first penetrate all the villi in- 
 discriminately, but as the process of obliteration advances in those 
 villi not destined to participate in the formation of the placenta, vas- 
 cular connections are only preserved between the vessels of the newly 
 formed cord and the villi attached to the serotina. As the amniotic 
 sheath forms around the rudimentary cord, the foetus performs a 
 movement of rotation in such a way that the umbilical vessels are 
 made to pursue a direct course toward their placental insertion. If, 
 owing to the adhesions between the rudimentary cord and either the 
 chorion or the amnion, the formation of the sheath is incomplete, the 
 vessels diverge, and are distributed to points more or less distant from 
 the placenta (Schultze). In the insertio velamentosa (Fig. 133), 
 hgemorrhage sometimes results from a rupture of a vessel at the time 
 of the breaking of the membranes — an accident which, unless speedily 
 followed by delivery, is apt to prove fatal to the foetus. 
 
 IIydatidiform Mole. 
 
 I. Morbid Anatomy. — Before the time of Cruveilhier, who is said 
 to have first demonstrated the difference between true hydatids and 
 the uterine hyd; tidiform mole, these morbid formations were regarded 
 as identical. Since his researches, it has been considered established 
 that the essential pathological process involved in the production of 
 the hydatid mole consists in a proliferative degeneration of the chori- 
 onic villi. This degeneration of the villi embraces h^'pertrophy of 
 their investing epithelium, of their connective-tissue cells, which may 
 also undergo mucoid degeneration, and of their mucoid intercellular 
 substance. The accumulation of the mucoid tissue imparts to the villi 
 the appearance of cysts with translucent, semi-fluid contents, varying 
 in size from that of a millet-seed to that of a walnut, and forming, by 
 
 * Mewis. Ztschr. f. Geburtsh. u. Gynaek., Bd. iv, Heft 1, 1879, p. 62.
 
 DISEASES OF THE OVUM. 
 
 290 
 
 their aggregation, growths which may attain the dimensions of a child's 
 Jiead, or in rare cases may reach such proportions as to distend the 
 uterus to the size usual at the full term of pregnancv. Smaller collec- 
 tions are much more frequently encountered than those of these 
 enormous proportions. The fluid of the cysts is albuminous, and closely 
 resembles the liquor amnii, but contains in the earlier stages a larger 
 proportion of mucin than the latter. At a later period the mucin is 
 less abundant, while the albumen increases in quantity. The larger 
 cysts are richer in water, but contain less mucin than the smaller ones. 
 Inasmuch as the degenerative process does not attack the entire villus, 
 portions of normal tissue intervene 
 between the cysts, and impart to 
 tlie degenerated mass the appear- 
 ance of grape-clusters — the cysts 
 i-epresenting the individual berries, 
 and the unaltered tissues their con- 
 necting stems. A certain number 
 of cysts are, however, attached to 
 a single continuous pedicle, instead 
 of possessing a separate stem con- 
 nected with a common trunk, as is 
 the case in the grape-cluster. If 
 the mole be formed, as is usually 
 the case, during the first month, 
 while the villi are equally devel- 
 oped upon the entire perij^hery of 
 the ovum, the degeneration will 
 involve its whole surface. In this 
 case the foetus, dying and becoming 
 disintegrated, may undergo com- 
 plete absorption, leaving the amni- 
 otic cavity emf>ty. The vessels of 
 
 the villi are under such circumstances completely obliterated, while nu- 
 Tuerous blood -coagula are found between the cysts. If, however, the 
 placenta be already formed at the beginning of the cystic degeneration, 
 the villi having become atrophied upon that part of the chorion which 
 does not participate in the development of the placenta, the neoplasni 
 is confined, as a rule, to the latter, although cysts, evidently owing their 
 origin to villi which have not undergone atrophy, sometimes occur 
 upon the smooth surface of the chorion. Should the hydatidiform 
 mole be of sufficient extent, under these circumstances, to destroy the 
 foetus, the more or less disintegrated remains of the latter are found 
 in the am.niotic cavity, which sometimes contains an excess of liquor 
 amnii. If only a few of the placental lobes or single cotyledons be 
 implicated, the growth of tlie foetus may not be disturbed. A healthy 
 
 Fig 1« 
 
 -SpenMieii tiom liMlatuliform mole, 
 m the Wood JIuseum
 
 300 THE PATHOLOGY OF PREGNANCY. 
 
 fostus is occasionally developed side by side with a hydatid mole.* 
 The hydatidiform mole is usually contained within the decidua. In 
 an interesting case reported by Volkmann, however,f the degenerated 
 villi had invaded the uterine blood-sinuses, and by pressure led to so 
 extensive an atrophy and absorption of the uterine walls as to leave 
 only a thin, transparent septum between the mole and the peritoneal 
 covering of the organ. The cavity formed by this process of erosion 
 in the uterine parenchyma was larger than the uterine cavity proper, 
 and presented numerous intersecting trabecule resembling the columnar 
 carneae of the cardiac ventricles. The destructive character of the 
 cystic degeneration is attributed in such cases to some unknown mor- 
 bid condition of the uterine walls, probably the result of malnutrition. 
 Schroeder J refers to two similar cases, in one of which the cystic de- 
 generation was attended by fatal peritonitis, and the other by rupture 
 of the uterus, and death from hfemorrhage into the peritoneal cavity. 
 
 II. Etiology. — Primiparffi are less frequently affected by the hyda- 
 tidiform mole than multiparae, although the actual number of preg- 
 nancies seems to exert a less marked predisposing influence than ad- 
 vancing age. The cystic degeneration usually occurs during the first 
 month of utero-gestation. According to Underbill,** the latter part 
 of the third month is the limit within which the disease can originate. 
 That the exciting cause of the hydatidiform mole may be a morbid ma- 
 ternal condition, is rendered probable by the repeated recurrence of the 
 disease in the same patient, by its coexistence with inflammatory de- 
 cidual disease or with extensive uterine fibroids, and by the presence, 
 in the majority of cases, of a cancerous or syphilitic dyscrasia on the 
 part of the mother. If the origin of the degeneration be maternal, as 
 it probably is in most instances, the degeneration of the chorion ante- 
 dates and produces the death of the foetus. On the other hand, the 
 fact that the morbid growth may owe its inception to fetal disease 
 seems demonstrated by those cases in which, as has been already stated, 
 a healthy foetus may be developed at the same moment with a hydatidi- 
 form mole. This view is further supported by those cases in whidi 
 death of the foetus is attended by so insignificant an amount of cho- 
 rionic disease as to render its active causative agency in the death of 
 the foetus highly improbable. Spiegelberg,|| however, is of the opinion 
 that the hydatidiform mole does not result from death of the embryo, 
 and that its cause is often to be sought in an abnormal development of 
 the allantois. The establishment of the true pathological relations of 
 the hydatidiform mole have led to the abandonment of the once preva- 
 
 * Spiegelberg, Lehrbiich, p. 332. 
 
 f Volkmann, Virchow's Archiv, Bel. xli. p. 528. 
 
 I ScHROEDER, Lehrbuch, p. 429. 
 
 * Underhill, The Hydatidiform Mole, Obstet. Gaz., January, 1879, p. 16. 
 
 II Spiegelberg, Lehrbuch, p. 333.
 
 DISEASES OF THE OVUM. 
 
 301 
 
 lent opinion that the neoplasm might be developed independent of 
 conception. The theory that a portion of retained placenta might 
 become affected with the hydatidiform disease, has also been refuted 
 by accumulated clinical evidence. 
 
 III. Symptomatology. — A leading sign of the hydatidiform mole 
 consists ill a failure of correspondence between the uterine enlarge- 
 ment and the computed period of utero-gestation. The uterus is 
 usually larger at any given stage of pregnancy than it naturally would 
 be in the course of normal gestation, but may be decidedly smaller in 
 those cases attended by early demise of the embryo. Lumbar and 
 sacral pains are prominent and distressing in proportion to the rapid- 
 ity of uterine development. The uterus imparts a peculiar doughy 
 feeling to the palpating fingers, and in rare instances plainly jjercep- 
 tible fluctuation. Individual parts of the foetus can not be distin- 
 guished through the uterine walls. The lower segment of the uterus 
 is remarkably tense. Ballottement yields negative results and fetal 
 movements are absent, although they may be closely simulated by uter- 
 ine contractions. The fetal cardiac sounds are diminished in inten- 
 sity or are quite imperceptible. There is a discharge from the uterus, 
 either constant or intermittent, consisting of disintegrated and unrupt- 
 ured cysts, cystic fluid, and blood, which, although usually not excess- 
 ive^ may be so much increased by uterine contractions induced by 
 overdistention as to seriously impair the general strength, or even to 
 induce death from exhaustion. 
 
 Abortion is usually produced by the mole before the sixth month, 
 but the expulsion of the neoplasm may be delayed until the normal 
 period of parturition, or even until a later season. The haemorrhage 
 and the characteristic discharge cease after the complete expulsion of 
 the tumor, but retained portions of the same may give rise to pro- 
 tracted bleeding. It is often impossible to distinguish the local signs 
 produced by the expulsion of a large hydatidiform mass from those 
 observed after normal delivery. 
 
 Diagnosis. — In cases of limited cystic degeneration it is often im- 
 possible to diagnosticate hydatidiform mole. The symptoms upon 
 which, in well-marked cases, the diagnosis is to be based are rapid in- 
 crease in the dimensions of the uterus, the presence of obscure fluctu- 
 ation, the impossibility of obtaining the fetal heart-sounds or of grasp- 
 ing any of the fetal members, negative result of ballottement, and 
 uterine contractions, attended by the mucous or muco-sanguiuolent 
 discharge containing the characteristic cysts. 
 
 Prognosis.— The prognosis of hydatidiform mole is determined 
 chiefly by the frequency and the violence of the attending haemor- 
 rhages. It is not extremely unfavorable in the majority of cases. 
 The existence of the peculiar form of cystic degeneration described 
 as the interstitial, intraparietal, or eroding variety would, however,
 
 302 THE PATHOLOGY OF PREGNANCY. 
 
 iiuturally render the prognosis excee;lingly gruve. 'V\\v fatality of 
 tliis class of cases results from their tendency to produce a rni)ture of 
 the uterus complicated by intra])eritoneal ha'morrhage, peritonitis, or 
 septicaemia. The life of the fcetus is almost invariably sacrificed. 
 
 Treatment.— The treatment is restricted to measures calculated to 
 control ha'morrhage and to promote the ex])ulsion of the diseased 
 mass. Most writers recommend non-interference so long as the ute- 
 rus remains passive. When contractions set in, the vagina should be 
 tamponed, and ergot given in full and repeated doses, until the mole 
 is expelled entire. The expectant plan is, however, not devoid of 
 danger. In once case, where the patient sulfered from labor-pains 
 for several hours before I saw her, the loss of blood was excessive. I 
 succeeded in removing with the hand, through the patulous cervix, 
 an enormous quantity of cysts, suthcient to lill a wooden ])ail. This 
 was followed by good contraction of the uterus anil arrest of the 
 hemorrhage, but the patient died two hours later from shock and 
 anremia. Unless, therefore, the patient is so placed that professional 
 assistance can be obtained at a moment's notice, the propriety of dilat- 
 ing the cervix so soon as the diagnosis has been established may well 
 be considered. Dilatation should be effected by the steel dilator, or by 
 the dilators of Barnes or of Tarnier, or even by tents, if rare is taken 
 to render them thoroughly aseptic. 
 
 After expulsion, or after the manual removal of the hydatidiform 
 (iysts, the uterus should be washed out with antiseptic fluids; or, in 
 case of hiemorrhage, its inner surface should be swabbed with the per- 
 chloride of iron. The irrigation of the uterine cavity with water, to 
 which only sufficient perchloride of iron has been added to give it a 
 wine-color, has often a powerful styptic effect. Underbill recom- 
 mends the continued einployment of ergot after delivery, and, in 
 cases of persistent ha;morrhage, the occasional introduction of the 
 laminaria tent, and, if necessary, the employment of Thomas's dull- 
 wire curette. 
 
 Retention in Utero of the Dead Fcetus. 
 
 In the normal uterus the causative conditions producing retention 
 of the dead fcetus are not invariably identical. If the placenta remain 
 adherent to the uterus after the demise ojf the foetus, the continued 
 vitality and uninterrupted development of the placenta sufficiently 
 explain the fetal retention. When, however, all connection between 
 the placenta and the uterus has been severed, retention is probably 
 i-eferable to the diminished irritability of those reflex nervous centers 
 which control the expulsive uterine efforts. The duration of retention 
 produced by adhesion of the placenta, in cases of single pregnancy, is 
 protracted until such time as morbid placental processes impair the 
 vitality of that organ and induce its separation. In multiple preg-
 
 niSKASlW OK 'I'll!-; OVUM. ;{,);{ 
 
 nanoios, aUciult'd by tli'Mlli of <»iic or nunc of l.li»> fd'liiKcs, Liu? laUt-r 
 arcMisiially oxpolli^d willi llio lioiilUiy I'cnlus al. tonii. Tlicy aro, liow- 
 ovcir, tt()iiiol,irti(>K cxprllcd carlior, and, in iiin< inHlaih-cH, lalcr llian lll(^ 
 iiornnil fdttus, and it nii.y in ^cncM-al (criiiH Ix! staled thai, rctcniion 
 pnxInriMl hy placcidal adlicsion vnry rarely (ixccccIh llin natural period 
 of ^fKHtaXioii. Ifelcniion due to diniinislied irritaliilily <d' llie rellex 
 CdiitcrH may iKMndelinildy prolon^cil. Licihiininu * Ih of t.lie npinion 
 tliat, all (laseH of rcdciit.ion protracted l»ey(in<l tJie norniid term (»!' pre;;- 
 lUiiK^y heloM^' in (JiiH calc^^ory. 
 
 'riio pailiolo^i(!al (dnui^^cH which the l'(etiis underyoes when retained 
 in the ntcruH af(.(!r il,H death vary with the e(»nditi<»n <d' I he. nieinhranew; 
 !. if their iid.e/^ril,y bo |»r('.H(!rv()(l, (In* tiioHl, iniporliiid. pat holojL,deal fetal 
 eondit.ioiiH reHidl.in;^' from the retention urv mnmmilieation, maeera- 
 iion, uiid fatly de;^renei-aJion. "I. l( the niendirnneM be rnptnred noun 
 aftor the doath of the fcetns, or if their rnptiin' be the eaiise of I be 
 Icr'minatioti of fetal life, mum miliea^tion ma,y (>nKii(t; or, in tlnwYent. 
 of th(! entraiKio of air itd.o the uterine! cavity, I he fetal IJHHueH may 
 undergo fjutrofacstivo chaiigttH. If nMininiilieidion h;is idre;idy iicenrred, 
 pulref.iclion docH not, tako phice.f 
 
 Muilllliilioaliun. Mummilii-nJion h niont fr<'(piently oliHerved in fo'- 
 tuHOH whoH(! (loath haH apparoiilly b(H'n the gradual residt of inanition 
 from imido(|uato hlood-Kup|)ly, this inHid!i<'iency of the nuttilive fluid 
 Ixiitig oftoM roforablo to torHion or c(»nHtri<!tion of the undiili(:d eoid. 
 Miimmi(i(ralion alVeets by pr<d'i'rence fo'tuKOH dying during the midtlle 
 HtagoH of g('st,a,tion. liiebmann J HuggentH thn,t tJus fact nniy be eon- 
 nocitod with the itugmenled r;ipi(|it,y of endonmosiH, du(! to tho larger 
 {»or(!()id,age of Halinc! ingr<'(lient.s then prcHoid- in tho jininiotic (luid, 
 or to tli(! fact that torsion and Hl,(fMOHiH «)f tluj (!ord are rnoHt liable to 
 oecui- id Ib.d, period (d' pregnaiKiy. M umnnlication oceurn chielly in 
 (!onnoetioti with twin pregnnricioM, one f(etun Infiiig fully d(!veloped 
 whiici th(f otluir bocom<!H mummilied. iu tJuH cuho tho pnworKicf of the 
 (l(!!id fo'tuH «loeH not usually (^xcito ttxpulsory uterine (dVorls lad'orc! Ilie 
 nornuil tornumition of prognatiey is reached, when both fietuHos are 
 HimultanooiiHly (hflivcfrod. in <:<'rl!iin r.ire instances the inumrrMlied 
 fo'tiis nuiy Ix' ex|»ell(!d either before or after the healthy on<', but its 
 delivery is uiiMttcnded by liM'tnorrhagc) or other unphfusant complica- 
 tion. When niiiinniilicMti<.n ;dTe(!ts a singlo foftuH, the retention is 
 supposeil t(» be due to abiiornuilly irdimate eoruMtction between Iho 
 placenta and tlu! ut,oniH. Symptoms closctly sirnidatitig thoHo of abor- 
 tion oc(!ur, l>ut tluty subside Ix-fore the pnxluct «»f (ionception is ex- 
 pollod, and probal)ly (!veu befon- the ruptun* of tho mend)ranes. Tho 
 UiituH thori bocotrios mumnnlied, wlnle the vitality <»f the pla.cnta is 
 
 *^ Ln';iiMANN, fkit,niK/. (loharlMli. ii. (iynwU., IM. hi. IH?I, \>\>.W, (V.i. 
 f SiMKiH'-i-UKiuj, liiilirh,, p. 'M7. 
 J LrKHMANN, op. cil., p. M.
 
 304 THE PATHOLOGY OF PREGNANCY. 
 
 not impaired. Under these circumstances the retention is never jiro- 
 longed beyond the normal period of gestation, and is thus distin- 
 guished from those cases of retention owing their origin to so-called 
 " missed labor." 
 
 A mummified ftetus is flattened from compression. Its viscera are 
 of soft consistency and of small dimensions. Its surface is shrunken. 
 The peritoneal and pleural cavities contain a scanty and discolored 
 fluid. The subcutaneous areolar tissue has disappeared, and the skin 
 lies in direct contact with the muscles. The placenta, Avhich is dry, 
 yellowish, and tough, is the seat of fatty degeneration, and contains 
 the residue of old extravasations. 
 
 Maceration. — The placenta of a macerated fretus (fcetus sanguino- 
 lentus) is ana3mic, soft, and friable. The cord, in wliich the vessels 
 are permeable, is cylindrical, smooth, spongy, and inelastic. Its coils 
 have disappeared. It is club-shajied at the fetal extremity, and its 
 color is brownish red. The amniotic fluid has a peculiarly repulsive, 
 sweetish, and sickening odor, unlike that of putrefaction. The fluid 
 is rendered turbid and of a greenish-yellow color by the admixture with 
 it of sero-sanguinolent fluid, and of meconium. The membranes, 
 which retain their normal consistence for a long time, finally become 
 friable, swollen, and discolored. A foetus of only one to two months 
 may be completely dissolved by the process of maceration. If the 
 foetus be more mature, its general form and the outline of its organs 
 are preserved, but granular degeneration and disintegration of their 
 anatomical elements are everywhere present. The ejiidermis is first 
 affected by the process of maceration. It is separated from the corium 
 by the formation of vesicles similar to those of pemphigus, which con- 
 tain either a reddish, sero-sanguinolent, or a clear serous fluid. The 
 corium is infiltrated with the same fluid, and presents the appearance 
 of brownish-red macerated parchment. The subcutaneous areolar and 
 adipose tissues are reddish and redematous. The oedema is most ap- 
 parent over the cranium, the abdomen, the feet, hands, and sternum. 
 The entire body is flaccid, and assumes, under the influence of external 
 pressure, curiously distorted shapes, being distended at some jioints 
 and depressed or flattened at others. The cranial sutures are separated, 
 the joints are disarticulated, and the periosteum has become detached 
 from the long bones. The vessels are filled with dark, grumous blood. 
 The serous cavities are distended with bloody serum. The brain is 
 transformed into a grayish-red pulp. All the viscera are infiltrated and 
 friable, the uterus and lungs preserving their normal consistence longer 
 than the other organs. Pigment masses and fat-crystals are deposited 
 in many organs. In rare instances the fetal organs become covered 
 with a greasy substance composed of cholesterin and the margarates of 
 soda, potassa, and lime. These saponified products are sometimes 
 termed, collectively, advpocere. No trustworthy inferences can be
 
 DISEASES OF THE OVUM. 305 
 
 drawn from the appearance of macerated foetuses as to the cause of 
 their decease, since the gross pathological conditions are identical 
 under all circumstances.* Apparent variations are duo to the respect- 
 ive periods of retention. The rapidity with which the process of 
 maceration occurs is variable, and its extent is therefore no criterion 
 of the time at which the fetal demise took place. 
 
 Seventy-five per cent of macerated foetuses are expelled, according 
 to Ruge,f before the thirty-first week, and transverse or breech-pres- 
 entations occur in nearly one half of all the cases. 
 
 The term missed labor was applied by Oldham to those cases in 
 which, the uterine expulsive efforts having been ineffectually made at 
 full term without other result than the escape of the waters, the 
 uterine contractions finally subside, leaving the foetus in utero. The 
 causes of missed labor usually cited are abnormal absence of uterine 
 irritability, or of that residing in the reflex nervous centers, obstructed 
 labor, and unusually close adhesions of the placenta. 
 
 Note. — The occurrence of missed labor has recently been disputed by Muller 
 (De la grossesse uterine prolongee indefiniment, Paris, 1878), who would refer all 
 such cases to gestations occurring external to the uterine cavity. Certainly the 
 criticisms of Miiller have greatly restricted the number of cases which formerly 
 were unquestionably assigned to this category. In certain of them the foetus ap- 
 pears secondarily to have made its way into the uterus through a communicating pas- 
 sage, while in others the pregnancy may have been primarily of tubo-uterine or of 
 mural origin. Still, Barnes has since related the history of a case (On the so-called 
 " Missed Labor," Obst. Trans., vol. xxiii, p. 81) which affords strong affirmative 
 evidence of the possibility of the prolonged retention of a foetus dying before the 
 end of gestation was reached. The circumstances were briefly as follows : Mrs. 
 
 B , aged thirty-nine, had borne three stillborn children. Five years later, m the 
 
 month of October, the catamenia ceased. The movements of the child were felt 
 between the third and fourth months. Between the eighth and ninth months there 
 was a flow of blood from the vagina, which, however, ceased in a few days under 
 the use of cold and styptics. At the end of three weeks the bleeding returned, but 
 became lighter at the end of a week, and then gradually disappeared. At no time 
 were there labor pains. At the end of January pieces of bone began to come away, 
 and portions of bone were removed by the finger and forceps after partial dilatation 
 of the cervix. In Febriiary, under chloroform, Dr. Barnes proceeded to empty the 
 uterus. As the hand could not be got through the uterus. Dr. Barnes extracted 
 the foetus with his craniotomy forceps. The foetus was a compressed mass, bones 
 emerging in the surface, the fleshy part greasy, soft, and putrid. It presented the 
 appearance of having reached the eighth or ninth month of gestation. The patient 
 showed considerable shock after the operation, but rallied the next day, and eventu- 
 ally recovered. Dr. Barnes was convinced, not only by examinations made during 
 the extraction of the foetus, but by the subsequent daily introduction of the sound, 
 that the cavity was continuous with the cervix, and that the dense wall felt in no 
 respect differed from the characters of uterine wall. To his mind, even a post- 
 mortem examination could hardly have made the case clearer. In the discussion 
 which followed Dr. Barnes's report it was, however, suggested by Sir Spencer Wells 
 and others that the case was really one of mural pregnancy. 
 
 * RuGE, Zeit. f. Geb. u. Gyn., Bd. i, Deft 1, 1877, p. 58. t l^i^-^ P- "^O- 
 
 20
 
 306 
 
 THE PATHOLOGY OF PREGNANCY. 
 
 Dr. Stanley P. Warren, of Portland, Maine, sends me the following histotf, 
 which seems conclusive : The patient menstruated last in January, 1884. In the 
 following May she was attacked with general peritonitis. The 28th of October was 
 computed as the probable terminus of gestation. At that time continuous cramp- 
 like pains were felt by the patient. The presentation of the child was transverse. 
 The cervix was not reached. For several days the pains recurred at night. By 
 the second week in November it was ascertained that the child was dead. There 
 was no further expulsive action. On December 30th, after vain attempts at dilata- 
 tion of the cervix, Caesarean section was performed, and a female child, weighing 
 eight and a half pounds, was removed from the uterine cavity. The patient died 
 from shock twenty-eight hours after the operation. 
 
 According to Kiichenmeister (Ueber Lithopadien, Arch. f. Gynaek., vol. xvii, p, 
 153), retention may result from obstruction due to hardening of the cervix, to car- 
 cinoma, to fibroids in the lower segment, and where pregnancy takes place in the 
 rudimentary cornu of a one-horned uterus. Retention due to obliteration of the 
 cervical canal he rejects ; but I have witnessed three cases of complete occlusion of 
 the vaginal vault, where it was necessary to dissect up a long passage to permit the 
 birth of the child, and where, without artificial aid, either rupture of the uterus or 
 retention of the child must have resulted. 
 
 The pathological processes presenting themselves in case of long- 
 continued retention and of missed labor vary with the entrance of air 
 into or exclusion of air from the uterine cavity. If the atmosphere 
 have free access to the uterus, the foetus undergoes putrefactive 
 changes. The soft parts, having been liquefied, escape, leaving the 
 osseous framework of the fretus in ntero. This may also be gradually 
 and partially disintegrated, liquefied, and expelled, but its complete 
 evacuation is not often effected by Nature's processes. If, however, 
 the cervix be narrow or unyielding, the continuous pressure of some 
 projecting and pointed bone may penetrate its tissues and force an 
 exit through the vagina, rectum, or anterior abdominal wall. A similar 
 irritation and penetration may induce supptirative metritis, and, event- 
 ually, fatal peritonitis, or septicsemia. 
 
 If the air be excluded from the uterus in cases of retention indefi- 
 nitely prolonged, the foetus either becomes mummified, and, forming 
 intimate connections with the uterus through the medium of inflam- 
 matory products, remains in ntero ^v\i\\o\\i giving rise to any symp- 
 toms, or it may produce by constant irritation suppurative metritis, 
 with abscess formation and the escape of pus externally. Access hav- 
 ing been thus afforded to the air, putrefaction and its consequences 
 will then ensue. 
 
 In rare cases of prolonged retention, the foetus becomes the seat of 
 adipocerous changes.* Calcification of the foetus (lithopaedion forma- 
 tion) occurs probably in cases of extra-uterine pregnancy only. 
 
 The retention of the dead foetus is comparatively devoid of danger. 
 Even if decomposition or putrefaction of the foetus occurs, it is 
 common for the products of disintegration to be eventually eliminated, 
 
 * Vide Case of Professor T. G. Thomas, N. Y. Med. Journal, vol. xxi, p. 163.
 
 THE PREMATURE EXPULSION OF THE OVUM. 397 
 
 without a fatal result, by natural efforts or by the intervention of ob- 
 stetrical art. There is good evidence, however, that the dead fa^tus 
 may, even if the access of air has been prevented, seriously impair the 
 patient's health. Lately I have witnessed the development of albu- 
 minuria subsequent to the death of the foetus, which disappeared upon 
 the induction of premature labor.* 
 
 Unless, therefore, labor sets in within two or three weeks after the 
 death of the foetus, the induction of labor is indicated. The excep- 
 tion to this rule would be in cases of twin pregnancy, where one foetus 
 was still living. In prolonged retention, the elimination of pieces of 
 bone should, as far as possible, be aided by the hand. If necessary to 
 dilate the cervix, care should be taken lest spiculae of bone be pressed 
 by the expanding body into the uterine tissues. Every precaution 
 should be taken subsequently to render the uterine cavity aseptic. 
 When the Csesarean section is performed and the uterine tissues are 
 found extensively infiltrated, it has been suggested that the Porro 
 operation may diminish the risks of infection. The efficacy of the 
 measure would of course depend upon the freedom of the parametria 
 from septic invasion. 
 
 CHAPTER XVL 
 
 THE PREMATURE EXPULSION OF THE OVUM. 
 
 Causes of abortion. — Disposition to abortion. — Immediate causes. — Symptoms. — 
 Moles. — Incomplete abortions. — Diagnosis. — Prognosis. — Treatment. — Prophy- 
 laxis. — Arrest of threatened abortion. — Treatment of inevitable abortion. — 
 Treatment of neglected abortion. — Removal of fibrinous polypi. — Treatment of 
 miscarriage. 
 
 Whex pregnancy is interrupted, during the first three months, by 
 uterine contractions leading to the expulsion of the ovum, the term 
 abortion is used ; in the fourth, fifth, sixth, and seventh months — i. e., 
 from the formation of the placenta to the time the child becomes 
 viable — it is proper to speak of the accident as immature delivery, or 
 miscarriage ; and, finally, a confinement occurring from the twenty- 
 eighth week, the earliest period of viability, to the thirty-eighth week, 
 when the fcetus possesses every indication of maturity, is distinguished 
 as premature delivery. 
 
 This purely artificial division is justified by praerieal differences 
 in the symptomatology and treatment of the groups thus separately 
 designated. 
 
 * Vide also Barker, On Puerperal Disease, p. 402. KEMtiJR, Retention «• 
 Utero of the Dead Fcetus. Trans. Iiid. State Med. Soc, 1875.
 
 308 
 
 THE PATHOLOGY OF PREGNANCY 
 
 Causes which lead to the Peematuke Interruption of 
 
 Pregnancy. 
 
 The underlying causes of abortion, miscarriage, and premature 
 delivery are the same. Causes of abortion are rarely of sudden occur- 
 rence. Usually the way is prepared, either by changes taking place 
 in the ovum, or by certain pathological conditions affecting the 
 mother. In either of these ways a disposition to abortion is produced. 
 When once, as the result of morbid changes, the attachment of the 
 ovum to the uterus has been rendered insecure, causes usually inopera- 
 tive suffice to determine uterine contractions and the time at which the 
 expulsion takes place. 
 
 The Disposition to Abortion.— The disposition may be due prima- 
 rily to any disease of the chorion, of which we have an example in 
 syphilitic degeneration of the villi. In most cases, however, death of 
 the foetus precedes and leads to disease of the chorion. The causes of 
 abortion resolve themselves, therefore, in large measure, into the causes 
 which produce death of the foetus. 
 
 The death of the foetus may be due to direct violence, as kicks and 
 blows upon the abdominal walls ; to diseases of the fetal appendages 
 (cord, amnion, chorion, placenta) ; to diseases of the decidua, especially 
 those which give rise to haemorrhage (before the complete formation 
 of the placenta, the separation of the decidua from the uterus inter- 
 feres with the nutritive supplies which go to the foetus) ; to febrile 
 affections, in which death results either from the high temperature, 
 from associated diseased conditions of the decidua, or, as in certain 
 acute infectious diseases, to the direct transfer of the poison from the 
 mother to the foetus ; and, finally, to excessive anaemia. Anaemia de- 
 veloped by pregnancy rarely affects the child. In acute anaemia from 
 profuse hajmorrhage, the child may die from asphyxia. In times of 
 famine great numbers of women abort. The disposition to abort ob- 
 served in corpulent women is probably due to the fact that the blood 
 is insufficient in quantity and quality to supply the wants of the 
 growing child. 
 
 The death of the foetus is followed by the expulsion of the ovum, 
 not usually at once, but after a longer or shorter period of time. Be- 
 fore the third month, in such cases of delay, the embryo, which con- 
 sists of hardly more than a heap of cells, may become macerated, and 
 absorption may take jjlace after the death of the embryo. Except in 
 cases of hydramnion, partial collapse of the ovum ensues. As soon as 
 the foetus dies, the circulation which passes from the foetus to the cho- 
 rion and placenta is suspended. The villi then become obliterated, 
 and undergo fatty degeneration. The decidua is affected by the same 
 process. With the diminution in the volume of the ovum, contrac- 
 tions begin. The villi, loosened in their attachments to the decidua,
 
 THE PREMATURE EXPULSION OF THE OVUM. 309 
 
 are drawn out, and the decidual vessels, exposed and subjected to in- 
 creased pressure, rupture, and haemorrhage results. The uterine con- 
 tractions are awakened and exercise an expulsive force upon the ovum, 
 which in its descent expands the cervix from above downward, and 
 passes finally into the vagina. In the first three months the ovum 
 is not infrequently expelled with membranes unruptured. From the 
 end of the third month onward such an occurrence is rare, though I 
 have seen an instance which happened in the sixth month. In the 
 early months the expulsion of an intact ovum is associated with in- 
 considerable haemorrhage. When the membranes give way, the em- 
 bryo and the fluid contents of the amnion escape first. With the 
 removal of the compression exercised by the ovum upon the inner 
 surface of the uterine walls, haemorrhage occurs, which continues, as 
 a rule, nntil the complete expulsion or removal of the membranes and 
 placenta. 
 
 Aside from the death of the foetus, with consecutive changes in 
 the chorion and decidua, and diseases of the fetal appendages leading 
 to death of the foetus, the predisposition to abortion may be the result 
 of primary defects or changes in the decidua alone. Of these changes 
 w^e recognize : 
 
 1. Atrophy of the Uterine Mucous Membrane. — The insufficient 
 development of the mucous membrane exercises an injurious influence 
 uj^on the development of the 
 ovum in cases only in which the 
 serotina and the reflexa are in- 
 volved. An abnormally small 
 and undeveloped serotinal sur- 
 face may give rise to a small pla- 
 centa, or the serotinal attach- 
 ment may be of such limited ex- 
 tent that the mere weight of the 
 ovum drags it downward and 
 converts it into a long, narrow 
 
 ,. . 1, ,1 !_■ ,^ Fig. 135.— Ovum, with imperfectly developed 
 
 pedicle. At other times, the re- decidua ; outer surface of vera. (Duncan.) 
 
 flexa may be but partially devel- 
 oped, or may fail altogether, and then the ovum, covered only by the 
 chorion, hangs by a pediculated attachment to the serotina. 
 
 In both these cases the uterine contractions, instead of at once 
 effecting the expulsion of the ovum, may force the ovum into the 
 cervix, where it may remain for a time, nourished by the long pedicle, 
 but arrested in its further descent by a contracted os externum. To 
 these cases the term cervical pregnancy has been applied. The cervix, 
 according to the month of pregnancy, is more or less spherically dis- 
 tended, and the corpus uteri above contracts down to nearly normal 
 dimensions. As the cause of this condition lies chiefly in rigidity of
 
 310 THE PATHOLOGY OF PREGNANCY. 
 
 the OS externum, it occurs most frequently in primipara. Even with 
 a patulous os, though rarely, a cervical pregnancy may be produced by 
 the resistance and firmness of the pedicle attaching the ovum to the 
 
 uterus.* 
 
 2. Hypertroi)liy of the Mucous Membrane.— Thickening of the mu- . 
 cous membrane is the result of endometritis, and may lead to abortion 
 in either of the following ways: The several forms of endometritis 
 may give rise to affections of the placenta, and thus prove fatal to the 
 foetus, or the thinned, dilated vessels of the diseased decidua may 
 rupture, and produce sanguineous effusions between the membranes. 
 
 The frequency of abortion in displacements of the uterus is prin- 
 cipally dependent upon associated endometritis. In anteflexion of the 
 uterus, sterility is common, but endometritis and abortion are rare. 
 In retroflexion, on the contrary, while there is slight obstacle to con- 
 ception, the congestion of the uterine walls and the altered conditions 
 of the uterine mucous membrane render abortion a frequent occur- 
 rence. 
 
 Eigidity of the uterine walls, which interferes Avith their due ex- 
 pansion, may lead to premature uterine contractions. In "this way an 
 imbedded flbroid or carcinoma may ultimately become sources of abor- 
 tion. Expansion of the uterus may likewise be hindered by old peri- 
 toneal adhesions or pelvic cellulitis. 
 
 • Finally, there remains a class of women in whose cases it is impos- 
 sible to detect either disease of the ovum or of the genital organs, yet 
 in whom abortion occurs, dependent, so far as our present knowledge 
 •goes, upon certain personal conditions of nerve irritability. Physical 
 and psychical sources of excitement which would be of small moment 
 in some women, in them suffice to interrupt pregnancy. 
 
 Immediate Causes of Abortion. — Changes in the ovum other than 
 rupture and escape of the amniotic fluid rarely lead at once and di- 
 rectly to abortion. The proximate causes which induce contractions 
 and the throwing off of the ovum reside for the most part in the ma- 
 ternal system. They consist of : 
 
 1. Hypercemia of the Gravid Uterus. — When the predisposing 
 causes have operated to weaken the attachments of the ovum to the 
 decidua, anything which determines the blood-currents to the uterus is 
 liable to produce extravasations of blood around the ovum, and awaken 
 uterine contractions. Because of this fact, we surround patients pre- 
 disposed to abort with every precaution during the periodic menstrual 
 congestion that not even pregnancy altogether suspends. Fevers, in- 
 flammatory affections of the genital organs, excesses in coitus, hot 
 foot-baths, valvular heart lesions, obstructions to the circulation of the 
 lungs and liver, may each lead to rupture of the decidual vessels. 
 
 * W. ScHULEix, Ueber cervicale Schwangerschaft, Ztschr. f. Geburtsh. und Gy- 
 naek., Bd. iii, H. 2, p. 408.
 
 THE PREMATURE EXPULSION OF THE OVUM. 3H 
 
 More frequently rupture follows jars to the body from vomiting, cough- 
 ing, and straining, from railroad journeys, from violent exercise, from 
 falls, and the like. 
 
 The importance of separating the predisposing from the immediate 
 causes of abortion is shown by the impunity with which often i)er- 
 fectly healthy women, with no abnormal conditions of the generative 
 organs, set all the usual restraints at defiance with the intent to inter- 
 rupt an undesired pregnancy. M. Brillaud Laujardiere relates the 
 case of a peasant who took his wife, while e)iceinte, behind him on 
 horseback, and started off with her at full gallop with the view of caus- 
 ing her to miscarry. Having thus thoroughly shaken her, he dropped 
 her suddenly to the ground Avithout slackening his speed. This brutal 
 manoeuvre he repeated twice without the least success.* On the other 
 hand, women eager for offspring, after an abortion, sometimes lay 
 undue stress upon slight imprudences, and make them the sources of 
 morbid self-reproaches, which it becomes one of the functions of the 
 physician to allay. 
 
 2. Uterine Contractions jiroduced hy Influences tohich act directly 
 through the Nerves. — Of this we have examples in the contractions 
 awakened by frictions of the uterus through the abdominal walls, in 
 the reflex contractions j^roduced by stimuli applied to the breasts, and 
 in those excited by strong mental emotions. 
 
 Symptoms. — As the detachment and expulsion of the ovum can not 
 possibly take place without rupture of the decidual or placental ves- 
 sels, haemorrhage becomes the constant and necessary result of every 
 abortion. In the first two months the haemorrhage resembles that of 
 a profuse menstruation. Pain is present, in part due to uterine con- 
 gestion, in part to the expulsion of blood-clots through the imperfectly 
 expanded cervix. The latter pains resemble those of obstructive dys- 
 menorrhoea. These symptoms last from four to five days. As the 
 ovum passes away unnoticed, enveloped in the clots, or piecemeal 
 with the decidua, women are apt to regard these early abortions as the 
 normal recurrence of a retarded menstrual jieriod. 
 
 After the second month prodromal symptoms are rarely wanting. 
 Among these may be mentioned fullness and weight in the pelvis, sa- 
 cral pains, frequent micturition, periodic labor-like pains, and a mu- 
 cous or watery discharge. These, followed by haemorrhage, indicate a 
 threatened abortion. The hwmorrhago. if slight, may cease, and the 
 pregnancy go on undisturbed. Usually, however, the haemorrhage 
 increases in amount, or after a brief cessation recurs. Contractions 
 set in, which become more and more pronounced, until finally the 
 ovum is expelled. 
 
 In a typical case of abortion, in which the ovum is thrown off 
 entire, uterine retraction and haemorrhage unite to effect the progress- 
 
 * T. GrALLARD, De ravortement an i)oint de vue iiuHlieo-legal, Paris, p. 24.
 
 312 THE PATHOLOGY OF PRE&NAXCY. 
 
 ive separation from below upward of the decidiia from the uterine 
 walls. The ovum then, covered by the refiexa and the detached de- 
 cidua, is gradually pressed downward, and dilates first the os internum, 
 next the cervix, and finally the os externum. The ovum passes into 
 the vagina, covered by the decidua vera, or drags the inverted decidua 
 after it. The emptied uterus then retracts down, and the hemorrhage 
 ceases. The aborted ovum is surrounded with coagulated blood. In 
 the first three months, when the death of the embryo has preceded by 
 a little time the completion of the abortion, every vestige of the em- 
 bryo may be found to have disappeared. Sometimes, in the third 
 month, a small placenta with shrunken umbilical vessels may now and 
 then be met with. 
 
 When the extravasation of blood upon the uterine surface of the 
 vera is considerable in amount, the vera is sometimes broken through, 
 and the blood effused between the vera and reflexa. Extravasation 
 may likewise take place between the reflexa and chorion, either in 
 consequence of the rupture of the reflexa, or from a haemorrhage start- 
 ing from the placenta, which finds its way along the Outer surface of 
 the chorion, and dissects away the reflexa. The pressure upon the 
 ovum, unless it has joreviously undergone collapse as a result of the 
 death of the embryo, leads to rupture and escape of the amniotic fluid. 
 The retained fetal and maternal membranes, with the intervening lay- 
 ers of coagulated blood, form a mass termed a mole. When the blood 
 coagula are fresh, the mass is termed the mola mngiiinea (blood-mole), 
 and when of older date the mola carnosa (flesliy mole). The cavity, 
 which is lined by the amnion, has usually an irregular surface. It is 
 very exceptional for extravasations to break through both chorion and 
 amnion, and thus form clots in tlie amniotic cavity itself. Moles sel- 
 dom exceed an orange in size, and usually are expelled between the 
 third and fifth month. 
 
 In cases where abnormal adhesions attach the vera and serotina to 
 the walls of the uterus, retained portions of the maternal membranes 
 may remain after the ovum is expelled. In another class — and this is 
 the rule after the third month — the fetal membranes rupture, and the 
 embryo escapes with the liquor amnii. While ordinarily the retained 
 portions quickly follow the discharge of the ovum or embryo, it fre- 
 quently happens that the uterus retracts upon its contents, the cervix 
 closes, and a period of repose follows. There is then produced what is 
 commonly known as an incomplete abortion. 
 
 Incomplete Abortion. — The various contingencies arising from these 
 cases of incomplete abortion are thus truthfully depicted by Spiegel- 
 berg : * 
 
 1. Most frequently haemorrhage continues at intervals, spontaneous 
 elimination gradually taking place as, through retrograde changes, por- 
 * Spiegelberg, Lehrbuch der Geburtshulfe, Jahr., 1877, p, 377.
 
 TUE PREMATURE EXPUI.SION OP THE OVUM. 513 
 
 tions of tlie retained membranes become successively loosened in their 
 attachments to the uterus. 
 
 2. In exceptional cases the hemorrhage ceases for a time entirely. 
 For days, weeks, and even months, the woman appears quite well. 
 Then suddenly strong contractions, accompanied by profuse hfemor- 
 rhage, usher in the elimination of the fetal dependencies. In a case 
 of my own, three months elapsed from the occurrence of the first 
 haemorrhage, which took place toward tlie end of the third month, 
 and was quite insignificant in amount, before the abortioii was com- 
 pleted. Meantime, as there were progressive abdominal enlargement, 
 supposed quickening, and milk in the breasts, the threatened abortion 
 was believed to have been arrested. Total retention, with a long in- 
 terval of repose, is thought to be due to complete adherence of the 
 l^lacenta, which continues to receive nutrient supplies from the uterus. 
 Spiegelberg believes that a menstrual period is the usual time at which 
 the discharge of the retained membranes takes place. 
 
 3. Of more frequent occurrence than the foregoing is the putrid 
 decomposition of the retained portions. It occurs chiefly in cases 
 where there is more or less complete loss of organic connection between 
 the placenta and the uterus. Decomposition in the non-adherent por- 
 tions is produced by the introduction of air during the escape of the 
 embryo, or through the subsequent passage of the finger into the ute- 
 rus, or, where portions of the ovum hang down into the vagina, by 
 absorption of septic matter from the vagina upward into the uterus. 
 As a result of putrid decomposition, the woman is exposed to septicae- 
 mia, and infection of thrombi at the placental site. Fatal results are, 
 however, rare, as decomposition is usually a late occurrence, setting in, 
 as a rule, only after protective granulations have formed upon the 
 uterine miicous membrane, and after the complete closure of the uter- 
 ine sinuses. Continuous fever, with intercurrent attacks of ha?mor- 
 rhage, is, however, set up, but passes away finally with the gradual dis- 
 charge of the decomposed particles, while the threatening symptoms 
 subside. Still, now and then septic processes lead to an unfavorable 
 termination. Local perimetritic inflammation is a common event. 
 
 4. Where there is a certain degree of relaxation with enlargement 
 of the uterine cavity, the fibrin of the extravasated blood may become 
 deposited about any uneven surface within the uterus and give rise to 
 a polypus-shaped body, suggestive in its mode of develojunent of the 
 stalactite formations in calcareous caverns.* These so-called iiln-inous 
 polypi generally develop around the dehri>i of an abortion, such as 
 retained bits of decidua, placental remains, and portions of the fetal 
 membranes. In some cases, likewise, thrombi projecting from tJie 
 placental site become the base of a loose fibrinous attachment. Pla- 
 
 * Frankel, Beitrag zur Lehre von fibriniisen Polypen, Arch. f. Gynaek.. Pd. ii, 
 p. 76.
 
 314 
 
 THE PATHOLOGY OF PREGNANCY. 
 
 cental polypi give rise ultimately to bearing-do wu pains and intercur- 
 rent hgemorrhages. They may even decompose, and endanger life by 
 septic absorption. 
 
 The retrograde changes that take place in a uterus after an abor- 
 tion correspond to those which occur in deliveries at full term. Where 
 
 Fig. 136. — Uterus, with basis of a fibrinous polypus after an alxiriioii. (Frankel.) 
 
 a suitable plan of treatment is not adopted, or where the importance 
 of care in the after-management is not adequately appreciated, sub- 
 involution is apt to follow. Of all sources of uterine disease, none 
 takes precedence of a mismanaged abortion. 
 
 Diagnosis. — The diagnosis is based upon the presence of pain, 
 hgemorrhage, dilatation of the cervix, and the descent of the ovum. 
 When the ovum can be felt through the patulous os the demonstration 
 is of course complete. A soft polypus may, however, present a decep- 
 tive resemblance to a small ovum. In all eases of pregnancy the exist'
 
 THE PREMATURE EXPULSION OB^ THE OVUM. ;J15 
 
 ence of hfemorrhage alone, even when disassociated from other symp- 
 toms, renders the probabilities of abortion sufficiently great to call for 
 the exercise of every precaution. It is not easy to recognize pregnancy 
 in the early months, but in doubtful cases the cessation of the menses 
 should be regarded as presumptive evidence of its existence. 
 
 The diagnosis of these pathological changes in the ovum and de- 
 cidufe which pave the way for abortion can not be made out with 
 certainty from mere subjective symptoms. Such changes may be 
 regarded as probable Avhen the size of the uterus does not correspond 
 to the supposed period of gestation. Thus, if the uterus at the lifth 
 month was no larger than is usual at the third month, the death of 
 the embryo with arrest in the development of the ovum would be 
 naturally inferred. 
 
 When the physician is summoned to a case of haemorrhage occur- 
 ring during pregnancy, he should at once examine the clots, where 
 they have been preserved, for traces of the ovum. The clots should 
 be broken up under water, and a careful examination made for floating 
 fringes of villi. The ovum, when expelled entire, is usually enveloped 
 in layers of coagulated blood, so that without tliorough search it would 
 easily pass unnoticed. If the coagula have been thrown away, and 
 the physician finds upon his arrival the cervix closed, so that he can 
 not 2)ass his finger into the uterus to explore its cavity, it may be im- 
 possible at once to determine whether the abortion has taken place 
 wholly or in part, or whether the entire ovum still remains in utero. 
 The subsidence of all symptoms points, as a rule, to a complete emp- 
 tying of the uterus, or to an arrest of the abortion, though in some 
 cases it precedes mole-formation. A renewal of the haemorrhage and 
 the absence of normal involution indicate the continuance of the ovum 
 in the uterus, or an incomplete abortion. 
 
 Prognosis. — The prognosis takes cognizance, of course, of the results 
 to the mother only. In the first place, it may be laid down in the way 
 of broad general statement, that all cases of spontaneous abortion (i. e., 
 excluding criminal cases) not complicated with other morbid condi- 
 tions are, under suitable medical guidance, devoid of danger. But, 
 in the second place, it must be borne in mind that the statement is 
 only true with the reservations that limit it, for in point of fact the 
 actual number of deaths from abortion is by no means inconsiderable. 
 Thus, the deaths from this cause reported to the Bureau of Vital Sta- 
 tistics of New York City between the years 18G7 and 1875, inclusive, 
 were one hundred and ninety-seven* — a number which falls short, in all 
 probability, of the truth, by reason of the many circumstances which 
 precisely in this condition tempt to concealment. The total number 
 of deaths during the same period from metiia was, according to the 
 
 * LusK, Nature, Origin, and Piovention of Puerjieral Fever, Transactions of the 
 International Medical Congress, Philadelphia, p. 8oO.
 
 316 THE PATHOLOGY OF PREGNANCY. 
 
 reports rendered, 1,947. Hegar * reckons one ubortiou to every eight 
 to ten full-time deliveries. If this proportion be correct, it would 
 seem to show that the mortality from abortion is hardly second to that 
 from puerperal fever itself. 
 
 Death, as a consequence of criminal abortion, is especially.frequent. 
 M. Tardieu found that in one hundred and sixteen such cases of which 
 he was able to ascertain the termination, sixty women died.f But even 
 in spontaneous cases death may take place from hemorrhage, from sep- 
 ticemia, or from peritonitis. In many instances the fatal termination 
 is fairly attributable to the ignorance, the imprudence, or the willful- 
 ness of the patient. How far the dangers of abortion may be neutral- 
 ized by proper medical assistance is best shown by the statistics of 
 large hospitals. Thus, I gather from the reports issued by Dr. John- 
 ston during his seven years' mastership of the Kotuuda Hospital, in. 
 Dublin, that in two hundred and thirty-four cases of abortion treated 
 in that institution there was but one death, and that not from puer- 
 peral trouble, but from mitral disease of the heart. Bellevue Hospital 
 is the receptacle annually of a tolerably large number of women suffer- 
 ing from incomplete abortions, many of whom enter the hospital in a 
 very unpromising condition from either excessive hemorrhage or septic 
 decomposition of the retained portions of the ovum. Yet, of the many 
 patients whose histories I find in the record-books of the hospital since 
 it has been customary to clear out the uterus in every case of incom- 
 plete abortion, all have recovered. 
 
 Treatment. — The treatment is divided into — 1. Prophylaxis in cases 
 of habitual abortion ; 2. Arrest of threatened abortion ; 3. Means 
 adopted to avert the dangers of a progressing abortion. 
 
 Prophylaxis. — Prophylaxis considers the cause which underlies, in 
 each case, the disposition to repeated abortion. One of the principal 
 of these causes is syphilis in one or both parents. It is just in these 
 cases that the triumph of the mercurial treatment has been most com- 
 plete. The treatment should be addressed to the parent affected, or 
 both parents should be subjected to the same treatment. 
 
 Among local conditions amenable to treatment may be mentioned 
 endometritis, displacements, and perimetritic inflammations. In re- 
 troflexions and retroversions, the best results often follow the rephu^e- 
 ment of the uterus and the employment of a suitable pessary. Xo 
 harm results from the use of pessaries during pregnancy. They should, 
 however, be watched, on account of possible vaginal irritation. After 
 the completion of the third month they should be removed, as the 
 uterus then remains in place without artificial assistance. When back- 
 ward displacement of the uterus follows abortion, reposition aids nor- 
 
 * Hegar, Beitrage zur Pathologie des Eies, Monatsschr. f. Geburtsk., Bd. xxi 
 (supplement), p. 34. 
 
 t T. Gallard, De I'avortement au point de vue medico-legal, Paris, 1878, p. 45.
 
 THE PREMATURE EXPULSION OP THE OVUM. 317 
 
 mal involution. When endometritis is secondary to extensive cervical 
 laceration the Emmet operation is indicated. 
 
 In carcinoma and large fibroids treatment is powerless. Where, 
 in such cases, sterility does not exist, happily for the mother, the 
 associated morbid conditions of the uterine mucous membrane and 
 the rigidity of the uteri ue walls lead commonly to the death of the 
 ovum and jiremature uterine contractions. Where a small fibroid in 
 the posterior uterine walls leads to sterility by the production of retro- 
 flexion, a pessary may, after replacement, at times be used with benefit. 
 
 One abortion sometimes follows another in rapid succession in 
 newly married women. While the first abortion may have been due 
 to some accidental cause, the sequence is often kept up by a morbid 
 condition of the endometrium, generated by the shortness of the inter- 
 val between the pregnancies, which does not allow time for the detach- 
 ment of the decidua and the restoration of the membrane to a normal 
 condition. In such cases, curetting is often of service, and a six weeks' 
 abstention from sexual intercourse may be usefully enjoined. 
 
 In certain diseases of the placenta, in which the respiratory func- 
 tion of the organ had suffered any marked diminution. Sir J. Y. 
 Simpson believed he had succeeded in averting the death of the foetus 
 by increasing the oxygen in the blood of the mother, through the ad- 
 ministration of chlorate of potash.* Chlorate of potash may be given 
 in doses of twenty grains, three times daily, for weeks at a time, with- 
 out injury to the mother. Though it has not always rendered me the 
 hoped-for service, the experience of other physicians, among whom I 
 may mention Dr. Fordyce Barker, appears favorable to its employ- 
 ment. 
 
 In the class of cases in which abortion results neither from disease 
 of the ovum nor of the uterus, but seems dependent upon some pe- 
 culiar condition of nerve-irritability, the patient should not oidy avoid 
 every known means of awakening uterine contractions, but should 
 exercise the utmost caution at the recurrence of the menstrual epochs. 
 Especially at the terminations of the second and third months a week's 
 quiet in bed should be insisted upon. Dr. E. J. Jenks f recommends 
 the viburnum prunifolium in cases where the habit of aborting has 
 been formed. He writes : " My mode of prescribing the viburnum is to 
 have the patient take from a half-teaspoonful to a teaspoonful of the 
 fluid extract four times a day, beginning at least two days before the 
 menstrual date, and continuing it not only during the usual period of 
 the menstrual flow, but two days longer than that discharge continues 
 when the woman is not pregnant." From the fourth month onward, 
 the danger of the occurrence of abortion rapidly diminishes. 
 
 * Sir J. Y. Simpson, Obstetric Memoirs, edited by Priestley and Storer, Edin- 
 burgh, 1865, vol. i, p. 460. 
 
 f Jenks, Viburnum Prunifolium, Trans, of the Am. Gyna?coI. Soc, vol. i, p. 130.
 
 318 THE PATHOLOGY OF PREGNANCY. 
 
 The Arrest of a Threatened Abortion.— Arrest may be accomplished 
 in cases in which the death of the ovum has not taken place, and 
 where the haemorrhage arises from a slight detachment only of the 
 decidua or placenta. 
 
 In every case of threatened abortion occurring in the early months, 
 a careful examination should be instituted to ascertain whether retro- 
 flexion or retroversion exists. In the genu-pectoral position, replace- 
 ment is easy. If the fundus is slowly raised by two fingers introduced 
 into the vagina, so soon as the horizontal line is reached the uterus 
 falls forward of. its own weight. Replacement alone, in certain cases, 
 suffices to relieve the congestion which furnishes the immediate cause 
 of the abortion. 
 
 In a paper read by Dr. J. A. Dol^ris before the Obstetrical Section of the 
 Ninth International Medical Congress, entitled The Treatment and Restoration 
 of the Cervix Uteri during Pregnancy, that distinguished French accoucheur 
 advocated the performance of trachelorrhaphy in certain cases of cervical lac- 
 eration during pregnancy, as a means of averting threatened abortion. 
 
 The subject is of such importance, that I take this opportunity of relating 
 the following personal experience : 
 
 Mrs. X. was married at the age of twenty. Ten months later she gave birth 
 to a vigorous child, which weighed ten pounds. The cervix was torn on the 
 left side to the vaginal junction. Three months after the birth of the first child 
 she became again pregnant. Very early in pregnancy she had repeated attacks 
 of hfemorrhage, with continuous sero-sanguinolent discharges. At the end of 
 six months she gave birth to a child which lived for a few hours. The placenta 
 was firmly adherent and was to a great extent impaired in its functions by the 
 presence of white infarctions. 
 
 In childbed the uterus became displaced backward, so that its reposition 
 was necessary. Owing to continued sanguinolent discharges, at the end of five 
 weeks the uterine cavity was curetted. This was followed witliin four weeks 
 by the symptoms of a new pregnancy. Again the i)atient had hemorrhages, 
 sero-sanguinolent discharges, and intermittent ])ains, and was confined almost 
 constantly to her bed. As she was earnestly desirous of carrying her child to 
 term, she eagerly accepted, when gestation was three months advanced, my 
 proposition to perfonn Emmet's operation. The result was immediate. The 
 pains, the discharges, the haemorrhages ceased as if by magic. The patient felt 
 herself perfectly well, and at full term gave birth to a girl weighing seven 
 pounds. 
 
 Pain in the back during pregnancy should be regarded by women 
 as a warning for them to temporarily abstain from their ordinary avo- 
 cations. With ever so slight a htemorrhage, they should at once be 
 made to lie down and keep perfectly still. Simple turning in bed may 
 start up fresh bleeding. Restlessness and mental excitement should be 
 allayed by opiates in full doses. Ice to the vulva, cold cloths to the 
 abdomen, and the internal administration of haemostatics, are not indi- 
 cated. The fluid extract of viburnum prunifolium is recommended 
 by Dr. Jenks, in teaspoonful ,doses every two or three hours, as long
 
 THE PREMATURE EXPULSION OP THE OVUM. 319 
 
 as its use seems to be demanded.* Tlie author's somewhat limited 
 experience has appeared favorable to the claims put forth for the 
 viburnum as a uterine sedative. Where the foregoing measures prove 
 successful, it is a safe rule to keep the patient in bed for a week after 
 the final disappearance of the threatening symptons. 
 
 In cases of ascertained death of the foetus, and in those of inevi- 
 table abortion, all measures calculated to retard the emptying of the 
 uterus should be at once abandoned. 
 
 In the first four months there are no unequivocal signs of the death 
 of the fcBtus. From the middle of pregnancy onward death may be 
 assumed, if, after repeated examinations, the absence of the fetal heart- 
 sounds and fetal movements is confirmed. 
 
 The signs of inevitable abortion are profuse haemorrhage, clots dis- 
 charged from the uterus, dilatation of the cervix from the descent of 
 the ovum, and a patulous condition of the os externum. Other symp- 
 toms consist of persistent uterine contractions, escape of the amniotic 
 fluid, and the presence of the embryo or of portions of the ovum in 
 the discharged clots. How far the ordinary signs may in given cases 
 prove delusive, is shown by a remarkable one reported by Scanzoni, of 
 a woman who was seized with profuse metrorrhagia in the third month 
 of pregnancy. Great numbers of clots were discharged. As all hopes 
 of saving the ovum were abandoned, ergot was used in large doses, a 
 tampon was placed in the vagina for thirty-six hours, a sound was em- 
 ployed to explore the uterus, and finally, as the bleeding continued for 
 three weeks, an intra-uterine injection of a weak solution of perchloride 
 of iron was resorted to. Eight weeks later the patient quickened, and 
 presented the distinctive evidences of a pregnancy advanced to the 
 sixth month. f 
 
 The Treatment of Inevitable Abortion. 
 
 In the treatment of inevitable abortion it is proper to distinguish 
 between cases of abortion proper and those of miscarriage. To avoid, 
 however, needless repetitions, it is only points of distinctive difference 
 to which, at the close, attention will be directed. The management of 
 premature deliveries differs in no respect from that of confinement at 
 term. 
 
 In the first two months little treatment besides rest in bed for a 
 few days is ordinarily required. In the exceptional cases the treat- 
 ment does not differ from that m the haemorrhages of the non-preg- 
 nant uterus. 
 
 In the third month we distinguish — 1. Cases in wliich the ovum 
 is thrown off entire; 2. Cases in which the sac ruptures and the em- 
 bryo escapes with the discharged fluid. 
 
 * Jenks, loc. cit., p. 130. 
 
 f Scanzoni, Lelirbuch der Geburtshillfe, Wiori, 1867, p. 83.
 
 320 
 
 THE PATHOLOGY OF PREGNANCY. 
 
 1. When in the third month the ovum is thrown ofE without rupt- 
 ure of the fetal membranes, the hsemorrhage rarely assumes dangerous 
 proportions. The uterine contractions press the ovum into the cervix, 
 which dilates, and, in primiparse, becomes somewhat elongated. As the 
 ovum descends, the body of the partially emptied uterus retracts. The 
 eliused blood coagulates in thin layers between the ovum and the uter- 
 ine walls. The ovum forms a tampon, which fills the cervix and re- 
 strains the hgemorrhage. 
 
 No active treatment is, therefore, demanded. A carbolized vaginal 
 douche may be used twice a day as a measure of cleanliness. All 
 attempts to disengage the ovum with the finger should be avoided, as 
 endangering its integrity. The vaginal tampon is unnecessary. It 
 should only be used as a safeguard, where patients live at a distance 
 from medical assistance and can only be visited at long intervals. As 
 it is never certain that the rupture of the ovum may not take place 
 during the course of its expulsion, the tampon may in such cases be 
 employed in anticipation of a possible increase of hemorrhage from 
 sudden collapse of the membranes. In multiparas the ovum seldom 
 remains long in the cervix. In primiparae, on the other hand, the 
 tardy dilatation of the os externum may lead to a retention of the 
 ovum in the cervix, lasting for days. As this condition is extremely 
 painful, it is allowable to dilate the os externum with the index-finger, 
 with Goodell's steel dilator, or even by incisions through the ring of 
 circular fibers which furnish the cause of delay. 
 
 Small portions of the decidua vera sometimes remain attached to 
 the uterine walls after abortion. They commonly do no harm, but 
 are discharged with the lochial secretion. The amount of the latter 
 after abortion is not usually large where the ovum has been expelled 
 entire. It is for the most part watery, and does not usually last longer 
 than a week. A protracted bloody discharge may, however, be main- 
 tained by decidual retention. This is most apt to result from meddle- 
 some interference with the intact ovum, or in criminal abortion when 
 the expulsion of the ovum has not been preceded by gradual changes 
 in the decidual uterine attachments. The decidua can be safely and 
 easily removed by means of the dull-wire currette. Peliminary dilata- 
 tion of the cervix is rarely called for. As an after precaution against 
 infection, cotton soaked in compound tincture of iodine should be 
 passed into the uterine cavity by means of the ordinary applicator. 
 
 2. When the sac ruptures and the liquor amnii escapes, the re- 
 moval of the pressure exerted upon the uterine wall by the intact 
 ovum is followed by profuse haemorrhage from the utero-placental 
 vessels. 
 
 The diagnosis of rupture may be made either from finding the 
 embryo in the clots, or, in the case of a dilated cervical canal, by the 
 direct examination of the uterine cavity. Although after rupture
 
 THE PREMATURE EXPULSION OF THE OVUM. 321 
 
 portions of the ovum may still be felt, we miss the smooth surface 
 of the fluctuating amniotic sac. When the embryo can not be found, 
 and the cervix is closed, profuse haemorrhage alone would render the 
 occurrence of rupture extremely probable. 
 
 The principles of treatment in these cases are very simple. The 
 indications are, to check the hemorrhage and to empty the uterus. 
 As to the best methods of attaining these results, opinions widely 
 differ. 
 
 When cases are treated with rest in bed, the internal administration 
 of ergot, and cold cloths applied to the abdomen and vulva, the loss of 
 blood is usually considerable, but the most of them terminate favor- 
 ably. In some, however, the hasmorrhage may prove so severe as even 
 to threaten life. Now, it is in every way desirable, for the future wel- 
 fare of the patient, to restrain the haemorrhage within the narrowest 
 limits. The most effectual means of arresting the hemorrhage is to 
 clean out the uterus. If, therefore, the physician at the time of his 
 visit finds the cervix sufficiently dilated to allow him to introduce his 
 finger into the uterus, he should not hesitate at once to remove the 
 retained portions of ovum. If the vagina is thoroughly disinfected 
 and the hands are surgically clean, the operation is absolutely devoid of 
 danger. It does not require any considerable amount of technical skill, 
 while the immediate results are in the highest degree satisfactory. 
 The patient should be placed crosswise in bed, with the hips drawn 
 well over the edge. The legs should be flexed and the thighs held, 
 where assistants can be obtained, at right angles to the body, to secure 
 the greatest degree of relaxation to the perineum and abdominal walls. 
 The right index-finger should then be passed into the vagina and 
 through the cervical canal, while the left hand, placed upon the abdo- 
 men, gradually presses the uterus down into the pelvic cavity so as to 
 bring it within reach of the examining finger.* This portion of the 
 act should be performed slowly, while every effort is made to divert the 
 attention of the patient. Hasty manipulations invariably excite in the 
 most willing of patients the full resistance of the abdominal walls. 
 When the point of the finger reaches the os internum, it is sometimes 
 necessary to pause for a minute or two to await a sufficient degree of 
 dilatation to allow the finger to pass beyond the insertion of the nail. 
 When the right finger is used, it should be made to pass upward with 
 its dorsal surface along the left side of the uterus to the opening of the 
 Fallopian tube, thence across the fundus to the right side. As the tip 
 of the finger passes down upon the right side, it presses the detached 
 
 * Professor A. R. Simpson (Transactions of tlie Edinburgh Obstetrical Society, 
 vol. iv, p. 237) recommends drawing down the uterus by means of volsellum- 
 forceps attached to the anterior lip of the cervix. I have once seen extreme h.-emor. 
 rhage follow this manoeuvre (seventh month of pregnancy), and now feel some 
 hesitation about its employment, at least in the later months. 
 21
 
 322 THE PATHOLOGY OF PREGNANCY. 
 
 ovum before it toward the os internum. By the time the finger has 
 thus made the circuit of the uterus, the ovum is pressed into the cervical 
 canal, and thence passes easily into the vagina. With the left finger, 
 the movement is exactly the reverse. The finger passes first, with its 
 dorsal surface directed to the right side, from the right Fallopian tube 
 across the fundus, and downward along the left side of the ut«rus. 
 The only resistance the finger meets is at the placental insertion, where 
 a certain amount of manipulation is required to complete the detach- 
 ment.* 
 
 Where the uterus can not be pressed down within reach of the 
 index-finger by force exerted above the symphysis pubis, it is permis- 
 sible to introduce the hand into the vagina ; but, in such a case, the 
 fingers are apt to become cramped, and freedom of manipulation is 
 impaired. A better means of overcoming the difficulty consists in 
 the administration of an anaesthetic In cases of extreme anaemia 
 chloroform should be discarded as too dangerous. Ether, hoAvever, 
 has often seemed to me, on the contrary, to possess a stimulating action, 
 and its use to be followed by increase in the volume and force of the 
 pulse. The relaxation produced by the anaesthetic makes it easy to 
 depress the uterus down to the pelvic fioor, whore it can be reached 
 with comparative ease. After the removal of the ovum, the cavity of 
 the uterus should be washed out with a stream of tepid carbolized 
 water, in order to bring away any small detached portions of the ovum 
 and decidua. In the manual extraction of the ovum, deliberation and 
 perseverance are the main elements of success. 
 
 If, when the patient is first seen by the physician, the cervix is not 
 sufficiently dilated to allow the finger to pass without force, the vagi- 
 nal tampon should be employed. The tampon restrains the haemor- 
 rhage, stimulates the uterus to conti-action, and allows time for the 
 employment of measures to rally a patient exhausted by profuse losses 
 of blood. The material of which it is made is a matter of indifference, 
 provided only it fills the vagina to its utmost capacity. In cases of 
 urgent need, a soft towel, handkerchiefs, strips of cotton cloth, damp- 
 ened cotton- wool, and the like, may be seized upon to meet a temporary 
 emergency. The time-honored sponge, on account of its porosity, is 
 least deserving of favor. When, however, the physician proposes to 
 leave his patient for a number of hours, the mere hasty filling of the 
 vagina through the vulva will not suffice. On the contrary, the high- 
 est degree of safety can only be secured by the closest observance of 
 the rules of art. 
 
 The first essential of a good tampon is that it be carefully packed 
 around the cervix uteri, and fill out the more dilatable upper portion 
 of the vagina. This can be accomplished only by the aid of a specu- 
 lum. The method I usually employ is one the credit of which, so far 
 * Vide HiJTER, Compendium der geburtshulflichen Operationen, p. 22.
 
 THE PREMATURE EXPULSION OF THE OVUM. 323 
 
 as the general features arc concerned, I believe, belongs to Dr. Marion 
 Sims. It consists in soaking absorbent cotton in carbolized water, 
 (two per cent) and, after pressing out any excess of tiuid, in forming 
 from the cotton a number of flattened disks of about the size of the 
 trade-dollar. After the vagina has been thoroughly washed with a 
 carbolized or boric-acid solution the patient is placed in the latero- 
 prone position, and the perina^uni retracted by a Sims speculum. 
 The dampened cotton disks are introduced by dressing-forceps, and, 
 under the guidance of the eye, are packed first around the vaginal por- 
 tion, then over the os, and thence the vagina is filled in from above 
 downward until the narrow portion above the vestibule is reached. No 
 other plan of tamponing with which I am acquainted can compare in 
 solidity and effectiveness with this. Its removal is accomplished by 
 the detachment with two fingers of a portion at a time. This part of 
 the procedure is moderately painful. Many methods have been sug- 
 gested to overcome in the removal the necessity of introducing the 
 finger into the vagina. A very ingenious one consists in attaching the 
 cotton to a piece of twine so as to form a kite-tail, which can be with- 
 drawn by simply making tractions upon the extremity of the string 
 left hanging outside the vulva. Professor I. E. Taylor uses a roller- 
 bandage. It is efficient, and, like the kite-tail described, can be easily 
 removed. Dr. F. P. Foster * advises the use of the lamp-wicking as a 
 nuiterial for the tampon. 
 
 No tampon should be allowed to remain in the vagina much over 
 twelve hours, and after its withdrawal, before proceeding to the exami- 
 nation of the uterus, the vagina should be cleansed by an injection of 
 tepid carbolized water ( 3 ij ad Oj). Often the ovum is then found 
 in the upper portion of the vagina or filling up the cervix. If this is 
 not the case, and the cervix is not dilated, so that manual extraction 
 may easily be performed, another tampon should be introduced. 
 
 It is customary from the outset to sustain the action of the tampon 
 by the administration of ergot, either in the form of the fluid extract 
 (thirty drops every three to four hours), or of a solution of ergotin, 
 given hypodermically (ergotin, gr. xij, glycerin*, 3 j, ten minims 
 twice in the twenty-four hours. In women with abundant adipose 
 tissue the injection should be made into the subcutaneous tissues of 
 the lower abdomen. In others, the outer surface of the thigh should 
 be selected). 
 
 If the patient is collapsed from loss of blood after tamponing, opi- 
 ates, tea, and alcoholic stimulants should be administered, the latter 
 in small but frequently repeated quantities, until the cerebral anaemia 
 is relieved and the capillary circulation restored. 
 
 If, after the removal, the cervix is found not to be dilated, a third 
 tampon may be introduced, and left in situ for another period of 
 
 * Foster, N. Y. Med. Jour., June, 1880.
 
 324 THE PATHOLOGY OF PREGNANCY. 
 
 twelve hours. The employment of the tampon is not, however, to be 
 recommended for a period much exceeding twenty-four hours. Its 
 continued iise is apt to irritate the vagina. In spite of carbolic acid, 
 it acquires an offensive odor. It generates septic matters, which, in the 
 long run, creep upward through the cervix into the uterine cavity, 
 and produce decomposition of the ovum. I prefer, therefore, in cases 
 of undilated cervix, after twenty-four hours of vaginal tamponing, to 
 resort to tupelo-tents. The tupelo-teut is most easily introduced 
 when the patient is placed upon her left side, with the perina?um 
 drawn back by Sims's speculum, and the anterior lip of the cervix 
 drawn down and steadied by a tenaculum (Sims's method). It may, 
 however, in the absence of an assistant, be introduced, with the 
 patient on her back, by the aid of a pair of strong dressing-forceps. 
 It should be long enough to pass well up through the os internum. 
 Before use the tent should be immersed for a moment in carbolized 
 water, and then dipped in iodoform. Witliin six to twelve hours 
 the tent should be removed, and, after a preliminary vaginal douche, 
 manual extraction be proceeded with in accordance with the rules 
 already given. 
 
 In manual delivery it is desirable to remove the decidua as well as 
 the ovum. When the cervix is patent this is easy, as the decidua is 
 then detached from the uterine walls. When the cervix is unchanged 
 the detachment is usually incomplete. In such cases it is advisable to 
 resort to the curette, should the symptoms make action necessary. 
 
 Inside the uterine cavity ovum-forceps should be used with caution. 
 I do not deny its serviceability or convenience on occasions. Its use, 
 however, does not furnish the certainty that the uterine cavity has 
 been completely emptied, which is obtained by the exploring finger. 
 When, however, the retained portions of the ovum have for the most 
 part left the uterine cavity, and occupy the cervical canal, the delivery 
 may at times be advantageously hastened by placing the patient upon 
 her side, and, with the cervix well brought into view by a Sims spec- 
 ulum, applying the ovum-forceps, under the guidance of the eye, within 
 the cervix to the sides of the placenta (Skene). But great care requires 
 to be exercised not to break away the fragile structures and leave 
 material portions behind. 
 
 Under like circumstances, Hoening* recommended a modification 
 of Crede's method for expression of the placenta. With the patient 
 lying upon the back, the operator, according to Hoening, should seek 
 to compress the body of the uterus between the left hand, laid above 
 the symphysis pubis, and two fingers of the right hand introduced into 
 the vagina. The measure is only practicable when the ovum has, to a 
 great extent, passed from the uterine cavity. It is more likely to be 
 followed by the retention of the decidua. As it is somewhat painful, 
 * Hoening, Scanzoni's Beitrage, Bd. vii, p. 213.
 
 THE PREMATURE EXPULSION OF THE OVUM. 325 
 
 and requires for success lax abdominal parietes, it possesses a limited 
 range of applicability. 
 
 Treatment of Neglected Abortion.— Where, following abortion, the 
 uterus has once been completely evacuated, haemorrhage ceases. A 
 slight lochial discharge persists for a few days during the period in 
 which the uterine portion of the decidua vera completes its period of 
 repair. If, therefore, a patient comes to us two or three weeks after 
 the supposed conclusion of an abortion, with the story of recurrent 
 haemorrhages taking place, as a rule, wdienever she leaves her bed and 
 assumes the upright position, it may be assumed, with an approach to 
 certainty, that portions of the ovum still remain within the uterus. 
 Oftentimes a fetid discharge points to the fact that decomposition has 
 been set up. The absorption of septic materials may, furthermore, 
 become the source of chills, of fever, and of great uterine tenderness. 
 In most cases, with rest in bed, the contents are discharged by sup- 
 puration, and recovery ultimately takes i)lace, but only after a slow, 
 protracted convalescence, during which pelvic cellulitis and pelvic 
 peritonitis occur as not uncommon complications. Haemorrhages, 
 peritonitis, and sei^ticfemia may, however, bring the case to a fatal 
 issue. The removal of the retained placenta and membranes is there- 
 fore indicated, not only as a measure calculated to promote recovery, 
 but to avert possible danger to life. 
 
 AVith regard to the operation for removal, the rules already given 
 are applicable. The following peculiarities should, however, be borne 
 in mind. In case the retained portions are undecomposed, the cervix 
 is usually found closed, and requires preliminary dilatation with the 
 tent. When decomposition has once set in, the os internum will, as a 
 rule, allow the finger to pass into the uterus.* When a decomposed 
 ovum is removed by the finger, a chill and a septic fever — which rapidly 
 disappear, however — are apt to follow in the course of a few hours. 
 This chill and fever result from the slight traumatic injuries inflicted 
 by the finger upon the uterine walls, wdiereby the capillaries and 
 lymphatics become opened up to the action of the septic poisons. 
 The fever ends in a short tinie, because the reservoir of supply is re- 
 moved with the debris of the ovum. If the uterine cavity, after the 
 operation, is carefully washed out with carbolized water, the septic 
 fever is often averted. After the irrigation a strip of iodoform gauze 
 pushed upward to the fundus with ovum-forceps acts beneficially both 
 as a means of disinfection and as a safeguard against luemorrhage. 
 The packing can be left in situ for twenty-four hours. The improve- 
 ment following the complete emptying of the uterus in these cases is 
 so decided, that of late years I have not allowed myself to be deterred 
 from proceeding actively, even when perimetritis and parametritis, 
 in not too acute a form, already existed. In practice, multitudes of 
 * HtTER, Compendium cler geburtshiilflichcn Operationcn, Leipsic, 1874. p. 32.
 
 326 THE PATHOLOGY OF PREGNANCY. 
 
 examples show that the products of inflammations situated in the 
 pelvis do not become absorbed so long as putrid materials are generated 
 in the uterine cavity. 
 
 The removal of a fibi'inous polypus, owing to its smoothness and 
 the small size of the pedicle, is often a Sisyphus's task. The separation 
 can only be successfully accomplished when the palmar surface of the 
 index-finger presses from above upon the point of attachment. This 
 necessitates a choice of hands. Thus, when the polypus is situated 
 to the left, the right index-finger sliould be employed, and the left 
 index-finger when the polypus is situated to the right. After the 
 detachment is complete, it is necessary to press the polypoid body 
 firmly against the uterine walls, and proceed with its withdrawal 
 slowly. If, as is sometimes the case, the polypus slips from under the 
 finger, the latter should be again passed to the fundus of the uterus, 
 and the attempt repeated. Snuill portions, not larger than a pea, can 
 be washed out by the uterine douche. When the polypus is situated 
 near the os internum, tlie latter will be found patulous, but when it is 
 well up within the body of the uterus, dilatation is a frequent prerequi- 
 site to removal. 
 
 For the removal of presumably small jiortions of retained ovum, 
 especially in cases where, owing to inflammatory conditions, I have 
 hesitated to make the circuit of the uterine cavity with my finger, 
 I have succeeded admirably by employing a toleral)ly firm Thomas's 
 wire curette.* 
 
 The Treatment of Immature Deliveries. — Fourth to seventh month. 
 — Distinctive of immatui-e deliveries are : painful periodic contrac- 
 tions, recognizable by the liand applied above the symphysis pubis, 
 rupture of the membranes and discharge of the foetus, the complete 
 formation of the placenta and umbilical cord ; while in abortion the 
 uterine contractions are obscure, the placenta is rudimentary, and the 
 ovum is frequently expelled entire. In the treatment of immature 
 delivery the tampon may usually be discarded. After rupture of the 
 membranes and expulsion of the foetus, the haemorrhage should be 
 controlled by grasping the fundus of the uterus in the hand through 
 the abdomen, and compressing the uterine walls firmly together. 
 
 The passage of the fcetus opens the uterus so as to allow, in the 
 fourth and fifth months, the introduction of two fingers ; in the sixth 
 and seventh months, that of the half-hand. In case compression of 
 the uterus does not arrest the hemorrhage and expel the placenta, the 
 cord should be carefully followed to its insertion, to determine the 
 
 * Skene, Med. Record. 1875. p. 59 ; Munde, Centralbl. f. Gyiiaek., 1878, No. vi, 
 p. 1. The patient should be jilaced in Sims's position, the perina^um should be 
 drawn back with Sims's speculum, the cervi.\ hooked down and steadied with a 
 tenaculum, while the curette is made to pass over all portions of the uterine surface. 
 Attached bits of placenta ai'e recognized by the resistance they offer.
 
 EXTRA-UTERIXE PREGNANX'Y. 327 
 
 side upon which the implantation exists. If the placenta is implanted 
 upon the right side, two or four fingers of the right hand, according 
 to the degree of cervical dilatation, should be passed up along the left 
 side of the uterus, across the fundus to the placental site. The de- 
 tachment should be effected with the tips of the fingers, and the pla- 
 centa pressed downward as the fingers descend along the right side of 
 the uterus. The left hand should be employed in the reverse direc- 
 tion, when the placenta is situated to the right. 
 
 CHAPTER XVII. 
 
 EXTRA-UTERINE PREGNANCY. 
 
 Definition. — Tubal pregnancy. — Pregnancy in rudimentary cornu. — Interstitial 
 pregnancy. — Tubo-abdoniinal and tubo-ovarian pregnancy. — Ovarian preg- 
 nancy. — Abdominal pregnancy. — Symptoms. — Terminations. — Diagnosis. — 
 Treatment in cases of early gestation.— Cases of advanced gestation (foetus 
 living). — Cases of gestation prolonged after the death of the foetus. 
 
 After coitus, the spermatozoa may make their way through the 
 Fallopian tubes to the pelvic cavity. It is possible, therefore, for the 
 ovum to become fecundated in any portion of the route from the ovary 
 to the uterus. In exceptional cases, the ovum may, after fecundation, 
 be arrested in its travels, and undergo development at some point out- 
 side the uterus. To these cases the term extra-uterine pregnancy has 
 been applied. 
 
 In the past it has been assumed that the ovum may develop within 
 the tube, in the ovary, or in the abdominal cavity — hence the terms 
 tn'hal., ovarian, and abdominal pregnancii; but modern research has 
 thrown doubt ujDon the existence of the two latter varieties, as a jsri- 
 mary condition. In any event they are extremely rare. 
 
 In Mr. Tait's* belief, all cases of extra-uterine pregnancy are nb initio of 
 tubal origin. When the ovum develops in the free part of the tube, rupture, he 
 holds, occurs at or before the fourteenth week. If rujjture occurs at once into 
 the abdominal cavity, death ensues from haemorrhage, or later from .suppuration 
 of the sac and peritonitis ; if rupture takes ])lace in the lower portion of the 
 tube between the folds of the broad ligament, the ovum may develop to full 
 term ; may die and be absorbed as an extraperitoneal haematocele ; may supjju- 
 rate and be discharged at or near the navel, or through the bladder, the 
 vagina, or intestinal tract ; may remain quiescent as a litho]);edion ; or may be- 
 come an abdominal pregnancy by secondary rupture. In the tubo-uterine or 
 interstitial form death occurs from intraperitoneal rupture before the fifth 
 month. Mr. Tait denies the possibility of a primary abdominal pregnancy. 
 The ovarian form he regards as possible but not proved. 
 
 *Tait, Lectures on Ectopic Pregnancy and Pelvif Ila-matocele.
 
 328 THE PATHOLOGY OF PREGNANCY. 
 
 Tubal Pregnancy. — The ovum may find lodgment in any part of 
 the tube. The cause of this anomaly is most frequently to be found 
 in the various forms of chronic salpingitis. Owing to the associated 
 loss of epithelium, the dilatation and other changes in the tube walls, 
 the two active forces which propel the ovum through the tube — viz., 
 ciliated movements and peristalsis — are weakened or destroyed, while 
 free ingress is afforded to the spermatozoa. Or, again, the passage of 
 the ovum may be interfered with by the secondary results of catarrhal 
 inflammations — such as the production of mucous polypi, of adhesions, 
 or of sac-like dilatations. Formerly great stress was laid upon the 
 etiological importance of flexions and constrictions resulting from old 
 peritoneal adhesions and inflammatory bands. Curiously enough, in 
 recent laparotomies for tubal rupture this cause has not played an im- 
 portant part. It is not quite clear whether the peritonitis formerly 
 observed so frequently at autopsies was not in most instances second- 
 ary. It is, moreover, possible that as a class, in cases where ante- 
 cedent peritonitis has existed as a cause, the hemorrhages result- 
 ing from rupture, owing to the agglutination of intestines and pelvic 
 organs, are circumscribed, and do not call for surgical measures of 
 relief. 
 
 Because of its connection with inflammatory processes, the occur- 
 rence of tubal pregnancy is often preceded by a long period of sterility. 
 When the obliteration is only partial, the spermatozoa, owing to their 
 small size, are not prevented from reaching the arrested ovum ; when 
 complete, on the contrary, they can only gain access to the ovum by 
 first passing through the patulous tube, and then migrating across the 
 rear of the uterus to the ovary or the open abdominal end of the tube 
 upon the opposite side. In a considerable number of cases, the corpus 
 luteum has been found upon the side opposite to the tube containing 
 the fecundated ovum. With the present prevailing views,* this phe- 
 nomenon is only to be accounted for by the hypothesis of the migra- 
 tion of the ovum across the peritoneal surface of the pelvis or through 
 the uterus from one tube to the other. 
 
 Kecent observations have shown that there is a tendency for tubal 
 pregnancy to recur. Thus Herrmann has reported a case where, in 
 performing laparotomy for tubal rupture, he found the remains of an 
 ovum in the other tube. Tait f has reported one and Veit J three 
 cases where, within a year or two after a first operation for tubal rupt- 
 
 * Mayrhofer, Ueber die gelben Korper, und die Ueberwanderung des Eies, de- 
 nies the whole doctrine of a distinct corpus hiteum of pregnancy, and claims that 
 corpora lutea are found at stated intervals, perhaps monthly, throughout the entire 
 period of pregnancy. Leopold, Die Ueberwanderung der Eier, Arch. f. Gynaek., 
 Bd., xvi, p. 24, however, found that after tying the right tube and removing the 
 entire left ovary in a couple of rabbits pregnancy still took place. 
 
 + Tait, British Gynaecological Journal, August, 1888. p. 178. 
 
 X Veit, Gesellsch. f. Geburtshiilfe und Gynaek. zu Berlin, May 10, 1889.
 
 EXTRA-UTERINE PREGNANCY. 
 
 329 
 
 ure, a second laparotomy was rendered necessary because of the occur- 
 rence of pregnancy into the tube of the opposite side. 
 
 Tubal i^regnancy is associated with the formation of a uterine de- 
 cidua which differs in no wise from the decidua of pregnancy, except 
 that the distinction into three layers is less marked. 
 
 In the tube a decidua likewise forms around the ovum. It contains 
 large epithelioid cells, as in uterine" gestation. It differs, however, from 
 the latter in the presence of connective-tissue fibers between the cell 
 groups, and in that next to the muscular coat there is a transition 
 zone in which cells and muscular and connective-tissue fibers are inter- 
 mingled. Klein * has reported the existence of decidual tissue be- 
 tween the villi in a specimen removed from a patient in whom rupt- 
 ure occurred seven weeks after the last menstruation. In more ad- 
 vanced cases there is no serotina, nor is there any maternal portion to 
 the placenta. The club-shaped extremities of the villi simply impinge 
 
 Fio. 137.— Intraperitoneal rupture of tube. 
 
 on the muscular walls. Concerning the decidua reflexa opinions are 
 conflicting. Frommel and Winckel maintain its existence. None 
 was discovered by Langhans, Leopold, Klein, and the majority of later 
 investigators. In Klein's cases tubal vessels opened directly into the 
 spaces between the villi. 
 
 In the early months the development of the ovum leads to a 
 spindle-shaped dilatation of the tube, associated with hypertrophy of 
 the muscular walls due to increase in the length and thickness of the 
 individual fibers. As regards the degree of hypertrophy, very great 
 
 * Klein, Zur Anatomie der Scliwangeien Tulic. Zeitschr. fUr Geburtshiilfe und 
 Gynaek., vol. xx, p. 288 et seq.
 
 330 
 
 THE PATHOLOGY OF PREGNANCY. 
 
 individual variations have been observed. Indeed, in the same sac a 
 thickening at one point may be accompanied by an excessive degree 
 of tenuity due to eccentric growth of the ovum at another. Now, the 
 ultimate fate of a tubal pregnancy is in large measure dependent upon 
 these anatomical differences. Unquestionably, early rupture is the 
 
 =3 i^ 
 
 rule. Mr. Tait says : " Out of an enormous number of specimens which 
 I have examined, I have entirely failed to satisfy myself that rupture has 
 been delayed later than the twelfth week." It seems to me, however, 
 carrying skepticism too far to refuse credence to the positive observa- 
 tions of others, made apparently with the utmost care and with full
 
 EXTRA-UTERINE PREGNANCY. 331 
 
 knowledge of possible sources of error, which seem to show that a tubal 
 pregnancy may exceptionally reach advanced or even the full term of 
 pregnancy. At present it seems fair to assume that, when the sac 
 which surrounds the ovum is composed of muscular and connective-tis- 
 sue fibers with an external peritoneal envelope, and directly communi- 
 cates with the Fallopian tube, the sac walls are of tubal origin. Of 
 course it is not possible to assert that no rupture has taken place in the 
 course of development. It is only known positively that rupture occur- 
 ring at the site of placental attachment gives rise to hemorrhage fatal 
 to the fa?tus ; and the same is true, with rare exceptions, where rupture 
 occurs at any jjoint of the peritoneal surface. That rupture has first 
 occurred into the cavity of the broad ligament in all the cases which 
 go on to the period of viability does not seem so absolutely certain. 
 The anatomical appearances, in some instances at least, indicate that the 
 exposure of the fetal membranes here and there through the maternal 
 sac results not so much from laceration as from the gradual separation 
 of the muscular fibers due to excessive stretching.* In most of the 
 cases in Avhicli the pregnancy reaches an advanced stage the develop- 
 ment of the tube takes place principally between the folds of the broad 
 ligament. The support furnished the tubal sac by the gradual unfold- 
 ing of the ligament layers hinders rupture. More rarely pregnancy 
 may go to the period of viability Avithout encroaching upon the intra- 
 ligamentous space. The tumor then rises above the pelvic brim, and 
 is furnished with a species of pedicle consisting of the uterine end of 
 the tube and of the broad ligament. 
 
 The first of the above, or the intraligamentous form, lies close to 
 the uterus, which it not infrequently crowds upward and forward. 
 The uterine end of the tube varies greatly in length. The fimbriated 
 extremity is unrecognizable. Usually no traces of the ovary are found. 
 In the so-called pedicled form the uterus is crowded to one side or re- 
 tro verted. The uterine end of the tube is usually long and thickened. 
 The corresponding ovary has generally been discovered. In both cases 
 the relations of the sac are often obscured by adhesions to adjacent 
 viscera. In the second half of pregnancy rupture of the sac and the 
 escape of the foetus into the peritoneal cavity may occur without no- 
 ticeable h;i?morrhage or without interruption of pregnancy. As the 
 pressure is removed by the escape of the amnrotic fluid, the placental 
 borders curl inward so as to furnish a cup-like space, while the mem- 
 branes sink downward and cover the upper placental surface. The 
 fu?tus in these cases may occupy the abdominal cavity, or a sac may be 
 formed by the agglutination of the adjacent viscera. 
 
 Werth has reported a case in Avliich death of the embryo occurred 
 in the second month, and was followed by haemorrhage which i)0ured 
 
 * Vtde tables of Wertli. BeitWige zur Anatoinie unci zur operativen Behaiullung 
 der Extrauterinschwangerschaft.
 
 332 
 
 THE PATnOLOGY OF PREGNANCY. 
 
 through the abdomiual end of the tube into the pelvic cavity and gave 
 rise to intraperitoneal hematocele. Similar observations have been 
 made by Veit and Westermark. This form Werth terms tubal abor- 
 tion, in another case described by Wyder the fimbriated extremity of 
 the tube was obliterated, and as a consequence the hemorrhage follow- 
 ing the separation of the ovum converted the ampulla of the tube into 
 a blood cyst the size of the fist.* 
 
 Pregnancy in the Rudimentary Cornu of a One-horned Uterus.— 
 This anomaly so closely resembles the tubal form of pregnancy that 
 the diagnostic distinction can rarely be established during life. In 
 tubal pregnancy rupture takes place, as a rule, in the first three months, 
 while the rupture of the cornu occurs somewhat later, usually between 
 
 Fig. 139.— Pregnancy in rudimentary cornu. (Kussniaul, observed bf Heyfelder.) 
 
 the third and sixth months. Cases have, however, been reported by 
 Turner,! Werth,J and Salin,* in whicli gestation went to full term. 
 Rupture takes place at the apex of the cornu. In several instances in 
 which surgical procedures have been employed for this anomaly, the 
 removal of the entire sac has been rendered easy by the presence of a 
 well-formed pedicle. 
 
 Interstitial Pregnancy. — The term interstitial pregnancy is applied 
 to cases in which the ovum is developed in the uterine portion of the 
 
 * Op. cit., pp. 105, 106. 
 
 X Archiv f. Gynaek., vol. xvi, p. 281. 
 
 f Edinburgh Med. Join-., May, 1886, p. 074. 
 « Centralblatt f. Gynaek., 1881, p. 221.
 
 EXTRA-UTERINE PREGNANCY. 
 
 333 
 
 tube. The latter measures about seven lines in length by one line in 
 diameter. At first the muscular walls hypertrophy and form around 
 the ovum a sac which projects from the upper angle of the uterus. 
 As, ordinarily, the growth of the muscular tissue does not keep pace 
 
 Fig. 140.— Interstitial pregnancy. (Hennig.) 
 
 with that of the ovum, rupture occurs at an early period. Of twenty- 
 six such cases collected by Hecker, all ruptured before the sixth month. 
 Tait says that, " so far as known, interstitial pregnancy is uniformly 
 fatal by primary intraperitoneal rupture before the fifth month." 
 Schwarz,* however, reports a case belonging to this category in which 
 the foetus was expelled into the uterine cavity. 
 
 The patient was known to be pregnant. Repeated ha?morrhages 
 indicated a threatened abortion. To avoid further dangers, the cervix 
 was dilated with the view to empty the uterus. On examination with 
 the finger the uterine cavity was found empty, but there was a piece of 
 membrane at the uterine opening of the left tube, wliich was removed. 
 The next day the finger detected membrane at tlie same site, and, be- 
 yond, a hard body. The uterus began to contract energetically. On 
 
 * Schwarz, Wiener nied. Blatter, 1886. In the abstract furnished by Grandin 
 in the American Journal of Obstetrics (January, 1887, p. 101). the date of pregnancy 
 IS not given. Similar cases have been reported by Dr. Charles :McIiurney (New 
 York Med. Jour., March, 1878, p. 273) and by Dr. Cornelius Williams (in the De- 
 cember number of the same journal, p. 595), both of which were followed by the re- 
 covery of the mother.
 
 334 
 
 THE PATHOLOGY OP PREGNANCY. 
 
 the fifth clay a foetus was passed by the vagina, the pains ceased, the 
 tumor largely disappeared, and the f)atient made a good convalescence. 
 
 Martin removed a male foetus 33 centimetres long (six months) 
 from the left uterine cornu. The patient recovered. Duvelius, who 
 examined the specimen, concluded that the ovum had 2)artially grown 
 into the tube and between the folds of the broad ligament. He 
 thought that rupture did not occur owing to the number of the muscu- 
 lar elements in the sac wall.* 
 
 A possible form of interstitial pregnancy is furnished by the 
 occasional existence of a canal, open at its two extremities, and appar- 
 ently a continuation or a bifurcation of the Fallopian tube. A case 
 reported by Dr. Gilbert, in the Boston Medical and Surgical Jour- 
 nal (March 3, 1877), where the head of the child could be felt just 
 above the os internum, covered by a thin mucous membrane, and in 
 which delivery was successfully accomplished by an incision through 
 
 Fig. 141.— Bifurcation of tubal canal. (Hennig.) 
 
 the partition, probably belonged to this variety. A similar case, in the 
 practice of Dr. H. Lenox Hodge, is reported by Parry {op. cit., p. 266). 
 
 In the post-mortem examinations the distinction between an inter- 
 stitial pregnancy and one in a rudimentary cornu is not easy to make 
 out. The chief points of difference consist in the fact that in inter- 
 stitial pregnancy the sac communicates by an orifice with the uterine 
 cavity, or is separated from the uterus by a partition, while in preg- 
 nancy in a rudimentary cornu the two halves of the uterus are united 
 by a muscular band, which is situated not at the upper angle but near 
 the OS internum. 
 
 Ovarian Pregnancy. — In spite of modern skepticism, there is little 
 question as to the occasional occurrence of ovarian pregnancy. The 
 specimen discovered by Patenkof in the Pathologico- Anatomical 
 Museum of St. Petersburg seems to answer all the requirements of a 
 
 * Martin, Ztschr. f. Geb und Gynaek., vol. xi, p. 416. 
 
 f Patenko, Casuistische Mitteilungen, Arch. f. Gynaek., vol. xiv. p. 156.
 
 EXTRA-UTERINE PREGNANCY. 335 
 
 demonstration. The right ovary was of the size of a hen's egg, and 
 contained a cyst with smooth walls filled with serum. In this he found 
 a body of a yellow color, of the size of a hazel-nut, which contained 
 cylindrical and flat bones. The most careful microscopical examina- 
 tion established the fact that the bones were those of a foetus, and not 
 merely the chance products of a dermoid cyst. The presence of 
 corpora lutea and follicles in the walls of the envelope proved that the 
 body was an ovary. The tube on the corresponding side was nowhere 
 adherent to the sac. The abdominal extremity was closed, and there 
 were no traces of fimbriae.* 
 
 Paltauf f relates a case of extra-uterine pregnancy in which there 
 was a sacculated condition of both tubes which communicated with a 
 cyst of ovarian origin. The ovaries were closely united. By means of 
 the ovarian cyst a complete communication was established between 
 the two tubes. In the large central ovarian cyst a clot was found 
 which contained an embryo corresponding in size to one of from forty- 
 five to forty-eight days' development. The origin of the condition 
 here met with is naturally a matter of speculation. 
 
 Abdominal Pregnancy. — In most cases of abdominal pregnancy a 
 connective-tissue proliferation is set up about the ovum, which sur- 
 rounds it with a vascular sac. The latter often attains a degree of 
 thickness which renders it comparable to the gravid uterus (Klob). 
 The walls keep pace, as a rule, with the growth of the ovum, and, as 
 they extend into the abdominal cavity, form adhesions to the intestines, 
 the mesentery, and omentum. It is claimed that organic muscular 
 fibers have been found in the sac, especially near the uterine attach- 
 ment. In this form the foetus most frequently reaches maturity. 
 
 In rare cases the ovum develops free in the abdominal cavity, with- 
 out the formation of pseudo-membranes, the foetus being surrounded 
 solely by the amnion and chorion. 
 
 The greater number of so-called abdominal pregnancies are un- 
 questionably of tubal origin. In reality they are for the most part 
 extraperitoneal, and result from a rupture in the tube walls occurring 
 between the folds of the blood ligament. In these cases the conditions 
 are not incompatible with continued fetal development, and gestation 
 may reach an advanced stage. 
 
 The question as to the occurrence of primary abdominal pregnancy 
 must be regarded as unsettled. The discovery of an ovum growing in 
 
 * Mr. Tait, in his recent work on Ectopic Pregnancy, refers to a specimen de- 
 scribed by Dr. Walter as one of primary ovarian pregnancy (sac had ruptured at 
 fifth month, and foetus had escaped into peritoneal cavity), which is now in the 
 Dorpat Museum, and suggests a careful investigation as to its real character. At 
 Werth's request this has since been made by Runge, with a complete confirmation 
 of the significance given to it by Walter in his original publication. Werth, 
 loc. cit., p. 64. 
 
 f Paltauf, Arch. f. Gynaek., vol. xxx, p. 4.j(5.
 
 336 THE PATHOLOGY OF PREGNANCY. 
 
 the peritoneal cavity with the tubes and ovaries demonstrably intact 
 would suffice to establish the abdominal variety. In the early months, 
 before the anatomical conditions are obscured by secondary changes, 
 there is no pretense that such proof has been obtained. In more ad- 
 vanced stages a good many cases of assumed abdominal pregnancy 
 have been placed in evidence. These, so far as my investigations per- 
 mit me to judge, are divisible into two classes : 
 
 1. Cases where the tubes are reported as intact, but in which there 
 exists a direct communication between the tube upon the affected side 
 and the sac cavity. Thus Treub, of Leipsic reports the following 
 instance : 
 
 Patient menstruated last about the middle of April, 1887 ; perito- 
 nitic pains, with symptoms of internal haemorrhage, on tlie ll^th of 
 June. At the end of July the same symptoms occurred, but were more 
 violent. Ballottement was distinct by the end of September. Life 
 was felt a week later. There were no fetal movements after November 
 24th. Septic symptoms developed, and laparotomy was performed 
 January 22, 1888, when the patient was nearly moribund. Death en- 
 sued the following night. 
 
 At the autopsy the annexa on the right side were normal. The 
 left tube measured ten centimetres and a half, which corresponded to 
 the length of the right tube. It was pervious throughout its entire ex- 
 tent. The fimbriated outer end communicated with the sac. There 
 was no apparent distention of the abdominal end of the tube. The 
 sac of the ovum was adherent to the posterior surface of the uterus 
 and of the broad ligament, to a few coils of intestines, to the sigmoid 
 flexure, and to the rectum. 
 
 Abdominal pregnancy was assumed by Treub because the tube had 
 its normal length and its natural direction, while the placenta was 
 attached to the posterior sac wall, which contained no muscular ele- 
 ments, even in the vicinity of the tube. It has been suggested, how- 
 ever, that this was a case where the fecundated ovum occupying the 
 infundibulum ruptured the tube walls at an early period of its growth, 
 and thence continued its development between the folds of the broad 
 ligament. It will be remembered that there were unmistakable symp- 
 toms of internal haemorrhage in June and in July. The length of the 
 left tube does not affect the question, as Werth * furnishes cases of un- 
 mistakable intraligamentous development where the same feature was 
 noted. 
 
 3. Cases where the tubes are reported as intact and not in commu- 
 
 * Werth, Beitrage zur Anatomie und zur operativen Behandlung der Extra- 
 uterinschwangerschaft, 1887. Vide Table A, containing sixteen cases of intraliga- 
 mentous tubal pregnancy. In No. 9, Scott's case, the length of the tube was given 
 at six inches ; in No. 12, Dreesen's ease, at fifteen centimetres; in No. 15, Martyn's 
 case, the statement is made that the tube was enormously increased in length.
 
 EXTRA-UTERINE PREGNANCY. 
 
 337 
 
 nication with the sac. Few of these merit criticism. Lately, however 
 new interest has been excited as to the possibility of primary abdomi- 
 nal pregnancy by a case operated upon in 1879 by Professor Miiller,* 
 of Bern. Extra-uterine and intra-uterine pregnancy existed at the 
 same time. At the eighth month spontaneous expulsion of the intra- 
 uterine foetus took place. The extra-uterine ovum Avas removed bv 
 laparotomy. Death ensued from ha?morrluige. The post-mortem in- 
 vestigation was conducted by Walker, who, in a carefully prepared 
 essay, concludes that the case Avas a typical one of abdominal preg- 
 nancy. The tubes and ovaries were in contact, but not adherent to 
 the sac. The latter had started originally from the bottom of the 
 cul-de-sac of Douglas, and only in the course of its subsequent develop- 
 ment had reached the uterine appendages. The correctness of the 
 author's deductions has not, hoAvever, passed unchallenged, most of the 
 recent reviewers regarding the history as indicating a tubal origin. 
 
 Schlectendahl f reports the discovery of an ovum near the spleen, 
 containing a foetus measuring fifteen centimetres in length, in a woman 
 who had died from internal hsemorrhage. The sac Avas the size of a 
 man's fist, and Avas surrounded by adherent intestines. The uterus and 
 tubes appeared normal. ' The value of this case as evidence on behalf 
 of abdominal pregnancy has been denied, but the facts related by 
 Schlectendahl certainly call for explanation. 
 
 Of very great interest are the cases of so-called secondary abdomi- 
 nal pregnancies, where rupture of the sac and the fetal membranes 
 takes place and the foetus passes into the abdominal caA^ty. Most 
 often the child dies at or soon after the time of rupture, but cases are 
 reported by Walter, Patuna, and Bandl,J where it continued to de- 
 velop within the abdomen. The presence of the child usually excites 
 an active proliferation of connective tissue, by means of which a sec- 
 ondary sac is formed, though in Jessup's case the child was absolutely 
 free in the abdominal cavity. If the child dies, it may either become 
 converted into a lithopaedion, or, through the vascular connective tis- 
 sue by Avhich it is surrol^nded, the soft structures'of the body may pre- 
 serve their integrity for years succeeding the fatal ending. 
 
 There are, in addition to the varieties already mentioned, histories 
 on record of the coexistence of extra-uterine and intra-uterine preg- 
 nancies, the latter occurring at the same menstrual period as the for- 
 mer, or subsequent to the death of the extra-uterine foetus.* 
 
 * Vide L. Bruhl, Zur Casuistik der ExtrauterinschAvangersehaft, Arch. f. 
 Gynaek., vol. xxx, p. 70, and Walker, Der Bau der Eihaute bei graviditas abdomi- 
 nalis, ViRCHOw's Arch., vol. cvii. 
 
 f Schlectendahl, Ein Fall von graviditas abdominalis, Frauenarzt, 1887, No. 2. 
 X Bandl, loc. cii., p. 63. 
 
 * Vide Broavne, Contribution to the History of Combined Intra-uterine and 
 Extra-uterine Twin Pregnancy, Avith an Analysis of TAventy-four Cases, Trans. Am. 
 Gynaec. Soc, vol. vi, p. 444. 
 
 22 -
 
 338 THE PATHOLOGY OF PREGNANCY. 
 
 Tubo-Abdominal and Tubo-Ovarian Pregnancy.— When the ovum 
 becomes lodged near the trumpet-shaped extremity of the Fallopian 
 tube it may grow outward into the abdominal cavity. Local peritonitis 
 is then set up, and plastic exudation is thrown out, forming an envelope 
 around the ovum, which is likewise bounded by the contiguous organs. 
 In tliis way the ligamenta lata, the ovaries, the mesentery, the in- 
 testines, the bladder, and the uterus, may all contribute to the invest- 
 ment of the fetal membranes. In case of rupture in the tubal portion 
 inflammatory products may form, and limit the extent of the injury. 
 At first, owing to its weight, the distended tube drops into the cul- 
 de-sac of Douglas. In advanced pregnancy, the spleen, kidneys, and 
 liver may become involved, and form part of the sac-walls around the 
 ovum. Usually the placenta is developed in the pelvic cavity.* 
 
 When the investment of the ovum is furnished by the tube and 
 the ovary, the term tubo-ovarian pregnancy is employed. The course 
 in either case does not materially differ from that of an abdominal 
 pregnancy. 
 
 The Symptoms of Extka-uterine Preg^tancy. 
 
 The earlier symptoms of extra-uterine preg^nancy do not materially 
 differ from those of the intra-uterine form. Menstruation usually 
 ceases, though not with the same regularity as in normal pregnancy. 
 The recurrence of the monthly flow for one or two periods is not an 
 uncommon incident. In some cases, too, a nearly continuous sero- 
 sanguinolent discharge of moderate extent has been observed;^ Up to 
 a certain point the hypertrophic changes of the uterus take place in 
 the usual manner. The mucous membrane is converted into a de- 
 cidua, and a mucous plug fills the cervix. In general terms, the length 
 of the uterus is greater the closer the contiguity of the ovum to the 
 uterus. In a few cases of tubal pregnancy there has been no increase 
 in the size of the uterus. The extra-uterine ovum may, in the course 
 of its growth, drag the uterus upward, or push it downward, forward, 
 or to the side, according to the site of its development. 
 
 Characteristic symptoms of extra-uterine pregnancy do not occur 
 until the ovum has reached a certain degree of growth, and in some 
 cases not until rupture has taken place. Often preceding rupture, or, 
 in abdominal pregnancies, the death of the foetus, the patient suffers 
 from paroxysmal pains in the sac, and uterine pains of a labor-like 
 character. The latter are associated with a sero-sanguinolent dis- 
 charge, and are followed by the expulsion of portions of the decidua. 
 
 The symptoms of rupture are the usual ones of internal haemor- 
 rhage, viz., yawning, languor, fainting, clammy perspiration, rapid 
 pulse, intermittent vomiting, collapse, and acute anaemia. After the 
 
 * Vide Bandl, Billroth's Handbuch der Prauenkrankheiten, 5ter Abschnitt, 
 p. 47.
 
 EXTRA-UTERINE PREGNANCY. 339 
 
 death of the ovum these symptoms may cease and not return again ; 
 whereas, if the ovum continues to grow, there may be repeated attacks 
 of haemorrhage and local peritonitis. 
 
 When the death of the ovum does not occur within the first three 
 to four months, the pressure of the tumor usually gives rise to dysuria 
 and constipation. 
 
 Terminations. — The investigations resulting from the recent wide- 
 spread interest in the diseases of the uterine appendages have shown 
 that tubal pregnancy is by no means of rare occurrence. Whereas, in 
 tubal and interstitial pregnancies, it was formerly believed that the usual 
 terminations were rupture of the sac, h£emorrhage, peritonitis, and 
 death, it is now known that in a pretty large percentage of cases the 
 ovum perishes at an early period of development; and, though the 
 sequelae of these so-called tubal abortions may cause discomfort or lay 
 the foundation for chronic invalidism, they do not necessarily lead to 
 a fatal result. As in cases of uterine abortion, the death of the ovum 
 is for the most part followed by haemorrhage, which may be confined 
 to the tube (haematoma tubae), or the blood may escape by the fimbri- 
 ated extremity into the peritoneal cavity, or, if circumscribed by adhe- 
 sions, it may give rise to the intraperitoneal form of pelvic haematocele. 
 Even when rupture takes place the haemorrhage is not necessarily fatal. 
 Mr. Tait insists on the relative harmlessness of most cases of haema- 
 toma due to rupture occurring between the folds of the broad ligament ; 
 while the records of salpingotomy show that, even with intraperi- 
 toneal rupture, the haemorrhage has often been found moderate in 
 amount, and did not in itself furnish the occasion for surgical inter- 
 ference.* 
 
 In abdominal pregnancies, which it has been seen are usually if not 
 always secondary to the tubal form, the ovum or foetus, as a rule, excites 
 a local peritonitis, attended with pain and fever, and followed by the 
 production of pseudo-membranes, which exercise a conservative influ- 
 ence by shutting off the ovum from the peritoneal cavity. Indeed, in 
 the exceptional instances where these inflammatory conditions do not 
 develop, the movements of the foetus within its own membranes may 
 give rise to such intense suffering as to cause the woman to die from 
 exhaustion (Schroeder). 
 
 In abortions at an early stage it often happens that no trace of the 
 embryo is found, and the diagnosis has to be made from the presence 
 of the chorionic villi. Even when abortion does not occur in the first 
 few weeks the child is apt to die prematurely. Sometimes, however, 
 gestation may advance to full term ; in which case labor-pains set 
 in, the decidua is expelled, and the child dies during the expulsive 
 efforts. In the majority of cases the dead foetus excites a suppurative 
 inflammation in the sac by which it is inclosed, and the patient dies 
 * Vide, as an instance, the cases reported by Orthman from Martin's Clinic.
 
 340 THE PATHOLOGY OF PREGNANCY. 
 
 either from general peritonitis or from profuse suppuration. In cases 
 where the peritonitis remains local and the suppuration is tolerated, 
 fistulous communications may form with one of the hollow viscera or 
 the abdominal walls, through which the contents of the sac may be 
 eliminated. Most frequently the opening takes place into the large 
 intestine ; quite often through the abdominal walls ; more rarely into 
 the vagina and bladder. In any case, the process of elimination is 
 slow, often lasting months, and even years. When the bones and soft 
 tissues have all been discharged, complete recovery may take place. In 
 the larger proportion of cases, however, if Nature is not assisted, the 
 patient perishes from exhaustion and blood-poisoning before the elimi- 
 nation is ended. 
 
 Sometimes the foregoing inflammatory changes do not occur as the 
 result of the death of the foetus, in which case the fluid contents of 
 the sac are re-absorbed, and the walls collapse and come in contact with 
 the fetal cadaver. The skin of the latter, and at a later period the 
 deep-seated soft tissues, undergo fatty degeneration, and form a greasy 
 substance consisting of fat, lime-salts, cholesterin-crystals, and blood- 
 pigment. Afterward the fluid portions are absorbed, so that nothing 
 remains but the bones, lime lamellee, and incrustations upon the walls 
 of the sac ; or the foetus may shrink up like a mummy, preserving its 
 shape and organs to the minutest detail. A foetus thus altered is 
 termed a lithopaedion. It may remain imbedded in connective tissue 
 for years without injury to the mother. The lithopaedion of Leinzell 
 was removed in 1720 from a woman ninety-four years of age, who had 
 carried it for forty-six years. The presence of the lithopaedion does not 
 prevent pregnancy from taking place. In some cases it may after years 
 excite suppuration, a result which is fostered, according to Spiegelberg, 
 by pregnancy and labor. Recovery may follow the -artificial extraction 
 of the foreign body, or death may result from inflammation and the 
 discharge of pus. 
 
 Note. — Kiichenmeister (Ueber Lithopadien, Arch. f. Gynaek., vol. xvii, p. 153) 
 distinguishes three conditions to which the term lithopaedion is applied : 
 
 1. Where, after absorption of the fluid, the membranes alone calcify, and the 
 foetus undergoes mummification. 
 
 2. Where, after absorption or escape of the fluid, the membranes calcify, and 
 calcification of the foetus occurs at points where the membranes adhere to the fetal 
 surface. 
 
 3. Where the foetus escapes into the abdominal cavity, and cretaceous matter is 
 deposited in the smegma covering the fetal surface. In this way calcified strata 
 form around the foetus and exert compression upon the contained tissues. Beneath 
 the chalky layers the tissues are mummified. A lithopaedion in the sense of a com- 
 plete petrifaction does not exist. 
 
 Diagnosis, — The diagnosis of extra-uterine fetation is based upon 
 the existence of the signs of pregnancy, the exclusion of an ovum within 
 the uterine cavity, and the presence of a tumor external to the uterus.
 
 EXTRA-UTERINE PREGNANCY. 341 
 
 In practice, however, there is a wide-spread difference of opinion as 
 to the practicability of an early diagnosis ©f tubal pregnancy. Dr. 
 Hanks has recently stated his belief that a diagnosis can be made in 
 ninety-five per cent of the cases we are called upon to attend. Mr. 
 Tait, on the other hand, thinks " he may be excused for maintaining a 
 somewhat skeptical attitude concerning the correctness of the diagno- 
 sis of these gentlemen who speak of making a certain diagnosis before 
 the period of rupture." 
 
 The problem seems simple enough. Given pregnancy, and having 
 ascertained that the ovum is not in the uterus, the diagnosis is effected. 
 But we all know that the subjective symptoms of pregnancy are decep- 
 tive, and that the pigmentation, the mammary, and the utero-vaginal 
 changes are not always so clearly defined in the first three months as 
 to make it safe in every case to positively diagnosticate pregnancy in 
 even the intra-uterine form. The advice to use the sound to demon- 
 strate the vacuity of the uterus in suspected cases has been the cause 
 of many needless abortions. Fortunately, the sound often does no 
 other harm than to add to our sources of error. Twice within a year 
 gravid patients have been sent to me with the assurance that the re- 
 peated introduction of the sound had shown the empty condition of 
 the womb. In one of them, after an anaesthetic was given, it was easy 
 to determine the presence of the head of the child through the cervix 
 at the internal os ; in the other I felt perplexed, and asked the opinion 
 of Dr. Thomas. He pronounced it an ordinary pregnancy, and the 
 event has shown that he was correct. Twice within a year, to my 
 knowledge, the abdomen has been opened in this city for supposed 
 extra-uterine gestation, and only ordinary gravidity was found. 
 
 In the main, our dependence must be upon local changes and local 
 symptoms. Thus a tubal swelling and enlargement of the uterus, as- 
 sociated with suppression of the menses, often followed after a brief 
 period by sero-sanguinolent discharges and increased flow at the men- 
 strual period, with paroxysmal pains radiating from the side of the 
 pelvis upon which the affected tube is situated, and with the expulsion 
 of the uterine decidua at the end of the second or in the course of the 
 third month, are to be regarded with suspicion. But a tubal sac is the 
 product of a variety of pathological conditions.* The uterine changes 
 in early months are inconstant. These sometimes correspond to those 
 of ordinary uterine gestation, but often there is neither perceptible en- 
 largement nor cervical softening to indicate pregnancy. Paroxysmal 
 pains are frequent in other forms of tubal disease, and menstrual 
 disturbances are common phenomena in uterine derangements. The 
 
 * Veit regards as an important distinction in the early stage, that whereas in 
 other forms of tubal enlargement the swelling may be hard or tense or fluctuating, 
 when due to an intact ovum it possesses a characteristic soft feel. Verhandlungen 
 der Deutschen Gesellsch. f. Gynaek., Third Congress, Leipsic, 1890, p. 162.
 
 342 THE PATHOLOGY OP PREGNANCY, 
 
 expulsion of the decidua, though a valuable sign, is not of constant 
 occurrence. In many tubal abortions the only symptoms are those of 
 pelvic hajmatocele. In many instances of early rupture of the tube 
 with hajmorrhage into the peritoneal cavity there are no antecedent 
 symptoms, or only those of ordinary pregnancy. In reading the re- 
 ported cases of the operative removal of pregnant tubes, it is surprising 
 to note in how many of them the diagnosis was only established by 
 the subsequent determination in the removed tubes of decidual cells 
 and chorionic villi. Undoubtedly a probable diagnosis prior to rupture 
 might be made in many instances if the patients could be subjected to 
 frequent examinations from the beginning of the pregnant state, but 
 this, in the nature of things, is rarely. practicable. 
 
 In the intraligamentous form the conditions for diagnosis are more 
 favorable. Here gestation is apt to be prolonged, and if rupture occurs 
 between the folds of the broad ligament the hemorrhage is limited in 
 amount. In this class the patients are apt to seek early professional 
 advice, owing to the discomforts from which they suffer. The swelling 
 at the side of the uterus is easily reached through the vagina, and we 
 have as distinctive signs a rapidly growing tumor, early fluctuation, 
 and the presence of pulsating vessels over the site of the tumor. 
 Bimanual examination under an anaesthetic, especially if the thumb be 
 introduced into the vagina and two fingers into the rectum, makes it 
 possible to determine that the tumor is independent of the uterus.* 
 
 After the third month it is not ordinarily difficult to determine the 
 existence of the pregnant state. Ballottement is usually perceptible at 
 an early date, and the fetal heart makes the diagnosis certain ; but the 
 greatest care needs to be exercised in the examination of the patient 
 and in the formation of an opinion concerning the extra-uterine situa- 
 tion of the ovum. In a suspected case violence in the attempt to 
 separate the tumor from the uterus may cause sac rupture. Grand in 
 believes the absence of contractions when frictions are applied to the 
 sac of an extra-uterine ovum should prove a most valuable aid to 
 diagnosis. Kiistner f curiously enough maintains that the existence of 
 contractions in tubal pregnancy should distinguish them from other 
 pelvic growths. Mr. Tait cites as a misleading condition an abnormal 
 thinness of the uterine walls. In my own experience, lateral flexion of 
 the uterus often simulates ectopic gestation to a surprising degree. In 
 these cases the fundus containing the ovum lies upon one side of the 
 pelvis. The cervix is crowded to the opposite side. Between the two 
 
 * According to Smolsky's observations, the tube in the first two months is the 
 size of a pigeon's egg, at the end of the second month of an English walnut, at two 
 and a half months of a hen's egg, at three months it reaches the size of the fist, and 
 at four months the size of two fists. Variations may result from hydramnion, 
 haMnato-salpinx, malformation, etc. Smolsky, Diagnostie et traitement de la 
 grossesse tubaire, Neuvelles arch, d'obstet. et de gynecologie, Dec, 1890, p. 649. 
 
 f MtJLLER's, Handbuch der Geburtshlilfe, a'oI. ii, part 2, p. 541.
 
 EXTRA-UTERINE PREGNANCY. 343 
 
 a deep sulcus is felt. If the patient is hysterical, these deranged rela- 
 tions are exaggerated by contraction of the abdominal muscles. No 
 difficulty in detecting the error 'is experienced when the patient is 
 anaesthetized, except in cases where the fundus is fixed to the side by 
 adhesions. In two instances seen by me the intra-uterine nature of 
 the pregnancy was only determined by the forcible introduction of the 
 finger through the cervix. Cases of retroflexion of the gravid uterus 
 with incarceration are likewise often difficult to distinguish from extra- 
 uterine pregnancy. 
 
 The distinction by physical signs between the tubal, the ovarian, 
 and the secondary abdominal form is scarcely practicable so long as 
 trained anatomists fail to agree concerning them when the abdomen 
 has been opened and the organs are exposed to view. 
 
 A review of the subject of diagnosis makes it apparent that many 
 cases of ectopic pregnancy present no symptoms previous to rupture. 
 In another class the existence of a suspicious tumor with few or none 
 of the corroborative signs should lead to a waiting policy, or, when the 
 symptoms are of a threatening character, to an explorative laparotomy. 
 It is well, however, to remember that with reference to this latter pro- 
 cedure recent popular interest in abdominal surgery has a tendency to 
 invest trifling anomalies occurring in gestation with a sinister impor- 
 tance. But there still remains a considerable class in which an early 
 diagnosis can be reached with reasonable certainty.* 
 
 Treatment. — The treatment of extra-uterine fetation varies in ac- 
 cordance with the stage of pregnancy and the condition of the foetus. 
 For the sake of convenience, we distinguish — 1. Cases of early gesta- 
 tion ; 2. Cases of advanced gestation (foetus living) ; 3. Cases of gesta- 
 tion prolonged after the death of the foetus. 
 
 1. Cases of Early Gestation. — The indication for treatment in the 
 early months varies with the conditions. If rupture has occurred, 
 care should be employed to ascertain, if possible, whether the resulting 
 hsemorrhage has taken place between the folds of the broad ligament, 
 or, if intraperitoneal, whether the blood is free in the abdominal 
 cavity, or is restricted to the pelvis by old adhesions. Circumscribed 
 effusions of blood due to ruptured tubes do not, as a rule, threaten life, 
 and disappear with time and with little other treatment than rest in 
 the recumbent posture. 
 
 If the outpouring of blood has taken place primarily into the ab- 
 dominal cavity, or as a secondary occurrence after the giving way of 
 the first barriers, laparotomy is unquestionably demanded. While it 
 is not denied that even in these extreme cases the effused blood may 
 be circumscribed by an adhesive inflammatory process, and that a few 
 patients may recover with an expectant treatment, the waiting policy is 
 
 * Hawley reported in the N. Y. Med. .Jour., June 16, 1888, a case where the 
 diagnosis made previous to rupture was conftrmed by laparotomy.
 
 344 THE PATHOLOGY OF PREGNANCY. 
 
 a gamble with life. On the other hand, the opening of the abdomen 
 for the purpose of removing blood and clots, and for the extirpation 
 of the tube-sac has been the means, since Mr. Tait demonstrated the 
 practicability of the operation, of saving multitudes of women from 
 impending death. The operation is not, as a rule, difficult. It involves 
 the separation of adhesions where these exist, the tying of the pedicle, 
 and the removal of the ruptured sac. In the intraligamentous form 
 it may be necessary to ligate the attached portion in sections. Where 
 a pedicle can not be readily prepared, Veit recommends the tying of 
 the broad ligaments at the two extremities of the sac before proceed- 
 ing to ligate the base. Previous to closing the abdominal incision 
 great care should be taken to insure the arrest of haemorrhage not only 
 from the stump but from the separated adhesions. 
 
 When the diagnosis is made previous to rupture the choice lies 
 between laparotomy and the employment of measures to destroy the 
 life of the embryo. In practice the decision is pretty certain to be 
 governed by other than theoretical considerations. Thus an experi- 
 enced operator, who possesses trained assistants and can command for 
 his patient the surroundings which are needful for success, will be apt 
 to select laparotomy. The risks have been proved to be small, and the 
 patient is relieved from possible future troubles due to retention of the 
 products of conception. But all men are not experts in pelvic surgery. 
 The danger which threatens the life of the patient is often imminent, 
 and assistance from afar is not always easy to obtain. Under these 
 conditions the indication for treatment is plainly the adoption of 
 measures to destroy the life of the foetus, and thus, by arresting the 
 growth of the ovum, to diminish the chances of rupture and of haemor- 
 rhage. 
 
 The methods which have heretofore been employed to destroy the 
 ovum are puncture of the sac, injections of morphia solutions, elytrot- 
 omy, and the faradic current. 
 
 Puncture of the Sac. — Puncture of the sac is usually easily effected 
 by the introduction of an exploring trocar through either the vaginal 
 or rectal wall. The operation is to be recommended on the score of 
 simplicity, but has not been attended with very brilliant results. Re- 
 coveries after puncture have been recorded by Greenhalgh, Tanner, 
 Stoltz, Jacobi, Koeberle, and E. Martin (two cases). Fatal issues 
 from septicaemia and peritonitis followed puncture in the hands of 
 Eouth, J. Y. Simpson, A. Simpson, Martin, Braxton Hicks, Thomas 
 (two cases), Conrad, Netzel, Hutchinson, John Scott, Gallard, and 
 Depaul. Frankel * withdrew nearly three fifths of an ounce of am- 
 niotic fluid from the sac without interrupting the course of preg- 
 nancy. 
 
 * FeXnkel, Zur Diagnostik und operative Behandlung der Tubenschwanger- 
 schaft, Arch. f. Gynaek., Bd. xiv, p. 197.
 
 EXTRA-UTEfllNE PREGNANCY. 345 
 
 Injections of Solutions into the Sac, designed to destroy the Fcetus 
 — This method was first suggested by Joulin.* He proposed injections 
 of sulphate of atropia (one fifth of a grain dissolved in a few drops of 
 water) into the sac by means of a long hypodermic syringe. His sug- 
 gestion subsequently was successfully carried into effect in two cases 
 by Friedreich,! of Heidelberg. The needle of the syringe, he advised, 
 should be introduced into the sac through the abdominal or vaginal 
 walls, a few drops of fluid should then be Avithdrawn, and its place 
 supplied by the solution containing the poison selected. Friedreich 
 employed by preference a fifth of a grain of morphia. The operation 
 was repeated every second day, until the diminished size of the ovum 
 afforded evidence that the result sought for had been accomplished. 
 T'he operation seemed to produce but slight inflammatory disturbance, 
 and the maternal system did not feel the influence of the narcotic. 
 Eennert \ has since succeeded in destroying the life of the foetus in 
 the fifth month of extra-uterine gestation by means of a single injec- 
 tion containing about half a grain of morphia. The patient recov- 
 ered after a protracted illness. Koeberle reported to the Gynaecologi- 
 cal Section of the Eighth International Medical Congress at Copen- 
 hagen a case of advanced abdominal pregnancy where the child was 
 destroyed by morphia injections. The foetus and placenta were ab- 
 sorbed. The recovery was complete. Six cases have been reported by 
 Winckel, and one by Fournier. Of the eleven cases, three died. 
 
 2iie Faradic and Galvanic Currents. — The transmission of the 
 faradic current through the ovum has proved a safe and efficient 
 method for destroying the life of the foetus during the first three 
 months of its existence. The application consists in passing one pole 
 into the rectum to the site of the ovum, and pres'Sing the other upon 
 a point in the abdominal wall situated two to three inches above Pou- 
 part's ligament. The full force of the current of an ordinary one-cell 
 battery should be employed for a period varying from five to ten min- 
 utes. The treatment should be continued daily for one or two weeks, 
 until the shrinkage of the tumor leaves no doubt as to the death of the 
 fcetus. 
 
 The successful employment of the faradic current in extra-uterine 
 pregnancy we owe to Dr. J. G. Allen, who reported two cases of re- 
 covery through its instrumentality in 187^. His first case occurred 
 in 1869, the second in 1871. Previously, in 1859, Burci had succeeded 
 in shriveling up the ovum, in a case of tubal pregnancy, with the 
 
 * JouLix, Traite complet desaccouchements, \). 968. 
 
 f CoHNSTEiN, Beitrag zur Schwangerschaft ausserhalb der Gebarmutter, Ai'ch. f. 
 Gynaek., Bd. xiv, p. 355. Hennig reports likewise a case operated on by Koeberle, 
 where profuse haemorrhage occurred. It is not stated whether the patient recov- 
 ered. (Die Krankheiten der Eileiter und die Tubenschwangerschaft, p. 138.) 
 
 X Rennert, Extrauterinsehwangerschaft im fiinften Monate, Arch. f. Gynaek., 
 vol. xxiv, p. 266.
 
 340 THE PATHOLOGY OF PREGNANCY. 
 
 galvanic current transmitted through the tumor by means of two 
 acupuncture needles. In 1866 Dr. Braxton Hicks tried the faradic 
 current, but abandoned it after the second application. Dr. Allen was 
 apparently in no haste to report his triumphs, but appears to have 
 mentioned them incidentally in the course of a discussion before the 
 Obstetrical Society of Philadelphia. So little pains did he take re- 
 garding his discovery that the subject was nearly forgotten, until a^ 
 new success was reported by Drs. Levering and Landis, of the Starling 
 Medical College, in 1877. Since then. Brothers* has collected fifty 
 cases in which electricity was employed. In twenty-five cases, to which 
 I can add a twenty-sixth from my own practice, and not included in 
 Brothers's list, the health of -the patient was ascertained to be good at 
 the end of periods varying from one to eight years. 
 
 There were no evil results in any of the cases traceable to the elec- 
 tricity. Of the four fatal ones, in that of Janvrin rupture of the tube 
 had undoubtedly taken place before the galvanism was employed ; in 
 that of Wylie the eight months' foetus was killed by injections of 
 morphia into the sac after electricity had been discarded ; and in the 
 cases of Duncan and Steavensen and Boulton and Steavensen electro- 
 puncture was employed, 
 
 Against the method, it lias been urged that the successes reported 
 are in themselves evidences of an erroneous diagnosis, that the faradic 
 or galvanic current endangers the integrity of the tube, and that the 
 ovum, after its vitality has been destroyed, is liable to produce suppura- 
 tion. But a 'priori deductions should not be allowed to outweigh the 
 evidence of carefully conducted experiments. It should be borne in 
 mind, however, that electricity. is only available in the first three 
 months, and that no one in this country advocates electro-puncture. f 
 
 Cases of Advanced Gestation. — After the third month it has now 
 come to be regarded as a settled rule that the removal of the foetus, 
 the placenta, and the investing membranes should be attempted as 
 soon as the diagnosis has been made. If complete extirpation of the 
 sac proves impracticable, it should be removed to the fullest extent 
 possible, as its presence when left in situ is capable of leading to in- 
 tractable sinuses and persistent suppuration. The older method of 
 stitching the sac to the abdominal wall and leaving the placenta to 
 come away spontaneously, fyrnished a certain number of favorable re- 
 
 * A. Brothers, Subsequent Behavior of Cases of Extra-uterine Pregnancy 
 treated by Electricity, American Jour. Obstet., vol. xxiii, No. 2, 1890. 
 
 f Dr. Franklin H. Martin {vide Goelet's Archives of GyucTeeology, 1891, p. 100) 
 has sought to show, by experiments on incubating hen's eggs, that the faradic cur- 
 rent is relatively worthless as a feticide agent, and recommends the substitution in 
 all cases of the galvanic current. If this should be established with regard to the 
 human ovum, it must be confessed it would greatly weaken, if not destroy, the argu- 
 ment in favor of electric treatment, since nearly all the reported successes have 
 been obtained by faradism.
 
 EXTRA-UTERINE PREGNANCY. 347 
 
 suits after the death of the child and the arrest of the circulation had 
 taken place. During the life of the child death from haemorrhage was 
 the nearly uniform result. The conclusion drawn from this experience 
 was to await the death of the foetus before operating, thus exposing the 
 woman to the manifold dangei'S arising from the presence in the peri- 
 toneal cavity of a growing ovum, or of a sac containing dead matter, 
 often in a state of putrefaction. 
 
 But with clearer anatomical views of extra-uterine pregnancy, it is 
 getting more and more to be recognized that the treatment of that 
 condition is subject to the ordinary rules of abdominal surgery. 
 
 The difficulties encountered in the removal of the fetal sac are the 
 result of excessive vascularity and extensive adhesions, but these 
 obstacles to success have of late been found in many cases not to be 
 insuperable. In the purely tubal form, where advanced gestation is 
 reached without rupture, the uterine end forms a pedicle which permits 
 the employment of the ligature en masse. In this category should be 
 placed the case of Olshauseu, and probably that of Eastman. In an 
 intraligamentous case, Breisky first stitched the sac to the abdominal 
 wound and removed the foetus. He then removed the stitches, ligated 
 the broad ligament on the side of the uterus, and separated the tumor, 
 tying at the same time any large vessels found bleeding on the cut 
 surface. By progressive ligation of the base from within outward 
 toward the pelvic walls, the sac with the contained placenta was 
 detached with but slight loss of blood. A portion of the sac which 
 had grown into the meso-C£ecum was enucleated. Packing with iodo- 
 form gauze was subsequently resorted to. 
 
 Schauta * has recently reported a method in the intraligamentous 
 form which promises important future results. The ovum and uterus 
 apparently constituted a single growth. It was impossible to ligate 
 between them. He succeeded, however, in applying a double ligature 
 to a peritoneal fold, which formed the residue of the ligamentum 
 infundibulo-pelvicum. After dividing between the ligatures he got 
 underneath the peritonaeum, which he severed by a circular line to 
 the right uterine cornu. The peritonaeum was then dissected away 
 from the sac wall without noticeable haBmorrhage, and the six months' 
 ovum was enucleated entire. Upon detaching the ovum from the 
 uterine wall there was considerable bleeding, requiring the provisional 
 employment of compression and the subsequent use of the suture. 
 The peritoneal sac was then attached to the wound, and drained by 
 Mikulicz's method. 
 
 In these four cases, all of which ended in recovery, success was due 
 to the complete extirpation of the sac. Werthf reported in 1889, to 
 
 * Schauta, Beitrage zur Casuistik, Prognose und Therapie der Extrauterin- 
 sehwangerschaft, Prag, 1891. 
 
 f Werth, Behandlung der Extrauterinschwangerschaft, Verhandlungen der
 
 348 THE PATHOLOGY OF PREGNANCY. 
 
 the Third Congress of the German Gynaecological Society, nine opera- 
 tions between 1887 and 1889. The case of Schauta increases the list to 
 ten. Of these, eight recovered and two died. It was not possible to 
 remove the entire sac in every case, but even partial extirpation, with 
 employment of ligatures to the placental vessels and removal of the. 
 placenta, has been found to lessen the risks of the operation and to 
 shorten the period of convalescence. 
 
 After the death of the foetus the same principles hold good so long 
 as the sac contents have not been infected. After putrefaction or pus 
 formation has set in the older method of stitching the sac to the 
 abdominal incision previous to opening it is still the best. After the 
 removal of the foetus the placenta should be left to separate spon- 
 taneously. While the detachment is taking place, it has been found that 
 a mixture of tannin and salicylic acid strewed upon the inner surface 
 of the sac is useful as a styptic and a disinfectant. 
 
 Deutschen Gesellschaft fiir Gynaekologie, 3te Kongress, p. 175. Other successful 
 cases were reported by Braun, Olshausen, John Williams, Lazarewitsch, and Treub. 
 Fatal cases occurred in the practice of Prochownik and L. Braun.
 
 OBSTETEIO SUEGEET. 
 
 CHAPTER XVIII. 
 
 THE INDUCTION OF PREMATURE LABOR. 
 
 Induction of premature labor. — Indications. — Contracted pelvis. — Habitual death 
 of foetus. — Diseases which imperil the life of the mother. — Operation. — Cathe- 
 terisatio uteri. — Intra-uterine injections. — Rupture of membranes. — Mechanical 
 dilatation of cervix. — Vaginal douches. — Tampon. — Choice of methods. — Care 
 of the child. — Artificial abortion. 
 
 The induction of premature labor is indicated in cases in which 
 the continuance of pregnancy, or delivery at full term, is associated 
 with risks to mother or child, or to both, which may be diminished 
 by bringing pregnancy to a close at an early period after the foetus is 
 prepared for extra-uterine existence. The time at which the latter 
 begins is usually placed at the twenty-ninth week. As, however, the 
 preservation of the child at so early a date is an exceptional occurrence, 
 and as a large proportion of those which by tender care are made to 
 survive the first danger of immaturity perish in infancy, commonly 
 falling a prey to hydrocephalus or to intestinal derangements, the in- 
 terests of the child call for the postponement of the operation as long 
 as practicable. Where the choice lies with the physician, the provo- 
 cation of labor is usually deferred until the thirty-third or thirty- 
 fourth week. The principal indications are : 
 
 1. Moderate Degrees of Pelvic Contraction. — In flattened pelves 
 measuring from two and three fourths to three and one fourth inches, 
 and in equally contracted pelves under three and one half inches, the 
 passage of a full-term child is not impossible, though usually diflScult 
 and dangerous. By inducing premature labor, however, owing to the 
 smaller size of the foetus, and especially to the increased compressibility 
 of the fetal head, we are enabled to diminish the mechanical obstacles 
 to delivery, and thus to improve the prognosis for both mother and 
 child. To the mother the advantage from the operation is in all cases 
 decided, while to the child not much is gained in the extreme degrees 
 of contraction. 
 
 The time at which gestation should be interrupted depends upon 
 the size of the pelvis and our estimate of the size of the fetal head. 
 The distance from the lower border of the symphysis to the promon-
 
 350 
 
 OBSTETRIC SURGERY, 
 
 tory should be accurately measured, and the side walls of the pelvis 
 carefully explored. Schroeder's measurements show that the bipari- 
 etal diameter of the head is, between the twenty-eighth and thirty-sec- 
 ond week, about three and one fourth inches ; between the thirty-second 
 and thirty-sixth week, nearly three and a half inches ; and that after 
 the thirty-sixth week the increase is insignificant.* 
 
 One of the most important questions to be decided in reference to 
 the induction of labor is the period to which gestation has advanced. 
 But this, in the absence of well-defined signs, it is easy to miscalculate. 
 Physicians have been misled by the large size of the uterus in twin 
 pregnancies and hydramnion into provoking labor before extra-uterine 
 existence was possible. 
 
 Ahlfeld has shown that the long axis of tlie foetus, when flexed in 
 utero, is almost exactly one half its entire length in an extended posi- 
 tion. He proposes measuring the former with a Baudelocque pelvim- 
 eter, by placing one extremity per vaginam upon the child's head, 
 and the other upon a point in the abdominal walls over the fundus of 
 the uterus at which the breech of the child is felt. Very nearly the 
 same results were obtained by measuring from the upper border of 
 the symphysis in place of passing the lower branch through the genital 
 canal. The following arrangement, based upon his tables, places be- 
 fore us in a practical way the result of his investigations, so far as 
 they apply to the questions involved in the induction of premature 
 labor : f 
 
 2. HaUtual Death of the Foetus. — It has been proposed that, when 
 in successive pregnancies the foetus perishes in utero during the latter 
 weeks of gestation, labor should be induced after the period of viability 
 has been reached, but before the time at which, according to previous 
 experience, the fatal ending was to be expected. This plan of treat- 
 ment does not apply to cases where death is due to syphilis, as a better 
 
 * ScHROEDER, Lehrbuch der Geburtshiilfe, 4te Aufl., p. 235. It is to be remem- 
 bered that the biparietal diameter is capable of a considerable degree of compres- 
 sion, and that it is usually the bitemporal rather than biparietal diameter which 
 has to pass the narrowest diameter of the pelvis. 
 
 f The arrangement is modified from one furnished by Stahl (Geburtshiilfliche 
 Operationslehre, p. 47). Owing to individual differences in the length of the foetus at 
 the same period of gestation, a considerable source of error inheres to the Ahlfeld 
 method of computation. It is, however, much less than those to which estimates 
 based upon the size of the uterus are subject. 
 
 Axis of foetus. 
 
 Length of foetus. 
 
 Biparietal diameter. 
 
 Duration of pregnancy. 
 
 iDches. 
 
 10 
 9i 
 9 
 
 8 
 
 Inches. 
 
 20 
 19 
 
 18 
 16 
 
 Inches. 
 
 H 
 
 3 
 
 Weeki. 
 
 38-40 
 35-37 
 81-34 
 29-30
 
 THE INDUCTION OF PREMATURE LABOR. 351 
 
 result is to be expected by subjecting both parents in advance to anti- 
 sypbilitic treatment. Little benefit, too, would be derived from pre- 
 mature labor where the death is due to organic diseases of the fcetus. 
 But where death is the result of inanition, dependent upon maternal 
 anaemia, degenerative changes or faulty development of the placenta, or 
 alterations of the umbilical cord, the operation is fully justifiable. 
 With the difficulty, however, of making the diagnosis and fixing the 
 time when labor should be induced, there have been but few cases in 
 which the procedure has furnished favorable results. 
 
 3. Diseases whicli imperil the Life of the Mother. — In these cases 
 the operation is primarily performed in the interests of the mother, 
 and is indicated, therefore, even when the child is known to have per- 
 ished. Sometimes, however, premature labor becomes a means of sav- 
 ing tlie life of the child, which shares the dangers that threaten the 
 maternal existence. In this category belong especially chronic affec- 
 tions of the heart and of the respiratory organs ; enormous distention 
 of the abdomen from multiple pregnancy, hydramnion, tumors, and 
 ascites, which occasion extreme dyspnoea ; pernicious augemia ; uncon- 
 trollable vomiting ; haemorrhages from placenta praevia ; chorea ; con- 
 vulsions ; and nephritis, associated with excessive oedema. In each 
 case, however, it is incumbent to carefully consider whether the special 
 condition is rendered more threatening by the existence of pregnancy, 
 and to weigh the question as to how far, for the time being, the dan- 
 gers are likely to be increased by the progress of labor. 
 
 Stehberger has proposed extending this indication to cases where 
 the preservation of the mother's life is hopeless, but in which prema- 
 ture delivery affords a chance of saving the life of the child.* 
 
 Operation. 
 
 A great number of methods have been proposed with a view to pro- 
 voke labor prematurely. Most of them, however, such as the adminis- 
 tration of ergot, of quinine, or of jaborandi, the stimulation of the va- 
 gina with carbonic acid, frictions of the breasts, and the like, do not 
 require anything more than cursory mention. The following proced- 
 ures alone possess any special claims to favor ; 
 
 Catheterization of the Uterus. — This method consists in the intro- 
 duction of a catheter, or, better still, an elastic bougie, between the mem- 
 branes and the walls of the uterus, and leaving the instrument in situ 
 until active labor sets in. In performing the operation it is a good plan 
 to place the patient in a recumbent posture upon a hard table, with the 
 hips brought near the edge, and the thighs well fixed upon the body. 
 After preliminary vaginal disinfection, two fingers guide the point 
 of the bougie into the cervix, the index-finger, passed to the os in- 
 
 * Stehberger, Lex regia und kiinstliche Frlihgeburt, Arch. f. Gynaek., Bd. i, 
 p. 465.
 
 352 OBSTETRIC SURGERY. 
 
 ternum, then follows the instrument, and as it enters the uterus directs 
 it to one side to prevent it from rupturing the membranes. In the 
 case of primipar^, preliminary dilatation of the cervix may be secured, 
 if necessary, by the use of a sponge-tent or of the vaginal douche. The 
 bongie should be pushed slowly upward with the disengaged hand and 
 allowed to follow its own course, between the membranes and the 
 uterus. To prevent the instrument from slipping down, two inches of 
 the extremity may be left outside the cervix to find support against the 
 vaginal wall. A retentive tampon is rarely necessary. 
 
 The method is tolerably certain. In favorable cases labor follows 
 its employment in the course of a few hours. As a rule, the response is 
 more prompt in multipara? than in primiparae. Sometimes, however, 
 no action is set up during the first forty-eight hours, or the pains ex- 
 cited are of a cramp-like character. In either case it is well to resort 
 to other additional measures. Outside of unwholesome hospitals, the 
 use of the catheter or bougie to excite labor is not associated with any 
 peculiar risks. The danger of detaching the placenta is not im- 
 minent, if the instrument be introduced slowly, as, owing to its elas- 
 ticity, the bougie tends to make its way around the placental margin. 
 In maternity hospitals, however, it may serve as a point of entry for 
 miasmatic poisons, and thus be followed by local irritation and puer- 
 peral septic affections. Because of this danger the solid bougie is pref- 
 erable to the hollow catheter. In all cases only a perfectly clean and 
 new instrument should be used. 
 
 Injections between the Uterus and Ovum.— Cohen, of Hamburg, 
 proposed in 1848 the separation of the membranes by injecting tar- 
 water through a long-nozzled syringe made to penetrate about two 
 inches within the uterine cavity. The nozzle was furnished with a 
 rounded extremity, and with openings upon the side. He recommended 
 that the injection should be continued until a distinct feeling of dis- 
 tention was experienced by the patient, which sometimes required the 
 employment of nearly a quart of the fluid (720 grammes).* This plan 
 has since been modified by the substitution of an elastic catheter for 
 the metallic tube, and by the injection of a few ounces of simple warm 
 water (98° Fahr.) in place of the aqua picea. In case of failure 
 with a single injection, it has been recommended to repeat the proced- 
 ure. Professor Lazarewitch has demonstrated that the nearer the irri- 
 tation is carried to the fundus the more certain and speedy the result. 
 He therefore employs a syringe with a central opening, and passes it as 
 near to the fundus as possible, f 
 
 When efficiently performed, the method possesses the advantage of 
 rapidly exciting uterine labor-pains. Kiinne reports fifteen cases in 
 which he resorted to it with complete success. He cautions against 
 
 * Cohen, Neiie Ztschr. f. Geburtsk., Bd. xxi, p. 116. 
 
 f Lazarewitch, Trans, of the Obstet. Soc. of London, 1868.
 
 THE INDUCTION OF PREMATURE LABOR. 353 
 
 using force in injecting, and recommends, as a means of avoiding the 
 passage of air into veins, the withdrawal of the catheter, and its re- 
 introduction, in case a haemorrhage should betoken that the placenta 
 had been impinged upon. Others have employed the method many 
 times witli entire impunity. Still, cases of sudden death have occurred 
 during its use, which have been referred to shoclv, to air getting into 
 the uterine sinuses, and to rupture of the uterus. While, perhaps, 
 the general results from uterine injections have not been less satisfac- 
 tory than from the employment of other measures for inducing j)re- 
 mature labor, the suddenness of death in the fatal cases has had a deter- 
 rent effect ui)on its extended employment. 
 
 Rupture of the Membranes. — This is the oldest of all the methods 
 now in use. It is best performed by means of a simple apparatus de- 
 vised by the Freiherr Braun von Fernwald, consisting of a goose-quill 
 sharpened like a pen and nicked upon its convex surface for the pas- 
 sage of a uterine sound. Thus mounted, with its point guarded by 
 the sound, it can be introduced, without risk to the maternal tissues, 
 -through the cervix to the ovum. Then, by simply pushing the quill 
 upward, the point is made to clear the sound and effect the puncture 
 of the membranes. The method is certain, though not always speedy 
 in its action. It is open to the objections which hold good in all cases 
 of premature discharge of the amniotic fluid. Hopkins recommended, 
 as a mode to provide for the gradual escape of the liquor amnii, tap- 
 ping the membranes with a sound at a distance from the os internum. 
 Rokitansky has shown, from the statistics of Braun's clinic, that in 
 hospital practice puncture of the membranes is the safest means of 
 inducing premature labor, diminishing as it does the chances of infec- 
 tion, which is the chief source of danger in all the measures where the 
 irritation is applied directly to the inner surface of the uterus. Though 
 in private practice I have never from choice selected this method, I 
 have witnessed many cases in which the membranes have ruptured 
 accidentally, and yet have failed to notice, either in the case of the 
 mother or child, the serious consequences which theory would lead us 
 to apprehend. It is not adapted for the higher degrees of pelvic con- 
 traction or for cases Avhere speedy delivery is desirable. 
 
 Mechanical Dilatation of the Cervix. — The dilatation of the cervix 
 with sponge-tents or laminaria is rarely resorted to, except as prepara- 
 tory to other measures. While the expansion of the tent softens the 
 cervix and excites uterine contraction, the effect is frequently tran- 
 sient. To be sure, the action may be kept up by a succession of tents 
 gradually increasing in size, but such a plan denudes the cervix of its 
 epitlielium, and is apt to lead to septic infection. 
 
 The Barnes dilator is a most efficient aid in cases of induced labor. 
 It should be surgically clean, and before its introduction both vagina 
 and cervix should be thoroughly disinfected. I have found it conven- 
 2.3
 
 354 * OBSTETRIC SURGERY. 
 
 lent to seize it, properly folded, with a pair of dressing forceps, by means 
 of which it can be passed into the cervical canal. I then withdraw the 
 forceps, and push the dilator upward with two fingers. The dilator is, 
 as Barnes has termed it, a water-bag. It should never be distended 
 with air, as rupture of the bag in that case might be speedily followed 
 by the death of the patient. As for the introduction of the smallest- 
 sized bag the cervix requires to be sufficiently expanded to permit the 
 passage of at least two fingers, it is useful chiefly as an adjuvant to 
 other plans of treatment. At first the dilatation should only be carried 
 to the extent necessary to render the cervix tense. When labor has 
 fairly begun, the fluid pressure of the dilator upon the cervix serves to 
 strengthen the uterine action. When left in situ, the instrument in- 
 sures the development of good pains. It should, however, be removed 
 from time to time, if not forcibly expelled into the vagina, and carbol- 
 ized injections should be employed to prevent infection. So soon as 
 the physiological softening of the cervix which results from labor has 
 been effected, rapid dilatation can be advantageously employed. When 
 the cervix is rigid, the rubber bag is only useful as a reflex exciter of 
 pains. To be sure, the rigid cervix can be forcibly dilated to almost 
 any extent by hydrostatic pressure, but, as a rule, it closes down to its 
 original dimensions so soon as the pressure is removed. In rare cases 
 forcible dilatation may lead to cervical laceration. 
 
 Tarnier has devised a bag which can be passed upward through the 
 cervix and distended in the lower uterine segment. It serves to par- 
 tially detach -the membranes, and excites by its presence active uterine 
 efforts. Its liability to rupture is the most serious objection to its em- 
 ployment. 
 
 The Vaginal Douche. — The vaginal douche was introduced into 
 practice by Kiwisch, in 184G. It consists in directing a stream of tepid 
 Avater with considerable force directly against the cervix. The stream 
 may either be furnished by a Davidson's syringCj or a continuous cur- 
 rent from a tube connecting with a vessel placed at an elevation above 
 the patient may be used. The latter is the safer method. The large- 
 sized fountain-syringe, made to hold a gallon of water, is a very con- 
 venient apparatus. The duration of each injection should be from 
 ten to fifteen minutes. At the outset, three douches in the twenty-four 
 hours suffice. Subsequently the frequency and duration should de- 
 pend upon the degree of action excited and the urgency which exists 
 for bringing labor to a close. Twelve are about the average nuniber 
 of injections required. In pressing cases they have been repeated as 
 often as once in three to four hours. The temperature of the water 
 employed should be about 106° Fahr, 
 
 In using the douche the patient should be placed across the bed, 
 and an India-rubber sheet should be so arranged under the hips as to 
 convey the water as it escapes from the vulva into a vessel beneath.
 
 THE INDUCTION OP PREMATURE LABOR. 355 
 
 Every care should be taken to avoid the introduction of air into the 
 vagina, and at the beginning of each douche precautions should be 
 adopted to facilitate the escape of the fluid. The forcible pressure of 
 the stream has been known to drive air contained in the vagina into 
 the cervix. The same accident has followed imperfection in the valves 
 of the syringe. 
 
 The douche acts by the M^armth of the water, by stimulation of the 
 lower uterine segment, and by dilatation of the vagina. After the 
 douche has' been continued for a time, the latter is sometimes distended 
 so as to be nearly in contact with the pelvic walls. 
 
 The vaginal douche as a means of inducing labor has of late years 
 fallen somewhat into disrepute. Its chief recommendation was the 
 supposed harmlessness of the procedure — a precious quality, to which 
 in reality it appears, however, to possess little claim. Numerous cases 
 have been reported where death has followed the accidental introduc- 
 tion of air, and sharp peritoneal symptoms, according to Kleinwiich- 
 ter,* have been known to result from the excessive distention of the 
 vagina. The dangers referable to the latter cause increase with the 
 repetitions of the douche. It is likewise claimed that its repetition 
 tends to lessen the efficiency of the uterine contractions. At present 
 its employment is generally restricted to the preliminary dilatation of 
 the OS, or to the sustaining of the action of other measures. 
 
 The Vaginal Tampon. ^ — Braun introduced an India-rubber bag, fur- 
 nished with a tube and a metal stop-cock, which, under the name of 
 the col2Jeiiryntei\ still plays a considerable role in obstetrical practice 
 in Germany. When filled with water in the vagina, it formed a pain- 
 ful and rather uncertain mode of inducing labor. It is now rarely 
 employed except in haemorrhage, and where it is desired to prevent 
 premature rupture of the membranes. Care should be taken to only 
 moderately distend the vagina, and not to continue the pressure for 
 any lengthened period of time. 
 
 Galvanization. — Bayer f urges the constant current as an available 
 means of exciting labor-pains. He recommends placing the negative 
 pole of a suitably constructed electrode in the cervix, and the positive 
 pole upon the abdomen near the fundus. Ten to sixteen elements 
 should be used for a j)eriod varying from ten to twenty minutes. The 
 advantages claimed for galvanism are, that it excites true pains, that 
 it does not produce strictures, that it causes the cervix to soften and 
 dilate naturally, and that by its use the dangers of infection are less- 
 ened. The chief drawback consists in the necessity for frequent 
 repetitions of the procedure before labor is brought to a close. Thus, 
 in the six cases where it was used by him, from two to thirteen appli- 
 
 * Kleinwachter, Prager Vierteljahrsschrift, 1872, Heft i, p. 56. 
 f Bayer, Ueber die Bedeutung der Electricitat in der Geburtsh. und Gynaek., 
 vol. xi, p. 89.
 
 356 OBSTETRIC SURGERY. 
 
 cations were made, and the time from tlie first application to the birth 
 of the child varied from two to eleven days. As the effect of the first 
 application is to soften the cervix and render it dilatable, galvanism 
 may in the future find its place as a substitute for tents, or the vaginal 
 douche, in the preparation of the lower uterine segment for the em- 
 ployment of accelerative measures. 
 
 Choice of Methods. — From the foregoing it will be seen that no one 
 of the different proceedings mentioned is entirely free from objection. 
 Aside, however, from infection — a danger more especially dreaded in 
 maternity hospitals — and the avoidable accident of driving air into the 
 veins, the most serious difficulties against which we have to contend 
 arise from the tardy dilatation of the os and the prolongation of labor. 
 Any of the methods are good if only they act speedily. It is advisable, 
 therefore, in practice to follow the excellent advice of Dr. Barnes, and 
 divide the induction of premature labor into two stages, in the first 
 of which provocative, and in the second of which accelerative, meas- 
 ures should be adopted. In the former category should be placed the 
 dilatation of the cervix with tents, the vaginal douche, and the cathe- 
 terization of the uterus ; in the latter, dilatation of the cervix with the 
 rubber bags, rapture of the membranes, and, in case of delay, delivery 
 with forceps or by version. 
 
 The plan I have generally followed consists in beginning in the aft- 
 ernoon with the vaginal douche, and following with the introduction 
 of a solid bougie, to be left in the uterus overnight. In many cases 
 labor is excited in the course of a few hours. In the morning, if the 
 process is delayed, the vaginal douche is repeated. There are few cases 
 in which, toward the end of the twenty-four hours, the cervix is not 
 found softened and well lubricated with mucus. The dilators should 
 then be employed, the operator taking his time, as permanent dilata- 
 tion is the object sought after. If the membranes come down well, 
 the dilator may be removed and the progress of the case left to Xa- 
 turei ' Often it is advisable to adopt the plan of Dr. Barnes, rupturing 
 the membranes when the cervix will admit three or four fingers, and 
 then dilating with the large-sized bag until the uterus is opened fully 
 for the passage of the child. Finally, according to the conditions 
 present, the physician may either await the termination of the labor, 
 or deliver by version or by lightly constructed forceps. 
 
 Care of the Child. — Premature infants possess slight powers of re- 
 sisting external agencies. The customary baths should possess a tem- 
 perature of 100° Fahr., or very nearly that of the amniotic fluid. The 
 chances of raising premature infants are greatly enhanced by feeding 
 them ^v^ith mother's milk. The artificial maintenance of the body-heat 
 is essential to the preservation of life in the early period of extra-uter- 
 ine existence. In a rude way this may be accomplished by placing 
 the child in warm cotton near the fire. Before the thirtv-second week
 
 THE INDUCTION OF PREMATURE LABOR. 
 
 357 
 
 the result in such cases depends almost entirely upon the unremitting 
 watchfulness and zeal of a devoted mother or nurse. Much better 
 results are, however, obtainable through the agency of the contrivances 
 of Crede and of Tarnier. 
 
 Crede's * apparatus possesses the advantage of cheapness and sim- 
 plicity. It consists of a tub made of copper with double walls and 
 floor. The compartment between the walls is capable of containing 
 thirty-five pints of water. For convenience in filling the compart- 
 
 FiG. 142.— Crede's apparatus for the inainteuanee of the bodylieat of piejnalure and feeble 
 
 infants. 
 
 ment, a funnel-shaped depression, provided with a stopper, is furnished 
 in the upper margin. A stop-cock below, at the opposite end, permits 
 the water to be withdrawn at will. In this vessel the child is placed, 
 enveloped in fine cotton or soft flannel. The coverings should reach 
 to the brim of the vessel, the face of the child alone remaining exposed. 
 Every four hours the space between the walls is to be filled with water 
 heated to 122° Fahr. When the water is first introduced, the tempera- 
 ture within the tub is about 1071°. In the last two hours it sinks to 
 about 99-|-°. In extreme degrees of prematurity, a more equable tem- 
 perature may be maintained by partially refilling every hour or every 
 half-hour. The child is to be disturbed as little as possible. It should 
 be removed only to be bathed and to be placed to the breast. The 
 napkins should be changed, as far as possible, within the vessel. 
 
 Crede's * apparatus has been employed in the Leipsic Maternity for 
 
 * Crede, Ueber Erwarmungsgerathe fiir friihgeborene und schwjichliche, kleine 
 Kinder, Arch. f. Gynaek., vol. xxiv, p. 128, Berlin, 1884. The precise measurements 
 of Crede's apparatus are as follows : Length outside, above, 39 inches, below, 25 
 inches; inside, above, 23^ inches, below, 2H inches. Width outside, above, 19 
 inches, inside, 15 inches; inside, above, 15 inches, below, 11 inches.
 
 358 
 
 OBSTETRIC SURGERY. 
 
 a ijcrioj of twenty years. The total number of children thus treated 
 amounted to six hundred and seventy-eight. The weight of these 
 children, with few exceptions, was less than five and a quarter pounds. 
 The tota'l mortality was eighteen per cent. Of twenty-four children 
 weighing between two and three pounds, twenty died; of one hun- 
 dred and fifteen children weighing between three and four pounds, 
 forty-two died; of four hundred and seventy-six children weighing 
 between four and five pounds, fifty-four died; while of fifty-two 
 children weighing between five and six pounds (seventeen twins), but 
 one died. 
 
 The incubator of Tarnier was first used at the Maternite, in 1881, 
 for the rearing of prematurely born children. It consists of a wooden 
 box with walls 0-10 to 0-12 centimetre thick, filled in with sawdust to 
 prevent loss of heat. A central partition divides the box into two 
 compartments, the one for hot water, the other for the infant's cradle. 
 
 A metal case, of a capacity of 
 about seventy-one litres, fits 
 into the lower compartment, 
 leaving a space of two to 
 three centimetres between its 
 walls and those of the box 
 for the free circulation of air 
 from below upward. The 
 capacity of the upper com- 
 partment is about eighty-six 
 cubic centimetres ; there is 
 free circulation of air be- 
 tween it and the lower com- 
 partment, and it is in com- 
 munication with the outer 
 air by means of two open- 
 ings — the one, on its iipper 
 surface, shut in by a double 
 plate of glass, the other, laterally, opening like a door, and allowing 
 exit to the cradle. In each corner of this upper compartment is a 
 hole for the escaj^e of the heated air from below. To the lower com- 
 partment, containing the hot water, is attached a thermo-siphon by an 
 upper and a lower tube. When the lamp under this siphon is lighted, 
 the heated water fiows through the upper tube into the chamber, dis- 
 placing an equal amount of water which flows back to the siphon. 
 Thus a current is established, the temperature of which can be raised 
 to the desired point. In cold weather it has been found necessary to 
 light the lamp three times daily, allowing it to burn each time about 
 two hours. The lamp should be extinguished when the tempera- 
 ture in the upper compartment is about two degrees above the heat 
 
 Fig. 143.— Section of hospital inc-uhator. (Tarnier.)
 
 THE INDUCTION OF PREMATURE LABOR. 359 
 
 desired. The registering thermometer may be laid alongside the 
 infant.* 
 
 In general, a mean temiierature of 86" Fahr. is sufficient, but 90° 
 is borne without harm. The children should be clothed in the usual 
 manner. The napkins should be changed five to six times daily. A 
 daily bath should be given. Children sufficiently developed to suckle 
 should be placed to the breast. Those too feeble to nurse are fed in 
 Paris upon asses' milk. The result of two years' trial of the incubator 
 at the Paris Maternite Auvard reports as follows : Of ninety-three 
 healthy premature children, thirty-one died ; of fifty-eight premature 
 children with complicating diseases, fifteen died. In comparing these 
 results, however, with those reported by Crede, it is necessary to note 
 that at the Maternite, in Tarnier's service, only children weighing four 
 pounds and less were placed in the incubator, while the limit in the 
 Leipsic Maternity was in general five and a quarter pounds. 
 
 Aktificial Abortion. 
 
 Artificial abortion is Justifiable whenever it offers the only hope of 
 saving the life of the mother. The morality of this general proposi- 
 tion is unquestioned. It is not, however, by any means easy to deter- 
 mine in a specified case whether the conditions which render the in- 
 duction of abortion a duty really exist. 
 
 The principal recognized causes for the operation which admit of 
 little dispute are : 1. Incarceration of the j^rolapsed or retroflexed 
 uterus when the dislocated organ can not be replaced. 2. Diseases of 
 pregnancy which immediately imperil life, and which have been vainly 
 combated by all the resources at our disposal. Qf these diseases the 
 most prominent is uncontrollable vomiting. Exceptionally, the indi- 
 cation may arise in affections of the heart, lungs, and kidneys, where 
 the symptoms are acute and peculiarly threatening. 
 
 The justifiability of abortion is, however, by no means so clear 
 when the danger to the mother first arises after labor has actually 
 begun. This is especially the case in extreme degrees of pelvic con- 
 traction, or where the presence of large tumors renders the parturient 
 canal impassable, as in these cases, by means of the Ca?sarean section, 
 there is always a probability of saving the life of the child, with a fair 
 prospect of preserving the existence of the mother. It is considered 
 right, under such circumstances, after a dispassionate and colorless 
 statement of the facts, to leave the decision to the mother and the 
 friends more immediately interested. When the operation is *per- 
 formed for contracted pelvis, the following figures will show at how 
 late a period it may be undertaken : 
 
 * Auvard, De la couveuse pour enfants, Arch, de Tocologie, October, 1883, p. 
 577. The account given above is copied from abstract furnished to the Am. Jour, 
 of Obstet., April, 1884, by Roliert H. Grandin.
 
 360 OBSTETRIC SURGERY. 
 
 Antero-posterior diameter of pelvis. Latest perioil for inducing abortion. 
 
 1^ inch. Beginniug of sixth month. 
 
 IJ inch. Beginning of iifth month. 
 
 1 incli. Four months and a half. 
 
 With less than an inch the difficulties of inducing abortion increase 
 to such a degree as to make the operation rarely advisable, or indeed 
 even practicable.* 
 
 The induction of abortion is accomplished by puncturing the mem- 
 branes with a uterine sound, or by dilatation of the cervix with a 
 sponge- or a tupelo-tent. In the early months dilatation by means of 
 a tent possesses the advantage of promoting the expulsion of the ovum 
 entire. In the sixth and seventh months the same means are available 
 that have been described in connection with the induction of prema- 
 ture labor. 
 
 Preparation of Aseptic >Spo?iges for Obstetrical Purposes.— The sponges em- 
 ployed should be of the finest quality. They should be pounded with a 
 wooden mallet until the cretaceous particles can no longer be felt, then 
 washed for ten minutes in a two-per-cent solution of permanganate of potash, 
 and washed and kneaded thereafter in a two-per-cent solution of bioxalate of 
 potash, till they become of a yellowish-white color, and no more sediment 
 remains in the solution. To remove the oxalic acid, they should be washed 
 in distilled water until no reaction is produced with lime-water. The sponges, 
 in this way freed of inorganic matter, should be allowed to soak two days in 
 a five-per-cent solution of carbolic acid. The carbolized sponges are to be 
 pressed out two or three times in a ten-per-cent solution of gum arable. A 
 knitting needle is passed into the sponge and a carbolized thread employed 
 to compress it into a cylindrical shape, care being taken not to give the sponge 
 a spiral turn in the winding. Then withdraw the needle, wrap in tissue paper, 
 and leave the sponge to dry. The drying usually requires three or four days. 
 Finally, remove the silk, file away rough portions, and place in metal box for 
 future use. (Method of Jungbluth, vide Zur Behandlung der Placenta Praevia, 
 Volkmaunsche Sammlung, No. 235.) 
 
 As to the choice of time when the operation should be performed, 
 opinions differ. Some prefer the first two months, on account of the 
 small size of the ovum and the slight development of the fetal tufts 
 at the decidua serotina. Most physicians wait till the first three or 
 four months have expired, as the diagnosis of pregnancy is then cer- 
 tain, the execution of the operation easy, and the detachment and ex- 
 pulsion of the fetal appendages more complete. 
 
 * De Soyre, Dans quels cas este-il indique de provoquer Favortement ? Paris, 
 
 1875, p. 68.
 
 FORCEPS. 361 
 
 CHAPTER XIX. 
 
 FORCEPS. 
 
 History. — Varieties of forceps ; short forcep;^- ; long forceps. — Action of forceps. — 
 Indications. — Preperations. — Forceps at outlet. — Operation; introduction; 
 locking ; tractions ; removal. — Forceps at brim ; operation. — Axis-traction for- 
 ceps. — Forceps in occipito-posterior positions ; in face presentations. 
 
 History. — The forceps, it is well known, is the invention of the 
 Chaniberlens.* It was held by them as a family secret, and utilized 
 purely as a means of gain. In the early part of the year 1670, Hugh 
 Chamberlen, who enjoyed a great reputation as an accoucheur, went to 
 Paris in the hope of finding a purchaser for it. Mauriceau, to test 
 the value of Chamberlen's pretenses, suggested that the latter should 
 attempt the delivery of a woman with extreme contraction of the pel- 
 vis, upon whom he had previously decided to perform the Cgesarean 
 section. Chamberlen declared that nothing could be easier, and at once, 
 in a private room, set about the task. After three hours of vain effort 
 he was obliged to acknowledge his defeat. The woman died ; the nego- 
 tiations for the sale were dropped, and Chamberlen returned with his 
 secret unrevealed to England. In 1672 Chamberlen published a trans- 
 lation of Mauriceau's work upoii midwifery, in the preface of which he 
 states : " My father, brothers, and myself (though none else in Ettrope, 
 as I know) have, by God's blessing and our own industry, attained to 
 and long practiced a way to deliver women in this case without any 
 prejudice to them or their infants, though all others (being obliged, 
 for want of such an expedient, to use the common way) do or must en- 
 danger, if not destroy, one or both with hooks." In 1688 Hugh Cham- 
 berlen went to Amsterdam and sold his secret to Roonhuysen for a large 
 sum, who in turn disposed of it to Ruyscli and others; and, as late as 
 1746 it was the rule of the Medico-pharmaceutical College at Amster- 
 dam that no one should practice midwifery without first obtaining the 
 secret measure, which was imparted by their examining body for a heavy 
 money consideration. In 1753 Jacob de Vischer and Hugo van de Poll, 
 who had acquired the secret from the daughter of a former possessor, 
 made it public property ; but the instrument turned out to be the sin- 
 gle-bladed vectis. Whatever doubts, however, this exposure may have 
 
 * Dr. J. H. AvELiNG, in an essay entitled The Chamberlens and the Midwifery 
 Forceps, London, 1883, concludes that the inventor proper of the forceps was 
 Peter Chamberlen the elder, who was taken by his father, a Huguenot fugitive, 
 from Paris to London in 1569. Dr. Peter Chamberlen, who purchased Mortimer 
 Hall, in Woodham, was the son of Peter Chamberlen the younger, a brother of the 
 inventoi-. Dr. Peter Chamberlen's son, Hugh Chamberlen. Jr., was the translator of 
 Mauriceau's work. His son, Hugh Chamberlen, Jr., was the one whose monument 
 is seen in Westminster Abbey.
 
 362 
 
 OBSTETRIC SURGERY. 
 
 Fig. 144.— Forceps of Cham- 
 berlen. 
 
 cast upon the nature of the Chamberlen secret were set at rest, in 1815, 
 by the discovery, in a former residence of the family in Woodhara, in 
 Essex, of a chest containing, besides letters and a variety of patterns of 
 the vectis, a number of pairs of forceps, fenes- 
 trated, without a pelvic but with an excellent 
 cephalic curve. Moreover, Chapman, in a 
 short treatise upon midwifery, published by 
 him in 1733, stated that "the secret men- 
 tioned by Dr. Chamberlen was the use of 
 forceps, now well known to the principal men 
 of the profession both in town and country." 
 And two years later, in a second edition of his 
 work, he published an engraving of the instru- 
 II J ~~\\ ment, which became known as Chapman's for- 
 
 I IjlUJj I ceps, though it did not differ from the one 
 
 used by the Chamberlens. 
 
 Since Chapman's publication the modifica- 
 tions made in the forceps by obstetric prac- 
 titioners have been exceedingly numerous. Indeed, nearly every man 
 widely engaged in midwifery practice finds it convenient to possess 
 his own forceps. With few exceptions, however, the various patterns 
 described by authors do not differ materially as 
 regards essential principles, but have each some 
 peculiarity of construction which fits them to 
 supplement a personal defect of the contriver, 
 or to meet some special indication. The forceps 
 is by no means a perfect instrument. It is im- 
 possible to construct it in such a way as to cover 
 every need. In consulting practice, it is con- 
 venient to possess a number of forceps for dif- 
 ferent emergencies. A good pair for general use 
 is necessarily a compromise between conflicting 
 aims, and requires, for successful use, experience 
 and intelligence to correct its deficiencies. 
 
 In selecting forceps it is well to bear the fol- 
 lowing points in mind : We have first to distin- 
 guish between the long and the short forceps. 
 
 Short Forceps.— The original instrument of 
 the Chamberlens furnishes the type of the short 
 variety. By referring to Fig. 144, it will be 
 seen that the Chamberlen forceps consisted of 
 two levers, made to cross each other like a pair 
 of scissors, with short handles, and blades diverging just beyond the 
 point of articulation. The blades were fenestrated, to lighten the 
 instrument and to enable them to seize the head with greater secur- 
 
 FlG. 145. 
 
 -Forceps of Smel- 
 lie.
 
 FORCEPS. 
 
 363 
 
 ity. They were furnished witli a cranial curve, as has been stated, 
 but were straight when viewed in profile. Though somewhat rude 
 in appearance, they were capable of rendering good service when the 
 head had once entered the pelvic cavity. Smellie, in place of the 
 mortise lock of the Chamberlen forceps, which required to be secured 
 by tape or cord, invented the easily adjusted English lock, and co^■- 
 ered the handles with wood and a durable coat of leather. The han- 
 dles were five and a half 
 inches in length, and 
 the blades six inches. 
 Short forceps, modified 
 somewhat from the 
 Smellie pattern, are 
 used by some prac- 
 titioners at the pres- 
 ent day. It has been 
 thought an advantage 
 that they can be con- 
 cealed in the pocket, 
 and slipped over the 
 child's head without 
 the knowledge of the 
 patient or of the as«- 
 sistants. Smellie laid 
 great stress upon this 
 point, and says : " As 
 women are commonly 
 frightened at the very 
 name of an instrument, 
 it is advisable to con- 
 ceal them as much as 
 possible until the char- 
 acter of the ojDerator is 
 fully established." In 
 these enlightened days, 
 however, secrecy is no 
 
 longer advisable. Indeed, the forceps ought never to be used without 
 such exposure of the vulva as will enable the operator to exercise every 
 precaution for the preservation of the perineum. 
 
 Long Forceps.— Smellie tells us he found, in pelves with jutting-in 
 of the sacrum, that he could not push the handles far enough back- 
 ward to include between the blades the bulky part of the head, which 
 lay above the pubes. He therefore, to remedy this inconvenience, 
 contrived a longer pair, curved on one side and convex on the other. 
 Thus, at an early period the necessity for long forceps was experienced 
 
 
 Fig. 146.— Levret's forceps.
 
 864 
 
 OBSTETRIC SURGERY, 
 
 Smellie was deeply impressed, however, with the dangers of high for- 
 ceps operations, and sought to diminish the risks incidental to them 
 by making the handles short, to free himself, as he said, from the 
 temptation of using too great force. 
 
 Levret, on the contrary, contemporaneously with Smellie, converted 
 the forceps of Chapman into a powerful tractor and compressor. He 
 retained the iron handles, but roughened the surfaces, and made them 
 slightly convex, to adapt them to the palms of the hand. The articu- 
 lation was effected by means of a pivot and a mortise. The chief pecul- 
 iarities, however, consisted in the weight and the length of the instru- 
 ment and in the extent of the pelvic curve. So far from these features 
 
 proving objectionable, they have 
 been substantially retained in mod- 
 ern French instruments. 
 
 The forceps of Smellie and 
 Levret are the two type-forms 
 from which are derived the great 
 number of the models in vogue at 
 the present day. 
 
 The Naegele forceps, exten- 
 sively used in Germany, in its 
 main features resembles the in- 
 strument of Smellie. It is, how- 
 ever, two inches longer, and there 
 is less disproportion between the 
 length of the handles and the 
 blades. The upper part of the 
 handles is furnished with trans- 
 verse shoulders, hollowed out for 
 the index and middle fingers of 
 the hand which exerts the trac- 
 tion force. The lock is that of 
 Bruninghausen, and consists of a pivot, surmounted by a flat button, 
 which fits into a notch upon the opposing blade. 
 
 The Simpson forceps possesses a relatively short handle, with trans- 
 verse shoulders, and indentations for the fingers of the under hand. 
 The English lock is improved by the addition of knees or projections 
 to diminish its mobility. The cephalic curve, in place of starting at 
 the lock, is carried away two and three eighths inches by straight, 
 parallel shanks, an arrangement which makes it possible to lock the 
 instrument outside the vulva even when applied to the head at the 
 brim, and which enables the operator to bring the head to the floor of 
 the pelvis without placing the vulva upon the stretch. The pelvic 
 curve does not exceed one inch and a half. I have been in the habit 
 of recommending this forceps to my classes of medical students, on 
 
 A B C 
 
 FiG. 147.— Naegele's forceps.
 
 FORCEPS. 
 
 365 
 
 account of the ease with which it can be applied, its solidity, and the 
 slight markings it leaves, under ordinary circumstances, upon the 
 
 Fig. 148.— Simpson's forceps. 
 
 child's head. It is, however, defective in compressive power, when 
 such action is necessary.* 
 
 The forceps of Hodge, of Wallace, and of White are extensively 
 used in this country. Like those of French make, they have metal 
 handles, and a lock composed of a movable pivot, which slips into a 
 notch at the moment of adjustment. They are, however, much 
 lighter and of more graceful outline. The shanks are long and super- 
 imposed. The blades are provided with wide fenestra?, through which 
 
 Fig. 149.— Hodge's forceps. 
 
 the parietal bosses are intended to project. I have tried each of these 
 instruments, and, thougli I cling to Simpson's forceps from habit, have 
 found them extremely serviceable. 
 
 Finally, in choosing forceps, it is well to remember that, if there 
 are none which are absolutely perfect, there are few which are really 
 poor. Objectionable features are very short handles and thin, spi'ingy 
 blades with sharp cutting edges. A good pair of long forceps renders 
 the possession of short forceps a superfluous luxury. 
 
 Action of the Forceps. — The forceps is primarily and essentially a 
 tractor. When properly adjusted, it serves as a handle by means of 
 which the head can be withdrawn from the parturient canal. Many 
 excellent operators are in the habit of combining with direct traction 
 
 * The instrument-makers of this city are accustomed to make for me an instru- 
 ment exactly copied from a pair of forceps hrovightby nie fiom Edinburj^^h in 1865. 
 Many of the forceps bearing? Simpson's name in this country have only a faint re- 
 semblance to the oii<rinal model.
 
 3(36 OBSTETRIC SURGERY. 
 
 a side-to-side swaying of the forceps-handles, with a view of determin- 
 ing the alternate descent of the lateral surfaces of the cranial vault. 
 No doubt these so-called pendulum movements increase the extractive 
 power of the forceps. The increase is, however, obtained at the expense 
 of the maternal tissues. If employed, therefore, only a moderate de- 
 gree of traction force should be exerted. As to the efficiency of direct 
 tractions, I am able to speak from experience. At first insisted upon 
 by the Vienna school, they have found warm advocates in ]\Iatthews 
 Duncan,* of London, and Albert Smith,! of Philadelphia. 
 
 The crossing of the forceps at the lock renders it impossible to 
 resort to traction without at the same time exercising compression 
 upon the child's head. When the forceps is applied laterally over 
 the parietal bones, moderate pressure is harmless to the child, and 
 undoubtedly facilitates in some degree the act of delivery. When the 
 head is high in the pelvis before rotation is completed, the lateral 
 application is rarely possible. If the forceps is applied obliquely, with 
 one blade over the side of the brow and tlie other over the side of the 
 occiput, bulging takes place in the opposite oblique diameter — a result 
 which tends to retard rather than to aid extraction. Nevertheless, 
 some compressive force is necessary at the brim to seize ihe head solid- 
 ly, and to avoid slipping of the blades. 
 
 When the blades of the forceps are introduced within the uterus, 
 contractions are apt to be excited. This so-called dynamic influence, 
 though an ancillary property of the instrument, is often of consider- 
 able service in aiding delivery. 
 
 Indications. — It would be an unprofitable undertaking to enumerate 
 all the conditions which render forceps advisable. The indications for 
 their use may be summed up in two general propositions. The forceps 
 is applicable — 1. In cases where the ordinary forces operative during 
 labor are insufficient to overcome the obstacles to delivery ; 2. In cases 
 where speedy delivery is demanded in the interest of either mother or 
 child. 
 
 Both these propositions are, however, subject to the limitation 
 that, in the selection of the mode of delivery, choice should be made 
 specially with reference to the maternal safety. Fortunately, in tlie 
 great proportion of cases the interests of both mother and child are 
 identical. 
 
 Preparations for Forceps Deliveries. — When it has been decided to 
 deliver by forceps, it is a good plan always to place the patient cross- 
 wise in bed, with the head raised by a pillow, and with the hips well 
 over the edge of the bed. To be sure, many prefer, in simple cases, to 
 
 * Duncan, Against the Pendulum Movement in working the Midwifery For- 
 ceps, Trans, of the Obstet. Soc. of Edinburgh, vol. iv, p. 19.5. 
 
 f Smith, The Pendulum Leverage of Obstetric Forceps, Trans, of the Am. 
 Gynaec. Soc, vol, iii, p. 235.
 
 FORCEPS. 3(57 
 
 disturb the patient as little as possible, and pride themselves upon being 
 able to slip on the forceps and deliver without the seeming of an opera- 
 tive procedure. This trifling advantage is, however, more than coun- 
 terbalanced by the increased risk of injuring the vulva and perinaeum, 
 when the operator is compelled to assume a constrained or awkward 
 position. 
 
 In this country, as in France and Germany, it is customary to 
 place the patient upon her back ; whereas in England she is made to 
 lie upon her left side. The difference is not material. In the descrip- 
 tion to follow it will be assumed that the dorsal position is the only one 
 likely to be selected. 
 
 At the beginning, it is well, in most cases, to bring the patient 
 under the influence of an anaesthetic. This I am accustomed to do 
 before changing the patient's position. In easy cases the accoucheur 
 can administer the anaesthetic before operating, and then leave the con- 
 tinuance of the chloroform- or ether-giving to any intelligent bystander 
 who acts under his supervision. In difficult cases, however, it is better 
 to send for a skilled assistant who is capable of taking entire charge of 
 the anaesthesia, that the operator's attention may not be diverted from 
 the work he has in hand. 
 
 Before applying the forceps, care should be taken to ascertain the 
 position of the head, and to make sure that tlie membranes have freely 
 ruptured. Forceps applied directly to the membranes might do harm 
 by causing a premature detachment of the placenta. The position of 
 the OS and the degree of its dilatation should likewise be determined. 
 In excessive anteversion the head sometimes bulges out the anterior 
 wall of the cervix, aiid thins the cervical tissues to such an extent that 
 the sutures, the fontanelle, and contour of the head can be distinctly 
 felt, as though the head had entered uncovered into the vagina; 
 whereas, in fact, the undilated os is situated high up, and with care 
 may be found looking backward in the direction of the sacrum. It is 
 only necessary to indicate the possibility of such a source of error to 
 insure the caution necessary for the avoidance of forceps applications 
 to the cervix. 
 
 As a preliminary to all obstetrical operations, both bladder and 
 rectum should be emptied. The vagina should be washed out with a 
 two-per-cent solution of carbolic acid. The blades of the forceps 
 should be thoroughly cleansed in a warm two-per-cent solution of car- 
 bolic acid or should be dipped in boiling water, and the hands of the 
 operator should be disinfected. Soap should be used as a lubricant for 
 the forceps blades and the hands. 
 
 Practically it is important to distinguish between forceps opera- 
 tions at the brim and those conducted after the head has entered the 
 cavity of the pelvis. The latter are simple, safe, and easy of accom- 
 plishment, requiring only skill in the management of the perinaeum ;
 
 368 OBSTETRIC SURGERY. 
 
 while the former belong in the category of capital operations, and call 
 for a large degree of patience, experience, and obstetrical tact to bring 
 to a successful issue. 
 
 Forceps at the Pelvic Outlet.— The special indications for forceps 
 when the head is low in the pelvis are so-called rigidity of the peri- 
 neum, stenosis of the vaginal orifice, and conditions demanding speedy 
 delivery. 
 
 The condition termed rigidity of the perinaeum is usually the sign 
 of failing uterine action. So long as the labor-pains are good, the ex- 
 ternal parts progressively soften and relax in preparation for the ad- 
 vancing head. If after the head reaches the floor of the pelvis the 
 pains lose their expulsive character, the perineum may be rigid simply 
 because the ordinary physiological forces which induce softening are 
 absent, or, in case softening has already begun, the perineum may 
 become rigid from the sustained pressure to which it is subjected. 
 In either contingency intermiUent tractions made witfi forceps, in 
 imitation of the natural mechanism, furnish the speediest and safest 
 method of overcoming the resistance of the soft parts. 
 
 Stenosis of the vulva is sometimes the result of old cicatrices. 
 Oftener it is found where there is faulty direction of the child's head, 
 the vertex bulging the perineum in place of serving as a dilating 
 wedge to the vulval orifice. The danger of central perforation of the 
 perineum is best averted by applying forceps and bringing the occi- 
 put well forward under the arch of the pubes. The commonest condi- 
 tions demanding speedy delivery are convulsions, exhaustion, and fe- 
 brile disturbances in the mother, and dangers threatening the life of 
 the child. It is, however, of great importance to keep in mind the 
 relation that the prolongation of the second stage of labor bears to 
 these very dangers. So long as the head advances through the par- 
 turient canal by regular progression, the vagina pours out an abundant 
 secretion of mucus, and relaxation takes place. If the advance of the 
 head is arrested from the dying out of the pains, or from other causes, 
 the continuous pressure exercised by the head upon the soft parts pro- 
 duces venous stasis, oedema, disappearance of the secretion, and finally 
 inflammatory infiltration. The genitals therefore become hot, dry, 
 swollen, and friable, the intensity of the symptoms depending upon 
 the more or less close adaptation of the head to the bony walls of the 
 pelvic cavity. It is easy to understand that with these conditions the 
 temperature rises and the pulse becomes frequent ; if the urethra is 
 compressed, retention of urine with convulsions may follow ; while, as 
 after-results, we may have phlegmasie extending to the pelvic cellular 
 tissue and thence to the peritoneum. Pressure too long continued 
 can produce necrosis, and, as sloughing occurs, vesico- and recto- 
 vaginal fistulas. At the same time there is reciprocal pressure exer- 
 cised by the bony walls upon the child's head, and close retraction of
 
 FORCEPS. 369 
 
 the uterus upon the foetus. The first cause may lead to retarded 
 heart action and intra-cranial extravasations of blood ; while the second 
 is a fruitful source of asphyxia, owing to the diminution of the mater- 
 nal blood-currents which circulate through the placenta. 
 
 In view of the foregoing, it will be seen that forceps is not alone 
 indicated in the presence of perils fully developed, but is of still 
 greater service as a prophylactic against the dangers of an unduly 
 lengthened second stage. 
 
 It is in vain to lay down well-defined rules as to the precise time 
 at which the forceps should be applied. Formerly it was advised to 
 wait for the advent of a thin, reddish-brown discharge. As the latter 
 simply consists of serum commingled with blood from overstrained 
 capillaries, it furnishes a sign that delivery has been delayed too long. 
 Some counsel applying forceps two hours after the completion of the 
 first stage of labor, and proclaim longer waiting a useless barbarity. 
 Clearly, however, it is not so much the length of the second stage of 
 labor which furnishes the indication for forceps as the degree of the 
 reciprocal pressure exercised between the head and the pelvis. A valu- 
 able index to this pressure is furnished by the caput succedaneum. 
 In the second stage, a scalp tumor of large circumference can only be 
 produced by the circle of the bony pelvis. Such a tumor, increasing 
 in size, without any evidence of progress in the delivery, is a signifi- 
 cant evidence of pressure, and furnishes, therefore, the most reliable 
 indication for forceps. 
 
 Whether the ease with which forceps can be applied at the outlet, 
 and the safety which attends its employment, justify its use as a 
 means of saving the j^hysician's time, or the patient from an addi- 
 tional half-hour of suffering, are questions which are at least de- 
 batable. I can only say that, with increasing experience, my own 
 practice has grown more and more conservative, and my own belief is 
 that true wisdom requires us to abstain from even trivial operations so 
 long as Nature is able to do her work without our assistance. 
 
 The operation consists of four acts, viz. : 1. Introduction of the 
 blades; 2. Locking; 3. Tractions; 4. Removal of the instrument. 
 
 Introduction of Blades. — In introducing the forceps, each blade, 
 if a long one with pronounced pelvic curve, should be seized like a 
 pen near the lock, and should be held nearly vertically, with the ex- 
 tremity in correspondence with the slit-like opening of the vulva. In 
 the Simpson forceps, which possesses only a moderate pelvic curve, 
 the handle should be lightly grasped in the half hand, and held at 
 the outset nearly parallel to Poupart's ligament. Owing to the ar- 
 rangement of the lock, the left blade should be passed first. The 
 handle should accordingly be held in the left hand, while two or three 
 fingers of the right hand, inserted between the head and the vagina, 
 serve to guide and guard the point during its introduction. The pas- 
 24
 
 370 
 
 OBSTETRIC SURGERY. 
 
 sage of the blade should take place only during the intervals between 
 the pains. It is customary to pass each blade at first opposite the 
 sacro-iliac articulation, and then to change the direction as required, 
 after the point has reached the Unea terminalis. 
 
 In introducing the forceps-blades, the two curves of the instrument 
 should be borne in mind. By directing the handle toward the thigh 
 of the mother which corresponds in name to the blade, the latter is 
 made to glide over the convex surface of the child's head ; by sinking 
 the handle, the pelvic curve follows the axis of the pelvis. The two 
 
 Fig. 150. — Introduction of blades. 
 
 movements should be made slowly but simultaneously, and under the 
 guidance of the inserted fingers. But slight force is necessary. The 
 point of the blade should impinge rather upon the fingers than upon 
 the child's head. When the left blade is in place, the handle should be 
 lowered and intrusted to an assistant. The right should be introduced 
 on the right side, under the guidance of two to three fingers of the left 
 hand, in accordance with the same general rules. 
 
 The cephalic curve of the forceps is intended to correspond to the
 
 FORCEPS. 
 
 sn 
 
 lateral surfaces of the child's head. When the rotation of the occiput 
 under the symphysis is complete, it is only necessary to sink the 
 handles to make the blades assume the natural position over the parietal 
 bosses. If the head is still in an oblique diameter, the forceps should 
 be applied in the opposite oblique diameter. When, therefore, the oc- 
 ciput is left anterior, the left blade should be allowed to remain oppo- 
 site the sacro-iliac articulation, while the right blade, by sinking and at 
 the same time rotating the handle, is swept forward to the right ace- 
 tabulum. If the head is right anterior, the left blade is at once swept 
 forward toward the left acetabulum, while the right blade is allowed 
 to remain opposite the sacro-iliac articulation. If the sagittal suture 
 
 Fig. 151.— Blades of the Tarnier forceps adjusted to the sides of the head at outlet. The arrow 
 indicates the direction taken by the right blade in its introduction. (FaraboBuf and Varnier.) 
 
 occupies the transverse diameter, the forceps should be applied in the 
 oblique diameter of the same name as the side toward which the occi- 
 put is turned. This is best accomplished by first applying the forceps 
 in the usual way ; then, leaving the occipital blade in the excavation to 
 the side of the promontory, with the guiding fingers inserted into the 
 vagina, direct the frontal blade forward toward the acetabulum. Dur- 
 ing this manoeuvre the handle should be held loosely. The forceps will 
 seize the head very nearly between the anterior frontal and the opposite 
 posterior pan'etal protuberance. The direct application of the forcejas
 
 372 OBSTETRIC SURGERY. 
 
 to the sides of the head, with one blade beneath the symphysis and the 
 other opposite the promontory, has, however, warm advocates. There 
 is no question that the head can be delivered in this way, but my own 
 experience has been entirely with the oblique method.* 
 
 Loching.—^heTi the occiput is rotated to the front, and the blades 
 are applied to the sides of the head, locking is a very simple matter. 
 The handles should be grasped in the full li^md, with the thumbs 
 directed upward. Coaptation is secured by slight movements of the 
 blades as the operator sinks the handles downward. 
 
 When the head is transverse it is often, on the contrary, difficult 
 to bring the separate parts of the lock in apposition. Under such 
 circumstances no force should be used, but the blades should be with- 
 drawn a little, and the attempt made to adjust the lock by gentle move- 
 ments in reintroducing them. 
 
 After locking, a tentative traction should be made to ascertain 
 whether the head is seized securely. In bringing the blades together 
 some caution should be observed lest the hair of the pubes, or the 
 labia, become included. 
 
 Tractions. — The instrument should be seized with the right or 
 stronger hand, with the back of the hand turned upward. In forceps 
 provided with transverse shoulders, the index-finger should be placed 
 over one shoulder, and the remaining fingers over the other. The left 
 hand, with the palm upward, seizes the handles from below and aids in 
 extraction. When the handles are far apart, the index-finger of the 
 left hand should be introduced into the vagina from time to time, to 
 determine the position of the forceps-blades, and to estimate the 
 amount of pressure upon the child's head during tractions. 
 
 Steady tractions are preferable to pendulum or rotary ones. Trac- 
 tions are most efEective Avhen made during a pain. This is especially 
 the case when the rotation of the head is incomplete. However, in the 
 absence of pains, it is often necessary to use the forceps as a substitute 
 for, instead of a re-enforcement of, the propulsive action of the uterus. 
 Pressure through the abdominal walls upon the uterus, made by a 
 skilled assistant during tractions, is here, as in other obstetrical opera- 
 tions, an adjuvant of great value. Tractions should not be too pro- 
 longed. When not made in unison with the pains, they should not 
 exceed one to two minutes in duration. The head should then be 
 allowed to recede. Haste in delivery exposes the patient to the dan- 
 gers of laceration and post-^Mrtum hgemorrhage. The alternate de- 
 scent and recession of the head soften the external parts, and are the 
 best means of overcoming rigidity. As the head advances, time should 
 be given for the uterus to retract upon its contents, for, when the 
 
 * In a recent beautiful work entitled Introduction a I'etude clinique et a la 
 pratique des accouchements, by Professor Faraboeuf and Dr. Varnier, the direct 
 application is strongly favored.
 
 FORCEPS. 
 
 373 
 
 pains are deficient, retraction after the sndden emptying of the uteriis 
 is apt to be imperfect or of short duration. 
 
 Tractions should at first be made downward, until the head has 
 descended below the symphysis pubis; they should then be made in a 
 horizontal direction until the occiput appears at the vulva. When in 
 doubt about the direction, the handles should be held loosely during a 
 pain, to serve as an index of the proper line of traction. If rotation has 
 not previously taken place, it may be aided by the forceps, though 
 
 Fig. 152.— Method of making tractions. 
 
 rotation usually occurs spontaneously as the head descends. If the 
 head was transverse, the forceps requires to be readjusted after rota- 
 tion, either by removing the blades and then reapplying them, or by 
 sinking the handle of the posterior blade and raising the handle of the 
 anterior one. 
 
 When the parietal bosses are in the act of passing through the 
 vulva, tractions should no longer be made during the pains. The 
 operator should stand to the right of the patient, and seize the handles 
 in the left hand. During the intervals of a pain, by alternately sink-
 
 374 
 
 OBSTETRIC SUKGERY. 
 
 ing uiid raising the handles, the perinaeiini and vulva can be gradually 
 difated. So soon as the convexity of the perini^um is marked, and 
 the parietal bosses press upon the commissure, it is better to sink the 
 handles during a pain, so as to flex the head to its greatest extent, and 
 cause the vertex to present. When the vulva is sufficiently dilated, it 
 is only necessary to raise the handles toward the abdomen to complete 
 the extrusion of the head and finish the delivery. 
 
 Removal— Although not generally recommended, it is always my 
 custom to remove the forceps so soon as the chin can be reached by the 
 
 :2# 
 
 Fig. 153.— Position of operator when head is on perinaeum. 
 
 index-finger introduced into the rectum. The head has then for the 
 most part emerged from the pelvis, and its extrusion, if it does not 
 occur spontaneously, can be easily effected by any one reasonably 
 familiar with the mechanism of parturition. The blades of the for- 
 ceps, though of no great thickness, still add something to the disten- 
 tion of the vulva. Moreover, with expert management, the guidance of 
 the head through the vulva and the utilization of all unoccupied space 
 beneath the pubic arch can be accomplished much more safely by the 
 hand than by the most skillful use of the forceps. The removal is ac- 
 complished by unlocking and reversing the direction the handles fol- 
 lowed in their introduction. To avoid compressing the soft parts
 
 FORCEPS. 
 
 3T5 
 
 against the rami of the pubes, I am accustomed to place two fingers of 
 the unemployed hand upon the upper border of the blade, and use 
 them as a fulcrum around which the blade should be rotated. 
 
 Forceps at the Brim. — The safe conduct of the head through the 
 pelvic brim by means of the forceps is an achievement which requires 
 an accurate appreciation of the dangers to be avoided and the difficul- 
 ties to be overcome. The forceps as a means of accelerating delivery 
 is sometimes called for when the head is at the brim in cases of acci- 
 dental haemorrhage, of placenta prtevia, of eclampsia, of pelvic ob- 
 struction, and in failure of uterine pains. 
 
 So long, indeed, as the head is movable at the brim, and version is 
 practicable, the latter operation furnishes the safer mode of delivery. 
 
 Fig. 154.— Forceps applied to head at brim. 
 
 After the waters have drained away, and retraction of the uterus ren- 
 ders version impossible, a tentative application of the forceps may be 
 made to test the adaptability of the head to the pelvic canal. Persist- 
 ent attempts to drag the head into the pelvis by brute force, after 
 moderate tractions have failed to effect an advance, should be regarded 
 as criminal, exposing as they do the maternal tissues unavailingly to 
 injuries which are always serious, and which may prove fatal. 
 
 When, however, the head has become fixed, which does not occur 
 until after the engagement of its largest circumference, and after the 
 dilatation of the cervix is complete, the difficulties of high forceps 
 operations are greatly diminished. Still, dangers to the mother arise 
 from the fact that the blades have to be passed into the lower segment
 
 376 
 
 OBSTETRIC SURGERY. 
 
 '^1, 
 
 of tlio uterus, where, owing to the extreme vuhierability of the uterine 
 tissues, lesions are onlv to be avoided by the patient carrying out of a 
 multitude of precautionary measures ; to the child, from the rarity of 
 the occasions which permit the blades to be ap- 
 plied to the sides of the head, to which the ce- 
 phalic curve is alone adapted. 
 
 Operation.— In introducing, the forceps, the 
 tips of the tingers of the guiding hand should be 
 inserted between the child's head and the cervix. 
 In this way we insure the entrance of the extrem- 
 ities of the blades into the uterus in place of into 
 the nd-de-sac of the vagina. It is generally cus- 
 tomary to apply the forceps to the sides of the 
 pelvis, without reference to the position of the 
 child's head. As a rule, under the conditions 
 mentioned, the head will be found to have been 
 seized obliquely— i. e., with the posterior blade 
 over the parietal boss, and the anterior blade 
 near the coronal suture. Thus applied, close 
 approximation of the handles is impossible, and 
 the tips are correspondingly separated from one 
 another. Considerable compression of the han- 
 dles is necessary, therefore, to prevent the in- 
 strument from slipping, the degree of pressure 
 depending naturally upon the extractive force 
 requisite to advance the head. The adjustment 
 of the lock often requires considerable patience, 
 and sometimes the exercise of moderate force is 
 necessary to bring the parts into juxtaposition. 
 
 Even when the instrument has been applied 
 according to the strict rules of art, it will be 
 found not infrequently that the upper border of 
 the anterior and the lower border of the pos- 
 terior blade will project beyond the tissues of the 
 scalp, and, unless managed with care, the exposed 
 edges are liable during extraction to cut deeply 
 into the soft structures of the parturient canal. 
 
 When the cervix is only partially dilated, the 
 forceps should be employed, not as an extractive 
 instrument, but simply to bring the head into 
 the cervical canal to act as a dilating wedge, by 
 means of which the gradual and safe expansion of the os may be ac- 
 complished. If the head be made to descend and then allowed to 
 recede at short intervals between the pains, in time the cervix will be 
 found to soften and yield in the same manner as a rigid perinaeum ; 
 
 Fig. 15.").— Taylin'V nar- 
 row-bladed forceps.
 
 FORCEPS. 377 
 
 whereas the resistance of an undilated cervix can only be overcome, 
 when violent tractions are made, by the production of lacerations ex- 
 tending to, or even above, the vaginal junction. In seeking to effect 
 dilatation of the cervix through the forceps, the utmost caution shbuld, 
 however, be observed. At short intervals the linger should be slipped 
 into the vagina to note whether the tension of the cervix is raised 
 during tractions to dangerous proportions. Especial attention should 
 be paid to the condition of the parts during a pain, as, when the uterus 
 contracts, the os externum, which previously was soft and dilatable, 
 frequently forms a sharp, resistant border. 
 
 Dr. I. E. Taylor has devised a long, narrow-bladed pair of forceps, 
 capable of introduction through a cervix measuring one and a half inch 
 in diameter, which he has used with advantage in the manner above 
 described at a very early stage of labor. 
 
 In cases where it is necessary to expedite delivery, the resistance of 
 the incompletely dilated os may be overcome by a number of incisions 
 about one fourth of an inch in depth, made with a blunt-pointed bis- 
 toury passed between the cervix and the child's head. It is very rare, 
 however, that this otherwise trivial operation is really called for. 
 
 In drawing the lieM through the superior strait, the tractions 
 should be made, as nearly as the perinfeum will permit, vertically 
 downward. In doing this, care must be taken lest the pelvic curve 
 be brought so far forward above the symphysis pubis as to subject the 
 maternal tissues to injurious pressure. On the other hand, it is neces- 
 sary not to prematurely raise the handles of the forceps, as, in tliat 
 ease, the head is simply crowded forcibly against the anterior pelvic 
 wall. The best means of avoiding these two difficulties is to exercise 
 great patience, and be content with a very gradual advance of the head, 
 as, by omitting anything like rude force, the risks arising from mis- 
 directed tractions are kept within the limits of safety. Many, indeed, 
 seek to prevent the anterior pressure of the forceps, by placing the 
 left hand upon the lock, and using it as a fulcrum around which ro- 
 tation of the instrument is effected, xis the right hand has then to 
 be employed at the same time to make tractions and to raise the 
 handles, the method requires both strength and expertness to be suc- 
 cessful. 
 
 In all high operations where the cervix is sufficiently dilated, I can 
 not too strongly recommend the ingenious forceps of M. Tarnier, which, 
 by its construction and action, obviates to a great extent the foregoing 
 objections to the more familiar models. 
 
 M. Tarnier's original model possessed two distinctive features : 1. 
 The shanks, in place of running forward continuous with the pelvic 
 curve, were bent backward, so that the handles, when placed horizon- , 
 tally, occupied a level three and a half inches above the plane of tlie 
 posterior curve of the blades. This Tarnier curve was intended to
 
 378 
 
 OBSTETRIC SURGERY. 
 
 make it possible to adjust tlie blades to the sides of the pelvis at the 
 brim, without subjectiug the soft parts in front or the periuffium below 
 to pressure. lu high operations such a curve is of undoubted advan- 
 tage," but at the lower strait, unless the blades are accurately applied to 
 the sides of the child's head, the posterior borders of the blades are apt 
 to cut dee])ly into the vaginal wall, so soon as the converging soft parts 
 embrace tightly the advancing head. Probably for this reason Tar- 
 nier, in his latest model, has restored to his instrument the ordinary 
 pelvic curve. 2. The second and permanent feature consists in the 
 attachment of two movable traction-rods to the lower curvature of the 
 blades. These rods are curved, according to the model employed, to 
 correspond to the lower border of the shanks. In Tarnier's instrument 
 the rods, when not in use, are affixed by projecting pegs. A trans- 
 verse screw, crossing the handles below the lock, approximates the 
 blades to the surface of the child's head. AVhen the instrument is 
 adjusted, the outer ends of the traction-rods are detached and inserted 
 into a socket-joint belonging to a strong steel bar with a downward 
 curve, and furnished with a transverse handle which can be moved in 
 any direction by means of a universal joint. Tractions are made by 
 means of this transverse handle alone. As' the head descends, the 
 handles proper rise upward and serve as an index to show the direction 
 in which the force should be exerted. By simply raising the traction- 
 rods in a line with the curved shanks, the blades of the forceps swing 
 
 Fig. 156.— Author's modification of Tarnier's forceps 
 
 always in the transverse diameter, and the head follows approximately * 
 the axis of the pelvis. To one accustomed only to the familiar forceps, 
 the facility with which delivery can be accomplished by Tarnier's in- 
 strument would seem hardly credible. 
 
 * I use the word "approximately," for my own experience does not sustain the 
 idea that the handles of the forceps furnish an infallible guide to the direction in 
 which tractions should be made. In this respect I am in entire agreement with 
 JT (pl^Be«'^en-Eingangs-Zangen, Vienna, 1885), viz., that the advantage 
 ot the Tarnier principle consists less in the mathematical accuracy of the trac- 
 tions than in the freedom of motion that the traction-rods permit to'the head
 
 FORCEPS. 379 
 
 t 
 
 Mr. Stolilnianu bus modified for me the original forceps of Tur- 
 nier by making tbe blades mucli ligbter, modeling tbem somewhat 
 after those of the well-known instrnmeut of Wallace. This alteration 
 makes their application, especially in contracted pelves, or through an 
 imperfectly dilated os, a much easier matter. In place, too, of the 
 very clumsy socket-joint into which the traction-rods are inserted, 
 he has substituted the key arrangement shown in Fig. 156, by means 
 of which the handle can be adjusted or removed in a few seconds 
 of time. 
 
 In spite of the example of the illustrious author of the axis-traction 
 principle, I still cling to the Tarnier curve. It enables the operator to 
 seize the head more advantageously at the brim, and, in my experience, 
 it facilitates greatly the descent of the head in the axis of the superior 
 straits. Mr. Stohlmann has recently made for me a pair of narrow- 
 hladed forceps wdth axis-traction rods and Tarnier curve, for eases in 
 which the dilatation of the cervix is insufficient to permit the introduc- 
 tion of the wide blades of the ordinary instrument. In high operations, 
 the operator will find axis-traction most effective when the patient is 
 j)laced upon ker left side. 
 
 When the head has been brought to the floor of the pelvis, unless 
 the occiput has previously turned to the front, it is a good j^lan to 
 remove the forcei)S and wait for spontaneous rotation to take place. 
 If a reapplication becomes necessary, an instrument Mith the ordinary 
 curve should be selected. 
 
 Professor Alexander Simpson, of Edinburgh, has contrived an ad- 
 mirable instrument for general use by adapting traction-rods to the 
 popular and widely employed forceps of Sir J. Y. Simpson. The rods 
 as well as the handles are permanent fixtures, so that there is no possi- 
 bility of the parts being mislaid when required for service. I have 
 given this instrument an extended trial, and regard it as a most valu- 
 able addition to my obstetric equijiment. With the head in the jDelvic 
 cavity it answers every indication. In high operations, however, I 
 have sometimes found it convenient to lay it aside for a longer forceps 
 with a backward curve. 
 
 As the solidity of the shanks in axis-traction forceps prevents the 
 blades from springing, the amount of pressure upon the head requisite 
 to keep the instrument from slipping has been found in practice not to 
 prove an element of danger to the child. 
 
 Forceps in Occipito-posterior Positions. — So long as the occiput 
 looks to the rear, it is the rule in midwifery practice to refrain from 
 the use of forceps, which, of necessity, prevents forward rotation from 
 taking place. An excej)tion to this rule, however, arises in cases of 
 a near danger to either mother or child, demanding speedy delivery. 
 As attempts to rotate the occiput around to the symphysis by instru- 
 mental means are rarely successful, it is advisable under such circum-
 
 380 
 
 OBSTETRIC SURGERY. 
 
 stances to apply the forceps directly to the sides of the child's head, 
 aud to imitate during delivery the mechanism of labor in occipito-pos- 
 terior positions. 
 
 Fig. 157. 
 
 -Occipito-posterior position. Traction in a downward direction to secure the descent 
 of the head beneath the pubic arch. (Faraboeuf and Varnier.) 
 
 The rotation of the occiput forward to the symphysis pubis by forceps 
 seems, a priori, a simple matter, aud it would be if the vagina were a rigid 
 canal with fixed extremities. In reality it is an elastic tube, closely applied to 
 the child's head, and enjoys a great degree of mobility. When, therefore, the 
 head is turned a quarter-circle within the pelvis, the soft parts, as a rule, are 
 turned with it. When the force is removed, the vagina, owing to its resiliency, 
 resumes its former position, and generally carries the head back to the original 
 point of departure. 
 
 ^'^'pIoLT- ''■"''//'"' ">'r'''VT position. Descent of forehead beneath pubic arch completed. 
 Elevation of liaiidle of forceps to aid the rotation of the occiput over the perinseum (Fara- 
 boeuf and Varnier.) ^ 
 
 If the sagittal suture occupies an oblique diameter, the forceps 
 should be applied in the opposite oblique diameter. As the liead de-
 
 FORCEPS. 381 
 
 scends, the occiput should be turned iuto the hollow of the sacrum. 
 At first, tractions should be made directly downward, until the fore- 
 head has passed under the pubic arch and the anterior fontanelle 
 makes its appearance at the vulva ; then, by raising the handles, the 
 small fontanelle should be brought forward to the commissure, and, 
 finally, as the vertex emerges from the vulva, the handles should 
 be slowly depressed, to aid the movement of extension by which 
 the delivery of the face and chin beneath the pubic arch is accom- 
 plished. 
 
 Forceps in Face Presentations. — When the face is deep in the pelvis 
 and the chin has rotated to the front, forceps applications are easy, and 
 do not differ materially from those in vertex presentation, except that 
 care should be taken to direct the blades far enough backward to se- 
 curely seize the occipital extremity of the child's head. Tractions 
 should be made in a horizontal direction until the chin has been 
 brought well under the symphysis pubis, when the handles should be 
 raised to lift the cranial vault over the perinseum. In oblique mento- 
 anterior positions, Spiegelberg advises introducing first the blade cor- 
 responding to the chin (posterior blade), as, in adjusting the second 
 blade and locking the forceps, spontaneous rotation usually takes jjlace. 
 
 In deep transverse positions, forceps operations should be deferred 
 as long as possible, as tardy rotation of the chin to the front is a physio- 
 logical peculiarity in face presentations. The forceps should be ap- 
 plied in an oblique diameter, with the concavity of the blades directed 
 to the side of the chin. Chin right, introduce the right blade pos- 
 teriorly, and bring the left blade forward to the left tuberculum ilio- 
 pubicum. An effort should then be made to rotate the chin to the 
 front. If the attemj)t prove successful, the forceps should be un- 
 locked, and the blades readjusted to the lateral surfaces of the head. 
 Tractions when the face is transverse should not be attempted. The 
 wide separation of the blades makes it necessary to compress the han- 
 dles firmly to prevent slipping. When this is done, pressure upon the 
 neck and thorax is unavoidable, so that extraction without sacrificing 
 the life of the child is hardly possible. 
 
 In high transverse positions, forceps should not be used, as rota- 
 tion is not then permissible, and the blades, apialied to the neck and 
 thorax on the one side and upon the cranium on tlie other, can not, 
 for the reasons just given, be safely employed in extraction. The 
 choice in such cases, when speedy delivery is called for, lies between 
 version and craniotomy. 
 
 In mento-posterior positions, the rotation of the chin to the front 
 by repeated applications of the forceps is inadmissible. In practice, 
 such efforts do not succeed, while they are calculated to inflict injury 
 upon both the mother and the child. Usually, if delivery becomes 
 necessary because of danger to the mother, craniotomy should be re-
 
 382 
 
 OBSTETRIC" SURGERY. 
 
 sorted to. Smellie, Hicks,* and Braiin, of Vienna, have, however, 
 each reported a case of forceps delivery by drawing the chm down over 
 the sacrum and perina^nm, wlien the occiput and calvarnim ghded 
 
 / 
 
 / 
 
 Fig. 159. — Taylor's method in mento-posterior positions of the face. 
 
 underneath the pubes. In two cases, I. E. Taylor f extracted the chil- 
 dren with straight forceps after bilateral incision of the perinaeum. 
 Unfortunately, both children were dead before the operation was un- 
 dertaken. ' 
 
 CHAPTER XX. 
 EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 
 
 Extraction in pelvic presentations. — Attitude of the physician. — Prognosis. — Posi- 
 tion. — Extraction of trunk. — Extraction by the feet ; by the breech. — Manage- 
 ment of the cord. — Liberation of the arms. — Exceptional cases. — Extraction of 
 the head. — Smellie's method. — Veit's method. — Head at brim. — Prague method. 
 — Forceps to the after-coming head. 
 
 We have already seen, in studying the management of breech pres- 
 entations, that the attitude of the physician during delivery, so long 
 
 * Hicks, On Two Cases of Face Presentations in the Mento-Posterior Position. 
 Trans, of the Obstet. Soc. of London, vol. vii, p. 56. Hicks likewise reports the 
 cases of Smellie and Braun. 
 
 f Taylor, On the Spontaneous and Artificial Delivery of the Child in Face 
 Presentations, N. Y. Med. Jour., Nov., 1869.
 
 EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 3S3 
 
 as no immediate danger threatens either the mother or the child, 
 should be one of watchfnl observation. As a rule, the results to the 
 child are unquestionably more favorable when Xature does her work 
 unaided. If, however, there be any faltering in the natural forces, the 
 physician should be in readiness to avert, by prompt interference, the 
 perils which in pelvic presentations are associated with delay. When 
 an artificial breech-presentation has been produced by internal version, 
 immediate extraction is usually advisable, as the act of version, when 
 the entire hand has to be introduced into the uterus, is apt to com- 
 promise the safety of the child. 
 
 Strong uterine contractions, a roomy pelvis, a dilated cervix, and 
 a relaxed state of the vaginal outlet, are conditions highly favorable to 
 the success of the operation. Under such circumstances, artificial de- 
 livery can be performed with celerity and ease. But these conditions, 
 however desirable, are not absolutely indispensable. Thus, extraction 
 is rarely indicated if the pains are good ; it is often necessary to deliver 
 before the cervix has reached the desirable degree of dilatation ; and 
 it is possible to drag the head of the child through a moderately con- 
 tracted pelvis without inflicting upon it any permanent injury. There 
 is always danger, however, in the last two cases, of not being able to 
 extract the child rapidly enough to save it from asphyxia. 
 
 The prognosis for the mother is generally favorable. Still, lacera- 
 tions are apt to follow the forcible delivery of the head through the 
 undilated cervix. 
 
 Extraction is commonly performed with the patient on her back. 
 In easy cases she may occupy the usual position in bed, while the phy- 
 sician places himself at her side. If difficulty is anticipated, the pa- 
 tient should be placed crosswise, with hips raised by a hard cushion, 
 and brought over the edge of the bed ; or, better still, may be placed 
 upon a table, as the operator is then enabled to draw downward in the 
 direction of the superior strait without kneeling before her. It is de- 
 sirable to have two assistants to hold the patient's knees. To one of 
 these should likewise be assigned the duty of making firm pressure, 
 during extraction, upon the fundus of the uterus. If anaesthesia is 
 thought necessary, a third assistant will be required. The question of 
 anaesthesia is not always easy to decide. Useful in unruly patients, 
 and where the entire hand must be passed into the vagina, its occa- 
 sional suspensive action upon the uterine pains and the loss of the 
 co-operation which intelligent patients are capable of affording are 
 alloys to its beneficent action in stilling pain. My preference is to 
 anaesthetize lightly at first, and then be guided by events as to whether 
 the insensibility shall be subsequently made complete, or the patient 
 be allowed to return to partial consciousness. 
 
 As in all obstetrical operations, in addition to the usual aseptic pre- 
 cautions, care should be taken to insure the emptying of the bladder
 
 3g^ OBSTETRIC SURGERY. 
 
 and rectum, and the operator should have iu readiness, in case of need, 
 forceps, a soft fillet, Avarni napkins, hot and cold water, and a small 
 English (No. 7) catheter, for use should the child be born in a state of 
 partial asphyxia. 
 
 The operation is divisible into three acts : 1. Extraction of the 
 trunk as far as the shoulders; 2. Extraction of the arms; 3. Ex- 
 traction of the head. 
 
 First Act: Extraction of the Trunk to the Shoulders. 
 
 The extraction of the trunk should take place slowly, with pauses 
 between the tractions, in imitation of the uterine expellent forces. 
 Tractions are best made during the pains only, when the latter do not 
 recur at too long intervals. It is desirable that the uterus be closely 
 retracted upon the child during the entire period of its expulsion. 
 Where this does not occur, the arms are liable to be brushed upward 
 to the sides of the child's head, the chin to become extended, and the 
 mechanism of the head-delivery to be disturbed. Hemorrhage, too, 
 is more likely to follow hasty delivery than where the uterus has had 
 time to pass slowly into a state of complete retraction. When, there- 
 fore, it is necessary to extract during the intervals between the pains, 
 firm pressure should be made upon the uterus through the abdominal 
 walls, so as to maintain them in close contact with the foetus. Steady 
 tractions are preferable to pendulum movements. Tractions should be 
 made downward and backward, in the direction of the superior strait, 
 until the breech meets with the resistance of the floor of the pelvis. 
 
 These general rules are applicable to every case of extraction. 
 Special differences of procedure result from the presentation of one or 
 both feet, and of the entire breech. 
 
 Extraction by the Feet. — If a single extremity presents, the foot 
 should be seized between the middle and index finger, with the thumb 
 upon the sole, or across the instep. It is not necessary to go in search 
 of the second foot, unless it crosses the first, or is reflected upward over 
 the child's back. When the leg is drawn outside of the vulva, it 
 should be wrapjsed in a warm napkin, and grasped by the entire hand. 
 Always, in seizing a limb, the thumb should be directed upward and 
 applied to the dorsal surface. The napkin serves partly to prevent the 
 hand from slipping, partly to protect the surface from air, which at 
 times is capable of exciting reflex respiratory movements. Tractions 
 should be made downward, to avoid friction at the symphysis pubis. 
 Until the pelvis is delivered, the child should be seized as near the 
 maternal parts as possible. The hand, therefore, should be shifted u])- 
 ward as the limb is drawn out of the vulva. Whichever extremity is 
 seized rotates forward under the symphysis pubis during extraction. 
 For this reason, when an election is practicable it is desirable to draw 
 upon the anterior leg, since owing to the slight amount of rotation
 
 EXTRACTION IX FOOT AND BREECH PRESENTATIONS. 385 
 
 involved there is less likelihood of derangement of shoulder and head 
 mechanism as these engage in the pelvis. So soon as the breech 
 reaches the pelvic floor, traction should be made more in an upward 
 direction, to facilitate the passage of the buttocks over the perinaeum. 
 After the breech has cleared the vulva, the index-finger of the free 
 hand should be carefully inserted into the fold of the posterior thigh, 
 while the thumbs of both hands are placed upon the sacrum. During 
 the subsequent extraction of the trunk the lower leg falls from the 
 vagina without special assistance. 
 
 If both extremities present, they should be seized so that the mid- 
 dle finger is placed between the feet, while the index- and ring-fingers 
 encircle the external malleoli. After they have passed sufficiently far 
 outside the vulva, the left leg should be seized with the left hand and 
 the right foot with the right hand. During extraction the normal 
 rotation of the child may be aided by dragging with somewhat greater 
 force upon the limb, which should be turned to the front. 
 
 Fig. 160.— Method of seizing the breech. 
 
 Extraction by the Breech. — When the breech alone presents, with 
 both extremities reflected upward parallel to the anterior surface of the 
 25
 
 3g(j OBSTETRIC SURGERY. 
 
 child, spontaneous delivery is sometimes, as pointed out by Tarnier, 
 prevented by the fact that the extended limbs act as splints which in- 
 terfere with the lateral flexion of the trunk, and, consequently, with its 
 accommodation to the curve of the parturient canal. If, m pure 
 breech cases, obstetrical aid becomes necessary, the operator is em- 
 barrassed by the absence of a natural handle by means of which extrac- 
 tion can be effected. 
 
 Theoretically, cephalic version by external manipulations, performed 
 during the latter part of pregnancy or in the early stages of labor, 
 most completely fulfills the required indications, viz., the saving of the 
 child with the least possible risk to the mother. That, in cases where 
 the breech is not engaged in the pelvic cavity and the membranes are 
 intact, external version may be successfully accomplished, has been 
 shown by Mattel, Hegar, and Pinard. Tarnier at first opposed the 
 measure on the ground of its impracticability and the risk of rupturing 
 the membranes before the version was completed, thus converting a 
 breech into a shoulder presentation, but more recently has practiced 
 the procedure in many cases without inconvenience to the mother or 
 child.* Its successful performance presupposes a relatively consider- 
 able quantity of amniotic fluid, the absence of reflex irritability in the 
 patient, and experience on the part of the operator in mapping out 
 the fretus through the abdominal wall. Ahlfeld f advises that in pri- 
 mipara? the hand be introduced immediately after the rupture of the 
 membranes, or at least while the introduction is still practicable, and 
 that the anterior extremity be brought down as a prophylactic measure, 
 leaving the child to be expelled subsequently by the natural forces. 
 The hand should be passed over the anterior surface of the child to the 
 knee ; the thumb should then be placed in the popliteal space, while 
 four fingers grasp the leg, flex it upon the thigh, and draw it down 
 into the vagina. The operation is facilitated by placing the patient 
 upon the side to which the chiUrs feet are turned. But Kiistner, in 
 common Avith most authorities, objects that the mancBuvre is apt to 
 weaken the uterine contractions and to favor prolapse of the cord. In 
 others words, in order to avert a remote danger, a near one quite as 
 serious is invited. 
 
 If, however, it becomes necessary to expedite delivery, without 
 doubt, in all cases where it is possible to pass the hand to the fundus 
 and bring down an extremity without imperiling the uterine struct- 
 ures, this method should be employed by preference. But emergencies 
 rarely arise before the breech has descended into the pelvic cavity. 
 Most frequently the membranes have already ruptured, and the uterus 
 has retracted upon the foetus. Under such conditions the intro- 
 
 * Ollivier, De la conduite a tenir dans la presentation de I'extremite pelvienne. 
 Mode des fesses, p. lO-S, Paris, 1883. 
 
 f Ahlfeld, Arch. f. Gynaek., vol. v. p. 174, Berlin, 1873.
 
 EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 387 
 
 ductiou of the hand and forearm over the anterior surface of the child 
 to the fundus becomes a serious undertaking, and may lead to uterine 
 rupture. Traction upon the extremity seized is not always followed 
 by its descent, and where force is used the descent may be accomplished 
 
 Fig. 161.— Method of seizing both extremities. 
 
 at the expense of a fracture. To be sure, the manoeuvre is supported 
 by the high authority of Dr. Barnes. " The wedge formed by the ex- 
 tended legs and the upper part of the trunk must," he says, " in some 
 instances at least, be decomposed Ijefore delivery can be effected." He 
 recommends complete anaesthesia, support of the fundus, gentleness in 
 passing the breech at the brim, and applying the fingers to the instep. 
 But Barnes does not conceal the difficulties of the operation, nor the 
 address requisite for its successful employment, and many accoucheurs, 
 less fortunate, have recorded their failures to decompose the wedge in 
 the manner advised. In a few cases, influenced by Barnes's teachings, 
 I have, under most difficult conditions, succeeded in bringing down a 
 foot ; nevertheless, I would advise the utmost caution in practicing the 
 method, and that in all cases the operator desist the moment address 
 fails and force becomes necessary. If, at the time intervention be-
 
 ggg OBSTETRIC SURCxERY. 
 
 comes necessary, the breech is well engaged, the foetus is of ordinary 
 size, and the resistance of the pelvic floor is inconsiderable, the expul- 
 sion of the child may sometimes be effected by graduated pressure 
 upon the fundus of the uterus. Should this measure prove ineffective, 
 manual extraction should be attempted. To this end the index-finger 
 should be inserted into the fold of the anterior groin and traction made 
 directly downward. By seizing th3 wrist with the disengaged hand, an 
 increase of traction-power can be exerted. If the breech is low, both 
 index-fingers may be employed— the one in the anterior, the other in the 
 posterior groin ; or the entire hand, passed over the sacrum, may seize 
 the pelvis with the thumb in one groin and the index-finger in the 
 
 other. 
 
 Many writers insist upon manual extraction to the exclusion of all 
 other methods ; but in primiparous women they are liable to fail at the 
 critical moment. Instrumental aids then become necessary. The 
 choice consists in the forceps, the fillet, the blunt hook, and, when the 
 child is dead, the cephalotribe. So far as the relative value is con- 
 cerned, I would recommend them in the order given. 
 
 The chief objection urged against the forceps is that, by its con- 
 struction, it is designed to seize the fetal head. As a consequence, 
 when applied to the breech to which its curves are not adai)ted, it does 
 not grasp the presenting part securely, and is liable to slip off when 
 tractions are employed, thus endaiigering the maternal soft parts. If, 
 with the view to prevent slipping, the handles be compressed firmly, it 
 has been argued that fracture of the thighs may result, the circulation 
 of the cord may be accidentally arrested, or fatal injuries may be 
 inflicted upon the foetus by the pressure of the points of the forceps 
 against the abdominal viscera. Miles,* to obviate these drawbacks, 
 has devised a pair of breech forceps, apparently well designed for seiz- 
 ing the pelvic extremity. As, however, a forceps of special construc- 
 tion is likely to be but rarely at the disposition of the physician when 
 an emergency calls for action, it is not without interest to know how 
 far the ordinary instrument is available in practice. Omitting earlier 
 authorities, we find in modern times Jacquemier declaring that " it is 
 inexact to state that the forceps would crush the pelvic bones, and in- 
 evitably kill the foetus by bruising and lacerating the abdominal vis- 
 cera." Tarnier stated, in his famous article on the forceps, published 
 in the Dictionnaire de medecine et de chirurgie, 1872, that, under 
 exceptional circumstances, neither Stoltz nor Dubois feared to apply 
 the forceps to the breech, and added that he had a number of times 
 imitated their practice with success for the mother, and sometimes for 
 the child. When the foetus was dead, he assured himself at the autopsy 
 that the forceps had produced no lesion either of the pelvis or of 
 
 * Miles, The Forceps in Difficult Breech Presentations, Am. Jour. Obst., vol. 
 xii, p. 135, New York, 1879.
 
 EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 3S9 
 
 the cibdo)iiinal viscera, lliiter, in his excellent treatise on Obstetri- 
 cal Operations (Leipsic, 1874), declares that no better instrument ex- 
 ists for the extraction of the breech. Dr. Henry Fruitnight, of New 
 York city, published in July, 1877, in the Virginia Medical Monthly, 
 a successful case where the forceps were used at the suggestion of Dr. 
 
 E. C. Harwood. Dr. I. E. Taylor has applied the forceps to the breech 
 six times with success. In 1877 Haake* published five cases in which, 
 as he says, to the astonishment of the physicians present, the extraction 
 with the forceps was easily and quickly ended without detriment to 
 the foetus. In the same year Agnew reported two successful cases to 
 the London Obstetrical Society. I once saw, in consultation with Dr. 
 
 F. A. Castle, a case of breech presentation in a primipara past her 
 thirtieth year, where, after ineffectual essays at manual extraction, I 
 applied the forceps over the sacrum and the anterior surface of the 
 
 Fig. 162.— Tarnier forceps applied to the thighs. (Ollivier.) 
 
 thigh. Though the breech had not completed its descent through the 
 cervical canal, and the parts were rigid, the child was easily extracted 
 in about fifteen minutes. The child was alive, and the trifling press- 
 ure-marks disappeared in a few days. Recently I have had occasion 
 to apply the forceps to the breech in the case of an elderly primipara, 
 where the rigidity of the soft parts was extreme. The operation occu- 
 pied nearly an hour. The patient suffered no inconvenience, and only 
 
 * Haake, Ueber den Gebrauch der Kopf zange zur Extraction des Steisses, Arch. 
 t Gynaek., vol. xi, p. 558, Berlin, 1877.
 
 390 
 
 OBSTETRIC SURGP^KV. 
 
 a slight abrasion was found npon the thigh of tho chihl which was 
 born living. Dr. Harvey, Professor of Midwifery m the Medical Col- 
 lege of Bengal, in an essay (1884), reports six cases. In three out ot 
 six the success was complete, in one the forceps was without avail, 
 while in the other two, although the instrument slipped, it did not do 
 so until it had brought down the breech, so as to allow him m one case 
 to get his fingers over the groin, and in the other to apply the fillet, 
 wliich he had previously failed to do. 
 
 Since the invention of axis traction by Tarnier a new impetus lias 
 been given to the method. With axis traction, not only is the resist- 
 ance offered by the parturient canal diminished, but, as Pmard states, 
 the pressure is regulated, and is not increased by traction. The fetal 
 
 Fig. ](i3.— The fillet in dorso-anterior positiou. (Ollivier.) 
 
 part is seized solidly, and with the least risk of harm. Ollivier reports 
 successes with Tarnier's latest model in his own practice, and in that 
 of Budin, Thomas, Berthout, Lobat, and Cayla. 
 
 Thus it will be seen that the weight of expei'ience is favorable to 
 the forceps as a breech -tractor, while the objections are mainly theo- 
 retical. The instrument is inadmissible so long as the breech does not 
 engage in the pelvic cavity. Haake limited its use to cases in whicli 
 the breech was already at the pelvic outlet, and only after complete 
 rotation had taken place. With axis-traction forceps the indication is 
 certainly extended, as a rule, to all cases where the breech has passed 
 the pelvic brim and the dilatation of the os is well advanced. If rota- 
 tion has taken place, the blades should be applied, respectively, over the
 
 EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 391 
 
 sacrum unci over the posterior surface of the thigh, as recommended by 
 Haake. If the hips are transverse, Ollivier advises that the blades be 
 applied to the lateral surfaces of the thighs. The application of the 
 blades over the trochanters, with the extremities overlapping the crests 
 of the ilia, is to be deprecated, as the ilia are conijiressible and allow 
 the forceps to slip (Ollivier). The extraction of the child should not 
 be made an exhibition of strength. The rigidity of the maternal 
 structures is rarely to be overcome by any justifiable degree of force. 
 The slow descent of the breech, effected by intermittent traction, best 
 insures the physiological softening of the tissues in advance of the pre- 
 senting part. As the genital canal softens and relaxes, but little force 
 
 Fio. 164.— The fillet in dorso-posterior position. (Ollivier.) 
 
 is required to effect the birth of the breech. The tractions are most 
 effective if made during the pains. They should be aided by simul- 
 taneous pressure exerted by an assistant upon the fundus of the 
 uterus. 
 
 If the forceps fails, or, owing to the non-engagement of the breech, 
 is contra-indicated and an extremity can not be brought down without 
 the employment of force, a resort to the fillet is admissible. The ob- 
 jections urged to its use are : 1. That the fillet is apt to become twisted, 
 and that, when moistened with the vaginal secretions, it may form an 
 uneven band, which, even with care, is capable of cutting deeply into 
 the tissues ; 2. That in some cases it causes partial extension of the 
 extremity, and, as a consequence, slips forward upon the thigh, whence
 
 392 OBSTETRIC SURGERY. 
 
 fracture of the thigh-bone becomes inevitable. The reports from tlie 
 Lying-in Institution of Munich, where, owing to the advocacy of 
 Hecker, the fillet has been assiduously tested, do not confirm the idea 
 that these accidents are of necessary occurrence. Thus, in the last re- 
 port of Von Weckberger Sternefeld, the records of thirty cases — twenty- 
 one primiparae and nine pluriparae — are given. The mothers all did 
 well. One of the children was in a macerated condition when the fillet 
 was employed. Of the remaining thirty, twenty-four were born living. 
 Of these, eight were partially asphyxiated, but seven were revived. In 
 no one of the children born dead was the result attributable to the 
 method of extraction employed. Twenty-three of the children left the 
 institution in a healthy condition. In four cases, deep pressure-marks, 
 but without excoriation, resulted from the use of the fillet. In the 
 others, either no traces of pressure were found or they were of an in- 
 significant nature. In all, the marks had disappeared in a few days. 
 In one instance only fracture of the thigh occurred. The back was 
 turned to the right and to the rear. Ollivier has shown that it is in 
 dorso-posterior positions that especial caution is called for when trac- 
 tion is made at the groin. A glance at Fig. 164 will show that it is 
 not easy in these cases to direct the tractions in such a way as to avoid 
 the partial extension of the thigh and the transfer of the pressure to 
 the shaft of the thigh-bone. This extension, Ollivier suggests, can be 
 prevented by passing the fingers into the rectum and pressing the 
 breech forAvard as tractions are made. The fillet should be jaassed 
 over the anterior thigh, the tractions should be of moderate force, 
 they should be made during the pains, and should be sustained by 
 external pressure made by a skilled assistant. 
 
 The passage of the fillet around the groin by the finger alone is by no means 
 always easy in the class of cases in which the fillet is principally indicated, viz., 
 in those where the breech is high and difficult of access. To be sure, with pa- 
 tience the knotted end of a handkerchief can sometimes be pushed around the 
 groin, or, failing in this, an elastic catheter with a loop attached to the ex- 
 tremity may be guided by a finger in the groin down between the thighs, to 
 serve as a means of conducting the fillet into position. 
 
 Many ingenious instruments have been especially devised to serve as porte- 
 fillets. Of these, Ollivier's instruments, modified by him from an invention of 
 Tarnier, will serve as an example. It consists of a long-handled blunt hook, 
 with a central tunnel and a terminal olive-shaped bulb. Through the central 
 canal a long piece of whalebone is passed. The extremity of the whalebone 
 terminates in a metallic eye, which occupies, when the whalebone is withdrawn, 
 a hollow space in the olive-shaped extremity of the blunt hook. Below the 
 handle the end of the whalebone is armed with a button, to prevent it from 
 being accidentally withdrawn into the canal. A screw above the handle serves 
 to fix the bone at any point deemed desirable. The blunt hook is adjusted by 
 passing it upward along the side of the child, directed to the front to a point 
 above the pelvis, and then directing the curve so as to adjust it to the groin. 
 The whalebone is then easily pushed forward until it is felt by the fingers of
 
 EXTRACTION IX FOOT AND BREECH PRESENTATIONS. 393 
 
 the physician between the thighs of the foetus. The metallic eye is next di- 
 rected by the fingers outside of the vulva. The attached fillet is easily with- 
 drawn by reversing the directions given. 
 
 The fillet employed may be of any material. In emergencies the nearest 
 object can be made to serve. It is desirable that the fillet should be adjusted 
 
 GrWtlAkUUBttO. 
 
 Fig. 10.5.— Porte-flllet. (.OUivier.) 
 
 without forming folds or creases. OUivier recommends passing a lacing through 
 a piece of rubber tubing the size of the little finger. The lacing should be 
 fixed by stitches to the ends of the tul)e, a i^rojecting portion serving to attach 
 the tube to the eye at the end of the whalebone. In Ollivier's experiments the 
 ^^^--JJibber tubing acted admirably in protecting the tissues of the child from harm- 
 ful pressure. 
 
 In the absence of other appliances, or should failure attend the 
 measures already described, it is well to remember that the blunt hook 
 owes its sinister reputation not so much to its inherent defects as to 
 lack of proper caution in its employment. It will not break the femur 
 if adjusted in the groin. It will not produce serious contusions if 
 the blunt end is carefully guarded by the finger. Injuries to the 
 maternal tissues can only occur where leverage movements are made. 
 So long as the pressure of the curved portion is confined to the groin, 
 serious lesions are not likely to be produced. Steady downward trac- 
 tions, made with moderate force and with a hand in the vagina to 
 guard the point of the instrument, and to give warning of commenc- 
 ing extension of the thigh, will in the rule suffice to prevent serious 
 accidents. 
 
 No instrument is capable of seizing the breech so securely as the 
 cephalotribe. If, therefore, the child be dead — a fact rarely to be de- 
 termined except in cases where the cord can be reached — the cephalo- 
 tribe, screwed tightly to the breech, can be trusted to act as a reliable 
 tractor. 
 
 Management of the Cord. — So soon as the cord has passed beyond 
 the vulva, dragging upon the navel should be avoided by genth' jjull- 
 ing the cord downward into one of the recesses to the sides of the 
 promontory until some resistance is experienced. Sometimes the cord 
 is found passing between the child's legs and up over its back to the 
 placenta. Then traction should be exerted upon the placental ex- 
 tremity, and an attempt made to slip the loop over the posterior thigh. 
 In the rare cases of failure to obtain its release, and where the cord is 
 wound around the child's body, either two ligatures or compression
 
 394 OBSTETRIC SURGERY, 
 
 forceps should be applied, aud the cord be divided between them, 
 whereupon every effort should be put forth to complete the delivery as 
 speedily as possible. 
 
 Seco^td Act: Liberation^ of the Aems. 
 
 When the Arms are flexed upon the Thorax.— After providing for 
 the safety of the cord, the pelvis of the child should be seized m the 
 two hands with the thumbs upon the sacrum. Traction should be 
 employed in a downward direction until the shoulder-blades make 
 their appearance. Then no time should be lost in liberating the arms. 
 If the latter are folded upon the chest, delivery is an easy matter. The 
 palmar surface of the corresponding hand is passed over the belly of the 
 child to the posterior arm (back to the right, right hand, and vice ver- 
 sa), while the extremities, wrapped in a warm cloth, are drawn in the 
 opposite direction. The forearm should be seized as near the wrist as 
 possible, and be brought down over the abdomen to the side of the 
 child. 
 
 When the Arms are extended.— Unless, however, great care has 
 been exerted during extraction to keep the uterus by external pressure 
 closely in contact with the foetus, the friction of the parturient canal is 
 apt to brush one or both arms upward to the sides of the child's head. 
 In such cases the difficulties involved in liberating the arms are often 
 very great. Here, too, owing to the increased amount of space afforded 
 by the curvature of the sacrum, an attempt should first be made to re- 
 lease the posterior arm. 
 
 Release of the Posterior Arm. — This is best accomplished by draw- 
 ing the lower extremities strongly upward and to the side, thereby 
 causing the posterior shoulder to sink deeper in the pelvis and to 
 furnish more room for the introduction of the hand ; then two fingers 
 should be passed along the side of the child to the elbow-joint, which 
 should be pushed across the face, and be brought down over the 
 thorax. 
 
 In case the foregoing manoeuvre can not be rapidly executed, 
 the operating hand may be removed, and the extremities of the child 
 may be drawn in the opposite direction, while the hand which at first 
 had seized the feet or breech should pass upward over the abdominal 
 surface to the posterior elbow. The latter should then be directed 
 forward, by means of two fingers in the Joint, toward the anterior 
 pelvic wall. 
 
 Whether the hand be passed behind or in front of the child, it 
 should be introduced slowly and without force during the intermis- 
 sion between the pains. Pressure should always be made at the joint, 
 and never upon the humerus. A forgetfulness of the latter rule is 
 apt to produce fracture. 
 
 Release of the Anterior Arm. — As there is rarely space enough be-
 
 EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 395 
 
 tweeu the sym})hysis aud the shoulder to allow the iingerrf to rqach the 
 elbow, it is customary after release of the posterior arm to rotate the 
 trunk so as to bring the anterior arm backward into the cavity of the 
 sacrum. This is accomplished with the least disturbance of the nor- 
 mal mechanism by seizing the released arm and drawing it upward on 
 the dorsal side of the child. The shoulders readily follow the move- 
 ment until the half-circle rotation is completed. 
 
 Exceptional Cases. — The shoulders, in place of rotating into the 
 conjugate diameter, may enter transversely into the pelvis. If the 
 back then be turned toward the symphysis, the hand should be passed 
 over the abdominal surface in search of the arms. The space oppo- 
 site the sacrum renders this movement one of easy execution. When 
 the back is turned to the rear, so long as the arms are flexed, the hand 
 should search for them under the symphysis pubis. If, however, they 
 are extended upon the sides of the child's head, it is rarely possible to 
 push the arms forward between the face and the symphysis pubis. 
 An effort should be made, therefore, to bring one arm to the rear by 
 rotating the thorax with the hands. Michaelis succeeded twice in 
 similar cases without rotating the trunk, by passing the hand behind 
 the dorsal surface of the child and drawing the elbow backward and 
 downward below the side-wall of the pelvis, and then pushing the 
 forearm over the thorax.* I have repeatedly tested this movement in 
 passing the cadaver of an infant through a bony pelvis, and find that 
 it can be accomplished without producing fracture or dislocation. Of 
 course, during the life of the child the result may be different. 
 
 Sometimes, in rotating the shoulders, the anterior arm becomes 
 displaced backward, so that the forearm is thrown across the neck of 
 the child. When this accident is of recent occurrence, the release of 
 the arm may be accomplished by pressing the thorax of the child back- 
 ward into the genital passage, and rotating the body in the reverse 
 direction from that which produced the difficulty. If, however, trac- 
 tions have been made upon the child until the head has entered the 
 pelvis, the arm may become so compressed between the neck and the 
 symph3^sis pubis as to render its liberation a very difficult if not im- 
 possible task. Then every resource should be quickly tested to turn 
 the shoulder of the displaced arm to the rear, either by raising the re- 
 leased arm, or by rotating the thorax, or by drawing upon the elbow. 
 In case of failure to obtain a speedy result, extraction may be at- 
 tempted without releasing the arm. To be sure, fracture of the 
 humerus is thereby rendered highly probable ; but if the bystanders 
 are forewarned that the risk is incurred in the interest of the child, 
 they are generally ready, where the life of the latter is preserved, to 
 condone the injury. 
 
 In setting a fractured arm, soft jiads should be baiulaged upon the 
 * Michaelis, Abhandlungen. Kiel. 1833. p. 230.
 
 3,j(3 OBSTETRIC SURGERY. 
 
 auterior and posterior surface to hold the extremities in position. The 
 posterior pad should run the entire length of the arm ; the anterior 
 pad need not extend below the elbow. The arm should then be band- 
 aged to the thorax. In two or three weeks consolidation takes place.* 
 In performing artificial rotation, it is well to bear the warning of 
 Dr. Barnes in mind, viz., " That the atlas forms with the axis a rota- 
 tory Joint, so constructed that, if the movement of rotation of the head 
 be carried beyond a quarter of a circle, the articulating surfaces part 
 immediately, and the spinal cord is compressed or torn.^f Pains 
 should accordingly be taken to note, when a half-turn is given to the 
 body, whether the head follows the movements of the trunk. 
 
 Third Act: Extraction of the Head. 
 
 In the extraction of the head we have to distinguish— 1. Cases in 
 which the head has entered the pelvis, and has only to overcome the 
 resistance of the perineum ; 2. Cases where the head is retained at 
 the brim by pelvic contraction, stricture of the os uteri, extension of 
 the chin, or insufficient expulsive action exerted by the uterus and the 
 abdominal muscles. 
 
 1. Extraction of the Head after it has entered the Pelvis. Smellie's 
 Method. — In the so-called Smellie's method the trunk of the child is 
 wrapped in a warm napkin and placed astride the operator's arm ; the 
 hand is then passed into the vagina, and the index and middle fingers 
 are placed upon the fossaj caninae to the sides of the child's nose. At 
 the same time, upward pressure is made with the fingers of the other 
 hand upon the occiput. By this means flexion of the head is induced. 
 Then by raising the trunk the face is rolled out over the perina3um. 
 This method possesses the advantage of avoiding the risks of injuring 
 the child which are incident to the other procedures. It requires for 
 its successful performance the completion of rotation, a small head, 
 and a lax perin^eum. 
 
 Combined Traction upon the Chin and Shoulders. — In case the fore- 
 going plan is not followed by immediate success, the two fingers upon 
 the fossae caninae should be introduced into the mouth, and the index and 
 middle fingers of the other hand should be forked upon the shoulders. 
 Tractions should be made somewhat downward, until the neck has been 
 drawn below the pubic arch and the chin has reached the coccyx. 
 Then, with occiput resting against the pubic walls, by a deliberate joint 
 movement of the two arms the body should be raised, and the face and 
 brow be made to rotate over the coccyx and perinaeum. By this method 
 there is obtained the greatest amount of traction force in combination 
 with the least degree of violence to the child. As the power is exerted 
 chiefly upon the shoulders, the fingers in the mouth are not likely to 
 
 * Spiegelberg, Lehrbuch, etc., p. 809. 
 
 f Barnes, Obst. Operations, Am. ed., p. 210.
 
 EXTRACTION IN FOOT AND BREECR PRESENTATIONS. 397 
 
 fracture the jaw, but by keeping the chin flexed and drawing gently 
 uto- it, the danger of twisting the neck, in cases where the rotaUon of 
 the face into the hollow of the sacrum is incomplete, is avoided. 
 
 Fig. 166.-Combmed traction upon mouth and shoulders. (Faraboeuf and Varnier.) 
 
 When the occiput is turned into the hollow of the sacrum and the 
 iorehead is pressed against the symphysis the process ^^^fl^f^^ 
 should be reversed. As the fingers are forked over the shoulders, the 
 back of the child should rest upon the arm. With one or two fingeis 
 
 . The combined traction upon the chin and shoulders is in Ge^a^y f own a 
 the Smeiiie-Veit modified method, the latter having warmly advocated the measure 
 In ISeT In a historical discussion of the subject Litzmann shows that, as regards 
 priority of description, the credit properly belongs to Maunceau.
 
 398 
 
 OBSTETRIC SURGERY. 
 
 of the other hand the ehiu should be flexed. Tractions should be made 
 downward, so that while the neck rests upon the perineum the fore- 
 head rotates under the symphysis pubis. 
 
 Ordinarily, when the head enters the pelvis in a transverse direc- 
 tion, the occiput rotates to the symphysis pubis during extraction. 
 Should the head, however, remain with its long diameter in the trans- 
 verse diameter of the pelvis, a hand introduced into the vagina, with 
 the back to the sacrum and the fingers over the chikFs face, may 
 
 sometimes be successfully employed to 
 rotate the latter into the sacral con- 
 cavity. 
 
 •2. Extraction with the Head at the 
 Brim. — W'itli the head at the brim, the 
 combined method as given above is 
 available in all ordinary emergencies. 
 As, however, the life of the child de- 
 pends upon the speedy extraction of 
 the head, it is well to become familiar 
 with the various procedures, as, by pass- 
 ing rapidly from one to another, a suc- 
 cessful result is often obtained, when 
 failure might have followed ineffectual 
 efforts in a single direction. 
 
 The Prague Method owes its mod- 
 ern name to tbe advocacy of Kiwisch, 
 ►Scanzoni, and Lange, all representatives 
 of the Prague school. It was, however, 
 nearly a century earlier described by 
 Pugh. It consists in seizing the feet 
 with one hand, and directing the body 
 of the child nearly vertically downward. 
 The fingers of the other hand are hooked 
 over the shoulders of the child, so that 
 the tips rest upon the supra-clavicular 
 region. Traction is exerted by both 
 hands simultaneously. In the absence 
 of pains, external pressure upon the head 
 should be made by an assistant through 
 the abdominal walls. Care should be 
 taken to avoid twisting the neck, and to preserve the normal relations 
 between the head and the shoulders. After the head has passed the 
 brim and fairly entered the pelvis, the hand upon the neck is em- 
 ployed as a fulcrum, while the extremities are raised rapidly toward 
 the abdomen of the mother ; the friction from the inner surface of 
 the symphysis pushes the occiput upward, and forces the face to de- 
 
 FiG. 167.— Extraction by the Prague 
 method.
 
 EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 399 
 
 Bcend into the hollow of the sacrum and to sweep over the peri- 
 nseum. 
 
 When the chin is directed to the front, and at the same time is 
 arrested at the symphysis pubis, if the occiput occupies the hollow of 
 
 Fig. 168.— The Prague method of extracting head. 
 
 the sacrum, the body of the child should, during the tractions, be 
 directed toward the abdomen of the mother, so as to cause the occiput 
 to rotate over the perineum. 
 
 The so-called Prague method is particularly serviceable in cases of 
 flattened pelvis, in which the chin normally is partially extended as the 
 head engages in the sagittal diameter of the brim. 
 
 Forceps to the After-coming Head. — The forceps to the after-com- 
 ing head has been condemned by some and warmly approved by others. 
 As, however, with its aid I have in a number of instances extracted 
 children alive in cases where the foregoing methods have failed me, it 
 is now my custom to have the blades duly warmed and ready to hand 
 before attempting manual extraction. The instrument is occasionally 
 of use in overcoming the resistance of a rigid perinseum in strongly 
 built primiparae, but is chiefly indicated when both occiput and chin 
 are arrested at the superior strait. With the chin anterior, the forceps 
 should be applied under the back of the child, and the handles raised 
 so as to bring the occiput into the hollow of the sacrum. With the
 
 400 
 
 OBSTETRIC SURGERY. 
 
 chin to the rear, the forceps should be applied uuder the abdomen, and 
 be used to draw the face into the sacrum. Where the arrest of the 
 head is due to stricture of the os externum or internum, the forceps 
 will sometimes bring the head rapidly through the cervix, when trac- 
 tion upon the feet only serves to drag the uterus to the vulva. In 
 stricture of the cervix, however, great care must be exercised to avoid 
 laceration, as uuder no circumstances are extensive ruptures of the 
 lower uterine segment so apt to follow as in the forcible extraction of 
 the after-coming head. Should this happen, the writer urgently 
 
 Fig. 169.— Chin arrested at symphysis. (ChaiIly-Honor6.) 
 
 counsels the immediate employment of the suture, as the dangers of 
 childbed are thereby diminished, and much immediate and prospect- 
 ive suffering are prevented. Tlie introduction of a large-sized catheter 
 into the child's mouth and drawing back the perinaeum have been 
 found useful as temporary means of introducing air into the child's 
 lungs, where delay attends efforts at delivery. 
 
 In extracting the after-coming head, the axis-traction forceps is 
 particularly serviceable. 
 
 CHAPTER XXI. 
 
 VERSION. 
 
 Cephalic version. — External method. — Combined method. 
 Wright.— Hohl. — Braxton Hicks. — Podalic version.- 
 nal version.— Neglected version.— Use of the fillet. 
 
 Version, or turning, is the term emiDloyed for the operations by 
 means of which an artificial change is effected in the presentation of 
 the child. It comprises the substitution of one pole of the foetus for 
 
 -Busch. — D'Outrepont. — 
 -Bipolar method. — Inter-
 
 VERSION. 401 
 
 the other, and the conversion of an oblique or shoulder presentation 
 into one in which the long axis of the fu3tus corresponds to the verti- 
 cal axis of the uterus. 
 
 It is customary to designate specifically the character of the version 
 by mentioning — 1. The presentation to be changed. Thus, versioii is 
 made from the head, the breech, or the shoulder, as the presenting 
 part. 2. The presentation to be effected. The term cephalic version 
 is used where the head is brought to the brim of the pelvis, and po- 
 dalic version where the feet are seized and the extremities made the 
 presenting part. 3. The method adopted by which version is accom- 
 plished. The expression external version is applied to manipulations 
 exclusively through the abdominal walls ; internal version, to the in- 
 troduction of the entire hand into the uterus ; and the combined 
 method to cases in which both hands, the one externally and the other 
 with two to four fingers introduced through the os, co-operate together. 
 
 Cephalic Version. — When it is simply required to rectify a faulty 
 presentation (shoulder or transverse), without reference to modifying 
 circumstances, cephalic version unquestionably deserves the preference. 
 In practiee, however, this method requires the concurrence of so many 
 favorable conditions that its employment is very limited. For instance, 
 there must be no comjjlications which call for rapid delivery. It would 
 be unsuitable in prolapse of the cord and in cases of placenta previa. 
 There should be nothing to prevent the child's head from entering the 
 brim of the pelvis. It should, therefore, not be attempted in con- 
 tracted pelves. A prolapsed arm, unless previously replaced, would 
 render the operation impossible. The child should enjoy a considera- 
 ble degree of mobility. An abundance of amniotic fluid contributes 
 much, though it is not indispensable, to success, as, even after the 
 rupture of the membranes, provided the uterine walls are sufficiently 
 relaxed, the head may be brought into the pelvis. Before rupture, 
 excessive sensitiveness to manipulations, and, after rupture, rigidity of 
 the uterus, stand in the way of success. 
 
 The operation may be performed by either the external or the com- 
 bined method. 
 
 Of the external methods the best is that which is known as AVi- 
 gand's (1807), which combines a suitable position of the mother with 
 manipulations through the abdominal walls. The mother is at first 
 made to lie upon her back, with knees fiexed, and with the abdomen 
 exposed or covered by some light material. The j^hysician stands by 
 the side of the patient, looking in the direction of her face. He be- 
 gins by laying his hands flat upon the surface of the abdomen, and 
 seeks with the one the head and with the other the breech of the fostus. 
 During the intervals of the pains, by gentle movements of the two 
 hands working simultaneously, he strives to press up the breech and 
 anterior surface of the child and to bring the head into the peb ic 
 26
 
 402 OBSTETRIC SURGERY. 
 
 brim. Should the uterus harden, all friction movements of the hands 
 should cease, and the efforts of the operator be confined to holding the 
 foetus steady in the position previously produced. The movement may 
 be aided by turning the woman upon the side toward which the head 
 is directed. As the fundus of the uterus sinks to the side upon which 
 the woman lies, it carries the breech of the child with it, while the 
 change in the uterine axis tends to throw the cephalic end in the op- 
 posite direction. 
 
 When the head is once brought to the brim of the pelvis it may be 
 retained in situ, if the patient lies upon her side, by the hand of an 
 assistant, or by a small, hard pillow pressed firmly against it. If the 
 patient lies ujDon the back, two compresses may be laid along the sides 
 of the uterus near the head, and a bandage ajoplied to the abdomen to 
 keep them in i^osition. When the pains are regular and the cervix 
 partially dilated, fixation of the head may be accomplished by ruptur- 
 ing the membranes and allowing the waters to escape. Until the 
 uterus retracts down upon the child, the head should be held at the 
 brim either by the two hands through the abdominal walls, or by the 
 thumb and four fingers of one lyind applied directly to jthe head 
 through the cervix. 
 
 The more important of the combined methods are those of Busch, 
 D'Outrepont, Wright, Hohl, and Braxton Hicks. They have in com- 
 
 FiG. irC— D'Outrepont's method, modified by Scanzoni. 
 
 mon the simultaneous employment of the external and internal hand. 
 They differ, however, in detail. The methods of Busch and D'Outre- 
 pont have now chiefly an historical interest. Busch introduced the 
 hand corresponding to the child's head through the vagina and cervix, 
 while counter-pressure was made with t!ie other hand upon the fundus
 
 VERSION. 403 
 
 uteri. The back of the hand is at first directed to the front. When, 
 however, its widest portion has passed above the symphysis pubis, the 
 back of the hand is turned to the concavity of the sacrum, and the fin- 
 gers are pushed up with care between the membranes and the uterus to 
 the head. The membranes are then ruptured, and during the escape 
 of tlie waters the head is seized by the fingers and thumb and drawn 
 into the pelvis, while the disengaged hand presses the breech toward 
 the median line. Every pains should be taken to prevent, with the 
 fingers, the prolapse of the cord, or of an arm,* during the escape of 
 the water. D'Outrepont seized the presenting shoulder between the 
 thumb and fingers of the hand corresponding to the breech, and, 
 during the intervals between the pains, pushed the shoulder upward 
 and in the direction of the breech until the head descended into the 
 pelvis. During this manoeuvre D'Outrepont simply used the external 
 hand to support the uterus. Scanzoni recommended that it should be 
 employed externally to press the head toward the pelvic brim.f 
 
 Wright's method differs from that of D'Outrepont, in that he em- 
 ployed, to seize the shoulder, the hand corresponding to the head, and 
 while he pushed the shoulder, without lifting, in the direction of the 
 curve of the uterus, he applied the remaining hand to dislodge the 
 breech, and move it toward the center of the uterine cavity. J 
 
 All the foregoing methods require for their successful performance 
 a movable foetus and a dilated cervix — conditions which render podalic 
 version safe and of easy execution. In practice, therefore, they have 
 never enjoyed any considerable degree of popularity. Of far greater 
 importance are the methods of Hohl and Braxton Hicks, which, pos- 
 sessing the advantage of requiring the introduction of two fingers only 
 into the uterus, can consequently be resorted to at an early stage of 
 labor. Hohl, like Wright, employed for internal use the hand corre- 
 sponding to the head. With two fingers in the cervix, he pushed the 
 top of the shoulder in the direction of the breech, and pressed the 
 head into the pelvis with the external hand. At the same time he in- 
 trusted to an assistant the task of seizing the fundus of the uterus be- 
 tween the palms of the hands, and directing it to the side toward which 
 the head was originally turned.* Braxton Hicks describes his method 
 as follows : " Introduce the left hand into the vagina as in podalic ver- 
 sion ; place the right hand on the outside of the abdomen, in order 
 to make out the position of the foetus and the direction of the head 
 and feet. Should the shoulder, for instance, present, then push it, 
 with one or two fingers on the top, in the direction of the feet. At 
 the same time pressure by the outer hand should be exerted upon the 
 cephalic end of the child. This will bring down the head close to the 
 
 * Scanzoni, Lehrbuch der Geburtshiilfe, 1867, Bd. iii, p. 63. t Op. cit., p. 65. 
 
 X Wright, Am. .Jour, of Obstet., vol. vi, part 1, 1873. 
 
 « Hohl, Lehrbueh der Geburtshulfe, 2te Auflage, 1862, p. 784.
 
 ^Q^ OBSTETRIC SURGERY. 
 
 OS ; then let the head be received upon the tips of the inside fingers. 
 The head will play like a ball between the hands, and can be placed m 
 almost any part at will. ... It is as 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." * Lately, Hicks has proposed to employ the external hand 
 to alternately press the head into the os and the breech to the fundus. 
 His plan differs from that of Hohl, in that he operates with the pa- 
 tient upon the side, and uses the left hand with the patient upon the 
 left side, and the right hand when she lies upon the right. He like- 
 wise dispenses with an assistant. f 
 
 Podalic Version.— Podalic version is indicated in the following cases : 
 
 1. The transverse presentation, where cephalic version is contra- 
 indicated, or attended with any considerable degree of difficulty. 
 
 2. In head presentations, where there is reason to suppose that the 
 result would be favorably influenced by bringing down the feet. As 
 illustrations of such conditions, we have faulty presentations of the 
 head and face, prolapse of the cord and extremities, placenta prsevia, 
 and contracted pelvis. The various contingencies which call for ver- 
 sion will be more closely considered in connection with the special 
 morbid conditions mentioned. 
 
 The operation may be performed by combined external and inter- 
 nal manipulations, or by the internal hand alone. 
 
 The Bipolar or Combined Method of Braxton Hicks.— In the bi- 
 polar method of turning, the two hands operate simultaneously upon 
 the extremities of the foetus. It may be carried out at will with the 
 patient upon the side or upon the back. The latter position is the 
 one which finds most favor in this country. The patient should be 
 placed transversely in the bed and the nates drawn to the edge. Two 
 assistants are required to hold the legs, which should be flexed and ro- 
 tated outward. As the beds in America are very low, where difficulty 
 in operating is anticipated it is sometimes advisable to remove the 
 patient after she has been anaesthetized to a table covered with a blan- 
 ket or woolen comforter. Complete anaesthesia is useful as a means 
 of facilitating the introduction of the internal hand, and maintaining 
 a relaxed condition of the uterus. Care should be taken that both 
 bladder and rectum are emptied. The hand selected for internal 
 manipulations should be of the same name as the side to which the 
 extremities are turned — i. e., feet to the right, right hand; feet to 
 the left, left hand. J; The fingers should be brought together in the 
 
 * Hicks, Combined External and Internal Version, Trans, of the Obstet. Soc. of 
 London, vol. v, p. 230. 
 
 t Hicks, Am. Jour, of Obstet., July, 1879, p. 593. 
 
 X In England the patient is delivered upon the left side, and the left hand is 
 commonly introduced into the vagina. In Germany, when the patient lies upon the
 
 VERSION. 405 
 
 form of a cone. The back of the haud and forearm should be well 
 lubricated with oil or lard. In passing the hand into the vagina, the 
 labia should be separated by the thumb and fingers of the disengaged 
 hand. Entrance is effected by directing the fingers toward the sa- 
 crum, and pressing backward upon the distensible perineum. In this 
 stage of the procedure hasty action is out of place. Patience and gen- 
 tleness are the prime requisites. Two or three fingers only need to be 
 carried through the internal os. When the presenting part is reached, 
 the external hand should be laid upon the abdomen, and pressure 
 brought to bear upon the breech. The two hands should then move the 
 extremities of the child in opposite directions. To quote Dr. Barnes, 
 " The movements by which this is effected are a combination of con- 
 tinuous pressure and gentle impulses or taps with the finger-tips on 
 the head (or shoulder), and a series of half-sliding, half-j)ushing im- 
 pulses with the palm of the hand outside." When the breech is well 
 pressed down to the iliac fossa, the membranes should be ruptured 
 during a pain, and a knee, which at this time is generally near the os 
 internum, should be seized and hooked into the vagina with the fin- 
 gers. As the breech is brought into the pelvis by tractions upon the 
 leg, the outer hand should be employed to press up the head until the 
 version is completed. 
 
 The manipulations described are to be conducted during the inter- 
 vals between the pains. Care should be taken not to hook down the 
 cord with the knee. When the lower extremities are reflected upward 
 upon the body so that a knee is not attainable, the breech may often 
 be brought down by a finger inserted into the fold of the thigh, or by 
 pressure upon some part of the pelvis. 
 
 The combined method of version, which we owe in all its essential 
 features to Braxton Hicks, is one of the most important contributions 
 to obstetrical practice of the present century. It possesses the price- 
 less advantages of enabling the physician to perform version early in 
 labor, and to accomplish the operation without in any way imperiling 
 the integrity of the uterus. The only prerequisites for success are : 
 sufficient dilatation of the cervix to permit the passage of two fingers, 
 a certain degree of fetal mobility within the uterine cavity, and a pre- 
 cise knowledge of the fetal position. After rupture of the membranes 
 and escape of the waters, the operation becomes more difficult, but is 
 even then not always impracticable. 
 
 Internal Version. — In internal version the entire hand is introduced 
 into the uterus. It is necessary, therefore, that the cervix should be so 
 far dilated that the hand can be passed without violence through the 
 cervical canal. Irregular uterine contractions require to be relieved 
 by hypodermic injections of morphia, with or without the addition of 
 
 right side, the left hand is employed inside : when upon the left side, the right hand. 
 The choice of hands, it will be seen, is not a matter of considerable importance.
 
 406 
 
 OBSTETRIC SURGERY. 
 
 atropia, or by the induction of comiDlete anaesthesia. As internal ver- 
 sion is not an indifferent operation, but may be followed by inflamma- 
 tions due either to injuries of the maternal tissues or to the introduc- 
 tion of infected air into the uterus, it should not be attempted until 
 the' impracticability of the combined method has been demonstrated. 
 It is applicable chiefly to cases in which a certain degree of uterine 
 
 retraction has followed upon the 
 escape of the amniotic fluid,* 
 
 The patient should be placed 
 upon the back or side ; the bladder 
 and rectum should be emptied; 
 and anaesthesia should be pushed 
 until the action of the abdominal 
 muscles is suspended. The exact 
 position of the foetus should be 
 carefully ascertained. The hand 
 should be rendered thoroughly 
 aseptic, and should be passed 
 slowly, after the expiration of a 
 pain, with the fingers formed into 
 a cone, through the vagina and 
 cervix, opposite the sacro - iliac 
 synchondrosis, upon the side of 
 the child's feet. At the same 
 time counter-pressure sliould be 
 maintained over the fundus uteri, 
 to prevent rupture of the vaginal 
 attachments. If the uterus begins 
 to contract, the fingers should be 
 spread out, and the operator re- 
 main passive until the pain sub- 
 sides. 
 
 In head presentations, the hand employed should be always the one 
 which corresponds to the side of the child's feet. In transverse presen- 
 tations, when version is performed soon after the rupture of the mem- 
 branes, before retraction of the uterus has taken place to any extent, 
 the choice of hands is of little consequence. This is especially true in 
 the dorso-anterior position. Thus, when the child lies Avith the head 
 to the left, feet to the right, and belly to the rear, the right hand may 
 
 * If the membranes are intact, and internal version is chosen in place of the bi- 
 polar method, one of three plans is open in practice: 1. Boer recommended passing 
 the hand between the membranes and uterus to the feet of the child, and then rupt- 
 uring the membranes; 2. Hiiter seized the feet of the child through the mem- 
 branes, and turned without rupturing; 3. Levret ruptured the membranes at the 
 OS uteri, and introduced the hand during the outflow of the water. The third plan 
 is the one most deserving of favor. 
 
 Fig. 171.— Version in head presentations. 
 (Chailly-Honorg.)
 
 VERSION. 407 
 
 be passed directly across the belly to the extremities of the child, or 
 the left hand may be made to pass from the breech, along the surface 
 of the thigh, to the nearest knee or leg. By the latter method the 
 danger of mistaking an arm for the leg is avoided. Should, in any 
 ease, doubt upon this score arise, the characteristic differences between 
 the hand and foot should guide us to a correct diagnosis. Thus, the 
 wrist enjoys greater mobility than the ankle, the fingers are longer 
 than the toes, the palm is shorter than the sole, the position of the 
 thumb is peculiar to the hand, and the pointed heel to the foot. 
 
 In the lateral position, the patient should be placed upon the side 
 to which the child's breech is turned, with the buttocks near the edge 
 of the bed. Here, obviously, the operator, standing in the rear of his 
 patient, would use with the greatest facility the hand corresponding to 
 the side upon which the woman lies (left side, right hand, and vice 
 versa). In dorso-posterior positions especially, the advantages of such 
 a selection are manifest. 
 
 In easy versions, it is correct practice to bring down one foot or 
 knee only. When one extremity is left reflected upon the abdomen, 
 the larger size of the breech more fully distends the cervix, and thus 
 prepares the way for the subsequent passage of the child's head. In 
 difficult cases, or when rapid delivery is to be effected, both feet should 
 be seized. A single foot should be held at the ankle between the thumb 
 and fingers. When practicable, the entire leg may be grasped with 
 the closed hand. When it is sought to turn by both feet, the middle 
 finger should be placed between them, while the ankles are held by the 
 second and fourth fingers. 
 
 While in uncomplicated cases it is not a matter of great importance 
 which extremity is selected, it is still proper to remember that, in ac- 
 cordance with the rule that the limb drawn upon moves forward under 
 the symphysis, the necessary amount of rotation is less when with the 
 feet to the rear the lower, and with the feet to the front the upper, ex- 
 tremity is subjected to traction. 
 
 As in the bipolar method, during the traction upon the foot the 
 external hand should aid versioA by pressure upon the head made 
 through the abdominal walls with the disengaged hand. 
 
 When, in transverse presentations, the membranes rupture, the 
 lower arm not unfrequently becomes prolapsed into the vagina. As a 
 rule, this complication does not embarrass version, though it may prove 
 a hindrance to the introduction of the hand. It is a good plan, in 
 arm presentations, to slip a noose of tape about the wrist, which serves 
 a twofold purpose, enabling us to draw the extremity up toward the 
 symphysis, or back against the perinasum, according as the hand is to 
 be passed posteriorly or anteriorly, and to hold the arm to the side of 
 the child's body during the performance of version, thus avoiding the 
 difficulties of arm delivery in the period of extraction. Dr. F. P.
 
 4:08 
 
 OBSTETRIC SURGERY, 
 
 Foster, in a case where the mobility of the child was unimpeded, used 
 the prolapsed arm as an aid to version in the followmg ingenious 
 manner : The child lay with the back to the front, the head upon the 
 right iliac fossa, and the left arm presenting. With the right hand in 
 the vagina, he seized the arm and pushed gently upward m the di- 
 
 Fig. 172.— Version in dorso-anterior position, first stage. Traction on lower limb. 
 (.Faraboeuf and Varnier.) 
 
 rection of the humerus. In this way he succeeded in elevating the 
 cephalic pole until with the index-finger alone in the cervix uteri he 
 managed to reach the breech of the child. With the point of his 
 finger he gently urged this along to the mother's right side, and soon 
 encountered the left foot, which he readily hooked down into the 
 vagina.* 
 
 When, after rupture of the membranes, aid is not promptly ren- 
 dered, the shoulder becomes crowded into the pelvic brim. If the 
 
 * Foster, On Prolapse of the Arm in Transverse Presentations, Amer. Jour, of 
 Obstet., vol. ix, p. 203.
 
 VERSION. 
 
 409 
 
 pains are feeble the uterus may remain relaxed, so that hours after- 
 ward version may be readily performed. If the pains are good, how- 
 ever, as the waters escape the uterus retracts, and finally becomes rigid- 
 ly applied to the surface of the foetus. Under these conditions, the 
 lower uterine segment, which contains the head and shoulder of the 
 
 Fig. 173. 
 
 -Version in dorso-anterior position, second stage. Traction on lower limb. 
 (FarabcBuf and Varuier.) 
 
 child, is often stretched to an extreme degree of tenuity. Version, 
 under the circumstances, is embarrassed by the difficulty of introducing 
 the hand into the uterus to seize the foot ; by the fact that when trac- 
 tions are made upon an extremity, in place of the child turning in 
 utero^ both child and the closely aj^plied uterus are apt to move to- 
 gether ; and by the danger of rupture due to the difficulty of lowering 
 the breech without simultaneously increasing the pressure exerted upon 
 the thinned lower segment by the child's head.
 
 ^^Q OBSTETRIC SURGERY. 
 
 In operating after the retraction of the uterus has become complete, 
 the physician should seek to effect the utmost relaxation by pushmg 
 anesthesia to complete insensibility. The hand should be mtroduced 
 slowly and with the utmost gentleness. Precipitate action, or an at- 
 tempt to overcome the uterine resistance by force, may cause fatal 
 rupture Tlie external hand should make firm counter-pressure upon 
 the fundus, to prevent the uterus from being torn from the vagina 
 The seizure of the lower foot is usually alone practicable, himpson, it 
 is true, regarded the secret of success in such cases as depending upon 
 
 Fig. 174.— Version in dorso-posterior position. Traction on upper limb. 
 (Faraboeuf and Varnier.) 
 
 making tractions with the upper limb, as tending to rotate the body of 
 the child upon its long axis, and thus favoring the release of the pre- 
 senting shoulder from its imprisonment. However rational all this 
 sounds in theory, rotation within a rigidly contracted uterus is easier 
 to represent by diagram tlian to carry out in practice. The result of 
 seizing the upper leg is usually to cross it with its fellow, and to twist 
 the child's body so as to injuriously compress the abdominal viscera. 
 By making tractions upon the lower leg, the breech is brought by the 
 shortest route to the uterine orifice. To be sure, by this manoeuvre the 
 body of the child is bent laterally, but lateral flexion does the child no 
 harm. In case of failure to effect version, a noose of tape may be
 
 VEESION. 
 
 411 
 
 placed upon the foot, and the hand returned to seek the other extrem- 
 ity. When the foot is within reach, the loop of the fillet, placed about 
 the fingers, is easily conveyed upward to the ankle. When, however, 
 the foot is high up in the vagina, where the movement of the fingers is 
 impeded, some form of instrument is needed to push the loop from the 
 
 Fig. 175.— Method of seizing the foot in breech cases. (Faraboeuf and Varnier.) 
 
 fingers over the foot. Unquestionably the most serviceable contrivance 
 to this end is the repositor of Carl Braun, which consists of a gutta- 
 percha rod sixteen inches in length, with an aperture two inches from 
 the extremity, through which the loop of a double tape is threaded. 
 When in use this loop is passed around the noose of the fillet, and is 
 then reflected over the end of the rod. Thus secured, the fillet is con- 
 veyed to the position aimed at. Then, by loosening the ends of the 
 tape, which during the upward movement are held to the sides of the
 
 412 
 
 OBSTETRIC SURGERY. 
 
 rod by the operator's hand, and by shaking the rod, the instrument is 
 easily detached, and can be withdrawn without difficulty. 
 
 If the operator does not care to release the foot, because of the 
 difficulties he has encountered in getting possession of it, the fillet 
 may be noosed around his arm, and thence be pushed upward over the 
 hand, to the seized extremity. 
 
 A device which in many instances has rendered me excellent serv- 
 ice, has consisted of an ordinary catheter threaded with a doubled 
 piece of twine, so that the loop projected from the eye of the mstru- 
 
 Fig. 176.— Braun's repositor. 
 
 Fig. 177.— Catheter used as repositor. 
 
 ment. This loop, after inserting the stylet into the catheter, I have 
 used in precisely the manner laid down for the employment of Braun's 
 instrument. 
 
 In case the second limb can not be reached, or where traction upon 
 both extremities fails to bring the breech into the cervix, an attempt 
 should be made to dislodge and elevate the presenting shoulder. This 
 can sometimes be accomplished, in accordance with the suggestion of 
 Professor Goodell, by bringing down the upper arm and turning the 
 child upon its long axis ; or, while the noosed foot is held out of the 
 way by the attached fillet, the hand corresponding to the child's head 
 may be introduced into the vagina and employed to press the present- 
 ing part away from the cervix. The raising of the shoulder should be 
 gradual, and should be performed with the utmost gentleness, as the 
 danger of uterine rupture is peculiarly enhanced by the thinned, over- 
 stretched condition of the lower segment. Meantime a skilled assist- 
 ant should exercise counter-pressure from without upon the fundus of 
 the uterus and upon the head of the child, and aid the descent of the 
 breech by rightly directed pressure. Eesolution to succeed, combined
 
 CRANIOTOMY AND EMBRYOTOMY. 413 
 
 with patience in manipulation, usually overcomes the obstacles pre- 
 sented by the most difficult cases. 
 
 In the few instances where failure follows all attempts to accom- 
 plish version, or where rupture is imminent, or where the child is 
 known to be dead, the obstacle to delivery may be overcome by decapi- 
 tation, and the removal of the head and trunk separately. 
 
 CHAPTER XXII. 
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 Craniotomy. — Indications. — Operation. — Perforators. — Method of perforating. — Ex- 
 traction after perforation. — Forceps. — Cephalotribe. — Action of the cephalo- 
 tribe. — Objections. — Application of the cephalotribe. — Cranioclast. — Crotchet 
 and blunt hook. — Cephalotomy. — Embryotomy. — Exenteration. — Decapitation. 
 
 Ckaxiotomy. 
 
 Craniotomy inch^des all the various oiierations employed to reduce 
 the dimensions of the child's head. Thus the term is apjilied — 1. To 
 the perforation of the skull and the evacuation of the brain-contents ; 
 and, 2. To the various procedures subsequently adopted to further 
 minimize and extract the cranial walls. 
 
 Indications for Perforation. — Perforation is resorted to, in cases of 
 mechanical obstacles to delivery, to overcome the disj^roportion existing 
 between the child's head and the parturient canal. As the operation 
 is jDerformed solely in the interests of the mother, it possesses a wider 
 range of applicability when the child is dead than when still living. 
 
 Perforation, in the dead child, is allowable in difficult labors so 
 soon as temporizing becomes dangerous to the mother. The mere 
 aesthetic advantage of removing by forceps an unmutilated child ought 
 not, if attended by any risk, to be allowed to weigh with the physician 
 against the welfare and safety of the parent. 
 
 If the child is alive, the question of perforation is one of the most 
 serious that falls to the lot of the conscientious physician. If the life 
 of the mother is at stake, and the sacrifice of the child is necessary to 
 her preservation, few would dispute at the present day the superiority 
 of the mother's claim to existence. Still, it is not sentimentality to 
 feel that it is an awful thing to destroy a living child before a clear 
 conviction is reached that conservative measures, which hold out the 
 hope of preserving both lives, are of little or no avail. The proper 
 position, however, of craniotomy, between the C cesarean section on the 
 one hand and forceps and version on the other, will be discussed in 
 the section upon the treatment of contracted pelves.
 
 414 OBSTETRIC SURGERY. 
 
 Operation.— When perforation has once been decided npon, there 
 sliould be no delay in its execution. By delay, the very object of its 
 performance— viz., the preservation of the life of the mother — is im- 
 periled.* 
 
 The patient should be placed in the usual obstetrical position, with 
 the knees flexed and the hips drawn over the edge of the bed. Chloro- 
 form is not requisite. It is useful, however, as a means of saving the 
 mother from painful after-memories. There is no operation in obstet- 
 rics in which the result depends so much upon thoroughness in carry- 
 ing out antiseptic details. If the head is not fixed at the brim, it 
 should be held firmly in position by the hands of an assistant, through 
 the abdominal walls, or the child should be turned, and perforation per- 
 formed on the after-coming head. 
 
 Complete dilatation of the cervix is not essential to the execution 
 of the operation. If the object is simply to relieve the maternal soft 
 parts from pressure, perforation may be performed at an early stage 
 of labor. When, however, it is intended to follow perforation by im- 
 mediate extraction, it is necessary to secure sufficient preliminary dil- 
 atation. In just this class of cases I have seen excellent results from 
 the employment of Dr. I. E. Taylor's long, narrow-bladed forceps, 
 which can be passed through a cervix dilated to scarcely an inch and 
 a half in diameter. They enable the operator to seize the head and 
 use it as a dilating wedge during and after a pain {vide p. 368). If 
 the cervix hangs empty in the pelvis, and the head can not be moved 
 from the brim, Barnes's dilators are often of great service. Unques 
 tionably, in many cases le=!S violence is done to the mother if simple 
 perforation is resorted to, the brain evacuated, and the dilatation of 
 the cervix left to be accomplished by the pressure of the gradually 
 collapsing head. This method, however, exposes the mother to the 
 dangers of septic poisoning, as, unless the pains should be good and 
 delivery rapid, decomposition of the foetus in utero speedily sets in 
 after perforation. 
 
 Instruments employed in Perforation.— Most of the perforating in- 
 struments in use in this country are patterned,' with modifications, 
 after the scissors of Smellie. Simpson's perforator is the one I have 
 been in the habit of employing. As compression of the handles causes 
 the separation of the perforating points, it can be easily managed with 
 one hand. The projecting shoulders, just beneath the cutting por- 
 tions, prevent the instrument from penetrating too far into the skull. 
 The edges and points of the blades are rounded, so that they are not 
 liable to injure the soft parts of the mother during the operation. The 
 
 * Spiegelberg states that between the years 1870 and 1877, of thirty-three cases 
 of perforation, three terminated fatally; while in the previous five years in which 
 the operation was performed, at a late period, of thirteen cases, seven ended in 
 death. (Handbuch der Geburtshiilfe, p. 833.)
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 415 
 
 cliief objection to the instrument arises out of these special measures 
 of safety, as, owing to its bluutness, considerable force has to be em- 
 
 FiG. 178.— Scissors of Smellie. 
 
 ployed to penetrate the skull, which increases, of course, the risk of 
 slipping. A better instrument is that of Monsieur Blot. It possesses 
 
 Fig. 179.— Simpson's perforator. 
 
 a spear-point, which makes it effective as a perforator. The blades, 
 when the instrument is shut, are superimposed, and are not capable 
 
 Fig. 180.— Blot's perforator. 
 
 of harming the maternal tissues. When the blades are separated, after 
 perforation has been accomplished, they readily cut the bony structure 
 
 Fig. 181.— Hodge's craniotomy scissors. 
 
 of the skull. Hodge's craniotomy scissors can be used as a perforator, 
 and afterward to cut away portions of bone. Dr. T. G. Thomas has
 
 416 OBSTETRIC SURGERY. 
 
 devised a perforator with a gimlet-like extremity, which is intended 
 to bore its way into the sknll. The opening is afterward enlarged by 
 a knife which lies concealed and gnarded in the body of the instrnment 
 
 182.— Thomas's perforator. 
 
 until required for nse. Mechanically considered, Thomas's perforator 
 is beyond reproach. It is, however, somewhat more difficult to keep 
 in order than those previously mentioned. 
 
 The basylist of Professor Alexander Simpson resembles in its gen- 
 eral features the perforator of Dr. Thomas. It is, however, much 
 
 Fig. 1S3.— Simpson's basylist. 
 
 heavier and of more solid construction. In the place of the concealed 
 knife it jDossesses two arms, which, when separated from one another, 
 act as powerful levers. The instrument is designed not only to 
 perforate the cranial vault, but, as its name implies, to break up the 
 base of the skull. When this action is rendered necessary, the basylist 
 should be pushed inward to the sphenoid bone, and a point selected for 
 perforation in front of the sella turcica. After boring well into the 
 
 Fig. 184.— Trephine perforator. 
 
 sphenoid, the lever is used to forcibly separate the base into two por- 
 tions. Ordinarily, the expulsion of the child can then be left to the 
 natural forces. 
 
 The Germans employ for the most part a long trephining perfo- 
 rator, Avhich removes circular segments from the scalp and the skull. 
 The trephine leaves behind no splintered portions of bones, and makes
 
 CRANI0T03IY AND EMBRYOTOMY. 
 
 417 
 
 an opening which is not likely to close from overlapping ; but it can, 
 on the other hand, be nsed only upon the cranial vault. 
 
 Previous to practicing craniotomy the bladder and rectum should 
 be emptied. The operator introduces his middle and index fingers 
 into the vagina, and presses them firmly against the most accessible por- 
 tion of the child's head. Great care, at this stage, should be exercised 
 
 Fig. 183.— Operation for perforating the child's bead. 
 
 to gain an exact idea of the situation and the extent of the dilatation 
 of the cervix. The operator then seizes the handle of the perforator 
 in the right hand, and passes the pointed extremity, under the guid- 
 ance of the fingei's of the left hand, to the region of the head at which 
 it has been decided the perforation is to be made. If convenient, a 
 suture or a fontanelle may be selected, in place of the bony table of 
 the skull. The perforator should be pressed against the cranium with 
 a boring movement until the cessation of resistance warns the operator 
 that the bony incasement has been traversed. In cases where the 
 skull is unusually thick or hard this part of the operation may prove 
 a matter of some difficulty. Care should be taken to hold the instru- 
 ment at right angles to the point of perforation, as otherwise it is apt 
 to glance from the rounded surface of the head. 
 27
 
 4^j^g OBSTETRIC SURGERY. 
 
 If the head, in place of being fixed in the pelvis, is situated high 
 up, every precaution should be taken in the operation. The head 
 should be pressed firmly against the brim through the abdomen by an 
 assistant. The perforator should follow the axis of the superior strait. 
 The point selected for perforation should be near the symphysis, as 
 the instrument is then much less liable to slip than if carried back- 
 ward toward the promontory. The fingers of the left hand should 
 keep constant guard upon its direction. Oftentimes, by way of pro- 
 tection, the operator introduces the entire half-hand into the vagina. 
 After the perforator has penetrated the skull, the opening should be 
 enlarged by compressing the handles and separating the cutting 
 blades; then, allowing the latter to close, the instrument should be 
 semi-rotated, and a second cut made at right angles to the first. Be- 
 fore withdrawing the perforator, it should be moved about freely to 
 break up the brain-mass. The rapidity and completeness of the col- 
 lapse of the cranial walls are, in a measure, dependent upon the com- 
 pleteness of the evacuation of the cranial contents. Care, too, should 
 be taken to pass the perforator into the foramen magnum to break up 
 the medulla oblongata, and thus to insure the death of the child before 
 delivery. Sometimes it is advantageous to wash out the brain-pulp by 
 injecting a stream of water into the cranial cavity.* 
 
 In face presentations care should be taken to pass the perforator 
 through the frontal bones, or through an orbit. Where neither of 
 these points is, however, accessible, it is possible to make the opening 
 through the roof of the mouth, behind the nasal fossae. 
 
 The perforation of the after-coming head is always a matter of 
 considerable difficulty. The point of the perforator has to be inserted 
 obliquely in place of at right angles to the skull, and therefore is more 
 liable to glance. On theoretical grounds it has been recommended to 
 insert the instrument either between the occiput and atlas, or through 
 a lateral fontanelle. In practice, however, such niceties are rarely 
 observed. , The operator simply passes the four fingers of the left hand 
 under the, symphysis pubis, and, while the feet of the child are drawn 
 dowuAvard and backward by an assistant, the perforation is made at 
 any point behind the ear at which the manipulation can be most 
 easily effected. Chailly recommends hooking down the chin of the 
 child, and perforating, as in face presentations, through the roof of the 
 mouth, f 
 
 * Von Weber has shown that no cephalotribe can fully decerebrate a perforated 
 head, in general only the small part of the brain being evacuated. lie has likewise 
 demonstrated that a greater amount of compression can be accomplished in case of 
 a fully than a partially decerebrated head. The head, therefore, that has been fully 
 emptied can be more easily extracted than one that has only been partially de- 
 prived of its contents. 
 
 f Cohnstein recommends cutting down upon the cervical and upper dorsal ver- 
 tebra% and then openmg into the spinal canal by dividing the laminai. Through
 
 CRANIOTOMY AND EMBRYOTOMY. 419 
 
 The trephine-perforator requires to be pressed firmly and steadily 
 against the parietal bone. Sometimes, when a large scalp-tumor exists, 
 it is necessary to make a preliminary incision through the integuments. 
 The trephine is not liable to slip, and is easily managed ; as it can not 
 be used either upon the after-coming head or in face presentations, and 
 as it is difficult to keep clean and in order, the less complicated lance- 
 pointed instruments have, however, enjoyed the preference in all coun- 
 tries outside of Germany, 
 
 Extraction of the Child after Perforation. — Formerly, after per- 
 foration, a waiting policy was by many thought desirable. Osborne, 
 indeed, recommended that at least thirty hours be allowed to elapse 
 before delivery, in case craniotomy was performed upon a living child. 
 The grounds for favoring a temporizing policy were found in the 
 softening and relaxation of the sutures, and the ease with which flat- 
 tening takes place after putrefaction has once set in. At present, 
 however, it is customary to extract so soon as the condition of the os 
 renders it safe to resort to the necessary operative procedures. This 
 change in practice results from altered views regarding the dangers 
 due to mere protraction of labor, to fear of septic poisoning, and 
 finally to improved methods now at our disposal for the termination 
 of labor. Extraction may be performed by the forceps, the cepha- 
 lotribe, the cranioclast, the crotchet, or the blunt hook. In some 
 cases version may be employed with success. Each instrument, each 
 method, has its limitations and its range of applicability. Usually, in 
 extreme disproportion, the operator finds it to his advantage to have 
 at hand a complete equipment, and to resort at different stages of 
 delivery to a succession of operative manoeuvres. The acceptance of 
 single measures and the Avholesale condemnation of all others are cal- 
 culated in difficult cases to lead to embarrassment and failure. A 
 study, therefore, of the capacity of the various extractive instruments 
 employed to deliver the perforated head is essential to the formation 
 of correct judgment as regards practice. 
 
 Forceps. — The use of forceps as an extractive instrument, after per- 
 foration, is recommended by Tarnier as follows : " As the application 
 of forceps has often succeeded in our hands, we do not hesitate to say 
 that it is a good operation, applicable above all to cases in which the 
 pelvic contraction is not considerable. The forceps possesses the ad- 
 vantage of being in the hands of every physician ; it seizes the head 
 firmly, and, by pressing the handles forcibly together, a sufficient evac- 
 uation of the cerebral contents is effected to secure a marked flattening 
 of the cranial walls. In making prudent tractions, one often succeeds 
 
 the opening a silver catheter can be passed to the cranial cavity, and be used to 
 break \ip the brain-mass, which should be washed out through the canal by injec- 
 tions of water. — {Yide Ein neues Perforations Verfahren, Arch. f. Gynaek., Bd. vi, 
 p. 505.)
 
 420 OBSTETRIC SURGERY. 
 
 in extracting the head withont any harm to the mother ; the danger 
 begins only with too violent tractions." * These remarks apply, how- 
 ever, to the powerful French forceps, which is capable of exerting con- 
 siderable compressive force. Hodge has found his forceps useful under 
 similar conditions.! The short handles and the great width between 
 the blades, in the English forceps, render it useless as a tractor when 
 craniotomy has been performed. 
 
 CepJialofribe.— On the 6th of June, 1829, Baudelocque, le neveu, 
 read before the Institut Royal de France a memoir upon a new method 
 of performing embryotomy. J He first pictured the dangers incident 
 to all operations effected with pointed and sharp-edged instruments 
 introduced Avithin the uterus. From the statistics of the previous 
 sixteen and a half years in the Maternite, he showed that half the 
 mothers thus operated upon died, and that the shortest of these opera- 
 tions lasted three quarters of an hour. He then described an instru- 
 ment he had invented, which he termed the cephalotribe, and repre- 
 sented that with it he could crush in an instant the base and parietes 
 of the fetal skull, forcing the brain from the orbits, the nostrils, and 
 the mouth, the integuments at the same time remaining intact and 
 forming a sort of sac, which sufficed to prevent the edges of the fract- 
 ured bones from inflicting injury upon the soft parts of the mother. 
 The autlior furthermore expressed his conviction that the cephalotribe 
 was destined to abolish and replace the perforator and the crotchet, 
 and that it could be employed successfully in pelves measuring but 
 two inches in the contracted diameter. 
 
 This early instrument was two feet long, and weighed over seven 
 pounds. In shape it resembled the forceps. To the handles a crank 
 was attached, destined to aj)proximate the enormous blades to one 
 another. The original cephalotribe has since been subjected to vari- 
 ous modifications, with a view chiefly to the removal of its repulsive 
 appearance. The observation of Chailly, in his Traite pratique des 
 accouchements, 1843, that perforation should always precede cepha- 
 lotripsy, led especially to the construction of lighter and more conven- 
 ient instruments. The dream of Baudelocque, that the cephalotribe 
 was destined to abolish the perforator, has never been fulfilled. 
 
 The models in use at the present day vary considerably in weight, 
 the extent of the pelvic and cranial curves, and the character of the 
 apparatus for producing compression. These different varieties are 
 simply expressions of the defective working of the instrument itself. 
 The shape of the blades possesses the greatest importance practically. 
 It is to be borne in mind that the cephalotribe is designed to act both 
 as a crusher and as a tractor. Now, it so happens that whatsoever 
 
 * Tarnier, Diet, lie Medecine et de Chirurgie, art. Embryotomie, vol. xii, p. 657. 
 t Hodge, On Compression of the Petal Head, Am. Jour, "of Obstet, May, 1875. 
 X A. Baudelocque, Revue Med., August, 1829, p. 321.
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 421 
 
 tends to make it available in the one direction is obtainable only by 
 the sacrifice of some corresponding advantage in the other. Thus, it 
 is evident that the greatest amount of crushing force is exercised when 
 the blades run nearly parallel to one another ; but, without a cranial 
 curve, the blades, in place of being applied to the convexity of the 
 child's head, open like scissors, and thus are liable to slip, if the in- 
 strument is employed as a tractor. Again, as the blades are usually 
 applied in the transverse or in an oblique diameter, it is necessary to 
 rotate the cephalotribe to make the flattened head correspond to the 
 flattened pelvic diameter, liotation of the cephalotribe within the 
 genital organs necessitates an instrument without pelvic curve ; and, 
 yet, where there is any considerable projection of the promonotory, a 
 straight instrument is apt to seize the head upon its posterior aspect 
 only, and thus the head is often forced from the blades, when com- 
 pression is used, like a cherry-pit, to use Cazeaux's simile, from between 
 the fingers. 
 
 Fig. 186 represents the French instrument of Blot, which is pro- 
 vided Avith a good pelvic curve, but the blades are in close approxima- 
 
 FiG. ist3.— CViJhalotribe of Blot. 
 
 tion to one another. In Scanzoni's cephalotribe. Fig. 187, the line of 
 greatest difference between the outer surfaces of the blades is nearly 
 The inner surface of the blades is supplied with a longi- 
 
 two inches. 
 
 Fig. 187.— Cephalotribe of Scanzoni. 
 
 tudinal ridge occupying the center, while the square extremities curve 
 sharply inward like pincers. The instrument possesses a pelvic curve 
 of two and three quarters inches. When the Scanzoni cephalotribe is
 
 4.22 OBSTETRIC SURGERY. 
 
 applied to the sides of the decerebrated head, the latter lengthens in 
 the axis of the instrument, but Munde reports that he has witnessed 
 the failure of the instrument to seize the head securely in the Wurz- 
 burg clinic, in three cases out of four. Fig. 188 represents a cephalo- 
 
 Fio. 188.— The author's cephalotribe. 
 
 tribe made for me some years ago by Messrs. Tiemann & Co., which 
 has met with considerable favor in New York and its vicinity. It has 
 a cephalic curve of two inches and a quarter, measuring from the 
 outer surfaces of the blades.* The pelvic curve is three inches and 
 two lines in extent. These measurements are similar to those of the 
 Prague instruments of Seyfert and Breisky. The blades are fenes- 
 trated and grooved upon the inner surfaces. The advantages of an in- 
 strument thus modeled are obvious. It is possible with its aid to seize 
 the head when movable above the pelvic brim. As the points ap- 
 proach each other closely after compression of the head is completed, 
 the instrument becomes a perfect tractor, holding the head as securely 
 as an ordinary forceps. Its construction is, however, virtually the 
 abandonment of two favorite but chimerical ideas regarding the ca- 
 pacity and mode of action of the cephalotribe, viz.. that it is capable of 
 flattening the head so that the latter can be drawn through a pelvis 
 measuring but two inches in the conjugate diameter, and that this can 
 be accomplished by rotating the instrument, as we have mentioned, so 
 as to make the flattened head correspond to the shortened diameter of 
 the pelvis. 
 
 The actual result of compression by means of the cephalotribe was long a 
 matter of dispute. Baudelocque, with his ponderous instrument, claimed to 
 have been able to instantly crush the skull, including the base. Kilian t relates 
 that in his first case of cephalotripsy he succeeded in breaking up the skull by 
 a single application into fifty-four pieces. Von Weber, however, made a large 
 number of experiments upon still-born children, employing for purposes of com- 
 
 * The advantages of making the blades parallel to one another are rather ap- 
 parent than real ; for, however effectively compression with such an instrument 
 may be applied, the head acts as a wedge, producing a separation at the extrem- 
 ities proportioned to the absence of the cephalic curve. Breisky and Seyfert have 
 insisted that it is better to transfer the greatest width between the blades from 
 the extremities to the points at which they come into immediate contact with the 
 child's head. 
 
 \ KiLiAX, Organ f. die gesammt. Medeein, Bd. ii, p. 279.
 
 CRANIOTOMY AND EMBRYOTOMY. 423 
 
 parison instruments of various patterns, and found that in no case did he suc- 
 ceed in fracturing the bones of the skull. Even after the complete evacuation 
 of the cerebral contents the bones would bend, but did not fracture. The result 
 was different, however, in cases where the cephalotribe was emploj-ed in actual 
 labor, where the head was subjected at the same time to pressure from the uter- 
 ine and pelvic walls. Under such circumstances the bones certainly may break, 
 if they do not invariably. Fractures he found, in fact, less common than simple 
 incurvations. Where a fracture took place in one bone it rarely extended to 
 contiguous ones, and, in general, contributed but little toward the actual reduc- 
 tion of the head. Winckel * presented three heads to the Obstetrical Society of 
 Berlin, upon which the cephalotribe had been used to facilitate delivery. Com- 
 pression, in these cases, had been employed in several diameters, and each time 
 the cracking sound elicited could have led one to suj)pose tliat the bones were 
 being reduced to small pieces, yet subsequent examination showed that only a 
 single bone, and that, usually, according to the position of the head, a parietal 
 bone, was broken to any extent, while the opposite side, generally the basis 
 cranii, was but slightly ruptured. Now, the greatest amount of compression 
 effected by the cephalotribe does not exceed two to two and a quarter inches. 
 The bizygomatic diameter, indeed, which measures three inches, is not, in or- 
 dinary cephalotripsy, attacked at all.t 
 
 It has always been objected to the cephalotribe that its application in the 
 transverse diameter increases the length of the head in the antero-posterior 
 diameter, or precisely where the pelvis is the narrowest, and thus adds to the 
 difficulty of delivery. This is no doubt true when the head is fixed in the pel- 
 vis, a fact which should lead us to give the preference to other instruments for 
 extraction after engagement has taken place. Above the brim, the cephalotribe 
 seizes the head usually in an oblique diameter, so that the compensation takes 
 place in the opposite oblique diameter. If the head is seized in the transverse 
 diameter, it may easily be rotated into an oblique diameter. Sometimes the 
 compressed head rotates spontaneousl}', so that the cephalotribe comes to oc- 
 cupy the conjugate, a thing obviously possible only in moderate degrees of 
 contraction. Artificial rotation of the cephalotribe into the conjugate is dan- 
 gerous, and should under no circumstances be attempted. It must be borne in 
 mind that the axis of the instrument is in a line between the upper border of 
 one blade and the lower blade of the other, and not in one drawn transversely 
 between them. If spontaneous rotation occurs, the instrument should be re- 
 moved, and the cranioclast employed as a tractor. Extraction with a powerful' 
 instrument like the cephalotribe can not be safely undertaken when the points 
 of pressure from the blades are the soft tissues between the symphysis and prom- 
 ontory. 
 
 Thus we find the cephalotribe useful in compressing the head 
 before it becomes fixed at the brim. It is, moreover, advantageous as 
 a tractor in moderate degrees of pelvic contraction. With two and 
 three quarters inches in the conjugate, the limit for its safe employ- 
 ment is, as a rule, reached. Of course it is understood that other 
 factors than the pelvic diameters may influence the result. Thus, 
 
 * Winckel, Kephalotripsie, Monr.tsschr. f. Geburtsk., Bd. xxi, p. 81. 
 f Fritsch, Der Kephalothryptor und Braun's Cranioclast, Volkraann's Samml. 
 klin. Vortr., No. 127, p. 870.
 
 424 OBSTETRIC SURGERY. 
 
 much dej^ends upon the size of the child's head, the resiliency of the 
 cranial bones, and the relations of the pelvic diameters to one another. 
 It is not disputed that the cephalotribe is capable, if force is used, of 
 accomplishing delivery through a smaller space than the one given ; 
 but the severe injuries to the maternal tissues which the instrument is 
 apt to inflict, even when every caution is exercised, make its employ- 
 ment dangerous in the higher degrees of pelvic deformity. 
 
 In 1863 Pajot * published a paper in which he stated that, while in cases of 
 distortion in which the narrowing did not exceed two and a half inches cepha- 
 lotripsy was a favorable operation, requiring the exercise of no great amount of 
 force, and but two or three applications of the instrument, below that point he 
 regarded it as nearly as dangerous as the Cajsarean section. In the belief that 
 these results were due to rude attemjits to drag an imperfectly reduced head 
 through the contracted space, he proposed that in all cases below two and a half 
 inches no tractions should be made, but, so soon as dilatation had ])roceeded far 
 enough to permit, perforation should be performed, whereupon complete dilata- 
 tion would occur more speedily, and cephalotripsy might be begun at an early 
 period of labor — a point in itself of considerable importance. While applying 
 the cephalotribe, one or two assistants should make counter-pressure over the 
 pubes to steady the head. The blades should be introduced as high as possible 
 by depressing the handles. After compressing the head, rotation, if it has not 
 occurred spontaneously, should be cautiously attempted. The slightest obstacle 
 should, however, be the signal for suspending rotation and withdrawing the 
 instrument, when Nature usually brings about rotation with astonishing ra- 
 pidity The instrument should then be reapplied, and the compression re- 
 peated. The same process should be gone through with a third time, after 
 which the woman should be placed in a convenient posture and given bouillon 
 to drink. Then, governed by the state of the pulse and the general appearance 
 of the patient, the quiet or excitement manifested, the weak or energetic char- 
 acter of the pains, the cephalotribe should be applied two or three times every 
 two, three, or four hours, leaving the expulsion of the foAus entirely to Nature. 
 M. Pajot has never found more than four applications of this procedure neces- 
 sary, while one or two have generally sufficed. After the passage of the head, 
 one or two applications of the instrument are required, as a rule, to reduce the 
 thorax. To be successful, however, it is requisite that the operation should be 
 resorted to at an early period of labor, when, as a rule, not more than six to 
 eighteen hours are needed for Nature to expel the uterine contents. Tractions 
 should be employed only in those cases to which one is called at a late period, 
 after the powers of Nature are exhausted. Objections to this plan of Pajot have 
 been made as follows : That there is risk of rupture of the uterus from the pro- 
 longation of the labor; that the uterus is exposed to injury from the spiculai at 
 the point of perforation; that, owing to the great rapidity with which decompo- 
 sition takes place after cephalotripsy, the bones of the skull are liable to become 
 denuded of their coverings; and, finally, that after a given period the mem- 
 branes become so far destroyed as no longer to protect the uterus from its de- 
 composing contents. Pajot replies by adducing seven cases in which he em- 
 ployed his method. Five of the cases were successful, and two terminated 
 
 * Pajot, De la cpphalotripsie repetec sans tractions, Paris, 1863.
 
 CRANIOTOMY AND EMBRYOTOMY. 425 
 
 fatally. The highest degree of deformity for which he operated was a case in 
 which the contracted diameter was something less than an inch and a half. 
 The patient died from ruptured uterus, due, according to M. Pajot, to attempts 
 made previous to his arrival to perform cephalotripsy with a badly constructed 
 instrument. 
 
 The application of the cephalotribe does not differ from that of 
 the forceps. AVhere perforation lias been performed, spicule of bone 
 should be carefully removed with the fingers. Confirmatory evidence 
 as to the direction of the head may be obtained by exploring the cra- 
 nial cavity with the finger, as, in this way, the exact position of the 
 base and vault may be determined. Great caution should be exer- 
 cised during the introduction of the blades not to injure the vaginal 
 or uterine tissues. It is not always easy to lock the instrument after 
 the blades have been adjusted. The left blade is easily placed, but 
 often the right blade is with difficulty brought forward to the cor- 
 responding transverse or oblique diameter. Compression should be 
 made slowly, and the opening made by the perforator should be care- 
 fully guarded lest cutting portions of bone protrude. Extraction 
 should take place under the guidance and protection of the fingers of 
 the left hand. 
 
 Sometimes the cephalotribe is used to compress and extract the 
 after-coming head in cases of moderate pelvic contraction. Under 
 such circumstances perforation is usually not a prerequisite. The 
 cephalotribe seizes the head securely, and acts with great power upon 
 the basis cranii. The increased diameters of the head accommodate 
 themselves more readily, too, to the long diameters of the pelvis than 
 in cranial presentations. When the head is retained in the uterus 
 after it has become detached from the body, it should be held by an 
 assistant through the abdominal Avails, and steadied by a crotchet in- 
 troduced into the foramen magnum, or fixed into an orbit, or in the 
 lower jaw. The cephalotribe may then be applied to complete the ex- 
 traction. 
 
 Cranioclast. — It is necessary to distinguish between two instru- 
 ments, each of which bears the name of cranioclast. The original 
 model was the device of Sir J. Y. Simpson, and was intended by him 
 to replace the cephalotribe. It is substantially a powerful pair of 
 craniotomy-forceps. The larger blade, which is intended to be placed 
 upon the outer surface of the head, is fenestrated and grooved. The 
 smaller one, for introduction into the perforated skull, is solid, and 
 supplied with ridges which fit into the grooves upon the opposite 
 blade. The two blades articulate by means of a button-lock. By a 
 twisting movement, the cranioclast, when applied, can be employed to 
 wrench off the bones of the calvarium, different portions of the skull 
 being seized successively with the view of accomplishing that result. 
 As the fractured bones are covered by the scalp, they are prevented
 
 426 
 
 OBSTETRIC SURGERY. 
 
 from inflicting injury during the subsequent course of delivery. But 
 the cranioclast is not only of use in breaking up the cranial vault, it is 
 likewise the most effective of all the instruments employed for extrac- 
 tion of the perforated head. 
 
 The principal defect of the Simpson 
 cranioclast is that it attempts to combine 
 in the same instrument the functions of 
 crusher and tractor. Now, as in the ceph- 
 alotribe, the devices which make it the 
 most effective instrument in the one di- 
 rection weaken its utility in the other, 
 Braun's modified cranioclast is intended 
 to serve purely as a tractor. All idea of 
 its undertaking to break up the skull is 
 discarded. The work of compression and 
 disarticulation is left to the counter-press- 
 ure of the pelvic walls, and to the em- 
 ployment of craniotomy-forceps and the 
 cephalotribe. The term cranioclast is 
 therefore a misnomer. Munde's proposed 
 substitute of " craniotractor " is descrip- 
 tive of its real action. Yet the modifica- 
 tions of Braun were as simple as they 
 have proved appropriate. A pelvic curve 
 has been given to the blades ; the handles 
 have been lengthened so that the lock, 
 even when the instrument is introduced 
 high up, is outside the vulva ; and, finally, 
 an apparatus for compression has been 
 added. The advantages of Braun's cranio- 
 clast over its rival, the cephalotribe, are 
 as follows : it is of comparatively small 
 size ; again, one branch lies inside the 
 head, in a space not otherwise occupied; 
 the outer branch imbeds itself in the soft 
 coverings of the head, and thus is pro- 
 After a few tractions the cranioclast occu- 
 pies the middle of the pelvis, where it can be so guarded by the hand 
 that it need not even come into contact with the vaginal walls ; as the 
 head is drawn into the pelvis, the pressure is not concentrated at one 
 or two points, bat is diffused over the entire pelvic rim ; the head is 
 therefore able to mold itself to the shape of the pelvis. Subsequent 
 to the use of Braun's cranioclast, extensive lacerations and injuries to 
 the maternal organs are rarely found. The cranioclast takes firm hold 
 of the head. It never slips during extraction. It is not apt to tear 
 
 Fig. 189.— Simpson's cranioclast. 
 
 tected from doins harm.
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 427 
 
 away when the cranium and scalp are seized together. The most 
 secure grip is obtained when the inner blade is passed to the base of 
 the skull, while the outer one is applied to the face or over an ear. 
 
 Fig. 190.— Braun's cranioclast. 
 
 Should the portion grasped tear away, the readjustment of the instru- 
 ment upon another part of the skull is easy. Thus, the inner blade 
 can be turned, of course, in any direction without difficulty, while the 
 
 Fig. 191.— Head of child after delivery with the cranioclast. (Simpson.) 
 
 outer blade is easily disengaged from the scalp-tissues and changed in 
 its position by direct pressure from the fingers and slight leverage 
 movements of the handle. 
 
 The cranioclast may often advantageously be used as a tractor in
 
 42S OBSETRTIC SURGERY. 
 
 cases where the head has been previously crushed and flattened by the 
 cephalotribe ; but, where extraction with the hitter is rendered difficult 
 by slipping, or by the inability of the operator to make the altered 
 diameters of the head correspond to those of the contracted pelvic 
 space, the immense superiority of the cranioclast consists in the capa- 
 city to seize the head antero-posteriorly, and thus to bring its length- 
 ened diameter into the transverse space of the pelvis. 
 
 The cranioclast enables us to extend the limits of safe delivery far 
 beyond what would be admissible with the cephalotribe, as with its aid 
 it is possible, after the partial or complete removal of the flat bones of 
 the skull, to tilt the chin downward, and draw the base by the edge 
 through the conjugate. In this way craniotomy may be resorted to 
 in pelves measuring less than two and three fourths inches antero-pos- 
 teriorly. Indeed, Barnes claims that one inch and three fourths in the 
 conjugate and three inches in the transverse diameter furnish sufficient 
 space for a successful operation.* 
 
 The proceeding to be pursued in these difficult cases is as follows : 
 After perforation introduce a forceps-blade under the scalp, and detach 
 the latter as far as possible from the cranial bones ; break up and wash 
 out the entire brain-mass ; seize the parietal bones beneath the scalp 
 with a good pair of craniotomy-forceps,f and break them away piece- 
 meal by a twisting movement of the wrist. The withdraAval of the 
 fractured bones is always a matter of delicacy. Unless the soft parts 
 are carefully guarded by the hand, the maternal tissues are apt to be cut 
 and lacerated by the sharp edges and splintered corners of the bones. 
 Skene J has found it a great aid, in some cases, to use a large-sized 
 Sims speculum to bring the head into view, and to go through the 
 various steps of craniotomy with the guidance of the eye. The sug- 
 gestion is an excellent one ; but when the head is high up, as is the 
 rule in difficult cases, I have not always found it practicable to expose 
 in this way the presenting part. Horwitz * recommends, in difficult 
 cases of the unexpanded cervix, to perforate through a large Fergusson 
 speculum. 
 
 After the removal of the parietal bones, the fenestrated blade should 
 be placed under the chin, or in the mouth, while the smaller one is in- 
 troduced inside the perforation, and applied so that the frontal bones 
 are included in the grasp of the instrument. The blades should then 
 
 * Barnes, Obstetric Operations, p. 402. For discussion of this point, see Treat- 
 ment of Contracted Pelves. 
 
 t Meigs's craniotomy-forceps has been largely used in America, and may be 
 confidently recommended. There are two forms, one straight and the other curved. 
 Dr. Taylor's modification consisted chiefly in increasing the length of the instru- 
 ment, so as to render it more available in operations at the superior strait. 
 
 t Skene, Trans, of the Am. Gyna;c. Soc, vol. ii. 
 
 » Horwitz, tber ein Perforations Verfahren, Ztschr. f. Geburtsh. u. Gynaek., 
 Bd. iv, p. 1.
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 429 
 
 be screwed tightly together by means of the apparatus for compression, 
 and the head turned so that its bizygomatic diameter is brought into 
 the transverse diameter of the pelvis. As the distance between the 
 orbital plates and the chin, including the instrument, does not exceed 
 
 Fig. 19^. — Meigs's crauiotomy-forceps (modified by Professor I. E. Taylor). 
 
 two inches, and the width of the base is only about three inches, !t is 
 evident that, in skillful and experienced hands, this method is capable 
 of almost indefinite extension. 
 
 After delivery of the head, the extraction of the body may still 
 cause difficulty. If, then, through an opening made with a perforator 
 between the clavicle and shoulder-blade the smaller blade be intro- 
 duced, and the outer blade be applied on the back, so that the two in- 
 clude the spine, the cranioclast will seize the trunk firmly, and is capa- 
 ble of exerting great force as a tractor. 
 
 Crotchet and Blunt HooTc. — As tractors, neither of these instru- 
 ments is much in vogue at the present day. It is well, however, to 
 become familiar with their uses, as we are not always placed where we 
 can have a complete armamentarium at our disposal. 
 
 Fio. 193.— Crotchet. 
 
 The crotchet is a steel hook, with a sharp-pointed extremity. The 
 shaft is either straight or curved to adapt it better to the convexity of 
 the head. In craniotomy the instrument is often useful in breaking 
 up the brain. It may be inserted into an orbit when it is desired to
 
 430 OBSTETRIC SURGERY. 
 
 bring tlie base of the skull end on into the pelvis. In default of either 
 cranioclast or cephalotribe, it may be employed to extract the perfo- 
 rated head. To this end it should be passed through the opening and 
 its point inserted into one of the bones of the cranial vault. Two fin- 
 gers of the left hand are then passed to the outer surface of the skull, 
 to serve as a guard and to make pressure against the point fixed upon 
 the inner surface. If much resistance is met with, the part is apt to 
 tear away, and a new hold has to be taken. When portions of bone are 
 broken away they should be removed with the fingers, to prevent their 
 doing harm. The process is often tedious, and in unskillful hands is 
 not devoid of danger. When the bones of the vault yield under trac- 
 tion, a more effective grip may sometimes be obtained by fixing the 
 crotchet at the foramen magnum or the sella turcica. Or, in place 
 of introducing the instrument into the skull, it is sometimes inserted 
 outside, behind the ear^ into the mastoid process, or into the occiput, 
 near the foramen magnum. The blunt hook, though not indispensa- 
 ble, is capable of rendering valuable service in delivering the head after 
 the performance of craniotomy. Dr. I. E. Taylor gives the preference 
 
 Fig. 194.— Dr. Taylor's right-angled blunt hook. 
 
 to a right-angled instrument. The blunt hook can not, of course, be at- 
 tached to flat surfaces of bone. It may be used, however, to draw down 
 the chin, or it may be thrust into an orbit. Where perforation has been 
 made upon the after-coming head, the blunt hook may be introduced 
 through the opening and traction made directly upon the base of the 
 skull. In difficult cases, delivery of the trunk is sometimes favored by 
 tractions made by a blunt hook inserted under the posterior shoulder. 
 
 Fer^io;^.— Version, with extraction by the feet, with or without 
 cephalotripsy, has been warmly commended by Bertin, Tarnier,* and 
 Taylor,t while it has been condemned in harsh terms by others. AVhere 
 it is practicable to perforate and turn early in labor, at a time when 
 version is easy, the method has the advantage of bringing the longest 
 diameter of the head into correspondence with the long diameter of 
 the pelvis, and favoring the molding of the head to the shape of the 
 canal it has to traverse. At the same time it avoids the dangers of 
 contusing the soft parts incident to the use of the cephalotribe. Dr. 
 Taylor recommends combining propulsion above the pubes with trac- 
 tions made upon the extremities. 
 
 * Tarnier, Diet, de medecine et de chirurgie, art. Embrvotomie, t. xii p 668 
 + Taylor. What is the Best Treatment in Contracted Pelves ? Trans, of the 
 Aew York Acad, of ]Med., 1875.
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 431 
 
 Great ingenuity has been exerted to devise some good way to overcome the 
 difficulty which grows out of the defectiveness of the preceding measures in 
 acting directly upon tlie base of the skull. Cephalotomy,* 
 or the removal of the head by segments, has been pro- 
 posed as a substitute for perforation and cephalotripsy. 
 Van Huevel's forceps-saw divides the head from crown 
 to base into two halves. Tarnier's forceps-saw removes 
 from the head a triangular segment, the apex of which is 
 cut from the skull-base. Dr. Barnes f has suggested the 
 application of Braxton Hicks's wire ecraseur to successive 
 portions of the head. Hubert's transforaieur is designed 
 to bore through the sphenoid, and thus to destroy the re- 
 sistance of the base. The sphenotribes of Valette, Hiiter, 
 and the Lollines, are a combination of the cephalotribe 
 and the transfarateur. Notwithstanding the principle of 
 cephalotomy is mechanically correct, the operation has 
 never met with any general acceptance, partly owing to 
 the high price and complicated structure of most of the yig. 195. — Segment re- 
 instruments required for its performance, ^d perhaps in nier*^'^forceps*'- Sw 
 part to the fact that, in the higher degrees of pelvic de- (P- Thomas.) 
 formity, where their advantages over the more familiar 
 
 methods would be theoretically most complete, the bulky nature of the forceps- 
 saws and the sphenotribes interfere with their employment. Tlie favorable 
 reports made by their inventors of the results they have personally obtained 
 render, however, a reference to the subject necessary. 
 
 Embkyotomt. 
 
 In a literal sense, embryotomy includes all the graver opera- 
 tions designed to diminish the volume and resistance of the foetus. 
 Custom has, however, restricted the term to those operations only 
 which are performed upon the trunk of the child. It is used, there- 
 fore, as a rule, in contradistinction to craniotomy, and not in its ge- 
 neric sense. 
 
 Indications for Embryotomy. — 1. In extreme degrees of pelvic con- 
 traction, where the size of the body obstructs delivery.J 2. In fetal 
 malformations, with abdominal enlargement due to pathological con- 
 ditions of the more important viscera, and in cases of extraordinarily 
 developed children. 3. In neglected transverse presentations, in which 
 version is impossible, or at least can not be performed without en- 
 dangering greatly the life of the mother. 
 
 * Tarnier, Diet, de Medeeine et de Chirurgie, art. Embryotoniie, p. 680. 
 
 f Barnes, Obstetric Operations, p. 411. 
 
 X It has been said that, in cases which do not demand the Ciesarean section, this 
 indication is not likely to arise. In the extraction of the child's body, however, 
 through a small justo-minor pelvis, which required for its completion upward of 
 twenty-five minutes, post-tnortem examination showed more extensive disturbances 
 from arrested pelvic circulation, due to compression from the child's body, than 
 from the lesions arising out of the performance of craniotomy.
 
 432 OBSTETRIC SURGERY. 
 
 Embryotomy includes two operative measures, viz., exenteration 
 and decapitation. 
 
 Exenteration.— By exenteration we mean the opening of one of the 
 large cavities of the trunk and the removal of the contained viscera. 
 It is most commonly indicated in transverse presentations, where de- 
 c.ipitation is not easy to perform, as in cases of extreme pelvic con- 
 traction with the head high up above the pelvis. The opening may be 
 made by means of a pair of curved scissors or the ordinary perforator. 
 The same precautions against injury of the maternal tissues have to 
 be observed as in craniotomy. In shoulder presentations an assistant 
 should press the fundus of the uterus downward. The operator at the 
 same time thrusts the perforator, or the scissors, between the ribs, and 
 then enlarges the opening by turning the instrument so as to make a 
 second incision at right angles to the first. Next, splintered portions 
 of bone should be carefully broken away wdth the fingers, until the 
 opening becomes sufficiently extensive to permit the introduction of 
 the half-hand. In tearing awJly the viscera, the fingers may, if neces- 
 sary, be aided by the volsella-forceps. The abdominal cavity may 
 be reached directly through the thorax by perforation of the dia- 
 phragm, or a fresh opening may be made through the abdominal walls. 
 
 After evisceration, the reduced bulk of the child renders it pos- 
 sible to proceed directly to seize the feet and perform version. This 
 method is, however, generally difficult, and endangers the distended 
 cervix and lower uterine segment. If, therefore, the shoulder is high 
 up, the breech, which is easily reached, should be drawn down with 
 the fingers or the blunt hook, in imitation of the mode of delivery in 
 spontaneous version. When, however, an arm presents, and the shoul- 
 der is crowded into the pelvis, the child may be drawn through doubled 
 upon itself, as in spontaneous evolution. 
 
 Decapitation. — Whenever, in neglected transverse presentations, the 
 neck can be easily reached, decapitation furnishes the simplest and 
 mildest plan for overcoming the difficulties which prevent delivery. 
 
 Fig. 196.— Braun's decapitating hook. 
 
 Decapitation may be effected in a number of different ways : 
 1. Draw upon the prolapsed arm to bring the neck well down and 
 within reach. Pass the finger or a blunt hook around the neck, and
 
 CRANIOTOMY AND EMBRYOTOMY. 
 
 433 
 
 then, carefully guarding the points, divide with a strong pair of scissors 
 by a series of short movements the soft structures and the vertebral 
 column. 
 
 2. In many cases the division of the neck can be advantageously 
 accomplished by Braun's decollator. This in:^trument is a modifica- 
 tion of the blunt hook. The terminal portion is, however, bent at 
 nearly an acute angle. 
 It is likewise flattened 
 from side to side, and 
 ends in a button-shajDed 
 extremity. The handle 
 is fixed at a right angle, 
 and is capable of im- 
 parting to the instru- 
 ment powerful leverage 
 movements. In em- 
 ploying the decollator, 
 the index and middle 
 fingers of the left hand 
 should encircle the 
 child's neck from be- 
 hind, while the thumb 
 is placed upon the an- 
 terior surface. The 
 neck should then be 
 firmly grasped and 
 drawn down into the 
 pelvis as far as jdos- 
 sible. The decollator 
 should be passed up 
 flat under the sym- 
 pliysis pubis along the 
 thumb of the opera- 
 tor, until the button- 
 end has advanced far 
 
 enough to be turned to the rear over the neck. Finally, the in- 
 strument should be seized by the handle with the right hand, and 
 rotated to and fro, while tractions are simultaneously made in a down- 
 ward direction. It is surprising how quickly, as a rule, the spinal 
 column may be divided by this manoeuvre. After the separation of 
 the vertebrae, care must be taken not to draw down with too much 
 force, lest the integuments and soft structures yield suddenly, and 
 violence be done by the rapid withdrawal of the instrument. This 
 accident may be avoided by using moderate tractions and dividing the 
 last remnant of the tissues with a pair of scissors. The decapitating 
 2S 
 
 FiQ. 197.— Braun's method of decapitation.
 
 434 
 
 OBSTETRIC SURGERY. 
 
 hook of Ramsbotliam, which is curved, and has a cuttiug edge upon the 
 concave part, is more difficult to apply, and is a less safe instrument in 
 unskillful hands. 
 
 3. Pajot originated an ingenious method of decapitation, which, in 
 default of special instruments, is capable of rendering valuable service. 
 It consists in passing a strong cord around the child's neck, and, by a 
 sawing movement, cutting through the parts. The vagina should be 
 protected by a speculum from the friction produced by the to-and-fro 
 movement of the string. The chief difficulty of the operation lies in 
 getting the string around the neck. Pajot caused a groove to be made 
 upon the concave surface of the blunt hook which forms a constant 
 attachment to one of the handles of the ordinary French forceps. 
 Through this groove he passes a string, to the end of which he fastens 
 a round lead bullet ; when the blunt hook is adjusted about the child's 
 neck, the weight of the bullet draws the cord downward so that it can 
 be reached by the hand of the operator. Dr. Kidd recommends attach- 
 ing a string to an elastic catheter armed with a strong stylet ; then, 
 
 »fiA<VA>y\fW(> » 
 
 Fig. 198.— Embryotome of P. Thomas. 
 
 after imparting to the instrument the proper curve, it should be passed 
 around the chdd s neck, and, as it is withdrawn, the string should be 
 used to drag a strong cord or the chain kraseur into place 
 
 Still more ingenious is the embryotome of Pierre Thomas, consist- 
 ing of two blades modeled after a somewhat expensive instrument de- 
 vised by M. larnier. The curved blade should be passed posteriorly 
 opposite the sacrum. The straight blade should be introduced in front 
 directly beneath the pubic bones. When adjusted, the extremities of
 
 CRANIOTOMy AND EMBRYOTOMY. 
 
 435 
 
 the blades are in apposition. Both blades contain a grooved canal. A 
 piece of whalebone armed with an ivory knob is then introduced into 
 the canal of the straight blade, while a long, flexible piece of whale- 
 bone provided with an ivory ring is passed into the canal of the 
 posterior curved blade. The descent of the posterior whalebone fur= 
 
 Fig. 199.— Embrj'otome adjusted around the neck of the child. 
 
 nishes the evidence that the canals of the two blades are in apposition^ 
 and that the longer piece has entered the posterior canal. When the 
 circuit is completed, a loop of cord is passed through an eyelet in the 
 end of the whalebone, and serves as an attachment to a chain-saw, 
 which, as it is drawn upward, leaves the groove and encircles the child's 
 neck. In decapitating the child by a to-and-fro movement, the soft 
 parts are protected by the blades of the embryotome.
 
 ^3g OBSTETRIC SURGERY. 
 
 CHAPTEK XXIII. 
 
 CESAREAN SECTION.-OPERATIONS OF THOMAS AND PORRO. 
 
 CjEsareaii section. - Ilislory. - Indications.-Operation.-After-treatment.-Prog- 
 nosis.— Operation of Porro,— Operation of Thomas. 
 
 The Cesarean Section. 
 
 The term Ccesarean section is applied to cases in which the foetus 
 is removed from the mother by au incision made through the abdomi- 
 nal and uterine walls. 
 
 Although the operation pretends to great antiquity, the earlier his- 
 tories are probably of mythical origin. The supposed references in 
 the Talmud are, according to Rodenstein, mistranslations of the 
 text. The same authority suggests that even the lex regis, attributed 
 to Numa Pompilius, which makes it obligatory upon the physician to 
 remove the child by abdominal section in case the mother dies during 
 pregnancy, was really added to the Roman law in the middle ages, with 
 the intention of giving force to the decretals of the Church, which 
 sought, through the Caesarean section upon the dead, to rescue the 
 child for the rite of baptism before its life became extinct. During the 
 sixteenth century there seems no reason to doubt the authenticity of 
 certain cases of laparotomy, performed during the life of the mother, 
 for the removal of the foetus in extra-ut3ri.i3 pregnancies. In 1581 
 Francois Rousset* published the historias of fourt3en successful Caesa- 
 rean sections, six of which were said to have been performed upon the 
 same individual. These cases were repeated from hearsay, and from 
 accounts taken from letters written by friends. Their genuineness 
 was challenged at the time of publication by the opponents of the 
 operation, and they are now generally regarded as resting upon ques- 
 tionable authority. The first operations mentioned after the publica- 
 tion of Rousset's work are said to have proved fatal. The earliest well- 
 authenticated record of Cassarean section conies to us from Germany. 
 It was performed in Wittenberg, by Trautmaun, in IGIO. The patient 
 lived from the 21st of April to the IGth of May. Scarcely any doubt 
 was entertained of her recovery, when she was suddenly seized with a 
 fainting-fit and died, contrary to all expectation, in about half an 
 hour. 
 
 Until a very recent date the Caesarean section was Justly regarded as 
 one of the most hazardous operations in surgery. Michaelis f collected 
 258 authentic cases, of which 54 per cent ended in recovery. Kayser \ 
 
 * Rousset. Traite nouveau de I'hysterotomotokie, on enfantement Cesarienne. 
 f Michaelis, Abhjmdlungen aus dem Gebiete der Geburtshtilfe, 1833. 
 X Kayser, De Eveiitu Sectionis Caisariie.
 
 *' CESAREAN SECTION.— OPERATIONS OF THOMAS AND PORRO. 437 
 
 added 80 new cases to those reported by Michaelis, and reduced tlie 
 recoveries to 38 per cent. Mayer* gathered 1,605 cases, with 54 per 
 cent recoveries. Pihan-Dufeilhay f collected 88 cases, published be- 
 tween 1845-'49, of which 57 per cent ended in recovery. Dr. Harris 
 (1888) gathered with great industry the histories of 153 cases per- 
 formed by the older methods in the United States, 56 of which, or 
 nearly 37 per cent, ended in recovery. Under this showing it will 
 be seen that at best fully one half of all the Ctesarean operations ended 
 fatally. Spaeth, writing before the conservative operation of Siinger 
 had changed the results of practice, said that there had not been a 
 single case in the lying-in hospital in Vienna during this century in 
 which the mother had survived. Baudon, writing in 1873, said, " In 
 Paris there has not been one successful case in eighty years, though in 
 the present century the operation has been performed on perhaps as 
 many as fifty women." 
 
 The responsibility for these results was due, in the first place, to 
 septic infection, the evils of which were especially experienced in hos- 
 pital practice, and to the postponement of the operation until death 
 impended. What was possible after eliminating these elements of 
 danger even with barbaric methods of surgery, was shown in a rejiort 
 by Harris, J in which he gave the history of nine women whose wombs 
 had been ripped up in advanced pregnancy by the horns of infuriated 
 cattle, with the survival of four women and four children. Again, 
 in six cases of self-inflicted Caesarean section, five of the women re- 
 covered. 
 
 Of hardly less importance in blocking progress was the persistent 
 superstition that the alternating contractions and relaxations of the 
 uterus forbade the employment of the uterine suture; Consequently, 
 the uterine incision was left to gape, and closure in favorable cases was 
 usually effected by an adhesive inflammation which united the uterine 
 to the abdominal walls. According to Sanger, only one instance is 
 known where complete union took place throughout the length and 
 depth of the wound. Sometimes cicatricial tissue extended the length 
 but not through the thickness of the incision, and was of a callous 
 consistency ; in others the line of union was at points of extreme 
 tenuity, disposing to hernial protrusions, and in subsequent pregnan- 
 cies to rupture ; while in others, again, union took place at intervals 
 only, with the formation of fistulous' openings, communicating with 
 the abdominal walls, or with circumscribed cavities in the abdominal 
 inclosure. Yet so strong are old prejudices, that even recently Porro's 
 proposition to avoid the risks of the gaping of the uterine wound by 
 
 * Mayer, notice by Bromeisl, Wien. med. Woch., 1868, No. 67 
 f PiHAN-DuFEiLHAY, Arch. Gen. de Med., 1861, t. ii. 
 
 I Harris. Cattle-horn Lacerations of the Abdomen and Uterus in Pregnant 
 Women, Am. Jour. Obst, July, 1887.
 
 ^3s OBSTETRIC SURGERY. 
 
 the removal of the entire uterus, was accepted as a surgical necessity. 
 Indeed, it has been in this country chiefly, where tradition exerts a 
 feeble influence, that prior to the appearance of Sanger's exhaustive 
 monoo-raph the suture enjoyed anything like a fair trial, and Sanger 
 strongly re-enforced his argument in favor of its employment by the 
 successes obtained through its agency by Polin, Brickell, Jenks, and 
 
 Lundgren. 
 
 The improved Cajsarean section of the present day is based upon 
 an early resort to the operation before the patient's strength is ex- 
 hausted by lengthy labor and the futile resort to measures to extract 
 the child by the natural passages ; upon the complete closure of the 
 uterine wound, and upon the employment of aseptic precautions, such 
 as are commonly used in abdominal surgery. Sanger is justly regarded 
 as its founder, for though others, and notably Harris, in this country, 
 had insisted upon the importance of the same factors, the great body 
 of the profession was still engaged in the task of showing that the 
 Ctesarean section had profited nothing by the recent advances in surgi- 
 cal science when Sanger's work * was published. The latter at once 
 awakened the dormant interest of the profession on the subject. Its 
 challenge to test the question of the practicability of the Csesareau 
 operation, as modified by modern principles, met with a ready re- 
 sponse, and the triumphant reinstatement of the measure in the do- 
 main of legitimate surgery followed. Since then the. mutilating oper- 
 ation of Porro has been restricted within narrow limits, and the croak- 
 iugs of the anti-Coesarean school are no longer heard. 
 
 Indications for the Caesarean Section. — As even the improved 
 Caisarean section is a hazardous operation, its performance is chiefly 
 justifiable in cases in which craniotomy and the delivery of the child 
 by the natural passages involve the life of the mother in still greater 
 peril. It is indicated, therefore, in extreme degrees of pelvic contrac- 
 tion, in the case of solid tumors which encroach upon the pelvic 
 space, and in advanced carcinomatous degeneration of the cervix. 
 
 The Caesarean section is permissible if the mother is moribund 
 and the cliild is known to be alive, where rapid delivery by the natural 
 passages is impossible It may be undertaken at the mother's request 
 if otherwise delivery can not be accomplished without the sacrifice of 
 the child. If in any case the decision is left to the physician, he 
 should regard the welfare of the mother as of paramount importance. 
 It has been said that if a woman, knowing herself to be incapable of 
 bearing living children, exposes herself to the repetition of pregnancy, 
 it becomes the duty of the physician to perform the Cesarean section 
 in the interest of the child. The duty of the physician is, however, 
 
 * Sanger, The Ca?s.arean in Cases of Uterine Fibromata ; Criticisms, Studies, and 
 Propositions for the Improvement of the Caesarean Section.
 
 CiESAREAN SECTION.— OPERATIONS OF THOMAS AND PORRO. 439 
 
 to his patient. He is not -to constitute himself either judge or exe- 
 cutioner. 
 
 Operation. — The success of Caesarean section depends in large 
 measure upon the control which the obstetric surgeon possesses over 
 the conditions under which the operation is performed. When it is 
 practicable, the patient should be prepared for the operation by full 
 baths, by disinfecting vaginal douches, by laxatives, by diet, and by 
 tonics. 
 
 The most suitable time to operate is after dilatation has begun, but 
 previous to the rupture of the membranes : after dilatation, because it 
 is desirable to provide a free outlet for the uterine discharges subse- 
 quent to the operation, and because the retraction of the uterus after 
 delivery, which furnishes the most efficient means of controlling 
 hemorrhage from the uterine wound, is best secured if the operation 
 is performed at a time when the contractions are strong and frequent ; 
 previous to rupture, because there is then greater probability of finding 
 the child alive and the maternal tissues uninjured. Unless, too, the 
 head or breech protrudes spontaneously through the incision made in 
 the uterine wall, the delivery is much more readily performed while 
 the membranes are iutact than after the uterus has retracted firmly 
 down upon the child's body. 
 
 The necessary preparations should meantime be made, and selected 
 assistants should have explained to them their respective duties. There 
 should be one assistant to take charge of the anesthesia, one to hold 
 the uterus after it has been turned out of the abdominal cavity, one for 
 the instruments, one to take charge of the newborn child, and, if still, 
 to aid in its resuscitation, and a trained nurse to wash and keep account 
 of the sponges. 
 
 Few instruments are required. The entire armamentarium should 
 consist of one or two scalpels, a pair of blunt-pointed scissors, a half- 
 dozen compression forceps, a needle-holder, curved needles, an irri- 
 gator, a powder-blower, aseptic towels, and vessels containing an abun- 
 dance of warm carbolized water. The sponges should be aseptically 
 cleaned* and carefully counted. A piece of rubber tubing will be 
 needed to place around the lower uterine segment to control the hem- 
 orrhage when the uterus is incised. For ligatures, silver wire, silk, and 
 catgut have each their advocates. At present silk is favored by Sanger, 
 Kelley, and others, as the preferable material — a choice in which I 
 
 personally concur. At the time of operation instruments, sponges, 
 
 » 
 
 * To render sponges aseptic they should first be boiled in a weak solution of 
 soda, and washed out in boiled water. They should then be soaked for two hours 
 in a solution of permanganate of potash (1 : 4,000), and. after repeated washings in 
 a four-per-cent solution of hyposulphite of soda, to which three to four per cent of 
 muriatic acid has been added, should be preserved in a five-per-cent solution of 
 carbolic acid. Zweifel, Arch. f. Gyn., vol. xxxi, p. 204.
 
 440 OBSTETRIC SURGERY. 
 
 wire, and silk sliould be jilaced in a two-per-cent solution of carbolic 
 acid. 
 
 The operator and bis immediate assistants should thoroughly wash 
 their hands and forearms with soap and water. The nails should be 
 cleaned with a nail-brush and nail-cleaner, and, after removing sapona- 
 ceous materials with alcohol, the hands and arms should be bathed for 
 several minutes in 1 : 1,000 solution of corrosive sublimate. During the 
 operation clean white aprons should be worn. 
 
 Preliminary to the operation the patient's bowels and bladder 
 should be emptied, and the vagina should be douched with a five-per- 
 cent solution of carbolic acid. During the induction of angesthesia 
 pains should be taken to make sure that the auscultiitory signs of foetal 
 life are present. After the patient has been placed upon the table 
 the pubes should be shaved, and the abdomen should be cleansed in 
 the usual manner with soap-suds, corrosive- sublimate solution, and 
 ether. 
 
 The abdominal incision should be made to extend from a point 
 above the pubes to one, three, or four inches above the navel. At this 
 stage it is convenient to pass a half-dozen long wire sutures through 
 the upper portion of the incision. For the moment the ends should be 
 left free. The child can be removed from the uterus in situ, in which 
 case an assistant should take pains to keep by external pressure the 
 abdominal walls in close contact with the surface of the uterus ; but it 
 is a great convenience first to turn the uterus out of the abdominal 
 cavity. This is accomplished without much difficulty, by first tilting 
 the uterus so as to cause it? left border to present at the incision, and 
 then pressing the abdomiail walls backward over the uterus. As it 
 emerges the assistant should envelop it in a warm carbolized towel, 
 and hold it at nearly right angles to the abdomen. The operator now 
 tightens the sutures in the abdominal incision to retain the intestines, 
 and places a flat sponge beneath the abdominal walls behind the uterus 
 to prevent the entrance of fluids into the peritoneal cavity. The rub- 
 ber tubing should be placed loosely around the lower uterine segment 
 beneath the presenting part, or, where there are plenty of assistants, 
 manual compression applied to the cervix may be employed to control 
 hajmorrhage. I prefer, instead of beginning at the fundus, by a series 
 of rapid strokes first to make a small incision down to the membranes 
 m tlie median line just above the lower segment, and then to extend the 
 incision rapidly upward with a pair of blunt-pointed scissors. If the 
 placenta is encountered, it should be detached with the fingers and 
 pushed to one side. The uterine incision should be between four and 
 five inches in length. If the membranes are intact, they should be rupt- 
 ured and the child should be rapidly extracted. The rubber ligature 
 should be tightened, if necessary, to control bleeding. As the uterus 
 retracts, the assistant sees that the abdominal incision is kept in close
 
 CESAREAN SECTION.— OPERATIONS OF THOMAS AND PORRO. 441 
 
 contact with the uterine surface. AVith a little care no blood or fluid 
 need obtain entrance into the abdomen during the entire operation. 
 
 In many cases the membranes peel off intact with slight traction, 
 and come away with the placenta. Adherent portions of decidua 
 should be carefully detached with the fingers. I have found it easy to 
 wash out the uterine cavity with a disinfectant fluid, by placing the 
 irrigator nozzle in the wound and pressing the cut surfaces together 
 while loosening for the moment the elastic ligature. The pressure of the 
 hands prevents hfemorrhage, and the stream passes out unimpeded 
 through the vagina. When this has been done the uterine cavity 
 should be sponged nearly dry and the inner surface powdered over 
 with iodoform by means of an insufflator. 
 
 The uterine incision should be closed by two sets of sutures, a 
 stronger one of wire, silk, or catgut for the muscular strvictures, and a 
 fine one of silk or catgut to approximate the peritoneal borders. The 
 muscular sutures should be introduced one half inch from the borders 
 of the incision, and passed obliquely downward to, but not including, 
 the decidua. Of these, eight to twelve are usually necessary. For the 
 peritonteum I have used an interrupted suture of fine silk, and have 
 employed with great satisfaction the Lembert stitch to secure close 
 union. Leopold advocates catgut for both deep and superficial sutures, 
 on the ground that they produce less subsequent irritation ; but care 
 must be taken to secure catgut of good quality, and to tie the deep 
 sutures with three knots. 
 
 After the suturing is completed a hypodermic injection of the 
 fluid extract of ergot should be made into the skin of the outer surface 
 of the thigh. The elastic ligature should then be loosened, and 
 manual compression maintained until firm contractions have been 
 secured. After replacing the uterus, the abdominal wound should be 
 closed without haste, and with punctilious care. A full antiseptic 
 dressing should be applied. The patient, finally, should be placed in 
 bed with hot bottles around her, and, in case of failing heart-action, 
 the usual restoratives should be applied. 
 
 As vomiting after the Cassarean section is rare, the administration 
 of liquid food by the stomach is possible almost from the first. Tym- 
 panites is sometimes distressing, but can often be relieved by injections 
 of soap-suds in chamomile infusion, while in severer cases a calomel 
 laxative may be administered (gr. ijss every five hours until action is 
 produced). The abdominal stitches should be removed from the 
 twelfth to the fourteenth day. In favorable cases the patient may sit 
 up by the middle of the third week. 
 
 Trained nursing, frequent visits, and promptness in meeting emer- 
 gencies count for much in securing favorable results. 
 
 In conclusion, it may be proper to state that if the patient's con- 
 dition at the outset is fairly good, and the operation is performed with
 
 442 OBSTETRIC SURGERY. 
 
 every attention to detail, such as a well-equipped hospital renders 
 possible, and the after-management is intelligently conducted, the 
 prognosis is hardly doubtful. Recovery will almost certainly follow, 
 and a new triumph will add to the fame of Sanger. 
 
 But if the patient has been operated upon in her own home, after a 
 lingering labor, without needed assistance, perhaps by the light of a 
 kerosene lamp and with preparations of a make-shift character, and 
 after the work is ended she is left to the care of ignorant, prejudiced 
 persons, it may be proper to call the operation by the name of Sanger, 
 but recovery, if it occurs, must be regarded as partaking of the nature 
 of a miracle. 
 
 Porro's Operation, or Ovaro-Hystorectomy. — The characteristic 
 feature of the Porro operation consists in the removal, after the per- 
 formance of the C^esarean section, of both uterus and ovaries. As 
 the result of experiments upon animals, its theoretical practicability 
 was demonstrated as early as 1769 by Cavallini, and later, in 1823, by 
 Blundell. G. Pli. Michaelis, in 1809, after referring to the danger 
 from reaction following injury to any of the abdominal viscera, goes 
 on to say : " That the danger specially depends upon this reaction, 
 we see not only from the often greater associated disorders in other 
 organs, but from the experience that, when the uterus has been re- 
 moved so that the reaction in other organs falls away, the danger 
 appears to be much lessened. Several cases are known where the 
 uterus has been excised by ignorant persons without the occurrence 
 of violent disturbances [Zufalle]. ... It is a question, therefore, 
 whether the Caesarean section would not be rendered less dangerous 
 by connecting with it the extirpation of the uterus." The ablation of 
 the uterus after Cassarean section was not, however, actually executed 
 upon the living human female until 1868. The first operation was 
 performed by Dr. Horatio R. Storer, of Boston, in the case of a patient 
 whose delivery was rendered impossible by the natural passages, owing 
 to a large-sized fibro-cystic tumor blocking up the pelvic cavity. The 
 haemorrhage which followed the incision into the uterine cavity prov- 
 ing frightful. Dr. Storer ligatured the cervix, and, having applied the 
 chain ecraseiir, slowly removed the mass. Both the child and placenta 
 were in a state of decomposition. The patient lived sixty-eight hours. 
 At the time of the occurrence the hardihood of the operator was the 
 subject of a good deal of unfavorable comment. 
 
 In 1874 Professor Edward Porro, of Pavia, having succeeded in 
 preserving the lives of animals from which he had removed the gravid 
 uterus, decided that, as soon as a chance offered, he would add to the 
 Caesarean section as a completive measure the ablation of the uterus 
 and its appendages. The sought-for opportunity presented itself on 
 the 31st of May, 1876. The patient had a rachitic pelvis, with an 
 antero-posterior diameter reduced to one inch and a half. The child
 
 CESAREAN SECTION.— OPERATIONS OF THOMAS AND PORRO. 443 
 
 was extracted living, and the mother survived. After the publication 
 of Porro's report, the two Brauns and Spaeth, of Vienna, where the 
 Cassarean section had been jDroverbially fatal (no case saved in this 
 century), resolved to give the new operation a trial. Spaeth led off 
 with a success in June, 1877. 
 
 In 1888 C. Braun von Fernwald had operated twelve times with 
 eight recoveries. Breisky operated seven times. All his cases recovered. 
 So, too, Leopold has had eight cases, with eight recoveries ; Krassawsky, 
 five cases, with one death ; Frank, six cases, with one death ; Fehling, 
 five cases, with one death ; Tait, seven cases, with one death ; and in 
 the Santa-Caterina Hospital, in Milan, ten women were saved in thir- 
 teen operations. But while in practiced hands, with favorable sur- 
 roundings and skilled assistants, the results have been brilliant, all op- 
 erators have not been so fortunate. Thus, Dr. R. P. Harris, who has 
 with untiring zeal made all questions connected with the Caesarean sec- 
 tion his peculiar province, informs me that the number of operations 
 performed to March, 1885, in which the uterus and its appendages were 
 removed after the extraction of the child, had swollen to 164 (3 mori- 
 bund at time of operation), of which 70 only ended in recovery, or a 
 little over 43 per cent. In a late paper * he states that in the five 
 years ending with the close of 1889 there were reported 158 operations 
 with 47 deaths, or a mortality of 29 per cent. 
 
 Chason, however, has collected 45 cases, reported between 1887 and 
 1889, with but six deaths, and in Meyer's f statistics for 1890 32 cases 
 are given, with five deaths ; an indication that the ill-success of the 
 earlier trials was due rather to faulty methods and to defective asepsis 
 than to the impracticable nature of the operation. The inferior rank 
 it now occupies as compared Avith the Cesarean section is not due to 
 its being more dangerous, but to the fact that it involves a serious 
 multiiation. The removal of the uterus and its appendages as a 
 sequence to the Caesarean section is, however, indicated : 
 
 In osteo-malacia, owing to the influence of ovaro-hysterectomy in 
 arresting that malady ; in uterine atony following the Sanger Cesarean 
 operation ; in cases where septic infection of the endometrium has 
 occurred during labor ; in new formatipns of the uterus, the removal 
 of which is coincidently desired ; in obstruction to the free escape of 
 the lochia due to cicatricial narrowing of the parturient canal, and in 
 complete rupture of the uterus with the passage of the child into the 
 abdominal cavity. 
 
 Operation. — The preparations and the details of the operation are 
 the same as in Csesarean section, with the exception of those which 
 have reference to the ablation of the uterus and the prevention of 
 
 * Status of Caesarean Surgery, Gyn. Trans.. 1891, p. 120. 
 
 f Jahresbericht ueber die Fortschritte auf dem Grebiete der Geburtshtilfe und 
 Gynaek., IV Jahrgang, 1891.
 
 444 OBSTETRIC SURGERY. 
 
 hsemorrliage. Careful attention to the details of antiseptic surgery 
 is essential to a successful issue. In Porro's first case the abdominal 
 incision was nearly five inches in length. After opening the uterus 
 • and removing the foetus, the placenta, and the membranes, Porro 
 lifted the emptied organ from the abdomen, and placed the serre-nceud 
 of Cintrat around the lower segment, just above the os internum. 
 The tissues were then constricted until all haemorrhage from the cut 
 uterine surface was arrested. The uterus was then cut away with a 
 bistoury, the stump was brought outside of the abdominal wound, and 
 held in position by strapping the handle of the serre-nmud to the pa- 
 tient's right thigh. Miiller modified Porro's original method by en- 
 larging the first incision upward sufficiently to enable an assistant to 
 lift the uterus outside of the abdominal walls, and by applying com- 
 pression above the cervix (either the wire ecraseur or the Esmarch 
 bandage) before opening the womb and removing the child. This 
 plan offers the obvious advantage of rendering the operation bloodless, 
 and of making it easy to prevent the entrance of the amniotic fluid 
 into the abdominal cavity. Breisky, Litzmann, Miiller, Taruier, and 
 Elliott Eichardson, of Philadelphia, found no difficulty in tlius draw- 
 ing the uterus outside the abdominal cavity ; Spaeth, "Wasseige, Tibone, 
 Chiara, and Carl Brauu, on the contrary, either encountered great diffi- 
 culties in performing the manoeuvre, or were obliged to abandon it 
 altogether. According to Harris, there have been forty-two Porro- 
 Miiller operations, with the saving of twenty-one mothers and thirty 
 children. The compressors which have so far been employed are the 
 Cintrat serre-nmud, the chain ecm^e^^rwith a Pean attachment, render- 
 ing it possible after detaching the chain from the handle to maintain 
 the constriction, the various forms of wire ecraseur, and the elastic 
 ligature. Compression should be made slowly, and should not be car- 
 ried to the extent of cutting through tlie peritonteum. Owing to 
 the' liability of wire to break, great care should be taken in its selec- 
 tion. In case of accident, a second instrument should be held in 
 readiness. 
 
 Fehling, whose excellent record we have already noticed, gives the 
 followmg directions : After careful disinfection of the abdominal sur- 
 face, the incision should be made in the median line. As the ab- 
 dominal coverings are for the most part thin, ligatures are rarely ne- 
 cessary. The peritonaeum should be divided upon a grooved director. 
 Then either a median incision is made through the uterine walls with 
 the uterus in situ and with the precautions against hfemorrhage de- 
 scribed in connection with the older operation, or, as recommended by 
 Miiller, the uterus, after enlarging the abdominal wound, should be 
 tilted laterally, and withdrawn outside the abdomen previous to sec- 
 tion. An elastic .ligature, placed rapidly around the lower uterine 
 segment, furnishes a safeguard against hsemorrhage. In the Porro
 
 CESAREAN SECTION.— OPERATIONS OF THOMAS AND PORRO. 445 
 
 operation proper the elastic ligature is used after removal of the child ; 
 in the Midler modification, Avhich Fehling prefers, the ligature is ap- 
 plied previous to uterine section. In the latter case the child should 
 be extracted as speedily as possible, for the sudden interruption of the 
 placental circulation is decidedly more dangerous to the child than 
 when it takes place gradually. The diameter of the ligature should be 
 about one third of an inch. After the removal of the child and the 
 tying of the cord, the field of the operation should be cleansed and the 
 after-birth should be removed. Feliling next recommends the apiDlica- 
 tion of a second ligature beneath the first. Then the uterus and ova- 
 ries are to be removed, the stump cauterized, and pins inserted above 
 the ligatures to prevent the recession of the stump. To insure the 
 speedy and complete union of the peritoneal surfaces the latter should 
 be carefully stitched to the stump beneath the ligatures. For this pur- 
 pose a round needle and carbolized silk should be employed. Single 
 sutures passing through the jjeritoneal borders and the uterine tissues 
 should be introduced below and to the sides of the stump, and two 
 sutures through the peritoneal borders and uterine tissues upon the 
 upper surface of the stump. Above the latter two or three more sut- 
 ures should be employed to bring together the peritoneal border alone. 
 The abdominal sutures should next be introduced, and, after a final 
 cleansing of the abdominal cavity, the wound shoivld be closed. For a 
 dressing Fehling employs iodoform, and fills the funnel-shaped space 
 around the remains of the uterus with chloride-of-zinc cotton. Above 
 he places iodoform gauze and cotton fixed in place by means of a wide 
 bandage. The dressing, except in cases of bleeding or fever, may be 
 left undisturbed for six to eight days. The separation of the stump 
 occurs from the twelfth to the fifteenth day. 
 
 Among recent proposed modifications Sutugin* recommends, as a 
 means of shortening the healing process, that, after the separation of 
 the elastic ligature, the stump should be first scraped and pared to se- 
 cure a raw surface, and that then the borders should be closed by liga- 
 ture. For a day or two he leaves in the lower angle of the wound to 
 secure drainage a tent of iodoform gauze about the size of the little 
 finger. 
 
 Frank opens the abdomen and the uterus and removes the foetus, 
 then inverts the uterus and applies an elastic ligature which includes 
 ovaries and cervix outside of the vagina. The abdominal wound is 
 next closed and the uterus is amputated below the ligature. In this 
 latter act the tissues are first incised down to the peritonseum, to 
 which a separate ligature of silk is applied. The recommendations for 
 this plan are said to be the simplicity of the technique, the rapidity 
 with which the operation can be completed, and the minimal risk of 
 
 * SuTUGix, Die Bedeutung des Porrosielien Kaiserschnittes, etc., Centralbl. far 
 Gynaek., 1889, No. CG.
 
 446 
 
 OBSTETRIC SURGERY. 
 
 infection, Frank has operated eiglit times in the manner described, 
 with the loss of but one patient.* 
 
 The intraperitoneal treatment of the stump, doing away with the 
 dangers arising from necrosis, is correct in principle, but up to the 
 present has not yielded as good results as the extraperitoneal method. 
 It is indicated, however, after the removal of myomata imbedded in 
 the pelvic cavity, and in cases where the Porro operation is employed 
 for uterine rupture, when, owing to the deep seat of the rent, it is im- 
 possible to form a pedicle of sufficient length to reach above the ab- 
 dominal incision. 
 
 The technique necessarily varies with the conditions. In general 
 terms it may be stated that the plan of operation consists in turning 
 out the uterus and applying a double series of ligatures to each of the 
 broad ligaments. Between the median and outer ligature row the tis- 
 sues are then divided and an elastic ligature is placed about the cervix. 
 After amputation of the uterus a wedge-shaped portion should be ex- 
 cised from the surface of the stump, the cervical canal after thorough 
 disinfection should be cauterized with the thermo-cautery, deep catgut 
 sutures should be introduced to close the internal orifice of the cervix, 
 and deep and superficial sutures inserted to approximate the muscular 
 and serous surfaces together. After the removal of the rubber ligature 
 the sutures should be tightened, and new ones introduced if oozing 
 should render the latter necessary. Bleeding from the uterine artery 
 is best controlled, according to Fritsch, by passing the central sutures 
 obliquely, and in such a way as to cross one another, thereby including 
 the vessel between them. Fritsch and Lohlein exsect the wedge of 
 tissue from above downward instead of in a transverse direction, so as 
 to make the line of the approximated surfaces run parallel to the ab- 
 dominal incision. Instead of dropping the stump they sew its perito- 
 neal surface to the abdominal peritonaeum, while sutures passed through 
 the abdominal walls and the extremities of the line of union on the 
 stump serve to hold the line between the cut surfaces of the abdominal 
 wound and above the peritonaeum. Subsequent oozing into the perito- 
 neal cavity is thus guarded against, while the healing is promoted by 
 suitably applied aseptic dressings. Fritsch, before closing the abdomen, 
 likewise employs a stitch to fasten the severed border of the broad liga- 
 ment on each side to the peritoneal surface of the stump. 
 
 In fibroids seated below the pelvic brim the cavity left after enucle- 
 ation should be closed by a series of deep and superficial sutures, or 
 where of krge size a counter-opening should be made into the vagina 
 and drainage secured below by means of iodoform gauze, while the 
 peritoneal borders of the capsule are sewed carefully together. In like 
 manner in uterine rupture when a rent extends into the broad liga- 
 ment, the safest plan seems to be to close the stump, after the amputa- 
 * Vide Beaucamp. Arch. f. Gynack., vol. xl, p. 117.
 
 CESAREAN SECTION.— OPERATIONS OF THOMAS AND PORRO. 447 
 
 tioii of the intact portion of the uterus and trimming of the torn bor- 
 der in accordance with the principles indicated, and then to treat the 
 rent in the ligament by a counter-opening into the vagina, by drainage 
 below, and by closure of the tear in the peritonaeum. 
 
 Thomas's Operation, or Laparo-Elytrotomy. — In Professor Thomas's 
 operation, the dangers of opening into the peritonaeum and wounding 
 the uterus are avoided by incising the walls of the abdomen in the line of 
 Poupart's ligament, lifting the peritoneeum, and dissecting down to the 
 vagina, dividing the vagina transversely, and then, having reached the 
 cervix, extracting the child through the passage thus artificially created. 
 
 The credit of defending the practicability of the extraperitoneal 
 delivery of the child above the pelvic brim belongs chronologically to 
 Ritgen. It was the natural outcome of the teachings of Abernethy 
 and Cooper, to whom we owe the ligation of the external iliac artery 
 without opening the peritonaeum. The modus operandi was carefully 
 thought out by Ritgen, and was put by him to the practical test Octo- 
 ber 1, 1821. The incision through the vagina, Avhich was made with 
 a sharj) bistoury in a longitudinal direction, was, however, followed by 
 such profuse haemorrhage that the operation was discontinued, and 
 the ordinary Caesarean section performed in its place. The patient 
 died at the end of fifty-eight hours.* 
 
 In 1823 Baudelocque the younger, unaware of the work of his 
 predecessor, advised an incision down to the j^eriton^eum along the 
 external edge of the rectus muscle, extending from the umbilicus to 
 two inches above the pubes, separating the peritonaeum from the iliac 
 fossa with the finger introduced into the lower end of the wound, in- 
 cising the vagina to a length of four and a half inches, and then leav- 
 ing the expulsion of the child to nature, or extracting it with the 
 short forceps. In 1884 he published an essay reporting two cases in 
 which he had tried his plan, modified, however, by substituting the 
 flank incision of Ritgen for that along the rectus muscle. Like Rit- 
 gen, Baudelocque did not complete his first operation, owing to the 
 extent of the vaginal haemorrhage. In his second case he succeeded 
 in delivering the child, which was, however, dead at the time of his 
 undertaking the operation. Having accidentally pricked the external 
 iliac artery, Baudelocque tied the common iliac, in order to arrest the 
 haemorrhage thence resulting. The labor was likewise complicated by 
 convulsions. Death took place on the fourth day. The merit of first 
 performing laparo-elytrotomy belongs, therefore, to Baudelocque. 
 
 In 1837 Sir Charles Bell, in his Institutes of Surgery, suggested 
 practically the same plan of procedure as that subsequently advocated 
 by Dr. Thomas. 
 
 * For the particulars of this and the succeeding cases, the writer is indebted to 
 Dr. Henry J. Garrigues's model essay On Gastro-Elytrotoiny, N. Y. IMed. Jour„ 
 October and November, 1878.
 
 448 
 
 OBSTETRIC SURGERY, 
 
 In 1870 Dr. Thomas, who was at the time unaware of the labors 
 of his predecessors, read a memorable paper before the Medical Asso- 
 ciation of Yonkers, giving an account of, first, laparo-elytrotomy per- 
 formed tentatively upon the cadaver of a woman dying in the ninth 
 month of pregnancy ; and, second, upon a living woman at the end of 
 the seventh month of pregnancy, who had been suffering from pneu- 
 monia for a week or ten days, and was at the time of his visit 171 ar- 
 ticulo mortis. The operation was undertaken in the interest of the 
 child, which Wcis extracted alive, and survived about an hour. In 
 1874 the operation was repeated by Dr. Skene. The patient had been 
 forty-eight hours in labor, and unsuccessful attempts at delivering her 
 by craniotomy had been resorted to. She was suffering at the time of 
 the operation from exhaustion and shock, which gradually became 
 more marked, and she died seven hours after. In 1875 and in 1877 
 Dr. Skene had the glory of successfully performing the operation 
 under circumstances of great difficulty, with the result in each case of 
 saving the lives of both mother and child. In 1877 Dr. Thomas had 
 the good fortune to obtain a like triumph. In England the operation 
 has been performed by Drs. Himes and Edes, both times in the inter- 
 est of the child, the condition of the mothers being well-nigh hopeless. 
 Both children were saved. In 1880 Dr. "Walter R. Gillette * extracted 
 by laparo-elytrotomy a putrid child, which he was obliged to perforate 
 and extract with the cephalotribe, the forceps and version having been 
 previously tried without success. The mother recovered with scarcely 
 an untoward symptom. 
 
 Itt 1883 Professor W. H. Taylor, of Cincinnati, operated with a 
 fatal result. Forceps, craniotomy, the cranioclast, and version had 
 been previously tried in vain. When laparo-elytrotomy was decided 
 upon, the patient was much exhausted, with a very rapid, feeble pulse 
 and elevated temperature. The patient died forty-four hours after 
 the operation. In the same year Professor Jewett, of Brooklyn, oper- 
 ated upon a patient who had been a Aveek in labor. The woman was 
 exhausted by long labor, and previous attempts at replacing the arm, 
 by the use of forceps and by attempts at version. The uterus was in a 
 state of tonic contraction, and the soft parts were excessively cedema- 
 tous. The child died before delivery. The mother died seventy hours 
 later of acute septicaemia. 
 
 In the year 1885 Drs. Skene and Jewett operated each successfully, 
 and since then an additional successful case has been reported by Dr. 
 McKim. The statistical results, therefore, of laparo-elytrotomy are 
 the saving of seven mothers in thirteen operations. But in no one of 
 the fatal cases were tlie conditions such as to render success a possi- 
 bility. 
 
 * Gillette, A Successful Case of Laparo-Elytrotoiny, Am. Jour, of Obstet., 
 January, 1S80, p. 98,
 
 CESAREAN SECTION.— OPERATIONS OP THOxMAS AND PORRO. 449 
 
 The vaginal haemorrhage noted in the cases of Ritgen and Baude- 
 locque can apparently be avoided by tearing the vagina transversely, 
 as recommended by Thomas, in place of incising it with a bistoury. In 
 four of the cases vesico-vaginal fistulse were produced, but all healed 
 spontaneously. The following description of the operation is bor- 
 rowed from the excellent essay of Dr. Garrigues, which has already 
 been quoted. It has received the sanction of Drs. Thomas, Skene, and 
 Gillette, with the exception that, in discussion, all have agreed that it 
 is desirable to insert a perforated drainage-tube through the abdomi- 
 nal wound into the vagina, and to keep the parts cleansed with anti- 
 septic injections. 
 
 Operation. — " The bowels having been emptied by an aperient and 
 a copious enema, and the os having been fully dilated by Barnes's water- 
 bags, if it is not so already, the patient is placed on her back, on a 
 long, narrow table covered with a mattress or quilts, rubber or oil- 
 cloth, and a sheet. The pelvis is well elevated on a hard cushion, the 
 head and shoulders slightly raised by means of pillows, the legs stretched 
 out. If, from some cause, it has been impossible to dilate the os fully 
 by Barnes's dilators, it is now done by the fingers, or if that is impossi- 
 ble too, it is dilated later through the abdominal wound. The patient 
 is anaesthetized. Since disinfection can not be carried out strictly, 
 and since its administration would give some additional trouble, it is 
 scarcely necessary to operate under disinfectant spray. 
 
 " The operator takes his place at the right side of the patient. Be- 
 sides one who administers the anaesthetic, four assistants are needed — 
 one on either side of the operator, and two in front of him. The first 
 assistant, standing at the left of the patient's chest, kys his flat hands 
 under the umbilicus and draws the uterus upward and toward the 
 left, thereby putting the skin in the right iliac region on the stretch. 
 Counter-extension may be made by the assistant placed at the right of 
 the operator. A slightly curved incision is made through the skin 
 from a point one inch and three quarters (4-5 centimetres) above and 
 outside the spine of the pubes, parallel to and an inch above Pou- 
 part's ligament, to a point an inch above the anterior superior spine 
 of the ilium. This incision may also be made in the opposite direc- 
 tion, from without inward. By a few touches with the edge of the 
 knife the external oblique muscle is laid bare, and spouting branches 
 of the superficial epigastric artery secured by holding-forceps. The 
 abdominal muscles are cut to the same extent, layer by layer, the ex- 
 ternal oblique, the internal oblique, and the transversalis, the first of 
 which is aponeurotic. The transversalis fascia is very carefully hooked 
 up with a fine tenaculum, and the knife carried horizontally, so as to 
 make a small opening in it, avoiding the peritonaeum that lies be- 
 neath it, separated from it by loose areolar tissue, and sometimes fat. 
 A director is introduced through the opening and pushed between the 
 29
 
 ^5Q OBSTETRIC SURGERY. 
 
 fascia and the peritonieum toward the inner and the onter angle of 
 the wound, and the fascia is cut. The best instrument for this pur- 
 pose is Key's hernia director, the one which Spencer AVells uses when 
 incising the peritonaeum in ovariotomy. It is firm, a quarter of an 
 inch (six millimetres) broad, slightly curved on the fiat, well rounded 
 at the end, and has on its concave side a groove that stops a quarter 
 of an inch (six millimetres) from the point of the instrument. Next, 
 the operator places the pulp of his fingers on the peritonaeum, separat- 
 ing it from the transversalis and iliac fascia, until he reaches the vagi- 
 na! wall. The second assistant, placed at the left of the operator, 
 holds the peritoneum and intestines, applying a fine, warm napkin 
 under his hands, in order to be sure not to let them slip. The first 
 assistant draws the uterus vigorously upward and toward the left, in 
 order to expose the deeper part of the vaginal wall on the right side. 
 A female silver catheter is introduced into the bladder by the third 
 assistant, placed at the left hip of the patient and held in the known 
 direction of the boundary-line between the bladder and the vagina, 
 below the ureter on the side on which the operation is being per- 
 formed. A blunt woollen instrument, something like the obturator 
 of a cylindrical speculum, only longer, is introduced into the vagina 
 and applied above the linea ileo-pectinea, raising the vaginal wall as 
 much as possible into the abdominal wound. An incision is made 
 parallel to the ileo-pectineal line and the catheter felt in the bladder, 
 as far below the uterus as possible, in order to avoid the ureter and 
 Douglas's pouch, and incise where there are fewest vessels, cutting 
 down on the obturator witli Paquelin's thermo-cautery, the galvano- 
 caustic knife, or simply cautery-irons (table-knives) only heated to 
 red heat. The surrounding parts are protected by the application of 
 wet compresses around the place to be cauterized. The incision made 
 by the cautery is extended forward toward the symphysis and back- 
 ward toward the promontory by placing the pulp of both index-fin- 
 gers perpendicularly on the edges, and api^lying the force in different 
 places in the direction of the os uteri and the ileo-pectineal line, so as 
 to tear the vaginal wall as far forward as is deemed safe in regard to 
 the bladder and the urethra, the locality of which organs is ascertained 
 by feeling the catheter held by the assistant, and as far backward as 
 the wound in the abdomen will allow. Now the catheter is withdrawn, 
 the membranes ruptured if the liquor amnii has not escaped before, 
 the uterus tilted as much as possible to the opposite side, and the os 
 drawn with the forefinger into the iliac fossa. 
 
 " The operator draws the child through the double Avound either by 
 simple extraction, or after turning, or by applying the forceps, accord- 
 ing to the presentation and other particular circumstances. The pla- 
 centa is expelled by compressing the uterus, and withdrawn through 
 the wound.
 
 CESAREAN SECTION.— OPERATIONS OF THOMAS AND PORRO. 451 
 
 " If bleeding occurs, the operator tries to check it by applying liga- 
 tures through the abdominal wound, holding-forceps, styptics, or cau- 
 teries, using a large wooden tubular sjjeculum ; or a Sims speculum 
 may, perhaps, give easier access to the bleeding vessel than anything 
 else. If it be impossible to check the haemorrhage, the vaginal wound 
 must be firmly tamponed from below through the rulva and from the 
 abdominal wound with cotten pledgets soaked in cold water and 
 squeezed, and held in siiu by broad straps of adhesive plaster round 
 the abdomen, as after ovariotomy. Except in the last eventuality, the 
 bladder is distended by injecting lukewarm milk in order to ascertain 
 if this organ has been injured. If so, the fistula is immediately sewed 
 with catgut, which need not be removed. The wound is cleaned by 
 injecting a stream of lukewarm carbolized water (two per cent), or a 
 solution of thymol (two per thousand), from the vagina and from the 
 abdominal wound. Next, the edges of the abdominal wound are 
 brought together by interrupted sutures, and the lower part of the 
 abdomen covered with borated or sali(?ylated cotton, and surrounded 
 by broad straps of adhesive plaster fastened to the hips, as in ovari- 
 otomy. A jaledget of cotton soaked in carbolized oil (1 to 10) is applied 
 at the entrance of the vagina." 
 
 Professor William M. Polk has demonstrated that the operation can 
 be performed as well upon the left side as upon the right.* 
 
 * Polk, N. Y. Med. Jour., May, 1883.
 
 THE PATHOLOGY OF LABOR 
 
 CHAPTER XXIV. 
 
 ANOMALIES OF THE EXPELLENT FORCES. 
 
 Precipitate labors— Tardy labors.— Irregular paitis in the first stage of labor.— 
 Treatment of protracted first stage.— Irregular pains in the second stage.— 
 Treatment of protracted second stage.— On the use of ergot in labor.— Irregu- 
 lar pains in the third stage ; treatment.- Painful labors : from hysteria ; from 
 rheumatism ; from intestinal irrjtation ; from inflammatory changes. 
 
 I]sr physiological labor the expelleiit forces are adequate to over- 
 come the resistance encouuterecl. Labor becomes pathological — 1. 
 When the pains are defective ; 2. When the resistance offered by the 
 soft parts or the bony pelvis exceeds the limits of safety to the mother 
 or the child ; 3. When natural delivery is rendered difficult or impos- 
 sible, owing to malformations or malpresentations of the fa?tus ; 4. In 
 consequence of dangerous complications, sucli as haemorrhage, eclamp- 
 sia, and prolapsed funis. 
 
 From a clinical j^oint of view the anomalies of the labor-pains are 
 divisible into pains in excess, weak pains, pains attended by an extreme 
 of physical suffering, and pains complicated by strictures. Physiologi- 
 cally, however, these different forms are far from composing distinct 
 conditions, isolated from one another. Thus, rigidity of the os is always 
 intensely painful, and is usually dependent upon feeble action of the 
 expellent forces. There is no standard of strength by which the weak- 
 ness or excess of pains can be measured. The terms are always rela- 
 tive, and are used with reference to the obstacles to be overcome. In 
 primiparse strong pains are requisite to induce softening and dilata- 
 tion of the cervix. In multiparse pains may be intrinsically weak, and 
 yet suffice to bring labor to a prosperous conclusion. Much confusion 
 of mind is often occasioned by the double sense in which the term 
 "labor-pains" is employed. Thus, it is frequently stated that the 
 pains are good, when an examination reveals only a feeble measure of 
 expellent force, the word " pains " representing nothing more than an 
 acute degree of physical suffering. Clinically, pains are to be judged 
 by the effects they produce. In practice it will be found convenient 
 to study the various forms of irregular uterine action in connection
 
 ANOMALIES OF THE EXPELLENT FORCES. 453 
 
 with the results of their influence upon the duration of labor. These 
 results are — 1. Precipitate labor ; 2. Tardy labor. 
 
 Precipitate Labors. — It is customary to ascribe precipitate labors to 
 an excess of the pains. The term excess is, however, only relative. 
 There is no reason to believe that the uterus ever acts with such a 
 degree of energy a.s per se to constitute a pathological condition. With 
 a large, roomy pelvis, a soft, dilatable cervix, a distensible vagina and 
 perinffium, labor may be terminated by a few strong pains. Such 
 rapid deliveries are not to be regarded with apprehension. As a rule, 
 they are followed by firm retraction of the uterus, and the continu- 
 ance of good contractions acts as a safeguard against haemorrhage. 
 The puerperal state usually pursues a favorable course. Aside from 
 the inconvenience which sometimes results when, perchance, women 
 are suddenly overtaken by labor-pains in the streets or in public places, 
 an easy, rapid labor is to be regarded as one of the varieties of normal 
 labor. Except the adoption of jirecautions against such untoward 
 accidents, they call for no special treatment. 
 
 When, however, the parturient act occurs in women who possess 
 an undue reflex irritability, which impels them to an excessive use of 
 the abdominal muscles, it is possible for serious mischief to ensue. 
 Thus, if the patient happens to be seized when in the standing posture, 
 the straining efforts may throw the child suddenly upon the floor ; but 
 even here the consequences are less detrimental than would be natu- 
 rally anticipated. The force of the fall is usually broken by the cord. 
 Lacerations of the latter take place at a distance from the navel, and 
 are not followed by haemorrhage. Post-partum haemorrhage, prolapse, 
 and inversion of the uterus are said to be possible occurrences, though 
 of extreme infrequency. When all the exiaellent forces are called into 
 play at an early period of labor, before the rigidity of the utero-vaginal 
 canal has been overcome, the violent straining has been known to cause 
 subcutaneous emphysema of the head and neck, to interfere Avith the 
 utero-placental circulation, and even to produce fracture of the fetal 
 skull. Excessive straining before the soft parts have been properly 
 prepared for the passage of the child may likewise lead to lacerations 
 of the cervix, vagina, and perinseum. 
 
 The proper treatment for this condition is to lower the reflex irri- 
 tability by hypodermic injections of morphia ; or, better still, by the 
 production of complete anaesthesia, so as to susjoend the action of the 
 voluntary muscles. 
 
 Tardy Labors. — For the proper understanding of labors protracted 
 beyond the period of safety by irregular uterine contractions, it is 
 necessary to bear in mind the principal features of normal delivery. 
 These are, contractions of the uterus followed by relaxation and dis- 
 tinct periods of repose ; stretching and thining of the muscular fibers 
 below the contraction ring, with retraction of the uterus above that
 
 454 THE PATHOLOGY OP LABOR. 
 
 point ; softening and dilatation of the cervix ; the fixation of the uterus 
 in the axis of the pelvis ; and the addition of the abdominal muscles to 
 the expellent forces. 
 
 The first requisite of every normal labor is that the pains shall be 
 good — i. e., shall possess a markedly expulsive character. We have 
 seen that for the uterus to perform work the contractions should not 
 be continuous, but distinctly rhythmical. For effective work, more- 
 over, the excursions of the uterus during a contraction should possess a 
 certain degree of amplitude, and the interval between the contractions 
 should be sufficient to allow the nervous system to recover from the 
 shock of pain. 
 
 Irregular Pains in the First Stage of Labor. — In the first stage of 
 labor pains are most frequently defective by reason of their short dura- 
 tion. As a rule, short, cramp-like pains occasion acute suffering. 
 When they recur with little or no interval between them, they are very 
 exhausting to the patient. As the cervix in such cases is tense and 
 rigid, it is to this condition that the delay is usually attributed. If, 
 however, the tissues of the cervix are liealtliy, the presentation is nor- 
 mal, and the pains preserve their expulsive character, rigidity of the 
 cervix is never an obstacle to delivery. The activity of the organic 
 changes which lead to softening and dilatation is closely related to tlie 
 activity of the uterine contractions. The exception to this rule in pri- 
 miparae is only apparent. To be sure, in them the firm, closely knitted 
 tissues of the cervix yield more gradually to the dilating forces than 
 in multipara. Indeed, in multii3ara3 we sometimes find the organic 
 changes in the cervix induced by contractions which liave hardly ex- 
 cited the notice of the woman ; but in primiparae, while good pains, 
 under the reservations mentioned, certainly induce softening of the 
 cervix, weak pains effect no changes in its tissues. 
 
 The uterine contractions may be abnormal from the commence- 
 ment of labor ; more frequently the loss of their expulsive character is 
 a secondary condition. In many primiparous women labor progresses 
 in an auspicious manner for a time, inspiring hopes of a speedy ter- 
 mination. Then the cervix, which had previously been dilating favor- 
 ably, becomes rigid, the sufferings of the patient during each contrac- 
 tion are enhanced, and further advance is arrested. This transforma- 
 tion is not to be accounted for by a spasm of the circular fibers of the 
 OS, but is the result of secondary changes in tlie action of the uterus 
 itself. The right understanding of the phenomenon in question ren- 
 ders it necessary to recall the physiological fact that the uterus is 
 endowed not only with contractility, but with retractile properties 
 likewise. These are shown in a marked way by the manner in which 
 the uterus closes upon its contents after the escape of the amniotic 
 fluid ; so, too, by the manner in which the uterus follows down the 
 foetus during the period of expulsion. Normally, the gradual closure
 
 ANOMALIES OP THE EXPELLENT FORCES. 455 
 
 of the uterus upon the ovum leads with a dilated os to the permanent 
 formation of the bag of waters. Thus it will be seen that in normal 
 labor retractility is a wholly beneficent possession of the uterus. When, 
 however, from any cause the cervix dilates slowly, and the pains are 
 strong and close together, as the uterus retracts upon the stationary 
 ovum, the excursions made by the labor-pains shorten, which thus tend 
 to assume the clonic form. The continuance of the same process leads 
 finally to the close investment of the ovum by the uterus, when the 
 only indication of contractility which remains is the increased harden- 
 ing of the uterus at short intervals. These changes in the character of 
 the contractions are marked by corresponding changes in the cervix, 
 the condition of the latter affording an index of that of the entire 
 uterus in much the same way that a furred tongue bespeaks a catarrhal 
 condition of the stomach. 
 
 These secondary changes in the pains are dependent upon a variety 
 of conditions. The tardy dilatation of the cervix, which stands in a 
 causal relation to them, may result from overdistention of the mem- 
 branes Avith amniotic fluid, or from their firm adhesion to the walls of 
 the uterus around the os internum — conditions which, in either case, 
 interfere with the stretching of the lower segment, and thus lead to 
 waste of uterine force by distributing it uniformly over the entire 
 ovum. Again, where there is lack of parallelism between the axis of 
 the uterus and that of the pelvic brim, the presenting part may, by 
 bearing especially upon the anterior portion of the lower uterine seg- 
 ment and of the cervix, exercise so little jn-essure upon the os that its 
 sphincter long maintains its integrity. Finally, irregular contractions 
 may be consequent upon faulty presentations, and upon any form of 
 pelvic obstruction. 
 
 A special and dangerous form of irregularity results when the mem- 
 branes rupture prematurely, and the entire amount of amniotic fluid 
 leaks away. This, to be sure, is a rare event, as the presenting part, as 
 a rule, acts as a valve which closes the lower segment of the uterus, 
 and prevents the amniotic fluid from escaping. When, however, ow- 
 ing to the small size, the uneven shape, or the hindered descent of the 
 presenting part, the accident in question takes place, as a combined 
 result of muscular retractility and the pressure of the intestines dur- 
 ing the pains, the uterus gradually conforms to the surface of the 
 fcetus. In this way the much-dreaded " dry labors " are produced. 
 The consequences are far-reaching. The retraction of the muscular 
 fibers about the child's neck in head presentations forms an impedi- 
 ment to natural delivery; the disturbance of the utero-placental cir- 
 culation endangers the life of the child ; the uterine walls applied to 
 the convex surfaces of the child become ana?mic, Avhile the re-entrant 
 portions, subjected to negative pressure, become hyperaemic and oedem- 
 atous, extravasations take place into the tissues, the walls are rendered
 
 456 THE PATHOLOGY OF LABOR. 
 
 friable, the contractions are associated with intense pain, and peritoneal 
 irritability develops.* 
 
 The prolonged retraction of the uterus may be followed in the end 
 by the entire cessation of pains, and paralysis may ensue. Uterine 
 retractility is not precisely the same force as that which causes the 
 expulsion^ of a fluid from an overdistended elastic sac, for retractil- 
 ity and contractility are in the uterus rarely disassociated from one 
 another. When the uterus ceases to contract, it forfeits, as a rule, 
 its retractile properties likewise, f It sometimes follows, therefore, 
 that, following prolonged tonic contraction, after the evacuation of 
 the uterus, the walls of the latter collapse like those of a pricked 
 bladder. 
 
 The Treatment of a Protracted First Stage.— The treatment of a 
 protracted first stage has for its object the mitigation of pain and the 
 restoration of their expulsive quality to the uterine contractions. No 
 plan of action should be decided upon without first carefully investi- 
 gating the cause of delay. The suspensive influence of a full bladder 
 or rectum is always to be borne in mind. In face, breech, and shoul- 
 der presentations, and in contracted pelves, the slow dilatation of the 
 cervix is the rule, and, with such exceptions as will be noted in their 
 appropriate connections, do not call for interference. A faulty posi- 
 tion of the uterus should, if possible, be rectified by suitable abdom- 
 inal support. Adhesions of the membranes to the lower uterine seg- 
 ment should be dissected up by the index-finger. In hydramnion, 
 rupture of the membranes, so as to allow the partial escape of the am- 
 niotic fluid, is sometimes serviceable. 
 
 If the length of the labor is simply due to the insuflftcient uterine 
 action, the conduct of the accoucheur will, in a measure, depend upon 
 the frequency and severity of the pains and the endurance of the 
 patient. If the pains occur at such intervals and with such mildness 
 that the patient is able to eat, to sleep, and to attend to ordinary 
 household duties, the dilatory progress of labor should cause no appre- 
 hension. In pathological conditions it is the element of pain which 
 is most to be dreaded. Pain long continued is a powerful nerve-de- 
 pressant When combined with starvation and deprivation of sleep, 
 it greatly impairs a woman's capacity to resist the perils of the pucr 
 peral period. While, therefore, the indication for treatment is clear 
 enough, it is not so easy in a given case to decide whether the remedy 
 should be applied first to the relief of pain, or whether efforts should 
 be directed at once to the acceleration of labor, so as most speedily to 
 place the patient beyond the hazards of parturition. As a rule, how- 
 ever, it may be stated that anodynes are appropriate in cases where the 
 
 * Lahs, Die Theorie der Geburt, pp. 285 et seq. 
 
 t Breisky, Ueber die Beh.imllwng der puerperalen Blutungen, Volkinann's 
 Samml. klin. Vortr., No. 14. p. 93.
 
 ANOMALIES OF THE EXPELLENT FORCES. 45Y 
 
 cervix is but slightly dilated, while accelerative measures naturally re- 
 ceive the preference in those where the first stage of labor is already 
 far advanced. 
 
 The pain-stilling agents from which the selection should be made 
 are the warm bath, chloroform, chloral by rectal injection, and mor- 
 phine, either alone or combined with minute doses of atropine. In prac- 
 tice it will usually be found convenient to begin with chloroform, and 
 then to sustain its action by the hypodermic injection of morphine, or 
 the rectal administration of chloral, suspending the chloroform so soon 
 as the tranquillizing effect of the latter is developed. Anodynes often 
 accomplish wonders in one of two ways : when, owing to the prolonga- 
 tion of the labor and its attendant pain, the patient's nervous energies 
 have become exhausted, the arrest of pain enables the woman to sleep, 
 and, with the recuperation of power that comes upon awakening, good 
 pains follow, which bring the labor to a happy termination. In other 
 cases, after the employment of the anodyne the parts apparently relax, 
 and an acceleration of labor follows. In these cases the oxytocic effect 
 is probably due to the quieting action exerted upon the spinal nerves. 
 It has been surmised that the nerves of the uterus derived from the 
 cerebro-spinal system possess inhibitory properties — a theory which, 
 if true, readily explains how severe pain suspends uterine action, and 
 how the quieting of pain would restore to the motor nerves their full 
 energy. 
 
 In a certain proportion of cases the effects of the anodyne or an- 
 aesthetic are of but short duration. In from ten to thirty minutes the 
 acute suffering returns, and the short truce is unattended with benefit. 
 There is an erroneous opinion that, so long as the membranes are un- 
 ruptured, this condition may be allowed to go on indefinitely. It is, 
 however, of the greatest importance that the length of the period of 
 non-interference should be governed by the strength of the patient. 
 There is nothing that requires more judgment in midwifery practice 
 than to decide when the time has arrived at which delay is fraught 
 with more danger than active interference. For my own part, I be- 
 lieve that many fair lives are needlessly squandered because of excess- 
 ive timidity begotten of imperfect obstetric teachings. 
 
 If iDain-stilling agents do no good, or if the first stage is already 
 far advanced, the physician should seek, by restoring to the pains their 
 expulsive character, to hasten delivery. 
 
 Of reputed service in cases of uterine insufficiency are the warm 
 vaginal douche, the dilating bags of Barnes, the introduction of a 
 bougie into the uterus, forceps, and the internal administration of 
 quinine, ergot, viscum album, borax, cannabis Indica, cinnamon, or 
 digitalis. 
 
 The bougie is applicable only to cases where the membranes are 
 intact, and where the pains are weak without being cramp-like in char-
 
 458 THE PATHOLOGY OF LABOR. 
 
 acter. It should in all cases be surgically clean, as otherwise it can be- 
 come the carrier of infection to the uterine cavity. 
 
 The vaginal douche possesses a wider range of utility. It is safe 
 and tolerably effective under favorable conditions. It promotes the 
 organic changes in the cervix, stimulates the uterus to contract, and 
 mechanically distends the vagina. Its action is, however, apt to be 
 slow and somewhat uncertain. In a case of overdistention of the 
 amnion, I once saw its employment followed immediately by complete 
 tonic rigidity of the uterine muscular fibers. 
 
 Of all the resources at our disposal, however, the water-bags of Dr. 
 Barnes stand easily at the head. Passed within the cervix, and dis- 
 tended so as to place the canal moderately upon the stretch, they not 
 only serve to mechanically dilate the os, but are most efficient as reflex 
 exciters of the labor-pains. If left in situ until expelled into the vagi- 
 na by the bearing-down efforts they awaken, the cervix will be found 
 to have lost its rigidity. If necessary, a larger dilating-bag should 
 then be employed in the same way. An attempt to dilate the cervix 
 rapidly and with violence is neither safe nor profitable. To obtain 
 permanent results it is essential to effect the organic changes in the 
 tissues which render them physiologically dilatable. In cases of tonic 
 rigidity of the uterus, the production of normal pains will sometimes 
 be assisted by rupturing the membranes and raising the head, so as to 
 allow a small portion of the amniotic fluid to escajio, previous to re- 
 sorting to the Barnes water-bags. 
 
 When, after rupture of the membranes, a segment of the head pre- 
 sents at the OS externum, the rubber bags are of less service. In such 
 cases often we are able to accomplish speedy dilatation by simply ask- 
 ing the woman to hold her breath, and to re-enforce the uterine pains 
 by the action of the auxiliary muscles. If this plan fails, forceps 
 should be applied, and the head be made to serve as the dilating body. 
 To avoid lacerating the cervix, the tractions should be intermittent, 
 and should be suspended during the acme of the pains. The rule 
 given for the preservation of the perinaeum will be found most service- 
 able in attempts to maintain the integrity of the cervix, viz., that the 
 extraction is most safely accomplished during the period of greatest 
 relaxation, and not at the moment of extreme tension. 
 
 Of the various internal remedies to stimulate uterine action, ergot 
 should, in the first stage of labor, be unqualifiedly proliibited. In 
 spite of numerous favorable experiences from its use, its tendency to 
 intensify tonic contraction of the involuntary muscular fibers makes 
 it always a perilous drug. The enthusiastic praises of quinine by Drs. 
 Fordyce Barker and Albert H. Smith, of Philadelphia, warrant fur- 
 ther trials of its efficacy. Dr. Smith says : " I do not hesitate to give 
 it in every case, because, even where there is no decided inertia at the 
 onset of labor, there may be failure of the powers of the mother from 
 
 I
 
 ANOMALIES OF THE EXPELLENT FORCES. 459 
 
 early exhaustion and fatigue, and we get the benefit of the qiiinia in 
 diminishing this tendency and also in promoting the condensation of 
 the uterine fiber after the delivery of the placenta, thus lessening the 
 dangers of post-])artuni haemorrhage and the annoyances of the after- 
 pains so commonly resulting from a slow condensation of the uterine 
 muscle."* He recommends the bisulphate in a fifteen-grain dose, 
 which he declares acts altogether beneficially as a stimulant to the 
 normal uterus. The other agents mentioned as possessing direct or 
 incidental ecbolic properties are now chiefly of historic interest. 
 
 Irregular Pains in the Second Stage of Labor. — In many cases the 
 pains maintain their normal quality until the completion of the first 
 stage of labor and the descent of the head to the floor of the pelvis. 
 AVlien in the second stage of labor the pains become inefficient and 
 lose their expulsive character, the non-advance of the head is usually 
 attributed to a rigid perinasum. But it is a matter of every-day expe- 
 rience that with really good pains and normal head mechanism the 
 perineum speedily loses its rigidity. Of course, it is not denied that 
 in primiparffi the organic changes which effect the softening of the 
 perinteum need for their accomi^lishment relatively stronger pains than 
 in multipara. The faulty action of the expellent forces in the second 
 stage is due either to exhausted nerve-power or to excessive uterine 
 retraction. In the former case, labor becomes powerless from the 
 feeble character of the juiius; in the latter, it results from the with- 
 drawal upward of the uterine muscle, and the consequent lessening of 
 the intra-uterine pressure. These cases of retraction are worthy of 
 special consideration. Thus, Hofmeierf found in a number of in- 
 stances where the head rested on the pelvic floor that the contraction 
 ring, which was made out by palpation through the abdominal walls, 
 was situated at from five to seven inches above the symphysis pubis, 
 so that the contractile portion of the uterus covered not more than 
 one third of the foetus. Under such circumstances, while the ^jatient 
 suffers from intense pain, the contractions of the partially emptied 
 uterus do not possess the force to overcome the resistance of a rigid 
 perinaeum. 
 
 Treatment — In all cases of protracted second stage, before decid- 
 ing upon the existence of uterine irregularity, both the bladder and 
 the bowels should be emptied, and care should be taken to exclude the 
 existence of obstruction from the bony pelvis If the only resistance 
 to be overcome is that furnished by the soft parts, weak pains should 
 be re-enforced by the action of the abdominal muscles. After rotation 
 of the head is completed, a new vis a tergo may be supplied by press- 
 ure applied to the breech through tlie abdominal walls after the method 
 
 * Albert IT. Smith, Retarded Dilatation of the Os Uteri in Labor, p. 27. 
 + IIoFMErER, Ueber Contraetionsverhaltnisse des kreissenden Uterus, Ztschr. L 
 Greburtsh. u. Gynack., Bd. vi, p. 164.
 
 460 THE PATHOLOGY OF LABOR. 
 
 of Kristeller, or by the modified form of expression recommended by 
 Bidder.* According to the latter, the physician should stand to the 
 left of his patient, and grasp the breech of the foetus with the right 
 hand ; he should then raise the breech and fix it in such a position 
 that the pressure applied will be best transmitted through the spinal 
 column to the cephalic end— a point to be determined by the fingers of 
 the left hand, which should likewise control the movements of the 
 head during the period of expulsion. The force, the frequency, and 
 the length of the acts of expression should of course be decided by the 
 judgment and experience of the operator. 
 
 ' Where the movements of flexion and rotation have been imper- 
 fectly performed, little is to be expected from any of the forms of 
 expression. The available remedies are then ergot and the forceps. 
 Of these, the advantages of safety and celerity are all on the side of 
 the forceps. Many practitioners, however, who have observed that in 
 practice ergot often acts likewise with speed and safety, accord to it a 
 large measure of confidence. But along with these more fortunate 
 experiences there is a shady aspect to be remembered. When the 
 tardy labor is due to tonic retraction, the use of ergot is calculated to 
 aggravate the sources of delay. In other cases tonic retraction is the 
 direct result of ergotic action, and, as a consequence of restricted 
 utero-placental circulation, the life of the foetus is jeopardized. When, 
 therefore, the drug is used, the heart-sounds of the foetus should be 
 carefully watched, and, with the first signs of failing force, the forceps 
 should be applied to rescue the child from the impending danger of 
 asphyxia. 
 
 Note on the Use of Ergot in Parturition. — Secale cornutum, or ergot, 
 the active principle of which is ergotin, according to Buchheim,t and ergotic 
 jicid, according to Zweifel,}: is universally acknowledged to increase the fre- 
 quency, length, and power of the uterine contractions during parturition, and 
 to finally induce a tetanic condition of the uterine muscular fibers. Its action 
 upon the unimpregnated uterus is the same in kind, but less marked in degree, 
 and of less constant occurrence. Robert,* on the other hand, denies the ecbolic 
 properties of either of those constituents. He maintains that it is cornutin, 
 which excites the uterine contractions, and that the abortifacient element is 
 sjihacelin acid, to which also the tetanic rigidity produced by ergot is due. 
 The views of high authorities in regard to the manner in which these effects 
 are produced present irreconcilable differences. Wernich || attributed the ecbolic 
 properties of ergot to irritation of the uterine nervous centers, induced by 
 
 * E. Bidder, Ziir Beurtheilung der Kristeller'schen Expressionsmethode bei 
 Kopflagen, Ztschr. f. Geburtsh. u. Gynaek., Bd. iii, p. 241. 
 
 \ BucHHEiM. Schmidt's Jahrb., vol. clxiv, p. 12. 
 
 t ZwEiFEL, Ueb. d. Secale corn.. Arch. f. exp. Pathol., vol. iv. 1875. p. 407. 
 
 * KoBERT. Arch, f.exp. Patliologie ii. Pathol.. Bd. xviii, p. 31G. 
 
 I' Werxich, Einige Versuch. ub. d. Miilterk., Beitrag. z. Geburtsh., vol. iii, 1874, 
 p. 102.
 
 ANOMALIES OP THE EXPELLENT FORCES. 461 
 
 arterial anaemia of the spinal cord and of the uterine tissues. This anaemia is 
 referred by him to loss of tone in and dilatation of the veins, whereby venous 
 congestion, leading to secondary arterial anaemia, is produced.* Other ob- 
 servers assume a primary contraction of the capillaries, with a consequent in- 
 creased arterial pressure, as the source of the anaemic irritation of the nerve- 
 centers; while still others believe direct stimulation of the uterine muscular 
 fibers by the ergot to be the cause of their exaggerated contractility, t 
 
 Kohler refers the uterine contractions producea by ergot to increased irrita- 
 bility of the peripheral nerves, in conjunction with anaemia of the spinal cord.J 
 These conflicting views pertain chiefly to points of purely theoretical interest, 
 and need not prevent the obstetrician from obtaining a clear conception of his 
 duty in the practical administration of ergot. The above-mentioned incontro- 
 vertible facts concerning its operation sufiice to guide tlie physician in the em- 
 ployment of this useful drug, even if he be unable at present to definitively 
 decide regarding the exact mechanism of its physiological action. 
 
 Ergot should never be exhibited during the first stage of labor, because the 
 tetanic uterine contractions, which it substitutes for the normal rhythmical ones, 
 tend to prevent the further dilatation of the os uteri and to deprive the foetus 
 of its blood-supply through the constriction of the uterine vessels. Should the 
 membranes have ruptured before the termination of the first stage, the adminis- 
 tration of ergot would endanger the life of the foetus by causing undue pressure 
 to be exerted upon the umbilical cord. We should also abstain from the use of 
 ergot during the second stage, unless it seem necessary as a pro^^hylactic against 
 post-partum haemorrhage. Even under these circumstances it should never be 
 administered if there be the slightest mechanical obstacle to delivery, or if the 
 fetal head be high up in the pelvic canal. Spiegelberg* insists upon the neces- 
 sity of carefully observing the fetal heart after the use of ergot, in order that 
 instrumental delivery may, in case of threatened asphyxia, be promptly resorted 
 to. Benicke records twenty-seven cases in which ergot was administered during 
 the second stage on account of inertia uteri. Spontaneous delivery occurred in 
 only seven of these cases. || Ergot is not specially adapted to the arrest of haem- 
 orrhage accompanying abortion. In these cases, and in haemorrhage caused 
 by retained shreds of the fetal envelopes, the appropriate treatment consists in 
 the tampon and in subsequent complete evacuation of the uterine cavity. The 
 only imperative exhibition of ergot is presented by the occurrence of post- 
 partum haemorrhage resulting from uterine atony. ^ The unyielding, tetanic 
 uterine contractions which it produces act most beneficently by occluding the 
 orifices of the bleeding vessels. Even under these circumstances it should, how- 
 ever, be withheld until after the expiilsion of the placenta, lest the uniform 
 uterine contractions lead to its prolonged retention or interfere with manual 
 efforts for its extraction. 
 
 Irregular Pains in tJie Third Stage of Labor. — The tardy expul- 
 sion of the placenta, due to atony of the uterus, is of rare occurrence 
 
 * Wermch, op. cit., p. 97. 
 
 f Benicke, Ueb. Anwend. d. Mutterk. in d. Geburtsh., Ztschr. f. Geburtsh. u 
 Gynaek., vol. lii, 1878, p. 174. 
 
 X Kohler, Schmidt's Jahrb., vol. clxiv, p. 14. 
 
 * Spiegelberg, Lehrb.. p. 414. || Benicke, op. cit., p. 178. 
 ^ ScHROEDER, Lehrb., fifth edition, p. 471.
 
 462 THE PATHOLOGY OF LABOR. 
 
 when the Crede method of expression is uniformly practiced. As, in 
 rehixed conditions of the uterus, blood pours from the patulous mouths 
 of the torn utero-placental vessels into the fundus, a free external 
 discharge of blood follows of necessity whenever contractions are ex- 
 cited—a fact to be borne in mind by an unpracticed obstetrician, lest 
 he mistake the simple conversion of an internal into an external 
 hajmorrhage for one produced by the manipulations which have been 
 recommended. The whole subject of atony in the third stage is, how- 
 ever, so closely associated with the occurrence of post-partum haemor- 
 rhage that its specific consideration will be reserved for separate study 
 in connection with the hemorrhages which take place during and 
 subsequent to labor. 
 
 After the birth of the child, retraction of the uterus is Nature's 
 safeguard against hajmorrhage. As a result of the abuse of ergot, or, 
 in other cases, from an abnormal adherence of the jjlacenta, such an 
 extreme degree of retraction may be reached before the completion of 
 the third stage as to lead to the imprisonment of the placenta within 
 the uterine cavity. In these cases complete retraction in the body of 
 the uterus is prevented by the presence of tlie jDlacental mass. Below 
 the latter, where no obstacle is opposed to the shortening of the mus- 
 cular fibers, a constriction results. The stricture is most pronounced 
 at the contraction ring. The lower uterine segment and the cervix 
 proper are usually in a sub-paralytic condition, and widen from above 
 downward to the vaginal insertion. From the shape thus imparted 
 to the uterus this condition is generally known as an "hour-glass 
 contraction." When met with for the first time, it is apt to prove 
 extremely puzzling. In following the cord upward, its continuation 
 through the stricture is sometimes overlooked. In several cases I 
 have known the pulpy mucous membrane of the lower segment to be 
 mistaken for an adherent placenta, and have been, in consequence, 
 summoned to assist in its removal. 
 
 Treatment.— By patient waiting, relaxation of the stricture usually 
 takes place spontaneously. The result may be promoted by the hypo- 
 dermic injection of morphine, combined with atropine. It is not, how- 
 ever, altogether safe to leave the patient before the expulsion of the 
 placenta has taken place; for, exceptionally, the muscular fibers of 
 the body of the uterus may relax prior to those of the lower segment, 
 and thus haemorrhage may result. Injections of ice-cold water were 
 recommended in such cases by Seyfert, as tending not only to restrain 
 hajmorrhage, but to promote regular expulsive uterine action. Forci- 
 ble dilatation is rarely necessary, and should be reserved for hemor- 
 rhages of an alarming character. In nearly all cases, however, it is 
 practicable, even in extreme examples, to extract the placenta in a 
 short time without force or violence. The plan I have followed of 
 late years, with uniform success, consists in introducing the index and
 
 ANOMALIES OP THE EXPELLENT FORCES. 403 
 
 middle fingers, with the whole hand in the vagina, to the point of 
 constriction. Then, by pressing the uterus downward, the fingers 
 are brought in contact with the pracen"tal border, Now, it is only 
 necessary to draw a single cotyledon into the canal to render the 
 further extraction a matter of certainty. Under the pressure of the 
 soft placental mass the stricture relaxes slowly. By combining ex- 
 pression with slight traction, the delivery is surely accomplished. The 
 principal difficulty of the operation lies in the manipulations needful 
 to bring the placenta at the outset to the point of stricture, but this 
 difficulty can be pretty certainly overcome by patience and the deter- 
 mination to succeed. During the period of withdrawal the operator 
 should be content with a very slow progression, proportioned to the 
 yielding of the stricture ; otherwise, the presenting portion of the 
 placenta tears away, when the labor expended is lost. 
 
 Painful Labors. — In nearly all forms of abnormal uterine contrac- 
 tions the pain of labor reaches a pathological degree of intensity. 
 Especially we have had occasion to call attention to the intolerable 
 suffering in cases of long-continued reciprocal pressure between the 
 uterus and its contents. 
 
 But acute suffering sometimes attends upon the preliminary stages 
 of labor. During the latter days of pregnancy in primipara?, often 
 for a few hours only preceding the advent of true labor-pains in mul- 
 tipara?, contractions occur which normally scarcely attract the atten- 
 tion of the patient. In rare instances, however, the suffering they occa- 
 sion is extreme. In hysterical women these preliminary pains are often 
 of an agonizing character, rendering it necessary to resort for their 
 relief to such palliatives as the warm bath, opium, and chloroform. 
 
 But, even where hysteria does not exist as a cause, the pains may 
 be so severe, while the cervix has still its normal length, that the 
 woman believes herself in labor, and, indeed, the contractions are as 
 painful as in actual labor. There are no febrile symptoms indicative 
 of inflammation either of the uterus or of its appendages. The pain 
 is like that in muscular rheumatism. Though the term rheumatism 
 of the uterus is often applied to this condition, its pathology is uncer- 
 tain. It is very probable that practitioners confound together, under 
 the foregoing title, a number of distinct affections, such as hysterical 
 hyperesthesia, intestinal irritability, and the early stages of inflamma- 
 tion. Excluding these morbid conditions, there remains a class of 
 cases practically important from the disappearance of the pain upon 
 the induction of intense diaphoresis. Patients who for days have 
 been treated with hypodermic injections of morphine with only mod- 
 erate results are often relieved as if by magic by placing them in a 
 warm bath, and then covering them with blankets, giving in addition 
 hot drinks and Dover's powder, until they become bathed in abundant 
 perspiration.
 
 ^Q^ THE PATHOLOGY OF LABOR. 
 
 It is often difficult toward the close of preguancy to distinguish 
 between colic-pains due to fecal accumulation or the presence of gases 
 in the stomach and intestines, troubles to which pregnant women are 
 especially disposed, and uterine contractions of a painful character. 
 Indeed, in the former case the uterus becomes involved to some ex- 
 tent, so that the cervix is felt during a cramp to simultaneously 
 harden. Moreover, after labor has actually begun, it may become 
 complicated by colic-pains, which exercise in turn a suspensive influ- 
 ence upon parturition. But the colic-pains are themselves inter- 
 mittent, and are therefore liable to be mistaken for those of labor. 
 Thus, it is possible to become involved in perplexities which time 
 alone can solve. Even when we have made out the diagnosis of 
 " false labor," and give an opiate for the relief of the patient, it may 
 happen that the first result of quieting the pain may be the accelera- 
 tion of labor. AVhen this does not occur, we should guard against the 
 return of the trouble by clearing out the bowels by purgatives or 
 enemata. 
 
 In normal labors, the pulse becomes more rapid at the beginning 
 of each pain, and continues to increase in frequency until the pain has 
 reached its acme, after which a gradual declination follows. But 
 sometimes labor is attended by marked febrile symptoms. There exist 
 rapidity of the pulse between the pains and a continuous elevation of 
 temperature. Now, if, at the same time, the uterine contractions are 
 the source of extraordinary suffering, there is strong reason for sus- 
 pecting that labor is complicated by inflammatory conditions of the 
 organs concerned in parturition. Thus, a latent pelvi-peritonitis may 
 be converted into the acute form by the several acts which comprise 
 normal labor, or the prolonged tonic contraction of the uterus upon 
 the foetus after the rupture of the membranes, especially in neglected 
 shoulder presentations and in contracted pelves, may give rise to inflam- 
 matory affections in the uterus itself. Again, in other cases, a salpin- 
 gitis, especially if of the purulent variety, may become the starting 
 point of dangerous local or general peritonitis. In either case the co- 
 existence of intense pain with febrile symptoms should awaken serious 
 apprehensions. Especially ought we to be upon our guard against the 
 treacherous lull in the symptoms that, as a rule, takes place when 
 labor is at an end. After a day or two we may expect a chill and the 
 return of the fever. In the early stages of metritic and perimetritic 
 trouble, a ten-grain dose of calomel often exercises a beneficent action 
 in arresting the disease. AVhere labor has so far advanced that the 
 induction of artificial diarrhoea is rendered impracticable, opiates, 
 though of inferior value, soothe the pain, and are our next most valu- 
 able resource.
 
 CONTRACTED PELVES. 465 
 
 CHAPTER XXV. 
 
 CONTRACTED PELVES. 
 
 Varieties. — Frequency. — Diagnosis. — Pelvic measurements. — Forms of the con- 
 tracted pelvis. — Justo-minor pelves. — Flattened non-rachitic pelves. — Rachitic 
 ilattened pelves. — Generally contracted, flattened pelves. — Irregular forms. — 
 Pseudo-osteomalacia. — Scholiosis. — Kyphosis. — Influence of contracted pelves 
 during pregnancy and labor. — Influence upon the uterus. — Influence upon the 
 presentation. — Influence upon the pains. — Influence upon the first stage of 
 labor. — Influence upon the mechanism of labor. — Effects of pressure upon the 
 maternal tissues. — Influence upon the fetal head. — Effects of pressure upon 
 the integuments ; upon the cranium. — Prognosis. ^ 
 
 Ix contracted pelves sometimes a single diameter, sometimes ^ ^^ 
 the principal diameters are reduced below the normal average, "^iie 
 relative proportion of the parts may be to a considerable extent pre- 
 served, or the pelvis may have been distorted by special morbid condi- 
 tions, giving rise to unequal development and changes of outline. 
 These peculiarities embarrass all attempts at classification. Still, the 
 study of the subject is greatly simplified by the fact that the dimin- 
 ished space is, in the great proportion of cases, located chiefly at the 
 brim. Aside from these, there remain a variety of irregular forms of 
 rare occurrence, each requiring a separate description and plan of 
 treatment. 
 
 It is to those cases in which the narrowing is chiefly at the brim 
 that the term " contracted pelves " is generally applied. The other 
 forms are all specially designated by some qualifying adjective defin- 
 ing their character. 
 
 Contracted pelves proper are divided into — 
 
 1. The pelvis aequabiliter justo-minor, in which all the diameters, 
 from the brim to the outlet, are diminished in very nearly equal 
 measure. 
 
 2. The flattened pelvis, contracted specially in the conjugate diam- 
 eter. In this form the transverse diameter may be normal, or may be 
 diminished. Thus, we distinguish — 
 
 a. Simple flattened pelves (transverse diameter normal). 
 
 J. Flattened, generally contracted pelves (narrowing in the trans- 
 verse as well as the conjugate diameter). ^ " 
 
 As it is rare to find two pelves possessing the same measure- 
 ments, the question arises as to the degree of antero-posterior short- 
 ening which suffices to distinguish the contracted from the normal 
 pelvis. 
 
 It is often customary to consider the contracted pelvis simply as 
 furnishing a mechanical obstacle to the passage of the child's head ; 
 but this is to overlook a great variety of very important modifications 
 30
 
 4:^ 
 
 THE PATHOLOGY OP LABOR. 
 
 to which it gives rise during pregnancy and labor. These remoter 
 influences are often observable in cases where labor, if considered from 
 the standpoint of length alone, would be regarded as normal. 
 
 Michaelis* and Litzmann,t whose investigations furnish the basis 
 of modern opinion regarding the contracted pelvis, place the limit at 
 three and a half inches for the simple flattened pelvis, and at four 
 inches for those likewise diminished in the transverse diameter. Yet 
 even above these limits the action of the narrow pelvis is not rarely 
 manifested in disturbance of the normal mechanism of labor. 
 
 In Germany, Litzmann, Michaelis, Spiegelberg, J and Schroeder 
 place the average frequency of contracted pelves at fourteen per cent, 
 and in my own field of experience, in the Emergency and Maternity 
 Hospitals of New York city, the ijimates of which are, however, 
 almost entirely of foreign birth, every variety and degree of pelvic 
 deformity finds abundant illustration. In our native American Avomen 
 abnormal pelves are rare. I frequently hear from country physicians 
 who attend lectures at the Belle vue Hospital Medical College that, in 
 long years of practice, they have never met with a single instance. 
 Yet it is impossible to study the cases of vesico-vaginal fistula re- 
 ported by Dr. T. A. Emmet * without arriving at the conclusion that 
 the existence of contracted pelves is frequently overlooked. Certainly 
 the immunity of American women is by no means so absolute as to 
 Justify the neglect in which the study of pelvic deformity has so 
 generally fallen. 
 
 The Diagnosis of Contracted Pelvis.— The diagnosis of pelvic de- 
 formity is based upon direct examination. Certain facts in the previous 
 history of the patient are often of substantial value in the way of con- 
 firmatory evidence, or by directing attention to the probable existence 
 of deformity. 
 
 Previous History. — Inquiry should be instituted regarding the oc- 
 currence of rickets in early childhood, and especially in this connection 
 as to the period of the appearance of the teeth. Late dentition is an 
 ordinary sign of imperfect bone formation. A cross baby, bottle-fed 
 or improperly nursed, suffering from repeated attacks of indigestion, 
 from restlessness at night, and profuse perspirations, who cuts the first 
 incisor teeth in the second year, has presumptively had rickets. A 
 history of this nature, even in the absence of the grosser evidences of 
 rickets, such as the square head, the pigeon-breast, the tumefied abdo- 
 men, small stature, spinal curvature, enlarged joints, and incurvation 
 of the long bones of the extremities, is to be regarded with suspicion. 
 Data of the kind mentioned are, however, often difficult to obtain, and 
 
 * Michaelis, Das enge Becken, Leipsic, 1865. 
 
 t Litzmann, Die Formen des Beckens, Berlin, 1861. 
 t Spiegelberg, Lehrbuch, 1878, Bd. ii, p. 426. 
 
 * Emmet, Vesico- Vaginal Fistula, William Wood, 1868.
 
 CONTRACTED PELVES. 
 
 46Y 
 
 it should be borne in mind tiiat not every case of mild rachitis is fol- 
 lowed by pelvic narrowing. 
 
 In'struction may likewise be obtained from the history of previous 
 labors. Though a protracted and difficult labor is by no means un- 
 common in well-formed primipar^e, it should stimulate us, both during 
 parturition and subsequent to delivery, to make a careful investigation 
 as to the capacity of the pelvis. A pendulous abdomen and faulty 
 presentations and positions of the fojtus occur with much greater fre- 
 quency in contracted than in normal pelves. 
 
 Certain of the rarer deformities proceed from inflammations be- 
 tween the sacro-iliac bones and at the hip-joint, from inequalities in 
 the length of the limbs, and from spinal distortion when these diffi- 
 culties occur in early childhood. 
 
 Pelvic Measurements. — The examination should be made with the 
 patient upon her back, placed preferably upon a hard table covered by 
 a folded blanket, or a woolen comforter. The head and shoulders 
 should be moderately elevated, the knees should be flexed, and the 
 pelvis brought as near to the edge of the table as possible. 
 
 Facility, in the recognition of abnormal conditions can only be ac- 
 quired by making it a habit to note the general features of the pelvis 
 in every case of labor which is committed to our charge. By experi- 
 ence we acquire a tolerably distinct idea of the relative thickness of 
 the bones, the inclination of the ilia to the horizon, the height of and 
 the angle formed by the symphysis pubis, the size and character of the 
 pubic arch, the length, breadth, and 
 curvature of the sacrum, the position 
 of the promontory, and the distance 
 between the ischia. 
 
 More exact information is deriv- 
 able from direct measurements be- 
 tween different prominent points in 
 the pelvis. Various pelvimeters have 
 been devised to facilitate the required 
 measurements. Those for determin- 
 ing the distance between certain ex- 
 ternal points are alone of practical 
 value. For this purpose the circle of 
 Baudelocque is the one I have most 
 constantly employed. It requires to 
 be used with caution on account 
 of the spring of the metallic arms. 
 Schultze's instrument possesses the 
 advantages of greater firmness and portability. The points selected 
 for measurement should be bony prominences, easy of recognition, 
 and not covered by soft parts. They should be such as to allow us 
 
 Fig. 200. — Baudelocque's pelvimeter.
 
 468 
 
 THE PATHOLOGY OF LABOR. 
 
 to form at least approximative conclusions relative to the diameters 
 of the small pelvis. Experience shows iis that, judged by these rules, 
 three measurements only are possessed of real importance, viz., the 
 distances between the anterior superior spinous processes, the distances 
 between the crests of the ilia, and the external conjugate diameter. 
 
 Fig. 201.— Schultze's pelvimeter. 
 
 In measuring the distances between the anterior superior spinous 
 processes, the accoucheur should stand by the side of his patient, and, 
 holding the arms of the pelvimeter between the thumb and fingers, 
 apply the points of the instrument to the spines external to the inser- 
 tion of the sartorious muscles. The points should then be pushed 
 backward a number of times along the outer edge of the crests of the 
 ilia, until, after a few trials, the greatest distance between the crests 
 has been determined. The average distances thus obtained are nearly 
 ten and a quarter inches between the spinous processes, and eleven 
 and a half inches between the crests of the ilia. A pelvis in which 
 these measurements are equal, or in which the relations are inverted 
 (i. e., where the distance between the spinous processes is greater than 
 that between the crests of the ilia), is rachitic in character. In rachitic 
 pelves of the second variety mentioned it is customary to select, in 
 measuring the distance between the crests, points situated two and a 
 half inches posterior to the spinous processes. 
 
 Any considerable falling below the normal average in these two 
 diameters would warrant the diagnosis of transverse shortening in 
 the inner dimensions of the small pelvis. Deductions as to the degree 
 of shortening should, however, be made with caution, as the relations 
 between the diameters of the large and small pelves depend upon such 
 variable factors as the thickness of the bones and integuments and 
 the height and inclination of the ilia to the horizon.
 
 CONTRACTED PELVES. 469 
 
 In measuring the external conjugate diameter the patient is turned 
 upon her side ; one extremity of the pelvimeter is then placed upon 
 the fossa just beneath the spinous process of the last lumbar vertebra, 
 while the anterior point is made to rest upon the middle of the upper 
 border of the symphysis pubis. The lengtli of the external conjugate, 
 or, as it is sometimes termed from its author, the diameter of Baude- 
 locque, is normally about eight inches. Baudelocque thought that by 
 deducting three inches from the external conjugate in spare women, 
 and three and a quarter inches in women of a fleshy habit, the conju- 
 gata vera could be determined. Litzmann has, however, strikingly 
 shown the fallacy of Baudelocque's deduction. In thirty cases, where 
 he had an opportunity to compare the measurements of the external 
 conjugate with the length of the internal conjugate as determined sub- 
 sequently by post-mortem examination, he found the mean amount to 
 be deducted was about three and a half inches. However, the amount 
 in individual cases widely varied, owing to differences in the thickness 
 of the bones and integuments, tlie maximum amounting to nearly 
 five inches, while the minimum did not exceed two and three fourths 
 inches. But, while the external conjugate does not enable us to esti- 
 mate to a fraction the length of the antero-posterior diameter of the 
 pelvic brim, it furnishes useful information as to the existence in gen- 
 eral of flattening. Thus, if the diameter of Baudelocque measures 
 less than six and one fourth inches, it may be assumed that the pelvis 
 is flattened. If the pelvis measures less than seven and a half inches, 
 flattening may be assumed in half the cases. Above seven and a half 
 inches, antero-posterior shortening is very exceptional.* 
 
 For internal measurements, the only practical pelvimeter is the 
 hand of the accoucheur. To be sure, it can only determine with ex- 
 actitude the diagonal conjugate, i. e., the distance from the lower bor- 
 der of the symphysis pubis to the promontory ; but from the diagonal 
 conjugate it is possible to calculate the conjugata vera with a closer 
 degree of accuracy than is obtainable by means of any of the ingenious 
 instruments designed to measure directly the diameters of the brim. 
 
 To ascertain the diagonal conjugate, the index and middle fingers 
 of the left hand should be introduced, well oiled, into the vagina. By 
 pushing the posterior vaginal wall backward, the points of the fingers 
 are made to reach the sacral vertebrae. Then, following the sacrum 
 upward, the promontory is reached. To do this it is necessary to sink 
 the elbow, and give to the fingers a nearly vertical direction. The 
 resistance of a rigid peringeum and the vaginal wall is best overcome 
 by continued, steady, upward pressure. It is often possible by this 
 method to reach the promontory in even normal pelves. During the 
 examination the patient should be requested to raise up her hips. The 
 
 * Litzmann, Ueber die Erkenntniss des engen Beckens, Volkmann's SammL 
 klin. Vortr., No, 20, p. 148.
 
 470 
 
 THE PATHOLOGY OF LABOR. 
 
 promontory is recognized partly by its convex surface, and partly by 
 the width of the cartilage which intervenes between it and the ad- 
 joining lumbar vertebra. In practice there are two possible sources of 
 error, viz. : an angle may form between the first and second sacral 
 vertebrae where the union has been incomplete, producing a "false 
 promontory " beneath the true one ; or the upper surface of the first 
 lumbar vertebra may project in such a way as to be mistaken for the 
 promontory in cases where the latter, as sometimes happens, forms 
 with the spinal column a very obtuse angle.* Such deviations are not 
 without practical interest, as the prognosis is rendered less promising 
 when the head, in place of a single .point of contact, has to overcome 
 the resistance offered by the surface of an entire vertebra. 
 
 The measure of the diagonal conjugate is taken by pressing the 
 middle finger firmly against the most salient portion of the promon- 
 
 'b^ 
 
 Fia. 202.— Normal inclination Fig. 20.3.— Diminution of angle Fig. 204.— Increase of angle 
 of the symphysis pubis. between symphysis and pel- between symphysis and 
 
 (Spiegelberg.) vie brim. pelvic brim. 
 
 tory, while the radial edge of the hand or index-finger is raised to the 
 Ugamentum arcuatum. The point of contact with the latter is then 
 carefully marked with the nail of the index-finger of the right hand. 
 It is desirable in withdrawing the fingers that they maintain, as nearly 
 as may be, the position assumed at the time of measurement. Finally, 
 with a small rule, the length from the mark of the nail to the tip of 
 the finger is readily ascertained. 
 
 In calculating the length of the conjugata vera from the measure 
 thus gained, it is necessary to reconstruct the triangle formed by the 
 two conjugates and the symphysis pubis. The diagonal conjugate is 
 the longest of the three sides. The length of the conjugata vera de- 
 pends on the height and inclination of the symjihysis pubis and thj 
 
 * LiTZMANN, Ueber die Erkenntniss des engen Beckens, Volkmann's Samml, 
 klin. Vortr., No. 20, pp. 152, 153.
 
 CONTRACTED PELVES. 471 
 
 degree of elevation of the promontory above the symphysis, as may be 
 readily seen by reference to the diagrams. 
 
 The height of the symphysis pubis may be determined by the finger 
 through the anterior vaginal wall. When the symphysis does not 
 measure above one inch and a half, the subtraction of two thirds of an 
 inch from the diagonal diameter will, under ordinary circumstances, 
 furnish very nearly the conjugate. When the symjihysis exceeds one 
 inch and a half, three fourths of an inch should be deducted.* 
 
 The inclination of the symphysis pubis to the plane of the brim 
 and the height of the promontory above the upper border of the pubes 
 can only be estimated. When any unusual deviations in either of 
 these regards are found to exist, some special allowance would need to 
 be made by way of compensation. It is just here that judgment and 
 experience furnish the best safeguards against vital inaccuracies. 
 
 In thin persons during the non-pregnant state the promontory 
 can sometimes be easily reached through the abdominal walls, and an 
 estimate made of the conjugate by deducting, from the distance thus 
 obtained between the jDromontory and the symphysis, the supposed 
 thickness of the intervening tissues. 
 
 The transverse diameters of the pelvic brim and cavity can be 
 neither directly measured nor calculated with any degree of certainty 
 from other measurements. 
 
 There are certain other dimensions which we find useful to deter- 
 mine in the rarer forms of distortion, and which will be mentioned in 
 their proper connections. For the three forms of contracted pelvis 
 which at present engage our attention, four measurements alone are 
 of practical value — viz., the distance between the anterior superior spi- 
 nous processes ; the distance between the crests of the ilia ; the exter- 
 nal conjugate ; and the conjugata diagonalis. 
 
 The Three Principal Forms of Contracted Pelvis. 
 
 The Pelvis JEquabiliter Justo-minor, or Symmetrically Contracted 
 Pelvis. — This, the rarest of the three forms, presents to the casual 
 view the appearance of a normal pelvis, except that the diameters from 
 the brim to the outlet are reduced in nearly equal measure.- We dis- 
 tinguish two varieties of this pelvis : 1. In the commoner variety the 
 woman may be of small, medium, or large stature, and her figure thick- 
 set, or, on the contrary, graceful and slender. Nothing in either her 
 size or carriage is indicative of any abnormal condition. The pelvic 
 bones themselves, both in their structure and in their connections with 
 one another, are free from all traces of morbid action. They are sim- 
 ply below the standard size. The pelvis as a whole is of the feminine 
 type. Litzmann has shown, however, that in the justo-minor pelvis 
 
 * Spiegelberg, o/j. cif., p. 433.
 
 472 
 
 THE PATHOLOGY OP LABOR. 
 
 the relations of the different parts to one another are not, as a rule, 
 absolutely the same as in the normal pelvis. Thus, there is diminished 
 width of the sacrum, due in special degree to the small size of the alae ; 
 the rotation forward of the promontory and the curving of the lower 
 extremity of the sacrum are less pronounced; the concavity of the 
 sacrum in the transverse direction is increased; the posterior sacral 
 surface is nearly on a level with the posterior superior spinous processes 
 in place of sinking forward between the ilia ; the height of the anterior 
 and lateral walls is proportionately lessened ; and, finally, there is often 
 an increase in the angle which the symphysis pubis forms with the 
 conjugate.* 
 
 These peculiarities point to a premature arrest in the development 
 of the bones, whereby the pelvis retains something of the infantile 
 type. The causes of arrest are in most cases traceable to general dis- 
 turbances of nutrition during early childhood, such as scrofula and 
 chlorosis, to rickets, which in place of leading to deformity exception- 
 ally exerts its influence in the suspension of bone-growth, and in rare 
 cases to the influence of hard labor and the carrying heavy weights 
 before the completed development of the body. A few cases in which 
 no morbid conditions can be elicited from the history of tlie patient 
 may perhaps be referred to some original defect in the primitive ma- 
 terial from which the bones were built up. Cases have been reported 
 in which this anomaly appeared to be hereditary, f 
 
 2. In veritable dwarfs the diminutive size of the pelvis may simply 
 correspond to the Lilliputian proportions of the entire skeleton. These 
 so-called dwarf pelves — pelves nance — are of the regular feminine type, 
 but the bones are slight, and united, as in the child, by cartilage. 
 They are extremely rare. In pelves of this variety the highest degree 
 of contraction is observed. J 
 
 Diagnosis. — In i\ve justo-minor pelvis all the external diameters are 
 diminished. At the same time rickets is excluded by the normal re- 
 lations existing between the spines and the crests of the ilia {vide p. 
 475). The diagonal conjugate is lessened. In estimating the conju- 
 gata vera it is necessary carefully to notice the height of the promon- 
 tory and the inclination of the anterior pelvic wall, as these are some- 
 times exaggerated and call for an increase in the amount to be de- 
 ducted.* By careful palpation of the two sides of the pelvis with the 
 
 * LiTZMANN, Die Formen des Beekens, Berlin, p. 40. 
 
 f MicHAELis, Das enge Becken, herausgegeben von Litzmann, p. 190 ; vide like- 
 wise, L5HLEIN, Zur Lehre voni Durchweg zu engen Becken, Ztschr. f. Geburtsh. u. 
 Frauenkr., Bd. i, p. 53. 
 
 X There is a third form of justo-minor pelvis, which is the concomitant of un- 
 developed organs of generation. As it occurs only in sterile women, it possesses 
 no obstetrical interest. 
 
 * On the contrary, owing to the shortness of the symphysis pubis, as a rule, the 
 average amount to be deducted is rather less than in normal pelves. Lohlcin Kunst-
 
 CONTRACTED PELVES. 
 
 473 
 
 half -hand introduced into the vagina, the fact but not the degree of 
 transverse shortening may be recognized. Still, in this way the ex- 
 istence of extreme contraction would be noticed.* Jjohlein maintains 
 
 Fig. 205.— Specimens from the Wood Museum (Bellevue Hospital). Drawn on same scale. 
 No. 1. Normal pelvis. No. 2. Justo-minor pelvls.t 
 
 that the addition of four fifths of an inch to the distance from the 
 lower border of the ligamentum arcuatum and the upper border of the 
 great sciatic notch, which can be measured by the finger without great 
 
 hiilfe bei der allg. Beckenenge) found the average in eighteen cases was three fifths 
 of an inch. 
 
 * LoHLEiN, Zur Becken-Messung, Ztschr. f. Geburtsh. und Gynaek., vol. xi, part 
 i, p. 33. 
 
 f Primipara, aged twenty-three. In labor three days previous to my seeing her. 
 Waters all escaped. Large scalp-tumor reaching nearly to vulva. Cervix rigid. 
 Os one third dilated and pushed down by scalp-tumor. Forceps tried. Afterward 
 perforation and craniotomy. Chin tilted and head brought through the pelvis by 
 the fronto-mental diameter. Patient died on third day. Extensive marks of press- 
 ure in the bladder opposite pelvic rami. Small circular perforation of uterus oppo- 
 site promontory. Conjugate diameter three inches. Transverse diameter of brim 
 four and a half inches. Slight Naegele obliquity on left side. Patient was fifty- 
 nine inches in height, and presented no signs of rickets.
 
 ^/j^ THE PATHOLOGY OF LABOR. 
 
 difficulty, furnishes a close approximation to the length of the trans- 
 verse diameter. In ordinary cases, it is fortunately safe to base prac- 
 tice upon the length of the antero-posterior diameter. 
 
 Flattened Pelvis. — AVe have seen that the characteristic of this 
 
 form is a shortened conjugate diameter. The transverse diameter re- 
 
 ^ mains at the same time normal, or may sink below the standard. A 
 
 special distinction is likewise to be made between the flattened pelves 
 
 of non-rachitic and rachitic origin : 
 
 1. The flattened non-rachitic form is the most frequent variety of 
 contracted pelvis. At a first glance, or previous to measurement, it 
 often produces the impression of a normal, well-formed pelvis. It is 
 occasioned by a sinking of the sacrum downward and inward between 
 the two ilia. As this movement takes place without any forward rota- 
 tion of the promontory, the antero-posterior shortening is not confined 
 to the brim, but extends throughout the entire pelvic cavity. Extreme 
 contraction is uncommon, the length of the conjugate rarely falling 
 below three inches. The flattening is of necessity associated with a 
 compensating increase in the transverse diameter. As, however, the 
 flattened non-rachitic pelvis is usually from the outset of small sizet, 
 the compensation hardly suffices to give to the transverse diameter 
 more than the normal dimensions. Indeed, it is not infrequent to 
 find a slight lessening in the transverse diameter associated with aur 
 tero-posterior contraction. 
 
 There is nothing definitely settled regarding the etiology of this 
 deformity. It has been attributed to lifting and carrying heavy bur- 
 dens before the age of puberty, to incompletely developed rickets, and 
 to retarded development. 
 
 During life it is not easy to distinguish between this form and that 
 of the symmetrically contracted pelvis. In both the external signs of 
 rickets are absent, the relations between the spines and crests of thoi 
 ilia normal, and in both all the external diameters may be somewhat 
 diminished. The stature of the individual furnishes no clew; for, 
 though both forms occur rather more frequently in diminutive persons, 
 there are numerous exceptions to the rule. The sinking of the sacrum 
 between the ilia is not easy to recognize. In a well-marked example, 
 however, the relatively greater shortening of the conjugata externa and 
 the diagonal conjugate,* with the difficulty of palpating the inner sur- 
 face of the pelvic lateral walls, furnish the prominent points for guid- 
 ance. Sometimes, when no bony union has formed between the first 
 and second sacral vertebrae, a double promontory may be left. 
 
 * In reckoning the true conjugate from the diagonal diameter, the same reduc- 
 tion needs to be made as in the normal pelvis, for, though the outward slant of the 
 symphysis is increased, this is compensated for by the diminished height of the 
 symphysis and low position of the promontory. (Litzmann, Volkmann's SammL 
 klin. Vortr., No. 20, p. 160.) 
 
 I
 
 CONTRACTED PELVES. 
 
 475 
 
 2. The rachitic form of flattened pelvis presents the following char- 
 acteristics : 
 
 The bones are of small size, but usually of normal texture. Some- 
 times, however, they are thin, and even translucent, while in other 
 instances they may be unusually compact and thickened. The ilia are 
 flattened, and run in a nearly horizontal direction. The anterior su- 
 perior spinous processes flare outward, so that the distance between 
 them dift'ers little from that between the widest points of the crests. 
 The promontory projects inward toward the symjjhysis pubis. The 
 upper portion of the sacrum sinks inward between the ilia, and lies 
 farther in front of the posterior superior spinous processes than in the 
 normal pelvis. The upper portion, too, is directed nearly horizontally 
 backward, while the extremity, usually at the fourth or fifth sacral ver- 
 tebra, is bent sharply for- 
 ward. The anterior sacral 
 surface loses its transverse 
 concavity, and becomes 
 either fiat from side to 
 side, or convex from the 
 bulging forward of the sa- 
 cral vertebra. The antero- 
 posterior shortening of the 
 brim is accompanied by a 
 compensating increase in 
 the transverse diameter. 
 As, however, the rachitic 
 pelvis is originally under- 
 sized, the transverse diameter rarely exceeds normal dimensions. The 
 horizontal rami of the pubes are flattened, and the acetabula are di- 
 rected to the front. The cartilage of the symphysis pubis generally 
 projects inward, the pectineal line is often unusually sharp, and at 
 times terminates at the insertion of the psoas muscle in a projecting 
 spine. Below, the ischia diverge from one another, and the arch of 
 the pubes is widened. 
 
 The result of these changes is to produce a shallow pelvis, with 
 contraction at the brim and widening at the outlet. The shape of 
 the brim varies between a long ellipse and that of a heart or kidney, 
 the different degrees of variation depending upon the extent of the 
 displacement forward of the promontory. Externally, owing to the 
 horizontal position of the sacrum, a depression exists in the lumbar re- 
 gion, the sulcus between the nates is broad and superficial, and the 
 anal orifice is exposed to view. 
 
 To apf)reciate the rachitic pelvis, it is necessary to bear in mind the 
 changes wrought by rickets in the bony structures. In the physiolog- 
 ical growth of the pelvic bones, new cell-elements develop beneath the 
 
 Fig. 306.— Flattened rachitic pelvis. (Wood's Museum.)
 
 ^^Q THE PATHOLOGY OF LABOR. 
 
 periosteum and adjacent to the cartilaginous borders upon the articular 
 surfaces. These cell-elements promptly ossify, and thus provision is 
 made for the increase of the bones in extent and thickness. Simulta- 
 neously with the formation of the new bone, medullary spaces are pro- 
 duced in the bony tissues by a process of absorption. Now, in rickets, 
 while the new cell-elements are deposited in such numbers that the 
 preparatory layer is often five to ten times the normal thickness, the 
 process of ossification is suspended or im])erfectly performed. Thus, 
 the rachitic pelvis consists of a number of more or less firm, bony 
 masses, covered with soft osteoid layers, with broad cartilaginous bor- 
 ders at the articular surfaces. These changes combine to increase the 
 pliability of the pelvis, and to retard its growth. 
 
 The pelvic deformity resulting from rickets is mainly due to the 
 weight of the superimposed body. The pressure from above which the 
 trunk exerts pushes the promontory forward toward the median line. 
 At the same time the upper portion of the sacrum rotates upon its 
 transverse axis, so that its posterior aspect is nearly on a line with the 
 horizon. The bodies of the vertebrae sink downward between the flex- 
 ile wings, whereby the concavity of the sacrum from side to side is 
 effaced. The pliant border of the iliac articulation yields somewhat, 
 and, as it is drawn inward by the sinking of the sacrum, the traction 
 of the strong sacro-iliac ligaments ajoproximates the posterior superior 
 spinous processes to one another. The traction of the sacro-tuberous 
 and sacro-spinous ligaments aids in hooking forward the lower extrem- 
 ity of the sacrum, though to this deformity the pressure exercised 
 upon the end of the spinal column by the half-sitting, half -recumbent 
 posture affected by rachitic children unquestionably contributes its part. 
 
 If we regard the sacrum as a fulcrum, and each os innominatum as 
 a lever, it is evident that the traction of the sacro-iliac ligaments, under 
 the pressure upon the sacrum from the trunk, would produce a separa- 
 tion of the innominate bones in front were it not for their firm union 
 at the symphysis pubis. The result of these two counteracting forces 
 is an increased incurvation of the bones at the point of weakest resist- 
 ance, which is situated near the articular surfaces. In advanced rick- 
 ets, where the bones are plastic and willowy, the linea arcuata is often 
 bent at an angle, so that the greatest transverse diameter divides the 
 pelvic brim into a posterior and anterior half. To the latter belong 
 the acetabula, to the former the two ilia. 
 
 The outward direction of the anterior superior spinous processes is 
 probably due in a measure to an arrest of development, as the S-shaped 
 curve of the crests of the ilia does not normally develop until after the 
 age at which rickets usually makes its appearance (Kehrer). The flat- 
 tening of the ilia is partly due to the drag of the sacro-iliac ligaments, 
 and partly to the action of the sartorii and gluteal muscles. The di- 
 vergence of the ischia and the wide arch of the pubes are the product
 
 CONTRACTED PELVES. 477 
 
 of the increased transverse diameter, and the attachments of the ro- 
 tator and adductor muscles of the thigh.* 
 
 The diagnosis of the rachitic form of flattened pelvis is easy, if the 
 characteristic changes are kept in mind. The prominent features to 
 which the attention needs to be directed are ; the relations of the dis- 
 tances between the crista ilii and the anterior superior spinous pro- 
 cesses (diminished difference, or distance, between the anterior superior 
 spinous processes may equal, or even exceed, that between the crests) ; 
 diminished distance between the posterior superior spinous processes ; 
 diminution of the external conjugate ; the form and direction of the 
 sacrum ; the shape of the arcus pubis ; and the marked projection of 
 the promontory. A false promontory at the second sacral vertebra is 
 not uncommon. The deduction to be made from the conjugata diago- 
 nalis in estimating the conjugata vera averages the same as in the nor- 
 mal pelvis. However, it is in rachitic pelves that the widest variations 
 in this respect occur, making it specially necessary in each case to ob- 
 serve the height of the promontory and the length and direction of the * 
 symphysis pubis. 
 
 Flattened Generally Contracted Pelves. — In this variety we distin- 1^ 
 guish likewise a rachitic and non-rachitic form, the latter occurring 
 rarely, the former with comparative frequency. 
 
 The non-rachitic form is apj^arently the joint product of a small 
 justo-minor pelvis and the forces which lead to a sinking of the sacrum 
 between the ilia. In these pelves a short symphysis and a low prom- 
 ontory contribute often to reduce greatly the difference between the 
 diagonal and the true conjugate. During life it is difficult to distin- 
 guish it from the justo-minor pelvis. 
 
 The rachitic form is found usually in persons of small stature. It 
 presents in a striking degree the marked peculiarities of the rachitic 
 pelvis. The existence of transverse narrowing is recognized by the 
 narrowness of the hips, by the ease with which, in internal examina- 
 tion, the side walls can be felt with the palmar surface of the half- 
 hand, and by the modifications it produces in the mechanism of 
 labor. 
 
 * While Litzraann (Die Pormen des Beckens) and Schroeder (Lehrbuch der Ge- 
 burtshulfe) lay special stress upon the weight of the body as the main factoi" in pro- 
 ducing the deformities of rickets, Kehrer (Zur Entwickelungs-Geschichte des rachit. 
 Beckens, Arch. f. Gynaek., Bd. v, 1873, p. 55) has shown that many of the changes 
 characteristic of rickets occur in congenital cases — i. e., before the action of the 
 weight of the trunk is brought into play. Kehrer refers the changes, therefore, in 
 the main, to muscular action. Fehling (Die Entstehung des rachit. Beckens, Arch, 
 f. Gynaek., Bd. xi, p. 173) ascribes the deformities in rickets to disturbances of 
 growth and persistence of the fetal type. Engel (Wiener med. Wochensehrift, 1873, 
 No. 40) sought to prove the deformities to be the result of partially arrested growth. 
 J. Veit (Die Entstehung der Form des Beckens, Ztschr. fiir Geburtsh. and Gynaek., 
 vol. IX, p. 347) furnishes strong evidence in favor of Litzraann's theory.
 
 478 
 
 THE PATHOLOGY OF LABOR. 
 
 (y 
 
 Fig. 207.— Small symmetrical rachitic 
 pelvis. (Wood's Museum.) 
 
 Irregular Racliitic Pelves. — For convenience' sake it seems desirable 
 to attach to the description of the flattened form the influence of two 
 additional forces, which, upon occasion, operate to still further modify 
 the shape of the rachitic pelvis. These are lateral pressure of the 
 heads of the thigh-bones at the acetabula and the various forms cff spi- 
 nal curvature which so commonly result from rickets. 
 
 Pressure at the acetabula is rarely an operative force, because rick- 
 ets usually is developed at the time of the first dentition — i. e., before 
 
 the child has learned to walk — and it 
 is not until after the disease has de- 
 clined that the child attempts to use 
 its lower extremities. In the excep- 
 tional cases in which the disease oc- 
 curs later, after the child has begun 
 to walk, the lateral pressure may act 
 in either one of two ways : 
 
 1. As a counteracting force to that 
 exercised by the weight of the trunk, 
 in which case the pelvis, provided the 
 pathological processes have only ad- 
 vanced to a limited extent, retains a 
 symmetrical appearance, and resembles closely the justo-minor pelvis. 
 The rachitic origin is betrayed by the shape of the ilia and the signs 
 of rickets in other parts of the body. At the outlet the antero-pos- 
 terior diameter is increased, and the transverse diameter somewhat 
 diminished.* 
 
 2. In cases of excessive softening of the bones, either from the se- 
 verity or the long duration of the disease, the acetabula are sometimes 
 pushed inward, upward, and 
 backward, and the symphysis 
 pushed forward, so that the 
 rami of the pubes meet at 
 an acute angle, or run nearly 
 parallel to one another. This 
 lateral compression, in con- 
 junction with the rachitic 
 projection of the promontory, 
 gives to the pelvic brim a tri- 
 angular or clover-leaf shape, 
 closely resembling the distortion produced in osteomalacia. The term 
 pseudo-osteomalacia given by Michalis f to this form is warranted by 
 the existence of certain features peculiar to rickets, such as the small 
 size of the iha, the distance between the anterior superior spinous 
 
 * ScHROEDER, Schwangerschaft, Geburt. und Woehenbett, p. 77. 
 t MicHAELis, Das enge Becken, p. 139. 
 
 Fig. 208.— Pseudo-osteomalacia. (Naegele.) 
 
 ^
 
 CONTRACTED PELVES. 
 
 479 
 
 processes, and the nature of the changes in other parts of the bony 
 skeleton.* 
 
 In curvatures of the spine the shape of the pelvis is affected, when 
 a compensatory scoliosis or kyphosis includes the sacral extremity : 
 
 1. In scoliosis (lateral curvature) all the rachitic features are usu- 
 ally strongly pronounced. The promontory is tilted to the side of the 
 incurvation, and is pressed by 
 
 the weight of the body toward 
 the corresponding acetabulum. 
 The ilium, owing to the in- 
 creased pressure at the acetabu- 
 lum from the femur of the 
 affected side, is pushed up- 
 ward, backward, and inward. 
 In extreme cases the approxi- 
 mation of the promontory to 
 the acetabulum may be such as 
 to prevent the entrance of the 
 child's head. The contracted 
 portion becomes, therefore, un- 
 available for obstetrical pur- 
 poses, f 
 
 2. In kyphosis (posterior 
 curvature) many of the charac- 
 teristic features of the rachitic 
 pelvis are reversed. As the 
 upper portion of the sacrum is 
 
 tilted backward, either the conjugata vera is increased or the i^revious 
 rachitic antero-posterior narrowing is greatly diminished. In the 
 movement of the sacrum upon its transverse axis the lower extremity 
 is thrown forward, and the conjugate of the outlet is thereby reduced. 
 Kyphosis, occurring at the beginning of rickets, diminishes the distance 
 between the tuberosities of the ischia, but has little effect upon the 
 inferior transverse diameter after the rachitic changes have once been 
 accomj)lished. 
 
 IXFLUEXCE OF THE CONTRACTED PeLYIS UPOX PrEGXAXCY AXD 
 
 Labor. 
 
 The influence of the contracted pelvis is not confined simply to the 
 embarrassment which the form and size of the pelvis afford to the 
 passage of the child in parturition ; it extends to the production of a 
 multitude of remoter effects, which are often regarded by the unin- 
 
 FiG. 209.— Scoliosis. (Litzmann.) 
 
 * The supervention of true osteomalacia upon rickets has been observed. 
 Spiegelberg, Lehrbuch der Geburtshiilfe, p. 490.) 
 f LiTZilA>'N, Die Formen des Beckens, p. TO. 
 
 ( Vide
 
 480 
 
 THE PATHOLOGY OF LABOR. 
 
 formed as isolated phenomena. These effects, which include faulty 
 positions and presentations of the foetus, unfavorable shape or position 
 of the uterus, abnormal character of the pains, and the like, enter in 
 turn, except where the mechanical difficulties are absolutely insur- 
 mountable, as inportant elements in the determination of the prog- 
 nosis. For our knowledge of this subject we are indebted almost 
 wholly to the enlightened labors of the Kiel professors Michaelis* 
 and Litzmann.f 
 
 Influence of the Contracted Pelvis upon the Uterus during Preg- 
 nancy.— In the early months the only way in which the contracted 
 pelvis exerts an influence is in sometimes favoring the dislocation of 
 the uterus backward. This action is liable to take place when, in the 
 second or third mouth, the uterus has been unusually depressed in 
 the pelvis, and the fundus has swung backward toward the sacrum 
 as the uterine axis approximates to that of the pelvic outlet. Under 
 such circumstances the jutting of the rachitic promontory is calculated 
 to mechanically interfere later with the ascent of the organ iuto the 
 abdominal cavity^ in which case the pressure of the inflated intes- 
 tines upon the anterior aspect of the uterus pushes the fundus over 
 the inclined surface of the sacrum, and retroversion is produced. As 
 the gravid uterus enlarges, owing to' the limited space within the pel- 
 vis the version gradual passes into a flexion, which, unless relieved, is 
 followed by symptoms of incarceration. 
 
 In the latter months of gestation the uterus, as a rule, is lifted to 
 a greater extent above the pelvis than occurs under normal conditions. 
 This elevation is due to the growth of the child, which is prevented 
 from sinking into the pelvis by the contracted conjugate. Sometimes 
 the upward tendency of the uterus is overcome apparently by the 
 resistance of the round ligaments, so that, while the head is retained 
 at the brim, the lower segment hangs empty in the pelvis. At the 
 same time the uterus possesses an unusual degree of mobility, in part 
 due to the lack of fixation afforded by the descent of the foetus into 
 the pelvis, and in part to the laxity of the abdominal walls and the 
 round ligaments. These latter conditions belong, of course, rather to 
 multipara than to women for the first time pregnant. 
 
 In close connection with these two events, viz., the elevation of 
 the uterus and its mobility, it is not uncommon to observe the higher 
 degrees of the so-called pendulous abdomen, caused by the anteflexion 
 of the gravid uterus. To this deformity, furthermore, the small stat- 
 ure of rachitic patients, the increased inclination of the pelvis, the 
 anterior projection of the lumbar portion of the spine, and the stretched 
 state of the abdominal walls, associated often with separation of the 
 recti muscles at the linea alba, all contribute their part. 
 
 * Michaelis, Das enge Becken, Leipsic. 
 
 t LiTZMANN, Volkraann's Samnil. klin. Vortr.," No. 23o
 
 CONTRACTED PELVES. 481 
 
 Influence of the Contracted Pelvis upon the Presentation of the 
 
 Foetus. — Faulty presentations occur in contracted pelves more than 
 three times as frequently as in those of normal dimensions.* Thus, 
 when, during the latter part of pregnancy, the narrow conjugate me- 
 chanically prevents the head from sinking into the pelvic cavity, the 
 head frequently glides sidewise or forward, to rest upon an iliac fossa, 
 or upon the upper border of the symphysis pubis. In pendulous abdo- 
 men the uterus, in place of being inclined, when the jjatient is in an 
 upright position, at an angle of thirty-five degrees, becomes nearly 
 horizontal, or may fall forward so that the fundus occupies a deeper 
 position than the inferior segment of the uterus. The great mobility 
 of the uterus admits likewise of extensive lateral movements. These 
 combined causes account for the lack of stability in the foetus and 
 the comparative frequency with which shoulder and breech presenta- 
 tions occur. When the head is fixed at the brim, the conversion of 
 tlie vertex into a brow or face presentation is often simply an exagger- 
 ation of the normal mechanism of labor in a flattened pelvis. If the 
 head, in place of filling the lower segment of the uterus, is retained at 
 the brim, the space left between the head and the uterine walls favors 
 prolapse of the cord and extremities. In like manner, in breech preS' 
 entations, when the breech is detained by the narrow conjugate, the 
 feet are apt to descend first into the vagina. 
 
 Owing to the progressive relaxation of the abdominal and uterine 
 walls with successive pregnancies, the frequency of these irregularities 
 increases nearly in proportion to the number of previous births. 
 
 Influence of the Contracted Pelvis upon the Labor-Pains.— When 
 the degree of pelvic contraction permits the delivery of the foetus by 
 the normal passages without resort to embryotomy, the favorable or 
 iinfavorable ending of the labor is in large measure dej^endent upon 
 the character of the pains. Good pains are of vastly more consequence 
 in narrow than in wide pelves. 
 
 Violent pains, where the mechanical obstacles are insurmountable, 
 either from the smallness of the pelvis, the faulty presentation of the 
 foetus, the position of the child's head, or its size and hardness, endan- 
 ger the integrity of the uterus. Indeed, unless the mechanical diffi- 
 culties are diminished by rectification of faulty positions and presen- 
 tations, or by embryotomy, or unless relief is afforded by the removal 
 of the child by Cesarean section, there is reason to dread in such cases 
 the occurrence of ruptured uterus, or, after retraction of the cervix, 
 that the uterus may be torn from the vagina. 
 
 Still more frequently weak pains are the cause of unfavorable ter- 
 minations. Weak pains lead to lingering labors. Even in moderate 
 
 '* Spiegelberg found that, of 544 labors in narrow pelves, the head presentation 
 occurred in eighty-three per cent, whereas the proportion is ninety-five per cent 
 in normal pelves. (Lehrbuch der Geburtshiilfe, p. 448.) 
 31
 
 482 THE PATHOLOGY OP LABOR. 
 
 degrees of coutractiou they fail to rectify unfavorable positions of the 
 head or to force the head by the brim into the pelvis. Under such 
 circumstances neither the forceps nor version can be employed without 
 serious risk, while, if a waiting policy is pursued, the amniotic fluid 
 gradually escapes, and, as the uterus retracts down closely upon its 
 contents, the foetus perishes from the gradually increasing hindrances 
 to the uterine and placental circulation. 
 
 In prolonged labors good pains alternate at intervals with those of 
 less force. There is no standard by which the quality of pains ])er se 
 can be determined. The quality of the pains is to be estimated rather 
 by the results which they accomplish. It may be stated as a general 
 rule, to which, however, there are numerous exceptions, that the strength 
 of the pains is proportioned to the strength of the resistance to be over- 
 come. Strong pains are on the Avhole rather more common in flattened 
 pelves, and weak ones in pelves contracted in all their diameters, with- 
 out, however, the rule possessing any such constancy as to lead one to 
 regard the form of the pelvis as alone possessing any decisive impor- 
 tance in the production of the result.* 
 
 In the first instance, the character of labor-pains depends upon the 
 innervation of the uterus and upon the thickness and integrity of its 
 muscular structures. The resistance which the narrow pelvis offers to 
 the expulsion of the child increases necessarily during the pains the 
 tension and irritation of the uterine walls ; and these, corresponding to 
 the degree of irritability and contractility of the organ, may i3rovoke 
 pains of unusual violence, which, in turn, terminate, when the resist- 
 ance is not seasonably overcome, in exhaustion ; or the uterine activity 
 may cease without any previous stage of increment ; or, finally, the ten- 
 sion and injurious pressure of the uterus may lead to local circulatory 
 disturbances, and to textural changes which in themselves weaken the 
 strength of the contractions. 
 
 Michaelis observed that the dangers to the mother and child grow, 
 as a general rule — to which, however, there are numerous exceptions — 
 in proportion to the number of confinements. The increased mortal- 
 ity, especially of the children, he attributed to a peculiar relaxation of 
 the uterus and its pelvic attachments, due to overexertion in previous 
 confinements, f But it must be borne in mind that there are other 
 results of contracted pelves which directly contribute to the fatality of 
 multiparous labors. Thus, we have seen that pendulous abdomen and 
 mobility of the uterus favor abnormal positions and presentations of 
 
 * Michaelis thought that the partial pressure of the promontory and symphysis 
 excited increased reflex action of the uterus in flattened pelves, whereas the com- 
 plete pressure of the head upon the brim in generally contracted pelves exercised a 
 paralyzing influence {Joe. cit., p. 185). This theory has been called in question by 
 both Spiegelberg {he. cit., p. 452) and Litzmann. (Volkmann's Samml. klin. Vortr., 
 No. 23, p. 177.) 
 
 t Michaelis, loc. cit., p. 152.
 
 CONTRACTED PELVES. 483 
 
 the foetus, complications of the utmost prognostic importance ; and, 
 again, that the displacements of the gravid uterus occur with special 
 frequency when the abdominal parietes have lost their supporting power 
 from the overdistention of previous pregnancies. Moreover, when the 
 uterus is not fixed during labor, the expulsive action of the abdominal 
 walls can not be called into play, and thus one of the most important 
 auxiliary forces is lost. Further sources of danger lie in the increased 
 size and hardness of the fetal head observed in later pregnancies, and 
 in the residue of inflammatory troubles which so often proceed from 
 the first difficult delivery.* 
 
 Influence of the Contracted Pelvis upon the First Stage of Labor.— 
 At the beginning of labor the head in contracted pelves is usually re- 
 tained above the os internum, while the lower segment of the uterus 
 hangs empty in the pelvic cavity. As, under these circumstances, 
 space is left between the head and the uterine walls, the entire column 
 of amniotic fluid acts directly during the pains upon the cervix uteri. 
 The dilatation of the cervix takes place gradually, from above down- 
 ward, as expansion follows upon the descent of the amniotic sac. The 
 shape of the bag of waters depends upon the greater or less degree of 
 resistance offered by the cervical walls. If the latter are soft and dis- 
 tensible, the usual semi-globular contour is maintained. If the cervix 
 offers any material resistance, the membranes, if sufficiently elastic, 
 protrude through the external os in cylindrical form. If, finally, the 
 chief opposing force to dilatation is situated at the os internum, a con- 
 striction may take place at that point, while below the membranes 
 assume a spheroid shape. As the result of these conditions an unim- 
 peded, wave-like movement of the amniotic fluid breaks against the 
 protruding membranes during the pains, the shock of which is apt to 
 produce premature rupture, an event which is all the more inoppor- 
 tune, because in early rupture the circumstances all favor the complete 
 discharge of the amniotic fluid. 
 
 After the rupture of the membranes, as the head does not descend 
 at once into the cervical portion, the os and cervix reclose, though 
 they continue dilatable in proportion to the degree of distention pre- 
 viously accomplished. Then, as under the influence of the pains the 
 head passes into the pelvis, it gradually once more unfolds the cer- 
 vical canal, and completes its dilatation. Should, however, the head 
 meet with any considerable resistance, so that the pressure of the 
 pelvic brim gives rise to the formation of a scalp-tumor, the latter 
 serves to dilate the cervical canal and the os externum. If the obstacle 
 U such as to prevent the complete descent of the head, two results are 
 l)ossible : 
 
 1. If the pains continue strong and no measures are adopted to 
 remove the disproportion, the uterus is either retracted up over the 
 * Spiegelberg, Lehrbuch der Geburtshiilfe, p. 453.
 
 484 THE PATHOLOGY OF LABOR. 
 
 head of the child as it remains above the brim, until the overdistended 
 vagina gives way, in which case the laceration occurs in a transverse 
 or oblique direction, and usually upon the posterior wall ; or the lower 
 segment of the uterus becomes compressed between the child's head 
 and the walls of the pelvis, and a thinning and bruising of the im- 
 prisoned portion take place. As the uterus contracts, its muscular 
 fibers drag upon the compressed and weakened tissues at the fixed 
 points, which yield finally to the tractile force, and rapture ensues. 
 
 2. If the pains are weak or fail outright, the lower segment of the 
 uterus remains undilated until either strong pains are excited or the 
 mechanical hindrance is so far removed by perforation of the head 
 that the weakened pains suffice to overcome the obstacle. 
 
 Influence of the Contracted Pelvis upon the Mechanism of Labor.— 
 When the pelvic contraction is not such as to render the entrance of 
 the head impossible, the mechanism of labor depends not only upon 
 the size and shape of the pelvic space, but upon the size, form, com- 
 pressibility, and position of the child's head. If a small, soft head has 
 to pass through a pelvis contracted to only a moderate degree, the 
 mechanism may not differ from that of a normal labor. In cases of 
 relatively great disproportion, delivery is only practicable where the 
 position of the head is favorable — i. e., corresponds in each case to the 
 peculiar shape of the pelvis. If the conditions are favorable, and the 
 pains are of normal strength, a segment of the head, after the period 
 of dilatation has been completed, is pressed into the pelvis. The size 
 of the segment depends upon the extent of the resistance offered, and 
 thus, at an early stage, it :^urnishes us a notion as to the degree of dis- 
 proportion existing. As labor progresses, the cranial bones change in 
 shape and overlap one another, so that the head gradually becomes 
 molded to the contour of the pelvic ring. When the largest circum- 
 ference of the child's head has become fixed at the pelvic strait, as the 
 contraction exists for the most part at the brim, the difficulties are 
 usually overcome ; and, where the pains continue good, the remainder 
 of the labor is accomplished in accordance with the ordinary mechan- 
 ism. If the pains fail, or the contraction continues throughout the 
 entire pelvic canal, artificial aid may be needed even after the brim has 
 been passed. 
 
 In the simple flattened pelvis the occipito-frontal diameter of the 
 head engages in the transverse diameter of the brim. Even when 
 the position is originally oblique, the intermittent contractions of the 
 uterus communicate movements to the smooth surface of the head, 
 which gradually bring its long diameter into correspondence with the 
 long diameter of the flattened pelvis. The head enters the brim with 
 Its posterior surface tilted toward the shoulder, the anterior parietal 
 bone presenting, and the sagittal suture running parallel with, and in 
 more or less close proximity to, the promontory. This lateral obliqui-
 
 CONTRACTED PELVES. 485 
 
 ty, or obliquity of Naegele as it is termed, is due simj^ly to the fact 
 that the narrowing of the antero-posterior diameter prevents both 
 parietal bones from entering the pelvis upon the same plane. When 
 the broad region between the parietal bosses meets with the resistance 
 of the conjugate, the occipital portion of the head glides to one side, 
 and the narrow bitemporal diameter engages in the contracted space. 
 In this position the occiput usually rests upon the linea terminalis. 
 Owing to the resistance ofEered to the occiput, the forehead sinks into 
 the pelvis, so that the large fontanelle occupies a deeper position than 
 the posterior one. 
 
 Before the head adapts itself, therefore, to the pelvic entrance, the 
 anterior parietal surface rests upon the symphysis, while the posterior 
 surface is impinged upon by the promontory near the large fontanelle. 
 The latter is felt low down, near the median line. The small fonta- 
 nelle, owing to the dip of the forehead, is occasionally out of reach. 
 Upon the side of the pelvis to which the forehead is turned, the space 
 is incompletely filled out. 
 
 Tlie adaptation of the head to the pelvic brim is the result of two 
 combined movements, which occur nearly simultaneously : 
 
 1. The symphysis pubis furnishes a pivot around which the head 
 rotates in the direction of the fronto-occipital diameter. As the head 
 is pressed into the pelvis from above, the posterior parietal bone is 
 flattened by the projecting promontory. During the descent the dis- 
 tance between the sagittal suture and the promontory gradually widens, 
 and the former approaches the median line. 
 
 2. We have seen that the head entered the pelvis at first with a deep 
 position of the anterior fontanelle. By the time, however, the bitem- 
 poral diameter becomes fairly fixed in the conjugate, the anterior fon- 
 tanelle moves upward and forward toward the side wall of the pelvis, 
 while the small fontanelle sinks downward, and occupies a position 
 near the center of the cavity. This movement is not simply a crowd- 
 ing of the entire head in the direction of the brow, but is due to a 
 rotation of the head upon an axis furnished by the conjugate diam- 
 eter,* the symphysis and the promontory furnishing the pivotal points. 
 
 By the time, in the rotation of the head upon its fronto-occipital 
 diameter, the posterior boss reaches the level of the promontory, the 
 largest circumference of the child's head has already engaged in the 
 straitened brim, and the influence of the pelvic flattening upon the 
 mechanism of labor ceases. Then, if the pains continue good, the 
 flexed head reaches the floor of the pelvis, the occiput rotates to the 
 front, and delivery is accomplished as under normal conditions. 
 
 In the justo-minor pelvis, the mechanism of labor is nearly the 
 reverse of that described in the flattened form. Thus, as a rule, 
 both parietal bones engage in the pelvic brim at the same time — i. e., 
 * LiTZMANN, Volkmann's Samml. klin. Vortr., No. 74, p. 557.
 
 436 THE PATHOLOGY OF LABOR. 
 
 the obliquity of Naegele is either slightly marked or absent altogether. 
 Again, the head may enter the pelvis in any of its diameters. To be 
 sure, the oblique diameter is the one it usually occupies. Still, Litz- 
 mann reports two cases in which the sagittal suture corresponded to 
 the conjugate diameter from the outset of the labor.* In the early 
 stao-es, it is not uncommon for the head to oscillate at the brim for 
 a time before fixation takes place. 
 
 Characteristic of transverse narrowing is the flexed condition of 
 the head from the moment it begins its descent into the pelvis. In- 
 deed, the flexion at the brim equals in degree that which usually ob- 
 tains only at the pelvic outlet. The small fontanelle occupies the 
 middle point of the pelvic space, the neck rests upon the linea termi- 
 nalis, the anterior portion of the head and brow are pressed against 
 the opposite pelvic walls, the long diameter of the head (from chin to 
 vertex) lies in the axis of the pelvis, and the face looks upward toward 
 the fundus uteri. If the transverse narrowing continues toward the 
 outlet, the extreme flexion is maintained after the brow has passed 
 below the level of the promontory. In such cases it may even happen 
 that the small fontanelle may make its appearance at the frenulum 
 in place of turning under the arch of the pubes. Sometimes the head 
 gets fairly impacted in the pelvis, and further advance is rendered im- 
 possible. When the pelvis widens below the brim, the small fontanelle 
 noticeably leaves little by little its central position. 
 
 In the generally contracted, flattened pelvis, the mechanism of 
 labor is influenced by both the antero-posterior and transverse short- 
 ening. As in flattened pelves, the head usually occupies the transverse 
 diameter, and the sagittal suture looks backward toward the promon- 
 tory. Before the head becomes fixed, it often balances at the conju- 
 gate, rocking to and fro, as the uterus falls from the one side to the 
 other. For a time, therefore, the position of the fontanelles varies 
 with that of the woman. If, however, the disproportion is not abso- 
 lute, and the pains suffice finally to fix the head, the latter usually 
 becomes strongly flexed, and the occiput descends first into the pelvis. 
 
 When the head does not enter the contracted pelvis in an advan- 
 tageous position, and the fault is not rectified either by the hand or 
 the action of the labor-pains, delivery of the child without perforation 
 often becomes impossible. The most dangerous of these faulty posi- 
 tions are : 
 
 1. Cases in which the lateral obliquity of Naegele is exaggerated, 
 so that the presenting part is formed by the anterior parietal bone. 
 The more striking forms usually occur in pelves with an extremely 
 narrow conjugate and a high promontory. The former maintains 
 the head high above the brim, while the latter imparts to the uterus 
 a posterior concavity. As the uterine curve is followed by the axis of 
 
 * LiTZMANN, Volkmann's Samml. klin. Vortr., No. 74, p. 545.
 
 CONTRACTED PELVES. 4S7 
 
 the foetus, the head is strongly bent toward the jDosterior shoulder. 
 Sometimes iu presentations of the anterior parietal bone the sagittal 
 suture lies above the j^romontory, and an ear can be left just behind 
 the sympyhsis. 
 
 2. Cases in which the pelvic brim is covered by the posterior pari- 
 etal bone. The sagittal suture is then directed to the front, some- 
 times lying even above the sujierior border of the anterior pelvic wall. 
 Near the promontory the squamous suture, and at times the ear, can 
 be felt. This peculiarity is rare in other forms of contracted pelves, 
 but occurs as often as once in five times (Litzmann) in flattened pelves 
 with coincident shortening of the transverse diameter, 
 
 3. In cases of well-marked kidney-shaped pelves, the head mav 
 engage in one side of the pelvis only. The occiput then enters usually 
 the side of the brim to which the back of the child is turned. 
 
 4. Brow and face presentations are simply exaggerations of the 
 anterior dip of the head, which we have seen is the normal mode of 
 descent during the early stage of labor in flattened pelves. Although 
 not peculiar to contracted pelves, they should always, when present, 
 lead to careful measurements of the pelvic diameters. They increase 
 the difficulties of delivery, not only because of the unfavorable rela- 
 tions of the diameters of the head to those of the pelvis, but because 
 the pelvic deformity interferes with the proper rotation of the chin 
 and forehead forward under the arch of the pubes. 
 
 In breech presentations, the delivery of the trunk takes place in 
 accordance with the ordinary mechanism in the normal pelvis. The 
 arms, however, are more liable to be reflected to the sides of the head. 
 
 In flattened pelves the after-coming head enters the brim in the 
 transverse diameter. The position of the chin, where the transverse 
 space is ample, varies with the degree of conjugate shortening. Where 
 the latter is only of moderate extent, the ordinary flexion of the head 
 may not be interfered with. If, however, the disproportion between 
 the head and pelvic diameters is considerable, partial extension takes 
 place. In cases of extreme contraction the entire head may be retained 
 at the brim. The chin is then usually turned forward so as to rest 
 upon one of the pubic rami, while chin and occiput occupy nearly the 
 same level. 
 
 In breech deliveries, the mechanism of the head's jjassage through 
 simple flattened pelves varies as the head engages in a state of flexion 
 or extension. In the former case, while the anterior parietal bone 
 moves downward over the symphysis, the transit-line marked by the 
 promontory upon the posterior parietal bone runs from its anterior 
 inferior angle, just in front of the ear, in an oblique direction upward 
 toward the parietal boss. "When, however, the head enters the pelvis 
 in a state of partial extension, a furrow is formed by the promontory, 
 which runs nearly parallel to the coronal suture. If, finally, the ex-
 
 i88 
 
 THE PATHOLOGY OF LABOR. 
 
 tension is complete, and the occiput descends first into tlie pelvis, 
 the marking of the promontory is found between the boss and the 
 lambdoidal suture. 
 
 In pelves contracted in the transverse diameter, extension of the 
 chin, unless the contraction be slight, proves an insuperable obstacle 
 to delivery. Flexion, however, is the rule, as the resistance which the 
 occiput meets with from the walls of the pelvis tends to direct the 
 chin toward the chest. 
 
 The Effects produced in Contracted Pelvis by the Pressure of the 
 Child upon the Soft Maternal Tissues.— The body of the child rarely, 
 and only in cases of extreme prolongation of the expulsive period, 
 leaves any traces upon the maternal soft parts. Injurious pressure 
 proceeds almost exclusively from the child's head. As the intrapel- 
 vic organs sustain excessive pressure when of short continuance more 
 easily than that which is moderate but prolonged, the most striking 
 lesions are produced in head presentations. The after-coming head 
 usually passes through the pelvis too rapidly to produce any pro- 
 nounced effects. The pressure is, as a rule, most marked at the brim, 
 where, as we have seen, the contraction is in the generality of cases 
 greatest, and where the pelvic canal is most encroached upon by 
 shuYY) projections. The pressure may be either diffused over the entire 
 periphery of the brim, or it may be more localized at certain definite 
 points. 
 
 Diffused jiressure occurs in justo-minor jx^lves, or where complete 
 accommodation of the child's head to the form of the pelvis takes 
 place. It gives rise to disturbed circulation in the hypogastric veins, 
 and as a further consequence to transudation of serum, and capillary 
 hfemorrhages in the tissues of the cervix, the vaginal walls, and exter- 
 nal organs of generation. 
 
 Circumscribed pressure leads to crushing, thinning, and at times to 
 the comjDlete destruction of the tissues acted upon, the extent of the 
 lesion depending upon the intensity and duration of the force exerted. 
 Usually the destructive action proceeds, following the direction of the 
 pressure from within outward — i. e., the injuries are more consider- 
 able, both in degree and extent, in the tissues next to the child's head 
 than in the deeper ones contiguous to the pelvic border. Complete 
 perforation of the tissues during labor is rare. Perforation is com- 
 monly the result of necrosis, the sloughing of the compressed tissues 
 taking place during the puerperal period. 
 
 The pressure from the promontory is brought to bear, with rare ex- 
 ceptions, upon the cervix uteri.* The supravaginal portion is more 
 
 * LiTZMANN, Volkraann's Samml. klin. Vortr., No. 23, p. 186. An exceptional 
 instance of pressure ending in perforation of the posterior vaginal wall has been 
 reported by Hofmeier (Zur Casuistik des Stachelbeckens, Ztschr. fur Geburtsh. und 
 Gynaek., vol. x, pp. 5, 6).
 
 CONTRACTED PELVES. 489 
 
 commonly affected than the vaginal portion. The consequent loss of 
 substance is of a funnel shape, starting from the inner surface, and 
 rarely penetrating through the peritonceum. The coverings of the 
 promontory are not affected by pressure. 
 
 Pressure from the upper border of the symphysis pubis usually 
 affects the vaginal Avail and the adjacent tissues of the bladder. Fis- 
 tulae resulting are therefore much more commonly vesico- vaginal than 
 utero-vesical. Here, too, the lesions are more extensive upon the inner 
 surface of the utero-vaginal canal, and diminish as they extend out- 
 ward. Thus, the destruction of tissue is greatest upon the cervical and 
 vaginal walls, is less marked upon the posterior bladder wall, while the 
 anterior wall exhibits only faint traces of injury. 
 
 Pressure from the lateral walls, and from the horizontal rami of the 
 pubes, occurs most frequently in faulty positions of the child's head. 
 Tlius, in brow presentations, the intervening tissues are apt to become 
 clamped between the occiput and the margin of the side wall. Again, 
 when the sagittal suture is directed to the front, and the posterior 
 parietal bone presents, a similar compression may take place between 
 the anterior wall and the child's head. Sharp bony projections from 
 the crests of the pubes are commonly covered by the tendinous attach- 
 ments of the psoas minor muscles. In case of long-continued labor, 
 however, the spinous outgrowths and sharp edges of the crests are 
 liable to rub through their protective coverings, and secondarily the 
 utero-vaginal tissues. 
 
 Influence of the Pressure of the Pelvis upon the Integuments of the 
 Child's Head. — One of the commonest results of the peripheral pressure 
 of the brim upon the child's head is the production of the scalp-tumor. 
 Its formation is usually associated with compression of the cranial 
 bones. As the bones overlap, the integuments of the engaged portion 
 of the head are thrown into folds. As, however, in consequence of 
 the obstruction in the venous circulation, transudation of serum takes 
 place into the subcutaneous cellular tissue, the folds subsequently dis- 
 appear, and a swelling ensues. It will be seen that conditions favor- 
 able to the production of the scalp-tumor are a soft, easily molded 
 head, and such degree of transverse pelvic contraction as serves to 
 render the circular pressure of the scalp complete. Owing to the lat- 
 ter condition, the scalp-tumor is found more frequently and more de- 
 veloped in justo-minor and generally contracted flattened pelves than 
 in simple flattened pelves with normal transverse dimensions. Usually 
 the tumor does not form until after rupture of the membranes. At 
 times, however, in justo-minor pelves the head may become so fixed 
 at the brim during the first stage of labor that a diffused swelling of 
 the scalp may follow while the membranes are still intact. A scalp- 
 tumor at the brim is of favorable import. It shows that the pains are 
 good. So long as the tumor continues to increase, if the presentation
 
 490 THE rATIIOLOGY OF LABOR. 
 
 is favorable, the aceommodatiou of the head remains a possibility. 
 The increase of the tumor serves, too, to fix the head at the brim, and 
 favors the overlapping of the cranial bones. It likewise gives to the 
 head the form of an elongated ellipse, a form most favorable to its 
 passage through the contracted pelvic canal. 
 
 Localized pressure-marks upon the child's head are derived, in the 
 great majority of cases, from contact with the promontory. With less 
 frequency they have their origin in pressure produced by the anterior 
 and lateral pelvic walls and the inward projection, in rachitic pelves, 
 of the cartilage at the symphysis pubis. They consist of round and 
 oval spots and reddened lines, which disappear in the ligliter cases 
 usually in from twelve to twenty-four hours. If the pressure has been 
 long continued, it may give rise to ulceration, or even to complete 
 
 destruction of the skin down to the 
 periosteum. While not usually danger- 
 ous to the child, in exceptional cases 
 they may become the starting-point of 
 suppuration in the surrounding subcu- 
 taneous cellular tissue, and thus lead to 
 fatal pyaemia. They are found with 
 greatest frequency upon the parietal 
 bones, especially ujDon the posterior one. 
 
 FIG. 210.-Pressure^mark upon skull, jy^^^.^ ^,^^^^^ ^|^gy ^^.^ situatcd UpOU 
 
 the frontal, and in very rare instances, 
 finally, upon the occipital and temporal bones. The situation and 
 direction of the red lines depend chiefly upon the manner in which 
 the head enters the pelvis. Thus, in simple flattened pelves, where 
 moderate extension occurs in the normal mechanism of labor, the 
 mark of the promontory runs along the posterior parietal bone, between 
 the boss and the large fontanelle, either parallel to the coronal suture, 
 or at first in the direction of the boss, and then later as flexion occurs 
 forward toAvard the frontal bone (Dohrn). In cases where transverse 
 shortening causes flexion of the head at the brim, the principal point 
 of pressure lies near the parietal boss, and the line runs obliquely for- 
 Avard toAvard the outer angle of the eye, or toAvard the cheek, accord- 
 ing to the extent of the flexion. Sometimes a red line running across 
 the forehead, nearly parallel to the coronal suture, is produced by 
 the pressure of the side Avail. 
 
 Pressure upon the ophthalmic vein, Avhen it occurs, leads to cedem- 
 atous SAvelling and hyperemia of the lid, and to increased secretion 
 from the conjunctiA'a. 
 
 Influence of the Pressure of the Pelvis upon the Cranial Bones.— 
 The so-called molding of the child's head, by Avhich it is made to con- 
 form to the size and shape of the pelvis, is chiefly effected by the dis- 
 placements and alterations in the form of the cranial bones. Of the
 
 CONTRACTED PELVES. 491 
 
 displacements, the most important consists iu the overriding of the 
 bones at the principal sutures. The most common site is along the 
 sagittal suture. Usually the posterior parietal bone is flattened and 
 depressed beneath its fellow. At the same time the curvature of the 
 anterior or presenting parietal bone is increased. In transverse nar- 
 rowing, the occipital bone is depressed along the lambdoidal suture. 
 The position of the frontal bones at the coronal suture is subject to a 
 variety of influences. As a rule, however, they are dej^ressed beneath 
 the parietal bones. Overlapi^ing often does not extend the entire 
 length of a suture, but may exist in one jjart, while in another the 
 bones may occupy the same level. Sometimes a displacement takes 
 place between the two lateral halves of the head in the direction of 
 the occipito-frontal diameter. This movement is supposed to be due 
 to the influence of the promontory, which pushes the posterior half 
 forward when the head is flexed, and backward in cases of partial 
 extension. 
 
 The compression to which the child's head is subjected, when pro- 
 longed and excessive, is apt to produce disturbed cranial circulation. 
 Rupture of the capillaries which pass from the surface of the brain to 
 the arachnoid sac, and to the sinuses of the dura mater, may give rise 
 to intracranial extravasations. The overriding at the sagittal suture, 
 in extreme cases, may cause laceration of the sinus longitudinalis. 
 Separation of the bones at the sagittal and coronal sutures sometimes 
 takes place while the coverings of the skull remain intact.* 
 
 In a small jiercentage of cases (7'3 per cent, Litzmann) furrow-like 
 depressions occur. The usual site is along the line of the coronal 
 suture, where they are formed by the promontory. In front a grooved 
 line is sometimes found near the squamous suture, produced by the 
 pressure of the anterior pelvic wall. Triangular depressions (the 
 spoon -shaped depressions of Michaelis) situated upon the posterior 
 parietal bone, between the boss and the large fontanelle, are of still 
 rarer occurrence. They are found chiefly upon the heads of prema- 
 ture children, where they are of sinister import. Actual fracture of 
 the skull in head presentations is extremely infrequent, and is gener- 
 ally due to the employment of the forceps. 
 
 In breech presentations, lesions of the scalp, owing to the shortness 
 of the time to which the after-coming head is subject to the pressure 
 of the contracted pelvis, are, in two thirds of the cases, absent alto- 
 gether. When they are present they are comparatively trivial, con- 
 sisting of slight swelling of the integuments, and now and then of a 
 red mark left by the promontory. The cranial bones, on the con- 
 trary, when rapidly dragged by the projecting promontory, are pecul- 
 iarly liable to serious injury. Thus, in breech cases, depressions, fract- 
 ures, and fissures of the parietal bones are much more common than 
 * LiTZ.MAXN, Volkmann's Saraml. klin. Vortr., No. 23, p. 191.
 
 492 THE PATHOLOGY OP LABOR. 
 
 in head presentations. Forcible tractions upon the trunk sometimes 
 lead too to a rupture of the squamous sutures, or even to separation of 
 the condyles from the occipital bones.* 
 
 Prognosis in Contracted Pelves.— The mortality to the mother is at 
 least twice as great as in normal pelves. The causes of this increased 
 death-rate are to be found in the concurrent action of a great variety 
 of influences. Among the chief of these is the prolonged labor, an 
 event which under all circumstances, especially after the rupture of 
 the membranes, tends to diminish the chances of recovery. This re- 
 sult is due to the strain upon the nervous system from the protracted 
 duration of the associated pain, to the depression of the vital powers 
 growing out of the fasting and loss of sleep which labor entails, to the 
 irritation and crushing of the soft parts, and, finally, to decomposition 
 of the fluids retained within the uterine cavity in cases where access 
 of air has taken place. In contracted pelves we have superadded to 
 these general sources of disturbance the special injurious effects pro- 
 duced by the pressure of the lower segment of the uterus, the vagina, 
 and the soft parts which cover the cavity of the small pelvis between 
 the hard head of the child and the bony walls. As the results of 
 pressure, we have seen that obstruction to the venous circulation, 
 oedema, capillary haemorrhages, superficial lacerations of the mucous 
 membrane, and at localized points necrosis and even complete separa- 
 tion of the interposed tissue may take place. These further lead to 
 metritis, endometritis, parametritis, and perimetritis, which are an- 
 nounced at times during labor, but more commonly subsequent to 
 confinement, by sharp elevations of temperature. When the destruc- 
 tion of tissue reaches the peritonaeum, general peritonitis follows, as 
 a rule. When the necrosed tissues become gangrenous from access 
 of air, the septic poisons generated spread through the cellular tissue, 
 and lead speedily to a fatal termination. Sometimes shock destroys 
 the patient during the first day or two following labor, before local in- 
 flammations have had time to develop. Further dangers to be appre- 
 hended are rupture of the uterus and the pelvic articulations, fistulous 
 communications with the bladder and the rectum, injuries to nerves 
 of the ischiatic plexus, post-partum haemorrhage as a consequence of 
 uterine exhaustion, and thrombus formation in the veins of the uter- 
 ine parenchyma. Even the operative measures resorted to for the 
 relief of the" patients are often new sources of peril, and their employ- 
 ment is to be regarded simply as a lesser evil. 
 
 For the child the action of the contracted pelvis is even more del- 
 eterious, f The infant mortality, in cases not requiring sacrificial 
 
 * C. RuGE, Verletzung des Kindes diirch Extraction bei Beekenlage, Ztschr. f. 
 Geburtsh., Bd. i, p. 74. 
 
 + Spiegelberg puts the mortality of the children at thirty-five per cent {vide Lehr- 
 buch der Geburtshiilfe, p. 464).
 
 TREATMENT OF CONTRACTED PELVES. 493 
 
 operations, is explained by the long duration of the labor and the 
 prevalence of faulty presentations and positions. In the majority of 
 instances death takes place from asphyxia promoted by the early rupt- 
 ure of the membranes, the complete escape of the amniotic fluid, the 
 prolapse of the cord, the disturbances in the utero-placental circula- 
 tion resulting from the retraction of the nterus upon the surface of 
 the child's body, and sometimes by the premature, separation of the 
 placenta. The prognosis for the child is especially unfavorable in 
 premature labors. This arises not alone from the increased frequency 
 of malpresentations, but from the diminished power of premature 
 children to resist external pressure. Thus, death may take place from 
 direct pressure upon the medulla oblongata through the thin bony 
 coverings of the head, or extensive cerebo-spinal effusions of blood 
 may result from the laceration of the delicate walls of the intracranial 
 and intraspinal vessels. 
 
 CHAPTER XXVI. 
 
 TREATMENT OF CONTRACTED PELVES. 
 
 Cases of extreme pelvic contraction, rendering delivery per vias natwales impossi- 
 ble. — Cases indicating craniotomy or premature labor. — Cases where extraction 
 of a living child at term is possible. — Premature labor. — Version. — Forceps. — 
 Expectant treatment. 
 
 The resources at the disposition of the accoucheur, in cases of con- 
 tracted pelvis requiring obstetrical aid, are the Caesarean section, the 
 induction of premature labor, craniotomy, forceps, and version. But, 
 before it is possible to form an opinion regarding the treatment best 
 suited to an individual case, it is necessary to first obtain a clear and 
 definite idea regarding the degree and character of the pelvic deform- 
 ity. We have, then, to settle the followiug questions : Has pregnancy 
 advanced to term? If not, does the case call for the induction of 
 abortion or premature labor ? If the end of utero-gestation has been 
 reached, is it possible to deliver the child through the natural passages? 
 Is the child living or dead? If the former, do the interests of the 
 mother require the sacrifice of the child's life ? If the conditions are 
 such as not to render it impossible for a living child to be born, in 
 what way can we best subserve the interests of both mother and child ? 
 The right choice of measures requires not only an accurate apprecia- 
 tion of the advantages, limitations, and drawbacks which inhere to the 
 measures themselves, but the extent to which the mechanical obsta- 
 cles to delivery are heightened or modified by those remoter influences 
 which we have seen are exerted upon the organic processes of labor by 
 the pelvic contraction. ,
 
 ^94 THE PATHOLOGY OF LABOR. 
 
 The greater the degree of pelvic narrowing, however, the more cle« 
 cided the influence of the pelvis becomes, and the more definite, there- 
 fore, the treatment. 
 
 For the sake of convenience it is customary to consider apart the 
 following classes : * 
 
 1. Cases of such extreme 23elvic contraction that the attempt to de- 
 liver the child through the natural passages is inadvisable. In these 
 extreme degrees of pelvic deformity premature labor holds out no hope 
 of saving the life of the child, and affords but a trifling advantage to 
 the motlier. If abortion is not produced in the early mouths, the only 
 resource is the Cesarean section or laparo-elytrotomy. The precise 
 limit at which the dangers from delivery through the pelvis rise to the 
 level of or exceed those from the Cesarean section is not easy to deter- 
 mine. It depends partly upon the size and ossification of the child's 
 head, and largely upon the experience and dexterity of the operator. 
 
 Michaelis, in the case of a dwarf scarcely three and a half feet 
 high, extracted a small child through a pelvis measuring but one inch 
 and a half in the conjugate diameter. The operation lasted two and 
 a half hours. At the end of two weeks the patient was able to resume 
 her household duties, f Dr. Osborn, in the celebrated case of Elizabeth 
 Sherwood, extracted a child through a pelvis measuring, as he believed, 
 but three quarters of an inch in its narrowest portion ! Barnes X ex- 
 tracted with perfect success a child through a conjugate Avhich, he says, 
 certainly did not exceed one inch and a half. It would be easy to go 
 on and extend this list, to show that there is no degree of conjugate 
 shortening that renders it utterly impossible to extract a mutilated 
 child. But the question which we should ask for our guidance is, not 
 what can possibly be accomplished by the skill and ingenuity of the 
 exceptionally experienced operator, who is capable of making whatever 
 rules he likes to govern his own actions, but what is the point at Avhich 
 men in every-day practice need expect to find the dangers from crani- 
 otomy and the Csesarean section rise to nearly the same level. Dr. 
 Parry collected seventy cases of craniotomy in pelves measuring two 
 and a half inches and nnder. Seven had to be terminated, finally, by 
 Cesarean section. Of the seventy women forty-three survived and 
 twenty-seven died. The work was not done by tyros, but by celebrated 
 obstetric surgeons. Thus, the best results of the ablest accoucheurs 
 before the days of antisepsis showed a mortality from craniotomy, in 
 the higher degrees of pelvic deformity, of nearly forty per cent. Un- 
 questionably this heavy death-rate has been lowered by modern aseptic 
 
 * The limits are those of Litzmann. Vide Ueber die Behandlung der engcn 
 Becken, Volkraann's Samml. klin. Vortr., No. 90. 
 
 f Michaelis, Abhandlungen aus dem Gebiete der Geburtshiilie, p. 151. The 
 operation lasted two and a half hours. 
 
 X Baknes, Obstetric Operations, p. 406.
 
 TREATMENT OF CONTRACTED PELVES. 495 
 
 methods ; still, in the hands of an operator of limited experience, I be- 
 lieve the Cesarean section, when timely made, offers ordinarily to the 
 mother a better chance of recovery. There are, of course, exceptions 
 to the rule. Most pelves measuring less than two and a half inches 
 in the conjugate belong to the category of generally contracted flat- 
 tened pelves. Where, exceptionally, the transverse diameter is not ma- 
 terially diminished, the difficulties of craniotomy are greatly lessened, 
 and, if at the same time the child's head be soft and compressible, a 
 comparatively easy extraction may give rise to false ideas concerning 
 the real dangers of delivery by the natural passages. These are due 
 chiefly to the fact that the operation has to be carried on within the 
 uterine cavity, when, owing to the contracted brim, no descent of the 
 head is possible. A long operation conducted within the uterine cavity 
 is always fraught with evil. 
 
 The dangers are not altogether mechanical. Even if serious lesions, 
 such as perforations, rupture of the uterus, and lacerated wounds, are 
 avoided, some contusion of the lower uterine segment is inevitable, air 
 enters freely the uterine cavity, the patient exhibits very commonly 
 the symptoms of profound shock, and the delivery is often followed by 
 post-partu7n haemorrhage, due to uterine inertia. The means employed 
 to check hemorrhage tend still further to depress the vital jDowers. In 
 many cases the uterus remains large and the labor is followed by ca- 
 tarrhal endometritis. This ordinarily mild puerperal affection is apt, 
 owing to the introduction of air and the presence of bits of necrosed 
 tissue, to assume a septic form, and pave the way to a fatal termination. 
 
 The contiguity of the peritonaeum likewise adds to the formidable 
 character of all suprapelvic operations. When the outlet of the pel- 
 vis alone is contracted, and craniotomy can be performed upon the 
 head after it has entered the vaginal canal, the dangers of extraction 
 are much diminished ; but even when recovery takes place, the un- 
 avoidable injuries inflicted often lead to life-long invalidism. 
 
 Cases of extreme degrees of the justo-minor pelvis are believed to be excess- 
 ively rare. Certainly tlie whole number reported since Naegele's day may be 
 easily counted on the fingers of the two hands. At full term the labor takes 
 place, provided the general contraction is such as to retain the head at the brim, 
 in one of two ways : 
 
 1. The uterus retracts up over the head of the child. If the head does not 
 descend, the vagina is drawn upward and is exposed to injurious tension. Should 
 nothing be done to relieve this condition, the thin vagina is liable to be rubbed 
 through by the pressure it encounters at the brim, and especially at the symphy- 
 sis pubis. Version would here be impossible, and the forceps would only en- 
 hance the risks. Perforation and decerebration would at once diminish the 
 pressure. With little over three inches in the conjugate and four in the trans- 
 verse diameter, the vault of the skull may be broken up with the cranioclast, 
 the chin tilted downward, and the head brought edgewise through the pelvis. 
 In this way, with moderate skill, it would be possible to extract a dead child.
 
 496 THE PATHOLOGY OF LABOR. 
 
 The operation of laparo-elytrotomy, however, seems so peculiarly fitted to these 
 conditions, that it deserves a trial in the interest of both mother and child. 
 
 2. The membranes rupture early, the waters gradually escape, and, as the 
 head does not descend, the uterus retracts down firmly upon the child. A scalp- 
 tumor forms, which fixes the head at the brim and pushes the cervix and lower 
 segment of the uterus before it. Here it would be proper to await for a time 
 the results of uterine action. As the transverse diameter can only be roughly 
 estimated, the head may lengthen out and adapt itself to the pelvic canal. But 
 the delay should not be too prolonged. If, in spite of the formation of the 
 scalp-tumor, the bony head remains unmoved at the brim, it is a question 
 whether it would not be the wiser plan to proceed at once to the Caesarean 
 section. 
 
 Naegele * reports the history of a dwarf whose pelvis measured but three 
 inches and seven lines in the transverse and three inches in the conjugate. He 
 delivered her with forceps of a five-and-a-half -pound child, but she died on the 
 tenth day. Heim reports the history of a dwarf with three and a quarter inches 
 conjugate and four and three quarters inches transverse diameter. Delivery 
 by perforation and forceps. Rupture of the three articulations.t 
 
 Spiegelberg reports a case with nearly the same dimensions. Child pre- 
 sented by the breech. Extraction difficult. Perforation of after-coming head. 
 Cephalotripsy. The patient died shortly after delivery. J I have reported a 
 case .where the conjugate was three and one sixth inches and the transverse 
 four and a half inches. Delivery by perforation, the cranioclast, and the 
 crotchet. The patient died on the third day (Trans, of the Am. Gynaec. Soc, 
 vol. iv). Kormann relates a ca.se nearly identical with my own, both as regards 
 its diameters and the existence of a slight lateral obliquity. After over three 
 days' labor the head adapted itself to the pelvis, and the child was extracted 
 alive by forceps. The mother died of peritonitis.* 
 
 Thus, of five women with generally contracted pelves, in which the conju- 
 gate ranged from three to three and a quarter inches, all died as a consequence 
 of delivery through the natural passages. 
 
 In cases where the uterus is rigidly applied to the child, and the cervix is 
 undilated, the propriety of laparo-elytrotomy is questionable. The operation 
 is not always a very easy one, and it certainly can not afford to be handicapped 
 by anything which would cause delay in the delivery after the vaginal rent has 
 been made. 
 
 There are, of course, in so rare a condition, scant statistics in favor of any 
 special plan of treatment. Michaelis reports a case of Mantz's, that of a woman 
 who had a pelvis measuring two inches antero-posteriorly and three inches in 
 the transverse diameter. Here the Caesarean section became a matter of neces- 
 sity rather than one of election. Twice the operation was performed with suc- 
 cess. A third time the result promised to be equally favorable, but the willful 
 and insubordinate conduct of the patient, as late as the twenty-seventh day, led 
 to her destruction. 
 
 In spite of the fact that in generally contracted pelves craniotomy is nearly 
 
 * Naegele, Das sehrag verengte Becken, p. 102. 
 •f LOHLEIN, op cit., p. 42. 
 
 X Spiegelberg, Lehrbuch der Geburtshiilfe, p. 444, vide note. 
 
 * KoRMAXN, Ueber ein allgemein verengtes, schrag verschobenes Becken, Arch 
 f Gynaek., p. 472.
 
 TREATiJENT OF CONTRACTED PELVES. 497 
 
 always practicable, a careful study of the ground convinces me that where 
 there is a diminution of nearly an inch in all the diameters, Csesarean section 
 holds out the best chance for saving the mother's life. 
 
 2. Cases hi wliicli tlie pdvic contraction is such as to prevent the 
 hirth of a full-term living child through the natural ^jcissages, but 
 in luhich extraction through the jJ&lvis furnishes the best chance of 
 saving the life of the mother. The choice of measures in this class of 
 cases lies between the Caesarean section, craniotomy, and, where the con- 
 dition of things is recognized early enough, the induction of premature 
 labor. In general terms we are authorized to assume such a degree of 
 disproportion in flattened pelves with the conjugate ranging between 
 two and a half and three inches, and in justo-minor pelves with a con- 
 jugate measuring three and a third inches. In, however, these less ex- 
 treme degrees of deformity, other elements than those of the size of the 
 pelvic canal enter into the formation of an opinion regarding the proper 
 procedure to be selected. I have, myself, in one case, extracted a child 
 weighing six and a half pounds by forceps, without much difficulty, 
 through a generally contracted flattened pelvis with a conjugate meas- 
 uring barely two and three fourths inches. Labor had lasted three 
 days previous to my seeing the patient, which was in consultation. 
 The child's head presented a singular appearance, from the molding it 
 had undergone, having been greatly flattened in its biparietal diameter 
 and enormously elongated in the occipito-mental direction. The child 
 died, however, shortly after birth. The mother recovered, though con- 
 siderable sloughing of the vaginal walls followed the long continuance 
 of the pressure which had preceded delivery. Grenser, in the Dresden 
 Hospital Eeports (1861-'63), gives three cases of children born alive 
 where the pelvis measured two and three quarters inches. In one of 
 these, where the labor lasted twenty-two hours, a living child was born 
 weighing six and a half pounds. 
 
 If, therefore, labor comes on at full term, an attempt should first 
 be made to gauge the degree of disproportion between the head and 
 the pelvic brim, for not only is it among the bare possibilities that a 
 living child may be expelled through a j^elvis measuring less than 
 three inches, but it is to be borne in mind that in pelvic mensuration 
 even the most expert may make errors of a quarter of an inch. In 
 any case it is well to preserve the membranes as long as possible. 
 Even craniotomy is more easily performed after complete dilatation of 
 the OS. After the waters escape, the lower uterine segment is subjected 
 to injurious pressure between the hard skull and the pelvic rim, the 
 damage done increasing of course with the duration of labor. By 
 early perforation and evacuation of the brain-mass this danger is 
 avoided. But craniotomy should not be performed so long as the hope 
 exists of saving the life of the child. The attempt should be made, at 
 least., before perforating, to form an estimate of the size of the child's 
 32
 
 V 
 
 498 THE PATHOLOGY OP LABOK. 
 
 head and its relations to the pelvic brim. An approximative result 
 may be obtained by palpating the head through the abdominal walls 
 above the pubes, and, so soon as the cervix is dilated and the head be- 
 comes pressed by the labor-pains firmly against the brim, by introduc- 
 ing the half -hand into the vagina to determine the extent of that por- 
 tion of the cranial vault which has entered the pelvis. When we have 
 ascertained the size of the segment beneath the pelvic border, and the 
 special points of the head which occupy the several pelvic diameters, 
 we are in a position to estimate the size of the portion above the brim, 
 and the mechanical difficulties which remain before the engagement of 
 the head can be accomplished. 
 
 In shoulder presentations, where, of course, version is necessary, 
 extraction alone should be first tried, and only when it is found impos- 
 sible to effect the delivery of the after-coming head by other means 
 should perforation be resorted to. Schroeder claims to have extracted 
 living children through pelves measuring but seven and a half centi- 
 metres (three inches) in the conjugate.* 
 
 The induction of premature labor in pelves having from two and 
 three quarters to three inches conjugate diameter possesses the merit 
 of diminished risk to the mother, and affords a chance of saving the life 
 of the child. Below two and three quarters inches the advantages of 
 premature labor may be fairly called in question. To be sure, Kiwisch 
 placed the biparietal diameter of the child's head in the thirtieth 
 week at two and a half inches. Seyfert, however, fixed it at three 
 inches, and later Schroeder obtained nearly three and a quarter inches 
 (8*16 centimetres) as the average between the twenty-eighth and thirty- 
 second week. In point of fact there is too little uniformity in the 
 diameters of fetal heads belonging presumably to the same week of 
 development to make average measurements of any practical utility. 
 It will be seen, however, that, in the higher degrees of pelvic contrac- 
 tion we are now contemplating, the biparietal diameter of the child's 
 head rarely falls within the limits of the narrowed conjugate. Still, 
 it is possible to deliver a living child through a pelvis estimated at two 
 and three quarters inches as late as the thirty-fourth week,f as the 
 head, owing to the pliability of the cranial bones in premature chil- 
 dren, is capable of sustaining a considerable degree of lateral comjires- 
 sion. Naturally the infant mortality in these cases is very large. In 
 addition to the ordinary increased risks attendant upon premature 
 labor, intracranial extravasations of blood from rupture of the deli- 
 cate cerebral vessels are extremely common. Litzmann found in 
 nearly one fourth of his cases (8 : 34) spoon-shaped dejiressions of the 
 skull. Though this lesion is met with upon the heads of living chil- 
 
 * Schroeder, Lehrbuch der Geburtshiilfe, p. 539. 
 
 f Wiener, Zur Frage der ktinstlichen Friihgeburt, Arch. f. Gynaek, Bd. xiii, 
 p. 99.
 
 TREATMENT OF CONTRACTED PELVES. 490 
 
 dren at full term, in the series of Litzmann four of the children were 
 dead at birth, three showed feeble signs of vitality, and in- one .only, 
 which lived but fourteen hours, was it possible to excite the respira- 
 tory process. Thus, the outlook for the child is by no means hopeful ; 
 but, inasmuch as, under three inches, the only operations which come 
 into competition with premtiture labor are the Cesarean section and 
 craniotomy, a small saving of fetal life is a powerful plea in its Justifi- 
 cation. But a stronger argument in its favor is the fact that the in- 
 duction of premature labor offers a milder procedure, which, within 
 certain limits, inures to the benefit of the mother. 
 
 Below two and three fourths inches the chances of saving the child 
 by premature labor are too slight to be weighed in the balance.* 
 Moreover, unless the child's head happens to be exceptionally small 
 and yielding, approximating the conditions to those which obtain in 
 immature deliveries, craniotomy in the end has usually to be resorted 
 to. Now, as premature labor offers no peculiar advantages in the per- 
 formance of craniotomy, and, as it is attended with certain risks of its 
 own, it is advisable, in very narrow pelves after the twenty-eighth 
 week, to await the normal end of gestation. 
 
 As the dangers to both mother and child are increased by delay, 
 Barnes has proposed combining version with premature labor in pelves 
 of less than three inches conjugate, as a means of accelerating delivery. 
 Milne by this method extracted a living child through a two and a 
 half inch pelvis. Budin has found by experimentation with artificial 
 2:)elves that a much less amount of traction force is requisite to drag 
 the head of a premature child through a flattened conjugate by the 
 feet than by forceps in cephalic presentations. 
 
 The time is probably not far distant when it will be possible to substitute 
 the Caesarean section for craniotomy within the limits of pelvic contraction 
 vmder consideration. Craniotomy requires rigid antisepsis, a sufficient arma- 
 mentarium, and an accurate knowledge of the parturient passage. With the 
 adoption of modern methods in hospital practice, Olshausen reports a death- 
 rate from craniotomy of 5-7 per cent; Cfed6, a death-rate of 8 per cent; and 
 Gusserow reports from Berlin a death-rate of 14-3 per cent, or, excluding cases 
 in which the death had nothing to do with the operation, the death percentage 
 was reduced to 8-3 per cent. Leopold had 71 cases with two deaths; but the 
 latter were from eclampsia, and were not the result of the operation.! 
 
 For the successful performance of the Caesaiean section there is needed train- 
 ing, adequate preparation, skilled assistants, and that the resistance of the patient 
 
 * In support of this opinion, which is thoroughly confirmed by my own experi- 
 ence, we have especially the authority of Spiegelberg, Litzmann, and Dohrn. 
 Milne (Premature Labor and Version, Edinburgh Med. Jour., vol. xix. p. 707) re- 
 lates a case where he was successful in a pelvis measuring but two and a half inches. 
 He states, however, that the space in the other diameters of the brim was ample, 
 which was certainly an exceptional advantage, as nearly all pelves with the higher 
 grades of deformity belong to the category of generally contracted rachitic pelves. 
 
 f Praegek, Der Kaiserschnitt, etc., herausgegeben von Dr. G Leopold.
 
 500 
 
 THE PATHOLOGY OF LABOR. 
 
 shall not be too much weakened by protracted delay. Of 252 cases operated 
 on according to the method of Sanger, between the years 1882-'89, inclusive, 
 63 (25 per cent) terminated fatally, but in 1890, of 61 cases, only 7 women 
 died (11-4 percent). The possibilities of the improved Csesarean section is, 
 however, best shown in the results obtained by single favored operators. Thus 
 Leopold had had up to August, 1890, 42 cases with four deaths, and in Leipsic, 
 of 36 cases, only 2 terminated fatally. Murdoch Cameron had 9 cases (simul- 
 taneous removal of the ovaries) with the loss of 1 patient. Sanger had 8 
 cases, Van der Meig 7 cases, and Schauta 15 cases without a death.* 
 
 3. Cases in loMch the pelvic contraction does not exceed the limits 
 within which the deliver ij of a living child at term is at least possible. 
 In this category belong the overwhelming majority of all instances 
 of contracted pelvis. It embraces not only cases in which the con- 
 junction of every favorable condition is essential to delivery, but those 
 moderate degrees of narrowing which are chiefly recognizable through 
 the influence they exert upon the mechanism of labor. It includes 
 flattened pelves with a conjugate of three inches and upward, and" 
 justo-minor pelves with a conjugate of over three and a third inches. 
 Below these figures the delivery of living children at full term is too 
 exceptional an event to be taken into account in any attempt at classi- 
 fication. 
 
 The obstetrical resources for overcoming the mechanical obstacles 
 afforded by moderate degrees of pelvic contraction are the induction 
 of premature labor, craniotomy, forceps, and version. Each one of 
 these measures has its strenuous partisans, who have expended much 
 unprofitable zeal in comparative estimates of their respective values. 
 It is a mistake to regard them as rival pretenders to favor. Indeed, 
 the very conditions which indicate one form of procedure often ex- 
 'clude the others from consideration. Good midwifery requires a just 
 appreciation of all the auxiliaries at our disposition and a careful study 
 of the circumstances which render them severally appropriate. 
 
 Premature Labor. — The indiscriminate induction of premature 
 labor in every case of contracted pelvis is particularly to be deprecated. 
 In the first volume of the Archiv fiir Gynaekologie Spiegelberg pre- 
 sented the statistics of 1,224 cases of full-term labor in contracted 
 pelvis, in which the maternal mortality was Q-Q per cent and the in- 
 fant mortality 28 per cent ; while in 271 cases of induced premature 
 labor the maternal mortality was 18*8 per cent and the infant mor- 
 tality 66 per cent. This startling discrepancy is due to the fact that 
 a very large proportion of labors in contracted pelves either terminate 
 spontaneously or require forceps only after uterine action has over- 
 come the obstruction at the brim. If all these minor cases be omitted, 
 a very different result is obtained. Thus, Litzmann found that in flat- 
 
 * Jahresbencht ueber die Fortschritte auf dem Gebiete der Gcburtshlilfe und 
 Gynaek., Ill Jahrgang, s. 294, und IV Jahrgang, s. 816.
 
 TllEATMEXT OF CONTRACTED PELVES. 501 
 
 tened pelves measuring from two and three fourths to three and one 
 fourth inches in the conjugate, and in justo-miuor pelves between 
 three and one third and three and a half inches, the maternal mortal- 
 ity after premature labor amounted to 7'4 per cent, while the loss of 
 life in labors at full term was 18-7 per cent.* But, in cases of recov- 
 ery, the advantages of premature delivery are by no means inconsider- 
 able, as, owing to the diminished head-pressure, lesions of the genital 
 canal are of rare occurrence, in striking contrast to the fistulfe, lacera- 
 tions, and cicatrices which so often follow delivery at full term. 
 
 The prognosis for the child, as shown by the statistics of premature 
 labor in contracted pelves, is decidedly unfavorable. In the restricted 
 class of cases we are at present considering Litzmann found that, 
 though twice as many children were born alive as at full term, the 
 actual number discharged alive from the hospital was about the same. 
 He concluded, therefore, that, Avhile the operation was decidedly indi- 
 cated in the interests of the mother, it offered a dubious advantage to 
 the child. It is, however, always injudicious to draw deductions from 
 hospital statistics alone. Especially is this true of feeble children, 
 born prematurely, whose ultimate chances depend in a peculiar degree 
 upon the care with which they are tended. 
 
 Dohrn, who objected to the statistics of Spiegelberg and Litzmann, 
 on the ground that the units of which they were composed repre- 
 sented, not parallel cases, but an endless variety of dissimilar condi- 
 tions, proposed, as a fairer way of testing the value of induced prema- 
 ture labor, to compare the results of the latter operation with those 
 of full-term labors in the same patients. Viewed in this way, prema- 
 ture labor in contracted pelves has been found to furnish unexpectedly 
 favorable results. Thus, Dohrn reports nineteen cases, with forty-one 
 children at term, of which thirty-seven died. In twenty-five preg- 
 nancies premature labor was induced, with fifteen living children, f 
 Kiinne and Berthold report eight cases, with twenty-four children at 
 term, of which eighteen died. In eighteen pregnancies premature 
 labor was induced, with thirteen living children. J Still more extraor- 
 dinary is the report of Milne. Six women gave birth at term to twelve 
 children, of which eleven were dead. In the succeeding thirty-eight 
 pregnancies premature labor was induced, and thirty-five children were 
 born living.* 
 
 The ordinary time for bringing on labor is from the thirty-second 
 to the thirty-fourth week. Most writers now agree that the oi^eration 
 
 * Litzmann, Ueber den Werth der kiinstlich eingleiteten Friihgeburt bei Beck- 
 enenge. Arch. f. Gynaek., Bd. ii. p. 194. 
 
 f Dohrn. Ueber kiinstliche Friihgeburt bei engen Becken, Arch. f. Gvnaek., Bd. 
 xii, p. 70. 
 
 I Kt'NNE, Fiinfzchn Fiille der kiinstlichen Friihgeburt; Berthold, Zur Statistik 
 der kiinstlichen Friihgeburt, Arch. f. Gynaek., Bd. vi, Ileft 2. 
 
 * Milne, Premature Labor and Version, Edinburgli Med. Jour., vol. xix.
 
 502 THE PATHOLOGY OP LABOR. 
 
 should be restricted to pelves measuring less than three and a half 
 inches in the conjugate, whereas above that limit it is best to await 
 the results of spontaneous uterine action. 
 
 Labor at End of Gestation.— But the physician may first be sum- 
 moned to a case of contracted pelvis after the end of gestation has 
 been reached, or he may at an earlier period have decided against the 
 induction of premature labor. 
 
 At full term, supposing the head to present, the latter, at the be- 
 ginning of labor, is prevented by the pelvic narrowing from entering 
 the brim of the pelvis, and is usually freely movable. The conduct of 
 the first stage of labor should be directed to preparing the way for the 
 subsequent delivery of the child. To this end every pains should be 
 taken to prevent rupture of the membranes until the cervical dilata- 
 tion has become complete. The patient should be cautioned against 
 restless movements in bed, and from bearing down during the pains. 
 Examinations joer vaginam should be made with great care, and should 
 be avoided except where absolutely necessary. The largest-sized Barnes 
 dilator, moderately distended with fluid, placed in the vagina to exert 
 counter-pressure upon the cervix, is at times of use where the mem- 
 branes have a tendency to protiiide in the form of a narrow cylinder. 
 
 Attention should likewise be directed to faulty positions and pres- 
 entations of the child's head. Should these be dependent upon a 
 pendulous abdomen, the fundus of the uterus should be elevated, and 
 the normal relations of the uterine axis maintained by a suitably ad- 
 justed bandage. Excessive lateral obliquity should be corrected by 
 placing the patient upon the opposite side. Should transverse nar- 
 rowing require a deep descent of the occiput, this can be furthered by 
 placing the woman upon the side to which the occiput is directed. 
 Where, on the other hand, it is desirable to promote the dip of the 
 forehead, the patient should be made to lie upon the side to which the 
 child's face is turned. The reason of this is obvious, as, when the 
 breech falls to a given side, the ceplialic pole has a tendency to move 
 in the opposite direction. The right use of position as a corrective 
 force depends upon the degree of accuracy with which the character 
 of the pelvic deformity is estimated, and upon a proper appreciation 
 of the mechanism appropriate to the ascertained deformity. 
 
 Where the sagittal suture looks forward toward the symphysis 
 pubis, so that the posterior parietal bone becomes the presenting part, 
 a firm compress above the pubes may be advantageously employed to 
 press the head backward and approximate the sagittal suture to the 
 median line. 
 
 The paint',, when weak and inefficient, should be strengthened by 
 the warm vaginal douche ; when the source of exaggerated suffering, 
 they should be mitigated by morphine, by rectal injections of chloral, 
 or by the administration of an anaesthetic.
 
 TREATMENT OF CONTRACTED PELVES. 503 
 
 Should, by good fortune, the rupture of the membranes bo post- 
 poned until after the completion of cervical dilatation, one of two 
 contingencies may follow : 1. The disproportion between the head and 
 the pelvis may prove to be slight, so that a considerable segment of the 
 cranial vault may be felt below the brim ; then, provided the head en- 
 ters the pelvis in conformity with the mechanical laws dictated by the 
 character of the pelvic deformity, the expulsion of the child may be left 
 to the natural uterine forces. 2. No engagement may take jjlace, the 
 head continuing freely movable at the brim. Under such circum- 
 stances the disjiroportion may be assumed to be considerable. The 
 physician has, therefore, to ask himself whether he shall await the 
 action of the pains, in the expectation that the head will gradually 
 adapt itself to the pelvis, or whether he shall at once jjroceed to per- 
 form version, and drag the child rapidly through the straitened diam- 
 eters. The forceps, as a means of delivery before fixation of the head, 
 should be discarded, not because it can not be employed with sliccess, 
 but because its use, even in the most skillful hands, is extra-haz- 
 ardous. 
 
 The question of waiting, or proceeding at once to version, is one 
 that will always be decided largely by the individual experiences of the 
 accoucheur. It is, however, vain to deduce rules of practice from the 
 conduct of those who have enjoyed exceptional opportunities, and who 
 usually have developed exceptional skill in some one special direc- 
 tion. It is to be remembered that in contracted pelves, in case the 
 pains prove inadequate to overcome the obstacles to delivery, the alter- 
 natives in head presentations are forceps and perforation. But there 
 are very few experienced operators who have not a more or less per- 
 sonal predilection for either forceps or version, and this unconscious 
 bias exercises, necessarily, to some extent, a determining influence upon 
 their choice. It is well known that there is hardly any subject which 
 has been the source of so much heated controversy as the one at pres- 
 ent under discussion. For the profession at large, however, there is 
 little to be gained from the spirit of partisanship. The general prac- 
 titioner requires instruction not only in the special advantages pos- 
 sessed by each measure, but need,3 to have presented to his attention 
 parallel statements of the dangers and difficulties from which neither 
 procedure is free. 
 
 Version. — In considering the application of version to the treat- 
 ment of contracted pelves, it is well to state in advance certain points 
 which are rarely alluded to, probably because they are matters of tacit 
 agreement between the contending parties to whose disputes we main- 
 ly owe our present knowledge in relation to the subject. 
 
 The first of these points is, that the intent of the operation is to 
 save tlie life of the child. In the case, therefore, of a dead child, or of 
 one in which the heart-sounds have notably begun to fail, version
 
 504 
 
 THE PATHOLOGY OF LABOR. 
 
 affords no advantage over perforation. For the same reason the condi- 
 tions must be such as to hold out a reasonable hope of rapid delivery 
 of the child's head, without the infliction of necessarily fatal lesions. 
 Now, there does not appear to be any well-authenticated case of the 
 extraction of a full-term living child after version through a flattened 
 pelvis measuring less than two and three quarters inches in the conju- 
 gate diameter. But even with three, or three and a quarter inches, 
 the result will still depend upon the length of the transverse diameter. 
 Thus, in extreme degrees of the justo-minor pelvis, with the reduction 
 of nearly an inch in all the diameters, the difficulties of delivering the 
 after-coining head, even with the aid of the perforator and the cephalo- 
 tribe, are well-nigh insurmountable. Again, the contraction should 
 be limited to the pelvic brim, for, where it is continuous, or progres- 
 sively increases toward the outlet, the fate of the child is not even 
 doubtful. 
 
 The other point of importance is, that with three and a half inches 
 and upward in the conjugate, no interference is, as a rule, called for. 
 Since it has become the custom to measure pelves with accuracy, the 
 profession has learned that these moderate degrees of deformity exer- 
 cise their influence not so much in a mechanical way as in the modi- 
 fying effects they produce upon labor. A large proportion of the cases 
 terminate spontaneously. If the pains fail prematurely, the conditions 
 are generally such as to make it an easy matter to deliver with forceps. 
 Difficulties only arise where the head is unusually large and incom- 
 pressible, or in faulty positions, such as the 
 anterior dip of the head in justo-minor 
 pelves, and the presentation of the posterior 
 parietal bone in the flattened varieties. 
 
 Thus, version is indicated in contracted 
 j)elves only where the child's heart beats 
 with nearly unimpaired vigor and in pelves 
 measuring between two and three quarters 
 and three and a half inches antero-pos- 
 teriorly, with the contraction limited to the 
 brim, and with sufficient amplitude in the 
 transverse diameter. 
 
 The advantages of version in contracted 
 pelves grow out of the unquestioned fact that 
 the after-coming head passes more readily the 
 contracted brim than the normal head-first 
 presentation. This superior facility is attributable to the entry of the 
 head by its smaller bimastoid diameter. At the same time, the fronto- 
 occipital descends in the transverse diameter of the pelvis. The press- 
 ure of the conjugate is encountered by the bitemporal diameter of 
 the child's head, which measures a half-inch less than the biparietaL 
 
 Fig. 211.— Base of skull. M M, 
 bimastoid diameter.
 
 TEEATMENT OF CONTRACTED PELVES. 
 
 505 
 
 Tractions upon the trunk of the child bring to bear simultaneously 
 pressure upon the head from many points in the pelvic walls. As a 
 result, bilateral flattening is effected, and a deep groove, usually near the 
 coronal suture, is produced in many cases upon the posterior cranial 
 surface by the pressure of the projecting promontory. The bulk of the 
 head is still further diminished by an overriding of the bones at the 
 sagittal suture, and, where the transverse diameter is insufficient, by 
 the crowding of the occipital beneath the parietal bones. A reduction 
 of the cranial contents is brought about by the retreat of a consider- 
 able portion of the cerebro-spinal fluid into the spinal canal. All these 
 changes are induced rapidly, and are not dependent upon the activity 
 and strength of the uterine pains. 
 
 The method of performing version and extraction in contracted 
 pelves io, with few modifications, the same as in pelves of normal size. 
 
 Fig. 212.— Method of employing suprapubic pressure. Head in the pelvic cavity. (Mund6.) 
 
 In contracted pelves great care requires to be taken lest the arms be- 
 come reflected upward to the sides of the child's head, or crossed upon 
 the neck. To avoid this difficulty it is desirable to introduce the 
 hand over the abdomen of the child, and bring down the arms before 
 the engagement of the shoulders. In extracting the head, tractions 
 may be made upon the lower extremities and shoulders according to 
 the method of Kiwisch, or they may be made with one hand upon 
 the shoulders, while two fingers of the other are inserted into the 
 child's mouth. Provided by either of these methods the relation of 
 the head to the shoulders is such that no twisting of the neck takes 
 place, the amount of force that can be employed without producing
 
 506 THE PATHOLOGY OF LABOR. 
 
 fat^l lesions is often something astounding. Thus, Eokitansky,* ex- 
 perimenting with the bodies of still-born infants, found the utmost 
 ctrength put forth by two men upon the trunk was insufficient to 
 cause rupture of the vertebral ligaments and separation of the artic- 
 ulations. It is usual, however, to combine pressure from above, 
 exercised by a skilled assistant upon the head through the abdominal 
 walls, with tractions from below. Schroeder states f that this practice 
 is coeval with podalic version. It was known to Cclsus and recom- 
 mended by Ambroise • Pare. It has found warm advocates in Pugh, 
 Wigand, Martin, Kristeller, and in this country in Taylor and Goodell. 
 Both the latter gentlemen have made valuable suggestions regarding 
 the technical management of difficult cases, which are well worthy of 
 special mention. Dr. Taylor X at first draws the body directly back- 
 ward while the head is forced by suprapubic pressure downward and 
 backward into the pelvis. So soon, however, as the head begins to 
 advance, he raises the body of the child and directs pressure upon the 
 head to be made downward and forward in the axis of the outlet. In 
 case of failure or delay, he has sometimes succeeded by intentionally 
 directing the back of the child to the sacrum, and then causing the 
 occiput to be pressed downward and backward into the nearest sacro- 
 iliac space, with the face looking upward, while traction is made in the 
 axis of the outlet. Dr. Goodell,* after first draAving in the direction 
 of the outlet, with the assistant pushing downward and backward, 
 reverses the direction, and sweeps the child's body backward upon the 
 coccyx, the neck likewise being forced downward and backward into 
 the hollow of the sacrum with all one's power. Where the projection 
 of the promontory is not very marked, he likewise recommends as some- 
 times of assistance a pump-handle movement, the range of oscillation 
 extending from the axis of the outlet anteriorly to very firm jiressure 
 on the coccyx posteriorly. 
 
 It is obvious from the foregoing description that version and ex- 
 traction in contracted pelves expose the child to perils of no insignifi- 
 cant character. Among the lesions Avhich have been observed as a 
 result of the extreme traction force necessary to bring the head rapidly 
 tlirough the narrow brim are fracture of the clavicles, fracture of the 
 humerus in difficult arm-deliveries, lacerations of the sterno-cleido- 
 mastoid muscles, rupture through the substance of a vertebra, extrav- 
 asations of blood into the cavities of the head and trunk, separation 
 of the condyles from the occiput, and of the squamous portion of the 
 temporal from the parietal bones, fractures and depressions of the 
 
 * RoKiTANSKY, Wieii. med. Presse. 1874, No. 45. 
 f Schroeder, Handbuch, Gte Aufl., p. 307. 
 
 t Taylor, What is the Best Treatment in Contracted Pelves? p. 23. 
 
 * Goodell, Clinical Memoirs on Turning in Contracted Pelves, Am. Jour, of 
 Obstet., A-ol. viii, p. 211.
 
 TREATMENT OF CONTRACTED PELVES. 507 
 
 skull, and rupture of the sinuses of the dura mater.* To be sure, 
 many of these accidents are not inevitably fatal, but they do not by 
 any means furnish the chief sources of danger. These result partly 
 from the respiratory efforts which are always excited by delay in ex- 
 tracting the after-coming head, and partly from the depressing influ- 
 ence exercised uj)on the fetal heart by pressure brought to bear upon 
 the base of the brain, f 
 
 Having thus made out, with great care, a full bill of particulars, 
 embracing all the acknowledged drawbacks to the j)erformance of ver- 
 sion in narrow pelves, we have next to consider how far these associ- 
 ated evils tend to invalidate the claim of version to be regarded as 
 facile princeps among conservative measures of treatment. The fol- 
 lowing records of the individual exiDerience of competent operators 
 will help us to solve this question. Kormann turned in nine cases of 
 contracted pelves. Seven children were born living and two dead. 
 All the mothers recovered. J Lowenhardt turned in twenty cases of 
 contracted pelves. Seventeen children were born alive, and three 
 dead. Only children that outlived the first week were counted in the 
 successful cases. The mothers recovered.* Groodell reports eleven 
 cases. Seven children were alive at birth, and four were still ; but of 
 the latter, one was extracted through a pelvis measuring only two and 
 a half inches conjugate diameter, and in one the case was complicated 
 by eclampsia. The mothers recovered. Now, not to go beyond these 
 forty cases, we obtain, as the result of version, thirty-one living infants, 
 without the sacrifice of a single mother. A number of the women in 
 whose previous labors craniotomy had been found necessary were de- 
 livered by version of living children. Lowenhardt placed in contrast 
 his own experience Avith the forceps in narrowed pelves presenting 
 degrees of contraction corresponding to those in which he had re- 
 sorted to version. In forty-five deliveries, sixteen children were born 
 dead and five died shortly after birth. Of the mothers, three died, 
 while twenty- one suffered from puerperal affections of greater or less 
 severity. 
 
 Now, if the foregoing testimony represented the entire truth, there 
 would be no good reason for discussing other plans of treatment. 
 They, in fact, show only how far special training and experience will 
 enable an operator to overcome difficulties by dexterity and address. 
 In the first case reported by Dr. Goodell the child was still-born. In 
 commenting upon the cause of death Dr. Goodell states frankly : 
 
 * C. RuGE, Verlctznngen des Kindcs diirch Extraction bei Beckenlage, Ztsehr. f. 
 Geburtsh., Bd. i. p. G8. 
 
 f DoHRN, Ueber Pulslosigkeit des Kindcs wiihrend Extraction an den Filssen, 
 Arch. f. Gynaek., Bd. vi, p. 3G5. 
 
 X Kormann, Arch. f. Gynaek., Bd. vii, p. 13. 
 
 * Lowenhardt, Wendung und Extraction das doniinirende Yerfahren bei Beck- 
 enenge, Arch. f. Gynaek., Bd. vii, p. 4'21.
 
 508 THE PATHOLOGY OP LABOR. 
 
 " Much force was needed to extract the head, but it was not made as 
 promptly and efficiently as I have since learned to make it." * 
 
 Another side of the question has been presented by Borinski,t who, 
 at the instigation of Professor Spiegelberg, collected the statistics of 
 version in contracted pelves from the Breslau Clinic between the years 
 1865-1872. In all there were ninety-three cases. Thirty-four chil- 
 dren were saved, and fifty-nine were born dead, or died soon after 
 birth. Fifteen mothers lost their lives. This seemingly disastrous 
 showing is capable, however, to a certain degree, of explanation. Thus, 
 twenty of the fifty-nine children born still died before version was 
 attempted. In nine of the cases the transverse as well as the conju- 
 gate was materially diminished. Of the children delivered through 
 these flattened generally contracted pelves, only one, and that a very 
 small one, was extracted alive. Still, there were fifty-eight cases of 
 version in ordinary flattened pelves, with the result that just one half 
 the children were born dead. In only three of the fifteen mothers 
 who died was the fatal result apparently connected with the opera- 
 tion. In the others, death was due to spontaneous rupture of the 
 uterus, placenta praevia, and nephritis, version having been resorted 
 to because of these complications. A considerable allowance should 
 be made, too, in the cases from the Breslau Clinic, for the fact that 
 the greater j^art of them took place in the out-department of the hos- 
 pital, when they were under the charge of midwives, who rarely send 
 for timely aid except in the presence of dangerous complications. In 
 eighteen instances the operation was performed on account of pro- 
 lapse of the cord, and in eighteen instances because of some maternal 
 affection. 
 
 Forceps. — In presenting this less favorable side of version in con- 
 tracted pelves, it is well incidentally to place in juxtaposition the re- 
 sults of the high forceps operation as given by Dr. Harold Williams 
 (American Journal of Obstetics, January, 1879). Williams collected 
 one hundred and nineteen cases, reported since 1858 where the forceps 
 was applied to the head above the brim. Of the mothers nearly forty 
 per cent, and of the children over sixty per cent, perished. The me- 
 chanical objections to the use of forceps at the brim are obvious. 
 When the head is molded to the contracted pelvis by the natural 
 forces, the head passes the conjugate with its long diameter in the 
 transverse diameter of the pelvis, with the two fontanelles on nearly 
 the same level, and with the sagittal suture looking toward the sacrum. 
 The posterior parietal bone rotates around the promontory, the latter 
 producing a furrow, which runs either along the coronal suture, or at 
 first in front of the parietal boss, and later, as flexion occurs, forward 
 
 * GooDELL. Trans, of the Internat. Med. Congr., Philadelphia, 1876, p. 777. 
 t BoRiNSKi, Zur Lehre von der Wendung auf die Fiisse bei engen Becken, Arch, 
 f. Gynaek., Bd. iv, p. 226.
 
 TREATMENT OF CONTRACTED PELVES. 509 
 
 toward the frontal bone. The bilateral compression of the head is 
 compensated for in part by a lengthening in the fronto-occipital and 
 partly in a vertical direction. 
 
 The forceps applied in the transverse or oblique diameter of the 
 pelvis prevents the former compensation from taking place. It in- 
 creases the width of the head, and thus adds to the difficulty of jmss- 
 ing the conjugate. Often it disturbs further the normal head mechan- 
 ism by causing premature flexion and rotation to take place. In each of 
 these ways it augments the difficulties of delivery, and renders neces- 
 sary the emi^loyment of an increased amount of traction force. With 
 forceps applied directly to the sides of the child's head I have had no 
 experience, but Dr. Goodell,* who has clearly pointed out the objec- 
 tions to this method in contracted pelves, has shown that they inev- 
 itably produce flexion, and cause the large biparietal diameter to j^ass 
 through the narrow conjugate. So long as the head does not engage 
 at the brim, there is no rivalry between version and forceps. The 
 latter should be placed under the ban as hardly less dangerous than 
 the Caesarean section. 
 
 Expectant Treatment. — Now, let us suppose that after rupture of 
 the membranes it is decided to resort to neither forceps nor version, 
 but to adopt an expectant course, until circumstances arise which shall 
 render active interference necessary. It is certain that a very consid- 
 erable portion of labors in contracted pelves terminate spontaneously. 
 Winckel f reports twenty-three cases in the Dresden Maternity in 1873, 
 and twelve cases in 1874-'?5. Of the thirty-five cases, two mothers 
 and three children died. Osterloh J reported one hundred and thirty- 
 nine cases from the Leipsic Maternity, between the years 1863-1872, 
 inclusive. There were one hundred and five cases where the pelves 
 measured from three to three and a half inches. Of one hundred and 
 six children, seven died. Of the mothers, four died. In thirty-four 
 cases where the pelves measured over three and a half inches, two chil- 
 dren died. All the mothers recovered. There were, however, forty- 
 two cases in all of puerperal disease terminating in recovery. Borinsky 
 reports from the Breslau Clinic two hundred and thirty-three spon- 
 taneous deliveries in contracted pelves, with one hundred and ninety- 
 two living children. There were ten maternal deaths, but four were 
 from non-puerperal intercurrent affections. Thus, in three large ma- 
 ternity hospitals there were in cases of contracted pelves four hundred 
 and seven spontaneous deliveries with the loss of fifty-three children, 
 and, from puerperal diseases, of twelve mothers. ■ !^ven in pelves meas- 
 
 * Goodell, Labor in Narrow Pelves, Trans, of the Internat. Med. Congr., Phila- 
 delphia. 1876, p. 788. 
 
 f Winckel, Berichte und Studien, 1874-'76. 
 
 X Osterloh, Einige Beitrage zu den spontan verlaufenden Geburten bei engera 
 Becken, Arch. f. Gynaek, Bd. iv, p. 520.
 
 510 THE PATHOLOGY OF LABOR. 
 
 uring less than three inches, now and then, the spontaneons birth of a 
 small living child takes place. 
 
 If we examine these results, we find that under favorable circum- 
 stances, in all but the extreme forms of pelvic contraction. Nature 
 will do her own work with the least expense of infant life, and with a 
 relatively small maternal mortality. On the other hand, the long-con- 
 tinued pressure upon the parturient canal incident to the molding and 
 adaptation of the head to the narrow pelvis, yields a large contingent 
 of inflammatory affections, which complicate the puerperal period and 
 protract the convalescence. By favorable circumstances Ave mean a 
 presentation and position of the child's head suited to the form of the 
 pelvis, and a sufficient degree of uterine activity. Rectification of a 
 faulty position of the head after the rupture of the membranes is 
 always a matter difficult of accomplishment. In case, therefore, the 
 brow presents, or the head engages with an excessive degree of lateral 
 obliquity (sagittal suture looking forward toward the pubes, or back- 
 ward toward the promontory), in place of wasting time in futile efforts 
 at correcting the malposition, version should be promptly performed. 
 In prolapse of the cord, which pccurs in about six per cent, of the 
 cases, the indication would clearly be version rather than replacement. 
 In eclampsia and face presentations most operators would preferably 
 resort to version. 
 
 Thus, we have finally the field of controversy between version and 
 other plans of treatment narrowed down to cases in which, after rupt- 
 ure of the membranes, the head remains above the brim, but the con- 
 ditions are such that Nature is capable of overcoming the mechanical 
 difficulties of delivery providing that the labor-pains are sufficiently 
 energetic. There is always an element of chance in this last condition, 
 which, however, is an essential one. If the pains are weak and pow- 
 erless, it may be possible, even hours after rupture of the membranes, 
 when the head has not become fixed, to still accomplish version. More 
 frequently, however, as the head but incompletely fills the lower seg- 
 ment of the uterus, the waters escape, the uterus retracts upon the 
 feetus, the cervix becomes oedematous and tender, and after a time 
 the temperature and pulse rise, betokening the presence of danger. 
 Sometimes the retraction of the uterus ends in the withdrawal of the 
 cervix over the child's head, and, in the failure of the latter to de- 
 scend into the pelvis, the vagina is drawn upward, and subjected to a 
 perilous degree of ^tension. It is easy to see that under such cir- 
 cumstances the time for version is past, and craniotomy is called for. 
 Because, therefore, where labor is left in contracted pelves to the spon- 
 taneous efforts of Nature, in a certain proportion of cases the insuf- 
 ficiency of the labor-pains leads to the necessity of sacrificing the 
 child, there will always be operators who, confident in their own skill, 
 will prefer to turn soon after rupture of the membranes, that they may
 
 TREATMENT OF CONTRACTED PELVES. 5H 
 
 keeja in their hands the control of the delivery. The bulk of pro- 
 fessional men will, on the contrary, so long as spontaneous delivery 
 is probable, prefer to wait, even though by so doing they may eventu- 
 ally find themselves obliged to fall back upon the perforator and the 
 crotchet. 
 
 AVhen the birth of the child is left to the contractions of the 
 uterus, re-enforced by the expiratory muscles, the physician should 
 assume the role of a watchful spectator. Safety to the mother and 
 the child requires that the time of the passage of the head through the 
 bony canal should not be too prolonged. So long as the head de- 
 scends steadily, however slow the progress may be, in case no compli- 
 cations demand speedy extraction, the physician should await the 
 results of uterine activity. Should the pains grow weak and inef- 
 ficient, they may be stimulated by the uterine douche, the introduc- 
 tion of the catheter into the uterus, and by small doses of ergot or the 
 viscum album, provided the inertia is not the result of pathological 
 changes in the uterine tissues. 
 
 When the advance of the head ceases, either from failure of the 
 pains or, as in justo-minor pelves, from the growing resistance of the 
 pelvic outlet, the rule should be to relieve the soft parts of the mother 
 as speedily as possible from the pressure of the child's head. Press- 
 ure too long continued ends in cedematous swelling, softening of the 
 tissues, arrest of circulation, and eventually in necrosis and gangrene. 
 When the integrity of the lower segment of the uterus has been im- 
 paired to any extent, perforation should be resorted to, and the child 
 sacrificed to the interests of the mother. If, on the contrary, the 
 changes are insignificant, and the mechanical difficulties not insuper- 
 able, by the use of forceps it may be possible to save the life of both 
 mother and child. But to avoid the first-named cruel alternative, the 
 forceps should be applied so soon as the requisite conditions for its 
 employment are reached. Of course, as the forceps is used solely to 
 save fetal life, in case the feeble heart-action of the child gives warn- 
 ing of impending asphyxia the interests of the mother are to be alone 
 consulted. 
 
 In estimating the mechanical difficulties to be overcome by the 
 forceps, it is necessary to determine how far engagement has taken 
 place, Litzmann * recommends that the physician ascertain by inter- 
 nal examination, combined with external palpation, both the size of 
 the segment of the cranium below the brim and how much of the 
 head remains to undergo compression before it can enter the j)elvis. 
 
 In ordinary flattened pelves, Litzmann found that in three fourths 
 of all the cases the pains alone sufficed to overcome the resistance of 
 the brim. W^hen the head had so far descended that the sagittal suture 
 
 * LiTZMANx, Ueber die Behandlung der Geburt bei engem Becken, Volkniann's 
 Samral. klin. Vort., pp. 715 et seq.
 
 512 THE PATHOLOGY OF LABOR. 
 
 had passed from three to four fifths of an inch below the promontory, 
 and the boss of the anterior parietal bone could be felt with ease 
 behind the symphysis pubis, extraction with the forceps was a task of 
 no great difficulty, even if before its application flexion had not begun 
 to take place. 
 
 In generally contracted flattened pelves, it is desirable that the 
 head should be transverse and well flexed, with the posterior parietal 
 bone at least three fifths of an inch below the promontory. With the 
 forehead and occiput resting upon the side walls of the pelvis, the 
 sagittal suture near the promontory, and an ear felt behind the 
 symphysis pubis, the prospects of forceps operations are extremely 
 dubious. 
 
 In justo-miuor pelves of moderate extent (conjugate three and a 
 half inches), the failure of the pains, which forms the necessity for 
 forceps, is rather the result of the paralyzing effect of the pressure of 
 the bony canal upon the entire circumference of the cervix than of 
 the absolute degree of pelvic contraction. The head descends in a 
 state of comj)lex flexion, with the large fontanelle at the pelvic brim. 
 If, as the head advances, the small fontanelle moves from the median 
 line, and the large fontanelle becomes accessible to the finger, it is 
 likely that the pelvis widens toward the outlet. If the forceps serves 
 only to bring the fontanelle down still deeper, and to increase the de- 
 clivity of the sagittal suture, the opposite condition obtains, which may 
 frustrate the delivery.* 
 
 In flattened pelves the forceps should be applied as nearly as pos- 
 sible to the fronto-occipital diameter of the head, as the latter needs 
 to descend into the transverse diameter of the pelvis. When applied 
 obliquely it tends to cause premature rotation, which increases the 
 difficulties of extraction. In justo-minor pelves the direction of the 
 blades is of less importance, as the head often descends sjiontaneously 
 in an oblique diameter. Success in high forceps operations depends 
 upon the degree of accuracy with which the tractions are made in the 
 axis of the pelvis. With the long-curved forceps, it is especially diffi- 
 cult to fulfill this requirement at the superior strait. Even when the 
 directions to draw vertically downward are faithfully carried out, a 
 considerable portion of the force is expended in the pressure of the for- 
 ceps upon the soft tissues lying between them and the anterior pelvic 
 wall. In careless hands this pressure is capable of inflicting a great 
 deal of injury, particularly where the blades of the forceps are passed 
 within an imperfectly dilated cervix, and where they project somewhat 
 beyond the child's head. Various devices have been invented to cor- 
 rect this defective working of the instrument. Pajot recommends 
 placing the left hand upon the lock to make pressure backward, while 
 with the right hand tractions are made downward and somewhat for- 
 * LiTZMAXN, Ueber die Behandlunjr der Geburt bei enerem Becken.
 
 TREATMENT OF COI^TR ACTED PELVES. 513 
 
 ward. I have generally succeeded by exerting a small amount only of 
 force at each traction, watching at the same time with great care the 
 direction of the blades in the pelvis. This method is pretty safe, and 
 in the end generally successful, but often requires a very considerable 
 outlay of time and patience. A pair of straight forceps, as recom- 
 mended by Dr. I. E. Taylor, will often enable one to draw more di- 
 rectly in the axis of the brim, and will succeed when the curved for- 
 ceps have had to be abandoned. Of late I have been in the habit of 
 using Tarnier forceps in high operations, and am able to give it my 
 cordial approval. The blades always swing in the transverse diameter 
 of the pelvis, while the traction force is exerted as nearly as possible 
 upon the center of the child's head. A few trials will convince the 
 most prejudiced opponent of the Tarnier forceps that it will at the 
 superior strait bring the head to the floor of the pelvis in much less 
 time, and with a less expenditure of force, than can be accomplished 
 by other methods. 
 
 The dangers from the forceps in contracted pelves are due not 
 so much to the pressure it makes directly upon the child's head and 
 the pelvic walls as to the compensatory bulging of the head in its 
 transverse diameter. When the head is fixed at the brim and the for- 
 ceps is applied to the forehead and occiput, it is evident that the only 
 change of form that can take place is in a vertical direction. Safety 
 in delivery requires that there should be no sudden augmentation of 
 the bilateral pressure, which would necessarily deepen the farrow made 
 by the promontory upon the posterior-lying parietal bone, and im- 
 peril the integrity of the maternal tissues confined at the conjugate 
 between the promontory and the pubes. Until, therefore, the head 
 has passed the narrow strait, tractions should be made with moderate 
 force, and with short periods of intermittence. After the head has 
 once descended to the floor of the pelvis the forceps should be removed, 
 and the head be allowed to rotate into the conjugate, then a forceps of 
 any pattern may be adjusted to the sides of the head, should further 
 aid be required to complete delivery. 
 
 So far we have considered cases in which the cervix was suf- 
 ficiently if not completely dilated before rupture of the membranes. 
 If, as is very common, the membranes rupture prematurely, the diffi- 
 culties and risks to both mother and child are greatly increased. With 
 rupture come, as we have already seen, escape of the amniotic fluid, 
 retraction of the uterus, and interference in the utero-placental cir- 
 culation. With an undilated os externum the cervix is stretched by 
 the head, and its thinned tissues are subjected to pressure from the 
 symphysis and promontory. Delay leads to arrest of circulation and 
 necrosis at the points of pressure, but here version and forceps are 
 alike impracticable. This leaves as the only alternatives perforation 
 and the Cassarean section. Timely aid, therefore, in such cases should 
 33
 
 514 
 
 THE PATHOLOGY OF LABOR. 
 
 be extended before a dangerous condition is reached. My first prefer- 
 ence just after rupture is the Barnes dilator, which not only serves to 
 expand the cervix, but, when employed promptly, helps to prevent 
 the escape of the amniotic fluid. Next to the Barnes dilator, and of 
 special utility when the waters have already escaped, I would place 
 the long, narrow-bladed forceps of Dr. Taylor for introduction through 
 the undilated os. With it the head can be grasped, and, when made 
 to descend and then allowed to recede in alternation, oftentimes the 
 rounded cranial surface will efficiently act as a dilating body, and se- 
 cure such a degree of expansion as will pave the way for the safe adop- 
 tion of other methods of delivery. 
 
 CHAPTER XXVII. 
 
 RARE FORMS OF PELVIC DISTORTION. 
 
 The Naegele oblique pelvis : morbid anatomy, etiology, diagnosis, mechanism of 
 labor in, prognosis, treatment.— The kyphotic pelvis : morbid anatomy, etiology, 
 diagnosis, prognosis.— Scolio-rachitic pelvis: anatomical characters. — Robert's 
 pelvis : anatomy, etiology, diagnosis, prognosis. — Spondylolisthetic pelvis : an- 
 atomical characters, diagnosis, prognosis.— Funnel-shaped pelvis. — Osteoma- 
 lacia. — Pelvis narrowed by exostoses. — Divided symphysis. 
 
 I. The Naegele Oblique Pelvis. 
 
 This variety of deformed pelvis derives its name from the author 
 who first systematically studied it and called attention to its impor- 
 tance as a cause of obstructed labor. 
 
 Morbid Anatomy. — The pathological characters peculiar to this va- 
 riety of deformed pelvis are, according to the classical description of 
 Naegele,* the following : 1. Complete anchylosis of one sacro-iliac 
 synchondrosis, or osseous union between the sacrum and one os innomi- 
 natum. 2. Destruction or defective development of the lateral half of 
 the sacrum and smaller caliber of the anterior sacral foramina on the 
 anchylosed side. 3. Diminished breadth of the os innominatum and of 
 the sacro-sciatic notches on the same side. The articular facet of the ili- 
 um, which corresponds to the sacral auricular surface, is less elongated 
 than on the non-anchylosed side. 4. The sacrum is displaced toward 
 the anchylosed side, and its anterior surface is turned in that direction. 
 The pubic symphysis is pushed to the healthy side, and is therefore 
 not directly opposite the promontory. 5. The internal surface of the 
 OS innominatum on the deformed side is flatter than the correspond- 
 ing sound bone, and the linea ilio-pectinea is but slightly curved. 
 
 * Naegele, " Das schragverengtes Beckcn," Mainz, 1850, p. 7.
 
 RARE FORMS OF PELVIC DISTORTION. 
 
 515 
 
 6. The sound side of the pelvis is not of an entirely natural shape, as 
 is shown by the fact that its ilio-pectineal line is straighter posteriorly, 
 and more curved anteriorly, than in a normal pelvis. ?. The results 
 of the deformities mentioned are : 
 
 (a) That the pelvis is contracted in that oblique diameter meas- 
 ured by a line passing from the acetabulum of the anchylosed side to 
 the opposite sacro-iliac joint, while the other oblique diameter is not 
 shortened, but even elongated in extreme cases, (b) That the dis- 
 tances between the promontory and either acetabulum, and those be- 
 tween the apex of the sacrum and the spine of either ischium, measured 
 from the affected side, are less than the corresponding distances on the 
 other, (c) That the distances between the tuber ischii of the anchy- 
 losed side and the posterior superior spinous process of the opbosite 
 ilium, and those between the spine of the last lumbar vertebra and the 
 anterior superior spinous process of the diseased side, are shorter than 
 the corresponding distances on the opposite side, (d) That the distance 
 of the superior posterior iliac spine of the anchylosed side from the 
 lower border of the symphysis pubis is greater than that between the 
 
 Fia. 213.— Naegele oblique pelvis. (From specimen in the Wood Museum.) 
 
 symphysis and the opposite posterior superior spinous process, (e) That 
 the walls of the pelvic cavity converge below, and that the pubic arch 
 is narrowed and approximated to the type of the male arch. (/) That 
 the acetabialum of the flattened side is directed farther forward than is 
 normal, while the opposite acetabulum looks almost directly outward. 
 We may add that the anterior surfaces of the bodies of the lumbar ver- 
 tebrae are directed toward the anchylosed side. The ilium is higher, 
 steeper, flatter, and reaches farther backward on that side. The pubic 
 arch looks toward the flattened side. The conjugata vera is somewhat 
 elongated. The transverse diameter is shortened at the inlet, and its 
 shortening progressively increases as the outlet is approached.* The 
 
 * ScHROEDER, Lehrb., p. 596.
 
 516 THE PATHOLOGY OP LABOR. 
 
 OS innominatum of the healthy side is somewhat displaced outward, 
 and is more markedly curved, hence the venter of the corresponding 
 ilium is directed more anteriorly than that of the anchylosed side.* 
 The deformity is most apparent at the inlet, which is compared by 
 Naegele to an oblique oval figure. The tuber ischii on the anchylosed 
 side is higher, and directed more posteriorly and internally than nor- 
 mal. This description will also apply to the ordinary oblique-ovate 
 pelvis, except so far as the anchylosis, which is the distinguishing 
 feature of the Naegele oblique, is concerned. 
 
 Etiology.— The essential cause of oblique-ovate pelvis in general 
 is continuous pressure directed against one of its lateral halves, the 
 weight of the trunk falling predominantly or exclusively upon the 
 lower extremity of the deformed side, and leading to displacement and 
 distortion of the pelvic bones. The conditions producing this pre- 
 dominant unilateral pressure are tabulated by Litzmann f as follows : 
 1. Lateral spinal curvature, usually of rachitic origin. 2. Impeded or 
 entirely abrogated function of one lower extremity. In this case the 
 deformity will affect that side the lower extremity of which is intact. J 
 The impairment or loss of function may result— (r?) from unilateral 
 hip-disease ; {b) from amputation of one lower extremity ; (c) from 
 an old dislocation of the femur upward and backward. 3. Unsym- 
 metrical sacrum, produced by defective development, or by atrophy of 
 one sacral lateral mass — (a) as the result of a defect in the original 
 formation ; (b) as the result of abnormal coalescence of the sacrum 
 and ilium in early life, whereby the growth of both was hindered ; (c) 
 as the result of a loss of substance from caries. Spiegelberg ** calls 
 attention to Lambl's statement that primary asymmetry of the sa- 
 crum may be due to coalescence of the sacral lateral masses and the 
 transverse processes of the last lumbar vertebra, whereby the outward 
 growth of the former is impeded. He also emphasizes || the fact that 
 simple chronic arthritis of the sacro-iliac synchondrosis produces sa- 
 cral asymmetry, without anchylosis, by inducing contraction and atro- 
 phic sclerosis of the contiguous osseous tissue. The continued use of 
 one shortened lower extremity is another cause of excessive pressure 
 upon the corresponding side of the pelvis. When this condition ob- 
 tains, the deformity will be on the side of the shortening. The sacro- 
 iliac synostosis, which has been alluded to as the distinguishing char- 
 acteristic of the Naegele oblique, as contrasted with the other forms of 
 the olbique-ovate pelvis, is sometimes the primary defomity, as will be 
 seen from the foregoing etiological table. The coalescence of the joint- 
 
 * Litzmann, Die Pormen d. Beckens, Berlin, 1861, p. G9. 
 t Litzmann, op. cif., p. 68. 
 
 t GussEROw, Arch. f. Gj-naek., Bd. xi, 1877, p. 264. 
 
 * Spiegelberg, Lehrb.. p. 475. 
 
 II Spiegelberg, Arch. f. Gynaek., ii, 1871. pp. 159 et ssq.
 
 RARE FORMS OF PELVIC DISTORTION. 517 
 
 surfaces is never, however, congenital, because the articulation is fully 
 formed before the appearance of the centers of ossification for the sa- 
 cral lateral masses. Nor can the synostosis be referred to involvement 
 of the joint-surfaces in the process of ossification, since this does not 
 occur in any true joint. The disappearance of the joint-cavity must, 
 therefore, be referable to an inflammatory process, resulting in adhe- 
 sion of the opposed articular surfaces. The inflammation may be either 
 of traumatic or of strumous origin. The results of unilateral pressure 
 upon the pelvis will depend upon the amount of pressure exerted, the 
 resistance of the bones, and the firmness of their connections. 
 
 Diagnosis. — The attention of the obstetrician will be directed to 
 the possibility of the existence of the oblique-ovate pelvis when the 
 subject limps and presents an inequality in the height of the hips or 
 evidences of antecedent gluteal abscesses. The diagnosis is assured by 
 a physical examination, which shows, in the first place, the distance 
 between the spinous process of the last lumbar vertebra and the pos- 
 terior superior spinous process to be considerably less on the deformed 
 than on the healthy side. The absence of this sign is, however, no 
 proof of the non-existence of the deformity. The distorted ilium is 
 higher than the other, and projects farther posteriorly than is normal. 
 A vaginal examination reveals the straight course of the ilio-pectineal 
 line on the side of the anchylosis, the deviation of the subpubic arch 
 toward that side, a disparity in the distances between the ischiatic 
 spines and the apex of the sacrum, and the deviation of the promon- 
 tory. Naegele * suggested, for the completion of the diagnosis, the 
 application of the following measurements, Avhich are equal on both 
 sides in the normal, but different in the oblique-ovate pelvis : 1. The 
 distance of the tuber ischii of one side from the posterior superior 
 iliac spine of the other ; on the deformed side it is shorter. 2. That 
 from the anterior superior to the posterior superior spine of the other 
 side ; shorter from the anterior spine of the deformed side. 3. That 
 from the spine of the last lumbar vertebra to the anterior superior 
 spinous process of the same side ; less on the contracted side. 4. That 
 from the trochanter major to the opposite posterior superior spinous 
 process ; shorter when measured from the affected side. 5. That from 
 the under surface of the symphysis pubis to the posterior sujoerior 
 iliac spine; longer on the narrowed side. These measurements are 
 only of avail in well-mark^ed cases, and may lead to erroneous con- 
 clusions if other diseases of the bones be simultaneously present. 
 The vaginal examination affords, on the whole, the most accurate 
 results. 
 
 Mechanism of Labor. — The mechanism of the birth, in an oblique- 
 ovate pelvis, is the following : If the promontory be retreating, the 
 sagittal suture of the fetal cranium enters the inlet parallel to the 
 * Naegele, op. cif., p. 174.
 
 518 
 
 THE PATHOLOGY OF LABOR. 
 
 longer oblique diameter. If, however, the promontory project con- 
 siderably, and is closely approximated to the ilium of the affected side, 
 no portion of the head can be admitted between them.* The cranium 
 will then enter the pelvis most easily with the sagittal suture in the 
 short oblique diameter, and will pass through tbe pelvic canal without 
 rotation. If the pelvis be originally small and the deformity marked, 
 the obstruction to labor may be complete. Should the pelvis, how- 
 ever, be roomy and the promontory retreating, no considerable impedi- 
 ment will be offered to parturition. 
 
 Prognosis. — It is obvious that the prognosis, for both mother and 
 cliild, is best when the pelvis was originally large, and far less favor- 
 able under the reversed condition. In the latter case the mother very 
 frequently succumbs and the child is only rescued by the Cesarean 
 section. Litzmann's f statistics report the death of twenty-two out of 
 twenty-eight mothers, five of whom perished undelivered, and that of 
 thirty-one children out of forty-one cases. These figures by no means, 
 however, fairly represent the average result, since many cases of slight 
 and moderate deformity escape detection. 
 
 Treatment. — In a case of extreme obliquity at the Bellevue Hospi- 
 tal, Avhere the distance between the ischia barely exceeded two inches, 
 I induced premature labor at presumably the twenty-ninth week. The 
 child was turned and lived long enough after extraction to receive 
 the rite of baptism. The mother made a speedy recovery. This case 
 affords a striking contrast to those reported by Litzmann. Undoubt- 
 edly, if the obliquity were always recognized at a sufficiently early 
 period of pregnancy, the induction of premature labor would favorably 
 change the prognosis. Very commonly, however, the condition passes 
 unperceived until delay in labor leads to a more careful investigation. 
 In such cases, if the head has entered the pelvic cavity, and the dimi- 
 nution of the space between the ischia is not excessive, a careful at- 
 tempt should be made with the forceps to test the adaptability of the 
 presenting part to the contracted diameter. Violent tractions should, 
 however, be avoided. Studley J has recently reported a case of coxal- 
 gic oblique pelvis in which fracture of the pubic rami upon the right 
 side resulted from forceps delivery. If the disproportion is such that 
 moderate tractions are unavailing to advance the head, or if the child 
 is already dead, perforation should be performed. Craniotomy at the 
 inferior strait is much less dangerous than ^t the brim. 
 
 If the head fail to enter the pelvis, we have to inquire whether the 
 result be due to absolute deficiency of the pelvic space, or to the fact 
 that the sagittal suture of the head corresponds to the shortened ob- 
 lique diameter. In the first event the case becomes a suitable one for 
 Caesarean section, while in the second version should be performed 
 
 * Litzmann. Monatsschr. f. Geburtsk.. xxiii, 1864, p. 268. 
 t Ibid., p. 284. X -^m. Jour, of Obstet., 1879, p. 269.
 
 RARE FORMS OP PELVIC DISTORTION. 
 
 519 
 
 with a view to bringing the long cephalic diameter into correspond- 
 ence with the opposite longer diameter of the pelvis. If extraction is 
 then fonnd to be impossible, perforation can still be performed upon 
 the after-coming head. 
 
 11. The Kyphotic Pelvis. 
 
 Morbid Anatomy. — The characteristic deviations of a kyphotic pel- 
 vis from the normal type are due to the unnatural direction in which 
 the weight of the superimposed trunk is communicated to the base of 
 the sacrum, as the result of an existing antero-posterior spinal cur- 
 vature. If a dorsal kyphosis be entirely compensated by a lumbar 
 lordosis, the former may 
 entail no pelvic distortion. 
 As a rule, the deformity is 
 most marked with lumbar 
 and sacral kyphoses, which 
 admit of no compensatory 
 lordosis, and least apparent 
 with remote dorsal kyphoses. 
 The effect of the altered di- 
 rection, in which the weight 
 of the trunk is transmitted 
 to the sacrum, is to force the 
 latter more deeply between 
 the ossa innominata and to 
 rotate its upper portion in 
 a posterior direction. The 
 displacement backward of 
 the inferior extremity of the 
 trunk causes the center of 
 gravity to be thrown far 
 behind the acetabula, and 
 produces a consequent dimi- 
 nution in the obliquity of the pelvis by elevating the anterior pelvic 
 parietes.* The change in the pelvic obliquity is antagonized by the 
 ilio-femoral ligaments, and the result of these opposing forces is as 
 follows : The sacrum is narrowed and elongated by the traction from 
 behind and above, and its upper part is displaced backward. Its 
 transverse concavity is increased and its longitudinal concavity dimin- 
 ished, f The bodies of the sacral vertebrae are on a plane posterior to 
 their transverse processes. The promontory is high and is directed 
 far backward. The upper anterior surface is sometimes convex while 
 the concavity of the lower part is preserved, and an S-like shape is 
 
 * Laxge, Arch. f. Gynaek., Bd. i, 1870, p. 231. 
 
 f Breslau, Monutsschr. f. Geburtsk., Bd. xxvii, 18C6, p. 319. 
 
 Fia. 214.— Specimen of kyphotic pelvis. (Litzmaim.)
 
 520 
 
 THE PATHOLOGY OF LABOR. 
 
 thus imparted to the sacral curve. The higher anterior sacral foram- 
 ina look upward. Owing to the tension of the ilio-femoral ligaments, 
 the anterior inferior spinous processes of the ilium are well developed. 
 The linecB iUo-pectinecB are only slightly curved. The subpubic arch 
 is narrowed. The spines and tuberosities of the ischia are abnormally 
 approximated. Owing to the narrowness of the sacrum, the posterior 
 superior iliac spines are in close proximity to each other, while the 
 spines and crest of the ilium are more remote than in a normal pelvis. 
 The venters of the ilia are expanded and directed to the front. The 
 transverse diameter of the false pelvis is therefore increased, while that 
 of the true pelvis is diminished. The symphysis is prominent, the 
 horizontal pubic rami meeting at an acute angle. At the inlet the 
 oblique and the conjugate diameters are elongated and the transverse 
 diameter curtailed. In the true pelvis the transverse diameters are con- 
 siderably and the antero-posterior diameter slightly shortened. These 
 diameters become still more contracted as the outlet is approached.* 
 If a lumbo-sacral kyphosis be present, the sacrum is shortened and 
 very narrow. If this kyphosis be situated very low down, it may be 
 compensated for by a low lumbar lordosis, which overhangs and ma- 
 terially contracts, the pelvic inlet, f 
 
 Etiology. — The cause of the spinal curvature resulting in kyphotic 
 pelvis is usually caries of the vertebrae. 
 
 Diagnosis. — The antecedent history and the discovery of kyphosis 
 will render the existence of this form of pelvis prooable. On more 
 careful physical examination, the shape and position of the sacrum, 
 the short interval between the spines and the tuberosities of the is- 
 chium and the posterior superior iliac spines, the wide separation of the 
 anterior superior iliac spines, the narrow pubic arch and prominent 
 symphysis, the flatness of the iliac venters, and the difficulty experi- 
 enced in reaching the promontory, will establish the diagnosis. The 
 differential diagnosis between a kyphotic pelvis and one deformed by 
 osteomalacia, with which it is sometimes confounded, will be readily 
 made by reference to these distinctive features and to the fact that 
 the transverse diameters of the false pelvis are elongated in a kyphotic 
 pelvis, the reverse obtaining in osteomalacia. 
 
 Prognosis. — The amount of obstruction offered to parturition will 
 naturally depend upon the grade of the pelvic contraction. The 
 prospects for the preservation of the child's life are not very favorable. 
 In some instances, as in a case reported by Korsch,J there existed a 
 considerable amount of mobility in the pelvic joints, which permits an 
 enlargement of the outlet and facilitates the parturient process. The 
 
 * HuTER, Ztschr. f. Geburtsh. u. Gynaek., Bd. v, 1880, p. 22. 
 t Feeling, Arch. f. Gynaek., Bd. iv, 1872, p. 2. 
 
 X EoRSCH, Ein wahrend der Gebnrt constatirter Fall von Beweglichkeit der 
 Gelenkverbindungen des kyphotischen Beckens, Arch. f. Gynaek., vol. xix, p. 475.
 
 RARE FORMS OF PELVIC DISTORTION. 521 
 
 gravity of the prognosis as regards the mother is the result in most 
 instances, not so much of the mechanical difficulties of delivery, as of 
 her feeble vitality, and the undeveloped condition of her heart and lungs. 
 Again, the spinal disease may be reawakened by pregnancy, and in child- 
 bed may lead to psoas abscess, and other suppurating processes. In 
 many cases the head enters the pelvis with the occiput rotated to the 
 rear. Owing to its smaller size the forehead is better adapted for en- 
 gagement beneath the narrow jjubic arch than the occiput, but perineal 
 laceration is more likely to occur, as the uterine force in fronto-anterior 
 positions is directed to the center of the iDsrinasum. 
 
 Treatment. — In first pregnancies it is a good rule to await the end 
 of gestation, as experience has shown that Nature may accomplish the 
 delivery, owing to the mobility of the pelvic bones, when the results of 
 the pelvic measurements would seem to indicate this to be impossible. 
 Before resorting to craniotomy, a careful trial should be made in head 
 presentations with forceps. After the head has entered the pelvis the 
 extraction of the child after craniotomy is usually not difficult. Witii 
 the head movable at the brim, neither craniotomy nor version are j)rac- 
 ticable. The Caesarean section is indicated. If the kyphosis is extreme, 
 so that the ribs overlap the ilia, the Porro method possesses the advantage 
 of furnishing more space for the overcrowded pelvic and abdominal 
 viscera. 
 
 III. SCOLIO-KACHITIC PeLVIS. 
 
 A brief allusion must be made to the anatomical characteristics of 
 a purely rachitic pelvis, in order to render the differences between it 
 and a scolio-rachitic pelvis intelligible. The leading pathological 
 features of the infantile rachitic pelvis consist in expansion of the sub- 
 pubic arch, prominence and lowering of the promontory, widening and 
 elongation of the sacrum, flatness of the venters of the ilia, between 
 which there is an abnormally wide interval, and in an irregularly 
 rounded, triangular, or kidney-shaped pelvic inlet.* These anatomical 
 features are not altered by the supervention of a scoliosis, but the 
 latter adds to the deformity already existing its own pathological char- 
 acters. The latter combine to produce a marked unilateral asymmetry 
 of the pelvis.f The most ordinary form of scoliosis consists in a 
 deviation of the dorsal vertebrae to the right and a comi^ensating lumbar 
 curve to the left. 
 
 The adult scolio-rachitic pelvis presents many points of resemblance 
 to the infantile, its leading peculiarities being the following : J The 
 entire pelvis is inclined toward the side of the lumbar curve, and rests 
 chiefly upon the corresponding thigh. The cause of the pelvic asym- 
 
 * Fehling, Arch. f. Gynaek, Bd. x, 1876, p. 1 ; Ihid., Bd. xi, lg77, p. 173. 
 
 f Kehrer, Arch. f. Gynaek., Bd. v, 1873, p. GO. 
 
 X Leopold, Das ykoliotisches und kyphotisch-rachitischc? Be( ken, Leipsic, 1879, 
 
 p. 7.
 
 52^ 
 
 THE PATHOLOGY OF LABOR. 
 
 metry is to be souglit in the increased weight thus thrown upon the con- 
 tracted half of the pelvis and in the counter-pressure exerted upon its 
 articular surface. The contracted half of the pelvis is higher and 
 more inclined than its fellow. The sacrum has sunk deep between 
 the ilia, and is narrower upon the side of the lumbar scoliosis. The 
 sacral vertebral bodies are sometimes displaced forward, project- 
 ing beyond the lateral masses. 
 The promontory is displaced 
 toward the contracted side, 
 and the corresponding lateral 
 mass is often narrowed. There 
 is rarely anchylosis of the hip- 
 Joint. The ilium is erect, looks 
 inward, and is narrowed antero- 
 posteriorly. Its crest is higher 
 than that of the opposite side. 
 'I'he symphysis is displaced 
 toward the uncontracted half 
 of the pelvis. The ilio-pecti- 
 neal line makes a sharp curve 
 inward near the sacro-iliac syn- 
 chondrosis, and then pursues 
 an undulatory course to tlio 
 symphysis, being notably bent 
 inward opposite the acetabu- 
 lum. On the uncontracted side 
 the corresponding line forms a 
 large and rounded arch. The 
 tuber iscliii on the side of the lumbar scoliosis is turned outward. The 
 oblique diameter of this side is greater, but the distance between the 
 sacrum and the acetabulum {distantia sacro-cotyloidea) is much shorter 
 than on the uncontracted side. The plane of the inlet is obliquely 
 cordiform, being contracted upon the side of the lumbar scoliosis and 
 expanded on the other. Exactly the reverse conditions obtain at the 
 pelvic outlet.* The conjugata vera is notably shortened by the pro- 
 truding promontory. The antero-posterior diameter of the outlet, 
 although contracted, still far surpasses the conjugata vera in lengtl.. 
 Other and independent pathological conditions may aggravate tlie 
 obstruction caused by the peculiar deformity in question. Thus, Hu- 
 genberger describes a case of scolio-rachitic pelvis complicated by 
 an extensive sacral hydrorachis.f 
 
 The peculiar deformity of a scolio-rachitic pelvis obstructs de- 
 livery by so narrowing the space between the acetabulum and the 
 
 * Leopold, op. cif., p. 10. 
 
 f HuGEXBERGER, Arch. f. GytiiU'Ic. B(l. xiv, p. 1. 
 
 Fig. 315.— Specimen of scolio-rachitic pelvis. 
 (Litzmann.)
 
 RARE FORMS OF PELVIC DISTORTION. 
 
 523 
 
 sacrum as to prevent any part of the fetal cranium from engaging in 
 it. Rotation is thus prevented, and the delivery must be accom- 
 plished, if indeed it be possible, by the same mechanism obtaining in 
 a justo-minor pelvis, the conjugata vera of which would be here rep- 
 resented by the distantia sacro-cotyloidea, and the transA-erse diameter 
 of which would correspond with the oblique diameter of the uncon- 
 tracted side. 
 
 IV. Robert's Anchylosed and Traxsverselt Contracted 
 
 Pelvis. 
 
 This very rare form of contracted pelvis was first described by 
 Robert in 1843. Its leading characteristics are bilateral sacro-iliac 
 anchylosis and absence or rudimentary development of the sacral 
 lateral masses. The sacrum is consequently very narrow, and only 
 slightly wider at its upper than at its lower extremity. The longi- 
 tudinal and transverse concavities of the bone are nearly or quite ob- 
 literated. In some cases the normal transverse concavity is trans- 
 formed into a convexity. The sacrum is deeply pressed between the 
 ossa inuominata. The posterior «. 
 
 superior iliac spines are conse- 
 quently closely aj)proximated, and 
 the ilia project far above the base 
 of the sacrum. The promontory 
 encroaches considerably upon the 
 superior strait. The iliac venters 
 are flattened and directed ante- 
 riorly. The linesB ilio-pectinege 
 are slightly or not at all curved, 
 and abnormally approximated. 
 The descending rami of the pubes 
 unite at an acute angle. The 
 ischiatic spines and tuberosities 
 
 are in close proximity to each other and to the lateral margins of the 
 sacrum. The dimensions of the pelvis are materially altered. 
 
 The transverse diameter is notably diminished and grows shorter 
 from above downward, so that at the outlet, in marked cases, it is rep- 
 resented by a mere crevice between the ischia and the pubic bones. 
 The form of the inlet is that of a long and narrow wedge with its apex 
 directed anteriorly. The average diameter of the outlet is less than 
 two inches.* The antero-posterior diameter is either of normal length 
 or but slightly shortened, since the projection of the promontory is 
 compensated for by the absence of the normal outward curve of the 
 lateral borders of the inlet. The pelvic canal is deeper than in a nor- 
 
 FiG. 216.— Robert's pelvis. (Lambl.) 
 
 * Spiegelberg, Lehrbuch, p. 482.
 
 524 
 
 THE PATHOLOGY OF LABOR. 
 
 mal pelvis.. In some cases there is asymmetry of the two lateral halves 
 of the pelvis. 
 
 Etiology.— The decisive agency in the production of the deformity 
 under consideration is the narrowness of the sacrum, which is chiefly 
 due to the diminished breadth of its lateral masses, but also in a cerr 
 tain measure to tlie small transverse diameter of the bodies of the 
 sacral vertebrae. Diversities of opinion prevail regarding the connection 
 between the narrowness of the sacrum and the sacro-iliac synostosis. 
 
 Some authors consider deficient development of the centers of ossi- 
 fication of the lateral masses as the primary event, and the anchylosis 
 as dependent upon this. Others regard the synostosis as tlie primary 
 change which determines the atrophy of the lateral masses,* and vari- 
 ously refer it to inflammatory processes or to arrested development.! 
 In some cases it would seem that the sacrum Avas originally of normal 
 breadth, but was narrowed and united with the ilium by osteitis and 
 arthritis-! The transverse convexity of the anterior sacral surface is 
 explained by the fact tliat the bodies of the vertebrse are pressed for- 
 ward by the weight of the superimposed trunk after the union of the 
 sacral lateral masses with the ilia, and at a time when the connections 
 between the bodi(^ and the lateral masses are still pliable and yield- 
 ing. The close approximation of the ilia and their parallel course are 
 referable to the narrowness of the sacrum and to increased lateral 
 pressure upon the acetabula.* The combined action of these agencies 
 produces the narrowness of the subpubic arch, the acutely angular 
 Junction of the descending pubic rami, the approximation of the iliac 
 crests, and the straight course of the lineae ilio-pectinese. 
 
 Diagnosis. — The diagnosis is partly based upon the abnormal ap- 
 proximation of the posterior superior iliac spines, wliich almost cover 
 the deeply seated si)inous process of the last liiml)ar vertebra, and upon 
 a similar approximation of the trochanters, of the tubera ischii, and of 
 the iliac spines and crests. A vaginal examination then reveals the 
 parallel course of the descending pubic rami and the striking diminu- 
 tion of the transverse diameter. The differential diagnosis between 
 the Uobert and the kyphotic pelves is based upon the absence of 
 a kyphosis in the former and upon the striking difference between the 
 respective transverse diameters. 
 
 Prognosis. — This is bad for the mother, inasmuch as labor is com- 
 pletely obstructed by the deformity, and operative interference is 
 always necessary. 
 
 The Caesarean section is indicated in the interest both of the mother 
 and the child. 
 
 * LiTZMANN, Die Formen des Beckens. Berlin, 1861. p. 62. 
 t Kehrer, Monatsschr. f. Geburtsk.. Bd. xxxiv. 18G9, p. 20. 
 t IvLEixwACHTER. Ai'ch. f. Gyiiaek., Bd. i, p. 156. 
 ^^ LiTZ.MAXx, op. cil., p. 65.
 
 RARE FORMS OF PELVIC DISTORTION. 525 
 
 V. Spondylolisthetic Pelvis. 
 
 This rare form of contracted pelvis was first described by Rokitansky 
 in 1839. Its principal pathological feature consists in the separation of 
 the last lumbar from the first sacral vertebra and in the descent of the 
 body into the pelvis, where the inferior, or in an extreme case the pos- 
 terior, surface of the body of the last lumbar rests upon the anterior sur- 
 face of the first sacral vertebra. The anterior surface of the last lumbar 
 vertebra is directed downward. The anterior surfaces of the fourth, 
 third, and second lumbar vertebrae form an arch, the most prominent 
 part of which, being nearest the symphysis, replaces the normal promon- 
 tory. The result of this displacement 
 is a considerable diminution in the 
 antero-posterior diameter of the pelvic 
 inlet. The descent of the lumbar por- 
 tion of the spine, which is gradually 
 accomplished, is attended by atrophy 
 of the intervertebral cartilages, and 
 frequently by osseous union between 
 the bodies of the lumbar and sacral 
 vertebras. The weight of the super- 
 imposed trunk being now transmitted 
 to the anterior surface of the sacrum, 
 instead of to its base, the pelvic center ^'« ^ir.-spond^^oUsthetic peu-is. 
 of gravity is displaced forward. This 
 
 is compensated for by a diminution in the normal pelvic inclination, 
 the anterior portion of the pelvis being tilted slightly upward. The 
 pressure upon the anterior surface of the sacrum forces its base back- 
 ward. The posterior superior iliac spines are thus widely separated, 
 and the apex of the sacrum is thrown forward, encroaching upon the 
 antero-posterior diameter of the outlet. In a case cited by Breslau,* 
 the sacro-iliac synchondrosis possessed great mobility. 
 
 The traction upon the ilio-femoral ligaments, which approximates 
 the tubera ischii, and the lateral displacement of the ilia, due to re- 
 cession of the sacrum, produce a shortening of the transverse pelvic 
 diameter, which becomes more marked in proportion as the outlet is 
 approached. 
 
 According to the recent investigations of N"eugebauer,f the spon- 
 dylolisthetic pelvis is far from being a very rare anomaly. Thus 
 Neugebauer has succeeded in collecting from various sources twenty- 
 three anatomical preparations and thirty clinical observations made on 
 living persons. 
 
 * Breslau, Monatsschr. f. Geburtsk.. Bd. xviii, 1861, p. 411. 
 t Dr. Franz Ludwig Neugebauer, Arch. f. Gynaek., vol. xix, p. 441 ; vol. xx, p. 
 133; vol. xxii, p. 347; vol. xxv, p. 347.
 
 526 
 
 THE PATHOLOGY OP LABOR. 
 
 Etiology.— Neugebauer, who has studied with unwearied patience 
 and zeal the anatomical specimens preserved in the museums of Eu- 
 rope, has shown that in true spondylolisthesis the body of the verte- 
 bra alone is concerned in the forward displacement, the arch, the spine, 
 and the transverse processes remaining in situ. The spinal canal un- 
 dergoes, therefore, an antero-posterior elongation, and the cord is not 
 subjected to pressure. This elongation takes place at the junction of 
 the arch with the body. It does not appear to be due either to caries 
 or an inflammatory process. The original cause of the anomaly Neuge- 
 bauer attributes in many cases to a congenital separation of the arch 
 from the body of the fifth lumbar vertebra, due to defective ossification, 
 in rare instances to traumatic fracture of the sacral articular processes, 
 and in some cases probably to fracture of the arches due to trauma- 
 tism. The latter cause he admits, however, to be hypothetical, as 
 where fractures have been observed it is not possible to determine 
 whether they occurred primarily, or whether they resulted secondarily 
 from the strain placed upon them in the forward and downward move- 
 ments of the vertebral body. 
 
 In a few instances the etiology remains unsolved. The deformity 
 never occurs suddenly, but progresses slowly under the pressure of the 
 trunk until the gliding movement is arrested by bony union between 
 the lumbar and sacral vertebra. Repeated pregnancies furnish me- 
 chanical conditions favoring the spondylolsthesis, though pregnancy is 
 not an essential element in the causation, as the accident has been ob- 
 served in males. 
 
 Diagnosis. — As a result of the deformity, the abdomen is protuber- 
 ant and the thorax is sunken between the prominent iliac crests. The 
 trunk, therefore, appears shortened, while the extremities are relatively 
 of disproportionate length ; the width between the troclianters is in- 
 creased ; the nates are flattened and pointed below with deep lateral 
 depressions, so that the posterior aspect of the buttocks possesses a 
 heart-shape and the base of the sacrum and the posterior superior 
 spines of the ilium are prominent. Along the spine a deep lumbo- 
 dorsal furrow is observable, and, owing to the diminished pelvic incli- 
 nation, the external genitals are directed to the front. The gait of 
 patients suffering from spondylolisthesis is peculiar. The steps are 
 short, the toes are but slightly turned out, and the footprints follow 
 one another in nearly a straight line. It is not, however, easy to de- 
 termine by external examination alone the difference between spon- 
 dylolisthesis and a deep-seated lumbo-sacral kyphosis. The internal 
 examination is best made, according to Neugebauer, in the upright or 
 lateral position. To determine the existence of the angle formed by 
 the projecting lumbar vertebra, the finger should be introduced along 
 the anterior vaginal wall in the axis of the superior strait directly to 
 the spinal column, and then should be passed downward to the seat of
 
 RAKE FORMS OP PELVIC DISTORTION. 527 
 
 displacement, carefully feeling in the descent the spinal vertebrse and 
 the extent to which the spine covers the pelvic brim. 
 
 Olshausen * first announced the fact that the point of division of 
 the abdominal aorta into the common iliac arteries is displaced down- 
 ward by the descending lumbar vertebras to such an extent as to en- 
 able the palpating finger, introduced into Douglas's cul-de-sac, to de- 
 tect pulsation in these vessels. Hartmann f was enabled to feel the 
 point of the aorta's division on the upper border of the fourth lumbar 
 vertebra, and Breslau J felt a pulsating vessel in the same situation. 
 Neugebauer states that this displacement is not pathognomonic, but 
 may be observed in other instances of spinal lordosis. The spondylo- 
 listhetic lordosis may be mistaken for the sacral deformity peculiar to 
 a rachitic pelvis. Breisky ** suggests that this error may be avoided by 
 attention to the fact that in the rachitic pelvis the sacral lateral masses 
 pass outward from the projecting promontory, while in spondylolisthe- 
 sis one can feel at the pelvic inlet only the rounded prominence of a 
 single vertebral body without laterally expanding wings. The pro- 
 jecting angle made by the body of the last lumbar vertebra with 
 the anterior surface of the sacrum is also easily accessible to palpa- 
 tion. 
 
 Prognosis. — The prognosis in cases of the spondylolisthetic, as in 
 other forms of contracted pelvis, depends upon the degree of the ob- 
 struction of the brim, and such collateral conditions as the size of the 
 child, the strength of the pains, and the position of the head at the 
 point of entry into the pelvis. Other things being equal, a deviation 
 of the spine from the median line is a favorable condition. 
 
 Swedelin,! from a careful study of the clinically observed cases, 
 concludes : 
 
 1. That where the false conjugate measures above 3| inches no dis- 
 turbance of labor is to be anticipated. 
 
 2. When the false conjugate measures from 3 to o^ inches, preg- 
 nancy may be permitted to proceed to term, as labor at term may be 
 expected to terminate favorably for both mother and child, without 
 the intervention of severe operative measures, 
 
 3. Labor at term, with a false conjugate measuring between 2^ to 
 3 inches, is extremely dangerous for the child ; the prognosis for the . 
 mother is likewise bad. 
 
 4. With less than 2^ inches in the false conjugate, extraction of the 
 child without craniotomy is hardly possible. 
 
 * Ohlshausen, Monatsschr. f. Geburtsk., Bd. xxiii, p. 204. 
 
 t Hartmann, Monatsschr. f. Geburtsk., Bd. xxv, 18G5, p. 469 ; Bd. xxxi, 1868, p. 
 285. 
 
 X Breslau, Monatsschr. f. Geburtsk., Bd. xviii, p. 411. 
 
 * Breisky, Ioc. cif., p. 9. 
 
 II Swedelin, Ein neuor Fall von klinisch beobachteter Spondylolisthesis, Arch, 
 f. Gynaek, vol. xxii, p. 250, 1880.
 
 528 
 
 THE PATHOLOGY OP LABOR. 
 
 5. In multiparse the prognosis is the more serious in cases where 
 the previous labor was difficult. 
 He advises, therefore : 
 
 1. Induction of premature labor at the thirty-second week, with a 
 false conjugate of less than 2f inches. 
 
 2. Induction of premature labor at the thirty-second week Avith a 
 false conjugate measuring between 2| and 3i inches. 
 
 3. Between 3^ and d^ inches, it is best to await the end of gesta- 
 tion, unless the feeble condition of the patient contra-indicates a wait- 
 ing policy, in which case premature labor should be induced in the 
 thirty-sixth week. 
 
 4. Premature labor is not indicated with a false conjugate exceed- 
 ing 3^ inches. 
 
 5. If the end of gestation has been reached with a false conjugate 
 of less than 2f inches, wait until danger threatens the patient, and 
 then decide between craniotomy and the Cassarean section. 
 
 6. With a false conjugate of less than 2J inches, the Caesarean sec- 
 tion is called for. 
 
 VI. Funnel-shaped Pelvis. 
 
 This term has been applied to two varieties of deformed pelves, 
 both of which are exceedingly rare. The inlet of the first variety is 
 either normal or but slightly contracted in all its diameters, but its 
 canal is gradually and progressively narrowed as the outlet is ap- 
 proached. The contraction affects chiefly the transverse diameter ; 
 but either this alone, the antero-posterior diameter alone, or both to- 
 gether, may be shortened. The lateral pelvic Avails converge consider- 
 ably, particularly in the vicinity of the outlet. The descending rami 
 of the pubic bones are closely approximated, so that the subpubic 
 arch forms an acute angle. The spines and tuberosities of the ischia 
 are in close apposition.* The sacrum is elongated and but slightly 
 curved, its position resembling that of the sacrum in a kyphotic pelvis. 
 It will be seen that these deformities produce a close resemblance to 
 the typical male pelvis. Pelves of this variety are frequently some- 
 what unsymmetrical. 
 
 The second variety of the funnel-shaped pelvis is so exceedingly 
 rare as to require only a passing notice. In this instance the deform- 
 ity is exactly the reverse of that just described, the inlet being very 
 narrow in either one or in all of its diameters, wliile the outlet is of 
 normal size or even abnormally wide in one or more directions.f 
 
 Etiology. — The causes of this deformity are imperfectly under- 
 stood. The former variety is believed to be due to arrest of develop- 
 
 * PoppEL, Monatsschr. f. Geburtsk., Bd. xxviii, 18G6, p. 234 ; Braun, Arcli. f. 
 Gynaek., Bd. iii, 1870, p. 154. 
 
 t Spiegelberg, Lelirbuch, p. 473.
 
 RARE FORMS OP PELVIC DISTORTION. 529 
 
 ment in the sacral lateral masses and to other causes co-operating to 
 alter the direction in which the weight of the trunk is normally trans- 
 mitted to the sacrum. This view seems to be confirmed by Schroeder's 
 observation that the funnel-shaped pelvis is of unusual frequency in a 
 certain German province, where the children are carried upon the back 
 in a position intermediate between the erect and the recumbent pos- 
 ture.* The weight of the body would in this case be transmitted to 
 the sacrum from above and in front, as in the kyphotic pelvis, rather 
 than from behind and above, as is the case in a natural position, and 
 the pelvis would neither acquire its normal anterior curvature nor its 
 posterior inclination. The same theory explains the failure of the 
 sacrum to exert its usual wedge-like action in separating the ossa in- 
 nominata, and accounts for the consequent approximation of the tubera 
 and spines of the opposite ischia. 
 
 Diagnosis. — In cases of slight deformity the diagnosis is difficult. 
 In well-marked cases the approximation of the ischial tuberosities, the 
 slight divergence of the pubic rami, and the acute subpubic angle are 
 readily appreciated. Arrest of the head after it has already descended 
 into the true pelvis will often be the first circumstance serving to di- 
 rect the attention to the possible existence of funnel-shaped pelvis. 
 Pelvic menstruation, with particular reference to the distance between 
 the spines of the ischia and to the width of the sacrum, will establish 
 the diagnosis. 
 
 Prognosis. — In the slighter grades of funnel-shaped pelves, the 
 prognosis is not grave. If the deformity be marked, however, the 
 child's life must almost invariably be sacrificed ; and gangrene of the 
 maternal soft parts, with resulting cicatrices and fistulas, or even with 
 caries of the pubic bones, may be the consequence of the excessive 
 pressure to which these tissues are liable. In a case reported by Schar- 
 lau the lesions already mentioned were accompanied by perforation of 
 the fundus uteri from gangrene, and by rupture of the right sacro-iliac 
 artery. f 
 
 The treatment consists in the induction of premature labor, or, at 
 term, in a cautious attempt to deliver with forceps. Should moderate 
 tractions fail to advance the head, perforation and extraction with che 
 cranioclast should be resorted to. 
 
 VII. Pelves deformed by Osteomalacia. 
 
 Osteomalacia is almost confined to females, and appears, ordinarily, 
 in the puerperal state. It usually attacks fully developed bones, but 
 may, rarely, affect them during their period of growth. It is gener- 
 ally observed in multipara?, although primipara? are in exceptional cases 
 
 * ScHROEDER, Lehrbiich, p. 582. 
 
 f ScHARLAU, Monatsbchr. f. Geburtsk., Bd. xxvii, 1866, p. 1. 
 34
 
 530 
 
 THE PATHOLOGY OF LABOR. 
 
 Fig. 218.— Osteomalacia. (Specimen 
 from Woofl's Museum.) 
 
 its victims. Each succeeding pregnancy is usually attended by a pro- 
 gressive development of the disease, which may, however, become non- 
 progressive, or even be completely and permanently arrested.* In a 
 case of this kind the bone is restored to its normal histological state, al- 
 though its deformity remains. Osteomalacia may involve the entire 
 osseous system, or be confined to individual bones. In the latter case 
 
 the long bones and the vertebras 
 are most frequently diseased, f In 
 puerperal osteomalacia the pelvis 
 and the vertebra? are predominantly 
 and often exclusively affected. The 
 disease is regarded as an osteomye- 
 litis, which, beginning in the center 
 of bones, advances toward their pe- 
 riphery. The essential pathological 
 process consists in the absorption 
 of calcareous matter, through the 
 Haversian canals, and in the sub- 
 stitution of hypertrophic medullary 
 tissue for the softened osseous struct- 
 ures. The natural result of the 
 changes is great friability or pli- 
 ability of the bones, according to 
 the stage reached by the disease, and their consequent distortion by 
 compression or traction. The bones are of very light weight. Their 
 transverse section reveals a porous, diploe-like structure. Their outer, 
 hard lamella is exceedingly thin, or entirely absent. The bones are 
 of a wax-like softness, being readily cut and molded. The term rub- 
 ber or elastic pelvis has been applied to those pelves whose bones 
 have reached this stage of degeneration. In the most advanced cases 
 the osseous tissue is represented merely by membranous sacs of peri- 
 osteum inclosing medullary tissue and fat. 
 
 Morbid Anatomy. — The osteomalacic pelvis presents the following 
 pathological anatomical features : The sacral lateral masses are very 
 narrow, and the entire bone, which is displaced downward between the 
 ilia, is sharply curved. The promontory is accordingly deeply do- 
 pressed and approximated to the symphysis as well as to the apex of 
 the sacrum, which is itself displaced forward and curved upward. The 
 promontory and the apex of the sacrum may, in marked cases, almost 
 touch each other. The ilia are placed almost vertically. Their crests 
 are elongated and sharply curved. The anterior superior spinous pro- 
 cesses are approximated. The posterior superior spinous processes are 
 in the same plane with the posterior surface of the last lumbar spinous 
 
 * WiNCKEL, Monatsschr. f. Geburtsk., Bd. xxiii, 1864, p. 321. 
 f LiTZMANN, Die Formen des Beckens, Berlin, 1861.
 
 RARE FORMS OF PELVIC DISTORTION. 53I 
 
 process. The iliac fossa is divided, near its middle, by a vertical fur- 
 row, which may be bifurcated at its lower end. A prominence corre- 
 sponding to either acetabulum encroaches more or less upon the pelvic 
 canal. In grave cases these prominences may even come in contact 
 with the promontory. The pubic bones are in close apposition, and 
 the pelvic inlet is consequently pointed anteriorly, while the symphysis 
 is prominent and sharply angular. The ascending rami of the ischia 
 and the descending rami of the pubes are apj)roximated, and the sub- 
 pubic arch is partly or completely abolished. The tuberosities of the 
 ischia are approximated. The deformities described may be asym- 
 metrical. The pelvic canal is greatly narrowed, the outlet usually 
 suffering more distortion than the inlet. The pelvic inlet and canal 
 are of triangular form, and assume, in the highest grades of the dis- 
 ease, the shape of the letter Y. The transverse diameter is always 
 contracted, and its shortening is more marked as the outlet is ap- 
 proached. The approximation of the ischial tuberosities and of the 
 pubic bones, together with the anterior displacement of the apex of the 
 sacrum, sometimes ahnost obliterates the outlet. 
 
 Etiology. — The etiology of this pelvic deformity may be divided 
 into — 1. That of the original disease ; and, 2. That of the resulting 
 distortions. 1. The causes of osteomalacia are obscure. Cold and 
 damp dwellings, insufficient air and light, inadequate aliment, and ex- 
 posure are cited as exciting causes ; * but it seems probable that these 
 alone are insufficient etiological agencies unless some undetermined 
 predisposing cause be already in operation. The disease is sometimes 
 observed to assume an endemic form, particularly in countries where 
 the above-mentioned exciting causes prevail, as, for instance, in the 
 Rhine provinces and in some parts of Italy. In the United States it 
 is only observed in isolated cases, usually in persons of foreign birth. 
 2. The immediate causes of the distortions are found (a) in the altered 
 structure of the bones, and (b) in the various forces acting mechani- 
 cally upon them, (a) The lime-salts, which impart stability to normal 
 bones, are greatly diminished. Although it is not definitely known 
 by what emunctories they are removed, it is probable that they are 
 chiefly excreted by the kidneys. Gusserow states that the proportion 
 of lime-salts in the milk of women suffering from osteomalacia is ab- 
 normally large.f Pagenstecher opposes this view.J (b) Tlie distor- 
 tions are chiefly produced, when once softening of the bones has oc- 
 curred, by the muscular traction and by the pressure exerted upon the 
 pelvic walls. This pressure will vary in direction and intensity with 
 the different positions assumed by the patient. If the dorsal decubitis 
 be long maintained, the sacrum is displaced forward and the ilia are 
 
 * Hennio, Arch. f. Gynaek., Bd. v, 1873, p. 519 ef seq. 
 
 t Gusserow, Monatsschr. f. Geburtsk., Bd. xx. 1803, p. 19. 
 
 } Pagenstecher, Monatsschr. f. Geburtsk., xix, 1SG2, p. 128.
 
 632 
 
 THE PATHOLOGY OF LABOR. 
 
 folded upon themselves, so that a vertical furrow traverses the iliac 
 fossae. In the erect position the sacrum is forced downward and for- 
 ward, dragging with it the posterior parts of the ilia, and increasing 
 the bend in the iliac fossa. The same effect is produced by the upward 
 and backward pressure exerted upon the acetabula by the femoral 
 heads. In the lateral position the ilia are forced inward, and the 
 transverse pelvic diameter is thus diminished. In the sitting posture 
 the apex of the sacrum and the tubera ischii are forced upward. The 
 deviations referred to above result from excess of pressure in some 
 given direction, or from unequal jn-ogress of the disease in the various 
 bones. 
 
 Diagnosis. — In the earlier stages the history of violent pains in the 
 pelvis and lower extremities will direct attention to the existence of 
 osteomalacia, and careful mensuration will reveal beginning distortion. 
 Pelvimetry is most satisfactorily performed during anaesthesia, which 
 permits the introduction of the entire hand within the pelvis. If the 
 disease be more advanced the diagnosis will be based upon the above- 
 mentioned morbid anatomical features, chief among which are the 
 prominent pointed symphysis, the parallel pubic rami, the approxima- 
 tion of the tubera ischii, the accessibility of tlie i)romontory to palpa- 
 tion, the curvature of the sacrum, and the folding of the ilia. 8pie- 
 gelberg insists on the value of the pliability of the pelvic bones as an 
 aid to diagnosis.* The pliability, although slight during pregnancy, 
 is more marked in labor. Its first sign is great sensitiveness to jiress- 
 ure over tlie symphysis.! Its grade can be decermincd by the method 
 recommended for pelvic measurements. 
 
 Prognosis. — The prognosis for the mother is very bad. The ma- 
 jority of patients succumb to the effects of pressure in labor, to the 
 results of operative interference, or to the exhaustion attending the 
 almost invariably progressive disease. Amelioration of the symptoms 
 and signs sometimes occurs when conception does not recur. In very 
 exceptional cases not only may the pathological process be arrested 
 but the normal histological character of the bone restored, (a) Even 
 in such cases, however, the pelvic deformity remains unaltered, and 
 would sadly cloud the prognosis if conception should recur. The 
 prognosis for the child is more favorable. In the beginning of the 
 disease, and in cases of pliable pelvis, the child maybe born uninjured. J 
 In more advanced cases a fair prospect of preserving its life is afforded 
 by a resort to the Cesarean section. 
 
 The treatment will depend upon the results of a careful exploration 
 
 * Spiegelbercj, Lehrbuch, p. 480. 
 
 t WiKCKEL, Monatsschr. f. Geburtsk. Brl. xxiii, 18G4, p. 81. 
 
 X Kezmarszky, Arch. f. Gynaek., Bd. iv, 1872, p. 537 ; Fasbexder and Plxlex, 
 Monatsschr. f. Geburtsk., Bd. xxxiii, 18G9, p. 177; Breslau, Jbid, Bd. xx, 18(52, p. 
 353; ScHiECK, Jbid., Bd. xxvii, 1863, p. 178; Winckel., iitrf., Bd. xxiii, 18G4, p. 81.
 
 RARE FORMS OF PELVIC DISTORTION. 
 
 >33 
 
 of the pelvic space. This should determine, first, whether it is possi- 
 ble to extract a living child through the natural passages ; or, second, 
 where that is out of tlie question, whether it is possible to deliver after 
 craniotomy. In estimating the chances it will be necessary to take 
 into consideration the pliability of the pelvis, it having been found 
 possible in many case§ of advanced softening to open up the pelvic 
 canal with the hand and deliver by version. Lazzati and Casati, in 
 Milan, found it was only necessary to perform Ctesarean section twice 
 in sixty-two cases. Litzmann in 1857 reported forty Cajsarean sec- 
 tions in eighty-five cases; fifteen years later Hugenberger reported 
 but four Csesarean sections in twenty-five cases (Spiegelberg). Lately 
 Porro's operation has been proposed by Levy in osteomalacia as a cura- 
 tive measure ; but of this further experience is necessary. 
 
 Pseudo-Osteomalacia. — It is possible for a rachitic pelvis, in which 
 the rachitic changes are excessive, to present a shape similar to that in 
 osteomalacia. This form is, however, distinguishable from the latter 
 through the hardness of the bones, their smaller size, the greater dis- 
 tance between the anterior superior spinous processes, and the traces 
 of rickets in other parts of the skeleton. 
 
 VIII. Pelves deformed by Exostosis, or by Osseous Tumors. 
 
 Fractures of the pelvic bones may be the source of pelvic deform- 
 ity, either by producing permanent displacement of the bones, or by 
 leading to such extensive deposits of 
 callus as to obstruct the parturient 
 canal. 
 
 Multiple exostoses of the pelvic 
 bones are of comparatively frequent oc- 
 currence, and are usually attended by 
 multiple exostoses of the entire osseous 
 framework.* The pelves in which they 
 are foiind are, as a rule, either of the 
 oblique-ovate or of the rachitic variety, 
 and the combination of these deform- 
 ities is naturally a serious one, since 
 the maternal soft parts are liable to con- 
 tusion and perforation at many points 
 during parturition. The ilio-pectineal 
 eminence is sometimes so unusually 
 prominent and sharp as to offer an 
 obstacle to parturition. The same is 
 
 true of the pubic crest and spine. Osteo-fibromata, sarcomata, en- 
 chondromata, and carcinomata connected with the pelvic bones con- 
 
 * Leopold, Arch. f. Gynaek., Bd. iv, 1873, p. 336 ; Kormann, Ibid., Bd. vi, 1874, 
 p. 473. 
 
 219.— Osseous tumors filling pelvic 
 cavity. (Naegele.)
 
 534 THE PATHOLOGY OF LABOR 
 
 stitute tumors of rare occurrence. They usually spring from the 
 sacrum or from the symphysis,* and are of various dimensions. 
 Some of them almost completely conclude the parturient canal, and 
 may constitute formidable obstructions to delivery. 
 
 In this connection may be mentioned as of rare occurrence anch}-- 
 losis of the coccyx, a condition which materially shortens the antero- 
 posterior diameter of the outlet. 
 
 IX. Absence of the Symphysis. 
 
 In this variety of deformed pelvis the symphysis is congenitally 
 absent, and is replaced either by strong fibrous bands extending be- 
 tween the opposing surfaces of the pubic bones, or by the muscles and 
 connective tissue of the perinaeum. It is accordingly designated by 
 Litzmann the split pelvis, f 
 
 Morbid Anatomy. — It is usually attended by ectopia vesicae and by 
 hiatus of the abdominal wall in the linea alba. In rare cases an ab- 
 dominal hiatus exists without a corresponding opening in the bladder. 
 If the split be located immediately below the symjjhysis, the urethrals 
 involved rather than the bladder, and is sometimes so defective that 
 cystocele may occur through the abnormal opening in its anterior wall. J 
 Both the external and internal organs of generation are imjjorfectly 
 developed. If the anterior wall of the urethral canal be absent, the 
 mucous membrane of the fundus vesicae is directly continuous with 
 that of the vaginal orifice. In other cases the bladder is only sepa- 
 rated from the vulva by a narrow bridge. Tlie vulva and anus are 
 often situated more anteriorly than normal, and the perinaeum is thus 
 diminished in thickness. The clitoris is bifurcated or absent, the 
 nymphfe are imperfectly developed, and the defective labia majora 
 widely separated. The vagina may be imperforate or partially oc- 
 cluded by a transverse septum. The uterus may be double and the 
 ovaries rudimentary.* In a case reported by "Winkler, separation of 
 the pubic bones had occurred at the symphysis, as the result of an 
 accident in early life, and they were only connected by bands of fibrous 
 tissue.! The sacrum of a split pelvis is displaced forward between the 
 ilia, its vertical and transverse curvature diminished, and its length 
 increased. The iliac fossfe are widely separated. The entire pelvis 
 is greatly flattened antero-posteriorly, and strongly resembles the 
 rachitic pelvis. 
 
 Etiology. — The cause of the existing deformity is found in the 
 
 * Harris, Am. Jour, of Obstet., vol. iv, 1872. pp. 633, 645 ; Braun, Monatsschr 
 f. Gebuitsk., Bd. xxi, 1863, p. 311. 
 
 t Litzmann, Die Formen dcs Beckons. Berlin. 1861. 
 
 t Kleinwachter, Monatssclu-. f. Gebiirtsk., Bd. xxxiv, 1869, pp.81 el seq. 
 
 * LiTZMAX.v, Arch. f. Gynack., B 1 iv. 1872. p. 272. 
 II Winkler, Arch. f. Gynaek., Bd. i, 1870, p. 346.
 
 ABNORMALITIES OF THE SEXUAL ORGANS. 535 
 
 inurejiised pressure to which the lateral pelvic walls are subjected owing 
 to the absence of the symphysis. The natural resistance to the sepa- 
 ration of the lateral pelvic parietes offered by the normal symphysis 
 being wanting, the weight of the superimposed trunk naturally forces 
 them apart posteriorly, while the pressure of the femora bends them 
 inward anteriorly. In some instances anchylosis of the sacro-iliac 
 joints occurs, as a consequence of an arthritis resulting from the in- 
 creased pressure thrown upon them by the lateral displacement of the 
 ossa innominata.* In other cases sacro-iliac synostosis is not present, 
 but the firmness of the pelvis is, nevertheless, such as to admit of un- 
 impeded locomotion. 
 
 CHAPTER XXVIII. 
 
 ABNORMALITIES OF THE SEXUAL ORGANS. 
 
 Atresia of the genital canal. — Vulvar atresia. — Vaginal atresia. — Cystoeele. — Recto- 
 cele. — Retention of urine. — Impacted calculi. — Vaginal hernias. — Cystic degen- 
 eration of the vaginal wall. — Vaginismus. — Echinococci. — Uterine atresia. — 
 Conglutinatio orificii externi. — Cicatrical atresia. — Rigidity. — Thrombus of the 
 cervix. — Symptoms of atresia. — Note on treatment. — Tumors, — Fibroids. — Can- 
 cer. — Ovarian tumors. 
 
 Atresia of the Genital Canal. Obstruction of the Gen- 
 erative Passages by Morbid Processes in Neighboring 
 Tissues. 
 
 I. Vulvar Atresia. — The term atresia., as here employed, implies 
 either partial or complete obstruction of the genital canal. 
 
 Atresia of the hymen is of more frequent occurrence ' than any 
 other variety of vulvar stenosis. f Unless unusually thick and rigid, 
 however, the atresia offers only a trifling obstruction to delivery. Its 
 chief importance is owing to the fact that it leads, in the unimpreg- 
 nated state, to retention and accumulation of the menstrual fluid, which 
 may occasion serious inflammatory, septic, or reflex nervous phenomena. 
 Adhesions of the labia majora and minora constitute other forms of 
 incomplete vulvar atresia. Their causes are often ulcerative processes 
 resulting from injuries, or developed during the course of variola and 
 other constitutional diseases. Under these circumstances they may 
 consist of unyielding cicatricial tissue, which either ruptures in labor, 
 or, forcing the head backward, leads indirectly to the exertion of 
 injurious pressure upon the recto-vaginal septum or upon the peri- 
 
 * Freund, Arch. f. Gynaek., Bd. iii. 1872. pp. 398, 406. 
 
 f Jexks, Atresia of the Generative Passages of Women, Chicago Med. Jour, and 
 Examiner, September, 1880, p. 4.
 
 536 
 
 THE PATHOLOGY OP LABOR. 
 
 ngeum. If the atresia be congenital, and not the result of cicatricial 
 changes, it will rarely constitute an impediment to parturition. When 
 the entrance to the vagina is very narrow, without exhibiting any 
 pathological condition, as is often the case with aged primipar*, it 
 may be extensively lacerated in labor. A rigid perinaeum is also well 
 known to constitute a serious impediment to the normal progress of 
 parturition. (Edema of the vulva, usually attendant upon albumi- 
 nuria, produces atresia, and the oedematous labia and perinaeum may 
 become gangrenous from excessive pressure during labor. Vulvar 
 hsematoma, or thrombus, if formed, as it rarely is, before delivery, 
 likewise obstructs the outlet of the parturient canal. A similar effect 
 is produced by cancers and polypi of the vulva, which are, however, 
 not often of sufficient size to occasion serious difficulty. 
 
 II. Vaginal Atresia. — This variety of stenosis of the generative 
 passages is either congenital or accidental, complete or incomplete. 
 
 (a) The congenital form may be either incomplete, in which case 
 the stenosis sometimes affects the entire length of the vagina, and 
 sometimes forms a circumscribed ring-like stricture,* or it may be com- 
 plete. In either case the atresia is due to arrested embryonic develop- 
 ment, which, in the latter instance, must have originated at a very early 
 period of fetal life. Congenital narrowing of the vagina independent 
 of any morbid process or any arrest of development is often observed, 
 but is of trifling consequence, being overcome by the hypertrophy and 
 relaxation accompanying pregnancy, and by the natural expulsive 
 forces. Absence of the vaginal canal does not necessarily imply ab- 
 sence or imperfect development of the uterus. Fallopian tubes, or 
 ovaries. 
 
 (b) Accidental vaginal atresia may be either complete or partial, 
 but is ordinarily of the latter form. Both varieties result from the 
 cicatrization following superficial or deep ulceration produced by con- 
 stitutional diseases or by local injury. The diseases during the course 
 of which vaginal ulceration occurs are chiefly diphtheria, variola, ty- 
 phoid fever, cholera Asiatica, and syphilis. The mechanical injuries 
 productive of vaginal stenosis are mainly those incident to protracted 
 labors, to the unskillful employment of instruments, or to the improper 
 performance of obstetrical operations ; but caustic local applications, 
 pessaries, excessive coition, or any local irritant of sufficient intensity 
 to produce ulceration, may lead to the same result. In consequence 
 of impaired vitality, ulceration and stenosis of the vagina may follow 
 normal labors unattended by any injurious pressure. Complete acci- 
 dental vaginal atresias are produced, as a rule, by grave mechanical 
 injuries, but may also follow the acute infectious diseases enumerated 
 above, although the ulcerations attending the latter usually lead to only 
 partial stenosis. 
 
 * ScHROEDER, Lehrljuch, Gte Aufl., p. 491.
 
 ABNORMALITIES OP THE SEXUAL ORGANS. 537 
 
 Mention may properly be made, in this connection, of various mor- 
 bid conditions involving tissue adjoining the vagina and resulting in 
 diminution of its caliber. 
 
 Simple prolapse of the anterior vaginal wall sometimes occurs,* 
 and, assuming an oedematous condition owing to the obstruction of its 
 circulation, decidedl}- constricts the parturient canal. Cystocele fre- 
 quently accompanies the prolapse of the anterior vaginal wall. If the 
 bladder be distended with urine, the cystocele presents a tense fluctu- 
 ating tumor of sufficient size to completely occlude the vagina. The 
 subjective symptoms of this condition are intense pain with vesical 
 tenesmus and dysuria. In some cases the cystocele is retracted by the 
 longitudinal cervical contractions, or it may be forced still farther 
 downward by the advancing foetus, producing obstructed labor and 
 even ruptute of the vesico-vaginal septum. 
 
 Prolapse of the posterior vaginal wall with rectocele produces 
 vaginal stenosis, especially if the rectum be filled with impacted feeces. 
 This condition is easily recognized by the characteristic feeling of the 
 fecal mass, which admits of indentation by the palpating finger. 
 
 Retention of urine becomes oftentimes a grave complication of 
 parturition, in that the distended bladder, by displacing the uterine 
 axis, prevents the jjresenting part from engaging in the superior strait. 
 The pressure it exerts upon the uterus also interferes with the efficient 
 contraction of that organ. The diagnosis is based upon the presence 
 of a tumor near the uterus, and often situated laterally from it, which 
 disappears as the urine is withdrawn through a catheter. The intro- 
 duction of the latter is often extremely difficult, owing to the com- 
 pression of the urethra and the retraction of the meatus urinarius 
 within the vagina. 
 
 Vesical calculi, if of any considerable magnitude, seriously obstruct 
 the caliber of the vagina by becoming impacted in the base of the 
 bladder, the urethra, or a cystocele, between the foetus and the pelvic 
 walls. Under these circumstances not only is the labor obstructed, 
 but contusion and rupture of the soft parts, resulting in vesico-vaginal 
 fistula, may ensue. 
 
 Impacted calculi have sometimes been mistaken for exostoses ; f 
 but attention to the fact that they are immovable during the pains 
 and movable in the intervals, together Avith the use of the vesical 
 sound, will prevent this error. 
 
 Vaginal hernia consists of a sac formed by the protrusion of the 
 vaginal wall, lined with the parietal peritonaeum and containing some 
 of the abdominal or pelvic viscera. The organs usually present in the 
 sac are coils of the small and large intestine, the middle portion of 
 the rectum with its elongated meso-rectum, parts of the omentum, 
 
 * Benicke, Ztschr. f. Geburtsh. u. Gynaek., Bd. ii, Heft 2, 1878, p. 250. 
 •f ScHROEDER, Lohrbuch, Ote Aufl., p. 500.
 
 538 
 
 THE PATHOLOGY OF LABOR. 
 
 portions of the urinary bladder, and sometimes blood, Avitli various 
 products of peritoneal inflammation. The location of the hernia is 
 usually in the posterior vaginal wall, although it may insinuate itself 
 between the uterus and the bladder, and, descending, produce hernia 
 of the labia majora. Perineal hernias are formed by hernial sacs 
 which pass behind the ligamentum latum and distend the jaerinaeum. 
 The intestinal vaginal hernia is the most important variety, inasmuch 
 as it may not only obstruct labor, but may itself become incarcerated 
 or strangulated, thus leading to symptoms of the gravest import. 
 The diagnosis, which can be rendered very probable by palpation per 
 vaginam, is made certain by a rectal examination. 
 
 Vaginal neoplasmata, the most important of which are carcinomata 
 and fibromata, are rare sources of vaginal stenosis, as is likewise 
 thrombus of the vagina. Slight obstruction to labor may result from 
 a pathological condition of the vaginal mucous membrane described 
 by Winckel,* under the title colpohyperplasia cystica, and consisting of 
 the development in the mucous membrane of numerous small and 
 closely aggregated flattened cysts. The cysts are believed to be pro- 
 duced by the distention of glandular depressions in the mucous 
 membrane with mucus, which, according to Zweifel,f eventually pro- 
 duces trimethylamine gas by decomposition. Others consider the loca- 
 tion of the gas to be in the interstices of the submucous connective 
 tissue. J 
 
 Vaginismus is rarely a cause of vaginal stenosis in labor, inas- 
 much as it is itself a cause of sterility. It has, however, been found 
 in certain instances to constitute so serious an obstacle to delivery as 
 to necessitate operative interference. In a recent instance in my own 
 practice the spasmodic contraction of an unusually developed levator- 
 ani muscle — -a spasm which was uncontrolled by complete chloroform 
 anassthesia — rendered forceps necessary. After prolonged effort extrac- 
 tion was accomplished, but the head was enormously elongated. The 
 child died of tetanus a few days after birth. In double vagina tlie 
 septum is sometimes a source of slight vaginal atresia. 
 
 Intrapelvic echinococci constitute a rare cause of vaginal constric- 
 tion. Wiener * collected seven cases of pelvic echinococci, most of 
 which occupied the loose connective tissue between the vagina and 
 rectum. The leading symptoms due to their presence during preg- 
 nancy were deep-seated traction in the pelvis, severe pain, vesical 
 tenesmus, dysuria, and constipation. Menstruation was undisturbetL 
 The tumors were, with one exception, so large as to completely ob- 
 struct the vaginal canal, rendering operative interference necessary- 
 
 * Winckel, Arch. f. Gynaek, Bd. ii, 1871. pp. 383, 406. 
 t ZwEiFEL, Arch. f. Gynaek., Bd. ix, p. 39. 
 
 X RuGE, Arch. f. Gynaek., Bd. ix, p. 465. 
 
 * Wiener, Arch. f. Gynaek., Bd. vi, p. 573.
 
 ABNORMALITIES OF THE SEXUAL ORGANS. 539 
 
 In one instance the contraction, from cicatrization of the hydatid cyst 
 following puncture, was so extensive as to produce vaginal stenosis. 
 Hydatids may be mistaken for exostoses of the bony pelvis, for ha3ma- 
 tocele, malignant intrapelvic tumors, pelvic abscesses, or cellulitis. 
 Their differential diagnosis is based uj)on the presence in the pelvis 
 of smooth, tense tumors not connected with the uterus, the gradual 
 development of the tumors without constitutional sym2)toms of any 
 gravity, the presence of similar tumors in other organs, particularly in 
 the liver, the hydatid thrill, which is not often observed on account 
 of the strong pressure to which the cysts are exposed, and, finally, 
 upon the examination of the cystic fluid. 
 
 III. Uterine Atresia. — Uterine atresias, which occur less frequently 
 than those of any other portion of the genital passages,* may be con- 
 genital or accidental, partial or complete. Complete atresias, observed 
 in parturition, have become so during pregnancy, since conception 
 would not otherwise have occurred. 
 
 Conglutinatio orificii externi, or adhesion of the lips of the os ex- 
 ternum, is occasioned by the superficial union of the opposing mu- 
 cous surfaces through the medium of inspissated epithelium or of new 
 connective tissue resulting from adhesive inflammation produced by 
 vaginitis or cervical endometritis. Schroeder f regards these atresias 
 as always incomplete, and seeks their origin in the gradual indu- 
 ration of tissues immediately surrounding the os, resulting from old 
 inflammatory processes. According to his views, this pathological con- 
 dition consists of deficient expansibility and not of real contraction 
 of the OS externum. On examination no marked induration of the 
 cervix is felt. The os externum is hardly perceptible to the touch, 
 and can often only be discovered by inspection. If the examination 
 be made during the first stage of labor the internal os is found widely 
 dilated, while the os externum remains persistently contracted and 
 conveys a sensation to the palpating finger akin to that produced by a 
 narrow and tense rubber band. If the finger or an appropriate in- 
 strument be firmly pressed against the os during the pain, it slowly 
 yields and is gradully retracted by the longitudinal cervical contrac- 
 tions. In default of such simple interference the cervical tissues 
 above the os externum become enormously distended, and may finally 
 be ruptured. Zweifel I refers this peculiarly unequal dilatation of 
 the cervical canal to an abnormal presentation of the fetal cranium 
 and to a consequent local expansion of the anterior uterine wall. The 
 OS externum having been simultaneously forced backward into the 
 hollow of the sacrum, the yielding anterior uterine wall then forms a 
 diverticulum which contains the presenting fetal part, and no dilating 
 
 * Jenks, op. cif., p. 5. 
 
 f Schroeder. Lehrbnch, 6te Aufl., p. 487. 
 
 X Zweifel, Arch. f. Gynaek., Bd. v, 1878, p. 149.
 
 540 THE PATHOLOGY OF LABOR. 
 
 force is exerted upon the external os. Benicke* was unable to dis- 
 cover in his cases the posterior deviation of the os which is assumed 
 by Zweifel as the basis of his hypothesis. 
 
 Cicatricial atresia of the os externum is rarer than the adhesive 
 stenosis just described. It is usually confined to the lips of the ex- 
 ternal OS, but may involve the cervical canal for a varying distance. 
 Its most frequent causes are post-partum ulceration, inflammation, 
 cauterization of the cervix, and mechanical irritation applied for the 
 purpose of producing abortion. The diminution of the uterine dis- 
 charges during pregnancy affords a favorable ojiportunity for the de- 
 velopment of the stenosis under consideration. If cicatricial atresia 
 exist, the os externum remains undilated in labor, the cervix becomes 
 immensely distended, and may even rupture, unless the os be dilated 
 by artificial means. The diagnosis rests upon the discovery, usually 
 easily made, of the cicatrized os externum. Should the latter have 
 retreated into the hollow of the sacrum, the diagnosis may only be 
 accomplished with difficulty, or the expanded cervical tissues be mis- 
 taken for the fetal membranes. This error is avoided by the discovery 
 of the direct continuity of the vaginal wall and the supposed mem- 
 branes, and by inspection through a proper speculum. 
 
 Abnormal rigidity of the os externum is often encountered in mul 
 tiparae as the result of genuine cicatricial processes or of fibrous hy- 
 pertrophy. This condition is especially observed in connection Avith 
 prolapse of the uterus. A similar rigidity in aged primiparse is due 
 to atrophic degenerative changes in the cervical tissues, or to hyper- 
 trophy of the portio vaginalis, f 
 
 I have met in my own practice witli an instance of atresia of the os 
 internum and of the adjacent structures, the result of cicatrices from a 
 former labor. At the time I first saw her the patient had been several 
 days in labor, and the waters had escaped ; she had a temperature of 
 102°, and was delirious from pain and exhaustion. While preparing 
 to perform the Caesarean section, rupture of the uterus suddenly oc- 
 curred, and the patient died in a few hours. 
 
 Haemorrhages occurring into the hypertrophied cervical tissue are 
 distinguished as cervical thrombi, and constitute obstacles to delivery. 
 The retraction and dilatation of the cervix may, further, be obstructed 
 by adhesions in the lower segment of the uterus between the decidua 
 and the chorion. 
 
 Acute elongation of the anterior lip of the os externum, in conse 
 quence of its incarceration between the foetus and the bony pelvis, and 
 of the resulting cedema of its tissues, is referred to by Ilirte I as a rare 
 but serious obstacle to delivery. 
 
 Parturition is sometimes delayed by double uterus. The obstruc- 
 * Benicke, op. cif., p. 252. f Benicke. op. ciL, p. 240. 
 
 X HiBTE, Arch. f. Gynaek.. Bd vii, 1875, p. 552.
 
 ABNORMALITIES OF THE SEXUAL ORGANS. 54I 
 
 tion may ia this instance be jDroclucetl by an hypertrophied unimpreg- 
 nated horn of the uterus.* Again, the oblique position of tlie im- 
 pregnated horn may produce abnormal presentations f or materially 
 interfere with the efficiency of the pains. 
 
 The uterine atresias produced by carcinomata, fibromata, and ova- 
 rian tumors are considered in another chapter. 
 
 Symptoms of Atresias of the Genital Canal. — The principal symp- 
 toms of atresia in the unimpregnated state relate to the jjartial or 
 complete retention of the menstrual fluids. If the stenosis be com- 
 plete the uterus is enlarged and fluctuating, while severe uterine pains 
 attend each monthly period. J The Fallopian tubes are dilated. Some 
 of the retained and decomposed menstrual fluid may be forced through 
 the tubes into the peritoneal cavity, producing serious or fatal joerito- 
 nitis. The mere dilatation of the uterus may become so excessive as 
 to produce peritonitis.* Septic poisoning is sometimes induced by 
 absorption of putrescent materials from the uterine cavity. A symp- 
 tom often serving to attract attention to the existence of abnormal 
 vaginal contraction is inability to perform the sexual act. 
 
 The most prominent symptom of atresia during parturition con- 
 sists, in general terms, of mechanical obstruction to delivery, which is 
 more or less serious in proportion to the degree of existing stenosis. 
 The special symptomatology of the individual pathological conditions 
 productive of atresia has been considered in connection with their 
 respective anatomical characters. 
 
 Note. — Atresias for the most part require to be treated each by itself, according 
 to the principles of surgical art,. In p. paper by Professor 1. E. Taylor, in the 
 fourth volume of the Transactions of the American Gynascological Society, entitled 
 Atresia of the Vagina. Congential or Accidental, in the Pregnant or Non-pregnant 
 Female, the author relates a case of seemingly complete imperforation of the vagina 
 complicating labor, where he succeeded, by scraping with the finger-nail during the 
 pains, in passing the index-finger through the intervening membrane to the child's 
 head, and eventually in securing an opening large enough for the birth to be ac- 
 complished. I had previously reported two similar cases, one in the New York 
 Medical Journal, and one to the Obstetrical Society. || The first, where I was aided 
 by Professor Fordyce Barker, occurred in Bellevue Hospital, and the second in 
 private practice. In both, similar success followed a gradual dissection of the 
 A'aginal walls with the finger. In such cases usually a depression, or a thinned 
 point in the tissues, indicates the direction to be followed. C. Braun states, how- 
 ever, that he has seen three cases where vesico-vaginal fistulns were produced by 
 this tunneling process, an admonition to extreme caution in its performance.^ For 
 stenoses of the vagina, dilatation should be employed, either by means of compressed 
 
 * MuLLER, Arcli. f. Gynaek.. Bd. v. 1873, p. 1.33. 
 t ScHATZ, Arch. f. Gynaek., Bd. ii, 1871. p. 2D7. 
 
 t DoHRN, Arch. f. Gynaek., Bd. x, 1876, p. 544; I. E. Taylor, Atresia of the 
 \"agina, Trans, of the Am. Gyna?e. Soc, vol. ix, 1880, pp. 9, 12. 
 
 # I. E. Taylor, loc. cit., p. 16. 
 
 II Trans, of the New York Obstet. Soc, vol, i, p. 44. 
 
 •^ I>RAUN VON Fernwald, Lehrbuch der gcsammt. Gynaek., p. 273.
 
 542 THE PATHOLOGY OF LABOR. 
 
 sponges, the tampon of slippery-elm (Skene), or the water-bag. When dilatation is 
 already well advanced, incisions may be used to aid in completmg the process. 
 
 Uterixe Tumors complicating Pregnancy, Parturition, and 
 THE Puerperal State. 
 
 I. Uterine Myomata.— 1. In Pregnancy.— Becmse of the disposi- 
 tion of uterine myomata to produce sterility, they naturally constitute 
 comparatively infrequent complications of pregnancy. They are sub- 
 divided, according to their location, into subperitoneal, interstitial, 
 and submucous myomata. The presence of either variety diminishes 
 the probability of conception, but none absolutely precludes the possi- 
 bility of its occurrence. In most instances, myomata produce no 
 symptoms during pregnancy, and do not disturb labor. 
 
 Subperitoneal myomata prevent conception and interrupt utero- 
 gestation only when they attain large dimensions, and their prejudicial 
 influence is then usually referable to the uterine retroversions or retro- 
 flexions which they induce. Interstitial myomata are more likely than 
 the preceding variety to occasion abortion or premature delivery, either 
 by producing uterine flexions, or by acting as the exciting cause of 
 haemorrhages, which are more severe when the placenta is located over 
 the site of the tumor. This statement applies particularly to post- 
 partum haemorrhages, inasmuch as the muscular atrophy induced by 
 the moyma prevents the ready and complete closure of the uterine 
 sinuses. 
 
 Submucous myomata rarely permit of conception, which, in the 
 event of its occurrence, is almost uniformly followed by abortion, due 
 usually to metrorrhagia. In cervical myomata, however, pregnancy 
 may progress to its normal termination. Myomata ordinarily partici- 
 pate in the uterine hypertrophy of pregnancy, becoming at the same 
 time softer and more succulent. This change in consistence, which is 
 referred to increased vascularity, to colloid transformation, and to serous 
 infiltration, is attended by dilatation of the lymphatics, Avhich may lead 
 to the formation of cysts. The softened tumor readily undergoes 
 changes of form under the influence of increasing intrapelvic pressure 
 and of uterine traction. It may become so flattened that it ceases to 
 be recognizable as a tumor, but regains its earlier shape after delivery. 
 
 The diagnosis of uterine myomata, particularly of the interstitial 
 and submucous varieties, is often attended during pregnancy by diffi- 
 culty, inasmuch as their symptoms and signs are obscured by those of 
 pregnancy. On the other hand, the existence of myomata may pre- 
 vent the recognition of pregnancy. Fibrous tumors may be mistaken 
 for fetal organs or for intra-uterine cystic tumors. Careful palpation 
 by the combined method with two fingers in the vagina, or the half 
 or entire hand in the rectum if necessary, should be employed to make 
 out the shape, position, and consistency of the suspected growth. As
 
 ABNORMALITIES OP THE SEXUAL ORGANS. '543 
 
 a further aid to diagnosis, Landau recommends puncture through the 
 vagina, by means of which the presence or absence of fluid and the 
 density of the tissues penetrated can be determined. 
 
 2. In Parturition and the Puerperal State. — Uterine polypi act as 
 impediments to deKvery only when they are situated beside or in front 
 of the advancing child, and are possessed of considerable size and con- 
 sistence. If the tumor be small, movable, and yielding, it may occa- 
 sion trifling obstruction to parturition, and may even be exj)elled by the 
 advancing foetus, after rupture of its pedicle. 
 
 Interstitial myomata, when corporeal, constitute impediments to de- 
 livery only when located in the lower segments of the uterus. Even 
 when thus situated, they often spontaneously recede from the pelvic 
 cavity under the influence of the longitudinal uterine contractions. 
 By exerting traction on the uterine parietes they aggravate the sever- 
 ity of the pains, and sometimes produce rupture of the uterine wall, in 
 which their growth has already determined atrophic degeneration. By 
 interfering with symmetrical uterine contraction, interstitial myomata 
 render the pains irregular and inefficient, besides predisposing to ante- 
 and particularly to post-partum haemorrhage. By altering the form of 
 the uterine cavity and preventing the engagement of the head in the 
 superior strait, this variety of myoma frequently produces abnormal 
 positions and presentations. In a case of my own eclampsia resulted 
 apparently from the same set of causes as those which obtain in multi- 
 ple pregnancy. They also predispose to the development of retro- 
 flexions in the puerperal state. When interstitial myomata are de- 
 veloped in the cervical tissues they almost invariably offer a mechanical 
 impediment to delivery, and are rarely capable of being displaced above 
 the superior strait. If, however, they have become intravaginal and 
 their base be not too extensive, they are often readily amenable to ap- 
 propriate surgical interference. In default of the latter, fatal com- 
 pression may be exerted upon the fetal cranium, or the vesico-vaginal 
 septum may be lacerated during labor. 
 
 Subserous myomata are ordinarily developed in the posterior uter- 
 ine wall. If connected with the body of the uterus and located above 
 the retro-uterine reflexion of the peritonaeum, they may be spontane- 
 ously extruded from the pelvic into the peritoneal cavity. They origi- 
 nate, however, most frequently in the cervical tissues, and, extending 
 downward, become retrovaginal, more or less completely occupy the 
 pelvic cavity, and offer, provided their size be at all considerable, an 
 insurmountable obstacle to parturition. This variety has been desig- 
 nated as the incarcerated uterine myoma. The prognosis is grave, a 
 fatal termination having been noted in one half of the mothers and 
 in two thirds of the children. 
 
 Treatment.— Myomata in most cases, it should be remembered, pro- 
 duce no symj)toms during i)regnancy, and do not disturb labor. If
 
 544 THE PATHOLOGY OF LABOR. 
 
 of small size, they may escape observation altogether. Their mere 
 presence, therefore, does not indicate ground for interference. As a 
 rule, it is well to observe a waiting policy until the need of assistance 
 becomes evident. 
 
 The induction of abortion where the tumor threatens to disturb 
 the later progress of pregnancy is a questionable expedient on account 
 of the tendency to profuse haemorrhage, and the difficulty of removing 
 the secundines. Dr. A. Kessler reported a case, which I saw with him 
 in consultation, where, after the expulsion of a four months' fcetus, it 
 was found impossible to reach the placenta. The latter occupied an 
 inaccessible position near the right cornu, far out of reach of the hand, 
 while the convexity of the tumor was so great as to interfere with the 
 working of ovum forceps or the curette. The patient died of septi- 
 c£emia. Kemoval of the uterus would possibly have saved her life. 
 
 Kaltenbach has reported a case where he performed the supravagi- 
 nal ampvitation of the uterus between the fourth and fifth months of 
 pregnancy, on account of myomata, the largest of wliieh weighed seven 
 pounds. They gave rise to unendurable pressure and to exhausting 
 hsemorrhages. The patient recovered. 
 
 T. Landau * has collected eighteen cases in wliich amputation of 
 the pregnant uterus has been performed, owing to disturbances pro- 
 duced by myomata. Of these, eleven recovered and seven ended fatally. 
 
 If the myomata are pedicled or subserous and of moderate size, their 
 removal during pregnancy by enucleation is justifiable if they threaten 
 complications. The prognosis is not unfavorable, for though in seven- 
 teen operations collected by Landau four patients died, one of these 
 had a large, broad-based multiple tumor, one suffered from nephritis, 
 and two occurred in the days of defective asepsis, hi two of the fatal 
 cases, and in four where recovery took place, abortion followed. If 
 myomata encroach upon or occupy the pelvic cavity, an attempt should 
 be made to raise them above the brim by sustained rectal or vaginal 
 pressure. 
 
 The most serious obstruction to the birth of the child is offered by 
 cervical and subserous myomata which encroach upon the pelvic space. 
 They are of rare occurrence. The treatment varies according to the 
 intra or extravaginal situation of the growth. In both instances, 
 where the child is living, operative interference should be postponed if 
 possible to end of pregnancy. 
 
 In the intravaginal form, room should be made for the exit of the 
 child by splitting the capsule and enucleating the myoma. Bleeding 
 from vessels should be controlled by compression forceps, and the 
 cavity should be filled, after the expulsion of the child, with iodoform 
 gauze. Even tumors of large size may be enucleated per vaginam if 
 
 * T. Landau, Zur Behandlnng derdurch Mrome Complicirten Schwangersehaft 
 und (xeburt. Klin. Vortrage, Neue Folge, No. 2G.
 
 ABNORMALITIES OF THE SEXUAL OEGANS. 545 
 
 they are first segmented {^^ mo7'cellement^'' of Pean), and are then re- 
 moved piecemeal. 
 
 Dr. P. F. Munde * has reported a case of pregnancy advanced to 
 the sixth month where an interstitial myoma of the anterior wall of the 
 nterus and of the cervix filled the pelvic cavity almost to the vaginal 
 orifice. After careful deliberation, Munde decided to remove the tumor 
 by enucleation. This he accomplished successfully ; the tumor weighed 
 three pounds. The foetus and placenta were then easily extracted. The 
 mother made a good recovery. Similar successes have been reported 
 by Schroeder, Grimsdale Danyon, and Braxton Hicks. Depaul enuc- 
 leated the morbid growth in the case of fibrous polypus, with a broad 
 attachment (six to seven centimetres) to the cervix. The patient died 
 two months later, but the tumor gave forth an extremely oifensive odor 
 at the time of the operation. 
 
 With small tumors it may be possible to extract the child first with 
 forceps or version, or after craniotomy, Chambazian reports twenty 
 forceps cases, in which twelve mothers and seven children were saved. 
 Of twenty version cases, only eight mothers and three children sur- 
 vived. But even then it is usually prudent to remove the tumor im- 
 mediately after the birth of the child, owing to the danger of septic 
 infection incident to the bruising of the tissues. Then, on checking 
 the h?emorrhage, the cavity should be filled with iodoform gauze. 
 
 Polypoid growths should be pushed back into the uterus, if pos- 
 sible, in cases where the pedicle is out of reach. When, however, the 
 tumor is shoved down in advance of the head, and the pedicle is ac- 
 cessible, it should be removed with the ecraseur or with scissors. 
 Chambazian f reports eight cases of extirpation performed during jDreg- 
 nancy, on account of haemorrhage, with one death, due not, however 
 to the operation, but to eclampsia. In eight cases of removal during 
 labor there was no death. 
 
 In pelvic obstruction due to extravaginal myomata the growth is 
 usually of cervical origin. As a rule, it develops in the pelvic con- 
 nective tissue behind the uterus, and is only roofed over by the peri- 
 tonaeum. As the Caesarean section or the Porro operation is indicated 
 in these cases of impaction, it is desirable, unless the symptoms due to 
 pressure are urgent, that interference should be postponed to the end 
 of pregnancy. 
 
 Sanger J collected forty-three cases of Cfesarean section complicated 
 by myomata. Of these, in thirty operations performed previous to 1874 
 but two recoveries were reported. Since 1874 there have been thirteen 
 operations, with five recoveries. Of these, in three cases — viz., in Tar- 
 nier's, Zweifel's, and Agnew's — the Porro method was followed, and all 
 
 * Munde, Am. Jour. Obstet., October, 1884, p. 1,061. 
 
 f Chambazian, Des fibromes du col de Tuterus, Paris, 1883. 
 
 I Sanger, Der Kaiserschnitt bei Uterus-Fibromen. 
 
 35
 
 546 THE PATHOLOGY OF LABOR. 
 
 terminated fatally. Of the ten cases in which the older method was 
 adopted, in five— viz., in those of Cazin, Cornelins Olcott, Martin, San- 
 ger, and Moses Baker — the patients recovered. In four of the five fatal 
 cases, the particulars are furnished in four. In that of Netzel, the 
 membranes ruptured three days before the operation ; in McCormack's, 
 the patient had been fifteen days in labor, and general peritonitis exist- 
 ed ; in T. G. Thomas's, the membranes had ruptured, and, previous to 
 operating, unsuccessful attempts at delivery had been made by means 
 of version, craniotomy, and embryotomy ; in Spiegelberg's, no contrac- 
 tion followed the section, and the patient died from exhaustion due to 
 hasmorrhage. 
 
 Since the appearance of Sanger's memorable work, of seven cases 
 where his method was employed in consequence of myomata, only that 
 of Leopold recovered. In the cases which terminated fatally the 
 patients were, however, all in a septic condition at the time of the opera- 
 tion. Still, owing to the excessive vascularity, the imperfect contrac- 
 tility, and the hindrances to drainage in myomatous uteri, the condi- 
 tions at present favor a resort to the Porro method. Successes have 
 been reported by Schroeder, Hofmeier, von Ott, and L. Landau., in cases 
 where the extraction of the child was followed by the removal of the 
 uterus. In each the intro-abdominal method was employed in the 
 treatment of the stump. 
 
 Landau's case was especially instructive. Tlie abdominal incision extended 
 from the symphysis to a hand-breadth above the navel. The uterus was turned 
 out, and after tlie adjustment of a rubber ligature the child was removed alive 
 by the uterine incision. In bringing the uterus forward the retro-uterine and 
 retro-cervical tumor was dragged out of the pelvic cellular tissue in which it 
 was imbedded. The elastic ligature was placed below the entire uterus, the 
 ovaries, and the tumor, the uterus was severed, and the tumor was enucleated. 
 The raw surfaces of the stump were first united by eight deep sutures, which 
 likewise included the bed of the tumor, and then the peritonaeum was drawn 
 from the sides to cover the wound. In this case it was thought best to em- 
 ploy drainage through Douglas's cul-de-sac by means of iodoform gauze, owing 
 to the enormous serous transudation of the tissues. The gauze was changed at 
 the end of forty-eight hours, and on the fourth and sixth days. On the seventh 
 day the wound was allowed to heal. The patient left the liospital after three 
 and a half weeks. The child weighed seven pounds at its birth, and throve 
 afterward. (Klinische Vortrage, N. F.,Ko. 26.) 
 
 Ott, after removing uterus and ovaries, left the retro-uterine tumor in situ. 
 The wound was closed by a triple-stage suture. As a consequence of the re- 
 moval of the ovaries, the myoma rapidly shrank to small dimensions. (Arch, 
 f. Gynaek., Bd. xxxvii, p. 88.) 
 
 II. Carcinoma of the Cervix Uteri.— 1. In Pregnancy. — Uterine 
 cancer, which is one of the gravest comj^lications of pregnancy, is, if 
 primary, almost without exception of ' cervical origin. Conception 
 often occurs in the earlier stages of the disease, and since it is only
 
 ABNORMALITIES OP THE SEXUAL ORGANS. 547 
 
 absolutely prevented by a carcinoma which completely occludes the 
 cervical canal, it occasionally takes place even in the later stages of 
 the neoplasm's growth. The existence of j^regnancy usually hastens 
 the development of the cancer, the more rapid growth of which is 
 probably referable to the increased vascularity of the uterus and to 
 the correspondingly augmented activity of its nutritive processes. In 
 rare instances the occurrence of pregnancy seems to arrest the devel- 
 opment of the local and general symptoms referable to the cancerous 
 growth. In the majority of cases the neoplasm does not interfere 
 with the completion of normal utero-gestation, although abortion or 
 premature delivery is a frequent result of its development. These 
 issues of pregnancy are most frequently determined by cancerous tu- 
 mors whose progress has invaded the higherj supravaginal portions 
 of the cervix, and is probably occasioned by the interference, on the 
 part of the neoplasm, with the normal process of uterine growth and 
 expansion. The traction exerted by the enlarging cervix upon the 
 unyielding tissues of the tumor may also produce a solution of their 
 continuity, and give rise to formidable haemorrhage. In very excep- 
 tional cases uterine carcinoma seems to protract the period of gestation 
 far beyond its normal limits, in which case the foetus dies and under- 
 goes the changes usual in retention. 
 
 2. 1)1 Parturition and the Piierperal State. — If the cancer be con- 
 fined to the lower margin of the cervical canal, the expansion of the 
 latter is not materially interfered with, and delivery may be safely and 
 speedily accomplished. If, however, the morbid process has involved 
 the entire portio vaginalis, or has even extended quite to the os inter- 
 num, the inelastic tissue of the cancerous growth has replaced the ex- 
 pansile muscular fibers, and an opening of sufficient caliber for the 
 passage of the foetus can only be produced by rupture and contusion 
 of the degenerated and unyielding cervix. The immediate result of 
 such a laceration is violent haemorrhage, which is, however, quite 
 amenable to treatment. The consequence of the excessive pressure 
 to which the cervix is subjected during labor is necrosis of the con- 
 tused tissues, which is frequently followed by fatal sejiticaemia. 
 
 The diagnosis is accomplished by the same means which are em- 
 ployed in the detection of cervical cancer in the unimpregnated con- 
 dition. 
 
 The prognosis is doubtful for both mother and child. The latter 
 is imperiled by its liability to premature expulsion, and by the me- 
 clianical obstruction to its birth produced by the tumor. The moth- 
 er's life is not only shortened by the rapidity of the cancerous growth 
 usually induced by pregnancy, but is jeopardized by her increased lia- 
 bility to abortion, post-partum haemorrhage, and puerperal fever. 
 
 Treatment. — During pregnancy, in cases where the disease is con- 
 fined to the cervical portion, either amputation or excision should be
 
 548 THE PATHOLOGY OF LABOR. 
 
 performed. The time selected for operation is usually the fourth 
 month. Abortion does not necessarily follow. In advanced stages, 
 where the carcinomatous process has invaded the contiguous tissues, 
 operative interference should be postponed until the end of gestation. 
 Just in proportion as the outlook for the mother grows questionable, 
 the interests of the child rise in importance. An extensive removal 
 of diseased tissue during pregnancy exposes the mother to the imme- 
 diate dangers of j)remature labor and subsequent septicaemia. Upon 
 the advent of labor, if the child be living, and the upper vaginal tis- 
 sues are largely involved, the Caesarean section or the Porro operation 
 certainly holds out the hope of saving one life, and probably does not 
 greatly increase the peril to which the other is exposed.* Dr. Fordyce 
 Barker stated that he met with three cases of spontaneous delivery 
 where the cervix was carcinomatous, in all of which the mother sur- 
 vived the childbed period. Such good fortune, however, is necessarily 
 rare, and is only likely to result in j^atients whose tissues are but mod- 
 erately affected. Frommel f reports a case from the Berlin Clinic 
 where, the child being dead, Schroeder broke away with his hands 
 large masses of the neoplasm, and thus provided a passage of sufficient 
 size to permit the extraction of the child by version. The patient was 
 discharged on the tenth day, but died a few days after. Alfred Gon- 
 ner | recommends that labor be allowed to proceed until dangerous 
 symptoms call for active measures, or the limit of physiological dilata- 
 tion is reached. Then, if the vagina is not too extensively implicated, 
 by means of incisions and the partial extirpation of the diseased mass 
 with the galvano-caustic wire, the thermo-cautery, and volsella forceps, 
 room should be made for the extraction of the child by forceps, or after^ 
 version. Of four cases thus treated, the mothers all recovered from 
 the immediate effects of the operation, and three of the children were 
 born living. 
 
 III. Ovarian Tumors. — 1. In Pregnancy. — Ovarian tumors, par- 
 ticularly those of the cystic variety, are quite often encountered as 
 complications of pregnancy. They usually antedate conception, but 
 may make their aj^pearance during pregnancy. Utero-gestation often 
 favors their development by increasing the general vascularity of the 
 pelvic viscera, although an arrest of growth and an actual retrogress- 
 ive metamorphosis of the tumor seem to be the occasional effect of 
 
 * Herman (Trans, of the Obstet. Soc, of London, vol. xx, p. 191) reports twelve 
 Caesarean operations, with four recoveries. In a case reported by the author in 
 1887, the patient lived two months after the Caesarean section, and then succumbed 
 to the ravages of the cancerous affection. The child has thriven up to date — 1881. 
 lieopold has performed the Porro operation twice for carcinoma with success, 
 
 f Frommel, Zur operat. Therapie d. Cervix-Carcinoms in d. Complication mit 
 Graviditat, Ztschr. f. Geburtsh. und Gynaek., Bd. v, p. 158. 
 
 X GoNXER, Zur Therapie der durch Carcinora des Uterus complicirten Schwanger- 
 schaft und Geburt, Ztschr. f. Geburtsh, und Gynaek., vol. x, p. 7. 
 
 I
 
 ABNORMALITIES OF THE SEXUAL ORGANS. 549 
 
 intercurrent conception.* This retrogressive process affects only cys- 
 tic tumors, and may result from the uterine pressure, which facilitates 
 the absorption of their contents. After delivery the cysts present on 
 palpation a relaxed and flabby condition. The natural tension of the 
 tumor is soon restored by the secretion of additional fluid, except in 
 those rare cases in which the compression of the gravid uterus seems 
 to initiate a permanent process of retrogression and absorption. 
 
 Wernich f advanced the opinion that the assumption by benign 
 ovarian tumors of a malignant character is determined by the occur- 
 rence of pregnancy, and Spiegelberg J regards this transition as posi- 
 tively established. The ovarian tumors under consideration may be 
 bilateral. If they be of moderate dimensions, they may not interfere 
 with utero-gestation or delivery, except by a slight aggravation of the 
 usual disturbances attendant upon pregnancy. An ovarian tumor is, 
 however, liable to occasion abortion or premature delivery if it be con- 
 fined by adhesions to the pelvic cavity, or be closely connected to the 
 uterus. Under these circumstances, abortion results from interference 
 on the part of the new growth with the natural uterine expansion, or 
 from the retroflexion which it induces. In rare instances a rotation 
 of the cyst upon its axis, followed by strangulation of its pedicle, is 
 observed. This deplorable accident leads to a lethal issue by shock, 
 by gangrene of the cyst and consequent sejDticsemia, or by heemorrhage 
 into the tumor and the peritoneal cavity, followed by peritonitis. The 
 rationale of the morbid phenomena referable to tumors of larger size 
 is entirely different. These tumors do not often occasion abortion or 
 premature delivery, but gravely complicate the later periods of preg- 
 nancy by means of the pressure which they, in common with the gravid 
 uterus, exert upon the abdominal and thoracic viscera. Ascites and 
 dyspnoea are the chief results of the augmented intra-abdominal ten- 
 sion. (Edema of the lower extremities is often observed. The ova- 
 rian cyst sometimes ruptures and produces fatal collapse, peritonitis, 
 or septicemia. The escaped cystic fluid may, however, be absorbed, 
 and pregnancy reach a natural termination. 
 
 Diagnosis. — If the ovarian tumor be of small size, it may be com- 
 pletely masked by the growing uterus, or may be mistaken for a por- 
 tion of the latter. If, on the other hand, the surface of the tumor be 
 irregular and nodular, the uterus may, at an early period of pregnancy, 
 itself be regarded as a part of the cyst. Palpation and auscultation 
 will, however, usually afford satisfactory diagnostic points of differen- 
 tiation. Especially the softness of the pregnant uterus contrasts with 
 the tense condition of an ovarian cyst. Moreover, the absence of the 
 menses in patients with an ovarian tumor, and an unusually rapid in- 
 
 * ScHROEDER, Lehrbuch, p. 309. 
 
 f Wernich, Beitr. z. Oeburtsh. u. Gyn., Bd. ii, p. 143, 
 
 X Spiegelberg, Lehrbuch, p. 297.
 
 550 THE PATHOLOGY OF LABOR. 
 
 crease iu the dimensions of the abdomen, shonld awaken the suspicion 
 of combined pregnancy and ovarian tumor. 
 
 3. In Parturition and the Ptmyeral State.— The dangers result- 
 ing in parturition and the puerperal state from ovarian tumors com- 
 plicating pregnancy are twofold, and consist (a) in the obstruction 
 to labor which they occasion and (b) in the results of the morbid pro- 
 cesses determined in the neoplasms themselves by the excessive press- 
 ure of the surrounding tissues. 
 
 (a) If the ovarian tumor is confined within the true pelvis in such 
 a way as to render its spontaneous or manual displacement impossible, 
 it may offer a most serious impediment to the expulsion of the fa3tus. 
 Dermoid cysts manifest a more decided tendency to contract adhesions 
 in the pelvis than other ovarian tumors, and afford on this account, as 
 well as because of the greater consistence of their contents, a worse 
 prognosis than any other variety.* Obstructed labor more frequently 
 results from the presence of small than from that of large ovarian tu- 
 mors, since the latter oftener escape into the abdominal cavity during 
 pregnancy, and are unable at any subsequent period to effect an en- 
 trance into the true pelvis. 
 
 (b) Even if the obstacle offered to parturition by an ovarian tu- 
 mor be trivial, the changes induced in its own substance by the par- 
 turient act may be productive of very serious results. The pressure 
 and traction exerted upon the pedicle of the cyst are often so severe 
 as to produce its strangulation, followed by necrosis of the tumor, 
 with consequent septic poisoning. Rupture of the sac, with its fatal 
 consequences, may also occur, or such severe contusions of the tumor 
 may be occasioned by excessive pressure as to result in gangrene of 
 its entire mass. The development of the foetus is, as a rule, not inter- 
 fered with by ovarian tumors. The latter manifest a tendency to very 
 rapid development in the puerperal state, except in those rare cases 
 characterized by permanent retrogressive metamorphosis and absorp- 
 tion. 
 
 Ovarian tumors are a dangerous complication of pregnancy and 
 labor. Jetter collected 215 cases with 04 deaths. Fortunately, how- 
 ever, the results of ovariotomy are as favorable in the pregnant as in 
 the non-pregnant state. The operation does not necessarily interfere 
 with the continuance of gestation. So soon as the existence of an ova- 
 rian tumor is recognized, therefore, in a pregnant woman, its imme- 
 diate removal is indicated, f When the time is a matter of election the 
 
 * SCHROEDER, op. cif., p. 501 . 
 
 t Olshausex (Krankheiten der Ovarien) 188G. collected 82 operations performed 
 by 44 operators. There were eight deaths, four of which took place before the days 
 of antisepsis. Olshausen operated fourteen times. Four of the mothers aborted 
 and two died. Schroeder {Vide Straty, Ztschr. fiir Geb. und Gynaek., vol. xii. p. 
 268) operated fourteen times. All the mothers recovered. Twelve of the children 
 (including twins) went to terra. Spencer Wells operated ten times. Nine women
 
 ABNORMALITIES OB^ THE FCETUS. 551 
 
 operation should be performed early in pregnancy. In the later 
 months the conditions are less favorable, owing to the excessive vascu- 
 larity of the pelvic organs and the consequent development of the ves- 
 sels in the pedicle. Pippingskold, however, operated successfully ujion 
 a woman seven hours before the birth of a full-term child. 
 
 The alternative of ovariotomy consists in abiding the end of preg- 
 nancy, and then, when the tumor interferes with the birth of the child, 
 in pushing it uj)ward above the pelvis or, failing after repeated effort, 
 in puncture of the cyst. The cul-de-sac of the vagina affords generally 
 the most convenient point for the introduction of the trocar. The best 
 time for tapping is during the existence of a pain, when the cyst is 
 rendered tense by pressure. 
 
 CHAPTER XXIX. 
 
 ABNORMALITIES OF THE FCETUS WHICH OFFER AN OBSTRUC- 
 TION TO DELIVERY. 
 
 Premature ossification of the cranium. — Hydrocephalus. — Encephalocele. — Hydro- 
 thorax. — Ascites. — Other causes of abdominal distention. — Tumors of the trunk. 
 — Monstrosities. — Double monsters. — Acardiaci. — Anoncephalous monsters. — 
 Abnormal positions. — Spontaneous version. — Spontaneous evolution. 
 
 I. Fetal Diseases which obstruct the Expulsion of the 
 
 Head. 
 
 Premature Ossification of the Fetal Cranium. — This condition is 
 characterized by the complete or nearly complete closure of the fonta- 
 nelles. The head, therefore, loses its compressibility, and no longer 
 undergoes those changes of form which constitute so imjjortant a part 
 in the mechanical processes of delivery. As the anomaly is apt to in- 
 terfere with brain development in infancy, the late Dr. John E. Blake * 
 advocated early jaerforation where the interests of the mother had to 
 be consulted. As I have never met with this form of dystocia in a 
 large number of instrumental deliveries, I can not but regard it as 
 extremely uncommon. 
 
 Hydrocephalus. — Congenital hydrocephalus of sufficiently marked 
 development to constitute an impediment to parturition is compara- 
 tively rare, occurring, according to the statistics of Madame La Cha- 
 pelle,f only fifteen times in 43,545 deliveries. It consists usually in a 
 serous effusion confined to the cerebral ventricles. The effusion may, 
 
 recovered and went to terra. A. Martin reports three ovariotomies. The mothers 
 recovered. Pregnancy was not interrupted. 
 
 * Blake, Am. Jour, of Obstet., vol. ii, 1879, p. 225. 
 
 f Spiegelberg, Lehrbuch, p. 525.
 
 552 
 
 THE PATHOLOGY OF LABOR. 
 
 however, according to Jaccoud and Hallopean,* be situated in the 
 meshes of the pia mater, in the cerebral parenchyma, in the subarach- 
 noid cavity, or between the arachnoid and the dura mater. 
 
 Etiology.— The etiological factors of the disease have not been as- 
 certained, although Herrgott f assumes an invariable causative relation 
 between coexisting cretinism and hydrocephalus. 
 
 Morbid Anatomy. — The accumulated serum compresses the cerebral 
 parenchyma and produces dilatation of the cranial cavity, which may 
 become excessive. The cranial bones become abnormally thin, being 
 in some instances no thicker than parchment. Their continuity may 
 be interrupted by apertures of varying size, through which the con- 
 tents of the cranium may protrude, constituting an encephalocele. 
 The skull is of disproportionate magnitude as compared with the face. 
 The head may attain the dimensions of that of an adult. The fore- 
 head is prominent and bulging, the sutures are widely open, and the 
 fontanelles of large diameter. The body of the foetus is usually well 
 developed, and of a size corresponding to the existing period of preg- 
 nancy, although spina bifida and other malformations may coexist. 
 Hydramnion frequently complicates hydrocephalus. 
 
 Diagnosis. — Cystic tumors, spina bifida, encephalocele, and the 
 skull of a macerated foetus, are most frequently mistaken for hydro- 
 cephalus. The differential diagnosis is based upon different signs, ac- 
 cording to the position and presentation of the foetus. If the head 
 present and be still above the superior strait, abdominal palpation may 
 sometimes detect a large, rounded, and hard tumor above the pubes, , 
 while auscultation discovers the maximum intensity of the fetal cardiac 
 sounds above the umbilicus. The abdomen is unusually distended. If 
 the head has descended somewhat into the pelvic cavity, palpation per 
 vaginam reveals a fluctuating sac, which becomes notably tense during 
 the jiains. In the interval between the uterine contractions, the broad 
 fontanelles, the thin bones, and the wide sutures are readily felt. 
 These signs may, however, fail if the cranial bones be thick and the 
 sutures already ossified. In this case the disproportion between the 
 forehead and face, the bulging frontal bone, and the prominence of the 
 superciliary ridges are important aids to a diagnosis. If tlie mem- 
 branes be ruptured, the hairy scalp may be felt. The diagnosis is easier 
 when the cranial cavity is not greatly distended. In case of a breech 
 presentation, the diagnosis, which is then more difficult, must chiefly 
 rest upon the detection, at the fundus, of a tumor larger than the nor- 
 mal fetal cranium. The previous occurrence of hydrocephalus in the 
 same subject and feeble fetal movements may, in this instance, slightly 
 facilitate the task of the diagnostician. 
 
 * Nouv. diet, de med. et chir.prat., vol. xiii, article Eneophale, p. 151. 
 t Herrgott, Des mal foetal, q. peuvent faire obstacle a raccouch., Paris, 1878, 
 p. 13.
 
 ABNORMALITIES OP THE FCETUS. 553 
 
 Mechanism of Delivery. — The course of parturition is sometimes 
 not materially impeded even by a largely developed hydrocephalic foe- 
 tus. This may be due, if the bones be attenuated, to the ready mold- 
 ing of the fetal cranium to the pelvis, or to rupture of the head and 
 escape of the serum, which event occurs chiefly in breech presentations. 
 The presentation materially affects the course of delivery. If the head 
 be forced with its greatest circumference against the superior strait, 
 it adapts itself less readily to the pelvis than when it impinges later- 
 ally or obliquely on the pelvic entrance. The difficulties of delivery are 
 increased if the cranial bones be firm and thick, or the sutures ossified. 
 Breech presentations are favorable to a speedy delivery, in that the 
 head is subjected during its descent to more equable pressure by the 
 pelvic parietes, and therefore assumes a conical shape best adapted to 
 insure its easy expulsion. Spontaneous delivery is, however, rare. In 
 the vast majority of cases operative interference becomes necessary. 
 
 Prognosis. — The child's life is usually sacrificed if the anomaly be 
 sufficiently marked to considerably protract parturition. Even if the 
 child be born alive, it will probably succumb at an early period of ex- 
 tra-uterine life. The prognosis with reference to the mother depends 
 largely upon the time at which obstetrical aid is extended, and upon 
 the nature of the remedial measures adopted. If the labor be too long 
 protracted, vesico- vaginal fistula may result from pressure of the fetal 
 head, or the mother may die from exhaustion or from rupture of the 
 uterus. Eupture of the uterus is comparatively frequent, having oc- 
 curred in sixteen out of seventy-four cases of hydrocephalus collected 
 by Thomas Keith. The laceration usually occurs in the vicinity of 
 the cervix, but is often located at the fundus uteri. The treatment 
 consists in puncturing the head with a fine trocar and allowing the 
 fluid to escape. If practicable, the child should be subsequently turned 
 and extracted by the feet. The forceps is useless, as it can not be 
 made to take a firm hold. If version is found to be attended with dif- 
 ficulty, the opening should be enlarged, and the head extracted with 
 the cranioclast. If the child is extracted by the breech without pre- 
 vious perforation ^of the head, in cases of difficulty, Tarnier recom- 
 mends section of the vertebral column and the withdrawal of the cra- 
 nial fluid by means of an elastic catheter passed to the brain through 
 the spinal canal. 
 
 Congenital Encephalocele. — This abnormality of the fetal cranium 
 consists in the accumulation beneath the scalp of cephalic fluid, with 
 or without an investment of meningeal or of cerebral tissue. The sac 
 containing the fluid is attached to the cranium by a pedicle of varying 
 length and form. The aperture through which the fluid originally 
 contained within the cranium finds exit may be produced by attenu- 
 ation of the cranial bones attendant upon hydrocephalus, or may be 
 due to arrested development. In some instances the encephalocele is
 
 gg^ TUE PATHOLOGY OF LABOR. 
 
 found still communicating with the cranial cavity through its pedicle, 
 but in others the latter is impervious. Encephaloceles vary in size 
 from hardly perceptible sacs to tumors of larger circumference than 
 the cranium itself. They may occupy any part of the periphery of 
 the head, but are most frequent in the frontal and occipital regions.* 
 The head may itself be hydrocephalic or normal. The cause of the 
 anomaly in question is not definitely known, but is inferred to be of 
 inflammatory nature. 
 
 Encephaloceles rarely obstruct delivery, because, their most fre- 
 quent seat being in the frontal or occipital region, they are expelled 
 either before or after the head. Their presence seems to determine 
 nutritive changes in the cranial bones, whereby the latter, being ren- 
 dered softer and more yielding, are more readily expelled. The amount 
 of obstruction caused by the encephalocele will reach its maximum 
 when the size is large, the pedicle short, and the seat lateral ; but simple 
 puncture usually suffices to evacuate the sac, and obviates further diffi- 
 culty. The prognosis for both mother and child is far better than in 
 cases of congenital hydrocephalus. 
 
 II. Abnormal Conditions of the Fcetus •which obsteuct the 
 Expulsion of the Trunk. 
 
 Hydrothorax, unattended by serous effusion into any other of 'le 
 closed cavities of the body, is infrequent, and when present is rardy 
 of sufficient extent to offer any impediment to delivery. Spiegelberg 
 encountered only one such case, and refers to but two others observed 
 by Hohl.f 
 
 Ascites, although more frequent than hydrothorax, ordinarily con- 
 stitutes an insignificant obstruction to parturition, on account of the 
 yielding character of the abdominal Avails and the small amount of 
 fluid usually present. It has, however, in some instances markedly 
 retarded delivery.;]; 
 
 Ascites and hydrothorax are more frequently associated than iso- 
 lated, and present, when combined, no inconsiderable obstruction to 
 delivery. Pericardial effusions of varying magnitu(fe may exist simul- 
 taneously with either or both of these affections.* 
 
 The size of the fetal abdomen may be so much augmented by dis- 
 tention or enlargement of its viscera as to obstruct labor. Among the 
 causes of abdominal distention from this source may be cited : 
 
 {a) Cystic degeneration of the kidneys ; || (b) dilatation of the uri- 
 
 * Herrgott, op cit, p. 121. . f Spieoelberg, Lehrbuch, p. 528. 
 X Martin, Monatssehr. f. Geburtsk., Bd. xxvii, 180G, p. 28. 
 
 * Herrgott, op. cit., p. 155. 
 
 II CuMMixs, Dublin Jour, of Med. Sci., May, 1873, p. 499 ; Voss, Monatssehr. f. 
 Geburtsk., Bd. xxvii, 1866, p. 28; Kanzow, Ibid., Bd. xiii, 1859, p. 182; Weg- 
 SCHEIDER, Ibid., Bd. xxvii, 1866, p. 27.
 
 ABNORMALITIES OF THE FCETUS. 555 
 
 nary bladder ; * (c) dilatation of the ureters ; f (d) fibro-cystic degen- 
 eration of a testicle still retained in the abdomen ; J (e) enlargement 
 of the liver, due to degenerative processes;* (/) enlargement of the 
 uterus, produced by secretions accumulated in its cavity, the cervix 
 being impermeable ; || (g) enlargement of the pancreas ; ^ (h) enlarge- 
 ment of the spleen ; () (i) one fcetus included within another. In this 
 case one foetus is completely invested by the integument of the other, 
 and is attached to the latter by a pedicle, which is usually inserted 
 either in the sacro-coccygeal, perineal, or cervical regions. I A case 
 of extensive anasarca of the foetus, characterized by the peculiar gelati- 
 nous nature of the fluid contained in the subcutaneous cellular tissue, 
 is reported by Keiller to have produced dystocia. Emphysema of the 
 entire fetal trunk may result from putrefaction occurring in the tissues 
 of a child retained for some time in utero after the escape of the am- 
 niotic fluid. • The putrefactive processes owe their origin to the en- 
 trance of air within the uterus. The gaseous products of decomposi- 
 tion are developed in all the fetal tissues and in the cavities of its body. 
 The skin is distended, translucent, and glistening. It crepitates on 
 pressure, and gas escapes from incisions carried through the cuticle. 
 The trunk and extremities are largely increased in volume, and their 
 augmented size offers an obstacle to delivery which the uterine forces, 
 probably already exhausted by prolonged expulsive efforts, can not 
 overcome. In such cases the bulk of the child should be diminished 
 by punctures of the skin to allow the gases to escape, and when the 
 head presents it should be extracted with the cephalotribe. Tractions 
 upon the extremities are liable to be followed by their separation from 
 the trunk. 
 
 Tumors developed in different parts of the fetal trunk may disturb 
 parturition. The most frequent site for these tumors is the sacral and 
 perineal regions, where they are developed between the sacrum, the 
 coccyx, and the rectum. Their size varies from that of a small wal- 
 nut to that of the fetal cranium at term, and it may even exceed these 
 dimensions. The tumors may be either cystic, fatty, vascular, carti- 
 laginous, osseous, or carcinomatous. So-called cysto-hygromata are 
 also frequently observed in this situation. Similar neoplasms may be 
 located in the axilla, upon the pectoral muscles, and in the anterior or 
 
 * Whittaker, Am. Jour, of Obstet., vol. iii, 1871, p. 380; Duncan, Edinburgh 
 Med. Jour., August, 1870. p. 163 ; Hartmann, Monatsschr. f. Geburtsk., Bd. xxvii, 
 1866. p. 273; Rose, Ihid., Bd. xxv, 1865, p. 425 ; Olshausen, Arch. f. Gynaek., Bd. 
 ii, p. 280; Kristaller, Monatsschr. f. Geburtsk., Bd. xxvu, 1866, p. 165; Heckek, 
 Jhicl, Bd. xviii, 1861, p. 373. 
 
 f Ahlfeld, Arch. f. Gynaek., Bd. iv, p. 161. 
 X Rogers, Am. Jour, of Obstet., vol. li, p. 626. 
 
 * Schroeder, Lehrbuch, p. 634. || Gervis, Obstet. Trans., vol. v, p. 284. 
 ^ Martin, Monatsschr. f. Geburtsk., Bd. xxvii, 1866, p. 28. 
 
 ^ Voss, o/A cit., p. 26. X Herrgott, op cif., p. 266.
 
 556 
 
 THE PATHOLOGY OP LABOR. 
 
 posterior cervical regions. Spina bifida, when accompanied by the 
 formation of a large hydrorachitic sac, constitutes another form of 
 congenital fetal tumor, and is most frequently observed in the lumbo- 
 sacral region. Ectopia of the abdominal viscera, hernias, hydatid cysts, 
 and encysted neoplasms of the abdominal walls sometimes constitute 
 tumors sufficiently extensive to impede parturition. We may also cite 
 anchylosis of the fetal joints, adhesions of the extremities to the trunk 
 or to one another, and rigor mortis, as rare abnormalities which inter- 
 fere with that pliability of the child requisite for its adaptation to the 
 parturient canal, and finally, adhesion of the foetus to the placenta or to 
 the uterine parietes as causes of dystocia.* 
 
 Diagnosis. — An accurate differential diagnosis between these varied 
 morbid conditions can, as a rule, only be made after delivery. If en- 
 largement of the trunk be present, the head or breech is born without 
 difficulty, but, the progress of parturition being then completely ar- 
 rested, an investigation easily reveals the existence of an abnormally 
 large trunk. A hvdrorachitic sac is liable to be mistaken in a breech 
 presentation for the fetal membranes. Its consistence is, however, not 
 altered by the occurrence of uterine contractions, and no fetal parts 
 are felt beneath the membrane, which is found to be continuous with 
 the fetal cutaneous surface. 
 
 III. Monstrosities. 
 
 Dystocia is more frequently produced by double monstrosities than 
 by any other variety. These are divided by Veit f into three principal 
 classes, characterized, respectively, by — 1. Incomplete double forma- 
 tion of the upper or of the lower extremities ; 2. Two separate bodies 
 united either by their upper or by their lower extremities; 3. Two 
 separate bodies attached to each other either by their al)dominal or by 
 their dorsal surfaces. 
 
 Diagnosis. — The differential diagnosis of the individual deformities 
 is usually impossible in the earlier stages of parturition. Even in the 
 succeeding stages it is difficult, since separate twins may present essen- 
 tially the same phenomena. The diagnostician will derive some assist- 
 ance from the facts that certain women seem predisposed to the devel- 
 opment of double monsters, and that certain smaller and easily recog- 
 nizable deformities of the extremities (as club-foot) are often merely 
 complications cf more important ones, and serve to indicate the exist- 
 ence of the latter. The family history may furnish valuable assistance, 
 inasmuch as the deformities under consideration are sometimes heredi- 
 tary. Double monsters are most frequently observed in multiparae; 
 but this fact is referred by Veit J to the relative numerical preponder- 
 
 * Whittaker, Am. Jour, of Obstet., vol. iii, 1871, p. 247. 
 
 f Veit, Volkmann's Samml. klin. Vortr., Volkmann, 1879, Nos. 1G4, 165. 
 
 + Veit, op. cit., p. 1318.
 
 ABNORMALITIES OF THE FCETUS. 557 
 
 ance of the former over primiparae. "When parturition has progressed 
 sufficiently to allow of introduction of the hand within the uterus, 
 should the necessities of the case call for this measure, the diagnosis 
 becomes clear. 
 
 Mechanism of Labor. — The natural forces suffice, according to the 
 statistics of Playfair and Hohl,* for the delivery of double monsters in 
 more than fifty per cent of the cases. This fact may be attributed to 
 the comparatively small dimensions of the foetus and to the frequent 
 occurrence of abortion or of premature delivery in cases of this nature. 
 The course of parturition in a case of the first variety is similar to that 
 obtaining when the head of a single foetus is of unusually large di- 
 mensions. The second variety does not ordinarily seriously interfere 
 with delivery, particularly if there be a breech presentation. In this 
 case the bodies pass through the parturient canal simultaneously, lying 
 parallel to each other. One head then passes along the hollow of the 
 sacrum and is first expelled, while the other is retained above the brim, 
 its neck being bent into close apposition to the pubes until after the 
 exjDulsion of its fellow. Should there, however, be a disparity be- 
 tween the lengths of the necks, both the heads may simultaneously 
 j)ass through the pelvic canal. When they reach the outlet, the head 
 attached to the longer neck is expelled. The second head must then 
 be expelled with the neck and shoulders of the former. Under these 
 circumstances, interference on the part of the obstetrician is usually 
 required. 
 
 Head presentations are the most common ones in cases of the third 
 variety, and the course of parturition is as follows : The head of one 
 foetus is born, that of the other being detained above the pelvic brim. 
 The trunk belonging to the first head then follows. Xext comes the 
 second trunk ; and, finally, the head belonging to the latter. Spon- 
 taneous delivery, when it occurs, is usually eifected in this manner. 
 Head presentations of the first variety, i. e., those in which a single 
 trunk possesses two heads, usually pursue the course Just described. 
 
 Prognosis. — The prognosis for the child is very unfavorable, owing 
 to its exiDulsion in an undeveloped condition and to the compression 
 exerted upon it during labor. The prognosis for the mother is favor- 
 able because of the usual small dimensions of the foetus and of the 
 freedom with which measures for the reduction of its volume are re- 
 sorted to in view of its probable early demise. 
 
 An acardlacus is a monster devoid of the heart. It is developed 
 simultaneously with a normal foetus, and is usually born after the lat- 
 ter. Its development, as already explained,! occurs in the following 
 manner : The balance of circulation in the anastomosing vascular sys- 
 tems of twins contained in a single chorion (and therefore of the same 
 sex) becomes disturbed, and the pressure in one system so preponder- 
 * Spiegelberg, Lehrbuch, p. 531. f Chapter on Multiple Pregnancy.
 
 558 
 
 THE PATHOLOGY OP LABOR. 
 
 ates over that in the other that the circulation of the latter is reversed, 
 and its hearts, lungs, and body atrophy. It now receives its nutritive 
 supplies from the normal foetus. As the result of congestion in its 
 umbilical vein, its connective tissue often undergoes hypertrophy and 
 cedematous infiltration. The same cause may result in hydrocephalus 
 or in the development of a monster presently to be described as an 
 
 Fig. 220.— Author's case of acardia. 
 
 anencephalus. The most common variety of acardiacus is known as 
 the acephalus, or headless monster. The amorphus is an acardiacus 
 without head or extremities. It is of rounded form, and its surface, 
 though ordinarily smooth, may present faintly marked tubercles, which 
 are regarded as rudimentary extremities. Tlie interior of the amor- 
 phus contains a rudimentary intestinal canal, cystic cavities, muscles, 
 and vertebrae. The umbilical cord is attached indifferently to any 
 
 i
 
 ABNORMALITIES OF THE FOETUS. 559 
 
 part of the body. The rarest form of the acardiacus is the acormiis, 
 or trunkless monster. It consists of an imperfectly devekjped head 
 with a rudimentary trunk. Its umbilical cord is attached to the cer- 
 vical region. 
 
 An anencephalus or hemicephalus is a monster with a well-devel- 
 oped trunk and a rudimentary head. The neck is short and the head 
 rests directly upon the shoulders, which are so unusually broad as to 
 constitute an impediment to delivery. The amount of amniotic fluid 
 is ordinarily large. The face is turned upward and the eyes are 
 prominent. The most common jjresentations for an anencephalus are 
 the transverse and the breech. Sometimes the face or the exposed 
 base of the skull presents. In such a case the diagnosis may be made 
 by recognizing the sella turcica and other bony prominences of the 
 base. Keflex actions may be produced by irritation of the medulla, as 
 it rests exposed upon the basilar process of the occipital bone.* This 
 deformity produces obstruction by permitting other extremities to enter 
 the pelvic cavity simultaneously with the diminutive head, and by the 
 unusual breadth of its shoulders. The latter are more readily expelled 
 when the parturient canal has been previously dilated by the passage 
 of the breech. 
 
 IV. Shortness of the CoRD.f 
 
 Though dystocia from shortness of the cord is of rare occurrence, 
 it should always be regarded as a possible source of delayed labor. 
 Shortness of the cord may be absolute, as in cases where its length 
 does not exceed a few inches ; or a normal, or very long cord, may, by 
 the formation of coils around the foetus, become taut as the foetus is 
 expelled from the uterus. 
 
 In the preliminary stage of labor the effect of shortness of the cord 
 is sometimes perceptible in the irregular heart-action of the fcetus, in 
 the recession of the head not due to the resistance of the soft parts 
 during the intervals between the pains, and in an interference with the 
 mechanism of labor as characteristic of an early period. In the second 
 stage the effects of the shortening may be experienced at the j^elvio 
 outlet. Usually, however, difficulty is not encountered until after the 
 expulsion of the head. 
 
 As the result of the tension to which the cord is subjected, it 
 stretches, and, as Duncan points out, some gain in distance from child 
 to placenta is obtained by the drawing out of the two insertions, the 
 navel and abdominal wall on the one hand, and the placenta and uter- 
 ine wall on the other ; or, if the cord encircles the child, length may 
 be gained by compression of the encircled parts. Stretching alone 
 
 * Herrgott, op. cit., p. 263. 
 
 f Matthews Duncan, Obstruction owing to Shortness of the Cord, Obstet. 
 Trans., 1881, p. 243; Chautreuil, Des dispositions des cordens, Paris, 1875.
 
 560 THE PATHOLOGY OF LABOR. 
 
 may permit natural birth to take place. If not, the continued tension 
 may result in the tearing of the cord, in partial inversion of the uterus, 
 or in the separation of the placenta. According to Duncan, the cord 
 yields to a strain equal to five and a half pounds for the weakest, and 
 fifteen pounds for the strongest. 
 
 AVhen the cord becomes taut during the expulsion of the foetus, the 
 anterior surface of the latter rotates forward so as partially to undo the 
 encircling and diminish the tension. In the completion of the birth 
 the cord lies close to the urethra, and forms a radius around which the 
 body revolves, a movement which Duncan aptly compares to spontane- 
 ous evolution in shoulder presentations. 
 
 Under these several conditions the fetal mortality is said to be up- 
 ward of twenty per cent. That of the mother is much less serious. 
 Aside from heemorrhages due to placental detachment, and rare in- 
 stances of uterine inversion, the most important consequences are those 
 which result from delayed labor. I have witnessed the following case, 
 which terminated fatally : The patient was a primipara, twenty-two 
 years of age, who, after five days of ineffectual labor, entered the 
 Emergency Hospital. Her temperature was 103"5° Fahr. She was in 
 great agony. The external genital organs were inflamed. The fetal 
 heart had ceased to beat, and meconium escaped from the vagina. The 
 head could be seen through the gaping vulva. After giving ether, I 
 applied forceps, but met with more resistance than I had anticipated. 
 After extracting the head, on passing up the finger I found the cord 
 tense, and coiled a number of times around the child's neck. When 
 about to sever the cord, a sudden pain was followed by the expulsion 
 of child, cord, and placenta together. The next day the external 
 genitals became gangrenous, and on the fifth day the patient iied from 
 a slough in the upper portion of the vagina, which communicated Avith 
 the peritoneal cavity, and had evidently been the result of the long- 
 continued pressure. 
 
 A positive diagnosis can only be made when the labor has so far 
 advanced that the cord can be felt with the finger. The treatment 
 consists in loosening the coils, where it is possible, or in severing the 
 cord, if accessible, and speedily extracting the infant. During expul- 
 sion the rotation of the child forward may be aided, and assistance 
 may be rendered, by external pressure downward upon the fundus of 
 the uterus. 
 
 V. Transverse Presextatioxs. 
 
 In so-called transverse presentations the axis of the child crosses 
 obliquely the axis of the uterus. A horizontal position of the foetus, 
 with both extremities occupying nearly the same level, is the rare ex- 
 ception. Usually the child lies obliquely with the head resting upon 
 an iliac fossa. When the uterus contracts, the shoulder is usually
 
 ABNORMALITIES OP THE PCETUS. 561 
 
 pressed down into the lower uterine segment; hence shoulder and 
 transverse presentations are frequently employed as synonymous ex- 
 pressions. In shoulder presentations prolapse of the lower arm or of 
 the cord are not of infrequent occurrence. 
 
 The position of the child with the head to the left, as the more 
 frequent one, is termed the first position ; with the head to the right, 
 the second position. According as the back of the child is directed 
 forward or to the rear, we further distinguish dorso-anterior and dorso- 
 posterior positions. The dorso-anterior position is the usual one. 
 
 According to Churchill's statistics, the frequency of transverse pres- 
 entations is 1 : 252, Spiegelberg found it 1 : 180, while in France the 
 combined statistics of Depaul, Dubois, and Pinard show a frequency of 
 1:117 (Charpentier). 
 
 The causes of this abnormality are to be found in the absence of 
 the conditions which contribute to the fixation of the cephalic extrem- 
 ity. Thus a predisposition is created by an excess of amniotic fluid, by 
 placenta pr^evia, by multiparity, by premature births, by death of the 
 foetus, and by uterine and pelvic deformities. 
 
 Diagnosis. — The existence of a transverse presentation can usually 
 be ascertained by means of external palpation. Thus, the hard, round 
 head can be mapped out in most cases in an iliac fossa, and the soft 
 breech of smaller size be felt at a higher level upon the opposite side. 
 Upon vaginal examination, the presenting part is commonly felt high 
 up at the level of the brim, so that it is sometimes necessary to intro- 
 duce the half or even the entire hand to arrive at certainty in diagnosis. 
 Great care should be exercised in passing the finger through the cervix 
 for purpos9s of exploration, as it is especially desirable to avoid pre- 
 mature rupture of the membranes. In an early stage of labor the 
 vaginal vault is flattened. With the advance of the first stage the 
 shape of the bag of waters corresponds to the resistance offered by the 
 cervical canal. In multipara, and in all cases where softening and 
 dilatation proceed rapidly, the ordinary globular segment may form 
 in advance of the presenting part; if the cervix remains rigid, the 
 membranes usually make their way through the cervical canal as an 
 elongated pouch, a condition which especially favors the early occur- 
 rence of rupture. Sometimes the diagnosis is made clear by the pres- 
 ence of a prolapsed extremity in the bag of waters. After rupture of 
 the membranes, the shoulder is recognized by feeling the scapula with 
 its spine, the arm-pit, the clavicle, and the ribs, and, in many cases, by 
 means of a prolapsed upper extremity. 
 
 The position is determined by the direction of the head and of the 
 back. Often these can be made out by external palpation alone ; by 
 vaginal examination, the relations of the scapula and clavicle to the 
 uterine walls, and the direction of the arm-pit, furnish the data for the 
 formation of the diagnosis. If the arm is prolapsed, it may be drawn 
 36
 
 562 
 
 THE PATHOLOGY OF LABOR, 
 
 outside the vulva. If the hand then be turned with the palm upward, 
 the arm is always of the same name as the side of the mother to which 
 the thumb is turned. If the presenting arm and the direction of the 
 head be known, the position of the back, whether to the front or rear, 
 is readily deduced. 
 
 Spontaneous Version". 
 
 The term spo7ifaneons versmi is applied to the process by which 
 either a transverse position is transformed througli Nature's unaided 
 eiforts into a longitudinal one, or to that by which a normal position 
 is either partially or completely reversed. Spontaneous version, which 
 occurs during pregnancy as a very frequent physiological phenomenon, 
 is observed with comparative infrequency during labor. It may be 
 partial or complete, according as the presenting member is displaced 
 laterally through either 90° or 180°, may occur before or after the 
 rupture of the membranes, and may result in the transformation of a 
 transverse position into either a head, a breech, or a footling presenta- 
 tion. According to the statistics of Hausemann,* cases of spontaneous 
 version after rupture of the membranes are nearly five times as fre- 
 quent as those occurring before their rupture. The same author states 
 that the head presented in eighty per cent of the cases occurring be- 
 fore rupture of the membranes, and the breech in seventy-five per cent 
 of those taking place after the occurrence of that event. Spiegelberg f 
 cites two cases from his own practice in whicli tlierc was an escape of 
 so-called "false waters," the real membranes remaining intact, and 
 attributes the occurrence of spontaneous version in such instances to 
 the change of uterine form rendered possible by the evacuation of the 
 false waters. 
 
 Etiology. — Among the conditions predisposing to spontaneous ver- 
 sion is the uterine atony incident to repeated deliveries. About two 
 thirds of all the women in whom spontaneous version occurs are, ac- 
 cordingly, multiparag,J and their average age is thirty years. Spon- 
 taneous version often recurs during several consecutive pregnancies of 
 the same individual. It is more apt to occur during deliveries effected 
 at term than in abortions or premature deliveries. A living foetus is 
 more frequently the subject of spontaneous version than a dead one, 
 and many authors attribute an important agency in the production of 
 the altered position to the active movements of the child. The uterine 
 contractions are necessarily weak in cases of spontaneous version occur- 
 ring before the rupture of the membranes, as powerful pains would 
 force the presenting part still farther into the dilated os and fix it im- 
 movably in the pelvic brim. On the other hand, the contractions of 
 the uterus during a spontaneous version which takes place after the 
 
 * Hausemann, Monatsschr. f. Geburtsk., Bd. xxiii. 1864, p. SOfi. 
 
 t Spiegelberg, Lfihrbuch, p. 539. % Hausemann, loc. cit., p. 213.
 
 ABNORMALITIES OF THE FCETUS. 563 
 
 escape of the amniotic fluid must be strong, as will be explained in 
 our remarks on the mechanism of the process in question. An undi- 
 lated cervix, powerful contractions of the uterine fibers, and a fully 
 developed child are essential conditions for the occurrence of spontane- 
 ous version after rupture of the membranes. 8ome authors consider 
 the presence of a certain amount of amniotic fluid indispensable to 
 the occurrence of spontaneous version in those cases taking place after 
 rupture of the membranes. It is also necessary in such instances that 
 the shoulder or other presenting part be freely movable, not having 
 yet been firmly fixed in the cervical or pelvic canal. 
 
 Mechanism of Partial Version. 
 
 1. Before Rupture of the Memljranes. — In this case the shoulder 
 usually presents, the head being lower than the breech. The os is only 
 partly dilated. The woman having assumed a position upon that side 
 of her body toward which the head is directed, the breech tends to 
 descend under the influence of gravitation, while the head is thus ap- 
 proximated to the cervix. The contractions of the uterine muscular 
 fibers now complete the version by exerting pressure ujjon the breech. 
 When the uterus has once regained its natural shape, the normal j^osi- 
 tion is retained by the foetus until the completion of parturition. In 
 other instances, the breech being lower than the head, the same mech- 
 anism leads to a breech or to a footling presentation, 
 
 2. After RujHure of tlte Membranes. — In this variety of spontane- 
 ous version the amniotic fluid has partially or entirely escaped, allow- 
 ing the foetus to be tightly grasped by the uterine muscular walls, 
 which, therefore, labor under a mechanical disadvantage. The os is 
 only partially dilated. The pains force the presenting part into close 
 contact with the os internum. Owing to the absence of an equally 
 distending bag of waters, the os does not dilate, and soon assumes a 
 condition of tetanic spasm, during which it can be felt as an unyield- 
 ing, cartilaginous ring. The contractions of the fibers at the fundus 
 uteri having now become more forcible, the fetal head or breech, as 
 the case may be, is subjected to violent pressure. Inasmuch, however, 
 as the unyielding os prevents any progress downward, the presenting 
 part is displaced laterally, and that part of the fcetus which previously 
 occupied the fundus is forced into the pelvic entrance. The uterus 
 next regains its natural form, the os dilates, and delivery is accom- 
 plished. 
 
 Mechanism of Complete Version. 
 
 Cases of complete version, which are very rare, consist in the trans- 
 formation of one normal longitudinal presentation into the diametrical- 
 ly opposite one, the part originally presenting having rotated through 
 180°, The mechanism is essentially identical with that just described.
 
 5(54: THE PATHOLOGY OF LABOR. 
 
 Version of this variety is only likely to occur when the amount of 
 liquor amnii is large and the child small, so that it is freely movable. 
 Spontaneous version before the rupture of the membranes occupies 
 only half the time required for its accomiDlishment after their rupture. 
 Twenty-four or thirty hours are often necessary for the completion of 
 the latter variety. Delivery, too, is accomplished more speedily in 
 cases of the former kind when version has once occurred. 
 
 Prognosis. — The prognosis for both mother and child is good in 
 spontaneous version before rupture of the membranes, but is graver 
 when the turning occurs after that event, contrasting unfavorably with 
 manual version, owing to the fact that injurious pressure is liable to 
 be exerted upon the prolapsed cord. 
 
 Labor when the Presentation" remains Transverse. 
 
 If the transverse presentation continues after rupture of the mem- 
 branes, the entire contents of the amniotic sac escapes, and the uter- 
 ine walls retract down closely upon the foetus, or the shoulder is pressed 
 into the pelvic cavity, the contraction-ring recedes, and the back of the 
 child is forced into the cervix and the thinned lower uterine segment. 
 In the latter case danger of rupture becomes imminent. Usually, if the 
 malposition of the child is not corrected by art, or rupture does not 
 occur, the rigid uterine walls closely compress the foetus, and the mother 
 in the end dies from the ensuing exhaustion, or from metritis, from 
 peritonitis, or from septicaemia. In rare cases, however, spontaneous 
 birth of tJie child may take place by the process termed evolution. 
 
 Spontaneous evolution is the process by which a shoulder presenta- 
 tion is transformed, within the true pelvis, into a combined breech 
 and shoulder presentation, and spontaneous delivery is then effected. 
 Since this may be accomplished in two different ways, there are two 
 corresponding varieties of spontaneous evolution. The first variety 
 was, according to Leishman,* described by Douglas, of Dublin, as 
 " spontaneous expulsion." Dr. Taylor f takes exception to Leishman's 
 statement, and affirms that the term spontaneous evolution was ap- 
 plied by Douglas to the mode of delivery in question. The second 
 was described by Roderer as " birth with double body " (" evolntio 
 conduphcato corjjore''^), and more thoroughly explained by Klein- 
 wachter.J 
 
 Etiology. — Various conditions contribute to the facility with which 
 this process is accomplished by Nature. The most important are 
 powerful pains, a roomy pelvis, and a small foetus. Of these condi- 
 tions, the first only is essential; Grenser* has demonstrated that a 
 
 * Leishman, a System of Midwifery, Philiulelj)hia, 1873, p. 337. 
 f Taylor, Am. Jour, of Obstet.. July. 1881, 
 
 ; Kleinwachter, Arch. f. Gynaek.. Bd. li, p. 111. 
 
 * Grenser. Jlunatsschr. f. Geburisk., Bd. sxvii, 1866, p. 445.
 
 ABNORMALITIES OF THE FCETUS, 
 
 565 
 
 contracted pelvis is not an insurmountable obstacle to spontaneous 
 evolution, provided the conjugate diameter be alone shortened. Nor 
 is small size of the fcBtus essential to the occurrence of the process in 
 question. Spiegelberg* states that it is often observed in cases where 
 the foetuses are mature and well developed. Softness and compressi- 
 bility of the child naturally favor the production of spontaneous evo- 
 lution, as is demonstrated by its frequent occurrence when the jDroduct 
 of conception has undergone maceration. 
 
 Mechanism. — The mechanism of the former and more ordinary 
 variety of spontaneous evolution is as follows : The presenting shoulder 
 is forced into the depths of the true pelvis by the violence of the uter- 
 ine contractions, instead of being diverted laterally, as is the ease in 
 spontaneous versions and becomes firmly fixed beneath the symphysis, 
 while the corresponding arm protrudes through the vulva. The body 
 
 Fig. 221.— Neglected shoulder presentation. Section through frozen corpse. (Chiara.) 
 
 of the fffitus is then so forcibly flexed that the breech and the head lie 
 in close proximity to each other. The former is in contact with the 
 sacro-iliac synchondrosis, while the latter is immovably held between 
 the breech and the upper border of the symphysis. The neck and 
 shoulder, which rest against the lower border of the symphysis, now 
 become the pivot upon which the foetus rotates. The trunk of the 
 foetus is driven beyond the shoulder, and the thorax, breech, and legs 
 are born in the order named. The other shoulder then follows, and 
 the head is finally expelled. 
 
 The mechanism of the second variety of spontaneous evolution, 
 designated by Roderer " evolutio conduplicato corpore^'"' which is much 
 
 * Spiegelberg, Lehrbuch, p. 541.
 
 566 
 
 THE PATHOLOGY OF LABOR. 
 
 rarer than the former, differs from it in some essential features. It is 
 greatly facilitated by softness and compressibility of the child, and 
 therefore occurs predominantly in cases of macerated foetus. It is 
 
 rarely observed in other cases, un- 
 less the foetus be unusually small 
 and its tissues greatly relaxed. 
 
 The shoulder is in this instance 
 forced downward and imprisoned 
 beneath the symphysis pubis, as in 
 the former variety, while the arm 
 protrudes from the vulva. The 
 trunk having been enormously 
 flexed, the head and thorax simul- 
 taneously enter the pelvic cavity, 
 the former being deeply imbedded 
 in the latter. The second arm and 
 shoulder lie between the breech 
 and thorax on the one hand, and 
 the head on the other. The pre- 
 senting shoulder having been ex- 
 pelled, the head and thorax are 
 born together, and these are fol- 
 lowed by the breech and the legs. 
 
 Prognosis. — The prognosis in 
 spontaneous evolution is good for 
 the mother, but very bad for the 
 foetus, since only immature chil- 
 dren are, as a rule, able to pass 
 through the ordeal of delivery by 
 this method alive. Kuhn, how- 
 ever, has reported a case of a child 
 born alive, weighing four and a 
 half pounds and measuring seven- 
 teen inches in length ; and Simon, 
 according to Spiegelberg, collected one hundred and twenty-five cases 
 in which fourteen children were born living. Three of the one hun- 
 dred and twenty-five mothers died. In the variety of spontaneous 
 evolution known as '-'■ evolutio conduplicato coiyore^'' which occurs in 
 the rule in small or macerated children, the prognosis is especially 
 unfavorable. In these latter cases Dr. Taylor* recommends, when 
 the perinaium is distended by the doubled body of the child, to make 
 lateral incisions to the extent of three to four inches at the vulva, and 
 thus remove the obstacle to delivery afforded by the pehic floor. 
 
 * Taylor, Am, Jour, of Obstet., July, 1881, p, 532. 
 
 Fig. 232.— Birth with doubled body. 
 vKleiuwachter.)
 
 ECLAMPSIA. 567 
 
 CHAPTER XXX. 
 
 ECLA3IPSIA. 
 Definition. — Clinical history. — Prognosis, pathology, and etiology. — Treatment. 
 
 Eclampsia is the term applied to convulsions, tonic and clonic in 
 character, the foundation of which is laid in processes connected with 
 pregnancy, labor, and childbed {eclampsia gravidarum, parturientium, 
 ■vel piterperartim). By this definition it is intended to exclude the con- 
 vulsions due to hysteria, true epilej)sy, and cerebral lesions, which oc- 
 currences in pregnancy are to be regarded simply as accidental compli- 
 cations. In eclampsia there is loss of consciousness during the attacks, 
 with at first a disturbance of the intellectual faculties m the intervals, 
 afterward deepening in severe cases into coma. Before entering upon 
 a discussion as to the probable nature of this affection, it is proper to 
 present a summary of its clinical manifestations. 
 
 Clinical His tori/. — Eclampsia is fortunately a tolerably rare event. 
 Its estimated frequency is in about the j)roportion of once in five hun- 
 dred pregnancies. The total number of deaths from this cause re- 
 ported to the Board of Health in New York city, in the nine years 
 from 1867 to 1875 inclusive, was 408. The estimated maximum num- 
 ber of deliveries during that period was 284,000, or nearly one death to 
 seven hundred confinements. The entire niimber of deaths occurring 
 in pregnant women from all causes during the same period was 3,342, 
 making the proportion of those from eclampsia as one to eight. In 
 the majority of cases, though not invariably, premonitory symptoms 
 announce the impending outbreak. Of these the most important are 
 headache, often limited to one side, vertigo, loss of memory, gloomy 
 forebodings, flashes of light before the e3"es, contracted pupils, ambly- 
 opia, sometimes amaurosis, ringing in the ears, dyspepsia, nausea, vom- 
 iting, dyspnoea, oedema of the face, of the labia majora, and of the 
 extremities, and, finally, and of first importance, the presence of albu- 
 men and of casts in the urine. 
 
 The attacks resemble those of ej)ilepsy, the cry only lacking. When 
 they occur during labor, the first convulsion often is preceded by a 
 short calm, in which the patient ceases to complain, closes her eyes, 
 and seems to have sunk into a ]3eaceful slumber. This deceitful truce, 
 which should always excite the keen attention of the physician, is fol- 
 lowed in a few minutes by convulsive movements of the orbicularis 
 oris muscle, giving to the patient a smiling aspect. Suddenly the eye- 
 lids open, the eyes become fixed, and the pupils contract. Then, in a 
 few seconds, the eyelids open and shut rapidly, the eyes move from 
 side to side or roll upward, while the pupils dilate and lose their sensi- 
 tiveness to light. Very rapidly the convulsive twitchmgs extend to
 
 568 
 
 THE PATHOLOGY OF LABOR. 
 
 the other muscles of the face, the mouth opens and is drawn to one 
 side, the head is moved from shoulder to shoulder, sometimes with 
 lightning-like alternations. Frequentl}^ for the first two or three con- 
 vulsions, the movements of the extremities are limited to the pronation 
 and supination of the forearm and to the closing of tlie fingers upon 
 the thumb. Afterward the arms, crossed upon the thorax, pass from 
 flexion to extension with great rapidity. The movements, as a rule, 
 are more pronounced iu the upper than in the lower extremities. 
 Sometimes the latter are fixed with tetanic rigidity, while at others 
 they are flexed at the knee and then drop of their own weight, now 
 upon one side, now upon the other. 
 
 As a consequence of the resulting disturbances in the circulation 
 and respiration, the carotids pulsate with great distinctness, the super- 
 ficial veins of the neck swell, the conjunctivae become injected, and 
 the face is c3'anosed ; the heart's action becomes intermittent, and the 
 breathing irregular and stertorous. 
 
 In the tonic convulsions, which occur intercurrently with clonic 
 ones, the head is inclined to one side, the mouth is drawn in the same 
 direction, the jaws are closed, the eyes are fixed, opisthotonus or pleu- 
 rosthotonus develops, the pulse becomes small and intermittent, the 
 respiration is suspended, tiie body becomes covered with a cold, clannny 
 sweat, and often involuntary micturition or defecation takes place. 
 The tetanic condition, after lasting from fifteen to thirty seconds, 
 gradually diminishes in intensity. 
 
 As the convulsions cease, the distortion of the face disappears, the 
 cyanosis diminishes, the eyelids droop, the mouth opens, and frothy 
 saliva, tinged with blood, escapes from the mouth and nostrils. Ster- 
 torous respiration marks tlie beginning of sopor. At first the patient, 
 unless the attack has been of unusual severity, can be roused when 
 spoken to. The depth of the sopor is proportioned to the violence 
 and frequency of the attacks. ^Yhen the convulsions are repeated, the 
 patient in the intervals can no longer be made to respond to inquiries, 
 but passes into a state of complete unconsciousness. The duration of 
 a single attack rarely exceeds a minute, and in a majority of cases lasts 
 from ten to thirty seconds. On account of the implication of the re- 
 spiratory muscles, attacks of long duration are scarcely compatible with 
 continued existence (Spiegelberg). 
 
 After a single seizure the sopor usually disappears in from one half 
 to two hours, and seldom persists beyond a single day. The number 
 of seizures in a single day may, however, be exceedingly numerous. 
 Thus, seventy convulsions have been reported by Braun,* eighty-one 
 by Brummerstedt,f and one hundred and sixty by Depaul.J 
 
 * Braun, Lehrbuch der gesaramt. Gynaekologie, p. 822. 
 t Brummerstedt, Bericht, etc., Rostock, 1866. 
 X Vide Spiegelberg, loc. cit., p. 556.
 
 ECLAMPSIA, 569 
 
 With very rare exceptions — of which, however, I have never seen 
 an example — the urine after the convulsions is found loaded with albu- 
 men, and contains an abundance of renal ejiithelium, often in a state 
 of fatty degeneration, casts, and sometimes blood-corpuscles. In all 
 cases of exceptional severity the urine is scant or absent altogether. 
 
 Terminations. — In favorable cases, after the expulsion of the ovum 
 the attacks cease or diminish in frequency and intensity, the pulse and 
 respirations become quiet, and the coma passes gradually into gentle 
 slumber. On awakening, the patient complains of headache and of 
 impaired memory, and possesses no recollection of the perils through 
 which she has passed. Pains are felt in the muscles, and in the tongue 
 when the latter has been injured to any considerable extent by the teeth. 
 
 But even after consciousness returns, the danger is still not ended. 
 Eclampsia predisposes to post-partum haemorrhage and to puerperal 
 inflammations ; or it may leave behind hemiplegia, amblyopia, an en- 
 feebled mental condition, or psychical disturbances, especially mania, 
 which, however, usually terminates spontaneously in the course of the 
 first three days. 
 
 In fatal cases death results from carbonic-acid poisoning, due to 
 tetanus of the respiratory mu.scles or to exhaustion of the nervous sys- 
 tem. Bailly relates the history of a patient who died of asphyxia, due 
 to swelling of the tongue. 
 
 Of anatomical lesions found in post-mortem examinations, the most 
 constant are hyperemia, more often an ansemic state, fatty degenera- 
 tion, and atrophy of the kidneys. The latter is rare, and in many cases 
 the renal changes are of moderate extent. In thirty-two examinations, 
 Lohlein * found in eight dilatation of one or both ureters and of the 
 pelves of the kidneys. The same author likewise has demonstrated the 
 existence of enlargement of the heart (the comparisons were instituted 
 with those of other pregnant women), indicative of increased arterial 
 tension. The brain-lesions were in most instances insignificant. 
 
 Prognosis. — The prognosis is always serious. In Dohrn's collec- 
 tion of 747 cases the death-rate reached 29 per cent ; in 104 cases col- 
 lected by Hofmeier f in Schroeder's Clinic the mortality was 33-4 per 
 cent. A better showing is made by Braun,J who was able to report 
 from Vienna in ten years, from 1869 to 1878, 73 cases, with twenty 
 deaths (26 per cent), five from peritonitis and fifteen from Bright's 
 disease alone. 
 
 The earlier the convulsions occur in labor, the more unfavorable 
 the prognosis. This is well shown by the statistics of Lohlein. Thus, 
 of eighty-three cases where the first convulsions occurred before or 
 during the first stage of labor, 40*5 per cent of the patients died. Of 
 
 * Lohlein, Bemerkungen zur Ekhimpsiefrage, Ztschr. f. Geburtsh. und Gynaek., 
 Bd. iv, Heft 1, p. 89. 
 
 f Hofmeier, loc. cit. | Braun, Lehrbuch der gcs. Gynaek., p. 833.
 
 570 THE PATHOLOGY OF LABOR. 
 
 fifteen cases where the first stage was completed, but one patient died. 
 Eclampsia, which develops first in childbed, usually pursues a favor- 
 able course. Ldhlein reports eight cases, with one death, which, how- 
 ever, was the result of infection. 
 
 The longer the labor the more difficult the delivery ; the deeper the 
 coma and the greater the insufficiency of the kidneys the more de- 
 pressing is the outlook. 
 
 It is very rare for the convulsions to cease previous to the expulsion 
 of the child. According to C. Braun, after delivery in thirty-seven per 
 cent the convulsions cease entirely, in thirty-one per cent they become 
 feebler, while in thirty-two per cent they continue for a time with un- 
 diminished severity. In childbed it is of favorable import when copious 
 diuresis sets in, and is followed by the disajDpearance of tlie albumen 
 and of the oedema. 
 
 As regards the children of eclamptic women, it is estimated that 
 fully one half are born dead, a result probably due to asphyxia from 
 the accumulation of carbonic acid in the blood of the mother. As the 
 results depend upon the number and duration of the attacks, it is 
 evident that the danger is greatly lessened after the completion of th^ 
 first stage of labor. 
 
 Pathology and Etiology. — As in discussions upon eclampsia it is 
 evident that the treatment advocated by physicians is governed almost 
 exclusively by theoretical considerations, it becomes of the utmost 
 importance to place before the student an exact statement of known 
 facts, with an attempt to estimate at their true value the deductions 
 which various observers have drawn from them. 
 
 Now, in the first place, in reviewing the foregoiug history of the 
 disease, we are brought face to face with the very striking coincidence 
 in the vast majority of cases between renal insufficiency and the con- 
 vulsive seizures. This insufficiency may or may not be associated 
 with albuminuria, though the two go jiretty constantly together. The 
 honor of first drawing attention to the relations between albuminuria 
 and puerperal convulsions belongs to Dr. John C. AV. Lever, who re- 
 ported in Guy's Hospital Reports, second series, 1842, fourteen cases, 
 in ten of which the urine was examined. Albumen was found in 
 greater or less quantity in nine cases ; in the post-mortem made in 
 the tenth case the death was discovered to have been due to acute 
 memngitis.* 
 
 These observations were followed by others from British physicians, 
 among whom may be mentioned Simpson, Garrod, Cormack, and 
 Eses; and in France treatises upon the subject Avere iDublished by 
 Cohen and Delpech, and by Devilliers and Eeguault. 
 
 * Vide Tyson, The Causal Lesions of Puerperal Convulsions, Philadelpliia, 1879. 
 To this excellent summary I desire to acknowledge my indebtedness for a deal of 
 labor saved, as regards the search for references.
 
 ECLAMPSIA. 571 
 
 In 1851 Frerichs pointed out clearly the close resemblance between 
 the convulsions occurring in pregnancy and the ur^emic convulsions of 
 Bright's disease. After reviewing the evidence with scientific pre- 
 cision, he concluded that " true eclampsia occurs only in pregnant 
 women suffering with Bright's disease, and it bears to the latter the 
 same causal relation as convulsions and coma in Bright's disease in 
 general ; it is the result of the uraemic intoxication, with which also 
 in its mode of manifestation it agrees." To this view Braun, in the 
 same year, and Wieger, in 1854, brought effective support by the pub- 
 lication of a great number of observations confirmatory, both in re- 
 spect to the clinical features and the j^ost-mortem appearances, of the 
 uraemic origin of puerperal convulsions. In 1857 Braun published 
 one of the most meritorious treatises upon midwifery to be found in 
 any language. In this work the new doctrine was presented with so 
 much skill and clearness that since then, in the minds of the great 
 body of practitioners, the terms eclampsia and uraemia have come to be 
 regarded as synonymous. 
 
 In order to understand the present position of the question, it is 
 necessary to review the objections which the uremic theory has had to 
 encounter. Among its earliest opj)onents was Seyfert, of Prague, who 
 occupying the vantage-ground as director of the maternity hospital of 
 that place, second only in size to the great maternity at Vienna, 
 furnished the clinical counter-experiences which have since proved the 
 most effective weapons in the hands of those who have regarded the 
 new doctrine as specious and heretical. The facts which, he insisted, 
 invalidated the claims of Frerichs and Braun were as follows : * 
 
 1. That convulsions may occur without albuminuria. 
 
 2. That the albuminuria is in many cases the effect and not the 
 cause of the convulsions. 
 
 3. That in many fatal cases the kidney-lesions were absent or 
 wholly insignificant. 
 
 4. That convulsions are rare in chronic Bright's disease which had 
 existed prior to pregnancy. 
 
 5. That in true ursemia, such as necessarily is produced by the 
 sujjpressiou of urine when, in uterine cancer, the ureters are invaded, 
 convulsions do not occur. 
 
 That, in the main, these propositions are correct, hardly admits of 
 question. But, in drawing conclusions from these, unnecessary stress 
 is laid upon the presence or absence of albumen in the urinary secre- 
 tion. It is the renal insufficiency, it should be fixed in the mind, and 
 not the albuminuria, which is associated with convulsions. The mere 
 
 * As T hiive copied this list from notes taken from the lectures of Seyfert, 
 delivered in the summer session of 18G5, I shall not consider it necessary to more 
 than incidentally refer to the corroborative testimony since advanced m support of 
 their validitv.
 
 5Y2 THE PATHOLOGY OF LABOR. 
 
 absence of albumen from the urine does not even exclude the existence 
 of Bright's disease. Braun is careful to note that in certain cases of 
 fatal eclampsia, in spite of the absence of albuminuria, the post-mortem 
 examination revealed amyloid degeneration of the kidneys and of the 
 heart-structures ; and, again, in others, of atroi)hy of both kidneys, 
 where the dropsy, and the albumen, and casts, wliich had been present 
 earlier in pregnancy, had entirely disappeared at the moment the con- 
 vulsions occurred. Bailly has shown that not rarely albuminuria in 
 pregnant women may disappear for several hours and then reappear 
 once more, so that it is possible for an examination to be made during 
 the short period when the urine ceases to be albuminous. 
 
 On the other hand, chronic nephritis does not necessarily imply in- 
 sufficiency of the renal secretion. Seyfert reported over 70 cases where 
 women suffering from Bright's disease became pregnant ; only two of 
 these had convulsions. Every observer has seen similar instances of 
 immunity. Nephritis in pregnancy brings with it its own peculiar 
 dangers. Of forty-six cases, chronic in character, reported by Ilof- 
 meier, only one third of the patients had eclampsia, but one half died. 
 Including acute and chronic cases together, Braun estinuitcs that only 
 sixty in the hundred develop uriemic convulsions. Ilofmeier found, 
 in five thousand births recorded upon the history-books of the Berlin 
 Clinic 137 cases of nephritis entered. Of these, 104 patients only 
 were attacked with eclam])sia. Professor Bamberger* reports from 
 autopsies of the " allgemeinen Krankenhaus " in twelve years 2,430 
 cases of Bright's disease, of which 152 were found in puerperal and 
 pregnant v/^omen, viz., 80 acute cases, 56 chronic cases, and IG cases of 
 atrophy ; puerperal eclampsia was recorded in 23 instances. 
 
 Flaischlen f found in examining 1,000 cases of pregnancy that albu- 
 men was present in twenty-six. In five of the cases the patients suf- 
 fered from catarrh of the bladder, and in two chronic nephritis was 
 diagnosed, leaving nineteen per thousand in whicli albuminuria was 
 dependent upon pregnancy. Of 537 cases (205 primipars, 242 multi- 
 paras) observed during labor or immediately after childbirth, albumi- 
 nuria was present in 93 women, of whom 73 were primiparte and only 
 20 were multipara. As the estimated frequency of eclampsia is only 1 
 to 500 cases of pregnancy, the mere presence of albumen is not neces- 
 sarily of grave prognostic importance. 
 
 Lohlein examined the records of thirty-two autopsies made upon 
 eclamptic women, and found in eight, or in twenty-five j^er cent of the 
 entire number, that dilatation of one or both ureters coexisted with 
 renal disturbances. He, therefore, pertinently inquires how far sim- 
 
 * Bamberger, Ueber Morbus Brightii und seine Beziehungen zii anderen Krank- 
 heiten, Volkraann's Saraml. klin. Vortr., No. 173, p. 1541. 
 
 t Flaischlen, Ueber Schwangerschafts und Gcburtsineren. Ztsehr. f. Geb. und 
 Gynaek., vol. viii, p. 358.
 
 ECLAMPSIA. 573 
 
 plo mechanical obstruction of the ureters may explain the apparent 
 development of urEemic manifestations in certain cases without the 
 warning furnished by albumen in the urine. 
 
 Finally, it is not claimed by even the most stalwart champions of 
 the urtemic nature of eclampsia that the convulsions which occur dur- 
 ing pregnancy and labor are invariably the result of the same cause. 
 Thus, Tyson says : " There are no reasons why we should exclude from 
 the causes of the convulsions in the puerperal state those which op- 
 erate to produce convulsions in the non-puerperal condition." So- 
 called cases of eclampsia without albuminuria, i. e., without unemia, 
 are admitted by Braun and Spiegelberg, and referred by them to reflex 
 stimulation of the vaso-motor and convulsive centers (Krampfcentren). 
 They advocate, however, separating them off into a class by them- 
 selves under the title of acute epilepsy, or eclamptiform attacks, a 
 distinction they believe warranted by their rarity and their benio-u be- 
 havior. 
 
 The objection drawn from the insignificance of the kidney changes, 
 frequently observed in post-mortem examinations, loses most of its 
 force when we remember that in a large proportion of cases the reten- 
 tion of excrementitious materials is due to acute suppression. Thus, 
 in the 104 cases of eclampsia reported by Hofmeier, the kidney symp- 
 toms developed suddenly. This sudden suspension of the urinary se- 
 cretion can only result, Spiegelberg* argues, from disturbances in the 
 renal circulation. A rapidly developed affection of the vessels would 
 leave no marked post-mortem traces, and would, in cases of recovery, 
 disappear as quickly as it had come. Were the kidney troubles due 
 principally, as was formerly supposed, to pressure of the gravid uterus 
 upon the renal veins, the kidneys should, in. post-mortem examinations, 
 exhibit evidences of congestion ; whereas, usually they are, on the con- 
 trary, found to be pale and anaemic. Besides, in cases of pressure from 
 ovarian and pelvic tumors it is usually the ureters and not the veins 
 which are implicated. The precise nature of the circulatory changes 
 is not, of course, definitely known. Spiegelberg suggests that either 
 the walls of the vessels are altered in such a manner as to interfere 
 with the process of diffusion, or that a reflex contraction of the vessels 
 due to a peripheral stimulus operates to cut off the blood-supplies to 
 the kidneys. Frankenhaeuser, having demonstrated a direct connec- 
 tion by means of the sympathetic nerve between the ganglia of the 
 kidneys and the nerve-filaments of the uterus, had likewise suggested 
 in effect that the albuminuria of pregnancy was due not to pressure 
 but to the excitation of the uterine and renal nerve plexuses. 
 
 Cohnheim supposes that the renal changes of pregnancy are due 
 primarily to reflex contraction of the arterioles of the kidney, and that 
 the albuminuria and the epithelial degeneration are secondary phe- 
 * Spiegelberg, Lehrbuch, p. 561.
 
 p^^^ THE PATHOLOGY OF LABOR. 
 
 nomena. Experimentally, Litten has shown that similar resnlts follow 
 upon the temporary narrowing of the renal afferent vessels by means 
 
 of ligatures.* 
 
 The statement contained in the fifth proposition relates to a curi- 
 ous fact, which has since received confirmation from the pathological 
 investigations of Cornil and Kanvier. In a very large proportion of 
 women who had died from uterine cancer the ureters were found oc- 
 cluded, with attendant dilatation and in some cases with hydrone- 
 phrosis. Of these Cornil wrote : " With these obstacles to the excretion 
 of urine we expected uraemic symptoms to be manifested, but they were 
 not. Although the attention of M. Charcot and myself was fixed 
 upon this point, we never saw either the epileptiform convulsions or the 
 coma peculiar to uremic poisoning." 
 
 A very different interest attaches itself, however, to the inquiry as 
 to the causes of the outbreak of convulsions. It is well known that 
 not every case of nephritis, or even of kidney insufficiency, is followed 
 by eclampsia, though convulsive attacks are much more common in 
 the uriBmia of pregnant than of non-pregnant women. Frerichs be- 
 lieved he had found the secret in supposing a ferment to develop in 
 the blood, which converted the urea into carbonate of ammonia. In 
 1870 Spiegelberg reported an examination of the blood of an eclamp- 
 tic woman by the latest methods, and demonstrated the presence of 
 ammonia in quantities sufficient to give color to the supposition of 
 Frerichs ; but, subsequent investigations proving negative, he con- 
 cluded that " ammoniiemia is to be regarded as one of the rarest causes 
 of convulsions." 
 
 An apparently much more scientific explanation was afforded by 
 the now well-known Traube-Rosenstein theory, which maintained that 
 eclampsia took place when, in persons rendered hydraemic by the loss 
 of albumen, the aortic pressure was suddenly increased, the increased 
 pressure giving rise successively to oedema of the brain, then to sec- 
 ondary compression of the vessels, and finally to acute anasmia. An 
 anaemic condition of the hemispheres would, it was predicted, produce 
 coma, while convulsions would ensue if the condition extended to the 
 motor centers. 
 
 The plausibility of this hypothesis was increased by the widespread 
 acceptance of the doctrine taught by Andral and Gavarret, that the 
 blood of all pregnant women is hydra3mic, and by the fact that the 
 existence of increased blood-pressure during the pains seemed naturally 
 to account for the frequency of convulsions in labor. For a number 
 of years after the announcement of the Traube-Rosenstein theory it 
 received from me complete acceptance; but my faith became after- 
 ward weakened by failing to find at post-mortem examinations the an- 
 
 * OsTHOFF, Beitrage zur Lehre von der Eclampsie und Uraemie, Sammlung klin. 
 Vortrage, No. 206, p. 1911.
 
 ECLAMPSIA. 5Y5 
 
 ticipated brain- changes, viz., oedema, anaemia, and flattening of the 
 convohitions. In nineteen examinations, Lohlein reported these alter- 
 ations in but a single case. In his Lehrbuch der Geburtshtilfe Spiegel- 
 berg sums up the objections in a somewhat contemptuous fashion. 
 First he asks why, if the pathogenetic symptoms, as assumed, are in- 
 variably present, eclampsia is of such rare occurrence, and in what 
 way the theory in question affords any explanation of eclampsia in 
 pregnancy and childbed : then he denies that eclamptic women are 
 for the most part hydrgemic, that hydrgemia and arterial pressure are 
 capable of inducing cerebral anaemia, and that the clinical evidences 
 afforded by the pulse and pupils are those produced by oedema. 
 
 Angus Macdonald reported in 1878 that in the examination of the 
 brain in eclamptic persons he found the meninges congested and the 
 venous sinuses filled with blood, while at the same time there Avas 
 marked ana3mia in the deeper layers of the brain-structure. The ven- 
 tricles, in place of being empty, as should have been the case accord- 
 ing to the Traube-Rosenstein theory of oedematous swelling, were 
 found filled with serum. In place of the doctrine of secondary com- 
 pression, he expressed his belief that the anaemia resulted from arterial 
 contraction due to irritation of the vaso-motor centers from excremen- 
 titious principles retained in the circulation by the insufficiency of the 
 kidneys. The ingenious theory of Macdonald, however, still leaves 
 unexplained the absence of convulsions in cases where the tissues are 
 necessarily loaded with urea, and their occurrence in instances where 
 either no kidney lesions were present, or where the kidney and cere- 
 bral symptoms were coincident. 
 
 The disposition to ascribe conAiilsions to cerebral ansemia is based 
 upon the experiments of Kussmaul and Tenner, who demonsti'ated 
 that convulsive twitchings might be produced in animals by tying the 
 carotids or by opening the large vessels of the neck and allowing 
 them to bleed to death. It is, of course, anticipated that anaemia due 
 to systole of the arterioles would be followed by the same results. The 
 phenomena of convulsions are twofold, viz., loss of consciousness and 
 tonic and clonic contractions. Loss of consciousness is easily to be ac- 
 counted for by anaemia of the hemispheres, precisely as in cases of 
 ordinary syncope. Convulsions occur, however, when the brain is re- 
 moved, if only the pons Varolii and the medulla oblongata are pre- 
 served. Deiters has shown that the motor fibers of the extremities 
 and the trunk have their first central terminations in the pons. Noth- 
 nagel * has proved that a collection of ganglionic cells in the substance 
 of the pons furnishes the motor center from which the convulsive im- 
 petus takes its departure. According to Schroeder van der Kolk, the 
 groups of gray matter for the cranial nerves are situated in the floor 
 
 * NoTHNAGEL, Ileber den epileptischen Anfall, Volkraann's Samral. klin. Vortr,, 
 Xo. 39, p. 313.
 
 576 THE PATHOLOGY OP LABOR. 
 
 of the fourtli ventricle and in tlie substance of the medulhi oblongata. 
 Any influence producing contractions of the arterioles through the 
 vaso-motor nerves would necessarily produce both coma and convul- 
 sions. As, however, convulsions may take place without loss of con- 
 sciousness, Nothnagel concludes that the same cause which acts indi- 
 rectly through the vaso-motor nerves may independently set in action 
 the centers of muscular movements. 
 
 The foregoing considerations have led writers to divide convulsions 
 into two classes, viz., those due to centric causes and those proceeding 
 from peripheral irritation. In both, cerebral anaemia plays an impor- 
 tant part. In the overwhelming proportion of cases, uremia is re- 
 garded as the fountain and origin of the evil, the term urmnia signify- 
 ing, of course, the action, not of a single constituent of the urine, but 
 of all the excrementitious principles, combined with that of increased 
 arterial tension. Whether, in exceptional cases, carbonate of ammonia 
 or cerebral oedema is present, is a matter of slight moment. The role 
 played by peripheral irritation is not, however, to be overlooked. 
 Without ureemia, though rarely, peripheral irritation can provoke 
 eclampsia. In uremic cases the greater proportion develop during 
 labor. In Lohlein's collection, a hundred and six in number, ninety- 
 three of the patients were parturient. Spiegelberg has frequently 
 seen convulsions awakened in the placental period by the mechanical 
 irritation of the uterus during the employment of the Crede method 
 of expression. 
 
 It may be assumed that the special source of irritation is derived 
 from uterine contractions, which the observations of Braxton Ilicks 
 and Frommel show are not confined to the time of actual labor, ])ut 
 occurs spontaneously during the entire duration of j)regnancy, aiul 
 continue through the retrograde changes of tlie childbed period. 
 Osthoff,* indeed, concludes that all cases of eclampsia have equally a 
 •reflex origin. Thus, an irritation jiroceeding from the uterus may be 
 transmitted through the sympathetic nerves to the kidney alone, ex- 
 citing contraction of the arterioles or, when sufficiently intense, it may 
 travel upward to the vaso-motor center in the medulla oblongata, and be 
 followed by contractions of the arterioles of the entire body. Evidence 
 of such general contraction is sujjplied by the high tension and slug- 
 glishness of the pulse, while the resulting anaemia of the great nerve- 
 centers furnishes the occasion of the epileptic attack. 
 
 The advantage of this formula as a working hypothesis is that it 
 renders intelligible what the uraemic theory has failed to do, the occur- 
 rence of eclampsia without kidney lesion, the frequent presence of kid- 
 ney derangement without eclampsia, and the special gravity of eclamp- 
 sia when complicated by kidney derangement. In questioning the 
 
 * Osthoff, Beitrage zur Lehre von der Eclampsie unci Uraemie, Volkmann'sehe 
 Saramlung klin. Vortrage, No. 29G.
 
 ECLAMPSIA. 577 
 
 connection between uraemia and eclampsia, the danger to life from the 
 retention in the circulation of excrementitious materials is in no wise 
 disputed. 
 
 Convulsions occur more commonly in primiparge than in multi- 
 parfB, especially in elderly primiparas, in twin pregnancies, and in 
 women with contracted pelves. They may occur epidemically in con- 
 sequence of atmospheric conditions, which probably interfere with the 
 functions of the skin, and thus indirectly increase the labor thrown 
 upon the kidneys. 
 
 Treatment. — The occasional examination of the urine of pregnant 
 women is to be regarded as an indispensable precaution. Faint traces 
 of albumen are not infrequently found in the urine of women with 
 harmless catarrhal affections of the bladder. Persistent albuminuria 
 calls for special prophylactic treatment ; for, though convulsions are 
 not to be regarded as the necessary consequence of nephritis, the pres- 
 ence of renal disease immensely increases the danger of sudden acute 
 suppression. Nephritis is, moreover, apt to be aggravated by the 
 pregnant state, and Hof meier has shown that in a considerable pro- 
 portion of the cases which have their origin in pregnancy the kidney- 
 lesions, contrary to the accepted belief, do not disappear spontaneously 
 after parturition. Flaischlen has, however, recently challenged Hof- 
 meier's conclusions. The true renal lesion of pregnancy he regards as 
 due to anasmia of reflex origin, the primary consequence of which is 
 anatomically an alteration in the epithelium of the glomeruli, and 
 clinically albumen in the urine without sediment. In its subsequent 
 course degenerative changes take place in the epithelium of the cana- 
 liculi, and great quantities of albumen with cylinders and epithelia are 
 found in the urine. It occurs first about the middle, or, more fre- 
 quently, toward the close of pregnancy. As distinguished from chronic 
 nephritis, in which the specific gravity of the urine is low and the 
 quantity increased, the specific gravity is high and the quantity dimin- 
 ished. The transition of this form into chronic nephritis he regards 
 as not proved, and a priori improbable.* 
 
 Every precaution should be taken, therefore, to remove from albu- 
 minuric patients all sources of mental excitement, to ward off attacks 
 of indigestion, and to defend them from colds. In oedema of the face, 
 the extremities, and the labia majora, a strict milk diet should be en- 
 joined, and the tincture of the chloride of iron, in full doses, should 
 be given at least four times a day, both for its diuretic and for its hsem- 
 atinic properties, and likewise to improve the tomis of the weakened 
 vessels. If the milk diet is badly supported by the patient, she should 
 be instructed to drink freely of the natural alkaline waters possessing 
 mildly diuretic properties, such as the Vichy, the Selters, the Buffalo 
 lithia-water, the Poland water, and others of like action. To remove 
 
 * Ztschr. f. Geburtsh. unci Gynaek., vol. viii, p. 354. 
 37
 
 578 THE PATHOLOGY OF LABOR. 
 
 the transuded serum, the skin should be compelled to aid the kidneys, 
 either by means of the Turkish bath or, where the latter is not avail- 
 able, by the wet-jDack. Mild laxatives, such as the Friedrichshall, the 
 Hunyadi, or the Saratoga Avaters, are useful in constipation of the 
 bowels. 
 
 If cerebral symptoms threaten the outbreak of convulsions, the 
 nervous irritability should be held in check by rectal injections of 
 chloral and the bromide of potassium (thirty grains each), and a hy- 
 dragogue cathartic should, be promptly administered. Free catharsis 
 unloads the blood of urea, diminishes the arterial tension, and relaxes 
 the arterioles. The immediate results are usually in the highest degree 
 satisfactory. The pain in the head, the sensory disturbances, the 
 stomach troubles disappear, and the patient becomes calm or sinks 
 into a gentle sleep. Lohlein recommends placing the woman in the 
 latero-prone position, in order to diminish as much as possible the 
 pressure upon the ureters and upon the renal veins. 
 
 So far writers are practically unanimous. Whatever differences 
 exist between them relate not to principles, but to the means best 
 adapted to accomplish the end in view. When, however, in sjiite of 
 palliative measures and hygienic precautions, the uraemic symptoms 
 have steadily progressed until the central nervous system has become 
 involved, the question comes uji for decision whether to i:)ersevere in a 
 plan of treatment designed merely to ward off impending danger, or 
 whether to place the patient without delay in a position of relative 
 safety by the induction of premature labor. The weight of authority, 
 it seems to me, is favorable to procrastination, the interruption of 
 pregnancy being regarded as an extreme measure, justifiable only in 
 cases of utmost peril. But premature labor with the indications thus 
 limited, is not likely to save many lives. My own convictions are 
 clear that, so soon as grave cerebral symptons develop, the period of 
 folded hands has passed. The relief to be obtained from chloral and 
 catharsis is, as a rule, of short duration, and we can not go on giv- 
 ing chloral and cathartics to the end of gestation, nor are we sure 
 that the first fortunate results can be reduplicated. Moreover, it is 
 necessary to take cognizance of the well-being of the foetus, which is 
 threatened by the continued circulation of urea in the maternal blood. 
 The induction of premature labor by means of the bougie, aided, if 
 needful, by the vaginal douche and the dilating bags of Barnes, is at- 
 tended with but moderate risk if resorted to after the uraemic symp- 
 toms have been got fairly under control ; if employed as a last re- 
 source, where other therapeutical measures have failed, its use is still 
 justifiable, though it then partakes rather of the nature of a forlorn 
 hope. 
 
 The indications for treatment during the outbreak are for the most 
 part the same as laid down for uremic symptoms unattended by con-
 
 ECLAMPSIA. 579 
 
 vulsions, viz., to lower the arterial tension, to diminish to the fullest 
 extent practicable the irritation of the vaso-motor and convulsive cen- 
 ters, and to restore to the kidneys their normal functions. Spiegel- 
 berg claims that these three indications are most completely fulfilled by 
 venesection. Professor Fordyce Barker pleaded for the restoration of 
 the lancet in the management of puerperal convulsions, insisting upon 
 the unmistakable clinical evidences favorable to its employment. In 
 my student-days in Paris, at the Hopital des Cliniques, where the an- 
 cient usage was in full favor, I well remember my first feelings of alarm 
 at the vigor of the treatment in vogue ; but, after carefully watching 
 the cases to the end, I was led to conclude that the claims of bleeding 
 in eclampsia rested upon a substantial foundation. 
 
 The special advantage of venesection lies in the rapidity of its ac- 
 tion ; incidentally it favors absorption and renders the patient more 
 susceptible to the influence of other remedies. It forms, therefore, 
 naturally the first step in the treatment of convulsions. The quantity 
 of blood to be withdrawn varies from eight to sixteen ounces, accord- 
 ing to the vigor, and, to some extent, according to the size, of the indi- 
 vidual. 
 
 In the May number of the American Journal of Obstetrics, 1871, Dr. H. 
 Fearn, of Brooklyn, contributed an article on Veratrum Viride in Large Doses, 
 as a Substitute for Bloodletting in Puerperal Convulsions, in which he recom- 
 mended the tincture of veratrum in doses varying from fifteen minims to a tea- 
 spoonful, repeated every five or ten minutes until the pulse became soft, or 
 vomiting set in. For several hours after the convulsions are arrested he ad- 
 vises the veratrum to be administered in smaller doses, in order to keep the 
 pulse below fifty to the minute. He claims that the large doses are devoid of 
 danger so long as the convulsions continue. According to Kenyon,* who has 
 recently contributed two cases successfully treated by veratrum, " the drug is 
 quickly absorbed, and enters the circulation rapidly. It enters the vasa vasorum, 
 and through them impairs the sensibility of the vaso-motor nerves, the blood- 
 vessels thus losing their tonicity and power of contraction " — all good argu- 
 ments for its use in convulsions if its safety can be established. 
 
 After bleeding, narcotics and anaesthetics should he resorted to, 
 with a view of preventing the renewal of the convulsions. Chloroform 
 and morphine have long been tested in practice, and have sustained 
 their claims to professional favor. From one sixth to one fourth of a 
 grain of morphine should be injected hypodermically, the same quantity 
 to be repeated in an hour in case of the convulsions returning. Chlo- 
 roform was formerly recommended in full anaesthetic doses, so as to 
 completely paralyze the motor centers. As, however, experience has 
 shown that complete and prolonged anaesthesia is in itself a source of 
 danger, it is advisable, except in cases where labor is nearly at a close, 
 
 * Kenyon, Treatment of Convulsions with Veratrum Viride, N. Y. Med. Jour., 
 October, 1879, p. 370.
 
 580 TPIE PATHOLOGY OF LABOR. 
 
 to restrict the chloroform to the pains, and to the restlessness which 
 is often the preliminary of a fresh seizure. 
 
 The discovery of chloral has added another invaluable agent to our 
 list of available antispasmodics and anfesthetics. It is my present 
 practice, after beginning with chloroform, to administer thirty grains, 
 each, of chloral and bromide of potassium by the rectum, and to sus- 
 pend the chloroform so soon as the sedative effects of the latter agents 
 become developed. The frequency with which the chloral should be 
 given depends upon the frequency and violence of the attacks. A 
 single dose will sometimes exercise a restraining influence for hours, 
 while in other cases in the course of an hour or two the dose will 
 require to be repeated. As a subsidiary measure, with a view to the 
 ultimate relief of the kidneys, the lower bowel should be cleared out 
 with an enema, and a cathartic (a drop of croton-oil, or calomel and 
 Jalap in case the patient is able to swallow) should be given by mouth. 
 
 Breus* warmly recommends the use of the hot bath as a prophy- 
 lactic measure in the renal affections of pregnancy, and as a measure 
 of treatment in conjunction with chloral during the eclamptic attack. 
 The plan he recommends consists in placing the patient up to the 
 neck in a bath of a temperature at first of about 102°, which should be 
 gradually increased to 110° or 112° Fahr. The bed for the reception 
 of the patient should be spread with two blankets covered by a 
 warmed sheet. After a half-hour the patient should be removed from 
 the bath, wrapped in a warm sheet, and placed upon the bed. She 
 should theu be enveloped in the blankets with only the face free, and 
 two more blankets should be laid above the preceding. In a few 
 minutes profuse perspiration sets in, and should be maintained for from 
 two to three hours The covers should then be removed gradually. 
 Foi thirst he gives soda or other sparkling waters. After the sweating, 
 the patients ordinarily sleep a few hours, when they feel well. A 
 comatose condition is no contra-indication, but renders the procedure 
 more difficult. The diaphoresis rapidly diminishes the dropsical symp- 
 toms, and is followed by a decided diminution in the amount of albu- 
 men in the urine. 
 
 As convulsions which occur after the advent of labor have a tend- 
 ency to recur so long as the labor continues, and in the larger propor- 
 tion of cases cease after the birth of the child, every obstetrical re- 
 source compatible with the safety of the mother should be employed 
 to hasten delivery. In the early part of the first stage the pains, if 
 sluggish should be stimulated by catheterization of the uterus. Braun 
 advocates rupturing the membranes, as he claims that the escape of 
 the amniotic fluid often diminishes the frequency and violence of the 
 convulsions. The water-bags of Dr. Barnes, if necessary, should be 
 
 * Breus, Zur Therapie der puerpcnileii Eeliiiiipsie. Arch. f. Gvnaek., vol. xix, 
 p. 219.
 
 POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 581 
 
 used to promote the dilatation of the cervix. Incisions through tlie 
 border of the os externum and accouchement force are unnecessary. 
 After the first stage is completed, if no mechanical disproportion exists 
 between the head and the pelvis, a careful attempt to extract the child 
 with forceps should be made. Every precaution should be used to 
 avoid injuring the softs parts. Obstetrical aid is only warrantable 
 where it can be employed without detriment to the mother. In in- 
 strumental cases, with the head high in the pelvis, I have had every 
 reason to feel satisfied with the Tarnier forceps, exchanging it, how- 
 ever, for one of English pattern so soon as the head is brought to the 
 floor of the pelvis. 
 
 When convulsions occur during pregnancy, the question as to the 
 advisability of at once provoking labor is by no means settled. The 
 material upon which to form an opinion is limited, as in most cases 
 labor-pains occur spontaneously (as a consequence of the convulsions). 
 Where medical treatment alone is employed it is certain that, in the 
 absence of labor-j^ains, a certain proportion recover, and pregnancy 
 may go on to comi)letion. On this account it is commonly advised 
 not to introduce labor as a complication into a state of affairs already 
 sufficiently dangerous and difficult to manage. So far as my own 
 experience goes, however, the practice of waiting upon Nature has 
 proved uniformly disastrous, while the induction of labor has furnished 
 me with a certain proportion of recoveries. Braun declares he has 
 known but one patient to recover between the fourth and sixth months 
 of pregnancy except where abortion had taken place. The question is 
 one, however, concerning which there exists a reasonable degree of 
 doubt, and which can not be settled by the hap-hazard experiences of 
 individuals. 
 
 In the treatment of convulsions during the childbed period the 
 agents used should be opium, chloral, veratrum, or digitalis. Chloro- 
 form and venesection should be employed with extreme caution, if, 
 indeed, they are ever entitled to confidence at that time. 
 
 CHAPTER XXXI. 
 
 POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 
 
 Normal agencies for checking haemorrhage. — Disturbances of contractility, of re- 
 tractility, of thrombus formation. — Treatment. — Method of securing contrac- 
 tion and retraction. — Treatment of cerebral anjemia. — Retained placenta. 
 
 The haemorrhages which occur immediately after the birth of the 
 child may have their origin in the uterus, the vagina, or the vulva. 
 It is customary, however, to consider those which spring from lacera-
 
 gg2 THE PATHOLOGY OF LABOR. 
 
 tions in a chapter by themselves, and to apply the term post-partum to 
 those hemorrhages only which arise from the placental site. 
 
 Unlike other grave complications of childbirth, ^jos^^ar^iow haem- 
 orrhage is not an uncommon event. It may follow the simplest of 
 labors, and, in case of an unprepared physician, it may carry his patient 
 in a few moments to the brink of death.- It is impossible to conceive 
 a tragedy more terrible than this. Occurring, as the accident does, 
 suddeiily, without warning, in the period of joy that follows the birth of 
 a living child, the sudden shifting of the scene becomes appalling. If 
 the mother dies at such a time, the luckless attendant who stands at 
 her bedside, a nerveless spectator, need never expect forgiveness ; nor 
 can he shield himself behind the recorded ill-successes of others. 
 Every competent accoucheur knows in his own heart that he has no 
 right to shirk his personal responsibility in cases of fatal jjost-jjartuni 
 hsemorrhage, or to meanly throw the blame upon Providence. 
 
 The treatment of post-partum haemorrhage is one of the most sat- 
 isfactory departments of obstetrical practice. In no other emergency 
 is the saving of life so little dependent upon chance, and so much upon 
 intelligent human intervention. Successful treatment is, however, less 
 the result of a . familiarity with the various procedures extolled by 
 writers, than of a correct understanding of the mechanism by means 
 of whicli the arrest of the ha?morrhage is to be effected. 
 
 Normal Agencies for checking HsBmorrhage.— In normal cases the 
 flow which follows the detachment of the placenta is of brief duration. 
 The torn arterial twigs retract spontaneously, the patulous mouths of 
 the veins become plugged with fibrinous clots, while the so-called ve- 
 nous sinuses, which are simply channels lined with endothelium, with- 
 out valves or walls, become bent, flattened, and obliterated under the 
 compression exerted by the muscular structures of the uterus. 
 
 The first requisite against ha?morrhage is the maintenance of firm 
 uniform contraction of the uterus. The contractions, which persist 
 with lessened force after the birth of the child, during their continu- 
 ance alone suffice to prevent haemorrhage from the placental site. The 
 two diagrams borrowed from Professor Breisky serve to illustrate the 
 mechanism by which this is effected. In the transition from a to h 
 the uterus, which shortly before harbored the entire ovum, becomes 
 reduced to a body not larger than the two fists. But the duration of 
 the contractions is short, with an ever-increasing interval between 
 them. If their cessation were followed by the return of the uterus 
 from h to a, the blood would once more rush into the sinuses, the 
 mouth of the veins would open, the thrombi would be washed out by 
 the pressure brought to bear upon them, and flooding would of neces- 
 sity ensue. That this does not take place is owing to the same force 
 which in labor keeps the uterus closed upon its contents during the 
 descent of the foetus— viz., tonic retraction.
 
 POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 583 
 
 The tonic retraction of the uterus is in part the consequence of 
 shortening of the muscuUir fibers, and in part of tlieir rearrangement, 
 a tliickening of the uterine walls resulting, as the cell-elements, in place 
 of standing end to end, assume a position more nearly parallel to one 
 
 Fig. 223. 
 
 another. Retraction is a permanent acquisition of the uterus, and 
 alone suffices to prevent the occurrence of haemorrhage. The differ- 
 ence between it and contraction is exhibited by the difference in the 
 consistence of the liost-partum uterus during and between the pains. 
 The contracted uterus is hard and firm like a billiard-ball, while the 
 retracted organ is relatively soft and relaxed. The two properties, 
 though distinct, are not, however, independent of one another. When- 
 ever the contractions are good, the retraction is well marked also. 
 Whatever diminishes the contractile powers of the uterus is followed 
 .by a corresponding falling off as regards its retraction. 
 
 In cases where the muscular structures of the uterus fulfill their 
 normal functions, the formation of thrombi is of subordinate impor- 
 tance as a means of arresting haemorrhage. Confined to the adherent 
 portion of the decidua serotina, they impart an uneven surface to the 
 placental site. Thrombi which extend to the intermuscular veins are 
 pathological. It is only when the uterus is flabby, and the muscular 
 action is in default, that the thrombi exercise any marked influence in 
 the control of haemorrhage, and even then they bear so close a rela- 
 tionship to puerperal thrombosis as to approach dangerously near to 
 the confines of pathology. 
 
 The causes of post-partum haemorrhage are to be sought for in dis- 
 turbances of the mechanism by which haemorrhage is normally pre- 
 vented. 
 
 Disturbances of Contractility. — Contractions of the uterus may fail
 
 gg^ TtlE PATHOLOGY OF LABOR. 
 
 from lowering of the muscular irritability. Atony follows most fre- 
 quently exhausting labor, artificial deliveries, rapid evacuation of the 
 uterus, especially in multiparse, where the failure to contract has often 
 the significance of a prolonged pause, excessive distention (hydram- 
 nios, twins), profuse haemorrhages, collapse, nervous depression, and 
 severe general ailments. 
 
 Again, in other cases, the functional disturbance may proceed from 
 some abnormal condition of the muscular fiber. Thus, the defects of 
 contractility may spring from incomplete development, as in anoma- 
 lies of formation, in textural changes due to some antecedent disease 
 or puerperal condition, especially as to the result of many previous 
 confinements, or finally from inflammatory infiltrations having their 
 source in the bruising of the lower uterine segment during labor. 
 
 The contractions of the uterus may be mechanically interfered 
 with over limited areas by retained portions of the placenta and of the 
 membranes, by peritoneal adhesions, by tumors in the walls of the 
 uterus or in the uterine appendages, or by a distended bladder or 
 rectum. 
 
 Disturbances of Retractility.— AVe have already seen that the tonus 
 of the muscular fibers is lowered, and that their rearrangement is in- 
 complete, whenever the uterine contractions are in default. At the 
 same time the retraction of the uterus may be directly hindered by 
 mechanical causes, especially by those which, like the placenta, the 
 ■membranes, or coagula of blood, when retained in the uterine cavity, 
 prevent, in spite of continued contractions, a sufficient closure of the 
 veins. 
 
 Disturbances in Thrombus Formation. — The disturbances whicli 
 interfere with the formation of thrombi occur for the most part in 
 those cases in which, owing to the defective action of the muscular 
 structures, the blood-stream arrives at the mouths of the vessels with 
 unchecked rapidity. As a consequence, coagulation does not take 
 place, or the coagula are of soft consistence, and ofter but feeble resist- 
 ance to any sudden increase of blood-pressure, or become mechanically 
 detached by restless movements on the part of the patient, or by strain • 
 ing with the abdominal muscles. 
 
 Outlying Causes of Post-partum Haemorrliage.— The remote causes 
 of post-partum haemorrhage — i e., those not immediately connected 
 with the uterus — all act by indirectly interfering with either the con- 
 tractility or the tonus of the muscular fiber, or with the thrombus for- 
 mation. This they do by influences exerted either through the nerv- 
 ous system or through the circulation. Thus, the muscular irrita- 
 bility may be impaired by general debility, by wasting diseases, from 
 impoverishment of the blood due to suffering and muscular effort, from 
 psychical impressions, and from the external influences of heat and 
 vitiated air. The normal tonus of the uterine muscles may be over-
 
 POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 585 
 
 come, and the formation of thrombi disturbed, by any condition of the 
 circuhitory system associated with increased pressure in the venous or 
 arterial trunks. The pressure in the uterine veins may be augmented 
 by the patient's getting up suddenly in bed, by acts such as coughing, 
 laughing, sneezing, vomiting, and defecation, in which the abdominal 
 muscles are called into play, and by all the conditions which pro- 
 duce chronic congestion of the pelvic organs. Increase of arterial 
 tension as a cause of haemorrhage is rare. Breisky mentions a case 
 where, in a multipara without valvular heart-disease, the cause of the 
 haemorrhage was apparently due to intense palpitation of the heart 
 associated with the hard, incompressible pulse indicative of arterial 
 fullness.* 
 
 Treatment. — It is not necessary to dwell upon prophylactic meas- 
 ures. As has been shown in the survey of the causes of post-partum 
 hcemorrhage, they comprise everything that has been said concerning 
 the proper management of labor. 
 
 Methods of securing Uterine Contractions. — It is my own practice, 
 and one I would urge upon others, to make provision in the simplest 
 of cases against the possible occurrence of hajmorrhage. In the be- 
 ginning of the second stage, I examine my Davidson syringe to make 
 sure that the valves are in good working order. I then direct a small 
 table to be set by the bedside of my patient, and place upon it a bowl 
 containing pieces of ice of about the size of a hen's-egg, brandy, sul- 
 phuric ether, neutral perchloride of iron, carbolic acid, ergot, a solu- 
 tion of morphia, a can of iodoform gauze, and a hypodermic syringe 
 filled with a fluid extract of ergot or two grains of ergotin in solution. 
 Within easy reach I likewise have placed a pitcher of hot water, 
 another of cold water, an empty basin containing the Davidson, or, 
 still better, a fountain syringe, and a bed-pan. All this requires but a 
 few moments' time, and it is of no mean advantage to feel, in case 
 haemorrhage follows the birth of the child, that all the appliances for 
 prompt action are in order and close at hand. 
 
 If hemorrhage takes place, in spite of the fact that the uterus has 
 been carefully guarded by external pressure during the period of de- 
 livery, draw the pillows from under the head of the patient, direct the 
 nurse to open the windows, and ijiject the ergot contained in the hypo- 
 dermic syringe into the outer surface of the thigh. Ergot by the 
 mouth acts too slowly to prove of service in the face of a great emer- 
 gency; besides, in many patients ergot by the mouth excites nausea, 
 and is not absorbed by the stomach ; hypodermically its action is, as a 
 
 * The foregoing description is little more than a transcript of the principles 
 enunciated in Breisky's clinical lecture, Ueber die Behandlung der puerperalen 
 Blutungen (Volkmann's Samml. klin. Vortr., No. 14, 1871). I have found them 
 of the utmost service to me in practice during the ten years past, and believe with 
 Breisky that they furnish the key to successful prophylaxis and treatment.
 
 586 
 
 THE PATHOLOGY OF LABOR. 
 
 rule, rai^idly developed. Then introduce the hand into the uterus. If 
 a full bladder interferes, draw off the urine with a catheter. 
 
 The introduction of the hand into the uterus I believe to be a 
 matter of the utmost importance. When combined with external 
 pressure it stimulates the uterus to contract. The placenta, if ad- 
 herent, should be detached with the tips of the fingers ; if loose within 
 the uterine cavity, it should be withdrawn slowly, taking care to re- 
 move the membranes entire. Bits of placenta or strips of membrane 
 should be carefully scraped from the uterus, remembering that this is 
 most easily effected during the contraction of the organ. Even if the 
 placenta and membranes are expelled apparently entire, it is still de- 
 sirable to pass the hand into the uterus to clear out clots, and to make 
 sure that no part of the ovum has been left behind. Once I lost a 
 hospital patient by neglecting this rule. The hemorrhage was checked 
 by compression, and upon careful inspection of the placenta and mem- 
 branes I convinced myself that everything had come away. The pa- 
 tient died on the eighth day, of se^jticaemia. The autopsy revealed 
 the presence of a small placenta siiccenturiata, of the existence of 
 which, aside from the haemorrhage, there had not been the slightest 
 indication. 
 
 So soon as the uterus has been emptied of everything capable of 
 preventing contraction and retraction from taking place, withdraw the 
 
 Fig. 234.— Bimanual compression of uterus. (Breisky.) 
 
 hand into the vagina, and, with the index and middle fingers in the 
 posterior cul-de-sac, press the cervix forward toward the body of the 
 uterus. With the external hand grasp the uterus through the abdomi- 
 nal walls, compress it firmly and push it downward toward the pelvis and 
 forward against the pubic bone. By this manoeuvre the cervix is closed, 
 the uterine walls are brought into contact with one another, and con-
 
 POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 587 
 
 tractions are stimulated by the direct irritation of the large cervical 
 ganglion and by the kneading of the fundus. Breisky states that in 
 many cases it is j^ossible to combine compression of the aorta with the 
 foregoing maniijulation. 
 
 If bimanual compression fails to speedily secure contractions, with- 
 out removing the internal hand, pieces of ice may be slipped into the 
 vagina,. and thence pushed upward into the uterine cavity. With rare 
 exceptions the uterus responds at once to the stimulus of cold applied 
 to its inner surface. Should it not do so, however, the bed-pan should 
 be placed under the hips, and boiled water of about 112" Fahr. should 
 be injected into the uterus, care being taken to expel previously all air 
 from the tube of the syringe. The injection should be made slowly 
 and without force, allowing the fluid to escape joari passu with its 
 introduction. 
 
 The most important factor in the arrest of haemorrhage unques- 
 tionably consists in acting promjitly upon the first signal of danger. 
 If through lack of preparation profuse haemorrhage should occur, the 
 overcoming of the resulting atony may tax to the utmost the re- 
 sources of the attendant. As an effective remedy against this condi- 
 tion the per-salts of iron added to the intra-uterine douche still enjoys 
 professional favor. It is, however, many years since I have found it 
 necessary to resort to their use. This I consider fortunate, for, though 
 there is abundant testimony as to the efficacy of the per-salts of iron in 
 post-pa rfum haemorrhage, the arrest of the flow appears, in some cases 
 at least, to have been achieved at too dear a price. Barnes refers the 
 haemostatic effect of the iron — 1. To its direct action in coagulating 
 the blood in the mouths of the vessels ; 3. To its action as a powerful 
 astringent on the inner membrane of the uterus, whereby the surface 
 becomes corrugated and the mouths of the vessels are coustringed ; 3. 
 To the fact that it often provokes some amount of contractile action of 
 the muscular wall. Trask, in recommending the substitution of tinct- 
 ure of iodine for the solution of the perchloride of iron, maintains that 
 it is the third mode of action that should be placed first in the order of 
 importance. This corresponds with my own experience. In two cases 
 Avhere Monsel's solution was used the uterus contracted promptly, and 
 the injection was followed by no disturbing effects. In the third the 
 uterus remained large and flaccid, notwithstanding the haemorrhage 
 was arrested. For two days the patient did well; on the third the 
 lochia became excessively offensive, the respirations stertorous, and the 
 pupils dilated ; general paralysis ensued, and death followed within 
 twenty-four hours of the attack. Although no autopsy was made, it 
 was clear to me at the time that the coagulation had followed the ves- 
 sels to the substance of the uterus, and that the fatal result was due 
 to the absorption of septic material by the large, soft thrombi, which, 
 by their disintegration, became the means of conveying infection to
 
 588 
 
 THE PATHOLOGY OF LABOR. 
 
 the remoter portions of the organism. Barnes formerly used the per^ 
 chloride of iron after preliminary removal of the clots, in the propor- 
 tion of one of iron to three of water. Most German authorities rec- 
 ommend the iron in a much more dilated form, and using it in no 
 fixed proportion, but simply to pour the iron, following Seyfert's pre- 
 scription, into the water until the latter assumes a deep wine-color. In 
 his later writings Barnes seems to regard a mixture of one part of per- 
 chloride to ten or twelve of watBr as adequate. 
 
 Wallace * praises vinegar as a certain and safe remedy for post-jxtr- 
 tum haemorrhage : " I pour a few tablespoonfuls into a vessel," he 
 says, " dip into it some clean rag or a clean pocket-handkerchief. I 
 then carry the saturated rag with my hand into the cavity of the ute- 
 rus, and squeeze it ; the effect of the vinegar flowing over the sides of 
 the cavity of the uterus and the vagina is magical. The relaxed and 
 flabby uterine muscle instantly responds. The organ assumes what I 
 will term its gizzard-like feel, shrinking down upon and compressing 
 the operating hand, and in the vast majority of cases the ha?morrhage 
 ceases instantly. Should one aj^plication fail to secure a sufficient con- 
 traction, the rag can be withdrawn, and a second or even a third can 
 be made, until the uterus shall contract sufficiently to stop the flow of 
 blood." 
 
 Probably the farad aic current is a most efficient agent in securing 
 contractions of the uterus, but, unlike vinegar and hot water, a bat- 
 tery is rarely on hand when needed. An olive-shaped bulb electrode 
 should be introduced into the uterus, and the other pole, a flat disk, 
 pressed upon the fundus ; or both poles may be applied directly over 
 the uterus through the abdominal walls. 
 
 I have in a number of instances seen Dr. I. E. Taylor succeed in 
 instantaneously causing the uterus to contract by slapjiing the lower 
 part of the abdomen smartly with a wetted towel. 
 
 Compression of the aorta through the abdominal walls is capable 
 of rendering temporary service. The method has been objected to on 
 theoretical grounds : first, because the compression is brought to bear 
 equally upon the vena cava as upon the aorta ; and, second, because 
 the pressure does not cut off the blood which goes to the uterus 
 through tlie aortic uterine arteries. As a clinical fact, however, it is 
 indisputable that the pressure does, temporarily at least, check the 
 hasmorrhage, a result attributed by Frankenhaeuser to the simulta- 
 neous stimulation of the aortic uterine plexus, as that portion of the 
 sympathetic nerve is termed which overlies the large vessels of the 
 trunk situated in the lumbar region. 
 
 The application of ice to the abdomen, or allowing a stream of cold 
 water to fall from a height upon the hypogastrium, however efficacious 
 they may prove as means of arresting hemorrhage, are open to the 
 * Trans. Am. Gynaecol. Soc, vol. iii.
 
 POST-PARTUM HEMORRHAGE AXD RETAINED PLACENTA. 589 
 
 grave objection that they add to ah*eady existing shock and to the 
 prostration produced by the loss of blood. 
 
 Methods of securing Uterine Eetraction. — Uterine contractions 
 afford only a temporary safeguard against hemorrhage. It is uterine 
 retraction that prevents recurrence. At first the hand furnishes the 
 most available means of exercising external compression. It likewise 
 possesses the advantage of being an intelligent instrument, capable of 
 conveying to the accoucheur instant warning of any tendency to relax- 
 ation. But, even after retraction is secured, its maintenance should 
 not be left to chance. Before leaving his patient, the physician should 
 provide some means of subjecting the uterus to sustained and equable 
 pressure. The usual method consists in surrounding the anteverted 
 organ with folded napkins or rolled stockings, and then applying a 
 bandage tightly to the abdomen to keep them in position. Unless 
 skillfully executed, this method accomplishes little more than to dis- 
 locate the uterus laterally. I have been in the habit of using a round 
 bag of rubber covered with brown muslin, which I i:)artial]y fill with 
 cold water, and apply over the uterus. The dry cold is of value as a 
 means of exciting contraction, while the hydrostatic pressure is evenly 
 distributed over the fundus of the uterus, and helps to fix it in the 
 median line. A reliable compress may be improvised in any house- 
 hold by partially filling a sack with moistened sand or common salt. 
 
 More recently Diihrsseu * has advocated the packing of the uterine 
 cavity with iodoform gauze. The method he pursues is as follows : 
 When the uterus does not respond to kneading and an ergotin injection, 
 he first, with the patient placed crosswise in bed, washes out the vagina 
 and uterus with a three-per-cent solution of carbolic acid, then passes the 
 fingers into the uterus to make sure that it is empty, and finally, with 
 the cervix drawn to the vulva with volsella forceps, or under the guid- 
 ance of two fingers passed to the cervix, a strijD of iodoform gauze is 
 pushed by means of uterine forceps to the fundus and cavity of the 
 uterus until the latter is completely filled. The result is said to be the 
 immediate arrest of hemorrhage due to the intra-uterine comj^ression, 
 and the contraction of the uterine muscle. Dr. Polk has tried the 
 method in the Bellevue Hospital, and has been favorably impressed 
 with its efficacy. Diihrssen advises that the packing be extended 
 from the uterus to the vagina to control hemorrhages due to lacera- 
 tions, but in tears of the cervix as well as in those about the vulva, the 
 practitioner will find the suture the safest, the simplest, and the most 
 certain haemostatic. 
 
 Treatment of Anaemia.— In consequence of excessive loss of blood, 
 the surface of the body becomes blanched, cold, and bedewed with 
 clammy perspiration ; a feeling of muscular prostration is experienced, 
 
 * DuHRSSEX, Ueber die Behandlung der Blutungen post-partum, Volkmann'sche 
 Sammhing, No. C-IT.
 
 590 
 
 THE PATHOLOGY OF LABOR. 
 
 with distress in the prrecordial region ; thirst follows the rapid absorp- 
 tion of serum from the parenchymatous organs to make good the loss 
 of fluid in the blood-vessels ; the pulse becomes small and frequent, 
 the respiration rapid, and air-hunger is developed as the result of the 
 deficient amount of oxygen carried by the attenuated blood-stream to 
 the tissues and the medulla oblongata. AVith these general symptoms 
 are associated special ones due to disturbances of the nerve-centers, as 
 restless movements from side to side, yawning, vomiting, perversions 
 of the special senses, fainting, and convulsions. 
 
 Now, it is to these latter symptoms, indicative of intense cerebral 
 anaemia, and directly imperiling the life of the patient, that treatment 
 requires to be especially addressed. The pillows should be withdrawn 
 from the head, the foot of the bed should be raised, hot bottles should 
 be placed to the extremities, and warm cloths to the head ; if syncope 
 occurs, the abdominal aorta should be compressed to reserve the entire 
 blood-mass for the upper portion of the trunk and the brain ; cerebral 
 congestion should be promoted by opiates (thirty drops of laudanum by 
 the mouth, or ten minims of Magendie's solution hypodermically in- 
 jected), and the flagging heart should be stimulated by hypodermic 
 injections of sulphuric ether, brandy, or whisky. The syringe should 
 be filled with the agent chosen, and the injection should be made deep 
 into the subcutaneous cellular tissue on the outer ])art of the thigh. 
 The effect upon the circulation is almost instantly manifested. Ex- 
 cept in cases whicli have passed beyond all possiliility of recovery, the 
 pulse reappears at the wrist, often, however, to fade away again in a 
 few minutes. The stimulant injections in many cases require to- be re- 
 peated a number of times before the circulation becomes re-established. 
 So long, however, as there is a perceptible response to the stimulus, tlie 
 case is never to be regarded as hopeless. 
 
 Dr. Gaspar Griswold has employed successfully in a number of 
 cases, where the heart had apparently beat for the last time, intra- 
 venous injections of ammonia, using for the purpose a five-per-cent 
 solution (the officinal solution diluted with equal parts of water), and 
 injecting with a hypodermic syringe from fifteen drops to a half- 
 drachm into one of the superficial veins of the forearm. 
 
 In the collapse resulting from excessive hemorrhage, the restoration 
 of blood to the circulation by transfusion is theoretically the rational 
 mode of treatment. In practice, however, the difficulties of the tech- 
 niqiie, the hesitation of bystanders to furnish the required blood, com- 
 bined with the somewhat unsatisfactory outcome of transfusion experi- 
 ments, are all obstacles to its employment. More favorable results 
 have, however, been obtained by substituting weak solutions of common 
 salt for blood in cases where transfusion has been'^ndicated. Although 
 -the saline solution can not replace blood, it has been proved to be a 
 harmless agent, and capable of performing a useful part by so far restor-
 
 POST-PARTUM HAEMORRHAGE AND RETAINED PLACENTA. 59 1 
 
 ing the meclianicul conditions of circulation as to furnish a basis for 
 analeptic treatment. The transfusion apparatus needed is of the sim- 
 plest character, viz. : A glass funnel, a piece of rubber tubing eighteen 
 inches in length, and a canula of glass or metal for introduction into 
 the vein selected. The strength of the solution employed should not 
 exceed five to six grains to the pint (0-6 per cent to 0-75 per cent). 
 Before ojierating the instruments, the utensils, and the solution should 
 be thoroughly sterilized. The temperature of the solution should be 
 from 100°-103°. The amount injected varies from a pint to a quart. 
 The transfusion should take place slowly, under a pressure of from ten 
 to eighteen inches. The ordinary time required is from fifteen to 
 thirty minutes. When the process is ended a double ligature should 
 be applied to the vein, and the wound should be covered with an anti- 
 septic dressing.* 
 
 After the heart's action has once been established, the efforts of the 
 physician should next be directed to the filling of the emptied vessels 
 and the restoration of the arterial tension. With the restoration of the 
 cardiac pulsations, the absorption from the stomach is very active and 
 rapid. To avoid vomiting, however, it is necessary that fluids adminis- 
 tered by the mouth should be given in small quantities and at brief 
 intervals. I usually begin Avith either hot strong tea, without milk, or 
 with brandy-and-water (1 : 2), at first a teaspoonful at a time, repeating 
 the quantity every minute, then giving a tablespoonf ul of any warm 
 liquid every five minutes, carefully testing the capacity of the stomach 
 to dispose of its contents, withholding everything with the first premo- 
 nition of nausea, until milk, broths, tea, gruel, and the like are found 
 to be tolerated in ordinary quantities. Fluid nourishment should be 
 continued hourly, with ice and water in the intervals, according to the 
 thirst experienced, until the radial pulse is restored to its normal full- 
 ness. For the successful management of these cases it is necessary that 
 the physician assume the entire charge. It is not possible to give direc- 
 tions to a nurse which may not at any moment require modification. 
 
 In cases of excessive loss of blood a tourniquet to each femoral ar- 
 tery, a roller bandage, or, better still, an Esmarch bandage applied the 
 length of the lower extremities, may be temporarily employed with a 
 view to saving the limited amount of blood in the circulation for the 
 important organs of the trunk and for the nerve-centers. 
 
 Where the pulse is extremely rapid, the subcutaneous injection of 
 one fiftieth of a grain of digitalin is reported to act favorably by caus- 
 ing contractions of the arterioles and of the uterus. 
 
 O^nates should be administered from time to time during convales- 
 cence, the frequency and quantity depending upon the intensity of the 
 headache which acute anaemia induces. 
 
 * Otto Leichtexsterx, Ueher Koohsalz infusion bci Verblutungen, Yolk- 
 maun'sche, Sammhing, No. 25, Xeue Fol^c, p. 253.
 
 592 THE PATHOLOGY OF LABOR. 
 
 The Puerperal Haemorrhages.— Ha?morrliages occurring after the 
 first day following confinement are the result either of the separation 
 of the thrombi from the placental site or of a congested condition of 
 the endometrium. 
 
 Before the consolidation of the thrombi is completed, the mouths 
 of single vessels may be opened by any sudden increase of pressure in 
 the uterine vessels. A relaxed state of the uterus, obstacles to retrac- 
 tion, fecal accumulations, and malpositions of the uterus predispose to 
 the occurrence of haemorrhage. Common causes of late haemorrhages 
 are sitting up or leaving the bed at too early a period, exertions in car- 
 ing for the infant, and straining at stool. In the case of a small, thin 
 woman who flowed profusely in the second week, I found the uterus 
 crowded backward and downward to the pelvic floor by the compress, 
 which had been too tightly bandaged upon tlie abdomen by the indis- 
 creet zeal of the nurse. 
 
 Where portions of the ovum have been allowed to remain behind 
 in the uterus, they may lead to the formation of fibrinous polypi, 
 which, as in the non-puerperal uterus, occasion a vascular condition of 
 the mucous membrane, and become the cause of protracted bleeding. 
 
 The treatment of late haemorrhages consists in rest in the horizon- 
 tal position, in carefully regulated diet, in emptying both bladder and 
 rectum, in the correction of displacements, and in the use of hot vagi- 
 nal injections. In excessive anteve'rsion a compress above the pubes 
 is indicated ; in retro-displacements, lifting the uterus into position, 
 maintaining it in place by a suitable pessary, is often at once followed 
 by relief. If other causes can be excluded the uterine cavity should 
 be explored, and retained bodies, if found present, should be removed. 
 When the cervix is patulous this can be accomplished by the finger ; 
 if the cervix is partially closed, or if inflammation be present, the wire 
 curette, can be used, as after abortion, without preliminary dilatation. 
 In curetting the uterus the operator should be mindful of the delicacy 
 of the newly forming mucous membrane, and should feel carefully for 
 the offending bodies. If the bleeding continues the uterine cavity may 
 be tamponed with iodoform gauzeN- 
 
 Retaixed Placenta. 
 
 Retained placenta is so frequently a cause of hindered uterine re- 
 traction that a few words concerning the etiology and treatment of 
 the condition form an appropriate appendix to the discussion of post- 
 partum haemorrhage. 
 
 Cases of so-called placental retention are often simply the result of 
 injudicious management. Thus, they may be caused by pulling in 
 such a way upon the cord as to draw the center of the placenta into 
 the cervix, so that, without allowing air to pass by the placenta to the 
 uterine cavity, extraction is rendered impossible; or, Avhen Crede's
 
 POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 593 
 
 method is practiced, the operator may, by pressing the fundus forward 
 against the pubes instead of downward in the axis of the pelvis, pro- 
 duce an acute anteflexion, with stenosis of the lower uterine canal. 
 
 True retentian may be due to the^ large size of the placenta or to 
 pathological adhesions, either of the placenta itself or of the chorion. 
 
 An adhe rent_j )lacenta is of rare occurrence, and can usually be 
 traced to a bygone endometritis. Separation normally takes place in 
 the areolar layer. If the glandular walls which constitute the septa 
 of the areola consist of tough intercellular substance instead of soft 
 tissue abundantly supplied with cells, the separation does not take 
 place, and the placenta remains adherent. The thick bands which 
 have to be severed in removing the placenta are in general the straight 
 trunks of the villi, which run from the chorion to the serotina, the 
 separation taking place not in the decidual but in the fetal layer. In 
 placentitis the bands consist of thickened decidual tissue extending 
 between the cotyledons. In either case the serotina is left nearly or 
 quite entire; in some instances, owing to their firm attachment, whole 
 lobules may be left behind. 
 
 Adhesions of the chorion may be due to thickening of the septa 
 in the areolar layer ; to defective involution of the cell-layer of the 
 decidua, thickened portions of which in consequence remain attached 
 to the separated chorion ; to secondary adhesions from consolidated 
 masses of fibrine, the remains of apoplectic effusions into the decidua ; 
 and, perhaps, to excessive development of villi upon portions of the 
 smooth chorion, from which proceed thick bands which are firmly 
 united to the decidua (Spiegelberg). Adhesions of the chorion inter- 
 fere with the separation of the placenta only when situated high up or 
 around the placental border. 
 
 The Artificial Separation of the Placenta.— AVhenever compression 
 of the uterus proves unavailing to procure the expulsion of the pla- 
 centa, the operator should seek to aid the delivery by the resources of 
 art. To leave the placenta within the uterus not only exposes the 
 patient to the risks of haemorrhage, but to the even greater danger of 
 decomposition and of septic poisoning. A digital examination will 
 indicate the proper course to be pursued. If the placenta be found 
 covering the os, a finger should be introduced to bring down a placen- 
 tal border. If no adhesions exist, moderate tractions upon the cord 
 will then suffice to deliver the placenta. Spiegelberg recommends 
 using the vaginal finger as a pulley to cause the tractions upon the 
 placenta to be made in a vertical direction. 
 
 If tractions upon the cord are insufficient, or if the cord begins to 
 tear, the outer hand should make counter-pressure upon the fundus, 
 while the fingers of the vaginal hand are passed upward into the uter- 
 ine cavity. At first a point should be selected where the placenta is 
 already partially detached, and the fingers should be employed to roll 
 38
 
 594 THE PATHOLOGY OP LABOR. 
 
 the placenta away from the uterine wall. If the attachment of the 
 placenta is firm, the fingers should be extended with the back of the 
 hand to the uterus, and the separation attempted by a side-to-side 
 movement, as in cutting the leaves of a book. Contractions are here 
 of great service, as they both facilitate the separation and serve to ren- 
 der distinct the border-line between the placenta and the uterus. 
 Hildebrandt advises following the cord upward and separating the 
 placenta with the hand covered by the membranes, as a means of 
 avoiding the dangers of infection and of injuring the internal uterine 
 surface. Spiegelberg says that in his experience this method has suc- 
 ceeded only where the placental attachment was loose and the separa- 
 tion easy. 
 
 Bands should be divided by pressing them between the thumb-nail 
 and the index-finger. When the placenta is situated upon the anterior 
 wall, the patient should be placed upon the side. When the placenta 
 is everywhere adherent, a thickened border should be chosen as the 
 point for commencing the detachment. In a very thin, diffused pla- 
 centa, it has been proposed by Ilohl to inject the vessels through the 
 umbilical vein. 
 
 The operati9n of separating the placenta should never be per- 
 formed hurriedly. Every pains should be taken to avoid injuring the 
 uterine surface, and as little jjlacental tissue as j)0ssible should be left 
 behind. 
 
 When the detachment of the placenta is completed, it should be 
 grasped from above in the full hand, and its expulsion should be 
 effected by external pressure. If portions of the membranes are torn 
 away during delivery, they should be sought for and carefully re- 
 moved. 
 
 In every case of artificial placental delivery the cavity of the uterus 
 should subsequently be thoroughly irrigated with warm carbolized 
 water. 
 
 CHAPTER XXXII. 
 
 PLACENTA PREVIA. — ACCIDENTAL HAEMORRHAGE. — INVER- 
 SION OF THE UTERUS. 
 
 Situation.— Varieties.— Frequency.— Causes of haemorrhage.— Clinical features.— 
 Prognosis. — Diagnosis.— Treatment.— Accidental haemorrhage.- Inversion of 
 the uterus. 
 
 Situation.— Normally the placenta, as we know, is situated at the 
 fundus and upon the side walls of the uterus. It is said to be prcBvia 
 when it occupies that portion of the uterus which is subject to disten- 
 tion during labor, or, in other words, to the spherical surface of the
 
 PLACENTA PREVIA. 595 
 
 lower portion of the uterus. Its clinical importance is proportioned 
 to the extent of the placental segment which overlaps the os internum. 
 Hence it is customary to distinguish — 
 
 Varieties. — 1. Placenta prcBvia centralis, where, after the dilata- 
 tion of the OS internum has become complete, the placenta only can be 
 felt. 
 
 2. Placenta jircevia partialis, where, with dilated os, there is recog- 
 nizable a portion of the membranes, as well as a segment of the pla- 
 centa. 
 
 3. Placenta prcBvia lateralis, or marginalis, where the placental 
 border stretches down to, but not beyond, the margin of the inner cer- 
 vical ring. 
 
 Observations which tend to prove the attachment of the placenta in 
 part to the cervical mucous membrane are unquestionably erroneous. 
 The fact, first stubbornly insisted upon by Professor I. E. Taylor, has, 
 at least among jDhysiologists, passed beyond the realm of dispute. 
 Kuhn,* who investigated the subject in conjunction with Carl Braun, 
 found that in no case was the placental portion which occupied the 
 cervical canal adherent to the canal-walls, but that in all post-morteni 
 examinations the remains of the jilacenta prgevia materna ended by a 
 sharp border-line at the os internum. 
 
 An exact central implantation of the placenta is extremely rare, 
 though its occurrence is not impossible. Usually in the so-called cen- 
 tral form not more than one sixth to one fourth of the placental sur- 
 face overlaps the os internum. The smaller segment is oftener found 
 upon the left side (37 :56, statistics of L. Muller).f 
 
 Owing to the deficient thickness of the decidua in the vicinity of 
 the internal os, the placental villi grow with less profusion at that 
 point, while by way of compensation in more favored localities they 
 attain to an excessive development. The placenta thus assumes a char- 
 acteristic uneven appearance. If the atrophic conditions exist over a 
 wide extent, the surface of the placenta is, as a rule, correspondingly 
 increased. 
 
 Another peculiarity not devoid of practical interest is the frequency 
 w^th which the placenta is found adherent to the uterine walls. Of 
 142 cases, L. M tiller showed that in 56 adhesions existed. The inser- 
 tion of the cord into the placenta is usually eccentric, often marginal, 
 and sometimes velamentous. As a consequence, prolapsed funis is a 
 common accompaniment of the anomaly. 
 
 Fortunately, placenta praevia is of rare occurrence. Miiller, by add- 
 ing together the statistics of various investigators, found reported 813 
 
 * Braun, Lehrbuch der ges. Gynaek., p. 555. 
 
 t LuDWiG MuLLER, Placenta Praevia. Stuttgart. 1877. Most of ray statistics are 
 taken from this work. They include those of Trask (Am. Jour, of the Med. Sci., 
 1856, vol. viii) and of most of the later writers, up to date of publication.
 
 596 
 
 THE PATHOLOGY OF LABOR. 
 
 instances in 876,432 births, or not quite one case in a thousand. Since 
 the opening of the Emergency Hospital in this city there have been 
 between 1,500 and 1,600 women confined in that institution. So far 
 there has been no case of placenta praevia. Lomer,* on the other hand, 
 estimates the minimum frequency in Berlin at one in 723 births. 
 
 Etiology. — The causes are unknown. The proportion of multiparte 
 to primipara3 is very large (6 : l).f Placenta prsevia is most frequent 
 in women who have borne children with great rapidity, and in preg- 
 nancies shortly following abortions, conditions which favor relaxation 
 of the uterine walls, dilatation of the cavity, and defective development 
 of the decidua. Miiller advances the theory that the descent of the 
 ovum is effected by contractions of the uterus soon after conception. 
 Such expulsive pains naturally lead to abortion. In certain cases, how- 
 ever, where the reflexa is absent, we have seen that the ovum may be 
 forced downward into the cervical canal, and lingering there may give 
 rise to " cervical pregnancy." Placenta prajvia Miiller believes to be 
 due to an abortion begun at an early period, but arrested at the lower 
 uterine segment to which the villi attach themselves, and enable the 
 rescued ovum to continue its development. Ingleby relates two curi- 
 ous cases where the orifices of the Fallojjian tubes opened near the os 
 internum, in one of which placenta praevia occurred three times, and 
 in the other ten times. 
 
 Clinical Features. — The chief clinical importance of placenta prae- 
 via results from the mode of its detachment during labor. In normal 
 positions the separation of the placenta is elfected by virtue of the 
 uterine contractions after the foetus has for the most part been ex- 
 pelled. In placenta praevia the separation is due to the stretching to 
 which the lower uterine zone is subjected in its conversion from a half- 
 sphere to a cylindrical canal, to permit the passage of the child. The 
 extent of unavoidable separation in advance of delivery is consequently 
 measured by the dimensions of the child's head, the largest circumfer- 
 ence of which is estimated as equivalent to a circle with a diameter of 
 four and a half inches. According to Duncan, the plane at which 
 spontaneous detachment ceases is reached at a distance of two and a 
 half inches by following the curve of the lower segment, and of one inch 
 and a half if measured in the direction of the uterine axis. Whereas, 
 in normal labor, the contractions of the uterus which determine pla- 
 cental separation close at the same time the orifices of the torn vessels, 
 tlie stretching of the lower segment in placenta praevia leaves tlie 
 mouths of the sinuses gaping, from which the blood pours until the 
 
 * Lomer, Combined Turning in the Treatment of Placenta Praevia, Am. Jour, of 
 Obstet., December, 1884, p. 248. 
 
 t Miiller collected from different reporters 1.574 cases— 227 of primipara^ and 
 1,347 of multipara?. Jiidell reports the multipara? at 90 per cent. King (Am. 
 .lour, of Obstet., October, 1880, p. 751) reports 183 cases collected in the State of 
 Indiana, in which the proportion was 20 primiparae to 103 multiparse.
 
 PLACENTA PR.EVIA. 
 
 597 
 
 stream is arrested either by art or by the supervention of syncope. Ag 
 the haemorrhage in such cases is the natural sequence of cervical dila- 
 tation, its occurrence during labor was termed by Rigby " unavoida- 
 ble " in contradistinction to hajmorrhages from detachment of the pla- 
 centa when situated near the fundus, 
 where the separation is attributable to 
 " accidental " causes. 
 
 The hemorrhages of placenta pra3- 
 via are not, however, limited to the 
 parturient period. Indeed, there is no 
 time in pregnancy when they may not 
 occur. When we consider that every 
 jar of the body affects the lower seg- 
 ment with more force than the fundus, 
 and that the thinned walls of the utero- 
 placental vessels are subject to increased 
 pressure in placental presentations, it 
 becomes evident that a very slight occa- 
 sion is sufficient to produce rupture and 
 haemorrhage. Thus placenta praevia is 
 a common cause of the pseudo-menstru- 
 ation of pregnancy; it creates a pre- 
 disposition to abortion, and, later in 
 gestation, to premature labor, the haem- 
 orrhages being due probably in the 
 first instance to accidental causes and 
 
 not to labor-pains. Not every case of haemorrhage is, however, fol- 
 lowed by labor. Indeed, in many instances thrombi form in the open 
 vessels, the bleeding becomes arrested, and pregnancy goes on for a 
 time undisturbed. The tables of Miiller show that in complete pla- 
 centa previa the first hsemorrhage occurs with the greatest frequency 
 between the twenty-eighth and thirty-sixth weeks, while in the in- 
 complete form it takes place most commonly after the thirty-second 
 week. In placenta praevia lateralis, haemorrhages are sometimes absent 
 up to the time of labor. Cases of pregnancy, and in part of labor, 
 without hemorrhage have been observed where the death of the foetus 
 has been followed by atrophic changes in the placenta. The recur- 
 rence of haemorrhage is oftentimes prevented by secondary shrinkage 
 of the placenta, due to pressure from the effused blood or to throm- 
 bosis of the vessels which supply the implicated cotyledons. 
 
 The hemorrhages of placenta previa are usually sudden without 
 premonitory warnings, without pain, often without any apparent occa- 
 sion, sometimes occurring at the time of urination, sometimes during 
 sleep. The quantity of blood lost in a single hemorrhage depends 
 upon the extent of the placental separation. The first outpouring may 
 
 Fig. 225.— Diagram shoving the unavoid- 
 able placental separation as a conse- 
 quence of cervical dilatation.
 
 gQg THE PATHOLOGY OP LABOR. 
 
 lead to intense anemia, and if repeated at a short iiiterval may cause 
 death. It is estimated that from one to three pounds of blood may be 
 lost in a single attack, and from four to five pounds in the course of 
 labor (Miiller). As a rule, however, the haemorrhages of pregnancy 
 are at first moderate in character, increasing in violence with each rep- 
 etition. A very formidable variety is the so-called '^ stillicidium," 
 where the blood issues drop by drop for days and even weeks in suc- 
 cession. The most violent hemorrhages occur generally in the earlier 
 part of the first stage of labor. As a rule, the extent of the haemor- 
 rhage is proportioned to the area of the placental segment attached to 
 the uterine surface subject to distention. The hemorrhage generally 
 ceases when the separation of the cotyledons is completed and, after 
 the rupture of the membranes, the pressure of the presenting part is 
 brought to bear upon the bleeding surface. During the height of 
 the pains, too, the haemorrhage is for the moment arrested (Spiegel- 
 berg).* 
 
 The number of abnormal presentations in placenta praevia is very 
 large. Thus, in Miiller's statistics, in 1,148 cases there were 272 trans- 
 verse and 107 breech presentations. The frequency of the anomalies 
 is partly attributable to the large proportion of premature labors, and 
 partly to the width and lax condition of tlie lower segment, and the 
 consequent want of stability in the foetus. 
 
 During the first stage of labor the pains are apt to be feeble and 
 the dilatation tardy. The causes of inertia are to be found in the thin- 
 ning of the muscular structures in the lower segment from the enor- 
 mous development of the utero-placental vessels ; in the attachment of 
 the placenta over the os, which mechjinically hinders dilatation ; and 
 in the fact that the ovum does not press directly upon the sensitive 
 nerves of the cervix. Secondary weakness often follows the continued 
 losses of blood and the prolongation of the first stage. "When the ob- 
 stacle afforded by the placenta to dilatation has been overcome, and, 
 consecutive to rupture of the membranes, the uterus retracts, in many 
 cases the scene speedily changes, and, in place of ineffective contrac- 
 tions, normal and often powerful pains develop. 
 
 As a rule, quite early in labor the cervix is found soft and dilat- 
 able ; but to this rule there are numerous exceptions. Strictures and 
 rigidity Miiller computes to exist in about twelve per cent of the cases. 
 
 Where the loss of blood in labor is continuous the woman grows 
 restless and complains of headache and vertigo ; the respirations become 
 short, interrupted, and sighing, and the pulse small, weak, and thready. 
 Toward the close unconsciousness develops, the brow is bedewed with 
 
 * This view was first advanced by Fountain in the Am. Jour, of the Med. Sci. 
 It has since been advocated by Duncan, Jiidell. Frankel, Spiegelberg, and others. 
 Miiller and Kuhn, however, dispute it, as justified neither by theory nor by ob- 
 servation.
 
 PLACENTA PR.EVIA. 599 
 
 cold, clammy perspiration, and finally convulsions usher in the fatal 
 termination. 
 
 Even after labor is over the danger is not ended. Post-partum hem- 
 orrhage may result from atony of the placental surface of the uterus, 
 or, after good contractions have been apparently secured, sudden re- 
 laxation may follow, and the blood pour out in a torrent, so that the 
 patient becomes a corpse before assistance can be rendered. Again, in 
 childbed the imperfect contraction of the uterus at times allows the 
 lochia to form a stagnant pool at the fundus, whence an ichorous dis- 
 charge flows constantly downward over the thinned walls and open 
 mouths of the vessels at the placental wound. The feeble circulation 
 predisposes to the formation of thrombi, which, when poisoned and 
 disintegrated, are conveyed into the general circulation and give rise to 
 the dreaded symptoms of pyemia. Mtiller found in two hundred and 
 seventy-three of his cases specific information given regarding the 
 puerperal state. " Puerperal fever " was recorded of seventy-nine pa- 
 tients, with fifty-four deaths. 
 
 Prognosis.— The prognosis of placenta praevia is necessarily ex- 
 tremely unfavorable. As many as one mother in four dies during or 
 shortly after delivery. Including deaths from puerperal jirocesses, 
 Mtiller estimates the total mortality at not less than from thirty-six to 
 forty per cent. Nearly two out of three of the children are born dead. 
 More than one half of those born living die within the first ten days. 
 In general terms it may be stated that the prognosis is the more seri- 
 ous the earlier the hemorrhages begin in pregnancy, the more profuse 
 the flow, and the shorter the intervals between the attacks. During 
 labor favorable conditions are a vertex presentation, good pains, rapid 
 dilatation, and an unbroken constitution. The maternal mortality is 
 twice as great in placenta previa centralis as in placenta previa later- 
 alis. In the city there is the special danger of infection ; in the coun- 
 try, of delay in obtaining medical assistance. Finally, it is impossible 
 to analyze the statistics of j^lacenta previa without coming to the con- 
 clusion that the result depends in a large measure upon the personal 
 qualities of the physician. A self-possessed man, cool, resolute, with 
 clear ideas of the anatomical conditions to be dealt with, will, if sum- 
 moned in season, apjjarently dejjrive even placenta previa of a good 
 share of its terrors. 
 
 Diagnosis. — There are no signs by which placenta previa can be 
 recognized in the first half of pregnancy. It may occasion abortion, 
 which is then characterized by the absence of pain, both previous to 
 the hemorrhage and during the period of expulsion. As a rule, the 
 ovum is expelled entire without rupture of the membranes. In the 
 second half of pregnancy, a hemorrhage occurring suddenly, without 
 ostensible cause and without wariiing, shoiild always be regarded with 
 suspicion. Upon digital exploration in placenta previa the vaginal
 
 gQQ THE PATHOLOGY OF LABOR. 
 
 fornix is found soft and boggy, and occasionally thicker upon the one 
 side than upon the other, where the placental presentation is incom- 
 plete ; ballottement is obscure ; the cervix is long, wide, and soft, and 
 contains at times vessels which pulsate distinctly ; the cervical canal 
 permits the passage of the finger to the os internum, which at first 
 offers resistance, but yields to gentle force. The diagnosis is rendered 
 positive only in cases where the lower surface of the placenta is actu- 
 ally felt through the cervix, its rough, spongy, granular texture suf- 
 ficiently distinguishing it from clots and other possible sources of de- 
 ception. 
 
 Treatment. — The history of placenta praevia brings into prominence 
 the central point to be kept steadily in view in practice, that there is 
 no safety for the mother so long as pregnancy continues. In a very 
 large proportion of cases, accidental haemorrhage occurring in the first 
 half of pregnancy leads to abortion, the management of which does not 
 differ from that cf abortions which take place in normal attachments 
 of the placenta. Of the one hundred and twenty-eight deaths from 
 placenta praevia collected by Miiller, not one occurred previous to the 
 seventh month. In the latter half of pregnancy, hemorrhage likewise 
 leads to premature expulsion of the ovum with such frequency that it 
 is reckoned that only one third of all cases reach the end of gestation. 
 
 Most authorities advise, in the presence of the haemorrhages of ad- 
 vanced pregnancy, that the physician maintain an attitude of expect- 
 ancy, postponing active interference, except in cases where the loss of 
 blood assumes alarming proportions, until the spontaneous advent of 
 labor. This policy is recommended partly in the interest of the child, 
 and partly because of the tendency in premature labor to rigidity of 
 the cervix, a complication which always in placenta praevia enhances 
 the risks of delivery. The wisdom of delay is, however, open to seri- 
 ous question. The fatality of placenta prajvia is due not so much to 
 the impotence of obstetrical art as to the losses of blood which occur 
 suddenly in the absence of professional assistance. The first haemor- 
 rhage, which serves as a warning as to the patient's condition, is fortu- 
 nately in most instances slight. With each recurrence, however, the 
 flow becomes more profuse. If the haemorrhages begin before the 
 child is viable, the chances of saving its life are in any event too small 
 to offset for a moment the welfare of the mother. Haemorrhages occur- 
 ring as early as the seventh month are, as a rule, the result of complete 
 placental presentation. To trifle witli such cases is the best way to 
 maintain the present mournful statistics. After the thirty-second 
 week it is safe to say that the child's life is less imperiled by the in- 
 duction of premature labor than by exposing it to the dangers of con- 
 tinued gestation. 
 
 On theoretical grounds, therefore, the induction of premature labor 
 is to be regarded as obligatory so soon as the diagnosis of placenta
 
 PLACENTA PREVIA. 601 
 
 jiraevia is established, or at least with the occurrence of the first haemor- 
 rhage. The practical results of this measure in the hands of its advo- 
 cates * plead still more effectively in its behalf. Thus, Dr. Gaillard 
 Thomas f reports eleven cases, with but two deaths, one resulting from 
 post-partum hoemorrhage coming on several hours after delivery, and 
 one from puerperal fever. Hecker X lost three cases in forty, Hoff- 
 mann two cases in thirty, and Spiegelberg four cases in seventy-four 
 early deliveries.* More recently Murphy || has reported fifteen cases 
 without a single death. In this connection I can not help quoting the 
 following impressive remarks of Dr. Barnes : " If the pregnancy have 
 advanced beyond the seventh month it will, as a general rule, I think, 
 be wise to proceed to delivery, for the next htemorrhage may be fatal ; 
 we can not tell the time or extent of its occurrence, and, when it oc- 
 curs, all, perhaps, that we shall have the opportunity of doing will be 
 to regret that we did not act when we had the chance." 
 
 In the management of placenta praevia it is very desirable that the 
 practitioner should have a perfectly clear idea of the nature of the 
 task he has to perform. The birth of the child can not take place 
 without preliminary expansion of the cervix. The cervix can not ex- 
 pand without detachment of the placenta. The principal objective 
 point of treatment, therefore, is the haemorrhage which occurs during 
 the stage of dilatation. Plans for restricting the flow within narrow 
 limits have been proposed without number by masters of the obstetric 
 art. The best plans are those which at the same time contribute to 
 shorten labor. The choice must be determined by conditions which 
 necessarily vary in different cases. The physician has at the outset to 
 particularly inform himself as to whether labor has begun or remains 
 to be inaugurated, as to whether the placenta praevia is complete or in- 
 complete, as to whether the presentation is normal and the pains are 
 good, as to whether the membranes have ruptured or are intact, and 
 as to the length and dilatability of the cervix. 
 
 If the cervix is long, narrow, and rigid, and the membranes are 
 entire, the vaginal tampon should be lesorted to as a temporary expe- 
 dient. The tampon strengthens the pains, and, by the compression 
 it exerts, causes coagulation of the blood which escapes from the uter- 
 ine vessels. Professor I. E. Taylor advises packing the vagina with a 
 surgical bandage, leaving one end outside the vulva, by means of which 
 it can be withdrawn without difficulty. Braun, after many years' ex- 
 
 * Premature labor in profuse or continuous haemorrhage has received the in- 
 dorsement in this country of Thomas, Taylor, Parvin, Pallen, and Taber Johnson. 
 
 t Trans, of the N. Y. "obstet. Soc. vol. i, p. 262. 
 X Statistics taken from L. Miiller's monograph. 
 
 * Spiegelberg's statistics do not, however, like those quoted from Thomas, in- 
 clude deaths in childbed. Thus, Spiegelberg's complete death-rate reached sixteen 
 per cent. 
 
 II Murphy, Brit. Med. Jour., 1884, p. 215.
 
 602 
 
 THE PATHOLOGY OF LABOR. 
 
 perience at Vienna with the colpeurynter, maintains the superiority of 
 hydrostatic dilatation. I use cotton, made into disks, and dampened 
 in a two-per-cent sokition of carbolic acid, crowding it into the upper 
 portion of the vagina with the aid of a Sims speculum. The choice 
 does not appear to be material if due attention be jiaid to the carrying 
 out of aseptic details. Having once introduced the tampon, the physi- 
 cian should not leave his patient until the labor is ended. After at 
 most four hours the tamjjon should be removed, and, after rendering 
 the vagina thoroughly aseptic, the cervix should be examined. A 
 second introduction of the tampon is rarely necessary, or, owing to the 
 dangers of septic infection, expedient. 
 
 So soon as the os will permit the passage of the finger, the vaginal 
 plug should be discarded. The operator will then have to choose 
 between one of two jjlans of action, viz., dilatation of the cervix by 
 means of water-bags, or version by Braxton Hicks's method. If dilata- 
 tion is decided upon, a Barnes rul^ber-bag, expanded sufficiently to 
 render the border of the os externum tense, fulfills admirably the prin- 
 cipal indications. It acts as an efficient tampon, it strengthens the 
 pains, and it dilates the cervical canal. As the latter expands, a 
 larger-sized dilator should be introduced. It is important, in order 
 to prevent hemorrhage, to maintain the tension of the external orifice. 
 On account of the softening which exists in the lower uterine segment 
 as a result of placenta previa, in a large proportion of cases the cervix 
 can be stretched with the utmost facility. If no ui'gent symptoms 
 call for immediate interference, it is desirable to render the dilatation 
 complete. It is not, however, always necessary. Indeed, Barnes, 
 Taylor, Spiegelberg, and Braun advise to proceed boldly with the de- 
 livery so soon as the os externum has expanded to the size of a half- 
 dollar, as by that time the expansion of the os internum is very nearly 
 completed, and as the soft cervical canal does not offer sufficient re- 
 sistance to materially interfere with the extraction of the child. The 
 distinguished success of the authorities mentioned in the field of prac- 
 tice under consideration lends great weight to their recommendations. 
 It is, however, more than probable that exceptional training and ex- 
 perience count in their case for quite as much as the plans of proced- 
 ure they individually favor. At any rate, in reviewing the statistics 
 of Trask and Miiller it becomes evident that rigidity of the cervix is 
 not a rare event in placenta praevia, and that the acconchemcnf force, 
 performed with a rigid cervical canal, is perhaps, next to doing nothing, 
 the most responsible cause of the mournful results they have placed on 
 record. 
 
 Jungbluth (Die Behandlung der placenta praevia, Volkmannsche Samm- 
 lung, No. 3,35), advocates the use of large sponge tents, rendered aseptic by 
 careful preparation, {inde p. 360), in placenta praevia. He claims in their favor 
 that they cause active uterine contractions, and act as an efficient tampon, so
 
 PLACENTA PREVIA. 603 
 
 that complete dilatation of the cervix can be secured without loss of blood. 
 He directs that the attendant shall first ascertain the direction and width of the 
 cervix and the distance of the os externum from the placenta. He then selects 
 a tent to correspond. With a sharp knife the tent should be cut across so that 
 when introduced its length shall not exceed that of the canal by more than an 
 inch. The abtruncated tent is to be seized in ovum forceps, the cut end is to be 
 dipped for a moment in hot water, and then, under the guidance of two fingers 
 in the vagina and with counterpressure from above, the tent is to be pushed up 
 the canal to the placenta, and held in place for ten to fifteen minutes, by which 
 time the expansion is sufficient to tampon the lower uterine segment. Jung- 
 bluth claims that if at the outset the external parts, the vagina, the instru- 
 ments, and the hands of the operator are surgically clean, the tent after its in- 
 troduction may be left eight or ten hours in situ without the slightest risk of 
 sepsis. 
 
 Sometimes one, sometimes as many as three or four, sponge cylinders are 
 requisite. If unfilled spaces are left, small tents should be inserted to secure 
 a complete tamponing effect. In no case should a vaginal tampon be used. A 
 comj^ress to the vulva will show if any leakage occurs. In that case it is an in- 
 dication that the tents have been faultily placed. They should then be removed, 
 and new ones should be introduced. A renewal of the tents is likewise re- 
 quired when, as the cervix softens and dilates, the finger can be pushed at the 
 border u])ward to the placenta. The vagina should be then washed with 
 carbolic-acid solution (two per cent), the hands disinfected, and the sponges 
 withdrawn by a leverage movement. In the partially expanded cervix three or 
 four cylinders tied together should be introduced and held in place in the 
 manner already described. A third renewal is rarely necessary. In answer to 
 the objection that the method is troublesome, Jungbluth argues that trouble 
 is of small consideration when life is at stake. 
 
 After the cervix has been duly prepared the membranes should be 
 ruptured, and a part of the amniotic fluid should be permitted to 
 escape. Then, if the j^lacenta possesses a lateral or a marginal attach- 
 ment, if the pelvis is of normal size and the pains strong and regular, 
 and if the head present, or at least can be brought down and fixed at 
 the pelvic brim- by external manipulations, the further progress of the 
 case may be left to Nature. Haemorrhage will then be prevented by 
 the pressure of the foetus in its descent through the utero-vaginal 
 canal. At first the method of expression advocated by Kristeller is 
 capable of rendering important service by promoting the speedy en- 
 gagement of the child's head. Ergot, too, cautiously administered, is 
 useful in strengthening the uterine contractions. Even if tonic con- 
 traction follow from its employment — an unlikely event in placenta 
 prtevia — the effect would be to close the sinuses and to furnish a fresh 
 barrier against haemorrhage. The forceps may be applied under the 
 same circumstances, and with the same restrictions, as in other con- 
 ditions. Where, however, the head is movable, the patient ansemic, 
 and hfemorrhage persistent, version, as furnishing the more rapid 
 mode of delivery, would receive the preference.
 
 QQ^ THE PATHOLOGY OF LABOR. 
 
 In cases of complete attachment of the placenta there should be 
 no trifling with half-way measures. If the cervix is long and rigid, 
 the vaginal tampon should be employed as a preliminary measure. 
 When the cervical tissues have become softened, and dilatation has 
 beo-un, the tampon should be removed. At this stage Barnes recom- 
 mends separating at once that portion of the placenta which is attached 
 above the inner orifice of the cervix. By so doing, " we remove an 
 obstacle to the dilatation of the cervix, for the adherent placenta acts 
 as an impediment." The operation is performed as follows: "Pass 
 one or two fingers, as far as they will go, through the os uteri, the 
 hand being passe" into the vagina if necessary; feeling the placenta, 
 insinuate the finger between it and the uterine wall ; sweep the finger 
 around in a circle, so as to separate the placenta as far as the finger 
 can reach. . . . Commoi\ly some amount of retraction of the cervix 
 takes place after this operation, and often the haemorrhage ceases." * 
 Next put in a Barnes dilator and rapidly expand the cervix. Mean- 
 time try and bring the breech down into the lower uterine segment by 
 external palpation. Both Taylor and Braun have found external ver- 
 sion easy, on account of the inert conditions of the uterine walls. When 
 the cervix has been sufficiently stretched to admit of delivery, two fingers 
 should be introduced, the placenta should be separated, the memlu'anes 
 ruptured, and an extremity should be seized without passing the entire 
 hand into the uterus. Extraction should then follow, the pressure of 
 the foetus preventing any considerable amount of haemorrhage. 
 
 Usually the right hand is chosen to seek the feet, as the placenta 
 more frequently overlaps the left side. Often a hint is furnished by 
 the fact that the overlapping portion of the placenta is separated to a 
 greater extent than the main body. Many times, however, it will be 
 necessary to change the direction of the fingers before the edge of the 
 placenta is reached. If external version can not be effected, the opera- 
 tor should push the hand forward into the uterus to find an extremity. 
 The arm acts during the search as a temporary tampon. Ha?morrhage, 
 which follows the withdrawal of the arm, will be arrested by the de- 
 scent of the breech. 
 
 The accidental rupture of the membranes before the cervix is pre- 
 pared for artificial delivery is hardly likely to occur in cases of placenta 
 praevia comi)leta. In cases of marginal implantation, dilatation with 
 water-bags should be employed in such a way as to compress the open 
 sinuses from which bleeding takes place. 
 
 * Barnes, Obstetrical Operations, p. 503. The artificial separation of the 
 placenta is unquestionably of service where it can be accomplished without dif- 
 ficulty. Much time should not, however, be lost in fruitless efforts, nor is it de- 
 sirable to persist if the separation can not be accomplished smoothly. Behm, 
 Hofmeier, and Lomer all urge in such cases passing the fin<;ers directly through 
 the placental tissue. The most alarming hsemorr"haf5~Teases when the leg is 
 brought down.
 
 PLACENTA PREVIA. 6O5 
 
 In 1861 Braxton Hicks recommended for the treatment of placenta 
 praevia turning the child by the two-finger method in an early stage of 
 labor, and, after rupture of the membranes, bringing down the breech 
 to tampon the bleeding vessels. This practice has been followed with 
 distinguished success by Hof meier * and Behm f and in the University 
 Hospital for AVomen, in Berlin. The cases reported from the latter 
 institution by Lomer| were 101, operated upon by nine different assist- 
 ants, with a total of 7 deaths. Hofmeier reported 37 cases with 1 
 death, and Behm 35 cases with no maternal death. Thus, in 178 cases 
 occurring in the practice of 11 individuals, there were 8 deaths, a mor- 
 tality of but 4-5 per cent. But Lomer had no death in 16 cases. The 
 addition of these latter to those of Hofmeier and Behm gives in the 
 practice of three individuals only 1 death in 93. To be sure, the life 
 of the child is made, by this premature version, a secondary considera- 
 tion. Hofmeier reports an infantile mortality of 67 per cent, that of 
 Behm was 80 per cent, while in Lomer's report the fetal death-rate 
 was only 50 per cent. However, many of the reported deaths were in 
 non-viable children, or were cases where the death of the child occurred 
 long prior to birth, Hofmeier advocates following up version by the 
 slow extraction of the child. By this means he has succeeded in 
 ending labor in the course of from half an hour to one hour and three 
 quarters. Behm counsels awaiting the spontaneous expulsion of the 
 child, or at least the complete dilatation of the cervix. Lomer says : 
 " In our cases we exert gentle tractions now and then, until the cervix 
 is completely dilated, and we then slowly increase the number and 
 strength of the tractions." Lomer sums up the advantage of the 
 method as follows : 1. It does away with the tampon, and the conse- 
 quent dangers of infection. 2. It allows us to operate early. 3. It 
 arrests haemorrhage with great certainty. 4. It gives time for the 
 patient to rally, for the cervix to dilate, and for pains to set in. It 
 therefore prevents post-partum hemorrhage. I have recently had 
 occasion to test this plan in a case of placenta previa completa, and am 
 prepared to speak most strongly in its favor, as both mother and child 
 were saved, though I still believe that a certain amount of preliminary 
 dilatation with Barnes's bags tends to enhance the chances of the child 
 without endangering the life of the mother. 
 
 After the birth of the child, the danger of post-j^artum hemorrhage 
 must be kept in mind. Every preparation should be made in anticipa- 
 tion of its occurrence. If bleeding persists after the fundus is felt to 
 
 * Hofmeier. Zur Behandlung der Placenta Pnevia, Ztschr. f. Geburtsh. und 
 Gynaek., vol. vii, p. 89. 
 
 f Behm, Die combinirte Wendung bei Placenta Pra?via, Ztschr. f. Geburtsh. und 
 Gynaek., vol. ix, p. 373. 
 
 X Lomer. Combined Turning in the Treatment of Placenta Praevia, Am. Jour, 
 of Obstet., December, 1884, p. 1233.
 
 II 
 
 Q^Q THE PATHOLOGY OP LABOR. 
 
 be firmly contracted, a speculum should be introduced, and the open 
 sinuses of the lower segment should be swabbed with cotton soaked in 
 some styptic form of iron, as recommended by Engelmann (vide Post- 
 partum Hemorrhage). Ergot should be given for several days, as 
 the danger of late hemorrhages is specially great following placenta 
 
 previa. 
 
 The utmost cleanliness and the use of disinfectant vaginal douches 
 must be insisted on during the childbed period, as the exposure of the 
 placental wound to the lochia, which constantly flow over it, renders 
 the patient especially liable to septic infection. 
 
 HEemorrhage from Normally Implanted Placenta.— The placenta, 
 even when implanted over the upper polar circle, the safe placental 
 seat of Dr. Barnes, may become detached to a greater or less extent 
 during pregnancy or labor, and may then furnish a flow of blood that 
 either remains internal and concealed or may find its way between the 
 decidua vera and reflexa, and thus escape into the vagina. 
 
 The hemorrhages from this variety of placental separation are 
 termed " accidental," in contradistinction to the " unavoidable " form, 
 which is the accompaniment of placenta previa. 
 
 The circumstances under which concealed hemorrhage takes place 
 are given by Goodell * as follows : (a) When the placenta is centrally 
 detached, and the blood accumulates in the cul-de-sac formed by the 
 firm adhesion of its margins to the uterine wall, (b) When the pla- 
 centa is so detached that the blood escapes into the uterine cavity 
 behind the membranes near the fundus, {c) When membranes are 
 ruptured near the detached placenta and the effused blood mingles 
 with the liquor amnii. {d) When the presenting part of the foetus so 
 accurately plugs up the maternal outlet that no existing hemorrhage 
 can escape externally. 
 
 ' The causes of internal hemorrhage, when such can be determined, 
 are for the most part similar to those considered in connection with 
 abortion. Thus, the circumstances leading to placental detachment 
 Goodell found to be irregular uterine contractions, external violence, 
 and undue exertion ; in seven the causes were purely emotional, and 
 ten took place during sleep. It occurs more frequently in multipara 
 and in the latter months of pregnancy. 
 
 The symptoms are an alarming state of collapse, pain often excess- 
 ive, absence or extreme feebleness of the pains of labor, marked dis- 
 tention of the uterus, sometimes a lateral bulging of the uterine walls, 
 a show of blood, a serous discharge, and blood in the liquor amnii. 
 
 The diagnosis in the concealed form may be extremely embarrass- 
 ing. The pain is often that of flatulent colic. The accident likewise 
 
 * Goodell. On Concealed Accidental Hapmorrhage of the Gravid Uterus (Am. 
 Jour, of Obstet., August, 1869, p. 281). This paper serves as a mine from which 
 most subsequent writers have drawn their data.
 
 PLACENTA PRiEVIA. G07 
 
 presents many features which resemble those of ruptured uterus ; but 
 rupture, by contrast, rarely occurs until after the escape of the waters, 
 the presenting part then receding from the os, and the uterus dimin- 
 ishing in size. 
 
 The prognosis is very unfavorable. Goodell reports : " Out of one 
 hundred and six tabulated cases, fifty-four mothers perished ; and out 
 of one hundred and seven children, six alone are known to have been 
 saved." I have had a case since his paper, where, after labor, I re- 
 moved at least a basinful of firm clots from the uterine cavity, and yet 
 both mother and child survived. 
 
 In cases of external ha3morrhage the diagnosis is easy and the 
 prognosis more favorable, the latter probably because the walls are less 
 flaccid than in the concealed form. 
 
 The treatment consists in the subcutaneous injections of ergot, in 
 dilatation of the os with Barnes dilators, in rupture of the membranes, 
 and in version. 
 
 In my own case, to which I have referred, the Barnes dilator acted 
 capitally, not only enabling me to expand the cervix, but exciting the 
 uterus to contract vigorously. The serious symptoms set in after the 
 membranes were ruptured, and compelled me to deliver with forceps. 
 In another case I should certainly first dilate, and, after ruptiire of the 
 membranes, should choose version and speedy extraction, and should 
 avail myself of a skilled assistant, whose duty it should be to compress 
 the uterine walls externally during the act of delivery. 
 
 Inversio Uteri. — Inversion of the uterus is a rare occurrence. 
 Braun states that, of two hundred and fifty thousand births in the 
 clinics respectively under the charge of 8paetli and himself, not a sin- 
 gle complete inversion has come to their notice. There was one case 
 in one hundred and ninety thousand confinements at the Eotunda 
 Hospital in Dublin. 
 
 The production of inversion is favored by a large, relaxed uterus, 
 the result of overdistention, of rapid delivery, or of haemorrhage. 
 The immediate cause may be either pressure exerted from above or 
 traction Irom below. The first may^jproceed from straining efforts, 
 especially in a sitting or kneeling position, or from attempts at pla- 
 cental expulsion before u^erme contractions have been secured ; the 
 second may proceed from 'a_short or coiled cord during expulsion, 
 from tractions upon the cord after the child is born, or simply from 
 the weight of the placenta. HennTg^*^ concludes that the attachment 
 of the placenta to the fundus, instead of a more lateral implantation, is 
 an active cause of the accident. 
 
 Inversion may be partial or complete. In the former the fundus 
 })resents a saucer- or cup-like depression ; in the latter the entire 
 
 * Hennig. Ueber die Ursachen der spontanen Inversio Uteri, Arch. f. Gynaek., 
 Bd. vii, p. 491.
 
 608 
 
 THE PATHOLOGY OF LABOR. 
 
 fundus descends into the vagina ; in extreme instances the cervix may 
 be inverted to tlie vaginal attachment. Dr. I. E. Taylor maintains a 
 mechanism for a certain number of cases, which consists in a rolling 
 out of the cervix, with gradual implication of the body and fundus. 
 
 The symptoms of inversion are shock and haemorrhage. The shock 
 is evidenced by the small pulse, coldextremities, vomiting, and sunken 
 features, and is due, in part at least, to the sudden diminution of the 
 intra-abdominal pressure and consequent plethora of the abdominal 
 veins; the haemorrhage results from imperfect contraction, and is 
 therefore proportioned to the extent of the uterine paresis. 
 
 Spontaneous reduction of incomplete inversion is not uncommon. 
 Cases of spontaneous reduction of the complete form have likewise 
 
 been observed, referable, accord- 
 ing to Spiegelberg,* to retrac- 
 tion of the ligaments acting 
 upon the uterus while in a re- 
 laxed condition. 
 
 The diagnosis is not diffi- 
 cult. The inverted uterus can 
 only be mistaken for a fibrous 
 polypus, but liy careful external 
 and bimanual palpation the de- 
 monstration of the absence of 
 the uterine tumor above the 
 symphysis would guard against 
 this error. 
 
 Tlie prognosis depends u})on 
 the promptitude of the operator 
 in restoring the fundus to its 
 normal position. Still, accord- 
 ing to Crosse's f statistics, one 
 third of the patients died either at once or within a month of the 
 occurrence of the accident. 
 
 Treatment consists in pressing the fundus upward with the fingers 
 or with the closed fist. To avoid tearing the uterus from its vaginal 
 attachments, care should be taken to employ counter-pressure with the 
 disengaged hand upon the upper border of the funnel-shaped depres- 
 sion. If the placenta is detached to any great extent, its separation 
 should be completed before replacement ; if adherent, no time should 
 be lost, but placenta and fundus should be pushed back together. If 
 the cervix is contracted about the inverted portion, an anaesthetic 
 should be given, and taxis should be employed. I can speak from ex- 
 
 * Spiegelberg. Lehrbuch, etc., p. 597. 
 
 t Crosse, An Essay, Literary and Practical, on Inversio Uteri, Trans, of the 
 Provincial Med. and Surg. Assoc, 1847, p. 344. 
 
 Fig. 2'.i6. — Inversion of uterus.
 
 PLACENTA PREVIA. 
 
 609 
 
 perience in favor of Noeggerath's metliod, which consists in indenting 
 the uterus in the neighborhood of a Fallopian tube, in place of acting 
 directly upon the fundus. 
 
 In a case seen by me in conjunction with Dr. Henry E. Crarapton, 
 of New York city, thirty-six hours after delivery, I succeeded, afttr 
 several fruitless efforts, in restoring the uterus by the following method : 
 First, the fundus was pressed upward through the cervical ring by the 
 thumb and fingers. The partially reinverted uterus was clearly felt 
 through the thin abdominal parietes, but it was found impossible to 
 
 Fig. 227. — First stage of replacement. Fig. 227a.— Second stage of replacement. 
 
 advance the hand through the ring beyond the knuckles. The hand 
 was therefore held steadily in place, with no attempt at a forward 
 movement, for about ten minutes. This was done with the intent to 
 procure a relaxation of tho constriction by means of continuous press- 
 ure. Then the thumb was withdrawn, and the circular uterine fold, 
 which still hung deep into the vagina, was pressed up on one side by 
 the fork formed by the thumb and index-finger. Finally, by indent- 
 ing the raised fold by the thumb, and at the same time making counter- 
 pressure upon the uterine ring through the abdominal walls, I was en- 
 abled to push the entire mass by the ring, and had the pleasure of feel- 
 ing the remainder of the inverted organ roll spontaneously into posi- 
 39
 
 g-j^Q THE PATHOLOGY OF LABOR. 
 
 tion. Tlie diagrams drawn for me by my friend, Dr. L. M. Yale, 
 will help to make intelligible the mechanism of the manoeuvre. 
 
 If the reinversion proves successful, the hand should be allowed to 
 remain within the uterus, and external pressure should be employed 
 until contraction is secured. The subsequent treatment does not differ 
 from that for uterine atony, already considered in connection with 
 post-particm hemorrhage. 
 
 CHAPTER XXXIII. 
 
 RUPTURES OF THE GENITAL CANAL. 
 
 Rupture of the uterus. — Etiology. — Patliological anatomy.— Symptoms and diag- 
 nosis. — Treatment. — Prophylaxis. — Treatment after rupture. — Rupture limited 
 to the peritoneal covering of the uterus. — Perforation from pressure. — Lacera- 
 tions of the vaginal portion. — Laceration of the vagina. — Laceration of the 
 vulva. — Thrombus of the vulva and vagina. — Rupture of the pelvic articula- 
 tions. 
 
 The genital canal may be ruptured in any portion of its course. 
 Thus, lacerations may take place through the perina?um and posterior 
 vaginal wall, in the vestibulum, in the fornix of the vagina, in the 
 cervix, in the uterus, and in the pelvic articulations. 
 
 Rupture of the Uterus. — Ruptures of the uterus, for the most part 
 at least, start from the lower segment, and thence extend upward to- 
 ward the body and fundus, or downward toward the vagina. They are 
 termed complete when the rent extends through to tlie abdominal 
 cavity, and incomplete when confined to either the muscular layers or 
 to the peritonaeum. 
 
 Bandl reported 19 cases in 40,614 labors (1 : 2,137), occurring in 
 nine years in the Lying-in Hospital at Vienna. Jolly, in Paris, found 
 230 cases in 782,741 labors (1:3,403), but he excluded from his list 
 lacerations of the cervix. Harris, whose authority as a statistician is of 
 the highest, estimates in the United States one case of ruptured uterus 
 to four thousand births. I found 47 deaths from this cause recorded 
 in New York between 1867 and 1875 inclusive, or about one death in 
 six thousand labors. But it is hardly probable that these figures rep- 
 resent anything like' the actual mortality ; for, whereas in 1875 eleven 
 deaths were returned, there were but four recorded in 1867, and none 
 in the years 1871 and 1872. It is not likely, moreover, that the 47 
 cases include any other than spontaneous ruptures, as naturally very 
 few physicians are brave enough to record as such ruptures due to 
 violent obstetric manoeuvres. 
 
 Hugenberger estimated the mortality from ruptured uterus at 95
 
 RUPTURES OF THE GENITAL CANAL. 
 
 611 
 
 per cent, C. Brann * at 89 per cent. Their statistics were made up 
 from hospital records. Jolly reported in civil practice 100 saved in 580 
 cases ; but this Harris f believes to be too favorable a showing, as the 
 proportionate loss is much less in published than in unpublished cases. 
 Of late years the treatment of this condition has, however, furnished 
 somewhat better results, and a careful study of the circumstances 
 which favor its production is capable of at least furnishing the ground- 
 work of a rational prophylaxis. 
 
 Etiology. — Rupture of the uterus may take place spontaneously as 
 the result of defective resistance offered by the uterine walls to the 
 pressure of the ovum, or it may 
 owe its origin to some external 
 mechanical force. 
 
 Kupture of the fundus is a 
 very rare exception. It may take 
 place under special abnormal 
 conditions, as in the one-horned 
 uterus, in imbedded myomata, 
 when cicatrices exist as the re- 
 sult of previous Ca^sarean sec- 
 tion, and in retrograde changes 
 of the uterine walls. 
 
 It is the great merit of Bandl J 
 to have shown that nearly all 
 ruptures begin in the lower seg- 
 ment, and are preceded by an ab- 
 normal thinning and distention 
 of that portion of the uterus situ- 
 ated between the ring which 
 bears his name and the os ex- 
 ternum. In normal labor it will 
 be remembered that during a 
 pain the fundus and body thick- 
 en, while the lower segment is 
 
 stretched by the ovum. So long as no obstacle exists which hinders 
 the progression of the ovum or the fcetus, this process ends in the 
 conversion of the uterus and vagina into one continuous canal. In 
 such cases the contraction ring is often but slightly indicated, and is 
 found in the neighborhood of the pelvic brim. 
 
 If, however, the descent of the foetus is prevented by any cause, the 
 resistance of the ligaments which hold the uterus in position is over- 
 
 * Braun, Lehrbuch der gesammt. Gynaek., p. 699. 
 
 f Harris, If a Woman has ruptured her Uterus, what shall be done in order to 
 save her Life? Am. Jour, of Obst., October, 1880. 
 
 J Bandl, Ueber Ruptur der Gebarmutter, Wien, 1875. 
 
 Fig. 228. — Diagram showing dangerous thinning 
 of the lower segment, owing to the non- 
 descent of the head in contracted pelvis. 
 (Bandl.)
 
 gj^2 THE PATHOLOGY OF LABOR. 
 
 come by the retraction of tlie fundus and body, and as a consequence 
 the contraction ring is withdrawn upward, the lower segment is 
 thinned, and in extreme cases nearly the entire uterine contents may 
 occupy the distended passive inferior segment. Under these circum- 
 stances it is possible at times to detect by palpation the contraction 
 ring a hand's-breadth above the pubes, or even in the neighborhood of 
 the umbilicus. The stretching of the tissues is most pronounced in the 
 upper portion of the lower segment, diminishing below until the vagi- 
 nal portion is reached, which, of course, is not subjected to tension. 
 
 Now, when, as the result of the birth of any considerable portion 
 of the child into the obstetrical cervix — as the stretched lower uterine 
 segment has been termed by Spiegelberg — the tissues of the latter 
 are distended so as to form little more than a membranous covering, 
 the conditions which threaten rupture are established. Thus, contrac- 
 tility is impaired; with each recurring pain, the child, driven still 
 farther from the uterine cavity, increases the pressure upon the already 
 enormously distended lower segment ; gradually the thinned tissues 
 separate ; the presenting part of the child is forced into the opening ; 
 at the height of a pain complete separation of the muscular tissues 
 takes place ; the peritoneum is lifted up from the underlying tissue, 
 and finally, in the majority of cases, is torn through, permitting tlio 
 partial or complete passage of the child into the peritoneal cavity. 
 The emptied uterus then contracts, and the expulsive pains cease. The 
 conditions which specially lead to a dangerous attenuation of the lower 
 uterine segment are the pressure of a hjdrocephalifi head, a neglected 
 shoulder presentation, and where the descent of the child is hindered 
 by pelvic contraction, by cicatricial tissue or by tumors obstructing the 
 parturient passage. Rupture is favored whenever augmented pressure, 
 as in lateral obliquity and anteflexion of the uterus, and in transverse 
 presentations, is brought to bear upon a limited area of the already 
 overdistended tissues. 
 
 There are very great individual differences in the distensibility of 
 the uterine and cervical tissues. In Avomen who have borne many 
 children, rupture may occur before any great degree of stretching has 
 been reached. In the case of which the post-mortem appearances are 
 given in Fig. 229, spontaneous rupture occurred in the tenth preg- 
 nancy. Labor commenced at noon, and the membranes, wliich had 
 begun to protrude through the vulva, broke near midnight. The pains 
 then became slow and feeble. At about three o'clock in the morning 
 sudden collapse occurred. On my arrival, thirty minutes later, I found 
 the pulse scarcely perceptible, the breathing hurried, and the extremi- 
 ties cold. As the head was well down in the pelvis, I applied forceps, 
 and extracted without effort a dead child weighing ten and a half 
 pounds. Previous to the collapse the patient had felt comfortable. At 
 the moment of its occurrence a distinct snapping sound was heard by
 
 RUPTURES OF THE GENITAL CANAL. 
 
 613 
 
 the hospital physician, Dr. J. D. Griffith, who sat several yards distant 
 from the bedside. The patient stated that she felt a sensation as 
 though a warm fluid was pouring into the abdominal cavity. As the 
 pelvis was ample and the presentation normal, and as there was no 
 irregularity of the labor-pains, tlie rupture could only be accounted 
 
 Fig. 829— Case of ruptured uterus (anterior surface), a, body of uterus ; 6, ring of Bandl ; 
 C-, thrombus, shining through the peritonaeum. 
 
 for by assuming a vulnerability of the uterine tissues, and probably a 
 clamping of the anterior lip between the head and the pelvic wall. 
 
 On the other hand, so great is the distensibility of the tissues in 
 certain cases that the foetus may pass entire from the uterus into the 
 cavity of the obstetrical cervix without laceration ensuing. 
 
 Bandl found that of 54G cases of rupture but sixty-four were in 
 primiparge. Their preponderance in multij^arae is for the most part
 
 Q^^ THE PATHOLOGY OP LABOR. 
 
 the result of the laxity of the round and lateral ligaments of the 
 uterus, which offer accordingly but slight resistance to the recession 
 of the contraction ring ; of the stretched condition of the abdominal 
 parietes, which jjermits obliquities and anteflexion to take place ; and 
 ■of the separation of the recti muscles, which interferes with the use of 
 the abdominal compress. 
 
 Of course, the loss of vitality over limited areas, resulting from the 
 compression to which the uterine walls are frequently subjected in 
 deformed pelves, enhances the disposition to rupture. It is likewise 
 obvious that the existence of extreme cervical distention should not 
 be overlooked in cases where operations are rendered necessary. The 
 old prejudice against all operations within the uterine cavity while 
 the cervix is undilated is based in great measure upon the real danger 
 of laceration which proceeds from the association in many cases of tlie 
 foregoing condition with difficult labor. 
 
 Pathological Anatomy. — Kupture may occur in any point of the 
 obstetrical cervix. More commonly it takes place upon the side. 
 Owing to the right lateral obliquity of the uterus, and the greater 
 frequency in shoulder presentations of head-left positions, the left side 
 is oftener affected than the right. The laceration may follow any 
 direction. Longitudinal tears occur usually in shoulder presenta- 
 tions, or where the head is of disproportionate size ; the circular rents 
 are for the most part limited to generally contracted pelves. The 
 combination of a transverse with a longitudinal tear, the two meeting 
 at a right angle, is not uncommon. It has been maintained on theo- 
 reotical grounds that spontaneous rupture is arrested by the contraction 
 ring. This is certainly the rule where tiiere has been no art interven- 
 tion, but cases reported by myself and others show that exceptionally 
 the rent may extend through the ring to the fundus when there 
 has been no interference. When the uterine walls possess unusual 
 distensibility, a laceration may take place in the peritonaeum while 
 the muscular structures remain intact. Again, in some cases, ow- 
 ing to an excessive elasticity of the peritonaeum, the latter does not 
 give way even when the child has partially escaped from the uterine 
 cavity. These incomplete ruptures are more likely to occur upon th(! 
 sides of the uterus, at the site of the folds of the broad ligament, 
 though, owing to the relatively loose attachments of the peritonaeum at 
 the lower segment, incomplete ruptures are not necessarily confined to 
 these points. The peritoneal wound is usually more extensive than the 
 uterine, but this rule has its exceptions. When the peritonaeum is late 
 m giving way the opening may be of small dimensions. 
 
 Some separation of the peritoneum from the underlying structures 
 is usually found in the neighborhood of the rupture. Its extent is 
 dependent upon the degree of tension to which the membrane was 
 subjected before laceration took place. At the body of the uterus the
 
 RUPTURES OF THE GENITAL CANAL. (515 
 
 close connection between tlie peritonaeum and the externul musculur 
 layer renders a separation at that point an impossibility. 
 
 In the case represented by Fig. 229 the peritoneum was, on the 
 other hand, dissected away anteriorly by effused blood as far as the 
 umbilicus. Hfematomata are the rule in incomplete ruptures ; in 
 complete ones they are also found in cases where the peritoneum has 
 been late in giving way — i. e., after a cavity of considerable size lias 
 been formed by its detachment. The borders of the laceration are 
 ragged. The body of the uterus rises high up in the abdominal cavity, 
 and is inclined to the side opposite to that at which the rupture has 
 taken place. 
 
 Symptoms and Diagnosis. — The occurrence of rupture may often- 
 times be foreseen and guarded against by the early recognition of ex- 
 cessive cervical distention. The development of the latter is possible 
 in any case of obstructed labor. Unless the abdominal walls are very 
 thick, the boundary between the firm, hard body of the uterus and 
 the thinned lower segment, in the form of a transverse or an oblique 
 furrow, may be made out by palpation through the abdominal walls. 
 Upon the sides the round ligaments, even between the pains, have the 
 feel of tense cords. Usually the stretching of the cervix is associated 
 with violent pain, with increased rapidity of pulse, and an anxious 
 expression of countenance. 
 
 If rupture occurs, the uterus inclines to the opposite side, the present- 
 ing part recedes, and often vomiting^ets in. When the rupture takes 
 place gradually, violent manifestations are exceptional. The pains even 
 then may continue, and force the foetus into the abdominal cavity. 
 
 In cases of sudden rupture the pains cease instantly, and symptoms 
 of collapse usually make their appearance.* Vomiting, prostration, the 
 cool skin, the rapid pulse, the drawn features, all point to internal 
 haemorrhage and shock. Blood flows from the vagina, and the present- 
 ing part recedes from the joelvic brim. 
 
 Certainty in diagnosis is reached when the uterus upon palpation 
 is found to be empty and the outlines of the child can be made out 
 through the abdominal coverings. If rupture takes place after the 
 presenting part has become fixed in the pelvis, internal exploration is 
 often out of the question previous to the birth of the child. Usually, 
 however, the existence of the rent is easily made out by the examining 
 hand. 
 
 *I employ here the term "usually" because in one instance a patient was 
 brought to the Bellevue Hospital in a fairly good condition. On examination I 
 found the child in the uterine cavity, but the head had receded, and, to my surprise, 
 my hand passed through a large rent to the intestines. Winckel (Lehrbuch der 
 Geburtshiilfe, p. 5G3) ascribes sudden symptoms of collapse to the direct introduc- 
 tion of large quantities of poison germs into the abdominal cavity, whereas in cases 
 of traumatism without mycosis the result depends upon the suddenness of the oc- 
 currence and the quantity of blood lost.
 
 Q^Q THE PATHOLOGY OF LABOR. 
 
 The passage of the child through the opening into the abdominal 
 cavity is usual ; but to this rule there are exceptions. I have seen three 
 cases, two complete and one incomplete, where the child remained 
 within the uterus in spite of the existence of extensive laceration. 
 
 The symptoms of incomplete rupture are, at the time of its occur- 
 rence, of less severity than the foregoing. The pain and collapse, the 
 cessation of uterine contractions, and the recession of the presenting 
 part are usually absent. Often the rupture may have existed for some 
 time without appreciable phenomena pointing to its existence. The 
 frequent pulse is the most constant sign. As incomplete ruptures have 
 almost always a lateral situation, large vessels are apt to be injured and 
 the internal haemorrhage to be profuse. 
 
 In rare cases subperitoneal emphysema, due to the entrance of air or 
 gases arising from putrefaction, may be recognized by the hand or by 
 the ear on the anterior surface or upon the sides of the uterus, and ex- 
 tending sometimes into the iliac regions. 
 
 Treatment — Prophylaxis. — In view of the serious prognosis in cases 
 of uterine rupture, the question of prophylaxis is one of peculiar in- 
 terest and importance. The outcome of Bandl's demonstration regard- 
 ing the etiology of the accident is to place in a clear light the responsi- 
 bility of the physician for its occurrence. If it can not always be 
 foreseen and prevented, there is no excuse for the accident when the 
 development of the recognizable conditions which lead to it is over- 
 looked, or where palpable warnings are neglected. 
 
 In multiparte with contracted pelves, where, as a consequence of 
 previous pregnancies, the ligaments are lax and the lower segment is 
 soft and distensible, it is desirable, so soon as the child is viable, to 
 induce premature labor, and thus to diminish the disjoroportion be- 
 tween the head and the pelvis. 
 
 If the conditions described by Bandl begin to develop during labor, 
 lateral obliquities should be corrected, either by placing the patient 
 upon the side to which the presenting part is turned, or by fixing the 
 uterus with compresses and a bandage in the median line. In hydro- 
 cephalus, puncture should be resorted to at an early period. 
 
 If the recession of. the body of the uterus continues, and the head 
 is movable, version should be performed, provided always that it can 
 be accomplished without violence. In the introduction of the hand, 
 every pains should be taken to correctly appreciate the additional 
 strain to which the cervical tissues are subjected. When an extremity 
 has been seized, and tractions are made, the contraction ring which 
 separates the body from the lower segment interferes alike with the 
 descent of the breech and the ascent of the head into the fundus. If 
 rude force is employed, the increased pressure that temporarily is ex- 
 erted upon the side of the cervix, which is bulged by the presenting 
 part, can easily give rise to rupture. To avoid any unnecessary strain
 
 RUPTURES OF THE GENITAL CANAL. 
 
 617 
 
 during version, counter-pressure should be made over the fundus of 
 the uterus by a trained assistant, while the operator controls the direc- 
 tion of the head by means of his free hand laid upon the abdominal 
 wall. 
 
 If the head is fixed in the pelvis, the forceps is usually available. 
 If, however, the head is movable and version contra-indicated, the for- 
 ceps is not likely to help the child, and is nearly certain to injure the 
 mother. In a few cases it 
 is possible to press the head 
 into the pelvis by force 
 exerted with the two hands 
 from above the pubes. 
 
 If craniotomy becomes 
 necessary, Bandl advises 
 seizing the head in the 
 forceps before using the 
 perforator, as even mod- 
 erate pressure upward in 
 the tense state of the cer- 
 vix may lead to laceration. 
 
 In neglected shoulder 
 l)resentations, pains should 
 be taken to ascertain 
 whether the child is living 
 before performing version. 
 This can at times be ac- 
 complished by passing the 
 hand upward near the 
 
 shoulder and feeling for pulsations of the cord. In all extreme cases, 
 the continued retraction of the uterus, by limiting the placental area, 
 is apt to produce fetal asphyxia. If the child is living, the conditions 
 are usually such that version can still be performed, provided care be 
 taken at the same time to press the head from without toward the 
 uterine axis. Excessive distention of the cervix develops much more 
 slowly in primiparae than in women who have had previous confine- 
 ments. If the child is dead, or where version is impracticable, decapi- 
 tation should be employed to release the patient from further danger. 
 
 Treatment after the Occurrence of Rupture. — If rupture is sus- 
 pected to have taken place, the child should be delivered without de- 
 lay. The means of delivery should be selected with the view to enlarge 
 the opening as little as possible. In vertex presentations, if the diag- 
 nosis is clear, it is advisable to perforate and extract with the cranio- 
 clast, as the child is rarely born alive where rupture has taken 2:)lace. 
 
 If the head only has passed through the rent, if the os is dilated, 
 and if the feet are felt near the pelvic brim, the withdrawal of the child 
 
 Fig. 230. 
 
 -Retraction in a case of shoulder presentation. 
 (Bandl.)
 
 g^g THE PATHOLOGY OF LA15011. 
 
 by version is usually effected without difficulty. If, however, the pel- 
 vic contraction is extreme, if the cervix is rigid, or if so large a portion 
 of the foetus has passed into the peritoneal cavity that its withdrawal 
 is liable to increase the size of the laceration, it is doubtless better to 
 incise the abdomen at the linea alba, and deliver through the artificial 
 opening. There is not only less shock, but the opening into the ab- 
 domen enables the operator to remove effused blood and amniotic fluid 
 from the peritoneal cavity. Still, the not uncommon impression that 
 the ruptured uterus furnishes a promising field for abdominal surgery 
 does not take into account that in many of the cases where laparotomy 
 is clearly indicated, the patient is practically moribund. The employ- 
 ment of the suture to close the uterine wound, in view of recent Cesa- 
 rean successes, sounds reasonable ; but it must be remembered that, 
 with ragged borders infiltrated with blood, with the stripping of the 
 peritonaeum, and with air or gases sometimes infiltrated into the sub- 
 peritoneal connective tissue, the conditions for union are in no wise 
 comparable to those which exist when a clean incision is made into 
 a perfectly normal muscular organ. However, in the cases gathered 
 by Harris for the United States, there were 53i^ per cent of recov- 
 eries. 
 
 The supravaginal amputation of the uterus, wiih suture of the peri- 
 tonaeum below the ligature, promises fairer results, though the deep 
 situation of the tear makes it difficult to secure a healthy pedicle. 
 Godsen collected seven cases, all of which terminated fatally, but more 
 recently Slavjansky, Krassowsky-Halbertsma, jMermann, Fontana, Coe, 
 "VViedow, and Kehrer have each reiwrted a recovery under seemingly 
 desperate conditions.* 
 
 If the abdomen is opened, even when hesitation is felt about the 
 deep suture or ablation, there should be none concerning the em- 
 ployment of the peritoneal suture, by means of which the complete 
 rupture is converted into an incomplete one with its more favorable 
 prognosis. 
 
 When the child can be removed by the natural passages without an 
 increase of the laceration, and the latter is confined to the lower seg- 
 ment, in all cases where rupture is incomplete, or where the uncer- 
 tainty as to the extent of the injury leads the physician to shrink from 
 abdominal section, clots in the vicinity of the opening should be re- 
 moved by the hand, firm contractions should be excited by manual 
 pressure, and every pains should be taken to secure by irrigation an 
 antiseptic condition of the genital tract. 
 
 As death, when not due to shock or haemorrhage, is most frequently 
 
 the result of septic changes in the retained fluids, a priori drainage 
 
 ought to prove an essential aid to treatment. The correctness of this 
 
 prevision has been realized by successes obtained through its instru- 
 
 * Vide paper by H. C. Coe, M. D., Med. Record, Nov. 2, 1889.
 
 RUPTURES OP THE GENITAL CANAL. 619 
 
 mentality by Frommel,* Mosbach, Graefe, Felsenreic]i,t Hecker,J and 
 Mann.* The plan recommended by the latter, based upon the experi- 
 ence of Gustav Braun's clinic, consists in taking a large-sized piece of 
 drainage tubing, and bending it in the middle, so as to leave the ex- 
 tremities of equal length. A large opening should then be made at the 
 arch, which is to be introduced through the point of rupture, and the 
 descending branches of the tube should be fastened together to prevent 
 the formation of a bridge of tissue between them during the process 
 of healing. The upper end of the drainage apparatus should be passed 
 from a half-inch to an inch beyond the torn borders of the uterine 
 wound, and the lower ends stitched with silk to the posterior commis- 
 sure. Over the vulva and the apparatus there should be placed an 
 antiseptic dressing, which should be changed several times daily. After 
 the first four or five days, by which time it may be assumed that pro- 
 tective adhesions will have formed in the neighborhood, a regular irri- 
 gation of the wound with a two-per-cent solution of carbolic acid 
 should be carried out, with a view to prevent a septic poisoning from 
 the decomposition of the pus and the lochia. 
 
 More recently, in the discussion before the Geburtshiilflich Gynaekolo- 
 gischen Gesellschaft,|| of Vienna, it was recommended to secure drain- 
 age, either as above, by rubber tubing, or by means of lamp wicking 
 (fifty threads) prepared with iodoform, while the vagina was loosely 
 packed with iodoform gauze. Drainage should be sujiported by every 
 means calculated to maintain uterine contractions and check haemor- 
 rhage. These objects are best secured by manual compression of the 
 uterus, either with or without conjoined pressure of the aorta, to be 
 continued if necessary for hours. Before leaving the patient a grad- 
 uated compress should be placed around the uterus, to maintain firm 
 uterine contractions, or, what I regard as preferable in these and analo- 
 gous cases, a rubber water-bag, which adjusts itself to the contour of 
 the uterus and is hardly less effective than the hand itself. 
 
 In the Vienna discussion alluded to Dr. Fleischman stated that in 
 eighteen cases of anterior rupture, five of which had been treated by 
 drainage, all died ; whereas, of fourteen cases of posterior rupture, of 
 five treated by drainage all recovered. 
 
 In certain of the reported cases of recovery where drainage was eni- 
 
 * Frommel. Zur Aetiologie unci Therapie der Utenisruptur, Ztschr. f. Geburtsh. 
 und Gynaek., Bd. v. Heft 2. 
 
 t Pelsexreich, Beiti-ag zur Therapie der Uterusriijitur, Arch. f. Gynaek., Bd. 
 xvii, Heft 3. 
 
 t Hecker. Centralblatt f. Gynaek.. 1881. No. x, 
 
 * Manx, Centralblatt f . Gynaek.. 1881, No. xvi. Drainage in the cases referred 
 to was employed in complete as well as in incomplete ruptures. The triumph of 
 the principle of drainage is best demonstrated by the fact that in most of the cases 
 gastrotomy was contra-indicated by reason of excessive shock. 
 
 II Sitzung's Berichte, 1888, No. 9.
 
 620 
 
 THE PATHOLOGY OF LABOR. 
 
 ployed an opening was let in the nterine wall commnnicating with an 
 adjacent sac formed eitlier by the folds of the broad ligament or by 
 false membranes which persisted after the removal of the dressings. 
 
 Rupture limited to the Peritoneal Covering: of the Uterus.— This 
 very rare form requires but brief mention. In all but ten cases have 
 been reported. It occurs nnder apparently normal conditions, without 
 premonitory symptoms. It is supposed to be due to deficient elasticity 
 of the peritonaeum, and may take place during either pregnancy or 
 labor. Death in the known cases resulted from internal hoemorrhage, 
 from peritonitis, or from shock (Spiegelberg). 
 
 Perforation from Pressure.— In stud}'ing the influence of the con- 
 tracted pelvis, we have already had occasion to consider the origin of 
 circumscribed losses of substance in the uterus due to the pressure of 
 the pelvic walls. In the present connection it is only necessary to state 
 that they are more frequently followed by recovery than the ruptures, 
 in favorable cases exudation closing the opening and the necrosed tissue 
 passing away through the vagina. 
 
 Lacerations of the Vaginal Portion of tlie Cervix. — Lacerations at 
 the OS externum of moderate extent are the nearly constant concomi- 
 tant of physiological labor. The " show " of monthly nurses consists 
 of mucus tinged with blood furnished from the slight tears which are 
 produced during the passage of the head through the cervical orifice. 
 At times, however, these lacerations may assume a pathological impor- 
 tance, reaching upward to the vaginal junction, or even, in extreme 
 cases, stretching outward through the upper portion of the vagina. 
 At the time of their occurrence, they give rise to no special symptoms. 
 After the birth of the child, they may become the source of post-jyar- 
 tmti haemorrhage, or they may interfere with involution, and during 
 childbed expose the patient to the risks of infection. In after-life they 
 furnish the foundation of a multitude of uterine disorders (Emmet). 
 They occur most frequently in primiparae, especially elderly ones ; in 
 oedema of the cervix ; in cases where the anterior lip, pushed downward 
 by the occiput, is caught between the head and tlie pubic walls, and 
 thus is prevented from retracting simultaneously with the posterior 
 lip ; and as a consequence of obstetrical operations. Severe lacerations 
 extending above the vaginal junction are most frequently produced in 
 pelvic deliveries, where the head is extracted by force through an imper- 
 fectly dilated os. 
 
 Most commonly these lacerations follow a longitudinal direction. 
 In rare cases, where there is extreme rigidity of the os externum, or 
 where, after the escape of the amniotic fluid, the head distends the an- 
 terior lip without pressing upon the os, a transverse rent may occur 
 through which the child may pass. Sometimes a longitudinal tear may 
 be combined with one running transversely, the lip then hanging by a 
 pedicle to the uterus, or the entire lip may be torn off. Isolated cases
 
 RUPTURES OF THE GENITAL CAXAL. 621 
 
 of so-called annular laceration have been reported, where the transverse 
 rent has extended through the whole vaginal portion, so that the lower 
 segment has been detached in the form of a ring. In these cases hsem- 
 orrhages very rarely if ever occur. 
 
 In addition to the ordinary principles which should govern the 
 management of every labor, Bandl lays great stress upon the pushing 
 up of the confined anterior lip as an important prophylactic measure. 
 
 Haemorrhage due to cervical laceration should be controlled by clos- 
 ing the rent with silver or catgut sutures. In view of the bad light by 
 which the operation has usually To be performed, the suggestion of 
 Schroeder, to draw the cervix with the volsella forceps outside the vulva, 
 while an assistant pushes the uterus down into the jDelvis from above, is 
 worthy of being borne in mind. With the wounded parts thus exposed, 
 the reparative operation advocated presents scarcely appreciable difficul- 
 ties to even the least surgical of attendants. 
 
 If no hemorrhage occurs, cervical lacerations are rarely recognized 
 except by physicians who take pains to invariably investigate the j^ost- 
 partum condition of every patient. As a rule, with strict antisepsis 
 they heal rapidly during involution. Nevertheless, it is my present cus- 
 tom to close all extensive lacerations with a continuous catgut suture. 
 After the expulsion of the placenta the operation is easy, is devoid 
 of risk, and is followed by speedy union of the torn surfaces. For 
 the gynaecological expert Veit recommends the passage of the sutures 
 without the aid of the speculum, by the touch alone. This he accom- 
 plishes by means of a needle seized at right angles with a long-handled 
 needle holder. The needle he passes first through the anterior, and 
 then through the posterior lip, under the guidance of two fingers of 
 the left hand, while the fundus is depressed by an assistant from above. 
 Traction upon the first suture materially aids in the introduction of the 
 others. 
 
 Lacerations of the Vagina. — Vaginal lacerations vary in gravity 
 according to their extent and position. In the upper part of the canal 
 they are, as a rule, continuous with ruptures begun in the uterus 
 or in the vaginal portion. In contracted pelves, where, owing to 
 excessive retraction, the head fills the vagina without entering the 
 pelvic brim, isolated lacerations of the vagina may follow the same 
 general causes as those which give rise to rupture of the uterus. Per- 
 haps the most common vaginal lesion is that produced by the un- 
 guarded blades of the forceps when applied diagonally in j)lace of 
 directly to the sides of the child's head. 
 
 In the lower portion of the canal these lacerations heal speedily 
 without serious symptoms, provided cleanliness be maintained from the 
 first. Lacerations of the fornix only are of great importance on ac- 
 count of their proximity to the peritonaeum, and because of the exposure 
 of the parametrium to septic absorption. The immediate closure, there-
 
 g22 THE PATPIOLOGY OF LABOR. 
 
 fore, of these rents with silver sutures ought to be attempted. Owing 
 to the laxity of tlie tissues, the difficulties of reaching the wound are 
 not excessive, while the dangers to be forestalled are of a peculiarly 
 threatening character. 
 
 The orio'in and nature of fistulous communications with the blad- 
 der and the rectum have already been considered in connection with 
 the pathology of labor. Eesulting for the most part from necrosis 
 due to pressure, they are rarely the immediate sequela? of childbirth, 
 the sloughing of the dead tissue taking place during the course of the 
 puerperal period. The treatment in such cases belongs properly to 
 the domain of gynaecology. The closure by suture is only available as 
 a plan of treatment in cases where complete laceration through the 
 tissues into the neighboring organs takes place during labor, as the 
 consequence of rudely performed obstetrical operations. 
 
 Lacerations of the Vaginal Orifice.— Owing to the small size of the 
 vaginal orifice, tears through the mucous membrane and erosions of 
 the vulva, and, in primiparge, the rupture of the frenulum, are to be 
 accounted as the almost inevitable consequences of childbirth. They 
 are the principal cause of the external soreness experienced after labor. 
 In healthy localities they heal rapidly, and are of but trivial impor- 
 tance. Of greater moment are deep perineal lacerations and those of 
 the vestibulum. 
 
 Lacerations of the Vestibulum. — Tears limited to the mucous mem- 
 brane are usually found after labor at the sides of the clitoris. In 
 exceptional cases these tears may involve the underlying erectile tissue 
 (bulbs of the vestibule), and become the source of profuse or, when 
 overlooked, even of fatal haemorrhage. The blood, which may be 
 either venous, arterial, or of mixed origin, spurts in jets or oozes as 
 from a soaked sponge. The recognition of the lesion is easy upon 
 inspection. It should always be thought of as a possible cause of post- 
 partum haemorrhage in every case where the flow continues after the 
 contraction of the uterus. 
 
 The bleeding may be temporarily arrested by pressing the tissues 
 with the finger against the inner surface of the pubic bones until 
 the expulsion of the placenta. Ligatures to the bleeding vessels, 
 owing to the complexity of the structures, are of no avail. In slight 
 cases a stream of cold water is a sufficient haemostatic. In others, 
 the bleeding requires to be checked by one or two deep sutures 
 introduced so as to bring the torn surfaces into apposition. If the 
 bleeding appears to come from one or two points, the jiinccx liemosta- 
 tiqnes are of service. Styptics and astringents are usually effective, 
 but they possess the drawback of augmenting the pain and soreness. 
 
 Lacerations of the Perinaeum.— In the chapter upon the :Manage- 
 ment of Normal Labor, the nature, origin, and prevention of perineal 
 lacerations have already been considered. The diagnosis is made by a
 
 RUPTURES OF THE GENITAL CANAL. 623 
 
 careful inspection of the genital organs after delivery. The extent of 
 the lesion is estimated by including the recto-vaginal septum between 
 the thumb and index-finger. 
 
 The treatment of perineal laceration consists either in keeping the 
 woman in bed until the wounded surfaces cicatrize, or in bringing the 
 parts into apposition by means of sutures, with the intent to secure 
 primary union. The first plan is sufficient if the wound be of slight 
 extent. If, however, the rupture extends to the sphincter ani, and 
 involves the entire perineal body, the vagina is left without support, 
 rectocele or cystocele ensues,^ the uterus sinks downward and becomes 
 displaced backward, and in the end prolapsus is apt to result. If the 
 sphincter ani and the recto-vaginal wall are involved, inability to re- 
 strain the bowels adds to the discomfort of the patient. This sequence 
 of symptoms, so familiar to gyngecologists, forms an urgent plea for 
 the resort to surgical means to repair the injury. Only a very credu- 
 lous j)erson really believes that he has witnessed union by first inten- 
 tion in extensive ruptures, as the result of tying the knees together 
 and enjoining rest upon the side. The action of the transversi-peri- 
 naei muscles tends to draw the torn surface apart. Moreover, the 
 necessity of separating the knees in passing urine, and to enable the 
 nurse to cleanse the genitalia, makes it impossible to keep them in 
 contact for any lengthened period. 
 
 To the immediate operation there is no valid objection. It is not 
 difficult, it is not extremely painful, and its performance, as a rule, 
 diminishes the risks of infection and shortens the puerperal period. It 
 is true that the object aimed at may not be attained. If labor has been 
 conducted in accordance with antiseptic principles, if no syphilis ex- 
 ists, and the vitality of the tissues has not been impaired by cedema or 
 long-continued pressure, failure is the exception. The argutnent that 
 the operation is in itself a confession does not deserve discussion. 
 
 For its performance the patient should lie upon her back, with her 
 hips well over the edge of the bed. Two assistants to hold the knees 
 are of great convenience. In ojjerations requiring the introduction of 
 not more than three or four sutures angesthesia may be dispensed 
 with. In lengthy operations, such as are necessitated by lacerations 
 extending up the posterior vaginal wall, ether should be given in place 
 of chloroform, and its administration should be intrusted to an experi- 
 enced person only. It can not be too often repeated that anaesthesia 
 after labor calls for the exercise of extreme caution. 
 
 The wound should be prepared by carefully washing away blood 
 and clots with warm carbolized water. For lacerations not extending 
 through the sphincter ani I use Peaslee's needle, which is furnished 
 with an eye at the point, and is set in a wooden handle. It possesses 
 the advantage of strength, a quality of no mean importance in making 
 the circuit of the redundant tissues with which we have to deal after
 
 624 
 
 THE PATHOLOGY OP LABOR. 
 
 labor. I use the silver suture, and after repeated trials have not been 
 able to convince myself that it can be equally well replaced by silk. 
 
 The first suture should be passed just in front of the anus. It 
 should be entered and brought out about a half -inch from the rupt- 
 ured borders. The others should follow at from one third to one half 
 inch intervals. Each suture should make the entire circuit of the 
 wound. This can be readily accomplished by guiding the point of the 
 needle through the residue of the perineal body Avith two fingers in the 
 anus and with the thumb upon the vaginal surface. To secure a 
 stronger hold for the last suture, the needle should be made to enter 
 the vagina above the upjjer angle of the rent, and the wire should be 
 made to traverse a portion of undenuded tissue before completing the 
 circuit. In closing the wound, great pains must be taken not to twist 
 the sutures too tightly, as in that case they are apt either to cut out or 
 to produce sloughing. 
 
 Sometimes, in rents extending through the sphincter ani and the 
 recto-vaginal septum, the simple perineal sutures will effect a satisfac- 
 tory union. Thus, in a patient at the Emergency Hospital, with a 
 laceration extending nearly to the cervix, and whose condition pre- 
 cluded a lengthy operation, I obtained an excellent result by passing a 
 single wire above the angle of the wound, and twisting the ends out- 
 side the perineum. As a rule, however, it is desirable to adjust the 
 edges with great care, first closing the rent upon the rectal side, then 
 bringing together the split in the mucous membi'ane upon the vaginal 
 side with transverse sutures, and finally bringing the lower borders of 
 the perinaeum together by a separate operation. This disposition is 
 the so-called triangular suture of Simon.* It requires fine needles, a 
 needle-holder, an adjuster, a wire-twister, and, in fact, all the para- 
 phernalia of the gynecologist. The length of the operation renders 
 necessary an anaesthetic, which should be ether rather than chloro- 
 form. The disgusting condition of a patient with laceration through 
 the recto-vaginal septum, where the healing process has been the result 
 of granulation, justifies the attempt to secure immediate union. 
 
 The requirements in the way of after-treatment are very simple. 
 The urine should be drawn every four to six hours with a catheter, 
 until the patient is able to pass her water spontaneously ; the bowels 
 should be kept open with salines ; and the knees should be tied loosely, 
 to remind the woman of the desirability of keeping them in contact. 
 The wound should be kept scrupulously clean. Whenever urine has 
 been passed the perineum should be washed with warm carbolized 
 water, then dried, and sprinkled with iodoform. Pads of iodoform 
 gauze should be placed to the sides of the sutures to prevent them 
 from causing ulceration of the adjacent soft parts. A little opium 
 
 * Vide Garrigues's excellent paper entitled The Ob.stetric Treatment of the 
 Permsura, Am. Jour, of Obstet., April, 1880.
 
 RUPTURES OF THE GENITAL CAXAL. ^25 
 
 may be given, if the pain experienced is considerable. Pain in child- 
 bed from any cause helps to depress the vitality. The perineal sutures 
 should be left a week in situ. Many ^Jromising cases are spoiled by 
 removing the sutures too early. The vaginal sutures may be allowed 
 to remain until the external union is sufficiently solid to permit the 
 introduction of the speculum. Catgut sutures for the rectum are to 
 be preferred when they can be obtained of good quality, as they obviate 
 the necessity of future removal. 
 
 For the more superficial lacerations of the perineum the serves 
 fines invented by Vidal de Cassis, and extensively used in Vienna, have 
 been warmly advocated in this country by Professor M. D. Mann,* and 
 by Garrigues.f My own experience with them has not been fortu- 
 nate ; but the better results from their use in the hands of their sup- 
 porters recommend them to trial. 
 
 Thrombus of the Vagina and Vulva. — Hfemorrhagic effusions into 
 the external organs of generation occur with greatest frequency in the 
 labia majora, more rarely in the labia minora, and occasionally be- 
 tween the superficial and median fasciae of the perineum. These ex- 
 travasations may form tumors beneath the subcutaneous or submucous 
 tissues of the vulva or vagina, which vary in size from that of a hen's 
 egg to that of a child's head. As a rule, the blood is poured out into 
 the cellular tissue seated below the diaphragm of the pelvis. The ex- 
 travasation may, however, stretch upward along the vagina to the cel- 
 lular tissue of the uterus, then posteriorly beneath the peritoneum to 
 the kidneys, and around in front to the navel and laterally to the iliac 
 fossae (Winckel). The source of the hasmorrhage may be venous or 
 arterial. The vessel from which the hsemorrhage takes place is usu- 
 ally situated in the lower portion of the vagina ; in less frequent cases, 
 in the vulva. 
 
 Symptoms. — The first sensation experienced at the time of the 
 rupture is usually one of intense pain, proportioned to the size of the 
 tumor and the rapidity of its formation, though in a case witnessed 
 by Professor Barker J this symptom was absent. As the effusion con- 
 tinues, swelling of the vulva, usually upon one side, results, and the 
 skin becomes blue and nearly translucent. The patient complains of 
 pain, and feels faint, while her lips and cheeks grow white. If the 
 sac contains fluid blood, fluctuation is detected ; after coagulation the 
 tumor has a soft, boggy feel. If the tension increases, the skin may 
 yield, the blood and coagula escape, and, if no means be adoj^ted to 
 arrest the hemorrhage, the patient may die in a few minutes from 
 acute anemia. 
 
 If the thrombus be of small size and situated low down, the after- 
 
 * Manx, The Immediate Treatment of Superficial Rupture of the Perinaeum, 
 Am. Jour, of Obstet., November, 1874. 
 
 f Garrigues, Ioc. cit. % Barker, Puerperal Diseases, p. 58. 
 
 40
 
 Q2Q THE PATHOLOGY OF LABOR. 
 
 symptoms may be of slight importance. The fluid may be absorbed, 
 the walls of the cavity unite, and the tumor disappear entirely. Tu- 
 mors of larger size produce symptoms referable to pressure, such as 
 back-ache, rectal obstruction, and ischuria. The vagina may be so 
 narrowed as scarcely to permit the passage of the finger. Rupture, if 
 not immediate, usually occurs spontaneously in the course of a few 
 days, and is, as a rule, preceded by necrosis of a portion of the de- 
 tached mucous membrane. The most frequent point of spontaneous 
 rupture is at the junction of the larger and smaller labium. If the 
 necrosed tissues become gangrenous, death from septicemia may result. 
 Winckel * sums up the various terminations of thrombus as follows : 
 1. Death from hsemorrhage, with or without precedent rupture; 2. 
 Death from decomposition of the sac contents, with consecutive sep- 
 ticemia or septico-pyagmia, most frequently after rupture or opening 
 of the sac ; 3. Eupture and recovery ; 4. Rupture, with formation of 
 fistula? ; 5. Absorption without rupture, followed by recovery. 
 
 Diagnosis. — The diagnosis is simple. The rapid development and 
 increase of the tumor, its bluish color, its elastic or fluctuating char- 
 acter, the sharp pain, and the acute anaemia, occurring independently 
 of uterine hemorrhage, sufficiently point to a sanguineous effusion 
 into the subcutaneous cellular tissue. The extent of the tumor must 
 be determined by rectal and vaginal exploration. It is only at the 
 begmuing that it will be found possible to ascertain the seat of the 
 hemorrhage, whether in the vulva, vagina, or perineum. Sometimes, 
 after rupture and the discharge of the clots, the bleeding vessel may 
 be detected. 
 
 Etiology. — The formation of the thrombous tumor, with rare excep- 
 tions, takes place during or shortly after labor. If the vessel rupture 
 in advance of the presenting part, the effusion may be immediate and 
 furnish an obstacle to delivery, or the descent of the foetus may check 
 the hemorrhage for a time, to break out afresh after the labor is ended. 
 In rupture due to necrosis consequent upon pressure, the hemorrhage 
 does not, of course, take place until sloughing occurs. Rupture may 
 follow excessive straining, rapid dilatation of the genital canal, or direct 
 injuries. A varicose condition of the veins does indeed create a pre- 
 disposition to rupture, but is by no means a frequent factor in the pro- 
 duction of the accident. Thus, it was present in but six of the fifty 
 cases collected by Winckel. 
 
 Prognosis. — The prognosis of vaginal thrombus is serious. Deneux 
 reported twenty-two deaths in sixty cases, a mortality evidently ex- 
 cessive ; Winckel reported six deaths in fifty cases ; Barker reported 
 two deaths in twenty-two cases; and Scanzoni one death in fifteen 
 cases. But statistics like these are apt to give rise to a misleading 
 impression. A thrombus |jer se is rarely a dangerous complication. It 
 * WixcKEL, Die Pathologic unci Therapie des Wochenbetts, 2te Auflage, p. 132.
 
 RUPTURES OP THE GENITAL CANAL. G27 
 
 may, however, become so either because after rupture no means are 
 adopted to limit the amount of haemorrhage, or because, in unhealthy 
 localities, the tense membrane covering the tumor is liable to become 
 gangrenous, and the vast vaginal wound furnishes at once a congenial 
 soil for the multiplication of septic germs, and an absorbent surface 
 by which the septic poison generated is afforded a ready entry into 
 tiie adjacent cellular tissue. Thus, Barker reports nine cases in pri- 
 vate practice, in all of which the patients recovered. Of thirteen 
 cases in hospital practice, two patients died of puerperal fever. The 
 prognosis is likewise less favorable in cases where there exists at the 
 same time extensive separation of the peritonseum. 
 
 Treatment. — The conditions of successful treatment are restriction 
 of the haemorrhage and the prevention of septicaemia. Early recogni- 
 tion of the accident is very desirable. 
 
 So soon as effusion is recognized the forceps should be applied, and 
 the head should be extracted as sjieedily as is consistent with the 
 preservation of the integrity of the maternal tissues. To quote from 
 Professor Barker's excellent treatise : " The exciting cause of the acci- 
 dent is the arrest of the circulation by the mechanical pressure of the 
 presenting part of the foetus. The sooner the pressure is removed, 
 the sooner the danger will be over and the less will be the injury to 
 t!ie parts." Moreover, as we have seen, the head in its descent acts as 
 a tampon, by means of which the haemorrhage, whether external or 
 in the submucous tissue, is temjiorarily held in check. If the tumor 
 in advance of the head is so large that the delivery can not be accom- 
 plished Avithout impairing the vitality of the sac-walls, the danger 
 should be averted by incising the thrombus and turning out the 
 coagula. 
 
 Haemorrhage after the birth of the child is apt to be very profuse, 
 especially if the sac has been opened either by spontaneous rupture of 
 its coverings or with the knife. So long as the sac-walls are intact, the 
 pent-up blood exercises a considerable pressure upon the bleeding ves- 
 sel. For this reason it is well to cover an opening, if one hapijens to 
 have formed, with lint soaked in a solution of one of the per-salts of 
 iron. The continuance of internal haemorrhage should then be checked 
 by means of a water-bag (a large Barnes dilator will suffice) intro- 
 duced into the vagina and distended with ice-water. The hydrostatic 
 pressure rarely requires to be maintained for longer than half a day, 
 during which time it should be repeatedly removed for a few moments 
 to allow the vagina to be cleansed by disinfectant injections. The 
 urine should be drawn with a catheter during the first forty-eight 
 hours, as every straining effort is to be carefully guarded against. A 
 tamjion of linen rags, or of cotton, is inadmissible on account of the 
 tendency it possesses to excite rapid decomposition in the lochial dis- 
 charges. Immediate opening of the thrombus, followed by em]] tying
 
 g28 THE PATHOLOGY OF LABOR. 
 
 the sac and filling the cavity with lint soaked in astringent solutions, 
 are measures which should, on account of the suppuration likely to be 
 thereby excited, be reserved for cases v/here milder procedures have 
 proved ineffective. 
 
 The ultimate opening of the sac, after the hemorrhage has once 
 been arrested, is rarely to be avoided. Still, cases are on record where 
 tumors the size of a man's fist have disappeared by absorption. As 
 this is the most favorable mode of termination, every effort should be 
 made to secure such a result. To this end quiet should be enjoined, 
 cold should be employed, and pain should be subdued by opiates. If, 
 however, the tumor increases in size, the skin becomes greatly dis- 
 colored, and vesicles form upon its surface, it is better to anticipate 
 threatened gangrene or rupture by incision. If the circumstances per- 
 mit of delay, it is better to wait three to four days to make sure of the 
 stoppage of bleeding. The best point for laying open the tumor is 
 upon the inner surface of the labium majus. The incision should be 
 two to three inches in length. After turning out the clots the cavity 
 should be irrigated with a bichloride solution (1 to 3,000) and should 
 then be packed with iodoform gauze. 
 
 Rupture of the Pelvic Articulations.* — Rupture of the pelvic ar- 
 ticulations may take place spontaneously where either inflammation or 
 excessive relaxation of the joints exists at the time of labor. More 
 commonly it is the result of difficult forceps operations performed in 
 cases of contracted pelves. The risk of the occurrence of this accident 
 is especially great when the forceps is applied to the head at the brim 
 and forcible tractions are made in a direction anterior to the pelvic axis. 
 
 The symphysis is the articulation which is principally exposed to 
 this form of injury, though it is obvious that no increase in the capa- 
 city of the pelvis consequent upon the separation of the symphysis is 
 possible without simultaneous rupture of at least one of the sacro-iliac 
 synchondroses. At the symphysis the rupture is apt to be complete, 
 at the synchondroses the rupture is usually confined to the anterior 
 surface. It may take place in the median line, or upon the side, be- 
 tween the cartilage and the pubic bone. If the injury be slight, the 
 synovial cavity of the symphysis may not be injured. At the synchon- 
 droses, opening of the joint-cavity is inevitable. An excessive degree 
 of the lesion is accompanied by laceration of the vagina, the bladder, 
 and the intervening connective tissue. 
 
 Occasionally the rupture of the joint is announced by a perceptible 
 sound, by intense pain, and, as the result of the increase in the pelvic 
 space, by rapid advance of the head. In the lighter forms, however, 
 which make up the bulk of the cases witnessed, there are no distinct- 
 
 * Ahlfeld, Die Verletzungen der Beckengelenke wahrend d. Geburt ui^d im 
 Wochenbett, Schmidt's Jahrbiicher, Bd. 169, 1876, p. 185; Spiegelbero, Lehr- 
 buch, p. 636.
 
 PROLAPSE OF THE FUNIS, ETC. 629 
 
 ive symptoms at the time of the accident. The pathognomonic sec- 
 ondary manifestations are outward rotation of the thighs and localized 
 pain, increased by movement of the limbs and relieved by fixation of 
 the pelvis. Objective evidence of rupture at the symphysis is afforded 
 by the movements produced at the articulation by alternate pressure 
 upon the ends of the pubic bones and by combined internal and ex- 
 ternal examination. If the rent extends to the vagina, the laceration 
 may be detected by the touch. Separation of the sacro-iliac synchon- 
 droses is rendered probable if violent pain is excited by alternately 
 pressing the anterior portions of the ilia together and then drawing 
 them apart from one another. Bladder disturbances are rare except in 
 cases where the separation at the symphysis is complete, or where the 
 rupture is followed by inflammation and the formation of pus. 
 
 The treatment consists in sujsporting the pelvis by means of a suit- 
 able bandage, in keeping the patient upon her back, and in maintain- 
 ing strict cleanliness. The bowels should for a time be kept confined. 
 As regards the first indication, Spiegelberg says an ordinary towel 
 properly folded and fastened at the pubes, with care taken to avoid 
 pressure upon the crests of the ilia, will answer all the requirements. 
 Eupture of the pelvic articulations, when not complicated by other 
 lesions, or by puerperal infection, run for the most part a favorable 
 course. During convalescence the patient should wear some form of 
 permanent bandage, such as has been recommended in cases of relaxa- 
 tion of the pelvic symphyses. 
 
 CHAPTER XXXIV. 
 
 PROLAPSE OF THE FUNIS, ETC. 
 
 Prolapsed funis. — Asphyxia neonatorum. — Collapse and sudden death during labor 
 and childlied from thrombosis, from embolism, and from entrance of air into 
 the circulation. — On the extraction of the child in case of death of the mother 
 in pregnancy or labor. — Tympanites uteri. 
 
 Whex the cord is felt within the membranes next to the present- 
 ing part, a funis presentation is said to exist. After the membranes 
 have ruptured, the cord descends into the vagina, in front of the pre- 
 senting part, and is then said to be prolapsed. Generally the cord 
 occupies one of the hollows upon the sides of the promontory ; less 
 frequently it descends opposite the lateral walls of the pelvis; the 
 site in front of the promontory or behind the pubes is very excep- 
 tional. 
 
 As regards the frequency of the accident, the experience of individ- 
 uals varies widely. Churchill collected 98,512 cases of labor in which
 
 g30 THE PATHOLOGY OF LABOR. 
 
 it occurred 401 times, or in the proportion of one to 245*5 cases. Dr. 
 Christisen, of Wyandotte, Michigan, met witli it 23 times in 1,516 
 cases. Meachem met with it 10 times in 931 cases. Mr. Bland met 
 with it, on the other hand, but once in 1,897 cases.* 
 
 Prolapse of the cord occurs only in cases where the presenting part 
 does not completely occlude the lower uterine segment. It is favored 
 by a long cord, by a deep placental site, by the insertic velamentosa, 
 by oblique and breech presentations, by prolapse of the extremities, 
 by hydramnios, by multiple pregnancies, and, above all, by the con- 
 tracted pelvis. On account of the more frequent concurrence of these 
 conditions in multiparae, the accident is oftener found in them than in 
 primparffi. 
 
 Duncan f has called attention to what he terms " expression of the 
 cord," i. e., where the cord is squeezed out of the uterus long after the 
 escape of the liquor amnii. Of this phenomenon he says that, during 
 labor and after the discharge of the waters : " All parts of the foetus 
 are propelled, but not at the same rate . . . ; and the rate of progress 
 of parts will vary according to the resistance. More mobile parts will 
 have, in consequence of that mobility, less resistance to encounter, 
 and it is plain that the limbs and the cord are the most mobile of the* 
 solid parts." 
 
 The diagnosis of prolapsed funis is easy. If necessary, the loo]! can 
 be drawn outside of the vagina. Previous to rupture it forms a smooth, 
 round, compressible, mobile body, not to be confounded with any other 
 floating object liable to be encountered within the ovum. AYhen the 
 pulsations of the umbilical vessels are distinctly felt, the child is dem- 
 onstrated to be alive. In the second stage, however, the pulsations 
 may cease for a moment during a pain, to return again in the ensuing 
 interval. As the heart sometimes continues to beat for a few minutes 
 after the circulation in the cord has ended, it is proper to carefully 
 auscultate before assuming death to have taken place (Spiegelberg). 
 
 The prognosis, so far as regards the children, is extremely unfavor- 
 able, more than one half dying during labor. This fatality is owing 
 to the pressure to which the cord is subjected during the passage of 
 the child through the pelvis. There are, however, a variety of cir- 
 cumstances which substantially modify the extent of the danger. Thus, 
 in transverse presentations the cord is scarcely or not at all exposed 
 to pressure. In breech presentations the prognosis is good, owing to 
 the soft consistence and small size of the pelvic extremity, and to the 
 fact that, where the life of the child is in peril, the conditions are such 
 as to permit of speedy extraction. 
 
 * These statistics I have borrowed from an article on the Presentation of the 
 Funis, by Dr. J. G. Meachem, reprinted from The Transactions of the State Medical 
 Society of Wisconsin 1880. 
 
 t Duncan, On Expression of the Cord, Obstet. Trans., vol. xxi, p. 302.
 
 PROLAPSE OF THE FtJ:NlS, ETC. 631 
 
 The most serious cases are those where prolapse occurs as a compli- 
 cation of head presentations. Engelmann found that the infant mor- 
 tality in the latter was sixty-four per cent, while in footling presenta- 
 tions it was but thirty-two per cent. Favorable conditions in head 
 presentations are a large, roomy pelvis and preservation of the mem- 
 branes until cervical dilatation is completed. Of unfavorable import 
 are a deep placental site, a contracted pelvis, and early rupture of the 
 membranes. 
 
 Treatment. — From the foregoing it will be seen that the one indi- 
 cation for treatment in this anomaly is to relieve the cord from press- 
 ure. The conduct of the physician in each individual case will depend 
 upon the presentation and the modifying circumstances. 
 
 If the head presents, so long as the membranes remain intact, and 
 the dilatation of the cervix is incomplete, an expectant attitude should 
 be maintained. Premature rupture should be guarded against by 
 placing the patient in the latero-prone position, by forbidding her to 
 strain, and by supporting the membranes by means of a moderately 
 distended Barnes dilator introduced into the vagina. It is not ra^-e in 
 this class of cases, as the head descends, for the cord to be withdrawn 
 upward into a place of safety. The more complete the dilatation be- 
 fore rupture, the more rapid the subsequent delivery of the child, and 
 the greater the chance, therefore, of preserving its life. If, however, 
 upon auscultation, there are signs of failing heart-action, an attempt 
 should be made to push the cord upward with the fingers through the 
 membranes. In case of success, in order to prevent a relapse, the sac 
 should be ruptured, and the head should be brought down so as to fill 
 the cervical canal. " ' 
 
 After rujiture of the membranes, if the cervix is well dilated, the 
 pains are good, and the head enters quickly into the pelvic cavity, the 
 case may be left to Nature. Spiegelberg mentions five cases, in his own 
 practice, where the birth of the child took place so rapidly that no 
 harm resulted from the descent of the cord. If the pains are feeble, 
 and speedy progress is not made, the forceps should be applied. 
 
 If, after dilatation of the cervix, the head remains high and mov- 
 able above the brim, the forceps should not be employed. It is then 
 dangerous to the mother, and offers but scant hope of proving of serv- 
 ice to the child. The choice in such cases falls either upon reposition 
 of the cord or v^ersion. 
 
 Reposition of the prolapsed cord, as the milder procedure, should 
 be first attempted. The reposition is most easily accomplished in the 
 knee-chest position, as has been beautifully demonstrated by Gaillard 
 Thomas.* . By the simple plan of reversing the direction of the uterine 
 axis, all the conditions which had previously favored the descent of the 
 
 * Thomas, Postural Treatment of Prolapsed Funis, Trans, of the Xew York 
 Acad, of Med., 1858.
 
 ^32 THE PATHOLOGY OF LABOR. 
 
 cord are made to promote its return into the uterine cavity. Thus the 
 intra-abdominal pressure is removed, tlie amniotic fluid is retained, the 
 liead is easily pushed to one side so as to permit the introduction of 
 the hand, and the cord tends to glide by its own weight over the de- 
 clivitv furnished by the anterior wall to the fundus. The loop should 
 be seized in the hollow of the hand, and should be carefully sheltered 
 from pressure. It should be shoved beyond the greatest circumference 
 of the head, and, where possible, to the back of the child's neck. As 
 in all cases where the hand has to be passed through the cervix, the 
 uterus should be sustained by pressure from without. AYith the ad- 
 vent of a pain, all manipulation should cease, to be renewed, however, 
 as relaxation follows. If the replacement proves successful, the hand 
 should be withdrawn gradually, while the head becomes fixed in the 
 lower segment. This latter result may frequently be expedited by 
 judiciously directed external pressure. As a precaution against relapse, 
 the patient should be placed in the latero-prone position, with the hips 
 elevated by a pillow. 
 
 The Postural Trentment of Prolapse of the Funis.— K. F. .T. Birubaum* finds 
 that quite frequent mention has been made by authors of the advantages to be 
 derived from posture in the treatment of cases of prohipsed funis. Tlie works 
 of Camper, published about the middle of the seventeenth century, and referred 
 to by Kiestra, he had no means of obtaining access to. Deventer t considers the 
 subject of prolapsed funis in extenso, takes up its different modifications, its 
 effect upon parturition and the life of the child, and the treatment it demands. 
 In cases where the cord was pressed against either ilium, he directed to place 
 the woman upon the corresponding side, with raised pelvis, and with the hand 
 (right hand if on the left side, and vice versa) to lift the head, replace the cord, 
 then, as seemed advisable, either to bring the head into the pelvis, or to turn 
 and extract by the feet. When the cord was pressed against the pubes or the 
 sacrum, he advised that the midwife should place the woman upon her knees 
 with her body thrown forward, and that, in this position, the accoucheur should 
 raise the head and return the cord ; if the woman should be too weak for this, 
 she should be placed upon the side with one limb drawn up under the body. 
 John Mowbray | advises that the woman, if strong enough, should be placed 
 upon her knees and elbows in cases where the cord lies next the sacrum or the 
 pubes. Henry Bracken, a pupil of Boerhaave,* proposed returning the funis 
 in head presentations, with the woman placed upon the knees, and afterward to 
 bring the fetal head into the pelvis. Ludwig Wilhelm von Knoer || devoted a 
 long chapter to funis presentations. He says: "Introduce the hand so soon as 
 the membranes rupture, and, according to the position of the child, perform 
 either podalic or cephalic version, placing the woman at the same time upon 
 
 * Monatsschr. f. Geburtsk., October, 1867. 
 
 t Operationes ehirurgic;« novum lumen exhibentes obstetricantibus, Lugd. Bat., 
 1701. 
 
 t The Female Physician, containing all the Diseases incident to that Sex, Lon- 
 don. 1724. 
 
 * Midwife's Companion ; or a Treatise of Midwifery, London, 1737. 
 II Frauen-Zimmer Medicus, Leipsic, 1747.
 
 PROLAPSE OF THE FUNIS, ETC. 633 
 
 her knees to prevent the protrusion of the cord." George Daniel Boessel* rec- 
 ommends turning in cases of funis presentation, and, in cases of difficulty, to 
 perform version with the woman placed ujion the knees. In recent times. Van 
 Kitgen has certainly been the most ardent partisan of postural methods of treat- 
 ment. In his work entitled Anzeigen der mechanischen Hulfen bei Entbin- 
 dungen, published in 1830, he recommends them in a great variety of circum- 
 stances, but not then for prolapsed funis ; but in his Lehr- und Handbuch der 
 Geburtshiilfe fiir Hebammen (Mainz, 1838) he says: "When the funis presents, 
 the midwife should instantly send for the accoucheur; meanwhile she should 
 herself place the woman, if strong enough, upon her knees and elbows, and 
 attempt the replacement of the cord ; if the woman is too weak to admit of 
 this, she should be placed upon her side, with elevated pelvis. That side 
 should be chosen upon which the funis is not situated. If the manipulation is 
 successful, the posture should be maintained to prevent a recurrence of the jjro- 
 lapse." He recommends the position upon the elbows and knees for cases of 
 prolapsed funis and transverse presentations in breech or foot presentations, also 
 where the head is movable above the brim, and where there is no attainable 
 presenting part. He advises returning the funis high up with the hand, and 
 then to let it fall into the uterus, where it would no longer be subjected to 
 pressure. After reposition, place the woman upon her side, with raised pelvis. 
 Sometimes the postural method suffices without any manipulations. Kiestra f 
 advises the position upon the knees and elbows in cases where the cord is felt 
 near the head previous to rupture of the membranes, to prevent the occurrence 
 of prolapse. After the rupture of the membranes, he says, the same position 
 should be employed to facilitate the return of the cord, and should be main- 
 tained until the head is fairly engaged in the pelvis. Where the position could 
 not be endured long enough, he counseled placing the woman in a half-kneel- 
 ing, half-recumbent posture, with the sides supported by cushions. Theobold, 
 in 1860, hit upon the same idea. He considered the most favorable condition 
 for the return of the funis was to place the woman upon her head, but, in view 
 of the difficulty attending the execution of this manojuvre, compromised the 
 matter by suggesting the position upon the elbows and knees. 
 
 The advantages of the postural method in the treatment of pro- 
 lapsed cord are beyond all question. It is, however, difficult to per- 
 suade the woman to long maintain so constrained an attitude, and the 
 cases are not rare where, in spite of gravity, the cord is exjjressed from 
 the uterine cavity. Efforts at replacement should not, therefore, be 
 long continued. It is impossible to handle the cord for any lengthy 
 period without enfeebling the force of the fetal heart. So soon, there- 
 fore, as it becomes evident that nothing is to be gained by further per- 
 sistence, the hand should be pushed up to the feet, and the safety of 
 the child should be secured by speedy extraction. In cases of con- 
 tracted pelvis the question of version must be decided with reference 
 to the interests of the mother, as a difficult breech delivery complicated 
 by prolapsed funis offers but a sorry prospect of saving the life of the 
 child. 
 
 * Grundlegung zur Ilebamnien-Kunst, Flensburg and Leipsic, 1756. 
 
 t Ncderl. Weekbl., April, 1855.
 
 634 
 
 THE PATHOLOGY OF LABOR. 
 
 If the membranes rupture and the cord is prolapsed while the cer- 
 vix is still narrow and rigid, an attempt should first be made to push 
 back the cord with two fingers after placing the woman in the genu- 
 pectoral position. As a rule, however, instrumental replacement will 
 be necessary. I have been in the habit of employing for the purpose, 
 as recommended by Dudan, a large English catheter, which possesses 
 the advantage of forming one of the ordinary properties of the phy- 
 sician. The method of using the instrument is as follows : A piece of 
 tape should first be fastened loosely around the cord, the stylet should 
 then be made to emerge at the e3'e of the catheter, and a loop of the 
 tape should be placed in the angle it forms. By returning the stylet 
 and pushing it forward to the extremity of the tube, the band is held 
 firmly. After replacing the prolapsed cord, the catheter is readily de- 
 tached by the witlidrawal of the stylet. Brauu von Fernwald, who is 
 the author of tlie best of the repositors made expressly for the pro- 
 lapsed cord, says that the catheter is almost the only instrument to 
 which he now resorts. 
 
 Instrumental replacement is apt to prove a veritable labor of Sisy- 
 phus. As one loop is pushed up another comes down, or the entire 
 
 mass is returned with infinite trouble 
 to the uterus only at once to be i^ro- 
 jected into the vagina. Roberton 
 has proposed a handy plan for such 
 Cases, which certainly merits a trial. 
 It consists in first passing a piece 
 of twine doubled through an elastic 
 catlieter, so that the loop makes its 
 appearance at the eye. Through 
 tliis loop, a loop of the cord should 
 be drawn. The ends of the twine 
 should then be knotted to prevent 
 them from slipping; the catheter 
 should be armed with a stylet, and 
 should be pushed upward into the 
 uterus, carrying the cord with it. 
 After introducing the catheter, the stylet should be withdrawn, and 
 the instrument should be left behind to keep the cord from again 
 prolapsing. 
 
 In one case Dr. Ashford* succeeded in attaching the cord to a 
 Gariel pessary. The latter was then carried into the uterus, and in- 
 flated to prevent its expulsion. 
 
 If neither the cord can be returned nor the child extracted, it is 
 proper to try by Braxton Hicks's method to convert the head presenta- 
 
 * F. A. Ashford, ' Ballooning' the Prolapsed Umbilical Cord, Am. Jour, of Ob- 
 stet., October 1878, p. 745. 
 
 Fig. 331.— Roberton's repositor.
 
 PROLAPSE OP THE FUNIS, ETC. 635 
 
 tion into one of tlie shoulder or, better still, of the breech, in order by 
 so doing to relieve the umbilical vessels from pressure. Of course, if 
 the prolapsed funis is associated with pelvic contraction, the rule here- 
 tofore given to consult first the safety of the mother remains the guid- 
 ing one in practice. 
 
 In face presentations version is indicated, as, owing to the imper- 
 fect manner in which the face closes the uterine orifice, replacement of 
 the cord is not likely to prove successful. If the opening through 
 which the cord makes its way into the vagina is produced by a pro- 
 lapsed extremity, the latter, of course, should be pushed back after the 
 cord has been returned. In footling cases the pressure on the cord 
 does not begin until long after the extremities can be reached and 
 utilized for extraction. In full breech cases, where the size of the pre- 
 senting part might interfere with the funic circulation, where it is pos- 
 sible to return the cord with the hand it is equally practicable to bring 
 down an extremity. In cross-births, before the shoulder becomes 
 wedged in the pelvis the cord is in no danger. No treatment is there- 
 fore necessary, except that indicated by the faulty presentation. 
 
 Suspended Animation or Asphyxia Neonatorum. 
 
 Definition. — The term suspended animation is applied to such 
 grades of congenital asphyxia in the living new-born child as are not 
 incompatible with the continuance of its life. A larger number of 
 males than of females are borne asphyxiated, and the children of primi- 
 parae are more liable to this condition than those of multipara. 
 
 Etiology. — A perfect comprehension of the etiology of suspended 
 animation must be based upon thorough knowledge of the physiology 
 of intra-uterine life and of the conditions necessary to its preservation. 
 
 During the period of gestation the child remains in a state of apnoea, 
 and the respiratory function necessary to its development is performed 
 by the placenta. So soon, however, as the child is born, in normal 
 cases, the thorax expands, the diaphragm contracts, and pulmonary res- 
 piration is established. The premature establishment of pulmonary 
 respiration while the child is still in the utero-genital passage, owing to 
 the absence of an atmospheric medium, is followed by asphyxia, and is 
 the usual cause of still-births. 
 
 The reason of the first respiratory movement in the child, whether 
 prior or subsequent to its "birth, has long been a subject for speculation. 
 Omitting earlier views, at present two theories contend for supremacy. 
 The one formulated by Schwartz maintains that in all cases the respira- 
 tory act is due to disturbed placental circulation, and the consequent 
 lack of oxygen in the blood of the child. Preyer, on the other hand, in- 
 sists that respiration is a reflex movement provoked by cutaneous stim- 
 uli. He admits, however, that a venous condition of the blood favors
 
 4 : 
 
 g36 THE PATHOLOGY OF LABOR. 
 
 the action of external stimuli by increasing the irritability of the respira- 
 tory centres. 
 
 As a contribution to the solution of the questions in dispute, Otto 
 Eno-strom* has recently reported a series of experiments made by him 
 upon gravid rabbits and guinea-pigs, in Preyer's laboratory. The ani- 
 mals were strapped to a board, and were then immersed in a saline solu- 
 tion (six per cent), which was kept at blood-heat by a special apparatus. 
 The head of the animal was placed above the fluid. A small incision 
 was then made in tlie abdominal wall, through which a uterine coruu 
 was allowed to escape into the saline fluid. The uterine walls were 
 next opened opposite the mesenteric attachment at the point of least 
 vascularity. As there was no haemorrhage to stain the saline fluid, it 
 was possible to observe the foetuses through the membranes in the clear 
 amniotic fluid. When this experiment was performed with address 
 and dexterity, the exposed foetus remained in a state of apnoea, and the 
 blood in the umbilical vein possessed a bright-red color, in marked con- 
 trast with dark hue of the blood in the umbilical arteries. 
 
 If now the cord was compressed through the membranes by the 
 thumb and index-finger of the warmed hand, or by self-closing compress- 
 ing forceps applied to the cord near to the placenta, and as far from 
 the foetus as possible, respiration followed in from three to six seconds, 
 and continued until death supervened from asphyxia. The same results 
 followed when the umbilical vein was pricked with a needle, or was 
 divided by scissors. Again, in other cases, to avoid the criticism that 
 external stimuli were not absolutely excluded by the manipulations em- 
 ployed, the mother was asphyxiated by carbonic-acid gas, or poisoned by 
 woorari, or bled to death by opening the carotid. Here, too, soon after 
 the blood in the umbilical vein became of a venous hue, respirations 
 occurred as heretofore, though all manipulations were carefully avoided. 
 It is, therefore, demonstrated that fetal respirations are excited, in the 
 absence of external sources of irritation, so soon as the blood in the 
 umbilical veins becomes darkened, or is cut off from the foetus. 
 
 On the other hand, in another series of cases, where the amniotic sac 
 was exposed under a blood-warm saline fluid, and the apnoea was not 
 disturbed, Engstrom gently pricked the extremities of the foetus with a 
 needle. Reflex movements were excited, but the apnoea continued. 
 When, however, deep puncture was made, the alae nasi dilated, the 
 mouth opened, and thoracic inspiration was evoked. The effect was, 
 however, momentary, and the apncea returned. 
 
 Again, in order to reduce the disturbance of the placental circulation 
 to a minimum, Engstrom, following a method invented by Preyer, 
 seized the head of a foetus with the thumb and index-finger through the 
 abdominal walls, and then cut through the abdominal coverings, the 
 uterine walls, and amniotic sac to the nose of the animal. The nose 
 * Ueber die Ursachen der Ersten Athembewegungen.
 
 PROLAPSE OF THE FUNIS, ETC. 637 
 
 was then lifted above the saline fluid and exposed to the atmosphere. 
 By means of powerful currents of induced galvanism applied to the 
 nasal organ, respiratory movements were excited, but ceased when the 
 current was removed. It seemed doubtful, however, whether inspiratory 
 acts did occur in either series of experiments so long as the placental 
 circulation was completely undisturbed. The existence of apnoea in the 
 foetus is not conclusive evidence that the opening of the uterus or the 
 compression of the uterine walls produces no derangement in the blood- 
 currents of the placenta. The results were often negative at the begin- 
 ning of the experiment, but, as the blood in the umbilical vein darkened, 
 the electric and mechanical irritants produced more and more marked 
 effects. 
 
 From these experiments it becomes evident that when the placental 
 respiration is suspended, the accumulation of unknown materials in the 
 blood is capable of exciting the respiratory center in the medulla 
 oblongata of the foetus without the aid of peripheral stimuli ; but that 
 the latter are capable of exciting the respiratory act before the internal 
 stimuli have increased sufficiently to induce independent action. Again, 
 it is a familiar fact that in moderate degrees of asphyxia in the new-born, 
 after the irritability of the medulla has been lowered to a point at 
 which no response follows from the venous condition of the blood, ex- 
 ternal stimuli are still capable of exciting respiratory movements. 
 
 Engstrom found, too, that when the foetus had breathed in the 
 amniotic sac, after respirations had ceased, and after the blood in the 
 umbilical vein and arteries had become of the same blue color, and the 
 nose and lips had become cyanotic, it was still possible to excite res- 
 pirations in some cases by opening the amnion and lifting the head so 
 as to expose it to the air, and in others by pinching the nostrils, the 
 ears, and the mouth. For the sake of convenience, I shall take the 
 liberty of recalling at this point the peculiarities of the fetal circula- 
 tion. The arterialized blood in the umbilical vein empties partly into 
 the portal vein, and is first distributed to the liver, and in part passes 
 by the ductus venosus into the inferior vena cava. The mingled venous 
 and arterial currents then enter the right auricle, and are in early 
 pregnancy directed by the Eustachian valve across the right auricle to 
 the left auricle, and thence pass to the left ventricle. As the heart 
 contracts, the blood is driven from the left ventricle to the aorta, and 
 is thence distributed by the large vessels which spring from the latter 
 to the head and upper extremities. The blood returned from the upi)er 
 portion of the body by the superior vena cava enters the right auricle, 
 where it passes in front of the Eustachian valve to the right ventricle. 
 With the advance of gestation, however, a gradual disappearance of the 
 Eustachian valve takes place, so that a part of the blood from the in- 
 ferior cava enters with that of the superior cava into the right ventricle. 
 The contraction of the right ventricle forces the blood into the pul-
 
 g38 THE PATHOLOGY OF LABOR. 
 
 monary artery, which distributes an insignificant quantity to the hmgs, 
 while the main current passes through the ductus arteriosus to the 
 aorta, by which it is distributed to the lower portion of the body. Now, 
 though the greater part of the regenerated placental blood is distributed 
 to the head and upper part of the body, it is mingled largely with 
 venous blood returning from other organs, and that which goes to the 
 respiratory center in the medulla oblongata is of a character which 
 would cause dyspnroic manifestations in self-breathing individuals. 
 
 During labor, especially in the last stage, the placental aeration of 
 the blood is interfered with by the uterine contractions, and in its 
 passage through the pelvis the surface of the child is subjected to 
 pressure and friction. At birth the body is exposed to the air. These 
 combined causes as a rule are followed by pulmonary respiration, 
 though in some instances of lowered irritability of the medulla pro- 
 longed apnoea follows the birth unless the child is made to cry by 
 vigorous slapping. 
 
 As the chest expands in the act of inspiration the lungs fill with air, 
 and the blood from the pulmonary artery pours into the opened pulmo- 
 nary vessels. The pressure in all the vessels of the body is diminished, 
 though in the thorax a partial compensation takes place from the aspi- 
 ration of blood from the veins which enter the intrathoracic sjDace. 
 The diminution of .pressure is greatest in the pulmonary artery. The 
 current which empties into the aorta becomes of feeble force, and final- 
 ly ceases altogether. The ductus arteriosus gradually closes, and the 
 pulmonary circuit becomes complete. The withdrawal of the blood from 
 the pulmonary artery and the force of aspiration lower the tension in 
 the aorta. The heart beats more slowly. The resulting diminished 
 arterial pressure is most felt in the extremities. The pulsation of the 
 umbilical arteries as a consequence ceases, and the placental circulation 
 is suspended. 
 
 In the asphyxia of new-born infants the suspended animation is, with 
 few exceptions, preceded by intra-uterine respirations. The causes of 
 the latter are to be found in tetanic contractions of the uterus and the 
 consequent diminished blood-supply to the placenta, in premature 
 detachment of the placenta, in compression of the cord, in acute anae- 
 mia, and in the sudden death of the mother. Of these, the compres- 
 sion of the cord is by far the most common. 
 
 The first effect of the compression of the cord is to arrest the cir- 
 culation in the umbilical arteries. The pressure in the aorta is thereby 
 augmented, and increased work is thrown upon the left ventricle of the 
 heart. Except in cases where the mouth and nasal passages are closed 
 by pressure, with the expansion of the chest, due to the irritation of the 
 medulla by the increased venosity of the blood, amniotic fluid, meco- 
 nium, and mucus are aspirated into the air-passages. When the com- 
 pression of the cord is temporary the circulation may be restored, and
 
 PROLAPSE OF THE FUNIS, ETC. 639 
 
 the apnoea may again return ; but in cases where the respirations con- 
 tinue, the capilhiries of the kings fill with blood from the pulmonary 
 artery, the intrathoracic venous congestion is increased, and the heart 
 action is lowered. As the irritability of the medulla sinks, the res- 
 pirations fail, the cavities of the heart fill with venous blood, the lungs 
 are congested, and in some instances subpulmonary ecchymoses result 
 from overdistention of the pulmonary vessels. Outside the thoracic 
 cavity, the venous trunks are often distended with blood. This second- 
 ary venous stasis is most marked in the vessels of the neck, head, and 
 brain, but to a less degree venous stases are likewise observed in the 
 abdominal organs and in the capillaries of the skin. 
 
 Suspended animation may exceptionally occur without antecedent 
 intra-uterine respiration. This is the case when disturbance or arrest 
 of the placental functions takes place in foetuses so immature that 
 their medullary centers can not respond to the irritation of insufficiently 
 oxygenated disassimilative products by originating the nervous impulse 
 necessary for the production of respiratory movements. Another cause 
 of suspended animation unattended by intra-uterine respiration is, ac- 
 cording to Schultze, a very slow progress of the placental respiratory dis- 
 turbance, and a consequent gradual diminution of the amount of oxy- 
 gen in the fetal blood. The deficiency in oxygen is at first so slight 
 as not to stimulate the medullary center, and when the deficiency be- 
 comes more marked, the irritability of the medulla has been so much 
 depressed that it is no longer capable of originating a respiratory im- 
 pulse. In this case the foetus dies or passes into a condition of sus- 
 pended animation without having breathed at all.* Compression of 
 the fetal brain due to a contracted pelvis, to intracranial haemorrhage, 
 to the use of the forceps, f or to delivery in breech positions, may occa- 
 sion death or suspended animation without exciting respiratory move- 
 ments. The rationale of such cases is as follows : Cerebral compres- 
 sion reduces or even arrests the heart's action by irritating the pneu- 
 mogastric nerve. The placental respiratory function is thus impaired, 
 the fetal blood is consequently deprived of oxygen, and the irritability 
 of the medulla so reduced that the latter can no longer originate re- 
 spiratory movements. J If intracranial extravasations are located upon, 
 the convexity of the cerebrum, they are comparatively innocuous, since 
 the medulla is not compressed. Their most pernicious effect is natu- 
 rally observed when they are situated at the base of the brain. 
 
 Morbid Anatomy. — Schultze recognizes two stages of suspended 
 animation, which correspond to the terms asphyxia livida and pallida, 
 usually employed to designate these respective conditions.** The 
 
 * Schultze, op, cit., pp. 103 et seq. 
 
 + DoHRN, Arch. f. Gynaek., Bd. vi. 1874. p. 365. 
 
 X Frankenhauser, Monatsschr. f. Geburtsk., Bd. xv, 1860, p. 368. 
 
 * Schultze, op. cit., pp. 6, 130, 147.
 
 u 
 
 g^Q THE PATHOLOGY OF LABOR. 
 
 boundary line between the two stages is marked by the loss, on the 
 part of the muscles, of their tonic contractility. In the first stage the 
 muscular tone is still jn-eserved. ' Although there are no spontaneous 
 muscular contractions, the extremities are not completely relaxed, nor 
 does the head drop. Reflex movements are easily produced by surface 
 irritation. The skin is dusky red or cyanotic, the cutaneous vessels are 
 turgid, the conjunctivae injected, and the eyeballs protruding. The 
 cardiac and umbilical pulsations are slow but forcible. The umbilical 
 vessels are fully distended. Respiratory movements usually occur only 
 after a certain interval. They are at first feeble, superficial, and at- 
 tended by facial contortions, but soon become more powerful. The 
 increased deficiency in oxygen, occasioned by delivery, often furnishes 
 to the medulla, in this stage of suspended animation, a stimulus of 
 sufficient intensity to cause spontaneous respiratory movements. The 
 same result is attained by irritation of the surface. If respiration does 
 not ensue from either cause, the child passes into the second stage of 
 asphyxia. 
 
 In the second stage of suspended animation, or asphyxia pallida, 
 the children are exceedingly anaemic. The conjuctivse are without 
 luster; the surface is col^; the sphincters are relaxed; the limbs, 
 head, and lower jaw hang loosely down. Reflex^moyements do not 
 occur. The cardiac beats are frequent and, feeble. The umbilical 
 pulse is almost or quite imperceptible. The umbilical vessels are 
 empty. Either no spontaneous respiratory movements occur or they 
 are few, snapping, and produced by the diaphragm, without the par- 
 ticipation of the facial, nasal, or maxillary muscles. The respirations 
 are ineffectual, since a post-mortem examination reveals little or no air 
 in the bronchi, which are usually filled witli fluid matter, and since 
 no rales are heard during the respiratory efforts. The medulla is so 
 completely paralyzed that the stimulus of the increased deficiency in 
 oxygen, attendant upon delivery, merely produces these futile respira- 
 tory efforts. Should artificial means succeed in restoring the child, 
 the first signs of its resuscitation will be refilling of the cutaneous 
 capillaries and returning muscular tonicity. The morbid anatomical 
 features of suspended animation vary according as that condition has 
 or has not been attended by intra-uterine respiration. In the latter 
 case the blood is dark and uncoagulated. The pulmonary vessels are 
 widely distended. The lungs are enlarged, heavy, and of a dark-red 
 color. Numerous pulmonary, subpleural subpericardial, and suben- 
 docardial ecchymoses are present. The pulmonary extravasations are 
 more extensive than in cases of asphyxia accompanied by intra-uterine 
 respiration, for the reason that, in the latter, the aspirated fluids offer 
 a certain support to the distended capillaries. Pulmonary congestion 
 and ecchymosis may be absent if the inspirations were ineffectual, in- 
 frequent, and of short duration. The obstruction of the pulmonary
 
 PROLAPSE OF THE FUNIS, ETC. 641 
 
 circulation further produces venous congestion of the surface, of the 
 abdominal organs, and of the encephalon resulting in subconjunctival, 
 meningeal, and cerebral hemorrhages. Ecchymoses may also be 
 found beneath and upon the pericranium. Aside from the extrava- 
 sated blood, no foreign matters are found in the bronchi. The absolute 
 proof that the asphyxia of still-born children, or of those born in a 
 moribund condition, was attended by iutra-uterine respiration consists 
 in the discovery, within the bronchi, of substances introduced by tho- 
 racic aspiration. When the proof is lacking, inspiration may still 
 have occurred, but the entrance of foreign bodies has been prevented 
 through occlusion of the nose and mouth by portions of the membranes, 
 or by close appositian to them of the maternal soft parts. The quan- 
 tity of aspirated material will depend upon its character and the force 
 of the inspirations. The tough cervical mucus penetrates only to the 
 trachea and primary bronchi. The liquor amnii, containing meconium, 
 vernix caseosa, and blood and downy hairs, may even reach the ter- 
 minal bronchioles. If air had found an entrance into the uterine 
 cavity, it is also present in the bronchi, and, exceptionally, in the 
 stomach and duodenum. The dilatation of the Eustachian tubes, as 
 a consequence of the first inspirations, permits, in some instances, ac- 
 cording to Wendt, * the penetration of liquor amnii into the middle 
 ear. The pulmonary ecchymoses are less numerous and extensive in 
 asphyxia attended by intra-uterine respiration than in the other va- 
 riety, for reasons above stated, but congestion and extravasations in 
 the abdominal and cerebral organs are quite as constant and important. 
 Diagnosis. — An important diagnostic symptom of beginning as- 
 phyxia is diminished frequency of the fetal he art-beat s, due to inhibi- 
 tion of the placental respiration.. This has no significance if it be 
 manifest only during the pains, since it is then a physiological occur- 
 rence due to the mechanical compression of the foetus or to expression 
 of the placental blood into the fetal vessels. If it persist, however, 
 during the interval between the pains, and be jirogressive, it is of seri- 
 ous import, betokening either considerable compression or irritation of 
 the medulla by an excess of deoxygeuated blood. The diminished 
 frequency is sometimes succeeded by increased rapidity of the cardiac 
 contractions, indicating p.arah'sis^ of the pneumogastric, and, conse- 
 quently, a more advanced stage of suspended animation, f This in- 
 creased rapidity is, probably, invariably preceded by the diminished 
 frequency of the heart's action already alluded to. The evacuation of 
 meconium is also diagnostic of asphyxia, provided it be not merely the 
 result of the mechanical compression exerted upon the child in breech 
 presentations. The appearance of the meconium is, probably, due to 
 the increased intestinal peristalsis attendant upon asphyxia, although, 
 
 * Spiegelberg, Lehrbueh. p. 667. 
 
 f HuTER, itloiiatsschr. f. Geburtsk., Bd. xviii, 1862, Supplem. Heft, p. 48. 
 41
 
 g^2 THE PATHOLOGY OF LABOR. 
 
 perhaps, in part occasioned by relaxation of the sphincters and com- 
 pression of the abdomen by the contracting diaphragm. The dis- 
 charge of meconium, accordingly, usually attends that form of sus- 
 pended animation in which intra-uterine respiration has occurred, and 
 is absent in those cases of gradually induced asphyxia unaccompanied 
 by respiratory efforts. The differential diagnosis between these two 
 varieties is completed, after delivery, by the detection of bronchial 
 rales, due to the aspiration of intra-uterine fluids, in all cases of intra- 
 uterine respiration except those in which the external air-passages 
 were occluded. The discharge of meconium is sometimes not in- 
 dicative of any pathological condition. Schultze * detected intra-uter- 
 ine respiration by abdominal auscultation, as well as by intra-uterine 
 palpation, and numerous observers have heard the vagitns uteriims, or 
 intra-uterine cry, which bears testimony to the entrance of air into the 
 uterus, and to the occurrence of respiratory movements, f When de- 
 livery has been partially accomplished, the diagnosis of asphyxia is 
 easily made from the failing fetal pulse, the cyanosis, the forcible re- 
 spiratory efforts, and the relaxation of the child's muscles. 
 
 Prognosis. — The prognosis depends largely upon the grade of the 
 asphyxia, although the cause of the latter is of still greater signifi- 
 cance. Suspended animation which is not accompanied by intra- 
 uterine respiration offers the best prospects for resuscitation. The 
 chances are smaller if inspiration has occurred, and the worst prog- 
 nosis is afforded by the occurrence of resi:)iration when the nose and 
 mouth are occluded, on account of the graver derangement of the 
 fetal circulation, and the more abundant pulmonary extravasations. 
 The presence of aspirated foreign substances clouds the j)rognosis by 
 interfering with efforts at artificial respiration, and by acting as the 
 exciting cause of atelectasis and of lobular pneumonia. The prognosis 
 is also rendered grave by the occurrence of intracranial haemorrhages. 
 The mortality of asphyxiated children in the first eight days after 
 delivery is, according to Poppel's statistics,^ seven times greater tlian 
 that of children born unasphyxiated, and the mortality in the first 
 week in direct proportion to the duration and gravity of the sus- 
 pended animation. 
 
 Treatment. — The indications for treatment are in all cases to clear 
 out the air-passages, to restore the i/ritability of the medulla, to in- 
 crease the force of the heart-contractions, and to relieve the plethora 
 of the heart and of the blood-channels of the thorax. 
 
 In cases Avhere the muscular tonus is preserved these indications are, 
 as a rule, easily fulfilled ; aspirated fluids and mucus should be cleared 
 
 * Schultze, op. cit.. p. 127. 
 
 t Kristeller, Monatsschr. f. Gehurtsk., Bd. xxv. 1865, p. 321 ; Baetschee, Ibid., 
 Bd. ix, 1857, p. 294; Mayer, Ibid., Bd. xxv, 1805, p. 341. 
 X PoppEL, op. cit., p. 57.
 
 PROLAPSE OF THE FUNIS, ETC. 643 
 
 from the fauces with the finger. If the nasal passages are obstructed, 
 mouth-to-mouth insufflation should be employed. The child should be 
 made to cry by flagellation, and the respiratory movements should be 
 further stimulated by alternately immersing the child in hot and cold 
 water. So far the procedure is a familiar one, but in a good number of 
 cases we know that in a few days the skin becomes dusky, the heart 
 action feeble, and the child has been temporarily restored to life only 
 in the end to die of atelectasis. As a means of guarding against this 
 fatal sequence, due in part to imperfect expansion of the lungs, in 
 part to lobular congestion, there is no method that rivals the one of 
 Schultze. 
 
 Schultze directs that the child should be grasped in such a manner 
 that the operator's thumbs rest, on either side, upon the anterior tho- 
 racic wall, while the index-finger occupies the axilla, and the remaining 
 fingers are placed diagonally across the back. The child is then al- 
 lowed to hang at arm's lengtli between the knees of the obstetrician, its 
 face being turned to the front. In this position the pectoral muscles 
 are made to draw the superior ribs upward, the abdominal muscles 
 draw the inferior ribs downward, and the weight of the liver causes the 
 descent of the diaphragm. By this means the capacity of the chest is 
 increased, and inspiration is produced. The child is next swung up- 
 ward, until the arms of the operator reach an almost horizontal posi- 
 tion. The swinging motion is then arrested, flexion occurs in the 
 child's lumbar spinal region, its head is directed downward, and its 
 lower extremities fall slowly toward the obstetrician until the whole 
 weight of its body rests upon his thumbs. In this way the chest and 
 abdomen are powerfully compressed, the diaphragm is forced upward, 
 and an efficient expiration results, and any retained adventitious mat- 
 ters are expelled from the air-passages. An inspiration is now pro- 
 duced by reversing the direction of the swing and returning the child 
 to its former position of complete extension, by which manoeuvre the 
 chest is made to expand and the diaphragm to descend. 
 
 By this method not only is good aeration of the lungs secured, but 
 the forcible expiration expels the materials aspirated from the bronchial 
 tubes. A still more important action, according to Schultze, is the re- 
 lief of the overloaded vessels as a result of the compression of the entire 
 thoracic contents. Thus, as expiration is produced by the upward 
 swing, the blood is pressed from the left ventricle into the aorta, and 
 from the right auricle into the right ventricle. The emptying of the 
 left ventricle makes room for the contents of the left auricle, and per- 
 mits the return current from the pulmonary veins. From the right 
 ventricle the surplus blood finds a passage into the aorta through the 
 ductus arteriosus. With the inspiratory swing blood is aspirated from 
 the peripheral vessels into the blood-channels of the thorax. The as- 
 pirated blood is, however, venous, as the semilunar valves prevent re-
 
 g^^ THE PATHOLOGY OP LABOR. 
 
 gurgitation from the aorta. By alternating the expiratory and in- 
 spiratory swinging movements the pump-working of the heart is 
 mechanically set in action. As the blood-streams pass through the 
 heart cavities, the systole increases in force and the arterial tension 
 is restored. 
 
 In cases of deep asphyxia, in which muscular tonicity is lost, and 
 the heart movements are scarcely perceptible, the methods at first em- 
 ployed should involve the minimum degree of disturbance to the child. 
 Active movements are, as a rule, speedily followed by the extinction of 
 heart pulsations. 
 
 The child should be laid upon a table and covered warmly. After 
 clearing the fauces and nasal passages a No. 8 English elastic catheter 
 should be passed, under the guidance of the fingers of the left hand, 
 through the larynx into the trachea, and aspirated matters should be 
 carefully removed by suction. Meantime, at intervals insufflations 
 through the tube into the bronchial tubes should be employed. After 
 each insufflation the chest walls should be compressed with the hand, 
 to produce expiration. By this means, little by little, the blood re- 
 ceives oxygen, and the returning irritability of the medulla is mani- 
 fested by occasional spontaneous respiratory movements. When the 
 color returns to the skin, and the heart's action is restored, artificial 
 respiration should be maintained, at first by means of Sylvester's 
 method, which is preferable to that of Schultze in feeble children, as 
 it involves less exposure and less violent manipulations. In Sylvester's 
 method * the child is placed upon its back with the shoulders raised 
 sufficiently to prevent the chin from falling forward on the breast. 
 The tongue is drawn forward to maintain a free entrance of air into 
 the windpipe. To imitate the movements of deep inspiration, the 
 operator grasps the arms above the elbows, and, raising them upward 
 by the sides of the head, he extends them gently and steadily upward 
 and forward for a few moments. At the same time the feet should be 
 fixed. According to Champneys, the effect produced is more than 
 twice as great when the arms are everted as when the* arms are in- 
 verted. This he attributes to the mode of insertion of the pectoralis 
 major muscle into the outer lip of the bicipital groove, eversion natu- 
 rally rendering this more tense. Expiration is effected by turning 
 down the arms and pressing them gently but firmly against the sides 
 of the chest. When the process has been repeated a few times, the 
 warm bath should be employed to prevent undue refrigeration of the 
 cutaneous surface. The method described should be alternated with 
 the baths until spontaneous respiration is maintained or the case be- 
 
 * Sylvester, The Discovery of the Physiological Method of inducing Respira- 
 tion in Cases of Apparent Death from Drowning, Chloroform, Still-birth, Noxious 
 Gases, 3d ed.. 1853 ; The True Physiological Method of restoring Persons Appar- 
 ently Drowned or Dead, and of resuscitating Still-born Children, London, 1858.
 
 PROLAPSE OF THE FUNIS, ETC. 645 
 
 comes hopeless. As the circulation improves, the swinging movements 
 of Schultze may often be employed with advantage. In prematurely de- 
 livered asphyxiated children these methods are inapplicable, since the 
 thoracic walls are so yielding as not to undergo the changes of form 
 requisite to the success of the methods described. In such cases insuf- 
 flation, through the catheter, following aspiration, of the foreign bodies 
 in the air-passages, is the oi^y available treatment. If the efforts at 
 resuscitation be successful, the child must, for the first few days after 
 its birth be kept particularly warm and be regularly nourished.* 
 
 Collapse and Sudden Death during Labor and Childbed. 
 
 We have already had frequent occasion to mention collapse during 
 or following labor as a sequence of hemorrhage, or of injuries to which 
 the genital passages have been subjected. Syncope is not an uncom- 
 mon result of exhaustion following prolonged labor, or even normal 
 labor in women with exceptionally sensitive nervous organizations. 
 Again, it may be caused by the cerebral anaemia produced by the re- 
 cession of blood from the nerve-centers when the intra-abdominal 
 pressure is suddenly diminished by the rapid emptying of the uterus. 
 Temporary syncope, if followed by complete restoration of the normal 
 circulation, has no positive prognostic significance. Where, however, 
 the pulse continues feeble and rapid, it should be, even in the ab- 
 sence of other grave symptoms, a subject of profound concern. The 
 arteries then gradually become empty, while the large venous trunks 
 fill with blood, and the sluggish current predisposes to the formation 
 of thrombi. 
 
 Apart from such rare accidents as ceVebral apoplexy, or heart rupt- 
 ure, or fatal endings from hemorrhage, from pulmonary congestions 
 and oedema, from eclampsia, from inversion and rupture of the uterus, 
 and acute septicaemia, the causes of sudden death are to be found in 
 pulmonary embolism, in the entrance of air into the circulation, and in 
 shock. 
 
 On Thrombosis and Embolism. — Thrombi owe their importance to 
 the disposition they possess to disintegrate and form emboli, which are 
 swept along by the circulation until arrested by the diminished caliber 
 of the peripheral vessels. A small clot forming in the left side of the 
 heart may block up an artery in the brain or in either an upper or lower 
 limb. The symptoms of the lesion in the latter case are the absence 
 of pulsation in the artery below the thrombus, with pain, coldness of 
 the surface, paralysis of the nerves of motion and sensibility if the 
 
 * The substitution of Sylvester's method for those of Marshall Hall and Schroe- 
 der, as given in the first edition of this work, is due to the very careful and satis- 
 factory investigations of Francis Henry Charapneys in reference to the amount of 
 ventilation secured by the dififerent methods of artificial respiration. (Med.-Chir. 
 Trans., vol. Lxiv.)
 
 646 
 
 THE PATHOLOGY OP LABOR. 
 
 arterial obstruction be sudden and complete, and in some cases gan- 
 grene of the extremity affected.* 
 
 Of much more common occurrence are venous thrombi. Indeed, 
 it may be stated that thrombosis of the veins furnishes the most fre- 
 quent cause of sudden death in labor and during the puerperal period. 
 As a rule, the clotting takes place in the femoral, the pelvic, or the 
 uterine veins. Spiegelberg f states that the emboli which become de- 
 tached during or shortly after labor proceed from clots formed at the 
 site of the placenta. 
 
 When the placenta is partially detached during labor, or the uterus 
 does not properly contract after the birth of the child, sudden haemor- 
 rhage, followed by syncope or marked weakening of the heart's action, 
 may lead to the formation of large, soft clots, extending from the open 
 mouths of the sinuses in the direction of the heart. These, by sudden 
 movements, by the douche, or under a powerful contraction, such as 
 oftentimes follows the rupture of the membranes or the expulsion of 
 the foetus, may be set adrift from their moorings, and be washed up- 
 ward through the vena cava to the right side of the heart, and thence 
 to the branches of the pulmonary artery. 
 
 It has been assumed, though not without question, that, owing to 
 the large proportion of fibrin in the blood during pregnancy and child- 
 bed, it is possible, when the heart's action is feeble, for spontaneous 
 coagulation to take place in the pulmonary artery. This theory, 
 originally broached by Meigs, has been warmly supported by Playfair 
 and Barker. Clinically, many striking facts have been adduced in its 
 support. Playfair argues that, when dyspnoea precedes phlegmasia 
 doleus, the same causes which have led to throml)osis of the femoral 
 veins have antecedently been at work in the formation of coagula in the 
 pulmonary artery. But the post-mortem evidence of such a connexus 
 is not conclusive. Dr. Mary Putnam Jacobi has reported the case 
 of a patient, dying five hours after labor, where precordial oppression 
 and dyspncea had been marked, and yet no lesions whatever were found 
 at the autopsy to account for these symptoms. Nor is it possible, 
 when we consider the frequency with which thrombosis of the uterine 
 veins precedes that of the veins of the thigh, to be sure, in the absence 
 of ^ post-mortem examination, that the dyspnoea observed by Pla^-fair 
 may not have been due to an embolus from a clot formed in a uterine 
 vessel. I would not, however, deny the possibility of Playfair's hypothe- 
 sis. I only wish to emphasize the fact that, so far as the evidence goes, 
 it lacks the positiveness of a scientific demonstration. According to 
 all ordinary experience, the force of the blood-current in the pulmonary 
 artery, except in the death agony, is sufficient to prevent spontaneous 
 
 * Barker, The Puerperal Diseases, p. 257 ; Barnes, Thrombosis and Emboli of 
 Lymg-in Women, Obst. Trans., vol. iv, p. 30. 
 t Spiegelberg, loc. cit., p. 661.
 
 PROLAPSE OF THE FUNIS, ETC. 647 
 
 coagulation from taking place. Virchow has, however, pointed out 
 that any of the few minor veins opening into the right auricle may be 
 the seat of the primary thrombus, and give rise to a large secondary 
 thrombus within the auricle. (Savage.) 
 
 The symptoms of stoppage in a large pulmonary vessel are intense 
 dyspno?a, air-hunger (to use an expressive German term), fluttering 
 heart-action, a feeble, rapid pulse, a cold skin, and striking pallor of 
 the countenance. Death may follow in a few minutes, or, where the 
 main trunk is free, the more violent symptoms may in the course of a 
 half-hour subside, to return, however, with the slightest movement or 
 without apparent cause, the patient dying in a few days from abnormal 
 lowering of the temperature, from dyspnoea, and cyanosis ; or, after a 
 succession of attacks, the thrombus may be absorbed, and, as I have 
 once seen, complete recovery may take place. 
 
 The Entrance of Air into the Circulation.*— The passage of air from 
 the uterine cavity into the circulation is rendered possible by the 
 presence of open sinuses, or of sinuses closed by soft, easily detached 
 thrombi. These conditions are always present previous to delivery in 
 case of partial separation of the placenta, and in the puerperal state, 
 especially in the latter, when, owing to debility resulting from the 
 undue prolongation of labor, the expulsion of the ovum has been fol- 
 lowed by imperfect retraction. 
 
 Air may be forcibly driven into the uterus by means of the uterine 
 or even the vaginal douche. For this veason the siphon syringe should 
 be discarded from midwifery practice. The objection to the continu- 
 ous stream furnished by a vessel placed at a height above the patient, 
 based upon the insufficient force of the current, is purely theoretical. 
 
 It is not necessary that the nozzle of the syringe should be intro- 
 duced directly into the uterine cavity for accidents to occur. AVienerf 
 has reported from Spiegelberg's clinic a case where collapse followed 
 the use of the vaginal douche, though the tube was free from air, the 
 hydrostatic pressure having forced air which had previously entered the 
 vagina up into the uterus. When, therefore, the douche is employed 
 to induce premature labor, the stream should at first be propelled 
 gently, and the vulva should be parted to permit the egress of con- 
 tained air. 
 
 Less familiar than these cases of forced air injection are well- 
 accredited instances of spontaneous entrance of air into the uterine 
 sinuses. This accident is rendered possible by the diminution of the 
 intra-abdominal pressure in certain body postures. Of these, the 
 three familiar to us through gynaecological experiences are, respectively, 
 
 * Vide Kezmarsky, Ueber Lufteintritt in die Bhitbahnen durch den puerperal. 
 Uterus. Avch. f. Gynaek., vol. xiii, p. 200. 
 
 f WiEXER, Zur Frage der kiinstlichen Friihgeburt bei engem Becken, Arch, fiir 
 Gynaek.. vol. xiii, p. 94.
 
 g^g THE PATHOLOGY OF LABOR. 
 
 the knee-cliest, the latero-prone, and the lithotomy positions. In child- 
 birth, under favoring conditions, the sudden rupture of the membranes 
 which had previously distended the vagina, or the rapid extraction of 
 the child, may be followed by the ingress of air into the uterus itself, 
 in some cases doubtless the recession of the uterus after its evacuation 
 favoring the occurrence of the accident. The entrance of air into the 
 uterus does, of necessity, do harm, or the harm may be limited to the 
 production of endometritis; still there are recorded cases where the 
 aspiration of air has been followed by almost instant death. 
 
 The post-mortem examinations of cases of death from air entering 
 the uterine sinuses show but little blood in the left side of the heart ; 
 frothy blood from the cut surfaces of the uterus ; air in the uterine 
 veins, the vena cava, the right side of the heart, and at the orifice of 
 the pulmonary artery ; the lungs anaemic, and containing frothy serum ; 
 the brain pale and infiltrated with serum. 
 
 Corresponding to these anatomical conditions, the hands during 
 life were cold, the pulse scarcely perceptible, the face blue and livid, 
 consciousness was lost, and the respirations were labored and jerky, 
 with all the symptoms of intense dyspna3a. 
 
 Nerve Exhaustion and Shock. — Twenty years ago these pathological 
 states played a conspicuous part in the etiology of sudden death during 
 childbirth. Now the fashion has changed. Such terms as " nervous 
 apoplexy " and " idiopathic asphyxia," which were employed as synon- 
 ymous expressions, belong to an almost forgotten nomenclature. 
 None the less the need remains to account for a class of cases in which 
 death takes place without recognizable organic lesions. 
 
 Instances of death attributed to heart paralysis are to be found in 
 the collections of McClintock * and Mordret ; f but to these objections 
 have been made, either that the post-mortem confirmation of the diag- 
 nosis was lacking, or that the examination was lacking in the com- 
 pleteness necessary to shut out other possible causes of death. Baart 
 de la Faille, J however, has more recently collected thirteen cases of 
 collapse in which the occurrence of embolism and the entrance of air 
 could with every probability be excluded. Cases where the absence of 
 all symptoms of pulmonary obstruction furnish certain evidence that 
 neither of these causes was operative may be found scattered through 
 medical literature.* 
 
 In the absence of visible lesions, or the characteristic symptoms of 
 the conditions to which death in childbed is usually referred, we have 
 
 * McClintock, Dublin Med. Press, 1853. 
 \ Mordret, Mem. Acad. Med., 1858. 
 
 X Baart de la Faille, vide Synopsis Monatsschr. fiir Geburtskunde, vol. xxv, 
 p. 318. 
 
 * Vide ease reported by 0. T. Schultze in American Practitioner, April, 1884. 
 likewise author's paper on Sudden Death in Labor and Childbed, Journal of the 
 American Med. Assoc, for recent examples.
 
 PROLAPSE OF THE FUNIS, ETC. 649 
 
 the right to attribute the melancholy issue to the same causes which, 
 outside of childbed, produce identical phenomena. In the torpid form 
 of shock the features are pinched, the eyes sunken and surrounded 
 by dark rings, the skin possesses a marble pallor, the hands and lips 
 are blue, the extremities are cold, sweat stands upon the brow, the 
 pulse is thready and scarcely perceptible, while, in contrast to cases of 
 pulmonary obstruction, the breathing, though it may be shallow, is not 
 difficult or labored, and, in spite of the extreme prostration of the 
 physical forces, the sphincters remain closed, and both consciousness 
 and sensibility are preserved. Sometimes these earlier symptoms are 
 followed by a stage of excitement in Avhich the face, with the exception 
 of the mucous membranes, becomes reddened, the eyes grow bright, 
 the patient becomes restless, complains of constant thirst, and bids her 
 friends farewell in anticipation of speedy death ; but, in spite of the 
 reviving color, the pulse continues too rapid to be counted, the skin 
 never regains its normal temperature, and the hopes of speedy restora- 
 tion to health are dashed by the gradual or sudden suspension of the 
 beatings of the heart. 
 
 Modern pathological investigation refers the phenomena of shock 
 to a reflex paralysis of the vaso-motor, and especially of the splanchnic 
 nerves, whereby the great mass of the blood is withdrawn from the sur- 
 face, and collects in the trunks of the coeliac, the mesenteric, and the 
 renal veins. Hence, the skin becomes cold, and is devoid of color save 
 at the points where a bluish hue is imparted by the stagnant blood still 
 lingering in the veins ; the muscles, deprived of blood, feebly respond 
 to the impulses of the will ; the empty vessels of the brain explain the 
 sluggish intelligence, the nausea, the vomiting, and the indifference of 
 the patient ; and, finally, during the diastole, the heart, pale and con- 
 tracted, receives but little blood, and the radial pulse fades to nothing- 
 ness because of the corresponding small amount of fluid propelled dur- 
 ing the systole into the arterial vessels.* 
 
 From works on military surgery we learn that it is in the defeated 
 army, among homesick soldiers, at the close of a wearisome war, after 
 great exertions and deprivations, that shock is developed in its severest 
 forms ; that the finer the organization, the more readily the manifesta- 
 tions occur ; that they are promoted by sudden losses of blood, and are 
 in a special degree evoked by abdominal injuries. 
 
 It certainly would be singular if similar conditions in childbed were 
 not followed by similar results. After labor, the nervous system of the 
 woman is depressed by pain, starvation, and loss of sleep. The sud- 
 den emptying of the uterus is followed by a recession of blood from 
 the head to the venous trunks of the abdomen. Haemorrhage, followed 
 by weakening of the heart's action, tends still further to increase the 
 venous stasis. In the old days of torture, shock often mercifully put 
 * Fischer, Ueber den Shok, Volkmann's Sararal. klin. Vortrage, No. x.
 
 Q^Q THE PATHOLOGY OF LABOR. 
 
 an end to the victim's anguish. Women in childbirth are at times 
 subjected to pain exceeding that of the rack and the thumbscrew ; and 
 the wonder is not that the circulation should occasionally show signs 
 of marked and even fatal disturbance, but that the nervous system, at- 
 tacked from so many directions, should, in the rule, triumph over the 
 adverse forces. 
 
 Treatment. — The treatment of pulmonary embolism, whether due 
 to air or a disintegrated thrombus, is necessarily for the most part pro- 
 phylactic. The proper precautions for avoiding the accidents described 
 are sufficiently indicated in the preceding discussions as to their etiol- 
 ogy. It is proper to remember that the nervous organization of woman 
 loses in powers of resistance as the penalty of a higher civilization and 
 of artificial refinement, and that it becomes, therefore, imperatively 
 necessary for the physician to guard her from the dangers of excessive 
 and too prolonged suffering. Especially I would raise my voice in 
 warning against the current opinion that the length of the first stage 
 of labor before the rupture of the membranes is a matter of indiffer- 
 ence. In pulmonary embolism the violence of the symptoms at the 
 outset of the attack is often out of proportion to the real gravity of the 
 lesion. A small embolus or air entering the lungs, finely subdivided, 
 may produce symptoms of dyspnoea which may be of temporary dura- 
 tion. In all cases, therefore, warmth should be applied to the surface, 
 and every effort should be made to maintain tiie action of the heart. 
 To this end injections of ether beneath the skin, and of ammonia into 
 the veins, are to be counted as most powerful adjuvants. In shock, 
 opium, atropia, and digitalis are theoretically indicated, and yet large 
 doses of the latter drug, as have been sometimes recommended, are 
 not unattended with risk, and may precipitate the final catastrophe. 
 
 Extraction of the Child in Case of Real or Apparent Death 
 OF the Mother during Pregnancy or Labor. 
 
 Death of the mother during pregnancy or labor may be threatened, 
 or may actually result, either suddenly or slowly, from various morbid 
 conditions which have been previously considered. Although sudden 
 death of the mother is more frequent at the time of delivery, in con- 
 sequence of haemorrhage, exhaustion, eclampsia, or rupture of the ute- 
 rus, it may occur at any time, particularly when due to pulmonary and 
 cardiac affections, or to cerebral embolism. 
 
 It is our present object to consider the methods of treatment best 
 adapted to the preservation of the child's life in those cases necessa- 
 rily attended by death of the mother, and to the preservation of both 
 mother and child whenever there is any probability of such a result. 
 Our inquiry may therefore be limited to those cases in which the 
 child is unquestionably living, and its viability undoubted. While the
 
 PROLAPSE OF THE lUNIS, ETC. 651 
 
 majority of recent authors upon this subject have recognized the pro- 
 priety of adopting prompt measures for the immediate extraction of 
 the child after the mother's decease, the same unanimity has not pre- 
 vailed either in regard to the propriety of operative interference before 
 the mother's death, or as to the most appropriate methods of opera- 
 tion. Schroeder * is content with the statement that, in case of ma- 
 ternal demise during parturition, efforts should be made to extract the 
 fa3tus per vias nafnrales by version or the forceps. In the event of 
 failure to accomplish delivery by this method, he advises immediate re- 
 sort to the Caesarean section. SiDiegelberg f recommends the Caesarean 
 section for all cases of maternal death, excepting those occurring in 
 the second stage of labor, as the surest method of preserving fetal life. 
 He makes no provision for those cases in which the mothers are appar- 
 ently dead, although actually in a state of syncope or asphyxia. Both 
 he and Max Runge J recommend the Cesarean section, even in cases 
 of impending death of the mother, in the child's interest, and dispar- 
 age efforts at extraction through the natural passages. Duer ^ con- 
 cludes («) that no operative procedure should be undertaken until there 
 is absolute certainty of the mother's death ; (b) that, death of the mother 
 being assured, the Caesarean section should be performed with dispatch 
 if the fetal head be above the pelvic brim ; (c) that, if the head have 
 engaged in the brim, the question of resort to the Ca?sarean section or 
 to extraction ^^er vias nafnrales becomes debatable. He condemns the 
 practice advocated by Rizzoli and Esterle, of resorting to forced de- 
 livery when the mother's death is imminent. 
 
 One of the most recent and comprehensive articles on the subject 
 of artificial delivery jper vias naturales is that of Thevenot,|| who, re- 
 ferring its original introduction to Schenk and Eigaudeaux, and its 
 development to Rizzoli, Heymann, and Depaul, ardently advocates its 
 adoption, to the exclusion of the Cesarean section. This method he 
 declares to be applicable {a) to those cases with normal pelvic confor- 
 mation in which the mother is dead, the labor somewhat advanced, the 
 OS dilated or dilatable, and the head at the superior strait ; {h) to cases 
 in which labor was only commencing, or had not begun at the time of 
 death ; (c) to cases frequently occurring, according to the author, of 
 apparent death of the mother (her real condition being that of syn- 
 cope), whether labor had or had not begun at the time of her apparent 
 decease ; and {d) to cases of impending maternal death. Thevenot's 
 arguments in favor of the method of treatment under consideration 
 
 * Schroeder, Lehrbuch, p. 712. f Spiegelberg, Lehrbueh, p. 269. 
 
 X Max Runge, Ueber die Berechtigung des Kaiserschnitts an der Sterbenden 
 und der mit ihm concnrrirenden Entbindangs-Verfahren, Ztschr. fiir Geburtsk. 
 und Gynaek., vol. ix, p. 245. * Duer, Am. Jour, of Obstet, January. 1879, p. 10. 
 
 II Thevesot, De I'acc. artif. par les voies nat. substit. a I'operation eesar. post- 
 mortem, Ann. de Gynec, tome x, October, 1878, p. 257; November, 1878, p. 339; 
 December, 1878, p. 412.
 
 g52 THE PATHOLOGY OF LABOR. 
 
 are, that the operation may be more promptly resorted to than the 
 Caesarean section, the preparations for and hesitations about which fre- 
 quently occasion fatal delays ; that it is of less vital importance that 
 the death of the mother be positively ascertained than in cases of Cae- 
 sarean section ; that it is a less repulsive proceeding ; that the results 
 are bettfer than in the Caesarean section ; that the method is not pro- 
 ductive of medico-legal complications ; and that it affords a numerous 
 class of parturient women, who are only apparently dead, a far better 
 chance of recovery than does the Cesarean section. Thevcnot cites 
 fifteen cases of accoucliement force employed upon women at the point 
 of death, in which thirteen infants were alive at birth, and six lived 
 permanently. Five of the fifteen mothers, who were apparently mori- 
 bund, recovered, and in three other cases the original diseases were re- 
 tarded, and their most distressing symptoms temporarily relieved. 
 
 Tympanites Uteri. — If air enters the uterine cavity previous to the 
 birth of the child, the dangers are not confined to its passage into the 
 venous circulation. Even when this latter accident does not occur, 
 the patient's condition in a lingering labor is perilous in the extreme. 
 The essential condition for the admission of air is rupture of the mem- 
 branes. As a result in many though not in all cases untimely re- 
 spiratory efforts are excited in the child. In very rare instances it is 
 said that the cry of the child, vayitus uterinus^ has been heard within 
 the nterus. Death speedily follows premature respiration, and, under 
 the combined influence of air, heat, and moisture, decomposition 
 rapidly develops. * The gases generated by putrefaction are some- 
 times of enormous volume, and the uterus furnishes a tympanitic 
 resonance upon percussion. As a result of prolonged labor, of the dis- 
 tention of the uterine walls, and of septic poisoning, the pains become 
 feeble and the patient suffers from dyspnoea, owing to the pressure 
 upon the diaphragm by the enlarged uterus and the colon, which like- 
 wise is found distended with gases. A stinking discharge, sometimes 
 mingled with gas-bubbles is always present. 
 
 The prognosis depends upon the intensity of the process and the 
 length of time allowed to elapse before operative measures are em- 
 ployed to remove the source of danger. Of sixty-four women, accord- 
 ing to Staude's report, thirty-two died, eighteen had severe puerperal 
 affections, and only fourteen recovered without further complications. 
 The indications for treatment are, to extract the child as soon as prac- 
 ticable when air has once entered the uterine cavity, to wash out the 
 uterus with disinfectant fluids, to use all available means to secure 
 continued retraction of the uterus, and follow every antiseptic pre- 
 caution during the puerperal period. 
 
 * Staude found putrefactive changes developed in foetuses born from three to 
 twenty-one hours after the access of air to the uterus. Ueber den Eintritt von Luft 
 in die Gebarmutter, Ztschr. f . Geburtsh. und Gynaek., Bd. iii, p. 204.
 
 DISEASES OF CHILDBED. 
 
 CHAPTER XXXV. 
 
 PUERPERAL FEVER. 
 
 Definition. — Frequency. — Morbid anatomy. — Endometritis and endocolpitis. — Me- 
 tritis and parametritis. — Pel vie and diffused peritonitis. — Phlebitis and phlebo- 
 thrombosis. — Septicaemia. — Earlier views concerning the natui'e of puerperal 
 fever. — The nature of puerperal fever as regarded from the standpoint of mod- 
 ern investigation. — General symptoms. — The symptoms of endometritis and 
 endocolpitis; of parametritis and perimetritis ; of general peritonitis ; of sep- 
 ticaemia lymphatica ; of septicfemia venosa ; of pure septica3mia. 
 
 Definition. — Puerperal fever is an infections disease, due, as a rule, to 
 the septic inoculation of the wounds which result from the separation 
 of the decidua and of the placenta, and from the passage of the child 
 through the genital canal in the act of jaarturition. 
 
 To maintain this definition it is, however, necessary to group by 
 themselves cases of childbed fever dependent upon causes which are 
 operative in the non-puerperal condition, though the latter imparts to 
 those causes oftentimes an exceptional activity and virulence. In this 
 category are to be placed especially scarlatina, typhus, typhoid, and ma- 
 larial fevers. It is to be borne in mind that the zymotic fevers may pro- 
 voke in the puerperal woman the same inflammatory lesions commonly 
 associated with puerperal fever.* This is in accordance with the well- 
 known surgical experience that a febrile paroxysm from any cause exerts 
 an unfavorable influence upon a wounded surface. 
 
 Like all brief statements, the writer is well aware that the foregoing 
 definition is necessarily imperfect, and stands in need of further lim- 
 itations to meet the requirements of exactness. Exceptions, however, 
 either apparent or real, will be noted hereafter in their proper connec- 
 tions. 
 
 Frequency. — In a careful search through the records preserved by 
 the Health Department of New York city, I found that from 1868 to 
 1875, inclusive, the total number of deaths for nine years was 248,533. 
 Of these, 3,342 were from diseases complicating pregnancy, from the 
 accidents of child-bearing, or from diseases of the puerperal state ; or, 
 in other words, 1 : 75 of all the deaths occurring during that period was 
 
 * Hervieus, Traite clinique et pratique des maladies puerperales, pp. 1073 etseq.
 
 g^j. DISEASES OF CHILDBED. 
 
 the result of the ijerformance of what we are in the habit of regarding 
 as a physiological function. 
 
 The deaths from miscarriage, from shock, from prolonged labor, 
 from instrumental delivery, from convulsions, from hasmorrhage, from 
 rupture of the uterus, and from extra-uterine pregnancy, and deaths 
 from eruptive fevers, from phthisis, and from inflammatory non-puer- 
 peral affections complicating childbirth, made a total of 1,395, or about 
 42 per cent of the entire number. The remaining 1,94:7 cases, vari- 
 ously reported as puerperal fever, puerperal peritonitis, metro-peritoni- 
 tis, phlebitis, phlegmasia dolens, pyaemia, and septicemia, represent the 
 very serious sacrifice of life resulting from inflammatory processes which 
 have their starting-point in the generative apparatus. If we apply the 
 general term puerperal fever to this class of cases, it will be seen that 
 the yearly average of deaths between the years mentioned was 215 -5, 
 and that the malady was the cause of nearly one one-hundred-and- 
 twenty-seventh of all the deaths occurring in the city. 
 
 More recently statistics have been prepared for me from the same 
 sources by my friend Dr. Rutson Maury for the five years from 1885 to 
 1889, inclusive, which show that the reported deaths from puerperal 
 sepsis were 1,105, or an annual average of 221. 
 
 The population of New York in 1870 was 942,292 ; in 1875, 1,1G9,- 
 305 ; in 1885, 1,553,730 ; in 1890, 1,755,292, It will be seen, therefore, 
 that the ratio of deaths has by no means kept pace with the increase of 
 the city's population. 
 
 A portion of this betterment is doubtless attributable to reforms in 
 the management of our lying-in hospitals. "Whereas, formerly these 
 institutions furnished nearly one sixth of the fatal cases of puerperal 
 sepsis, they now, when properly equipped and organized, afford the 
 safest places of refuge for parturient women. There has likewise been, 
 without doubt, an improvement in results among the well-to-do classes. 
 Among these there is a widely diffused belief that puerperal fever is a 
 preventable disease, and that for its occurrence tlie physician should be 
 held responsible, and this leads to greater painstaking on the part of the 
 latter, even when he is disinclined to accept the deductions from mod- 
 ern scientific teaching. Among the poor, in their own homes, I do not 
 believe that the dangers of childbed have been perceptibly lessened, for 
 in Dr. Maury's statistics it appears that even in the past five years one 
 tenth of the deaths in women between the ages of fifteen and forty-five 
 are due to causes connected with childbirth, and that one twentieth of 
 the deaths among women in the child-bearing period are due to puer- 
 peral sepsis. 
 
 Max Boehr,* in his now-famous statistics, reckons that one thirtieth 
 of all married women in Prussia die in childbed. The Puerperal 
 
 * Untersuchungen iiber die Haufigkeit des Todes im Wochenbett in Preussen, 
 Zeitschr. f. Geburtsk. und Gynaek, vol. iii, p. 82.
 
 PUERPERAL FEVER. 655 
 
 Fever Commission* appointed by the Berlin Society of Obstetrics and 
 Gynaecology arrived at the conclusion that from 10 to 15 per cent of 
 the deaths occurring in women during the period of sexual activity 
 were due to childbed fever, and that this disease destroyed nearly as 
 many lives as small-pox or cholera. But puerperal fever differs from 
 either small-pox or cholera in that the latter presses largely upon the 
 aged and the very young, while the former gathers its victims exclu- 
 sively from a selected class — viz., from women in adult life, the moth- 
 ers of families, whose loss, as a rule, is a public as well as a private 
 calamity. 
 
 Before proceeding to consider the nature of puerperal fever, it is 
 desirable to first recall the anatomical lesions with which it is associated. 
 These, it will be found, are for the most part inflammatory processes, 
 having their starting-point in injuries of the genital passage produced 
 by parturition, complicated in many cases by septic changes in the blood, 
 by secondary degeneration of parenchymatous organs, and at times by 
 phlegmonous and erysipelatous affections in remote as well as in the ad- 
 jacent serous and cutaneous tissues. 
 
 Morbid Anatomy. — The primary lesions connected with puerjjeral 
 fever are so various that the student will find it convenient to classify 
 them according as they are situated in the mucous membrane of the 
 utero-vaginal canal, the parenchyma of the uterus, the pelvic cellular 
 tissue, the peritonasum, the lymphatics, or the veins. Not, indeed, 
 that such an arrangement is strictly in accordance with clinical expe- 
 rience — as a rule, the inflammatory processes are rarely limited to a 
 single tissue — but because the prognosis and treatment are determined 
 in great measure by the tissue-system which is predominantly affected. 
 The significance of puerperal inflammations, wherever seated, likewise 
 depends upon whether they are local and circumscribed or whether 
 they present a spreading character. 
 
 Personally, I have found the following classification, based on that 
 of Spiegelberg,f of great utility as a means of keeping in mind the 
 principal points to Vv'hich inquiry should be directed in estimating the 
 significance of the febrile conditions of childbed : 
 
 1. Inflammation of the genital mucous membrane. — Endocolpitis, 
 endometritis, and salpingitis. 
 
 a. Superficial, suppurative. 
 h. Ulcerative (diphtheritic). 
 
 2. Inflammation of the uterine parenchyma, and of the subserous 
 and pelvic cellular tissue. 
 
 a. Exudation circumscribed. 
 
 b. Phlegmonous, diffused ; with lymphangitis and j)ya3mia (l3'm- 
 phatic form of peritonitis). 
 
 *Zeitschr. f. Geburtsk. und Gynaek, vol. iii, p. 1. 
 
 f Ueber das Wesen des Puerperalfiebers, Volkmann's Samml. klin. Vortr., No. 3,
 
 656 
 
 DISEASES OF CHILDBED. 
 
 3. Inflammation of the peritonaeum covering the uterus and its 
 appendages. — Pelvic peritonitis and diffused peritonitis. 
 
 4. Phlebitis uterina and para-uterina, with formation of thrombi, 
 embolism, and pyaemia. 
 
 5. Pure septicsemia. — Putrid absorption. 
 
 Endocolpitis, Endometritis and Salpingitis.— In the superficial sup- 
 purative form of inflammation the mucous membrane of the vagina is 
 swollen and hypertemic, the papillae are enlarged, and the discharge is 
 profuse ; in the vaginal portion of the cervix the labia uterina are 
 oedematous and covered with granulations Avhich bleed at the slightest 
 touch ; in the cavity of the body there are increased transudation of 
 serum and abundant pus-formation. The deep structures of the uterus 
 are usually not affected. Sometimes the inflammation extends to the 
 tubes — scdpingitis — or, passing outward through the fimbriated ex- 
 tremities, it may spread over the adjacent peritonaeum. 
 
 The small wounds at the vaginal orifice are at times converted into 
 ulcers with tumefied borders. These so-called puerperal ulcers are 
 covered with a grayish-white layer. They are associated usually with 
 oedematous swelling of the labia. Under favorable sanitary conditions 
 the layer, which consists in the main of pus-cells and necrosed tis- 
 sue, is thrown off, and the surface heals by granulation. The ulcera- 
 tive form of inflammation is very rare outside of crowded hospitals. 
 
 Diphtheritic ulcers are situated with greatest frequency in the 
 neighborhood of the posterior commissure, or around the vaginal ori- 
 fice. In rarer instances they are found upon the anterior wall and in 
 the fornix of the vagina, in the cervix, and upon tlie site of the pla- 
 centa. The borders are red and jagged ; the base is covered with a 
 yellowish-gray, shreddy membrane ; the secretion is purulent, alkaline, 
 and fetid ; and the adjacent tissues are cedematous. From the vulva 
 they may extend to the perinteum, or pursue a serpiginous course 
 down the thighs. In the uterus and about the cervix they vary as re- 
 gards size, and are either of a rounded shape or form narrow bands. 
 The intervening portions of tissue which have not undergone destruct- 
 ive changes swell and stand out in strong relief. Where the entire 
 inner surface has become necrosed, it is often covered with a smeary, 
 chocolate-brown mass, which, when washed away with a stream of 
 water, leaves exposed either the deepest layer of the mucous membrane 
 or the underlying muscular structures. 
 
 Not infrequently the inflammatory process extends to the tubes, 
 which swell and become tortuous. The tubal canal fills with pus, or in 
 diphtheritic forms, with a fetid, brownish, ichorus material. The dis- 
 tention is most marked at the ampulla?. Usually the fimbriated ex- 
 tremities of the tubes are closed by adhesive inflammation. Sometimes, 
 however, they remain patent, and permit the purulent secretion to 
 spread over the adjacent peritonaeum.
 
 PUERPERAL FEVER. 657 
 
 Metritis and Parametritis. — In ulcerative endometritis, and even in 
 the extreme suppurative form, the parenchyma of tlie uterus likewise 
 becomes involved. The changes which are designated under the term 
 metritis consist, in the first place, of oedematous infiltratiou of the tis- 
 sues. As a consequence, the organ contracts imperfectly and becomes 
 soft and flabby, so that sometimes, upon post-mortem examination, it 
 bears the imprint of the intestines. 
 
 In diphtheritic endometritis, the destructive process may attack 
 the muscular tissue, and give rise to losses of muscular substance — 
 a condition known as necrotic endometritis or putrescence of the 
 uterus. 
 
 Inflammatory changes are rarely lacking in the intermuscular con- 
 nective tissue, which exhibits, in j^laces, serous or gelatinous infiltration, 
 with, afterward, pus-formation, and with here and there small abscesses. 
 The sero-purulent infiltration of the connective tissue is specially 
 marked beneath the peritoneal covering of the uterus either behind or 
 along the sides at the attachment of the broad ligaments. In the 
 same situations the lymphatics, which normally are barely perceptible 
 to the naked eye, are sometimes enlarged to the size of a quill, and are 
 characterized by varicose dilatations occurring singly or presenting a 
 beaded arrangement. In the substance of the uterus the dilated ves- 
 sels are liable to be mistaken for small abscesses. The pus-like sub- 
 stance contained in the lymphatics is composed of pus-cells and of 
 micrococci. From the cellular tissue surrounding the vagina, or that 
 beneath the peritoneal covering of the uterus, the inflammation may 
 spread by contiguity of tissue between the folds of the broad ligament, 
 and thence pass upward to the iliac fossae. Usually the process is uni- 
 lateral. After the inflammation has crossed the linea terminalis it may 
 take a forward direction, above the sheath of the ilio-psoas muscle, to 
 Poupart's ligament, or it may creep upward, following the course 
 according to the side affected, of the ascending or descending colon, 
 to the region of the kidney. It is rare for inflammation of the cellular 
 tissue to travel around the bladder to the front. In such cases it pur- 
 sues its course between the walls of the bladder and the uterus, and 
 along the round ligament to the inguinal canal. In a few cases the 
 cellulitis mounts above Poupart's ligament, between the peritonaeum 
 and the abdominal wall. 
 
 The course of the inflammation is not simply fortuitous, but fol- 
 lows prearranged pathways in the connective tissue. Konig* and 
 Schlesinger f have shown that when air, water, or liquefied glue is 
 forced into the cellular tissue between the broad ligaments the injected 
 mass has a tendency to invade the iliac fossae. In Schlesinger's ex- 
 periments, if the canula of the syringe was inserted into the anterior 
 
 * Arch, fler Heilkunde, 3 Jahrg., 1862. 
 t Gvnaekologische Studien, No. 1. 
 42
 
 g^g DISEASES OF CHILDBED. 
 
 layer of the broad ligament, the glue spread between the folds to the 
 abdominal end of the Fallopian tube ; thence, following the track of 
 the vessels, it passed to the linea terminalis ; and finally mounted up- 
 ward along the colon or swept forward to Poupart's ligament, until the 
 advance wjis stopped at the outer border of the rotind ligament. If 
 the injection was made to the side of the cervix through the posterior 
 layer at the junction of the cervix and the body, the posterior layer 
 gradually bulged out, the peritonaeum was lifted from the side wall of 
 the pelvis, and the glue passed beyond the vessels to reach the iliac 
 fossa. If the injection was made to the side of the cervix through the 
 anterior layer, the glue passed between the bladder and the uterus, 
 and forward along the round ligament to the inguinal canal, while 
 another portion of the fluid passed between the layers of the broad 
 ligament, and reached the peritoneal covering of the side walls behind 
 the round ligament. If the injection was made in the m^edian line, in 
 a peritoneal fold of Douglas's cul-de-sac, the fluid traveled forward 
 upon one side along the round ligament, and thence to the posterior 
 wall of the bladder. 
 
 The term parametritis, introduced into use by Virchow, is, proper- 
 ly speaking, limited to inflammation of the connective tissue imme- 
 diately adjacent to the uterus, the older one of pelvic cellulitis furnish- 
 ing a more comprehensive designation for cases where, as a consequence 
 of a progressive advance from the point of departure in the genital 
 canal, the remoter regions have likewise been invaded. Connective- 
 tissue inflammation presents, as the first essential characteristic, an acute 
 cedema, the fluid which fills the gaps and interspaces consisting of 
 transuded serum rendered opaque by the presence of pus-cells or pos- 
 sessing a gelatinous character. In the mild, uncomplicated cases, the 
 oedema disappears rapidly. Where the cell-collections are of mod- 
 erate extent, the entire process may vanish without leaving a trace of 
 its existence. If the cell-elements, on the other hand, are present in 
 great abuadance, they, as a rule, first undergo fatty degeneration, and, 
 after the absorption of the fluid portion, form a hard tumor composed 
 of a fine granular detritus, which under favorable circumstances like- 
 wise, after a few weeks, becomes absorbed. In rare cases, abscess-for- 
 mation in the tumor results. 
 
 In the cellulitis resulting from the more intense forms of septic 
 infection, and especially when complicated by diphtheritis, the tissues 
 seem as if soaked with dirty serum, and contain scattered yellowish 
 deposits, which soon present, even to the naked eye, the appearance of 
 pus-collections. This sero-purulent cedema is always associated with 
 lymphangitis, the lymphatic vessels possessing varicose dilatations and 
 beaded arrangements similar to those already described in the uterine 
 tissue. The foregoing changes are most distinct in the firm connective 
 tissue adjacent to the uterus and at the hilum of the ovary, while they
 
 PUERPERAL FEVER. 659 
 
 are less clearly traced in the loosor structure of the broad ligament 
 (Spiegelberg). 
 
 In favorable cases the infliimmation is circumscribed, or at least is 
 limited, by the nearest lymphatic glands. In cases of more severe in- 
 fection it spreads rapidly, and justifies the title bestowed upon it by 
 Virchow of parametritic malignant erysipelas. 
 
 Pelvic and Diffused Peritonitis. — Inflammation of the pelvic peri- 
 toui^um may proceed from severe attacks of catarrhal endometritis, the 
 inflammatory process either traversing the uterine tissue or passing 
 through the Fallopian tubes to the adjacent serous membrane ; in cases 
 of cellulitis it may follow the penetration of pus corpuscles and coccus 
 forms through the lymphatic intersjiaces and between the endothelia 
 into the peritoneal cavity. 
 
 As a rule, pelvic peritonitis is not attended with much exudation. 
 The latter is situated upon the folds of the peritongeum limiting the 
 cul-de-sac of Douglas, upon the ovaries, and upon the broad ligaments. 
 In favorable cases it consists of fibrinous flakes and fluid pus. If the 
 latter is abundant, it may become encysted by the formation of adhe- 
 sions between the pelvic organs. 
 
 General peritonitis may result from the extension of a pelvic perito- 
 nitis, from the introduction of infectious materials into the abdominal 
 cavity as a consequence of rui)tures of the uterus or vagina or of per- 
 foration of walls of pus collections, whether contained in the tubes or in 
 the pelvic cavity, or from the transport of poison through the lym- 
 phatics into the peritoneal sac. In the first cases, which are character- 
 ized by the formation of pus and fibrin, the intestines are distended 
 and the diaphragm is pushed upward. The process begins with capil- 
 lary injection of the peritonaeum, with exudation upon the dejDcndent 
 portions of the abdominal space, and with the appearance of leucocytes 
 about the vessels and in the exudate. This is followed by fibrinous exu- 
 dation upon the intestines, which unites them loosely together. The 
 endothelial cells of the abdominal sac swell and their nuclei multiply ; 
 later, the exudate increases and becomes purulent or watery, but is al- 
 ways mixed with fibrin. The enlarged endothelial cells strip off, the 
 peritoneal and intestinal walls swell and are infiltrated with leucocytes 
 and cells from the division of the connective-tissue corpuscles. By a 
 continuance of this process granulation tissue is produced, which unites 
 adjacent tissues. The watery constituents of the exudation are then 
 absorbed, or pus collections persist, surrounded by pyogenic membranes. 
 
 These encysted collections may undergo caseous changes or become 
 ichorous, or may perforate into an intestine, the bladder, the vagina, or 
 through the navel. 
 
 In the so-called peritonitis lymphatica the inflammatory symptoms 
 are at the outset lacking. The abdominal cavity is found filled with a thin, 
 stinking, greenish or brownish fluid composed of serum and micrococci.
 
 g^Q DISEASES OF CHILDBED. 
 
 The intestines are lax and cedematous, and tlie muscular structures are 
 paralyzed, with the resulting tympanitic distention. The peritoneal 
 covering of the intestines is devoid of luster and covered with injected 
 patchest or is stained of a dark-brown color. Death often ensues be- 
 fore the occurrence of exudation. 
 
 Septic forms of pelvic inflammation are often associated with 
 oophoritis, the dilated lymphatics either extending to the substance of 
 tlie ovaries, where they may lead to the production of small abscesses, 
 or, as a result of blood dissolution, the organs become soft, pulpy, and 
 infiltrated with discolored serum, and present haemorrhagic spots dis- 
 tributed over the surface. 
 
 Phlebitis and Phlebo-thrombosis.— The formation of throml)i in the 
 uterine and pelvic veins is sufficiently common during the puerperal 
 period. The coagulation may result from compression or from enfee- 
 blement of the circulation. A predisposition to its occurrence is created 
 by relaxation of the uterine tissue. A normal thrombus is in itself 
 harmless. In time it becomes organized, and the occluded vessel is 
 converted into a connective-tissue cord, or a channel may form through 
 it which permits the passage of the blood-stream. When, however, 
 septic microbes obtain access to a thrombus, it undergoes rapid disin- 
 tegration, and the particles get swept away into the circulation until 
 arrested in the ramifications of the pulmonary artery. Wherever these 
 poisoned emboli happen to lodge, inflammation is set up in the adjacent 
 tissues, and abcesses result (pya?mia nniltiplex). Sometimes countless 
 collections of pus may form in the lungs. Less commofily abscesses are 
 found in the liver or spleen, originating either from emboli which have 
 already made the pulmonary circuit, or from thrombi in the i)ulmonary 
 veins. 
 
 Inflammation of the veins (phlebitis) sometimes occurs when the ves- 
 sels have to traverse tissues in or near the uterus infiltrated with puru- 
 lent or septic materials. The endothelium then undergoes prolifera- 
 tion, and thrombosis is produced. Phlebitic thrombi do not necessarily 
 break down, and may in that case act as a barrier to the progression of 
 septic germs into the circulation (Spiegelberg). As a rule, however, 
 under the influence of inflammation and infection, they become con- 
 verted into puriform masses. 
 
 The thrombi grow by accretion in the direction of the heart. They 
 may extend from the uterus through the internal spermatic, or through 
 the hypogastric and common iliac veins, to the vena cava. Sometimes 
 the thrombus may be traced back to the placental site. 
 
 Septicaemia. — From these local conditions, sooner or later, secondary 
 affections develop in distant organs. The general affection is, in great 
 part at least, likewise of local origin. Sometimes, however, where the 
 poison, which enters tlie system through the lymphatics and veins, is 
 very active and abundant, death may follow from acute septicaemia
 
 PUERPERAL FEVER. 661 
 
 before the changes in the sexual organs have had time to develop. 
 The fatal result, in these cases, is probably due to paralysis of the heart. 
 After death, jmst-moi'tem decomposition rapidly sets in, the blood is 
 sticky, and swelling is found in the various parenchymatous organs. 
 
 The secondary affections consist in the metastatic abscesses already 
 noticed as produced by infected emboli, in circumscribed purulent 
 collections due to the conveyance of septic materials into the blood- 
 current through the lymphatics, in ulcerative endocarditis, in inflam- 
 mations of the pleura, the pericardium, and the meninges, and in 
 purulent inflammation of the Joints. 
 
 Saprsemia (Putrid intoxication). — This term was invented by 
 Matthews Duncan to apply to the fever which results from the absorp- 
 tion into the blood of sepsin and the ptomaines, the products of putre- 
 faction, in distinction from the febrile forms due to the entry into the 
 circulation of bacteria capable of reproduction. In saprsemia the fever 
 and general symptoms rapidly disappear when the source of poison 
 supply, usually the uterine cavity, has been washed clean and thoroughly 
 disinfected. 
 
 A study of the nature of puerperal fever will best show how inti- 
 mately these seemingly distinct processes are linked together. 
 
 Earlier Views concerning- the Nature of Puerperal Fever.* — Ac- 
 cording to the teachings of Hippocrates, Galen, and Avicenna, of 
 Ambrose Pare, of Sydenham, and of Smellie, the fevers of puerperal 
 women were attributable to the suppression of the lochia. For twenty 
 centuries this doctrine was accepted almost without dispute, the best 
 clinical observers confounding a symptom which is often lacking with 
 the cause of the disease itself. 
 
 In 1686, Puzos f taught that milk, circulating in the blood, is at- 
 tracted to the uterus during pregnancy and to the breasts after con- 
 finement, but tliat milk metastases may form in other parts, and 
 produce the symptoms of malignant or intermittent fever. In 1746 
 A. de Jussieu, Col de Villars, and Fontaine advanced in support of 
 this theory the fact that they had found, on opening the abdomen in 
 women who had died from an epidemic which raged that year in 
 Paris, a free lactescent fluid in the lower portion of the abdominal 
 cavity and clotted milk adherent to the intestines. This doctrine, 
 which seemed to be based upon, and to accord with observation, found 
 many adherents in France. It lost ground, however, when, in 1801, 
 Bichat pointed out the true nature of the abdominal effusions of women 
 who had died in childbed, and demonstrated that they were to be found 
 likewise in peritoneal inflammations occurring in men and in non- 
 puerperal women. 
 
 * For data given, and for a great variety of historical information, vide Her- 
 viEux, Traite clinique et pratique des maladies puerperales. 
 f Premier memoire sur les depots lacteux.
 
 QQ,2 DISEASES OF CHILDBED. 
 
 While, during the second half of the eighteenth century, the doc- 
 trine of milk metastasis held full sway in France, in England and 
 Germany the dominant leaders in medicine referred the causes of 
 puerperal fevers to inflammations of the womb and of the pei'itonaium. 
 With the advances made in pathological anatomy in the beginning of 
 the present century, France taking the lead, stress was likewise laid 
 upon inflammations of the veins and of the lymphatics. The vitality 
 of the doctrine of local inflammations is well shown by the records 
 kept by the Health Board of this city, where a large proi)ortion of 
 the deaths returned from childbed fever are entered under the head 
 of metritis, of peritonitis, of metro-peritonitis, and of puerperal phle- 
 bitis. 
 
 In opposition to the doctrines of the so-called localists, the theory 
 that puerperal fever is an essential fever, and as much a distinct dis- 
 ease as typhus fever, typhoid fever, or relapsing fever, has been strenu- 
 ously advocated by some of the most distinguished clinical teachers 
 who have devoted their attention to obstetrical science. 
 
 Fordyce Barker, in his classical work upon the Puerperal Diseases, 
 states the arguments against the local origin of tlie diseases as follows : 
 1st, that puerperal fever has no characteristic lesions ; 2d, that the 
 lesions which do exist are often not sufficient to influence the progress 
 of the disease or to explain the cause of death ; 3d, that there may be 
 inflammation, even to an intense degree, of any of the organs in which 
 the principal lesions of puerperal fever are found, and yet the disease 
 will lack some of the essential characteristics of puerperal fever ; 4th, 
 that the lesions are essentially different from spontaneous or idiopathic 
 inflammations of the tissues where these lesions are found ; 5th, that 
 puerperal fever is often communicable from one patient to another 
 through the medium of a third party, and that this is not the fact in 
 regard to simple inflammations in puerperal women. 
 
 However, neither Barker nor those who entertain views similar to 
 his question the local origin of many febrile affections in childbed, but 
 claim that purely local inflammations have each their characteristic 
 symptoms, which differ from those of true puerperal fever ; tliat puer- 
 peral fever is a zymotic disease of unknown origin ; and that local 
 lesions, where they coexist, are not the primary source of trouble, but 
 are secondary to changes in the blood. 
 
 In 1850 James Y. Simpson* published a short paper On the 
 Analogy between Puerperal and Surgical Fever. This article may well 
 be regarded as the foundation of the modern doctrine concerning puer- 
 peral fever, and is well worthy of perusal at the present day; for, 
 though in the then existing state of pathology many of the links were 
 wanting which have since raised the argument to nearly a mathemati- 
 cal demonstration, the paper furnishes a brilliant example of the 
 * Edinburgh Medical Journal.
 
 PUERPERAL FEVER. 663 
 
 scientific foresight wliicli is able to discern the truth even where tlie 
 evidence lacks completeness. 
 
 In 1847 Semmelweis, who was at that time clinical assistant to the 
 Lying-in Hospital at Vienna, made the startling assertion that " puer- 
 peral patients were chiefly attacked with puerperal fever when they had 
 been examined by the physicians who were fresh from contact with 
 the poisons engendered by cadaveric decay ; that fever ensued in the 
 practice of those who, after post-mortem examination, washed their 
 hands in the usual manner, whereas no fever or but few cases of disease 
 followed when the examiner had previously washed his hands in a solu- 
 tion of chloride of lime." In the face of insult, ridicule, and abuse Sem- 
 melweis maintained this position for years, almost unaided, with fanatical 
 persistency. It was easy for his opponents, for the most part man- 
 agers of the great lying-in asylums, to show from clinical experiences 
 the weakness of so one-sided a theory. But the employment of the 
 equivocal demonstration /r/Z^-Ms in nno,faIsus in omnihns, served only 
 as a temporary defense against the laxity which prevailed in hospital 
 management only a quarter of a century ago. Though Semmelweis 
 died with no other reward than the scorn of his contemporaries, it is 
 impossible at the present day to so much as contemplate the abuses he 
 attacked without a shudder. 
 
 In 1800 Semmelweis published the result of his ripened experience 
 in a treatise entitled Die Aetiologie, der Begriff und die Prophylaxis 
 des Kindbett-fiebers, in which, abandoning his earlier exclusive posi- 
 tion, he maintained that puerperal fever arises from the absorption of 
 putrid animal substances, which produce first alterations in the blood, 
 and secondly exudations. He distinguished between cases in which 
 the infection was introduced from some external source, and which he 
 believed to be the most frequent variety, and those where the poison 
 was generated in the system. The sources from which the infection 
 is derived he believed to be — 1st, from the dead body, regardless of age, 
 sex, or disease, no matter whether the latter is of puerperal or non- 
 puerperal origin, the virulence depending upon the stage of decom- 
 position ; 2d, diseased persons, whose malady is associated with decom- 
 position of animal tissue, no matter whether the affected person suf- 
 fers from childbed fever or not, the decomposing matter alone furnish- 
 ing the product from which infection is derived ; 3d, physiological 
 animal substances in the process of decomposition. As carriers of 
 infection, he regarded the fingers and hands of the physician, midwife, 
 or nurse, sponges, instruments, soiled clothing, the atmosphere, and, in 
 brief, anything which, after being defiled with decomposing animal 
 matter, was brought into contact with the genitals of a woman during 
 or subsequent to parturition. Absorption takes place from the inner 
 surface of the uterus or from traumata in the genital canal. Infection 
 seldom occurs in pregnancy, because of the closure of the os internum,
 
 QQ^ DISEASES OF CHILDBED. 
 
 the absence of wounded surfaces, and because of the rarity with which 
 examinations are made; during dilatation infection is common, but 
 exceptional during the period of expulsion, because the inner uterine 
 surface is at that time rendered inaccessible by the advance of the 
 child; in the placental and puerperal period infection occurs from 
 utensils and instruments, but chiefly through the access of atmospheric 
 air when the latter is loaded with decomposing organic matter. In 
 rare instances, auto-infection may result from spontaneous decomposi- 
 tion of the lochia, of bits of decidua, of coagula of blood, of necrosed 
 tissue, or in consequence of severe instrumental labors. In a v/ord, 
 puerperal fever was, according to Semmelweis, no new specific disease, 
 but a variety of pyemia. 
 
 The Nature of Puerperal Fever as regarded from the Standpoint of 
 Modern Investigation. — The older beliefs in the suppression of the 
 lochia and the metastases of milk have long since been relegated to the 
 domain of old nurses' lore, and do not call for serious discussion. The 
 localist theory, that puerperal fever is a metritis, a peritonitis, a phle- 
 bitis, or an inflammation of the lymphatics, is, as mortuary records 
 show, still adhered to by many practitioners, and, as we have seen, is 
 Justified by the fact that puerperal fever is, with rare exceptions, asso- 
 ciated, at some period of its progress, with certain inflammatory pro- 
 cesses which have their starting-point in the generative apparatus. 
 But the localist theory leaves out of view the existence of blood-poison- 
 ing, and yet the coexistence of a blood-poison with the local lesions is 
 an essential feature of puerperal fever. It was this defect which gave 
 to tlie advocates of the specificity of puerperal fever their real impor- 
 tance. Modern investigation has, however, proved that the puerperal 
 poison is septic in character, and that puerperal fever is really a surgical 
 fever, modified, however, by the peculiar physiological conditions 
 which belong to the puerperal state. 
 
 Thus, it has been found that, in the human subject, and in expari- 
 ments made upon animals, septic poisons introduced into the system 
 following or near delivery produce lesions similar to those found in 
 puerperal fever. As a further coincidence, it has been noticed that, 
 as in puerperal fever, the lesions from direct septic poisoning have 
 nothing characteristic about them, producing in one case pyaemia, in 
 another partial peritonitis, in another general peritonitis, in another 
 diphtheritis, while in others the lesions are comparatively trivial, these 
 differences being due to variable facta, such as the qualities of the 
 septic poisons, the points of entry into the organism, and the resistance 
 offered by the invaded tissues. 
 
 There is one experimental point of extreme practical importance in 
 connection with puerperal septicaemia— viz., that if the injection of a 
 septic fluid be made directly into a vessel, toxic effects speedily follow, 
 but are transitory, unless the amount of the fluid be large, or its viru-
 
 PUERPERAL FEVER. 
 
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 Q^Q DISEASES OF CHILDBED. 
 
 lence exceptional, or the animal veiy young; whereas very small 
 amounts injected subcutaneously, by developing rapidly spreading 
 phlegmonous inflammation, resembling malignant erysipelas in man, 
 are capable, after a period of incubation, of producing fatal results ; or 
 they may, if injected into a shut cavity or underneath a fascia, lead to 
 the development of an inflammation of an ichorous character. In other 
 words, the eliminating organs sufUce, under ordinary conditions to re- 
 move from the blood an amount of septic fluid which would prove fatal 
 if injected into the tissues. To produce similar results the injections 
 into the blood need to be repeated at intervals. This experience leads 
 us to the conclusion that, in the tissues, septic poisons possess the 
 capacity of self-multiplication, and that from the local inflammation 
 set up a supply is formed from which poisonous matter is continuously 
 poured into the circulation. 
 
 The capacity of self-multiplication with which septic materials are 
 endowed has been found to be the property of certain parasitic bodies 
 termed bacteria. The prevailing pathogenic organisms in puerperal- 
 fever cases, according to the researches of Doleris, consist of bacilli or 
 rods, and of micrococci in the varieties of monococci or single points; 
 of diplococci, double points; and of streptococci or chain and wreaths. 
 Staphylococci are sometimes found in parametritic abscesses, or even in 
 the uterine cavity. It is conceded, however, that the stre2)tococci are 
 the important factors in the production of infection. 
 
 Without entering upon diflficult and unsettled questions concerning 
 the manner in which disease germs accomplish their destructive work 
 during the puerperal period, it may be stated that, in the first place, 
 they generate, as one of their vital functions, toxic substances which 
 kill the tissues, excite inflammations, produce fever, and give rise to 
 nervous disorders. 
 
 The bacilli are the agents of putrefaction. Their action is local. 
 They attack dead tissue only (clots, bits of placenta, shreds of mem- 
 brane, portions of decidua). They do not themselves invade the tis- 
 sues. The products of putrefaction contain certain poisons termed 
 ptomaines, which when they enter the circulation, cause a general in- 
 toxication. AVhen the offending substances are removed from the 
 uterine cavity, the systemic symptoms disappear. 
 
 The instinct which prompts the employment of the disinfectant 
 douche in cases where there is a stinking lochial discharge is a sound 
 one, but it is a common clinical observation that in many cases the 
 symptoms continue thereafter unabated, and that, likewise, in severe 
 and even in fatal forms of puerperal fever the lochia are free from 
 odor. 
 
 True infective puerperal fever has no direct connection with putre- 
 factive organisms. It is the product of the streptococci, which not 
 only are in themselves highly poisonous, but possess the faculty of
 
 PlaU IK 
 
 Microscopic Sections in Puerperal Endometritis. (Bumm.) 
 F{g 1. 
 
 
 
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 -•^''lj;'*S5':i""
 
 ft'g3 a . 
 
 
 iSi?-: 
 
 
 
 :2>h 
 
 ^ #P^ 'J <*w 
 
 
 -'?-^?^::^:
 
 PUERPERAL FEVER. 667 
 
 invading living tissue. But the putrefactive and the infective germs 
 are generally present together. It is surmised that when they are thus 
 associated, the putrid endometritis excited by the one furnishes a con- 
 genial soil which favors the multiplication of the other. 
 
 DESCRIPTION OF PLATE IV. 
 Microscopic Sections in Puerperal Endometritis. (Bcmm.) 
 
 Fig. 1. — Section through decidiia removed by curette in case of putrid endo- 
 metritis (ninth day of childbed), a, necrosed layer of decidua infiltrated with putre- 
 factive germs ; b, reaction layer, showing nuclei of the leucocytes. 
 
 Fig. 2. — Section through decidua in case, of septic endometritis (seventh day 
 of childbed). Plate cultures furnished streptococci pyogenes, staphylococci aurei, 
 and several saphrophytes. a, necrosed layer of decidua ; b, reaction zone ; c, gland 
 lumina; d, section through vessels: e, remains of glandular epithelium. 
 
 Fig. 3a. — Section through decidua and adjacent muscular walls from a puer- 
 peral woman who died of acute sepsis, with septic peritonitis, on the fourth day of 
 childbed, a, necrotic decidua ; b, muscular tissue. 
 
 Fig. 3b. — Portion of Fig. 3a more highly magnified. Streptococci growing be- 
 tween the muscular fibers, as in erysipelas. 
 
 Fig. 5. — Section of uterine wall in lymphatic peritonitis (death on twelfth day). 
 a. lymph vessel filled with streptococci; b, eruption of the fungi into the adjacent 
 muscular tissue, which has become necrosed. Arborescent distribution. 
 
 Earely the streptococci pass from the uterine cavity by the Fallo- 
 pian tubes to the periton.eal sac. This probably only happens when 
 the tubes have been rendered patent by antecedent disease. In many 
 instances the action of the streptococci is confined to the inner surface 
 of the uterus. In these cases and in those of ordinary putrid endome- 
 tritis a layer of leucocytes forms next to the necrosed tissues which 
 acts as a w^all to prevent the penetration of the germs into deeper-lying 
 structures. In the event of general infection, this barrier has been 
 feebly developed, and was easily broken through by the invading host. 
 
 In the lymjihatic form of septicaemia tlie streptococci pass, sometimes, 
 through the narrow gaps between the muscular fibers to the peritoneal 
 surface of the uterus, or, more frequently, they enter the canalicular 
 spaces in the connective tissue forming the framework of the genital 
 canal which is continuous with subperitoneal connective tissue of the 
 pelvis. From the canalicular spaces they enter the lymphatics. Cel- 
 lulitis is excited by their presence, and the lymphatic glands become 
 inflamed and enlarged. In the walls of the uterus the lymphatics 
 are, in places, found distended with cocci, which excite inflammatory 
 processes in the neighborhood followed by necrosis of the muscular 
 structures, by migration into the softened tissue of masses of leucocytes, 
 and by the formation of small sequestered abscesses (Bunim).* 
 
 In pernicious forms they produce a sero-purulent oedema, which 
 spreads rapidly with a wave-like progress after the manner of erysipe- 
 las ; or, in milder cases, the progress of the disease germs is arrested by 
 
 * BuMM, Histologische Untersuchungen ueber die puerperale Endometritis. Arch, 
 f. Gynaek. Bd. xl, pp. 398 et. seq.
 
 gg3 DISEASES OP CHILDBED. 
 
 the lymphatic ghiuds or the resistance offered by the tissues themselves, 
 and the ordinary circumscribed phlegmon is produced. By the lym- 
 phatics which accompany the vessels of the Fallopian tubes they reach 
 the ovaries (puerperal ovaritis), and by the broad ligaments they pass to 
 subperitoneal tissues of the iliac and lumbar regions. Through the same 
 system they are conveyed to the great serous cavities of the body. In 
 the peritontfium they give rise, unless death occurs too speedily, to 
 pya3mic peritonitis, which, unlike the traumatic form, is attended with 
 but little pain. The wide stomata upon the abdominal surface of the 
 diaphragm allow the facile entrance of the organisms into its lym- 
 phatics. Waldeyer found, in diaphragmitis, the lymphatics of the dia- 
 phragm filled with bacteria. And thus, following the lymphatic sys- 
 tem, the frequency, in severe types of puerperal fever, of inflammation 
 of the serous membranes of the peritoufeum, the plural, the pericardi- 
 um, the meninges, and the Joints finds an easy explanation. Nor is it 
 altogether accident which determines in different cases the precise serous 
 membranes which are affected. The widespread ramifications of the 
 lymphatic system would naturally give rise to eccentric inflammations 
 in place of those following the apparent continuity of tissues. 
 
 When the streptococci infect wounds about the vulva and in the va- 
 gina the resulting process is apt to be local unless the germs possess an 
 unusual degree of virulence. As regards their effect upon wounds of 
 the cervix, the question is still open to debate, but here, too, it is prob- 
 able that the tendency is to the formation of circumscribed inflamma- 
 tions. 
 
 The streptococci are detected with difficulty in the blood during life. 
 A few hours after death they swarm in that fluid. That they do, how- 
 ever, enter the general circulation during life is incontestable. Steurer 
 writes : " As the kidneys are the great filters of the human system, I 
 never neglected to examine them, and almost invariably found micro- 
 cocci filling the arterioles and glomeruli." This is in correspondence 
 with what occurs in other septic diseases, and accounts for the albumi- 
 nuria and interstitial nephritis which often supervene in the advanced 
 stages. They are likewise found in the liver and in the spleen. Doleris 
 assures us that in puerperal fever, by repeated trial, especially after a 
 chill, he has never failed to demonstrate their presence in the circula- 
 tion. They do not, however, multiply in the blood during life. AVhen 
 they come in contact with the red corpuscles, the corpuscles stick to- 
 gether and form larger or smaller clots in the blood. They then are no 
 longer able to pass through the minute capillary networks, but are 
 arrested in the vessels (Koch). The micrococci in the resulting infarc- 
 tions multiply and migrate into the vessels and cellular tissue of the 
 neighborhood. Thus fresh foci of infection are formed. Or, by their 
 destructive action they may, when situated near the serous surfaces, 
 penetrate into the serous cavities, and in this way indirectly occasion
 
 PUERPERAL FEVER, 669 
 
 peritonitis, pleurisy, memngitis, and purulent inflammations of the 
 joints. When the micrococci enter directly into the circulation they 
 sometimes, in passing through the heart, adhere to the endocardium 
 and the valves, where they cause exudation and ulceration, and give rise 
 to the so-called endocarditis ulcerosa puerperalis. The red globules of 
 the blood undergo changes of shape, assume a stellate aspect, and rap- 
 idly disappear. The white globules are greatly increased in numbers, 
 and the blood itself becomes nearly colorless. A certain amount of 
 light is thrown upon these blood changes by Doleris, who added mi- 
 crococci to the fresh blood of a frog and watched the ensuing changes 
 under the microscope. The micrococci could be seen in the act of pen- 
 etrating the red globules, which thereupon lost their color and became 
 shrunken, and, following the discharge of the organisms, which mean- 
 time had multiplied in an astonishing manner, little or nothing of the 
 original globules remained. 
 
 The thrombotic form of infection has been studied by Bumm in the 
 veins which spring from the placental site. He found that the migra- 
 tory movements of the cocci from the endometrium followed the axis 
 of the thrombus, and thence spread outward toward the vein walls. The 
 latter then became infiltrated with round cells, which quickly made 
 their way into the canal of the vessel. A disintegration of the clot was 
 associated with these occurrences, and thus the vessel became filled with 
 a detritus composed of leucocytes, of parasitic organisms, and of the 
 debris of the thrombus. In other instances, according to Doleris, micro- 
 cocci derived from the blood are deposited upon the central extremities 
 of the clots ; beyond these depots a fresh inflammation is set up, fol- 
 lowed by fibrinous coagulation. Thus the micrococci become impris- 
 oned between two plugs. The same process may be repeated until a 
 series of abscesses is formed. For a time no mischief may ensue- 
 Finally, however, the resistance of the outworks is overcome, an embo- 
 lus becomes detached, and an infectious abscess is opened into the blood 
 — an event which is announced by an intense chill and the familiar sys- 
 temic derangement. 
 
 In septic diseases death takes place from apncea, partly from the 
 inability of the blood-corpuscles to carry oxygen to the tissues — and 
 partly from paralysis of the nerve centers. 
 
 In estimating the susceptibility to sepsis in the puerperal state it is 
 necessary to take into account the blood changes induced by pregnancy, 
 the effects of shock and exhaustion in protracted labors, the frequency 
 of haemorrhage, the deep situation of puerperal wounds, the presence 
 of clots, decidua, and dead tissue in a state of disintegration or decom- 
 position, the ease with which deleterious matters are absorbed by the 
 wide lymphatic interspaces, the serous infiltration of the pelvic tissues, 
 the exaggerated size of the lymphatics and veins, and the proximity of 
 the peritoneal cavity.
 
 Q^Q DISEASES OF CHILDBED. 
 
 Samuel,* in speaking of the immunities and dispositions to septic 
 poisoning, says : " The statistical frequency of septic puerperal dis3ase 
 is due tothe length of the parturient canal, to the fact that through 
 this long passage there must pass all the pathological and physiological 
 excretions, and to the soiling of these parts with fingers, instruments, 
 and secretions which have become the bearers of sepsis." He found, 
 on the other hand, that it was extremely difficult to produce a progress- 
 ive ichorous condition by daily painting an open stump with a septic 
 fluid,t though the same was readily obtained when an infinitesimal 
 quantity of septic fluid was injected underneath a fascia. 
 
 We have seen that when septic organisms are introduced into the 
 uterine cavity there are individual difi'erences in the ensuing results. 
 Thus, in many cases, their action is limited to the production of local 
 inflammatory troubles and to self -limited systemic disturbances, while 
 in others they overcome all resistance and lead to the most far-reaching 
 changes in the blood, in the circulatory apparatus, in the parenchyma- 
 tous organs, and in the serous cavities. The reason for these differences 
 are to a certain extent a matter of conjecture. It is, however, admitted 
 that the virulence of disease germs may be modified by culture experi- 
 ments, or by seemingly accidental conditions. Bumm maintains that 
 what is termed virulence is an acquired power of bacteria to withstand 
 the destructive influences upon them of the saps and tissues, and to 
 multiply within the living body. That the innate powers of resistance 
 to morbific agencies differs in individuals seems probable. Kehrer re- 
 minds us that, before the antiseptic period, it was not uncommon for a 
 practitioner fresh from an autopsy upon a puerjieral woman who had 
 died of lymphatic peritonitis, to examine patients in labor with hands 
 which had been simply washed in soap and water, and that of the 
 women thus infected a certain number had violent or even fatal forms 
 of sepsis, while others were scarcely perceptibly affected. Doubtless, 
 when the uterus is firmly contracted, the clots in the orifices of the 
 placental veins are small, and the invasion of cocci is hindered by the 
 compression of the lymphatic sj^aces, and vice versa. With a flabby, re- 
 laxed uterus, the soft thrombi and the widely dilated absorbents furnish 
 favorable conditions for the spreading of infection. 
 
 While insisting upon the septic character of puerperal fever and 
 its association with the presence of streptococci, it is not pretended 
 that inflammations of the pelvic organs in childbed may not proceed 
 from other causes. Indeed, I have myself witnessed cases where peri- 
 tonitis has seemingly started from old intraperitoneal adhesions, or 
 was secondary to ulcerative processes in the caecum or the descending 
 colon. I am inclined, likewise, to agree with Genzmer and Volk- 
 
 *Ueber die Wirkung des Fiiiilniss-Processes auf den lebenden Organisraus. Arch, 
 f. exp. Pjithologie. vol. i, p. 343. 
 t Loc. cit., p. 339. 
 
 I
 
 PUERPERAL FEVER. 671 
 
 maun * tliat there is such a thing as an aseptic surgical fever due to the 
 absorption of the products of physiological tissue-changes at the seat of 
 injury. In surgical cases, even where the precautions of Listerism 
 have been faultlessly observed, febrile movements of considerable in- 
 tensity, but of no prognostic signification, are of frequent occurrence. 
 AVhile, in puerperal women, we can never exclude the possibility of the 
 septic infection of puerperal wounds, it is in accordance with clinical 
 experience to assume that a higli fever belonging to the aseptic class 
 may coincide with a septic process of insignificant proportions. 
 
 General Symptoms. — As in other infectious diseases, there is, from 
 the time of the entry of the poison into the system up to the outbreak 
 of fever, a distinct period of incubation. The first febrile symjDtoms 
 usually occur within three days of the birth of the child. An attack 
 coming on a few hours after childbirth is indicative of infection dur- 
 ing or previous to labor. The third clay is the one upon which, ordi- 
 narily, the beginning of the fever is to be anticipated. After the fifth 
 day an attack is rare, and at the end of a week patients may be regarded 
 as having reached the point of safety. Apparent exceptions to this 
 rule are j^robably referable to cases of mild parametritis, in which the 
 initial fever and the pain were insufficient to attract attention to the 
 existence of local inflammation. 
 
 The symptoms of puerperal fever vary with the character of the 
 local afCections, and with the extent to which the general system par- 
 ticipates in the disturbed action. The different groups of j^uerperal 
 processes possess the following pathognomic symptoms — viz., increased 
 temperature, enlargement of the spleen, disturbed involution, and 
 sensitiveness of the uterus upon pressure (Braun). 
 
 In most cases, the fever is ushered in by chilly sensations or by a 
 well-defined chill. This symptom, however, does not possess much 
 prognostic importance. A chill is significant of a sudden change be- 
 tween the temperature of the skin and that of the surrounding me- 
 dium. It may, therefore, be absent in pernicious forms of fever, pro- 
 vided only that the temperature changes are inaugurated slowly, 
 whereas it may follow a trifling increase of the body heat if, as some- 
 times happens in sleep, the moist skin is exposed to cool currents of 
 air. Eepeated chills indicate phlebitis and pyaemia. 
 
 In order to grasp the many symptoms of puerjoeral fever it is neces- 
 sary to keep separately in mind the clinical features of each of the local 
 processes, although in fact the latter rarely occur singly, but to a 
 greater or less extent in combination with others. 
 
 The Symptoms of Endometritis and Endocolpitis.— The uncompli- 
 cated catarrhal inflammation of the uterus and vagina is the most fre- 
 quent and the mildest of the diseases of childbed. In endometritis the 
 
 * Genzmer and Volkmann, Ueber septisches und apeptisches Wundfieber, Samml. 
 klin. Vortriige, No. 131.
 
 672 
 
 DISEASES OF CQILDBED. 
 
 uterus is large, flabby, and sensitive upon pressure ; the after-pains are 
 often unusually severe, involution is retarded, and the lochia become 
 fetid, remain sanguinolent for a longer period than usual, and at the 
 outset may be temporarily suspended. Sometimes the large intestine 
 is distended with flatus. In endocolpitis the vaginal discharge is thin 
 and purulent, the patient experiences pain and burning in the acts of 
 defecation and urination, and, where the wounds of the vulva and 
 vao-ina assume an ulcerative character, there is often found at the same 
 time inflammatory oedema of the labia. 
 
 The fever in these cases is ushered in frequently, but not always, 
 by chilly feelings, and the tsmperature reaches its height usually upon 
 the evening of the third or fourth day, is remittent, almost intermit- 
 tent in character, and rarely exceeds 102° to 103° Fahr. In mild forms 
 the occurrence of the fever is often overlooked, or is referred to dis- 
 turbance produced by the secretion of the milk. In severer attacks 
 the febrile symptoms may continue from three to seven days. At the 
 end of a week the swelling of the labia subsides, the discharge becomes 
 thick, and ulcers, if present, begin to assume a healthy granulating 
 appearance. 
 
 In diphtheritic ulcerations, and in endometritis due to decompos- 
 ing remains of the ovum, the local condition is often complicated by 
 the invasion of the neighboring tissues. 
 
 The Symptoms of Parametritis and Perimetritis (Pelvic perito- 
 nitis *). — The symptoms of these two alfeetious, as would be naturally 
 expected from the proximity of the peritonaeum to the pelvic con- 
 nective tissue, for the most part overlap. It must be very rare for one 
 form to occur entirely independent of the other. For this reason it 
 will be found convenient to consider first the symptoms common to 
 both morbid processes, and subsequently to direct attention to what 
 are believed to be points of distinction between them. 
 
 During the period of incubation there are usually no prodromic 
 symptoms Elevations of temperature in the course of the first twelve 
 hours following labor are equally frequent under perfectly normal con- 
 ditions. Suspicious symptoms are disturbed sleep, excessively painful 
 after-pains, and a pulse of 80 to 90. 
 
 The beginning of the fever occurs, in 90 per cent, within the first 
 four days of childbed ; most frequently upon the second or third day, 
 and taking place upon the fourth day in scarcely 12 to 15 per cent of 
 the cases. If five days have elapsed without fever, the period of dan- 
 ger, with very rare exceptions, may be regarded as having passed. 
 
 At the outset the fever, especially in perimetritis, is ushered in by 
 
 * The following clinicjil history, together with the statistical details, is borrowed 
 in great part from the description of Olshaiisen (Ueber puerperale Parametritis und 
 Perimetritis, Volkmann's Samml. klin. Vortr., No. 28), the exactitude of which 1 
 have had abundant opportunity to verify.
 
 PUERPERAL FEVER. 673 
 
 chilly sensations or by an intense chill. The temperature rises rap- 
 idly, though the highest point is usually not reached before the sec- 
 ond, and in rare cases not before the third day. In most cases, the 
 heat in the axilla exceeds 103°, and may even mount up to 105°. The 
 decline occurs gradually, the fever ending in 70 per cent in the course 
 of a week, in 20 per cent in two weeks, and only in 10 per cent ex- 
 tending beyond that period. Protracted cases indicate abscess formation. 
 
 The fever does not, however, always pursue a regular course. In 
 place of progressively declining until the termination is reached, the 
 high temperature of the second day may be attained upon one or more 
 occasions. The morning remissions are at first slight, but become 
 marked as the disease approaches its close. In cases of long duration 
 the morning hours are often free from fever, a circumstance calculated 
 to mislead a physician who sees his patient but once a day. A pulse 
 of 80 to 90 beats, a disturbed sleep, lack of appetite, and sensitiveness 
 to pressure upon the sides of the uterus are, however, symptoms which 
 should serve as a warning of some disturbing cause, and should lead 
 the physician to renew his visit in the latter part of the day. 
 
 If, from a mistaken notion that the morbid process has come to an 
 end, the patient is allowed prematurely to resume her household duties, 
 the pains across the abdomen and along the hip and thigh return, and 
 an examination reveals the existence of exudation in the pelvic cavity 
 or upon an iliac fossa. 
 
 Errors of this kind are most frequent in cases of parametritis as- 
 sociated with slight peritoneal inflammation, as the local pain is then 
 insignificant, and the initial chill, happening on the third or fourth 
 day, is apt to be ascribed to engorgement of the breasts. 
 
 Relapses after the complete disappearance of febrile disturbance 
 occur in 15 to 20 per cent. They are usually shorter, but sometimes 
 more obstinate, than the original attack. As a rare exception may be 
 mentioned cases with evening remissions and morning exacerbations. 
 
 In circumscribed pelvic inflammations the pulse rarely exceeds 120 
 beats to the minute. A pulse of 140, of more than half a day's dura- 
 tion, betokens severe septic complications, and is therefore of evil 
 omen. In some cases the slow pulse observed after labor makes its 
 influence felt in the first day or two of the fever, so that the curious 
 phenomenon may be witnessed of a temperature of 104° coinciding, for 
 a time, with a pulse ranging between 50 and 70 beats to the minute. 
 
 As regards other symptoms, headache and sleeplessness are rarely 
 absent. Profuse sweating follows the first febrile attack, and frequent- 
 ly recurs during the course of the disease. 
 
 Pain is present at the onset in the majority of cases, and is then 
 
 usually most violent. The spontaneous pain, which is due to the 
 
 affection of the peritonaeum, subsides in great part in the course of one 
 
 or two days, but the sides of the uterus remain sensitive to pressure. 
 
 43
 
 Q^^ DISEASES OF CHILDBED. 
 
 In the rare cases of pure parametritis, however, this symptom may 
 be absent altogether. The pain, like that from the inflammation of 
 serous membranes, is of a lancinating character. Sometimes it is asso- 
 ciated only with the contractions of the uterus. After-pains occurring 
 under unusual circumstances, as in primipara? or after the third day, 
 are to be regarded with suspicion. 
 
 Vomiting occurs occasionally, but is comparatively rare, unless the 
 peritonitis becomes diffused and spreads to the region of the stomach. 
 The appetite is lost, and only returns, as a rule, with the departure of 
 the fever. The tongue is coated and moist, and constipation is com- 
 mon. In other cases there is diarrhoea, with rumbling in the bowels, 
 but without pain or tenesmus. The urinary secretion is rarely inter- 
 fered with, and, when this is the case, it indicates the extension of the 
 inflammation to the peritoneum covering the bladder. 
 
 Most cases of perimetritis and parametritis terminate in five or ten 
 days, the fever and other symptoms gradually subsiding. When, as 
 may happen in exceptional instances, the temperature falls suddenly 
 from a high degree to one below the normal level, the body grows icy 
 cold, the pulse becomes small and irregular, and symptoms of collapse 
 develop. But, in twelve to twenty-four hours, the symptoms of collapse 
 subside, and the disease reaches its end with a disappearance of the 
 alarming manifestations. 
 
 If the fever subsides within a week, exudation is somewhat rare. 
 Its continuance beyond that date should lead to a careful exploration 
 of the pelvic organs. The exudation is usually demonstrable in the 
 course of the second week or at the beginning of the third week. It 
 is recognized, according to its location, by external or by internal ex- 
 amination, or, where the deposit is considerable, by both methods. 
 In many cases the deposit is extra-peritoneal, and is situated between 
 the folds of the broad ligament, above and to the sides of the vaginal 
 cul-de-sac. It has generally a rounded form, though with less con- 
 vexity than fibrous and ovarian tumors. Sometimes, however, the 
 tumor is flat below, like a board. It seldom exceeds in size that of a 
 large apple. In fresh exudations the sensation produced is often that 
 of a hard tumor surrounded by a softer layer, due to continued succu- 
 lence of the soft parts. In a few weeks they may reach or exceed tlie 
 hardness of a fibroid tumor. The older the tumor, unless suppuration 
 sets in, the less sensitive it becomes. Often the exudation extends to 
 the pelvic walls. The uterus, as a rule, is fixed, and, in cases of large 
 tumors, becomes pushed toward the opposite side, while, as a conse- 
 quence of later shrinkage,, the fuudus may be drawn permanently 
 toward the affected side. 
 
 The cul-de-sac of the vagina is rendered broader and flatter by the 
 pressure of the deposit, or, Avhen the tumor is deep enough, the vagi- 
 nal surface may be rendered convex. Behind the uterus the exudation
 
 PUERPERAL FEVER. 675 
 
 is, as it were, flattened antero-posteriorly, and in some cases it may be 
 felt in tlie form of rigid bands between the posterior ligaments which 
 inclose the cul-de-sac of Douglas. The ante-uterine tumors have a 
 spherical shape and depress the vagina anteriorly. 
 
 Tumors situated in the iliac fossa have a more or less convex form, 
 and may be of such considerable size that the swelling may be recog- 
 nized by the eye through the abdominal walls. As the exudation be- 
 tween the broad ligaments may, in these cases, have been slight from 
 the beginning, or may have subsequently disappeared by absorption, 
 the iliac tumors have often, apparently, a spontaneous origin. 
 
 Sometimes the uterus is surrounded by exudation, and the entire 
 pelvis appears as though it were a mold filled with a solid mass. The 
 fornix is then often pressed downward, and irregular rounded massed 
 are to be felt through the vaginal walls. 
 
 The recognition of parametritic tumors through the abdominal 
 coverings is possible when they are situated above Poupart's ligament, 
 in the upper portion of tlie broad ligaments, and in the iliac fossae. 
 
 Unquestionably many supposed parametritic tumors have been 
 really cases of salpingitis with accompanying intraperitoneal deposit 
 of lymph. 
 
 The pain and the functional disturbances in the pelvic organs de- 
 pend upon the size and situation of these inflammatory deposits. Of 
 the functional troubles, may be mentioned frequent and painful mic- 
 turition, obstinate constipation and difficult defecation, contractures 
 of the ilio-psoas muscles when the exudation is seated beneath the 
 sheath or between the muscle and the pelvic bones, disturbances of 
 motility in the abductor muscles, paresis of the lower extremities, and 
 radiating pains in the upper portion of the thigh and in the renal and 
 lumbar regions, produced by pressure upon the obturator, the crural, 
 the cutaneous, and the sciatic nerves. 
 
 So long as fever is present, the exudation rarely diminishes. If ab- 
 sorption takes place in one point, growth almost certainly follows in 
 some other direction. When, however, the apyretic period is reached, 
 the exudation, as a rule, disappears rapidly, so that often in the course 
 of six weeks no trace of its existence remains. In a smaller number, 
 the solid mass may persist for months or even years. 
 
 After the fever has departed the patient usually feels well. The 
 sleep and appetite return, the night-sweats disappear, the pulse often 
 falls to 50 or 60 beats, and the temperature is in many cases, for a time, 
 subnormal in character. 
 
 Where the fever persists for from five -to six weeks, there is always 
 a suspicion of abscess formation. With the exception of afternoon 
 fever and night-sweats, the patient may feel very comfortable. Then 
 the exudation becomes sensitive, the spontaneous pains recur, sleep 
 is lost, and locomotion, defecation, and urination occasion acute suffer-
 
 ere 
 
 DISEASES OF CHILDBED. 
 
 ing. The fever becomes violent, chills announce the presence of pus, 
 and finally, about the seventieth or eightieth day, perforation of the 
 abscess takes place. The usual seat at Avhich the pus is discharged 
 is Just above Poupart's ligament ; next, in frequency, perforation takes 
 place into the colon, and in rare instances into the bladder, the uterus, 
 and vagina. Fortunately, of very rare occurrence is the discharge of 
 pus into the peritoneal cavity, which is naturally followed by acute 
 peritonitis. Another likewise unfrequent but most dangerous acci- 
 dent is the septic infection of the abscess — an occurrence referred by 
 Olshausen to the diffusion of intestinal gases through the Avails of the 
 tumor. 
 
 In suppuration of parametritic exudations the pus commonly forms 
 in small scattered collections, and rarely gives rise to large abscesses. 
 
 Although parametritis and perimetritis are usually found associated 
 together, there are always cases in which the one form of inflammation 
 so far predominates over the other as to justify an attempt to establish 
 a clinical distinction between them. 
 
 In the beginning of the attack, sharp pain, high fever, and tym- 
 panitic distention of the lower abdomen are symptomatic of inflamma- 
 tion in the pelvic peritonaeum. AVhether the cellular tissue is simul- 
 taneously implicated can only be determined by a digital examina- 
 tion after the abdominal sensitiveness has subsided. The absence of 
 the objective signs of cellulitis would then contribute to prove that 
 the case had been one in which the peritonaeum had l)een in the main 
 affected. On the other hand, moderate fever, pain elicited only on 
 pressure, and tympanitic distention confined to the colon, coinciding 
 with exudation between the folds of the broad ligament, would be in- 
 dicative of a nearly pure cellulitis. 
 
 A palpable exudation is by no means the necessary product of peri- 
 toneal inflammation. Indeed, in many cases, the distinctive symptoms 
 of the latter may be present for from four to eight days, and may then 
 subside without leaving a trace of its existence at the pelvic brim. 
 
 The demonstration of a fluid effusion by noting the change of level, 
 upon shifting the position of the patient, is rarely possible, either be- 
 cause the quantity is too small or because it quickly becomes confined 
 by pseudo-membranous adhesions between the intestines. 
 
 Bandl * mentions as a sign of local peritonitis, sometimes notice- 
 able, a number of resistant points or tumors near the pelvic brim or 
 above one of the iliac foss«, due to a matting together of the intestines 
 or to their adhesion to the uterine appendages. They are distinguished 
 from solid tumors by their emitting a tympanitic sound upon percus- 
 sion, and by their changing position in consequence of an accumulation 
 of urine in the bladder or of faces or gases in the bowels. Again, all 
 tumors may be reckoned as intraperitoneal which very rapidly form 
 * Handbuch der Frauenkrankheiten, red. von Billroth, 5ter Abschnitt.
 
 PUERPERAL FEVER. 677 
 
 behind or to the side of the uterus from inclosed exudation-products, 
 and which at the same time rise far above the level of the pelvic brim. 
 If, however, they- start from the cul-de-sac of Douglas, and do not 
 much exceed the linea terminalis, or if they occupy an iliac fossa, it 
 becomes very difficult to decide whether they are of intra- or extra- 
 peritoneal origin. The peritoneal exudation, however, long remains 
 soft and fluctuating. It arises, as a rule, behind the uterus, and does 
 not exhibit a tendency to spread to the sides or to the anterior or pos- 
 terior pelvic walls. 
 
 Still more difficult is it to decide as to the seat of exudations met 
 with beneath the abdominal walls. When diffused and continuous 
 with a pelvic deposit, the diagnosis is uncertain. It is only safe to as- 
 sume the peritoneal origin of extravasations of a rounded form, of a 
 fluctuating consistence, and when they are situated high uj) and are 
 disconnected from exudation at the pelvic brim. An opening of the 
 abscess through the navel would indicate a peritoneal source, while 
 the discharge through the abdominal parietes would point to a seat in 
 the connective tissue. 
 
 After the perforation of an abscess, the fever and pain subside ; the 
 wound, if external, either closes in the course of one or two weeks, or 
 fistulas form which become the source of protracted suppuration. 
 
 In psoas abscesses, the exudation extends beneath the sheath of the 
 muscle or between the iliacus and the bone. In puerperal patients, 
 they proceed from an inflammation originating in the broad ligament. 
 They are situated too deep to be easily palpated. The pains they 
 occasion are referred rather to the hip or knee than to the abdomen. 
 The contracture of the psoas muscle furnishes a diagnostic sign which 
 distinguishes this form from the superficial abscesses of the iliac fossa?. 
 The pus eventually is discharged beneath Poupart's ligament, in the 
 lower portion of the inguinal fossa, at some point upon the crest of the 
 ileum, or exceptionally along the thigh. Often the discharge is main- 
 tained for months. 
 
 The Symptoms of General Peritonitis (Suppurative). — This form 
 generally begins with the usual symptoms of pelvic inflammation, but 
 the tenderness, which at first was limited to the side of the uterus, grad- 
 ually spreads over the entire abdomen. The abdominal pain is of a 
 tearing, lancinating, sometimes colicky character. It is increased by 
 the slightest bodily movement, by jarring of the bed, or even by the 
 weight of the bedclothes. 
 
 As a consequence of the peritoneal inflammation and of the ac- 
 companying exudation, the muscular walls of the bowels become para- 
 lyzed, and tympanitic distention results from the accumulation of gases. 
 In the dependent portions of the peritoneal cavity it is often possible 
 to demonstrate, by percussion, the presence of fluid exudation, though 
 distinct fluctuation is rarelv to be made out. The size of the abdomen
 
 g/j.g DISEASES OF CHILDBED. 
 
 is due much more to the tympanites than to the amount of effusion. 
 Sometimes the liver, with the diaphragm, is pushed by the swollen bow- 
 els to the level of the fourth or third rib, and exercises such a degree 
 of compression upon the posterior portion of the lungs as to place the 
 patient in danger of suffocation. The respirations are jerky and at- 
 tended with a moaning sound. 
 
 The loss of muscular power in the intestines permits the contents 
 of the middle portion to pass unchecked toward the duodenum, and 
 thence, upon accidental contractions of the abdomen, tliey may jjass to 
 the stomach and be ejected by vomiting. The first vomited matter has a 
 dark-green color, and that ejected afterward presents the color of in- 
 testinal matter. Constipation at the outset may be subsequently fol- 
 lowed by colliquative diarrhoea. 
 
 The fever begins, as a rule, though not always, with an intense chill, 
 the temperature rises to 104°, and the pulse becomes small, hard, and 
 resistant. Its frequency rapidly increases, varying from 1"^0 to KiO 
 beats to the minute. The skin is sometimes dry, sometimes drip])ing 
 with perspiration. In fatal cases, as the end approaches, the tempera- 
 ture frequently falls, while tlie pulse becomes more rapid, the face as- 
 sumes a pinched, anxious exjjresrfion, sweat gathers upon the foreliead, 
 the extremities grow icy cold, and the patient dies in collapse. The 
 duration of peritonitis averages not more than from four to six 
 days. 
 
 In cases of recovery the pulse imi)roves, the vomiting ceases, and 
 the tympanites disappears. The diffuse exudation tlien becomes con- 
 verted into circumscribed tumors, which, on palpation, are felt on the 
 side of the pelvis and extending upward to the level of the umbilicus. 
 Upon internal examination, the uterus is often found (lej)ressed by tiie 
 weight of the fluid, which likewise may bulge the nd-de-sac of Douglas 
 into the pelvic cavity. Sometimes the exudation may ]>ecome encysted 
 above the pelvis and leave the contents of the latter free. In still otiier 
 cases, the uterus may become attached high up to the abdominal walls, 
 so that the vaginal portion disappears and tlie os is reached with diffi- 
 culty. 
 
 The peritoneal exudation may, as in pelvic inflammations, become 
 absorbed and disappear. When, however, it is surrounded by loops of 
 intestines, it is apt to undergo purulent and septic changes, and the ab- 
 scesses may then become discolored and filled with stinking gases. The 
 patient, whose previous improvement has been watched with delight, 
 now loses appetite, the pulse becomes frequent, the strength fails, and 
 death may follow from septic fever or from rupture of abscess into the 
 abdominal cavity. 
 
 In the pyaimic form — a still more deadly variety of peritonitis — the 
 symptoms differ materially from those which have been recounted. 
 As, however, it constitutes only a single one of the pathological
 
 PUERPERAL FEVER. 
 
 679 
 
 changes connected witli the poisoning of the blood througli the lym- 
 phatic system, its consideration belongs properly to the stndy of the sep- 
 tic infection. 
 
 The Symptoms of Septicaemia Lymphatica (Septic).— The symptoms 
 of blood-poisoning in the infectious diseases of childbed vary to a con- 
 siderable extent according to the channel through which the septic 
 •germs enter the general circulation. In the murderous epidemics which 
 prevail in lying-in hospitals the lymphatics are, as a rule, the vessels 
 primarily invaded. It is to this form that the cases already described 
 belong, where, with diphtheritic patches upon the utero-vaginal canal 
 and sero-purulent oedema of the parametrium, there are associated pye- 
 mic peritonitis and deformation of the blood-corpscules ; or where, fol- 
 lowing the migrations of the round bacteria, the serous cavities become 
 successively involved, septic vegetations gather upon the heart, and the 
 glomeruli of the kidneys become choked with micrococci. The lym- 
 phatic form of septicsemia develops soon after labor, and is always 
 ushered in by a chill. The temperature rises to 104° or even higher, and 
 the pulse is thin and frequent. The abdomen swells rapidly, without 
 being especially painful. Indeed, painless distention of the intestines 
 is one of the characteristics of an acute invasion of the lymphatics. 
 Peritoneal effusion is absent in cases which run a rapid course, and is 
 distinctly recognizable only in a peritonitis of long continuance. The 
 effusion is not so much due to exudation as to a transudation of serum 
 with which micrococci are commingled. At the same time the tongue 
 is moist, but slightly coated, and at times quite clean. Sometimes there 
 is diarrhoea, due to catarrh or to a diphtheritic affection of the colon. 
 When the bowels have been constipated, the administration of a pur- 
 gative may provoke discharges which it may be found difficult to arrest. 
 The skin is bathed in perspiration. At the beginning and during the 
 course of the disease, bleeding at the nose is not of infrequent occur- 
 rence. 
 
 Toward the end, tlie pulse runs up to 140 to 160 beats, while in 
 many cases the temperature falls. Immediately after death the heat 
 of the body may for a short time exceed the highest point reached dur- 
 ing life. The respirations are superficial and jerky. In many instances 
 the face, the neck, and the fingers are blue from defective oxygenation 
 of the blood. At the same time, the skin becomes clammy and the ex- 
 tremities cold. 
 
 The sensorium, in cases which run a rapid course, is usually affect- 
 ed at an early period. The patients appear somnolent, are restless in 
 bed, have light delirium, and respond only when spoken to loudly. As 
 a rule, they make but little complaint, and, were it not for the dyps- 
 noea, would have nothing to disturb their sense of comfort. Very 
 few, even as death approaches, have any idea of the danger that 
 threatens them. Now and then, in place of stupor, great restlessness,
 
 ggQ DISEASES OF CHILDBED. 
 
 and even a maniacal condition, is developed. Albumen is usually found 
 
 in the urine. 
 
 Pleurisy, so frequently associated with lymphatic septicaemia, is fre- 
 quently double, more rarely single, and begins, as a rule, with sharp 
 pain in the side and an aggravation of the previous dyspnoea. Pericar- 
 ditis is less frequent, and occurs usually, without symptoms, toward 
 the close of life. The joint affections are characterized by redness and 
 swellino-, and by pain, Avhich is sometimes so great that touching the 
 inflamed part suffices to arouse the patient from sopor. Sometimes 
 fluctuation is felt, but death occurs before perforation and discharge of 
 the pus. 
 
 The most frequent ending is death, which follows in from two to 
 twenty-one days, and, as a rule, between four and seven days, liecovery 
 is, however, possible. 
 
 The Symptoms of Septicaemia Venosa (Phlebitis uterina, Pyaemia 
 metastatica).— The putrid infection of a thrombus at the placental site 
 may take place within twenty-four to forty-eight hours after labor. 
 Usually, however, the approach is insidious, and the disease develops 
 from an apparently insignificant endometritis or parametritis ; or the 
 patient, with the exception, perhaps, of a tired feeling, of slight chilly 
 sensations, and of profuse perspiration, may not have been conscious of 
 any indisposition for days preceding the attack, or even until the first 
 getting up from childbed. The initial chill, in typical cases, is charac- 
 terized by its violence and duration. In some cases it may last for 
 hours. It is accompanied and followed by high temperature, the fe- 
 brile attack ending with profuse perspiration as in intermittent fever, 
 with which it is apt to be confounded. The fall in temperature often 
 assumes the form of a prolonged remission. 
 
 In many cases, the pulse rises and falls with the variations in the 
 body heat, while, in others, it remains permanently above the average. 
 A frequent pulse is always a suspicious symptom in childbed, even where 
 the other symjitoms are apparently normal. 
 
 Erratic chills announce the lodgment of emboli in distant organs. 
 With the formation of metastatic abscesses in the lungs and other 
 parenchymatous organs, the t3']3ical character of the disease changes. 
 In place of chills occurring at irregular intervals, followed by remis- 
 sions and periods of apparent improvement, the fever is continuous, the 
 pulse becomes small and rapid, while sopor, slight delirium, a dry skin, 
 a dry, brown, cracked tongue, and a moderately tymjianitic abdomen, 
 give the case the appearance of one of typhus fever. 
 
 Peritonitis is present in hardly one third of the cases. The abdo- 
 men is therefore flat and soft, and often is not sensitive upon pressure. 
 Icterus, due to disintegration of the blood-corpuscles, is an ominous 
 symptom. 
 
 Death usually occurs in the second or third week. In the typhus-
 
 PUERPERAL FEVER. 681 
 
 like cases, however, it may follow the first attack speedily. Recovery is 
 possible where the organs secondarily affected are not of too great im- 
 portance. 
 
 A combination of the lymphatic and venons forms of septicaemia is 
 not uncommon in cases running a protracted course. 
 
 The Symptoms of Pure Septica3mia.— Under the title of pure septi- 
 caemia should be placed cases in which the absorption of morbific ma- 
 terials into the blood gives rise to symptoms of intense blood-poisoning 
 without the development of local lesions. A common exaniiDle of this 
 form is met with in the fever which results from the presence in the 
 uterus of decomposing coagula or portions of retained ovum, the fever 
 subsiding with the removal of the disturbing cause. The symptoms 
 are often similar to those produced by the injection of putrid materials 
 containing rod-like bacteria into the vessels of animals. As the long 
 bacteria do not possess the capacity of self -reproduction in the blood, to 
 produce fatal results the quantity of putrid fluid injected must be large 
 or be frequently repeated. This form is said not to be inoculable. In 
 like manner we sometimes meet with cases of intense septic poisoning 
 followed by speedy death, in which the post-mortem examination re- 
 veals only changes in the blood and softening of the parenchymatous 
 organs. 
 
 CHAPTER XXXVI. 
 
 PUERPERAL FEVER {Continuecl). 
 
 Causes. — The atmosphere.— Inoculation.— Season of the year. — Social state. — Rela- 
 tions to zymotic diseases.— The prevention of puerperal fever.— Treatment.— 
 Vaginal and uterine injections.— Iodoform bacilli; opium; leeches; stupes; 
 laxatives ; quinine ; salicylate of sodium ; Warburg's tincture ; veratrum 
 viride; digitalis; antipyrine ; alcohol ; cold. — Treatment of peritoneal effusions 
 and inflammatory exudations. 
 
 Causes of Puekperal Fever. 
 The Atmosphere.— Micrococci multiply in hospitals when organic 
 materials favorable to their growth are present in sufficient quantities. 
 Perrin, Quenquand, and others have shown that the hospital wards in 
 Paris, especially those upon the surgical and maternity divisions, con- 
 tain an infinite number of vibrios, bacteria, and all the coccus forms 
 (Charpentier). Robin has demonstrated the existence of albuminoid 
 matters in water condensed upon vessels containing freezing mixtures 
 and placed in overcrowded wards of hospitals. When the results of 
 crowding become manifest, these albuminoid matters not only impart 
 a fetid odor and putrefy with great rapidity, but rapidly impart putre- 
 faction to healthy muscle and normal blood with which they are
 
 gg2 DISEASES OF CHILDBED. 
 
 brought into contact. Pasteur was able, by the microscopic examina- 
 tion of the lochia from patients in the services of Ilervieux and Lucas- 
 Champonniere, to predict, from the character of the contained organ- 
 isms, an impending attack of fever in advance of the slightest symptom 
 betokening danger. 
 
 The quality of the agents which pervade the air where hospital 
 patients are confined is an important element in the genesis of febrile 
 outbreaks. The bacterium termo, which causes putrefaction, is not in 
 itself, as we have already mentioned, a source of danger. A stinking 
 odor is not necessarily incompatible with a low mortality rate. The 
 importance of the common forms of bacteria, according to Pasteur, re- 
 sults from the fact that by their power to consume oxygen they pave 
 the way for the active development of the pernicious germs, nearly all 
 of which thrive only in media in wliicli that element has been materi- 
 ally diminished. Again, there is reason to believe that the same germs 
 are not always equally active for evil. The resistance of micrococci to 
 carbolic and salicylic acids is found, experimentally, to depend in a 
 measure upon the nature of the vehicle in whicli they are cultivated 
 (Buchholz). The action of septic fluids varies, too, with the age of 
 the infusions, with the materials employed, and with the conditions 
 under which the poison-germs are generated. 
 
 It was unquestionably the lochial discharge whicli, before the days 
 of antisepsis, made it such a difficult task to keep a maternity ward in 
 a healthful condition. Putrid blood has been found to be the most 
 favorable material for septic experiments. In the summer months, so 
 long as the windows were open and the air was diluted by the continu- 
 ous passage of fresh currents, the patients usually enjoyed immunity 
 from puerperal fevers. In the autumn, so soon as it Ijccame necessary 
 to close the windows partially, on account of the cool nights, it was not 
 uncommon for the more trivial disturbances, such as so-called milk 
 fever, the hospital pulse, and catarrhal affections of the genitalia, to 
 manifest themselves. Through the months of February, March, and 
 April the mortality was usually greatest. During the winter months 
 there was, as a rule, crowding of patients, insufficient ventilation, stag- 
 nation of the air, and the rapid accumulation of disease-germs. That 
 the later winter months should prove the most perilous is in accord- 
 ance not only with the theory of continuous accumulation, but with 
 the experimental fact that weeks sometimes elapse before a decompos- 
 ing substance acquires the highest degree of virulence. 
 
 Apart from the nosocomial malaria of hospitals, there is reason to 
 believe in the influence, at times, of certain general widespread atmos- 
 pheric states which affect the entire community. In the year 1871 
 the mortality from childbed in Xew York was 399 ; in 1872, 503 ; in 
 1873, 431 ; in 1874, 439 ; and in 1875, 420. Now, the excess in the 
 deaths for 1872 was due wholly to an increase in the cases of mctria,
 
 PUERPERAL FEVER. 683 
 
 those from ordinary accidents remaining nearly the same as in the 
 preceding years. The disease certainly did not extend into the city 
 from the hospitals serving as foci, for the mortality at Bellevue Hos- 
 pital was hardly more than half the usual average. There was no 
 especial mortality that year from either diphtheria, erysipelas, or scar- 
 latina, but the aggregate mortality was the largest known in the his- 
 tory of the city. There are no positive data connecting the civil deaths 
 from puerperal fever in 1872 with parasiticism, but the prevalence of 
 epizootics, of epidemic catarrhal affections, of peculiarly fatal forms of 
 pneumonia and other diseases which are now attributed to the presence 
 of minute organisms in the atmosphere, renders such a soi;rce highly 
 jirobable. 
 
 It is proper to say here that, though the argument is very strong 
 in favor of regarding the genitalia of puerperal women as the exclusive 
 point of entry of infectious materials into the system, it seems impos- 
 sible at the present time to make all the facts coincide with such a 
 theory. I have the records of a number of cases occurring during an 
 epidemic of puerperal fever in which patients were either attacked 
 with fever previous to parturition, or in whose cases the unusual length 
 of labor, the frequency of post-jjartum hemorrhage, and the imperfect 
 contraction of the uterus immediately after confinement, were signs of 
 some abnormal influence exercised upon the economy at an early period 
 of labor previous to the existence of traumatism. That deleterious ma- 
 terials may find other channels for entering the system than a wounded 
 surface is evidenced by the cachectic condition not unfrequently pro- 
 duced in physicians by too assiduous attendance in dissecting-rooms 
 and places in which post-mortem examinations are conducted. One 
 severe and rapidly fatal case of puerperal fever which occurred in Belle- 
 vue Hospital I find it impossible to attribute to any other cause than 
 that the woman, for five months previous to her confinement, served 
 as a helper in a lying-in ward. The post-mortem examination dis- 
 closed no special local lesions, but her symptoms were those of in- 
 tense septicaemia. French writers report instances of toxemic condi- 
 tions developing in young midwives during puerperal-fever epidemics. 
 While we are not prepared to go as far as Tarnier, who says, " It is 
 probable that the hmgs, by their extent and activity, offer conditions 
 most favorable to absorption, and that often, if not always, it is by 
 them that poisoning occurs," it does not yet seem time to give up the 
 idea that, under exceptional circumstances, the respiratory and the 
 digestive tracts may allow the passage of materials of a septic char- 
 acter. 
 
 Inoculation.— Unquestionably the most frequent source of puer- 
 peral fever is by inoculation ; and yet, no longer than thirty years ago, 
 the doctrine was combated as a pernicious heresy by both Meigs and 
 Hodge, of Philadelphia, at that time regarded as the best authorities
 
 gg^ DISEASES OF CHILDBED. 
 
 upon obstetrical questions in this country. Hodge, addressing his 
 students, said : " The result of the whole discussion will, I trust, serve 
 not only to exalt your views of the value and dignity of our profession, 
 but to divest your minds of the overpowering dread that you can ever 
 become, especially in women under the extremely interesting circum- 
 stances of gestation and parturition, the ministers of evil— that you 
 can ever convey, in any possible manner, a horrible virus, so destruct- 
 ive in its effects and so mysterious in its operations as that attributed 
 to puerperal fever " ; and Meigs, in his letters to students, writes : 
 " I prefer to attribute them to accident or to Providence, of which 
 I can form a conception, rather than to a contagion of which I can 
 not form any clear idea, at least as to this particular malady." Con- 
 trasted with these rhetorical utterances, in an essay published in 1843, 
 by Prof. Oliver Wendell Holmes, entitled " Puerperal Fever as a 
 Private Pestilence," the opposing testimony in favor of contagion 
 was presented with equal literary and scientific skill. The evidence 
 was complete and conclusive, and has exercised a most beneficial in- 
 fluence upon the practice of midwifery in America. With his many 
 claims to our admiration and esteem, there is probably no title which 
 Professor Holmes wears with greater pride than th^t of pioneer in a 
 movement that has done so much to prevent the slaughter of innocent 
 women and the wrecking of happy homes. 
 
 The ordinary carriers of infection are unquestionably the unclean 
 hands, instruments, utensils, clothing, wash material, and the like 
 which are brought in contact, during or after labor, with the genitals of 
 the female. 
 
 Barnes and other English writers lay considerable stress upon cases 
 of puerperal fever due neither to contagion nor to atmospheric con- 
 ditions, but to the poisoning of the patient by her own secretions. 
 There is justification for this view in the fact that even normal lochia 
 contain bacteria, and, when inoculated into animals, produce in them 
 affections of an ichorrhfemic and septictemic nature. When death 
 takes place, the tissues of animals thus treated are found to be filled 
 with round bacteria. Furthermore, the disease artificially produced is 
 in itself infectious, and can be continuously propagated in other ani- 
 mals. But it may be asked, " Does not tliis admission cut both ways? 
 How is it possible, if even normal lochia possess virulent qualities, that 
 childbed is ever unattended by accessions of fever ? " To this we can 
 only answer that the reasons for immunity in ordinary cases are only 
 known in part. Karewski * and other experimental investigators have 
 shown that the virulence of the lochia increases proportionately to the 
 number of days that have transpired since the birth of the child, and 
 
 * Experimentelle Untersuchun£:en iiber die Einwirkungen puerperaler Secrete 
 auf den thierischen Organismus, Zeitschr. f. Geb. und Gvnaek., Bd. vii, 2ter Th., 
 S. 331.
 
 PUERPERAL FEVER. 685 
 
 that, during the first three days, the locliia are comparatively harmless. 
 Meantime, the retraction of the uterus, the closure of the sinuses, and 
 the formation upon the wounded surfaces of protecting granulations, 
 all act as natural barriers to the penetration of poison-germs. But, 
 aside from these reasons, there is undoubtedly an unknown quantity 
 calling for further investigation, which, in the absence of positive 
 knowledge, we are content to term the predisposition of the individual 
 patient. The vagina after childbirth possesses all the conditions most 
 favorable for the production of putrefaction, viz., the access of air, 
 fostering warmth, and stagnating fluids charged with dead tissue. It 
 is probable that the first of these needful conditions is, in normal la- 
 bors, happily wanting in the uterine cavity. In these days of intra- 
 uterine medication it is well to bear in mind the relatively greater 
 frequency of infection through vaginal and cervical wounds, as com- 
 pared with that which takes place through the denuded intra-uterine 
 surface. The term auto-infection may, with propriety, be employed 
 as a distinctive appellation to designate those attacks of fever which, 
 in the absence of any demonstrable cause, occur in the early days of 
 childbed, and which there, quoad vitam, pursue a favorable course, 
 and to cases of so-called late infection — i. e., where, after the fifth day, 
 the accidental opening of a healing wound permits the tardy absorption 
 of poisonous secretions ; but with the reserve that the primary cause 
 is, in point of fact, atmospheric, and the predisposing condition the 
 susceptibility of the individual. Cases of auto-infection are in this 
 country extremely rare, if not unknown altogether, in salubrious or 
 rural districts. 
 
 Seasons. — On another occasion I have shown that in New York 
 city the death-rate from puerperal fever is nearly twice as great during 
 the six months from December to May, inclusive, as from June to 
 November. The greatest mortality occurred in February and March, 
 comprising . rather more than one fourth the entire amount. The 
 smallest number of deaths occurred in September and October, in 
 which months but one thirteenth of the entire number took place. 
 
 Social State. — That puerperal fever, in its harvest of death, does 
 not spare the wealthy and well-to-do classes is too familiar a truth to 
 be worthy of discussion. That, however, the Avealthy do enjoy special 
 immunities as compared with the less-favored members of society, I 
 have shown by comparisons made between sections of the city which, 
 though lying side by side, exhibit in a marked degree the two extremes 
 of wealth and poverty. Thus, the mortality among the representatives 
 of the lower social strata, in proportion to population, was from three 
 to six times as great as that among the more fortunate classes. 
 
 Relations to Zymotic Diseases. — In investigating, some years ago, 
 the nature, causes, and prevention of puerperal fever,* I prepared, 
 * Trans, of the International Med. Congress, Philadelphia, 1876.
 
 ggg DISEASES OF CHILDBED. 
 
 from the statistics of the Health Board of New York city, tables ex- 
 tendino- over a period of nine years to answer the inquiry as to whether 
 tliere was any relation between the frequency of deaths from scarlatina, 
 diphtheria, and erysipelas and those from metria. Previous to their 
 publication, I was anticipated in my deductions by a paper upon the 
 same subject by Matthews Duncan.* Neither Duncan nor myself 
 found any such relation existing between the statistical frequency of 
 puerperal fever and the zymotic diseases mentioned. There was, how- 
 ever, nothing in our investigations to invalidate any direct testimony 
 which tends to show that, in individual cases, a real connection between 
 puerperal fever and the zymotic diseases may exist. Indeed, it seems 
 to me to be fairly established that a poison may be conveyed from 
 patients suffering from either of the foregoing morbid processes which 
 may be absorbed by the puerperal woman, and may, in her, give rise to 
 an infectious fever possessing an intense degree of virulence. 
 
 Prevention, — Doleris formulates the indications for effective pro- 
 jihylaxis as follows : 1, prevent the introduction of germs (antisepsis 
 before confinement) ; 2, paralyze their action (antisepsis after confine- 
 ment) ; 3, shut up the doors — veins, lympluitics, and Fallopian tubes 
 (employment of means which promote uterine contraction). 
 
 The results in the application of these rules are best shown in the 
 modern statistics of lying-in hospitals. The records of the Health 
 Board between the years 1868 to 1875, inclusive, showed that at that 
 time nearly one sixth of the deaths from metria in New York city were 
 contributed by the hospitals. To cite a single example : In the year 
 1873 there were 449 births in Bellevue Hospital ; there were 2") ma- 
 ternal deaths, 15 of which were the result of septic infection. The 
 proportion of one death from sepsis to thirty cases of childbirth 
 was at that time the usual one in the maternities of tliis country and 
 of Europe, reported differences being rather of bookkeeping than of 
 fact. There was always, likewise, a large unreckoned contingent of 
 patients with pelvic inflammatory troubles which ended in recovery. 
 In 1874, between the 1st of January and the 11th of June, of lOG 
 patients confined, 31 died of puerperal fever. Similar fatal epidem- 
 ics were, at that time, of not infrequent occurrence in the best ap- 
 pointed maternities. 
 
 During the years 1885 to 1889, inclusive, 837 Avomen have been 
 confined in the Emergency Hospital, and there have been 10 
 deaths, i. e., nearly 1 to 82. A glance at the record shows that these 
 cases are the best illustrations of the difficulties with which the institu- 
 tion has to contend, and of the value of the antiseptic principle. 
 
 * On the Alleged Occasional Epidemic Prevalence of Puerperal Pyaemia, or 
 Puerperal Fever and Erysipelas. Edinburgh Mod. Journal, March, 1876, p. 774. 
 Recent observations have shown that morphologically the streptococci of erysipelas 
 and those of puerperal fever are indistinguishable.
 
 PUERPERAL FEVER. ggT 
 
 Thus, there were five deaths from eclampsia. The patients were 
 all sent to the hospital after the convulsions had gained full headway. 
 
 One was a case of placenta previa. The labor had been lengthy 
 and the htemorrhages profuse before the patient was admitted. 
 
 One was a case of Cesarean section, performed on account of the 
 obliteration of the cervix and vagina by cancer. 
 
 A patient was sent to the Emergency in labor, with delirium tre- 
 mens. She died twenty-four hours after delivery. 
 
 There were two deaths following version in neglected shoulder 
 presentations. Both women had been in labor several days previous to 
 admission. The children were dead, and decomposition had set in. 
 
 In two cases the women had been respectively two and one half and 
 four days in labor when admitted. The children were dead. There 
 was a stinking discharge and commencing decomposition of the foetus. 
 
 In tAvo cases the high-forceps operation had been performed surrep- 
 titiously by unqualified persons. In both instances, the lower uterine 
 segment was ruptured, and death speedily followed. 
 
 In a twin pregnancy, where one child was delivered by forceps and 
 the second by version after a long labor, death occurred from sep- 
 ticaemia. 
 
 There remains one other case, concerning which no record has been 
 preserved. 
 
 Thus, of the sixteen deaths, one, or possibly two, can be construed as 
 due to puerperal fever. 
 
 I have ventured to offer these particulars because there is no pre- 
 tense that the Emergency is a model for imitation. It has no fans for 
 ventilation ; no provision for a rotation of wards. It is intended for 
 the homeless class. It receives constantly women with high temper- 
 atures due to infection before their entrance, or who have been days in 
 labor, or who have been subjected to unavailing attempts at artificial 
 delivery by outside physicians. It therefore furnishes an excellent test 
 of the value of modern antiseptic methods. 
 
 Now, the regulations by which these results have been obtained are 
 comparatively simple. The patient, on her entrance into the hospital, 
 receives a full bath. A rectal injection is given. The lower abdomen, 
 the inner surfaces of the thighs, the pudenda, and the anus are 
 scrubbed with soap and water, then washed with plain water, and 
 finally cleansed with a 1 : 1,000 solution of corrosive sublimate. The 
 vagina is first douched with soap and water, and then with a 1 : 5,000 
 solution of corrosive sublimate. In operative cases these douches are 
 repeated before and after the introduction of the hand or instru- 
 ments. The Bellevue Hospital internes, while on duty, are not per- 
 mitted to visit the dead-house or the erysipelas pavilion. They are not 
 allowed to assist at surgical operations, nor to take part in the dressing 
 of wounds. When in attendance upon a case of labor, both interne and
 
 ggg DISEASES OF CHILDBED. 
 
 nurse wash their hands and forearms with soap and water, with pure 
 water, and with corrosive-sublimate sokitiou (1 : 1,000), Before an 
 internal examination is made, the hands are freshly washed with the 
 bichloride solution. Infrequent examinations are recommended. In- 
 struments are placed in a 2-per-cent solution of carbolic acid. After 
 they have been used, they are boiled and polished for future service. 
 
 The Crede method of expelling the placenta is employed. Ergot 
 is given to secure good uterine contractions. In all cases after labor 
 the vagina is douched with the bichloride solution (1 : 5,000). In 
 cases of protracted labor, of high-forceps operation, of version, or of 
 any manipulations by means of which air is admitted to the uterine 
 cavity, the douche, after preliminary vaginal irrigation, is extended to 
 the uterine cavity. The external parts are then dusted with iodoform, 
 and are covered with a piece of gauze freshly wet with bichloride solu- 
 tion (1 : 5,000). Outside is placed a pad of oakum. The dressing is 
 changed once in six hours, at which time the genitals are scrupulously 
 cleansed. During childbed no vaginal douches are given. 
 
 In the main, the plan of treatment carried out is tluit introduced 
 by Garrigues at Charity Hospital five years ago. Its success is attested 
 not only by the absence of deaths due to septic infection, but by the 
 morbidity in the wards. The temperatures rarely rise above 100^°, 
 and, as a rule, do not reach 100°. But the plan of treatment presup- 
 poses intelligent instruments. For us these are supplied, on the one 
 hand, by the training-school for nurses ; on the other, by the hospital 
 interne, who enters upon his duties thoroughly familiar with the re- 
 quirements of surgical cleanliness. The occasional appearance on the 
 scene of an individual who uses his " common sense " — i. e., one who 
 does not believe there is any harm in witnessing an autopsy, or in visit- 
 ing a companion in the erysipelas ward, or in holding the pus basin in 
 an operation for pyo-thorax — is almost certainly followed by tempera- 
 ture elevations, which add fresh testimony to the efficacy of a rigid 
 observance of antiseptic regulations. 
 
 It is, however, to be acknowledged that there is by no means una- 
 nimity among authorities in relation to certain of the rules prescribed. 
 Thus, the pad to the vulva is sneered at, by many, as savoring of the 
 heresy that the air can become the source of contagion. For my own 
 part, I believe an antiseptic dressing and pad are of immense service in 
 hospital practice, where patients are aggregated together, as a means 
 of preventing the decomposition of the lochia. The latter is inevitable 
 upon the external parts when the ordinary napkin is employed. It 
 seems to me incontrovertible that the air does thereby become contami- 
 nated, and it is doing violence to the evidence to deny the pernicious 
 influence of a germ-laden atmosphere upon puerperal wounds. The 
 argument that such an admission has a tendency to weaken the per- 
 sonal responsibility of the physician is childish. Aside from the fact
 
 PUERPERAL FEVER. 0g9 
 
 that science is based upon truth, and not upon teleological considera- 
 tions, the belief in a twofold origin of puerperal fever simply doubles 
 his responsibility. To be sure, Leopold* found that of 427 patients 
 in the Dresden Maternity, who had not been examined or treated with 
 corrosive sublimate previous to confinement, only 7 had a rise of tem- 
 perature, and this fact taken by itself would seem to indicate that 
 direct contact alone is capable of producing infection. But these 
 patients were confined under favorable sanitary conditions. Szabo,f 
 on the contrary, during an epidemic of fever in the Pesth Maternity, 
 gave orders that no examinations should be made. Of 90 patients con- 
 fined under these conditions, more than one third had febrile disturb- 
 ances ; and two of the patients, upon whom, in one case, sutures and, 
 in the other, serres-fines were employed for perineal laceration, died. 
 The researches of Ott J and Thomen * show that in healthy women 
 the bacteria contained in the lochia are found, not in the upper por- 
 tion of the vagina, but near the introitus, which would certainly indi- 
 cate that they are ordinarily derived from external sources. At any 
 rate, since the use of the pad at the Emergency Hospital, it has been 
 possible to do away with the old-time rotation of wards, and the febrile 
 temperatures, which once were so marked a feature of the winter 
 months, when the windows were closed, are now no longer observable. 
 
 The subject of prophylactic douches, during labor, has likewise been 
 one of endless contentions. In private practice they are certainly 
 needless. Their employment at the Emergency has not, however, been 
 the result of theory, but has been the outcome of the condition of the 
 patients admitted, most of them having been examined previously by 
 not overfastidious midwives or physicians. 
 
 The differences which divide obstetrical authorities concerning the 
 ante-partum douche is not so much the result of conflicting experiences 
 as of doctrinal convictions. Thus, Barnes, Ahlfeld, Kaltenbach, and 
 others, have shown that, in spite of every pains taken to exclude con- 
 tact-infection, temperature elevations will occasionally occur in child- 
 bed. These febrile disturbances they regard as the product of a 
 materies morli^ existent in the genital canal prior to labor ; or, to use a 
 term which at present is not only a designation, but a war-cry, such 
 cases are due to auto-infection. It is a matter of common agreement 
 that, in severe cases of puerperal infection, the utero-vaginal canal 
 swarms with bacterial forms, and that, of these, the streptococcus pyo- 
 genes is the most certain accompaniment of specific inflammatory 
 
 * Leopold, Dritter Beitrag zur Verhiitung der Kindbiltfiebers, Arehiv f. Gyna- 
 kologie, vol. xxxv, p. 149. 
 
 fSzABO, Zur Frageder Selbstinfection, Ibid., vol xxxiv, p. 153. 
 t Ott, Zur Bacteriologie der Lochien, Ibid., vol. xxxii. 
 
 * Thomen, Bacteriologisehe Untersuchungen Normaler Lochien, etc., Ibid., vol. 
 xxxvi, p. 247. 
 
 44
 
 ^QQ DISEASES OF CHILDBED. 
 
 troubles. When convalescence sets in, the coccus forms correspond- 
 ino-ly disappear from the lochial discharges. But the vagina at all 
 times contains a varied assortment of bacterial germs. Nothing would 
 seem simpler, therefore, than the deduction that these germs are al- 
 ways potential sources of evil. As a logical outcome of this doctrine, 
 its extreme supporters insist upon a complete sterilization of the vagina 
 in every case of labor as an ordinary prophylactic precaution. Thus, 
 Steffeck * advises the irrigation of the vagina during labor, at two-hour 
 intervals, with a litre of corrosive-sublimate solution. To increase its 
 efficiency he introduces two fingers into the vagina to scrub, during 
 the douche, first the vaginal mucous membrane and then the interior 
 of the cervix. Doderlein f recommends that the vagina be first rubbed 
 thoroughly with a preparation of creolin and molliu, and then be irri- 
 gated, for ten minutes, with a creolin solution. 
 
 Fortunately, these suggestions, which would have a tendency to 
 handicap fatally the employment of antiseptic measures in midwifery, 
 have not been received with much favor, even by the partisans of the 
 doctrine of auto-infection. But, on the other hand, the pathogenic 
 character of the germs contained in the vagina has been disputed. 
 Thus, Artemieff I says that " the lochia of perfectly healthy puerperal 
 women contains no micro-organisms." Bokelmann ** maintains that a 
 healthy, normal puerperal woman is a priori to be regarded as aseptic. 
 He objects to attempted sterilization on the ground that the measures 
 emjDloyed mechanically delay the progress of labor by the removal of 
 the normal vaginal mucus, and at the same time render more vulner- 
 able the tears, the excoriations, and the surfaces from which the epi- 
 thelium has been detached. 
 
 Kaltenbach,|| althougli a defender of auto-infection, states that in 
 easy, rapid, births the germs are carried away by blood, amniotic fluid, 
 and the passage of the child ; but in tardy labors, or in case of the 
 premature rupture of the membranes, the entrance of germs into the 
 uterine cavity is facilitated, and many may remain in the uterus and 
 become a source of danger. Diseases resulting from auto-infection are 
 lighter in character than those due to inoculation. Infection is first 
 preceded by putrefaction. A complete destruction of germs is unne- 
 cessary ; those that remain in ittero are rendered harmless by ordinary 
 injections. Even Winter states that, in the present condition of our 
 
 * Steffeck, Ueber Disinfection des weiblichen Genital-canals, Zcitschrift flir 
 Geburtskunde, vol. xv, p. 395. 
 
 f Doderlein und GCnther, Disinfection des Geburts-canals, Archiv fur 
 Gynakologie, vol. xxxiv, p. 111. 
 
 X Artemieff, Micro und bacterioscopische Untersuchungen der Lochien, Zeit- 
 schrift f. Geburtskunde, vol. xvii, p. 174. 
 
 * Bokelmann, Die Antisepsis wahrend der Geburt, Ibid., vol. xvii, p. 341. 
 II Kaltexbach, Archiv f. Gynakologie, vol. nxxv, p. 489.
 
 PUERPERAL FEVER. qqi 
 
 bacteriological investigations, it is not right to carry out the attempts 
 at complete sterilization recommended by Steffeck and Doderlein. 
 
 In private practice, under ordinary conditions, the presence in the 
 vagina of infectious forms of bacteria is hardly conceivable, except in 
 cases where they have been directly imported by the finger or by in- 
 struments. This statement is based both upon microscopic investiga- 
 tions and upon clinical experience. So far, it has not been possible, m 
 the rare instances where beaded cocci have been found in the vaginal 
 secretions, ante-partum, to obtain by pure cultures a product capable 
 of giving rise to spreading inflammations ; and in rural districts, even 
 with not overcleanly surroundings, immunity from infectious puer- 
 peral diseases is the rule. That, however, the vagina, which is not a 
 hermetically closed tube, should, like the atmosphere, contain germs 
 capable of producing putrefaction is hardly doubtful. Under healtliy 
 conditions the uterine cavity, on the contrary, contains no bacterial 
 forms, and it is not invaded by them in normal parturition, a fact at- 
 tributed to their feeble migratory power and to the downward current 
 of the secretions. Con<litions which favor the passage of germs from 
 the vagina into the uterus are relaxation of the uterine walls, and mem- 
 branes hanging from the cervix. The increased morbidity which ac- 
 companied the once popular vaginal douche in childbed was doubtless 
 owing to the circumstance that, while of feeble disinfectant power, tlie 
 injected stream furnished in many instances a direct highv/ay to the 
 uterine cavity. True midwifery antisej^sis consists not so much in 
 douching as in furthering physiological processes. Under normal cir- 
 cumstances, a proper handling of the patient during labor will effect 
 more in the way of prophylaxis than the most effective germ-destroy- 
 ing agents. When, however, hands or instruments are introduced into 
 the uterine cavity, the case is different. It would be hardihood then 
 not to precede the operative measure by thorough vaginal disinfection. 
 
 In private practice too great pains can not be taken with the sani- 
 tary surroundings. The sheets and the napkin or pad to the vulva 
 should be matters of personal supervision. Slovenly laundry work is 
 dangerous. I prefer the pad because it is destroyed after having been 
 once in use. The employment of napkins which have been left in a 
 pail until putrefaction is well advanced, and are then soaked and dried 
 before the fire by the monthly nurse, is a familiar procedure, and a 
 direct temptation of Providence. 
 
 In city homes close inquiries should be made in reference to the 
 condition of closets and sewer connections. My attention was first 
 drawn to the similarity of typhoid and septic fever in puerperal cases 
 by a patient sent to the hospital in a moribund condition. Her child 
 had been removed by a high-forceps operation, and the cervix was 
 badly lacerated. I regarded her symptoms as typical of puerperal fever, 
 but the post-mortem examination showed a perfectly healthy condition
 
 692 
 
 DISEASES OF CHILDBED. 
 
 of the pelvic organs and the characteristic intestinal lesions of typhoid. 
 Durino- the years of low water supply in New York, I have many times 
 heen called to see patients with high fever who were undergoing the 
 customary douchings, while, in the adjoining closet, the basin into which 
 the dejecta of the patient were being thrown was washed out, once or 
 twice daily, by a pitcher of water poured into the basin by hand. The 
 dano-ers of defective house sanitation have been ably presented by my 
 friend Professor Playfair, and I find it difficult to understand the 
 attitude of those who find no harm in the condition I have described 
 because, they say, it does not affect the drinking water. 
 
 A physician from the country called upon me to consult me about 
 an epidemic of puerperal fever in his practice. I asked him many 
 questions, but received no enlightening answer as to the cause. The 
 physician was intelligent, and had seemingly taken every needful pre- 
 caution. As he was about to leave me I inquired whether there was 
 any diphtheria in his neighborhood. He answered, he had " lots of 
 it," and seemed surprised that I should connect the diphtheria and 
 puerperal fever together. It seems to me a thoroughly false idea that 
 a physician can attend erysipelas, diphtheria, and scarlet fever, and at 
 the same time pursue his midwifery practice with impunity, provided 
 he makes free use of corrosive sublimate and carbolic acid. Indeed, I 
 am almost disposed to regard as a special form of blindness the preva- 
 lent faith that parturient and puerperal women can only be infected 
 by the finger and through the vagina. 
 
 Treatment. — When the germs characteristic of septic infection have 
 once entered the tissues they are beyond the reach of the physician. 
 Except, however, in cases of acute septicaemia, where the quantity of 
 poison introduced into the circulation at the outset is excessive, the 
 patient rallies from the immediate shock, and, provided no fresh pyro- 
 genic material finds its way into the system, recovery is to be antici- 
 pated. The indications for treatment are, therefore, to neutralize the 
 puerperal poison at the point of production, in order to prevent its 
 causing further mischief, and to adopt measures caknilatod to enable 
 the patient to tolerate its presence, when once absorbed, until it is 
 either eliminated or loses its harmful properties. 
 
 Toward the fulfillment of the first indication it is to be recom- 
 mended that, in every case of fever of puerperal origin, the vagina be 
 cleansed with a 2 to 3 per cent solution of carbolic acid or corrosive 
 sublimate (1 : 3,000) every four to six hours. The douche in itself is 
 absolutely harmless. To avoid carbolic or corrosive-sublimate poison- 
 ing, it is, however, necessary to make sure that no portion of the in- 
 jected fluid be retained in the vagina. In most cases the infection 
 starts from the wounds of the vagina and of the cervix. Then, too, 
 the tendency of the secretions to stagnate in the vaginal cul-de-sac, 
 bathing as they do the cervical portion, is a prolific source of septic
 
 PUERPERAL FEVER. 693 
 
 trouble. In all but the mildest cases the vaginal orifice should be ex- 
 amined with reference to the existence of puerperal ulcers. All ne- 
 crotic patches should be touched with hydrochloric acid, with a 10-per- 
 cent solution of carbolic acid, with iodoform, or, what I personally 
 prefer, a mixture composed of equal parts of the solution of the per- 
 sulphate of iron and the compound tincture of iodine. The latter 
 acts as a powerful antiseptic, while the former, by corrugating the 
 tissues, closes the lymphatics and shuts up the portals through which 
 the septic germs penetrate into the system. 
 
 Intra-uteriue injections, in spite of the prevalent belief that they 
 constitute the rational treatment for puerperal fever, should be resorted 
 to with extreme circumspection, as they interfere with the localizing 
 processes by which most of the pelvic inflammations become self- 
 limited ; they help to extend the morbid condition of the uterine 
 cavity to the tubes, and, if continued long enough, they paralyze the 
 uterine walls, so that after death the fundus is found to contain a dirty 
 pool alive Avith bacteria. 
 
 Eunge reports an epidemic of puerperal fever in Gusserrow's clinic 
 brought about by the employment of intra-uterine irrigations, during 
 which the mortality rose to 3-8 per cent. With the abolition of the 
 irrigations the mortality sank to -39 per cent. In 1880 Fischel intro- 
 duced the so-called permanent irrigations into the Prague Maternity. 
 Of 880 patients, 9 died of sepsis. The irrigations were then prohibited. 
 The following year, of 933 patients, only 3 died from the same cause, 
 and in 1882, of 521 patients, there were no deaths from sepsis. Fehl- 
 ing, who limited the use of intra-uterine injections to special moment- 
 ary indications, reported, in 1880, 415 confinements without a single 
 death. Unless the infection proceeds from the uterine cavity, they are 
 unnecessary. Nor must it be forgotten that puerperal women are not 
 exempt from febrile disorders other than those due to sepsis. Before 
 the douche is used the breasts should be examined. The douche can 
 help but little in acute and suppurative inflammations awakened by 
 labor, and in patients who have had chronic unilateral salpingitis ante- 
 dating pregnancy. In cases of true puerperal infection, due to the 
 penetrative form of micrococci and associated with spreading forms of 
 inflammation, the use of the douche is probably idle, and no more effect- 
 ive than washing the surface of the skin in an external erysipelatous 
 process ; and yet it is common to persist in the practice in spite of 
 negative results. 
 
 The employment of the douche in fevers resulting from the ab- 
 sorption of toxine due to the putrefaction of clots, membranes, and 
 bits of placenta within the uterus, on the other hand, is followed by 
 immediate favorable results, and by the prompt disappearance of 
 danger. But it is to be remembered that this is a clumsy attempt to 
 remedy the results of past remissness.
 
 694 
 
 DISEASES OF CHILDBED. 
 
 The indications for the douche as popularly employed are especially 
 vao-ue. One man is governed by the odor of the lochia, but the odor in 
 ordinary catarrhal endometritis is offensive, and yet all such cases re- 
 cover unless aggravated by the douche. Again, as Bumm has pointed 
 out, the products of tissue disintegration may be virulently poisonous 
 and yet the odor may be absent. Others, again, use the douche when 
 the temperature reaches 102°. But tlie temperature-guide leaves out 
 of sio-ht the multitude of temporary temperature elevations due to 
 trivial local troubles, to psychical causes, and to malaria. 
 
 The operation of cleansing the uterus should be conducted with the 
 most scrupulous care. The syringe employed should produce a con- 
 tinuous and not an interrupted stream, and all air should be expelled 
 from the pipe. The tube to be passed through the cervix should be of 
 glass, of the size of the little finger, and bent somewhat to conform to 
 the pelvic curve. Tlie vagina should first be subjected to a tliorough 
 disinfection, by way of precaution against conveying septic materials 
 into the uterus. The introduction of the tube should be made with 
 the guidance of two fingers passed through tlie external os. But 
 slight force is requisite to reach the internal os. It is neither neces- 
 sary nor desirable to push the tube to the fundus. The fluid injected 
 should be tepid, and, if carbolic acid is used, of the strength of two or 
 three drachms to the pint; if corrosive sublimate is em])h)yod, the 
 strength should not exceed 1 : 3,000. It sliould be introduced very 
 slowly, and pains should be taken to insure its unimpeded escape, 
 which can usually be accomplished by pressing the anterior wall of the 
 cervix forward by means of the glass tube. 
 
 I would strongly recommend, after the douche, the introduction of 
 the iodoform bacillus of Spaeth and Braun. The formula recom- 
 mended consists of — 
 
 I^ lodof ormi 20 grammes. 
 
 Gummi Arabici, 
 
 Olyceri-nae, 
 
 Amyli puri aa 2 grammes. 
 
 Ft. Bacilli No. iij. 
 
 If the fever persists, it is sometimes desirable to follow tlie advice of 
 Doleris and of Braun von Fernwald, and explore tlie uterine cavity 
 with the curette for retained bits of tissue. But it is time to stop 
 treatment at this point. There is nothing more fatuous than the ex- 
 pectation of curing the patient by redoubling the vigor of the treat- 
 ment. 
 
 Of the symptoms, the first in order which calls for treatment is 
 usually the peritoneal pain. It is, as we have seen, commonly of a 
 lancinating character, and is associated with hurried breathing and 
 extreme frequency of the pulse. So soon as the pain is once fairly 
 under control, the violence of the onset begins to abate. It should be
 
 PUERPERAL FEVER. 595 
 
 met, therefore, by the hypodermic injection of from one sixth to one 
 third grain of morphia in soh;tion. The anodyne action should be 
 maintained by doses administered by the mouth in quantities and at 
 intervals suited to the severity of the case. The most important object 
 to be secured is freedom from spontaneous pain. It is, moreover, good 
 practice to push the opiate until pain elicited by pressure is likewise 
 controlled, provided it can be accomplished without producing nar- 
 cosis. In susceptible patients and in localized inflammations the quan- 
 tity required may not be very great, while, in acute general peritonitis, 
 the tolerance of the drug exhibited by puerperal women is sometimes 
 extraordinary. Thus, a patient of Alonzo Clark took the equivalent of 
 934 grains of opium in four days ; a patient of Fordyce Barker, 13,909 
 drops of Magendie's solution in eleven days ; and one of my own, at 
 the Maternity, the equivalent of over 1,700 grains of opium in seven 
 days.* In this latter instance the patient was to all appearance mori- 
 bund when the treatment was begun. Thus, the features were pinched, 
 the face was drawn, the pupils were dilated, the finger-tips were blue 
 and cold, the respirations were rapid, and the pulse was scarcely per- 
 ceptible. In this condition the large doses of opium did not produce 
 narcosis, but were followed by restoration of the circulation, by normal 
 breathing, and by the disappearance of the symptoms of shock. Any 
 attempt to relax the treatment was at once succeeded by a recurrence 
 of the alarming symptoms. At the expiration of the disease, the opium 
 was discontinued abruptly without detriment to the patient. 
 
 In contrast to cases of acute peritonitis, an extreme susceptibility to 
 opium is often observed in the pyasmic variety. Here opiates seem to 
 me rarely to do good. They do not hinder the migrations of the round 
 bacteria, there is rarely pain to relieve, and I have sometimes thought 
 that their administration was simply the addition of a second poison 
 to the one which already was overwhelming the nervous system. 
 
 In pelvic peritonitis, in the course of forty-eight hours, plastic exu- 
 dation is thrown out and the pain to a great extent subsides. From 
 this time very moderate doses of opium, as a rule, are needed to make 
 the patient comfortable. 
 
 In France, leeches applied to the abdomen are much used as a 
 means of relieving peritoneal sensitiveness. That they do this is be- 
 yond question. Their disuse in this country is due probably more to 
 popular prejudice than to their inefficacy. 
 
 In the beginning of an attack a turpentine stupe to the abdomen is 
 a source of comfort to many women, while the sharp counter-irritation 
 exercises possibly a favorable influence upon the course of the disease. 
 At a later period I commonly employ flannels wrung out in water and 
 covered with oil-silk to prevent speedy evaporation. It is an old ex- 
 
 *The details of this ease have been reported in the Am. Jour, of Obst., Oct., 
 1880, p. 864, by Dr. F. M. Welles, who conducted the administration of the opium.
 
 QQQ DISEASES OP CHILDBED. 
 
 perience that, in the beginning of a puerperal fever, the provocation of 
 loose stools by purgatives is frequently followed by a fall in the tem- 
 perature and a great improvement in the patient's condition. The re- 
 sult however, is far from uniform, as in other cases these artificial 
 diarrhoeas have a tendency to aggravate the peritoneal symptoms. 
 Owino- to this uncertainty in their action, purgative remedies should be 
 administered with caution, not from any tlieory as to their eliminative 
 powers, but because of the ascertained existence of fecal accumulation. 
 In pelvic inflammations, castor oil in two- or three-tablespoonf ul doses, or 
 five to ten grains of calomel rubbed up with twenty grains of bicarbon- 
 ate of sodium, as recommended by Barker, may be given when thus 
 indicated. After the bowels have once been freed, however, the pur- 
 gative should not be repeated. In cases of intense local inflammation 
 and in general peritonitis, enemata should alone be employed for the 
 removal of constipation. 
 
 Every increase of body heat is associated with rapid tissue waste, 
 with enfeebled heart-action^ and with exhaustion of the nerve-centers. 
 Since the modern recognition of the deleterious effects of high tem- 
 peratures per se, antipyretic remedies in place of the old-time cardiac 
 sedatives have come to play the leading I'ole in the treatment of fevers. 
 
 Of internal antipyretic agents, quiuia enjoys a deservedly liigli re- 
 pute. In the remitting forms of fever it may be administered in five- 
 grain doses, at intervals of four to six hours. Given thus in medium 
 doses, it moderates the fever, diminishes the sweating, and in most 
 patients lessens gastric and intestinal disturbances. In continued 
 fevers it should, on the contrary, be given in a single dose large enough 
 to procure a distinct remission. By making a break in the febrile 
 symptoms, if only of a few hours' duration, a retardation of the de- 
 structive processes is accomplished. At the first administration, twenty 
 to thirty grains may be given. In favorable cases the temperature 
 falls in the course of a few hours below 101°. When the hiijli tem- 
 perature is only temporarily held in check, at the end of twenty-four 
 liours, if all symptoms of cinchonism have disappeared, the same dose 
 should be repeated. If the doses mentioned, given in the manner pre- 
 scribed, produce no perceptible effect upon the fever, their continuance 
 may be regarded as unnecessary. 
 
 C. Braun and Richter speak favorably of the action of salicylate of 
 sodium.* It possesses antipyretic properties, though in a less degree 
 than quinia. It is, however, rapidly absorbed, circulates through all 
 the parenchymatous organs, and finally is discharged unchanged in the 
 urine. It is said by Binz, in small doses, to hinder the action of the 
 disease-producing ferments, while it leaves untouched the normal fer- 
 ments of the organism. It is of special service where quinia is not 
 
 * Richter, Ueber intrauterine Injectionen, etc., Zeitschr, fur Geburtsk. und 
 Gynaek., Bd. ii, Heft 1, p. 146.
 
 PUERPERAL FEVER. 597 
 
 well tolerated, or when given fifteen to twenty grains at a time, every 
 four to six hours, as an adjuvant to large single doses of quinia. The 
 remedy should be continued until all traces of febrile disturbance have 
 disappeared. 
 
 A more powerful remedy than salicylic acid, where quinia has 
 failed, is the Warburg's tincture. Some patients find, however, that 
 it is somewhat difficult to retain upon the stomach. 
 
 Antipyrine, antifebrin, or phenacetin, given in conjunction with 
 quinia, are usually efficacious in producing temporary reductions of 
 temperature, and are in the rule well borne. Their administration, 
 however, calls for watchfulness, and their employment should be sus- 
 pended in case they are found to impair the quality and force of tlie 
 pulse. 
 
 Braun recommends in severe cases, where quinia alone is without 
 effect, to give in addition from twelve to twenty-four grains of digi- 
 talis in infusion, ^jer diem, until its specific action is produced. Unlike 
 veratrum, digitalis effects a permanent slowing of the heart. By pro- 
 longing the cardiac diastole and contracting the arterioles, it allows the 
 left ventricle to fill, restores the arterial tension, diminishes correspond- 
 ingly the intravenous pressure, and promotes absorption. Its tend- 
 ency to produce gastric disturbances and the distrust felt as to its safety 
 have prevented its becoming popular in practice. 
 
 Alcohol as an adjuvant to treatment is indicated in all cases, 
 whether quinia or salicylic acid or veratrum be simultaneously em- 
 ployed. It stimulates and sustains the heart, it retards tissue-waste, 
 and is in itself an antipyretic of no mean value. Usually I give it in 
 conjunction with quinia, one or two teaspoonfuls hourly, of eitlier 
 whisky, rum, or brandy, in accordance with the recommendation of 
 Breisky.* 
 
 The antipyretic action of drugs is probably due for the most part to 
 some direct influence they exert upon the oxygenation of the tissues. 
 Of course, the less the fire the less the heat. It is well, however, to sup- 
 port their internal administration by the external employment of cold. 
 Cold owes its effect in fevers partly to the abstraction of heat from the 
 body-surface, and, in a still more important degree, to the impression 
 which it produces upon the nervous system. In healthy persons the 
 action of cold is to increase the consumption of oxygen and the pro- 
 duction of carbonic acid. The additional heat thus generated renders 
 it possible to sustain the vicissitudes of climate. In fevers the primary 
 effect of cold is similar in character. Its main therapeutical action is 
 derived from its secondary influence upon the nerve-center which regu- 
 lates the body-heat. If the cold employed be sufficiently intense or 
 sufficiently prolonged, there follows, not always immediately, but in the 
 course of an hour or two, a marked lowering of the temperature, which 
 * Ueber Alcohol unci Chininbehandlung, Bern, 1875.
 
 g^g DISEASES OF CHILDBED. 
 
 can only be accounted for by assuming an indirect influence exerted 
 through the sympathetic nerve and the medulla oblongata. This pecul- 
 iarity renders the external application of cold a most valuable addition 
 to the therapeutical resources available in fevers. 
 
 In cases of moderate severity frequently sponging the patient with 
 cold water will be found to be a grateful practice. An ice-cap to the 
 head, where the blood lies near the surface, will often affect the entire 
 temperature of the body. From immemorial times it has been em- 
 ployed to control delirium and promote sleep. An ice-bag placed over 
 the inguinal region is locally beneficial to deep-seated pelvic inflamma- 
 tions, and, according to Braun, is capable of effecting a rapid fall of 
 temperature. Ice-cold drinks should be freely allowed. 
 
 In fevers of great violence, the systematic application of cold, by 
 means of baths or the wet pack, is capable in some cases of rendering 
 important service. The temperature of the bath should range from 
 70° to 80°. Its duration should not exceed ten minutes. The patient 
 should, when removed to the bed, be wrapped in a sheet without dry- 
 ing, and should be comfortably covered. In employing the wet pack 
 two beds should be placed side by side. The body and thighs of the 
 patient should be wrapped in a sheet wrung out in cold water, and be 
 allowed to remain in the pack from ten to twenty minutes. As the 
 sheet becomes heated the patient should be placed in a fresh one upon 
 the second bed, and the transfers should be continued until the desired 
 fall of temperature is effected. Braun chiims that four packs are 
 equivalent in action to one full batli. 
 
 In some instances it must be admitted that the full bath is followed, 
 in spite of hot bottles to the feet and the administration of stimulants, 
 by such a degree of depression and impairment of cardiac force, as 
 shown by the persistent coldness of the extremities, that it has been 
 necessary to discontinue it. Ou the other hand, I can look back 
 upon cases, apparently so desperate that the condition of the patients 
 was looked upon as hopeless, where they proved the means of saving 
 life as by a miracle. Of course, the difference depends upon whether 
 the high temperature is the sole cause of the alarming symptoms, or 
 whether the latter are, in part, due to blood-dissolution and secondary 
 changes in the parenchymatous organs. 
 
 The use of the coil in fever, whether of rubber or of metal tubing, 
 \^y^^ can highly recommend. Either the night-dress or a towel should be 
 placed between the coil and the skin. A current of cold water passing 
 through the tube rapidly abstracts the surface heat, and is usually 
 grateful to the patient. The lowering of the temperature by this 
 means is much slower than by cold affusions. Disturbance of the 
 patient is, however, avoided, and the method, so far as I have tried it, 
 has been free from the objections incident to the direct application of 
 water to the skin.
 
 PUERPERAL FEVER. 
 
 699 
 
 It is hardly necessary to state that in puerperal, as in other fevers, 
 the patient's strength requires to be sustained and the waste of tissue 
 to be repaired, as far as possible, by the regulated administration of 
 liquid food, as milk and beef-tea, in such quantities as can be borne by 
 the stomach. Probably in the future laparotomy is destined to play a 
 prominent role in the treatment of puerperal peritonitis. Price has re- 
 ported a number of successes which recovered after early operation 
 followed by irrigation and drainage. The favorable results are to be 
 expected, he states, when peritonitis is the result of localized disease, as 
 in pus collections or gangrenous conditions of the tubes and ovaries. 
 The idea of accomplishing good by washing out the peritonjeum in 
 lymphatic peritonitis is chimerical. The peritonitis is only a single 
 symptom of a general systemic poisoning. The obstacle to popular- 
 izing laparotomy as a resource in the treatment of puerperal fever has, 
 so far, been the difficulty of differentiating the cases. Thus, Baldy 
 states, " If there is pus in the tube it is easy to settle the question." 
 " In the vast majority of cases," he adds, " in which I have been asked 
 to decide for or against the operation, I have advised waiting, and all 
 these cases have recovered." And again, " The great question is to de- 
 cide whether pus be present or not, and it requires caution, or we shall 
 be led into many operations which will be unnecessary." * 
 
 In the treatment of encysted peritoneal effusions, and in inflam- 
 matory exudations into the pelvic and adjacent cellular tissue, after 
 the acute symptoms have subsided the attention should be directed to 
 the afternoon fever and to promoting the assimilation of food. So 
 soon as the sweating and fever are checked, the absorption of the 
 })lastic materials begins. The most important agents for accomplish- 
 ing this object are quinia, in moderate doses, combined with some 
 form of alcohol and with tepid sponging. Deep-seated pain in the 
 iliac region is best relieved by a large blister upon the side over the 
 point where the tenderness is felt. Prolonged rest in bed should be 
 enjoined. Even after convalescence is well advanced, so long as the 
 exudation remains unabsorbed, the resumption of household duties is 
 pretty certain to be followed by a relapse or by the development of a 
 chronic condition of a most intractable description. The sooner the 
 patient's stomach can be got to digest and absorb beefsteak and iron, 
 the more speedy will be her recovery. 
 
 In pelvic exudations the hot vaginal douche, warm baths, and the 
 application of flannels wrung out in water to the abdomen aid in di- 
 
 * PitZe Price, Early Operation in Purulent Peritonitis, Med. News. Aug., 1890, p. 
 143 : Discussion on Dr. Geo. Shoemaker's paper on Puerperal Septic;pmia before the 
 Obst. Soc. of Philadelphia, the Am. Jour. Obst., Nov., 1889. p. 1194; Maury, The 
 Indications for Laparotomy in the Treatment of Puerperal Fevers, Trans, of the 
 Am. Gryn. Soc, 1891, p. 248 ; Hirst, The Position of Abdominal Section in the 
 Treatment of Septic Peritonitis after Childbirth, idem, p. 461.
 
 tjQQ DISEASES OP CHILDBED. 
 
 minishing the local pain, and, perhaps, in catising a disappearance of 
 the tumor. The action of mercurials or of iodide of potassium in 
 melting away plastic inflammatory materials is sometimes very strik- 
 ing, but more frequently they either do no good or else do harm by 
 disturbing the digestion. 
 
 If fever, chills, and sweating announce the presence of pus, the 
 most careful exploration should be made to determine, if possible, the 
 seat of suppuration. It is of great advantage to treat pelvic abscesses 
 as abscesses are treated elsewhere in the body. If the redness of the 
 skin above Poupart's ligament indicates a tendency to point in that 
 direction, an aspirator-needle should be introduced to make sure of 
 the diagnosis. If the sac is near the surface, a free incision should 
 be made and the pus should be allowed to escape. In many cases, I 
 make these incisions three to four inches in length. The redness of 
 the external skin makes it certain that the abscess has become adherent 
 to the abdominal wall, and that the incision consequently will not 
 communicate with the peritonaium. After the abscess has been opened 
 it should be cleansed, and the cavity should be filled with iodoform 
 gauze. I can recommend this plan as essentially a mild procedure. 
 With a large opening for the discliarge of pus, the fever and sweating 
 disappear, the appetite returns, and the abscess fills rapidly by granu- 
 lation. With a small incision, hectic is apt to pensist, and the abscess 
 to end in the formation of interminable fistula?. 
 
 If softening and bagginess or distinct fluctuation indicate that the 
 pus can be reached through the vaginal cul-de-sac, the aspirator- 
 needle should be inserted- deeply at the suspected point, and, if a large 
 amount of pus is detected, an incision should be made with a long- 
 handled bistoury, using the needle as a director, and nuiking the 
 opening large enough to permit thorough irrigation with a disinfect- 
 ant douche, and packing of tiie cavity with iodoform gauze. With 
 drainage and cleanliness, cases of the longest standing may be expected 
 to recover. 
 
 P. F. Mund6 * has reported a number of cases of chronic character 
 where the aspiration of pus has been followed by rapid absorption of 
 the intrapelvic exudation. The presence of pus was suspected be- 
 cause of a boggy, doughy feeling in the exudation tumor. In a certain 
 number of cases, however, the patient is saved from chronic invalidism 
 only by abdominal section and the removal of pus-containing tubes or 
 ovaries. 
 
 * Diagnosis and Treatment of Obscure Pelvic Abscess, etc., Arch, of Med., De- 
 cember, 1880.
 
 PUERPERAL INSANITY. YOl 
 
 CHAPTER XXXVII. 
 
 PUERPERAL INSANITY. — PHLEGMASIA ALBA DOLENS. — DIS- 
 EASES OF THE BREASTS. 
 
 The insanity of pregnancy, of childbed, of lactation.— Phlegmasia alba dolens.— 
 Defective milk secretion. — Galactorrhoea. — Sore nipples. — Subcutaneous inflam- 
 mation of the breast. — Submammary abscess. — Parenchymatous mastitis. — 
 Galactocele. — Prophylaxis of ophthalmia neonatorum. 
 
 The Ixsaxity of Pkegnancy, Childbed, and Lactation. 
 
 When we remember the marked perturbation of the nervous sys- 
 tem, in even normal pregnancy, from reflex causes, from disorders of 
 the digestion, and from depravation of the blood, it is not strange 
 that the same conditions which give rise to moral perverseness, to 
 the loss of memory, to hysteria, or to hypochondria, should likewise 
 prepare the way for the outbreak of the more pronounced forms of 
 mental derangement. In character, the psychical disturbances of child- 
 bearing women do not differ from those which develop under ordinary 
 circumstances ; but so active are the causes during the period in ques- 
 tion that of the insane who crowd the public asylums, in one eighth, 
 according to Tuke, the malady is of puerperal origin. In many 
 women there exists in advance an hereditary disposition to insanity, 
 the events of pregnancy and childbed, which are commonly associated 
 with the ultimate attack, acting simply as the sparks which fire the 
 mine. 
 
 During pregnancy the prevailing form of mental disturbance is 
 melancholia, Avith sometimes a tendency to suicide. The prognosis is 
 favorable when the disease develops in the early months and follows 
 physiological depression and hypochondria ; unfavorable in severe at- 
 tacks occurring first in the latter half of pregnancy, or where preg- 
 nancy intervenes in the case of insanity previously existing. As a rule, 
 these patients can be best cared for in Avell-regulated private institu- 
 tions, where they are not subjected to the good-intentioned expostula- 
 tions of intimate friends. 
 
 The pains of labor in excitable persons are said to give rise at times 
 to a transitory delirium ; but this certainly is of very rare occurrence 
 in these days of anesthetics. The indications for treatment are, of 
 course, to relieve the pain and to hasten the birth of the child. 
 
 Mania may occur in any severe puerperal affection. It has been 
 observed not only in the various forms of metritis, but even, accord- 
 ing to Winckel, as a result of sore nipples and very painful inflam- 
 mations of the breasts. The delirium in these cases rises and falls 
 with the fluctuations in the underlying malady, and is thought to be 
 dependent upon associated cerebral hyperaemia. The maniacal mani- 
 festations may consist, when there is freedom from suffering, of agree-
 
 Y02 DISEASES OP CHILDBED. 
 
 able hallucinations— the patient often singing or wearing on her face 
 a rapt expression ; or, if the pain is great, she may, on the other hand, 
 see forms Avhich threaten her, so that in terror she cries for help, 
 springs from bed, and strips off her clothes in the effort to escape the 
 source of danger. The prognosis depends, of course, upon the gravity 
 of the morbid condition, of which the mania is only a symptom. The 
 treatment, with the exception of dry cold to the head, is that of the 
 main affection. 
 
 Again, puerperal mania may proceed from an hereditary predispo- 
 sition or from diseases antedating pregnancy, in either case the puer- 
 peral state acting as the proximate but not as the fundamental cause 
 of the outbreak. The attacks may be accompanied by erotomania, 
 by nymphomania, by religious anxiety, or by the cUlire de persecution. 
 It may be evoked by psychical impressions. It occurs at an early 
 period of childbed, when the strength is wasted by j)ain, excitement, 
 or fever. 
 
 Finally, puerperal mania may be caused by exhausting losses of 
 blood, by intense pain, by eclampsia, or by anything which occasions 
 cerebral congestion. In this, the so-called idiopathic form of puer})eral 
 mania, the attack is generally preceded by sleeplessness, indistinctness 
 of speecli, by restless movements, and the refusal to take food. At 
 the beginning of the attack the delirium is usually of a noisy charac- 
 ter, the patients screaming, praying, or preaching in a declamatory 
 fashion ; or they try to get out of bed and to escape from the room by 
 the doors or windows. Sexual excitement is rare, the disposition to 
 strip off the night-dress and ex})ose tlie jjcrson proceeding not from an 
 erotic impulse, but from a desire to escape from some fancied restraint. 
 Attempts to control these patients by force are apt to excite them to 
 renewed violence. This acute stage is followed by melancholia, charac- 
 terized by weeping, praying, and fears concerning tlie commission of 
 the unpardonable sin. As a result of the mental depression, suicidal 
 tendencies develop in a considerable proportion of the cases. The 
 period at which the outbreak first attracts notice occurs most fre- 
 quently within the first two weeks. 
 
 The indications for treatment are to check profuse, exhausting dis- 
 charges, to support the patient's strength, and to insure perfect quiet. 
 AVith the first sign of trouble, the child should be taken from the breast, 
 liquid food should be given at frequent intervals, care should be taken 
 to keep the bladder and the rectum empty, the room should be dark- 
 ened, and its temperature should be regulated. The activity of the 
 skin should be promoted by means of the sponge-bath. The sacrum 
 should be watched and strapped with adhesive plaster if bed-sores 
 threaten. Furniture, pictures, or any articles which disturb the patient 
 should be removed from her sight. There is no condition in which 
 trained nursing can do so much toward effecting recovery. The
 
 PUERPERAL INSANITY. Y03 
 
 nurse's duties are to administer food, to see that urination is regularly 
 performed, to keep the patient covered, and to prevent her from doing 
 harm to herself or others. Members of the household who can not 
 resist the impulse to show the insane woman the folly of her delusions 
 should be regarded as disqualified from entering the sick-room. Pas- 
 toral visits are rarely beneficial. If the patient becomes violent, it is 
 usually possible for the family physician to obtain obedience without 
 the exercise of restraint or force. So important is the question of 
 personal influence in the management of puerjaeral insanity that the 
 success of home treatment is almost wholly dependent upon the con- 
 trol which the physician has acquired over the morale of his patient 
 previous to the occurrence of her malady. Narcotics do not cure, but 
 when they produce a few hours' sleep they certainly promote recovery. 
 There is hardly one in the entire list which has not, at some time, done 
 me good service. My preference is for chloral and the bromide of po- 
 tassium (aa gr. xxx) in solution, and administered by the rectum. To 
 procure an effect from moderate doses, it is, however, necessary that 
 the narcotic be given, not during the period when the patient is most 
 voluble and restless, but either after she has become quieted by judi- 
 cious management or during a natural interval of calm. Cold to the 
 head is often very effective in relieving headache and cerebral conges- 
 tion. If the stage of exaltation passes into that of melancholia, the 
 question of continued home-treatment becomes a serious one. The 
 mother sometimes exhibits not only indifference, but even a positive 
 dislike, to her child, which makes it a risky thing to leave them alone 
 together. Again, owing to the suicidal tendencies which often go with 
 melancholia, it never is safe to allow the patient to pass out of observa- 
 tion, as is shown by the following case : A young woman, after her first 
 confinement, had an attack of mania, for which she was sent to a pri- 
 vate asylum. Shortly after, she was removed by her friends to her own 
 home. There her sweetness and passive resignation disarmed sus- 
 picion. One day, however, she dropped her sewing, put on her hat, 
 and, bidding her mother a pleasant good-by, walked quietly down to 
 the river— a half-mile away— and composedly lay down in the shallow 
 stream, near the bank, so that the water covered her face. From this 
 position she was rescued by some men who were mowing in a field near 
 by, and by them was carried insensible to her home. The next day she 
 was returned to the asylum, where she soon made a good recovery. 
 
 The insanity of lactation is either the result of cerebral anaemia or 
 a relapse from a previous attack. It begins, as a rule, six to ten weeks 
 after confinement. In most cases it assumes the form of melancholia. 
 The prognosis is good if the disease is treated in season, by stopping 
 lactation and by removing the debility upon which it depends. 
 
 In general, the prognosis of puerperal mania is favorable, more than 
 sixty per cent, of the cases ending in recovery. In private practice the
 
 704 
 
 DISEASES OF CHILDBED. 
 
 number is probably much larger. During convalescence care should 
 be taken to secure to the patient rest, sleep, nutritious food, and a daily 
 evacuation of the bowels, and little by little she should be brought back, 
 once more, to old habits and the responsibilities of existence. 
 
 Phlegmasia Alba Dolens. 
 
 Phlegmasia alba (Mens is the term applied to a swelling of one or 
 both lower extremities, occurring usually between the tenth and twen- 
 tieth day after confinement, and characterized by pain, tension of the 
 skin, and a milk-like whiteness of the surface. Owing to its color 
 and its supposed origin, it has received the popular name of milk-leg. 
 Phlegmasia is an affection of the connective tissue, and is associated in 
 most, but not in all, cases with thrombosis of the veins. 
 
 The origin of the swelling is somewhat obscure. In a certain pro- 
 portion of cases phlegmasia is obviously the extension of an inflamma- 
 tory process from the genital organs to the perinaeum, the nates, and 
 the upper portion of the thig^h. If confined to the subcutaneous and 
 intermuscular cellular tissue, the vessels may not become affected. 
 When, however, the morbid changes follow the sheaths of the vessels, 
 the walls of both veins and lymphatics tliicken, and in most cases sec- 
 ondary thrombus formation results. 
 
 In other instances, the thrombus formation is apparently the pri- 
 mary lesion. It may occur spontaneously from slowing of the blood- 
 current. A predisposition to thrombosis is created by varicose veins. 
 The vessels usually involved are the crural and its branches, the tibial 
 and peroneal veins. Again, the intravenous coagula may start from 
 the placental site, and, extending along the pampiniform plexus to the 
 hypogastric vein, may thence occlude the crural to Poui)art's ligament, 
 or, passing upward by the spermatic veins, they may obstruct the vena 
 cava. Sometimes the occlusion of one crural vein is succeeded by that 
 of the other, phlegmasia in that case developing in both extremities. 
 
 Thrombus formation may begin during pregnancy, and is then 
 usually attended with pain at the seat of trouble, and with stiffness in 
 the toes or the dorsum of the foot. As a rule, however, the disease is 
 rare before the second week following labor. Often it is preceded by 
 gastric disturbances, as lack of appetite, a furred tongue, and consti- 
 pation, by chilly sensations, and by a heavy feeling in the affected limb. 
 A careful examination sometimes reveals the existence of inflamed or 
 thrombosed veins in the leg, in the popliteal space, or upon the inner 
 surface of the upper portion of the thigh. If the affected veins are 
 superficial, the redness and swelling may be obvious to the eye. 
 
 The first characteristic symptom is the development in the limb of 
 a dull, dragging pain, which is increased by motion. Tenderness to 
 pressure is only experienced along the course of inflamed vessels. 
 
 In primary thrombosis, the swelling usually begins at the ankls;
 
 PHLEGMASIA ALBA DOLENS. 7O5 
 
 and spreads rapidly to the knee and upward to tlie inguinal region ; 
 in secondary thrombosis, extending from the uterine sinuses, and in 
 the superficial form of phlegmasia, the swelling, on the contrary, trav- 
 els commonly in the reverse direction, viz., from the inguinal fold to 
 the ankle. 
 
 The onset may or may not be announced by a chill. Fever often 
 precedes and accompanies the attack. It is, however, in uncompli- 
 cated cases, of a mild type, and sinks to the normal point long before 
 the swelling of the limb subsides. Severe chills and intense fever, 
 with marked remissions, are symptomatic of metastatic pyaemia. Other 
 complications may essentially modify the course of the disease. The 
 pain, the tenderness, and the febrile disturbance are usually greatest 
 in the phlegmonous form of swelling, which starts from the genital 
 organs. 
 
 The ordinary termination of phlegmasia is by absorption of the 
 thrombus, with restoration of the circulation. As this takes place, 
 the tension of the skin subsides and the parts pit upon pressure, as 
 in ordinary oedema. As the swelling and pain subside, the mobility 
 of the limb becomes restored. The period of extreme tension lasts, as 
 a rule, for from five to eight days. Recovery takes place slowly, the 
 dispersion of the tumor requiring from three to six weeks. 
 
 A less common result consists in the permanent obliteration of the 
 vessel by the conversion of the thrombus into a solid connective-tissue 
 cord, in which case the extremity may long continue heavy, and loco- 
 motion be attended with difficulty. 
 
 In rare instances the process may terminate in suppuration and 
 abscess formation. The prognosis of a pus collection in the vicinity 
 of a vessel, resulting from periphlebitis, is usually favorable, the symp- 
 toms that it occasions disappearing when the abscess is opened and 
 the pus is allowed to escape. When the suppurative process is of a 
 spreading character, undermining the skin and attacking the inter- 
 muscular cellular tissue, the destructive changes may assume frightful 
 proportions. Thus, in hospital practice, we sometimes witness cases 
 where the muscles are dissected from one another, and are bathed 
 in an ichorous fl^iid, with greenish particles of necrosed tissue adher- 
 ing to them, death ensuing from intense septicaemia. 
 
 Sometimes a thrombus becomes infected and undergoes puriform 
 softening, with detachment of small particles, which, entering the cir- 
 culation, give rise to infarctions and metastatic abscesses ; or a large 
 fragment may be separated accidentally from a normal clot, and, pass- 
 ing by the vena cava and the right side of the heart, may cause sudden 
 death by plugging the pulmonary artery. 
 
 The prognosis, from what has been said, is evidently dependent 
 upon the origin of the phlegmasia and upon the nature of the com- 
 plications. The principal indications for treatment are, opium to al- 
 45
 
 YQg DISEASES OF CHILDBED. 
 
 leviate pain, cathartics, if needed, to unload the bowels, quinine, iron, 
 and good food to sustain the strength, and rest for the swollen ex- 
 tremity. The latter should be raised somewhat higher than the body, 
 and during the early stages of the swelling should be wrapped, as rec- 
 ommended by Dr. Fordyce Barker, in cotton-batting and oil-silk. The 
 tenderness should be mitigated by the application of soothing liniments. 
 If vesicles form upon the surface, they should be punctured and the 
 fluid be allowed to escape. When the extremity begins to pit on press- 
 ure and the tenderness to subside, absorption should be promoted by 
 gentle frictions with alcoholic lotions and by bandaging the entire 
 limb evenly with a flannel roller. Until every trace of tenderness and 
 thickening has disappeared from the veins the patient should under 
 no circumstances be allowed to leave her bed. The danger of death 
 from sudden obstruction of tlie pulmonary artery is always present 
 until the thrombus has disappeared or become firmly organized. 
 
 For some time after recovery has taken place the limb will swell, as 
 the result of standing or of protracted exercise, a condition which, as a 
 rule, is greatly benefited by the patient wearing a long elastic stocking. 
 
 Diseases of the Breast. 
 
 Defective Milk-secretion. — A scanty milk-secretion, due to lack of 
 mammary development, to extreme youth, to polysarcia, or to the 
 mature age of the mother, is not amenable to treatment. Temporary 
 insufficiency, resulting from defective nutrition, may sometimes be 
 remedied by a regulated nitrogenized diet, by the tincture of iron, an 
 outdoor life, and by the consumption of large quantities of fluid. A 
 diet composed for the most part of milk is strongly to be recom- 
 mended. If the baby is feeble, and sleeps or cries when put to the 
 breast, it is a good plan for the mother to borrow, for a time, a healthy 
 infant with strong suction powers to stimulate the glands to perform 
 their functions. Cataplasms of castor-oil leaves or fennel-teas possess 
 no claims to confidence. 
 
 Galactorrhoea. — An abundance of milk is not pathological, the 
 quantity quickly accommodating itself to the wants of the child. A 
 constant dribbling of milk from the nipple, or (jalactorrlicea^ an affec- 
 tion which may continue long after lactation has been suspended, acts, 
 like any other profuse discharge, in exhausting the strength and in 
 producing a wasting of the tissues. The treatment consists in inter- 
 rupting lactation, in compression of the breasts, and in the employ- 
 ment of such dietetic measures as are best calculated to repair the 
 general health ; of special measures, saline laxatives and the internal 
 administration of iodide of potassium are of most repute. 
 
 Sore Nipples. — Under the term sore nipples are included a number 
 of lesions which, in spite of their seeming triviality, possess consider- 
 able importance, not only on account of the suffering they occasion,
 
 DISEASES OP THE BREAST. ^qY 
 
 but because thoy furnish tlie starting-iioint of most cases of mammary 
 abscess. 
 
 A simple erytliema, associated with great tenderness, is a common 
 trouble at the beginning of lactation, to which, however, jn-imiparai 
 are more subject than multiparc^. It is a good plan to anticipate this 
 difficulty by instructing the patient to wash the nipples daily, during 
 the last weeks of pregnancy, with some astringent or alcoholic solu- 
 tion. In childbed, in addition to strict cleanliness, great benefit is 
 derived from folding a linen rag around tbe nipple and keeping it con- 
 stantly wetted with Goulard's extract, a teaspoonful to a tumbler of 
 water, until the sensitiveness and redness have disappeared. Before 
 applying the child to the breast, care should be taken to wash away 
 the deposited carbonate of lead. 
 
 In many women, owing to the maceration and loosening of the 
 epithelium from the oozing of the colostrum, suckling of the child is 
 followed by the formation of small vesicles, which eventually rupture 
 and produce isolated erosions. Under favorable conditions, these ero- 
 sions become covered with crusts beneath which the healing process 
 takes place. If, however, the crusts are removed by suckling before a 
 new layer of epithelium has had time to form, the simple excoriation 
 may be converted into an ulceration with deep destruction of tissue. 
 If the child be suffering from sprue, the transfer of the oi'dium albicans 
 may impart to the wounds of the nipple an aphthous character. If the 
 primary vesicles, in place of remaining isolated, coalesce, the nipple 
 may become bared of its epithelium, over a considerable extent of its 
 surface. The papillae then enlarge and give a raspberry-like appear- 
 ance to the exposed structure. 
 
 Fissures of the nipples are excruciatingly painful, and are capable 
 of exciting even a high degree of fever. They occur with greatest fre- 
 quency in nipjiles which have been flattened by the pressure of corsets, 
 or in Avhich the natural fissures between the papillae are of unusual 
 depth. Most commonly they are seated at the base of the organ. 
 Either they may develop from the erosions just described, or the clefts 
 upon the surface may become covered by crusts composed of dirt and 
 colostrum, which, when torn away by the nursing child, detach the 
 delicate underlying epithelium. 
 
 As regards the treatment, it is well to bear in mind that, with 
 cleanliness and the removal of irritating matters from the wounded 
 surface, the worst cases of sore nij^ples will get well in from twenty- 
 four to forty-eight hours, provided lactation is suspended. The object 
 of treatment, therefore, is to cure the lesion without interfering with 
 the nursing of the child. This is comparatively easy when but one 
 nipple is affected, as the child need only be applied to tlie sound side. 
 In that case, however, the excessive tension which results from the 
 suspension of lactation should be relieved by stroking the breast from
 
 Yog DISEASES OF CHILDBED. 
 
 the base toward the apex with the hands, or by getting the nurse to 
 draw the milk with her mouth, or by means of a breast-pump with a 
 wide, trumpet-shaped extremity. The healing process can at the same 
 time be promoted by lead-loLions, by a solution of tannin, or by some 
 astringent ointment. My rule is to keep upon the nipple a rag wet- 
 ted with the Goulard's extract, as described for erythema, during the 
 patient's waking hours, substituting therefor a carbolized ointment 
 during the hours of sleep, when the drying of a lotion would cause the 
 rag to adhere to the raw surface. If the child be troubled with sprue, 
 special attention must be taken to cure its mouth, and the develop- 
 ment of the oidium albicans upon the nipple should be prevented 
 by frequent washings with solutions of boracic acid or of the sulphite 
 of sodium. 
 
 Cracks are much more rebellious to treatment than simple erosions. 
 If of any extent, the nipple should be drawn to one side, so as to 
 expose the fissure, which should be touched with the point of the 
 mitigated stick of nitrate of silver. As the effect of the latter is 
 intended to be local, it should be applied dry, the lymph furnished 
 by the denuded surface affording the requisite moisture. I mention 
 this trivial detail, as, in hospital practice, I have sometimes seen the 
 entire nipple robbed of its epithelium, owing to the mistake made 
 by the house-physician of first dipping the pencil in water, and then 
 allowing the strong solution to diffuse itself over the sensitive sur- 
 face. The compound tiiu-ture of benzoin, strongly recommended by 
 Professor Fordyce liarker, makes a good stimulating application to 
 cracks of the nipple. Though somewhat painful, when used for the 
 first time, it is afterward easily tolerated. 
 
 If both nipples are simultaneously affected, lactation can not of 
 course be entirely interrupted without drying up the milk, but the 
 intervals between the acts of nursing should be lengthened as much as 
 the comfort of the mother will permit. If the milk will not come 
 without tugging, the flow should be furthered, before ap]ilying the 
 child, by stroking the breasts. Of nipple shields I am not able to 
 speak with much enthusiasm. Many, if not most, infants resent the 
 ordinary rubber ones, and refuse to suck through them. A more 
 acceptable form is one provided with a rubl^er tu1)e ami mouth-piece 
 such as commonly goes with nursing-bottles, but it is apt to drive 
 away the milk if its use is long persisted in. Legroux recommends a 
 bit of gold-beater's skin, fastened to the breast by means of collodion, 
 and perforated with a needle over the portion which covers the open- 
 ings of the lactiferous ducts. But, even without these aids, in time a 
 cure can usually be effected by perseverance in the use of the remedies 
 already mentioned. It is necessary to stop nursing altogether only 
 when the nipples are hopelessly flat and misshapen, or when mastitis 
 threatens.
 
 DISEASES OF THE BREAST. Y09 
 
 For eczema, lead, zinc, or white-precipitate ointment may be em- 
 ployed. In obstinate cases, a solution of corrosive sublimate (gr. v ad 
 3 J) is recommended by Hebra. 
 
 Subcutaneous Inflammation of the Breasts.— The subcutaneous in- 
 flammation may be confined to the areola, which then becomes red, 
 swollen, and excessively sensitive. This form generally terminates in 
 suppuration, and may form fistulous communications with the lactif- 
 erous ducts. Sometimes the inflammation begins in the sebaceous 
 follicles, giving rise to small boils around the nipple. 
 
 In other cases inflammation may extend beyond the areola, and 
 either give rise to localized abscesses, or, when due to the septic infec- 
 tion of excoriated nipples, assume an erysipelatous character. 
 
 The treatment of both these forms consists in the application of 
 warm lead-lotions, and in the early evacuation of the pus. To avoid 
 cutting into tlie milk-ducts, the incision should radiate from the nipple. 
 
 Inflammation of the Submammary Connective Tissue. — This rare 
 condition owes its origin, according to Billroth, in most, if not in all, 
 cases to abscess formation in the deep-lying glandular structures, the 
 pus perforating the fascia-like connective tissue at the base of the organ 
 into the loose connective tissue situated between the gland and the 
 pectoral muscle. The breast is in consequence lifted from the trunk, 
 and can be moved to and fro, as though it rested upon a water-bed. 
 The skin is not reddened, but is sometimes markedly cedematous. 
 The pain is deep-seated and dull ; the fever is high and continuous ; 
 the axillary glands swell, and movements of the arm are hindered by 
 the increase of the i^ain they occasion. Stoltz is said to have removed 
 from such a sac twenty ounces of pus. So soon as the pus formation 
 is recognized, and the fact can be early determined by means of an 
 aspirator-needle, a free incision should be made at the lower portion 
 of the gland, and the wound should be treated with the antiseptic 
 precautions which will be given in connection with parenchymatous 
 mastitis. 
 
 Parenchymatous Mastitis. — Inflammation of the glandular struct- 
 ures of the breast develops usually in the first four weeks after confine- 
 ment. It is characterized by pain, high fever, and nodular enlarge- 
 ment of the affected lobules. The attack usually begins Avith a sharp 
 chill. These symptoms are sometimes observed three to four days 
 after the birth of the child, at the beginning of lactation, but then are 
 usually temporary, the commencing mastitis terminating in sponta- 
 neous resolution. Mastitis leading to abscess-formation belongs, for 
 the most part, to a later period, occurring most frequently in the 
 third or fourth week, long after the first inflammatory symptoms 
 have subsided. 
 
 Puerperal mastitis is quite commonly believed to be due to emo- 
 tional causes, to cold, to blows, or to " caking " from milk retention
 
 ^^Q DISEASES OP CHILDBED. 
 
 —all suppositions of extreme convenience as relieving the physician 
 from responsibility for their occurrence. They certainly, however, 
 play a subordinate rule in tlie etiology of the affection, the lesions of 
 the nipples furnishing, with perhaps rare exceptions, the starting-point 
 from which the inflammation travels to the glands, either passing to 
 the deep-seated tissues by the lymphatics, or following the track of 
 the lactiferous ducts to the glandular acini.* The exact anatomical 
 structure of the resulting nodular masses is, for the most part, matter 
 of conjecture. Only this much is known certainly, that they are 
 composed in part of glandular structures and in part of the swollen 
 interstitial tissue ; tliat the lactiferous ducts are either constricted or 
 closed ; that suppuration takes place both in the connective tissue and 
 in the acini ; and that the large abscess-cavities form from the coales- 
 cence of small pus-collections. The walls of the abscess are, therefore, 
 never smooth, but are uneven, with projecting portions of glandular 
 tissue which has, as yet, not undergone disintegration. The milk- 
 secretion is arrested in the affected lobules. If, as sometimes happens, 
 a large duct is perforated, pus may be discharged with the milk, or, in 
 case the abscess opens externally, a milk-fistula may be produced. 
 When several foci of inflammation exist, they may suppurate in suc- 
 cession, so that abscess after abscess may develop, and the morbid 
 condition be protracted for weeks, and even months. If the abscesses 
 break spontaneously, at a point unfavorable for the discharge of pus, 
 fistulous passages are liable to be produced. In hospitals, as the result 
 of long-continued suppuration and necrosis of tissue, entire lobes may 
 undergo destruction, with subsequent cicatricial fonnation and ensu- 
 ing deformity of the breast ; or, with the access of unwholesome air to 
 the abscess-cavities, the sloughing tissues may become gangrenous and 
 death may follow from septicemia. 
 
 The first important point as regards tlie treatment of parenchyma- 
 tous mastitis is to take the child from the breast. If this is done 
 early, in a very large number of cases the inflammation will disappear 
 without advancing to suppuration. If lactation is continued, espe- 
 cially when sore nipples persist as a complication, tlie chances of 
 avoiding abscess-formation are extremely small. In cases of pain due 
 to excessive fullness of the milk-ducts, partial relief should be given by 
 means of mammary expression. For the pain, opium, for the fever, 
 a full dose of quinine, should be administered. A saline cathartic acts 
 as a derivative and diminishes the hyperaemia of the breasts. As tlie 
 
 * Baum (Zur Aetiologie der puerperalen Mastitis, Arch. f. Gynaek., vol. xxiv, p. 
 262) discovered diplococci in the pus obtained from a mammary abscess. These 
 diplococci were subjected to pure culture, and in the fifth generation were inoculated, 
 by means of a hypodermic syringe, into his own skin and into that of two other 
 persons. The inoculations were followed by hardening, fever, suppuration, and the 
 formation of sinuous cavities.
 
 DISEASES OF THE BREAST. ^11 
 
 pain of the inflammation is augmented by the weight of the organ, 
 the breast should be raised and supported by a suitable bandage.' 
 Much comfort is often afforded by the local application of belladonna, 
 in the form either of an ointment or of the liniment diluted with 
 three or four parts of opodeldoc. Considerable relief is likewise ob- 
 tained by laying a flannel wetted with a lead-and-opium wash over 
 the breast, and placing on the outside some water-proof substance to 
 prevent speedy evaporation. A large flaxseed-poultice lessens pain by 
 reason of its heat, but should not be employed, at least so long as the 
 hope of absorption has not been abandoned. Indeed, previous to 
 suppuration, dry cold (ice-bag), which is both sedative and antiphlo- 
 gistic, deserves the preference.* 
 
 So soon as there are evidences of pus, such as bogginess, oedema, 
 or reddening of the skin, the abscess should be opened with antisep- 
 tic precautions. If the inflamed acini are situated near the surface, 
 fluctuation is early apparent. In deep-seated abscesses, the precise 
 situation of the pus collections is not easy to determine. If the. 
 matter is doubtful, it is better to first insert an aspirator-needle into 
 the breast rather than to subject the woman to a painful operation, 
 which, if misdirected, may require to be repeated. 
 
 In Billroth's clinic f the following plan is adopted in opening ab- 
 scesses of the breast : The surface should first be cleansed with soap 
 and drenched with a solution of carbolic acid or of thymol. The 
 incision should be a half -inch in length, and should radiate from the 
 nipple. A drainage-tube should be instantly introduced, and the pus 
 should be gently expressed, after which the breast should once more be 
 bathed with a disinfectant fluid. The entire breast should then be 
 enveloped in antiseptic gauze covered with water-proof material. 
 Finally, after packing the periphery with oakum, especially beneath 
 the breast and in the axilla, the dressing should be fastened with a 
 bandage extending over the thorax from the neck to the umbilicus. 
 In doing this, care should be taken to pack sufficient cotton beneath 
 and around the sound breast to prevent its surface being pressed into 
 contact with that of the thorax. If the abscess is large and sinuous, 
 the dressing should be changed in twenty-four hours,' and then 
 should be left in place for from three to five days. By these means 
 the organ is equably compressed, the pus is prevented from . decompos- 
 ing, and the discharge is promoted, all conditions which tend to pro- 
 duce a painless course and a i-apid recovery. If, while the bandage is 
 applied, the patient once more suffers from pain and fever, it should 
 be removed, and any new abscess in the process of formation should 
 be opened and treated in the same manner. 
 
 * Vide CoRSEN, The Treatment of Maiiiinary Abscess, Am. Jour. Obst., January, 
 1881, for account of favorable experiences. 
 
 f Billroth, Handbuch der Frauenkrankheiten, zehnter Abschnitt, p. 23.
 
 712 
 
 DISEASES OF CHILDBED. 
 
 By the practice recommended, even in bad cases, the ugly scars 
 and deformities of the breast, which sometimes follow the older poul- 
 tice treatment, are avoided. 
 
 In fresh cases, the pus is never decomposed, and irrigation of the 
 wound is unnecessary. In old cases, on the contrary, which have 
 been treated by small incisions and without antiseptic precautions, the 
 pus is often acid, and possessed of irritating properties. For these 
 neglected abscesses I can enthusiastically recommend the method of 
 Billroth, which consists in placing the patient under an anaesthetic, 
 enlarging the openings so as to permit the passage of the finger, and 
 breaking down the thin partitions between the abscesses, so as to con- 
 vert them as far as possible into large communicating cavities ; while 
 this process is going on, the tube of an irrigator should be passed by 
 the side of the finger, and tlie cavity should be waslied with a 3-per- 
 cent solution of carbolic acid until, at last, the fluid comes away clear 
 and unstained. Drainage-tubes should then be introduced, and the 
 breast treated in tlie antiseptic manner already described. By this 
 plan I have succeede^l in closing uj) sinuses of long standing in the 
 course of two to three weeks. 
 
 It is hardly necessary to add that the recovery of the patient is 
 always aided by good food and an abundance of frcsli, pure air. 
 
 Galactocele. — In very rare cases, owing to the obliteration or stop- 
 page of one of the milk-ducts, the sinus may become distended with 
 milk, and form a cyst termed a galactocele. Usually it is of small 
 size, but in the often-quoted case of Scarpa the breast attained such 
 dimensions as to reach to the thigh. Upon puncturing the tumor 
 with a trocar, ten y)ounds of milk were removed, which in all respects 
 resembled human milk of nornuil quality. 
 
 The Prophylaxis of Ophthalmia Neonatorum.— In 1881 Credo* rec- 
 ommended that, in lying-in asylums, as a ])reventive measure, the eyes 
 of all children immediately after birth should be washed with pure 
 water, and that, thereafter, a single drop of a 2-per-cent solution of 
 nitrate of silver should be dropped between the parted lids by means 
 of a glass rod. This plan has since been tested in the principal ma- 
 ternities of Europe with the most satisfactory results. It possesses no 
 apparent drawbacks. In exceptional instances, swelling of the lids, 
 injection of the conjunctiva, and a hypersecretion of mucus or serum 
 have been observed, but the reaction has been trivial, and has disap- 
 peared in from twenty-four to forty-eight hours. 
 
 * Crede, Die Verhiitiing der Augen-Entzundung der Neugeborenen, Arch. f. 
 Gynaek, vol. xvii, p. 50, and vol. xviii. p. 367.
 
 APPENDIX. 
 
 S YMPH YSIOTOMY.* 
 
 The doctrine of the separation of the pelvic bones due to soft- 
 ening at the articulations during pregnancy, and especially at the time 
 of labor, was taught by Hippocrates and Avicenna.f Galen maintained 
 that the pelvic symphyses were true joints. Vesalius, on the other 
 hand, insisted that the bones of the pelvis were united by ordinary 
 cartilage. The prestige of Vesalius as an anatomist exerted a great 
 influence upon the opinions of his contemporaries. When, in 1519, 
 Jacques Amboise invited the most eminent physicians and surgeons of 
 Paris to be present at the dissection of a woman executed for child 
 murder a few days after the birth of the child had taken place, few 
 responded, and yet on this occasion he demonstrated that a separation 
 of the pelvic bones existed, and that it was not a pathological condi- 
 tion. Pinaeus, who was present, was greatly interested, and took notes 
 of the lecture, the leading points of which he reproduced in a brochure 
 published in 1575. In this Pinaeus stated that of the pelvic Joints the 
 symphysis was most affected. The synchondrosis, he said, was like a 
 sponge, which swelled during pregnancy, and became dry subsequently. 
 The resulting softening was due to a physiological succulence caused 
 by pregnancy. He recommended the employment of cataplasms, of 
 inunctions, and of hip-baths as means to enhance the normal process. 
 To aid him in winning converts to his doctrine he associated with him 
 the eminent physician Riviere, who had likewise studied the physio- 
 logical changes at the Joints due to pregnancy. If, said Riviere, one 
 flexes during labor both thighs upon the abdomen, and at the same 
 time everts them, the foetus descends with each pain, owing to the 
 separation at the symphysis. Pinaeus went further, and said one might 
 even divide the symphysis to facilitate difficult labor, and quoted Galen 
 to the effect that the contents are of more value than the receptacle, 
 and that one ought to stretch or even incise, the latter in the interest 
 
 * From Dennis' System of Surgery, vol. iii, by permission of Messrs. Lea 
 Brothers & Co. 
 
 f For these historical details I am indebted to the recent work of Franz Ludwig 
 Neugebauer, Ueber die Rehabilitation der Schamfugentrennung, Leipsic, 1893. 
 
 713
 
 714 
 
 APPENDIX. 
 
 of the former. There is no doubt, says Pinseus, that in this instance 
 the foetus is of the greater importance. 
 
 Among the eminent authorities whom we find later enlisted on the 
 side of the doctrine that the pelvic dimensions are increased as a con- 
 sequence of pregnancy and labor may be mentioned Sylvius, Fernel, 
 Deleurye, Riolauus, and Morgagni. 
 
 As a fruit of these studies symphysiotomy was performed as a sub- 
 stitute for the Caesarean section with the view of saving the child by 
 Jean Claude de la Courvee at Warsaw in 1585, and by Plenck in Ger- 
 many in 1766, upon women who had died during labor. 
 
 But as a means to facilitate labor on the living subject in cases of 
 contracted pelvis the first definite proposition came from Jean Rene 
 Sigault in 1768, while he was a student of medicine in Paris. 
 
 The first actual operation, it is now claimed, was performed by 
 Domenico Ferrara in 1774, in the Hospital for Incurables in Naples. 
 Ferrara had studied in Paris and had heard of Sigault's proposition in 
 1768. The case ended fatally, but it possesses a special interest because 
 it was in the same hospital that a century later Morisani had the honor 
 of restoring the discredited procedure to a recognized place in the 
 practice of obstetrics. 
 
 The suggestion to employ symphysiotomy was at the time received 
 by the Paris Academy of Medicine with scant favor, but in 1777 Sigault 
 had an opportunity to subject his theoretical views to a practical test. 
 The patient, Mme. Souchot, the wife of a soldier, was three feet eight 
 inches high and thirty-nine years old. The pelvic conjugate was 
 estimated at two inches and a half. She had previously been confined 
 four times; all the children were born dead. In the third pregnancy 
 labor was induced at the eighth month, but the birth was very difficult, 
 and was followed by prolapse of the vagina. In the fourth i)rcgnancy 
 (1775) Sigault, despairing of obtaining a living child, wished to try 
 symphysiotomy, but the proposal was declined. The fifth pregnancy 
 occurred in 1777. Labor began on the 30th of September. The head 
 presented. Meantime the patient had given personal thought to her 
 case. She was most anxious for a living child. She had heard of an 
 operation performed experimentally, with a favorable result, upon a 
 parturient sow by Camper, one of the greatest authorities of his day. 
 She decided therefore to submit herself to the novel experiment. She 
 even picked the necessary lint, and cheered her despairing husband 
 with the hope of a living child. 
 
 The operation was performed on the night of October 2d by the 
 light of a lamp held by a maid, and with the assistance of Alphonse 
 Leroy, the future historian of the event. Sigault divided the symphy- 
 sis with an ordinary bistoury. He then ruptured the membranes, and, 
 aided by Leroy, extracted a living child by the feet. The separation at 
 the symphysis during delivery was two inches and a half, and after the
 
 SYMPHYSIOTOMY. 7I5 
 
 birth was eight lines. The hgemorrhage was trifling. The wound was 
 dressed with lint, and a bandage was applied to the pelvis. The pa- 
 tient had no fever, and nursed her child. On the fourth day the band- 
 age was removed, as it distressed her ; the bowels moved on the sev- 
 enth day; there was at first incontinence of urine from injury to the 
 urethra, but this gradually disappeared. On the fourteenth day 
 Mme. Souchot moved without assistance from one bed to another; 
 on the twenty-fifth day she sat up in bed, and on the forty-sixth day 
 she went, unaided, but wearing a bandage, down four flights of stairs 
 to the street and to church. Afterward she walked, resting on her 
 husband's arm, up the steps to the lecture-room of the Faculty of 
 Medicine, and was examined by a number of the professors. 
 
 The operation naturally caused an extraordinary sensation. The 
 Faculty of Medicine awarded to Sigault a silver medal.* Enthusiastic 
 ovations were prepared in his honor, and he was regarded as a bene- 
 factor of the human race. But the triumph was of short duration. 
 The French Academy of Surgery under the lead of Baudelocque op- 
 posed to the new measure a most determined hostility. The ensuing 
 cases were not all equally successful. It is not now easy to determine, 
 amid the conflicting statements that have come down to us, the exact 
 truth as to the issue of those early operations. 
 
 vSiebold was successful in saving the mother in 1778. Sigault 02:)cr- 
 ated six times, with the loss of one mother and five children. Leroy in 
 four operations lost one mother and one child. De Cambon in four 
 cases lost one mother and two children. It musl be remembered that 
 at the time mentioned Caesarean section, the rival procedure, was in 
 Paris and Vienna nearly uniformly fatal. f The heavy mortality 
 among the children was probably not directly connected with the oper- 
 ation, but was due in most cases to the conditions which furnished the 
 indications for the operation or to delays in its performance. 
 
 But it was not so much the statistical results about which the early 
 combatants were concerned. The supporters of the Cfesarean section 
 maintained that in the cases is which symphysiotomy was advocated as 
 a substitute for the older measure the increase of space obtained by 
 division of the symphysis was not sufficient to permit the extraction of 
 the living child, except with the infliction of dangerous injuries to the 
 sacro-iliac articulations. In proof of this Baudelocque demonstrated 
 upon the cadaver of a rhachitic dwarf that, it spite of symphysiotomy, 
 
 * " Pour recompenser I'inventeur d'une decouverte si utile a i'humanite, on ferait 
 graver une medaille en son honneur comine temoignage de reconnaissance et d'ad- 
 miration." 
 
 f Baudon in 1873 wrote that there had not been a successful case in Paris in 
 eighty years. Spaeth, before the appearance of Sanger's well-known work, found, 
 in looking over the records, that there had been no recovery from the operation in 
 the Vienna lying-in hospital during the present century.
 
 716 
 
 APPENDIX. 
 
 he was unable to procure the descent of the head into the pelvis, even 
 with powerful traction by the forceps. When, finally, he succeeded by 
 the employment of force exerted from above, combined with lateral 
 pressure applied to the child's head, rupture of the pelvic joints fol- 
 lowed. In the fatal cases referred to which occurred in the practice of 
 Leroy, of Sigault, and of Cambon it was found at the post-mortem 
 examination that the posterior articulations had ruptured and were 
 filled with pus. However, in each of these four cases the conjugata 
 vera was less than two inches and a half — a degree of pelvic contrac- 
 tion which recent symphysiotomists regard as contraindicating the 
 operation, at least at the end of gestation. 
 
 As the outcome of his experiments Baudelocque concluded that sym- 
 physiotomy was admissible only in cases where the conjugata vera was 
 not less than two inches and three quarters, and that the divergence 
 of the pubic bone should not be allowed to exceed one inch.* 
 
 In the cases of apparent success Baudelocque alleged that the oper- 
 ation was unnecessary, and that Nature or the forceps would alone have 
 sufficed to achieve the desired result. -It was of course natural that in 
 those tentative days the after-effects of pubic section did not always 
 correspond to the expectations of its advocates. While the extent of 
 the consecutive injuries was doubtless exaggerated for ])artisan pur- 
 poses, the histories reported sufficed to throw further discredit upon 
 what was theoretically pronounced a questionable procedure. 
 
 The outcome of the controversy was so complete a victory for the 
 Caesarean school that in France, England, Germany, and America 
 most writers on obstetrics either omitted all mention of symphysiotomy, 
 or referred to it either as a subject for invective or as a matter of his- 
 torical interest. 
 
 In Italy alone symphysiotomy never fell into complete disfavor, but 
 was always recognized as an admissible measure in the treatment of 
 contracted pelves. In the table of Neugebauer, compiled from the 
 statistics of Morisani, of Harris, and of Desforges, of the 136 cases 
 known to liave been operated uj)on between the years 1770 and 1806, 
 56, or about two fifths of the entire number, occurred in Italy. Be- 
 tween the years 1815 and 1841, Galbiati operated 18 times. The re- 
 sults in Italy were indeed not particularly satisfactory. Thus in the 
 56 cases 22 mothers were known to have recovered, 18 were reported to 
 have died, and in 16 the issue was in doubt; 16 of the children were 
 born alive, 22 died, and in 18 cases the result was uncertain. 
 
 In 1863, Morisani,! of Naples, published a memoir on the pelvic 
 contractions and the indications they afford at the time of birth, in 
 
 * Vide Die Symphyseotomie und ihre wissenschaftliche Begriindung, von Dr. 
 Wehle, Arbeiten aus der Koniglichen Frauenklinik im Dresden, 189;J, 8. 3 and 9. 
 
 t Vide Caruso, Contribute alia pratica della siufisiotomia, Annali di Ostetricia 
 e Ginecologia, April, 1893 (foot-note No. x).
 
 SYMPHYSIOTOMY. 71 7 
 
 which he endeavored to determine by experiments on the cadaver the 
 mechanism of the increase of the diameters of the superior strait after 
 symphysiotomy, and the average increase obtained. As a result of 
 these investigations he was convinced that, in spite of the chissical ob- 
 jections to the operation, the gain in the pelvic space was real, and 
 tliat, within certain limits, to be determined by clinical experience, the 
 operation was reasonably devoid of risk. 
 
 Between July 25, 1858, and February 4, 18G5, Harris tells us there 
 was no known case in which symphysiotomy was employed. At the 
 latter date Professor Bcllozi, of Bologna, operated, but the patient suf- 
 fered from tuberculosis, and died twelve days afterward from pneu- 
 monia. On January 5, 1866, Morisani performed his first operation. 
 Both mother and child were saved. This success marked the begin- 
 ning of a new era. 
 
 At the meeting of the International Medical Congress in London 
 in 1881, Morisani was able to publish 50 operations that had been per- 
 formed in Naples between 1866 and that date, with the saving of the 
 lives of 41 mothers and 41 children. It seems strange now to recall 
 the slight impression these results then made, and yet they were all the 
 more remarkable as at the time of this report aseptic methods were 
 sparingly practiced. In the same year Novi,* whose name stands 
 hardly second to that of Morisani in the history of the revival of 
 symphysiotomy, published an important memoir on the same subject 
 of a statistical and clinical nature. In 1883, Mangialli f in Italy, and 
 our own Harris,^ in two memorable papers strove to further awaken 
 general interest in what they regarded as a coming revolution. Again, 
 in 1886, Morisani made a report of the cases that had been operated 
 upon in Naples between 1881 and that date. They were 18 in num- 
 ber. The results were unfavorable : 8 of the mothers were lost ; 5 of 
 tlie children were born dead. The contrast between this lamentable 
 outcome and the brilliant contemporaneous record of the Caesarean sec- 
 tion was too striking. Outside of Italy the battle was regarded as lost. 
 
 In the month of October, 1891, Spinelli went, at the suggestion of 
 Morisani, to Paris to place before the medical profession of France the 
 most recent achievements of the Neapolitan school in symphysiotomy. 
 Between 1888 and 1891 he was able to report a succession of 24 cases, 
 with the recovery of 24 mothers and the saving of 23 children's lives. 
 In a lecture * delivered before the assembled Paris accoucheurs he 
 
 * Novi, La Sinfisiotomia refugiata presso la Scuola Napoletana. Napoli, 1881. 
 
 t Mangialli, Una probabile resurrezione nel campo dell' ostetricia operativa, 
 Annali di Ostetricia, ecc„ 1883, p. 6 {vide Caruso). 
 
 X Robert P. Harris, A. M., M. D., The Revival of Symphysiotomy in Italy, The 
 Am. Journ. of the Med. Sciences, Jan., 1883. 
 
 * Spinelli, Les resultats de la Symphyseotomie antiseptique a I'Ecole obstetri- 
 cale de Naples, Annales de Gynecologie, Paris, Janvier, 1893.
 
 718 
 
 APPENDIX. 
 
 demonstrated the operation upon the cadaver. He taught that, thanks 
 to symphysiotomy, a full-terra child can be extracted iu a pelvis meas- 
 uring not less than two inches and a half (sixty-five millimetres), and 
 that with proper antiseptic precautions, and within the limits indicated, 
 the operation is devoid of danger. 
 
 Among the first to accept the new doctrine was Pinard,* who on 
 December 7, 1891, delivered at the Baudelocque Maison d'Accouche- 
 nients a lecture in which he earnestly and eloquently defended sym- 
 physiotomy. By means of a pelvic section he furnished a most strik- 
 ing illustration of the reality of the pelvic increase consequent upon 
 the division of the symphysis, and at the same time he expressed his 
 conviction that the operation was not, as the rule, difficult of execution, 
 and that it could be performed without injuring the bladder or the 
 peritoneum. On February 4, 1892, he performed his first operation, 
 which ended favorably both for the mother and the child. 
 
 In March, 1892, Charpeutier, after a personal visit to Naples, fur- 
 nished to the French Academy of Medicine an admirable digest of the 
 subject which had a widespread circulation. In April, Caruso f con- 
 tributed an important paper containing the recent Neapolitan statis- 
 tics, and giving practical details concerning the indications, the meth- 
 ods of operation, and the care of patients after the operation. He 
 declared that with antiseptic precautions there should be no mortality 
 from section of the symphysis, and that in the case of a fatal result 
 the death should be attributed to the operator rather than to the opera- 
 tion. 
 
 Finally, general interest was awakened in the subject in America 
 by Harris's J article, read before the Gyniecological Society in October, 
 1891, and through the publication of a successful case by Professor Jew- 
 ett,«of Brooklyn. 
 
 Anatomy. — To operate intelligently and with reasonable assurance 
 of success a knowledge of the anatomy involved becomes a matter of 
 prime importance. Fortunately, following the visit of Spinelli to 
 France, Faraboeuf, Avho became greatly interested in the rehabilitation 
 of Sigault's work, entered enthusiastically upon the labor of supple- 
 menting the defective and vague teachings of the ordinary text-books 
 by clear and definite descriptions of the structures involved. The beau- 
 
 * Pinard, De la Symphyseotomie. 
 
 t F. Caruso, contributo alia pratica della sinfisiotomia, Annali di Ostetricia e 
 Ginecologia. 
 
 X Harris, The Remarkable Results of Antiseptic Symphysiotomy, Gyna;cological 
 Trans., 1892. 
 
 * To Professor Jewett belongs the honor of contributing the first published case 
 of symphysiotomy in America. His Vjore date of September 'SO, 1892, but the first 
 actual case in the United States, according to Dr. Harris, was one operated upon 
 by Dr. Joel 0. Williams of Denison, Texas, in 1880. Both mother and child are 
 still livintr.
 
 SYMPHYSIOTOMY. 
 
 719 
 
 tiful studies of the eminent Paris professor were at once made by Pi- 
 nard and Varnier the foundation of their practice in the Hopital Baude- 
 locque. The remarkable triumphs which ensued are the incentives 
 which prompt me even at some length to place them at the disposition 
 of the English-reading medical public* 
 
 One of the first results of substituting observation for deductive rea- 
 soning was to demonstrate that Matthews Duncan was incorrect in 
 maintaining that the sacral articulation slopes backward and inward in 
 the direction of the median line, and that the fact that the sacrum does 
 not under pressure drop from the arch is due to the sacro-sciatic liga- 
 ments which hold it in position as part of the bony ring. On the cou- 
 
 FiG. 233.— Transverse pelvic section near the superior strait, pubic bones separated by a finger's 
 breadth : experiment of Faraboeuf, showing that the sacrum actually forms akey to the 
 pelvic arch, and is not simply held in place by the ligaments. If a longitudinal section be 
 made through the sacrum in fi-ont of the li2:aments, the resected portion remains solidly in 
 situ until a considerable degree of pubic separation has been effected. (Faraboeuf.) 
 
 trary, a series of sections through the sacro-iliac articulations at differ- 
 ent points, made parallel to the pelvic brim, sufficed to demonstrate 
 that the shape of the sacral articular surface is such that the sacrum, 
 in its insertion between the ilia, in reality forms a keystone to the pel- 
 vic arch. In a striking experiment (Fig. 233) Faraboeuf has shown 
 that if a frontal section of the sacrum be made from above downward 
 and in front of the ligamentous attachments, the anterior segment, so 
 long as the pelvic ring is closed, is held tightly in place by the iliac 
 
 * The privilege to use the accompanying illustrations, which have been to me, 
 invaluable in studying the operation of symphysiotomy, I owe to the courtesy of 
 Professor Faraboeuf.
 
 720 
 
 APPENDIX. 
 
 '"■ ^ -S';;ris'„i?Serr™f„z»„t;LVa"i^^^^^^^^
 
 SYMPHYSIOTOMY. 
 
 721 
 
 pressure alone. The loss of the support due to this pressure must be 
 borne in mind after division of the symphysis and in cases where, after 
 symphysiotomy, the pubic union remains incomplete. 
 
 The ligaments by which the fastening of the pelvic bones is secured 
 posteriorly are short, strong, and inelastic. They run for the most part 
 in a transverse direction. Passing from above downward, the first in 
 order is the ilio-lumbar, which extends from the transverse process of 
 the lower lumbar vertebra outward and backward and is inserted into 
 
 Fig. 235. — The hollow of the auricular surface is seen to follow in a circle, the center of which is 
 situated at the first tubercuUim conjngatum. and is indicated in black. In fresh specimens 
 many fibrous bundles pass f ro'Ti the tuberosity of the ilium to the joint, forming the liga- 
 mentuin vagum or axillary ligament. 
 
 the iliac crest. It fulfills the function of hindering the disposition of 
 the last lumbar vertebra to glide forward over the inclined plane of the 
 base of the sacrum. Tlie most important bands traverse the sacro- 
 iliac articulation. They are arranged in three groups : 
 
 First. A ligament passes from the transverse process of the sacrum 
 across the upper border of the auricular surface to the tuberosity of the 
 ilium, not far from the iliac crest. 
 
 Second. Below the above the sacral surface offers a number of 
 tuberosities formed during the developmental period by the fusion of 
 the sacral transverse processes, and by the junction of the sacral verte- 
 46
 
 T22 
 
 APPENDIX. 
 
 br£e. Each process separates into an ascending and descending branch, 
 which unites with corresponding branches above and below to circum- 
 scribe the sacral foramina. The tuberosity thus formed at the linea 
 transversa between the first and second sacral vertebra is situated at a 
 point near the middle of the auricular surface. It looks upward, out- 
 ward, and backward, and furnishes attachments to a great number of 
 
 Fig. 236.— Lateral view of sacrum : t, the first sacral transverse process : 1, 2. and 3. the tuber- 
 cula conjupata. The line A represents the axis about which the ilium turns after symphys- 
 iotomy. The line d represents the plane of the superior strait. 
 
 bands (the ligamentum vagum), varying in size, in tliickness, and in 
 direction, which are distributed to a pyramidal eminence on the inner 
 surface of the iliac tuberosity, 
 
 TJiird. The tuberosity between the second and third vertebra cor- 
 responds to the lower border of the auricular surface. It looks toward 
 the internal surface of the posterior superior spinous process, to which 
 it is attached by a short, thick ligament named by Farabwuf the liga- 
 ment of Zaglass. 
 
 Each auricular surface forms the arc of a circle hollowed upon the 
 sacral and in relief upon the iliac side. The smooth surfaces of the 
 articulations covered with cartilage permit a restricted movement of 
 rotation (Fig. 234). The center around which this movement takes 
 place is situated in the vicinity of the first sacral tuberosity, the liga- 
 ments at which point have, in consequence, sometimes been termed
 
 SYMPHYSIOTOMY. 
 
 723 
 
 "axillary," but the irregular distribution of the ligamental bauds has 
 led Farabceuf to compare the ilium to a button badly sewed to the 
 sacrum. 
 
 The extreme degree of forward rotation of the promontory is pro- 
 duced in a person slightly bent and carrying a heavy weight upon the 
 
 Fig. 237.— Separation of the pubis after symphysiotomy of 2^ inches ; detachment of the peri- 
 osteum from the ilium at d equals on the average If inches : s. /., relaxation of the sacro- 
 iliac ligaments ; B, transverse section throug-h the first sacral vertebra of an infant three 
 months old ; n, neural portion ; c, costal portion. 
 
 shoulders. In an acrobat balanced upon a trapeze, with the cross-bar 
 beneath the loins, with the lower limbs hanging downward, and with 
 the trunk acting upon the sacrum, the promontory is moved backward 
 and the coccyx is rotated forward. In the former instance a narrow- 
 ing, in the latter a widening, of the conjugata follows.
 
 f24 
 
 APPENDIX. 
 
 Clinically, similar conditions may be ijroducod in the recumbent 
 posture by acting upon the ilia (the long arms of the lever). Thus, 
 by flexing the thighs so as to touch the chest the ilia are rotated up- 
 ward and the conjugate is shortened, or by placing the patient with 
 the hips at the edge of the bed or table, and with the thighs hanging 
 
 Fig 238 —With the njijht thigh hel.1 forciblj .n flpxion and adduction, the right ilium is made 
 fast to the sacrum. By the abduction of the left leg the disjunction of left sacroiliac artica 
 lation is then accomplished. 
 
 downward (Walcher's position), the ilia are made to move in an oppo- 
 site direction. As the pubis rotates in the direction of the coccyx the 
 antero-posterior diameter of the brim is lengthened, with a correspond- 
 ing diminution in that of the excavation and of the outlet. The dis- 
 placement communicated to the pubic end of the lever by these methods 
 amounts to very nearly an inch, while that at the sacro-iliac joint barely 
 equals one fourth of that amount.* The actual gain to be derived from 
 position, therefore, Farabonif regards as insignificant, and yet when 
 dealing with the contracted pelvis previous to engagement the smallest 
 increase at the superior strait is deemed precious by the bedside at- 
 tendant. 
 
 After section of the symphyses each lateral wall of the pelvic exca- 
 vation turns outward, as upon a hinge, around the sacrum. The axis 
 of this movement descends obliquely downward (Fig. 2.3G) and some- 
 what inward in a line touching the upper and lower cornua of the 
 auricular surfaces. The posterior ilio-transverso ligaments as a whole 
 are not affected by the separation of the pubic bone. Only a few fibers 
 
 * The moYement at the pubis ParabcBuf estimates approximately at twenty mil- 
 liraetres, and that at the pacro«jliao point at about fivo millimetres.
 
 SYMPHYSIOTOMY. 
 
 725 
 
 of the ligamentum vagum situated in front of the axis are put upon 
 tlie stretch, and the exercise of a little force may be required to com- 
 l)lete their rupture. 
 
 The fibers of the periosteum which constitute the anterior sacro- 
 iliac ligaments are the first to feel the effect of the disjunction at the 
 pubis, especially those fibers which are farthest removed from the axis 
 — i. e., from the cornua of the auricular surfaces: the separation be- 
 gins, therefore, at the linea innominata, and thence passes a short 
 distance outward.* It is confined to the ilia alone. Above and below 
 it is limited to the vicinity of the extremities of the articulation (Fig. 
 2'M). The stripping up of the periosteum may, however, be increased 
 if at the beginning of rotation a tuberosity of the ilium upon either 
 side comes into contact with a bony projection upon the sacrum. 
 
 Experience shows that the pubic bones as they separate follow very 
 nearly the plane of the superior strait. The sacro-pubic distance is 
 increased until a point opposite the sacro-iliac joint is reached. As the 
 
 Fig. 239. — Symmetric separation after symphysiotomy. The sacro-pubic distance is increased 
 by the outward rotation of the iliac" The chief gain is due, however, to the projection of 
 the parietal boss between the pubic bones. When the separation of the latter equals SJ 
 inches, the available utero-posterior space is augmented by more than an inch. 
 
 axis of this rotation has an oblique direction, a marked descent of the 
 pubic extremities results. To use a familiar illustration of Faraboeuf, 
 the movement is like that of the door of a street lamp upon hinges 
 attached to a sloping side. An asymmetrical separation at the sacro- 
 iliac articulations is indicated when the lateral halves of the pelvis 
 occupy different planes. An exaggerated difference of level in the 
 
 * " A few centimetres " (Faraboeuf).
 
 726 APPENDIX. 
 
 pubic bones, at times amounting to an inch and a half, may be pro- 
 duced by forcibly flexing one limb while the other remains extended. 
 
 The weight of the flexed thiglis in abduction suffices ordinarily to 
 so far overcome the resistance offered by the sacro-iliac fastenings as to 
 permit a separation of an inch at the pubis. Beyond that point a cer- 
 tain amount of force may be requisite to strip up the periosteum and 
 to rupture the fibers of the ligamentum vagum, which are situated in 
 front of the axis of iliac rotation. If by mischance the outward pressure 
 applied to the knees, by means of which the sacro-iliac separation is 
 produced, acts unequally upon the two sides, furtlier separation upon 
 the side where it is already sufficient may be arrested by forcible adduc- 
 tion and flexion of the thigh (Fig. 238). This mananivi-e reapplies the 
 ilium to the sacrum, and enables the operator to employ forcible abduc- 
 tion upon the other knee until a symmetrical separation has been 
 attained. 
 
 The advantages to be won from symphysiotomy are derived from 
 three sources : 
 
 First. The increase of the sacro-pubic distance. In a pelvis meas- 
 uring two and a half inches in the conjugate the gain, according to the 
 measurements of Farabanif, when the separation of the pubic bones 
 (Fig. 339) amounts to two and a quarter to two and three quarter 
 inches, is very nearly a half inch. 
 
 Second. In the engagement and descent of the head a segment of 
 the latter occupies the space between the separated pubic bones. The 
 resultant gain is dependent upon the width of the gap and the convex- 
 ity of the child's head. Faraboeuf estimates this roughly, with the an- 
 terior parietal boss occupying an interval measuring from two to two 
 and a quarter inches, at three quarters of an inch. 
 
 The advantage from these two sources, therefore, should be placed 
 at very nearly an inch and a quarter.* 
 
 Third. The forced extension of the thighs adds a few lines to the 
 superior strait, but this addition is at the expense of the pelvic cavity. 
 In estimating the justifiability of symphysiotomy, therefore, it is neces- 
 sary for this reason to take into account not only the size of the conju- 
 gate, but the curve of the sacrum, and the distance between inter- 
 mediate points situated upon the inner surface of the pubis and of the 
 sacrum. 
 
 In the ordinary flattened pelvis after section the spontaneous sepa- 
 ration of a few lines which ensues is followed by the descent of the 
 posterior frontal bone and ear, due to the sinking of the pubis, upon 
 which the anterior frontal bone rests. With forced separation the 
 latter sinks to the level of the boss, and the posterior car descends 
 
 * In minor degrees of pelvic contraction the relative advantage is slightly less- 
 ened.
 
 SYMPHYSIOTOMY. 
 
 T27 
 
 beneath the promontory, to which the posterior frontal bone is ap- 
 plied. Engagement is then accomplished by the rotation of the head 
 around the promontory, by means of which the entrance of the an- 
 terior cranial surface into the pelvic cavity is effected. But this 
 mechanism is dependent upon a sufficiency of the sacral curve.* 
 
 It is important, furthermore, to remember that in cases where the 
 
 Fig. 240.— ShowinK the fusion of the liga- 
 mentuin arcuatum and the fibrous 
 covering. 
 
 
 Fio. 241.— The section is made a little be- 
 low the upper border, and displays the 
 bony epiphysis on each side. 
 
 adjustment of the head to the pelvic space is close the entrance of the 
 head at the brim may be facilitated by the backward rotation of the 
 promontory produced by the extension of the thighs. On the other 
 hand, when the engagement is interfered with by the contact of the 
 posterior parietal surface with the sacrum, a utilizable gain in the me- 
 dian pelvic diameter may be realized by the movement of counter- 
 rotation jiroduced by flexing the thighs and lifting the extremities of 
 the pubic bones. 
 
 Finally, it should be remembered that the increase of space result- 
 
 K ** ^ f *. "^^,'5 
 
 
 Fig. 242. — Transversf and sac^ittal sections through the symphysis of a yonng woman. The 
 
 fjosterior ridge is short, but the periosteum is literally packed With bundles of fibro-Oarti- 
 age, pursuing for the most part a horizontal direction. 
 
 ing from symphysiotomy is not confined to the antero-posterior diame- 
 ter, but extends to iill the dimensions of the pelvis. 
 
 The Symphysis. — The bones of the pubis are connected by a plug 
 
 * Farabojiif estimates that in a pelvis measuring two and a half inches (sixty 
 millimetres) antero-posteriorly the extraction of the child after symphysiotomy be- 
 comes extremely difficult, where the median pelvic diameter is not three to four 
 fifths of an inch (fifteen to twenty millimetres) longer than at the brim.
 
 (28 
 
 APPENDIX. 
 
 composed of pure cartilage where it comes in contact with the surfaces 
 of the bones, and of fibro-cartilage toward its center. Both the inter- 
 vening plug and the ends of the bones are enveloped in a periosteal 
 covering, re-enforced by tendinous attachments from the adjacent 
 muscles. 
 
 During early life the pubic bones at the symphysis are convex. 
 
 Fig. 243.— Transverse section of the external genital organs of the woman close to the lower 
 anterior surface of the pubes and symphysis: rf. insertions of the recti muscles; p. inser- 
 tion of pyramidalis. The clitoris and its suspensory ligament have been cut away ; the 
 fossa, and the longitudinal ligaments are exposed ; the rami of the clitoris are cut across, 
 and the opening beneath the symphysis is brought into view. 
 
 The cartilage which serves for their growth and nourishment is thick 
 and hyaline. After puberty, however, there forms in the cartilage at 
 a point which is destined later to become the angle of the pubis a bony 
 process which gradually extends to the upper border of the pubic body, 
 to its anterior surface, and to the surface of the symphysis itself.
 
 SYMPHYSIOTOMY. 
 
 729 
 
 As a consequence of the tardy growth of tliis process it is practi- 
 cable, in a parturient woman under twenty, to make an incision either 
 directly in the median line or a third of an inch to the side of the 
 median line in the hyaline cartilage, which still separates the rounded 
 epiphysis from the pubic border. At fl later period, after the union of 
 the epiphysis and the body is completed, the bony surfaces are no 
 longer rounded, but are uneven and traversed by grooves and ridges. 
 These, though the intervening space is in reality ample, have a tend- 
 ency to catch the knife of the unwary operator, and thus to give rise to 
 fables regarding the bony anchylosis of the symphysis during the child- 
 bearing period. 
 
 The solidity of the pelvis is due not so much to the fibro-cartilage 
 
 i;\iiiiiiiiiiii(!iii(!ii;i(,;;'///',7.' 
 
 Fig. 244. — Median section through the fibro-cartilaginous plug between the pubic bones. The 
 flbro-tendinous covering is thin behind, where two subjacent synovial cavities may be no- 
 ticed — thick above at the attachment cf the adminiculum (a) and in front at the insertion of 
 the recti {D} and pyramidal (p) muscles : very thiclc below where it forms the ligamentura 
 arcuatum. 
 
 at the pubic articulation as to the glistening pearly fibers by which the 
 cartilage is enveloped and re-enforced. 
 
 Upon the posterior surface the prominence which marks the line of 
 bony union between the pubic bones is covered by tlie periosteum. 
 This latter, at the upper portion of the symphysis behind the recti 
 muscles, is strengthened by the access of fibers from distant sources, 
 as, for instance, from those which border the pubic crests. Below, 
 beneath the pubic arch, it forms the ligamentum arcnatum. Ante- 
 riorly the symphysis is increased in thickness by the accession of a vast 
 number of tendinous elements which intercross at the median line. 
 
 When an incision is made through the adipose tissue of the mons 
 veneris, and the divided surfaces are drawn well apart, the operator 
 exposes laterally the attachments of the muscles of the thigh to the 
 bony ridges which border the symphyseal space. Overlying these are
 
 rso 
 
 APPENDIX. 
 
 two longitudinal bands derived, for the most part, from the external 
 pillars o'f the inguinal ring. Above, the internal pillars cross at the 
 median line and are attached each to the bony ridge upon the opposite 
 side. Below, at a variable distance from the arch, the filaments which 
 form the suspensory ligaments'of the clitoris are brought into view. 
 Between the longitudinal bands a grooved depression, which attains its 
 
 Fig. 245.— Dpep portions of tlie vulvar region— symphysis, clitoris, bulb, lower layer of the pni- 
 neal fa.scia. The left ramus of the clitoris has been detacheri from the arcli "and carried to 
 the right. The left bulb has been removed. The excision of the left half of the suspensoiy 
 ligament brings into view, beneath the arch, the cellular layer in which are located the 
 veins of the neck of the bladder, of the urethra, and of the clitoris. 
 
 maximum width and depth on a line with the arch, may be felt by the 
 finger. 
 
 The flattened tendon of each rectus muscle is attached to the an-
 
 SYMPHYSIOTOMY. 73I 
 
 terior surface of the pubis below the upper border. This distance is 
 greatest at the median line, where it may reach a half inch or more. 
 The tendon is covered by the pyramidal muscle. The external half is 
 fiat, and is attached in front of the upper border of the pubis upon its 
 own side. The inner half passes downward for a somewhat greater 
 distance without fusing with the fascial covering of the symphysis. It 
 tlien begins wholly or in part to adhere and to intercross with the ten- 
 don of the opposite side. At a lower point its fibers separate and be- 
 come interwoven with the transverse fibers of the underlving tendi- 
 nous structures, and finally descend to form insertions en echelon into 
 the bony ridge opposite the side from which they had their origin. 
 
 When the recti are separated there is often found beneath a little 
 fat a small triangular body, the adminiculum, attached by its base to 
 the upper border of the symphysis and of the pubic bones. Its apex is 
 confounded with the linea alba. It receives fasciculi from the recti 
 muscles, to which it serves as a tendon. Its base is riddled by small 
 perforating vessels. This body may furnish a certain amount of re- 
 sistance when an attempt is made to pass the finger behind the sym- 
 physis. 
 
 After section of the mons veneris the operator has therefore to cut 
 through — 
 
 1. The fibro-tendinous coating (perichondi-ium), anteriorly thick 
 and complex in structure, posteriorly composed of jieriosteum alone. 
 The latter is thick in its upper portion. It can be reached only by di- 
 viding the space between the recti muscles and the linea alba and after 
 breaking through the adminiculum. 
 
 2. The fibro-cartilaginous plug, thick above and below and in 
 front, where it is, for the most part, confounded with the perichon- 
 drium ; behind it is narrowed by the approximation of the pubic 
 bones. 
 
 Tlie Relations of the Symphysis to the Adjacent Pelvic Organs. — 
 It will be remembered that in ordinary labor the head, in its transit 
 through the parturient canal, stretches the levator and pushes back 
 the coccyx, and, as it passes through the vulvo-vaginal outlet, forcibly 
 dilates the ischiatic layers of the perineal fascia. But after symphysi- 
 otomy the head moves forward to profit by the gap in the bony ring. 
 A strain is thereby placed upon the anterior vaginal wall, which, unless 
 met by some counter-support, may endanger its integrity. Below, at 
 the vulva, the separation of tlie bones is limited somewhat by the crura 
 of the clitoris, by the fascia in front of the urethra, and perhaps by the 
 pubic attachments of the bladder. When the tension to which these 
 structures are exposed becomes excessive, they are liable to give way, 
 and an extensive laceration of the vagina to the side of the urethra 
 may ensue. For this reason a careful watch should be kept upon the 
 space between the pubic bones, and, either by the hands of assistants
 
 ^-o9 APPENDIX. 
 
 or by instrumental means, the gap should not be allowed to exceed the 
 narrowest limits rendered necessary for the passage of the child. 
 
 The crura of the clitoris are solidly attached to the inner surfaces 
 of the ischio-pubic rami, and are adherent to the lower layer of the 
 pelvic floor, across which are distributed the terminal branches of the 
 pubic artery — viz., the arteries of the corpora cavernosa, the urethral 
 artery, and the dorsal of the clitoris, all vessels of insignificant size. 
 
 Fig. 246.— The vessels upon the pelvic surface of the symphysis : on the left Ride the arteries 
 alone have been preserved : on the right side both veins and arteries are visible. The blad- 
 der is drawn downward by two hooks, puffing the pnho-vesical liiraments on the stretch on 
 each side of the median fossa, into which penetrate the two anterior vesical arteries, 
 branches of the pudic artery. 
 
 The cavernous tissues are enveloped in a fibrous sheath which is re- 
 duced to a minimal thickness at the long and narrow point of contact 
 between the crura and the pubic arch, where, indeed, the albuginea is 
 apparently replaced by the periosteum. The adhesions of the fibrous 
 sheaths to the periosteum are very firm, and extend upward to a vari- 
 able extent along the ridges which serve as the points of insertion to
 
 SYMPHYSIOTOMY. 
 
 733 
 
 the adductor muscles. In the fossa between the ridges the clitoris is 
 free. The crura ascend and unite to form the body at a variable 
 height, sometimes on a level with the arch, sometimes above the mid- 
 dle of the symphysis. 
 
 When an incision is made at the mons veneris and the divided tis- 
 sues are drawn well to the side by retractors, the aggregation of lamellae 
 and of filaments known as the median suspensory ligament of the cli- 
 
 FiG 247 -Anterior siirface of inflated bladder, showing: the dor.=al. the cayernoiis. the urethral, 
 and anterior vesical veins, branches of the internal pudic. The pin indica es the d.vulmK 
 fine between the two currents-viz.. the upper pelvic, above the levator am, and the lower 
 perineal, on the uro-genital (perineal) floor. 
 
 toris is exposed to view. These are inserted into the dorsum of the 
 clitoris and into the unattached portions of the crura. The clitoris 
 and the suspensory ligament occupy the symphyseal fossa, which, at its 
 base above the pubic arch, measures about three quarters of an inch m 
 width.
 
 '34 
 
 APPENDIX. 
 
 If the suspensory ligament is cut across, and the clitoris is drawn 
 downward, the pubic arch is exposed. 
 
 The vessels are imbedded in a fibro-cellular covering, by means of 
 which the vesical veins are applied to the bladder, the urethral to the 
 urethra, and the dorsal to the clitoris. These vessels therefore accom- 
 pany these organs when the latter are detached from the pubis. 
 
 The veins upon the inner pubic surface, though ten to twenty times 
 
 FiQ. 248.— The separated pubic bones, showing veins behind sj-mphysis and veins of the bladder. 
 
 larger, can distribute only the blood received from the arteries. TV'hen 
 the venous circulation has been impeded by labor, pubic section may 
 be therefore attended temporarily by the outflow of the imprisoned 
 blood, but the apparent haemorrhage is readily controlled by the tam- 
 pon. After the veins are once emptied they can only convey the blood 
 carried to them by the arteries.
 
 SYMPHYSIOTOMY. Y35 
 
 Tliere are no vessels in the fibro-cartilage of the symphysis. In the 
 periosteal covering there are only capillaries. Upon the posterior sur- 
 face of the pubic bones the vessels are small and need not occasion con- 
 cern to the operator. 
 
 The pubis is about two inches in height. The thickness is very 
 nearly an inch when the posterior eminence which marks the line of 
 union of the pubic bones is pronounced (Fig. 242). The eminence is 
 most marked near the center, and diminishes toward the upper and 
 lower borders. At the latter points, indeed, the feeling communicated 
 to the finger when introduced from the front is rather that of a de- 
 pression. 
 
 Operation. — The operative methods employed in pubic section vary, 
 for the most part, in minor details. The results obtained by Morisani 
 and the Italian school place their rules of procedure in the front rank 
 as regards importance. To avoid confusion, however, I have thought it 
 best to lay especial stress upon the scheme formulated by Faraboeuf 
 and based upon his careful anatomical investigations. It differs 
 chiefly in precision from tiiat devised by the Neapolitan school. It 
 leaves nothing to chance, but serves at each step as a guide and a 
 warning. Moreover, its value has been amply sustained by the clinical 
 experiences of Pinard and of Varnier at the Hopital Baudelocque in 
 Paris. 
 
 If consistent with the safety of the mother and child, it is impor- 
 tant that labor be allowed to continue until softening, and, as far as 
 possible, dilatation of the utero-vaginal canal is secured. Where a 
 speedy ending is of importance the preparatory stage may be furtherel 
 by means of the Barnes dilators or, as recommended by Pinard and 
 Varnier, by the Champetier bag. It must be remembered that when 
 the support furnished by the pelvic bones in front has been lemoved, 
 the liability to laceration of the anterior soft structures, if forceps or 
 version is employed, is greatly increased by rigidity of the parturient 
 canal. Moreover, the life of the child is additionally imperiled — a 
 matter of special importance in an operation the object of which is the 
 saving of infant life. 
 
 Before commencing the operation the patient should take a full 
 bath, the bowels should be cleared out by an enema, and the bladder 
 should be emptied. In all cases the pubes and labia should be shaved ; 
 the abdomen, the external parts, the vestibulum, the anus, and the" 
 internal surface of the thighs should be cleansed by scrubbing with 
 soap and water and washing with sterilized water, with alcohol, and 
 with a solution of corrosive sublimate. It should not be forgotten 
 that the patient, the armamentarium, and the personnel in symphys- 
 iotomy require aseptic precautions as careful and minute as those 
 resorted to in abdominal surgery. The operation demands assistants 
 familiar with surgical methods, and who have studied the steps of the
 
 ^gg APPENDIX. 
 
 operation. The chance successes in tenement-houses and amid un- 
 favorable surroundings have contributed to a feeling of unwarranted 
 security on the part of many operators. The brilliant records that 
 have been made in the past have, however, been limited to a small 
 number of conscientious students of the subjects. It should be re- 
 membered that the general statistics up to date exhibit a heavy mor- 
 bidit}^ and that one in nine cases where symphysiotomy has been per- 
 formed has ended fatally. 
 
 At the time of the operation the patient should be placed in the 
 dorsal position, with the hips drawn to the edge of the operative table, 
 and with the thighs flexed and moderately everted. The latter should 
 be held by two reliable assistants. The inopportune dropping of a 
 limb after symphysiotomy has been the occasion of the violent separa- 
 tion of a sacro-iliac joint. The operator sits or stands between the 
 thighs of the patient. An expert is needed to adininister the anaes- 
 thetic, a nurse or physician conversant with the methods of treatment 
 employed in the asphyxia of new-bora infants should be in readiness, 
 and to promote dispatch an assistant is desirable to pass instruments, 
 to aid with the ligatures and dressings, and to supervise aseptic meas- 
 ures. 
 
 In determining the situation of the symphysis, it should be remem- 
 bered that the line of bony union is continuous with the rima vulva', 
 the meatus, and the clitoris. Any variation in the direction of the 
 symphysis is communicated to these organs. The spines should be 
 located with the finger, and the upper border of the symphysis should 
 be marked for future guidance. A line should likewise be drawn 
 transversely below to indicate the situation of the ligamentum arcua- 
 tum, which is easily recognized by the finger through the vestibulum 
 below the clitoris, or, externally, to the side of the clitoris through the 
 skin. The clitoris, as has been already stated, is a longitudinal land- 
 mark, but, as it is attached at variable levels in different subjects, is 
 not a guide of latitude. Faraboeuf recommends the tincture of iodine 
 as a clean agent for tracing the upper and lower symphyseal bound- 
 aries. 
 
 During the incision the index and thumb of the left hand should 
 be employed to put the tissues uj)on the stretch. This is especially 
 necessary if the incision is to be downward. The primary incision 
 should be about three inches long, beginning an inch and a half above 
 the pubis and extending downward to the line previously drawn to 
 define the site of the lower extremity of the symphysis. When the 
 clitoris is attached high up Faraboeuf advises a lambda (a) incision, 
 the open triangle below, the sides of which should not exceed three 
 quarters of an inch, enabling the operator to avoid contact with that 
 organ. When the decussating fibers of the fascia are reached, the di- 
 vided tissues should be drawn well apart with retractors, and the linae
 
 SYMPHYSIOTOMY. 
 
 737 
 
 alba should be neatly exposed, at first above and then below, by strokes 
 with the bistoury. In this way the parellel ridges which furnish the 
 attachments to the adductor muscles, and which are covered by the two 
 long longitudinal bands, are brought into view, and the intervening 
 fossa, the sulcus between the spines, and the site of the pubic arch may 
 be felt by the examining fingers. 
 
 When the sulcus between the spines is not easily determined, 
 Xeugebauer advises the alternate extension and flexion of a limb to aid 
 
 Fig. ^49.— Division of the snsppnsory ligament. The clitoris is drawn downward, and the lipa- 
 ment is put upon the stretch by the forked extremity of the grooved guard. The ligament 
 is then seized by the forceps and cut across by a knife. 
 
 in its localization. Farabceuf counsels making traction upon the cli- 
 toris, and then carefully palpating the anterior symphyseal fossa be- 
 neath the suspensory ligament to determine the gap below the pubic 
 arch. 
 
 The clitoris should next be detached from the symphysis, and its 
 vessel placed beyond the roach of accidental injury. To accomplish 
 47
 
 738 
 
 APPENDIX. 
 
 this, traction should be made upon the extremity of the clitoris with 
 the thumb and index finger to bring into relief the filaments of the sus- 
 pensory ligament, which should next be seized by forceps, and should be 
 cut across, above the forceps, by a bistoury. The section should be deep 
 and should extend the width of the fossa to the lateral ridges. The 
 weight of the forceps frequently suffices to cause the descent of the 
 filaments attached to the clitoris and of the clitoris itself. The serous 
 opening beneath the symphysis is then exposed to view, or, when the 
 arch is not perfectly -smooth and glistening, a blunt object, like the 
 
 Fig. 250.— The divided suspensory ligament is drawn downward to expose the passage beneath 
 
 the arch. 
 
 handle of a scalpel or the rounded extremity of the grooved guard used 
 later for the protection of the posterior symphyseal vessels, may be em- 
 ployed to scrape the surface from above downward to the crura of the 
 clitoris. 
 
 After the arch has been brought into view the retractor should be 
 shifted to the upper portion of the divided tissues. The covering 
 fascia should be incised with the cutting surface of a scalpel for a half 
 inch from above downward, beginning at the line previously traced to 
 indicate the upper boundary of the spines. The button-hole opening 
 thus formed should be extended upward for an inch and a half with a
 
 SYMPHYSIOTOMY. 
 
 739 
 
 pair of scissors, the blunt-pointed blade of which should be passed 
 beneath the linea alba. The recti muscles are thus exposed, between 
 which the surgically clean extremity of the left index finger should be 
 inserted. 
 
 If the adminiculum obstructs the way, it should be broken through. 
 Under the guidance of the finger the extremity of the grooved guard 
 should be employed to separate the layer of fat and connective tissue 
 containing the vessels which need to be protected from injury. The 
 line of denudation should follow the ridge which marks the articu- 
 lation behind, and should extend downward until the pubic arch is 
 
 Fig. 251.— Preliminary incision of the outer 
 covering: between the recti with the 
 cutting surface of the scalpel. 
 
 Fig. 252. — Extension of the openin? made 
 by the scalpel by means of scissors. 
 
 reached. The grooved guard should then be withdrawn, and, with its 
 direction reversed, should be passed beneath the arch behind the pubis 
 from below upward, still under the direction of the finger. When the 
 upper border of the pubis is reached the fingers should be withdrawn 
 and the guard should be held in close contact with the posterior ridge. 
 If the head of the child interferes with the foregoing manoeuvre, it 
 should be held above the pelvic brim by the liands of an assistant.
 
 i40 
 
 APPENDIX. 
 
 For the section of the symphysis Faraboeuf counsels a thin, short, 
 narrow blade. He advises that a deep incision from above downward 
 be first made through the outer fibrous covering, and then with the 
 knife held vertically, with the cutting surface to the front and with 
 
 Fig. 25:3.— Introduction of the flnger and of the p-oovp<l 
 Kuard by the suprapubic route. 
 
 Fm. 254.— 
 Knife of Faraboeuf. 
 
 the point upon and behind the syni])hysis, to divide the periosteum, 
 the fibro-cartilage, and the pubic arch. Only tl)e extremity of the 
 blade should be employed. Care should be taken to follow the same 
 route from beginning to end, and, as the periosteum is approached, the 
 pubis should be separated to a slight extent by a moderate abduction 
 of the knees. 
 
 When the section is completed tlie abduction of the knees by as- 
 sistants is followed by a moderate degree of divulsion at the sacro-iliac 
 articulation. If bleeding results, it should be checked by a tampon of 
 sterilized gauze. If the symptoms are not urgent and the pains arc 
 adequate, Morisani and his pupils in Italy and Zweifel of Leipsic prefer 
 leaving the expulsion of the child to the natural forces. As a tempo- 
 rarv support during the continuance of labor Caruso advises a bandage 
 of bichloride gauze (.1 : 4,000) around the hips. It is claimed by its ad-
 
 SYMPHYSIOTOiMY. 74I 
 
 vocates that this plan is not the source of unusual pain to the mother, 
 and that the gradual expansion of the pelvic diameters by the spon- 
 taneous passage of the child is attended with the least degree of risk to 
 the two lives involved. 
 
 Faraboeuf, on the other hand, insists that forcible divulsion should 
 
 Fig. 255. — The grooved puard passed behind the symphysi';. employed to protect the vessels 
 and organs from the knife during the incision. 
 
 be employed by the operator directly after section, as engagement is 
 thereby rendered easy, and needless compression of the child's head is 
 avoided. Pinard and Yarnier report most favorably of this practice 
 in the Hopital Baudelocque. The anatomical lesion ensuing, when 
 employed within proper limits, is confined to the separation of the 
 periosteum from tlie ileum for one or two inches. Not a single im- 
 portant ligament, nerve, or vessel will be injured. The measurements 
 of Faraboeuf place the degree of permissible separation of the pubic 
 bones at two and three quarters inches (seven centimetres). "Within
 
 742 
 
 APPENDIX, 
 
 that limit, in a given case, the distance should be determined by the 
 diameters of the child's head.* 
 
 The force applied to the knees to accomplish the necessary separa- 
 tion of the ligaments at the sacro-iliac joints should, in the main, be 
 eJfected by slow, continuous pressure. This is best accomplished by 
 the operator, who stands between the thighs of the patient, and who, 
 holding the knees with the hands, forces them apart by synchronous 
 movements. In this way he should strip oif, stretch, and break 
 through the resistance at the auricular surfaces, fiber by fiber. But 
 the movement must be intelligently conducted, otherwise the liga- 
 ments may yield suddenly and the separation become excessive; or the 
 resistance of a sacro-iliac articulation, due in rare instances to anchy- 
 losis, more commonly to varying thicknesses of the fibrous connections, 
 or to a retro-articular point of bony contact, may lead to an unequal 
 degree of separation upon the two sides. x\s the outward rotation of 
 the ilia is always attended by a descent of the pubic extremities, the 
 asymmetry is easily recognized by their differing levels. A very im- 
 portant point in Faraboeuf's instruction has been the demonstration 
 that it is possible, by flexion and adduction of the thigh, with the 
 weight of the body thrown upon it, to produce complete fixation at one 
 joint, while force is exerted upon the other. ( Vide Fig. 238.) 
 
 When the child's head is at the pelvic brim advantage may be taken 
 of the increase of the sagittal diameter produced by the extension of 
 the lower extremities, and, during descent, of the increase of the sacro- 
 pubic diameters due to forced flexion. At the outlet, owing to the 
 lack of the pelvic planes, it is usually necessary to employ artificial 
 means to rotate the antero-posterior diameter of the head from the 
 transverse to the conjugate diameter. If forceps or version is resorted 
 to, it must be remembered that unlike ordinary labor, owing to the 
 lack of support in front, it is the anterior vaginal wall and bladder, 
 rather than the perineum, which are endangered. The ga})ing, there- 
 fore, at the pubic bones should be restrained, as far as compatible with 
 the birth of the child, by pressure upon the sides of the pelvis exerted 
 by the hands of assistants, or, still better, by the fixation-forceps con- 
 trived by Farabceuf. 
 
 When labor is ended three sutures of strong silk should be passed 
 through the entire thickness of the fibro-tendinous covering of the 
 symphysis to the bone, beginning outside the longitudinal band which 
 
 * Farabceuf has invented an ingenious instrument, termed by him the *' men- 
 purateur-levier-prehenseur," which is capable at the same time of measuring the 
 bilateral diameter of the child's head and of serving as a lever to further its descent. 
 By it the necessary degree of separation can be estimated in advance with approxi- 
 mate exactitude. He has likewise devised a pelvimeter by means of which the 
 antero-posterior diameter of the pelvis can be accurately measured in place of being 
 ^estimated.
 
 SYMPHYSIOTOMY. 743 
 
 furnishes on each side the boundary to the symphyseal fossa. In tying 
 
 Fig. 256.— Symphysiotomy. The division of the symphysis is accomph'shed by (1) section be- 
 tween the recti muscles, to sever as far as possible the hard, creaking bundles of the fibrous 
 covering, and to trace in front a line corresponding to the groove of the guard, which is 
 held firmly against the ridge corresponding to the articulation behind. (2) By means of a 
 short, narrow blade, with a rounded extremity the operator then cuts through the symphysis 
 from above downward, with the cutting edge of the blade dii-ected forward,and under the 
 protection of the grooved guard.
 
 744 
 
 APPENDIX. 
 
 the sutures care should be taken to bring the pubic bones into close 
 contact — an action admirably accomplished by the fixation-forceps of 
 Faraboeuf. 
 
 Caruso * gives the Italian method as follows : Prepare and disinfect 
 everything required for the operation (matting, gauze, sutures, a curved 
 blunt-pointed bistoury with solid handle, forceps, etc.). Place patient 
 in obstetrical position at edge of bed ; shave the pubes and labia ma- 
 
 FiG. j;57. — Mode of introduction of sutures. These should he of stronp: silk, and should be in- 
 serted from the outer borders of the lon^ritudinal bands, keeping close to the bones. It is 
 best to begin on the right side, which presents the greatest difficulty. 
 
 jora ; disinfect suprapubic region, vulva, perinaMim, and vnlvo-vaginal 
 canal; introduce silver female catheter into the bladder. Then try to 
 determine the situation, the height, the width, and the direction of the 
 articulation. Feel the upper border and the sulcus between the spines, 
 the lower border, the anterior and posterior fibrous coatings. Determine 
 the relief furnished by the interosseous fibro-cartilage. Commence in- 
 cision 1-5 centimetres above the symphysis; cut vertically downward 
 through the soft structures, directing the incision to the left when in 
 tlie proximity of the clitoris: seven to eight centimetres will suffice. 
 Separate the recti, and nick the insertions if necessary to facilitate access 
 to the prevesical tissues. Then, holding the palmar surface of the in- 
 dex finger against the inner surface of the pubis, push downward to the 
 
 * Caruso, Contributo alia pratica della sinfisiotoinia, Aniiali di Ositctricia e 
 Ginecologia, No. 4, April, 1892.
 
 SYMPHYSIOTOMY. 
 
 Y45 
 
 lower border of the articulation. An assistant should hold the urethra 
 downward and to the right with a sound, while the operator cuts with 
 a blunt-pointed bistoury from above downward and from before back- 
 ward, until the triangular ligament is reached. 
 
 At this point, however, Caruso advises raising the handle of the 
 knife, and, while he continues to cut downward, directs the blunt ex- 
 tremity to the front. The separation is announced by a peculiar 
 creaking characteristic sound 
 
 and by the space (three to ^^--^ ' '*"'' 
 
 four centimetres) between tlie 
 pubic bones. At this mo- 
 ment the cavity produced by 
 the separation of the pubis 
 should be tamponed with cor- 
 rosive-sublimate gauze. Dur- 
 ing the birth of the child the 
 ilia should be supported by 
 assistants. Finally, six to 
 seven sutures should be passed 
 through the soft tissues, tak- 
 ing pains to include the peri- 
 chondrium for at least a cen- 
 timetre from the divided ar- 
 ticular surfaces. Then dress 
 with sublimated gauze and 
 with sterilized cotton. 
 
 Recently, Dr. Edward A. 
 Ayers has reported four cases 
 of symphysiotomy in which 
 the subcutaneous method was 
 employed. The mothers all 
 
 recovered. In one instance twins were delivered ; both survived. In 
 another instance a child weighing seven pounds was born, and is still 
 living. Two of the children were born dead. 
 
 Dr. Ayers's operation consists in raising the clitoris and passing be- 
 neath a narrow sharp-pointed scalpel through the mucous membrane 
 from below upward in the line of the symphysis, to within a half inch 
 of the upper pubic border. A straight blunt-pointed bistoury is then 
 substituted, and is employed to cut through the tissues of the 
 joint. Meantime the bladder and urethra should be held to one side 
 with a sound, and a finger in the vagina should follow the blunt 
 point of the bistoury dui'ing its descent through the tissues of the 
 joint. 
 
 Theoretically, the advantage of preserving the integument intact 
 does not seem to justify the sacrifice of the steps by means of which 
 
 Fig. 258 —Tying: the sutures, while the bones are 
 held in place by Faraboeuf s forceps.
 
 Y4(5 APPENDIX. 
 
 haemorrhage is surely guarded against, and the bladder and retrosym- 
 physeal space are protected. 
 
 Doubtless the weak side of symphysiotomy is the imperfection of all 
 the methods thus far devised to secure coaptation of the parted sur- 
 faces after the operation. Ordinary bandages and binders become 
 quickly soiled and require frequent changes. Metallic contrivances to 
 exercise pressure on the hips and plaster-of-Paris bandages chafe the 
 skin and lead to the formation of bed-sores. To a less extent the same 
 is true of rubber-plaster strips which encircle the pelvis. For this rea- 
 son Dr. Dawbarn recommends not to surround the pelvis entirely, but 
 to use strong adhesive-plaster strapping four inches wide, starting just 
 behind each trochanter and crossing over the pubis. If, then, the first 
 strap is re-enforced by two further thicknesses of plaster, he states that 
 a very reliable splint is produced.* The proposition to favor the union 
 of the pubic bones by placing the patient upon a cot-bed with sloping 
 sides seems open to the objection that in the prolonged dorsal position 
 painful points of pressure will of necessity be developed. 
 
 For these and similar reasons especial stress must be placed upon 
 direct suturing of the symphysis, either by silver wire passed through 
 the bones by means of drills adapted to the purpose, or by strong silk 
 sutures made to traverse the fibrous structures which overlie the carti- 
 lage and anterior borders of the pubic bones. The latter plan is advo- 
 cated by Farabffiuf, by Pinard and his colleagues at the Baudelocque 
 Hospital, and by Caruso in Italy. By the aid of deep sutures the acci- 
 dental loosening of the external belt is deprived of much of its impor- 
 tance. In all cases the patients should lie with outstretched limbs and 
 with the feet turned inward. Pinard commends highly a bed manufac- 
 tured by Bonamy and Sarnoy, of Paris, of which the essential part is a 
 frame with cross-strips of webbing to be placed beneath the patient. 
 When the bed-pan is employed the frame is raised by means of pulleys, 
 and lifts the body of the patient from the bed without subjecting the 
 pelvis to any disturbing movement. 
 
 A certain degree of diastasis following symphysiotomy is by no 
 means rare. It is, however, for the most part, temporary, ending after 
 weeks or even months in solid union. A slight degree of mobility 
 does not prevent ordinary exercise in the erect position. An extensive 
 separation may be the source of great discomfort. In one instance 
 which came under my notice, where recovery ultimately took place, 
 the patient's sufferings were for a time extreme, and led her frequently 
 to beg me, when making my hospital visits, to put an end to her 
 existence. 
 
 Prognosis. — In the 278 cases of symphysiotomy collated by Xeuge- 
 
 * A Case of Syinphysiotomy, by Robert H. M. Dawbarn, The Am. Journ. of Ob- 
 stet., March, 189G, p. 3G2.
 
 SYMPHYSIOTOMY. 747 
 
 bauer * between the yegirs 1887 and 1894 there were 31 deaths— i. e. the 
 .mortality was 11 per cent. In the report of Morisani (at the Inter- 
 national Medical Congress in Eorne, 1894) the same result was obtained. 
 Of 260 children alive at the time of operation, 17, or 19 per cent, died 
 during or a few hours subsequent to labor. In 1894,f according to a 
 second report by Neugebauer, there occurred, so far as he was able to 
 collect them, 106 cases, but details were only given in 89. There were 
 in the latter number 8 maternal deaths (9 per cent), while the infantile 
 mortality was 13, or 15-3 per cent. Harris reported from the United 
 States and Canada 74 cases in fifteen years to June, 1895 (71 in the last 
 two years and seven months) : 10 mothers and 18 children perished. 
 The gross mortality, therefore, both maternal and infantile, will be seen 
 to be heavy. Deductions made from these and similar aggregations are, 
 however, apt to be misleading. They make no allowance for appren- 
 tice-work, and yet in every new operation a certain number of casual- 
 ties is the sad price by which experience is purchased. They do not 
 take into account the deaths for which the operation is in nowise re- 
 sponsible — viz., those resulting from non-puerperal diseases in childbed, 
 from septic infection incurred during labor, from eclampsia, from the 
 lowered vitality of the patient due to long waiting, and from injuries 
 resulting from attempts at forcible delivery. 
 
 A juster perspective is obtainable from the study of the reports of 
 selected operators of large experience. Thus Morisani in 55 cases op- 
 erated upon by him between March, 1887, and October, 1893, had a loss 
 of but 2 mothers and 3 infants. Zweifel has had 27 cases (to the end 
 of 1894), with the loss of two infants and with no maternal deaths. J; 
 Caruso in response to a personal letter wrote me that for the year 1894, 
 from January 1st to November 28th, there had been in Naples 12 sym- 
 physiotomies. The mothers all recovered ; 3 infants died. Gueniot 
 has had 10 operations ; the mothers recovered, 1 child died. Pinard 
 has reported that up to January 1, 1896, of 69 symphysiotomies in the 
 Hopital Baudelocque 7 mothers and 8 children died ; 2 of the mater- 
 nal deaths were due to pneumonia, and 4 to infection incurred before 
 entrance into the hospital. He regarded none of the accidents and 
 complications as due to the operation. Queirel * states that in 55 cases 
 occurring in the practices of Pinard and Varnier before the employment 
 of symphysiotomy, in 193 cases of pregnancy, 152 children perished, 
 whereas since its employment 41 children have been saved. 
 
 The evidence is therefore clear that in experienced hands and under 
 
 * Fremmel's Jahresbericht fiir Geb. und Gyniik., 1893, art. by Neugebauer. 
 t Idem., 1894. 
 
 X Vide Heinricius, Ein Fall von Symphysiotomie, Monatschr. f. Geb. und Gynak., 
 April, 1896, p. 298. 
 
 * QuEiRKL, Symphysiotomie et le Forceps au Detroit Sup., Ann. de Gyn., Feb., 
 1896.
 
 i-j^j^ APPEXDIX. 
 
 proper conditions the prognosis of symphysiotomy both as regards 
 mother and child is favorable, and that the operation is entitled to a 
 high standing among the measures available in the treatment of dif- 
 ficult labor. Its worst enemies are those who preach its simplicity, and 
 who io-nore the risks involved in its emplovment. It is not in all cases 
 easy of accomplishment. The avoidance of luymorrhuge and lacera- 
 tion calls for constant vigilance, and the after-treatment involves an 
 infinite amount of painstaking. 
 
 Indications. — Symphysiotomy is advocated in contracted pelves as a 
 substitute for high forceps, for version, and for premature labor to 
 diminish the infant mortality due to these manoeuvres. It finds its 
 natural place in moderate degrees of pelvic deformity. Below two and 
 three quarter inches in the flattened and three inches in the juxto-minor 
 pelves, owing to the risk of lacerations of the vesical and utero-vaginal 
 tissues incident to the excessive separation of the pubic bones, it pos- 
 sesses a questionable advantage over the Ca??arean section. As an ad- 
 ditional resource in obstetric practice its importance can not be too 
 highly valued. That its revival makes all other measures, which im- 
 peril to a greater extent the life of the fa^tus, criminal, is an assumption 
 that seems hardly warranted. An operation wiiich to date has involved 
 a maternal death-rate of 11 per cent,* which even in skilled hands may 
 be attended by serious injuries to the soft parts, and which is often 
 followed by a tedious convalescence, to my mind siiould not be un- 
 dertaken without the consent of the parties interested. 
 
 Between two and three quarter inches and three inches (three to 
 three and a quarter in juxto-minor pelves) I should personally prefer 
 symphysiotomy. It is less dangerous than the CiBsarean section, and 
 the alternative is usually craniotomy and the basiotribe. Above three 
 inches in flattened pelves the chances are more favorable than is gen- 
 erally thought to the birth of the child by the natural passages. Leo- 
 pold reports twenty-one cases in one year where the pelvis measured 
 from three inches to three and a half inches in which spontaneous 
 delivery took place. If accommodation of the head to the pelvis does 
 not occur as a result of uterine action, before deciding upon symphysi- 
 otomy the physician, it seems to me, should consider conscientiously 
 his own qualifications, the character of the assistance at his command, 
 and the extent to which antisepsis in the given case is practicable. 
 
 * Of course, many of the deaths were not due directly to the operation. Com- 
 parisons, however, are made with otlier measures where the same exceptions could 
 justly be claimed.
 
 IKDEX. 
 
 ABDOAfEN : 
 
 appearance of, in pregnancr, 86, 94, 99, 100, 
 
 105, 2T8. 
 discoloration of, in pregnancy, loO. 
 fat, iu wall of, obscui'ing pregnancy, 102. 
 fetal, enlarged, obstructing labor, 554. 
 ice to, in post-part um haemorrhage, 588. 
 in anteversion and anteflexion, 278. 
 injuries of, producing abortion, 308. 
 in puerperal state, 249. 
 inspection of, in pregnancy, 100. 
 pain in, during pregnancy, 87. 
 palpation of, in pregnancy, 100. 
 pendulous, in contracted pelvis, 4G7, 480. 
 
 in double uterus, 278. 
 size of, in pregnancy, 94, 111. 
 skin of, in pregnancy, 87, 100, 105. 
 striae upon, in pregnancy, 87, 100, 105. 
 Abdominal muscles, action of, in labor, 129. 
 Abdominal plates, 49. 
 Abdominal pregnancy, 42, 327, 335, 3-39. 
 
 varieties of, 336. 
 Abdominal tumors : 
 
 diagnosis of, from pregnancy, 102, 549. 
 Abortion i^vide labor, premature), 307. 
 alcohol in, 323. 
 anaemia, causing, 308, 351. 
 ana?stliesia iu, 322. 
 arrest of threatened, 318. 
 artificial, 359. 
 
 indications for, 359. 
 bougies to produce, 351. 
 carbolic acid in, 323, 324, 325. 
 care of child after, 356. 
 catheterization to produce, 351, 356. 
 causes, immediate, of, 310. 
 anteflexion, 310. 
 
 hyperemia of gravid uterus, 310. 
 infectious diseases, 260 et seq., ZO^. 
 uterine contractions, trom nervous influ- 
 ences, 311. 
 causes, predisposing, of, 113, 308. 
 atrophy of uterine mucous membrane, 309. 
 
 549 
 
 Abortion : 
 
 hypertrophy of uterine mucous mem- 
 brane, 310. 
 cellulitis in, 325. 
 chill in, 825. 
 chloroform in, 322. 
 cold in, 318, 321. 
 collapse in, 323. 
 complete, 319 et seq. 
 cord, care of, in, 326. 
 corpulence causing, 308, 
 Crede's method in, 324. 
 curette in, 317, 320, 324, 326, 
 death of loetus cau.-ing, S08. 
 definition of, 307. 
 diagnosis of, 314. 
 disposition to, 308. 
 
 douche in, 320, 322, 323, 324, 325, 326, 356. 
 emesis causing, 118, 351, 359. 
 ergot, use of, in, 320, 321, 323, 461. 
 ether, use of, in, 822. 
 exercise, violent, causing, 113. 
 expulsion of placenta iu, 324. 
 famine causing, 308. 
 hiemorrhage in, 309, 311, 312, 313, 319, 325. 
 
 326, 339. 
 in anfemia, 115. 
 in cancer of cervix, 310, 547, 
 in cardiac diseases, 268, 351. 
 in cholera, 264. 
 in chorea, 275, 351. 
 incomplete, results of, 312, 319, 320. 
 in contracted pelvis, 494, 497, 498, 500. 
 in decidual diseases, 308. 
 indications for, 349, 494, 497, 500. 
 diseases which imperil life of motlicr. 
 
 351. 
 habitual death of foetus, 3.50. 
 moderate pelvic contraction, 849, 359, 494 
 497. 
 in double uterus, 278. 
 induction of, 349. 
 in eclampsia, 578, 581,
 
 750 
 
 INDEX. 
 
 Abortion : 
 in emesis of pre;xnancy, 119 et seq. 
 in emphysema, 270. 
 in empyema, 270. 
 in endometritis, 285, 286, 287. 
 in heart diseases, 268. 
 in hydatidiform mole, 301. 
 in hydramnion, 124, 292. 
 in icterus, 266. 
 in malarial fever, 264. 
 in measles, 261. 
 in multiple prejjnancy, 124. 
 in nephritis, 273. 
 in ovarian tumors, 549. 
 in pernicious anaemia, 115. 
 in phthisis, 270. 
 in placenta praevia, 597, 600. 
 in placentitis, 289, 304. 
 in pneumonia, 269, 359. 
 in prolapse of uterus, 282. 
 in relapsing fever, 264. 
 in retention of dead foetus, 307. 
 in retroflexion, 279, 280, 310, 316. 
 in rubeola, 261. 
 in surgical operations, 270. 
 in syphilis, 272, 350. 
 in typhoid fever, 264. 
 in typhus fever, 264. 
 in uterine hernia, 283. 
 in uterine tumors, 542, 544, 547. 
 in variola, 261. 
 in vomiting, 119, 351, 359. 
 lochia in, 320, 325. 
 
 membranes, retention of, in, 312, 325. 
 methods for producing, 351, 360. 
 mole, due to, 312. 
 mortality from, 315. 
 neglected, treatment of, 325. 
 operations for induction of, 351, 360. 
 
 catheterization of uterus, 351. 
 
 choice of, 356. 
 
 death from, 355. 
 
 douche, vaginal, 354. 
 
 galvanization, 355. 
 
 injections between uterus and ovum, 352. 
 
 mechanical dilatation of cervix, 353, 360. 
 
 rupture of membranes, 353. 
 
 tampon, vaginal, 355. 
 opiates in, 315, 323. 
 ovum-forceps, us? of, in, 324. 
 pain in, 311. 
 
 pelvic cellulitis, complicating, 325. 
 peritonitis, coinplieating, 313, 325, 355. 
 placental detachment in, 325. 
 polypi, fibrous, removal of, after, 313, 326. 
 prognosis in, 315. 
 prophylaxis of, 316. 
 recurrent, 317. 
 retention of membranes in, 312, 313, 325. 
 
 Abortion : 
 
 rupture of uterus in, 353. 
 
 septicaemia, complicating, 313, 325. 
 
 shock, in artificial, 353. 
 
 sponge-tents in, 324, 353, 360. 
 
 stimulants in, 323. 
 
 subinvolution after, 314. 
 
 symptoms of, 311, 319. 
 
 tampon, vaginal, use of, in, 320, 322, 323, 
 324, 326. 
 
 tents in, 324, 353, 360. 
 
 threatened, arrest of, 318. 
 
 time for, 349, 360. 
 
 treatment of, 316. 
 of threatened, 318. 
 prophylactic, 316. 
 when inevitable, 319. 
 when neglected, S25. 
 
 tubal, 339. 
 
 version in, 356. 
 
 viburnum prunilbliura in, 317, 318. 
 
 violence causing, 308. 
 
 with monsters, 557. 
 Abscesses : 
 
 in mastitis, 709. 
 
 in phlegmasia alba dolens, 705. 
 
 in puerperal lever, 600, 661, 674, 677, 680, 
 700. 
 
 pelvic, aspiration in, 700. 
 
 psoas, in puerperal fever, 077. 
 Acardia, in multiple pregnancy, 229. 
 Acardiacus, 557. 
 Accidental haemorrhage, 594, 597, 606. 
 
 treatment of, 607. 
 Accouchement ^f or ce^ in placenta prsevia, 602, 
 
 652. 
 Accoucheur^ armamentarium of, 206. 
 Accphalus, 558. 
 Acid, muriatic, in nausea, 117. 
 Aconite, in face-ache, 122. 
 Acormus, 559. 
 Adipocere, 304, 306. 
 ^Eqitahiliter justo-ininor pelvis, 465, 471, 485, 
 
 495, 512. 
 After-coming head : 
 
 forceps to, 399. 
 
 in contracted pelvis, 487. 
 
 perforation of, 418. 
 After-pains, 224, 244, 252, 672. 
 Air, collapse and death from entry of, into 
 uterine vessels, 355, 647. 
 
 fresh, in pregnancy, 112. 
 Air-passages, catheterization of, in asphyxia 
 neonatorum^ 644. 
 
 development ot, 48, 64. 
 Albumen, of blood, in pregnancy, 89, 115. 
 Albuminuria: 
 
 in eclampsia, 567, 569 et seq. 
 
 in hydrnmnion, 292.
 
 INDEX. 
 
 751 
 
 Albuminuria: 
 
 in pregnancy, 91, 118, 2G2, 268, 273, 275, 307. 
 
 in septicaemia, 680. 
 
 treatment of, 577. 
 Alcohol, use of, in abortion, 323. 
 
 in puerperal fever, 697. 
 Alimentation, rectal : 
 
 in anaemia, 114. 
 
 in emesis, 119. 
 Alkalies, in albuminuria, 577. 
 Allantois, 51, 52, 61, 63. 
 Amaurosis, in eclampsia, 567. 
 
 in pregnancy, 91. 
 Amblyopia, in eclampsia, 567, 569. 
 
 in pregnancy, 91. 
 Amenorrhcea of pregnancy, 92, 93. 
 Ammonia, intravenous injection of, in cere- 
 bral anaemia, 590. 
 
 in heart-burn, 121. 
 
 in pneumonia, 270. 
 
 in pulmonary embolism, 650. 
 Amn ion, 47, 50, 60, 61, 63, 64, 123. 
 
 anomalies of, 290. 
 causing inertia uteri^ 455. 
 
 dropsy of, 75, 95, 103, 124, 290, 561. 
 
 fluid of, 61. 
 Amniotic fluid, 61. 
 
 anomalies of, 290. 
 
 composition of, 61. 
 
 deficiency of, 293. 
 
 escape of, 132, 312, 320. 
 
 obscuring pregnancy, 95. 
 AmorpTiug^ 558. 
 
 Ampulla, of Fallopian tube, 19. 
 Amputation, spontaneous intra-uterine, 296. 
 Anaemia: 
 
 alimentation, rectal, in, 114. 
 
 causing abortion, 308. 
 
 causing insanity, 703. 
 
 cerebral, causing eclampsia, 574, 575. 
 
 ether, use of, in, 590. 
 
 hypodermic injection of ammonia in, 590. 
 
 transfusion in, 590. 
 
 treatment of, 589. 
 
 in abortion, 323. 
 
 indicating abortion, 351. 
 
 in extra-uterine pregnancy, 338. 
 
 in labor and childbed, 645. 
 
 va. placenta jircBvia, 598. 
 
 in post-pai'tum haemorrhage, 589. 
 
 in pregnancy, 114, 122. 
 
 in thrombus of vagina and vulva, 625. 
 
 pernicious, in pregnancy, 114. 
 treatment of, 114. 
 Anaesthetics : 
 
 in abortion, 322. 
 
 in breech and foot presentations, 383, 387. 
 
 in brow presentations, 190. 
 
 in Caesarean section, 439. 
 
 Anaesthetics : 
 
 in craniotomy, 414. 
 
 in diagnosis of pregnancy, 102, 341. 
 
 in eclampsia, 579. 
 
 in forceps deliveries, 367. 
 
 in inverslo uteri, 608. 
 
 in irregular pains of first sta^e of labor, 457. 
 
 in midwifery, 225. 
 
 in normal labor, 210, 225, 268. 
 
 in painful labor, 463, 502. 
 
 in precipitate labor, 453. 
 
 in Thomas's operation, 449. 
 
 in version, 404, 406, 410. 
 
 post-partum, 623. 
 Ancesthesia, in pregnancy, 91, 102, 281. 
 
 in retroflexion, 281. 
 Anasarca, fetal, causing dystocia, 555. 
 Anchylosis of fetal jomts, causing dystocia, 
 
 556. 
 Anencephalus, 559. 
 Anodynes : 
 
 in eclampsia, 579. 
 
 in emesis of pregnancy, 117. 119. 
 
 in lacerations of pcrinaeum, 624. 
 
 in mania, 703. 
 
 in neuralgia, 122. 
 
 in painful first stage, 4G3. 
 
 in post-partum, ha'niorrliage, 585. 
 
 in precipitate labor, 453. 
 
 in protracted fljst stage, 456. 
 
 in puerperal fever, 464, 695. 
 
 in puerperal state, 252, 705. 
 
 in shock, 650. 
 
 in vaginal thrombus, 628. 
 Anorexia, in pregnancy, 114. 
 
 post-partum, 248. 
 Anteflexion, in pregnancy, 116, 278, 310. 
 
 in the puerperal state, 244, 249, 592. 
 Anteversion in pregnancy, 80, 278. 
 
 normal, 16. 
 Antipyretic treatment of puerperal fever, 696, 
 697. 
 
 by quinia, 696. 
 
 by salicylate of soda, 696. 
 
 in scarlatina, 263. 
 Antipyrine, in puerperal fever, 697. 
 Antiseptic treatment, of puerperal patients, 
 
 253, 687 et seq. 
 Antiseptics in Caesarean section, 439, 441. 
 Anus: 
 
 development of, 63. 
 
 imperforate, 256, 296. 
 
 laceration of sphincter of, 623. 
 Aorta, compression of, in post partvm haem- 
 orrhage, 24, 588. 
 Apnoea of fojtus, 635, 636, 638. 
 Apoplexy, utero-placental, 288. 
 Appetite in pregnancy, 114. 
 
 after delivery, 240.
 
 [52 
 
 INDEX. 
 
 Apron, Hottentot, 4. 
 Arbor iiitce iiterina^ 13, 31. 
 
 development of, 31. 
 Area, germinativa, 47, 50. 
 
 embryonic, 47, 48, 62. 
 Areola, mwrnmce, 88, 90, 94, 99. 
 
 follicles, sebaceous, of, 88. 
 
 in the puerperal state, 249. 
 
 of preguancy, 88, 90, 94, 99, 249. 
 
 secondary, of Montgomery, 88, 94, 99. 
 Armamentariura of accoucheur, 206. 
 
 for breech presentations, 384, 388. 
 
 for Csesarean section, 439. 
 
 for lacerations, 624. 
 
 for post'partum hsemorrhage, 585. 
 Arms : 
 
 liberation of, in breech presentations, 394. 
 when extended, 394. 
 when flexed, 394. 
 
 release of anterior, 394. 
 
 release of posterior, 394. 
 
 setting of fractured, 395. 
 Arteria aortica, 24. 
 Arteria uterina, hyporjas'.rica, 23. 
 
 in pregnancy, 98. 
 
 uterine bruit in, 96, 9a, 100, 103. 
 Arteries : 
 
 aorta, 68. 
 
 internal spermatic, 25. 
 
 ovarian, 25. 
 
 pulmonary, 68. 
 
 thrill in, in pregnancy, 100. 
 
 umbilical, 53, 60, 66, 250. 
 
 uterine, 23, 24, 59, 77, 79, 103. 
 
 vaginal, 10. 
 Articulations : 
 
 anchylosis of fetal, obstructing labor, 556. 
 
 of fetal head with spinal column, 171. 
 
 pelvic, 145, 275. 
 
 pelvic, mobility of, in labor, 148, 275. 
 
 rupture of, 628. 
 
 sacro-iliac, 145. 
 Artificial feeding of infants, 257. 
 Artificial respiration, in asphyxia neonato- 
 rum, 643. 
 
 Schultze's method of, 643. 
 
 Sylvester's method of, 644. 
 Ascites, fetal, obstructing labor, 554. 
 
 indicating abortion, 351. 
 
 in ovarian tumors, 549. 
 
 mistaken for pregnancy, 102. 
 
 obscuring pregnancy, 102, 268, 292. 
 Aseptic dressing, after labor, 225. 
 Asphyxia livida, 639. 
 
 pallida, 639. 
 Asphyxia neonatorum, 215, 368, 4G0, 617, 635. 
 
 definition of, 635. 
 
 di.ignOsis of, 641. 
 
 etiology of, 635. 
 
 Asphyxia neonatorum : 
 
 in first stage, 640. 
 
 in second stage, 460, 640, 
 
 morbid anatomy of, 639. 
 
 prognosis of, 642. 
 
 respiration, artificial, in, 643. 
 
 treatment of, 642. 
 Aspiration of pelvic abscess, 700. 
 
 of air-passages, 644. 
 Asthenia, in pregnancy, 114. 
 Astringents : 
 
 in post-part um hemorrhage, 587, 622. 
 
 in puerperal haemorrhage, 592. 
 
 in vaginal thrombus, 628. 
 Atelectasis after asphyxia, 643. 
 Atmosphere, poisons in, causing puerperal 
 
 fever, 681. 
 Atony, uterine, in third stage of labor, 461, 
 584. 
 
 causing spontaneous version, 562. 
 
 forceps in, 375. 
 
 in double uterus, 278. 
 Atresia of genital canal, 535. 
 
 symptoms of, 541. 
 
 treatment of, 541. 
 Atresia, uterine, 539. 
 
 from cervical thrombus, 540. 
 
 from cicatrices, 540. 
 
 from congluiinatio orificii externi, 539. 
 
 from elongation of anterior lip, 540. 
 
 from ovarian tumors, 548. 
 
 from rigidity of os, .540. 
 
 from tumors, 541, 542, 547. 
 
 treatment of, 541. 
 Atresia, vaginal, 536. 
 
 accidental, 536. 
 
 congenital, 536. 
 
 from cystic degeneration of vaginal walls, 
 538. 
 
 from cystocele, 537. 
 
 from ccchinococci, 538. 
 
 from neoplasmata, 538. 
 
 from prolapse, 537. 
 
 from rectocelc, 537. 
 
 from retention of urine, 537. 
 
 from thrombus, 588, 625. 
 
 from tumors, 588. 
 
 from vaginal hernia, 537. 
 
 from vaginismus, 538. 
 
 from vesical calculi, 537. 
 
 treatment of, 541. 
 Atresia, vulvar, 535. 
 
 Atrophy, of uterine mucous membrane, caus- 
 ing abortion, 309. 
 Atropia, use of, in protracted first and second 
 stages of labor, 457, 462, 650. 
 
 injection of, in extra-uterine pregnancy. S45 
 
 in salivation, 121. 
 
 It shock, 650,
 
 INDEX. 
 
 T53 
 
 attitude of foetus, 72 et seq. 
 a^uscultation, as aid to diagnosu^ of prcg 
 nancy, 96, 10-2, 106. 
 
 Axis: 
 
 of inferior pelvic strait, lo-i. 
 of superior pelvic strait, 152. 
 
 Bacilli in puerperal fever, 666. 
 Bacteria: 
 
 action of, on blood, ':68. 
 
 in normal lochia, 245, 684. 
 
 i., puerperal fever, 606 .^.e^., 081, 689. 
 
 Bagd^vaters,132,139,209,4b3. 
 in breech cases, 198. 
 
 nmture of in abortion, 320, 3o3. 
 
 ruptuieoi 182,342,600. 
 
 Eallottfiment, 96, 101, 1^4, lo^, , 
 
 in hydatidiforra mole, 301. 
 Bandage, application of abdominal, 224, 25o. 
 Bandl rins? of, 84, 137, 611. , 
 
 ^ews otrregavding changes in gravid uter- 
 
 us, 84. 
 Barnes's dilator: 
 
 in accidental luemorrbage, C07. 
 
 in breech presentations, 204. 
 
 in craniotomy, 414. 
 
 in ecliimpj^ia, 580. 
 
 in hvdatidiform mole, 302. 
 
 in iiilernal hieinorrhage, 607. 
 
 in laparo-elytrotomy, 448. 
 
 in placenta prsevia, 602 et seq. 
 
 in prolapsed funis, 631. 
 
 in protracted first stage of labor, 45., 458 
 
 in vaginal thrombus, 627. 
 
 to induce premature delivery, 3o3, 3o6. 
 Bartholin, glands of, 6. 
 Basylist, Simpson's, 416. 
 
 "cold, in puerperal fever, 698. 
 
 in scarlatina, 263. 
 hot, in eclampsia, 578, 580. 
 in painful labor, 463. 
 of ncw-bora infant, 256. 
 warm, in tardy labor, 457. 
 Battledoor placenta, 298. 
 Bed, preparation of, for labor, 20b. 
 Bedstead, obstetrical, 206 _ , „^, 0.5 
 Binder, application of abdominal, 224 -o5. 
 
 in relaxation of pelvic symphyses, 276. 
 Bismuth, subnitrate, in nausea of pregnancj 
 
 117. 
 Bladder: _ ^ 
 
 calculus in, obstructing labor, 537. 
 
 distention of fetal, <^^^'^'^- 
 distention of, retarding labor, 4ob, 084. 
 
 in pregnancy, 88. 
 Blastodermic vesicle, 47, 50. 
 epiblast of, 47, 48, 50. 
 hypoblast of, 47, 48, 50. 
 mesoblastof,47,48,49,50. 
 
 48 
 
 Blastophore, 46. _ 
 Bleeding, in eclampsia, 579, 581. 
 
 Blood: ca n^ 
 
 changes of, in pregnancy, 88, 11 rf. 
 
 defibrinated, in emesis, 118. 
 development of corpuscles ot, 4». 
 Jninsfusion of, in post-partu.^ hemorrhage. 
 
 590. 
 vessels, development of, 48. 
 Blunt hook : 
 iu breech cases, 388, 393. 
 Taylor's, 430. 
 use of, in craniotomy, 429. 
 Bodies, Wolfaan, 29. 
 Bones, development of, 48, 64. 
 
 pressure of pelvis on, 490. 
 Borax, in pruritus, 123. 
 Bottle for artificial feeding of inlants, 259. 
 
 care of, 259. 
 l^-n'protracted first stage of labor, 457. 
 
 to produce abortion, 351, 356. 
 Bowel, paralysis of, in puerpeval fever, 678. 
 
 Brain, development ot, 48, 64. 
 
 Brtndy, ^n post-p.rtura hemorrhage, 590. 
 
 Breasts : 
 anatomy of, 246. 
 areola of : „,> 
 
 in pregnancy, 88, 90, 94, 99. 
 in puerperal state, 249. 
 secondary, 88, 99. 
 care of, in puerperal state, 255. 
 changes in, during pregnancy, 87, S8, 9U, 
 94, 99, 105, 106. 
 during puerperal state, 249. 
 diseases of, 701, 706. 
 abscesses of, 709, 711. 
 causes of mastitis, 709. 
 defective milk, 706. 
 erythema, 707. 
 galactocele, 712. 
 galaetorrhosa, 706. 
 inflammation of, 709- 
 mastitis, parenchymatous, 709. 
 
 treatment of, 710. 
 nipples, fissured, 707. 
 nipples, sore, 706. 
 treatment of, 707. 
 
 erectility of, 83. 
 
 in case offetal death, 106. 
 
 in new-born child, 2.50. 
 in puerperal state, 249, 254, 255. 
 of good wet-nurse, 256. 
 pain in, during pregnancy, 8., 94, 99. 
 symptoms of, relatin- to pregnancy, 87, 88, 
 90,94,99,105,106. 
 
 veins of. in pregnancy, 87, 94, 99. 
 veins 01, lu I 382-390 (wrf« 
 
 Breech presentations, 169, 197, ^e^ oav v 
 presentations, breech).
 
 754 
 
 INDEX. 
 
 Breech presentations : 
 
 arms, liberation ot, in, 394. 
 
 asphyxia in, 639. 
 
 causes of, 197. 
 
 configuration of foetus in, 202. 
 
 cord, management of, in, 204, 393. 
 
 diagnosis of, 191, 198. 
 
 exceptional cases of, 395. 
 
 extraction in, 382 et stq. 
 
 forceps in, 388, 399, 639. 
 
 frequency of, 197. 
 
 head in, 200, 396, 399. 
 
 heart-sounds in, 103. 
 
 in contracted pelvis, 487. 
 
 in hydrocephalus, 552, 553. 
 
 irregularities in mechanism of, 201. 
 
 mechanism of, 199. 
 
 membranes, bag of, in, 193. 
 
 prognosis in, 203. 
 
 l)rolapse of cord in, 629. 
 
 rotation in, 199, 395. 
 
 shoulders in, 199. 
 
 traction, direction of, in, 385. 
 
 treatment of, 204. 
 Bregma, 70, 166. 
 
 Bright's disease, causins: eclampsia, 571. 
 Brim of pelvis, 151, 154, 157, 169, 465 {vide 
 strait, superior). 
 
 ai>plicatiou of torceps at, 375. 
 
 circumference of, 152. 
 
 diameters of, 151, 154, 157, 169. 
 
 extraction with head at, 393. 
 
 Tarnier's forceps at, 377. 
 
 Taylor's forceps at, 377. 
 Broad ligaments, 14. 
 Bromides, use of: 
 
 in chorea, 275. 
 
 in eclampsia, 578, 580. 
 
 in emesis of pregnancy, 118, 119. 
 
 in insomnia, 122. 
 
 in nausea, 117, 119. 
 
 in puerperal insanity, 703. 
 Brow presentations, 169, 194, 481, 487. 
 
 configuration of head in, 194. 
 
 diagnosis of, 194. 
 
 meclianLsm of, 194. 
 
 prognosis in, 195. 
 
 treatment of, 196. 
 Bniit^ uterine, in pregn.ancy, 96, 98, 100, 103. 
 
 effect of pains on, 97. 
 
 placental, 24, 98. 
 Brunettes, areola of, 88. 
 Bulhi vestihuU vagina;, 4, 162. 
 
 erectility of, 5. 
 
 laceration of, 622. 
 
 pars intermedia of, 5. 
 
 Cesarean section, 436. 
 abdominal wound, closure of, after, 441. 
 
 Csesarean section : 
 
 after-treatment of, 441. 
 
 anaesthesia in, 439. 
 
 armamentarium for, 439. 
 
 assistant's duties in, 439. 
 
 checking haemorrhage in, 440, 441, 444, 446. 
 
 closure of wound after, 441. 
 
 definition of, 436. 
 
 disinfection in, 439 et seq. 
 
 dressing of wound after, 439, 441. 
 
 ergot in, 441. 
 
 extraction of foetus after, 440. 
 
 hicmorrhage in, treatment of, 440, 444, 446. 
 
 history of, 436. 
 
 incision in the abdominal wall during, 440. 
 
 incision into uterus during, 440. 
 
 indications for, 438, 494, 497, 499, 513, 518, 
 521, 524, 528, 533, 618, 651. 
 
 in real or apparent death of the mother, 
 651. 
 
 instead of abortion, 359. 
 
 instruments neces.-^ary for, 439. 
 
 in uterine tumors, 545, 548. 
 
 membranes, rupture of, in, 440. 
 
 operation of, 439. 
 stages in, 440. 
 
 Porro's operation in, 442. 
 
 preparations for, 439, 440. 
 
 prognosis of, 436 et seq., 443, 444. 
 causes for bad, 443. 
 in lying-in hospitals, 437, 439. 
 
 removal of placenta in, 440. 
 
 statistics of, in United States, 437. 
 
 stump, treatment of, in, 446. 
 
 sutures in, 441. 
 
 Thomas's operation in, 447. 
 
 time for, 439. 
 
 treatment, after-, of, 441. 
 Calcareous degeneration : 
 
 of cord, 298. 
 
 of foetus, 306, 327. 337, 340. 
 Calculi : 
 
 impacted, mistaken for exostoses, 537. 
 
 vesical, obstructing labor, 537. 
 Calomel : 
 
 in Cesarean section, 441. 
 
 in metritis, 464. 
 
 in perimetritis, 464, 696. 
 Camplior, in insomnia, 122. 
 
 in pniritus, 1 22. 
 Canal, cervical, 13, 83, 106. 
 Canal, genital: 
 
 atresia of, 535. 
 
 ruptures of, 610. 
 Cancer, uterine, 310, 438, 546. 
 
 vulvar, 536. 
 Capvt svccedanenm : 
 
 in brow presentations, 194. 
 
 in contracted pelvis, 483, 489.
 
 INDEX. 
 
 755 
 
 Caput succedaneum : 
 
 indicating iorceps-delivery, 3fi9. 
 
 in face presentations, 190. 
 
 in forceps-deliveries, 369. 
 
 in puerperal state, 250. 
 
 in vertex presentations, 181. 
 Carbolic acid : 
 
 m abortion, 320, 322-325, 354, 356. 
 
 in Cuesarian section, 440. 
 
 in care of cord, 256. 
 
 in erosions of cervix, 120. 
 
 in mastitis, 711. 
 
 in perineal rupture, 623. 
 
 in pruritus, 122. 
 
 in puerperal state, 224, 253, 693. 
 
 in Thomas's operation, 451. 
 
 in uterine rupture., 619. 
 Carbonic-acid water in nausea of pregnancy, 
 
 117. 
 Carbonic oxide, increase of, in blood during 
 
 prcy:nancy, 89. 
 Cardiac diseases, complicating pregnancy, 
 266, 351,359. 
 
 causing abortion, 266, 351, 359. 
 Carunculoi inyrtiformes : 
 
 formation of, 7, 105. 
 Casts, in eclampsia, 567, 569 et seq. 
 Cathartics : 
 
 in eclampsia, 578, 580. 
 
 in pregnancy, 115. 
 
 in puerperal state, 254. 
 Catheter : 
 
 in asphyxia, 644. 
 
 in reposition of cord, 412, 634. 
 
 post-partum^ 252. 
 Cattieterization : 
 
 in labor, normal, 208. 
 
 in post-partum hemorrhage, 586. 
 
 in retention, 537. 
 
 in retroflexion, 281. 
 
 of air-passages, in, aspJii/xict neonaiorum, 
 644. 
 
 uterine, to produce premature delivery, 351, 
 580. 
 Cat's chorion : villi of, 56. 
 Caul, 133. 
 Cellulitis : 
 
 in abortion, 325. 
 
 in puerperal i'ever, 658. 
 Center, motor, for uterine contractions, 126. 
 Cephalic version, 401. 
 Cephalalgia, in pregnancy, 122. 
 
 in puerperal state, 248. 
 Cephalotomy, 431. 
 Cephalotribe, 420. 
 
 action of, 422, 423. 
 
 application of, 425. 
 
 B.iudclocque's, 420. 
 
 C!ot's, 421. 
 
 Cephalotribe : 
 
 dangers of, 424. 
 
 in breech cases, 388, 393. 
 
 in obstructed labor, 555. 
 
 Lusk's, 422. 
 
 objections to, 423. 
 
 Scanzoni's, 421. 
 Cephalotripsy, 425. 
 Cerebellum, development of, 48, 64. 
 Cerebral vesicles, 63. 
 Cerebrum, development of, 50, 63. 
 Cerium, oxalate, in nausea of pregnancy, 
 
 117. 
 Cervix uteri, 12, 26. 
 
 anatomy of, 13, 26. 
 
 apparent shortening of, in pregnancy, 81. 
 explanation of, 83. 
 
 arbor mtoi of, 13. 
 
 atresia of, 539. 
 
 canal of, 13, 83, 106. 
 
 cancer of, 310, 438, 546. 
 
 changes of, in pregnancy, 79, 80, 81-86, 95, 
 105, 116, 138, 282. 
 
 connective tissue of, 17. 
 
 cysts of, 542. 
 
 dilatation of, in labor, 131, 137, 13^, 199, 
 302, 455, 483, 540. 
 mechanism of, 131. 
 
 dilatation of, in emesis of pregnancy, 119 
 et feq. 
 to induce abortion, 353, 360. 
 
 double, 277. 
 
 erectility of, 26. 
 
 erosion of, in pregnancy, 81, 116, 120. 
 
 examination of, in pregnancy, 104, 105. 
 
 ganglion of, 27, 77, 126. 
 
 glands of, 19, 81. 
 
 hyperemia of, in pregnancy, 138. 
 
 liypertrophy of, 282. 
 
 in placenta prsevia, 600. 
 
 in puerperal state, 243, 249. 
 
 laceration of, 105, 203, 539, 540, 620. 
 
 lip, anterior, obliteration of, in pregnancy, 
 83, 105. 
 
 mechanical dilatation of, to produce abor- 
 tion, 353, 360. 
 
 mucous membrane of, 19, 81, 95. 
 
 myoma of, 542. 
 
 non shortening of, in pregnancy, 81-83, 85. 
 
 peculiarities, anatomical, of, 26. 
 
 portio vaginalis of, 12. 
 lacerations of, 620. 
 
 position of, in pregnancy, 82-85, 104. 
 
 stricture of, 539. 
 
 thrombus of, 540. 
 
 tumors of, 542. 
 
 ulcers of, in puerperal fever, 656. 
 
 veins of, 26. 
 
 walls of, 17.
 
 756 
 
 INDEX. 
 
 Child {vide foetus) : 
 
 asphyxia of, 215, 368, 635. 
 
 -bed, disease of, 653. 
 insanity of, 701. 
 physiology and manageinciit of, 238. 
 
 breasts of new-born, 250. 
 
 care of premature, 356. 
 
 conditions iniiuenciuj^ size of, 69. 
 
 extraction of, in real or apparent death of 
 mother, C50. 
 after perforation, 419. 
 
 icterus of new-born, 250. 
 
 length of new-born, 69. 
 
 milk prepared for, 257. 
 
 size of, 69. 
 
 weight of new-born, 69. 
 Chill, post-partum^ 238, 248. 
 
 in abortion, 325. 
 
 in fetal death, 106. 
 
 in labor, 134. 
 
 in phlegmasia, 705. 
 
 in puerperal fever, 464, 071 et seq. 
 Chin, traction on, m breech cases, 396. 
 Chloral : 
 
 in chorea, 275. 
 
 in eclampsia, 578 et seq. 
 
 in emesis of pregnancy, 117, 119. 
 
 in face-ache, 122. 
 
 in insomnia of pregnancy, 122. 
 
 in puerperal insanity, 703. 
 
 in tardy labor, 457, 502. 
 Chloroform : 
 
 effect of, on pains, 227. 
 
 in abortion, 322. 
 
 in chorea, 275. 
 
 in craniotomy, 414. 
 
 in diagnosis of pregnancy, 102. 
 
 in eclampsia, 579, 581. 
 
 in face-ache, 1.2. 
 
 in labor, 210, 226, 208, 457, 463. 
 
 in pruritus, 122. 
 
 post-partum, 623. 
 Cholera, causing abortion, 204. 
 
 complicating pregnancy, 203. 
 Chorda dorsalis, 49. 
 
 Chorea, complicating pregnancy, 114, 274. 
 351. 
 
 indicating abortion, 351. 
 
 treatment of, 275. 
 Chorion: 
 
 abortion from disease of, 308. 
 
 formation of, 51, 52, 53, 64, 123. 
 
 permanent, 53. 
 
 villi of, 51, 52, 54, 55, 289, 329. 
 in cat, 56. 
 
 inhydatidifbrm mole, 298. 
 in mare, 55. 
 Cicatrices : 
 
 atresia, uterine, from, 540. 
 
 Cicatrices : 
 
 of OS, obstructing labor, 540. 
 
 of vagina, obstructing labor, 536 {vide 
 atresia, vaginal). 
 Ciliated epithelium, columnar : 
 
 in Fallopian tube, 21, 42, 328. 
 
 influence of, on migration ol ovum, 42. 
 
 in glands of body, 18. 
 
 in glands of cervix, 19. 
 
 in peritonaeum of batrachians, 42. 
 Circle of Baudelocque, 467. 
 Circulation : 
 
 disorders of, in pregnancy, 114, 115. 
 
 entrance of air into, 647. 
 
 fetal, 66, 68, 250, 637. 
 
 varicose veins due to disorders of, in preg- 
 nancy, 88, 115. 
 Cleavage of ovum, 46. , 
 
 Clitoris : 
 
 anatomy of, 3, 102. 
 
 bulbs, terminal of, 3. 
 
 corpus of, 3. 
 
 crura of, 3, 162. 
 
 development of, 33, 64. 
 
 frenulum of, 4. 
 
 glans of, 3. 
 
 prreputium of, 4. 
 Cloaca, 48. 
 
 Coccygeus muscle, 160. 
 Coccyx, anatomy of, 142. 
 
 mobility of, 142, 149, 534. 
 Codeia, in emesis of pregnancy, 119. 
 
 in insomnia, 122. 
 Coiling of cord, 204, 215, 290. 
 Coitus, in pregnancy, 113, 116. 
 Cold: 
 
 in abortion, 318, 321. 
 
 in mastitis, 711. 
 
 in post-partum hfcmorrhage, 585, 627. 
 
 in puei-peral fever, 697. 
 
 in puerperal mania, 703. 
 Collapse, in labor and childbed, 645, 648. 
 
 in abortion, 323. 
 
 in extra-uterine pregnancy, 338. 
 
 in internal haemorrhage, 606. 
 
 in uterine rupture, 615. 
 Colostrum, 248. 
 Colpeurynter : 
 
 in abortion, 355. 
 
 in placenta pr.nsvia, 002. 
 Colpohyperplasia eijstica : 
 
 vaginal atresia i'rom, 538. 
 Columns, vaginal, 9. 
 
 Commissures, anterior and posterior, of la- 
 bia, 3. 
 Complications of pregnancy, 260. 
 Computing day of confinement, 108-111. 
 Conception, 40, 42. 
 
 date of, 106.
 
 INDEX. 
 
 75^ 
 
 Confinement, prediction of day of, lifS-lll. 
 Congenital encephalocele, 553. 
 Conglutinatk) orijicil externi: 
 
 atresia from, 5.59. 
 Conjugate diameter of pelvis, 151. 
 
 measurement of diagonal, 4G9, 470. 
 
 measurement of external, 4(!9. 
 
 measurement of vera, 469, 470. 
 < 'onstipation : 
 
 iu pregnancy, 88. 90, 116, 118, 122, 339. 
 
 in retroflexion, with incarceration, 250. 
 
 post-partum, 240, 675, 078. 
 Oonstridor vagina', 162, 214. 
 Contracted pelvis, 465 {vide pelvis, con- 
 tracted). 
 
 Ctesarean section in, 438. 
 
 diagnosis of, 466. 
 
 frequency of, 466. 
 
 varieties of, 465. 
 Contractions, uterine, 127, 311. 454, 582. 
 
 center fur uterine, 126. 
 
 hour-glass, of uterus, 462. 
 
 painless, 130, 131. 
 
 pelvic, resources of treatment in, 493. 
 
 ring, 137, 138, 462, 611, 014. 
 Convulsions, puerperal, 567 {vide eclampsia). 
 
 indicating abortion, 351. 
 
 indicating forceps, 368, 375. 
 
 in placenta pra^via, 599. 
 Cord, umbilical, 00 {vide ftinis). 
 
 anomalies of, 293. 
 
 arteries of, 60, 61, 250. 
 
 calcareous degeneration of, 298. 
 •care of, in abortion, 326. 
 
 in infants, 256. 
 coiling of, 204, 215, 296. 
 cysts of, 297. 
 degenerations of, 297. 
 expression of, 630. 
 formation of, 00, 63, 64. 
 fully developed, 61. 
 gelatin of, 61. 
 htemorrhage from, 453. 
 hernias of, 296. 
 in puerperal state, 250. 
 knots in, 295. 
 
 laceration of, in precipitate labor, 453. 
 length of, 61. 
 
 ligation, late, of, 216 et seq. 
 management of, in breech presentations, 
 
 393. 
 marginal insertion of, 298. 
 prolapse of, 510, 561, 629 {vide funis, pro- 
 lapse of), 
 reposition of, 631. 
 shortness of, causing dystocia, 559. 
 souffle in. 98. 
 
 stenosis of vessels of, 297, 303. 
 structure of, 61. 
 
 Cord: 
 torsion of, 293, 303. 
 traction on, in labor, 220, 221. 
 traction on, in retained placenta, 463, 593. 
 tying of, in labor, 215, 216, 236. 
 vein of, 61, 250. 
 vessels of, 60, 01. 
 Cordiform uterus, 34. 
 Corium, development of, 48. 
 Cornua, of uterus, 33. 
 Corpulence, causing abortion, 308. 
 Corpus, of uterus, 12. 
 Corpus liiteum: 
 anatomy of, 39, 40. 
 false, 41. 
 formation of, 39. 
 true, 41. 
 Corrosive sublimate, use of, in obstetrics, 687, 
 
 688, 690, 692, 694. 
 Cortex, of ovary, 23. 
 Cotton, absorbent, after labor, 
 Cotyledon, placental, 56, 59. 
 Cracked nipple, 708. 
 Cramps in pregnancy, 88. 
 Cranial presentations, 169 et seq. {vide presen- 
 tations, vertex). 
 Cranioclast, 425, 617. 
 action of, 425 ct seq. 
 application of, 428. 
 Braun's, 426. 
 Simpson's, 425. 
 Craniotomy, 413. 
 anaesthetics in, 414. 
 basylist of Simpson in, 416. 
 before version, 430. 
 Blot's cephalotribe in, 421. 
 Blot's perforator in, 415. 
 Braun's cranioclast in, 426. 
 cephalotribes in, 421. 
 contraindications for, 499. 
 contrasted with version, 494. 
 craniotomy-forceps of Meigs in, 428. 
 crotchet and blunt liook in, 429. 
 dangers of, in contracted pelvis, 495. 
 definition of, 413. 
 extraction of child after, 41 9. 
 forceps in, 419. 
 
 Hodge's craniotomy scissors in, 415. 
 in brow presentations. 197. 
 in contracted pelvis, 494, 497, 499, 503, 610, 
 
 513, 519, 521, 528, 533. 
 indications for perforation in, 413. 
 in fixce presentations, 418. 
 in multiple pregnancy, 235. 
 in rupture of uterus, 617. 
 instruments used in, 414, 420. 
 in uterine myoma, 545. 
 Lusk's cephalotribe in, 422. 
 operation of perforation in, 414, 428.
 
 758 
 
 INDEX. 
 
 Craniotomy : 
 
 Scanzoni's cephalotribe in, 421. 
 
 Simpson's cranioclast in, 425. 
 
 Simpson's perforator in, 414. 
 
 Smellie's scissors in, 415. 
 
 speculum in, 428. 
 
 Taylor's forceps in, 414. 
 
 Thomas's perforator in, 415. 
 
 trephine perforator in, 41G, 419. 
 
 version after, 430. 
 Craniotractor, 426. 
 Cranium, fetal, 70, 165. 
 
 base of, 165. 
 
 fontanelles of, 70, 165, ISO, 183. 
 
 premature ossification of, 551. 
 
 sutures of, 70, 165. 
 
 vault of, 165. 
 Cravings, morbid, in precrnancy, 91, 118. 
 Cream, use of, in artificial feeding, 257. 
 ('rede's incubator, 357. 
 Credo's method of placental expression, 220. 
 
 in abortion, 324. 
 OristcB vaffince, 10, 105. 
 Crotchet, 429. 
 
 delivery of trunk after craniotomy with, 
 430. 
 Cul-dt-mc of Douglas, 9, 15. 
 Cuneiis, 2. 
 Cunnus^ 2. 
 Curette, in abortion, 317, 320. 324, 326. 
 
 in mole, 302. 
 
 in puerperal fever. 694. 
 
 in puerperal lifemorrhage, 592. 
 Cyanosis neonatorum^ 68 (tide asphyxia neo- 
 natorum). 
 Cystitis, in puerperal state, 252. 
 Cystocele : 
 
 atresia, vaginal, from, 537, 623. 
 
 obstructing labor, 537, 623. 
 Cysts : 
 
 in hydatidiform mole, 298, 299. 
 
 of cord, 297. 
 
 of ovary, differentiated from pregnancy, 
 101, 550. 
 
 of placenta, 289. 
 
 of uterine myoma, 542. 
 of vaginal walls, 538. 
 
 Deafness, in pregnancy, 91. 
 Death : 
 
 delivery of child in, 650. 
 
 fetal, causing abortion, 308. 
 diagnosis of, 106. 
 
 real or apparent, of mother in pregnancy or 
 labor, 650. 
 
 sudden, in labor and childbed, 645. 
 Decapitation : 
 
 after failure of version, 413, 617. 
 
 Braun's decollator in, 433. 
 
 Decapitation : 
 
 in embryotomy, 432. 
 
 methods of, 432. 
 
 Pajot's method of, 434. 
 Deeidua, 51, 53, 124, 125. 
 
 diseases of, 284. 
 producing abortion. 308, 309. 
 
 tatty degeneration of, 125. 
 
 glands of, 125. 
 
 in extra-uterine jiregnancy, 329. 
 
 rejlexa, 54, 123, 125, 286. 
 
 reparation of, in puerperal state, 241. 
 
 serotiiia, 54, 125, 242. 
 
 vera, .53, 123, 125, 286. 
 Decollator. Braun's, 433. 
 
 use of, in decapitation, 433. 
 Deformities, pelvic, 465 {vide pelvis, con- 
 tracted). 
 
 absence of symphysis, 534. 
 
 contracted pelvis, 465. 
 
 exostosis, 533. 
 
 liattened pelvis, 465, 469, 474, 512. 
 
 fractures, 533. 
 
 funnel-shaped pelvis, 528. 
 
 generally contracted pelvis, 477. 
 
 in-egular forms of contracted pelvis, 478, 
 533. 
 
 kyphotic pelvis, 479, 519. 
 
 Naegele oblique pelvis, 514. 
 
 osteomalacic pelvis, 529. 
 
 pscudo-osteomalacic pelvis, 478, 533. 
 
 rachitic pelvis, 475, 478. 
 
 Eobcrt's anchylosed and transversely con- 
 tracted pelvis, 523. 
 
 Scolio-rachitic pelvis, 521. 
 
 Spondolistlietic pelvis, 525. 
 Degeneration : 
 
 adipoccrous, of foetus, 304, 306. 
 
 calcareous, of cord, 298. 
 
 caleaieous, of tetus, 306. 
 
 fatty, of fa-tus, 306. 
 
 hydatidiform, of placenta, 298. 
 
 placentid, 299. 
 Delirium, in emcsis of pregnancy, 118. 
 
 in labor, 701. 
 Delivery : 
 
 care of patient atter, 224. 
 
 forceps, preparations for use of, in, 366. 
 
 immature, 307. 
 treatment of, 326. 
 
 premature, 307. 
 treatments of, 319. 
 Dermoid cysts of ovary, 550. 
 Descent of foetus, in normal labor, 171. 
 
 in face presentation, 186. 
 Desquamation of new-born, 250. 
 Development : 
 of abdomen, 64. 
 of air-passages, 48.
 
 INDEX. 
 
 759 
 
 Development : 
 of allantois, 63. 
 of amnion, 63, 64. 
 of anus, 63. 
 of back, 63. 
 of blood, 48. 
 of blood-vessels, 48. 
 of bones, 48, 64. 
 of brain, 48. 
 of cerebellum, 50. 
 of cerebral vesicles, 63. 
 of cerebrum, 50. 
 of chorion, 64. 
 of clitoris, 64. 
 of cloaca, 48. 
 of cord, 63, 64. 
 of corium, 48. 
 of digestive tract, 48. 
 of dorsal plates, 49, 62. 
 of ear, 63, 64. 
 of epidermis, 48. 
 of extremities, 63, 64. 
 of eyes, 63, 64. 
 of face, 64. 
 of M, 65. 
 of foetus, 48, 62. 
 of fontanelles, 64. 
 of genito-urinary organs, 48. 
 of glands, 48. 
 of hair, 48, 64, 65. 
 of head, 63, 64, 65. 
 of intestine, 48, 50, 63. 
 of jaws, 64. 
 of labia, 64. 
 of lanugo, 64, 65. 
 oflips,^64. 
 of lungs, 48. 
 of medulla, 50. 
 of mouth, 48, 63, 64. 
 of muscles, 48. 
 of nails, 48, 64, 65. 
 of navel, 65. 
 of neck, 64. 
 of nerves, spinal, 48. 
 of nervous system, 50. 
 of nose, 48, 64. 
 of ovum, 35, 62. 
 
 of organs of generation, female, 29. 
 of palate, 64. 
 of penis, 64. 
 of placenta, 64. 
 of rectum, 63. 
 of ribs, 64. 
 of scalp, 64. 
 of scrotum, 64, 65. 
 of skin, 48, 64. 
 of .skull, 64. 
 of spinal column, 48. 
 of stomach, 48, 50. 
 
 Development : 
 
 of testicle, 65. 
 
 of thorax, 64. 
 
 of umbilical vesicle, 63, 64. 
 
 of uterus, 30. 
 
 of vagina, 30. 
 
 of vernix, 65. 
 
 of vertebrae, 49. 
 
 of viscera, abdominal and thoracic, 48, 62. 
 
 of visceral arches, 63. 
 Diabetes, complicating pregnancy, 274. 
 Diameters of pelvis, 150 etseg., 169. 
 
 bis-iliac, 151, 468. 
 
 conjugate, 151, 469, 470. 
 
 diagonal conjugate, 469, 470. 
 
 oblique, 152, 469. 
 
 transverse, 151, 471. 
 Diameters of fetal head, 166 et seq. 
 Diarrhoea, in pregnancy, 90, 118. 
 
 in puerperal fever, 678. 
 Diet, in pregnancy, 112, 114, 117. 
 
 in puerperal state, 253. 
 Digestion : 
 
 disorders of, in pregnancy, 90, 93, 114, 116. 
 
 of new-born infant, 250. 
 Digestive tract, development of, 48. 
 Digital examination in labor, 207. 
 Digitalis, use of: 
 
 in eclampsia, 581. 
 
 in hemorrhage, 591. 
 
 in pneumonia, 270. 
 
 in puerperal fever, 697. 
 
 in shock, 650. 
 
 in tardy labor, 457. 
 Dilator, Harnes's: 
 
 in accidental haemorrhage, 604. 
 
 in breech presentations, 204. 
 
 in craniotomy, 414. 
 
 in eclampsia, 580. 
 
 in hydatidiform mole, 302. 
 
 in placenta praevia, 602-605. 
 
 in prolapsed funis, 631. 
 
 in protracted first st^ge of labor, 457, 458, 
 514. 
 
 in Thomas's operation, 449. 
 
 in vaginal thrombus, 627. 
 
 to induce premature delivery, 353. 
 Dilator, Gill Wylie's, use of, 127. 
 Diphtheritic patches in puerperal fever, 656, 
 
 657, 686. 
 Discus proligerus^ 37, 38, 39. 
 Diseases complicating pregnancy, 91, 113, 
 261 (vide pregnancy, diseases compli- 
 cathig). 
 
 albuminuria, 91. 
 
 amaurosis, 91. 
 
 amblyopia, 91. 
 
 amniotic fluid, deficiency of, 293. 
 
 anaemia, 114.
 
 760 
 
 INDEX. 
 
 Diseases complicating pregnancy : 
 anassthesia, 91. 
 anomalies of cord, 293 et seq. 
 anteflexion, 11 G, 278. 
 anteversion, 80, 278. 
 ascites, 95. 
 
 cardiac diseases, 89, 266. 
 ccpLalaljjia, 122. 
 cholera, 263. 
 chorea, 114, 274. 
 
 circulation, disorders of, 114, 115. 
 coiling of cord, 2C4, 215, 296. 
 constipation, 88, 90, 116. 
 cord, anomalies of, 293. 
 cysts of cord, 297. 
 deafness, 91. 
 death of foetus, 106. 
 degenerations of cord, 297. 
 diabetes, 274. 
 diarrhoea, 90. 
 dizziness, 91. 
 dropsy, 88, 114, 116. 
 dyspnoea, 90, 114. 
 emesis, 93, 99, 116, 117. 
 emphysema, 270. 
 empyema, 270. 
 
 endometritis decidua, 284^286. 
 exanthemata, 261. 
 face-ache, 91, 122. 
 flatulence, 112. 
 gangrene, 115. 
 goitre, 89. 
 heartbura, 112, 121. 
 heart-disease, 89, 266. 
 hernias of cord, 296. 
 bydatidiform mole, 298. 
 hydrsemia, 89, 115. 
 hydramnion, 95. 
 hypertrophy of heart, 89. 
 hysteria, 114. 
 icterus, 206. 
 
 incontinence of urine, 88. 
 indigestion, 90, 93, 114, 116. 
 insanity, 114. 
 maceration of foetus, 804. 
 malarial fever, 122, 264. 
 mania, 91, 114. 
 
 mummification of foetus, 303, 306. 
 nausea, 90, 93, 99, 116, 117. 
 neuralgia, 88, 91, 114. 
 oedema, 88, 114, 115. 
 osteopliytes, 89. 
 palpitation, 114. 
 paresis, 91. 
 
 pelvis, contracted, 465. 
 phthisis pulmonalis, 270. 
 placental diseases, 287. 
 plethora, 88. 
 pleurisy, 270. 
 
 Diseases complicating pregnancy : 
 pneumonia, acute lobar, 2G9. 
 
 prolapse of uterus and vagina, 282, 283. 
 
 pruritus, 91, 121. 
 
 relapsing fever, 264. 
 
 retroflexion, 116, 279, 307, 310. 
 
 retroversion, 116, 279. 
 
 rubeola, 261. 
 
 salivation, 90, 94, 99, 118, 121. 
 
 scarlatina, 262. 
 
 small-pnx, 261. 
 
 syncope, 91, 114, 118. 
 
 syphilis, 271. 
 
 tumors, uterine, 542. 
 
 typhoid fever, 264. 
 
 typhus fever, 264. 
 
 varicose veins, 88, 115. 
 
 variola, 261. 
 
 vertigo, 91, 114. 118. 
 
 vomiting, 93, 99, 116, 117, 359. 
 Diseases of childbed, 053. 
 Diseases, relations of zymotic, to puerperal 
 
 fever, 685. 
 Di.splacemeuts of uterus, 80, 110, 278, 279 
 et seq., 310 {vide uterus, displacements 
 of). 
 Dizziness in pregnancy, 91, 114, 118. 
 Dolores prescujieiites 124, 127, 131. 
 Dorsal plates, 49, 62. 
 Double uterus, 34, 277, 540. 
 Douglas, cul-de-sac of, 9, 15. 
 Douche, uterine : 
 
 in abortion, 320, 322-325, 354, 356. 
 
 in hydatid mole, 302. 
 
 in post-part urn hi^morrhage, 589. 
 
 in puerperal fever, 688, 693, 694. 
 
 in retained placenta, 594. 
 Douche, vaginal : 
 
 in abortion, 320. 322. 
 
 in Ca'sarean section, 440. 
 
 in forceps deliveries, 367. 
 
 in placenta previa, 603, 606. 
 
 in pregnancy, 113. 
 
 in protracted first st.age of labor, 457, 458, 
 502. 
 
 in pruritus, 122. 
 
 in puerperal fever, 699. 
 
 in puerperal htemorrhage, 592. 
 
 in puerperal st.ite, 224, 253, 693. 
 
 in retained placenta, 594. 
 
 to prevent puei-peral fever, 687, 688, 692, 
 699. 
 
 to produce abortion or premature delivery, 
 354, 356. 
 Dress, in pregnancy, 113. 
 Dropsy : 
 
 complicating presnancy, 88, 114, 115. 
 
 of amnion, 75, 95, 103, 124, 290, 561. 
 obscuring pregnancy, 95.
 
 nfDEX. 
 
 761 
 
 Dry labor, 455. 
 Ducts : 
 
 lactiferous, 247. 
 
 ofMiiUer, 30. 
 
 Wolffian, 29. 
 Ductus arteriosus, 66, 68, 250. 
 
 after birth, 250, 038. 
 Ductus Teiiosus, 06, 637. 
 Duration of pregnancy, 106. 
 Duvemey, tflands of, 0. 
 
 ])yspna;a, in pregnancy, 'JO, 114, 292, 351, 
 549, 567. 
 
 in pulmonary emboli?m, 647, 048. 
 Dystocia, 555, 556 et seq. {vide labor, painful, 
 obstructed, and tardy). 
 
 from double monsters, 556. 
 
 from fetal emphysema, 555. 
 Dysuria, from retroflexion of gravid uterus, 
 with incarceration, 280. 
 
 in cystocele, 537. 
 
 in extra-uterine pregnancy, 339. 
 
 Ears, development of, 63, 64. 
 Echinococci, vaginal atresia from, 538. 
 Eclampsia, 507. 
 
 abortion in, 578. 
 
 albuminuria in, 567, 
 
 anaesthetics in, 579. 
 
 bath, hot, in, 580. 
 
 bleeding in, 579. 
 
 bromides in, 578 et seq. 
 
 cathartics in, 578. 
 
 cerebral anaemia in, 575. 
 
 chloral in, 578 et seq. 
 
 chloroform in, 579 et seq. 
 
 clinical history of, 567. 
 
 definition of, 567. 
 
 dilator, Barnes's, in, 580. 
 
 etiology of, 570. 
 
 forceps in, 368, 375, 581. 
 
 fi-equency of, 567. 
 
 in cholera, 264. 
 
 in chronic nephritis, 273. 
 
 in placenta prtevia, 599. 
 
 ill post-part urn hemorrhage, 590. 
 
 in uterine tumors, 543. 
 
 mania in, 702. 
 
 morphia in, 579. 
 
 oedema of brain in, 574. 
 
 pathology of, 570. 
 
 phlebotomy in, 579. 
 
 prognosis in, 569. 
 
 symptoms, premonitory, of, 567. 
 
 terminations of, 569. 
 
 treatment of, 577. 
 
 uraemia in. 571, 576. 
 
 urine in, 569, 577. 
 
 venesection in, 579. 
 £crasevr, Hicks's wire, in cephalotomy, 431. 
 
 Bcraseur : 
 
 in embryotomy, 434. 
 
 in Porro's operation, 444. 
 
 in uterine myoma, 545. 
 Ectopia of abdominal organs obstructing la- 
 bor, 556. 
 Elastic stockings in pregnancy, 116. 
 Elbow, diagnosis of knee from, 199. 
 Electricity : 
 
 in emesis of pregnancy, 117. 
 
 in extra-uterine pregnancy, 345. 
 
 in induced labor, 355. 
 
 in post-jmrtum hemorrhage, 588. 
 Elytrotomy in extra-uterine pregnancy, 346. 
 Emaciation in pregnancy, 114, 118. 
 Embolism, pulmonary, 045. 
 Embolus, pulmonary : 
 
 collapse and death from pulmonary, in la- 
 bor and childbed, 645. 
 
 ether, in treatment of, 650. 
 
 in puerperal fever, 66u, 6S0. 
 
 symptoms, 647. 
 
 treatment, 650. 
 Embryo : 
 
 anatomy of, 50, 62. 
 
 circulation of 60-08. 
 
 development of, 48. 
 
 layers of, 47, 48, 62. 
 
 nourishment ot, 50. 
 Embryology, 62. 
 Embryonic area, 47, 48, 62. 
 Embryonic spot, 02. 
 Embryotome of P. Thomas, 434. 
 Embryotomy, 413, 431. 
 
 decapitation in, 432. 
 
 exenteration in, 432. 
 
 indications for, 431. 
 
 version in, 432. 
 Emesis : 
 
 anodynes in, 117, 119. 
 
 induction of abortion for, 118,351, 359. 
 
 in hydramnion, 292. 
 
 m incarceration of I'elroflexed uterus, 280, 
 359. 
 
 in pregnancy, 93, 99, 116, 117, 567. 
 treatment of, 116, 118. 
 
 in puerperal fever, 674, 678. 
 
 in rupture of uterus, 015. 
 
 in shock, 649. 
 
 narcotics in, 119. 
 Emphysema : 
 
 abortion in, 270. 
 
 complicating pregnancy, 270. 
 
 fetal, causing dystocia, 555. 
 
 subcutaneous, in precipitate labor, 453. 
 
 subperitoneal, in rupture of uterus, 616. 
 Empyema : 
 
 complicating pregnancy, 270. 
 Encephalocelc, congenital, 553.
 
 762 
 
 INDEX, 
 
 Endocarditis : 
 in pregnancy, 267. 
 in puerperal fever, 669. 
 Endochorion, 53. 
 
 Endocolpitis, in puerperal fever, 656, 671. 
 Eudometritiis, cervical, 539. 
 Endometritis decidua^ complicating preg- 
 nancy, 272, 284, 310. 
 Endometritis de:idua catarrhalis^ or hydror- 
 
 rTicaa gravidarum^ 286. 
 Endometritis decidua chronica diffusa^ 284. 
 Endometritis decidua poli/posa^ 285. 
 Endometritis decidua tuberosa, 285. 
 Endometritis in puerperal fever, 656, 657, 671. 
 Enema, an eclampsia, 580. 
 in labor, 208. 
 
 nutritive, in pregnancy, 114. 118. 
 post-partum, 254. 
 Epiblast, 46-48, 50. 
 Epiblastic spheres, 46. 
 Epidermis, development of, 48. 
 
 m maceration of loetus, S04. 
 Episiotomy, 214. 
 
 Epithelium, cylindrical, ciliated : 
 in glands of cervix, 19, 81, 95. 
 in glands of uterus, 18, 20. 
 of breast, 247. 
 of ovary, 25, 36. 
 of ovum. 37. 
 of tube, 21,42. 
 Erectility : 
 cervical, 26. 
 of nipple, 88. 
 
 of Fallopian tube (theoretical), 41. 
 of vaginal bulbs, 5. 
 ovarian (theoretical). 27. 
 uterine (theoretical), 26. 
 va'Tinal (theoretical), 9. 
 Ergot : 
 contraindications for, in parturition, 461. 
 indications for, in parturition, 224, 460, 
 
 607. 
 physiological action of, 460. 
 u.«e of, after normal labor, 224, 460, 688. 
 in abortion, 320, 321, 323. 
 in Ciesarean section, 441. 
 in hydatid mole, 302. 
 in long second stage, 460. 
 in parturition, 224, 460. 
 in placenta prjevia, 603, 606. 
 in post- partt/m haemorrhage, 585. 
 in protracted first stage of labor, 457, 458, 
 461, 511. 
 Ergotin, for varicose veins, 116. 
 
 in abortion, 323. 
 Erosions, on cervix, in pregnancy, 81, 116, 
 120. 
 in puerperal state, 243. 
 treatment of, 116, 120. 
 
 Erotomania, 702. 
 
 Erysipelas, how related to puerperal tcver, 
 
 686. 
 Estimation of date of confinement, 108. 
 Ether : 
 
 in abortion, 322. 
 
 in anasmia, cerebral, 590. 
 
 in Caesarean section, 4S9. 
 
 in embolism, pulmonary, i 50, 
 
 in forceps delivery, 367. 
 
 in labor, 226. 
 
 in lacerations, 623. 
 
 in nausea of pregnancy, 117. 
 
 in pulmonary embolism and shock, 650. 
 
 post-partiim^ 623. 
 Eunuchs, female, genital organs of, 156. 
 Eustachian valve, 66, 08, 637. 
 Evisceration, 432. 
 
 Evclutio condiiplicato corpore, 564, 565. 
 Evolution, spontaneous, 564. 
 
 etiology of, 564. 
 
 mechanism of, 565. 
 
 prognosis, 566. 
 Examination of patient : 
 
 method of conducting, in labor, 206. 
 in pregnancy, 99. 
 Exanthemata in pregnancy, 261. 
 Exenteration, in embryotomy, 432. 
 Excavatio : 
 
 tecto-titerina, 15. 
 
 vesico-iderina, 15. 
 Exercise, in pregnancy, 113, 122. 
 Exhau>tion, nerve, and shock, 648. 
 
 treatment, 650. 
 Exochorion, 53. 
 
 Exostosis, pelvic deformity from, 533. 
 Expression of head, in labor, 212. 
 Expression of placenta : 
 
 by Crede's method, 220, 324. 
 m contracted pelves, 506. 
 in irregular pains of third stage of labor, 
 
 459, 403. 
 in placenta prtevia, 603. 
 Expulsion, spontaneous, 564. 
 Extension, of fetal head, in face presenta- 
 tions, 186. 
 
 of fetal head, in normal labor, 177. 
 External rotation : 
 
 in face presentations, 188. 
 
 in normal labor, 177. 
 Extraction of fa?tus : 
 
 alter perforation, 419, 428. 
 
 by breech, in breech presentations, 385. 
 
 by feet, in breech presentations. 384. 
 
 by forceps, in breech cases, 388. 
 
 in Csesarean section. 440. 
 
 in craniotomy, 419. 
 
 in foot and breech presentations, 382 it seq. 
 
 in pelvic presentations, 382.
 
 INDEX. 
 
 763 
 
 Extraction of fcetus : 
 
 in real or apparent death of mother in preg- 
 nancy or labor, 'J50. 
 
 relief of arms in, 394. 
 Extraction of trunk in breech cases, 384. 
 Extra- uterine pregnancy (vide pregnancy, 
 extra-uterine), 280, 3--i7. 
 
 abdominal, 327, 335, 339. 
 
 collapse in, 338. 
 
 definition of, 327. 
 
 diagnosis of, 280, 340. 
 
 electricity in, 345. 
 
 clytrotomy in, 346. 
 
 haemorrhage in, 327, 346. 
 
 interstitial, 332. 
 
 ovarian, 327, 328, 338. 
 
 peritonitis in, 339, 340. 
 
 secondary, 339. 
 
 symptoms of, 338. 
 
 terminations of, 327, 333, 339. 
 
 tubal, 327, 328. 
 
 tubo-abdominal, 338. 
 
 tuboovarian, 338. 
 
 treatment of, 343. 
 
 (a) in cases of early gestation, 343. 
 
 (b) in cases of advanced gestation. 346. 
 
 (c) in cases of gestation, after death of 
 foetU'^, 348. 
 
 Eyes, development of, 63, 64. 
 
 Face-ache in pregnancy, 122. 
 Face, development of, 64. 
 Face- presentations (vide presentations, face), 
 169, 184, 186. 
 
 abnormal mechanism of, 188. 
 
 causes of, 184, 481, 487. 
 
 configuration of head in, 189. 
 
 craniotomy in, 418. 
 
 descent in, 186. 
 
 development of, 64. 
 
 diagnosis of, 190. 
 
 extension of fetal head in, 186. 
 
 external rotation in, 188. 
 
 flexion of foetus in, 188. 
 
 forceps in, 381. 
 
 frequency of, 184. 
 
 heart-sounds in, 103. 
 
 mechanism of, 186. 
 
 membranes, preservation of, in, 191. 
 
 mistaken for breech, 191. 
 
 perforation in, 418. 
 
 prognosis in, 191. 
 
 prolapse of cord in, 630. 
 
 rotation of foetus in, 187. 
 
 treatment of, 191. 456. 
 F;dlopian tubes, 12, 19, 30. 
 
 ampulla of, 19. 
 
 anatomy of, 19, 30. 
 
 cylindrical ciliated epithelium in 21,42 328. 
 
 Fallopian tubes : 
 
 dilatation of, in atresias, 541. 
 
 fecundation in, 42. 
 
 fimbnae of, 19. 
 
 in extra-uterine pregnancy, 328. 
 
 infundibulum of, 42. 
 
 isthmus of, 19. 
 
 mucous membrane of, 21. 
 
 muscles of, 20. 
 
 non-erectility of, 41. 
 
 ostium abdominale of, 19. 
 
 position of, in pregnancy, 79. 
 Famine, causing abortion, 308. 
 Faradism : 
 
 in emesis of pregnancy, 117. 
 
 in extra-uterine pregnancy, 345. 
 
 in post-partum hiBmorrhage, 588. 
 Fascia, pelvic, 161. 
 Fat, in abdominal wall, obscuring pregnancy, 
 
 102. 
 Fat, development of, 65. 
 Fatty degeneration of fcetus, 306. 
 Fecundation, 42-44. 
 
 changes in ovum after, 44. 
 Feeding, artificial, of infants, 257. 
 
 natural, of infants, 254. 
 Faeces, of infants, 251. 
 Fever : 
 
 malarial, complicating pregnancy, 264. 
 complicating the puerperal state, 653. 
 
 milk, 247. 
 
 puerperal, 653 (vide puei-peral fever). 
 
 relapsing, in pregnancy, 264. 
 
 scarlet, complicating pregnancy, 262. 
 
 typhoid, in pregnancy, 264. 
 
 typhus, in pregnancy, 264. 
 Fibroid tumors, differential diagnosis of, 
 from pregnancy, 101. 
 
 of placenta, 290. 
 Fillet, use of, in breech and foot cases, 388, 
 391. 
 
 in version, 411. 
 Fimbria? : 
 
 of Fallopian tube, 19. 
 
 ovaricce, 42. 
 Fissure of nipple, 707. 
 Fistulae after Thomas's operation, 449. 
 
 caused by calculi, 537. 
 
 caused by contracted pelvis, 466, 489, 541 
 622. 
 
 caused by slow labor, 368. 
 Flattened pelvis, 465, 469, 474, 512. 
 
 non-rachitic, 474. 
 
 rachitic, 475. 
 irregular, 478. 
 Flatulence in pregnancy, 112. 
 Flexion of fetal head : 
 
 advantages of, 172. 
 
 in contracted pelves, 486.
 
 164: 
 
 INDEX. 
 
 i'lexion of fetal head: 
 in face presentations, 188. 
 in normal presentations, 171. 
 Floor, pelvic or perineal, 159, IGO. 
 Fluctuation, uterine, in prc<rnaucy, 100. 
 iluid, amniotic, 61. 
 anomalies of, 290. 
 composition of, 61. 
 deficiency of, 293. 
 obscuring pregnancy, 95. 
 Foetus : 
 
 abdominal enlargement of, obstructing de- 
 livery, 554. 
 abnormalities of, obstructing delivery of 
 
 trunk, 554. 
 abnormalities of, obstructing labor, 551. 
 adiiesions of, causing dystocia, 556. 
 adipocerous cliangcs in retained, 304, 306. 
 anasarca of, causing dystocia. 555. 
 anchylosis of joints of, 518, 556. 
 ascites of, obstructing delivery, 554. 
 at term, 68, 165. 
 attitude of, 72 et seq. 
 bladder, dilatation of, 554. 
 causes of death of, 308. 
 circulation of, G6-68, 250, 637. 
 configuration of, in breech presentations, 
 
 202. 
 congenital hydrocephalus of, 551. 
 cord of, anomalies and diseases in, 293. 
 cranium of, 70, 165, 551. 
 dead, retention of, in utero, 302. 
 death of. 106, 308. 
 
 from torsion of cord, 294. 
 
 indicating abortion, 350. 
 
 in nephritis, 273. 
 
 producing abortion, 308. 
 degeneration, adipocerous, of, 306. 
 
 calcareous, of, 3<'6. 
 
 fatty, of, 306. 
 
 of liver of, 555. 
 descent of, in labor, 171. 
 development of, 62. 
 
 in successive months, 62. 
 
 in first month, 62. 
 
 m second month, 64. 
 
 in third month, 64. 
 
 in fourth month, 64. 
 
 in fifth month, 64. 
 
 in sixth month, 65. 
 
 in seventh month, 65. 
 
 in eighth month, 65. 
 
 in ninth month, 65. 
 
 in tenth month, 65. 
 diagnosis of death of, 106. 
 diameters of head of, 1 66 et seq. 
 diseases of, obstructing delivery of its head, 
 
 551. 
 ectopia of viscera of, 556. 
 
 Foetus : 
 emphysema of, 555. 
 
 encephaloccle of, obstructing labor, 553. 
 extraction of: 
 
 in breech and foot presentations, 382 et 
 seq. 
 
 in Csesarean section, 440. 
 
 in craniotomy, 419. 
 
 in pelvic presentations, 382 et seq. 
 
 instruments for, 414, 419. 
 
 with head at brim, 398. 
 face of, 70, 105. 
 fatty degeneration of, 306. 
 liexion of, in labor, 171, 172. 188. 
 fontanelles of, 70, 165, 183, 551. 
 funis of, anomalies in, 293. 
 habitual death of, as cause for inducing 
 
 abortion, 350. 
 head of, at term, 70, 105, 165 et seq. {vide 
 
 head, fetal). 
 heart -sounds of: 
 
 in asphyxia, 641. 
 
 in breech presentations, 105. 
 
 in face presentations, 105, 190. 
 
 in head presentations, 105, 183. 
 
 in hydatidiform mole, 301. 
 
 in hydramnion, 292. 
 
 in hydrocephalus, 552. 
 
 in pregnancy, 96, 97, 101, 103, 106. 
 
 in tardy labor, 460. 
 hydrocephalus of, obstructing labor, 551. 
 hydrothorax of, obstructing hilwr, 554. 
 in extra-uterine pregnancy, 340. 
 in first month, 02. 
 in second month, 64. 
 in third month, 64. 
 in fourth to eighth month, 65. 
 in ninth to tenth month, 65. 
 lanugo of, 02, 64, 68, 69. 
 length of, at term, 69. 
 liver of, fatty degeneration of, 555. 
 maceration of, 304. 
 meconium of, 62, 69, 199, 250. 
 monstrosities developed from, 556. 
 movements of, in pregnancy, 75, 95, 96. 
 9S-100, 106. 
 
 active and passive, 96. 
 
 in hydatidiform mole, 301. 
 mummification of, 303, 306. 
 pancreas of, enlarged, 555. 
 papjjracens, 231. 
 positions of, 72, 76, 170. 
 
 classification of, 170. 
 
 first, 76. 
 
 in multipara?, 75. 
 
 in pluriparse, 75. 
 
 occipito-posterior, 170, 179. 
 
 second, 76. 
 presentations of, 72 {vide presentations).
 
 INDEX. 
 
 ro5 
 
 Fo2tus : 
 pressure-marks on head of, 490. 
 putrefiiotion of, iu retention of, 303, 305, 
 
 312. 
 release of arms of, 394. 
 retention, in- titfro^ of dead, 302, 547. 
 rotation of, in labor, 173. 
 sangui)wleiitus^ 304. 
 size of, in succe:^sive months, 02 it seq. 
 spleen of, enlargement of, 555. 
 sutures of, 70, 1G5, 183. 
 tumors of trunk of, obstructing labor, 554, 
 
 555. 
 urine ot, 61, 250. 
 vernix caseosa of, fiS. 
 weight of, at term, 69. 
 Folds, medullary, 48. 
 
 Follicles, Graafian, 23, 35, 36 {dde Graafian 
 follicles), 
 sebaceous, of areola, 88, 99. 
 Fontanelles, 64, 70, 165, 183. 
 closure of, in obstructed labor, 551. 
 in hydrocephalus, 552. 
 large, 70, 166. 
 small, 70, 166. 
 Foot presentations, 169. 
 diagnosis of, 198. 
 extraction in, 382 et seq. 
 management of cord in, 393. 
 Foramen ovale., 66, 68, 250. 
 after birth, 250. 
 valve of, 66, 68. 
 Foramen, obturator, 158, 159. 
 Forceps, 361. 
 action of, 365. 
 after-coming head, to, 399. 
 anaesthetics in application of, 367. 
 application of, 369, 376. 
 
 to after-coming head, 399. 
 asphyxia from, 639. 
 at the pelvic brim, 375. 
 at the pelvic outlet, 36s. 
 blades, introduction of, 369, 376. 
 breech, of Miles, 388. 
 Chamberlen's, 361. 
 Chapman's, 362. 
 contrasted with version and craniotomy, 
 
 493 et seq. 
 craniotomy of Meigs, modified, 429. 
 deliveries by, preparation for, 366. 
 douche, before, 367. 
 Hodge's, 365, 420. 
 liistory of, 361. 
 in abortion, 356. 
 in atony of uterus, 368. 
 in brow presentations, 197. 
 in contracted pelvis, 497, 503, 508. 511 et 
 
 seq. 
 in craniotomy, 419. 
 
 Forceps : 
 
 in death of mother, 651. 
 
 indications for, 366, 369, 545, 651. 
 at pelvic outlet, 368. 
 
 in double vagina, 538. 
 
 in eclampsia, 581. 
 
 in face presentations, 381. 
 
 in foot and breech presentations, 388. 
 
 in heart-disease, 268. 
 
 in multiple pregnancy, 235. 
 
 in occipito-posterior positions, 379. 
 
 in placenta pricvia, 603. 
 
 in premature labor, 356. 
 
 in prolapse of funis, 631. 
 
 in prolapse of vagina, 283. 
 
 in protracted second stage of labor, 457, 
 458, 460. 
 
 in rupture of uterus, 617. 
 
 introduction of blades of, 369, 376. 
 
 in Thomas's operation, 450. 
 
 in vaginal prolapse, 283. 
 
 in vaginal thrombus. 627. 
 
 lacerations from, 621. 
 
 Levret's, 364. 
 
 locking of, 372. 
 
 long, 363. 
 
 Lusk's modification of Tamier's, 378, 379. 
 
 Naegele's, 364. 
 
 operation of introduction of, 369, 376. 
 
 ovum-, use of, in alwrtion, 324. 
 
 position for, 367. 
 
 preparation for delivery by, 366. 
 
 removal of, 374. 
 
 selection of, 362, 365. 
 
 short, 362. 
 
 Simpson's, 364, 379. 
 
 S'l'ellie's, 363. 
 
 Tarnier's, 377, 390, 400, 513, .'^81. 
 
 Tarnier's, modified by Lusk, 378. 379. 
 
 Taylor's, at brim, 377, 513. 
 
 Taylor's narrow-bladed, 377, 414. 
 
 time for application of, 309. 
 
 traction on, direction of, 366, 372, 373, 377. 
 
 volsellar 432. 
 
 "Wallace's, 365. 
 
 White's. 305. 
 Forces, expellent, action of, 135. 
 
 anomalies of, 452. 
 Fornix, 9, 613. 
 
 laceration of, 621. 
 Forehead, spots on, in pregnancy, 91. 
 Fourchette, 4. 
 
 Fov.ier's solution in nausea, 117. 
 Fractures, caused by contracted pelvis, 491. 
 
 causing pelvic deformities, 533. 
 Frenulum clitoridis, 4. 
 frenulum. viilva.i 4. 
 in pregnancy, 105. 
 
 laceration of, iu labor, 134.
 
 '60 
 
 INDEX. 
 
 Ftaiidus of uterus, 12. 
 development of, 30. 
 Fungi in milk, 258. 
 Funic souffle, 98. 
 
 Fimis, 60, 64 (vide cord, umbilical), 
 anomalies of, 293 ei seq. 
 arteries of, 60, 61. 
 calcareous degeneration of, 298. 
 care of, in abortion, 326. 
 
 in infants, 256. 
 coiling of, 204, 215, 296. 
 cysts in, 297. 
 diseases of, 297. 
 expression of, 630. 
 formation of, 60. 
 fully developed, 61. 
 gelatin of, 61. 
 iiiemorrbage from, 453. 
 hernias of, 296. 
 in puerperal state, 250. 
 knots in, 295. 
 
 laceration of, in precipitate labor, 453. 
 length of, 61. 
 ligation, late, of, 216. 
 management of, in breech presentations, 
 
 393. 
 marginal insertion of, 298. 
 presentation ot, 629. 
 prolapse of, 510, 561, 629. 
 
 diagnosis of, 630. 
 
 in breech cases, 204. 
 
 prognosis of, 630. 
 
 treatment of, 631, 
 
 postural, 632. 
 
 reposition of, 631 ei seq. 
 
 by instruments, 634. 
 
 by postural treatment, 632. 
 shortness of, causing dystocia, 559. 
 -souffle in, 98. 
 stenosis of vessels of, 297. 
 structure of, 61. 
 torsion of, 293. 
 tying, in labor, 215, 236. 
 vein of, 60, 61. ♦ 
 
 vessels of, 60, 61. 
 Funnel-shaped pelvis, 528. 
 
 Gait, feminine, 154. 
 
 Galactocele, 712. 
 
 Galacton-hoea, 706. 
 
 Galvanism, in extra-uterine pregnancy, 345. 
 
 Galvanization to produce premature labor, 
 
 355. 
 Gal vano - cautery, in Thomas's operation, 
 
 451. 
 Ganglion, cervical, 27, 77, 126, 127. 
 
 in pregnancy, 77, 127. 
 Gangrene, from oedema of pregnancy and 
 
 labor, 115, 536. 
 
 Gastrotomy (tide Ciesarean section) : 
 in puerperal peritonitis, 699. 
 
 in uterine rupture, 618. 
 Gauze, iodoform, in puerperal state, 688. 
 Gelatin of Wharton, 61. 
 Gelseniium, in face-ache, 122. 
 Generation : 
 
 anatomy of female organs of, 1. 
 
 development of lemale orgau.s of, 29, 48. 
 Genital canal : 
 
 atresia of, 535. 
 symptoms of, 541. 
 
 ruptures of, 610 {ride lacerations). 
 
 uterine atresia of, 539. 
 
 vaginal atresia of, 536. 
 
 vulvar atresia of, 535. 
 Germinative spot, 39. 
 Germinative vesicle, 39, 45. 
 
 disappearance of, 45. 
 Germs in puerperal fever : 
 
 bacteria, 666 et seq., 681, 689. 
 
 micrococci, 666 etseq., 681, 689. 
 Gill Wylie's treatment of emesis, 120. 
 Glandulm vestibulares : 
 
 majores, 6. 
 
 minores, 5. 
 Glands : 
 
 Bartholin's, 6. 
 
 cervical, 19. 
 
 decidual, 125. 
 
 Duverney's 6. 
 
 labial, 5. 
 
 mammary, anatomy and chancres of, in 
 pregnancy, 87, 88, 90, 94, 99, 105, 106, 
 247. 
 
 mucous, of the vulva, 5. 
 
 salivary, activity of, in pregnancy, 90, 94, 
 99, 118, 121. 
 
 sebaceous, of the nympha?, 5. 
 of areola, 88. 
 
 thyroid, changes in, during pregnancy, 89. 
 
 uterine, 18. 
 pod-paHum, 242. 
 
 vaginal, 10, 162. 
 
 vulvar, 5, 162. 
 Glans clitoridis, 3. 
 Goitre, in pregnancy, 89. 
 Graafian follicles, 23, 35, 36. 
 
 developed, 38. 
 
 discuf prolic/erus in, 37. 38. 
 
 macula of, 39. 
 
 memhrana r/ranvlosa of, 37« 
 
 memhrana propria of, 37. 
 
 number of, 38, 39. 
 
 stigma of, 39. 
 
 theca follimli of, 36, 38. 
 
 tunica fihrosa of, 36, 38. 
 
 tunica propria of, 30, 38. 
 
 young, 38.
 
 INDEX. 
 
 767 
 
 I 
 
 Gravid uterus : 
 
 anteflexion of, 116, 278. 
 
 anteversion of, 80, 278. 
 
 hernia of, 283. 
 
 prolapse of, 282, 359. 
 
 retroflexion of, 116, 279, 369. 
 with incarceration, 280, 359. 
 treatment of, 280. 
 
 retroversion of, 116, 279. 
 Gravitation, causing head presentations, 74. 
 Groove, primitive, 48. 
 Guarana, in cephalalgia, 122. 
 Gummata, placental, 290. 
 
 Ilwmatoma : 
 
 in uterine rupture, 615. 
 Hremoglobin in pregnancy, 89. 
 Hair, development of, 48, 64, 65. 
 Hallucinations, in emesis of pregnancy, 118. 
 Hand, selection of, for version, 406, 407. 
 Haamatocele, in extra-uterine pregnancy, 339. 
 Hematoma tubce, 339. 
 
 vulvar, 536. 
 Hsemorrhage : 
 accidental, 594, 597, 60G. 
 concealed, 600. 
 external, 606. 
 
 forceps indicated by, 366, 375. 
 from cervical laceration, 620. 
 from normally implanted placenta, 603. 
 in abortion, 309, 311, 312, 313, 319, 320, 325, 
 
 326. 
 in Cuesarean section, control of, 440. 
 in contracted pelvis, 488, 491. 
 ill extra-uterine pregnancy, 327, 338, 339. 
 in labor, third stage of, 134. 
 in multiple pregnancy, 236. 
 in placenta praevia, 597, 599, 601, 605. 
 internal, 606. 
 
 in Thomas's operation, 449, 451. 
 in uterine cancer, 547. 
 in vaginal thrombus, 627. 
 post-partuTn, 249, 581. 
 anodynes in. 585. 
 armamentarium for, 585. 
 astringents in, 587, 622. 
 causes of, 279, 569, 583, 620, 622, 627. 
 chlorofoi-m, efl'ept of, on, 227, 623. 
 disturbances of contractility as cause of, 
 
 583. 
 disturbances of retractility as cause of, 
 
 584. 
 disturbances of thrombus formation, caus- 
 ing, 584. 
 electricity, use of, in, 588. 
 ergot in, 461. 
 
 in contracted pelvis, 492, 495. 
 in double uterus, 278. 
 in fevers, 264. 
 
 Haemorrhage : 
 
 in forceps-deliveries, 372. 
 
 in hydramnion, 292. 
 
 in lacerations, 620. 
 
 in multiple pregnancy, 236. 
 
 in placenta prsevia, 601, 605. 
 
 in premature labor, 309, 311, 312, 313, 319, 
 325, 326, 339. 
 
 in precipitate labor, 453. 
 
 intra-uterine injections in : 
 of iodine, 587. 
 of iron, 587. 
 
 in uterine tumors, 542, 543, 547. 
 
 methods of producing uterine contractions 
 in, 585. 
 
 methods of producing uterine retractions 
 in, 589. 
 
 normal agencies for checking, 582. 
 
 outlying causes of, 5y4. 
 
 symptoms of, 589. 
 
 transfusion of blood in, 590. 
 
 transfusion of milk in, 590. 
 
 treatment of, 461, 585, 622, 627. 
 
 treatment of cerebral anaemia in, 589. 
 pueqieral, 592. 
 
 astringents in, 592. 
 
 treatment of, 592. 
 unavoidable, 597, 606. 
 vinegar in, 588. 
 Haemorrhoids, in pregnancy, 88, 115, 130. 
 
 in puerperal state, 254. 
 Head, fetal, 70, 165. 
 after-coming, forceps applied to, 399. 
 
 perforation of, 418. 
 articulations of, with spine, 168. 
 at term, 165. 
 base of, 165. 
 circumference of, 168. 
 configuration of, in breech presentations, 
 200, 396, 399. 
 
 in brow presentations, 194. 
 
 in contracted pelvis, 489. 
 
 in face presentations, 189. 
 
 in vertex presentations, 180. 
 descent and extension of, in face presenta- 
 tions, 186. 
 descent and flexion of, in labor, 171, 486. 
 development of, 63-65. 
 diameters of, 166 et seg. 
 diseases which obstruct delivery of, 551. 
 entrance of, into pelvis, 171. 
 extension of, in labor, 177. 
 external rotation of, in face presentations 
 
 188. 
 external rotation of, in labor, 177. 
 extraction of, in breech cases, 396, 398. 
 flexion of, in face presentations, 188. 
 fontanelles of, 64, 70, 165, 183. 
 molding of, in vertex presentations, 179.
 
 768 
 
 INDEX. 
 
 Head: 
 positions of, 170. 
 pret>eutations, V2-75, 168. 
 
 heait-sounds in, 103. 
 restitution of, 178. 
 rotation of: 
 in breech presentations, 199, 395. 
 in brow presentations, 194. 
 in face presentations, 103, 187. 
 in normal labor, 173. 
 in vertex presentations, 173. 
 scalp-tumor on, 181, 190, 194 (vide caput 
 
 succedaneum). 
 sinking of, 105. 
 sutures of, 1G5. 
 vault of, 1(55. 
 Headache in pregnancy, 122. 
 in eclampsia, 567, 509. 
 post-partum, 24S. 
 Heart : 
 diseases of, complicatiug pregnancy, 89. 
 
 266, 310, 351, 359. 
 hypertrophy of, in pregnancy, 89. 
 sounds, fetal, iu iireguaucy, 96, 97, 101, 103, 
 106, 342, 460, 641. 
 disappearance of, in pregnancy, 105. 
 effect of pains on, 97. 
 frequency of, in the sexes, 97. 
 maximum intensity of, 98. 
 in hydramnion, 292, 293. 
 in hydrocephalus, 552. 
 Heart-burn in pregnancy, 121. 
 Hemicephalus, 559. 
 
 Hemisjjheres, cerebral, development of, 50, 63. 
 Hernia : 
 congenital, 550. 
 of cord, 296. 
 of gravid uterus, 283. 
 of vagina, atresia from. 537. 
 of vulva, 538. 
 Hiatus sacral is, 142. 
 Hilum, of ovary, 22. 
 Hips, Avidening of, in pregnancy, 86. 
 Hodge's forceps, 365, 420. 
 Hook: 
 
 blunt, 388, 393, 430. 
 in breech and foot cases, 388, 393. 
 in craniotomy, 430. 
 Braun's decapitating, 433. 
 Ramsbotham's decapitating, 434. 
 Taylor's, 430. 
 Hospitals, maternity, 686 et seq. 
 Hottentot apron, 4. 
 
 Hour-L'lass contraction of uterus, 224, 462. 
 Hydatidiforin mole, 231, 298. 
 abortion in, 301. 
 anatomy, morbid, of, 298. 
 diagnosis of. 301. 
 etiology of, 300. 
 
 Hydatidiform mole : 
 
 prognosis ot, 301. 
 
 symptoms of, 301. 
 
 treatment of, 302. 
 Hydatids, pelvic, causing atresia, 538. 
 Hydraemia of pregnancy, 89, 115, 280, 574. 
 Hydramnion, 75, 95, 103, 2'dO. 
 
 as cause for abortion, 124. 
 
 as cause of precipitate labor, 292. 
 
 as cause of tardy labor, 455, 584. 
 
 diagnosis of, 293. 
 
 etiology of, 290. 
 
 indicating abortion. 351. 
 
 in hydioceplialus, .552. 
 
 obscuring pregnancy, 95, 103. 
 
 prognosis of, 293. 
 
 symptoms and signs of, 292. 
 
 treatment of, 293, 456. 
 in labor, 456. 
 Hydrocephalus, 551. 
 
 causing uterine rupture, 612. 
 
 diagnosis of, 552. 
 
 etiology of, 5.''.2. 
 
 following premature labor, 349. 
 
 mechani.-ni of labor in, 553. 
 
 morbid anatomy of, 552. 
 
 prognosis in, 553. 
 
 treatment of, 553. 
 HydroiThaia gravidarum, 286. 
 Hydrotliorax, fetal, obstructing labor, 554. 
 Hygiene of i)rcgnancy, 112. 
 Hymen : 
 
 anatomy of, 6. 
 
 annularis, 7. 
 
 atiesia of, 535. 
 
 cribj'ijormis, 7. 
 fimhriatus, 7. 
 
 imperforatus, 7. 
 
 in pregnancy, 105. 
 
 in puerperal state, 249. 
 Hyoscyamus in insomnia, 122. 
 Hypertemia, venous, in pregnancy, 115. 
 Hyperosmia in pregnancy, 118. 
 Hypertrophy, of uterine mucous membrane, 
 
 causing abortion, 310. 
 Hypnotics in pregnancy, 122. 
 Hypoblast, 47, 48, 50. 
 Hypobla^tic spheres, 46. 
 Hysterectomy, for myoma, 544. 
 Hysteria, in pregnancy, 114, 708. 
 Hysterotomy, 424 (vidt Cesarean section). 
 
 in hernia of uterus, 284. 
 
 Ice, use of, in nausea of pregnancy, 117, 119. 
 
 in haemorrhage, 587, 588. 
 
 in mastitis, 711. 
 
 in puerperal fever, 698. 
 Icterus : 
 
 abortion in, 266.
 
 INDEX. 
 
 TOO 
 
 Icterus : 
 
 in pregnancy, 266. 
 
 neonatorum, 219, 250. 
 Ileus, due to retroflexed gravid uterus, 280. 
 Ilia, anatomy of, 142, 143, 150, 468. 
 Ilio-pectineal line, 144. 
 Imperforate anus, 250, 296. 
 Impregnation, 42-44 {vidu fecundation). 
 Incarceration of retrofle.xcd gravid uterus, 
 116, 279, 359. 
 
 of prolapsed uterus, 282. 
 
 treatment of, 280, 316, 359. 
 Incisions, vulvar, in labor, 214. 
 Incontinence of urine in pregnancy, 88, 279. 
 Incubator : 
 
 Crede's, 357. 
 
 Tarnier's, 353. 
 Indigestion in pregnancy, 88, 90, 114. 
 Inertia uteri, 454. 
 
 causes of, 282, 292, 455, 598. 
 
 treatment of, 456. 
 Infant, new-born, 250 {vide newly born 
 child). 
 
 artificial feeding of, 257. 
 
 bath of, 25G. 
 
 bottle for, 259. 
 
 breasts of. 250. 
 
 cafut succedaneum of, 181, 190, 250. 
 
 cardiac ventricle of, 250. 
 
 care of, 256, 356. 
 
 care of bottle of, 259. 
 of cord of, 256. 
 
 changes in circulation of, 216, 250. 
 
 circulation of, affjcted by thoracic as^sira- 
 tion, 218. 
 
 cord, late ligation of, in, 216. 
 
 digestion of, 250. 
 
 ductus arteriosus of, 250. 
 
 faces of, 25L 
 
 foramen ovale of, 250. 
 
 icterus of, 219, 250. 
 
 loss of weight of, 251. 
 
 meconium of, 250. 
 
 navel of, 250. 
 
 nursing of, 254. 
 
 ophthalmia of, 712. 
 
 selecting wet-nurse for, 256. 
 
 skin of, 250. 
 
 sprue in, 259. 
 
 tumor on presenting part of, 250. 
 
 umbilicus of, 250. 
 
 urine of, 250, 251. 
 
 weight, loss of, in, 251. 
 
 wet-nurse for, '.i56. 
 Inforctions, puerperal, 608. 
 Infarctions, placental, 288. 
 Infectious diseases complicating pregnancy, 
 
 260. 
 Infundibulum tuh<z, 42. 
 49 
 
 Injections : 
 between uterus and ovum, to produce abor- 
 tion, 352. 
 hypodermic, 
 in anaemia, cerebral, 590. 
 in embolism, pulmonai-y, 650. 
 intra-uterine, in post-partum haemorrhage, 
 
 587. 
 intra-uterine, in puerperal fever, 688, 693, 
 694. 
 in puerperal haemorrhage, 592. 
 vaginal, 
 after removal of retained placenta, 594. 
 in protracted first stage of labor, 457,502. 
 to prevent puerperal fever, 687, 688, 692, 
 
 699. 
 to produce abortion, 354. 
 Inoculation, causing puerueral fever, 683. 
 lusalivation in pregnancy, 90, 94, 99, 118, 
 
 121. 
 Insanity : 
 in pregnancy, 91, 114, 701. 
 of lactation, 701, 703. 
 puerperal, 701, 703. 
 Insertion, marginal, of cord, 298, 630. 
 Insomnia in pregnancy, 122, 292. 
 Insufflation in aspTajxia neonatorum, 643. 
 Internal version, 401, 405. 
 Interstitial pregnancy, 332. 
 Intestine : 
 
 development of, 48, 50, 63. 
 Intoxication, putrid, 666. 
 Inversio uteri, 607. 
 
 treatment, 608. 
 Involution, uterine, 240. 
 Iodine, injection of, 693. 
 
 in post-partum hiiemorrhage, 587. 
 Iodoform gauze, use of. imst partum, 592, 688, 
 7C0.^ 
 in haemorrhage, 589, 592. 
 Iodoform in pelvic abscess, 700. 
 Iodoform suppositories, in puerjieral state, 
 
 694. 
 Iron : 
 injection of, in post-partum, haemorrhage, 
 587. 
 in puerperal fever, 693. 
 in puerperal ha>morrhage, 587. 
 in albuminuria, 577. 
 in chorea, 275. 
 in hydatid mole, 302. 
 in phlegmasia, 706. 
 in pregnancy, 114, 122. 
 Ischia, anatomy of, 142, 144. 
 spine of, 145, 153. 
 tuberosity of, 145. 
 Ischio-cavernosus, 162, 163. 
 Ischuria, in vaginal thrombus, 626. 
 Isthmus of Fallopian tube, 19.
 
 •770 
 
 INDEX. 
 
 Jaundice : 
 
 in new-born child, 250. 
 
 in pregnancy, 266. 
 Jaws, development of, 64. 
 Joints : 
 
 anchylosis of letal, obstructing labor, 556. 
 
 mobility of pelvic, in labor, 148, 275. 
 
 pelvic, 145, 275. 
 
 sacro-iliac, 145. 
 
 Kidneys : 
 
 cystic degeneration of fetal, 554. 
 
 diseases of, indicating abortion, 359. 
 
 pathological changes of, in eclampsia, 569 
 et seq. 
 Kiesteine, 94. 
 
 Knee, diagnosis of, from elbow, 199. 
 Knots in umbilical cord, 295. 
 Koumyss, in emesis of pregnancy, 117. 
 Kyphotic pelvis, 479, 519. 
 
 Labia, changes in, during pregnancy, 86. 
 
 adhesions of, 535. 
 Labia mojora, 2, 64. 
 
 changes in, during gestation, 86, 104, 105, 
 115, 131. 
 
 commissures, anterior and posterior, of, 3. 
 
 development of, 64. 
 
 gangrene of, 536. 
 
 hernia of, 538. 
 
 oedema of, in pregnancy and parturition, 
 86, 115, 131, 134, 249, 536, 567, 577. 
 
 thrombosis of, 5, 536, 625. 
 Labia 7ninora^ 3. 
 
 sebaceous glands of, 5. 
 
 post partum, 249. 
 Labor, 123. 
 
 action of abdominal muscles in, 129. 
 
 action of expellent forces in, 135. 
 
 action of pains on uterine walls in, 128. 
 
 action of vagina in, 129. 
 
 aniemia in, 645. 
 
 anoesthetics in, 225. 
 
 antisepsis in, 225, 688 et seq. 
 
 armamentarium for, 206. 
 
 bag of waters in, 132. 
 
 bed, preparation of, lor, 206. 
 
 cancer of cervix in, 547. 
 
 catheterization in, 208. 
 
 causes of, 123. 
 
 cer\ical dilatation in, 131, 137, 139. 
 
 cervical laceration in, 131. 
 
 chill in, 134. 
 
 chloroform in, 210, 226. 
 
 clinical course of, 123, 130. 
 
 collapse in, 645, 648. 
 
 contraction of uterine ligaments in, 128. 
 
 contractions, uterine, in, 127, 131, 135, 
 462. 
 
 Labor : 
 
 painless, causing cervical dilatation, 81, 
 130 et seq. 
 cord, care of, in, 215. 
 date, computation of, 108-111. 
 death, sudden, in, 645, 650. 
 detinition of, 1 23. 
 deliiiuni in, 701. 
 dry, 455. 
 
 duration of, 135, 207. 
 eclampsia in, 567. 
 enemata in, 208. 
 episiotomy in, 214. 
 ergot in, 224, 457, 458, 4G0, 461, 511. 
 ether in, 226. 
 examination in, 99, 206, 
 expulsion of trunk in, 178. 
 extension of head in, 177. 
 external rotation in, 177, 188, 201. 
 faintness in, 134. 
 false, 464. 
 fever in, 464. 
 forceps in, 369. 
 
 haemorrhage in third stage of, 134. 
 labia in, 131. 
 
 laceration of frsenulum in, 134. 
 laceration of perina?um in, 134. 
 mechanism of, 140, 168. 
 
 abnormal, in vertex presentations, 179. 
 
 in abnormal face presentations, 188. 
 
 in breech presentations, 199. 
 
 in brow presentations, 194. 
 
 in contracted pelvis, 484, 495, 502. 
 
 in face presentations, 186. 
 
 in irregular breech presentations, 201, 
 5G4. 
 
 in noiTnal presentations, 171. 
 
 in occipito-posterior positions, 179. 
 
 witli monstrosities, 557. 
 
 normal, 171. 
 
 descent and flexion in, 171. 
 rotation in, 173. 
 extension in, 177. 
 external rotation in, 177. 
 restitution in, 178. 
 expulsion of tnnik in, 178. 
 metritis in, 464. 
 missed, 304, S05. 
 natural, 169, 171. 
 normal, 171, 205. 
 
 anaesthetics in, 210, 225, 268, 457. 
 
 armamentarium for, 206. 
 
 bed in, 206. 
 
 care of patient after, 224. 
 
 chloroform in, 226, 457. 
 
 conduction of, 205. 
 
 cord, care of, in, 215. 
 
 delivery of shoulders in, 178, 199, 215, 
 396.
 
 INDEX. 
 
 Yn 
 
 Labor : 
 
 duration of, 207. 
 
 enema in, 208. 
 
 examination of patient in, 206. 
 
 nianajrement of first stage of, 208. 
 
 management of second stage of, 209. 
 
 management of third stage of, 220. 
 
 placental period of, 134. 
 
 posture in, 208-210. 
 
 preliminary preparations for, 205. 
 
 preservation of perinteum in, 193, 210. 
 
 retention of urine in, SOS. 
 
 treatment of lacerations after, 224. 
 
 tying cord in, 215. 
 obstructed, 551 (vide obstructed labor), 
 cedema in, 130, 368. 
 painful, 463. 
 
 anajsthetics in, 463. 
 
 cessation of, alter diaphoresis, 463. 
 
 from hysteria, 463. 
 
 from inflammation of or around genital 
 organs, 464. 
 
 fiom intestinal irritation, 464. 
 
 from rheumatism, 463. 
 painless, 130. 
 pains of, 127, 129, 452. 
 
 contracted pelvis affecting, 481. 
 
 influence of, on organism, 130. 
 pathology of, 452. 
 
 pelvis, contracted, complicating, 479. 
 phenomena, clinical, of, 123, 130. 
 physiology of, 123, 127. 
 posture in, 20S-210. 
 precipitate, 453. 
 
 consequences of, 453. 
 
 in hydramnioft, 292. 
 
 treatment of, 453. 
 prediction of date of, 108-111. 
 premature, 307, 349, 500 {vide abortion). 
 
 care of child after, 356. 
 
 catheterization of uterus to produce, 351. 
 
 choice of methods to produce, 356. 
 
 from puncture for oedema of pregnancy, 
 115. 
 
 in anaemia of pregnancy, 115. 
 
 in cholera, 264. 
 
 in heart diseases, 268. 
 
 indications for, 349, 500, 578, 600, 616. 
 
 induction of, 349. 
 
 in eraesis of pregnancy, 119. 
 
 injections between uterus and ovum to 
 produce, 352. 
 
 mechanical dilatation of cervix to pro- 
 duce, 353. 
 
 operations lo produce, 351. 
 
 rupture of membranes to produce, 353. 
 
 tampon, vaginal, to produce, 355. 
 
 time for, 349. 
 
 vaginal douche to produce, 354. 
 
 Labor : 
 preparations for, 205. 
 preservation of perina^um in, 210 et seq. 
 pressure of uterus in, 140. 
 pulse in, 130, 464. 
 
 rupture of membranes in, 132, 140, 208. 
 stage of: 
 
 first, 131. 
 
 anesthetics in, 226. 
 
 anodynes in, 456. 
 
 bloody discharge in, 131. 
 
 influence of contracted pelvis on, 483, 
 495, 502. 
 
 irregular pains in, 454. 
 
 management of, 208, 454. 
 
 pains in, 131. 
 
 posture in, 208-210. 
 
 treatment of long, 456, 650. 
 second, or stage of expulsion, 133. 
 
 auEesthetics in, 210, 225. 
 
 forceps in, 369. 
 
 irregular pains in, 459. 
 
 management of, 209. 
 
 pains in, 133. 
 
 perinagum m, 134, 210 et seq. 
 
 posture in, 210. 
 
 treatment of long, 459. 
 
 urethra in, 134. 
 
 third or placental period, 134. 
 anipsthetics in, 227. 
 atony in, 458. 
 chill in, 134. 
 
 in multiple pregnancy, 232. 
 irregular pains in, 461. 
 management of, 220, 461. 
 symptoms, precursory, of, 130. 
 syncope in, 134, 645. 
 tardy, 453. 
 
 anodynes in, 456. 
 
 Barnes's dilator in, 457, 458. 
 
 bougies in, 457. 
 
 causes of, 455. 
 
 douche, vaginal, in, 457, 458. 
 
 ergot in, 458, 460. 
 
 expression in, 459. 
 
 hour-glass contractions of uterus in, 462. 
 
 in double uterus, 278. 
 
 irregular pains in first stage of, 454. 
 
 irregular pains in second stage of, 459. 
 
 irregular pains in third stage of, 461. 
 
 quinia in, 458. 
 
 treatment of, 456, 459, 462. 
 
 •with short cord, 560. 
 temperature in, 130, 464. 
 theory of causes of, 127. 
 time of beginning of, 108-111, 123. 
 tumors, ovarian, in, 550. 
 tumors, uterine, complicating, 542. 
 unnatural, 169.
 
 772 
 
 INDEX. 
 
 Laboi ; 
 
 urine, mcreasc of, in, 136. 
 
 uterine contractions in, 1'27, 131, 135, 462. 
 
 uterine retraction in, 138. 
 
 uterine ligaments : 
 contraction of, in, 128. 
 
 uterus, descent of, in, 130. 
 
 vagina, inliucnce of, on, 129, 131. 
 Laceration : 
 
 at vaginal orifice, 484, 536, 622, 625. 
 
 in foot and breech cases, 383. 
 
 of cervix, in labor, 105, 131, 203, 354, 372, 
 377, 453, 539, 540, 620. 
 treatment of, after labor, 224. 
 
 of frenulum in labor, 134, 622. 
 
 of genital canal, 610. 
 
 of perinaium, 134, 203, 210-214, 224, 249, 
 622. 
 treatment of, after labor, 224. 
 
 of uterus, 010, 620. 
 
 of vagina, 453, 484, 543, 621, 622. 
 
 of vestibulum, 622. 
 Lactation, 240. 
 
 fever of, 247. 
 
 in cholera, 264. 
 
 insanity of, 701, 703. 
 
 of pregnancy, 94, 701. 
 Laminaria tents, 353. 
 Lanugo, 62, 64, 65, 68. 
 Laparo-elytrotoniy, 436, 447. 
 
 details of operation for, 449. 
 
 Lffimorrliage, control of, in, 449, 451. 
 
 history of, 447. 
 
 prognosis of, 448. 
 
 in contracted pelvis, 494. 
 Laparotomy {vide gastrotomy) : 
 
 in extra-uterine pregnancy, 343, 344, 346. 
 
 in puerperal peritonitis, 699. 
 
 in uterine rupture, 018. 
 Lateral plates, 49. 
 Laxatives : 
 
 in albuminuria, 578. 
 
 in icterus neonatorum, 251. 
 
 in puerperal fever, 696. 
 
 in puerperal state, 254. 
 Leeches : 
 
 fecundation of ovum of, 44. 
 
 in puerperal fever, 695. 
 Length of foetus at term, 69. 
 Levator ani, 159, 214. 
 Liffamenta lata, 14. 
 Ligaments : 
 
 broad, 14. 
 
 contraction of, in labor, 128. 
 
 pelvic, 146. 
 
 pubo-vesical, 161. 
 
 recto-uterine, 15. 
 
 round, 16. 
 
 sacro-sciatic, 147. 
 
 Ligaments: 
 
 uterine, contraction of, in labor, 128. 
 
 vesico-uterine, 15. 
 Ligameritum : 
 
 arcuatum, 470. 
 
 ovarii, 16. 
 
 teres, 16. 
 Ligation, late, of cord, 216 el seq. 
 Linea alba, post partvm, 249. 
 Linea termi/ialis, 144, 151. 
 Lip, anterior cervical, obliteration of, in preg- 
 nancy, 83, 105. 
 
 uterine atresia, by, 540. 
 Lips, development of, 64. 
 Liquor aninii, 61. 
 
 escape of, in abortion, 320. 
 Lithopaidion, 303, 327, 337, 340. 
 Liver : 
 
 acute atrophy of, 266. 
 
 disease of, causing abortion, 310. 
 
 degeneration of fetal, 555. 
 Lochia, 241, 245, 249, 252, 255, 684, 689. 
 
 alba, 245. 
 
 inabortio'j, 320, 325. 
 
 in cholera, 263. 
 
 lactea, 245. 
 
 quantity of, 245. 
 
 rubra, 245, 255. 
 
 serosa, 245. 
 Locking : 
 
 of children in multiple pregnancies, 234. 
 
 of forceps, 372. 
 Locomotion : 
 
 impeded, in labor, 130. 
 in pregnancy, 88. 
 Longings in pregnancy, 90, 112. 
 Lungs, development of, 48. 
 
 abortion from disease of, 310, 351, 359. 
 
 capacity of, in pregnancy, 'JO. 
 Lusk's modified Tarnier forceps, 378, 379. 
 Lutein cells, 40. 
 Lying-in period : 
 
 duration of, 255. 
 Lymphatics of uterus. 28, 77. 
 
 inflammation of, in puerperal fever, 657. 
 679. 
 
 of pelvis, in pregnancy, 29. 
 
 Maceration : 
 
 of fattus, 304. 
 Magnesia, for emesis, 121. 
 Malarial fever complicating pregnancy, 122, 
 264. 
 
 causing abortion, 264. 
 
 in puerperal state, 653. 
 Malformations (vide monstrosities) : 
 
 of child, 556. 
 Mamma : 
 
 acini of, in pregnancy, 87, 247.
 
 INDEX. 
 
 773 
 
 Mamma : 
 
 anatomy of, 87, 246. 
 
 areola of, 88, 90. 
 in pregnancy, 87, 88, SO, 94, 99, 105. 
 in puerperal state, 249. 
 secondary, 88. 
 
 chancres of, in pregnancy, 87, 88, 90, 94, 99, 
 105. 
 
 diseases of, 706 et seq. 
 
 in case of fetal deatb, 1-06. 
 
 lines on, in pregnancy, 88, 105. 
 
 nipple, ercctility of, 88. 
 
 secretion of milk in, 246. 
 
 signs of pregnancy relating to, 87, 88, 90, 
 94, 105. 
 
 veins of, in pregnancy, 87, 94, 99. 
 Mania {vide insanity) : 
 
 etiology of, 569, 701, 702. 
 
 in pregnancy, 91, 114. 
 
 prognosis of, 702. 
 
 puerperal, 701. 
 
 treatment of, 702. 
 Manipulation, conjoined, in pregnancy, 104. 
 Marasmus, in pregnancy, 114, 118. 
 Marc's cliorion, villi of, 55. 
 Marginal insertion of cord, 298. 
 Marital relations in pregnancy, 113, 116, 317. 
 Mastitis, parenchymatous, 709. 
 
 abscesses in, 709. 
 Maternity hospitals, appointments of, 686. 
 Meatus X(rethrce^ 5. 
 Meconium, 62, 69, 199, 250, 641. 
 Mechanism : 
 
 abnormal, in vertex presentations, 179. 
 
 of abnormal face presentations, 188. 
 
 of breech presentations, 199, 487. 
 
 of breech presentations, irregularities in, 
 201. 
 
 of brow presentations, 194. 
 
 of dilatation of cervix, 131 
 
 of face presentations, 184, 186. 
 
 of labor, 140, 171. 
 effect of contracted pelvis on, 484, 495. 
 
 of normal labor, 171. 
 
 of occipito-posterior positions, 179. 
 
 with monsters, 557. 
 Medulla, development of, 50. 
 Medulla, of ovary, 23. 
 Medullary folds, 48, 49. 
 Medullary groove, 49. 
 Medullary tube, 50. 
 Melancholia {vide insanity) : 
 in pregnancy, 91, 701, 703. 
 treatment of, 702. 
 Membrana granulosa, 37, 38. 
 Membrana propria, 36, 37. 
 Membrane, mucous : 
 of cervix, 19, 81, 95. 
 of ovary, 23, 36. 
 
 Membrane, mucous: 
 
 of tubes, 21, 42, 329. 
 
 of uterus, 18-20, 77, 81, 242. 
 
 of vagina, 10, 85, 104. 
 Membranes : 
 
 adhesion of, 455. 
 
 artificial rupture of, in labor, 208, 580. 
 
 preservation of, in face presentations, 191. 
 
 retention of, in abortion, 312. 
 
 rupture of, in abortion, 320. 
 
 rupture of, to produce abortion, 353, 360. 
 
 rupture of, in placenta previa, 603. 
 
 spontaneous rupture of, 132, 140, 208. 
 Memory in pregnancy, 91, 114, 567, 569, 
 
 701. 
 Meningitis in puerperal fever, 669. 
 Menses : 
 
 diminution of, from fear, 93. 
 
 suppression of, in pregnancy, 92, 93, 99. 
 Menstruation, 39 et seq. 
 
 last, as aid to prediction of date of confine- 
 ment, 108. 
 Mesenteric folds, 50. 
 Me.«oblast, 47, 48, 49, 50. 
 Metritis, as result of retroflexion of gravid 
 uterus, 279, 280. 
 
 calomel in, 464. 
 
 from retention of fojtus, 306, 313. 
 
 in contracted pelvis, 492. 
 
 in labor, 464. 
 
 in puerperal fever, 657. 
 
 in transverse presentations, 564. 
 Micrococci : 
 
 action of, on the blood, 664. 
 
 in lochia, 245. 
 
 in puerperal fever, 660, 666 et seq., 681. 
 Micropyle of Keber, 43. 
 Migration of ovum, 41, 51. 
 
 time required for, 42. 
 Milk, 94, 99, 246. 
 
 absence of, in pregnancy, 94. 
 
 anatomical considerations relating to, 246. 
 
 condensed, 258. 
 
 composition of, 248. 
 
 fever, 247. 
 
 in albuminuria, 577. 
 
 in breasts of new-born, 250. 
 
 in women not pregnant, 94. 
 
 -metastases, 661. 
 
 of one cow, 257. 
 
 peptonized, in emesis, 118, 119. 
 
 of good wet-nurse, 256. 
 
 preparation of, for infants, 257, 258, 
 
 secretion of, 246. 
 defective, 706. 
 
 sterilization of, 258. 
 
 transfusion of, 590. 
 
 uterine, 55, 56. 
 Milk-leg, 70'a; {vide phlegmasia alba dolens).
 
 774 
 
 INDEX. 
 
 Miscarriage, 307 (vide ahortion). 
 
 treatment of, 326. 
 Missed labor, 304, 305. 
 Mola, 312. 
 
 carnosa, 312. 
 
 sanguinea, 312. 
 Mole, hydatidiform, 231, 298. 
 
 anatomy, morbid, of, 298. 
 
 diagnosis, 301. 
 
 etiology, 300. 
 
 prognosis, 301. 
 
 symptoms, 301. 
 
 treatment, 302. 
 Monstrosities, 556. 
 
 acardiacus, 557. 
 
 acephulus, 658. 
 
 acormus, 559. 
 
 amorphus, 558. 
 
 anencephalus, 559. 
 
 diagnosis of, 556. 
 
 hemicephalus, 559. 
 
 mechanism of labor with, 557. 
 
 prognosis in cases of, 557. 
 Mons Veneris, 2. 
 ilorhus coxarius, causing pelvic deformities, 
 
 516. 
 Morning-sickness of pregnancy, 90, 93, 99, 116. 
 
 treatment of, 116, 118. 
 Morsits dial/oli, 20. 
 Morula, 46. 
 Morphia {ride opium) : 
 
 in anosmia, cerebral, 590. 
 
 in cliorea, 275. 
 
 in eclampsia, 579. 
 
 in emesis, 117, 119. 
 
 in extni-uterine pregnancy, 345. 
 
 in neuralgia, 122. 
 
 in pogt-partum haemorrhage, 585, 590. 
 
 in precipitate labor, 453. 
 
 in protracted labor, 457, 462, 502. 
 
 in puerperal fever, 695. 
 
 in shock, 650. 
 
 in vaginal thrombus, 628. 
 Mouth, development of, 48, 63, 64. 
 Movements, fetal, in pregnancy, 64, 76, 96, 
 98, 99, 100, 106. 
 
 active, 96. 
 
 movements of pelvic joints, 148, 275. 
 
 passive, 96. 
 
 simulation of, 96. 
 Mucous membrane : 
 
 changes in, in pregnancy, 19, 81, 95. 
 
 of cervix, 19, 81, 85. 
 
 of Fallopian tube, 21, 42, 329. 
 
 of milk-ducts, 247. 
 
 of OS, in pregnancy, 19, 81, 95. 
 
 of ovary, 23, 36. 
 
 of uterus, body of, 18, 242. 
 
 of vagina, 10, 85. 
 
 Mucous plug, 81. 
 Miiller, ducts of, 30. 
 
 ring of, 84, 85. 
 Multiparae, pregnancy in, 105. 
 Multiple pregnancies, 228. 
 
 acardia in, 229. 
 
 conduct of labor in, 236. 
 
 development of children in, 229, 231. 
 
 diagnosis of, 232. 
 
 entrance, simultaneous, of both children 
 into pelvis, in, 234. 
 
 fatus jtapijraceus in, 231. 
 
 forceps in, 235. 
 
 frequency of, 228. 
 
 haemorrhage in, 236. 
 
 labor in, 232. 
 
 locking of children in, 234. 
 
 maiKi^rement of, 228, 236. 
 
 mummification of foetus in, 303, 306. 
 
 origin of, 228. 
 
 premature labor, indicated by, 351. 
 
 presentations in, 233. 
 
 prognosis in, 236. 
 
 treatment of, 236. 
 
 varieties of, 228. 
 
 version in, 236. 
 
 weight of children in, 231. 
 Mummification of ttetus, 303, 306. 
 Muscles : 
 
 action of abdominal, in labor, 129. 
 
 development of, 48. 
 
 pelvic, 157. 
 
 recti, in pregnancy, 87. 
 
 uterine, 16, 77, 78. 
 hyperplasia of, 77, 78, 124. 
 Myomata, uterine, 542 {vide uterus, myoma- 
 ta of;. 
 
 diagnosis of, from pregnancy, 101. 
 
 Naboth, o^•ula of, 19, 81. 
 Nacgele oblique pelvis, 514. 
 
 forceps, 364. 
 
 method of computing date of confinement, 
 109. 
 Nails, development of, 4^, 64, 65. 
 Narcotics : 
 
 in ana?mia, cerebral, 590. 
 
 in chorea, 275. 
 
 in eclampsia, 578, 579. 
 
 in emesis, 117. 
 
 in lacerations of perinseum, 624. 
 
 in neuralgia, 122. 
 
 in painful first stage, 463. 
 
 in phlegmasia, 705. 
 
 m post-part urn haemorrhage, 590. 
 
 in protracted first stage, 456. 
 
 in protracted third stage, 462. 
 
 in puerperal fever, 695. 
 
 in puerperal insanity, 703.
 
 INDEX. 
 
 775 
 
 N;ite3, changes in, in pretrnancy, 87, 105. 
 Nausea, of pregnancy, 90, 93, 99, 116, 117. 
 
 in eclampsia, 567. 
 
 in shock, 649. 
 Navel : 
 
 changes of, in pregnancy, 87, 100. 
 
 of new-born child, 250. 
 
 relation of fundus to, in pregnancy, 111. 
 Neck, development of, 64. 
 Negresses, areola of, 88. 
 Neoplasmata : 
 
 placental, 289. 
 
 uterine atresia from, 541, 542, 547. 
 
 vaginal atresia from, 538. 
 Nephelis vulgaris : 
 
 fecundation of ova of, 44. 
 Nephritis, indicating abortion, 351. 
 
 in eclampsia, 571. 
 
 in pregnancy, 272. 
 Nerve exhaustion and shock, 648. 
 
 etiology, 648. 
 
 treatment, 650. 
 Nerves of uterus, 27, 77. 
 Nervous system : 
 
 development of, 48, 50. 
 
 diseases of, in pregnancy, 88, 91, 114, 122. 
 Neuralgia in pregnancy, 88, 91, 114, 122. 
 New formations in placenta, 289. 
 Newly bom child, 250 ( vide infant). 
 
 asphyxia of, 215, 368, 635. 
 
 breasts of, 250. 
 
 caput succedaneum of, 181, 190, 250. 
 
 cardiac ventricle of, 250. 
 
 care of, 250, 356. 
 
 circulation of, 216. 250. 
 
 desquamation of, 250. 
 
 ductus (wteriosus of, 250. 
 
 fteces of, 251. 
 
 foramen ovale of, 250. 
 
 icterus of, 219, 250. 
 
 milk prepared for, 257, 258. 
 
 navel of, 250. 
 
 nurse for, selection of, 256. 
 
 nursing of, 254. 
 
 ophthahnia of, 712. 
 
 size of, 69. 
 
 urine of, 250. 
 
 weight of, 69, 251. 
 Nipples : 
 
 changes in, during pregnancy, 88, 90 94. 
 
 cracked, 708. 
 
 erectility of, 88 
 
 erosions of, 707, 708. 
 
 fissured, 707. 
 
 sore, 255, 706. 
 shields for, 255, 708. 
 treatment of, 707- 
 Nose, development of, 48, 64. 
 Notches, sacro-sciatic, 145. 
 
 Nucleus, vitelline, 45. 
 Nurse, wet, selection of, 256. 
 Nursing : 
 
 contra-indications for, 254. 
 
 in pregnancy, 254. 
 
 intervals for, 254. 
 Nutrition in pregnancy, 89, 90, 91. 
 Nux vomica in nausea of pregnancy, 117. 
 Nyctalopia : 
 
 in pregnancy, 91. 
 
 in puerperal state, 568. 
 Nymphffi, 3 {vide Labia minora). 
 
 sebaceous glands of, 5. 
 Nymphomania, 702. 
 
 Obliquity, lateral, of Nsegele, 170, 
 Obstructed labor, due to — 
 
 abdominal tumors of foetus, 554. 
 
 abnormaties of foetus, 551 et seq. {lids 
 foetus). 
 
 aeardiacus, 557. 
 
 anchylosis of fetal joints, 556. 
 
 arm, extended, 394. 
 
 ascites, fetal, 554. 
 
 atresia, uterine, 539 {vide atresia). 
 
 atresia, vaginal, 536. 
 
 atresia, vulvar, 535. 
 
 bladder, distended, 554. 
 
 calculi, 537. 
 
 coiling of cord, 204, 215, 296. 
 
 cystoccle, 555. 
 
 displacements, uterine, 116, 278 et seq., 310. 
 
 ectopia of abdominal organs, 556. 
 
 encephalocele, congenital, 553. 
 
 faeces, impacted, 208. 
 
 fatty growths, 555. 
 
 fibrous growths, 538. 
 
 hernias, vaginal, 538. 
 
 hernias, visceral, 556. 
 
 hydrocephalus, fetal. 551. 
 
 hydrothorax, fetal, 554. 
 
 hymen, persistent, 535. 
 
 hypertrophy of cervix, 282, 542. 
 
 knots of cord, 295. 
 
 locked twins, 234. 
 
 monstrosities, 556. 
 
 morbid growths of genital canal, 535 et seq. 
 
 multiple pregnancy, 234. 
 
 ossification of fontanelles, premature, 551. 
 
 ovarian tumors, 548. 
 
 perineum, rigid, 368, 459, 536. 
 
 rigor mortis, fetal, 556. 
 
 short cord, 559. 
 
 spina bifida, 556. 
 
 transverse presentations, 560. 
 
 tumors, intrapelvic, 533, 542. 
 Obturator foramen, 159. 
 Occipito-postcrior positions : 
 
 forceps in, 379.
 
 776 
 
 INDEX. 
 
 Occipito-posterior positions: 
 
 mechanism of, 179. 
 
 rotation in, 175. 
 Odontali^ia in pregnancy, 91. 
 Oidema : 
 
 cerebral, in eclampi^ia, 675. 
 
 cervical, in labor, 540. 
 
 indicating abortion, 351. 
 
 in eclampsia, 567, 577. 
 
 in labor, 130, 308, 620. 
 
 in maceration of fojtus, 304. 
 
 in pregnancy, 8S, 114, 115, 130, '268, 273, 
 279, 549, 567. 
 
 placental, 288. 
 
 vulvar, in labor, 130, 636. 
 
 vulvar, in pregnancy, 88, 114, 273, 279. 
 Oophoritis, in puerperal fever, 668. 
 Oosperm, 45. 
 Operation : 
 
 tor Cte.sarean section, 439. 
 
 for causing premature labor, 351. 360. 
 
 for cephalotripsy, 4'25. 
 
 for embryotomy, 413, 431. 
 
 for extraction of foetus in breech presonta^ 
 tions, 382 et seq. 
 
 for lacerated nerinajum, 623. 
 
 for perforation in craniotomy, 414, 428. 
 
 for producing abortion, 351. 
 
 Torro's, or ovaro-hystorectomy, 442. 
 details of, 443. 
 
 Fehling's modification of, 444. 
 history of, 442. 
 
 Thomas's, or laparo-elytrotomy, 436, 442. 
 details of, 449. 
 
 ha^morrhaije, control of, in, 449, 451. 
 history of, 447. 
 proffnosis of, 448. 
 Ophthalmia neonatorum, prophylaxis of. 712. 
 Opiates : 
 
 in abortion, 318, 323. 
 
 in anajraia, cerebral, 590. 
 
 in chorea, 275. 
 
 in eclampsia, 579, 531. 
 
 in emesis, 117, 119. 
 
 in insomnia, 122. 
 
 in lacerated pcrinanim, 624u 
 
 in mastitis, 710. 
 
 in neuralgia, 122. 
 
 in painful first stage, 463. 
 
 in peritonitis, 464. 
 
 in phlegmasia alba dolens, 705. 
 
 in post-part)im hnemorrhage, 585, 590, 591. 
 
 in precipitate l.ibor, 453. 
 
 in protracted labor, 457, 462. 
 
 in puerperal fever, 695. 
 
 in puerperal state, 252. 
 
 in shock, 650. 
 
 in vaginal thrombus, 628. 
 Opisthotonus, in eclampsia, 568. 
 
 Organs of generation : 
 
 abnormities of, 635. 
 
 anatomy of female, 1. 
 
 changes in, during pregnancy, 77 ct seq. 
 
 development of, 29. 
 
 external, 1. 
 Orifice, oral, development of, 48, 63, 64. 
 Orijicium ■vaf/iiue, 6, 7. 
 Os innominatum, anatomy of, 142. 
 Osteomalacia : 
 
 pelvic deformity from, 529 (»i(/«; pelvis, de- 
 formed, osteomalacic). 
 
 pseudo-, 478, 533. 
 Osteophytes in pregnancy, S9. 
 Os tincce, 12. 
 
 internum, 13. 
 
 closure of, during pregnancy, 82, 85. 
 Os uteri : 
 
 changes of, in pregnancy, 80-S6, 95, 105. 
 in puerperal state, 243. 
 
 dilatation of, in labor, 131, 137. 
 causes of, 137. 
 in emesis, 119. 
 
 elongation of anterior lip of, in labor, 540. 
 
 erosions on, during pregnancy, 81, 243. 
 
 mucous membrane of, 19, 81, 95. 
 
 oedema of anterior lip of, in labor, 540. 
 
 rigidity of, atresia from, 540. 
 
 thrombus of, in labor, 540. 
 Ova, number of, 41. 
 
 primordial, 36, 38. 
 Ovarian : 
 
 cysts, diagnosis of, from pregnancy, 101, 
 550. 
 
 pregnancy, 327. 3-34, 338. 
 
 tuuiors, diagnosis of, 549. 
 
 tumors, obstructing labor, 548. 
 Ovaries : 
 
 anatomy of, 21. 
 
 arteries of. 25. 
 
 cortical substance of, 23. 
 
 development of, 30. 
 
 diseharice of ovum from. 39. 
 
 epithelium, cylindrical ciliated, in, 23, 36. 
 
 erectility, theoretical, of, 27. 
 
 follicles of. 23, 36-39. 
 
 hilum of, 22. 
 
 ligament of, 16, 21. 
 
 medullary .substance of, 23. 
 
 poritonreum, relations of, to, 22. 
 
 Porro's operation to remove, 442. 
 
 position of, in pregnancy, 79. 
 
 relation to Wolffian bodies, 30. 
 
 tumors of, in pregnancy and the puerperal 
 state, 548. 
 diagnosis of, 549. 
 
 tunica (tlhvgitiea of, 23. 
 
 veins of, 26. 
 Ovariotomy, in pregnancy, 550.
 
 INDEX. 
 
 Ovaritis, puerperal, G63. 
 O»aro-hi/storectomij, 442. 
 
 details of, 443. 
 
 Fehling's method in, 444. 
 
 Frank's method, 445. 
 
 Iiistory of, 442. 
 Ovulaof Naboth, 19, 81. 
 Ovulation, 39. 
 
 iruppression of, in prcirnancy, 93. 
 Ovum : 
 
 abdominal plates of, 49. 
 
 amnion of, 50. 
 
 anatomy of, 38, 62. 
 
 area germinatira of. 47, 50. 
 
 embryonic, 47, 48, 52. 
 
 blastodermic vesicle of, 47, 50. 
 
 changes in, subsequent to fucuudatioa, 44. 
 
 chorda dorsalis of, 49. 
 
 chorion of, 51, 53, G4. 
 
 cleavage of, 46. 
 
 deutoplasm of, 39, 45. 
 
 development of, 35, 62. 
 
 discharge of, from ovary, 39. 
 
 discus proligerus of, 37, 3S, 39. 
 
 diseases of, 284. 
 
 dorsal plates of, 49, 62. 
 
 embryonic area of, 47, 62. 
 
 epiblast of, 47, 48. 
 
 epithelium, cylindrical ciliated, in, 37. 
 
 fecundation of, 42^4. 
 
 -forceps, in abortion, 324. 
 
 germiuative spot of, 39. 
 
 germinative vesicle of, 39, 45. 
 disappearance of, 45. 
 
 hypoblast of, 47, 4S. 
 
 membrana granulosa of, 37, 38. 
 
 mesoblast of, 47, 48. 
 
 micropyle in, 43. 
 
 migration of, 41, 51, 328. 
 
 morula of, 46. 
 
 polar globule of, 45. 
 
 premature expulsion of, 307 {vila labor, 
 premature). 
 
 primitive trace of, 48. 
 
 primordial, 30, 38, 39. 
 
 pronucleus of, 45. 
 
 removal of retained, 321. 
 
 segmentation of, 46. 
 
 size of, 38. 
 
 time for migration of, 42. 
 
 tubus medullaris of, 50. 
 
 umbilical vesicle of, 50. 
 
 vitelline membrane of, 38. 
 
 vitellus of, 39. 
 
 yolk of, 39. 
 
 zona pellucida of, 38. 
 Ovum-forceps : 
 
 use of, in abortion, 324. 
 Oxygen, in nausea of pregnancy, 117. 
 
 Oxytocics : 
 
 after normal labor, 224. 
 
 contra-indications for, 461. 
 
 in abortion, 320, 321, 323, 351. 
 
 indications for, 224, 460. 
 
 in parturition, 224, 461. 
 
 in placenta prsevia, 603, 606. 
 
 in post-partum hsemorriiage, 585. 
 
 in protracted first stage of labor, 457, 458. 
 
 physiological action of, 460. 
 
 Pack, wet, in puerperal fever, 698. 
 
 in albuminuria, 578. 
 Pad, antiseptic, 225, 253, 688, 691. 
 Pains : 
 
 action of, on uterine walls, 128. 
 
 after-, 224, 244, 252, 672. 
 
 anomalies of, 452. 
 
 causes of, 130. 
 
 character of, 129, 130, 452, 454. 
 
 contracted pelvis, ali'ecting, 481. 
 
 duration of, 128. 
 
 effect of chloroform on, 227. 
 
 efi'ect of, on fetal heart, 97. 
 
 good, 452, 454, 4b2. 
 
 in abdominal walls, during pregnancy, 87. 
 
 in abortion, 311. 
 
 in breasts during pregnancy, 87, 94, 99. 
 
 in first stage, 131. 
 
 in second stage, 133. 
 
 irregular, in first stage, 454. 
 
 irregular, in second stage, 459. 
 
 ii regular, in third stage, 461. 
 
 labor-, 127, 129, 452, 454, 4S2. 
 
 influence of coriti'acted pelvis on, 479. 
 influence of, on organism, 130. 
 
 premonitory, 131. 
 
 seat of, 130. 
 
 strong, 452. 
 
 weak, 452. 
 forceps for, 368. 
 Palate, development of, 64. 
 Palpation, abdominal, in pregnancy, 100. 
 
 vaginal, 99, 103. 
 Palpitation of heart in pregnancy, 114, 292. 
 Pancreas : 
 
 dilatation of fetal, 555. 
 Papillae, vaginal, hypertrophy of, in pregnan- 
 cy, 86, 105. 
 Paqueliu's thermo-cautery, in Thomas's op- 
 eration, 450. 
 Parametritis from retroflexed gravid uterus, 
 280. 
 
 in contracted pelvis, 492. 
 
 in puerperal fever, 657, 658, 672. 
 Paresis in pregnancy, 91. 
 Parturition, 123 [vide labor). 
 Patches, brown, in pregnancy, 91. 
 Pathology of labor, 452.
 
 m 
 
 INDEX. 
 
 Pathology of pregnancy, 260. 
 
 Pelvic abscess, 674, 700. 
 
 Pelvic brim, 151, 154, 157, 169 {i)ide brim, 
 
 pelvic). 
 Pelvic cavity, general direction of, 151, 153. 
 Pelvic cellulitis, in puerperal lever, 658. 
 Pelvic measurement, 407. 
 external, 467. 
 instruments for, 467. 
 iriternal, 469. 
 
 of conjugata vera, 151, 469, 470. 
 of diagonal conjugate, 469, 470. 
 of external conjugate, 469. 
 of transverse diameter, 471. 
 Pelvic peritonitis in puerperal lever, 659, 668, 
 
 672. 
 Pelvic walls, lengtli of, 150. 
 Pelvimeter, 407. 
 circle of Baudelocque, 407. 
 Schultze's, 407. 
 
 the hand as, for internal measurements, 469. 
 Pelvimetry : 
 external, 468. 
 instruments for, 407. 
 internal, 469. 
 Pelvis : 
 abscess in, 674, 700. 
 adult, causes of its conformation, 155. 
 aquaMliter justo-minor^ 465, 471, 485, 495, 
 512. 
 diagnosis of, 472. 
 agents shaping the adult, 155. 
 anatomy of, 140 et seq., 154. 
 arteries of, 158. 
 articulations of, 145. 
 mobility in, 148, 275. 
 rupture ot, 628. 
 as a whole, 149. 
 axes of, 150, 152, 153. 
 brim of, 151, 154, 157, 169. 
 
 inclination of plane of, 147. 
 cavity or canal of, 151, 153. 
 conjugate of, 151, 469, 470. 
 contracted, 465. 
 
 as indication for abortion, 349, 359. 
 Ctesarean section in, 438. 
 diagnosis of, 466. 
 from history, 466. 
 from measurements, 467. 
 effects in, of pressure on mother, 488. 
 effects in, of pressure on child, 489. 
 effects of, on labor, 479. 
 extravasations, intra-cranial, in, 491, 498, 
 
 506. 
 fascia of, 161, 162. 
 forms of, three principal, 471. 
 fractures in, 491. 
 frequency of, 466. 
 generally, 477. 
 
 Pelvis, contracted : 
 
 influence of, in pregnancy and labor, 479. 
 on cranial bones, 490. 
 on first stage, 483. 
 on labor-pains, 481. 
 on mechanism of labor, 484 et seq. 
 on position of foetus, 485, 486. 
 on presentations of foetus, 480, 481. 
 on uterus in pregnancy, 480, 612. 
 irregularly : 
 pseudo- osteomalacia, 478, 533. 
 kyphosis, 479. 
 rachitis, 478. 
 scoliosis, 479. 
 labor, at term, in, 502. 
 pi-ognosis in, 492. 
 scalp-tumor in, 483, 439. 
 symmetrically, 471, 474. 
 treatment in, 486, 493. 
 
 by CiBsarean section, 494, 499. 513, 
 
 518, 521, 524, 5ii8, 533. 
 by craniotomy, 494, 499, 510, 513, 519, 
 
 521. 
 by forceps, 497, 503, 508, 511. 
 by laparo-elytrotomy, 494. 
 by premature labor, 500. 
 by version, 498, 499, 503 et seq. 
 expectant, 509. 
 
 when child can not be delivered 
 
 through natural passages alive, 494. 
 
 when child may be delivered through 
 
 natural passages alive, 500. 
 when craniotomy or abortion must be 
 performed, 497. 
 varieties of, 465. 
 deformed, rare forms of, 514. 
 deformed by — 
 absence of symphysis, 534. 
 exostosis, 533. 
 fractures, 533. 
 morbus coxae, 516. 
 osteomalacia, 529. 
 rachitis, 475, 478. 
 diameters of, 150 et seq., 157, 169. 
 difference between — 
 adult and infantile, 155. 
 female and male, 154. 
 exostosis of, 533. 
 exudations in, treatment of, 700. 
 fascia of, 161, 162. 
 female, 154, 156. 
 flattened, 465, 469, 474, 512. 
 general, 465, 477, 512. 
 mechanism of labor, in, 484 et seq. 
 non-rachitic, 474. 
 rachitic, 475. 
 diagnosis of, 477. 
 irregular, 478. 
 simple, 465, 512.
 
 INDEX. 
 
 19 
 
 Pelvis: 
 floor of, 159, ICO. 
 forceps at brim of, 375. 
 
 at outlet of, 368. 
 funnel-shaped, 528. 
 inclination of, 147. 
 inclined planes of, 153. 
 justo-niinor, 4G5, 471,485. 495, 512. 
 kyphotic, 479,, 519. 
 
 treatment of, 521. 
 large, the, 149. 
 ligaments of, 146. 
 lymphatics of, iu preirnaney, 29. 
 male, 154. 
 
 measurements of, 467, 469. 
 movements in joiiits of, 148, 275. 
 muscles of, 157 ei seq. 
 Naegele's oblique, 514 {vide obliqu'.). 
 nana, 472. 
 osteomalacic, 529. 
 
 anatomy, morbid, of, 530. 
 
 diagnosis of, 532. 
 
 etiology of, 531. 
 
 prognosis of, 532. 
 
 treatment of, 532. 
 oblique, of Naegelc, 514. 
 
 anatomy, morbid, of, 514. 
 
 diagnosis of, 517. 
 
 etiology of, 516. 
 
 mechanism of labor in, 517. 
 
 prognosis in, 518. 
 
 treatment in, 518. 
 outlet of, 152, 159. 
 outlet of, forceps at, 368. 
 planes of, 150. 
 
 inclined, 153. 
 pressure of contracted, on cranium, 490. 
 pseudo-osteonialaeic, 478, 533. 
 rachitic, 475, 478. 
 rela.xution of symphysis of, in pregnancy, 
 
 275. 
 Eobert's anchylosed and transversely con- 
 tracted, 523. 
 
 anatomy, morbid, 523. 
 
 diagnosis, 524. 
 
 etiology, 524. 
 
 prognosis, 524. 
 scoliotic, 479. 
 scolio-rachitic, 521. 
 small, the, 150. 
 soft parts of, 157. 
 spondolisthetic, 525. 
 
 anatomy, morbid, 525. 
 
 diagnosis, 526. 
 
 etiology, 526. 
 
 prognosis, 527. 
 straits of, 151, 152. 
 symphysis of, relaxation iu, 275, 628. 
 
 absence of, 534. 
 
 Pelvis : 
 
 tumors of, indicating abortion, 359, 533. 
 
 veins of, 158. 
 
 walls of, their length, 150. 
 Penis, development of, 64. 
 Pepsin, in nausea of pregnancy, 117. 
 Perforation, 413. 
 
 extraction of child after, 419. 
 by forceps, 419. 
 by cephalotribe, 420. 
 
 indications for, 413, 497, 617. 
 
 in face presentations, 418. 
 
 instruments for, 414 (vide perforators). 
 
 of after-coming head, 418. 
 
 of uterus, from pressure, 610. 
 
 operation, how perfoimed, 414. 
 
 point I'or, 418. 
 
 preparations for, 414. 
 Perforator, 414. 
 
 Blot's, 415. 
 
 Hodge's cranial scissors, 415. 
 
 Simpson's, 414, 415. 
 
 Smellie's scissors, 414. 
 
 Thomas's, 416. 
 
 trephine, 416, 419. 
 Pericarditis, in puerperal fever, 680. 
 
 fetal, obstructing labor, 554. 
 Perimetritis, in contracted pelvis, 492. 
 
 in retention of Itetus, 313. 
 
 in puerperal fever, 672. 
 Pcrinseum : 
 
 body of, 162, 164. 
 
 connective tissue of, 164. 
 
 dilatation of, in labor, 134. 
 
 fascia of, 161. 
 
 gangrene of, 536. 
 
 in labor, 134. 
 
 laceration of, in labor, 134, 203, 211, 224, 
 453, 622. 
 
 muscles of, 162, 164, 214. 
 
 preservation of, in labor, 193, 210 et seq. 
 
 rigidity of, obstructhig labor, 368, 459, 
 536. 
 
 thrombus of, 625. 
 
 treatment of lacerated, 224, 623. 
 in labor, 224. 
 
 in pueqieral state, 224, 249. 
 Period, lying-in, duration of, 255. 
 
 placental, of labor, 134. 
 Peritoneum, relations of, to ovaries, 22. 
 Peritonitis, as result of incarceration of retro- 
 fle.xed gravid uterus, 280. 
 
 after labor, 464, 492, 564. 
 
 in abortion, 313, 325, 355. 
 
 in atresia, 541. 
 
 in extra-uterine pregnancy, 339, 340. 
 
 in ovarian tumors, 549. 
 
 in puerperal fever, 659, 668, 672, 677, 680. 
 
 in retained foetus, 306, 313.
 
 780 
 
 INDEX. 
 
 Pessary, in retroversion and retroflexion of 
 
 gravid uterus, llfi, 278, 317. 
 Phantom tumors, difterentiation of, from 
 
 pregnancy, 102. 
 Phlebitis and phlebo-thromLosis in puerperal 
 
 fever, 660, 680. 
 Phlebotomy in eclampsia, 579, 581. 
 phlegmasia alba dolens^ 646, 701, 704. 
 abscesses in, 705. 
 etiology, 704. 
 history, clinical, of, 705. 
 origin of, 704. 
 prognosis of, 705. 
 treatment of, 705. 
 Phthisis complicating pregnancy, 270. 
 
 abortion in, 270. 
 Physician, visits of, during the puerperal 
 
 stale, 252. 
 Piles, in pregnancy, 88, 115. 
 Pilocarpine, in salivation, 121. 
 Pinces Muiostatiques, 622. 
 Placenta : 
 
 adh erent, 221, 462, 593. 
 anatomy of, 51, 54. 
 anomalies of, 287. 
 in circulation, 288. 
 in development, 288 
 in foiTa, 287. 
 in position, 288. 
 apoplexy of, 288. 
 arteries of, 58, 50. 
 artificial separation ot, 593, 604. 
 hattledoor, 298. 
 bruit of, 24, 98. 
 
 calcireous degeneration of, 289. 
 cotyledons of, 56, 59. 
 
 arteries of, 59. 
 cystic degeneration of, 289, 299. 
 degenerations of, 289, 317, 351. 
 
 in cholera, 263. 
 development of, 54, 64. 
 expression of, by Credo's method, 220, 
 324, 462. 
 in tardy labor, 463. 
 expulsion of, physiology of, 221. 
 fatty degeneration of, 289, 351. 
 fetalis^ 56. 
 fully developed, 58. 
 functions of, 59. 
 in abortion, 324, 325. 
 in Caesarean section, 440. 
 infarctions of, 288. 
 inflammation of, 289, 290, 304. 
 in multiple pregnancy, 232. 
 membranacea, 288. 
 new growths in, 289. 
 normally implanted haemorrhages from, 
 
 606. 
 aedema of 288. 
 
 Placenta : 
 prrevia, 594. 
 
 abortion in, 597, 600. 
 accouchement force in, G02, 603. 
 anaemia in, 598. 
 cervix in, 600. 
 clinical features of, 596. 
 diagnosis of, 599. 
 dilator, Barnes's in, 602 et seq. 
 douche in, 606. 
 ergot in, 603, 606. 
 etiology of, 596. 
 foitalts, 56. 
 forceps in, 375, 603. 
 frequency of, 595. 
 hemorrhages in, 597, 599, 601, 605. 
 history, clinical, of, 596. 
 indicating abortion, 351. 
 presentations, abnormal, in, 598. 
 prognosis of, 599, 600, 605. 
 pyaemia in, 599. 
 situation of, 594. 
 tampon in, 601. 
 thrombi in, 238, 249, 599. 
 treatment of, 600, 601. 
 by Barnes's dilator, 602, 604. 
 by detachment of placenta, 604. 
 by ergot, 603. 606. 
 by forceps, 603. 
 by tampon, 601, 604. 
 by version, 602, 603. 
 varieties of, 595. 
 retained, 221, 461, 462, 581, 584, 586, 592. 
 in abortion, 312, 325. 
 prevention of. 221, 463. 
 treatment of, 325, 351, 463, 593. 
 site of, posf-partum, 242, 249. 
 spuria, 288. 
 
 structure of, fully developed, 58. 
 svcce/ituriata, 288, 586. 
 syphilis of, 272, 290. 
 tlirombosis of sinuses of, 288. 
 tumors in, 2b9. 
 uterina, 57. 
 vascular spaces of, 57. 
 villi of, 54-57, 290. 
 in cat, 56. 
 in marc, 55. 
 Placentitis : 289, 290, 304. 
 
 abortion in, 289, 304. 
 Planes of pelvis, 150, 153. 
 Plates : 
 abdominal, 49. 
 dorsal, 49, 62. 
 lateral, 49. 
 Plethora of pregnancy, 88. 
 PleurL^y, chronic, complicating pregnancy, 
 
 270. 
 Pleuritis, in puerperal fever, 669, 680.
 
 INDEX. 
 
 781 
 
 Pleurosthotonus, in eclampsia, 568. 
 Plexus : 
 hypoijaBtric, 27. 
 painpinitbrmis, 25. 
 uterinus, 25. 
 niagnus, 27. 
 J'licce. : 
 
 reeto-zderincB, 15. 
 vesico-tderinix, 15. 
 Plu!?, mucous, of cervix, 81 . 
 Plural prcffnaucy, 228 i^vide pregnancy, mul- 
 tiple). 
 Pneumonia, acute lobar, complicating preg- 
 nancy, 269, 35!). 
 Podalic version, 401, 40i. 
 Polar globule, 45. 
 
 Polypus, fibrinous, removal of, 326. 
 causing puerperal luemorrhages, 592. 
 in abortion, 313. 
 simulating menses, 93. 
 vulvar, 536. 
 Porro's operation, 442 (ride ovaro-hystorec- 
 tomy). 
 details of, 443. 
 
 Fehling's modification of, 444. 
 Frank's modification of, 445. 
 history of, 442. 
 in uterine tumors, 545, 548. 
 Porte-fillet, 392. 
 Portio vaginalis of cervix, 12. 
 
 lacerations of, 620. 
 Positions : 
 changes of, 76. 
 classification of, 170. 
 definition of, 76. 
 diagnosis of, 183. 
 first, 76. 
 
 fore.xamination, in pregnancy, 99. 
 forceps, use of, in occipito-posterior, 379. 
 in breech presentations, 197. 
 in contracted pelvis, 486. 
 in multiparEe, 75. 
 in primiparEe, 75. 
 mento-posterior, forceps in, 381. 
 oblique, as cause of face presentations, 184. 
 occipito-anterior, 170. 
 occipito-posterior, 170, 179. 
 forceps m, 379. 
 lacerations in, 214. 
 mechanism of, 179. 
 rotation in, 175. 
 transverse, forceps in, 381. 
 second, 76. 
 Post-partum htemorrhage, 581 (vide hsemor- 
 
 rhage, pod-partum). 
 Posture : 
 
 in first stage of labor, 208. 
 in second stage of labor, 209, 210. 
 Praputium clitoridis, 4. 
 
 Prague method of extraction with head at 
 
 the brim, 399. 
 Precipitate labor, 453 (^vide labor, precipi- 
 tate). 
 Pregnancy : 
 abdomen in, 86, 94, 99, 100, 105, 278. 
 abdominal, 42, 327, 335, 339. 
 collapse in, 338. 
 definition of, 327. 
 diagnosis of, 280, 340. 
 electricity in, 345. 
 clytrotomy in, 346. 
 haemorrhage in, 327, 346. 
 injections into sac in, 345. 
 interstitial, 332. 
 mtraligamentous, 331. 
 laparotomy in, 343, 344, 346. 
 ovarian, 327, 328, 338. 
 peritonitis in, 339, 340. 
 puncture of sac in, 345. 
 recurrence of, 328. 
 secondary, 339. 
 septiciemia in, 340. 
 symjitoms of, 338. 
 terminations of, 327, 333, 339. 
 treatment, 343. 
 
 of advanced cases, 346. 
 
 of cases prolonged after death of fos - 
 
 tus, 348. 
 of early cases, 343. 
 tubal, 327, 328. 
 tubo-abdominal, 338. 
 tubo-ovarian, 338. 
 acardia in multiple, 229. 
 accidental complications of, 260. 
 air, fresh, in. 112. 
 albuminuria in, 91, 262, 268, 273, 275, 567, 
 
 569, 577. 
 alimentation, rectal, in, 119. 
 amaurosis in, 91. 
 amblyopia in, 91. 
 amenorrhoea in, 92, 93. 
 amniotic fluid obscuring, 95. 
 anaemia in, 114, 122. 
 angesthesia in, 91, 102. 
 anodynes in, 117, 119. 
 anorexia in, 114. 
 anteflexion in, 116, 278. 
 anteversion in, 80, 278. 
 appetite in, 90, 114. 
 areola in, 88, 90, 94. 99, 240, 
 ascites, in, 102. 
 auscultation in, 96, 102, 106. 
 auscultatory signs of, 96, 102, 106. 
 ballottement in, 96, 101, 104. 
 bladder and rectum, functional disease '•'t'. 
 
 in, 88. 
 blood-changes of. 88, 113, 115. 
 bowels in, 90, 118.
 
 782 
 
 INDEX. 
 
 Pregnancy : 
 
 breasts in, 87, 88, 90, 94, 99, 105, 106. 
 
 brown patches in, 91. 
 
 bruit, uterine, in, 96, 98, 103. 
 
 cancer of cervix in, 546. 
 
 carbonic dioxide, increase of, in, 89. 
 
 cardiac diseases in, 89, 266. 
 
 carunculas in, 105. 
 
 cathartics in, 115. 
 
 ceplmlalgia in, 122. 
 
 cervical, 309, 596. 
 
 changes, in abdominal walls in, 87. 
 
 in blood in, 88, 113, 115. 
 
 in breasts in, 87, 88, 90, 94, 99, 105, 106. 
 
 in cervix uteri in, 80-86, 95, 105, 116. 
 
 in entire organism in, 88. 
 
 in heart in, 89. 
 
 in hips in, 86. 
 
 in nates in, 87, 105. 
 
 in navel in, 87, 100. 
 
 in nipple in, 88, 90, 94. 
 
 in OS uteri in, 80-86, 95, 105. 
 
 in sexual apparatus and neighboring or- 
 gans in, 77, 105. 
 
 in thighs in, 87. 
 
 in thyroid in, 89. 
 
 in umbilicus in, 87. 
 
 in uterus in, 77, 105. 
 
 in vagina in, 85, 105. 
 
 in vulva in, 86, 105. 
 
 in walls, abdominal, in, 87, 100, 105. 
 character in, 91. 
 cholera complicating, 263. 
 chorea complicating, 114, 274. 
 circulation, disorders of, in, 114, 115. 
 coiling of cord complicating, 296. 
 coitus in, 113, 116. 
 complicated by : 
 
 albuminuria, 91, 262, 268, 273, 275, 567, 
 569, 577. 
 
 amaurosis, 91. 
 
 amblyopia, 91. 
 
 anaemia, 114. 
 
 anaesthesia. 91. 
 
 anomalies of cord, 293. 
 
 anomalies of placenta, 287. 
 
 anteflexion and anteversion, 80, 116, 278. 
 
 ascites, 95. 
 
 calcareous degeneration of cord, 298. 
 
 cardiac diseases, 89, 266, 310, 351, 359. 
 
 cephalalgia, 122. 
 
 cholera, 263. 
 
 chorea, 114, 274. 
 
 circulatory disorders, 114, 115. 
 
 coiling of cord, 296. 
 
 constipation, 88, 90, 116, 118, 122. 
 
 conti-acted pelvis, 479 et seq. 
 
 cramps, 88. 
 
 cysts in cord, 297. 
 
 Pregnancy, complicated by : 
 deafness, 91. 
 death of foetus, 106. 
 deficiency of amniotic fluid, 293. 
 delirium, 118. 
 diabetes, 274. 
 diarrhoea, 90, 118. 
 dizziness, 91. 
 dropsy, 114. 
 
 dyspnoea, 90, 114, 292, 351, 549, 567. 
 eclampsia, 567. 
 eme.sis, 93, 99, 116, 117. 
 emphysema, 270. 
 empyema, 270. 
 endometritis, 272, 284-286. 
 exanthemata, 260. 
 face-ache, 91, 122. 
 flatulence, 112. 
 gangrene, 115. 
 goitre, 89. 
 headache, 122. 
 heartburn, 112, 121. 
 heart-disease, 89. 
 hernias of cord, 296. 
 hernias of uterus, 283. 
 hydatidifonii mole, 293. 
 hydremia, 89, 115. 
 hydramnion, 95, 103, 290. 
 hyperosmia. 118. 
 hypertrophy of heart, 89. 
 hysteria, 114. 
 icterus, 266. 
 
 incontinence of urine, 88. 278. 
 indigestion, 88, 90, 114, 118. 
 insanity, 91, 114, 701. 
 insomnia, 122. 
 knots in cord, 295. 
 locomotion, impaired, 88. 
 maceration of foetus, 304. 
 malarial fever, 122, 264. 
 mania, 91, 114. 
 measles, 261. 
 missed labor, 304, 305. 
 mummification of foetus, 303, 306. 
 nausea, 90, 93, 99, 116, 117. 
 nephritis, chronic, 272. 
 neuralgia, 88, 91, 114, 122. 
 oedema, 88, 114, 115, 130, 268. 
 osteophytes, 89. 
 palpitation, 114. 
 paresis, 91. 
 phthisis, 270. 
 placentitis, 289, 290. 
 plethora, 88. 
 pleurisy, chronic, 270. 
 pneumonia, 269. 
 prolapse of uterus, 282. 
 prolapse of vagina, 283. 
 pruritus, 91, 121.
 
 INDEX. 
 
 783 
 
 Pregnancy, complicated by : 
 
 relapsing fever, 264. 
 
 retention of dead fostus, 302. 
 
 retroflexion, 279. 
 
 retroversion, 279, 
 
 rubeola, 261. 
 
 salivation, 90, 94, US, 121. 
 
 scarlatina, 262. 
 
 stenosis of umbilical vessels, 297. 
 
 syncope, 91, 114, 118. 
 
 syphilis, 271. 
 
 taste, perversions of, 91, 118. 
 
 torsion of cord, 293, 303. 
 
 tumors, ovarian, 548. 
 
 tumors, uterine, 542, 546. 
 
 typhoid fever, 264. 
 
 typhus fever, 264. 
 
 varicose veins, 88, 115. 
 variola, 261. 
 vertigo, 91, 114, 118. 
 vomiting, 90, 93, 99, 116, 117, 359. 
 complications of, accidental, 260. 
 constipation in, 88, 90, 116, 118, 122. 
 contractions of uterus in, lOlj 131. 
 cravings in, 91, 118. 
 deafness in, 91. 
 delirium in, 118. 
 diabetes in, 274. 
 diagnosis of, 91. 
 diagnosis of dead foetus in, 106. 
 diagnosis, differential of, 101 et seq. 
 diagnosis of multiple, 232. 
 diarrhoea in, 90. 
 diet in, 112, 114, 117. 
 digestion in, 90, 93, 114, 116, 464. 
 discoloration of skin in, 91. 
 disorders of, 113. 
 
 distinction between first and second, 104. 
 dizziness in, 91, 114, 118. 
 dolores presagientes in, 131. 
 douche, vaginal, in, 113. 
 dress in, 113. 
 
 dropsy in, 88, 114, 115, 130, 279, 567. 
 dropsy of amnion in, 95, 103. 
 duration of, 62, 106, 123. 
 dyspnceain, 90, 114. 
 eclampsia in, 567. 
 
 effects of, on nervous system, 91, 114, 122 
 
 electricity in, 117. 
 
 emesis in, 93, 99, 116 ef seq., 280. 
 
 emphysema complicating, 270. 
 
 empyema complicating, 270. 
 
 endometritis during, 272, 284. 
 
 ergotin in, 116. 
 
 exanthemata in, 260. 
 
 exercise in, 113, 122. 
 
 exploration, methods of physical, 99. 
 
 extra-uterine, 280, 327. 
 
 face-ache in, 91, 122. 
 
 Pregnancy : 
 fetal heart-sounds in, 96, 97,101, 10 3, 106. 
 flatulence in, 112. 
 foetus, death of, in, 106. 
 frenulum in, 105. 
 frequency of multiple, 228. 
 funic souffle in, 98. 
 gangrene in, 115. 
 haemoglobin in, 89. 
 hfemorrhoids in, 88, 115, 130. 
 heart-burn in, 112, 121. 
 heart, hypertrophy of, in, 89. 
 heart-sounds, fetal, in, 96, 97, 101, 103. 106. 
 hernia, of cord in, 296. 
 
 of uterus in, 283. 
 hips in, 86. 
 hydraeniia in, 89, 115. 
 hvdrsemic oedema in, 88, 114, 115, 130, 279. 
 hydramnion in, 95, 103, 290. 
 hygiene of, 112. 
 hymen in, 105. 
 hyperosmia in, 118. 
 hysteria in, 114. 
 ice, use of, in, 117, 119. 
 icterus complicating, 266. 
 impaired digestion in, 88, 90, 114. 
 incontinence of urine in, 88. 
 increase in size of abdomen in, 86, 94, 99, 
 
 100, 105. 
 in one-horned uterus, 332. 
 in double uterus, 277. 
 in multiparse 105. 
 in primiparse, 105. 
 
 insalivation in, 90, 94, 99, 121. 
 
 insanity in, 91, 114, 701. 
 
 insomnia in, 122. 
 
 inspection of abdomen in, 100. 
 
 interrogation of patient in, 99. 
 
 interruption, premature, of, 307. 
 
 interstitial, 332. 
 
 irritability in, 113. 
 
 iron in anaemia of, 114, 122. 
 
 journeys in, 113. 
 
 kiesteine in, 94. 
 
 knots in cord, complicating, 295. 
 
 labia in, 86. 
 
 lactation in, 94. 
 
 locomotion in, 130. 
 
 "longings" in, 90, 112. 
 
 lungs, capacity of, in, 90. 
 
 malarial fever in, 122, 264. 
 
 mammas in, 87, 88, 90, 94, 99, 105, 106. 
 
 management of, 112. 
 
 mania in, 91, 701. 
 
 marasmus in, 114, 118. 
 
 marital relations in, 113, 116. 
 
 melancholia in, 91, 701. 
 
 measles in, 261. 
 
 memory in, 91, 114.
 
 784 
 
 INDEX. 
 
 Pregnancy : 
 nnenses in, 92, 93, 99. 
 
 methods of physical examination in, 92, 99. 
 milk in, 94. 
 
 morning sickness in, 90, 93, 99, 280. 
 movements of fcetus in, 75, 95, 96, 98-100, 
 
 106. 
 multiple, 228. 
 
 abortion in, 124. 
 
 acardia in, 229. 
 
 conduct of labor in, 236. 
 
 development, unequal in, 229, 231. 
 
 diagnosis of, 232. 
 
 entrance, simultaneous, of both children 
 into pelvis, in, 234. 
 
 foitus papyraceus in, 231. 
 
 frequency of, 228. 
 
 hiemorrhagc in, 236. 
 
 hydramuiou in, 291. 
 
 labor in, 232. 
 
 locking of children in, 234. 
 
 management of, 228, 236. 
 
 origin of, 228. 
 
 placenta m, 232. 
 
 premature labor induced in, 351. 
 
 presentations in. 233. 
 
 prognosis in, 236. 
 
 prolapse of cord in, 630. 
 
 treat?ncnt of, 236. 
 
 varieties of, 228. 
 
 version in, 23. 
 
 weight of children in, 231. 
 nates in, 87, 105. 
 
 nausea and vomiting in, 90, 93, 99, 116. 
 navel in, 87, 100. 
 nephritis in, 272. 
 nerves in, 91. 
 
 nervous irritability in, 91, 113, 114. 
 neuralgia in, 88, 91, 114, 122. 
 nipple in, 88, 90, 94. 
 nutrition in, 89-91. 
 nyctalopia in, 91. 
 odontalgia in, 91. 
 oedema in, 88, 114, 115, 130, 268, 273, 279, 
 
 567. 
 osteophytes in, 89. 
 OS uteri in, 80-86, 95, 105. 
 ovarian, 327, 334. 
 ovaries, position of, in, 79. 
 ovariotomy in, 550. 
 ovulation, suspended, in, 93. 
 pain, abdominal, in, S7. 
 
 mammary, in, 87, 94, 99. 
 palpation of abdomen in, 100, 
 palpitation in, 114. 
 paresis in, 91. 
 patches, brown, in, 91. 
 pathology of, 2t;0. 
 pelvis, contracted, in, 465. 
 
 Pregnancy : 
 pernicious anaemia complicating, 114. 
 pessaries in, 116. 
 phthisis complicating, 270. 
 physical exploration in, 99. 
 physiology of, 77. 
 piles in, 88, 115. 
 placentitis in, 289. 
 plethora of, 88. 
 pleurisy complicating, 270. 
 pneumonia complicating, 269. 
 prediction of end of, 105, 111. 
 premature labor, in anaemia of, 115. 
 prolapse of uterus and vagina in, 282, 359. 
 pruritus in, 91, 121. 
 pulse in, 89, 118. 
 puncture in oedema of, 115. 
 quickening in, 95. 96, 98, 99, 101, 110. 
 rectal touch in, 104. 
 relapsing fever complicating, 264. 
 relaxation of symphysis in, 275. 
 respiration in, 90, 118. 
 retardation of menses in, 92. 
 retroflexion in, 116, 279, 307, 310. 
 
 incarcerated, 280. 
 retroversion in, 116, 279, 480, 542. 
 rubeola complicating, 261. 
 salivation ia, 90, 94, 99, 118, 121. 
 scarlatina complicating, 262. 
 secretions in, 114. 
 senses in. 91. 
 signs of, 92 tt seq. 
 
 size of uterus in, 77, 80, 100, 110, 130. 
 skin, care of, in, 113, 118. 
 smell, perversion of, in, 91. 
 souffle, funic, in, 98. 
 sounds, use of, in, 101. 
 speculum, use of, in, 104. 
 spots, cutaneous, in, 91. 
 striae, abdominal, in, 87, 100, ,105. 
 striae, mammary, in, 87, 105. 
 suppression of menses in, 92, 93, 99. 
 surgical operations during, 276. 
 sympathetic diseases in, 93. 
 syncope in, 91, 114, 118. 
 syphilis, com[)licuting, 271. 
 taste, perversions of, in, 91, 
 temperature in, 118. 
 thighs in, 87, 105. 
 thirst, in, 118. 
 thorax in, 90. 
 tin-ill, uterine, in, 100. 
 thyroid gland in, 89. 
 tooth-aciie in, 91. 
 torsion of cord in, 29S, 303. 
 transfusion in, 114. 
 tubal, 327, 328. 
 tubo-abdominal, 338. 
 tubo-ovarian, 334, 338.
 
 INDEX. 
 
 785 
 
 Pregnancy : 
 tumors, uterine, corapliciiting, 542. 
 tympanites in, 102. 
 typhoid fever complicating, 264 . 
 typhu3 fever complicating, 264. 
 umbilicus in, 87, 100. 
 urethra in, 105. 
 
 urination, frequency of, in, 88, 280. 
 urine, increase of, ni, 91. 
 uterine bruit in, 96, 98, 103. 
 uterus in, 77, 80, 95, 101, 105, 110, 116. 
 vagina in, 85, 104, 105. 
 vauinal touch in, 99. 103. 
 varicose veins in, 88, 115. 
 variola complicating, 261. 
 veins in, 94. 
 vertigo in, 91, 114, 118. 
 vomiting in, 90, 93, 116, 280, 359. 
 vulva in, 86, 104, 105. 
 weight in, 90, 114. 
 Precipitate labor, 453. 
 
 Premature labor, 307, 349, 500 {vide labor). 
 Preparations for labor, 205. 
 Presentations, 72, 168. 
 breech, 169, 197, 382. 
 
 anaesthesia in, 383, 387. 
 
 armamentarium for, 384, 388. 
 
 arms, liberation of, in, 394. 
 
 breech, extraction by, 385. 
 
 blunt hook in, 388, 393. 
 
 causes of, 197, 481, 552. 
 
 changes of, 75. 
 
 configuration of fretus in, 202. 
 
 contracted pelvis, influence of, on, 481, 
 487. 
 
 cord in, 204, 393, 630, 635. 
 
 definition of, 72. 
 
 diagnosis of, 191, 198. 
 
 exceptional cases of, 395. 
 
 extraction in, 382 et seq. 
 
 extraction of head in, 396, 398. 
 
 feet, extraction by, 384. 
 
 foi'ceps to after-coming head in, 399. 
 
 fillet in, 388, 391. 
 
 forceps to breech in, 388. 
 
 frequency of, 197. 
 
 heart-sounds in, 103. 
 
 in contracted pelvis, 481. 
 
 in maceration of foetu^, 305. 
 
 in twin labors, 233. 
 
 irregularities in mechanism of, 201. 
 
 knee, diagnosis of, from elbow, in, 199. 
 
 liberation of arms in, 394. 
 
 management of cord in, 393. 
 
 mechanism of, 199, 487. 
 
 membranes, bag of, in, 198. 
 
 mistaken for face, 191. 
 
 operation of extraction in, 382 et seq. 
 
 Prague method of delivering head in, 398. 
 50 
 
 Presentations : 
 
 prognosis in, 203. 
 
 release of arms in, 394. 
 
 rotation of foetus in, 199, 395. 
 
 traction, direction of, in, 385. 
 
 treatment of, 204, 456. 
 
 trunk, delivery of, 384. 
 brow, 169, 194. 
 
 anesthetics in, 196. 
 
 causes of, 194, 481, 487, 510. 
 
 diagnosis of, 194. 
 
 forceps in, 197. 
 
 head, configuration of, in, 194. 
 
 prognosis in, 195. 
 
 treatment of, 196, 456. 
 cause of predominating, first, 170. 
 cephalic, 169. 
 
 diagnosis of, 182. 
 classification of, 169. 
 cranial, diagnosis of, 182. 
 face, 109, 184. 
 
 causes of, 184, 481, 487. 
 
 configuration of head in, 189. 
 
 cord, prolapse of, in, 635. 
 
 craniotomy in, 381, 418. 
 
 descent of foetus in, 186. 
 
 diagnosis of, 190. 
 
 extension of fetal head in, 186. 
 
 external rotation in, 188. 
 
 flexion in, 188. 
 
 forceps in, 381. 
 
 frequency of, 184. 
 
 heart-sounds in, 103. 
 
 in contracted pelvis, 481. 
 
 influence of contracted pelvis on, 481. 
 
 mechanism of, 184, 186. 
 abnormal, 188. 
 
 membranes, preservation of, in, 191. 
 
 mistaken for breech, 191. 
 
 perforation in, 418. 
 - prognosis in, 191. 
 
 rotation in, 187. 
 
 treatment of, 191, 456. 
 
 Schatz's method in, 192. 
 foot, 169, 202, 481. 
 
 extraction in, 382 et seq. 
 funis, 629. 
 head, 72, 169. 
 
 causes of, 72. 
 
 diagnosis of, 182. 
 
 heart sounds m, 103. 
 knee, 202. 
 natural, 169. 
 normal, 169. 
 pelvic, 169, 382. 
 
 extraction in, 382. 
 preponderance of head, 72. 
 shoulder, 169, 456, 481, 498, 561, 612. 
 
 version in, 498.
 
 Y86 
 
 INDEX. 
 
 Presentations : 
 
 transverse, 169, 560, 564. 
 embryotomy in, 432. 
 version in, 404, 406. 
 unnatural, 169, 543, 598, 
 vertex, 169, 170, 179. 
 configuration of head in, 180. 
 diagnosis of, 182. 
 trequency of, 169. 
 
 theories to account for preponderance of, 
 72-74. 
 Pressure of uterus in labor, 140. 
 Primiparffi, signs of pregnancy and parturi- 
 tion in, 105. 
 Primitive groove, 48. 
 Primitive streak, 48. 
 Primitive trace, 48. 
 Primitive vertehrse, 49. 
 Primordial ovum, 36, 38, 39. 
 Prolapse : 
 of cord, 629. 
 of gravid uterus, 282. 
 
 causing abortion, 282. 
 of vagina in pregnancy, 283, 537. 
 Promontory, false, 470. 
 Promontory, of sacrum, 141. 
 Pronucleus : 
 female, 45. 
 m.ale, 45. 
 Pruritus in pregnancy, 2, 91, 121. 
 Pseudo-osteomalacic pelvis, 478, 533. 
 Psoas abscess in fiueii^cral fever, 677. 
 Pubes, anatomy of, 140, 144, 150, 155. 
 Pudendum, definition of, 1. 
 
 rima of, 2. 
 Puerperal disease*, 653. 
 Puerperal eclampsia, 567 (vide eclampsia). 
 Puerperal fever, 653. 
 abscesses in, 659-661, 674, 675, 677, 680, 
 
 699, 700. 
 alcohol in, 697. 
 analogy between it and surgical fever, 662, 
 
 664. 
 anodynes in, 695. 
 antisepsis in, 687, 690. 
 aspiration in, 700. 
 atmospheric causes of, 681. 
 auto-inoculation in, 684, 690. 
 bacilli, in, 666. 
 bacteria in, 666 et seq.^ 681. 
 blood-poisoning in, 664 et seq. 
 causes of, 495, 547, 681. 
 
 inoculation, 683. 
 cellulitis in, 657, 658. 
 chills in, 671, 673, 676, 678-680. 
 classification of lesions of, 655. 
 clinical history of, 671 et seq. 
 symptoms of endocolpitis and of endo- 
 metritis, 671. 
 
 Puerperal fever : 
 
 symptoms of general peritonitis, 677. 
 symptoms of parametritis, 672. 
 symptoms of perimetritis, 672. 
 symptoms of septicaemia, 679. 
 definition of, 653. 
 
 diphtheritic patches in, 656, 657, 679, 686. 
 emboli in, 660, 680. 
 endocarditis in, 669. 
 endocolpitis in, 656, 671. 
 endometritis in, 656, 671. 
 erysipelas, how related to, 686. 
 frequency of, 653. 
 germs in, 666 et seq. 
 history, clinical, of, 671. 
 infarctions in, 668. 
 mfection, sources of, in, 663. 
 inflammation : 
 of genital mucous membrane in, 655. 
 of peritonaeum, uterine, 655, 659, 672, 677. 
 of subserous pelvic cellular tissue in, 655, 
 
 659. 
 of uterine parenchyma in, 057. 
 inoculation of, 683. 
 lesions of, 655. 
 meningitis in, 669. 
 metritis in, 657. 
 
 micrococci in, 660, 666, 668, 669, 679, 681. 
 microspores in, 666, 681. 
 morbid anatomy of, 655. 
 mortality of, 653, 686. 
 nature of, 661, 664. 
 non-bacteritic variety of, 670. 
 oedema in, 667. 
 oophoritis in, 659, 668. 
 origin, non-local, of, 662. 
 pains in, 672 et seq. 
 p.iramctritis in, 657, 658, 672. 
 patiiological anatomy of, 655. 
 pelvic cellulitis in, 658. 
 perimetritis in, 672. 
 peritonitis, general and pelvic, in, 659, 668, 
 
 672, 677, 680. 
 phlebitis in, 660, 680. 
 phlebo-thrombosis in, 660, 680. 
 pleuritis in, 669, 6S0. 
 prevention of. 686. 
 pulse in, 672, 673, 678-680. 
 pyferaia in, 660, 680. 
 relations of, to zymotic diseases, 685. 
 salpingitis in, 656. 
 sapnemia in, 661. 
 scarlatina in, 2G3, 653. 
 seasons, relations of, to, 685. 
 septicirmia in, 655, 660, 679, 681. 
 hjmphatica, 679. 
 pure, 681. 
 venosa, 680. 
 sewers, affecting, 691.
 
 INDEX. 
 
 78' 
 
 Puerperal fever : 
 social state, relation of, to, 685. 
 nyinptoms of, 671. 
 temperature in, 671 et seq. 
 theory of milk metastases in, 661, 664. 
 thrombi in, 660. 
 treatment of, 686, 692. 
 
 by alcohol, 697. 
 
 by anodynes, 695. 
 
 by antipyretics, 696, 697. 
 
 by antipyrine, 697. 
 
 by baths, 698, 699. 
 
 by cauterizing ulcers, 693. • 
 
 by cold, 697. 
 
 by curette, 614. 
 
 by digitalis, 697. 
 
 by douche, intra-uterine, 693, 694. 
 
 by douche, vaginal, 687, 688, 692, 699. 
 
 by enemata, 687. 
 
 by laparotomy, 699. 
 
 by laxatives, 696. 
 
 by leeches, 695. 
 
 by opium, 695. 
 
 by poultices, 6 ;5. 
 
 by quinia, 696, 
 
 by salicylate of soda, 696. 
 
 by stupes, 695. 
 
 by veratrum viride, 697. 
 
 by Warburg's tincture, 697. 
 
 by wet-paek, 698. 
 treatment of peritoneal effusions, 699, 700. 
 tympanites in, 678, b79. 
 ulcers in, 656, 679. 
 vibrios in, 666, 681. 
 virus of, 666. 
 vomiting in, 674, 678. 
 zymotic diseases, relations of, to, 685. 
 Puerperal state, 238. 
 abdomen in, 249. 
 after-pains in, 224, 244, 252. 
 air in, 253. 
 antemia in, 645. 
 anodynes in, 252. 
 anteflexion in, 244, 249. 
 antisepsis in, 253, 688. 
 appetite in^ 240. 
 bandage in, 255. 
 binder in, 224. 
 bowels in, 240. 
 breasts in, 249. 
 
 care of, in, 255. 
 cancer, uterine, in, 547. 
 care of patient in, 224. 
 catheterisra in, 252. 
 cervix uteri in, 243, 249, 547. 
 chill in, 238. 
 
 closure of sinuses in, 243. 
 collapse in, 648. 
 convulsions in, 567 et seq., 581. 
 
 Puerperal state : 
 cystitis in, 252. 
 death in, 645. 
 
 decidua, reparation of, in, 241. 
 diabetes in, 240. 
 diagnosis of, 249. 
 diet in, 253. 
 douche in, 224, 2^3. 
 duration of, 255. 
 eclampsia in, 567, 581. 
 embolism in, 645. 
 enemata in, 254. 
 ergot in, 224. 
 fevers in, 653. 
 general functions in, 240. 
 hgemorrhoids in, 254. 
 hymen in, 249. 
 insanity in, 701. 
 involutio uteri in, 240. 
 iodoform in, 592, 688, 700. 
 labia in, 249. 
 la.xatives in, 254. 
 lochia in, 241, 245, 249, 255. 
 loss of weiglit in, 135, 240. 
 malaria in, 653. 
 management of, 238, 251. 
 milk-fever in, 247. 
 milk, secretion of, in, 246, 
 nursing in, 254. 
 pad, antiseptic in, 225, 253. 
 passing urine in, 252. 
 perinseum in, 224, 249. 
 physiology of, 238. 
 placental site in, 249. 
 pulse in, 239, 248, 645. 
 relation of, to pathological conditions. 
 
 238. 
 retention of urine in, 240. 
 scarlatina in, 262, 653. 
 secretion of milk in, 246. 
 separation of decidua in, 242. 
 shock in, 648. 
 sinuses, closure of, in, 243. 
 sleep in, 251. 
 syncope in, 645. 
 temperature in, 239, 247. 
 thrombosis in, 238, (^45. 
 treatment of, 238, 251, 687 et neq. 
 tumors, ovarian, in, 5.50. 
 tumors, uterine, complicating. 542. 547. 
 urine in, 240, 252. 
 uterus, position of, in, 244, 249. 
 
 involution of, in, 240. 
 vagina in, 105, 244, 249. 
 vaginal ulcers in, 693. 
 visits of physicians in, 252. 
 vulva in, 249. 693. 
 washing of vagina in, 224, 253. 
 weight, loss of, in, 135, 240.
 
 Y88 
 
 INDEX. 
 
 Pulse : 
 
 in eclampsia, 568, 
 
 in labor, 130, 645. 
 
 in placenta previa, 593. 
 
 in j)ost-partum hsemoiTliage, 590. 
 
 in pregnancy, 89, 118. 
 
 in puerperal fever, 672 et seq. 
 
 in puerperal state, 239, 248, 645. 
 
 in pulmonary tlii-ombosis, 647, 648. 
 
 in shock, 649. 
 
 in uterine inversion, 608. 
 
 in uterine rupture, 615. 
 Pupils in eclampsia, 567. 
 Puncture, in osdenia of pregnancy, 115. 
 
 followed by premature labor, 115. 
 
 in extrau-terinc pregnancy, 344. 
 Pyaemia, bacteria in, 660, 668, 680. 
 
 in phlegmasia, 705. 
 
 in placenta praivia, 599. 
 
 in puerperal tever, 600, 680. 
 
 Quadruplets, 228, 230. 
 Quickening, 95, 96, 99, 101, 110. 
 
 date of, 95, 110. 
 Quinine : 
 
 as antiphlogistic, in puerperal fever, 696. 
 
 in cephalalgia, 122. 
 
 in chorea, 275. 
 
 in mastitis, 710. 
 
 in phlegmasia, 706. 
 
 in pneumonia, 270. 
 
 in protracted lirst stage, 457, 458. 
 Quintuplets, 228. 
 
 Rachitis, deforming pelvis, 466, 472, 475, 
 
 478. 
 Rales, Laryngeal, in delivery, 215. 
 Rectal eneraata : 
 
 in anaemia, 114, 118. 
 
 in emesis, 118, 119. 
 
 in labor, 208. 
 Rectal touch, in" pregnancy, 104. 
 Kectocele, atresia, vaginal, from, 537, 623. 
 Rectum, development of, 63. 
 
 in labor, 456. 
 
 in pregnancy, 88. 
 Relapsing fever, complicating pregnancy, 264. 
 Repercussion (vide ballottement). 
 Reposition of cord, 631. 
 
 of uterus, in retroflexion, 280, 281. 
 Repositor :' 
 
 Braun's, 411. 
 
 catheter used as, 412, 634. 
 
 in version, 411. 
 Respiration : 
 
 artificial, in asphyxia neonatorum^ 643. 
 Scliultze's method, 643. 
 Sylvester's method, 644. 
 
 in pregnancy, 90, 118. 
 
 Respiration : 
 intra-uterine, 638. 
 physiology of, 635, 638. 
 Restitution, in face presentations, 188. 
 
 in vertex presentations, 178 {vide external 
 rotation). 
 Retained placenta, 221, 225, 461, 581, 584, 
 
 586, 592 {_vide placenta, retained). 
 Retention : 
 in utero^ of dead foetus, 302. 
 of urine — 
 
 in labor, 208, 537. 
 in pregnancy, 208, 2S0. 
 in puerperal state, 240, 252. 
 Retinitis, in nephritis, 273. 
 Retraction ring, 137, 138. 
 Retraction, uterine, 137, 454, 459, 582, 584. 
 Retractores uteri ^ 15. 
 
 Retroflexion of gravid uterus, 116, 279, 307, 
 310, 480, 542, 549, 592. 
 abortion in, 310. 
 with incarceration, 280, 359, 480. 
 diagnosis, 280. 
 treatment, 280, 316, 359. 
 Retroversion of gravid uterus, 116, 279, 480, 
 
 542, 592. 
 Ribs, development of, 64. 
 Rickets, causing pelvic deformity, 466, 472, 
 475 {vide rachitis.) 
 Rigid OS, atresia from, 540. 
 Rlma pudendi^ 2. 
 Ringof Bandl, 84, 137, 611. 
 Kingof Miiller, 84, 85. 
 Ring, retraction or contraction, 137, 138. 
 Robert's anchylosed pelvis, 523. 
 Rotation of fetal head, 173. 
 conditions of, 174. 
 
 excessive, in breech presentations, 202. 
 explanation of, 175. 
 external, in normal labor, 177. 
 in breech presentations, 200, 396. 
 in brow presentations, 194. 
 ill face presentations, 187. 
 in vertex presentations, 173, 177. 
 Rubeola complicating pregnancy, 261. 
 
 with pneumonia, 201. 
 Rupture : 
 in extra -uterine pregnancy, 838. 
 at orifice of vagina, 484. 536, 622, 025. 
 of cervix, 105, 203, 539, 540, 620. 
 of genital canal, 610. 
 of membranes, 132, 140, 208. 
 
 to produce premature labor, 353, 360. 
 of pelvic articulations, 628. 
 of perinajum, 134, 203, 211, 224, 453, 622. 
 of uterus, &\Q{vide uterus, rupture of the) 
 
 in contracted pelvis, 481. 
 of vagina, 621. 
 of vestibule, 622.
 
 INDEX. 
 
 789 
 
 Sac: 
 
 injections into, in extra uterine pregnancy, 
 345. 
 
 puncture of, in extra-uterine pregnancy, 
 344. 
 Sacro-iliac articulation, 145. 
 
 rupture of, 628. 
 Sacrum, 141, 154. 
 
 alee of, 141. 
 
 anatomy of, 141. 
 
 dimensions of, 142. 
 
 hiatus sacralis of, 142. 
 
 lineoe transversce of, 141. 
 
 male and female, 154. 
 
 superficies a uricularis of, 142. 
 Salicylate of soda in puerperal fever, 696. 
 Salivation in pregnancy, 90, 94, 99, 118, 121, 
 
 181. 
 Salpingitis, causing tubal pregnancy, 328. 
 
 in puerperal fever, 656. 
 Saprsemia in puerperal fever, 661. 
 Scalp-tumor, 190, 250, 369, 483, 489. 
 
 in brow presentations, 194. 
 
 in face presentations, 190. 
 Scarlatina : 
 
 in pregnancy, 262. 
 
 jjuerperaliS; 262, 653. 
 Schultze's diagram for computing pregnancy, 
 
 109. 
 Scirrhus of uterus, obstructing labor, 541, 547 
 
 {vide atresia, uterine"). 
 Scolio-rachitic pelvis, 479, 521. 
 Scoliotic pelvis, 479. 
 Scrotum, development of, 64, 65. 
 Seasons, relation of, to puerperal fever, 685. 
 Sebaceous glands : 
 
 of areola, 83. 
 
 of foetus, 68. 
 
 of labia, 5. 
 
 of nymphfe, 5. 
 Secondary areola, 88, 94, 99. 
 Section, Csesarcan, 436 {mde Ca?sarean sec- 
 tion). 
 Secretion : 
 
 disorders of, in pregnancy, 114. 
 
 of milk, 246. 
 Segmentation of ovum, 46. 
 SemSn, 43. 
 
 Senses, special, affections of, in pregnancy, 91. 
 Septicicmia : 
 
 albuminuria in, 680. 
 
 bacteria in, 666 et seq. 
 
 in abortion, 313, 325. 
 
 in atresia, 541. 
 
 in extra-uterine pregnancy, 340. 
 
 in ovarian tumors, 549, 550. 
 
 in puerperal fever, 655, 660, 679-681. 
 
 in retention of dead foetus, 306, 313. 
 
 in transverse presentations, 564. 
 
 Septicaemia : 
 
 in tympanites uteri, 652. 
 
 in uterine cancer, 547. 
 
 in vaginal thrombus, 626. 
 
 li/mphatica, 679. 
 
 pure, 681. 
 
 symptoms of, 679 et seq. 
 
 venosa, 680. 
 
 vibrios in, 666. 
 Septum : 
 
 recto-vaginale, 9. 
 laceration of, 623. 
 
 urethro-vagiiiale, 9. 
 Serous lochia, 245. 
 
 iSerres fines, in perineal laceration, 625. 
 Ssrre-noiud, 444. 
 Sex, prediction of, 97. 
 Sexual organs, abnormities of, 535 
 
 changes in, in pregnancy, 77, 105. 
 Shield, nipple, 255, 70S. 
 Shock, and nerve exhaustion, 492, 495, 549, 
 608, 615, 620, 648. 
 
 anodynes Ln, 650. 
 
 in artificial abortion, 353. 
 Shortening, apparent, of cervix in pregnancy, 
 81. 
 
 explanation of, 83. 
 Shoulder presentations, 169 (vide transverse 
 
 presentation). 
 Shoulders, delivery of, 178, 199, 215. 
 
 in breech cases, 396. 
 Signs of pregnancy, 92 et seq. 
 
 auscultatory, 96, 102, 106. 
 Simpson's forceps, 364, 379. 
 Sampson's perforator, 414. 
 Sinciput, 70. 
 Sinus urogenitalis, 33. 
 Sinuses, closure of, in puerperal state, 238, 
 243. 
 
 foiTnation of, 24. 
 
 uterine, 24, 59. 77, 125, 238. 
 Skin, development of, 48, 64. 
 
 care of, in pregnancy, 113, 118. 
 Skull, development of, 64. 
 Sleep in puerperal state, 251. 
 Sleeplessness in pregnancy, 122. 
 Smegma praputii, 5. 
 Smell, perversion of, in pregnancy, 91. 
 Smellie's scissors, 414. 
 Social state, relation of, to pueq^eral fever, 
 
 685. 
 Soda in pruritus, 121. 
 Sopor in eclampsia, 568. 
 Souffle, funic, 98. 
 
 uterine, 98, 103. 
 Sounds, use of, in pregnancy, 101, 341, 
 
 360. 
 Speculum, use of, in craniotomy, 428. 
 
 in diagnosis of pregnancy, 104.
 
 790 
 
 INDEX. 
 
 Spermatozoa, 43. 
 
 locomotion of, 43. 
 Sphenotribe, 431. 
 Sphincter vaginae, 9. 
 
 Spina bifida, as obstruction to labor, 556. 
 Spinal column, articulation of fetal head with, 
 168. 
 
 develoi^mcnt of, 48, 64. 
 Spinous processes of ilia, distance between, 
 144, 150, 468. 
 
 of iscliia, 145, 153. 
 Spleen : 
 
 enlargement of fetal, 555. 
 
 in puerperal fever, 671. 
 Spondolisthctic pelvis. 525. 
 Sponges, aseptic, preparation of, 360, 439. 
 Sponge-tents, use of, in abortion, 353, 360. 
 Spontaneous amputation, intra-uterine, 296. 
 Spontaneous evolution, 364 {vide evolution). 
 Spontaneous version, 562 {olde version). 
 Spot : 
 
 embryonic, 47, 48, 62. 
 
 germinative, of ovum, 39. 
 Spots, cutaneous, in pregnancy, 91. 
 Stage of labor : 
 
 effect of contracted pelvis on first, 483, 495, 
 502. 
 
 irregular pains in first, 454. 
 
 irregular pains in second, 459. 
 
 irregular pains in third, 401. 
 
 management of first, 203. 
 
 management of second, 209. 
 
 delivery of shoulders in, 178, 199, 215. 
 preservation of periiiJEum in, 210 et seq. 
 tying cord in, 215, 236. 
 
 management of tbird, 220. 
 
 treatment of long first, 456. 
 by anodynes and ana?st'netics, 466. 
 by Barnes's dilators, 457. 
 by bougies, 457. 
 by douche, vaginal, 457. 
 
 treatment of long second, 459. 
 Staphylococci in puerperal fever, 066. 
 State, the puerperal, 238. 
 
 abdomen in, 249. 
 
 after-pains in, 224, 244, 252. 
 
 air in, 253. 
 
 anodynes in, 252. 
 
 anteflexion in, 244, 249. 
 
 appetite in, 240. 
 
 bandage in, 255. 
 
 bowels in, 240. 
 
 breasts in, 249. 
 care of, 255. 
 
 catbeterism in, 252. 
 
 cervix, the, in, 243, 249. 
 
 chill in, 238. 
 
 closure of sinuses in, 243. 
 
 complicated by scarlatina, 262. 
 
 State, the puerperal : 
 
 cystitis in, 252. 
 
 decidua, reparation of, in, 241. 
 
 diabetes in, 240. 
 
 diagnosis of, 249. 
 
 diet in, 253. 
 
 duration of, 255. 
 
 enemata in, 254. 
 
 general functions in, 240, 
 
 h£emorrlioids in, 254. 
 
 hymen in, 249. 
 
 involution in, 240. 
 
 labia in, 249. 
 
 laxatives in, 254. 
 
 lochia in, 241, 245, 249, 255. 
 
 loss of weight in, 135, 240. 
 
 management of, 238, 251. 
 
 milk, secretion of, in, 246. 
 
 milk-fever in, 247. 
 
 nursing in, 254. 
 
 passing urine in, 252. 
 
 perinaeum in, 224, 249. 
 
 physiology of, 238. 
 
 placental site in, 249. 
 
 pulse in, 239, 248. 
 
 relations of, to pathological conditions, 238. 
 
 reparation of decidua in, 241. 
 
 retention of urine in, 240. 
 
 scarlatina in, 262. 
 
 secretion of milk in, 246. 
 
 sinuses, closure of, in, 243. 
 
 sleep in, 251. 
 
 temperature in, 239, 247. 
 
 thrombosis of placental vessels in, 238. 
 
 treatment of, 238, 251. 
 
 tumors, uterine, complicating, 542. 
 
 urine, passing of, in, 240, 252. 
 retention of, in, 240. 
 
 uterus, position of, in, 244, 249. 
 involution of, in, 240. 
 
 vagina in, 105, 244. 
 
 visits of physician in, 252. 
 
 washing vagina in, 224, 253. 
 
 weight, loss of, in, 135, 240. 
 Stenosis, of umbilical vessels, 297. 
 Stethoscope, use of, in diagnosis of preg- 
 nancy, 102. 
 Stiqmafolliculi^ 39. 
 Stiil-births, 635. 
 
 Stillieidium in placenta prsevia, 598. 
 Stimulants : 
 
 in abortion, 323. 
 
 in cephalalgia, 122. 
 
 in cerebral anaemia, 590. 
 Stockings, elastic, in pregnancy, 116. 
 Stomach, development of, 48, 50. 
 Strait : 
 
 axis of inferior pelvic, 153. 
 
 axis of superior pelvic, 152.
 
 INDEX. 
 
 791 
 
 Strait : 
 
 circumference of inferior, 152. 
 
 circumference of superior, 152. 
 forceps at, 355. 
 
 inferior pelvic, 152. 
 
 superior pelvic, 151. 
 Striee : 
 
 abdominal, in pregnancy, 87, 100, 105. 
 
 mammary, in pregnancy, 88, 105. 
 
 on nates and tliighs, in pregnancy, 87, 105. 
 Stump, treatment of, in Porro's operation, 446. 
 Styptics : 
 
 in post-partum haemorrhage, 587, 622. 
 
 in puerperal hajmorrhage, 592. 
 
 in puerperal state, 693. 
 Subinvolution after abortion, 314. 
 Sugar in urine, /)ci«<-/'a/'<M»i, 240. 
 Superfetation, 231 {vide pregnancy, multiple). 
 Superficies auricularis, 142. 
 Surgery, obstetric, 349. 
 Surgical operations : 
 
 abortion from, 276. 
 
 during pregnancy, 276. 
 
 prognosis, 276. 
 
 time for, 277. 
 Suspended animation, 635 {vide asphz/xia ne- 
 onatorum). 
 Sutures, 70, 165. 
 
 coronal, 70, 166, 183. 
 
 frontal, 70, 165. 
 
 in Cesarean section, 441. 
 
 in hydrocephalus, 552. 
 
 in uterine rupture, 400, 621. 
 
 lambda, 70, 166, 183. 
 
 premature ossification of, 551. 
 
 sagittal, 70, 183. 
 Symphysiotomy. 713. 
 Symphysis pubis, 145, 154, 471. 
 
 absence of, 534. 
 
 anatomy of, 145. 
 
 in male and female, 154. 
 
 relaxation of, in pregnancy, 148, 275. 
 
 rupture of, 628. 
 Synchondrosis, sacro-iliuc, 145. 
 
 motion at, 275. 
 
 rupture of, 628. 
 Syncope : 
 
 in child'>ed, 645. 
 
 in labor, 134, 645. 
 
 \n post-partum haemorrhage, 590. 
 
 in pregnancy, 91, 114, 118. 
 Syphilis : 
 
 causing abortion, 272, 308, 350. 
 
 complicating prognaucy, 271. 
 
 of placenta, 290. 
 
 Tampon : 
 in abortion, 320, 322, 323, 324, 326, 355. 
 in hydatid mole, 302. 
 
 Tampon : 
 
 in placenta praevia, 601, 604. 
 
 in uterine prolapse, 282. 
 
 in vaginal prolapse, 283. 
 
 method of applying, 322, 323. 
 
 to produce premature delivery, 355. 
 
 uterine, in haemorrhage, 592. 
 Tannin in pruritus, 122. 
 Tardy labor, 453 {vide labor, tardy). 
 Tarnier's forceps, 377-379, 390, 400. 
 Tamier's incubator, 358. 
 Taste, perversions of, in pregnancy, 91. 
 Taylor's forceps, 377, 414, 513. 
 Temperature : 
 
 in labor, 130. 
 
 m post-part um state, 239. 
 
 in pregnancy, 118. 
 
 in puerperal fever, 671, 672. 
 Tenesmus, vesicle, from retroflexed incar- 
 cerated gravid uterus, 280. 
 Tents, in abortion, 121, 324, 353, 360, 602. 
 
 in hydatid mole, 302. 
 Terminal bulbs of clitoris, 3. 
 Testicle : 
 
 development of, 65. 
 
 fibro-cystic degeneration of fetal, 555. 
 Thecafolliouli of Graafian follicle, 36, 38. 
 Thighs, strim on, in pregnancy, 87, 105. 
 Thirst in pregnancy, 118. 
 Thomas's operation, 447. 
 Thorax in pregnancy, 90. 
 
 development of, 64. 
 Thrill in uterine artery during pregnancy, 
 
 100. 
 Thrombus : 
 
 arterial, 645. 
 
 cardiac, 646. 
 
 causing collapse and death in labor and 
 childbed, 645. 
 
 in placental vessels, physiological, 238, 
 249. 
 
 in placental sinuses, 288. 
 
 in placenta prsevia, 599. 
 
 in septicaemia, 660. 
 
 in veins and lymphatics during phlegma- 
 sia, 704. 
 
 of cervix, 540. 
 
 of labia, 5. 
 
 of OS, in labor, 540. 
 
 of uterine sinuses in labor, 238, 583, 584. 
 
 of vagina, 538, 625 {vide vagina, thrombus 
 of), 
 anodynes in, 628. 
 
 of vulva, 5, 526, 625 {vide vulva, thrombus 
 of). 
 
 treatment of pulmonary, 650. 
 
 venous, 646, 660. 
 Thyroid gland, hypertrophy of, in pregnan- 
 cy, 89.
 
 792 
 
 INDEX. 
 
 Torsion of cord, 293, 303. 
 Touch, vaginal, in diagnosis of pregnancy, 
 99, 103. 
 
 rectal, in pregnancy, 104. 
 Trace, primitive, 48. 
 
 Trachelorrliapliy, to prevent abortion, 318. 
 Tractions, on forceps, 366. 
 
 axis, 390. 
 
 direction of, 366, 372, 373, 377. 
 
 time for making, 368, 372. 
 
 on cord : 
 in labor, 220, 221. 
 in retained placenta, 463, 593. 
 Trans/orateur,B.u'ben''s, in ccphalotomy, 431. 
 Transfusions of blood and milk m posi-par- 
 tiim hasmorrhage, 590. 
 
 apparatus for, 591. 
 
 in anffimia of pregnancy, 114. 
 
 in cerebral ancemia, 590. 
 Transverse diameter of pelvis, 151. 
 Transverse presentations, 1G9, 560. 
 
 version in, 404, 406. 
 Transversus perinei, 162, 164. 214. 
 Trephine-perforator in craniotomy. 416, 419. 
 Triplets, 228, 230. 
 Trunk: 
 
 delivery of, with crotchet, 430. 
 
 expulsion of, in labor, 178, 554. 
 
 extraction of, in breech cases, 384. 
 Truss in hernia of uterus, 284. 
 Tubal pregnancy, 328. 
 Tubes, Fallopian, 12, 19, 30. 
 
 ampulla of, 19. 
 
 anatomy of, 19, 30. 
 
 dilatation of, in atresias, 541. 
 
 fimbriated extremity of, 19. 
 
 isthmus of, 19. 
 
 mucous membrane of, 21, 329. 
 
 muscles of, 20, 
 
 non-crectility of, 41. 
 
 ostium abdominale of, 19. 
 
 position of, in pregnancy, 79. 
 Tuhis medullar is, 50. 
 Tumors : 
 
 abdominal, diagnosis of, from preg!iancy, 
 102, 549. 
 
 fetal, causing dystocia, 554. 
 
 fibroid, of uterus, in pregnancy, 102, 542. 
 
 indicating Cesarean section, 438. 
 
 intrapelvic, causing atresia, 533, 542. 
 
 osseous, deforming pelvis, 533. 
 
 ovarian, 548 (vide ov&ry, tumor of), 
 in parturition, 55f>. 
 in pregnancy, 548. 
 in puerperal state, 550. 
 obstructing labor, 548. 
 
 parametritic, in puerperal fever, 674. 
 
 phantom, differentiation of, from preg- 
 uancv, 102. 
 
 Tumors : 
 placental, 289. 
 scalp, 181, 483. 
 alter birth, 250. 
 in brow presentations, 194. 
 indicating forceps, 369. 
 in face presentations, 190. 
 uterine : 
 complicating pregnancy, parturition, and 
 
 puerperal state, 542 et seq. 
 producincf atresia, 541, 546. 
 vaginal, causing atresia, 538. 
 Tunica : 
 albuginea of ovary, 23. 
 Jibrosa of Graafian follicle, 36. 
 propria of Oraafian follicle, 36. 
 Tupelo tents in abortion, 121. 
 Turning, 400 {vide version). 
 Twin-pregnancy, 228, 230, 233 (tide preg- 
 nancy, multiple^ 
 Twins, locking of, obstructing labor, 234. 
 Tympanites : 
 in Ca'sarean section, 441. 
 in puerperal fever, 676, 677, 679. 
 mistaken for pregnancy, 102. 
 uteri, 652. 
 Typhoid fever complicating pregnancy, 204. 
 
 in puerperal state, 653. 
 Typhus fever complicating pregnancy, 264. 
 in puerperal state, 653. 
 
 Ulcers in puerperal fever, 656, 693. 
 Umbilical cord, 60 (vide funis). 
 
 anomalies of, 293. 
 
 arteries of, 53, 60, 61, 250. 
 
 calcareous degeneration of, 298. 
 
 care of, in infants, 256. 
 
 coiling of, 204, 215, 296. 
 
 cysts in, 297. 
 
 degenerations of, 297. 
 
 diseases of, 297. 
 
 expression of, 630. 
 
 formation of. 60. 
 
 gelatin of, 61. 
 
 hernias of, 296. 
 
 in new-born, 250. 
 
 knots in, 295. 
 
 laceration of, in precij)itate labor, 453. 
 
 late ligation of, 216, 236. 
 
 management of, in breech presentations 
 393. 
 
 marginal insertion of, 298. 
 
 prolapse of, 510, 561, 629. 
 
 reposition of, 631. 
 
 shortness of, 559. 
 
 souffle in, 98. 
 
 stenosis of vessels of, 297. 
 
 structure of fully developed, 61 
 
 torsion of, 293.
 
 INDEX. 
 
 793 
 
 Umbilical cord : 
 
 ante-mortem, 295. 
 tying of, in labor, 215, 23G. 
 vein of, 53, 60. 
 vessels of, 53, 60. 
 - Umbilical vesicle, 50, 52, 60, 63, 64. 
 Umbilical vessels, 53, 60, 06. 
 
 stenosis of, 297. 
 Umbilicus: 
 arteries of, 53, 60, 66. 
 changes of, in pregnancy, 87, 100. 
 of new-born child, 250. 
 Unavoidable haemorrhage, 597, 60 i. 
 Uraemia : 
 in eclampsia, 571, 576. 
 in retroflexion, 280. 
 Urea in amniotic fluid, 61. 
 Ureter : 
 
 dilatation of fetal, 554. 
 Urethra in pregnancy, 105. 
 
 in labor, 134. 
 Urinary calculus, obstructing labor, 537. 
 Urination, involuntary, in pregnancy, 88, 
 2S0. 
 frequent, in abortion, 311. 
 Urine : 
 albumen in, during pregnancy, 91, 118, 273, 
 567. 
 during eclampsia, 567, 569 et seq. 
 during septicemia, 680. 
 atresia from retention of, 537. 
 casts in, in eclampsia, 567. 
 expulsion involuntary, of, in pregnancy, 88. 
 incontinence of, 88, 280. 
 increase of, in labor, 130. 
 
 in pregnancy, 91. 
 in hydramnion, 292. 
 kiesteine in, 94. 
 of foetus, 61, 250. 
 of infant, 250, 251. 
 passing, in puerperal state, 252. 
 post-partum, 240. 
 retention of, in pregnancy, 208, 280, 368, 
 
 537. 
 retention of, in puerjieral state, 240, 252. 
 suppression of, in eclampsia, 573. 
 Uterine : 
 atony in double uterus, 278, 540. 
 
 in third stage, 461. 
 bruit, in pregnancy, 96, 98, 103. 
 douche : 
 
 in abortion, 320, 325, 326, 354, 356. 
 in hydatid mole, 302. 
 in post-partum htemon-hage, 587. 
 in puerperal fever, 683, 693, 694. 
 glands, IS. 
 inertia, 454, 461. 
 insufficiency, 454, 457, 401. 
 pain in pregnancy, 127, 131, 
 
 Uterine : 
 paralysis, 454. 
 souffle, 98, 103. 
 
 tumors obstructing labor, 542. 
 vessels, air in, 647. 
 Uterus : 
 abnormal conditions of, 277. 
 abnormities of, 33, 260, 277. 
 action of, in labor, 135. 
 action of pains on walls of, 128. 
 amputation of, in rupture, 618. 
 anatomy of, 10. 
 anteversion and anteflexion of, 80, 116, 278. 
 
 causing abortion, 310. 
 
 in puerperal state. 244, 249. 
 arteries of, 23, 24, 59, 77, 79, 103. 
 
 in pregnancy, 77, 79, 95, 101, 105. 
 
 internal spermatic, 25. 
 
 tiirill in, during pregnancy, 100. 
 
 uterlna hypogastrica , 23. 
 atresia of, 539 (vide atresia, uterine), 
 atrophy of mucous membrane of, causing 
 
 abortion, 309. 
 Mcornis, 34. 
 body of, 12, 18. 
 
 bruit in, during pregnancy, 96, 98, 103. 
 cancer of neck of, 546. 
 
 treatment of, 547. 
 catheterization of, to produce abortion, 352, 
 
 580. 
 causes of enlargement of, 78. 
 cavity of body of, 13. 
 center, motor, for contractions of, 126. 
 cervix or neck of, 12. 
 changes in, in pregnancy, 77-86, 105, 116, 
 
 131, 1.37. 
 compression of, in labor, 220. 
 contractions of, in labor, 127, 311, 454, 582. 
 contractions of. in pregnancy, 101, 124, 127. 
 
 effect of chloroform on, 227. 
 
 method of causing, in post-partum ha'm- 
 orrhage, 585. 
 cordiformk, 34. 
 corpus of, 12. 
 cornua of, 33. 
 
 curetting of, in puerperal haemorrhage, 592. 
 development of, 30. 
 didelphi/s, 34. 
 dilatation of fetal, 555. 
 dimensions of, post-partum, 241, 244, 249. 
 displacements of gravid, 80, 110, 278,310, 
 480. 
 
 double. 34, 277, 540. 
 causing abortion, 278. 
 drainage of, 618. 
 duplex, 341, 277, 540. 
 erectility (theoretical) of, 26. 
 evacuation of, in abortion, 320, 321. 
 fluctuation in gravid, 100.
 
 i94 
 
 INDEX. 
 
 Uterus : 
 fimdus of, 12, 130. 
 gangrene of, in retroflexion, 280. 
 glands of, 18. 
 gravid, TT, 95, 101, 105, lOG. 
 
 anteversion and anteflexion of, 80, IIC, 
 278. 
 
 retroflexion of, 116, 279, 310,. 480. 
 
 retroversion of, 116, 279, 480. 
 with incarceration, 280, 859, 480. 
 growth, early lateral, of, 79, 123. 
 hernia of gravid, 283. 
 liour-glass contraction of, 224. 
 hypero3mia ot gravid, 310. 
 hypertrophy of mucous membrane of, 310. 
 incarceration of i-etroflexed, 2^0, 359. 
 injections between, and ovum, to produce 
 
 abortion, 352. 
 injections into, mpost-pat-tiim hemorrhage, 
 
 587. 589. 
 in puerperal peritonitis, 678. 
 in puerperal state, 241, 244, 249. 
 inversion of, 453, 560, 594, 607. 
 involution of, 240. 
 irritability of, in gestation. 127. 
 laceration of cervix of, 105, 203, 453, 539, 
 
 620. 
 ligaments of, 15, 16. 
 
 contraction of, in labor, 128. 
 lymphatics of, 28, 77. 
 measurements of gravid, 78. 
 motor center of, 126. 
 
 mucous membrane of, 18-20, 77, 81, 242, 
 309. 
 
 atrophy of, 309. 
 
 crypts in, 55, 242. 
 
 hypertrophy of, 310. 
 muscles of, 16. 
 
 in pregnancy, 77-86, 124. 
 myomata of, 542 et seg. 
 
 treatment of, 543. 
 nerves of, 27, 77, 126, 311. 
 neck of, 12. 
 one-horned, pregnancy in rudimentary 
 
 cornu of, 3."2. 
 OS internum of, 13. 
 paralysis of, 456. 
 
 perforation of, from pressure, C20. 
 peritonaeum of, 16, 79. 
 Porro's operation for removal of, 442. 
 position of, in puerperal state, 244. 
 
 in pregnancy, 75. 
 
 post-partum, 244. 
 prolapse of, complicating pregnancy, 282, 
 
 359. 
 reflex action of, causing vertex presenta- 
 tions, 75, 126. 
 removal of, by Porro's operation, 442. 
 retention in, of dead fcctus, 302. 
 
 Uterus : 
 retraction of, 137, 454, 459, 582. 
 
 methods to cause, 589. 
 retroflexion and retroversion of gravid. 
 116, 279, 359, 480. 
 
 treatment of, 280, 316, 359. 
 rupture of, 353, 387, 400, 410, 412, 443, 
 481, 484, 492, 540, 542, 553, 610, OiO. 
 
 clinical history of, 615. 
 
 diagnosis of, 615. 
 
 etiology of, 611. 
 
 pathology of, 614. 
 
 treatment of, 616. 
 semi-parfiti/s, 34. 
 septus Mlocularis, 34. 
 shape of gravid, 80, 100, 123. 
 sinking of gravid, 80, 90, 130. 
 sinuses of, 24, 59, 77, 125, 238. 
 size of, in liydatidiform mole, 301. 
 
 in pregnancy, 77, 80, 100, 110. 
 
 posf-pa7-tum, 242, 244, 249. 
 softening of, in pre.unancy, 194. 
 thrombi in sinuses of, 583, 599. 
 tumors of, complicating prciinaucy, 542. 
 
 causing hemorrhage, 584. 
 tympanites of, 652. 
 unicornis, 34. 
 veins of, 24, 59, 77. 
 
 in pregnancy, 77, 124. 
 
 thrombi in, 646, 660. 
 vessels of, and of its appendages, 23, 124, 242. 
 weight of gravid, 78, 124. 
 
 in puerperal state, 241. 
 weight of virgin, 78. 
 
 Vagina : 
 
 absence of, 536. 
 anatomy of, 8, 162. 
 arteries of, 10. 
 atresia of, 536. 
 
 accidental, 536. 
 
 congenital, 536. 
 
 from calculi, 537. 
 
 from cystic degeneration, 538. 
 
 from cystocelc, 537. * 
 
 from double vagina, 538. 
 
 from cchinococci, 538. 
 
 from neoplasmata, 538. 
 
 from prolapse of vagina, 537. 
 
 from rectocele, 537. 
 
 from retention of urine, 537. 
 
 from thrombus, 538, 626. 
 
 from vaginal hernia, 537. 
 
 from vaginismus, 538. 
 
 from vesical calculi, 537. 
 bulbs of vestibule of, 5, 102. 
 changes of, in pregnancy, 85, 105, 131. 
 changes of, in puerperal state, 244, 249. 
 color of, in pregnancy, 104.
 
 INDEX. 
 
 795 
 
 ^'agifta : 
 columns of, 9. 
 constrictor of, 162. 
 cristce of, 10, 105. 
 cystic degeneration of, 538. 
 clevelopineut of, 30. 
 double, 277, 538. 
 douche in : 
 
 in abortion, 320, 322. 
 
 in pregnancy, 113, 122. 
 
 ill puerperal hEemorrbage, 592. 
 
 in puerperal state, 224, 253, 693. 
 
 in long first stage of labor, 457. 
 
 in retained placenta, 594. 
 
 to cause abortion, 354, 35(5. 
 
 to prevent puerperal fever, 687, 092, 
 699. 
 erectility, theoretical, of, 9. 
 examination by, in pregnane}-, 99, 103, 
 
 206. 
 fornix, of, 9. 
 glands of, 10, 162. 
 influence of, on labor, 129. 
 in pregnancy, 85, 104, 105, 131. 
 in puerperal state, 244, 249. 
 laceration of, 453, 484, 543, 621. 
 laceration of orifice of, 484, 536, 622, 625. 
 muscles of, 9, 162. 
 
 in pregnancy, 85. 
 ojdema of, in pregnancy, 114. 
 orificiwm of, 6, 7. 
 papillfE of, 10, 86, 105. 
 
 hypertrophy of, 86, 105. 
 mucous membrane of, 10, 85. 
 
 in pregnancy, 85, 104. 
 neoplasms of, 538. 
 non-erectility of, 9. 
 
 orifice of, 6, 7. 
 prolapse of, in pregnancy, 283, 537. 
 
 from laceration, 623. 
 sphincter of, 9. 
 
 stenosis of, indicating forceps, 368. 
 structure of walls of, 9. 
 tampon applied to : 
 
 in aBortiou, 320-324, 326, 355. 
 
 in hydatidiform moie, 302. 
 
 in placenta pra3via, 601. 
 
 to produce abortion, 355. 
 thrombus of, 538, 625. 
 
 anodynes in, 628. 
 
 atresia from, 538, 625. 
 
 Barnes's dilator in, 627. 
 
 diagnosis of, 626. 
 
 etiology of, 626. 
 
 prognosis ol", 626. 
 
 symptoms of, 625. 
 
 treatment of, 627. 
 ulcers of, 536, 693. 
 veins of, 10. 
 
 Vagina : 
 
 in pregnancy, 85, 626. 
 walls of, their structure, 9. 
 Vaginal columns, 9. 
 
 Vaginal douche, 113 {vide douche, vaginal). 
 Vaginal growths, atresia from, 538. 
 Vaginal touch, in the diagnosis of pregnancy, 
 
 99, 103. 
 Vaginismus, atresia from, 538. 
 Vagitus nterinus, 642, 652. 
 Valve : 
 Eustachian, 66, 68, 637. 
 of foramen ovale, 66, 08. 
 Varicose veins in pregnancy, 88, 115. 
 Variola in pregnancy, 261. 
 Vaseline in pruritus, 121. 
 Vectis, 362. 
 Veins : 
 cervical, 26. 
 
 hEemorrhoidal, in pregnancy, 115. 
 inflammation of, in puerpei-al fever, 660. 
 internal spermatic, 26. 
 mammary, in pregnancy, 87, 94, 99. 
 ovarian, 26. 
 pelvic, 158. 
 thrombi in, 646, 660. 
 umbilical, 53, 60, 66, 250. 
 uterine, 24, 59, 77, 046, 60O. 
 utero-ovarian, 25, 26. 
 vaginal, 10. 
 
 varicose, in pregnancy, 88. 115, 626. 
 elastic stockings in, 116. 
 ergotine in, 116. 
 
 in vaginal and vulvar thrombus, 626. 
 Venesection in eclampsia, 579, 581. 
 
 in pneumonia, 270. 
 Ventilation in hospitals, 682, 689. 
 Veratrum viride : 
 
 in eclampsia, 579, 581. 
 in puerperal fever, 697. 
 Vernix caseosa, 65, 68. 
 
 removal of, 256. 
 Version, 400. 
 after complete retraction of uterus, 409. 
 after craniotomy, 430. 
 after embryotomy, 432. 
 after rupture of membranes, 405. 
 anaesthetics in, 404, 406, 410. 
 cephalic, 401. 
 
 Braxton Ilicks's method, 403, 404. 
 Buseh's method, 402. 
 combined methods, 401, 404. 
 D'Outrepont's method, 403. 
 external method, 401. 
 Hohl's method, 403. 
 Wigand's method, 401. 
 "Wright's method, 403. 
 combined, 401, 404. 
 decapitatii:>«> in, 413.
 
 796 
 
 INDEX. 
 
 Version : 
 external, 401. 
 
 hand employed in, -106, 407. 
 in accidental hsemorrhasre, GOG. 
 in breech and foot cases, 204, 38G. 
 in brow presentations, 196. 
 in contracted pelves, 498, 499, 503 et seq. 
 in craniotomy, 430. 
 in death of mother, 651. 
 in face presentations, 3S1. 
 in head presentations, 404, 
 in heart diseases, 268. 
 in lateral positions, 407. 
 in multiple pregnancy, 23G. 
 in placenta prsevia, G02, 603. 
 iu prolapse of funis, 631, 633, 034. 
 in rupture of uterus, 61G. 
 in Thomas's operation, 450. 
 internal, 401, 405. 
 
 in transverse presentations, 404, 406. 
 in uterine myoma, 645. 
 neglected, 408. 
 podalic, 401, 404. 
 bipolar method, 404. 
 combined method, 404. 
 indications for, 404. 
 repositors, use of, in, 411. 
 spontaneous, 562. 
 etiology, 502. 
 
 mecbanism of complete, 563. 
 mechanism of partud, 503. 
 prognosis in, 564. 
 use of catheter as repositor in, 412. 
 use of tillet in, 411. 
 use of repositor, Braun's, in, 411. 
 Vertebrae, primitive, 49. 
 
 Verte.x presentation, 169 et seq (iride presen- 
 tation, vertex). 
 Vertigo in pregnancy, 114, 118. 
 
 in eclampsia, 507. 
 Vesicle : 
 blastodermic, 47, 50. 
 germinative. of ovum, 39, 45. 
 
 disappearance of, 45. 
 umbilical, 50, 51, 52, 60, 63, 64. 
 Vesicles, cerebral, 63. 
 development of, 63. 
 Vessels : 
 cervical, 26, 27. 
 collapse and death from entrance of air into 
 
 uterine, 355. 647. 
 umhilical stenosis of, 297. 
 uterine, 23, 79. 
 entrance of air into, 355, 647. 
 Vestibnlum, 4. 
 bvlbi of, 4, 622. 
 glandidce of, 5, 6. 
 laceration of, 622. 
 Vibriones in septic£emia, COG, 6§J. 
 
 Viburnum prunifolium in abortion, 317, 318. 
 
 in salivation, 121. 
 Villi, chorial, 51-53, 56, 64, 289, 329. 
 abortion from degeneration of, SOS. 
 of cat, 56. 
 of mare, 55. 
 placental, 56. 
 Vinegar in posi-paHtini hDcmorrhage, 588. 
 Virus of puerperal fever, 006. 
 Visceral arches, 63. 
 
 Visits of physician in puerperal state, 252. 
 Vitelline membrane of ovum, 38. 
 Vitellus, or yolk, of ovum, 39. 
 appearance of nucleus of, 45. 
 segmentation of, 45. 
 Volsella forceps in embryotomy, 432. 
 Vomiting: 
 causing haemorrhage, 585. 
 in incarcerated retrctiexed gravid uterus, 
 
 280, 359. 
 induction of abortion for, 117, 351, 359. 
 in eclampsia, 567. 
 in hydramnion, 292. 
 in pregnancy, 90, 93. 99, 116, 117, 351. 
 in puerperal fever, 674, 078. 
 in rupture of uterus, 615. 
 in shock, 649. 
 Vulva, 2. 
 atresia of, 535. 
 cancer of, 536. 
 changes in, during pregnancy, 86, 104, 105, 
 
 115. 
 color of, in pregnancy, 104. 
 connicens. 2. 
 erosions of, 622. 
 fourcliette of, 4. 
 frenulum of, 4. 
 hfematoma of, 536. 
 Mans, 2. 
 
 laceration of, 536, 622. 
 glands of, 5, 162. 
 
 in pregnancy, E6. 
 oedema of : 
 
 in labor, 130, 368, 620. 
 
 in pregnancy, 86, 104, 105, 115, 131, 134, 
 
 280, 536. 
 in puerperal state, 249. 
 polypus of, 536. 
 pruritus of, 122. 
 
 stenosis of, indicating forceps, 368. 
 thrombus of, 5, 536, 625. 
 diagnosis of, 626. 
 etiology of, 626. 
 prognosis, of, 626. 
 symptoms of, f 25. 
 treatment of, 627. 
 ulcers of, in puerperal fever, 656, 693. 
 varicose veins of, in pregnancy, 88, 104, 
 115, 626.
 
 INDEX. 
 
 T97 
 
 Vulvo- vaginal: 
 follicles, 5, 6. 
 glands, 5, 6. 
 
 Wallace's forceps, 365. 
 
 Walls of abdomen obscuring pregnancy, 
 
 102. 
 Waters, false, 562. 
 Water, hot, in lia?morrhage, 587. 
 Weight : 
 
 gain of, during pregnancy, 90. 
 
 less of, in pregnancy, 114. 
 
 loss of, in puerperal state, 135, 240. 
 
 of f(jetus at term, 69, 251. 
 
 of foetus in multiple pregnancy, 231. 
 
 Weight : 
 
 of gravid uterus, 78. 
 
 of virgin uterus, 78. 
 Wet-nurse, selection of, 256. 
 Wet-pack, use of, in puerperal fever, 698. 
 Wharton's gelatin, 61. 
 Whisky in yost-'partum h.Tinorrhage, 5£0. 
 White's forceps, 365. 
 Wolffian bodies, 29. 
 
 Yolk of ovum, 39. 
 
 Zona pcllucida of ovum, 38, 46. 
 Zymotic diseases, their relation to puerperal 
 fever, 685. 
 
 THE END.
 
 I 
 
 4
 
 THE DISEASES OF 
 IMkMY km CHILDHOOD. 
 
 J^or the Use of Students and Practitioners of Medicine. 
 By L. EMMETT HOLT, A. M., M. D., 
 
 Profes&or of DUeases of Children in the JVeiv York Polyclinic ; Attending Physician to 
 
 the Babies' Hospital and to the JS'ursery and Child's Hospital^ Is-ew York; 
 
 Consulting Physician to the New York Infant Asylum^ and to the 
 
 Huspital for Puptured and Crippled. 
 
 With 7 full page Colored Plates and 203 Illustrations. Cloth, $6.00 , 
 sheep, $7.00 ; half morocco, $7.50. 
 
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 Azaerican Medico-Surgical Bulletin: 
 
 " This work is in every sense of the word a new book ; for, while the best work of other 
 authors in this and other countries has been di'awn upon, especially that in tlie form of 
 monoi^raphs and in the flies of paediatric literature, the majority is derived trom the author's 
 own clinical observations. Obsolete dicta handed down from te.xt -book to te.\t-book are 
 here conspicuously absent, and nothing has been accepted which has not been carefully 
 tested. ... It is not veuturinar too much, after a careful perusal of these pages, to predict 
 for tliis volume a pre-eminent and lasting position among the treatises upon this subject. 
 We heartily recommend that it iiud a place not only in the library of every physician, but 
 wide open at the elbow of every man who desires to deal intelligently with the problems 
 which confront liim in the treatment of infants and children intrusted to his care." 
 
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 " This mainiflecnt work is one of the most valuable recent contributions to medical liter- 
 ature. It will rapidly win its way to a front rank with other standard works upon kindred 
 subjects. It is as nearly complete as a treatise upon tliis subject can be." 
 
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 " When one recalls the teachings of a decade or two ago and compares the inculcations 
 of to-day, he can scarcely help recognizing that ' old thing's have passed away, and all 
 things have become new.' The volume befoi-e us is practically the record of information 
 obtained by the author from eleven years of special study and practice, so that nearly every 
 subject is presented from the standpoint of personal observation and experience. The 
 information given is therefore reliable, for Y)r. Holt is a close observer and a careful student 
 of his ripe experience. ... In short, this book appears to us to be the best all-round, up-to- 
 date book for practitioners and students of children's diseases that we know of." 
 
 Medical Progress : 
 
 " The work before us is one which reflects great credit upon the distinguished author. 
 r>r. Ilolt has long been known as a most industrious and painstaking investigator, and in 
 this volume he sustains that reputation. The work, we may say in a sentence, is fully up 
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