•5^ v^ \^ IMAGE EVALUATION TEST TARGET (MT-3) L .<^ /. 1.0 I.I I, 50 ^^^ MMHB 1^ Uii 12.2 m 1.25 liu II '-^ ^ 6" - ► V] vl / 4\</ .1 HiotDgiaphic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. MS80 (716) 872-4S03 4^ •%^ CIHM/ICMH Microfiche Series. CIHM/ICIVJH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques Technical and Bibliographic Notaa/Notaa tachniquas at bibiiographiquaa Tha inttituta has attamptad to obtain tha baat original copy availabia for filming. Faaturaa of this copy which may ba bibliographicaily uniqua, which may altar any of tha imagas in tha raproduction, or which may significantly changa tha usual mathod of filming, ara chackad balow. n D E 1/ D D D □ Colourad covars/ Couvartura da coulaur |~~1 Covars damagad/ Couvartura andommagAa Covars restorad and/or laminatad/ Couvartura rastauria at/ou palliculia I I Covar titia missing/ La titra da couvartura manque I I Colourad maps/ Cartas giographiquas an coulaur Colourad ink (I. a. othar than blue or black)/ Encra da coulaur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other materiel/ Rell6 avec d'eutres documents Tight binding may cause shadows or distortion along Interior mergin/ La reliure serrAe peut causer da I'ombre ou de la distortion la long de la marge intArleure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajoutAes lors d'une restauration apparaissent dans la texte, mais, iorsque cela 6tait possible, ces pages n'ont pas Mt film6es. AdditionsI comments:/ Commentaires supplAmantaires: L'Instltut a microfilm^ la mallleur exemplaire qu'il lui a 4t* poasibia da se procurer. Lea details da cet exemplaire qui sont peut-Atre uniques du point de vue bibllographiqua, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la mAthoda normale ua filmage aont indiqute ci-dessous. I — I Coloured pages/ D Pages de couleur Pages damaged/ Pages endommagAes Pages restored and/oi Pages restauries et/ou pelliculAes Pages discoloured, stained or foxe< Pages dicoiortes, tachetAes ou piquAes Pages detached/ Pages dAtachias Showthrough/ Transparence Quality of prir Qualit* InAgaia de I'lmpression Includes supplementary materii Comprend du material supplAmentaire |~~| Pages damaged/ I — I Pages restored and/or laminated/ r~n Pages discoloured, stained or foxed/ I 1 Pages detached/ [~n Showthrough/ I I Quality of print varies/ I I Includes supplementary material/ Only edition available/ Seule Edition disponible Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed ^o ensure the best possible image/ Les pages totalement ou partiellement obscurcies par un feuillet d'errata, une pelure, etc., ont At A fiimAes k nouveau de fapon A obtenir la meilleure image possible. Varioui pagingi. This item is filmed at the reduction ratio checked below/ Ce document est filmA au taux de reduction indiquA ci-dessous. 10X 14X 18X 22X 26X 30X y 12X 16X 20X 24X 28X 32X Ills du difiar jna laga rata > alura. J 32X Tha copy filmad hara haa baan raproducad thanka to tha ganaroaity of: University de Sherbrooke Tha imagaa appaaring hara ara tha bsst qualify posaibia conaidaring tha condition and lagibility of tha original copy and in kaaping with tha filming contract spacificationa. Original copias in printad papar covars ara filmad beginning with tha front covar and anding on tha last paga with a printad or illustratad impras- sion, or tha back covar whan appropriata. All othar original copia* ara filmad beginning on tha first paga with a printad or illustratad impres- sion, and anding on tha last paga with a printed or illustratad impression. The last recorded frame on each microfiche shall contain the symbol -^ (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure ara filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: 1 2 3 L'exempiaira film* f ut reproduit grAce A la gAn6rosit* de: Univenit< da Sherbrooke Les images suivantas ont it* raproduites avac la plus grand soin, compta tenu de la condition at de la nattett de rexemplaire film*, et en conformity avac les conditions du contrat de filmage. Les exemplairas originaux dont la couverture en papier est imprimte sont filmte en commengant par la premier plat et en terminant soit par la darnlAre paga qui comporte une empreinte d'impression ou d'lllustration, soit par la second plat, salon le cas. Tous les autres exemplairas originaux sont fiimte an commen9ant par la premiere page qui comporte une empreinte d'impression ou d'illustration et en terminant par la dfirniira page qui comporte une telle empreinte. Un dt^s syml.toles suivants tiipparattra sur la derni*k«» iir.age de cheque microfiche, seion le cas: le symbols — ► signifie "A SUIVRE", le symbols V signifie "FIN". Les cartes, planches, tableaux, etc., peuvent Atre fiimAs A des taux da reduction diffArants. Lorsqua le document est trop grand pour Atre reproduit en un seul clichA, il est film* d partir de Tangle supArieur gauche, de gauche d droite, et de haut an bas, en prenant le nombre d'images ndcessaira. Les diagrammes suivants iilustrent la mAthode. 1 2 3 4 5 6 I'noxTisriECK. I i^ -'••< (|i liri i'"it' 3."1 (p. I (•'iir. L'09 (J Fie. -Ml (I )•) (I ' PI. lil (l>. ml tlic K. Vrelcs. 2. .Mr>illl MM-linll shi,\\ ilj;; l||l' I'dlltidll dl' till' Visci'l'll III lllrir lluriiml iPiisiliuMS ' Ilil'killSnll). (/'"' thldiln fii I'iij. ,;/..',,'.) «J'i I AN AMERICAN TH XT- BOOK OF OBSTETRICS FOR PRACTITIONHRS AND STUDHNTS BY James C. Camiron. M.I).. HnwAun P. Davis, M.l). RoBi-.KT L Dickinson, M.D.. Chari.hs Warkington Haki.i;. M.D., Jamis H. HrHKRiDOh. M.D., Hf.nry J. (lARRiGiKs, M.D.. Barton Cookk Hirst, M.D. Charms Ji-wktt. M.D.. Howard A. Kki.i.y. M.D. Richard C. Norris. M.D.. Chaincf.y D. Pai.mfr, M.D. THi:opH!i.rs Parvin. M.D.. Gkorgi-: A. Pii-rsoi.. M.D. Hdwari) Rkynoios M.D., Hi-nry Schwarz. M.D. Richard C. Norris. M.D.. Hditor. ROBKRT 1..^ i^lCKINSON. M.D.^AlCT HdITOR. 117/7/ X/ulRLV U(}(i COLORI'.n AM) KUUATA. V\f :i.'i (p. 4;{|. Th(> laliolliiiB on the cut of "axis of liriiii " shouUI lio •'pliiii«- 11 liriiii." , Kl^' 3.'i (p. 48). Ill the legend, for "luultiimrai" read "nullipaia'." Fii;. 209 (i>. 3,S.")). In the legend, the (one-eixth natural size) should be (fetus JiiciJixth natural sizf). riir. 211 (|>. 3>SS). In the lesond, for "axis of inlet" read "plane of inlet." FiS. 2(!r» (p. 4."»(!). Thi> fi«uiea A and H should lie leverst^d to a«ii'c with the k'l'ud. J PI. ISMp. IGG). The legend should read as follows: 1. The nor-^ravid womb lud the «ame at eight months, with varying heights of the fundus marked in pek.s. 2. Position of the chiM and the utoni'< in a ease of pendulous abdomen. PHILADELPHIA : W. B. SAUNDERS 92s WALNUT STREHT ^1^^-A.^ :^ s^. MDCCCXCV BiBLlOTwrp, ,r FROXTisriKrE. M Mr^iiil x'ciiiiii -.Imw ill;; tlif icliii i.iii oi tlir vi-ii rii in ilicii' iiui'iiml |Mi.sitiiiiis ' liii'Uiiisiiii), (/!//■ ililnilf I'll I'iij. ,'.'. ji. !,;.] h AN AMERICAN THXT-BOOK OF OBSTETRICS FOR PRACTITIONERS AND STUDENTS James C. Camiron. M.I).. Hdwakd P. Davis, M.D. RoBHKT L. Dickinson. M.D.. Chari.ks Wakrington Hari.k. M.D., Jami-s H. Htheridgi:, M.D., Henry J. (lARRiGiKs, M.D.. Barton Cooke Hirst, M.D. Charles Jewett, M.D.. Howard A. Kelly, M.D. Richako C. Norris. M.D.. Chaincey D. Palmer, M.D. Theophilis Parvin, M.D., George A. Piersol. M.D. Edward Reynolds. M.[)., Henry Schwarz, M.D. Richard C.^ Norris. M.D.. Editor" Robert I..' Dickinson. M.D.^Aia Editor. 11777/ Xr.ARLY 000 COLORED AND //AU'.fOXIi //JJ'STRAThhVS. t PHILADELPHIA : W. B. SAUNDERS 92=5 WALNUT STREET MDCCC.XCV ^S^^^-A-^ fy C>:^^ > \ t^ BiBLlOTWrpi ,r <'<'l'Ylil(,IlT, ls;i,'), KY W. II. S.\ (• N I) K US. WrSTCOTt t, THOMSON ILtCIHOTVMCHb HH.LAU* PRFSS Of W B SAUHUIHS PHIL«D«. PREFACE. .\l>VAXCKs in the science and art t)f ohstotrica liave kept jKice with the advances wliieh liave characterized all hr.mches of medicine and snrjjjerv. Althoufjh nur stand- ard text-l)(M)ks of ol)stetrics have <K'casionally l)cen rcrlKcit, an entirely new text-l)(M»k containing the writings of more than one individnal has not a|)]H'ared during the last decade. The Amkuican TloXT-IiooK ov Omstktimcs (»wes its existence to the fa(^t that it seemed pnicticahle to prodnce a work which should not only endxHly the teachings <tf several prominent American obstetricians, thus reflecting all recent progress made in the theory and practice of obstetrics, but should also l)e a standard teaching-work ft>r students and a guide for practiti<»ners ; for this pur|M»se the authors selected are those possessing experience as teachers of (»bstetrics in sevend of the leading iuedi<'al schools and hospitals of America. Tiie especial design in ])repariug this volume was to make clear those departments of obstetrics that are at once so important and usually so (»bscure to the medical student. Therefore the ol)stetric emergencies, the mechanics of normal and al)normal labor, and the various manipidations recpiired in obstetric surgery are all described in great detail, the text being elucidated with mnuerous illustrations and diagrams whicii will mate- rially assist the student to grasp the complex problems of o|R'rative obstet- rics. The diseases of the fetus and of the new-born infant are given sepa- rate secti<»ns of the volume, this subject being discussed more frdly than is usual in obstetrical works in the Kuglish language. An cft'ort has been made t(» render attractive the sections upon Anat(»my and Knd)ryology. While the various authors were each assigned special themes for discus^-' sion, nevertheli'ss an attempt has been made so to correlate the subject- matter as to preserve throughout the text a logical sccpu'iice not always found in composite publications. The writing of the subjects assigned to Or. Charles Waniugton Karle was only fairly begun when his untimely and widely-lamented death (M-curred. The Kditors were gratified to secure for the revision and completion of Dr, KarK''s manuscript one of his asso- ciates, Dr. M. J. Mcrgler. The table of C'(»ntents indicates the authorship of each section — a feature which doubtless will give sjitisfaetion. One of the just claims of this text-book to originality is that an attempt has been ma<le to carry out systematically the following ])riuciplcs in its illustration : All figures to be drawn to scale; a uniform scale to be adopted, usually (Uie-third or one-sixth life si/e ; in wigittal sections the same half always to be shown for case of comparison ; full labelling to be made tliret'tly on the drawing, to which should be given as much artistic treat- 7 'v '*f ' «(» i ' »* aii . |" * i'iii:i\[('i:. iiicnt as would Ih' coiiipiitiltlc witli clciiriM'ss iiixl witli tciicliinj; (|iiii1itv. Tlic scale »»!' i\\v cuts in iu«»st previous te.\t-l)ooks, au<l the clioiee of the sajfittal section — rijrht or left — have varied. In this hook the left half of the section has prefer.ihly heen chosen, hecause it is the (»ne made familiar to practitioners l>y the treatment of patients in the latero-prone posture. Kach ixirrowed cu^raviuf; has been (-redited t<» its sourci' in all cases where it eoidd he tr.iced. When alterations have not heen extensive these cuts are designated, respectively, as " redrawn from " or " lutNliticd from " the original. When such corrections and additions have heen inadi' as to eonstitut*' practically a new drawing, the origin of the cut is nirely in«licated. Where there may seem to he strong resemltlant'c to older work, without credit, it will he found that new pliotogr.iphs or sketches are the hasis of the new illustration. The htM'ntwcd cuts have all lu-en redniwu, excepting those rcpHKhiced from the i»ld copper-plates of Hunter and Smcllie — a stand- ard of artistic excellence set for us hy the most fam<»us engravers of Kngland. France, which has furnished our specialty with its stock-cuts for decades, gives the "American 'I'cxt-Hook" many suggestions through the work of Faniheuf and \'arnier. To (Jermany ohstetrics owes much gratitude for that aceuriicy in t(»pogr:iphical anatomy which had its rise in the heautifully pic- tured sections of Bniun, Schroi'der, Waldeyer, and Zweifel ; while we thank Scotland, through the atlases of Mart, IJarhour, and Wehster, for the know- ledge of the structure of the pelvic Hoor. Some of the finest pathological specimens illustrated in this text-hook were photogniphed at the Army Medical Museum at Washington, 1). ('., through the painstaking ccairtesy of Dr. I). S. Lamh, while Dr. Farcpdiar Fer- guson gave access to the New York Hospital Cahinet, and Professors Piersol and Hirst each hrought forward some of their most striking preparations. We are indehted to the staff of artists, Messrs. Max Colin, W. A. ('. Pape, H. ('. Lehmann, F. V. Baker, A. W. Doggett, F. Deck, W. H. Richard- son, and others, hy whose skill and years of patient labor art ha.s been placed at the servi<'e of scientitic illustnitiim. Only through an iniprecedentcd liberality on the ])art of the jHiblisher of a medical text-book has it been possible thus to re-illustrate an entire depart- ment of medicine. To Mr. W. H. Saunders, for his imremitting courtesy, patience, and generosity, we tender our thanks. The Kditors desire to acknov.ledge their indebtedness to Mr. John Vansant for valuable assist- ance in coiKhicting the mechanical (h'tails (tf the work and for the prej)- aration of the Index. The j)laii of this text-book, the exposition of only the latest ideas in pathology, the es|H'cial care that directions for treatment shall be particular an<l full, the avoidance of conHicting statements, and the wealth of illus- tration, are (jualities which, it is hoped, will make this work an efficient guide to those who study or who pr.U'tise Obstetrics. lilCIIAKD C. XOHRIS, liOBEUT L. I)I( KINSON. .I.CII.Vl .M:i KDWAl CONTRIIUFTORS J. CIIALMKUS CAMKUOX, M. J) MMtorni.y, .„•. ""siMtal, I'l.ysiaan Am.uchcM.r t„ ti.e M.mlreal KDWAHI) 1>. DAVIS, M.JJ., IVoCsscr .,(• ()l,s,etri..s, JeHe.^,.,, M^II^H r I "^ "'''"'r''''''" ''"'-^^ <''i"iiMl f'l.ysic.i,n, Cl.il.l.vn-.s l>o,.art^K..u^I„^vard li" pul^ 'tl ' "^ ""'''""'' ^■'''"'"^' UOIJEIITL. DICKIXSOX, M. 1,., ]{ - '"^ "- ^-^ •" '-' ^-^i^o' <u..\..e^;;;;;;i;:;!;:::;:;::;;;:;;;t--' ^^-i-.. t'lIARLKK WAUKIN(}T()X KARLK, M. J).,^ l-ate I'rofi'ssor of < )l)stHiii's in Hip fnll,.,,,. c i>i • • •fAMKS If. KTIIElili)(;i.;:viD^ Professor of (iviii.i..il..<»»r .... i /»i . . . 'HCAfJO, III. «>l<«.st to S,. Jo,.p„-s Hospital, Chiea^a ^^'•'^•^■"»n "„s,„tal ; ronsuI,i,.j, ,iyne- IIKXRYJ. (iAURKUKS, IVI. I)., IVofessor of ()|,sjt.t,.i,.s ■„ ,|„. V„„. v i t. ^"''^^^' ^'<>RK. M-^s nosp.,a. a„.. ,0 „.. <i,r,na„ F>ispe„s^ ' '^ '^:':J'^ ^ '>^-"'"*^'^' «' «t. HARTOX COOK,.: HIRST. M. ,>., I'rofessor of ()bsfp(ri,Hi r' • • I*"I',AI)Kl.i>itrA. y "- r.vin.Mn Charity and to iJ Preior 2 IT:"' ''"'"""■"'^' < »>>stotrieian ""**P""I. i-U: '" "^^-"'"n K^'feat; (Jyncc-oloffist t.. the Howar.l ("HAltLEs JKWETT, M. I). I'rofeKsor of ( >l,st..tr'io. a,„I PoHi^.r,- r , , ^HOOKLYN, N. Y. '" Kings County Hospital, vU: '"""^"'""ff < ■.vnec-olog.st to Htislnvick Hospital and HOWARD A. KKLLY, M D * "oceasc<l. 10 voNTiiiiurrons. RICIIAIll) ('. NOUIIIS, M. I)., l'nii,Ain.i,nMA. lA'ctiiriT (111 Cliiiicnl ami < )|K'riitiv»' Olwtolric's, I'nivprsity of I'ciUHylviuiia ; Olmti-l- riciaii in Charge of llic I'rcston Hi-ircal, l'liila<lfl|iliia ; NM^itinK < )l)stc(ri('iaii to the l'liila)lcl|iliia IIiM|>ital; ( iiiir>iil(iiiK OltNti-triciaii anil < iyiu-coloKirit to tin- Soii|lieast«>m I>is|i('nr4an- uiiil IIos|iital lor Woiiicii and ( liililrcn ; < iyiifcoloKiNt to llii* MotluNliHt K|iisco|ial lloHpiial; Follow of tlu' Aiiii'rinui t iyiu'foio>;[jca! SiH-ii-ty, vXv. CHAUNt'KY 1). 1»ALMKH, M. I)., 'im ixnati, Ohio. I'rofi-ssor of Ol>sli'lri(N, of Mcdiral anil Sur^fical I )is«'ast's of Wonii'ii, and of Clinical ( iyni'«'olo>?y in tlu- Mi-dical ('olU'>;«' of Ohio; Olistetrician and ( >yni'colo>{ist to tin- Cin- cinnati Hospital; Con.xuliiiiK (iynecMilogist to the tiernian I'roteHtant ami I'reHhyterian Hospitals in Cincinnati, etc. TIIEOPIlILrS I'AUVIN, M. 1)., IMiii-adkmmiia. rrofrnMorof Olwti'tricM and of l>i.seiiMi>M of Women andChildri'ii, Ji'tlerson Medical Col- lege ; Kx-1'resiilent of the Indiana State Medical Society, of the Association of Ameri- can Medical Jonrnalists, of the American Meilical Ass<M'iation, of the American Academy of Meiliciiie, of the Philadelphia Olistetrical SH-iety, anil of the American ( lynecolojf ical Society, etc. (JEORGK A. IMKllSOL, M. 1)., 1'rofes.sor of Anatomv in the I'niversitv of I'emisvlvania. I'IIII.ADKM'IIIA. EDWARD REYNOLDS, M. D., HiWTux, Mass. .Assistant in Olwtetrics. Harvard I'niversity ; Physician to < )nt-Patieii.t> in Hoston I.yin>j-iii Hospital ; Assistant in ( Jynecolojry, liostoii City Hospital; Fellow of the Amer- ican ( iynecoloj;ical Society, the Ohstetric Society of lioMon, etc. HENRY SCHWARZ, M D., St. Lot is, M«). Professor of ( iynecology in the St. Tenuis Medical Collejie (Medical I>eparttncnl of Washington I'niversity) ; Consnitint; ( iynccolojjist to the Female Hospital ; (iynecologist to the Kvan^elical liiitheran Hospital, etc. i i- * mwil CONTENTS. f: I. THE GENERATJVK OKCiANS. I. Amitoiny of the I'c'lvis(l>ioi>i()|) "^* II. Anatomy of the I<Y'nmIe(; '/erative Organs (Piersol) . . . , . ;,^ III. I'liysiolofry of the Female «.Lnerative Organs (Piewol) . . . . . . 70 II. PREGNANCY. I. Physiology op Pregnancy 1. Development of the Emhryo and Fetus (Piersol) 74 ± Physiology of tlu» Fetus (I'jersol) ' ' .S. Multiple ('onfepti(«is(I»iorsol) ',,, 4. (-hanger in th(> .Maternal Organisms induced by Pregnancv (I'lersol and Palmer*) . h ^^ly^y lli» II. Diagnosis op Pregnancy 150 1. Symptoms and Signs of Pregnaney (Palmer) j.-.n 2. Duration of Pregnancy (Palmer and Piersol) . . m .'J. Prolongation of Pregnancy (Palmer) ... ,-q* 1 /o m. Hygiene and Management op Pregnancy (Palmer) . . . i,so IV. Pathology op Pregnancy . INa 1. Diseases of the Several Systems (Davis) jg- 2. General Disorders of Pregnancy (Davis) ifHj 3. Acute Infectioni dur.ng l»regnancy (Davis) 9.'}^ 4. Accidents and SurgicalOperations during Pregnancy (Davis). ^48 5. Diseases of the Ovum (Etheridge) .~r., G. Abortion («"theridg(>) . . "'' " ' 2.(9 7. Extra-uterine Pregnancy (Kelly) ^-i 8. Disea.ses of the Fetus in Utero (lOarle and I^Ierglerf) . . . . . . 295 * "General ChanRes" (,,p. ir,3-ir,9) contributed by Dr. Palmer t The manuscripts of Dr. Earle were revised and completed by Dr. M. J. Mergler. 11 ^■w* mm m^mm ■mp tm 12 CONTENTS. III. LABOR. PAOB I. Physiology op Labor 318 1. Phenoiuemi of Normal Labor (Dickinson) 321 2. Clinical Course of Labor (Di<'kinson) 383 n. Conduct of Normal Labor 341 L Antisepsis (Jewett) 341 2. ]\[anagenient of Normal I^abor (Jewett) 349 Obstetrical Examination 340 1. Diagnosis of Fetal Presentation and Position 3r)0 2. External Measurement of the Pelvis SHS 3. AiK'stlu'sia 3()2 Examination iluring Labor 3(5r) Management of the First Stage 3(57 Management of the Second Stage 3(18 Management of the Third Stage 37() in. Mechanism of Labor 384 1. Ciassitication of Jiabor (Reynolds) 3SG 2. The Fetus (Reynolds) ■^*'l 3. Diagnosis, Freciuency, and Prognosis of the Several Varieties of Labor (Reynolds) -^'^^ 1. Vkktkx Pkkskxt-.tioxs (Reynolds) -117 A. Mechanism of the First Stage of Labor *i-3 li. Mechanism of the Second Stage of Labor . . -130 C, Mechanism and Management of the Third Stage of Labor . 440 1). Mechanism and Management of Posterior Positions of Vertex Presentations '"*- 2. FAfK PuKsKxrATioNs (Reynolds) "l^^ :Mechanism and >ranagement "^''^ 3. Huow Pkkskntation's (Reynolds) ■!*'<» INIechanisiTi an 1 Management ■**'♦* 4. Pkia'K- Pkkskntatioxs (Reynolds) "l^O Mechanism and Management *'" 5. FooTT>iX(i Pkkskntatioxs (Reynolds) ''^^ ]Mechanism and Management ^^"^ C. Thaxsvkksk Pukskntatioxs (Reynolds) "^^^ INIechanism and Management ^'^ 7. Pu(H-Al'SKl) EXTUKMITIKS (Reynolds) 492 PAGE 318 321 333 . 341 . 349 . 349 . 3r.o . 3r).s . 3()2 . 365 . 30)7 . 3(18 . 37() . 384 . 386 . 401 )f . 407 . 417 . 423 . 430 •. 440 if . 442 . 458 . 4()0 . 4G6 . 400 . 470 . 470 . 4S7 . 487 487 , 488 , 492 CO^^TENTS. 13 IV. Dystocia . . . page 1. ANOMALU>. ,N THK FoKCKS OF LaROH (W^v.t) 1 DeHeient Power of the Uterine Muscle; Inertia Uteri (ili.t) ""Peril's" """"""^"^ 5. ^tage.„e,U of Labor Obstructed by the Conunonest l-^orn.; f Contracted Pe,vi,s: a Hin.p.e Flat, a Rachitic Flat, and n fwer.erally-coMtractetl Pelvis (Hirst) «. Obstruction to Labor on the Part of the .S<,ftMaternal Struc-' tures ,n the Parturient Canal (Hirst) 7. Obstruction to Labor on the Part of the Fetus (Hirst)' " 2. Dystocia lie to AccinKXTH and Diskasks I. Accidents to the Umbilical Cord (Parvin) ^. dystocia due to Hemorrhage (Parvin and Sclnv. ■^. Dystocia due to Diseases of the Mother ^>nrv^n^ 493 493 493 497 498 510 543 . 54() . 501 • . . 573 • . . 573 irz*) .... 581 Mother (Parvin) (jo;} IV. THE PUERPERIUM. I. Physiology op the Puerperium (Jewett) n. Diagnosis op the Puerperal State (Jewett) m. Management op the Puerperium (Jewett) . IV. Pathology op the Puerperium t'l I. IXUUn.>. TO T„K (JKX.TAL OUCAXH KOLLOWIXf;" LaHOK ^'^ (hchwarzand Norrisf) ^^aisok II. I>IH>:ASKs or T„K SKX.'AL Okgav.S ''"" 1. Puer|)eral Infection ((Jarrigues) ... ^'^^ 2. Subinvolution (Norris) .... ^'^"^ 3. Hf'"">rrhages in the Puerperium (Norris) 4. Anon.alies of the Nipples and Hrea.sts (Norris) .). I>Jseases of the Nipples (Norris) .... 0. I>i«^«isesof the Hrea.sts (Norris). ..... 7. Arrest of Lactation (Norris) H. Anomalies in the Milk-secretion (Norris) . . . . . . " ' ' 7,;^ III. Diskasrs of THK NOX-HKXUAI. OWJAX.S ... 649 65() /34 7;J8 745 747 751 707 1. F.'ver due to ("auses other than Puerperal Infection (Norris) -*. Intercurrent Diseases (Norris) u^orri.s) . 3. Diseases of the Urinary Organs (Norris) 4. I>I«t"a><es of the Nervous System (Norris) IV. Ra,.„. ok Si^nnKx I)fat„ ,x thk Pcikupkuum (Norris) 778 778 780 785 790 801 ■■pav mmmm mumm 1 1 I 14 CONTENTS. V. THE NEW-BORN INFANT. PAOK I. Physiology op the New-born Infant (Etheridge) 807 n. Pathology op the New-born Infant (Karle) 813 1. Medical and Surgical Diseases Incident to tlie Birth of the Child (Karle) 8i;i 2. Traumatic Injuries of the New-born (Earle) 823 3. Deviations from Some of ttie Physiological Processes which characterize the Pearly Life of the Infant (Earle) 826 4. Infectious Diseases of the New-born (Earle) 835 5. Geneml and Unclassified Disejises of the New-born (Earle) . . . 851 6. Hygiene and Therapeutics soon after Birth (Earle) 85!) 7. Premature Infants (Etheridge) 861 VI. OBSTETRIC 8URGERY. I. Instrumental Operations (Cameron) 867 General Requirements and Preparation for Operation, 867— Pass- ing the Catheter, 808— The Doudie, 870— Curettage, 872— The Tampon, 874 — Episiotomy, 877 — Premature Induction of Labor, 878— Artificial Dilatation of the Via Uteri, 882— The Forceps, 884— Sympliysiotomy,* DO") — Cesannin Section, 917 — I^apro-elytrotomy, !)2r)— Craniotomy and Embryotomy, !)2(). n. Manual Operations (Dickinson) 941 Vkhsion— Varieties, !>41— Methods, 942— Indications for the Operation, 942— Contra-indications to Version, 943— Dan- gei-s of Version, 943. 1. External N'ersion 944 2. Bipolar Version 94(5 3. Internal Version 951 in. Celiotomy for Sepsis in the Child-bearing Period (Hirst) 968 Index 977 * "Sympliysiotomy" (pp. 905-917) contributed by Dr. Jewett. PACK 807 813 813 823 826 835 851 859 861 867 AN AMERICAN TEXT-BOOK 941 944 94() 951 OF OBSTETPvIGS MM ANATOMY (»F TIIK I'KLVIS. I'l-AIK 1 'I'hi' nliitliili lii'twccii .lie inl\ is mill llir inlvic (irKMiis iiiiil I lie siiifiu'r ciC tlic licidy : v. iirmiiniitnry of tlio -iici'iiin ; s, -.ymiiliysis iMiliis ; i', I'll in I lis ol' llir iilcrus ; o. tlic nv.-iiy iiiiliriiciil liy tlif I'lilluiiiiiu t\il)o; tlio lint' il' till' I'Siills lllllsck' lllilii'Mti'il : 11, till' Irrllllll. Il ANATOMY OF TIIK I'KLVIS. Plate 2. '-<r/'-v a m-x \ I IschiaC N.^ r&litroyiiy Ifansvense \. // cot- *S,ii?^- \ ^|N, '■•""■"'■"■••sn|-,,..lvisMll„i,n,vu,l,,nmsv..rs.ili,u.,li ..Urs, , IS. ■_'. Hiiiiiutcrs of pelvic milU't. m AX A]MERICAX TEXT-BOOK OF OBSTETRICS. I. THE GENERATIVE ORGANS. I. Anatomy of the Pelvis. Four bones — the two ossa initoniitiatd. the sucritm, and the coccyx — tuke part in the Ibrniation uf the pelvis; each of these, in tnrn, is composed of a nniuher >>t' segments wliieh in early life are distinct and unitC'l by intervening cartilane. The pieces comprising the innominate bone — the Hiuin, the puhh, and the hch'uuii — earliest unite, although the imi(Hi of the several portions of the acetabulum is not complete until from the eighteenth to tiic twentieth year. The sacral and the coccygeal segments fuse still later, tho.se of the coccyx re- Fiii. 1.— Ki'imiK' pelvis (tino-tliini natural size). niaining movable until middle life, while the attachment of this bone with the .sacrum occurs late in life. Diwing the usual period of ehildbearing, therefore, the segments composing the posterior boundary of the pelvis arc ununited, and, in the lower or coccygeal jiart of the wall, are capable of yielding to the demands of parturition for increased antero-posterior or conjugate iK'lvic diameters. The pelvis viewed in its entiretv presents an inverted truncated cone (Fig. 1), 2 * 17 II 'I 18 AMJJJi/CA.y TKXT-JiOOK OF OUSTKTIilCS. sli^^litly coniprcssod trinn heforc backward, mIioso base is dinrtt'd upward and forward, and whose sniallor end looks downward and l)ac'kward. Tlio sacrum and the coccvx occupy a median j)osition beliind, an<l contribute tiie posterior Mall, the innominate bones expaiuling laterally and meeting in front to form the pubic arch and symj)hysis. The space include<l within these bony walls is divided into two ])arts l)y a plane passing through the middle of the sacral promontory behind and the up))cr border of the symphysis jtubis in front. The portion of the l)ody- cavity lying below this plane constitutes the true jtrfri>< ; the portion lying above this j)lane, included within the widely expanded iliac bones, the verte- bral column, and the abdominal pai'ietes, constitutes the falne pc/vin and be- longs to the abdominal cavity, to the contents of which it affords support and protection. The true or /csnrr pr/ris is a short curved canal whose superior xtriilf, or inlet, is marked l)y the brim, a bony ring defined by the anterior border of the ])romontory of the sacrum behind, the ilio-pectineal lines laterally, and the j)osterior margin of the pubis in front. The plane of the inferior strait, or outlet, jtasses through the tij) of the coccyx, the tubera ischii, and the lower border of the symphysis pubis. In addition to the foregoing planes marking the upper and lower boundaries of the true pelvis, two others, corresponding with its widest and most contracted pai'ts, are recognized with advantage. The j)lane of (jreatest pelric expanxion extends from the union between the second and third sacral vertebrie behind to the middle of the symphysis pubis in front, its lateral boun<laries corresponding on either side with the mid-jioi:it of the imier surface of the acetabulum. The plane of least pelcie diameter lies somewhat lower, being defined In- lines passing through the sacro-coccygeal articulation, the ischial spines, and tlie lower third of the symphysis pubis : this plane, marking as it does the point of greatest permanent constricticm, really constitutes the pelvic outlet in an obstetrical sense more than do the lower and more vielding confines to which the term is usually apjjjied. The superior strait, or inlet, of the true pelvis is slightly cordiform in outline, since the low-arched jiosterior border of its generally oval figure is encroached ujion by the sacral promontory, the indentation, however, i)eing much less in tiie female than in the male pelvis. The dimensions of the inlet (PI. 2. Fig. 1) are represented by the antero-iv)s- terior or conjugate diameter of 11.5 centimeters (4^ inches), measured from the middle of the promontory of the sacrum to the middle of the upper l)order of the symphysis pubis, and the transverse diameter of l^J) centimeters (o| inches), determined by the greatest distance between the ilio-pectineal lines; since, liowever, the pubic portion of the pelvic brim lies slightly in advance of the posterior surfiice of tiie pubis, the available antero-posterior diameter, or obstetric conjnf/ftte, is .somewhat less tlian the anatomical dimension, measuring 11 centimeters (PI. 2. Fig. 2). Su])plementarv to these measurements, the ob- lique diameters of 12.75 centimeters (5| inches), measured from the intersection of 4 1 AXATO-VV or Tin: aKSKliATIVE ()/,'(/ A xs. 19 the siuTo-iliac articiiIatioM witli the ilio-pwtiiical lino to tlie \n\\>'w spino of the ite side, are usually iioted. The HR'asiirciuciits of tho jilaiif of i/initfut 0|)|)0S orin in <>uro is iKMUg To-pos- (iin the nlor of crs (o| linos; tmoo of lotor. or lasuring Itho ob- ;'tion of 'PI r.r]>(i)i.sioH incliido an antoro-postorior dianiotor of 12.7-> coiitimotors (o^ inches) and a ti'ansvei*8e diameter of 12.0 eentinietors (o inches). Tho jilmtr of hint (liinenxintix possesses an aiitoro-posterior diameter of 11 tvnt i motors (4iJ inches), as measured between the end of tho sacrum and the ?'ummit of tho ]»ubi(! arch, and a transverse diameter of 11 contimeters (4^ inches), taken between tho inner siu'faoe of tho ischial l)ones near their posterior border; the distance separating tho spinie ischii is about 10.") centimeters (4J- inches). Tho infrrior xfroif, or anatomical outlet, of the |M'lvis, although loss regular in outline than tho inlet, jutssossos a geiuM'al ovate form, the smaller end of tho Hgure being <Iirocted anteriorly, while its larger end is impressed by the prominence of the coccyx ; in addition to tho latter point, two other osseous pro- jections, the tubera ischii, aid in defining tiie boundaries of the outlet. Between Fiii. J.— Feninlo iiclvis, viewed from liel^w, with liniments (oiu'-thircl luitiirnl sizeV those tuberosities in front is included the subpubic arch, bounded by the pubic and ischial rami, while behind, between them and tho sacrum, lie the deep saero- si'iatic notches, which are bridged over an<l converted into foranuna by the greater and lesser sacro-sciatic ligaments (Fig. 2). The d!memio)i.s of the phntc of the jiclrii- out/rf (1*1. 2, Fig. 2) include the antoro-postorior diameter of 9 continietor-i (."U inches), measured from the tip of the coccyx to tho summit of the pubic arch, and tho transverse «liametor of 11 coiitimotors (4f inches), measured between the middle of tho i.schial tuberosi- ties. It must be reinembored, however, that while tho antoro-j)ostorior diame- ter under ordinary conditions is only 9 centimeters (3^ inches), tho mobility of tho coccyx is usually such that this diameter, or obstetric conjugate, is increased to 11 centimeters during parturition (1*1. 2, Fig. 2). The carltif of the true ])elvis, as ap|)ears from tho foregoing, is an irregular cylinder of somewhat varying diameter; the imaginary jjc/c/c axis is producal 20 AMi:i<'/(A.\ THXT-IiOOK OF oiisrt:Tiiics. \\ II 1)V uniting; tlie coiitral points of the aiitt'r(>-|M)storic»r (liaiiu'terfi of tlie superior, the iiifi-rior, and tiie interinediate plaiu's above dt'serilMMl. The pelvic cavity is enclosed Ity the smooth snrfac«'s prescnteil i)y the surrounding l)ony parts; its anterior wall, foruiiKl by the symphysis and the bodies of tiie pid)ic bones, is convex and shorter tliaii the posterior, measuring but little more than 4 centimeters (about \\ inches) in depth ; its {wsterior wall, inchuling the con- cave anterior surfaces of the sacrum and the coccyx, is much longer, cxtoinl- iiig ll.o centimeters (abitut A\ inches) from the sacral pronumtory to the end of tiie coccyx. The lateral walls correspond with the broad (piadrilateral .sur- faces of the ischial biKlies, and present an intermediate depth of 9 centimeters (3^ inches). The j)onl(lon of the pelvis, evidently, must vary with the changes in the j)osture of the body. In the erect attitude the plane of the inlet of the true pelvis is well elevated, forming with the horizontal an angle of about 55° (5U° to G0°), the inclination being generally somewhat greater in the female; the plane of the outlet coincides more closely with the horizontal, subtendinj^ with the latter an angle of about 11° (Pi. 3, Fig. 1). In the erect position the planes of the perpendiculars let fall from the anterior superior iliac spines and from the symphysis pubis coincide ; the base of the sacrum lies about 9 centi- meters (3i inches) above the upper border of the symphysis, the tip of the coc- cyx at the same time being about 2 centimeters (-J inch) above the summit of the subpubic arch. The (ixin of the pcfric inlet is directed forward and upward, toward the umbilicus; if pndongetl downward, it strikes the tip of the coccyx. The axis of the outlet, naturally downward and a little backward, will meet the promontory if extendtKl upward. The plane of the symphysis forms un angle of from 90° to 100° with that of the pelvic brinj. The importance of obtaining definite information concerning the dimensions of the pelvis, but, at the same time, the impossibility of determining many of the foregoing measurements on the living subject, has led to the substitution of external, readily accessible measurements which bear a direct and constant relation to the internal diameters. The most useful of these external meas- urements include — the distance between the anterior superior iliac spines, 26 centimeters; the distance between the iliac crests, 29 centimeters ; the dis- tance between the greater trochanters, 31 centimeters ; the distance between the spinous process of the last lumbar vertebra and the upper margin of the jiubic sym|!liysis, or external covjuf/dte, 20J centimeters ; the distance between the posterior sui)erior spinous ]>rocess and the anterior superior spinous jM'ocess of the opjiosite iliac bone, (»r the ohlhiue diameter, 22 centimeters; the distance between the ischial tuberosities, 11 centimeters. These external diameters, which are readilv obtained bv means of direct measurements bv the pelvimeter, bear sufficiently constant relation to the internal diameters to make them of much ])ractical importance. As j)ointed out by Klein, however, the antero-posterior diameter is subject to considerable normal variation. The aver- age thickness of the bony walls at the ])oints of measurement being known, the subtraction of this amount from the ascertained external diameter evidently J k\ ANATOMY ()!• IIIK I'Kl.N IS. I'LATK ». itiition instant iiieas- dis- ?t\voon lot" the jtweeii [)inotis lietcrs ; :tornal DV the make 'f, the aver- [n, the flently I I i I pelvis, shiiw iiiii iiiiiitt 1. Stljjittlll StM'tiftU l)f it'inilii- |u-i \ ijN, >in n^ I im II nil 11 >iii II ji 1 jiiiii I II iMfi I nil i 1 1 iniiii' stnicliircs ciiiiiiKisiiiu' tlic |ii'lvic llonr: 1, pi'lvii' lii^-cin, \\ liidi iil wliili' line splits: (■-') mill nliluratnr Ciiscia ■ li, ii lliiii inMitiiiiiiil slii'ct, tlic .iiinl l'as<'iii i^li, ciivcriiiu tin um-i i.n :.iii im i- m mi li'Viiliir inii liiMscli'; ."i, (l, tlic sin>riinr iinil iiifcrior liiycrs ul' tlu' liiilliKUliir li;.'aiiK'lit ; 7, .s, lU'cp illiil silpiT liciiil liiyi'is (if till' puriiit'iil fasciii; 'J, skin. iniiiil anil ulistitiical iliaiiutiTs, i I)in>;niin of the into rcctu-Yi'sical fascia iiforior surliicf of the f^ |;f AXATOMV OF TIIK GENERATIVE ORGANS. 21 supplies (lata comparable with the recognized average of the internal diniensionii Thus, the distance between the lower edge of the spinous process of tho last hinihar vertebra and the middle of the upper margin of the syni})hysis, meas- twed by the pelvimeter, is 20 centimeters; from this are deducted the 9 centi- meters which represent the c()nd)ined average thickness of the vertebral bixly and the pubic symphysis, the remaining 11 centimeters corresponding closely with the conjugate of the superior strait as determined by dirctt measurement. The size of the female pelvis, although presenting many individual varia- tions, is not inifavorably iuHuenced by stature, since short women often rossess pelves of more than average breadth. The distincftive characteristics of sex are acquired after puberty, although, according to Fehling, indications of these peculiarities are present ever, at biri'i. Some asymmetry of the pelvis, as of other parts of the body, is usually to be detected. Fio. ;!.— Male pelvis (slifjlitly less tliim uiietliinl iinturni size). The following table exhibits the average dimensions of the ftdly developed female pelvis, the measurements being taken from the dried pelvis : Ceiuimeters. (ireatest iHstaiKv betwi'on crests of ilia -JS I)ist;miv lietweeii :iiiterii>r superidr iliiic spines -J.') l>i>taiii'e between last Imiibar siiiiu' ami front "I" sviiiphysis ]mi)is 'JO TiUK Pi:i,vis. Antero-pnsterior niaiiieter Transverse l>iiimeter OMiciue Diiuneter (Centinietors). u'entiineters). (.Centimeters). Plane (if (lelvie inlet 11. i:i,.") l-J.") I'laiie (if presitest expansion .... 1'_>.7.') \'1.'>0 Plane of greatest contrai-tion ... 11. 11. Plane of iielvic outlet l>.o (increased to ll..') em. \\, \\J^ liy ilisphK'enieiit of eoeey.xi. The (lifttiiu/ulfiliin;/ rlinrdcfn-isficK of the femtde pelvis (Fig. 1) as C(mtraste<l with the corresponding portion of tiie male skeleton (Fig. ;}) incliule slighter 99 AMERICAN TEXT-BOOK OE OBSTETRICS. '■^ bones with less marked imiscular impressions; less height of the entire pelvis; greater breadth and eapaeity of the true pelvis, but, owing to the more verti- eally placed iliac bones, relatively and absolutely less expansion of the false l)elvis than in the male (Thane). l>oth the inlet and the outlet are larger in the female, the outline of the pelvic brim approaching uu»re nearly the circular form, owing to the slighter ])roJection of the sacral promontory. In the female pelvis the sacrum is broader and less concave, the depth of the symphysis is less, and the subpubic arch is wider, embracing from 90° to 100° as against 70° in the male. In addition to individual peculiarities, the iuHuences of race markedly impress the general form of the pelvis, particularly tiie relation of the antero- posterior to the transverse diameter : the broad, cordiform outline of the Caucasian lemale pelvis is replaced by one nearly circular among the native Australians ; among the Bushman and ^[alay women the usual ratio between the conjugate and transverse diameters becomes so altered that the outline of the pelvis is an upright oval, the antero-posterior dimension surpassing the transverse. Articulations of the Pelvis. — The comjionent bones of the pelvis are united with one another by four articulations (Fig. 4): one in front, between Fii:. -4.— Wiimlo jii'lvis (viowoil from nbovo) witli linamoiits (niic-tliinl natural size). the two pubic bones ; two behind, between the iliac bones and the sacrum ; and one between the sacrum and tiie coccyx. The opposed bony surfaces are closely united by til ro-cartilaginous jtlates and external ligamentous bands, and admit of very limited motion ; these articulations, tlieretbre, are usually classed as amphiarthroses or symphyses. The pubic articulation, or i^i/tnjihi/si.s puhis (Figs. 5, 6), is formed by the approximation of the two oval articular facets occupying the mesial borders of the pubic bones, which are connected by the interj)osed fibrous disk and the sur- t: ANATOMY OF THE GEXERATIVE ORGANS. 23 Ituiu ; Ls aro ■iiially \y the ?rs of sur- rounding external ligaments. The slightly convex surfaces are covered with i)lat('s of cartilage which fill up the inequalities of the bones, the opposed sur- faces being held together by the intervening mass of fibrous tissue and fibro-car- V*: 'irptn r Fig. ">.— Section across symphysis pubis, sliowing interpubic disli. tilage constituting the interpubic disk (Fig. o). This layer, which projects ante- riorly and posteriorly beyond the adjacent bony margins, is thickest in front ; the tlcrti'iency of the intermediate tissue above and behind sometimes results in the formation of an interspace or fissure. The fis- sure within the interpubic disk extends usually about half the length of the cartilage, and is produced during life by the absorption of the tlljid-cartilage : it aj)pears after the seventh ycai', and is of larger size and more constant ill tlie female. While undue tension exerted upon the joint during labor may j>redispose to tlic production of this fissure, the latter is not a sequence necessarily of pregnancy, as is siidwn by its existence in pelves of males and of virgins. A slight separation of the pubic syiiipliysis during pregnancy is regarded by iiKiiiy as probable; this tendency, however, is reduced to a minimum through tlie bracing effected by the decussating fibres i>f the oblique muscles. Tiie external ligaments which additionally strengthen this articulation are the ante- ridi', the posterior, the superior, and the inferior. The (interior pnlm lir/ament, of considerable thickness, consists of several strata of interlacing fibres, the deepest of which passes directly across between tlic l)oiies in front of the interpubic di-k, with which they are blended ; the superficial layers include oblicpie interlacing fil'.res continued from the tendons (pf tlie external oblifpie and the recti muscles, and of the more superficial adductors of the thigh. The jtnxterior piihic lif/amext consists of a few sparingly distributed fibres which unite the bones behind, and it is little more than the somewhat thick- ened ])criosteum. The Kiiprrior pxhic lif/atnent is represetited by a meagre bundle of fibres occupying the upper surface of the articulation. Fiii. (■).— Frontiil soctidii tlirnuch syiui>liysis pubis, oxpusiiiK interpubic cleft (Fnrabcuf). ^T* 24 AMERWAN TEXT-BOOK OE OBSTETRICS. The inferior or subpubic lif/avienf, on the contrary, is thick and triangular in form, and it contrihtites the smooth boundary to the summit of the sub- pubic arch. Througliout the middle of its span the ligament is closeh' united Sufifrior peh'ic h[^at'tent. Inferior pubic ligiinit'}it. Fig. 7.— Anterior view of synipliysla iml)is. i 1(5 \i\ 1 with the interpubic disk, being attached at the sides and below to the descend- ing pubic rami (Fig. 7). The sdcro-iliac articukdion (Fig. 8) lies between the lateral surfaces of the sacrum and the ilium ; the rough articular surfaces of both bones are covered by thin plates of cartilage, that on the sacrum being thickest. With the ad- vance of age these cartilages often be- come roughened and partially separated by spaces containing a glairy fluid. Not infrequently the apposed bones are united by intervening bundles of fibrous tissue, these bands constituting the intei'osseous ligament. The prin- cipal bonds of union are the anterior and posterior ligaments. Tiie anterior sdcroiliae lir/ament comprises :i nundxT of thin irregular fibrous bundles stretching between the front of the sacrum and the adjacent border of the iliac bone. Associated with the upper and lower margins of this ligament are thickened bimdles of fibrous tissue that spread over the ilium respectively as far as the ilio-peetineal line and the posterior iliac spine; Fig. 8.— Section tlirouuli tlic Kit Micro-iliiic iirtiiu lution il.usi'liku). A.YATOJrV OF THE GEXERATIVE ORGANS. 25 4 these bands constitute tlie supe)'ior and the inferior sacro-iliac ligaments sonio- tiraes described. The posterior sacro-iliac lir/ament, which is of jrreat strength, extends be- tween the back of the sacrum and the posterior border of the iliac crest. The general direction of the fibres is downward and inward from the ilium ; some of the fasciculi, however, pass almost horizontally, while a special bundle extends nearly vertically from the posterior superior iliac spine to the third and foiirth sacral segments, and forms the obli(iHe sacro-iliac li(/ament. The sacro-coccygeal articulation includes the oval fawt at the end of the sacrum and the base of the coccyx, and it corresjiontls in its ligamentous struct- ures with the intervertebral joints, to which series it belongs. The bones are united by the anterior, the posterior, and the lateral bands as well as by the interposed intervertebral disk. The anterior sacro-coccygeal ligament is the continuation of the anterior common ligament of the vertebrae, and it consists of a few irregular bands of fibrous tissue that pass from the anterior surface of the sacrum to that of the coccvx to blend with the periosteum. The liosterior sacro-coccygeal ligament, stronger than the preceding, is the prolongation of the posterior common ligament, and it descends from its attach- ment around the lower orifice of the sacral canal, the lower hind wall of which it lartjoly forms, to the posterior surface of the coccyx. Additional posterior bands descend from the sacrum to the coccyx as con- tinuations of the interspinous ligaments intimately blended with the aponeuro- sis of the erector spinse ; the lateral expansions which connect the corinia of the ,ered the ad- ?n be- rated luid. )ones of :uting pr in- terior amcni >gular Ml the jacent us of ■r the pine ; 'xM ii 'im M fe 1 w '.^ iH -{,''■ M '■Jj Fiii. 9,— Variation in sacral curves (Hirsf) : P, jironiontory of sacrum ; C. coccyx. the last sncral segment to the coccygeal cornua constitute the supracornual or lateral liga,nents. The intertransverse ligament is reprcsentod by fibrous bands wliicli pass tVom the lower lateral angle of the sacrum to the transverse pro- cess of the firsi piece of the coccyx. The Intervertebral dixk is a rudimentary member of the series of fibro-car- tilagiiious plates interposed between the vertebrie ; a distinct cavity sometimes exists within this disk (Cruveilhier), especially mIicu tiie coccyx is freely movable; this mobility seems increased during pregnancy. 2G AMEIilCAy TEXT-BOOK OF OBSTETRICS. The coccviroai sct;iiioiits lire lield togetlier In- the extensions of the anterior ami posterior li^iunciits and In* the rndinicntary intervertebral disks which lie between. The indivi»hial pieces remain distinct in the t'eniale dnring early adolescence, bnt become nnitcd bv tiie close of the childbearinj; period ; in later lite ossification l)et\vecn tiic sacnnn and the coccyx sometimes takes place. Closely associated with tiie boundary of the true pelvis are the important sacro-sciatic ligaments. The gmd or pontcrior sacro-f<ciatic lit/amoif extends from the posterior inferior spine of the ilium, the lower tubercles of the sacru?n, and the inferior portion of the lateral border of the sacrum and the coccyx ,'o the inner mar- gin of the ischial tuberosity, whence tiie fibres are continued along the inner edge of the adjoining ramus as the falciform process, the concave border of which aftords attaelimeiit for the obturator fascia. The IcKscr or anterior f<(a'ro-sci<ttic h'f/ament, triangular in form, passes from its wide attaciiment on the lateral margin of the sacrum and the coccyx to the spine of the ischium, thus dividing the large space enclosed by the great sacro- sciatic ligament into an upper larger oj)ening, the great sacro-sciatic foramen, and a lower smaller aperture, tiie lesser sacro-sciatic tbramen. The anterior boundaries of these foramina are respectively the greater and lesser sacro- sciatic notches of the innominate bone. Muscles of the True Pelvis. — The osseous and ligamentous framework of the true pelvis is supplcmeiiti'd by muscles and fascia which complete its boundaries as well as somewhat lessen its cajiacity, these structures, iiowever, being so located that they but slightly diminish the size of the parturient canal. In order to facilitate a study of the faseiie, a consideration of the muscles related to the cavity and floor of the true ptlvis first claims attention. These muscles, on each side, are four in number — the obturator internus, the pyriformis, the levator ani, and the coccygeus. The obturator intrrntiK muscle (1*1. 3, Fig. 2) comes in close relation with the jielvic cavity throiigluiut a considerable part of its extended origin, which in- cludes almost the entire part of the |)elvis contributed liy the innominate bone. The muscle arises from the inner surface of the obturator membrane, except at its lower part, the fibrous arch completing the canal for the obturator vessels and nerve, and the inner surtace of the innominate ixme anteriorly and internally between the obturator foramen and the margin of the piibie arcli, and poste- riorly and externally from the foramen as far as the ilio-pectineal line above and the sacro-sciatic notch behind. The external surface of the muscle rests upon the hip-bone and the obturator memiirane; its inner or jiel vie aspect is covered by the obturator fascia, the continuation of the |)elvic, and comes in relation with the internal piidie vessels and aceompanying nerve. The piirljitrinix muscle arises by digitations from the second, third, and fourth sacral segments between and external to the anterior sacral foramina, from the ilium below the interior posterior spine, and from the great sacro- sciatic ligament. In its course to the great sacro-sciatic foramen, through i ANATO.)fr OF THE GEXEItATIVE ORGANS. 27 which tlie niiisclo oscapcs to seek iiif«ortion into the lemur, its fan-shaped mass aids in forniing the posterior and outer wall of the pelvie cavity. The remaining two uuisdes, the levator ani and the coecygeu.s, are of especial interest, since they largely sui>plement the fascia* in the formation of the septum, or pdrlc <li(ij)lu-<if/ii}, which stretches across the bony canal and materially aids in supporting the vagina and the rectum and in the constitution of the floor of the pelvis. The /cvdhr ani (Figs. 10, 11), the most important muscle of the pelvic dia- phragm, in general, with its fellow of the opposite side, presents the form of a horseshoe, open in front, rather than that of a funnel, as very commonly stated. The true relations of this nuiscle have especially been emphasized by Luschka ten th the cli in- bone. cei)t at Is and nally poste- above le rests ?pect is jmes in rd, and ramina, t sacro- hrough Fiii. 111.— Femnle polvis, shewing tlio foriii iiml attac'linu'iits of the leviituros ani muscles (Dickinson). ami liy Dickinson, whose descriptions are here utilized. These two nuiscles con- stitute a sling attached to the pubis in front, and, sweeping almost horizontally backward, embrace the vagina and the rectum and become attached posteriorly to tlic coccyx. While fuliilling the function indicated by its name, the action of rill. U— FomaU' lu'lvis, sliDwIng tlii' lovatort's ani nuisflt's fruni liofcuv anil bolow (Dickinson). the levator ani is especially to drag the lower ends of the vagina and rectum furwju'd to the level of the symphysis. The mu,<cle consists of numerous thin flat bmidles often separat(!d from one another by intervals filled bv comiective TT" 28 AMEIiK'AX TEXr-nOOK OF OBSTETRICS. w m ;i:< i! 'i ;■ li tissue, by moans of wliidi all arc united into a nieinbranoiis sheet. The origin of tiie levator ani is partly luiny anil partly fascial. The bony origin provides for the ant«'rior and ])osterior j>ortions of the nnisdo, the intervening and most extende<l part arising from the tendinous arch which bridges over the obturator interims. The anterior portion takes origin i)rincipally from the horizontal ramus of the ]>ubis, about 1.25 <'enti meters (|- inch) from the middle of the symphysis, and 3.5 centimeters (If inches) below the ujiper Ixmlcr of the ramus. The pnxterior portion is narrow, l>ei!ig little over .5 centimeter (about -} inch), and arises from the inner side of the ischial spine in front of the origin of the coccygeus. The broad intcrreninrf portion of the muscle springs from fascia along a curved line extending from the back of the pubis to the ischial spine, the low- est point of its sweep lying 5.5 centimeters (2^ inches) below the ilio-pcctineal line. This curved line of tendinous origin closely corresponds with the posi- tion along which the division of the j)elvic fascia divides into the inner recto- vesical lamella and the obturator, the line of separation being marked by thickening of the fascia which produces the tendinous marking or the " white line." The origin of the muscular fibres is by tendinous bands, which may not, however, although closely ass(X'iate<l, be directly connected with the line. The course of the fil)res of the various parts of the muscle varies : stretch- ing down and back, the fibres divide into unequal portions, of which one ))asses to the anterior aspect of the rectum, another to its posterior and lateral surfaces, while the fibres attachiMl to the pubic i)one extend along the vagina, with which they are united by strong connective tissue, but do not terminate within its walls. Tiie belly of the muscle sweeps backward, almost horizon- tally, surrounding the rectum, the margins or edges of the muscular band being often especially thickened ; when hypertropliied, as this portion of the muscle sometimes is, severe vaginismus, dyspareunia, and dystocia may result. Accord- ing to the observations of Dickinson, the inner edge of the levator ani lies about 1.5 centimeters from the vaginal orifice, the position of the nuiscle being indicated by a sharply defined double band. Contraction of the muscle causes the U])])er end of the vaginal canal to rise from 15° to 20° toward the pelvic brim. The average muscle exerts a j)owe?' of ten j)ounds. The insertion of the post-rectai part of the levator ani varies with its ])osi- tion : the posterior and smallest part is attached by tendon to the front of the fourth coccygeal vertebra ; the middle part becomes aponeurotic and joins its fellow at the tip of the coccyx ; and the anterior and largest part unites directly, without tendinous structiu-e, with the muscular bundles of the oppo- site side. The cocoi/f/citi^ muscle supplements the levator ani behind, jiresenting a tri- angular sheet which ])asses from the ischial spine to the adjacent surfaces of the coccyx and the sacrum. The muscle arises by its ajiex from the spine of the ischium and from the inner surface of the pelvic fascia, and expands to be inserted by its base into the lateral margin of the coccyx and the lower jiart f A.XATO.VV OF THE dEXEliATIVJ': OliGAXS. 20 of tlio sacrum. The pelvic (surface of this muscle aids in supportinj^ the rec- tum, anil its external surface is closely relatetl with the lesser sacr. <ciatic ligament. PascisB of the Pelvis. — The pelvic fascia is the direct continuation of the iliac and transversalis fascial sheets. It is attached laterally along the pelvic hrim and around the origin of the obturator internus, and behind it extends over the pyrifonuis ami the adjacent nervous trunks as far as the sacrum ; anteriorly it closely follows the outline of the obturator internus, aids in bounding the inner opening of the obturatt»r canal, and at the h)wer part of the pubic symphysis becomes attached to the anterior pelvic wall. A thickened band of light colored fascia, the so-called " white line" (see p. 28), which extends from the lower part of the posterior surface of the symphy- sis to the ischial spine, indicates the position along which an inner or visceral tg a tn- faces of line of Is to be [er part Fiii. ]J.-Sas;ittiil se('ti( III showing rulatiuns of the several layers of fascia withiii tlio pc'lvic fl()or (Dickinson). lamella, the rcctn-rcsical faxcia, diverges from the parietal or main pelvic sheet ; the latter, which adheres t(» the ])elvic wall and covers the obturator internus muscle, is now known as the ohtumtnr fascia ; the latter, therefore, is that part of the parietal lamella of the j)elvic fascia that lies below the "white line" and forms the external fascial investment of the ischio-rectal fossa, the deep triangular recess included between the ischial tuberosity and the contiguous parts of the innominate bone and the external and inferior sur- face of the muscles of the pelvic diaphragm. A thin sheet given off from the parietal layer or obturator fascia below the " white line" covers the under •ST" 30 AMKlilCAX TEXT-liOdK OF Oli.STKTJilCS. iTr ^l siii'tiK'C of the levator ani niii.solt' and coiistitntcs {\wuu<il nv isr/iio-rrHa/ funvia. Tiie internal pndie Iddod-vessels and the aceoinpanyinir nerve in tlieir conrse across the onter wall of the isehio-reetal fossa are invested l»y an additional special layer of the ohtnrator fascia, which thus separates the vessels from the fossa and encloses them within Aleuck's canal. The viHccral (lonclld, or the ncto-irsmil fdncht, is, as ])()inted out l)v Wehster, a structure of great imj)ortance in enabling the pelvic floor to resist inter- abdominal pressure at the jx'lvic outlet. .Springing from the parietal layer along the " white line," the recto-vesical fascia covers the inner and ujtper sur- face of the levator ani and continues over the muscle to the bladder, the vagina, and the rectum, where it divides into four layers — the vesical, the vesico-vagi- nal, the recto-vaginal, and the rectal. The irslcal liii/rr expands over the lower lateral aspect of the bladder, forming of that organ the lateral true ligaments, which become greatly thinned out as they pass over its walls. The anterior part of the visceral lamella on each side is attached to the back of the lower part of the pubis in front, lat- erally to the symj)hysis, and behind passes to the anterior surface of the bladder to become the anterior true ligament of this organ : the .space between these bands, the pubis, and the bladder, sometimes called the "space of Retzius," is occupied by the retropubic tix.'^uc, consisting ]>rincipally of adipose and areolar tissue. The vmco-vcKjinal Inner extends between the bladder and the anterior vaginal wall, and aids in coimecting these )>arts by its firm union with both, blending with the attachment of the j)osterior ])art of the bladder to the uterine cervix. The recld-vtif/iiial layer passes between the vagina and the adjacent wall of the lower part of the rectum ; the union, except l)ehind the U])per part of the vagina, is very intimate, while below, this layer is contimious with the fibrous tissue of the jH'rincal body. The rccff/l hii/er extends behind the rectum and is attached to its walls, becoming continuous with the corresponding layer of the opposite side. The Pelvic Floor. — The exact structures which should be regarded as taking ])art in the constitution of the pelvic floor has occasioned nnich dis- cussion, since by some authors its constituents are limited to those structures which directly contribute to the c'ontinuity of tlie se|)tum closing in the jielvic outlet, while by others all ])arts directly or indirectly contributing to the sup])ort of this septum, as the bladder, the upper part of the vaginal canal, the uterus, and the rectum, are included within the category of the floor. In the present consideration of the ])elvic floor only those structures will be included that directly contribute to its formation, thus excluding, with Symington, tlie bladder and the uterus, and reckoning as belonging to the floor only those ])ortions of the walls of the vagina and of the rectum that lie inti- mately united with the septum. The close relation which these excluded organs bear to the ])elvic floor, howev(>r, must not be overlooked, since by their intimate connection with the tissues of the floor, on the one hand, and by ^ A^^ATOMV OF TJII-J GENEltATIVK OliGANS. 31 lall of of the fibrous walls, <1(>. rdod as •h dis- Kictiiros polvio .ii]>]H)rt uterus, i'os will with 111' floor |io inti- ceUulocl |nce by ind bv I tiieir suspensory ajiparatus, on the other hand, they exert an important influ- ence, as eniphasizeil by Webster, in supportinjj the tissues closing the outlet of the pelvis. The pehlc floor, in the sense here accepted, is bounded externally by the skin and internally by the peritoneuni, and includes the several intervcninjj; structures which stretch across between the ossei»-Iiganientous boundaries of the pel VIS and enclose the irregular outlet of its cavity. Viewed in mesial sa<''ittal section, the floor is seen to be divided by the vaginal slit into two portions, an anteri<»r and a posterior, which have been designated by JIart, respectively, as the pubic and the sacral segments. Tile (inferior or juihit- wijmenf appears triangular, being attached to the pelvis in front, and including the structures lying between the symphysis and the vaginal orifice ; the urethral and the anterior vaginal walls, together with the dense intervening fibrous tissues, contribute largely to this portion of the floor. T\\c posierlor or sacral fief/mcnf includes the structures between the vaginal orifice and the posterior bony pelvic wall, to the sides of which it is closely attached. The portion of this segment interposetl between the vaginal slit and the anus constitutes the inijiortant perineal body (Fig. 13), whose elastic yet resistant tissues enable the septum to undergo great distention during labor. The perineal body is triangular in sagittal section, and its boundaries are the posterior vaginal wall in front, the anterior wall of the rectum bchiiul, and the integument between tiie vaiiina and the anus below. The base of tlie perineal body measures about 2.G cen- timeters, and the height from 30 to 36 centimeters. In addition to the strong bnudles of fibro-elastic tissue and invol- untary muscle that constitute the body, it is traversed by the muscles which join in the common tendinous perineal centre. The female perineum proper — by which term is to be understood the anterior portion of the pelvic floor included between tlie iscliio-j)ul)ie rami as far back as a line drawn through the tubera iscliii — corresponds in general with the similarly situated structures in the male, subject to the modifica- tion brought about by the mesial cleavage of the jnirts by the vulvo-vaginal opening. The perineum must be distinguished from the perineal body, the latter iiu'luding onlv the limited tissues interveninii between the vasxina and the anus. As in the male, so also in the female ])erineum, the fascia? constitute im- portant and resistant structures (Figs. 14-10). (^f these structures there are three : the deep layer of the superficial fascia (corresponding with Colics' OftA NAVl CUUOMf ^ Levator fbscia • .Ifiansuiar Lifmtt jupfrnciiUliyer. •Sup-Perintal faidi j/<irJ Fig. 1:'..—Siii.'ittiils('ctinn of llic perineal hi Illy, sli(iwiiij.'it.-ciiiiii"inoiit.>itrii( turi's (lilVsizi'V tvi AMKIilCAX Ti:XT-l}f>f)K OF fHiSTF/PlilCS. fiiscia), the superficial or inferior, and the deej) or superior layer (»t' the trian- ^liilar li;;anient. 'I'liese f;i>eial layers are attaelietl at various levoiis to the is«'hio-pul)ic' rami anteriorly and laterally, and eonverge as they pi'oeeed baek- /'.rtei Hill iiifir/icial /"• t ith'iil >rrf:-i\ /iitiriiu/ su/'iificial /l< ilHul IlilVC. Su/'i>fUitil /'vrinfal iH/.iy. /'i/'i y/,>y />tii/t'tu/ii/ Me>- c. l'iu/i\' iwrff. luliinal f'lulic artery. In/vriiir lumor- rhoiiliil artery. htjeri, r lt> nio} - rh.i/ttal nerT'i'. /*'«*// ;/('WA iiHtit' of f>t riiu'UHl. ni'ii Yw.. 11.- r,v..f.i- -ninTticiiil stnu'turi'S of tlu' fiiniiU' in'riiifuin (Wt.'issiO. ward to lieeoine continuous at the jwsterior free bonU'r of the so-oall(Hl "peri- neal shelf," the middle of which marks the j)erineal etiitre. The interval enclosed between the superficial fascia and the su{)erfieial or inferior laver of the triangular li"ament is divided l>v the irenital orifice into two trianLiular spaces which toj;ether correspond with the nupirficiid pcrhiati intii-HiKicc. The various strovtures contained within this space include the crura of the clitoris witl) tlic a^•(K•iat(•d ischio-eavernosus muscles; the bulbi vesti!)uli, with the spariiitily developed constrictores vajrinse, the homolojiues of the l)ull)o-cavernosiis; rlie Miperficial traiisversi periniei ; the tjlands of Bar- tholin ; toirether with the superficial perineal vessels and nerves. ( )n removal of the skin and the superficial fascia the ixcliio-cdi'irnoHUH muscles appear as slender hands which arise from the inner surface of the tuberosities and rami of the ischium and the pubic rami, and conver<je toward the anterior commissure of the <renital fissure, to be inserted into the cavernous bodies of the clitoris, these muscles correspondinu: closely with those of the male except in size, their reduced dimensions aifreein»«; with the diminutive clitoris. The hii/hn-cdrcnioxiis, or cnnxfrh'tor v(i(/i)i(t' muscle, is represented l)y atten- uated fibres which pass on either side of the vairinal orifice over the bulbi ves- tibidi and the slender stalks conneetini; them with the clitoris. The action of these fibres seems to be laruiely confined to exerting pressure upon the adjacent I A\ATit.)/y OF Tin: (;/:\/:/i'Ai7\'/-: oav,m.v\. 33 triun- to the I baik- niasscs of crcctilf tissue, witli little, if any, tlirect role iis ('(nistrietors of tl iUf't-rftcial .iif'ryfii.iiil il /'!> infill (•iiiliiiilit! )■■ ■ /i, iiior- :,/ artt-ry. r //. nil')- 'a/ iie'Ti'- ,tlis i I lit 1 1- of 'Clllll. ed " peri- ii'i' ticial or itice into pir'nicdl liulo tlu" the bulbi inoh>^tit'!^ Is of Bar- ((« nuipclos iherositics 10 anterior bodies of ale except oris, by attcn- Hilbi ves- aetion of le adjacent I va;iiiia, conipressioii o f thi- d I eanal heiiiir exerc iscd, al reativ s tate« tl contractions of tlie anterior pnitioiis df the levator ani innsi-le. The Kiini I'ticidl frininirrMii.s /nrinn i imiseles elosely resemble those of the male, beiiij;, however, redneed in >i/.e. They arise from the imier snrface of the tidierosities and rami of the ix-hinm, in close relation with the origin of the ischio-eavcrnosi, and extend inward towaril the perineal centre, where they blend with the fd)res of the sphincter ani and the constrictores vajrina'. The roof of the snperticial interspace is formed by the inferior or >i>iperfiri(d Uiijcr of the trianjfidar ligament, the somewhat thickened anterior part of tjie Ilorsai T4'in of clitoris. Ditisitlii rtiiy of clitoris. Inferior f<uilenilal nerve. Artery of hiilh. Puiiic ntr-ie. Internal /•Uilic artery. Inferior licinorrhoiiiat artery Inferior heinorrlioidal nerve. Teni/inous /lerineal centre. Su/ieeticiat traH.^7'ersHS /fcrimri inusc/e. FliJ. l.i.— r>i.«si'('tliiii 111' fi'inaU' |«'riiU'Ui" : nii tlic left siiU' tlu' piiiimil iiiiisclts an- cximihimI ))y the nllioliiiii uf tlu' pi'i'iiii 111 liix'iu : mi lln' rifjlit sido tlii' iiiiisclo mid tlu' suiiirliciiil InyiT oI'IIk' liiiiii'^'uliir li^Hiiiriit liiiVL' tii'i'ii ri'iiiuMil, tluTi'liy <.'.\|nisiiii,' till' (k'l'ii Iiiyir nl' tlu' liKiiiiu'iit iiinMlilioil riniii \Vl■i^.sL'l. (l('('|) fascia of the perineum. This layer is utta«'lu'd antero-laterally to the jMiho-ischial rami above the line of attachment oi' the stiperticial fascia, and stretches almost horizontally across the snbpnbic arch to the posterior perineal border, where it fuses with the other layers takin>i- part in the perineal ledt>e. The superior or <leejt Itti/er of the triangular ligament is a resistant fd)rous scptmn which expands inward on each side from its line of attachment ahnig the ischio-pnbie rami and constitutes the Hoor of the anterior extensions of the ischio-rectal fossa\ at the posterior margin of the ])erineal ledge joining the superficial layer in the conunon fusion of the fascial layers occurring at that point. This layer may be regarded as a rcHcetion deriveil from both the obturator and the reeto-vesical fascia, since the septum is forme<l by the union of the contribution given otf laterally from the obturator fascia with that sup- 3 34 AMEIilCAX TEXT-JiOOK OF OBSTETJilCS. m 'A !'? pliod niosially by the iccto-vcsical fania : tliis relation is c's|K't'iaIly evident in frontal sections passinu' tlirontrh the iseliial tuberosities. Tlwdicj) pcfiiiad iiifcrsjKWc lies between the interior and superior layers of the triansrnlar liuainent, and it contains within its wedii'e-shaped area the urethra and tile surronudinti' venous plexuses, the internal pudic artcM'ies and acconi- ]>anyin<; veins and (h>eper nerves, and the fibres of the deep transversus ju'ri- n;ei nniscle, liere divided by the ifcnital fissure, and represented by thin trronps of variable muscular tissue surroundinii' the urethra. On riMuovinii; th(~ skin and fascia, that part of the p(>lvic floor lyinsr ]>oste- rior to the perineum j)roper is divided by a median ridye extendinj^ from the ■ i 5 i' 1 Fk;. ir.,-Iiissi(lin!i of fcmiilc pcriiii'iiin. slinwiii',- tlir lici'iicr >tnuturc~ iiftir r'lnnvnl (if'tlir hviitur iiml >pllill(tr|- lllli imiM'lo illlllrll UKiililkil llnlll Wi'isM'i, jierineal centre to the tip of tlie coccyx, that consists of the lower end of the rectum surrounded by the tleep nniscnlar band of the KjJiiiirtn- aiu r.iiiriniN. Tiiis muscle comprises voluntary fiiscicidi wiiich extend from .he perineal centre in front, where they blend with the fd)res of the superficial transverse jH'riucal and va<iinal ctmstrictor, t- the ti|) ol" the coccyx bi'hind, eneIosiiij«' the anus in their course. Su|ierticially the anal s]»hiiicter is closely related with the int(^iiment, deeply with the levatorcs ani and the internal sphincter; the nuiseular tissue of the rectum is closely related to the <'xterual sphincter, since numerous bauds of the former blend with the encirclini; fasciculi of the s^)hiucter. Externally the anal spliiucter comes in contact in it-< deeper parts wish the tissue occupyiuLi' the iscliio-rectal fossa'; the latter extend as two I AXATO.Vr OF TIIH GLWKRAT/ 1'/-: OAV,'.LV,s'. 3.') deeply rcci'dinu; spaces whose siii)erioi' IniiiiKlarv follows the lower surlaee of the levatores aiii. The isclii'o-n'ctal fossce arc continued anteriorly and posteriorly within the pockets situated respectively above the triansiular lii>'ainent and the sacro-sciatic ligaments. Viewed in sagittal sections passing through these recesses, the ;l of the •.r/c/'/C'.v. Iperineal Inisverr-e [sing the led with jter; the |er, since of the |)er parts as two I'p.. iT.-lii.^sc'clidii i>r liiiiiilc iHTiiR'nni. sliDwiii!; sn|M'rli(iiil liloud-vi'sscls ntul iicrvi's 'SnvaEri'): C, clil.iri-; 1/, :iU'iitiis iiriimriiis ; T. v:i'^iiial ii|-ilicc; .1. iniu> ; ", ruccyx: T. Iiiliri' i>chii; /., Micin-M'iiilic liiiiiiiH'iil , 1, 1', iiiti'i'iiiil imilii' nrtrry, iiiviiitr <ilV its iiilcrinr liciiinrilinicliil ''-'o, ciitiiin'niis, iiml iiiiiMiilar linniilus ' ', I); 'i, suiuTliciul in'riiiciil ; s, lutiry nf Imlh- ~.". tcnjiliiiil hnuirlH's u'oiiiix tn ilni-siiin iiiiil CMViiiiHiis liudifs nf clituris; in, pin lie lU'lVi'; II, lu'iuiMrliiil jl iiii.l iiiuscMiliir . IJI liniuclu'S : 1;'., 1 1. iiiliT- iial ami I'xurniil suiHTlicial inTincjil lU'rvcs : l."i, comiiiiiiiicaliinis willi iiiUrinr innlciiilal iicrvi' iliu ; 17, rciiitimiatinii III' lU'cp liraticli nf lunlic iutvi', tcniiiiiali.iL' is ilursnl iicivi- nl' flituvis 1 1"'' : I'.i, hriniiial lu i'js 111' ilii) inniiiiinl iioi'vo ; jn, siiinll sciatii' ; 'Jl, cii' 'iic m ^ liranrlics : n. cut Mirlncr nl' i;luti'i\s niaxi- iiiiiv; ^, ^iiliiiii'tcr ani ; c. U'vatnr aiii : il. tniiis versus |H',iMi'i ; ' , li\illiii-(avi'riin>us ; ,;', ^.-racilis ; <i. isrliui- cavi riiHMis ; //, I'xivaiisiiai of cnis I'lituriilis ; /. ailiiui'tu ■ ma^iinis, is( liio-re( lal fossa presents an oudine, as descril)e<'. hy Anderson, not unlike tiiat of an anvil. In frontal ft" )ns the fossa appears as an opi'U A-shaped nrcss except at its extreme lads, where, as just desciihed, the perineal k-dge and the sacro-seiatic liganivr.t? close in the space helow. The 'V(K)(^ir.s•^'(/.s■ (<! the ?>"lviv' H lor include the arterial brai ehes derived fkMif 3(5 AM Eli IVAN TEXT-BOOK OE OBSTETRICS. :l I \ ! ■( (lifcctly (ir iudirictly iioiii the aiitorior division of the internal iliac, and the vcnons trunks accoiupanyinir the arteries, as well as the venous plexuses occur- riiiLT in close relation with the vesico-vauinal walls (Fi>r. 17). The iiill'rior vesical and the vaginal arteries, touether with twigs from the external pudie, siippU'ini'nt the branches derived troni the internal pudic, of which the inlerior hemorrhoidal and the superficial j)erineal especially supply the muscular structures connected with the pelvic Hoor, The superficial peri- neal artery pii'rces the superficial fiiscia and gains the superficial jierineal interspace, supplying the contiguous structures and giving off the transverse perineal branch. Tile eontinuatit)n of the internal ])udie artery maintains a more deeply situ- ated course, lying along the lateral boundary of the deep perineal interspace between the two layers of the triangular ligament. In this position are given off the arteries of the vestibular bulbs and of the crura of the clitoris, '"^he internal pudic terminates, after piercing the anterior layer of the triangular ligament, as the dorsal artery of the clitoris, from whicli twigs extend ♦•» the corpus cavcrnosuin, the glans, and the prej)uce. The n///N of the |)elvie floor consist of the trnidvs which dose'v cdrrespond with the arteries, of which veins the most important ari' the tributaries of thn pudic vein and those which pursue an independent course and take part in the formation of the rich vesico-vaginal and hemorrhoidal ])lexuses. The iniTcti sup|tlying the structures of the Hoor are derived principally from branches of the sacral nerves, either directly or after their formation of the plexus, snpplementeil i)y some few filaments from the ilio-inguinal as well as Ity nuiucnuis l)ranches from the neighboring hyjxigastrie ]>lcxus of the sympathcti<' (IM. 4). Th(> anterior division of the fourth saoral nerve supplies important nniscu- lar structures, including the levator ani, the sphincter ani, and, in conjunction with the fifth sacral, the coeeygcus. 'i'he <upcrlicial perineal branches of the jMidic and the inferior pudendal brani li of tii(> small sciatic nerve chiefly provide for the integument and tli'- nioi'e -nperticial structures of the pelvic Hoor, including the perineal miiscle.- (ihe ix'hin-cavernosi, the constrictor vagiiuv, and the transvcrsi pcriinei) and the more external portions of th<' genitalia; the ilio-inguinal contributes fila- ments to tlie Ial)ia. The terniiuation of the pudic nerve ])asscs forward as the diminutive dorsal nerve of the clitoris. Sympatlu'tic filamcMits from (he hvpoga>tric plexus are additionally distributed to those part abundant vascular tissue. contaiuMii; 11. Anatomy of the Female Generative Organs. 'i'he structures coii-iituting the female reproductive apparatus consis, ^>i' thi'ce group. (1) the external, (_) the intermediate, and (.'>) (he interna! generative organs. 1. External ■ rgaiis of generation (I'! o), ,^r he i/n.'!"!l(i, include the mon- veneris, (he labia maioia and minora, the i''ti r! l!)- ;■■ >tibule with the d the occur- )ni the lie, of supply 1 pcri- ClilK'ill iisvcrse Iv sit\i- ei^pacc given ;. 'Hie angular 1 ♦.. the ■s of thc^ It in the incipally lation of I as well s of the niuscu- unt'tinn ->u* londal nid til" nuiscU' luei) and )utfs lila- •ward .IS roni the ()ntainiii;j; UdUSlS, >'! intt'rn;i' icluth' llie with tlie ANATOMY <»F TllK I'KIAIC IT.OOi;. I'l.ATi.; 1. 'J ■/. :, ^ ■r. U i~ t~ 7. ,i^ ^"^ H I, St W^ 4- ANATOMY OF THE GENERATIVE ORGANS. 87 meatus iirinariii.s, and the vaginal orifice. These parts are collectively known as the vulva or pmkmJum. The mons vcnerk presents an eminence surmounting the pubes in advance of the vulva, and is composed of stout integument abundantly supplied with crisp hail's, and a thick cushion of subcutaneous adipose and areolar tissue upon which the rounded contour of the part depends. The labia niajora, the homologues of the scrotum in the male, arc two con- sj)icuous longitudinal folds of integument extending from the mons veneris downward and backward to within about 2,5 centimeters (1 inch) in front of the anus. The elongated fissure included between these folds, the uro- f/cnital orifice, occupies almost a horizontal position in the ertKit posture, and is limiteil by the anterior and the posterior commissure, formed by the union of the labia in front and behind. Immediately within the posterior commissure a crescentic fi)ld extends transversely and constitutes the fourchette ; the space between the latter and the posterior commissure is the fossa navicularis. The labia majora are continuous anteriorly with the mons veneris, and are thicker in front than behind ; they present the usual ai)pearance of integument, being covered on their outer surfaces with scattered hairs and pigmented epidermis; their protecte<l inner surfaces are more delicate in texture than their outer surfaces, and where least exposal they partake somewhat of the character of a nuicous membrane. The tegmental fold of each labium includes areolar tissue, some involun- tary muscle, and a considerable mass of fat which receives the distal end of the round ligament of the uterus. Descent of the ovary into the labium occurs in very exceptional cases, the displac(xl organ following the round ligament and taking up a position within the labium after traversing the inguinal canal. 'I'he labia in the young and wcll-developfKl subject are closely approximated and occlude the vaginal orifice. The labia minora, or the nymphm, are two thin diverging folds of delicate skin that lie protected within the greater labia, so that their arched free borders are often completely covered and not visible externally ; luiless arti- (iciall" separated their mesial surfaces lie in dose contact. The nymphse are subject to great individual variation in size, in s(mio cases, as conspic- Mt)usly seen in Hottentot women, reaching excessive dimensions; usually they extend downward and backward from the clitoris (about 3,5 centimeters) along the genital fissure, iadiiig away at the sides of the vaginal orifice. Directly continuous with the lai)ia majora externally, their smooth iiuier siu'fiices pass directly into tlie mucous membrane of the adjacent vestibule, which they closely resemble in appearance and structure, Vascidar papilhe and well-developed sebaceous fi)llicles are common to both surfaces of the nympha^, but sweat-glands, hairs, and fat are wanting, Tiie interior of ciicii fold contains abundant venous spaces, which, in (onnection with the uustriped muscle pres(>nt, produce a structure resendding erectile tissue. The converging and often unsynunetrical lal)ia min(»ra, just l)efore meeting anteriorly, separate into two divisions, the outer and nj)per Itaflets continuing mm h 38 AMERICAN TEXT-BOOK OF OBSTETRICS. ;U 5 : « ^1 »; ! i \ 1 1 || : 11 ovor tlio clitoris to unito to form tlio prcjuifiinn vlitoridis, tlio lower or inner lamina' joininii: Ih'Iow tlic jilands to eonstitutc the //■(■/(» m c/i(ori(liK. The f//7o/7.s', the homoloyiK' ol" the penis, presents i^reat similarity to the male orojan, possess ins; all the parts of the latter rethieed in size and inllneneed l)v the absenee of the urethra and by the cleft and nuxlitied condition of the corpns spon<::iosnm as represented l>y the hnlhi vestihuli. The somewhat laterally eom])ressed hody of the clitoris consists of the dimin- ntive corj)or(t cdrcriKmi, which diveriic behind and are attached by their ernra alono; the pnbic and ischial rami, the snspensory lij^ament aiding in niaintain- ijiu: the })osition of the origan. In front the cavernons bodies are capped by the rounded i//ini>< c/ifnridis, wlii<'h contains papilhe occupied by arterial tufts and the peculiar special nerve-endings, the (jctiitnl vorjuixch'n. The nerves of the clitoris are relatively better developed than the corrcsjiondinir ones of the penis, the organ beinii the especial seat of voluptuous sensation. Sebaceous follicles surround the glans, and they are also present in the outer layer of the prepuce, being almost wanting, however, on the glans itself. These follicles secrete s.il -tances prone to decomposition and to the production of a jteculiar odor. The erectile tissue constituting the dimimitive corpora cavernosa and the glans eovresvonds in structnr(> with similar tissues within the jtenis. Two small nnisei.'s, (he ischio-cavernosi or ercctorcs clitoridis, extend from the ischial tuberosities to be inserted in the crura of the clitoris, and correspond with the homologous muscles of the tnalc. The vcslihiilc includ(>s the triangular space lying between the clitoris in front, the vaginal orifice behind, and the nymph.'c at the sides. Its smooth mucous surface is broken by (he urethral o])eniug, the lorafus KriiKiriiis being situated in the mid-liiic of (he j^osterior v(>stibnlar wall about 2 to 2.5 centimeters (1 inch) behind the clitoris, slightly in advance of the orifice of the vagina. The iifliuti'i/ iiic(tti(s varies in form, but oftenest appears as an ov(»id cleft, frequently presenting short irregular lateral branches, surrounded by a border of .'^lightlv corruirated elevated iiiiicoiis membrane, due to the encircling ring of muscular fibres (PI. o). The /)ii//>l vrsfihiili are two elongated leech-shaped masses (about '2.5 centi- meters in length) situated on cither side of the vestibule a little behind the nymjiha', and attached above to the crura of the clitoris by means of a con- tracted iutermediate portion, the y^^/z'N iittcniicilid/ix. They are composed prin- cipally of close and intricate venous plexuses eorrespouding with the tissues of the male corpus spongiosum, of which part the biilbi vestibuli must be regarded as the cleft hoiiiologue. The eoiistrictores vagina' muscles lie in close relation with the bulbs, and by their contractions, as during sexual excitement, com- press the venous cliaiiiicls and render the tissue turgid aiid erect. The ghivdx of ItdrfJkol'nt, the homolognes of Cowpers glands, are two ronn<l or oval yellowish bodies (about 1 eeiitimeter in diameter) which lie on either side of the lower part of the vagina. These bodies are less deeply situated than the corresponding structures in the male, being eontaincHl within (;KNi;i!Ai'l\ I". <)lHiAN> I'l.ATi; ccilti- iiil the a <'()n- il priii- <I1('S of ji'ardctl 'lation , coni- V fwo lie on Ip('|tly within lUniHl.v.'s^.'N of Ihr \'v]\\- iliourL't'i-y .-in.! .lac.l.i ; tln' lUitriiMr pnrt of (lir | .'h i- lui- 1 ii ivmnviM. Mini tlicMiiiMrr mi.l llir ;nii.ii,,r va-lnal w.-ill \\:i\<- hv,\\ iwirlinlly .ul «»iiy. Iliv uhtu- i~ .Iniw n up iiml tlic '^w^ r i *!, '•'. §il ■'il {:' I mmrr ■ i -^.- (iKNKHATlVK (>U(iANS. I'LATK H. I'l'lvic (iririitis in silii nf ii yniiiitf wuiimii nf sixteen yeiirs ; scon from ntiovo after eii refill removal nf the interlines \v itjiiiiit ilisliirliiii'/tlie reliitiniis : .(, iiliilniniiial aurtii ; \'i \ inferior Venn eava ; /'.-■. psnas niannus ; I'l. iMnninMlory of .".aenitii ; /.'. ent reetiun : /», |i. neli nf limmliis ; /.'/ , hi.dy of nierns ; /T. I'lnnius of nterus ; /; , M.iilder: '), ovary; 7', l'iillo|iian lulie; /,'/ , roiiinl liLiiiineiil ; (V, nivter- ii.\, uNarian aitery ireilrawii IVoni Walilevi'n. ffT^- ^li M: J l!i 'Mil' ri MXTKKN'AI. GKNEUATIVK ORGANS. I'l.ATi: 'i. M!flJ!lV\l(A '■ DlAGPAVi 1. \'iri;iii liyiiHti. J. ('hiinii'ti'ri>tii' hyiiu'ii iiiiil I'lHirclu'tlr of n nmrrinl unin.iii: \:iv^r u linkli'il luliiii iiiiiioia Mild |iri'|iiici'. :i. Miilliiunii. slmu in-; I'l'iiuiiml nl' liyiiirii, iH.uchiiiL; Miilrri..i- .iikI |m.-i Mmiiiicl uiill, si'iii- ill |>i riiii'iiiii, liil'^r l:ilii:i mil Ji ii;i. 1. |li)if,'nilM nil a ililViTrlit ^ciilr IViiin Ihr I'n'ii.HiiLi li.;iirf>. w %\\ i;\i'i;i:N.M. (ii;M:i;ATi\ !■; ()1;(;a.ns. l'U\TE 0. I I <i ) .' 1 a > / > a I i -•a yr ^^ff-. i*» ■"-v;*:.v^-; ^v J I i s > fe a: < ll^ i A^ATO^fV OF THE GENERATIVE 01i(,'AJV,S. 39 the superficial perineal interspace, and not between the two layers of the tri- angular ligament. They arc niuco-serous racemose glands, and pour their secretion upon the mucous membrane by long slender ducts which, after an oblique course, open into the vestibule just external to the vaginal orifice. Dorsiil L rvi of liitor is. />.>r.\u/ tirti-ry of c/itt'ih. rtt'yy o/iorplts i'a7't'rn<>sutn. Deep f^et iiwtil artery. Artery i>/ lulb. Tentlit'ous peri- neal eentre. Kic. IS.— nissc'cHcm of foniale perineum, Rhowlnp the vestibular bull) and tin? clitoris (Weisse). TIk! liymen consists of a thin, usually cre-soentic duplicature of mucous niendjrane, strengthenetl by fibrous tissue, stretched across the posterior part of the vaginal opening, which it i)arHy occludes. The hymen varies greatly in form and in extent, at times being represented by a slight semilunar Ibid Fiii. 111.— Kroclik' strut'tures of tlio fi'malo K'l'iiitalia, iiarticularly tlic liiK'lily vascular bullii vcslibuU (Kobelt). whose concavity looks upward toward the pid)es, at other times forming almost a complete and imperforate membranous septum. The variations in the shape and extent of the fold and its (srifice ine'ude the circular, cleft-llk(>, cordiform, cribriform, and other types, well illustrated on Plate (J. Uupture of the hi* '.1 1 ^ i I!H . }l 40 AMERICAN TEXT- BOOK OF OliSTETElCS. hynieu usually, but by no moans necessarily, occurs durinj]j the first sexual intercourse ; in rare cases the septum persists until the event of parturition. In women who have borne children the orifice of the vagina is surroundeil by irregular j)apillary elevations, the cavuncalce myrtiformes : these are the remains of the ruptured hymen, but are usually present only after labor has taken place, since, as established by Schroeder, the rent hymen is converted into these eminences as the result of the pressure incident to chiklbeariug, and not to coitus. Dorsal neive. Poisal artiiy. Porstt/ 7't\'/i of clitoris. Moatus uri- >uirii4s. Art,-ry of /'l<ll\ jt. Artery to gland. jj_^ / 'hho-iuiginal I 'itl7'o-vai;inal Jiut. Lt~ihitor fascia. Frohe. Pef/i perineal iinisele. Sn/'ey/itial l<:yer of triitn- git/itr lii:ament relh\led. Peep layer of supet/ieial perineal fascia rejlecteil. Tendinous centrr '..-''' of perineum. Flo. 'JO.— |)isso('<ii)ii ol" fomnle poriiu'iim, showing stnicturos within tho dcop intLTfa.scinl perineal intiTspuco; tlii' vnlvn-viifiinal f;lan(ls, liowovcr, lu'lonj^ to the snpi'rlieial spaee, but arc sliown resting on tlie lieeper stnictiires (Weissc). The /(7»<//c urethra (Fig. 21) is short, being only about 4 centimeters in length, and lies beneath the .symphysis pidjis, firmly imbedded within the ante- rior vaginal wall. It descends from the neck of the bladder to the vestibule almost vertically, presenting usually, however, a slightly marked d()id)le or sig- moid curve, or at least a curvature, forward. Its vestibular orifice, the meattin iiriiKirln.'i, is indicated usually by an elevation of the mucous membrane situated from 2 to 2.0 centimeters behind the clitoris. The meatus marks the most con- stricted part of the canal, the average diameter of which is about .(J centimeter. Owing to the elastic character of its ti&sues and to the yielding nature (»f the surrounding structures, the female urethra is ca])al)le of great distention, a matter of importance in examination of the bladder. The walls of the urethra comprise a nmcous, a subinucou,'^, and a nuiseular layer. Tiie nuico.si is covered by stratifie<l .stpiamous or transitional epithelium directly continuous with that of the bladder; tubular glands oecnir near the vesical end of the canal, where tho mucous mend)rane is soft and .spongy. Skene has called attention to the existence of two small tubes (from 10 to 20 millimeters in length) which lie within the nuiseular walls of the female urethra and which open by minute orifices situated about 3 to 4 millimeters within or above the meatus. These tubes probably represent the remains of (Jiirtner's duct derived from the fetal WoltHan duct. ANATCnfV OF THE aENERATIVK OlidANS. 41 sexual iritioii. dwl l)y oinain.s taken o these ' coitus. The .suhmueous stratum contains much elastic tissue and a rich venous plexus. Tlie muscular tissue of the hUwUler is continued over the urethra as an inner longitudinal and an outer circular layer, in addition to which the tube receives an investment between the layers of the triangular ligament from the compressor urethne or deep transverse perineal muscle. The muner- ous blood-vessels and nerves of the female urethra are derived from the same sources as those of the vagina. The female bladder, relatively broad and capacious, bears important rela- tions to the vagina and the uterus. When empty and relaxed the organ lies entirely within the true pelvis, Iwhind the pubes and usually to one side; the fundus is then greatly flattened out and somewhat indented, so that the cavity of the bladder and the urethra together a})pear Y-shaped in section (Fig. 22), the widely-separated hinder limb and the corresponding posterior vesical wall lying against the upper part of the vagina and the lower segment of the uterus ; Km Jl.— Siinittii; .section, showing ri'Intionsiuul form I'siK'i'iiiUy of tlii' bladder, un'thrn, anil vayiiia (Hart): [', r, urethra; li, li, blatUlor. sometimes, however, the emi)ty organ is strongly contracted, the cavity of the bladder then presenting a slit-like lumen. Maxinnim distentii>n carries the bladder, together with the peritoneum, well above the pubes, with the conse- (pient tendenty to backward displacement of the uterine fundus. 77ic Fniudc Ureter. — The urt>ter in the female (IMs. 7, 8) presents peculiar- ities in its relations within the pelvis tiiat deserve notice. After the usual relations of tiie abdominal portion of its course — proceeding downward and inward uj)on tlie i)soas muscle and its fascia, being erossetl by the ovarian ves- sels, and crossing the iliac vessels about 1.5 centimeters below the division of the common iliac artery — the ureter passes into the true pelvis in front of the sacro-iliae synehondrosis, thence upon the cjbturator interims muscle and its fascia toward its termination, rmming beneath the root of the broad ligament. About opposite the origin of the vesical and uterine arteries from the yt 42 AMERICAN TEXT-BOOK OF OBSTETRICS. internal iliac, the nreter forms a sweeping curve which is most pronounced where tiie uterine artery crosses the ureter, about on a level with the os exter- num. The ureter crt)sses the uterus at a point closely corresponding with the position of flexure of the uterine body upon the cervix, here lying between the vesical venous plexus laterally and the utero-vaginal venous plexus and the uterine artery internally. The h)wer part of the ureter passes at first at the side of the upper thinl of the vagina; it then reaches the vesico-vaginal septum, within which it lies for 1.5 to 2 centimeters before entering the bladder-wall. The ureter does not extend lower than about the middle of the anterior wall of the vagina; as it rests directly upon the latter, it is encloscHl for a :y Promontory. ,..' ■X hi. .cS> ..c»- Ovario-pelvic ligament. — Tube. -Ovary. Broad ligiimcnl. Uterus. ^' I'c^^' ^.^Hetropiibu ' triangle. Bladder. X I ; I , I •^■s^"' „„„„ I ! ' I ' I N '' I ' Inrernal sphincter anl. ""n 1 I r ' / •W I I lUilho-caTcrih <s//s. \Lev)ftor.\ '•'J' E.\ter)iat spluncter. Klii. 22.-Mi'siiil sictidii, slmw iiij; llic rcliitiiiii nf tlu' x isccni in llu'ir imrinHl |»isiti(iii (Uickiiisuii). short distance (about 1 centimeter) within a distinct fibrous sheath continuous with the bladder-wall (Waldeyer). The course t)f the tircter within the vesical wall is obliquely downward and inward for a distance of al)out 1.5 centimeters. The lower part of the tube, from its investment by the above-mentioned sheath to its termination, is cylindrical in form, in contrast with the remaining fiattened portions of the canal. 2. Intermediate Organ. — Thv V(uihia. — Tlie nuiseido-mend)ranous canal of the vagina fi)rms the intermediate tract connecting the internal and the A» ANATOMY OF THE GENERATIVE ORGANS. 43 external organs of generation. Piercing the pelvic floor with its lower end, it lies chiefly within the cavity of the pelvis, in relation with the bladder and the urethra in front and with the rectum behind, the vcdco-vaginnl and the redo-vaginal fiej)fa intervening. The axis of the vagina (Fig. 23), while corresponding in general with that of the pelvic cavity, resembles that of the urethra and the rectum in i)resenting a double or S-like curvature. The axis of the lower third of the vagina corresponds closely with the plane of the pelvic brim ; that of the upper two-thirds lies parallel with the axis of the lower third of the rectum, forming almost a right angle to the axis of the anal extremity of the gut. The two jirincipal vaginal walls, the anterior and the posterior, ordinarily lie in contact except at the sides, where the lumen of the canal laterally \ Fig. 2.'!.-SiiKittal section of fi'iiiiilo yiolvis, shinviiif; axis of the vngina. expands. In cross-section, therefore, tiic vaginal passage under normal con- ditions appears H-shaped (Fig. 24) ; when distended it is club-shaped, being more capacious above than below, where the entrance marks the least diameter. The shorter anterior wall (Fig. 25) extends from the vaginal entrance to the apex of the corresponding utero-vaginal recess or anterinr fornix, and measures aboiit 6.5 centimeters, or about 2}j inches; seen from behind, this sin-face appears triangular in its g(>ueral form, the base being above, corre- sponding witii tile greater sui)erior diameter of the canal. Tiie anterior wall is very conspicuously marked by transverse /vff/"' (Fig. 20), wliich are especially promiiienl in tlic virgin; an additional vertical fold, the anterior co/Hmn, is ■^"K 44 AMERICAN TEXT- BOOK OF OBSTETRICS. 'J pn sent at the lower part of tlie passage, where, also, this wall, distinctly thicker than its fellow, is most robust. riie posterior wall, nuieh the longer, extends from the vaginal orifice or the hymen to the apex of the dcc\) poderior fornix (Fig. 25) or retro-cervical fossa ; it lies in front of the anterior rectal wall, with which, thronghont its lower two-thirds, it is united by areolar tissue. The posterior wall measures about 9 cen- timeters, or about S^ inches, in length, being broader above than below ; its supe- rior third receives an imperfect covering of the peritoneum which forms the most dependent portion of the anterior wall of Douglas's pouch. While distinctly less corrugate<l than the anterior wall, the pos- Fk;. 2(.— Sfctioii illiistriitiiiK the chariiptoristic Fig. 25.— SiiKittiil section, showinK vn(;iniil wnlls form of till' viiniiml clfll (Ut'iilc) : Tn, urolhra ■ nnil roliition of cervix uteri tskuiie). IVi, viitfiim ; ],, levator aiii ; Ji, rcctuiu. terior surface in the virgin possfct;ses numerous transversely disposed ruga; as Fill. ■Jf).— Sntfitfiil section of viifiinii of a virgin, Fio. '27.— Suuittnl section of vagina of a multipara, stiowiii;.' rufjous (iiiiilitiou of walls ami ciilarKeJ oiie-lialf natural size (Hart), iiliper extremity (Hart). well as a vertical, and sometimes double, posterior column. Siibscfpient to the dilatation incident to parturition the vaginal nigte are much less conspicuous '^ ■■>^/ AXATOMV OF THE GENERATIVE OBGAXS. 45 ^/ (Fi<'. 27), tluiso on till' posterior wall often alino.'^t ciitirt'ly disappearing, leav- ing^the .somewhat pouched surface relatively smooth ; the folds of the anterior wall are retaine.1 to a much greater extent. Ill ,sfn(rfiiir the walls of the vagina consist of a mucous membrane, a nius- c:ilar coat and a Hhrous tunic. The mucosa is covered by a thick stratified, squamous epithelium, and possesses numerous papilla. The rugic include within their structure not only the tissues t»f the mucosa, but also bundles of involuntary muscle and large veins. True (jlawh, if found at all, are repre- sented bv a few sparingly distributed tubular structures within the upper part of the vairinal mucous membrane, the acid secretion which bathes its surface beiii"- the iiroduct of the general mucosa. The deepest part of the mucous mem- brane that corresponds with the submucous layer, is succeeded by the iims- cular coat, composed of an inner circular and an outer longitudinal stratum of u list ri pod muscle. The fibrous tunic consists of a dense coat, rich in fibro-elastic tissue, which is derived as a prolongation of the recto-vesical fascia and materially con- tributes to the strength of the vaginal wall. The lower extremity of the canal is encircled by a thin plane of muscular fibres constituting the con- strictor vatiiiiic muscle, and is closely attached to additional bands derived from the levator ani. Bhod-vcsscls and Xerves. — The vascular and nervous supplies of the vagina arc verv <>;enerous. The arteries are derived from the vaginal, the internal pudic, the vesical, and the uterine branches of the internal iliac. Correspond- iiif veins return the blood to a large extent, in addition to which the vaginal plexus surrounds the lower part of the canal and communicates freely with the iieiirliboriug vesical and hemorrhoidal plexuses. The urethral plexus around the upper jiortion of the urethral canal receives the dorsal veins of the clitoris. Witiiin the submucosa large and plentiful venoirs radicles, together with b;ui(ls of involuntary muscle, give this layer the charaftter of erectile tissue. Till' hjinphatics of the vagina constitute two groups, those from the lower and the upper portions of the canal. The former join the lymphatics of the external genital organs and end within the superior or oblique set of inguinal glands ; the latter, together with the vessels from the lower part of the uterine body and the cervix, proceed outward Avithin the broad ligament, joining with the lymphatics from the oviduct and the ovaries, and terminate in the lumbar glands. The nerves of the vagina are contributions from both the symjiathetie and tiie corcbro-spiual system. The branches of the former are derived from the infe- rior hypogastric |)lexus, those of the latter from the fourth sacral and the pudic nerve. The sympathetic fibres are largely distributed to the vascular tissues. ."5. Internal Organs of Generation. — The Uterus. — The uterus, the thick- ened and specialized segment of the generative tube for the reception, the reten- tion, the development, and the final expulsion of the product of conception, in its mature liut virgin condition is a slightly pyriform body whose thick, dense walls enclose a narrow, cleft-like cavity. The organ lies within the pelvis, 46 AMKIilCAX TEXT- BOOK OF OBSTKTIiTCS. li' w^ I. « lickl by sii|)i)ortiiii>' ptTitoiical folds and niiisi-idar hands oxtoudinii; between tlio bladder in front, the reetuni and the sacrinn behind, an«l the j)elvie walls at the sides; the most (le{)endent porticm of its lower and smaller segment, the cervix, projeets within the upper part of the vagina. The rit'f/in uterus (Figs. 28, 2!>) measures about 7.5 eenti meters (about 3 inehes) in length, 4 centimeters (about H inches) in its greatest widtli, and Tn/v. I\ouui/ h'^ti' ment. ffriionium. Fundus. Hotly. Internal its. Ct'irix. Exttiiial OS. — Anterior surjuee. Fl(i. 2f<.— Anterior vii'W of vir^'in utiriis. sli(i« - Fni. 2(1.— Sniiittnl section of virgin litems, show- inpr reliitioiis of cervix to eorpiis iittri and ivllee- iiif; ]>ositioii of os internum, fusiform cliiiriieter of tiou of i>eritoneum nt istlinuis. tlie cervical canal, iintl relations of the peritoneum. about 2.5 centimeters (1 inch) in thickness ; of the entire organ, approxi- mately three-fifths belong to the body and two-fifths to the neck, the latter being relatively much longer in the nulliparous adult than after pregnancy has ^i 1 ^ PORTlOtI/ VflCIN/lL PoRTIOHl, Fio. 30.— Diiieram illiistrntin!.' the reliitiuns of the uterus lo the vni.'inn, hladder, nnd peritoneum. occurred. The division of the uterus into body and neck is indicated exter- nally by the con.stricted ixihuutx uteri, which is situated about midway in the organ ; internally, hoAvevcr, this botuidary is uncertain, since the contours of the cervical mucous membrane gradually pass into those of the general uterine lining. A.yATO.W OF THK (! EXFIiATI VE OlidAXS. 47 ,cen tlie wallt? at ,cnt, the (about 3 ilth, ami Anh-rioy sui/itce. , uterus, show- 1 clmnutor uf If juTitoiiuum. }, approxi- the latter inancy lias |H' ritoneum. oatcd oxtcr- (hvay in the contours of leral uterine ,1 5! The pvritoriu I'ndi/ is almost flat on its anterior surface, hut i)osteriorly is (11 sti net Iv convex ; its superior and anterior arched border is thick and rounded, and passes over into the slightly convex lateral borders at the superior antrles. The upper part of the orgiui, includinjj its superior arched border, constitutes the fumhis and is completely invested with peritoneum. The serous covering of the'anterior surface extends oidy us far as the isthmus, whence it is reflected to the nei'^hborino; vesical wall. I'he peritoneum on the posterior wall is complete, since the serous membrane is prolonged downward and backward about 2.5 cen- timeters bevond the cervix upon the posterior wall of the vagina before passing to the rectinn. The later.'-.l borders mark the attachment of the broad ligaments. The ccrri.r, sli<rhtlv spindle-form in general outline, may be divided into three portions or zones (Fig. 30), the supravaginal, the intermediate, and the intravao-inal. The first of these zones occuines the upper half of the cervix, extending somewhat farther forward along the anterior surfaee, where it comes in relation with the bladder, than posteriorly, where covered by the peritoneum of Douirlas's jiouch. The intermediate ])ortion includes the zone of vaginal attachment, hence it is narrow and oblique, extending higher behind than in front. The intravaginal segment, or o.s uteri, projects within the vaginal canal in such manner that its axis is directed toward the posterior wall, and it /■'nni/lis split I'pi'lt. Funtfus. Ihtrn. \thiiii ///i titw. Fl(i. 81.— Cnvity uf utorus disiiluyud by ri'nidvttl uf iintorior wall. / 'ti^i^in.i Fii;. oJ.— Vir.L'in \iti'rus laid ii|n'ii, slidwitiir the I'uguu.s foiKlitidii uf tin.' ct'rvi.v. presents the transversely oval orifice of the cervical cavity, bounded by the rounded and prominent anterior and po.<terior lij)s or labia, the anterior of wliieli is somewiiat the thicker anil shorter. The proportion between the body and the cervix varies with ay-e : in the vouny; virgin adidt the uterus is about ecpially divided between these segments ; in early life the cervix greatly pre- ])on(lerates over the imperfectly developed fundus; while after childbirth the fundus never returns to its former size, always remaining enlarged and nearly twice its original length (Fig. 31). With the advent of old age the entire organ suffers marked atrophy. 48 AMKllKAX TEXT-liOOK OF OliSTr/riilCS. I 1 ;i A .1 H 4 f m\'''^ if Tlu^ cdritif of till- riri/lii uterus is very narrow, tlic iippositioii of the iiiitcrior aiul jjostcrior walls of its liody reducing tlw space to littlo more than a lonjfitu«liiial cleft, as .seen in mesial sagittal .sections (Fig. 21)). Viewed Ku.. :'.S.— Casts (if tlu' cavitiis of uttTi (if viiricms iikos niid coiKlitidiis (inoditk'd from lliini'iimini) . 2, ;i, liiuii iinilliiniin' (if fif,'lit(.'t.ii mid twciity-fdur years; 4, fniiu u wdiiinn of forty-i'iKlit yi'ais who had (iiR- cliild liftcrii years iirevious. from in front, the uterine cavity is triangular, the expanded base extending be- tween the orifices of the oviducts, and the ai)ex corresponding with the inner Kl(i. Ii"i. — Kiniit mill )ir(>- lile views of easts of the l"i(i. :U. -Casts (if tlie eaviliis of uteri frmii i"i) a uulliiiara of sixty uterine eavity of a iiew- ei'.'hl years, mid K'n from a iiarmis siilijeet of seventy years iiiiodilied from liorn infant (modilied from Jla;,'eiiiaiinl. HaKeiiiann). opening of the cervical canal. On account of the encroachment of the uterine walls, the cavity of the uterus between the angles presents concave outlines. The vdvUji of fhe cervix is fusiform, being of larger diameter at its niiddh: than at the vmh,t\H' "■•< inlcnunit and the o.s (wtcnniin. Theos internum, which marks the point of greatest contraction, possesses a lumen of circular outline; the AXATOMV OF TJll-: (1 KNKIiATI Vl-l OlidANS. 4!> 1 ol' the ore than Vicwwl llaci'iiiinnil- I'lirs who had (Midinj; l>f- i the inner l-l'nint mill )>r(v I' (•ii>l> iif Ihf ity 111' II IH'W- (iiiuiliUcdl'nim the uterine I outlines. its niiddU: hnini, which Lutline; the OS externum heforf i)r(\LMiaucy appears as a narrow, lransver>ely phiced oriliee. Tlie antcriiir ami posterior walls of the virgin eervical eaiial exhihit coiispic- u.iMs plications (lepeiitlinii' upon the arruntreinent of the hundles (if inuseular ti-.<ue- these Y\\\ivc are arranj>eil asprin<'ipal loiijiitudinal l"olds, the anterior and posterior eohunns, from whieh seeon<lary plications extend laterally. These eorrn-iatious collectively form the nrhor rihr (Fij;. 85) of the uterus, being hest marked in the virgin and being etVaced by repeated jjarturitions. Striichiir. The uterine walls include a mucous, a nniseular, and a serous coat. The miifnsa consists of a tiuiica jn-opria of delicate bundles of tibm- elastic tissues covered by an epithelium c<-v<posed of a single layer of ciliated culunmar n'lls. Numerous wavy tubular depressions, the ntfrliir tjUinilx (Fig. ;}(')), are also lined by the ciliated epithelium. Since a subnuicous layer is Flii. oi'i.- Scctiiiii iif Iniiium iitrnis, iiiclmlinu' iiiiiciisu m) anil ailjacciit iiiusciihir tissiu' (M ; c, I'liithi'- lium c'f I'liT Mnliicc mill tulailar utiriiii' k'hiiiIs c/i : .;', ilcrpcst hiyer nf iiuicusn, (iiiitiiiiiiiig riuiiU uf ghiiiils; /i, .slnuids of uuu-stripcil iiiusrlr pi'lR'trHting witliili thu mucosa U'l'-'i'sol). wautino', the blind and often forked extremities of these glands abut directly upon the muscidar tissues. The ccrriatl nuicosa differs from that of the body, being thicker and tinner, sup[)lied with papilhe, and covered with stratified s(piamous epithelium within the lower third. In the upper half or two-thirds of the cervix the e])itheliiim is ciliated colninnar, similar to that of the body. In addition to the tidtular follicles, the representatives of the usual uterine glands, numerous short, widely- expanded nuicous crypts lie within the cervical mucosa. Retention of the .secretion of some of these mucous sacs often takes place, the resulting greatly distended cysts appearing as translucent yellowish vesicles, the so-called oridiv Nnhuthi. In its meagre su]>ply of glands the mucous nuMubrane of the lower part of the cervix still further resembles that of the adjacent vaginal surlace. The mitsmldr coat (Fig. 37) of the uterus consists of bundles of luistriped nuiscle (Fig. 38) .separateil by bands of connective tissue and surrounding vas- cular channels. Although irregularly arranged, the muscidar tissue is disposed no AMi:iil<'A\ TEXT- HOOK OF OUSTKTltWS. I in tliree geiuTal .strata — an inner, :i niiihllc, and an uutcr layer. 'J'iie inner layer, Yvi. :'.T.— Arruiimiiuiit of uturiiu' iniisiU', us f,vv\\ from in fnmt after rcmovul of siTcms coat (llulii'i. composed prineipally ut"luiigitiKlinal biiiKlles, is in direct contact with the nni- Fi(i. :;>.— A, i.suliitfil iiaisi'li-'ck'iiu'nts <if tlic iiiiii|ir(.'L:iiiiMt uttTus ; li, culls fmiu \\w orjjuii sUditly nftt'r ili.'liviTV iSiippfy ,. cosa, and issometinies regarded as belonging totliatlayer, as being a hypertrophied r lavor, ^m AXATOMy ()/' Till': GENEliATIVK <)/{(; A. \S. 51 niiiscularis nuu-osfp. TIjc iiiiddN' layer is most robust, and tonus the <rroater part of tlif iiiiisciilai- coat, foiisistiii-,^ i-hicHy of himdli's liaviii^^ a general circii- lar disposition. 'I'liis layer is also distinj^iiisiicd by tiic niiiiicroiis lar<;c venous cliaunels enelosed between its bundles, lienee the ivahh;. '<li(ifinii vdnru/ari: Tiio outer lavcr ineliKle-; botli eireidarand lon<;itndinal bundles, the latter predoini- natiu"- and lvin<;' in elose relation with the superimposed serous coat. Mimy binidles of tlie tiMter layer pass into the broad li<j;ameuts ; .some of these enter the round lijianients and aeeompany the areolar tissue and the blood-vessels eoniposinji' these strnetures toward the ^roin, while others extend alonj; the oviducts and ovarian lijiaments. Mnseidar l)ands pass also from the uterus into its siipportintj: folds, the saero-uterine band bein<>: |)articidarly robust. The nmsculatnre ol' the cervix is distinj;uished by greater regularity in its arrange- , (Hc'lio). the mu- 1 '^lisM*"' roaiiJKrnmcnt. X.,. ^-'t*-- I'lDidus, l-'ii., :;'.i.— lir.iiiil li^'iiMicnts viewed IVdiii the piisterini .-iirl'iice, sllll\vin^' uterus, nviiliU'ts, ami ovaries ; tile iiiitunil |iipsitiiiii nC tlie latter has beeu ili.stiirlieil iu eciiiseiiuenee nf tlie separation (if lliu supiiortiug atlaeluiieiits. Iiurtly after •rtroi)hied mont, which includes a distinct inner longitudinal, a middle eircnlar, and an outer longitiulinal layer. 'Pile ticroiiH ciHit of the utenis comprises the usual constituents of the peritoneum. Lir/ainctitK. — The supporting aj)paratus of the uterus consists of two parts, the folds of peritoneum and the muscular bands which extend froiii the uterus to adjacent structures. The first group includes two anterior, two lateral, and two posterior ligaments ; the second group, the so-called " muscular ligaments," is represented by the utero-inguinal, the ntero-ovarian, the utero-pelvie, and the utero-sacral imiscular bands; the last of these, the utero-sacral, are included within the posterior jieritoneal folds; the remaining ones lie between the layers of the lateral or broad liiraments. 52 A^n^:/i'/(•A^' thxt-book or onsTETiucs. V I ; TliL' atitirior /if/(iiiuit(f< inv two iiK-()ii.<picuon.s semilunar jwritoncal folds wliidi pass hctweon the ujtpL'i- part of tiio cervix on each siile to the adjacent posterior surface of the hlachlcr, and bound the vex ico- uterine pouch. The latend or broad (ii/tnnotts (Fig'. '59), as implied by their name, are two wide duplicatures of peritoueiun that extend from the sides of the uterus and the vagina to be attached to the lateral wall and the Hoor ol' the jH'lvis. Kach of these broad folds j)resents four borders, tlu; suj)erior, the inferior, the inter- nal, and the external ; of these but one, the sujjcrior, is free, the t)thcrs being intimately joined with neighboring j)arts. The siijierior or free border encloses till' oviduct, whose tortuous course it follows as far as the tind)riatetl end ; at this point the ])lication diverges toward the j)elvie wall and forms the hij'iot- dibido-pelvie I'Kjdinent, which fold connects the end of the tube with the side of the pelvis and transmits the ovarian vessels. The inferior border is united with the recto-vesical fascia covering the levator ani, the subperitoneal tissue intervening between its diverging lamclhe giving transit to bhtod-vessels and nerves as well as to the ureter. The intenud border is attached to the sides of the uterus and the vagina, the blood-vessels and nuiseular bands passing into the tissue of the broad ligament lu'tween its divergent layers. The external border comes in relation with the obturator fascia and affords transit Ibr the uterine vessels and the round ligament. The broad ligaments enclose Avithin their serous folds structures of import- ance (Fig. 40). Along their unattached superior nuu'gins lie the oviducts ; a TUBE UrrfE Kii;. 10.— Dianniniinatic >uction nf liroiul lit-'iiiiu'iit, showing ri'latimis of tlio u> uitiit.'(l stnicturos. little lower and anti-riorly an' siliiatctl the round ligaiucnls ; jiosteriorly, the ovaries and their muscular attachments ; numerous blood-vessels, nerves, and lymphatics, together with the parovarium, the ))aro(>phoroii, and the utero-pel- vic bundles of involuntary muscles which ])ass from the uterus and the vagina to the obturator fascia, are additional structures inchi<led within these folds. The roinul //V/ro/Kvi/.v (Fig. 41) are two llattened cord-like bands, from 10 to 12 centimeters in length, attached to the upper segment of the uterus in i'ront of the oviducts, and extending from this ]ioint downward, outward, and forward, winding round the deep cjiigastric artery on the inner side of the external iliac artery, to the internal orifii'cs of the inguinal canals, through which they pass .1X1 70.1/ r OF THE (iKNKRATIVK OlidA^XS. O.i Uls which posterior '?, arc two itorus and is. Karh tlio iiiter- K-rs bi'injj; '/• encloses i\\ end ; at the iuj'iin- he side of is united neal tissue essels and 1 the si(U's ds passin;j: lie external iisit for the to hlend with the tissues of the labia niajora. 'i'he round lijranient possesses a eoveriui.; of peritoneum, and in the yoinij; subject a funnel-like depression marks of import- )viduet.s ; a Y'Ui. 11." liisM'ilinM iilllu' pelvic Drains, ^llll^^ ini; llii' n'liilinii nl'tlic nlHldiiiiiiiil piirictcs liitlu' numil liuii- iiuMls :iiicl I lie liliiiMir: l,:i. till' ulililcriitfil liyiui^'ii^tric nrtrru's ; -J, llu' urni'liiis i Knur^'cry iiinl .liu'nln. a tubular extension of the peritoneal sac^ alouij the cord as it leaves the abdomen ; this extensiiiii eoiistitutes the ccuud of Xiick, ami is homoloijous with the pro- I stnicluros. 1 eriorly, the nerves, and e utero-ju'l- the va<i:na esi' folds. •omlOtol2 in front of nd forward, xternal iliac ■h they pass i l''|ii. I'.'.- I'lisU'iini' vifu orilie iiliTus mill oviiriiv, u idi ih,. |„Ti|niiciil fiil.N (■i>iii|i..-iiiu iIh- l.ioail li(;ii- lurlll-- mill llic lltcrii rrrtlll I'uxmi < liimliliril IViilil lliiilu'i'l. ccssiis vaii'iiialis of the male, it is ii-iially (.blitrratcd after earlv life, but iiiav jicrsist, and, in I'arc rases, be accompanied ! an abiK.niially descended ovarv, ••^m 54 AMERICAN TEXT- BOOK OF OnSTETRIVS. which then occiipios a position within the hibia, behind the peritoneal sac. In structure the round lii>'anient consists of bundles of connective tissue and blood- vessels, together with plain ninsenlar tissue derived from the uterus. The jtosfcrinr QV ircto-u((fi)ie. VKjimivHtH are two peritoneal folds which pass backward from the cervix and the upj)er part of the vagina to become con- tinuous with the serous covering of the second portion of the rectum. The deep fossa included between these folds laterally, the uterus anteriorly, and the rectum posteriorly constitutes the poKch of J )oiigl<tfi (Fig. 42), wiiich is fre- quently occupied by coils of small intestine. lietween the layers of the posterior ligaments flat bands of involuntary muscular tissue, the so-called tifcro-mcraf. tl! S ' I l:):.i ! .!' f; it mi i' Vu.. l;'..— Siifiitliil scctidii III' I'ciiiiilc iiflvis, sliuwiiiir tlir ulcrcisiicnil lifjaiiu'iits susiicinUn).'- tlic uti'i'us, nlsii till' iPiiliic si':_'iiK'iit imrt III' Ilir --uiiiiipiliML' iipinii'atiis of tlu' utiTUs (Dickinsdiii. ligdiiK'tits (Fig. 43), extend on each side from tiie highest segment of the cervix to the sides of the sacrum, at tlie level of the sacro-iliac juncture. These bands, among the most important parts of the supporting a])paratus of the uterus, are intimately related witii tlie muscular coat of the rectum, which tube they encircle near the union of its tii'st and second ])arts ; laterally and anteriorly they are in close relation with the pouch ol" Douglas. The y>o.s///rj*( of the norma! uterus (Fig. 22) during life has received considera- tion from many investigators, whose conclusions, however, have been s(» contra- dictory and uncertain that almost every situation of the organ has in turn been regarded as representing its normal relation. This discrepancy has been due in large measure to the methods of examination employed, which include observations on the cadaver, biniMMual examination of the pelvic organs of the living subject, and I'ro/.en sections of tlie parts shortly alter death. The examination ol' the viscera in the cadaver in the usual way, even when carried out with -kill and j)reeaution, nui.-t necessarily be untrustworthy JXATO^Vr OF THE (lEXERATIVE ORGANS. 55 sac. In id blood- lich pass jiue con- 111. The jrly, and c'li is fre- postorior •ro-sdcnil 'I Tt '';(-- as to the details of topos^rapliical relations, on account of the uncertainty in- trodiicwl bv icason of the unavoidable post-mortem alterations and ine\ itable distortions affecting the organs. The apparent exactness of the method of fro/en sections likewise is iiiifavoral)]y influenced by the relaxation after death of the sui)porting bands which during life maintain tlic positions of the organs ; it follows, therefore, that the testimony of sections cannot be accepted as unim- peachable evi(l(>nce as to relations during life, since the relations presers'cd are oiilv those existing at the time of fix- ation ; likewise, the possibility of en- countering the effects of pathological chansres in fro/en s(>ctions must also be appreciated. The testimony of the most competent and careful investiga- tors points to the conclusion that the most valuable and trustworthy observa- tions as to the norn;.d position of the uterus are to be gathered from careful examinations of jiroporly ])reserved bodies, where the organs have been hardened in situ immalidtc/i/ after death. The results of such investigations closely agree with the opinions of tiie most expert observers derived from repeated examinations on the living subject. Fig. 44.— DiiiKnuiis illustratinK rniifro df va- rintiou in ])i).sitiuii of uterus as nllVctcd liy ilis- tontlon of the bladder (Van do Warker). the cervix ;e bands, Items, are tube they anteriorly eiiiisidera- ■o conlra- tiirii been s been due li include fans of the way, even •ustworthv Fn;. 4ri.- T.ciimitudinal portion of iMiUopiaii tulic, expivsimr llu' coiiipliciiti'd loiiL'iludiiiiil plications of tlie iii.H'osa wliicli e.Npami into tlie liuilniie (.Sappeyj. In accordance with the conclusions ba.><ed on suHi grounds, the normal uterus most ])robal)iy occupies a position almost horizontal in the upright posture: the lundiis, ustiiiUy slightly to one side of the mid-line, r(>sts on the bladder and is directed forward and upward, while the cervix forms a slight deflt>ction with the axis of the uterine bodv and looks down and backward auaiii.^^t the riC, AM hi? /('AX TKXT-JIOOK OF OBSTETRICS. %i I * i-; i i - ^ III I I \ \ posterior vaginal wail. Wliotlu'r tiic uterus lies most frequently to tlic right or to the left of the mid-line is still in dispute; the latter position, to the right, is probahly most usually encoinitored (His), although the opposite con- dition, as shown on IMate 8, is certainly uot uncommon. The topographical relations between the uterus and tiie bladder are so close that the position of the womi) is materially iuflnenced by vesical distention. The range of varia- tion in tiie position of the normal uterus is diagrammatically represented by Figure 44. The ofi<li(cf,s, or F((//(tj)i<in UiIx'k (Fig. •■>8), the representatives of the un- united portions of the fetal Miillerian ducts, extend from the superior rounded angles of the uterus, within and along the free upper margin of the broad ligaments for a distance of from 10 to 12 centimeters, to the vicinity of the t)varies, wiiere each terminates in an expanded fumiel-shaped orifice, the pavil- ion or i)ift(n<lil))ilinn, surrounded by a series of fringed processes, tho Jitiibrue (Fig. 45). P^xamined in carefully-preserved specimens retaining the typical ])o>ition of parts, the tube at first passes outward closely related with the pelvic Hour; it then turns ujnvard along the altached anterior border of the ovary, when, after reaching the upper pole of the gland, the tube bends downward upon the free posterior border and the inner surface of the ovary (Figs. 22, 41), which are by this means partly masked (Waldeyer). The oviduct commences at the iinier attached extremity as a narrow tube, the istlnnus, about 2 millimeters in diameter; during its further slightly wavy course it gradually gains in width until the tube measures 4 millimeters or more, when it again becomes somewhat nai'- rowed, but beyond the ovary it rapidly expands into the ampulhe and the fimbriated extremity (Fig. 4G). The lumen of the tube is narrowest at its inner end, where it opens into the cavity of the uterus by a minute orifice, the osfhtm infcrinoi}, which scarcely admits a bristle ; the diameter of the canal gradually increases until it presents, just l)efore its fnial ex])ansion into the fimbriated orifice, a distinct opening, the oxtimn (thdoinind/c (from 4 to tJ millimeters in width), situated at tiie bottom of the cleft-like (le[)ressi()n leading from the attached border of the fimbriated exj>ansion. Sfriichiir. — The ovichict consists of three coats — an inner nuicous, a middle muM'ular, and an outer serous. The iini<'fiitf< lining presents numerous longi- tudinal folds (Fig. 47) ; these become more consj)icuous within the inf"undibu- hnn, where they greatly increase in size and complexity and terminate in the sinuous border of the fimbriie. All parts of the canal, including its ex](anded ri'.. Ii'i,— I'liiti^n nl'liri)H(l li!.'iuiifiit stri'tcli'"' '-■■ : Imw tlio imnivnrimii (i>i lyiiin ln'twci'ii Um.- fulils lunl I'oi - .stiiiK or the lioini-tuli(.' and fi'oss-Hiliuk'S (lii'jioiibiuir). AXATOJfV OF TIfl': GENERATIVE ORGANS. hi niitor (-11(1, :uT clothed by a .single lavor of ciliated columnar cells, whoso ciliary current sweeps from the fnnhriic toward the uterine end of the tube. At the free cdce of the fimbria} the columnar epithelial cells give place to the low, i)late- lil<(' elements of the peritoneum covering the exterior of the tube. (Jlands are al)sent within the nuicons membrane of the ovi(hict. The viKscnhir fiuiic includes a i)rincipal inner layer of circularly-disposed bundles of involuntary jcle and a sii'ditly-develoj)ed outer layer of longitudinal binidles. The muse a middl(> lis longi- lundibn- ite in the xpanded 1 Fir,. I".— Traiisvt.Tsi' si^ction i>f l-'iillnpinn tiiln', slKiwiiiir the ciiiiiiiliciitcil nrrniiKcmcnt fjf tlic I<ingitii(liniil jilicatiiiiis wliicli iiri.' licii' rut acniss (Mnrtin). f<erous enat consists of the fibro-elastic stroma and endothelium of the general periton(\il investment contributed by the broad ligament. The />/o«(/-C('.s.s(7.s of the oviducts arc branches from the ovarian and the uterine arteries and the corresponding veins, the arteries possessiug an tunisu- ally tortuous course. The ncrirn are derival from the ovarian and uterine plexuses, and consist of both meduUated and ])ale fibres. TItr OvdricK. — Each ovary jireseuts a flattened ovoid mass, somewhat almond-shaped, which appears as an appendage of the posterior surface of the broad ligament (Fig. 'V,)), to which the organ is attached by its straighter anterior l)order. The dimensions vary with the individual as well as with the condi- tion of function:il aetivitv ; the longest diameter usnallv measures about 3.0 oontimcters, the width about 2 centimeters, and the thickness a little ov«'r 1 centimeter. The weight of the ovary is ordinarily between (! and 7 grams, the right being eoiniuouly slightly heavier and larger than the left ovary. The anterior border alone is attached ; the arched posterior border and the broad surfaces arc free and are covered with modilicd peritoneum, the f/enninal ^^"9 58 AMERICAN TEXT-nOOK OF OBSTETRTCS. ; '^ epithelium, directly coiitinnous with tlio serous eoverinj; of the broad ligament. The position of the ovaries in fiita (PI. 8; Fij;s. 22, 41) and <lnrinf; life, at least before the permanent displacement attending jm^gnaney has taken place, /'UHtft/\ of uttrus I'/i'ro-tT'tir/'itn l-'io. 4s.— Ovury natural sizt').^\ith tin' Kalln])ian Uihv \n relative iiositiun, nCa wnniaii Iwenty-thrcu years of age (Sutttm). is probably such that the long axes of the organs are nearly vertical (Wal- deyer, His, Cunningham) and correspond closely with the sagittal ])lane, so that the broader surfaces may be spoken of as internal and external rather {/inibritP)^. I 'milium. -■^ ihuirian i MIL. I tirus. /^^f ih..,i,/ Round lii;ti}uent. Fiii. I'.i.— Oviiriiin sac nr nccss oii tlie jHisti'iior iispi'd uf the broiKl ligament inidiiilioil from Iticlmrd Ijy lilaml Siittciiii. tlian as antorior and jxjstcrior. Tlio ))()siti()n of the riiiidiis uteri i.s a faetor ot' luumout in deteniiiiiing tiie ovarian axis, .>^ince, as pointed out by Ili.s, the f ,: AXATOMV OF THE GEXERATIVI': ORGANS. 59 igamcnt. rt life, at en place, null of the uterus when not occupying a mesial position predisposes to increased ol)li(luitv of the ovarian axis of the opposite side. The smaller and lower end of the ovary, or the uterine pole, points toward the uterus witii which it is united by means of the fil)ro-muscular bands consti- Fuflihfi of' iltrrus. y-thrcf years cal (Wal- ])lane, so lal rather rum Kiclmnl - a factor His, tlie I CoilToiiiti::/ tul'i\ ()ritry. CV;T7*.r. Fiii. .'ii,— rtcnis, tiiln's, mill uvurii's (if ii fliilil (SuUolll. Yfi.. ,'.11— Ovary mid tiilic> iimtiiriil size) nt' ii wnii . of sixty-riiilit yi'iirs (SiittmO. tutiii"' the (iriiridu /If/dinent ; the uj>per and blunter end, or the fiibol pole, after being embraced by the arching oviduct, receives the lower border of the finiiiriated extremity of the Fallopian tube, and is further connected to the wall of the pelvis by the nntfio-pelvic folil of the j»eritoneuni. The ovary lies within a ])eritoi)eal recess, the_/b.s'.sa onirii (dandius), which occu})ies the posterior part of the side wall of the pelvis, usually boimded by the internal iliac aitcry and the ureter behind and the obturator vessels and nerve in front. i>oth the anterior an<l posterior borders of the gland, as well as its inner sur- face, are closely related to and are partly masked by the curves of the oviduct. Sfriictnre. — The ovary is divided into the corfe.r and the viediil/a (Fig. 52), the boundaries ol' which are conventional and not sharply defineil. The cnrfe.r includes the juM'ipheral zone, containing the (iraatian follicles and the ova, and occupies ap])roximately the outer third of the organ. The viednl/a embraces the remaining central portions of the organ, in which the blood-vessels, enter- ing tlu'ough the hilum, are ccmspicuous. The bulk of the organ consists of the orarhni .sfro^na, a peculiar form of connectivi' tissue in which lie imbedded the Graatian follicles, distinguished by the great number of its spindle-cells. Tliese cells are especially closely packed in the cortex immediately beneath the surface covered by the germinal epi- V "IP 60 AMFJilVAX TEXT-BOOK OF OBSTETIilCS. % ^ i ) f'l i I If m. f h ^ :.^ ,5 i tlioliiini, ill which i^itiiation thov constitute a hiyer of greater density than the adjacent stroma, to wiiich the name tunica (ilhuyinca is a])|)lie(l ; this stratum, ^jtm-^ however, is onlv a eondeiisation of the ordi- mono; the immature follicles are others in Fl(i. 'iJ.— Seel inn df liiiniuii oviiry. inrluiliiiK oortox : ((, (.'vniiiniil f]iitlu'lium nf I'rci' surfiict' : b, tMiiica iilbiij.'iiu'ii ; c, iicriplu'riil strnmii ('(iiitniii- iiif; inimuluiv (inmllim tnlliclcs (i/i; i. wcll-iid- Viiiici'il liilliilc ('nun wlinsi.' wiiU nu'nilininn ixriinn- Icisii 1ms luirtiiilly si'iiiiniti.Ml ;,;'. cnvity ol'li(|U(ir lul- liciili : II, ovum summniU'd liy ci'll-nniss cuiisti- tntinf,' (liscns i)riilii;i.'i'ns (Picrsnl). Kic. ."iii.— Ovary with ninturc (irnnflnn fdlliclc nbont roiuly to burst (UibcMnont-Di'ssiiiKm's). various stages of more advanced develoi)ment, where the ova are encircled by twt) or more rows of pijlygonal cells which by their division give rise to the numerous elements lining the follicle. Both the ova and the surrounding cells are derivatives of the germinal epi- tlidium covering the free surface of the ovary, from which they dip into the stroma as cylindrical cell-cords. With the increase in size which accompanies their development the (Jniatian follicles pass toward the inner limits of the cortex bordering on the mc<lulla, where they undergo further enlargement ; after a time their diameter includes almost the entire cortex, and extends from the medulla to the surface of the ovary, the position of the follicle becoming evi- dent on the free surface as a distinct projeetior. (Fig. 53), marking the point at which the final rupture of the sac and the escape of the ovum take place. The mature (Jraafian follicles apjiear as clear, slightly elongated vesicles 8 to 12 millimeters in diameter ; they are defined from the surrounding tissue by a condensed layer of the ovarian stroma, the fhcca fol/iculi. Within the thcea fol- lows the iiicuihninfi f/rdiiKlnsa, consisting of many layers of small polyhedral epithelial cells. At one j)oint the inembrana granulosa presents a thickening which encloses the ovum and constitutes the discux pvolif/crus. The cells of the discus next the ovum lie vertical to its surface, forming a radial zone, the cornna ritfJiatd. Within this layer lies the sexual cell, the ovum, which will be considered more fully in the section relating to its developnieut. The formation of new follicles continues only for a short time after birth; AXATOMV OF TITK (iKXFJiATIVE OliCAXS. 61 (jvisu's aro tlicii mitst miinerous, the fntiro number ooiitaincd witliin the two ovaries of the child beiiij; ewtiniated at over seventy thousand. In view of tiic unquestionably iarji'e number of follieles in very yoimj!; ovaries, and the relativelv small proportion of ova which reach maturity, the defeneration of nianv follicles ai'ter attaininji; a certain development seems certain. The atrophic; remains of such dciicnerating' Graafian follicles continually encountered point conclusively to the fate of a lar<>;e contin<,rent The mcdnlla contrasts with the corte.\ l>y .' Kxjser structure and the numl)cr and size of its vascular, and particidaily its venous, canals. A con- siderable amount of involuntary muscle is intermingled throughout the fibrous tissue soijarating the blood-vessels. Irreguhir groujjs of polyhedral cells aiv encountered between the fibrous bundles of tlie medulla ; these elements, the intcvMitial cclh, represent the remains of atrophic parts of the fetal WoUHan bodies. On the escape of the ovum, surrounded by the cells of the discus pro- lii>('rus the ruptured and partly collapsed follicle becomes filled with blood i)oured out li'om the torn vessels of the walls of the follicle. Subse(pieut chaii<''<s lead to the conversion of the follicle into a corpus Itdcidu. This characteristic structure is formed by the ingrowth and rapid proliferation of the vascular tissue of the fi)llicular wall, spindle-shaped connective-tissue cells and lar«>(' cells containing yellow pigment, hitch), being the most active ele- ments in the process. The history of the corpu- luteum is materially affected bv the occurrence of pregnancy, since, instead of being almost entirely absorbed within a few weeks, as is the rule with the ordinary bodies, when fertilization takes place they ])ersist until after the end of gestation. It is usual therefore, to distinguish the corpus hitcvm of pref/iuoieif, or the corpus vcrniii, from the corpus hifeum of iiictistruation. The mode of growth is iden- tical in both, the stinudus of impregnation leading usually to excessive devel- opment. The primary blood-dot occupying the ruptured follicle becomes invaded bv the eidarged and thickened wall, which soon beeouKs corrugated, the plications encroaching upon tiie clot and increasing to such an extent that the folds crowd against one another and eventually form an irregular broad envelope surrounding the remains of the central clot. When jnvgnaucv occurs the processes are continued beyond their usual length, resulting by the enil of the first mouth in the production of a mass from 12 to '20 millimeters in diameter, characterized by a brilliant yellow ])eri])heral zone siu'rounding a lighter centre. This condition is succee<led by the gradual reduction and cica- trization of the central area and the lighter tint of the now greatly corrugated broad outer belt. By the end of gestation t\w white nucleus constitutes about one-third of the entire corpus luteum, which has already become somewhat smaller (10 to 13 millimeters) than at the sixth month. After delivery absorption jmigresses rapidly, but fi>r some months later the ]>osition of the corpus is distinguishable. The characteristic yellow color of these bodies is due to the presence of a peculiar pigment, hdchi, and not merely to disinte- grated blood. r ni it :-<«. f 1 ! i 1 i ^ (i2 AMKIilCAX TEXT-nOOK OF OllSTKTnWS. Tl»c pf'ctiliaritiis distiiijinisliiiiji' the forpiis liitciim of pregnancy from that of mc'iistnuitioii havi' Iniijjj km regarded as of especial signilicaiiee as stipplv- iiijj;' positive evidcnec that ])r<'i;iiaii('y has tak ii phiee. WhiU' the presence of the typical yellow liody iiiiist he rejiarded as stro .<>;ly iii<licativ(! of such condi- tion, the occasional encounter in the ovaries of inidouhted virgins of <'or- pora lutea possessing the characteristics of those of pregnancy, as recorded by 'I'lll;- nil VI.— Oviirir.s (if t\v i|■t.'iIl^, show iiit; Im-p' cciriKirii liitiii. rcscinliliii^' tlmsf of iirctriiiinry (Hirst). • Ilir.st (Fig. 54), should lead to some reservation and to a demand for cor- rohorative evidence in the acceptance of these bodies as infidlible signs of the existence of pregnancy. Tlic VdYovar'mm. — The jHirontrinin, the cjxiujihoron, or the nrf/an of J-ioscimiiif/cr, consists of a grouj) of inconspicuous tui)ular structures within the broad ligament, between the oviduct and the t)vary, not far from the attached border of the latter organ (Fig. 4(i). The parovarium consists of a series of fi'om twelve to eighteen short (iibitlcx which lie irregularly parallel, their ovarian en<ls slightly converging, and which are connected at their opposite extremities with the longitudinal licod-fiihc of larger diameter extending for some distance within the broad ligament toward the uterus. The tubules are lined with low columnar epithelial cells, the representatives of the elements clothing the embryonic canals. The ])arovarium represents the partially obliterated remains of portions of the Woiniaii body of the fetus; the short canals correspond with the tubules of the body, whil(> the head-tube is identical with the u|)per ])art of the Wolff- ian duct. Wlii'U this latter canal persi.-ts throughout the greater part of its original extent, it constitutes Udrtner'x duct, the homologue of the vas deferens; the entii'e parovarium corresponds morphologically with the tubules constituting the globus major of the epididymi>. Additional fetal remains in the form of rudimentary tubules are sometimes encountered within the broad ligament in the vicinity of the ovary, although situated rather nearer the uterus than the parovarium. These strnctui'cs con- stitute the jxiraojilinraii, ;md represent the atrophic transverse tubules of the lower ])art of the ^\'ol^iau body, being homologous with the paradidymis of ANA"'K)fV or Tin-: aEXEliATlVE OltdAXS. 6;', tin tliiit siipply- «'ll(-'(! of li fojuli- (»f" (Mtr- )1(1('(1 l)V ry (llirsi). 1 ibr cor- sigus of nrf/(ni of ithin the attached series of lei, their opposite luliiig for 1)11 les are elenieiits )rtions of e tuhules le Woltt- part of the vas le tuhiiles )iiietiiues although iires eon- les of the (Ivniis of Fi(i. .^fi.-siHlUcd liyiliitiil iit- tiichcd tu liuiliriiiti'J cxtrfiiiity of l''iillii]iiini tiilic (NfW Yiirk llos|iital C'llljillL'tl. the male. The closed tnhules of the paroophoron are lined with low cohinniar epitheliinn and are often oceludcd hy partially shed cells. The tubules of these atrophic organs possess a practical interest from their liability to become diseased and converted into cysts which may assume Iarg(! diameters. 'fhe .st<i/l<<'if lii/(l<iliil "f Morgagui fre(|iiently forms a conspicuous a|)peiKlage to the broad liga- iiieiit near the limbriated extremity of the ovi- duct O''-' •"*'"^)' '''''■'* l»'duncidated vesicle, which varies urcatlv in size, represents the remains of the nrniMphros, being connnon to both sexes. Lmw ,,,,|ii,iiii;ir or eubuidal epithelium forms the lining ,,!' it- (lilatcil sac and stalk so i'av as pervious. The Vessels and Nerves of the Internal Generative Organs. — The vascular and nervous su])plies of the uterus and its apiHiiilaues and of the ovaries are so intimately related that they may conve- iiiciitlv be considered together. These organs receive their blood from three ^,, ,,!,.,,.; — the uterine, the ovarian, and the finiicidar arteries (IM. 7). Tile iihrinr artery is given off from the internal iliac close to the ])elvic wall, aloiii;' w Inch it runs as far as the broad ligament, within whose folds it then p:i-st'>, in front of the ureter, toward the cervix uteri. After giving oif twio-s wliicii surround this part of the uterus the artery ascends along the body (if the uterus, sending oif branches which anastomose with those from the oppo- site -iile to encircle the organ. The upper terminations of the uterine freely (■(imiiiuiiicate with the branches of the ovarian and the funicular arteries. The (iniriiin arterij, the homologue of the spermatic, is a l>ranch from the alidfimiiial aorta, and gains entrance through the iufundibulo-pilvic band into the liinad ligament, within which it divides into its two principal branches — the i)il»(l ;iiid the ovarian. The tubal branch extends along the border of the oviduct, .-ending numerous twigs for the nutrition of the tube and the tissue of the limad ligament. The ovarian proprr is of larger size, and passes close to the tree holder of the ovary, which it particularly supplies, tiiially anastomosing with the nieriiie and funicular arteries iicai- the upper angle of the uterus. The /iiiiiri(/ar artcrif is given off from the vesical, after which it joins the round liuanieiit at the internal abdominal ring and divides into ascending and (hseeiiding iii'anclies, the latter jiassing into the labium along with the liga- ment, tiiere to anastomose with the external jmdic ; the former ascends back- ward within the liLiameiit as far as the angle of the uterus, where it Joins the ovarian and the uterine arteries. The riliis of the uterus and of the ovaries are large and numerous and tend to tiirni plexiibrm netwin'ks. Those of the ntrriiK, always large, but of enornioii- size during ])rcgnancy, form a plexus within the broad ligament, which |)h'\iis subse(|ueutly gives place to a trunk which accompanies the Miteiy and terminates in the internal iliac vein. The ovariim reins are pMititiihii'ly well developed in the vicinity of the hilum ; within the broad ■iili 6J .ij//;A7r.i.v Ti:.\T-r,(K>K or oiisTi/rix'ics. m lijrniiiciit tlicy (in'iii :iii iiitriciitc incsliwork, the jxiiiijiinij'onii jih.niH, wliicli siirroiiiids tlic iirlt'iy and uii tin' ri<f|it si<l»> tcniiiiuitcs in tlu' inl"i'ri(»r cava, on tlic k'f't ill flic I'ciial vein. Tlic siili|icritoii( al tissue cdiitains irrcat nnmhcrs oi' vciKiiis cliaiincls, tlic presence ni' wliieli is a iiiatter oi" practical import. Tlic fi/iiijtIiti/irK (IM. 9, Fi;rs. 2, 8) e(Hinccte(l with tlic internal (irjrans ol' "fen- eration iM'ifin as intcfstitial lyiuph-clel't.sand radicles which these viscera, in coin- uterus. ^ i .,u Fiii. 'iCi.— Nerves III' llu> pelvic (irfiiiiis of tlie feiimle ( Kninkriiliiiusein : 1. nerves to fundiis of uterus ; '.'. ri^'lit Fiilliiiiiiin Hibe: ;l, ri«lit nmiiil liKiinieiit; I, nerves tn Fiillnpiiiii Hilie; ."., edMiinniiieiUion between oviiriiui iinil uterine nerves; i\, civiiriim plexus nf veins: 7, ovariim vein; s, nerve (nissinn tci join oviiriiiu plexus ; 'J. liniliriiited extremity (if Fiillopinii tulie ; in. relleeteil peritcmeDUi ; II, uterine nerves; p.", supe- rior liypnpistric jilexus ; i:!, briinehes from liypofiiistrie plexus to uterus ; 11, inferior liyponiistrie plexus ; l-'i, vi'sieiil nerves ; 1(1, eonimunicMtinn briinehes to vesical plexus; 17, eervieiil n'ln^'lion ; !.'», brunches of hypoi-'iistric plexus to cervical ^'aim'lion : I'.i. first siicral nerve; jn, branches i>assini.' .obladil.'r ; 'Jl, brunches jiassins: between bladilcr ami rectum; 'JJ, commnnicatiiii.' brniiches from second sacral to cervical ^iin- KJion ; ■-';!, branch from third sacral nerve to cervical pini-dion ; 'Jl, second sacral nerve : '.'."i, branclu-s from third sacral nerve to vagina and bladder: 'Ji, branches jiassinn from fourth sacral to cervical Kan^rlion. iiion with others, po.s.se.s,s in larj^e luiinbers. The ve.s.sels thus orijiinatiii<:; are arranjfed as three principal groups : 1. The .set conipo.sedof tho.-^e coming from the body of" the uterii.s, the ovary, and the oviduct, which end in the prevertohral lymph-glands in front of the aorta and the interior cava ; 2. Those from the IIS, wliicli r cava, on t inimhcrs 11 import. IIS of ircll- •a, ill coin- I — 1 — 2 111 us (if iitcrns; lion lii'twi'cii I join oviirian vos; IJ, sM]ii'- istric iilcxii." ; Ijraiiclu'S <if ; 'Jl, lininclK'S I'lTvical j.'!in- niiiclics I'm mi 1 fjiinnlion. [latiiig- are iiii)<>; from evortehral from tlie rsmmmmm "v^^fp^niF'p.w ujn' w^i' ■' ti EXPLANATION OF I'l.ATK ',». Fl(i. 1.— I.yni|iliiili<s (ifllic lit. ■ru'i, which hiis hrcii tiinu'd lorunril (Siippcy) : A, imrtii ; ii, cnnimipn iliiu's: c, liif'Mriiitiiiu iiitii iuU'iiml lunl fxtiTiial iliacs: n, vcim cnvii liifi'rior; i:, cniiMiKin ilinc veins; K, iiti'i'iis topiili'd I'nruiinl ; lu ri'clmii ; ii, lijiiiiiu'iit iiuitiiiK micmmii with lil'tli liimliMr viTlrhni ; 1, lyiiipli- iitic vi'ssi'ls jmssini; muli'i' nyarii's to follinv llu- cuiirsi' ol' oviiriiin vcj-si'ls; 'j, lym|iliiitics from huily nl' ntcnis, whicli ctkI in lyin|ih-j;hiii(l.s iiccoiniiniiyiiiK thi' iliac vessels; :!, lympli-Kliinils iccciviiiK Hie lymiili-vcssels of iinieims menihraiie uf cavity o( hoily ; I, I, lyinplialics from lower portion ol'snrt'ace of litems, ^'oin^' to tlic> L'lanils lniiind intenuil iliac vessels, which ulaiuls (:"i) vary in niiiiihi'r and volume. iiiiiiion iliacs ; c, eyteniiil veins; ii.nnlers; i, reelniu; K, iitenis; i,. II, (I, ovaries ; ij. i), romiil li^tamenl ; J, siiperlicial iiverKiiii; trunks ol' same, emptying into lymph ulanils {I); 7, 7, lyniphati<' plexus mrse of iilero-ovariaii veins; 10, 11, lining' ovarian iilexiis, with l''|i.. J.- l.yniphiilics of the iielvic \ iscera .■iml the aliclomeli (Sappey i : ii Mini in; rnal iliacs; o, vena cava inferior: o, common iliiK cervix; M. M, section of vniiina: N, N, Fallopian tiihes renal lymphatics; :',, eonverKiin; trunks of same, eiiip . ol tho ovarii's; ><, ii, trunks lei'eiviiit,' ovarian plexus followiiiK' ( «lanils receiving the lymi.liatics from ovaries; r_', lymphatics from fiiinlus, |omiii^ oviinaii pie.Mis, n.yu same lermiiiatioiis ; II, ulanils receiving (le) trunks from siirliices and hi.rilers of liody of nteriis; I'l, lymphatics ori^'inatinu; in lower liart of cervix, mucous memhrane of uterine cavity and va^:inlll for- liices; 1(1, lymph-ulands occnrriiD-'aloiiK' the course of these vessels; 17. elVerenl vessels of these ^-lands takiMt; their course to the glands lieiieatli external ilia(; vessels ; Is, lymphatics which proceed from the posterior surface of the cervix, ti'rminatinu' in the lihiiids accompanyini.; the internal iliac; I'.', excep- tional lymiih-lrnnk from cervix passinj.' to filand in front of lifih liimhar verlehra; Jn, another excep- tional lyinph-ulaiid anil vessel situated alon^r the course of the common iliilc. Fiii. :f.- Lymjihatics of the breast (Sappey): a, celliilo-adipose cnshioii siipportinn mammary ulaiid ; II, contour of mammary Klaiid : i , superlicial blood-vessels; 1, network of siiperlicial lymphatics; '-', net- work of lymphatics orinliiatihi,' in and draiuiii); the lobules of the uhiiid ; :i, lartrc lymphalic trunks orii;- inaliri),' in the |ieripheral network ; I, plexn.s of lymphatics haviim their origin in the di'eper parts of the t;liiiid; .'i, large vessels orik'inatinj,' in the inner jiart of tills plexus; (i, 7, .s, larizc lymphatic trunks. ' t h (iKNKKATlVK oltd ANS. Pi, Air, 0. 11, (MlllllllOIl iliiic veins; 1 ; 1, lyiui'li- •,,111 l""ly I'f ■(■I'iviiiK llH> il'siurmT 111' 111 vnlllUU'. ; r. (•yli'riiii\ K, uliTUs ; I , ■J, i.ii|u'rli(iiil iliiitic I'li'xiis veins; m, H. jilcxiis, Willi >f iitiTUs; l,"i. I viiniiiiil I'lT- llirsc ^'Imiils |inil'l'l-'il IVnlll lie; I'.i. cXKii nlluT I'XCl'p- iiiniy ultunl : ilics; ■-', ml- \v tniiili!' iii'iK- r p; Its 111' llic Iniiilcs. > - 1 I \ iii].liiiiir- ■i| Uii' uliTii^, u lilrli luis lircM turin'il lonMH il Mipi'i'V . J. I ymi'liiiiii'v III till' |irl \ II' \ 1^11 111 Mini mIiiIiiIih'Ii ,-ii|i|M'y , '.\ I > iii|iliiil ii - ■ I' llir lui n-l -ii|i|iiy ^"mmm ;: i m I l! f I ! I f II % ■4 ,,i ! AXATOJfV or THE (i KXERATIVi: OlidAXS. Go •ft cervix anil adiacciit part of the vagina, whicli extend along the base of the broad licrament and terminate within the internal iliac u;lands of the pelvis near the iltao arterv at its point of divi.-^ion ; •■'». 'I'hose which accompany the ronnd lig- an'ient and eni]»ty into the in>;ninal irlands. These latter, as in the male, hichide two groups, those lying along the conrse of Poupart's ligament, wliich constitute the ohiiquc s(!t and receive the lymphatics from c"ie genitalia, and .1 :irraii"'C(l about the sai^henous opening as the vertical set, into which emptv the suporlicial lynii)hatics of the lower limb. The great abundance of the Ivmiihatirs of the uterus, the cervix, and the vagina is a matter of nnich prac- tical importance, since tluse channels furnish the paths by which septic mat- ters mav invade and affect parts widely removed from the focus of infection. The nerves (Fig- 5^) of tlie uterus, the ovary, and the oviduct are derived partly from the sacral nerves, particularly the third and the fourth, and partly from'the svm])athctic sy>tem as represented by the hypogastric and ovarian plexuses. The nerves include, therefore, both medullated and pale fibres, the latter beiii"- especially destined for the blood-vessels and the masses of invol- untary nniscular tissue. The Mammae. — The mammary glands, being really but highly specialized and urcatlv developed sebaceous follicles, belong to the integument, and, strictlv reirardcd, have no place among the sexual organs. The closely asso- ciated functional relation of these organs in furnishing the nutriment for the ni'wlv-born animal, however, as well as convenience, has made it customary to describe them in connection with the organs of generation. The present pur- pose will rc(iuire the consideration of the glands as developed in the female alone, the rudimentary organs of the male being disregarded. The iiiaimnary glands of the human female (Fig. 57), as seen in well-devel- oped women prior to pregnancy, protected by the integument and the fascia' and the associated masses of adipose tissue, collectively form a j)air of hemispherical ])rominences, the breasts, surmounted by the conical mainmi/kt or nipples. The breasts as a whole are not (piite circular in outline, since their attached bases present slight extensions inward over the sternum as well as outward, above and below, toward the axilla. Neither is the gland always limited by the deep fascia, since small aggregations of the glandular tissue may pierce the fascial septum and lie upon or become ind)edded within the pectoral muscle — a matter of much practical moment in amputations of the mamma for malig- nant disease. The size of the breasts depends so evidently upon the functional condition of thi> glandidar tissue and the quantity and tonicity of the surrounding adi- pose tissue and other ]n'otectiiig structures that the dimensions of the organs must iiichidc a wide latitude of variation. The breasts may be said ordinarily to extend from the third to the seventh rib and from the sternal bonier to the anterior axillary margin, with a pi'ominciicc depending nnich upon the amount of tilt or updu the condition of the gland. The nijiple is usually siiuated on a line correspdnding with the level oi' llie fourth rib, being directed somewhat outward and iipwanl. :! ^ ^: i' ;; l! 1 , '.-'■ M ■I m AMi:i;i< AX TKXT-JIOOK OF (UlSTETIilVS. Viii'viiii:' witli the uciicriil ('(implcxidii, tlic nipple is of a roseate or a ])iiil<- isii-l)ro\vii tint, and is siirroiiiided at its base hy tlie (ircola, an area ol" niodilied inte<fiinieiit al»oiit an ineli in dianii'ter, posse>sin<i- tlie same color as the nip|)le. The eliaiiii'es in tlie a|tpearanee of this /one indiieed hy pre«rnaney are more or less permanent, the dee|)ly pitiinented areola of the dark hrnnette nevi'r re- F>rsl n'fi. ifilli iii/i'xiiiiiiiit. ■ — (ii.tiufNiiir ti.^sUt-. Mass 0/ a,Uf'osi '/mtt' /.iwst'r /r, /(';•((/ muscle. Intt^rirstal muscles. /nfrr/i'/'it/uf (/.r'.'/r'A- ;i\sut\ Illili/l ll'IIS i/lIlt Aifif'uUa . -. CiitHiiltlai ff'sxur. . r*'y!phi-ial <u i»i.~ Mitss <y" iii/i/'ii.f ti.ssHi\ Fiy'y<^Ui sr/>ia. Intyguiiii'iit lln izoiitiil axis of Si.xth yib. Extt-rna! fl'li iu< tiiH^Lii'. — i' I'll.. .''T.—l/'iitzituiliMiil xTtinii III' iiiMiiiiiiiiiy t-'liiinl in siVk ,■ friizi'ii siitiji'ct iif twi'iily yours iTi'sHit). jrainiiiL!.- its former tint ; in lijiht Itlondes the darkeninji; of the areola uecom- panyiim' |)ret:naii<'y is often very sliuht. and mav sphsecpiently almost entirely disappe;'!'. The skin eoverinu' the areola i- eharaeterized by its variable j)i<j;mentation, l>y it> delicacy. i)y the absence of siilxiitancons adipose tissue, and bv the prest'nee of lar<i(' sebaceons follicles, and, in addition to wi'll-develop"d sweat-Li'land-, -m;ill uroiips of ulandiilar ai'ini. the acccssDr;/ nii/k-(/f(ni<Is, of which I'lMiu five ti) twelve arc ii.-iially present. The sebaceous follicles (hiring pregnancy become tjrcatly increased In size and Ibrm prominent ele- vations, the '//(//((/.v o/' J/«y///yn//(('/7/. In addition in independent ducts open- .LV.i7-o.i/r OF Tin-: ai:xi:iiATivi-: <>I!(;axs. 67 a pinU- nodiiuHl ' nipplt'. innlT ol" I'VIT IV- <i,il iiiiiscle. muscles. fascia. I a.ris of ■ M' (.11 the -iirt:i<'i' <>' ''"' :"'«'"'''• ^'i'' acccssorv <j;laii(ls somctiincs are connoctcd uhh the inilk-tiil'c- travcrsinn- tlic ni|.i)lc. Iiuth tlir iiipplt' and the arcohi ctmtaiii luiiiicroiis hiiiidks of mistripcd nuisciihir ti-tie- arraiiuvd as ciividar _ .jZi*C>-^.rfi and radlatin-- til'n-, which ivsp.md to „.,.rhanical ^ timuhition. The contrac- tion of the ciivnlarly disposed fil.res ,.iiuses the lupple to iH'conio ni(.rc .^ p'ron.iu.'nt nr ••erected;" tlic radial : til.rcs. nil thi i.trary, tend to depress ,„• ivtraci the iiijiph'. ^^ Thi' ,v(ry,///(.v //••>•••<■'" oi" the niannna >;j|t', consists of an aunn'Mation of pyramidal masses I frnm fifteen to twenty in nnm- 1),,,.) nf acini and Awi^ wliieli corre- spond with I hr l.ihescomposinjj: the oru'an (Fit:'. •">''^)- ''•"■'' '"'"' I't'P'"'"'*'"^'^ '' •'^'",-'<' hiiihlv developed and spcciali/ed seha- ceims -ilaiul. \vho>e excretory tnhe is tiio htcfifcr(iii''< or (/(il<icli'})lii>roiis duel, and whose secretoi'v pnrtioii is the associated ^roiip i»l' acini. The individual component u'land^, of hrciisi, the rm iiHvini: iiccti rcuK.viMi to >iin\v 11 • ill.. »1.,. ...... .1..,. I tho ducts mill acini I. Vslk'V CiMiiviTi. tli(> lolies. are invested hy the .-nrroiind- ' in"- connective tissue wliieh constitutes the <reiieral supporting framework of I'lii. .'iS,— Arrimt'ciiu'iit nf uluinliiliir tissue rs(Tcstiit). ,1a acciini- 4 entirely ^mentation, iiid l)y tilt' -dcvelop"<l Ills follicles inincnt cle- iliicts open- I •J I J.:^z:^i^/^ Vw. -. iiimi ..I iniuiiniiirv L'liiiiil 'luriiiL' l:i' miIom i>liictyi: •!, n, liplmlcs nl' ^ccrcliiiu tissue, cdii- slsliiii.' I'l' iicliii 'li.hs liiiccl with nctivc c|iillicliuiii , i , r, sccliuiis (if cxcicluiy ilui t^ ; <l.il. iMtcrlxhular (I'lincclivc li^siic. the oruan and the >c|)ta. The latter penetrate within llic a<ri;rou;atioiis of acini ainl >iihdivide the lohes into loltiilcs. ^m 68 AMEIilCAX TEXT-BOOK OF OBSTETRICS. In > f 'Ifi I ^^h Before the occurrence of ]>re«::imncy and of the functional activity asi^o- ciated with lactation the secreting tissue forms hut an insignificant portion of the entire voluni(> of the nianinia (Fig. 59), hut during lactation the acini become enormously developed, tiie lobules of true glandular tissue being readily discovered as nodular masses within the more yielding areolar adijKtse envelope. Under the stimulus of the unusual demands made upon the organ under such conditions, it is ])rol)able that new glandular tissue is formed as extensions of the existing a(!ini. The (tcini of the fully developed but non- functionatiny; or<>an are lined bv a siny-le laver of >liort columnar or polyhedral e])ithelial cells, the protoplasm of which appears gran- ular. Th(! cells rest upon a delicate mem- brana propria which envelopes the aciiuis and which is continued on to the minute excretory ducts with which the acini are connected. These passages, lined with a modilication of the glandular epithelium, join with others to form larger tubes, whicli in turn tal\(> part in forming the interlobular canals. These canals are superseded by the wider excretory tubes draining the entire lobe, which, directly or after joining other tubes, become the con- verging lactiferous or galactoj)hor()Us ducts. The /(K'fifrroHfi diictt^ (Fig. (30) on reaching the areola undergo dilatation and form the utnpulhv, or vii/k-si)iuses. These amptdlic lie beneath the areola, and during lactation attain each a diameter of from 4 to millimeters, constituting important reservoirs for the milk secreted during the periods intervening be- tween the evacuations of the gland. At the base of the nip])le these ducts undergo a re- duction in size and become closely collected, the larger tubes occupying the centre of the grouM ; siuTo'inded by areolar and liiusciilar tissues, they ascend to the summit of the mammilla as indc])eudcnt tubes, whei'e they ternunate by distinct orilices which open into minute <le|)rcssions occii|)yiug th(>. apex of the nipple. The ( pithelium lining the ampullie and tli(> lactiferous ducts is of the low (•olumnar or ciil)oi<lal vai'icty ; within a slwtrt distance of the termination of the ducts upon the nii)ple, the lining of the tubes changes its character to cor- respond with that of th(^ adjoimug epidermis, becoming stratified sfpiamous. The changes taking place within the lining cells ol" the a<'ini on the estab- lishment of lactation arc verv marked. In the earliot stage of activitv, when Klc;. I'lil.- DisMM'liiiii <•( !>rciisl, slmw iw susiiciisMy li^'iinu'iitx uiiil iiulk <liicl>- (A.-^ll- y CiiMiPi'r). [XATOMY of the CENI'UiATIVK ORGANS. (59 ty asHO- ii'tion of he acini le bcinp; • adipose ho orpm that now )ns of the \)iit non- lolo hiyor opitholial >arrt ^ran- •ato nioni- loiniis and exoi'ctory K'tod. ludilication kith others take part Is. These r excretory c'h, directly >e the con- is (hicts. M\ reachinji; 1 iorni the ii\ipiillic lie ation attain nilliineters, or the milk venin^ 1)C- hd. At the Idcrii'o :» ''''- V coUeeted, tntre of the the snnunit inet oriliees ph'. ,,f tlie low Imination <it ;icter to cnr- Llitaniotis. In the estab- Itivity, when tl Hi.w of milk first begins, many acini still retain their primitive condition ft" ^ UtUtv- ill >n'''' ^'•^^'^^ t''*-* elements oecnpying the central parts of the 4 1 lo- iind'i"" li'tt^' degeneration, some becoming disintegrated, while others .'i . „• ,,, iirwses whicli constitnte the colo.stnim-corhi(.sc(cfi fonnd in the % are cast on .!•' ""■■ -t ,„il|. .lurino- tlw lirst feu- days. Tl ' iii)ii"i'iii'^' ui'iundar protoplasm of the cells at rest becomes invaded by - ., |,.,,p, v,iirii (iinctionalaetivity begins, and, as secretion progresses, it becomes , ,. una;.! displaced by the aecnmnlation of oil-globnles within the cell. i rpi , ,,,j„,iir /li-diops exist at first as sejiarate particles, which gradnally increase ^ . ^j ,j|,,ji (i](.v become confluent and form a single large globule occupying r 1 ,,,,.,,. I j, ;■ n;itt (if the cutirc ccll. The nucleus in consequence is displaced . ' I (1,,, Mcilnherv, next the basement membrane, where it lies imbedded jj]iji, ii, . diiii belt of protophism occu])ying the outer zone of the cell. ^ r|'jii. .,(1].; within a single acinus generally contain very unecpial amounts of 1 oil • -^iiiix' "' ''"' <'k'iii*-'"ts are so loaded that the entire cell is occupied by the ■'k oil-driip. wliilr. ou tiio other hand, tiie neighboring cells may contain so little % oil that till' ]>r(scuce of the fatty particles is masked by the protoplasni. 1 I'xtwccii diiM' extremes all gradations may be found. ,| ['iKiii atiiiir-ing a certain tension the contained oil-globules, escaping in the % (lin'ctiiHi I i' liii-t resistance, are discharged into the cavity of the acinus, where tlicv tonctliii' with the graiudar debris of old epithelial cells, are collected wiiliiii ail iiKiiiMiinous fluid and cctnstitute the /(icfiferous secretion, or milk. Diuini'' scent inii the acini possess a comparatively wide lumen, the epithelial lavor fiirmiiii: l>iit a thin lining to the irregidar spherical or tubular spaces. At tlic cr-sation of lactatiou the acini bceome once more reduced to narrow tiiliiili's, iiianv lu'iug atrophic, siu'roundcd by t\u\ thin jirejmnderating areolo- ailipii^e tis-iH'. \\'ith each succeeding ])rcgnaucy a new period of cellular aiiiviiv and mw giowth takes place in the preparation of the gland for its active I'tMc during lactation. Tlirclo-c (if the jK'riod of sexual activity is followed by gradual ]icrmancnt ati'dliliv of tlic secreting structures, so that secretions of the uuuunue of aged wdiiicii sIkiw little more than the atrophic remains of the sometime conspic- uiiiis uland-aciiii iinl)ed(led within the connective tissue which, with a variable aiiKiimt III' lilt, now constitutes almost the entire bulk of the organ. Tlic hliioil-nKsc/s of the mamma are derived from two sources : principally fnim the iiuci'iial mammary artery, through its j)erforating branches within the <i'C(iii(l, lliiid, and foiu'th intercostal spaces, and from the axillary artery du'diiali the thoracic branches, the long thoracic or external mammary artery (ilicii sending otf robust twigs for the supply of the gland. The (•(■//(.>-■ retiu'uing the blood from the deeper part of the organ follow the (•(irrespoiiding arteries ; the superficial veins form a subcutaneous plexus which liecdiiM's conspicuous during lactation. a|P 'I'lw hjiiiiihitlivx are very iniinerous, as denionstrated by the brilliant prepa- ratidiis made by Sappey (IM. !•, I'^'ig. ;j), and they constitute a superficial and a (lee|ier ,-et. flic former exist as an intricate subcutaneous network in which ^r^mm '•: 70 AMi:iiI('AX TEXT-nOOK OF OliSTETlilCS. i ^l I:,,' 4 I! t the larpjer vessels are situated at tlie |)erij)lierv, and join the lympli-j>ath.s cun- verfijin<r toward the axilla. The deeper lyin])hatie vessels aceoinpany the deeper veins and pass dtl' in two jrroiips : one set enters the axiUa and termi- nates in the eostal uroup of axiMary lympli-i>;hinds ; the other takes its eourse into tlie thorax and eonininnieates with the eliain of lynipliatic no(hdes sitnated behind the sternuni. The profuse supply of lyniphaties and the intimate rehi- tions these hear to tlie lymph-<:>;hinds situated deeply and at some distanee greatlv facilitate the conveyance of infectious materials to other jiarts, there to establish, as in the case of carcinoma mamnue, new foci of disease. The itcrrcn supplying the mammary gland are derived from the cervical plexus through the superficial descending supraclavicular branches, and from the fourth, fifth, and sixth intercostals ; mnnerous sympathetic filaments accompany the latter into the substance of the gland. Variations in the munber and position of the mamma; have frerpieiitly been observed. While reduction in number or absence of these organs is extremely rare, increase in their munber, as well as abnormal location, is by no means of great infrequency. The nipple alone may be involved, being either nudtiple or supi)ressed, or entire additional glands may be present. tSajH'ntninci-ari/ inanniKv have been observed in many locations, among which the arm, the axilla, various parts of the anterior body-wall, the back, the buttock, and the thigh are the most conspicuous. The interesting observations of (). Sehultze on the presence of definite "milk-ridges" along the antero- lateral aspect of the trunk in embryos, extending from the root of the upper limb to the inguinal region, suggest the location in which supernumerary manuiue are most freijuently encountered, such superfiuous organs resulting from the j^ersistence and develoj)ment of areas which ordinarily disappear. The presence of such markedly aberrant mamniie as those found on the back, the arm, or the l)uttt)ck is less easily exjilained, since they arise probably in consequence of the uniisual development of structures representing the ordi- nary sebaceous glands of the integument of the part. Til. Physiology of the Female Generative Organs. 1. Ovulation. — The diifereutiatiou of certain of the cells derived from the ingrowth of the germinal (■j)itlielium coveviug the young ovary into the scwual elements proper, the ova, takes j)la('e very early, so that at birth the formation of the ova is already nearly eoiiq)lete(l, the production of new cells aftei- l)irth being very limited, ;uid probably entirely ceasing after the se<'ond year (I)isehotf, Waldeyer). The ovaries of the child of two years, therefore, eon- tain the full <jUota of ova, although the vast majority of these cells always remain iiiiiuatui'e and undeveloped. i he entire nundjer of these primitive sexual elements >tored up within tiie ovaries of the young child has been esti- mated at about seventy tliousand. While it is probable that a variable number of the inunature ova umlergo partial development befi)i'e puberty, yet the advent ol' sexual matiu'ity at that ju'riod marks the establishment of the full A.\.\TuMy or Tin: (iexhuativi-: <jr<!A.\s. 71 hs con- iiiy the 1 ternii- i? course situated lite rela- (listance •ts, there se. ccTvieal 111(1 from tihmieuts refiuently or}i;ans is ictii, is by •eil, being sent. Diig which back, tlie iservations he antero- the ujiper niunierary vesultiiifr isappear. the back, )bably in the (inH- from tlie tli(> sexual urination ,rlls alter coiid year cibre, eon- ■lls always jirimitive .; lu'di esti- )\v number V, yet tlie of the full 1 r(MPiil;U' (li'V('loj)Mieut of the (Jraafiau follicles and tiieir contained ova, niiKUiit'd l)v thi' usual attendant phenomena of menstruation. TliroU'dinut the entire childbearing peri(jd, or from about the fifteenth to I lit tiic loriv-lifth year, the development of the (Jraafian follicles, terminat- ■ If III till' nipiiiic of tlie follicles and the discharge of the ova, is eontinualiy ~......;i.., riie liberation of the ova usuaiiv takes i)lace at dcHnite times, oeclll I Miii. 1 11^ .1 J liieji ill >'i'iieral coincide with the menstrual epoclis, one or mon^ ovu being ^ .f free ;il eiieli period. This agreement, however, is by no means necessary jiiviiinlile. -iitee nrithttio)!, as tiie ripening and discharge of the sexual cle- Piits i- lei'iiiid, undoubtedly proceeds independently of menstruation. The rioe Inuiuni ovnin is a typical spjierical cell, about O.'i millimeter in ji'iineter. euii-isting of granular protoplasm or the rlf(//i(s, in which lies a luicleii- iir '/(/v;i//irf/ nWc/r, about 0.040 millimeter in diameter, containing a \vell-iii:iri<t'd iiiieleolus, the ffcrw hud t^pof. The proper cell-wall is the fitc/lliie jiiciiihri'iii. M -tnictiire of great delicacy, and often overlooked, outside of which the ovum is invested by the conspicuous zona piUnvithi (about 0.01 millimeter thick), wlii'h '""^'^ ''^' regarded as a secondary envelope contributed by the oclls lit' die -mroniidiug discus proligerus. Tlie I'lillv-ileveloped (iraatian follicle is ovoid, and consists of an external inve-tiiu'iit 'i' v;i~eiilar connective tissue, t\w (iniica fihroKa, which is lined by !i thick liiver of granular polyhedral epithelial cells, the )iiciiiljr<ni(( f/)-(uiulosn. ^^, point tluse cells are continued as a mass which immediately invests the (iviiiu ;iiiil wliicli is known as the (fiNcm proli(/('nt.s. The interior of the well- ^s^;:,:-^^^ ■i^:m I'M. r.l.-Si'ctinii nf \vrn-(k'Vi.'l(i)ioil (iniiiliau t'nIIicU' from IniniMii rmliryu i Vnii llcrlVt : tlio oiiuIosimI iivmii I'lPiitiiiii.- two iiurlri. (|evrlo|ieil liijliele (Fig. Gl) contains a Huid, the /itpior j'oUlcii/!, separating the (iviim ami il- -iirroiinding discus from tli(> opposite wall of the sac. The most |iruiiiiiieiit part of the ripe follicle is less vascular than those jiarts subjected to l('s> pi-es>iire, one spot, the lii/nin fal/lcii/i, being free from blood-vessels, and eorrc-poiKJiiig with the point at which the distended matured sac, from 2 ti) ] iiiilliiiieters ill diameter, liiially ruptures. i /ir^m 72 A mi: HI CAN TKXT-IiOOK OF OnSTETRICS. I I - -I I ! I 2. Menstruation. — At iv<riilar intervals throiiglioiu the childhrariii}; period tlie liniiiji; ol' the uterus uiuh'rffoes changes primarily designed to prepare a lavoraitle resting-phiee for the prothiet of eoneeption. In tiie ease of the non-oreurrenee of pregnaney these rhaiiges terminate in the disintegration of the uterine nnieous membrane and in the discharge of blood, mneus, and tissne- del)ris that constitutes tiie ])iienomena of menstruation. Siionld |)regnaney occur, menstruation is, as a ruK', suspended (hiring the entire time that the em- bryo is within the uterus, reappearing usually from six to eight weeks aftci' the birth of the child. Kxceptions to the customary ])rompt cessation of men- struation are by no means infretpient, the catameiiial phenomena often recurring with regularity during the early mouths of gestation. The anatomical explan- ation of this variation is found in the tiiet that the uterine cavity is not obliter- ated by the apposition of the decidua reHexa against the mucous nuMnbrane of the uterus or the decidua vera until the end of the lifth month. The very rare occurrence of the menses throughout gestation is jirobably associated with an abnormal and imperfect fusion of the deciduse. The reputed instances of women menstruating only during })regnaucy must be viewed with sus])ieion, since the discharge in such cases probably always results from pathological conditions of the cervical canal. The complete menstrual cycle, which typically oeeujues twenty-eight days, may be divided into fotu' stages (Marshall), following one another in regular sequeiuie and lasting a definite proportion of the entire jieriod : (1) The first or crmstructiir st(i(/e is one of ])reparation for the reception of an ovum, and is characterized by the fi)rmation of a menstrual decidua in the j)reparation of which swelling of the mucous membrane, enlargement of the uterine glands, and inereasc of the connective tissue all take place. This stage probably lasts about one we(>k, and is followed, when pregnancy has not occurred, by dcgeuerative changes. (2) The second or (Icfifriirfirc xUir/c is marked by the destructive ])roeesscs which give rise to the usual phenomena of the menstrual ])eriod, including the discharge of mucus, blood, and disintegrated uterine mucous membrane. Five days constitute the average duration of the menstrual flow, although its continuance may be extended or curtailed, owing to individual peculiarities. (3) The third or veparatiir sUu/c is one of re])air, during which the dee])cr and unaffected parts of the uterine mucous membrane institute constructive processes which within the short period of from three to four days result iu the formation of a new nuicosa. (4) The fourth or qi)lcsce)d star/c includes the remaining twelve or four- teen days of the menstrual cycle, and represents the (|uiescciit period j)rcceding the initiative changes marking the beginning of the next ju'riod. The relations b<>tweeu ovulation and menstruation are of great interest, fi)r, although the discharge of the ripened ovum and of the degenerated uterine decidua takes ))lace usually simultaneously, it is well established that it is neither invariably nor necessarily so, since authenticated observations have shown that menstruation mav be unattended bv the liberation of an ovum. While these A.y.iyoMy of the nEXEIlATIVK (JliUAXS. 7;j •iiijT period jjrcpare a ii.so of tlic '•jratioii of" aiul tissiic- juvfriiancy lat the ern- es al"t( r the n oi' ini'ii- II reeiirriiifjj ral ex])laii- lot oblitcr- ■inbraiic of e very rare lhI with an istaiices of suf<j)icion, athological two processes, as a rule, may he rej^arded as associated, tlie deteriiiination of the exact r(>Iatinn hetween the diseiiarged ovum and the uterine chan-'es coin- ,.id,.ntly takiii- place i.s not yet positively estahli.shed. It may be assumed that the til-! nr constructive staj^e in the eycle of uterine ehanj,^es is particularly favorable Im tli<> reception of the ovum : this being the case, it is evident that the prepaiMlinn of the uterine mucous mendn-ane cunnot be directed toward the n..rptl..n nf the ovum, whose discharge takes place with the coincident meii^tiiKil i.h.'ih.ii.ena, since it is probable that at least a week is occupied in the tran^it of the <'.i:g from the „vary to the uterus. Marshall's eonclu.ions that "the ^l.ri.!iia o( a particular menstrual period is related, not to the ovum' discharo..! ar lli;i( period, but to the ovum discharge.l at the preceding period " :uv lullyunnntcd by the more exact data furm'shed l)v ean-ful observ ition The well-k.H.vn coincidence of ovulation and menstruation finds its partial explauatinn, nt least, in the marked congestion of tlu, ovaries and the eonse qiient -.inniilatiu,, and vascular engorgement which the nterus experiences by reason ot th.' .lose arterial anastomoses between the vessels of these oro-ans the iv^iiltin^ inrgescence probably being an important factor in establis^iin'i; die inciistnial Mow. " eight days, in regular ?ception of idiia in the iient of the This stage cv has not c processes , including meiubraiie. Ithough its iliarities. the deejier 'onstriictive )s result in ve or fonr- l1 })reeeding nterest, for, ited uterine it is neither shown that While these IMAGE EVALUATION TEST TARGET (MT-3) 1.0 1.1 |50 ^^~ lii^^B *^ Ui 12.2 2.0 lb |40 Ml nmSsBSE '■25 11'-^ 1'-^ ^ 6" ► ^ ^ /: c% Photographic Sciences Corporation rs WiST MAIN STRKT WnSTER.Nr. usto (716)872-4903 4^ \ iV r^\ r ^^ ^\ ^oN , o^ , li 'll li II. PHEGNAISl Y. I. PHYS10J.0GY OF PlIEGXANCY. 1. Development of the Embryo and the Fetus. 1 . Maturation and Fertilization. — Cuincidi'nt witli tliogrowth of'thcGraaf- iaii I'olliclc, wliidi ciilininutcs in the rupture of the i^ac and tlie disdiarge of" the liiju*)!' i'ollieuli and the egg surroundeil by the di.seus ])roligenis, the ovum |)a.s.ses through a series ot'ehanges eolleetively termed VKitnratiou, hy whieh the female sexual cell i.s prepared lor the reeeption of the male element, without the com- pletion of "ivhieh preparation fertiii/ation of the ovum is impossible. The iuaturation of the ovum consists essentially in the very nne<jHal and repeated dicisiun of the egg, by whieh two minute portions of its substance. ■<■•■'. Fic. t'.2.— Portions of ovn of Aftrrias rjtnrialii', showing clmncos iillcctiiiK the f^erminiil vesicle nt the bfniiiiiiii); of iimturiitioii iHortwiK): ". uiTiiiliml vesicle: h, neriiiiiml .simt, eomi>osed of nuoleiu iiiul puraiiueleiu (c) ; il, iiueleiir s|iiiiille in pmeess of I'nrniutinn. tiw j)of(ir bodiex, ore extruded ; the remainder of the cell after the completion of this cycle returns to a «|uicscent condition to await the advent of the male sexual element, ^[aturation takes place entirely independently of the inHu- Kiii. f)H.— Forinit ^t^•■:^ \itln-iiis <iliiriiili» (llertwiu'i ; /i.", poliir spiniile ; jih', first polur H, niieleiis retiirninn to conilitlou of rest. encc of the malt! or of the i)robabilitv of fertilization, everv th 1 hef healtl IV ovum uiKlcrgomg tnese clianges Detore it Deeomes sexually ripe t bet The process, in brief, consists of the following phases : (a) The migration of the germinal vesicle or nucltnis toward the periphery of the cell (Fig. ()2) ; (6) the rupture and the disap[)earance (»f the nucleus, and the formation of the rilYSIOLOGY OF PREaXAXCY, 75 thcGraaf- rge of tl>e 11 111 i)asscs he liMuale t the coiu- etjxml and substance, vesicle nt the f iiui'leiu anil completion the male the intlu- l)U', first polur Itliy ovum migration (Fig. 02); tion of the * 4' unclear Hi)iii(llc anil other elements of the coniplicat«I (Tcle of iiulireet eell- divisioii • ((•) tlif extrusion of a minute portion of the ovum as the jirHt polar Imlii (Fig- <»'^'/ ('0 '^'""'t quiescence followed by a rejietition of division, n-siiltiii"'- ill giving ott' the second polar boily ; ( ) the establishment of e(|iii- libriinu tlic iiupiaraiice of a new and smaller nucleus, the female pvonuclem A « » I: ■-■ ■ • ^ ■■•■■ v,-'"iV#'**'^.'-*'* •■i'l V-..---- . ■••v^'i •■.,'^ Ki(i. (U.-A.niatnrc nviim (if ochiiuis : v, feniole pronucleus; it. imnmturc ovarian ovum of cclilnus (llertwiK). (Fig. ()1). ami the return to a condition of rest. Maturation usually takes i)lace just lu'fore the rupture of the folli(!le and the escape of the ovum. On tlie (diiipletion of the phenomena of maturation, the ovum is prepared for the reception of the male element, the met^ting of the sexual cells in mam- mals iisiiallv taking jilace within the iipj)er portion of the oviduct. Tiie iimiiher of the more vigorous seminal elements deposited within the vaiiiiia that work their way through the uterine cavity and into the oviducts must l)e l»iif an insigniticant part of the entire number lodged about the exter- nal OS. Of thdse, moreover, fortunate enough to overcome the obstacles pre- "•ViV-''".'-''i^')i-V-'f'^ I'll.. I'm.— I'lirl inns nCtlii' iivii i>{ AnliiiiiK filttriali/', sliowintillu'miiiniHcli iiiiil fiisiim nf tlic s|icrnialozip(in Willi till' iivuiii I lli'ilw iiii ; (1. t'lTtillziiii; niiili' clcniint ; 'i. cli'vatinn "f iiriilu|ilii.sni iif I'trn ; '>', li", stiij-'i's (pI lllvinli III' Ilir liiail III' lln' siHTniato/rinll witll till' iiviini. seiiteil ti) tiieir progress within the uterus and tubes, but a single spermatozoon actually takes part in the fertilization of the ovum. .\fter reaeliing the surface of th(> egu and penetrating the Z(»iia pelliicida tlie siiceessfiil spermatozoon is met by a slight jirojectioii of the protoplasm of the ovum, with which the head of the male element soon becomes blended (Fig. <i.')). The tail is lost, and the head later sinks within the substance of tilt' egg. Siil)sef|uently the jiosition <»f the impregnating element is indicated ill « ^1^ (6 AMHlilCAN TEXT-nOOK OF OnSTElJtJCS. l»y the ajjjwarance of a small round or ovoid bmly, tho iiuik' itnmuclvuM (Fig. G6, A, IJ), whose vicinity is rendered eonspieuons by the radial striation marking the surrounding protoplasm. The male and female pronuclei now ap|)roach, and sooner or later meet and become blendinl, their union prtKlucing the «//- vwutdthm-niwUxiH (Fig. 6(), C) from which are formed the new generations of elements, to the constitution of which both parent-cells have contribut(Hl. Jt is of interest to note that, since the parts of the sexual cells most eon- cerued in th(! priKluction of the segmentation-nucleus an; rich in chromatin, a fusion of the nnclein seems to Ihi the essential feature ol" the process of fer- tili;{ation. The blending of both parent-cells within the segmentation-nucleus furnishes the ex])lanati(m as to the fundamental manner of transmission to the ottspriug of the individual j)eculiarities of both father and mother, since the new being depends for its origin upon a nucleus to which both parents have contributed and by which the characteristics of b(»th are perpetuated. Should the mature<l lemale element fail to meet the spermatozoon, the ovum after a few days loses its vitality and perishes. The period during which the human egg retains the possibility of fertilization has been variously estimated, about eight days being the pntbable limit of the retention of this power, since the death of the unfeeundated ovmn usually occurs belbre the egg reaches the uterus. 2. Segmentation. — The meeting and fusion of the male and female pro- lUK'lei, already describetl, result in the fornuition of the new segmentation- nucleus (Fig. 6(J, (-'), whose appearance institutes the process of cell-division by Fk;. I'lCi.— a, fiilili/.fd iivn uf cphlniis U'lrtwiui: tlii' iiml>' (ti) iiml tlio tViiiiilc proniicU'iiK iU) arc npiiroiicliiin:: iji It llicy liiivi' iiliiiDSt fusoil ; c, iivum nf ofhlnus nftor coinpU'tiKii uf fi'rtili/iitinn (Uort- witri: f.ii., si');iin'iitiiti(iri luii'lcus. which the original egg-cell gives rise to an extendinl series of generations, leading to the ])ro(luction of the blastoderm. Since the youngest human embryo carefully examiiunl and recordinl — that of Iteichert — was already j)robabIy twelve days old, the early phenomena of impregnation and segmentation have never been observed in man. Direct observations upcm higher mammals, as the dog and the rabbit, have supplied our hnowledgi! of the details of these early stages of «levelopnu'nt, which, in the main, probably closely correspond with the changes taking place within the luunan ovum. Nagel's examination of a ripe human ovum and the dis- SKci.MKNTAl'lo.N oK IIIK oVIM. I'l.AlK 10. -IM (Fig. nuuking ; tlu' «<'.V iitioiis of iUhI. ii«)st <:on- oinatiii, a ss of li-r- •n-mu'leus lion to the , siiHV the rcMtt* have 1. tozoon, the ioil tlir/mg 1 variously :ion of this "ore the egg female pro- if mentation- -division by fi'V-.^... Oiil,'' ..// i->!,l.-< ,rlh ihiUi ••■li' , ,/A hin>-y '/•// r i«^. >• (■(•//.i. iM Itlllziitlou illort- jreneratiot>s, lorded— that Lnoniena of (lan. l>irc<'< Live sujudi*''! It, \vhi<'h, in Iplaee within land thedis- I i St..Mi\iMiciN,- I ■:. I'liiirriiin'. illii^lr.iliii'j llic ■icuiii'iil.'ilinii irrilii' iiiiniiiii.'iliiiii nvmii > \ll"ii ni.iiii|iM,ii,anfr !■; \. llc'Ui'iliMi. I. Iiiiiui'iiiii i<|.ii -iiiliiiu llir icliiliiiii i.r ihi' |iiliiiiii\ liiyii> III iln- liliislmlcnii ' Hniiiu'tl, friT!^ PJIYSIOLOdY OF PltEdNANCY. 77 •ovcrv of the nroscnco of two polar ImmHos, as in other manimal.s, still further jiistiHcs the assumption of this similarity. The minute amount of food-yolk possessctl by the nianinialian egg is uni- fornilv (listril)'''tetl throughout ita protoplasm, and is not colla;ted as a distinet hodv • siieh ova are therefore known as akcithul. As inttuenewl by the amount and arrangement of the yolk, these ova experience entire cleavage diniu"' their division, and are said to undergo total segmentation, being thcrc- fori' liohhl""!!''- •'^'"^'*^ t''*' resulting cells may be regarded as practically e(pial in >^i/.t' tli'i'' '^I"' "^'^ segmentation may further l)e designatcnl as aptttl. The huniaii ov'iiii. therefore, is technically described as an alecithal, holoblastic ocr<r imil(i'j:(iiii,i: e<iual segmentation. Mil, .1-1 ilin'ftlv after the apj)earance of the nucleus of segmentation, the i)li, iininiiKi "f t't'll-division apjjcar within the parent-cell, the cycle resulting ill till' lurniatiDii of the first pair of daughter-cells (1*1. 10, Figs. 1-3). These (•(•11> ill tiiiii "hccome the seat of similar activity by which four cells are pro- (liKcil, the i)n'i'ess of cell-division continuing until the original element is rep- resoiitcil l)v niMiiv generations of direct offspring. "While, for convenience, the s(M.|ii(iitatioit of the mammalian egg may be regarded as etpial, yet, when cIiM'lv oxaiiiiiit'd after the third or fourth cleavage, a slight difference may be noted in the >iz<' "f the resulting elements, or hldatomeira. This discrepancy, iiisiiniiticaiit in its individual variaticm. Incomes gradually manifested by the separation ol'tlie blastoineres into an inner and an outer ccU-grnup, the cells of the (iiitpr irrniip undergoing n>ore rapid increase than those of the inner group, which latter "clls, in conseiiuence of this inequality in growth, gra(lually are invested hv an enveloping layer composed of the outer cells (PI. 10). This iiroeess of eovering-in progresses until the outer cells constitute a complete envelopo, the entire segmcntetl ovum now corresponding with the nndberry mass, or morula, of the older anatomists. Examined in section, the ovum at this stage consists of the single layer of outer cells, to the inner surface of which at one point adheres the less- expaiidcKl gnmp composeil of the inner cells, the space between the two, the xrt/iiiniMioii-i-drll;/, being ocn'tipiinl by a clear albuminous fluid. This stage of tlio liolldw sphere of the mammalian ovum is known as the bhistula or bktslddirniii- vesicle (PI. 10, Fig. 4). The flirt lier changes within the blastida are marked by the rapid and enormous increase in the size of the oviun, in consequence of which increase the outer cell-layer undergoes great extension, with corresponding attenuation di' its elements, which are change<l into thin, scale-like ])latcs. Coiiieideiitly with these changes aflecting the layer of outer elements, the group of inner cells has undergone an important although inconspicuous modifieation, in consequence of which a differentiation of these cells into a rapidly proliferating peripheral layer, next the thimied-out stratum of invest- inif outer cells, and a more slowly dividing central mass has taken jdace (I'l. 10, Fiiis. 1-.'}). This peripheral layer is the primitive ectoderm proper ; the iuiuT mass is the primitive entoilerin. "s AMi:itirAx TKxr-naoK of oustetkics. Ile.ul- S.ul,- of IllllSfll. lllMlll. /'riiiiit/T'i I'll.. I'lT.— Kinliryoiiic nrt-n of riiMiit cmliryo iK. V. lU'iit'iU'iii: iirlinitivc stroiik lic),'imiiiiK in <rll-|>ri>liftTutiiiii, known as the "nmU' of llcnsi'n." With (lie f^rowtli of tln' ft-tcMlcrmic hiyor the primarv oiit'T cells l)eeoine more atteiiiiiite*!, and alter a time hleml with the (levi'lopiiijj eeto<lermic tissue, the two toojether eoiistitiitin^ the early true ectoderm. When this strnetnre is examined its surface is loimd covered with Hat elements, liisilorm in profile, known as liuulnr^ celif (1*1. 10, V'l^. 4), which later disappear and seemingly take little or no role in the formation of the permanent ectcxlermic structures. The cells of Uanl)or are j)robably the remains of the attenuated layer of the jmntary outer et^Ils. The ectoderm expands on all sides imtil the ento<lerin as well as the entire yulk-eavity of the ovum is com- pletely encl(»sed. If a mammalian ovum at about this stage be exainine<l from the surface, the l)last«Klermic vesicle on one side presents an c»val or j)yriform field of greater den- sity : this is the nnbrifonal r(/r<7, and corresponds to that portion of the blastula especially concerned in the <levelopment of the embryo. Very early a linear opacity known as the primitiir titredk' (Fig. 67) makes its appearance at the smaller or posterior pole of the embryonal area, and seemingly grows for- ward toward the centre of this field. On se<'tion the primitive streak is seen to deiwiid upon a line of proliferat- ing tissue which marks the j)osition of fusion and intimate luiion of all the embryonal blastodermic layers (Figs. 68,09). Very soon the primitive streak becomes occupijnl by a meilinn longitudinal furrow, the prim Hire f/roove. The significance of this pre-end)ryonic structure is still a subject of nuich discussion. Without entering into the details of the somewhat theoretical and ctmiplicated considerations of the subject, it may bo mentioned that there are amj)le grounds for accepting the views of His, Miuot, and others that the primitive streak of the higher types represents morphologically the fusion of the lips of the hltts- inporr — the opening formed among the lower types by the invagination of the l»lastodermie vesicle at one point in the j>roduetion of the f/aatrnfa nfdffc. In contrast with the usual appearance of mammalian ova, the early human ovum is characterizcil by the precocious development of villous projections, so that as early as the twelfth day, as represented by Reicliert's ovum (see Fig. 8-1), its exterior presents well-marked elevations. These villi, however, are not luiiformly distributed over the ovum, but are limited to the marginal zone of the compressed spherical oi:\r^ the two flattened sides being smooth aiul devoid of villi. The embryonic area corresponds in position with one of the poles of the shorter axis of the ovum that connects the smooth sides, although at this stage little if any trace of the embryo is to be seen. I'llYSlOLOGV OF rJlKdXAXVY. 79 s l)ecoinc lie tissue, tlu> early lucturt' i« I covorod n profile, [), Fij?- -*)' ingly take ion of the ires. The lie remains le primary umis on all veil as the ua is com- abont this surl'aee, the klo presents greater »len- thc blastula irly a linear irance at the grows for- X prolilerat- >n of all the Initive streak u'oovc. The li discussion. fomplieatetl iiple f^rounds ve streak of of the hlm- liition of the utagc. early human projections, s ovum (see |iUi, however, he marpual |)oin(T smooth with one of ;niooth sides, )(' seen. Coineidently with the fiirtiier growth and differentiation of the two- iavercil blastula, a third layer, the mmidcnn, makes its appearance (Fig. 08). riio ori""in of tills laiM-na is still a subject of" nuieh discussion, but it .uay be •iccrpted as denionstratetl that the mamnialiasi mesmlcrm arises from two ^^^,„.^.^,^ principally by a splitting ofl' or dclamination from the cntoilerm, ii.r. re It tnt ,,, HI 'II i.'i, r.- - -., I tioi .11 nis* llic jirlniitlvo stroiik of raliMt embryo (Kiillikor) : rr, prtodcrm ; nx. rr. i\xinl rrto- .liiiii uii'l' I i.' '"'•- prolifLTiitlon, iw shown by kiiryokini-tic ligur(.'S (k) ; enl, vuUhK'Tui ; m, mcMoileriu. ^iipulinirni"! by a jtroliferfition involving the e<'toderm along the anterittr iiiirt 111' ill'' I'liniitive streak. This latter structure therefore marks the axis jiluiiL' wlilili coiuplete fusion of the three blastodermic layers takes pla(»i Ixlure til"' rciiiialion of the true embryo has started. The primitive streak is a transient structure, and gives rise to no part of the embryo; later it ciitiivly (lis:i|>p('ars. Tlic jrrowtli of the mesoderm is rapid, and s(»on protluces a layer partic- iilarlv (Icvcliipt'd toward the caudal pole of the embryo, expanding in broad Intcnil tit'kls on cither side. Viewed as a whole, the mestKlermic sheet ap|X}ars i>vrit'oriii, with its smaller end directed anteriorly or opposed to the corre- snoiitling part of the embryonal area. At first a continuous layer, the / 'rimitivf s''i>"ve. Ufginning amnion foiti. ixtMl I I" l\ir:,/,l/ I'liii-iiil liiyer ,'/ mrsi'ilerm. Entothrm. Y\u. I'.'.i.-TninsviTsc siTdon of the ombrymilt" nroa of a fourteen and a half day ovum of shcop (Bonnet). mesoderm later l)ecomes displacxxl along the immediate axis of the embryo, this division resulting in the formation of two closely approxinmted but Bepanitod halves : in each of these a paraxidl and a lateral (rod are further to be vei'(t<rniz<'<l. The latter •ndergocs cleavage by the formation of the intra- me-dderiuie bod if-ca nl if or the cclnm (Fig. 6!() ; the resulting upper and lower jlaiiiellie eoiislitute respectively the parietal and visceral layers of the meso- [dorni. Tile parietal or somatic layer joins the ectoderm to form the soma^o- « ■ T.'-r' T I f 1 1 ii 80 AMHIiFCAX TKXT-HOOK OF OBSTKriUCS. jtleurc ; the viscj'iiil or Hplaiiclinic layer uiiIIoh with the eiilodorm to form the «y>Aoic/(/i»>y>/«M/'t" (Fijr. 70). Tlio.«e Htriictures hiter prinhice the iMKly-walla and the wall;-* of the primitive <lij?e.stive tiiln'. About tli(! emi of the second week the Iniman ovnm enters npon tiio uarlie:jt initial stages of the formation of the embryo proiHT. In addition tu Axiiil time. , \iuiai laiuil Soiiiitf. Latrtiit Ziine I'll?'//)' wilhiu tomilt. Lateral f>liitts/or boiiy-ivtitii. iMileral pUitis/or giil-tr4tit. — I'ariital mtiodtrm. ritu rot>er)lonfiit Liivily. M,;iulU>y fihlltS. _ Mttiulliiry Jurrmv. Viteitine ?'(•/«. FKi. 70.— Tninsvorso sci'ticni nf ii scvcntcrii ami a half day slu'i'|i ombryo (lionnot). the primitive streak, which, as above stated, is a transient strnctnre havini: nothing directly to do with the embryo, the fundamental developmentiil pnx-esses include the formation of the neural fnldn and the neural camil, the chorda dorsalis or noto- i'hoyil, and the somites or provcrlcbra: Neural Canal.— T\\c de- velopment of this strneturc consists first in the aj)|x>ar- ance of the neural or medul- lary folds, which together constitute a A-shaped dupli- eature embracing the anterior extremity of the primitive streak ; by the thickeniiit: and the approximation of tlio summits of these folds tlio neural or medullary (jroove is j)rotluced (Fig. 71). This furrow is later convertctl into the neural canal, the early reprer>entative of the nervous system, by the further growth and union of the folds along the dorsal line of contact, the closure Iwing lir«t eftected near — not, however, at — the cephalic extremity of the embryo, imt some little distance farther caudally, at a position which later corresponds with Kiu. 71.— Siirliice vii'W of ana )pi'lluciila (if an eighti'ou hour c'hii'k I'lnbrvu (llalfniin. i rj/ys/ftLoffV or rJiKaxAycv. 81 to form upon the addition to ,1/ nitioii"')'!. imnet). u'turc liavinu flcvolopini'"*"' ncuv<tl canal. miUs or nolo- le somUvs <>v „,,i.__Tlio d.- this strnctun' in the apiwar- ural or vmM- •hich together -shapetl dueli- ng the aiitcrinr the primitive he thickcninir ximation of tlio l,esc fohls tlio Hilary yroove is |ig. 71). This oonverteil into anal, the early of the nervtms further growtli >sure being lir^t ihe embryo, imt irresponds witli ^ ,< I tlic ctTvical region of the spinal eord. The extrt-nie e<'phalieend of the neural ( ■ nil nndergoefi expansion into three primitive hrain-vesieles. The neural Inl.js of tlie caudal portion for a long time remain widely separated. ( 'hordii Dorsiilix. — Tiie appearance of the chorda ^loraalin, or tlie notochorfl, -I' lili-lie-; tiic earliest representative of the IttwjiUuUual axis which constitutes the fiuulaiiuiital characteristic of all vertebrates. While the earliest develoj)- t of this striK'tnre has not been observed in man, it is fair to assiune a ■In-e (i.irespoiideiuie with the prcK-ess as studiwl in other niannnals. In these the mesial p(>rti"ii of the entoderm gives rise to a eell-group (Fig. 72) which rpidiiiilK- iMcoiiies separated from the inner layer and displaced, so that the /• .:•,/•■"» C/i'Slllf.' Amnion. rarifial mesoderm. Celhma^s/or U'o/Jjian iody. - Celom. - Afesotlielium. Vtisnitive iiii/olluliuiM. y/siirni mesoderm. Xofcc/iord. I- ii. :.'.- rriiiisVLisi' M'ltiipii of II llrti'on and a half day shepp embryo posscsHing seven somiteH (Bonnet). rc^ullini: (cll-iiiass forms a slender cylinder which stretches from the anterior extreiiiitv nt'the end)ryo to its caudal pole. On section the notochord appears as an oval irnnip of wlls situatinl immediately beneath the neural groove or e;iii;il and ahove the entotlermic layer (Fig. 74). The notochord, for a time represpiitiii^f the longitudinal axis of the embryo, is usually replaced Sy the pcnnaiu'iit vertei»ral axis, at first cartilage and later bone. The remains of this eiuliiyonal structure in man are seen in the central areas of spongy iiiiiterial oeeiipying the intervertebral disks. Si,mit(''<- — flie formation of the somlfm or provcrfvbrw marks the estab- lisliiiient of the segmentation which later is permanently efik'ttnl by the devel- o|)ment (»f the vertebra and the associated parts of the trunk. The production of the somites is so closely related to that of the mesoderm that the primary arr:ii)i:(iiieiit of this important sheet must be rwalletl. After its origin from the (loiihie source of entoderm and ectoderm, the mesoderm rapidly expands laterally, the growth being particularly active toward the caudal pole of the enihrvo, in eonsecpiencc of which the layer becomes pyriform in outline when stH'ii from its upper surface. At first a contimtous sheet, the further develop- ment iif the neural groove from above downward and of the notochord from If «2 AMt:iil<'A\ TIIXT-JUHJK OF OliSTKTJtlCS. Iff t Im'Iow n|>\vHr(l s<H)ii divitlcs tlu> iiicscHlci'inic tnti-t aloii^ the cinhrvonic axiis into two j;rt".it wiiifTs ( Fij;. ".'>). Facli of tlicso wiiijjfs iiii*l(>i'^<N's ('iirtlu>i' ditUM'ciitiatioii into a paraxial Itantl no.xt till* uiitUlino, an*l a lateral |)latt> which hliMids away laterally into the l»ini,n. Msoiit'im l\i>i,i,t/ ff/i i,'t/i-rfH /Vr«»<i/>'> (I II) ■ I'l' iiiinlhil liiiil i.ii-,ily. f'liiiii. Yv,. 7;l.— Tnilisversf scctinii of n sixteen iiiid ii liiilf iliiy sliee|(emliry(i (f<<iimet). Exlfinion i'f . floni widely extending niesoderniie area (Fijr. 74). The lat«ral mesoderm ie jdate nndergoes cleavage intct an upper and a lower huiuna which respectively adhere to the ectoderm an<l the entoderm. The upper and ont<'r of the result- ing two-luyertnl lamelhe constitutes the soninfojihiiir ; the inider and iimer one, Mlilultil ry Juriow. I 'lule/l Eittiiii-tiii . vii'svtit'i tit. Aiiniit'ti rarii'tal iiii-stHii't m . Cfliwi. I'hi mi/ tiitsi'i/t'rm. Noiochoril. Soiiiitf. Cut entoiterm. Kli;. 71— Transverse section nf a sixteen anil a Inilf iltiy slieep emiiryo jxiKscssiud six somites (Honnet) the ni>l(im-hnnpleure. The sj)ace included l>otwcen the two leaves of the cleft lateral iiiestMlerm is the primitiir body-nmty or celom, which afterward Ixxjomcs the pleuro-peritoncal cavity. DKVKI.orMKNT OF THK FKTAI- MKMnUANKS. Pixtk II. iixirt inti» into llif Jixtf'i^"'" IH't). 1 rospoctivi'ly "tho rt'sult- 11(1 iiHH r oiH . //..«</ /,./,/^ Amiiiim Yolk sac. Ciioi.il rari.t.il Vtt'SOiii'* f"- 0-!o>" |s..inilos(Bonm'ti fes of the ch'tt rwaril becc>">»'" hnniot/i sif. r.iiiltrvo. lu'iioH \ M). Iiiiigniiiis illiutriiting thu furiimtion of the maiiimitliiin fetal nivnibniiu's (inndilU'd fnnu Koulc). WftW^ Mil ^ n: ■i * i i ( DKVELOl'MKNT OF TIIK FKTAL MEMHKANKS. 1'latk 12. AliautoU Site. Amnion I / 'itvllim- Vfskif. Vasiula* villi of piaicntai chorion. Ewhrvo. Non-p/tuental thorion. f I'illi o/chori.m \ jroniioutw. Mlantoit. btOod-Z't'sst'U, I, 'J. DiH^nniis fUustratin^ tlu* Inter sitiuts nf (lie rnnnalioii of tlio iiuitiiinMliaii iVtiil inoniltrant's llMDililir*! tVollI iv(Mllr). ^ '! i ! ; I II ! , i I' I 1 PHYSIOLOGY OF PREGNANCY, 83 S t The paraxial band of inosoderm does not undergo doavajre as do the neighboring hiteral niesoderiuic areas, but instead it suffers a transverse divis- ion into a series of small quadrilateral luvi-.s, the .soriutcn or pimrrtehrtv. These areas first appear immediately behind the cephalic expansion of the neural canal and progress toward the caudal pole, at particular stages of tho luuuan embryo, as from the twenty-first to the thirty-fifth day, forming ;; series of eonspicnous markings on each side of the dorsal mid-line as far as the extreme caudal extremity (Fig. V2d). The somites are transient and are not represented by adult structures, since tlie segmentation of the permanent vertebrse which later appears does not cor- respond with that of the somites, the areas producing the vertebra- falling in such manner that portions of the somites are embraced by a single vertebra. While not directly related to the formation of the vertebral colunui, the somites con- tribute to the production of the important muscular tissues, since the outer portions of their masses become converted into peculiar flattened bands, the ,niis<>h'-pkdes, from which proceeds the development of the great tracts of vol- untary muscle, at first of the trunk, later of the limb appendages. 3. Petal Membranes. — Coincidently with the ])rogress of the fundamental ))r()cesses just described, the formation of envelopes for the j^rotcction and establishment of means for the further nutrition of the embryo takes place : tliese envelopes are known as the fetal mcinhrancii (Pis. 11, 12), which, in con- nection with the structures derived from the thickened uterine lining, con- stitute the membranes thrown off at birth. The amnion (Pi. 11, Figs. 4, 5), the earliest of the envelopes, ai)pears soon at't(>r the formation of the neural folds and groove as duplicatures of the soma- toplenre which start in front, behind, and at the sides of the embryo. The anterior amniotic fold in luan grows with unusual rai)idity, and, aided by the lateral folds, soon covers in the embryo from before backward, the caudal extremity being the last to be enveloped. The line of union of the several (lii|)licatures has received the name amniotic fiuture. Examined in section, the amnion is seen to comprise not only the ectodcrmic tissue, but also the exten- sion of the parietal or somalopleuric layer of the mesoderm. On reference to the Figures of Plate 1 1 this relation will be seen illustrated, as well as the mode by which the fi)lds meet over the dorsal siu'face of the embryo to form the anmi- otic sac, which, when entirely closed, contains the anuiiotic fluid separating the envelope from the developing animal. While union and fusion of the innermost layers of the ecto-mesodcrmic folds of the somato])]eure produce the true am- nion with its contai.t.etl sac lined with ectoderm, the separation of the fused outer lamina; of the duplicatures from the amniotic portion gives rise to a sec- ond externally-lying envelope, the falxc amnion, or xcronx membrane, in which tile disposition of the component layers is reversed, since the ectoderm lies with- out, and the mesodcrmic tissue next the included space. The latter is directly eiintinnons with the interval between the parietal and visceral lamina? of the cleft mesoderm, and is the cxtra-cndnyonal portion of the primitive body- eavity, which thus extends widely beyond the limits of the embryo proper. 1!1»/ /TTT 84 AJ/EItlCJX TEXT-BOOK OF OIiST£TIlICS. ; t h With the acciimiihitioii ot' the liquor aninii the iUuiiiDii becomes separated iVoiii the embryo aiitl is pushed a};ainst tlie surroiuidiiijif eiivelofies. 77ui amnlotk'jiukl, or liquor (iiiniii, is a serous fluid prochioetl probably bv the amnion itself, having a spceitic gravity varying from 1.007 to 1.008; it contains from 1.07 to 1.06 per cent, of dry solids (ProehownicU). The amount of the amniotic lluid is subject to great variation, the average quantity at full term being between 700 and 800 cul)ic centimeters, or less than one liter. Not- withstanding numerous investigations, there appears to exist no constant rela- tion between the quantity of the amniotic fluid and the weight of the chiUl or of the after-birth. In addition to the evident use of the fluid for the mechanical protectiftn of the end)ryo, it is probable that it affords a source of water to the developing animal, since there is stung evidence to show that the fluid is con- tiimally swallowed during the greater part of intra-uierine existence. Toward the later months of gestation the pressure induced by the growing fetus and the large amount of the amniotic fluid pushes the amnion into close contact with the surrounding false amniim, the two becoming closely, although not inseparably, unitetl by the end of gestation. As the embryo gratlually assumes a more definite general form, the roots of the true amniotic folds sink more and more ventrally until they meet, thus closing in the body-cavity and forming its anterior wall. In the early stages, when the yolk-sac or umbilical vesicle communicates with the widely open gut-tract by means of its broad stalk, approximation of the somatic plates is prevented. With the decrease of the umbilical vesicle and the corresponding diminution in its stalk the ventral plates grow together and rapidly close the ])I('uro-peritoneal cavity excej>t at one point, the umbilical opening, through which ])ass those structures that conntvt the embryo with organs lying with- out its IkkIv, as the umbilical and allantoic blood-vessels and stalks with their acconqtanying liunina. Tlic Alhudoix. — The allantnis appears as an outgrowth from the hind-gut (PI. 11, Figs. 5, 6) after the primitive digestive tube has become well defined and j>artially closed. When typically developed the allantois grows out as a free sac into the space between the true and the false amnion, raj)idly increasing in size. In man, however, the allantois at no time exists as a free vesicle, since it almost at once forms attachments with the structures extending from the cautlal extremity of the human embryo as the abdominal .stalk (Fig. 7o), in which is included the lumen of the imprisoned allantoic sac. The primary function of the allantois is to act as a receptacle for the excre- tory allantoic fluids thrown ofl' by the Wolffian bodies, by which primitive orjrans the effete matters are removed as bv tiie kidnevs at later stages. Sub- .sequently the allantois takes an imj)ortant part in building up the chorit)n, from which the fetal contribution to the nutritive apparatus of the placenta is directly derived. The abdominal stalk is peculiar to the human embryo, in which it very early appears as a pedtmcidated extension of its caudal portions to the sur- rounding false amnion, over wliich it expands and with which it fuses, tlie PHYSIOLOGY OF FREGNANVY. 85 I separated >es. iibly by the itcontuin:s niut of the t full term liter. Xot- nstant rela- ichiUlor of nieehanieal water to the HiiUl is eoii- ;e. Toward ig fetus and •lose eoutact dthough uot , the roots of 'V meet, thus early stages, widely t)peu latic plates is •orresponding idly elose the ling, through lying with- is with their the hind-gut well defined ows out as a ly inereasing free vesiele, tending from %,dk (Fig. 75), for the exere- lieh primitive stages, ^^nb- the ehorion, le plaecnta is which it very ns to the sur- li it fuses, the allantoic tissue taking part in the formation of the ehorion (Pi. 12, Fig. 1). The allantois in man, therefore, is never free, and finds its expres-sion in the entodermie diverticulum, which passes from the hind-gut through the abtlom- iiial stalk toward the diorion.* Wliatever its initial mo<le of formation, the allantoic tissue grows with rapidity and extends over the inner surface of the false amnion, with whieh it soon becomes intimately united, the two mend)ranes together constituting the chorion a structure of much imiK)rtance in providing for the nutrition of the cmbrvo durinir the last two-thirds of its intra-uterine sojourn, by reason of its active participatinn in tlie formation of the placenta. Tiie allantois being a direct outgrowth or evagination of the in-imitive gut, its wall consists of an inner entodermie and an outer mesodermie layer — ex- tensions of the splanchn()])leuric tissues forming the digestive tid)e. (oinci- dentlv witli the later development of the allantois, blood-vessels extend from the arterial trunks of the end)ryo within the mesodermie layer of the sac and invade this tissue, which has become closely united with tiie false amnion in their joint j)roduction of the ehorion. Fk. .Ji-l] ■111.1,,, ImSw" niiitiriiiiiiimlic Pi'ctiiiiiP rcprrscntiiiK uniwth nnd nrrniiBPmont of the nninion in the tiirlitst sta«i'S (if Uic li\imim eiubryd (Hist. The cJiorioii, covered with simple and compound villi, is at first devoi<l of blood-vessels, and is composed of the ectodermic and entodermie layers on its outer and inner surfaces, between which lies the thicker lamella formed by the fuse<l amniotic and allantoic mesodermie strata. Shortly after the establish- ment of the chorion, the arteries conveyed by the allantois spread out within the mesodernnc layer of the chorion and invade the villi, which then display vascular loojis within th(>ir characteristic leaf-like, club-shaped processes. These processes often consist of a main i>rimarv stalk from which second- ary twigs branch, from which diverge the ultimate leaves. * Tlip term ''chorion'' is hero nscil in a restricted sense as indicntintr the nieiiihranc resiiitiiiK from the fusion of tlie false amnion and the aUantoie tissue : l)y some authors (Minot) (lie "chorion" represents tlie entire extra-embryonic somatopleure, which gives rise alike to the true and the false amnion. I i «G AMKRICAX TKXT-JiOOK OF OBSTETIilCS. Tlic form and arraiim'iiu'iit of tlio villi varv soinowliat with tlio duration of prcjiiiancv : at the tiiinl month, or when the phu'onta is formed, the villi are >short, thiek-.set, and of irregular shape; later they become less irrej^ular, and the sceondarv branches leave the parent stems less aeutelv ; finallv, at full terni, the villi are more regularly dispostnl and their branches have bec<»me long and slender and less closely set. The recognition of the villi of the cho- rion is often a matter of much practical importance, since their ])resence, as determined by microscopical examination of suspicious matters discharged ^tcr raffiiKiiii, is positive evidence of the existence of pregnancy. Their j)eculiar arrangement, and their flattened, petal-like fornj, together with their vascular connective-tissue stroma and epithelial covering, usually suffice to establish the diagnosis. T/if Plactida (ind Ihrifluw. — The primary uses of mechanical protection atforded by the membranes in mammalian end)ryos are supplemented by the important rofe of assisting in establishing an efficient nutritive organ through which the maternal tissues may extend the necessary aid to the maintenance of the developing animal during the latter two-thirds of its intra-uterine life. Such organ is the placenta, in whose ])rodiiction both fetal and maternal struct- ures take an active part. The early villi of the chorion are practically identical in all parts where developed. Very soon, however, the villi occupying the area which later will correspond with that of the placenta exhibit unusual growth, and outstrip in size and vigor those of the remaining parts of the envelope. This ditlerence in the dcveIo])nicnt of the villi marks the division of the mend)rane into the cliorioti frnn(l(>.-<i(m and the chorion hire, the former being that jiart of the <'linrion wiiich contril)Utes the fetal portion of the placenta (Fig. 7G). The villi of tiie chorion la-ve undergo gradual atrophy and finally disappear. The fertilized ovum on reaching the uterus, after descending the oviduct, becomes entangletl and retained within the folds of the soft, thickened mucous mend)rane prepared for its reception. Immediately after its lodgement, which is usually in the vicinity of the fundus, the uterine mucosa takes steps to secure the imprisonment of the ovum by means of a circular fold which gradually rises around the egg until it is completely enclosed within the new envelope formed by the reflected uterine tissue. In view of the fact that the mucosa of the uterus is discarded at the close of labor, the thickened uterine lining is appro])riately termed the ihcldua ; of this mend)rane three regions are recognized : the (hci(fi((i rcfc.va, or that por- tion which encloses the ovum by the reflected folds; the (hvUJud rcf(t, or that jmrtion which constitutes the greater part of the general lining of the uterine cavity ; and the (hvlihtu .scrotum, or that portion of the uterine lining includcil within the embryonic sac completed by the reflexa (Fig. 7G ; PI. l.*?). Tlic decidua serotina derives especial signiflcance from the fact that it contributes the maternal jiart in the formation o^' the jylacenta. The changes afl'ecting the maternal tissues consist prinnu'ily in proliferation of the epithelium and the glands, the latter becoming greatly enlarged both in '*^i % ; ihiratioii villi iiH' j;nlar, iiiul ly, at inll ve become »f tlic cliu- is irosen<'e, n harmed per >ir vai ■C'U liar ifular ;tal)lish the pr DtOOtlOIl lUed by tlio ran tbroniiii nti'iiance o utonno life prn [il striK't- parts where t'h later will (I outstrip in litVereiu'c iito the us ( ane J iiav t oi' the g! 7G). The >near. fil>pe tl le ovit liict, :('ne(l imieons ut, whieh step; eiiu vkes to fold whieh thin the mw ■d at the close (hridua ; nf [, or that por- ; rcva, or that if the nteriiie lude.1 The nin<>; me it contribults II pv )liferatinii lartred both in i;r.l.ATH>NS ol- rKTlS ANI> iniciwr.K I'l.Aii: i:t. ^■5 ^ > I tD _J rilYSIOLOGY OF PREGXANVY 87 size aiul in the nnml)or of the tubules, the increase particiihirly involving tiicir deeper parts. Subsecpiently the j)ressnre exerted upon this hypertro- i)iiied tissue by the rapidly growing embryo and its surroiuiding structures induces atrophy and degeneration, so that i\w outermost part of the thickened uterine nuicosa becomes the ntnitum compada, and the middle part the stratum snoin/ioauia (Fig. 77). The limited zone embracing the fundi of the tubular uterine glands remains unaftected, and, after the expulsion of the structures Mucous /fhii; -vitliin it-fi'iitt/ itttia/. Fi(i. 7(i.— Uittgram illustratiiis ri'lations of structures of the humnn ntorus nt the end of the seventh week of pretinaney inioditied from Allen Thompson). constituting the after-birth, institutes the processes of repair by which the new mucous membrane of the uterus is produced. As the result of the secondary degeneration of the epithelial jwrtions of the titerine mucosa the vascular cho- rionic villi are brought into close relations with the vascular connective tissue of the uterus, by which the interchanges between the fetal and Uiaternal cir- culations are facilitated. The relations between the fetal and the maternal parts of the placenta, in m 88 AMKlilCAX TEXT- HOOK OF OliSTKTIilCS. the simplest type such as posspssoil hy the hog, consist ossontially in the rccoj)- Kiii. 77.— Scrtion tliriiiii;li iiterint' wnll nnrt nttnclii'd )ilii(>i'iitii (WnnmT): », iilciiiic wall rciKlcri'iI spotii.'y liy urciilly-iU'Vi'luiicd iili'iilU' siinisis (h.<i : mi, Ipniiiclii's (if uteri lU' tirti'iy : (/.<. rU riilim >frnliiiii ; f, line of si'|iiinitii>ii ;./';<. rcliil imrlinii nf iilnci'iiin, tmisisliiiu' nf a miiss of viis<'iiliir fcliil villi ir.r.i.i, sur- roiindiil liy tlic iinitiTiiiil liluoil .'•iniisi's : mn, iiiiinioii coviiiiit; fri'i' iuliriml Mirliicc of pltici'iita. tion of tlic simple chorionic villi within ccdTcspondinj; »lc|)rcs^ions in the Fi'i. (>.— I'lari'iitii vifWLMl from iiliriiic surfaci' of aitacliiiu-iit, slmw iii'_' ilivi>ions iiitocotylcdoiis (Itidloo). niatornal tifisues, the circnlation of the villi coining int(» close ap]>ro.\imation ^ i)i:vi:i,(>r.MKNT or tiik rirn s and ris ai'1'i;m»a(;i:s. |'i.\ti:ii. tlio rcccj)- iMiII niKlcrfd i» xriiliim ; x, " K'l'-i.', Mir- iitii. 'IIS ill t\ le I ■/. T 1, 5 3 * - » i • ^» — C . 'r C:T 3 — r -I ~ r i :: 1 si-- ■■ I." (Hidldo), iniiitioji Ci5! ! ■! ,Twr- I rilVSlOUKlY or I'UFJiNAycV, 89 with tlic ciiliirfr^Hl l)l<MHl-V('ssrls uf the nictlicr. Tliosf. simple relations iM-c.Dic c..m|.li."ite.l ii. the hi^rluT inaii.inals an.l in man l.y the .-..mplcx ehaiaeter of the ehoiionie villi, whose im>jr„lar fonn and <lisi)ositi..n are fin-ther masked l.y iutual attaeliments formed between the tips of many largo villi and the maternal tissne (I'l. 14). The disappearance of the epithelial portions of the nterino mneosa hrinjrs the ti'tal villi into close relation with the prnlilcrate<l connective tissne of the mneosa, with a diminution in the structures separating' the fetal and the Fig. T'.t.— Plncontn at full tiTm. showing supcrflclnl ilistributinn of lilood-vossi-lji (MinotV maternal circulation. Coincidently with the chansies atfectint^ the decidua serotina, the capillary hlood- vessels of this part of the uterine mucous mem- brane underifo enormous expansion, so that finally they arc converted into the lartre and conspicuous blood-spaces occupyinu; tlio intervals between the attached chorionic villi and the adjacent maternal tissue. These intervillous blood-spaces, the enormously dilated maternal capillaries, an- supplied by arterial twigs and are draine<l by corresponding vcikjus truidvs connected with the larger uterine vessels. Notwithstanding the attachment of many large villi, the greater number, coiiiprised by the smaller villi, are not so ' ' ■" m 90 AMK/i'K'Ay TKXT-JiOOK OF OBSTETIUVS. I 1 / i ; iV hound down, their fVoo omls floatiiiij within tho largo lakes of maternal blood, in»rn whieh they are separated bv the attenuated and atropine endothelial wall of the spaee alone. The human plaeenta at full term, as soon after the expulsion of the after- birth, is a diseoidal mass, usually t)val, sometimes eireular, but often irregular in outline, about 18 «'entinieters in diameter and 2.5 to •"> centimeters in thiek- uiss. It pre>eiits an inner smooth siu'faee, eovereil by the amnion and look- ing toward the fetus, and an outer rough, spongy, uterine surface of attaeh- nu'iit sidulivided by furrows into numerous more or less distinct areas or votjilalonx (Fig. "8) composed of the lacerated decidual tissue and vessels torn through at the time of the separation of the placenta, the decidua serotina split- ting, one |)art adhering to the outer surface of the placenta, the other remaining attached to the lUerine wall. In contrast with the dark blood-clot hue of this tissue, the smooth, shining amniotic surfice appears of a generally lighter, somewhat mottled tint, made uj) of reddish-gray patches alternating with yellowish areas, which depend respectively upon the contained blood and the fetal villi, whose colors shine through the superimposed transparent anniion. riu' j)laceutal blood-vessels (Fig. 7{() — the two umbilical arteries and the single umbilital vein — s]ireatl out in all directions from the usually eccen- tric point of insertion of tlu- umbilical cord, when <listeuded with blood their courses being readily traced both by sight and by touch beneath the overlying auuiion. The arterial twigs arc more superficial than the veins, which arc considerably hcger in diauu'tcr. lioth sets of vessels j)ass from the smaller to the larger twigs without anastomoses. Strurtuir. — If the freshly-cut surface of the thickness of the placenta be caretully examined with the unaided eye or with a low magniiyiug glass, the entire organ is seen to be composed of an inner and an outer membranous boundary, between wliii-h is included a thick spongy layer contributing almo>t the entire thickness of the organ. ( 'loM'r investigation shows that the spongy layer is composed of the loosely held masses of chorionic villi (Fig. SO), with the intervillous blood-spaces, separated into the I'otyledonous areas by con- nective-tissue se|)ta. The outer mem- wianous boundary consists of the con- densed portion of the decidua serotina, which atlhcres t(» the fetal villi and sup- plies the outer wall to the blood-spaces ; the inner boiuidarv incluiles the denser portion ol' the chorion together with the adherent anuiiou. .Microscopic examination of' the spongy placental tissue, as seen in sections ]•■;,;. VII _|>,,,-[|,in nf illji'clrcl \\\\\\> \'T'<\\ ii'iilii ■•(■ nliniii livi' mmillis i Mini.t 1.1a- it cnial blood, )thclial w;ill A' tho aftor- L'li irrcfi'iilar ITS in tliit'k- m and looU- of attacli- iict areas or vi'ssels torn •rotina split- T rcniaininu: t hno of tills idly liii'litcr, iiatint; with lood and the rent amnion, 'rit's and tlio ■nally cccon- l)lo(»d tlicir 10 ovc'rlyiiii>; S wliicli arc the smaller placenta l»e llie unaided ii'lass, the niposi'd of nemltranoiis nehiiK'd a iiiii' alnio>t ■an. CloMT le spongy insely held iT. SO), with , separated l»y eon- iiitei- iiiein- f the enii- la serotiiia, i and snp- ind-spaees ; •ether with in sections riiYsioiJx.y or i'ni':(ixAy<'y. 91 tFi.rs. SI S-J), .-hows the villi, althongh ditlering greatly in si/e, to lu' made ■I J"i,,. s) -..<(, ,.(j,,,| (I,,., |||,_r)| jiliici'iitii <if si'vi'ii iiiiiMllis in s(VmMinnti; .Im, iniinliiii : Clm, I'luirinii ; 17, r(K>t "f :i vinii> ; r/. si'i'tidii-i 111' niniiliciitiiiiis nl' Ilic villi iinioiis.' Ilu' liinli'iiinl liluud spiici's ; /», (Ircp liiviT of the iliiiiliia, >liouiin.' iciniiiii^ nl' ciilniiicd L'lniicls (if sUiiHim s|i(m);ioMiiu ; IV, uliriiiL" Ii1(iuiI-vi.'ssl'1 ConiU'i'lfil Willi |iliii'('iiliil >iinis : )li\ miiM'iiliir wnll of mIitus. up of a stroma of eiiihryoual connective tissne containing large liranched cells I I if I 1 > 1/ 11- 92 A.VERIf'AX TEXr-BOOK OF OBSTEmiCS. and hi ood- vessel. s ; these latter consist of the larger twijjjs, eneased hv the rohiisl ])riniary stalks, and of all i^radations of size to the slender caiiillarv lodps supplying the terminal petal-like processes. The extei'ior of the very yoiiiiu villi is covered hv a layer of chorionic e])ithelinni, but this soon becomes I( -s distinct, and after the fourth month it no longer c(mstitutes a continuous lavi r but is present only in patches. The ectodermic epithelium covering the clio- Klc. sj — A. si'ctidii tlirdUL'li iimrf-'iii nf iilnceiitu at fuU tcnii (Miiidti: /'. /', ilcop liiycr iif lU'ciilim . )V, c>liiirii>nic villi viiriimsly cut. Mnnil-vcsst'ls iiijrcli'il ; >/. iiiiirL;iiiiil s)iiicc nearly fvcc fnnii villi; n, alrniiliic ('Xtra-|ilai'cmal villi: I'h'i. clKnidii : h, vi'ssel of uliTiiif wall; I'ih. caiializiMl tiliriiic (UTivr.l ri-Miii laiKliiiid clKniuuic fctoilenii. B, <k'cicl\ial tissui' I'rcim plari'Uta at full leriii : (/,(/', (k'l'idiial cillv r, lilixul-vi'ssi'l. rioM, as described by Laugliaus. Kastscheidio, and ]\[iuot, consists oi" a dicp and a superficial stratum, the cells of the latter assuming a Ihittened, scale-likr form. Sections of the ])laceuta din-ing the later months uf gestation fail to rcvciil any delinite I'udothelial partition between the exterior of the villi and iIk maternal blood-spaces, the villi seemingly coming directly in contact witii tln' blood of the mothei-. The determination ')f the existence or absence of a ili>- tinctwall to the bloo(l->;|)ace has given rise to nmch discussion an<l contlictiiigMs- sertion. The solution of the (juestion. a-< so often is th(> case, seems to be fdiiml in the more careful study of the developmcMit of tiic tissues, which study ha^ shown that in the earliest stages the fltal villi arc separated from the maternal blood-vessels bv an intervening laver of decidua as well as bv the endotheliiiin PHYSIOLOGY OF PREGNANCY. 93 by the robist apillary loojis lie very yoiinjx 1 becomes Ir^^s itinuoiis lavi r, erinj!; the cIm- '&<?, 3., li 1>^ (7 :i^ liiycr (if <U'cii\\iii; fife I'ruiu villi: n, \/.vi\ lilil'illr (li riv. 1 /. iV, ill'cilllUll lrH>. islsts oi" a tli'ili tciK'il, sealo-lilic III fail to I'cvciil villi and tlic tiitact with tlic )seiire of a (h»- i(l<'onrti('tiiv/:is- eius to be Iniunl ,hi('h study ii;i- )in the inatcnial the eiKU)theliiiiii t'( w of the vessel- With the progressively increasing capacity of the enormously dilated blood-capillaries into the blood-spaces the compression and atrophy of the' interposed structures follow-first of the decidual tissues, and finally of the VKCular endothelium, during the later months of pregnancy the external surface of the chorii>n and its villi constituting the immediate wall of the maternal blt>od-si)ace. ,. , , i -i- i i • 4 Umbilical Cord.— The formation ot the human umbilical cord is closelv related t.. the primary abdominal stalk. The latter, as already noted, mav i)e reoanlod as the extension of the embryo— a^ a sort of pedicle connect- imrits caudal parts with the chorion and containing the allantoic diverticulum. In°the early statics the somatic folds which form the amnion bear the same relation to "the al)dominal stalk as they do to the more anterior parts of the embryo ; later they bend around the stalk to meet and join on its ventral surface, the amnion in consequence becoming separated from the stalk, which thus becomes gradually enclosed within a tubular amniotic sheath. The closure of the soinatoplciuic folds around the abdominal stalk imprisons the umbilical or vitelline duct within a space which is, in fact, part of the celom. This space soon becomes giratly reduced, and finally is obliterated. The foregoing rela- tions point out the iact, strongly emphasized by Miuot, that the umbilical cord is covered with the direct extension of the emltryonic somatopleure, and not with theanminii, :is is often asserted, since the amnion gradually becomes sepa- rated from the embryo along the cord as far as its distal end, where it still remains eoiiiiccted. The iiicst important constituents of the umbilical cord in its earlier con- dition are flic two iiiiibilieal arteries, the two umbilical veins, the allantoic diverticulum, and the extension of the celom containing the vitelline duet and, possibly, traces of the vitelline vessels. Ijater, the umbilical veins fuse and constitute a single vessel ; the allantoic lumen and the celomic space atrophy and disap])car. The atrophic vitelline or umbilical duct long remains, even after I)irth tlie vesicle ami its duct appearing as a minute sac and stalk lying between the amnion and the chorion, in close proximity to the placenta. The liiimaii iimbilital cord at birth measures about 55 centimeters (22 inches) in leiio-tii. with tVo.'n 15 to 160 centimeters (6 to 64 inches) as the extremes of its variations ; its diameter is from 10 to 15 millimeters {'^ to f inch). The cord usiiallv joins the inner smooth surface of the placenta eccentrically, its insertion at times being marginal, or, in rarer cases, even altogether outside the immediate area of the placenta. The apparent twisted condition of the cor'i i.s often very marked, the spirals, sometimes to the number of thirty or more, being ('m|)hasized by th(> contained blood-vessels. While this phenomenon has long been known, a satisfactory explanation of the twisted appearance, which begins ix'fore the third month, still remains to be given, notwithstanding nu- merous theories and discussions. A point of especial interest, as poiiit(>d out by Minot, is tliiit tliere is no evidence that i\w entire cord really undergoes torsion, but rather that the blood-vessels become coiled within the soft ti.ssue as the result of an excessive unequal growth still insufficiently tinderstood. ■}]' ■■ ( '^r ff 94 AMU RICA X Tr-:XT-JiOOK OF OBSTETRICS. The structure of" the cord includes an external covering of epithernuii directly continuous at its distal end with that of the amnion. The bulk df the cord consists of the peculiar form of enibrvonal connective tissue known ;is the jel/i/ of Wharton, rich in branched cells with anastomosing protoplasmic processes. Shortly beyond the iwnbilical opening both caj)illarics and nerves are apparently wanting ; lymphatics, in the sense of definite canals, are also absent. In addition to the lar^e umbilical blood-vessels, epithelial mfi>-(s indicate the remains of the allantoic diverticidum and the vitelline duct. o. Development of the External Form. — Adoptingthedivisionssuggotcd bv His, it is convenient to distinguish three stages in the development of the human subject. Tiie Mdfn' of the orntn end)races the first two weeks of gc>t;(- tion, and is occupied by the earliest developmental processes; the oiihri/nn,,! star/e includes from the third to the fittli week, during which time the cliaiac- teristic end)ry()iial features are pronounced and the principal organs and svmptoms are well established; the remr.ining weeks of pregnancy are devoud Xoi\w fetal .sVa^c, during which the cmbryi lal characters are gradually replaird bv those of the fetus and the full-term child. While it is evident that iki sharp demarcation separates these stages, yet certain well-jironounced chaiai'- teristics distinguish, in general at least, end)rvns of j)articular developmciitid epochs, and conse«piently serve to determine their ])robable age nofwithstandiiii; individual variation. Stage of the Orum. — Oj)]iortunitics for examining early human ova are rare, the youngest well-authciiticated and carefidly-observed specimen being iIk classical ovum of about twelve davs described bv Keichert (Fig. H'.)). The Fl(i. K!.— nuiiinn (iviiiii of iiliuut tuflvc diij s i lii'iclu'iti : A. rrmit view ; H. siile vkw. 'I'lic villi iirr xiii lu bf liiiiitcil ill ili.-tiil)Utiiiii. Iriiviiii; llic pules livo. a])pearanc<' of this ovum emphasizes the early and precocious devcdopmeiit nf the villi which encircle the flattened lenticular vesicle (o.o millimeters in ih greatest dianu'ter by '.).'.] millimeters in thickness) as a closely set e(|uatnrial zone. ( )f the embryo proper no trace was discoverable, a patch of thickcncil cells alon<' representing the embryonal area. The earlier processes of mu- mentation and blastulation hav(> never been observed in the human ovum, Sta(/f (f the Kinhri/o. — The thirteenth ami fourteenth days witness the evolution of the early emi)ryonal form as effected by the development of tin medullary groove and canal and their cephalic expansion. The embryo is attached by the allantoic stalk to the surrounding mend)raiies, the axes of tin I'HYSJOLOtiy OF PREGNANCY. 95 of epithelium The bulk nf ssue known ;is ; [n'otoplasiiiic es iiiul nerves anals, are siUd ithelial nl!l^H■s ■nine (hict. ision8snjr>r»'>'i'il lojMnent of the ,veeks of ire>lii- tlie ODhrjimial inie the ehanic- Kil orj^ans iiml ney are devntiil ichially replinvd >vi»lent that im uounced charar- • (k'velopnu'iilal notwitlistandiii",' lan ova are rare, •inien heinii' tlif (Fiir. h:\). The IV. 'I'lu' villi iiri' Mvii ilevelopnuMit nl' i meters in it- V set e(|natorial tell of tliiekciiiil n-oeesses of m'i.'- luunan ovuiii, avs witness tlif feiopinent of tlic riie enihrv<i \- , the axes of tiic stalk nnd the npright embryo generally coinciding (Figs. 84, 85 ; see also big. 97) • what flexure exists at this time is backward, and residts in a concave dor- sal oiitlii'ie. The ventral aspect of the embryo of this stage is largely occupied bv the relatively huge vitelline sac, which freely communicates with the imi)er- fectlv <lefinod gut along almost the entire length of the embryo. The preco- cionslv developed amnion has completely enveloped tlie end)ryo and its stalk as faVas the distal attachments of the latter. The heart is first represented by two longitiulinal fokls corresponding with the primary halves from which ,.«f-«",""- Fiii. M.— Ilinniui eiiiliryn nf iitinut the fiftei'iitli iliiy (His) : the cmbryu is nttiirhed to tlic wiill iiC the blastoiltriiiic vt>i(lc hy niciUis (if tlu' iimliilicul ur iilltiiitnic stiilk, and is eiifldsi-d witliin tlu' auiiiicm ; the hiViXK- vilrlliiir snc I'nily niinimm catos with tlu' still widoly ojn'ii gut. the organ is foniicd ; slightly lai.er, these folds fuse into a single heart, which then :ij)pears as a coiispicuoiis projection between the yolk-sac and the cephalic vesicle. Tlic third week (Fig. Hit) is productive of many imjiortant additions to the exterior of the embryo, its form becomes more definite ; the brain-vesicles, together with the uptic vesicles and the auditory sacs, are difierentiated ; the visceral arciies and the corresponding fiu'rowsare formed ; the yolk-sac is much more constricted, and its narrower coimectitii with the gut foreshadows the later vitelline stalk. By the twenty-first day the first rudiments of the limbs appear. The finu'th week (Fig. 86) is marked by gretit increase in size and by conspicu- ous changes which give to end)ryos of this age distinctive features, growth being relatively more active at this period than at any other. With the termination of the third week the embryo is still erect. During the next day Hexion takes '^ '^'^^'^m'^mmmmim 'T «Hi 96 AJfKRICAA'^ TEXT-liOOK OF OBSTETRICS. ! • i ,: 1 place with groat rapidity, so that during the tweiity-tliird day the cephalic aiul caudal poles of the embryo actually meet or even overlap, the dorsal outline approximating a circle (Figs. 8G, 87). The individual brain-vesicles are bcitci' developed, as are also the visceral arches and furrows, the eyes, ears, and nn-o; the heart has increased in size, and the limb-buds have become more ]iin- nounced. At tiie end of the twenty-third day extreme flexion has taken place, from which time until the close of the fourth week the embryo gradually becomes less tightly coiled on itself, the larger and more conspicuous land slowly rising and leaving tiie tail. During the latter half of the fourth week, in addition to the iucrcax',! development of the visceral arches, the individual cej)halic flexures becdiiio F'lii. S').— Mumiiii iiiiliryn of nhdut the thirti'i'iitli day (His): the cimiiiil \\u\v (if tlio inibrvd i-imi iiiM'ti'il Willi the lilii^tciilcniiic vusirlf liy tiifiiiis of the lilpcloinimil oi- iillantcic >tiilk ; the iiiiiiiinn .ihiiiil; (MimpUli'ly rncliiscs tlu' I'liiliryii, luid tho lari.'f vitclliiii' sac ciimimiiiii'ati'S tliroiighout tlit' Krtalrr |»iit cil' t!\c iiiitriil siirfai'i' liy iiicaiis of the uiicliisi'd >;ut-tra('t. very conspicuous. These flexures consist of a sharp bending of the aiih- rior ])arts of the head upon the posterior half, resulting in a chauiic nl nearly 90° in the cephalic axis, with the production of a I'onspiciiiiii- ^ limine nee marking the position of the midbrain. Posteriorly, the ccrvinil iC\uro sharply imlicates the junction of the cephalic and trinik segments; t;i, the; caudally, the dorsal and citccygeal flexures mark less pnuioMnccd cliiingi'- !!i the direction of the embrvouie axis. On cither side of the (hirsil mid-line, extending from the cervical flexure to the tip of the caudal extremity, a series of prominent (piadrilateral areas indicate the position of tlie somites nr provertebrie (Fig. 8(5, 11 and 12). The (levelopnient of the vinwnd archeti reaches its highest expression by tlio ■C- '^■■S. vs. the ceplialic and le dorsal outline esidos are boitur , oars, and ik.-o; t'oiiio more pni- has taken place, nbrvo gradually •OUSpicUOUS ll(!l(l to the incrcaM',1 flexures beeuiin' • iif the ciiibrvd is ci'ii ;k ; till' aiuiiiipu nlriii.ly iKluiiit till' KTi'atii- I'iifl lin<z: of the aiiti- j in a chaiip' nl' )t' a eonspicium- iorly, the eerviial trunk seiriiK'nts; less pronoiiiKvil side of the tlnixil ' eaudal extrcniilv , \ of tiie soniitis (11 expression hv tlic PHYSIOLOGY OF PREGNANCY. 97 tennination of the fourth week, when the series of arches is seen in its best condi- tion (si'c Fijj^. 1 29). In man and in manimals fivearchesare successively developed from before backward, the last, however, being scarcely differentiated and very inconspicuous. Tlie first arch when fully formed is partially divided into an upper and a lower secondary division, the maxilkmj and mandibular processes, g^'--' iS !f Si I 1 1 5= = a js S .; a. S ti 3 . D » = \ St i:.-2 . -! ** 1 7 "o S § r ♦* ' "" 3 it -2 '3. iJ « = >> f §ii 5 -> c - w c — ;rt .. y: ■S - — • ^r ^ .2 7 > "o H CJ i; ■s times day ■itclli •3 £ -* i> ire u =4 tc C y .C ' S s i-? '■5 •c 3 = V c > •» * " •£ •J o -, c S 3 = •i^ •" -r- c :'• o t; c S > ^ Hi ? -k 111 - 3 = S feS 5 ■• 3 1 S S O il "^^; s 1 - .^. K ^ S t; ti: — • —• t- w E- ':. ~ I * ■^ >■■£. e 3 = ^ s <" - « - Jl ^ ZJ C "t^ .' s- :j § £ i? . o E = .i 3 >. JZ t ~ r; *^ *-* w s ■^' i ! ^- § " 5"i i^ /. ^- -r >- 1 .' - «■ J= C- .i. ■■ « *; t- 7-. w . s — i- i> c i- •= .- .ti « -) *- fc. ~ - ' = c ■C B '2 O .5f .- S " 1) <s ^ »- 80 eddied from the parts to whose construction thev respeetivelv largely con- tribute. The maxillary processes of the first arch, in connection with the"inter- vening ,m.v.-/.o./a/ process, c-ontribute the parts which eventually become the upper boundaries of the oral cavity ; the mandibular processes of the same •rcl.jou, to fJ.rm the lower boundary of the mouth. During the fifth week M.e ma.-g,ns of the centrally pnyecting naso-frontal plate differentiate into two ^■a' f 98 AMERICAN TEXr-liOOK OF OBSTETIilC^ I I ' h secondary processes, the processus globulatrs, forming the inner borders of tiie nasal pits, and the l(((era( J'ronial processes, which contribute the outer wall nf the nasal fossa) and separate these depressions from the eyes. These proces-os normally unite co form the continuous structures around the nose and the mouth. Faulty union or imperfect closure of the interveniu}; fissures jjives rise to the varieties of hare-lip and cleft ])alate and to other forms of congenital facial defects. The second or hi/ohJ arch, as well as the third, fourth, and filiii arches, eventually fuses with its neighbors and loses its identity; a simihir fate awaits the intervening outer visceral furrows or "clefts," with the e.\(( ii- (• Fl(i. ,h7.— lit'vclii|iiiiciit iif tlu' fucc iif till' liniimii cnihryo (Ilisi : A, oiutirvd of alumt twcnly-iiiiic iliiy-. Till' imsci-l'ninliil pliiti' ilillriciitiiiliiif; iiitu priMTssus nl'ilnilnivs, tnwiiril »liicli tlir iiiiixillury |inM-.-v - 111' lii>l visc'cnil iinli iirc cxlciuiiiin. li, ciiiliryu nf nljniit tliirly-lniir diiys : llii' j.'lciliiiliir, liitcnil, IVi'iiMl, ami iimxilliiry jirdi't'sscs lire in iiiiiKi.-^iticiii ; tho )iriiiiitivt' npcniiiK is imw bfttiT ik'liiuil. (', I'lrihrjn nf alicjut the i'if;litli Week: iiniiii'iliatr Ijniiiiilarirs of iiiniitli arc iimre lU'lliiitc and the nasal (irilicr- iirr jiartly fnrratil, cxtiTiial ear appearing. !•. eiiihryu at end of seeond nidutli. tion of the first, since they gradually become obliterated by the fusion ol' the surrounding arches. The first outer furrow, or hjiomandlhuhtr cleft, coiitrili- utes largely to the formation of the external aiiditoiy canal, while the sur- rounding portions of the mandibular and hyoid arches contribute the ti.-..«iii' from which the external ear is derived. '^_ plIYSIOLOaY OF I'RFAiNAXCV. 99 borders of llie ; outer wall ■ if l^hcse proces-os ! nose and the •OS jjivos rise tn onfifonital faciiil iirtli, and lilili itity ; a slniiliir with the exci |)- luiit twciily-ninc .layv If iimxilliiry )ii-nii-M'. lllllllir, lllUTIll, I'l-nlltill, ik'liiu'il. •'. uiiiliryiMif 1 the niisiil iirilicf- iiri' the fusion of the lav cleft, I'onlrili- 1, while the mh- tribute the ti«iie nc Second Mnnfli.— The fifth and sixth weeks (Figs. 8G, 88) add to the size and the general advanced development, altiiough the phenc.nienal rate of growth of the preceding week is replaced by more gradual increase. The limbs con- stitute the niost^characteristic features of this jjeriiKl, since what prior to the fifth week were but rudimentary limb-buds now undergo differentiation into distinct segments, at first two, then three. Toward the close of the fifth week the flattened terminal segments representing the future hands and feet exhibit distinctions as tliin marginal plates and thicker proximal portions. The man^inal areas very soon exhibit traces of the digits as small elevations sepanited by shalktw grooves which gradually extend toward the free ends. The fore lilnl)s appear slightly earlier than the hind limbs, and retain this lead throughout their development. By the middle of the sixth week the fingers are sufficiently developed to project be- yond the hand, although the toes are Fir., ss -lliimiin embryo of nhout six weeks, ciilart-'i'il livo times (lUs). KiG. 89— Hnmiin emiiryo of nbcmt seven weelvS, onlarfied live times (His). just beginning to bo outlined, and represent a stage of ten to fourteen days later. Coiiicidently with these changes the general development of the embryo has steadily progressed (Fig. 89), with the result of supplanting the embryonal characteristics by those of distinctly fetal type. The head, though propor- tionately large, has become partially once more raised ; the boundaries of the month have become definitely located ; the external parts of the eye, the ear, and the nose are well advanced ; and the general contour of the trunk has assumed more of the characters of the child. Tlie second month witnesses the disappearance of the cervical flexion and T '■"^ 100 AMUR/CAN TEXT-HOOK OF OBSTKTRICH. i t i i m h^ tlif fiirtlier liftinj; of the head, wliich is still very larj^e (Fig. 90). The i'acc shows distinct advaticemcnt toward its completed typo, although the nose is \v\ unduly hroad, and indications of the fissures surrounding the mouth arc dis- cernible. The limbs pn^joct from the body, and the fingers, including tlio differentiated thumb, and the toes are well defined. By the close of the secuud Fio 90.— Ilunian ciiil)rjii of ntioiit lijilit mid n liiilf wcoks, eiiliirciMl five times fUis). month the fetus measures from 25 to 30 millimeters (1 to 1^ inches) in leiiirth and weighs from 15 to 20 grams. The Third 3Ionth.— The third month establishes the htmian form, although the head still unduly preponderates. The limbs have acquired their definite shape, and the imperfect nails are present on both fingers and toes. Durinir this month the external organs of generatii>n become definitely differentiated, ?^.^.,J:^ :w. PHYSIOLOGY OF PRKCiXANCY. 101 90). The face 1 the nose is yet mouth arc dis- , inchuling ilie ise of the secom] 3 ^ times (Ilis). inches) in loiii:t!i 1 form, althdiiuh etl tlieir dciinitr 1(1 toes. Diiriiii: Iv ditferentiiitcil, ; y.it ahhoujrh tlicv niaUo their appearance several weeks earlier. At the end of this p(Ti(Hl tiie fetus measures about 7 centimeters (2J inches) in length and weighs alK)Ut 120 grams (4 ounces). The Fourth J/o/i//*.— Short hairs, devoid of pigment, appear on the scalp and on some other parts of the body, which is now coveriHl with firmer skin of rosv hue. The eyelids, nostrils, and lips are closed. The anus opens, and the coils of intestine, which before extended into the und)ilical cord, now lie entirely witiiin tiie ainlominal cavity. The point of emergence of the umbil- ical cord lies low down, close to the pnbes. The head forms about one-fourth of the entire body; the bones of the skull, while ossifying, are still widely separatcil. The sexual distinctions of the external organs are well defined. At the end of this pcrioil tiie length of the fetus has increased to about 12.5 cen- timeters (o iiiciics), and its weight to between 230 and 240 grams (7J ounces). The Fifth Mnnth. — Tlie heart and the liver share with the head in the undue preponderance wliicli tliese parts present. The contents of the small intestiiu^ — the meconiiMii — show traces of l)i!e, being of a pale yellowish-green color. The lower extremities are now longer tiian the arms; the nails are well formed. Hairs are more plentiful, but are devoid of color. At the termination of this month the fetus measures 20 pcntimeters (8 inches) in length and weighs about 600 iTams ( 1 ixtuiid). The fetal movenu^nts are now distinctly felt by the mother. The Si.rth .Uoiifli. — The surface presents many wrinkles and a dirty-reildish hue- the sebaceous coating, the veniix cascona, begins to appear. This whitish substance is composed of the dead and shed surface-epithelium, mingled with the secretions of the sebaceous glands; its primary function is the protection of the fetal integument fnmi maceration by the amniotic Hnid. Eyebrows and eyelashes begin to grow. The length of the fetus by the end of this period has increased to ."iO centimeters (12 inches), and its weight to about 1 kilogram or 1000 grams (2 pounds). The Scmitk Month. — The continued deposition of subcutaneous fat causes a general appearance of greater plumpness, although the surface is still some- what wrinkled ; hairs about 5 millimeters (^j inch) in length ; eyelids arc now permanently open. The liver is still relatively large ; meconium occupies the entire large intestine ; the testicles have descended as far as, or even into, the inguinal canals. Children born at the end of this period may survive, although they usually succund). The fetus now measures about 35 centi- meters (14 inches) and weighs about \h kilograms (3 pounds). The Ehjhfh Moiith. — This and the succeeding month are occupied by in- crease in bulk rather than by great gain in length. The skin assumes a brighter flesh-color ; the scalp is plentifully supi)lie(l with hair ; the nails almost reach the finger-tijis. The vernix casensa forms a complete coating ; the lanugo, or embryonal down, iK'gins to disappear. The subcutaneous fat has increased, giving less harsh outlines to the body. The close of this month finds the fetus measuring about 40 centimeters (16 inches) and weighing from 2 to 2| kilograms (4 to 5 jKtunds). The A'inth Month. — The fetus at full term presents usually a well-rounded 102 AMKRWAN TKXr-nOOK OF OIlSTKTRICfi. body, from wliicli tlio lamifio lias almost entirely ilisappearod. The skin is loss highly colorwl, and is covered in places, particularly the head, the axilla, the groin, and the flexor surfaces, with u layer of protecting irruix. Both l(>.s. tides have descended into the scrotum ; in the female the labia niajora an in contact. The intestinal tract contains the dark-greenish-colored mrcnn'n'm^ consisting of the setfretiuus of the intestines and the liver niixttl with the (pi- Ki(i. '.II.— Diatrriini illustnitinn tlic outlines (if tlio limiinii futus at viiriDUs stai^oB, from the end uf iliv seeiind tu the end of the eiglith week, niHuiiilii'd live times imoditied nfler Midi). tholium from the digestive tube, together with epidermis and lanugo •swalluwi'd by the fetus. The umbilicus has reached a position aImo.st exactly in tlic middle of the body. The first epiphyseal o.s.sification to apj)ear, that of tlio lower end of the femur, is often ti»e oidy erne present, but ossification niiiy have commenced also in the upper epiphyses of the tibia and the hum(m>, '4l... v. I'liYsioLOdv or piii'MXAyry. \0'.\ The skin i< [•ad, till' axilla, nix. Both tos- , majora ait in red mrcnii'h'iii, il with the ( pi- from tlio end '■I'llie fter Mi'.U). !lIlUfr<) SWallnWi'd t exactly in tlic )ear, that of tlif ossification iiiiiy 11(1 the hunicniN \ ro.iveiiicnt •^impl'' '"•■tl""l *•»' deteniiiiiing the approximate length of the A-tiis at a.iv period duriiiL^ g.-tation has Ihk,... given by iraasc. The length in c^.n(inu.t..rs ..lav roughly he estimated np to the ..i.l of the fifth month by ,<jum-i„!, the month; beyon.l the (-nd of the fifth month, by mnlhplyim, the month "l)V the eominoii .•...•llicit'nt 5. • , , .. Computed hy this method, the approximate greatest or entire lengtlis ol the fi'tiis for the At till' t'lld lit' ^(■vera! months are : MlOIll h the lin«tli = 1X1=^ 1 ci-ntimetor = I iiu-li. 'J iiiontlis ••{ " S 10 - '2 X- = -1 coiitiuieten) -= 1' iiiilieH. = 3S " = H " = 10 --= 12 = 14 =: l(i = IS = 20 3 < 3 = » 4X4 r= l(i oX'^ = 25 liX'-> -:30 TXT) =r 35 S X •'> ^40 i) X 5 ^- 4.-) 0X5 r= oO The full-term fetus measures, on an average, iihoiit 50 centimeters (20 inches) in its entire length, and weighs from 3 to ^ kilograms (from to 7 ponnds), the average weight for boys being ;}340 gnims (7 pounds, (J uiinees), and that fiir girls 3190 grams (7 pounds). The individual variations in weight of new-born eliildreii include a wide latitude, as indicated by the extremes of 717 urams (1 pound, }>i ounces) and ()123 grams (13 pounds, 8 (-(inccs), as accepted by Vierordt. Cliildrcn really exceeding 5 kilograms (about 10 pounds at birth are very rare, notwithstanding numerous reputed eases. Waller, how- ever reports a case of a living infant, delivered by him with fi)rceps, that weighed lo pounds 15 ounces! [n addition to sex, boys being heavier than ifirls the size of the child is materially influenced by the conditions ot ma- ternal parentage; thus: (1) Young mothers have the smallest children, and mothers i»et\veeu thirty and thirty-five years have the heaviest. (2) The weight of the child increases with the number of previous pregnancies, providing that the successive children are of the same sex and that the pregnancies do not follow too rapitlly ; the children of primiparte, therefore, average less tliiin these of miiltipaiw. (3) The weight of the child increases with the weight (Gassner) and the length (Frankenhausen) of the mother. In addition, ob- viouslv, all causes adversely afi'ecting the physictil condition of ilther parent may exert an iiiifavor hie influence on the vitidity and develo])nient of the fetus. 6. Development of the Circulatory System. — The vtiscnlar system is formed by the development of two parts, at first entirely distinct — the extra- embryonic blood-vessels, and the central circulatory apparatus re{)resented by the heart and the great primary trunks. The extra-embryonic blood-vessels constitute successively two distinct systems, the vHcUlne and the (dhnfoic cir- culation. The first of these in mammals and in man is comparatively unim- portant ; the second is of the utmost importance, since it takes an active part jgk securing the nourishment of the embryo from the maternal tissues by means of the formation of the placental circulation which it becomes. m 104 AMERICAN TEXT-BOOK OF OBSTETRICS. i ,b m Very early in the development of the embryo the germinal area becoiiios mottled by the appearance at its periphery of an irregular network of braiK h- ing patches of darker *int than the surrounding tissue, due to the active 0( 11- prolifenulon. These patches are the blood-itilamh of Pander, so called fntiii the active rdlc playetl by them in the production of vascular tissue — vessels and blood-cells. By tiie extension of the blood-islands an;1 the newly-foriiuHJ vessels the circulation within the area vasculosa (PI. 15) rapidly extends ci n- trally and toward the embryo, with which communication is later established by the vitelline arteries and veins, large trunks which connect with the cephalic and cauilal extremities respectively of tlie primitive circulatory apparatus which has meanwhile been developed within the embryo. The significance of the vitelline circulation in mammals is probably merely suggestive of its lar greater importance in the lower types, where absorption of nutritive materials from the large and conspicuous yolk constitutes an evident reason for its development. In man and in mammals it is doubtful whether the vitclliiu' circulation contributes mitritive substances in any appreciable degree. Coincidently with the decrease in the yolk-sac and its vitelline circulation, the vessels supj)lying the allantoic tissues become more prominent, the growth of the two systems proceeding in inverse order. The conversion of a portion of the vascular chorion into the fetal contribution of the placenta advances the imjiortance of these vessels to that of the placental circulation, as iirst represented by the two umbilical veins and the two umbilicid arteries, tiic latter the direct continuations of the intra-embryonic hypogastric arteries. Later, the two veins fuse within the allantoic stalk, thereby producing a sinjrlc venous trunk which accompanies the arterial stems. Within the body of the fetus, however, the umbilical veins, which there remain separate, develop unequally, the right suitering atrophy and finally disappearing, while ilic left increases in size and persists until birth as the important umbilical vein euii- veving the blood to the liver. The Heart. — t\)incidently with the formation of the j)rimarv extra-einhrv- onic blood-vessels within the vascular area, the heart early begins its deveiop- Kl<:. !i'J.— Section nf iiirly cmliryo (if riilihit d'HTsoli, sluiwlm; tHu Mimnitc liciirt tulics (//, //i: •. Iiriniiti\c ciKldllicliiiiii: cm, iiu'sndcrm loniiiiii,' cure line wiill ; ic, i ctiMlcrin ; cii. cMHiiIcnii ; <(^', tolil> |iri- (luciiiK ventral wall nf ^tit-tract ; lnj, luad-KUt ; <i. n', priiiiitivc anrta ; ii, iicnral canal. mont. The first trace of this im])ortaut <n-gan appears as a folding off ami hollowing out of a limited mesodcrmic area on each side ; the two heurt-liilKs vs. al area becomes ivork of braiidi- the active cdl- •, so called frmn r tissue — ve^^^l'ls lie iiewly-foriiK'd (lly extends ci u. later establislicd with the cephalic latory apparatus Tlie significaiu'c fgestive of its tar itritive materials it reason for its her the vitellino degree. illine circulation, mcJit, the growth sion of a portion >lacenta advaiioos •culation, as lirst lical arteries, tlio )ogastric arteries. iroducing a siiii^lc II the body of the separate, develop ng, while the hit inbilical vein cdM- lary extra-em lirv- )egiiis its devclop- VITKLUNE ClRCrLATION. Plate 15. r lii'iirttulH'S (//, II r. f, fi\ic«lcriii ; ;;/', I'nliU |ir"- 'iiiiiil. a ft tiding off ami he two heart-tiilx* '''■'■'///>,,, Vas..,n,u' ,,n^M nf H.vriMlny rnl,l,i( vnihryu MC. V. ll,.n,.,l,.,Mn,,l .iuli,-,,n : .•,,|,ill,,ri, s Mnt vhnu 'ji sinus is strii to hi., iiilciiiil. II : till' li'i'iiiiMiil I'-1.- Tn PHYSIOLOGY OF PREGNANCY. 105 tlins formed lie within the .splanchnic mesoderm and are at first widely sepa- rated from each other (Fig. 92). With the bending together and approxima- t" 1 .)f the visceral layers in the formation of the gnt-tract the heart-tubes are brought into apposition, and finally fuse, the union resulting in the production ■1 "m Fig 03— niiiu'iaiiis iiiiislratiiiff arrnngoment of primitive heart and aortic arches (modified from AWcn Tliuiii|i<niii; 1, \ itilliiu' viiiis rfturninK tilood from vjisculnr nron ; L', venous segment of heart- tube' It iiriinilivi' viiilriclc; 1, tniiicus arteriosus ; .">, 5, upper and lower primitive aorta;; 5', .V, continu- ation of iloublc aorta as vessels to eatulal pole of embryo ; li, vitelline arteries returning blood to vascu- lar area. of a short, straight reooptacle, into the caudal end of which empty the vitelline veins and from the cephalic extremity pass the primitive arterial trunks (Fig.'o;]). This early straight heart-tube, lying attached to tlie floor of the pharyngeal region, is very transient, since the rapidly increasing length of the organ, its A n Fill. HI.— .\, ; . of human embryo of li.iri mm. (His) : n, truncus arteriosus ; b, |)rimitive ventricle ; C, vencais sitfi, "' it. Iieiirt of human eml)ryo of about 3 uim. (His) : a, truneus arteriosus; 6, venous Mgnient ibihii. r , ' ii litivi vi'utriele (in front). ends luing rela»iv('ly fixed, soon necessitates tlexion, which take.s place in l)oth aagitta! :ind ti'ansver.>;e planes, and results in giving to the tube the S-form. The lower and posterior limb of the heart receives the great veins and is the ajnjts irnotiiLs (Fig. 94) ; the lower and anteriorly directed loop is the auricular 106 AMElilCAN TEXT-BOOK OF OBSTETRICS. or venous conipartiueiit ; the upiier and posteriorly ilireoted loop is the vcnti iV- ular or arterial compartment j the upper limb is the tvuncm artcr'wims, innw which arise the jirimitive aortic arehen. The heart, therefore, at this stage — about the fourteenth day — consists essentially of two imperfectly separntid Fiti. 95.— A, lu'iirt of human oinbryo of about -..a mm. (His): n, atrium; f(, portion of atrium cnrn.. spoiulinK with auricular appendage ; c, trunt'us artcriosu.s ; (/, nuric\ilar canal ; c, i)rimitivc vi'ntricli . ij heart of huma cmliryo of about the lil'tli week (His): a, left auricle; b, right auricle; c, trunci'S iirlirid- sus ; '/, intorve- tricular groove ; c, right ventricle ; .;', left ventricle. divisions — a lower and posterior venous chamber and an upper and anterior arterial compartment — into and from which pass the larger primitive venous and arterial trunks. The venous or auricular division during the third week develops two con- I !'.. Kiii. %.— A, section of heart of Imnian embryo of 10 mm. (His) : n. septum spurium : h. iiiterauricular septum; c, mouth of siiuis reunieiis; »^ right auricle; c. left Jiuriclc ; /'. auricular canal; ;/, ri^-lit vin- tride ; It. interventricular septum ; /, left ventricle. It. section of heart of human embryo of abmit tin fifth week (His): ii, septum spurium: h, auricular septum; c, opening of sinus reunieus (leader piissts through foramen ovaho; (/.right atrium; (.left atrium ;/, sci)tuni intermedium: ;;, right ventricU': J. ventricular septum ; (, left ventricle. .spiciions lateral dilatations which assnme a position above and behind thco^imv- ing arterial chamJK'r. The.se dilatations are the uuricnfa)' appanhtf/rs (Fiir. 951. which ft)r some time are the most conspicuous parts of the auricles. At tlii- PHYSIOLOGY OF PliKGXANCY. 107 s the veiitric- teriosus, IVdin ; this stagi — ctly scpariUuil tion of iitrium cim- ■iiuitivi.' vi'UtrirU'. It. li; ; c, truncfs iirHTio- per and antoridr primitive venous levelops two con- T "^ ■urium ■• ('. inU.nuir.cuto ll.iv -MiiiiU; ;/. rii:M v>* ,u .•ml.ryo >,f «l'"iitili' 1„- .„ rlKl.t vi'Ulriulo;).. |l behind the ^nt.w- kvuriclcs. At till. time the auricular and ventricuhir portions of the heart are imperfectly sepa- ,..,ted bv a marked constriction, the canalis auvkulark. Diii-iii"' the Iburth week the conversion of the single into a double heart iiu'Uf's bv the gi'adual growth of jjartitions from above downward within tlie auricle, and from below upward within the ventricle (Fig. 9G, a) ; in addi- . ^ ' ^1^^. p,-iiiiitive auriculo-ventricular canal becomes divided by the formation f .' '-inecial i):irtition, the ncptum intermedium. The division of the heart- 1 • uibcr- proLnv><es to complete separation, with the exception of an orifice in tl lower part nt' the interauricular septum, which orifice remains until shortly ft>- birth a- the foramen ovale. The entrance of the venous blood into the auricula!' c.Miij.artiueut is effected for some time through the single opening of tl e sinus veiiosus. Guarding this orifice are folds of the cardiac lining, one of which foMs becomes prominent as the Eustachian valve, directing the blood- current tlirouuli the foramen ovale. Later, the sinus venosus becomes included witliiu the wall of the heart, and the three principal venous trunks emptying within tlie sinus — the two ducts of Cuvier and the primitive inferior vena cava— open direct Iv into the auricular cavity by as many separate orifices; that ol" 1 lie left Cuvierian <luct is represented by the mouth of the coronary fiinti- which this trunk eventually becomes. The truncus arteriosus, the ante- rior priiiiaiv nrtcrial trunk, undergoes an indep(!ndent division by the forma- tion of the (lorfic siptinn, the partition beginning at some distance from the heart and ai)pi'oaching the latter from above downward. The vessels residting from tlic division of the single trunctis arteriosus afterward become the aorta and the i)idnionarv artery, and are limited respectively to the left and right halves ot' the ventricidar compartment by the simultaneously developed inter- Ventricidar septum. The primitive heart, as well as the earliest blood-vessels, consists of a doulile wall, tiie outer layer representing the muscular and fibrous tissue, and the inner laver representing the endothelial lining. These two coats are for a time entirelv distinct, the endothelial heart representing the general arrange- jBient and division of the organ, and lying within the surrounding layer as a ihrunkeii east within a mould (see Fig. lOS). The interval separating the endo- thelial from the nmscnlar heart later becomes bridged by numerous comiecting bands of tissue, the network of trabeeuhe becoming closer and the intervening maces smaller as development ]>rogresses. The consolidation of the cardiac walls, however, never is coiv detely accomplished, indications of its imperfec- tions heiiig clearly seen in the arrangement of the conspicuous columH(V carneic of the adidt oriran, in which the more or less isolated bands represent the thickened remains of the bridging trabeeuhe connecting the endothelial heart tjrith the denser surrounding capsule. « Artcrii's nf flic luinx. — The early arterial circulation of the fetus dif- fers in many details from that of the later .stages. C\)nspicuous among these ^ffer(>nres is the development of the series of aortic arches which extend fnmi the anterior end of the truncus arteriosus around the primitive pharynx, ^thin the visceral arches, and converge into the dorsal longitudinal vessels, ' I r; •i' 108 ami:ricax text-hook of obstetrics. tlic- primlUvc aort<r, on each sitlc. Five pairs oi' aortic arches (Figs. 93. 97) .ire Vui. '.17.— Ilmiiiin t'liihryci of hImmu tlinc wot-ks, showiiitf vi.sceriil arclips iiiul furrows Hiid tlici; nli liims to aortic iinlu's i lli.si : nix, inn, mii.xilliiry iiinI iimiulilmliir proci.s.si'.s of first visceriil arch ; (i /-ii '■ lirst to foiirlli aortic arches :Jr, rv, primitive jiiniilar ami cardinal veins ; ilf, ihict of f'uvicr; al. i; atri.i and vcntri(dc of primitive heart : v, vitelline sac ; vn, iln, ventral anil ilorsal aortic ; or, ot, optic iM\"k vesicles ; iir, ud, nmliilical veins and artcrii's ; ir, vitelline vein ; nl, allantolH. fornu'tl, the first pair lying witiiin tiic (■()rre.<p(»n(.liiig niaiulibuhir arch, tlR'l;L>; J'JirSIOLOGV OF riiEGNANCY. 109 within the tissues of the imperfectly defined fifth visceral bow. The first jjair •r '^t •ipiH'iirs and soonest disappears, all five at no time being found simul- <lv fiillv (Ic'Vt loped, since by the twentieth day, when all are present, the .••, 1- ucIhs have already partly atrophied. These aortic arches in man and in nianinials transiently represent the branchial circulation of gill-bearing f • ■ ■ ilioir identity in the higher animals is lost in the metamorphosis which tiiermi.lergo in the devel.)pment of permanent trunks. Til ' I'lte of' the several aortic arches and their relations to persistent struc- tures is l)rictly iis i'ollows (Fig. 98) : ^ (]) Tiie lirst or mandibular aortic arch early in the fourth week loses its midille segment, th(! anterior limb taking i)art in the formation of the external -zur ■iiC -vv uv -—aL •■Ud -UV 1(1 furrows iinJ thci.- nla 1st visceriil iirch : n '-" '' li,t(.f(""vier: nM.Hlri.m Inrtii-, <»■,«(. opt ii'iiii'l"!' ibular arch, tlio In- G'W"'-"' 111 ID/ /i/ Right siiKiavHi'!. /tinofiiiniifr iirityy. As^Ohlillg illOtil. ^ External carotiii. _ Intfriuil earot'ui. I 't'rtcbial artery. Arch of aorta. Lt'ft su/h'iavitiH. Ductus arteriosus. Pulinonary trunk. Desceniiiu^ aorta. Fio. as— I>iiii;raiii illiislnitiim: llio Into ol'tlio aortic arches in mammals and man fraodifieil from Rathkc). carotid artery and its brauchcs; the posterior or aortic limb aids in forming pe internal carotid artery. (2) The seooiid arch has a fate identical with that of the first, its straighter ▼entral and dorsal limbs taking part in producing the carotids. ' (3) Tiie third arch, whieli remains almost comj)lete, gives rise to the connec- flon iM'twcon the external and internal carotid arteries, to the latter of which the arch particularly contributes. (4) The fourth arch undergoes important changes resulting in its retention on the two sides, since from it are largely derived the innominate, together ifith the subclavian and vertebral arteries on the right side, and the important ilbh of the aorta on the left. > i 110 AMKIilCAX TEXT- no OK OF OBSTETRICS. (o) The fifth ai'cli is devoted to the production of the pulmonary arteries, a small portion of tlio right areh persisting as the right pulmonary artery, inul a larger part of the left giving origin to the corresponding pulmonary arti ry and the duetus arteriosus. During the fifth week, as betbre noted, the truneus arteriosus undergoes dl\ is- ion into two tuhes by the formation of the aortic septum ; the resulting aortic tube retains connection with the fourth arch, becoming the ascending portion of the arch of the aorta, while the right tube becomes connected with the filth arch and fornis the pulmonary vessel. The two primitive aortae for a time extend on each side of the notochurd as longitudinal vessels which almost completely terminate in the large omphalo- mesenteric or vitelline arteries supplying the circtdation of the yolk-sac, tiip early continuation of the aortic stems being slender, relatively insignificaDt branches which extend toward the caudal pole of the embryo. With the develt»pment of the earliest allantoic structures the posterior segments of tlio two primitive aortse unite to form a single trunk, the dorsal aorta, the fusion beginning about the junction of the cervical and thoracic regions and |)ro- cceding caudally. At a slightly later period the aortic trunk divides, at the end of the lumbar region, into the allantoic arteries, which pass along the allantoic stalk and are distributed to the chorion, and later to the fetal placenta; thcv are then known as the umlnlical arteries as far as the bodv-wall, bcintr continued within the embryo as the hypogastrics. The primitive allantoic arteries eventually become the common and the internal iliac arteries, the external iliaes being formed as new branches when the limbs arc developed. After birth, when the fetal placental circulation ceases, the distal parts of tlie hypogastrics beyond the bladder atrophy and remain as solid fibrous cords passing to the und)ilicus ; the proximal |)arts of these vessels retain their lumina and persist as the superior vesical arteries. Vcinx of the Fetus. — Toward the close of the embryonal period, about the fourth week, the venous arrangement includes three distinct sets of vessels rct'irning the blood to the heart (PI. 16) ; these are — (1) The Cuvierian vein?, returning flic l)lood from the body of the embryo; (2) the vitelline veins, re- turning the blood from the circulation of the yolk-sac; (3) the allantoic, later the umbilical, veins, returning the blood from the chorion and the developing placental structures. The early systemic veins consist of an up])er trunk, the anterior eardinnl or primitive jugular veins, by which the blood from the liciiil is carried to the heart, and the jtnsferior earifinafs, collecting the blood Inmi the triuik and the important Wolffian bodies. These vessels, along with the viti'lline and allantoic veins, pour their blood into a common receptacle, the sitiiis reiiiisits, which opens directly into the primary auricular division of the heart. For a short time these veins are about etpial in size and are evenly developed on the two sides ; soon, however, the results of unequal growth become manifested in the disproportionate advance of some and the retrogression of others. The vitelline veins in man, as may be anticipated from the relative insig- res. nonary arterit ^ , a )naiy artery, iiiul juluionary artery i undcrf^oes «li\ is- e resulting aortic isoending portion te<l with the iiftli of the notoeliuril le hu'ge oraphalo- the yolk-sae, tlic vely insignificant l)ryo. With tiie ' segments of tlio I aorta, the fiisidii regions and pro- ik divides, at the li pass along tlic the fetal placenta; body-wall, being rimitive allantoic iliac arteries, tlie lbs arc developed, listal parts of the lolid fibrous cords }ssels retain tlioir nal period, about inct sets of vessels e Cuvierian veins, vitelline veins, ic- the allantoic, hiter nd the developing II upper trunk, the lood from the lieiid ng the blood IVoin ds, along with the lion receptacle, tlie lar division of tbo ^ize and are evenly ual growth become le retrogression of the relative insig- :•'* i '' !«' !1 i 1 DEV! li! ir ill Ilnmnii (Miihryci ircciiiistriicli'il) of twciitv-six ilnys, viowofi fnim the li'ft siilc; niiiKiiiliiMl 'jn (limiutcrs (iifdi- I". Miill ; ///. til Xll., Ilir cnmiiil iicrvrs : 1, s, fj. iiml 5, rcsprclivrly llir liisl rcrviciil. Ilic i'it,'lilli icr- vii'iil, llic tufll'lli lliniiicic. inul tlir lll'ih lii.iilnir spiiiiil iicivi'; ,1. I'., tln'' innlitury vrsirli'; 1,'J, ;t, I, n>|ii'('- tivi-ly lir-t, scc'oiiil. iliinl, iiinl rniiiili plmi-yiiL'ciil imiUcIics; 7', lliy''"iil l)iiily ; W, lii'iincliiis; /..liver; A', kid- iii'y. " 'I'lii' ildttcil liiK's iiiiliciito tlii.' f.\livmitii.'S. "»Jl., I>EV! F THE FETUS. Plate 16. i^k i-m m mniiirnMl 'jr) (liiimclcis rvinil. llK' finlitli 'IT- lius; /„ Mvit; A', ki'l- Iltimnn embryo, same ns prcreriin,!); fisure, b>it tnken nt a deeper plniie (nftcr F. Mall): //, divcrtieulum contriliiitiiii,' tlu'"iiral iinrtinii ul' tlic pituitary liody; Jl iiilmvi'l, nriiiiitive imiiitli; 1, '_', If, 1, pliiiryiideal poiiclii-.s: /;, liriiiiilius ; /', pancreas; /,. liver; II'. /.'., Wnlltiaii liddy; II'. /»., Wdllliaii ihiet ; K, kidiiey; C, cloaeii ; o, (ipeiiiiigs liy wliieli pleuru-iiorituiieul ciivitio.s eoiiuiuiiiicaie ; l\ papilUrunu projection into lower opeiiiii),'. M !'■' m ''iik.i niYSIOLOU Y OF PltEGNAXCY. Ill nifi.an.-c of tl.o lutuninalian yolk-snr, novor roach tho .lovclopmont .seen in lowiT tV|H-< M'lcr l)a>siii<,^ aloii^r tlio vitclliiit' stalk and iiitonn^r at the unibil- ionl ..|)enin.r. the veins im. in In.nt and then at tho sidos <.f that part of the priniitivo .mt-tract oorrospon.Unf; with tho (hiodonnin, and bcoonic dosoly asso- ciated with the Hvor (Fi)?. 99). The vitelline veins become connect(Hl by three newlv formed transverse trnnks, thns establishing two vascnlur ring's which -•^"irele the ^\\\. The early direct connniniication above these rings with the ^s' VA" TS l-f iVD VA' yy Yia. '.111.— Povfliipnu'iit uf the |»irtiil <'irrulation of tlio human cmliryo df iilidUt thnu und ii half woiks (Marsha I'l, a ft IT Mis) : /'.I. paiurfas; 7*/, i litest iiu's ; 7'.s', st(iiiia<'h ; 117), l>ili'(lu('t ; T.l, left nllantdic vein ; Kd'. rij-'lit allaiitnic vein: I'.l", anterior detaehed pDrtimis of the allantnic veins ; r/C, diietiis venosus ; VO, portal vein; IT. vitelline vein; VV, portions of sinus annulares which disapj)ear; H", liver. sinus venosiis becomes lost, and at the same time pctrtions of the remaining parts of the vitelline veins become interrnptod, while a new capillary system appears within tiie hepatic tissue, whieh lias meanwhile surrounded the vessels, and provides coinmiinication l)etween the veins themselves. Those portions of the vitelline vessels that ])ass from the up])er venous ring to the capillary network' are known as the vemv. advc/icntes : they become the branches of the |K>rtaI vein ; those ])ortions which pass from the capillary network to the sinus yenosus, forming now relations, an; the twmr. revehente.s and they become the hepatic reins. The vitelline veins at their lower communication become com- pletely I'liscd and receive veins from the intestinal tract, thus forming the main portal trunk. The allantoic veins after the establishment of the placental circulation are loiown as the umbilicnl vcinn, of which for a time there are two. They fuse within the allantoic stalk, but remain as distinct vessels within the embryo, IfOnniiig within the lateral walls, for a much longer period. During the Iburth week the comicction of the allantoic veins with the siims venosus is •lljet, and shortly afterward the right vein becomes much smaller than its ow, and finally undergoes atrophy. The mueh larger left allantoic or ..iSiS**' ,^ 1 . V 1^ I 1^ i|l!i t?, ;) 112 AMKniCAX TEXT-nOOK GF OBSTETRICS. umbilical vein joins the primitive purtal vein jnst as this vessel enteiv the hepatic tissue. The early condition of the placental circJilation for a time is siich tliat all blood retnrnini!; by tlie allantoic vein must traverse the ca|)illary netwink of the liver in order to <>;ain access to the heart, since both vitelline and allantoic veins have lost their direct communication with the sinus vcnusus. After a time, however, the liver is no longer capable of givint; passage to the rai)id]y increasing volume of the placental circulation, and then a direct (nin- munication is establislied between the portal vein and the right hepatic vein. This new jiassage is the duclus venoms, by which the greater ])art of the Mdud is carried to the heart without traversing the hepatic snbstance. The systenn'c veins arise partly from the primary venous trnnks ami jwrtly as new vessels. The ducts of Cuvier receive the primitive jiiuular veins above and the cardinal veins below. The primitive jngulars lat(>r become the permanent external jngnlars, the internal jngulars being formed a« new trunks. The Cuvierian ducts, which undergo change of direction and lengthening, take a position almost vertical, becoming the superior t'emr rdni, of which tiiere are at first two. The develoiiment of tiie heart induces tin- disappearance of the greater part of the left superior cava, the proximal end, however, remaining as tlie insignificant coronary sinus which directly (i|)(ii< into the right auricle. >i itli the atrophy of the left caval trunk a ikw transverse communication is necessitated to convey the blood from the left side to the remaining and enlarging superior cava\ This need is su])]ilie(l liv the formation of the transverse ju;/H/ar, which later becomes the greater pan of the left innouiinate vein. The fiite of the once important posterior cardinal veins is linked with tin history of the Wolflian bodies, whose venous outlet these veins largelv mv. AVith the atro])liy of the Wolt!ian bodies the cardinal veins become Ks. important, their final fate being ])artial disappearance and partial pcrsistcncv as the a/ygos veins of adult anatomy. The inferior vena e<tva j)resents a complicated development, for the detail- of whicii we are largely indebted to the recent investigations of lloclistettir. The infi'rior cava is developed partly as an independant trunk, and [cirtiv depends upon the ap])ro])riation of already existing veins. A new vosd i- formed from the proximal end of the ductus venosus, from the point wlm. that canal joins the hepatic veins, downward as far as the superior mesentnii artery, when it divides into two brandies which join the ))rimitive cardinal-, This new vessel contributes the he|)atic ])ortion of the inferior vena cavn. The further course of the latter vessel, as well as of the right common ili;i' vein, is provided for by the enlargenuMit and extension of the lower part nt the right i>rimitive Cardinal vein, that of the opposite disappearing. Tin external iliacs and tlie greater part of the left common iliac vein are ikh vessels. 7. Development of the Digestive Tract. — The formation of the digestive tube consists essentially in the fbhling otf, closure, and isolation of that iimi: esscl enters tlic lie is siich that ipillary notwdvk th vitelline ami e sinns veiinsus. itr passage In the icn a direct cDm- rlit hepatic vein, part of the lihiml anee. nous trunks ami primitive juiiular vc jugulars later 5 being formed ;i> of tlirectioM aiul \pct'ior vcmr runi, heart induces tlio the proximal cml, ich directly njxn. ival trunk a luw ood from the lift eed is supplii'd l>y es the greater \K\n is linked with tin veins lai'gely aiv, veins become hv partial persistcmv Pin'SIOLOGV OF PREGNANCY. 113 ( tn nt, for the (lct:\il- s of Iloclistctt.r, trunk, and paitK V new vi'-si'l i> 1 the point wlidv uperior mesciiti'iii irimitive cardiiiak lierior vena i-ni o-ht common ili;i'' the lower p;ui "t isappearing. Th iliac veni arc m« ion of thediut'^tivt dation of timl i<;ir; of the v(dk-sie innncdiatelv in contact with the axial portions of the ento- derm ''rhi< ditrcrcntiation is efleeted by the ventral extension and appn)xi- niation of the widclv expanded splanchnopleure, which, bending together mir JOG) .n-ad.iallv doses to form the primitive gut— at first freely openuig into the yorU-sac, finally completely isolated from the latter except through the communication maintained by the narrow und)ilieal duet. Bv the fifteenth dav the gut has become defined to such extent that three parts" are distiniruishahlc-the fore-gut, the mid-gut, and the hind-gut. The fore-<inf whicii includes the cephalic third of tiie tube, gives rise to the phar- ynx 'the esophaoiis, and the stomach, the latter organ early appearing as a fusiform enlariic.nent of the i)rimitive canal. The anterior end of the fore- gut reaches a.^Tfar forward as the marked cephalic flexure opposite the mid- brain, and at Hrst is separated from the primitive oral invagination, or sto- Atttni,*». Mesoiiiim. Pa} U'tal ntfsoJt-rm. ntt-sotit'f III. i/iiil ca7'ily. Fi(i. loo.-TriiiisvtTse soction nf ii sixtoon ami a half <lny shei'p cmtiryo (Bonnet). Ejctensioit of leli'iii. matoihrum (Fig. 101, A, w), by a septum consisting of the opposed eetoderinie and entodcrmic layers. After the rui)ture of this partition, which hapj)ens during the fifteenth day, the primitive jiiiarynx and oral cavity are directly continuous. A scries of four diverticula (>xtend bet'.v(>en the visceral arches, and constitute the p/i<ir!/)i</((tl jwiicJic-y or in >i'r riscrml furvowi^ [F\^. lOG ; IM. IH). Tiiese evaginations of the pharyngeal lining are of interest, since the first pouch becomes converted into tiie Kustachian tube and the tympanic cavity, the third pouch into the early epithelial tiiymus body, and the fourth pouch into the Jateral ))ortion< of tiie early thyroid body. From the ventral surfiice of the fore-gut, at the end of its pharyngeal division, there grows out the diverti'U- fatm, which gives rise to the respiratory tube and the epithelial parts of the julnionary tissues. 8 1 if I i|l(i 114 AMERICAN TEXT- BO OK OF OBSTETRICS. The mid-gut, at first in free communication with the yolk-sac through tho wide yolk-stalk, gradually becomes tubular and elongatetl, forming a narrow- V-shaped loop whose straight and almost parallel limbs are attached behind to the dorsal wall of the body-cavity, above to the terminal part of the fore-gut at the stomach, and below to the hind-gut (Fig. 102). The apex of the loop receives the reduced yolk-stalk or umbilical duct, thereby becoming attached A '5 - -->-v Fii;. 101.— RoronstriK'tiona of huiiinn emliryo of nbcmt liftei-n rinys (His) : nn\ mci\ pcv, anterior, mid- ille, Hiiil iiiislerior inimiiry tpriiiiivi'siclts ; nr, n/, iiptic iiiwi otic visiclcs ; ^^ soptuin lictwifii jjriiinlivc (iriii cavity mid liciidtrut ; /»/, iiriniitive mil; r, /ii. vciitriciiliir iiiid iiortic.' si'tiiiii'iits ol' liciirt ; n', iiorlic iirrl) : ivi, <lii, ventral mid di)r!-nl iKirtii' ; /, liver; //<;, liiiiduid ; "C luitdeluird ; s, Sdiiiites; <»•, sinus reimieii>; IT, vitelline veins; »r, un, uiiihilieal veins mid arteries; it!, allantois. to the ventral body-wall. The mid-gut gives rise to the entire small intestiiio and to the greater ])art of the large intestine. The liver and the pancreas aic formed as diverticida and outgrowths from tho lumen and the epithelial lining of the duodenal portion of the mid-gut. T/ic hind-f/nt soon loses its individuality and contributes the lower segment of the large intestine. In its j)rimitive condition the hind-gut PHYSIOLOGY OF PREGNANCY. 115 ough tho a narrow jehind to 5 fore-gut ' the loop ' attached hi -a ^ - tV ^ -,/,/ i.:.. • • •"1 — V-, y ti, r^.._ ir, , iintcrior, mii\- wt't'ii (iriiuitivc iirl ; 'i', iinilii' sinus rt-'Uiii"."*; lall intestine )ancreas arc lelial linin.i; the h>\v<r le hind-giit i„.h,des that portion of the g«t-traet lying behind the open mid-gut and ter- minating blindly in the sharply flexed caudal pole of the embryo ; the greatly stomach. /.I'ssi-r Clime _ of stomach. thl'lltt'f Clli'Vt oj sioiutich. -^Aortii. Atei^ogiis- triiim. Sfilecii. Esophagus. Stomach. Lrs.'icr cur-'a- tut'C. ^Celiac a.vis. J\incrcas. lUh-diict, Sufieriiir nii\<:eii- i,tiiall in- teric artciy. testinc. Mcscntci V. Inferior mesen- teric artery. Rectum. Fig. K)2.-Intestinnl .'nnnl of luimnn embryo of six wc't'ks ^'i'ulllt^ Amis. Cecum. Vitelline duct. Fig. 103.— Digestive the sixth wcelv (Tolilt) visceral peritoneum. Mesogastriuiii. S/>leeii. Greater curva- ture. Pancreas. Duodenum, Posterior body- ivaii. Large intestine. /tectum. trnet of human embryo of : arrangement of primitive dilated clo.sed end of the tube constitutes the cloaca, the for a time of the excretions of both the alimentary and A Lung. Stomach. common receptacle the urinary tracts. B Bile-duct. -. Vitelline diu -—.. Rectum. Pancreas. Rectum. Fi(i. 101.— A, alimentary tract of human embryo of thirty-two days. H, alimentary tract of human embryo of thlrty-tive days ^His). Tlie lumen of the allantoic sac, surroiuided by the tissue of the allantoic stalk, extends from the ventral aspect of this space. At a later period communi- cation with the exterior is established by the formation of the anal oririce. The external position of this opening is indicated by the anal invaf/ination of tlie ectoderm or > jctodcmii. ■'rTT '1 r:> m 1,1 ■ 1 I. i I*' :1 116 AMERICAN TEXT-BOOK OF OBSTETRICS. During tlie early part of the fourth week the intestinal tube, composed of its several characteristic segments, lies in the sagittal plane attached to the dorsal wall of the body-cavity by the straight primitive mesentery (Fig. 10;)). A few davs later a period of rapid growth is inaugurated, the intestinal tiihe increasing in length with far greater rapidity than the abdominal cavi'v expands. In consequence of this inequality in growth the small intestines become twisted and coiled, while the large gut takes up a position in fidiit or ventrally, and above the turns of the smaller tube. During the fifth week (Fig. 104) the esophagus elongates and the stomnch acquires its characteristic form as well as an obliquely transverse position, its A Fig. lori.— a, nutliiio of iiliiiu'iiliiry <'iiiiul of Inimnn Piiibryo of Iwi'iity-t'inlit iliiys (His); i>h, pituitiiry fiissn ; ^/, tciiitnii.' ; /j-, priiiiitivo larynx; (i, csoiilianus ; //■, traclioa ; hj, Imifr ; .-•, .stiiiiinch ; >), pancri'iis, M, lii'iiatic iluct; vil. viti'lliiic liiict; al, Hllantuis; /(</, liiiid-KUt : H'rf, WnUVum duct; k, kidiify. H, oulliin' of alinu'iitary canal of liunian emtiryo of tliirtytivi' clays iHls) : ph, iiituitary fossa : tp, tonniii' ; Ix. iniiiii- tivu larynx; o, t'S()i)hanns; t,-, traclioa; Ig, Iiuik; n. stoiiiacli ; ;), pancreas; lul, lic]>ati{,' duct; p, ccriini: ri, climca; A-, kiilncy; ii, anus; ,<;;y, Kciilal eminence ; (, caudal process. former left side becoming directed anteriorly and upward, its former right >i(lc looking backward and downward. The cecum for a time is situated high ii|i and in dose reiatittn with the transversely ])]a('ed jtortion of the large intestine; later the blind end of this part of the gut de.'^cends, owing to the developnuiit of an intermediate portion which a.ssumes the position and characteristics of the ascending colon. The cecum for a time is of uniform size ; its further growth, however, is marked by the failure of the apical p<trtion to keep pace with the increase in size of the remaining parts of the gut ; in consequence, that portiou which morphologically represents the end of the cecum remains as a naridw tubular attachment connected with the head of the large gut, this apj)eii(higo constituting the appendix vcrmifoniiis — the oldest part of the cecum. "t»-i.A .'oniposed uf iched to tlie ^ (Fig. lO:^,). testinal ttilio iiinal cavity »11 intestines ;ioii in fn.iit the stomach position, Its li lis) ; })>>, piliiitiiry ;), pilniTl'lls , hd, liiii'y. 1!, outliiK' tmiKiiL' ; Ix, iiriiui- duct ; c, ci'iMim: ner right >itli' latod high up rtrc intostiiu'; clcvclopiiunt (U'istics ol'tlif rthcr growth, pace with the , that portion as a narmw lis appemhiiije 11 m. PJIVSJOLOGY OF PREGNANPy. 117 The connection of the yolk-stalk or vitelline duct (Fig. 105) with the intes- tinal canal rapidly hcconies less conspicuous, and by the end of the fifth week the yolk-stalk has but slight connection with the gut. The position of the A h Viv,. KW.— lU'CMiiistructioiis of human embryo of iibout sovontoiMi Jiiys (His): or, optic and nt, otic vesicles; ni\ iic', luitoeliord ; hil<f, heiulgul; y, mid-KUt ; hit, iiiiidgiit ; vk, viti'lliiio sac; I, liver; r, In, primitive ventricle and trnneiis arteriosus; ra, lid, ventral and iloisal aorta^; mi, aortic arches; jv, primi- tive jugular vein : cr, cardinal \ein ; dc, duct of Cuvier; iiv, iiu, umhilical vein and artery ; al, allantois ; Id', umbilical curd. jimctuio of the vitelline duct with the intestinal tract varies greatly, but usually corresponds with a point within the small intestine from 40 to 60 eentiineters (1(3 to 24 inches) from the ilio-eecal valve. When the usually atrophic cord is replaced by a tubular rece.ss, the persistent portion of the duct con.stitutes ^Teckel's diverticulum, a structure of interest. The vitelline duct may remain pervious throughout its iiitra-embrvonal extent, resulting .'sometimes in congen- ital umbilical (i.stula. The ventrally situated intestinal loops lor a time extend "TT^smmmwm I I i > ^m^. 118 AMERICAN TEXT-nOOK 07' OBSTETIilCS. through the uinbilit'al Dpciiiiig into the alhintoic stalk, in which, up to t!ie twelfth week, t ley are normally present; after the third month, however, the coils are permanently withdrawn into the abdominal cavity. The liver first apj)ears about the fifteenth day as a diverticulum (Fig. Kiii) from the ventral wall of the fore-gut, surrounded at its end by a thick la\i'r of cells. The organ is rapidly formed, the single diverticulum almost iminc. diately dividing into two, which in turn send ott" secondary and tertiary spront- like extensions of solid cell-masses. These cylindrical masses anastomose and form networks of cells throughout the mesodermic tissue assigned to the pro- duction of the liver. The spaces within the meshworks are occupied by the ricldy vascular mesodermic tissue which suii])lies the connective tissue and tlie contained blood-vessels and bile-ducts. The pancreas (Fig. 105) and the salivary glands are developed as solid outgrowths from the epitheliuiu of the digestive tract. The cylindrical ceil- masses at first are slender, solid, and rather dub-shapod at their free ends. They later acquire a lumen and expand into the characteristic compartments of a racemose ghi'.i. 8. Respiratory Tract. — The respiratory tract is closely related in its devel- opment with the digestive canal, since it is formed by a direct evagi nation from the ventral wall of the lower portion of the ])rimitive pharynx. The primitive trachea grows downward for some distance parallel with the esophagus, ami tlicn divides into branches which correspond to the primary and secondary bronchi (Figs. 104, 105); subsequently each of these undergoes repeated dichotoinoiis division, the resulting twigs in turn giving rise to smaller branches until the ultimate compartments of the pulmonary tissue are developed. The smailci- primary bronchioles are solid cylinders at first, their lumina appearing later. The cntodei'niic jiortion of the res])irat()rv iivict, directly derived from that of the j)riniary digestive tube, forms the epithelial parts of the organs, the cdii- nective tissues and vascular constituents of the same being products of tlie mesodermic tracts into which extend the epithelial masses. 9. Development of the Genito-urinary Organs. — The early stages of the human end)ryo, as well as of other mammals, mark the a[)pearance (u' the paired Wolffian bodies and the Wolffian ducts, which for a time repre- sent a functionating excretory apparatus (IM. 16), the ancestor of the per- manent kidneys. The Wolffian duct, appears about the fifteenth day as a longitudinal cell- mass extending throughout the posterior half of the end)ryo. The duet is fi)rnied by the evagination and isolation of ])ortions of the mesothelial liniiii; of the body-cavity, the resulting cylindrical cell-mass forming a cord that extends at first to the surface ectoderm, with which it has temporarily close relations (Fig. 107). These a|>pearances have given rise to the views advanced by sev(!ral investigators, according t(» which the Wolffian duct is ectodermie in origin. Careful examinations of suitable |)reparations show that the relations of the developing Wolffian duct to the ectoderm are only secondary, and that the initial steps in the formation of the duct occur, as stated, as evaginations ot' t ' ■' "'!*. PHYSIOLOGY OF PREGNANCY. 119 1, tip to tlie owever, tlie 1 (Fig. lOi!) thick layer nu).st iniiDc- iary sproiit- stoinose and I to the piD- ipiod by tlio ssue and the ped as Sdlid imlrical n II- ir free cuds. arapartaK'iits in its devcl- ;ination fmin 'he priiuilivo giis, and tlit'ii dary bronclii dichotoiiioiis les until the The snialh'i' leaving later. from that of uns, the t'oii- )ducts of the y stages of )pearance oi' time ro|>ro- of the pei- itudiiial ecll- The duct is helial liiiiiiir a cord that )orarily close Avs advanced 'ctodermic in the relations ary, and tiiat iigiuations of the inesotlicliuin ; the Wolffian duct therefore is a product of the mesodorn.. After a time the blindly terminating distal ends of the duets sink centrally and accpiire a communication with the cloacal expansion of the hind-gut. At first the ducts are solid cylinders ; subsequently they possess a lumen. Fi(i. HIT— Transverse section of sixteen day sheep embryo (Bonnet) : ec, ectoderm ; en, entoderm ; pm, pn'rictiil inesdilerni ; rm, viscernl mesoderm; am, amnion; nrnx, amniotic sac; t, »', somites; a, a', aor'tie ; «( , nutocliord ; », neunil cuiial ; Wd, Wolffian duct ; \Vb, Wolffian body. Some days later, usually about the eighteenth day, the Wolffian bodies appear as a scries of short cylinders (Fig. 108) which form as buds from the mesotiiclium of the body-cavity entirely independently of the development of the Wolffian duct. These rcxls of cells at first are solid ; during the fourth week tiicv acqiiire lumina and become the Wolffian tubules, and later grow toward and join with the Wolffian ducts. The closed ends of the tubules iiw IIW IVb Kit;. IDS.— Transverse section of seventeen day sheep embryo 'Honnet) : n»i, amnion ; ns, amniotic sac; n, neural canal ; x, smiiite <lill'erentiated into muscle-plate; IIV?, Wolffian duct; H7i, Wolffian body; pm, parietal mesoderm ; vm, visceral mesoderm ; n, n, fiisinn i>rimitive aortic ; i, intestine. become expanded and then invaginated by the apposition of blood- veis.sels sent into the bodies from the aorta. The tufted blood-vessels and the invaginated tubule constitute the Malpighian bodies of the W^olffian bodies, the predeces- sors of the similar structures of the permanent kidney. All parts of the Wolffian bodies, therefore, are derived from the mesodermic tissues. Second- ary tubules are formed as outgrowths from the primary ones whose origin has been sketched above. Trf^¥J^: I. .1 120 AMERICAN TEXT-BOOK OF OBSTETIIICS. The Wolffian bodies iiicrea.se rapidly during the .second month, ganiinff in size by tlie growth of the primary tubules and by the formation of new ones. These bodies act for a time as fiuietionating excretory organs, the period of tiieir greatest development l)eing about the eighth week. After this time tlioy undergo retrogressive change, so that by the fifth month the Malpighian bodies have largely disappeared and the eiitire organs become atrophic. In view of important ditferences in growth, functional activity, and UKtr. phological signiticaiit-e of various parts of the Wolffian body, there are reeog. ^i I Fl(i. init.— Heoonstnicti'd luimnn embryo of nbcmt twenty-cinht days (His): /-/I', brnin-visicUs, »ii', nriinil canal; ncli, nutuclKiril : nt. (illlutury )iit ; i\itu, cardiac ventridt' and anridc; rii,tln, ventral and dcirsal aorta' ; dn', termination of dorsal aorta ; th, median jiart of thyroid body ; Ir, larynx ; In, liiii); ,■.■, stoniHcli : ;i, imncreas; /, Intestine: /'. intesto-vitelline duct: nl. allantoic duct; k. kidney; nv, li.ft superior vena cava : cr, cardinal vein : ;ir. portal vein ; iii.«, vena ascendens, collecting blood from iniiliil leal and jiortal veins ; ui\ iiniliiliial vein. iiized an anterior xcgmcnt, corresponding with the head-kidney of lower types, always backward in its deve]t)pment in mammals ; a middir scfpneiif, wliidi from its relation to the generative organs in their formation may be regiudoil as the sexual portion of the orgtui ; and a posicrior xri/mrnf, likewi.se nuli- mentary in development and in the nature ol' the organs to which it contributes. The middle .segment is of most imi)ortance both functionally and mor|)lio- logically : this portion is sometimes designated the mefioncphron. The Mitlkridii JJucf. — Coincidentlv with the ibrmation of the WolHiaii >^i!A»jlL. PHYSIOLOOY OF PREGNANCY. 121 ga'Ping in f new ones, i period (if IS time tlicy ;hian bodies ,-, and nior- •e are recog- -da -th -ti -va -cv ■P P' -da , brnin-vi'sick's; : I'd, </(!, vi'Utiiil liiryiix ; ';/, liini.'; kiiliii'V ; I'lv, Kit bluoil friiiii iiuil'il- lower tyjHs, tf/menf, whicli be rejiiii'dod ikewise nidi- it contributes. and nioriilio- the WuliViaii duct dnrin<r the fourth week, an extended ridge of thickenetl me.sothelium appears along the outer side of each Wolffian body, from whicli, however, this rid.rc is entirciv independent. These ridges represent tiie early condition of thc^MiiiU'riiiii ducts, the luiuina appearing within the cell-cords about the fifth week. The .Miillcrian duct ends blindly below, and later po.ssesses an ex- panded, truuipet-siuipcd anterior end. Its important morphological relations are considered in subsequent paragraphs. Tlie permanent excretory organ, the kidney, and its duct, the ureter, are derived primarily as outgrowths from the lower end of the Wolffian duct (PI. 16 h; Figs. 105, 109). About the fourth week a diverticulum grows from the hinder end of the duct forward and dorsally into a mesodermic area close to and beiiind the lower end of the Wolffian body. The tube thus formed is tlic primitive ureter, which extends within the mesodermic ti.ssue, where, after expanding into the immature pelvis, it breaks up into a number of tubes cor- responding with the cftlices, from which pass epithelial cylinders representing the epithelial portions of the uriuiferous tubules. Later the vascular mesoderm contributes the primitive glomeruli, which meet the expanded ends of the tubules and take |>art in the further development of the Malpigliian bodies of the kidnev. Bv the end of the second month the definite character of the renal structure has become established. As tiie permanent organ increases in size and functional importance the Wolffian body rapidly atrophies, so that by the end of tlie fonrtli month its activity as an excretory organ has disappeared, the parts still remaining bearing relations to the sexual apparatus alone. The bladder is the j)ersistent and expanded proximal j)ortion of the allan- toic duct which retains its lumen, while that of the distal segment of the same duct lo.ses its lumen about the fifth week, becoming converted into a solid fibrous cord, the Hrachi(i<, which stretches from the summit of the urinary blad- der to tiie umbilicus. Tiie bladder therefore differs from the kidney and the ureter in possessing a lining derived from the entoderm, and in not being entirely of mesodermic origin. The formation of the internal generative organs consists of two distinct developmental processes, the development of the sexual glands and that of their excretory passages. At the end of the first month the mesothelial cover- ing of the Wolffian bodies, along their inner borders, shows an extended area of thickening and proliferation, the resulting elevated bands, the genital ri<h/es, being the earliest traces of the sexual glands. For a short time these glands are of an indiffi'reut type (Fig. 110), the diffi'rential charaeteri.sties of the two sexes not being manifested, seemingly, for .some days ; the primitive male gland then exiiiiiits a disposition to form networks of tortuous anastomosing cell- cords (Fig. Ill), the fcn'eriMiners of the .seminiferous tubules ; the female gland, on the contrary, possesses a larger number of the primlt'n'c sexual cellf<, and evinces a tendency of its elements to arrange themselves into grou]>s in which the larger primitive (.v;i I'ccinne central figures. Microscopical examination of the .sexual primitive glands even at the end of the fifth week is capable of dis- tinguishing the future sex of the being. It is highly probable, as emphasized f? ' v 122 AMJ':n/f'A.\ TExr-itooK or onsrETnrcs. End ,■/ Mtil- 1)\ Xiifjol, that inherent sexual differenees exist in the glantls Irom their oarli(-t appearance, and that the recognition of the indiflerent stage depends large Iv upon our iuiperlivt appreciation if these distinctions. The development of the second ]>;iit of the sexual apparatus, the system cf excretory passages, depends upon the ;i|)- ])ropriation and modification of alrcalv existing tubes, the tuhules of the Wolil'. ian l)(Kly, the WoltHan duct, anil the Gi'Mitat process ( /<■«;> or c/itoris). Genital fohls. Fig. 110.— iJiiiKram roprcscntiiiR tlio inililTirciit stnge in the devoli)i)iiu'iit of tlic KiiiiTiitivu uigiiiis (modifiiMl from AUl'Ii Tlioniiisoiii. Kio. 111.— Intcrnnl penerative orgnns of a luiile fi'tiis of i\t)out fourtoi'ii weeks (Wiildeyer, ■ t, Ws- tick'; >, epididynils ; «■', Wipllliim duct; «•, ;, /..r jiiirt of WoHlinn body; [U Kii'ierimculiim tc'sti^. ^rrdlerian duct. The fate of these .structures varies with sex. In the feniiijo (Fig. 112) the Miillerian ducts are mo.st important ; they develop into the ovi- t'intbria. Piirfi-uriiini _^^ I'tiroophoron. llicl. Bartholin s l^iitiui. Fiii. ll'J.— iJianrnm illustriitiiif: cliinii,'cs tiiliiiic place in dovelopinent of female u'ciierative ornaii.s Uiioditied from Allen Thompson i. Kif^ IIH.— IntiTiial orcans of a female fitusnf nhoMt fcjnrteen weeks (Waldeyer): o, ovary; '.ipo- iiplioron or parovarium ; ic', Wollliaii duct ; w, .Miil- lerian dnct ; u\ lower part of the Wdlllum l.nilv. ducts, and, after becoming fused, into the uterus and the vagina, while tlic Wolffian bodies and duct give rise at best to atrophic structures. The \\M- 1 I » -* iicir oarli( -t >iuls largely ociation <<i second pa it (> systom t't' upon the :i|)- n ot" ali'oaily ,fthoWolli- Lict, aiul the e (iri;nns <( » "i"le Wnldfyor, '. tis- m duct ; "■, ''■ ■•■r iiu'uliim testis. In the toiiiale ) into the nvi- if a fumnle fitns nl ■ r): o, ovary ; c, I'l'O- lllian iliict ; m. Mul- II' Wuiman Imdy. ;ina, while tlic The Wclrt- riTYSIOLOGY OF PRKGNANCY. 1'23 i'ln hodv ill the female contributes the transverse tubules of the parovarium or e',)oo|)horon the upper part of the WoltHan duct renuiining as the head-tube of the same atropine organ (Fig. 113). When the Wolffian duct persists it con- stitutes Gartner's duct. In the male subject (Fig. 114), on the contrary, the E/iiiliih'inis. liiilymis. heryans. Flo. lU— Pingrani illustratiiiK chnnfjcs tnkiiK; pl'icc in devclnprnont of male generative ot.'ans (modified from Alien Tlunnpson). Wolffian tubules and the Wolffian duct contribute the important system of excretorv tubes represented by the vasa effisrentia, the coni vasculosi, the tube of the e-Mdi(lvmis, and the vas deferens, while the Miillerian duct is atrophic, its extreme eiuls alone remaining as the sessile hydatid of IMorgagni, closely connected with the globus major of the epididymis, and as the sinus pocularis or nternx nnm-nVinuii, o])ening into the prostatic portion of the urethra. The atrophic tubules of the lower segment of the Wolffian body in both sexes contribute rudimentary organs, the 'pnrndldxjmh and the parodjtlioron resiteetivelv, which consist of a few tortuous tubules situated in the epididymis and in the broad ligament near the parovarium. The stalked hydatids of Morgagni, which are common to both sexes, probably represent portions of the atrophic liea<l-ki(lney and its duct. The External Genital Orr/ans. — Until the ninth or tenth week the external genitalia affi)rd no positive information as to sex, since these parts until this time represent a practically indiffiiM'cnt type (Fig. 115). Up to the sixth week the external openings of the gut and of the urinary tract are received within a common cloacal recess whose recto-urogenital orifice is siu'moiinted by a small conical elevation, the r/enital tubercle ; the lower and posterior surface of this eminence is divided by a furrow, the e/enital groove, bounded by thickened lijis, the c/enital foUh ; outside the latter a less con- spicuous elliptical fold constitutes the genital ridc/es. The end of the genital tubercle enlarges and forms a knob-like expansion, the primitive glans either of the future penis or of the clitoris. Toward the end of the second month 1"! 'T/T^r 124 AMKIUCAX TKXT-IiOOk' OF OliSTETItlCS. 51 the imporfl'rtly foniKHl septum bctw-'on the rpctiim and the iiriiio^ciiitnl pis. snge rosu'lu's pt'rfi'ctioii, wlicrcby tlio coniplcte separation between the alinit ni- arv anil genito-urinarv canals is .'tleete*!. In tiie male (Fig. 1 15, c, i;, (i)tlii' genital tiiberele elongates to form the jwuls while the lips of the genital furrow on its under surface unite to form the penile portion of the urethra ; eoint-idently, the closure of the edges of tlio urinogenital passage takes jilaee, the tube thus formed becoming continuous with the anterior part of the urethra just formed. The primitive genitiil ridges or outer genital folds grow together and eventually form the scrotiiin, into which the testicles descend shortly before birth. In the female (Fig. 115, D, F, h) the genital tubercle remains relatively small PH YSIOLOa Y OF PliKaXA NCY. 12C )}]jt'iutal pis- thf aliiui iit- I'ln tlic ptiiix, to form I lid 1/ -</ — 'V -A'- nonitiil riiliii-; ■ ital ritino ; ;;''. ;;ii 1), F, 11, iTtllll re ; Ji'i'. lu'riiu'iiiii Id!/, viijiina. nj^ contimioib initive fii'iiitnl 11 the scrotiiiii. elativelv small and Loconio^ the elitori.s ; thr fio.utal furrow roninins open, tho boi.n.mj; Rental i fo\ih f..rn.inir th." h.l.ia ...inora or the ny.nplias a.ul the external fohl. tornnng '' the I'lhi-i i.njorn At first the elitoris i.s disproportionately largo, but later it •^ becomes'ove.^sluuloNve.1 hv the rapidly growin- labia. Usually, by the end of A/ti/u/Mrj/ furrow. £ teiitrm. Cmh-fl tHiiDiitrm. A»iniim FiirieUil iiiisoilerm. Cdi'iii, mesuiierm. iXotochfli;/. S,'i)iitf. Gilt entoiierm. Fig. llti.-Transvirsr sictidii (if a sLMuen ami a half .lay sliiH'l) finbryo i.osst'SslnK' six scmiitos (llimiu't). the third niontli tlie e.xteriial sexual characteristies of the fetus are e,stabli.she<l beyond doubt. Jmperfk-t develo])iueiit, especially faulty union, of certain parts of the primitive genitalia produce the condition.s which give ri.se to ap- parent herinaphroditisni : true hernia|)hrodites, while not imjiossibilities, are Edoiiirm Amnion. raru-tal mesoderm. Cell-tiiass/or U 'oljfia » ioify. Celom ■ MesothcUiim. J'rimithif indothiliuvi. luSL<-r,t/ mesoderm. A'otOi'hord. B. 117.— Transverse sortion I'f a fiftooii and a half day sheep embryo possessing seven somites (Bonnet). ;^^^ainong the rarest maliorniations, since in them the formation of true sexual organs of both, sexes nin.st take ]dac(> in tlie same individual. 10. Development of the Nervous System. — The initial stage in the pro- duction of the great <<M'ebro-.spinal nervous axis is the formation of the medul- lary folds and groove ^^Figs. 116, 117), one of the earliest of the fundamental 126 AMKIilCAX Ti:XT-liOOK OF OBSTEritlVS. '■■. h'' processes in the development of the embryo. At the thirteenth day the neural groove is widely open throughout its extent ; two days later, by tiio beginiiinif of the third week, the groove has becuino converted into a closed canal by the ai)- proxinuition of the thickened neural plates along the dorsal mid-line. Tlic cephalic extremity of the neural ciiiial, Antt'irr /•raiii-Trs/c'/f. .l//(/,//.' I'raiiii'fsklf. /'usti) h>r /'rain-7'esich-. l-'ore-brai>i. Primary optic I'esicic. Stalk 0/ o/'tic ■■i-siile.^ --' into -brain Miii-brain Uiittihrain Intel 'hi ain^ Cefhalicfl,: Fofi'-brain. Ol/actoiy lobe. OftiL stalk: Ml,i-h.,in. llln.l: [t'tn- I'.iin Ccicbral porlin ,/ pituitary Iviiy. Pontine Jh.xiirc \'\i.. US. liiiiiinims ilUistriitiiii; tlio iiriniiiry iiiicl soc- uiuliirv si'iiimiitiilinii ul' tlu' Imiiu-tulu' iHniiiU't). l"i(i. llii.— Diiinrain shdwiiiK rolntimis nf liiain- vi'siclos anil lU'xuros (lidiiiuH. even before closin*e, becomes expanded into three jtriiuarj/ bfdiii-rcxirliK, tin. anterior, tiie middle, and the posterior. The anterior and the posterior nf these vesicles very soon subdivide into sccoixhtri/ compartments, the arraiii;v- ment of the brain-segments then being, from before backward, tho forc-hriiin, the iiif('i'-/>r(ilu, the iiiid-hniiii, the liiiid-bnuii, and the (iftcr-hrain (Fig. IIS), Coincidently with tliese changes the cerebral axis has sntFered marked tl(- flection ( Fig. 11!*) from its original aliiK^st straight condition. By the lllicciitli day the cranial tlcxure is strongly jironounced, a bend of almost 00° tiikiiis; place opposite the mid-brain (Fig. 120, a). During the fourth week fnrtlur marked changes appear; the bend opposite the miil-brain, or mcKou'CjilKili,' Jfc.i'Uir, has increased almost to 180°, so that the ventral surfaces of the iiitn- brain and the hind-brain lie nearly in contact (Fig. I'iO, n). The jiiiiitinii ol' the brain and the sjtinal cord is marked by the ccrfli'dl Jlcrtirc, wliiih forms ail angle of about !(0°. A third bend, the miiourplid/ic or froiitnl tli.r- lire, apjM'ars oj)posite the primitive cerebellum and the pons, and has its ciiii- vexity directed ventrally or in a manner opposite to the disposition of tin other curves (Fig. 1*20, r). The development of the individual jiarts of the brain dejiends lariiclv upon local thickenings of j)arts of the walls of the cerebral vesicles, wlicivliy areas of notable thickness arc produced, as in those which give rise to tin corpus striatum and the optic thalamus ; the cleavage of the fore-brain and iL ingrowth of connective-tissue structures accompauying the growth ol' tin l)rimitive falx likewise exert a profound iiiHuence in shajiiug the parts ardiiiii lay the no;;ral the l)eginirmg vc hasbeconio mil by the uji- ■keiictl utiinil litl-iine. Tlu' > neural canal, Cephalic flc.xu 'v. MU-l'.iin. llitui-. utiii. .Af'tcrhain : r-'liitious of I'laiii- rdiii-vrxiclix, \\w ]w ]n>storior dt' nts, the arraiiiii. the fori'-lmiiii. In (Fiii'. H^l rcil nuivkiHl do- \y the tit'ti'iMitli lost 00° takius: til week t'urtliiT ■OS ol' the illtrr- The jmiitiiin flexure, wliiili (' or frouliil thi'- xud has its cou- sposition oi" tlii' depends lari;ilv vesicles, \vluT(l>y jrive rise to tin' .re-hraiii ami tli' ivrowlh I't till the )»arts avdUiM J'JIYSIOLOdY OF PRKUyA.WY. 127 the lateral and tl.ir.l ventrieles. The ai>pearanee of sueh eou.miss.n-al bands as the corpus calk.sum and the fornix still further njodilies the adjacent struy- Fl(i iL'd— Hriiiiis (iriiiniiiiii fiiiliryos I'niiii rt'constniclii'iis liy His. A, hmiii fnuu lil'tcfii diiy iMiil)ry(); B, from tliivi" niui .1 linU-vvofk nnl.ry.. ; C. from sovon iiii.l a hiilfwook fetus ://., il<, mh. hh. „h. foiv-. inter-, mid- hind-, mill alU'rl>riiin vesieles ; -). optie vesicle; or. otie vesiele; in. infnnililmlnm : in. nuiinmilliiry process; ;)/', pontine tlexniv; IVr. I'onrtli ventriele ; )''.-, eervieiil lloxure ; ul. ollaetory lolie; h, basilar artery ; ;), pituitary reeess. tures. Tlie brain-vesicle UMderu;oinf>: least chanjic is the niid-braiu, since its walls remain niiclct't and retain their primary relations to (he enclosed canal. I! •3v— c/t </.._ ^ l-'io. IJl.— A, mesial seelion thronnh Imiiii of a linnnin felns of (hh ami a half montlis i iiisi : cli, cere- ,))rai In luisphere ; u. opti<' thalamns ; ,//», foranu'M <if Monro; ol/. oil'ae!i>ry lolie: ;>, pitniliiry luuiy ; nii), Jncdiilla ohliincala : iv/, corpora iiMaiiriucniimi ; eh. cen'liclUim. II, lirain of linnnui t'elns of three nmntlis ■iJHish (i/>'. iill'aetory lohe; Cfl, corpns striatum; ii/. I'orpora iiiniclrij-cinina ; e/i, cereln'Uum; vio, nu'iluUii siblonj;ala. mhe relative position of tlit> initl-brain, however, iin<lei'ii;oes jri-cat ehaiiii'c, its original situation as the liijrhest part of tiie entire encephalon being gi'aduaiiy 'n... 128 AMERICAN TEXr-BOOK OF OBSTETRICS. it ( ? I t' f '! 5! i S J; I appropriated by the enormously developed eerebral mantle formed by the raiiid- growing cerebral hemispheres ; in eonsequeiice of tlic covering in of the mid. brain thus effected, the derivatives of this segment, as the corpora qundri- gemiiia, occupy a ])()8ition in the base of the adnlt brain instead of liicii' morphologically normal place. The extent to which the cerebral miniilc /hV Flii. VJJ— Kitiil brain at llio lii'Kinniiit; (if thi' einlitli iikpiiIIi (Mihalkovics) : A, supiTior, H, latinil.c, nu'sial Mirtacc : U. lissiircof Itolainln : yirc, iirocciitral lit^snri' : S//, Sylvian lissiirc : ii'li>. iiittTparictal lissurc ; jii/c, iiariito-uccipilal lissiirf ; p//, purallel lissuri' ; calhii, calldso-niarfiinal lissure; uiw, uncus; ('(i/c, cilou. riui' li.<suro. covers the remaining parts of the enceplialon, including the cerebelhini, is distinctive of the luiman brain (Figs. 121, r22). The inter-brain undergoes great ditlerentiation, its derivatives forming niiincr- ous highly specialized organs, among which are the eyes and the pineal and j)ituitarv bodies. For the con)plicatcd details of the development of the various parts of the brain the reader must be referred to the special works im embrvology. The following table, however, modified from liertwig, will scrvf as a general indication of the genetic relations existing between the more im- portant parts of the enceplialon and the primary cereiiral segments: Dl'.VKLOrMF.NT <1V THK HfMAN I')KAIN. I'ltlMAKY Vesiclks. I. AntiTiiir |)riinary hrain- vi'sicji'. SErosnAKY VEfilCI.KI*. Floor. KooF. Sides. n. Middle iiriinaiy iiriiiii- vcsiclc. Ill, I'dsliTiiir i liriiiiary hrain visiclo. 1. Anti'rioriKTt'nr (inat ccnliral niantlt". corpiis Lateral Korebrain. ab'il spaces; eiillusuni; fiinii.x. veiitri (ilfaelnry lubes. Optie eliiasiii : I'iiieal bndy ; ; I iptii' tlialaini. I'liirdven Inter-brain. luber eine- pusierinrenin- reuiii : iul'iui- iMis>.iiri- ; ve- dibiilinii ; I'or- liiiii iiitrrpiis- piira nuiiiiniil iluni. :!. Cerebral pedini CurpnrM (|uad- ilenieulale .\(|Ue(luet .Mill-brain. eles ; pusle riueniina. i bodies: , of Syl- ri(ir perliirated i braeliiil. i vius laniinit. I. Tuns \'arn!ii. .Xnli'rlnr nieil- Superior anil llind-braiu, ullin y mIuiii ; middle pe- eeri-b'eillllil ; dlllleles id' i |His|eriiir tiled ei'reliellmii. ! iillarv velum. Kuurtli venlri- (de. Ji. .Medulla ublnU- 'lliiu e..\eriiiL' Ilileriiir pe- After-bniin. pita. of pn-lerinr diiiiele« nf purl 111' I'liinill eereliellum. ventrli li'. PHYSIOLOGY OF PREGNANCY. 129 by the rajiid- of tlio \\\\i\. pora quinlri- toad of tiioir L'bral inantlo ii'rior, B, liiliiiil.c. itrrparii'tiil li-Mirc. uncus ; cah\ mXai cerebellimi, U ornnn^ntiiiMT- tho piiK'iil and )|)ment of tlio )ceial works (ni witr, will sci'vc n the more iiii- nts: A. HriiiiiiiiiuitUv id li, Uniiii "l"lk i- I The spinal cord i.< formed primarily by the thiekening of the lateral wall of the neural tube, the latter becoming reduced to a narrow passage, later the centrd oaual At first grav matter alone exists, but with the formation of the nerve-fibres the white tracts appear (Fig. 123). The nerve-fibres connected Ecttidirm. White matter. \ Dorsal commissure Spin'ilga Di'isat root. l\ii:>itl >i«'t: S/>iiial nerzc. ,/^^ ^m^'' / Outer mei/nliitrv :oi:e. Central ciinui. S'otochord. Ventral commissure. Y\\\. IJM.— Traiisvor^f scLtiou of (Ifvoloping spinal coril (if a twenty-two day sheep embryo (Bonnet). with the spinal cord ditfer in origin according to their function whether they are motor or soiisorv, the former proceeding as outgrowths from the nerve-cells within the cord, the latter as processes from tiie cells of the spinal ganglia ; these latter centres, in addition to the sensory fibres i)assing into the cord, send to the lU'iipiicry fil)rcs l)y which sensory impressions are conveyed. The s\jm- patludc iicrroiiti si/stcin originates from the spinal ganglia, from which portions are separated as tiic organs of the sympathetic ganglia. It may therefore be acce|)tcd as an axiom that all nerve-fibres are produced as direct outgrowths from j)rc-c.\istiiig nerve-cells, and, further, that all portions of the great nervous svstcm mav he referred to the primary neural folds. 1 1 . Development of the Organs of Special Sense. — The history of the specialized organs of touch, taste, and smell, as represented by the various forms of tactile lu'rvc-endings, such as the corpuscles of Mei.ssner, Vater, etc., the taste-buds, and the Schneiderian mucous mendirane, belongs to a consider- ation of the histogenesis of these structures rather than to a brief outline of salient featiwes in general development; suttiee it here to add that the organs of taste and smell consi,<t essentially of tissue which has become specialized into iieMro-e|»itlielium, the perceptiv(> elements consisting of modified epithelial cells bearing close relations to the nerve-fibres. The various forms of tactile corj)nscles receive more or less highly developed sheaths from mcsodermic tissues. The organs of sight and of hearing, on the contrary, claim greater attention on account of the profound embryological proeei^ses in.stituted in Itheir formation. The development of the cjic consists e.-;sentially in the formation of two ni Ml I [Mil t I ! (■ i i .•'I' 130 .lJ/J5'/?/CJ.y TEXT- BO OK OF OBSTETRICS. ectodermic epithelial pDiiclies, the optic vesicle and the lens-sac, around wliili the adjacent luesoderm dilierentiates into vascular and fibrous envelopes. '! ho Fig. I'Jl.— Scotioti through Fic. 12'v— Se( uon through lu'iiil of ton day nibliit I'lii- (ievi'lopiii),' ojo cif ulfvoii diiy liryo.o.xliiliitiiit-'priinary nptic riibliit inihryo (I'iursol) : H, vi'ssc'l (Oi ]initni(linK frniii fnii'-liriiiii ciuini'cttMl by stalk fore-lirniii (7)t iiiul cciminjr in with ojitic vosii'lo (o), whose oontnct withsurfiic'ei'Cto('.orni antoridr wall Is partly invaRi- (f); m, surrounding mesodorm natod: /, thickenod and du- (Piersol). prtssod lonsareii. Fl<;. 12fi.— Suction through dcvil. ),i||,_, cyo of ck'von and a half day rahlii; ,1,1. bryo (Tiorsol): IS, foro-bniin coniirrud with dptii' vesicle (<;), nearly etlin-..! |,y ap|iositinn of Invnninated anterinr x;.. nient u'l with jposterior wall (/<i; /, hnv. sa" eonipletely closed and separati'il rn.ni ectoderm ; I. tissue within secondarj upii,. cup derived from stirroundinn niescUrm. first trace of the visual organs appears very early — at the fifteenth day — as tlie conspicuous optic vesicles (Fig. lJ8i v.'iiich are formed as lateral evaoiim. tions from the hinder part of the ante- rior primary l)rain-vesicle ; later, w Ikm the optic vesicle oi>ens into the ccicbial cavity by means of the o])tic stali<. tlir latter communicates with the inter- brain. The original optic vesicle -noii exiiibits indentation <jf its anterior \\;ill (Fig. r2o). the invagination iinioio.- A Fro. 127.— Section through developing eye of thirteen day rabliit emliryo il'iersoli : », eiloderni : /, lens, consistiiit.' of anterior inicleated division reprt'sentinu'lliiii IronI «all of lenssae, and ^'really thickened posterior division coniplelely lill in;.' ciiv- ity of sac by eloniiated lilires whose nui'iel present creseentic zone (J) ; /i, posterior iiiunieiileil layer: r. specialized anterior ri^tiiial layer: /. jioinl w here layers ofoptjr vesseN become continMous : », ex- tri'MU' peripheral seeticiu of tissue of primitive optic nerve connected with vascular tunic in oecu- pyiuK posterior surface of lens: ni. surroundinir mesoderm, which (at t) nro«s between lens and retina. V\i,. li;s,-.\, brain of two ilay chick eiiihryu: li, brain of human embryo of three week^ dli,«' Shows the developuuMit of the optic vesicles aiiij liniin-vesicles: //), fore-brain: ;", inter-brain. •«. optic vesicles. ing until the displaced layer conies in contact with the posterior and iiiitir »l_. '•!^|' round wl.iili elopes ''.'he liriiiij;li ilt'Vil' (.ills; lilt' ilay ralil.ii <ii;- v-bniiii I'diiinciid IK'lirly OlVlin-,1 hy llltl'd HIltlTinl >,;.. ir wall ( id: '. Inis- imii soimniti'il rn.iu hill si-'('(iii(Iar\ 'iptic lUiidiiiuinfMiiliTiu. th tlay — :i> tliu es (Fig. 1-J8I, iteral ov;ii:iii:i- rt of the aiitc- Ic ; later, \\ lien ito the eerel)ral optic stalk, tiir ith the iiitcr- tic vesicle m"iii ts anterior \v;ill ition pro<j,r(>>- ,l:iy chick I'lllliryir ilircc wci'k^ dlis' (ijltic Vl'sirlcSUIl'l ,h, iiitiT-brain. "'. erior and mitrr PHYSIOLOGY OF PREGXANCY. 131 undi<tiirl)ed segment. The cavity of the original vesicle is now represented by the hemispherical cleft between the two layers. The cavity newly formed by the invagination of the ])riniary vesicle becomes the optic cup, antl repre- sents the space later occupied by the crystalline lens and the vitreous body. Coincidcntly with the changes of the optic vesicle, the surface ectoderm at first exhibits a depression lined by thickened cells; this recess or pit rapidly .-^/ ' r^t-s' I'n;. Vl'.K Ilmiiaii ciiiliryn nf atiout twmty-i'iKliI ilays iMis); l-V, tirain-vcsicU's ; P, /-, J"', /'. cuplialic, ciTvical, iliirsal. ami Uiiiihar lU'Xiin's ; d/i, eye; o/, ciptic vt'siclc ; o/. iiUaclnry pii; hij-, mi/, max- illary and niamlilmlai' prnccssfs (pf lli'st visceral urcli ; ,</), ^•iIlll^ iircccrviculis; li\ li". heart; /, /', liiiihs , n(8, alliiMtnic !.|ulk ; lii, villmi-, churidii. deepens ami expands, and finally becomes the closed and isolated lens-sac, lying within the month of the (tptic cnp, which it largely Hlls (Fig. 120). The fate of the layers com|)osing the optic cup, bricHy statetl, is the forma- tion of the various parts of the retiiu.l tract, the outer and posterior layer becoming the characteristic -;heet of retinal [jigment ; the blood-vessels antl the m^' flu: 1 ■ I i; m !■< 132 AMJ'JIx'JCAy TEXT-BOOK OF OBSTETlilCS. connt'ctivo-ti.s.<ue elements of the retina are secondary ingrowths (Fig. 127), The hinder wall oi' the lens-sac nndergocs great proliferation, growth, aiid thickening, and eventually tills the entire sac, the lens then continning as a solid body composed of specialized epithelial elements. The surrounding mesoderm contributes the blooil-vessels, the vitreous bo,] ; the choroid, and the sclerotic coat, including the iris and the cornea with llm exception of the anterior epithelium of the latter, which is ectodermic in origin. The eyelids, which appear toward the entl of the second month, aio developed as duplicaturcs of skin above and below the eye ; about the end of the third or the beginning of the fourth month the lids meet and unite, tlic eyes remaining closet! until near the end of gestation, when the lids peniia- nently separate. The ear includes several distinct developmental processes, since the gcii('si> of the auditory apparatus of man includes the formation of the external, the middle, and the internal ear. The external ear is closely related to the history of the first outer visceral furrow, the external canal being, with some minor variations, the representa- tive of this cleft, and the expanded parts constituting its pinna, resultiiii.r from the fusion and metamorphosis of the auditory tubercles (Fig. 129) >iir. rounding the outer end of the visceral furrow. The middle ear is formwl by the persistence and further expansion of tlio first pharyngeal pouch, hence possesses an entodermic lining. The tyiii|)aiii( membrane includes contributions fntm all three layers, its outer epitlicliinn being ectodermic, its inner epithelium entodermic, and its fibrous tissue niexi- dermic, in origin. The /;(/'r/(a/ rrn- consists of the morphologically older ectodermic ])orti(iii, which is rejiresented by the complicated membranous labyrinth, and the surrounding mesodermic cnvelojic, which becomes the bony capsule, and \\\v connective-tissue structures intlnddl between the osseous and the nieinlna- nous labyrinth. The earliest appearance of the ear< takes place about the fifteenth dav, when on each side of the hind-brain ;i depression lined by thickened ectoderm (Fig. 130), the (ific pit, is formed. Al- m(»st immediatcdy these pits becmn' converted into sacs, the otic ve.vrle.s, In the closure of their mouths, and sodii lose all connection with the ectodenti, 't'j.A.jNa. ■•,1 ..■„ 4/ \-^*rf-, ' X ii Flii. l:W.— Si'ctiiin tliriiuj.'h <U'vi'I(iiiiiiir nir nf niiR' Mini a liiilf iliiy niMiit iMuKryu i I'iiTsiil' : ., (•ctcMkTiu tliickclii'il 1111(1 iiiviij;iiiiilcil to firru iiu- <li|(iry pit (at oi : iii, siirrciuniliiij; siill iiinliiriTcti- tiatcil iMi'Scidoriii ; >i. liiiiiif; nf iicunil tiihc; r. bliMiil-vrssel. King entirelv surrounded bv iiic-d- dermic tissue some little distance hc- neatli the free surface. The otic vesicle appears pyrifi)rm, that part corresponding with the closed mouth becoming ex- tended ; this elongation soon becomes more pronounced, so that the now sumk- PHYSIOLOGY OF PREGNANCY. 133 i (Fig. 127). growth, and tinning as a itreous bodr, nea with llio ct'.Mlerinic in (I luontli, arc it the end of nd nnite, the 3 lids poriua- ce the geiusiv ! external, tho outer vis('(>ral he reprcsciita- nna, resuhine Pig. 129) Mir- pansion of tlic The tyniitanic tor opitlicliiim IS tissue iiu'>(i- orniic portinn, intli, and \\w psulc, an<l tin urcs iiirliidcil 1 tlie uii'inlira- nce of the cars Hftoc'iitli day. 10 hind-hraiiia oiiod ootodci'ia ornicd. Al- pits hcciiiiii oiU' irxicli'x, liy lutlis, and >m\ tho octiidt'iiii. lod l)v iix'Sd- (> distanrc lit- riio otic vcsiclf II hoooininir ''X- tlie now sdiiii- what flattened sac presents a conspicuous outgrowth, the reccsms labyrlnthi (Fig. 131, a). The otic vesicle a.ssnnies greater irregularity on account ot the appearance, durin.r the fifth week, of a blunt diverticulum, anteriorly and vontrally directed, which is tlie earliest trace of the future nienibranous cochlea, and, shortly after, of dorsal projections on its outer side, which foreshadow tho scniiciVci.lar 'canals (Fig. 131, H, c). Before the end of the fifth month, the chief coinpartiuent of the vesicle, by this time of considerable size, undergoes Km. iai.-I)L'vi'l('|iiiU'nt dltlie mcmViranous lahyrintli of tlie human ear (W. ITis, ,Ir.1. A. lift laby- rinth of eniliryi) of ahoiit four wooks. outor .sitie : v. c, vestibular and cochlear portions; rl, reees>us labyrinthi, H. Kit liibyriuth with parts of facial and auditory nerves of embryo of about four and a half weeks: r/, recessiis labyrinthi; ,»,■.(■, jiw, esc, superior, posterior, and external seniicirc\ilar canals; .'-■.sac- cule; f, cochlea; rn.jn, vcstibulnr and facial nerves; vg, eg, gg, vestibular, cochlear, anil geniculate tian- glift. (', left labyrinth of embryo of about five weeks, from without and below : labelling as in preceding figure. subdivision by the formation of a coiLstricting fold into a dorsal division, the priinitivo utricu/ut^, and a ventral division, the primitive sdcciilm. Tho nidi- mentary .soniicircular canals and tho jirimitive ooohloar duct open rospectivoly into the ntriclo and the saccule. Tho rece.<sus labyrinthi has become nioan- \vhilo greatly elongated, and its proximal end cleft into diverging tubes at tho formation of a .septum. Those limbs of the recess open into diil'oront spaces, one entering into the saccule, tho other into the utricle. The jiermaiiont arrangoniont is now establi.<hod whereby ctmimunioatioii betwoon tho divisions of tho membranous vestibule, tho utricle and the sac- cule, is ctfcctod only by tho indirect pas.«ago through tho limbs of the ductus endolymphaticiis. Tho primary otic vesicle thus becomes tho complicated nieinl)ranoiis labyrinth, and the octo'^^rmic epithelial lining undergoes ditVcr- entiation in the formation of the highly specialized structures, as tho organ of Corti and tho macula> acusticre, for the perception of transmitted stimuli. The mosoderm immediately surrounding tho membranous labyrinth later undergoes imjiortant oliaiigos, whereby tho tissue next the opitludial structures is converted into the connective ti.ssuo enveloping and supporting the delicate I&0' f''-^ ^ mI i in f l;]4 AMERICAX TEXT-BOOK OF OBSTETIilCS. DESCilDING.«t VENA CAVA Flii. I3'.'.— i)i;iL;r;ii]i nC fftiil circiiliiticiii ln'luri' liirtli ; tin' iirinws iiidiciiti' tlii' cuiirsi' (if Ihu tiluoil- cumTit ; the i-iilcirs slmw llic (■ImnicliT 'if the lilncul ciirrifil liv tlic ililfcTriit vi'ssrls. I »'»"-' - m-^^ *^l m PHYSIOLOGY OF FREG.XANCY. 135 mmi liirsodf the blucil- •nt vcssi'ls. Fig. IX).— Diagram of eirculatiim aflor liirtli ; llic ihictiis votinsus. the fniamon ovalo, and the iluctus arti'iiiisus arc now clostHl and iin hinjior tnii.siiut iMirtimis of tlio bhiud-current. 136 AMEIilCAy TKXT-liOOK OF OBSTETlixCS. II I . / I • ,t 1 1 1.- ■ I ''I cpitliolial labyriiitli, wliilc tlif tissue slightly removed ^nves rise to the periitio cartilaginoiis eapsule which later is replaeed by bone. The important spicks oceupietl by the perilymph are formed relatively late, since the\ arise by ih,, breaking down and channelling of the mesoderm surrounding the j)itli' linl tubes. In the cochlea, for example, the ductus cochlearis, with its epitli. lial lining, represents genetically the oldest l)art, while the scala vestibuli ami tlic scala tympani are of more recent origin, since they are formed by partial ills. ajipearance of the mesodermic tissues. 2. Physiology of the Fetus. Nutrition and Growth. — It is evident that the life of the ovum, what- ever its character, whether vertebrate or invertebrate, picean, amphilujin, reptilian, avian, or mammalian, can only be maintained when the fundaiiK ntnl necessities of life — adetpiate supplies of oxygen, water, and suitable noiiiisli- ment — are provided. The ovum and the early embryo being witliout means df securing these advantages, such provisions must be ensured by the arraiigenu'iu of the immediate environments, whether these be within the maternal tissue. or within the protecting structures (»f the shell or the surrounding medium. The loss of yolk, which there is good reason for believing the mammalian ovum has suffered during its evolution, is compensated by the nutritive inato- rials supjdied to the developing ovinn by the adherent discus proligerus. and by the secretions of the oviduct and uterus which are taken into the intciiur of tlie egg by osmosis through the zona pellucida and the jirimitive ehdridn, The Fetal Circulations. — The earliest circulation, the vitelline (PI. 15), j, well established during the third week. The blood passes from the network i>\' the vascular area, by means of the large vitelline or ompliah-mcscnfcric irin^. into the sinus vcnosus, and then, after mingling with the blood returned Iv the systemic veins from the body of the embryo, into the auricular seginent of the young heart. From the anterior or ai'terial end of this organ tin blood is carried by the truncus arfcr'iosus into the aortic arches, hence into tin ])rimitive aortte, a small portion ])assing into vessels su])plying the enihrvu, while the greater part enters the vitelline arteries and once more gains tlu vascidar area. The development of the allantoic vessels and the jilacental circulatidii necessitates additional blood-currents, in the direction of which the imw rapidly developing heart and liver exert an important influence. For a tinu all the bloml returning from the placenta passes through the liver iiclinv reaching the heart ; later, when the hepatic capillaries can no longer aecoimiid- date the entire placental circulation, the <Jiictn.s irnosus is established. During the later months of gestation the so-called " fetal circulation " (Fig«. 132, 133) presents the following details: After purification by the respiratdiv interchanges carried on within the jilacenta by association with the matcimil circulation, the blood is conveyed by the single umbilical vein to the nndt r sur- face of the liver ; here the current divides, one part Joining the venous IdiMil within the portal vein collected from the intestines, and traversing the hepatic :o the pcvlitir portaiit spicis \ arit^c In tlio the })ith' lial I its opith( liiil itibiili and tlic hy jnu'tial ilis- D ovum, wliat- n, amphili'mii, le tundaiiHiital liable noiirisli- thout means (if le arrangcnu'iit laternal tis-tio- idhig nicdiuni. he nuiniinaliaii nutritive luatr- proligerns, and iito the intcriiir mitive clinridii, ine (PI. 15), i. the network dt' ncscntvric cf //i.<, k1 returned ly rieukvr segiuom this organ tlic . henee into tin- isr the enihrvo, more gains tlu ntal cirenlatiiiii vhieh the imw L-e. F<-U' a liiiii' lie liver hotiji'i' niger aeconiiiin- ished. •ulation " (Fig^. tlie respiratory h the maternal the under snr- le venous lilnml sing the lieimtk' I'livsioLOdY OF piij:..XAycy 137 capi 1 i Maries to reach the liepatie veins, tlie other jiart passing into these vessels direet'lv hy means ..." the thietus venosus. On reaehing the inferior eava tl»e arterial piarcntal hi^Mxl, i)iit slightly euntaminated i)y a(hnixture of the contents of tiie portal vein, is pound into the stream of venous blood returned by the inferior eava from tlie lower parts of the b(Mly, and is carried into the heart as part of the mixed stream. On entering the right auricle a fold, tlie Eusta- '•liian valve, directs the blood l)rought i)y tlie infe'-lor eava across the auricular cav'itv through the forameti ovale into the left auricle. Mingling with the small (luaiititv of blood returned from the uninflated lungs by the pulmonary veins, the blood-current passes through the auriculo-ventrieular opening into the left ventricle, by the contractions of which it is propelled into the aorta, and distribntcil bv the branches of that vessel to all parts of the body. The blood <iatliered from the head and the upper extremities and returned to the ri'dit auricle by means of the superior eava passes directly through the auricle and right auriculo-ventrieular orifice into the right ventricle, crossing in its course the blood-stream entering by the inferior cava. The contractions of the ri'dit ventricle send the blood thus returned by the superior cava into the pulmonary art<'ry and on to the lungs. These organs, being still unin- flated are incapable of receiving more than a small part of the blood supplied from the ventrii-le; the excess, however, is carried by means of a newly- formed channel, the durtw nrkrionm, which extends from the beginning of the left pulmoiiarv artery to the aorta. The blood carried through this canal niino-lcs with that descending the ixovhi ; on reaching the hyjiogastric arteries a large part of the current passes to the placenta for oxygenation, only a small proportion of the stream continuing within the systemic arteries for the supply of the lower parts of the trunk and the inferior extremities. It will he noticed tliat after joining the current within the inferior vena cava the blood circulating within the fetus is nowhere purely arterial, but is always ccmtami- nated hv the admixture of blood already distributed to other parts. The distinctive features of the fetal circulation are the ductus venosus. the ductus arteriosus, the tbramen ovale, the hypogastric arteries, and the umbili- cal vein. After birth, with the establishment of the res])iratory function and the pulmonary circulation, the accessories to the arrangement of the placental blood-current umlcrgo atrophy and largely disappear. While immediately instituted, these changes are not fidly efleeted until some time after birth. Obliteration of the distal ]>arts of the hypogastric arteries first occurs, and is usually completed by the third or the fourth day after birth. The ductus veno- sus and the umbilical vein are generally closed bv the end of a week. The duc- tus arteriosus usually closes within a few days, and is completely impervious by the third week after birth. I'ermanent closure of the foramen ovale is delayed for some time, the blood being excluded from the left auricle by the Upposition of the edges of the valve, which are kept in jdace by the increasing pressure from the left side exerted by the blood rettu-ning from the lungs. :After a time the edges of the valve coalesce with the margin of the foramen ovale and the opening becomes permanently closed ; not infrequently, how- jT-'-'TYTm l:\H AMi:ni('Ay ti-lvt- no oa' or oustktiucs. i ! f i ) i| ^" I I M...-^ I'vcr, iiioiitlis elapse belore the union heeonies eoniplete. In ea.se tliis union j^ never perfeetlv elleeteii, ii suiiill e(iniinnnieation may remain tlinaigliont 111; as a eonjfenital deteet, of sli^'lit or grave import depending upon tlie extent uf the fanhy union. Tlie estahlisliiiient of tlio vitelline eireulation, the Hrst one of the pnilnyo, marks the introdnetion of an important nutritive apparatus in animals jKKssessiiijr large volks, which in tiiem eonstitute sourees of nourishment of great eoiise- (pienee. In man and other mammals, however, the appeiU'ance of the vitelline eireidation must be regarded rather as the expression of formative proe( sses whose usefulness has largely disappeared in eonsequenee of the profound modifieations whieh the diminutitm of yolk and the greater dependence on tlic maternal tissues have witnessed. ^Vhile in mammals the exposure ot the fetal blood-stream over the extended walls of the vitelline sac or umbilical vesicle affords an opportunity for a limited exchange i)f gases, the amount of nutritive materials directly taken up and appropriated by the end)ryo nui>i li|. very insignificant. The deficiencies of the vitelline circulation in mammals, iiowever, are coin. pensatcd by the active development of the allantoic ves.sels and their fuitiiei' specialization into the all-important placental circulation, whereby the nspi- ratory and nutritive necessities are secured to the fetus throughout the last two-thirds of gestation. The j)lacental eireulation, by means of which the respiratory interchange nt' gases and the passage of nutritive sul)stances from the maternal blood to tiiat of the fetus is effected, is undoubtedly the principal, and practically the sdlc, source of those substances necessary to maintain the life of the developing ani- mal. The /it/KO)' (tiniiii has long been regarded as an additional source of initii- tive materials, in view of the fact that this ffuid is undoubtedly swallowed by the embryo and taken into its intestinal canal, as .sliown by its presence, a< well as the presence of hairs and epidermal cells at a later .stage, within the gut. The comi>osition of this fluid, however, renders it highly improbi.!;!;i that it contributes in any appreciable degree to the nourishment of the (ctiis. containing as it does nearly 90 per cent, of water. Tlic liciuor aninii, never- theless, serves an important purpose in supplying the water neees.sary fur the fetal tissues, since the latter must contain \>ater in excess, according to Preyer, in order to extract the albumen and the salts from the blood broujrlit by the umbilical vein. The fetal jdacental vessels convey albumen, salts, and water from the mater- nal blood into the circulation of the fetus, as well as the oxygen absorlKiJ by the red blood-cells during their sojourn in close proximity to the siriuse* filled with the blood of the mother. The soluble .salts probably pass Inmi the maternal blood into the fetal blood by simple osmosis. That the alliii- minous substances, however, are so transferred is very doubtful, but the soliitinii of this question, it must be admitted, so far has been unsatisfactory. The ingenious explanation advanced by Rauber, that a physiological transmigration of leucocytes from the maternal tissues into the fetus furnishes the means of this union is iighout lil us the extent nf f the onil)rv(i, luls possessing' t' jrrcat cdiise- ;)f the vitelline itive proe( >sw the proi'diiiiil cmlenee on tlic cposiire oi' the :; or iunl)ilic;il the ainoiiiit of inhrvo nui-( lie «r I'over, are cmn- d their fiirtlur ■reby the rcspi- itlhont the \a>\ interchaii^o of »1 blood to tiint tieully tli<> siilf, developinji ani- souree of niiti'i- V swaUownl liy its presence, ;i< tage, witliin tlio dy iinprobi.M" 3nt of the fetus, anmii, never- r necessary fur !, aeoordini; to blood bronirht Tom the inatcr- xvgen absDi'bcil to the siinifc* ably pass fiMiu That the alltii- biit the solntinii isfaetory. Tlii' transmigration !S the means of V rjiYSJOLoav or PUKaxAXCV. r.vj trans) nsportation of particles of albumin, fat, lecithin, and similar substances, lacks eontirniati(Ui. 15y some the evidence is regarded as strong that they pass over in tlu- form of soluble peptones. That substances in solution pass from the maternal circulation into that of the fetus has been provetl by direct exiwrimcnts with iodin ((Jusserow, Kru- kenlurg, Ilai.llcn), salicylic" acid (Henicke), and pc.fassium ferrocyanid (Fehl- ing). The investigations of /weifcl demonstrated the free and rapid passage of chloroform administered during parturition from the maternal blood into the uml)ilical circ.dation, and, cousecpiently, the highly pn.bable inHuence of the anesthetic upon the fetus. The result of attetupts t(. introduce substances in a condition of fine division, but not in solution, such as vermilion, India ink, fat, etc., have been negative, the seeming exceptions where such particles were found in tlu,' fetal circulation after injection being attributable to injury of the blood-vessels. Tlie migration of formed elements, such as the pathogenic bacteria of anthrax, typhus, etc. or the colorless blood-corpuscles, from the circulation of the motlier into the ti'tal blood is a (piestion about which there is nuich dirtcrence of opinion. Regarding the blood-cells, moreover, the investigations of Sanger point to the improbability of such migration taking place, since in leukemic conditions of either mother or child the blo{Hl of the remaining organism may retain its normal proportions. The experiments of Savory and (Jusserow have shown that in animals in which the fetus is poisoned by strycliiiia the poison may pass from the letal circulation into that of the mother. Certain substances administered to the mother pass into the liquor amnii, as in the case where iodin is given (Krukenberg). That the fetus takes no part in producing this eifect is shown by the fact that the drug is found in the liquor amnii even when the product of conception is dead (Haidlen) ; further, that coloration of the amniotic Hnid after the injection of sodium sulphindigo- tate into tiie jugular vein of the mother is unattended by the presence of the substance within either the kidneys or the lu-ine of the fetus (Ziuit/). The staining of tiic maternal tissues composing the decidua by the pigments con- tained within tiie meconium emphasizes the fiiet that substances within the liquor amnii may in turn affect the mother. The respiratory and metabolic changes within the fetus are carried on by means of the oxygen taken up from the maternal circulation by the fetal blood-stream in its passage throtigh the placenta, in exchange for the carbonic acid and other products of tissue-change. So long as this interchange of gases takes place without interruption in the placenta, the fetal circulation contains an excess of oxygen, since, notwithstanding the small amount derived from the mother, the (piantity of this gas thus obtained more than snttices for the nectls of the embryo, and induces a condition of apnea. When the placental circu- lation is interrupted, however, as by compression of the umbilical cord or bv premature se])aration of the placenta, the fetus perishes with all the symptoms "of asphyxiation. 140 A ME RICA X TEXT-BOOK OE OBSTETIUCS. I i Till' direct jinidf of" the source of oxygen from the ulaeenta has been .-up. plied bv the investigations of Colinstein and Znntz, who examined the blodd of the umbilical vein in sheep, and found it richer in oxygen than tliat wiiliin the umbilical arteries, although the difference between the arterial and the venous blood during intra-uterine life is nuich less marked than after liiith (Ilallibin-ton). The sj)ectroscopic analysis of blood from the human umbilical vessels bv Zweilel showed the presence of the oxyhemoglobin bands before respiration was established. The consumj)tion of oxygen by the fetus, as measured by the necessities of its own heat-production, is relatively small, since the maintenance of its tem- perature is greatly facilitated by being surrounded by the lifpior amnii, the warmth of which is almost 0(]ual to that of the fetal blood. The fetus is still further favored by being sjiared the necessity of taking within its lung- and alimentarv tract substances which nuist be warmed to its own temperatun' at the expense of its own heat. The presence of the warmed liquor amuii als, prevents caloric loss by cither radiation or evaporation. The pre-natal functions of the fetus include limited activity of the ki(hi(v> and preparatory exercise of the organs and glands connected with the alimentarv tract an<l the integument. The early excretory apparatus of the embryo is represented by the WolfViaii bodies and their ducts and the allantois. The yellowish fluid collected witliiii the allantoic sac after its secretion by the Wolffian bodies camiot be reganldl as urine in the strict sense of the term, since its elaboration long ]>recedc- tlio development of the fetal kidneys. There is, however, a similarity between the usually alkaline allantoic fluid and the later secretion of the fetal kidiiev-, the fluid often, i)ut mtt invariably, containing m-ea, uric acid, the alkaliiu chlorids, phosphate*, and sidphates, as well as iron, calcium carbonate ami allantoiil. The early jiresence of urea an<l the urates renders it highly |iivli- ai)le that the decomposition of albumin with oxidation begins at an early [teridd of intra-uterine life, the excreted substances being taken from the still ini]Hr- I'cctlv ditl'erentiated fetal blood. 'J'lie tpiestion whether the kidneys under normal conditions re<rularly seenti iM'ine l)efore birth has receiveil much attention and various answers. Tin weight iif evidenec und(inl)tedly establishes the exercise of such fimctldii, inn exactly the periml at which the secretion of urine first takes ])lace is still midi- termincd. .\ftcr the estaitlislimeiit of coinnninication i)etween th" bladder ainl tiic cxterinr uf the body bv the formation of the urethral canal, the lu'iiic i- discharged, during the later weeks of gestation, into the amniotic fluid, with wlndi it is in part swallowed by tlii' fetus. The coloring matters of the urine aiv elaborated uidy in vci'v liniitcil (|iianlities. as shown by the well-known pali tint of the fluid voided liy the new-born child. niijislirc Triii-f. — The pre-n:ital activity of the glands connected with tin fetal alimentary tract is a matter of nuicli interest in view of the deinainl- made upon these organs immediately after birth to supply I he ferment- nen- sary in the procc-.- of digestion and assimilation. Tiie inherent ditliiiillii- ■M i rilVSIOLOGY OF PREayAXCY. 141 liuji been >np- loil tl'o li'udd in that wiiliiii oriiil ami the lan aft or I'irtli man uniliilicnl bands b( lovo ^ ncoc'Sfiitic- of lice ol" '\y tiiii- nor aninii. ilic ho ibtus is -till I its hnisr- ami toniporatiiic m nor anniii al> . of tlio kiihu'vs I the aliiiuntarv bv tho Wolflian collootod within inot be ri'irai'did in<r jn'ocotlc- the lihirity bctwctn ic fetal kiilin'v-, id, the all<alim' arbonatr ami ( it highly |inili- an early iicriml the still iniiM!- i-i'irnlarly scci'cti' answers. Tlif eh i'nnctioii, Imi jice is still iiM'l'- tli'bladtlrr ami nal, the iiriiH' i- lnid,\vithwtii'li ,,!' the urine an well-kill >\vn jiali nneeted with tin ,,f the diiiiaiiil> . ferment- ncir- (■rent ditli'iiliif attending the investigation ..f the subjeet in the human fetus have left our knowledge on inanv points still far from satisfaetory. The siliva of the fetus has reeeived mueh attentii)n with a view of deter- niiniii.- the p'lrseiiee or al.seuee of ptyalin. While the results of the observa- tions by various investigators are contradietory, the positive evidence of the presenee of tliis ferment in the saliva of the new-born obtained by Hehiffer is important. This olwerver demonstrated the unmistakable presenee of ptyalin in the salivary secretion of three new-born children, thus showing that the capal)ility of coiivertintr starcii into sugar exists in the saliva from birth— a iLt the more remarkable when the absence of the opportunity for the exercise of this power is icealled, tiie character of the early food recpiiring neitlier stareli nor dextrin. It has been sliown that the ptyalin i~ : «t elaborated in- ditfereiitlv by the salivary glands, but that its presence is limited to the .secre- tion and tissue of the parotid. The relatively tardy development of the labial and other glands of the oral cavity is in accord witii the observed slight activity of the secretory function of the moutli of the fetus. Tlie trii^tric secretions of the new-born iiave been fotnid to contain pepsin and remiiu immediately after birth, pepsin digestion and the power of curdling milk heiiiu; estaldislied within a tew hours. Tlie observed ditferences in the amount of pepsin contained in specimens of the unicous membrane of new- born eliildreu probably depend upon tiie variability in the development of the gastric <rhuids, as luiinted out by Sewall. Tiie pancreatic fl'/meuts are j)robal)ly represented before birtli by the pres- ence of tri/jisiii, wiiich acts especially upon the proteids, and a fat-splitting ferment {pducirdliii, .•<lf(tpxui), i)ut not by (imi//<>jisin, which resembies ptyalin in possessing the power of attacking starch. liangendorH' demonstrated the presence of trvpsiii in the j)ancreas of the fetus at tiie fiftii and sixtii month ; Zw'cifel, tliat <if pancreatiu at birtli. The large amount of fatty and albu- minous matters in tlie milk ;it onC'. sug^ 'sts the necessity of the early |)rep- aration of the dige-tive ii'rmeiits rciiuiri d for the disposition of these substances. The iiitc'^iual secretions at birth differ widely from those of a slightly later period. In t.iis respect the observation of Werber, showing the relatively larger niimher of Briiuner's glands in the new-born than during later life, is of interest, although the function of the glands within the fetus is not obvious. The liver early develops, and soon becomes the most con.-picuoiis organ connected with the fetal digestive apparatus. Its large size suggests an early activity, which, in fiet. observations on mammalian (Miibryos confirm. A sub- stance resembling bile has been found in the small iutestiues from the third to the fifth inoiith, and later in the large gnt ; in this niMterial, from tt'tuses of the third mouth, Zweifel found the bile-acids and the biliary piguients. The iiiecoiiinm, the contents of the fetal intestinal canal at birth, jircsonts a dark, iirowuish-green or almost black appearance, and a sott, viscid, pitch- like consisienee. Its source has been the subject of interesting investigation, but much relating to its origin still remains to be investigated. Tlw produc- tion of meconium seems chiefly related to the Ibrmation of bile, since it is If ' I / Ill' (■■ il; [i/! 142 AMEIilCAy TEXT-BOOK OF OBSTETRICS. ' 'J > I . ! ; i absent before this secretion is i)t»nre(l into the intestinal eanal, as well a- in eases of malformation in which the elaboration of bile is wantinfi:. The \ icw attribnting to the swallowed liiiuor amnii an active rv/c in the formation of the meconium is opj)osed bv the presence of this substance in malformed fetuses in which the ])ossibility of entrance of the amniotic fluid into the inus- tines was jirechulcd. Jjcfore the secretion of bile meconium is not present, llennijr obsi :\(.,1 liifht vellowish-green meconium in a fetus at the ben-innino^ of the Iniinl, month. The l)e<iinning of the fifth month usually marks the period linin which the meconium is constantly present. This substance, in addition tn the bile, consists of the unabsorbed portions of the intestinal nuicus and juices. the secretions of the glands of lirumicr and of the ]>ancreas, and of tiie >\v;il- lowcd amniotic li(|ui(l, together with such remains as leucocytes, intestinal cpi- thelium, lamigo, epidermal cells, and fat from the vcrnix caseosa carried jnt,, the gut-tract along with the li(]Uor anniii. The chemical composition of meectniuni, as ascertained by Zweifel, indiulo-: from 20 to 27 per cent, ol" solids, of which about 1 per cent, is inorganii', tho remainder organic; the amount of fat and fat-acids and of cholesterin is the same — about .75 per cent. The inorganic constituents include the ])hospllat^^ and sul|)hates of magnesium and calcium, Mxlium chlorid, and oxid ol' iron, The i)rineipal organic substances are the more or less changed bile-salts, tin unaltered bile-pigments, bilirubin and biliverdin, and mucin. .'). Multiple Conceptions. The fecundation of more than a single ovum, or, as often less accunitdv termed, " nndtiple ])regnancy," is by no means an infrequent occurreiicc, ;i> the munerous births of two or more children testify. Afnltiple conci ptioib may result in the birth of twins, triplets, and, as great rarities, (pia(lni|il(t.«; a nund)er of well-authenticated instances of five children at one time niv recorded ; and even an apparently trustworthy case of the birth of six, i;,i|i bovs and two girls, has been reported by Vassalli. The reputed biiilis in excess of this nundjcr arc apocryphal. The most extensive series examined with a view of determining tlir iv|;i. five frc(|ueiicy of multiple conceptions is that studied by (}. Vcit. wiiici, included the records of thirteen million births in I'rnssia. According tn tlif-i statistics, twins occur imee in (SS births; triplets, once in 7910; ami (|iiail- ru])lets, once in .'571. 12(). About a dozen autlicntic cases of liv(~ at a liini: arc recorded in medical literature ( Kaltenbach). The statistics of (lilllivii; countries seemingly point to considerable variations in the fre(iuency (if twin-. thus, in Bohemia twins occur once in about GO births, while in I'^-aiKv ilnv appear only once in every lOd. Keccnt statistics supplied by the linaid >: Health of \<'W York and of I'iiiladelphia ])Iace the frc(pieney of twin liiiili- in these cities at 1 in every \'2*^ i)irths. In acc(>pting such conclusions, linw- ever, ])ossible errors arising from ditlerences in the character and coniplctoiii- of the statistics compared niu-t not be overlooked. ', ^^^^W^*"" ■* .iJr.i... ,ui PHYSIOLOGY OF PltEGXAyCY 143 as well u in ct. TIU' \ U'W ', Ibrmatidii df in inaH'oi'inwl into the iiius- of tlio t'li'irili K' period lidiii addition tn tlu' ('US and juicos. ml of the >\v:il- 3, intostiuiil cpi- iisa carried iiitu 'iWeifel, iiu'ludo- is inorganii', tlio ■holesterin is tlie I' the ])hosph!ito> lid oxid of iron, rod bik'-saUs, the in. n loss aeeiu'iitcly nt oeeurreneo, ;!• tiple eonecptiom ties, quadnii»k't>; at one time aiv birth of six. U\\ repnted hiilli> in rmininu; tlic ivla- V (I. Veit. wliii'ii Aeeordinir '" du-i 7910 ; and ^\\\\\\- „f |iv(> at ;i I'ii'ii. iti^ti<'s of ditVcivn: •ctiueney of t«i'i- 1,. in FraiHv ili.v by the r«":>i'.l '■: ■ney of twin Im'ili- conclusion-, li"«- ■r and eomitletom- Of loO.OOO twin i)regnancies .studied by Veit, in one-third both children were bovs ; in shglitly le.<s than one-third both were girls ; and in the remain- ing third both .sexes were represented. Twins are more frequent in multipane than in pnnuparic. Iiidividuid and inherited tendencies seem also to i)e factors in tiie oecnrrenee of nudtiple conceptions, since plural birtiis .^^ometimes renilcr /particular women or certain lamilies con.-ipicuous. Twins usuallvdeveloi) from two distinct ova derived from the same or from different Graalian ve.-icles, which may be separated widely or which may even be contril)nted bv dilferent ovaries, as shown by the i»re,«ence and location of the corixira Intea. When derived from a single ovum, the existence of a double germ iuav be assmned, with, however, the possibility borne in mind that the twins mav have arisen as the result of complete fusion of a single germ, as emphasized bv Ahlfeld in his investigation of the production of double monsters. Twins originating in this manner are termed " homolo- ffous" and are cliaractcrized by remarkable physical and mental similarity. Of 600 eases of twins, Ahlfeld foiuid but .sixty-six ])roceeding from a single ^(T, Twins derived from a single oviun are always of the ."iame sex ; tho.se from two ova may hi' of different or of the same sex. The arrangenii'nt of the fetal membranes of twins depends upon the mode of their ut'i-;i'i. The decidua vera is always simple ; the decidua rcHexa, on the contrajv. !.- double when the ova become attached to widely .separated parts of the uterine wall. The clioi"on, being i)riinarily derived from the zona pelhicida, is single when the twins originate from two germs contained within a .single ovum, but double when they arise from .separate (}g^^^. The amnion is primarily always single, since this membrane is produced as an outgrowth and extension of the end)ryo it.self. In those eases where twins occupv a common amniotic .sic, a .secondary fusion of the two originally di.stinct .sacs has occmred by the breaking down and absorption of the .septum which for a time .separated them. The placenta is at first double, since each fetus forms its own allantois and resulting placental area. When the twins origiiuite from different ova the placenta may remain permanently distinct, but even in such ca.ses fusion of the placental areas eventually takes ])lace. The ])l:icental vessels of single-ei>-gi'(l twins almost invariably anastomose, so that the placental become more or less completely fu.sed, the conunon nutritive area then consisting of three parts, an Intermediate, indiffl'rent area being enjoyed in conunon, in addition to the par- ticular i)art which mini.sters es|)eeially to each fetus (Ilyrtl). The anastomosis of the placental vessels may result in the mo.st profound impressions in those case"- where marked diirerences exist in the developmeiU and vigor of the two fetuses, since the circulation of the weaker fetus may be unfavorably inffu- enced, even to the extent of reversal (Ahlfeld), by the overpowering force of %t of its stronger brother. Disastrous atrophy and the production of an aoardia are among the results attributable to such conditions. When one fi'tus succundxs, the press,,,.,, exerted during the growth of the living child gradually r^ luces the mass of the dead product of conceptii.n, until . /i ■t i "ii Bpii 144 AMKlilCAy TEXT-liOOK OF OliSTETItlCS. fllMi! ;:j fiiiallv it is ropro.seiitcd by tlio groatly flattened ami atteiiiiattd remains inijiii>- oned against the uterine walls, then eonstitnting the " letus papyraeeus " u\ tJK.. teratologist. CVtnspieuoiis, and sonietiincs remarkable, disparity in the pcrllr- tioii of growth and development may exist in twins at birth, the more t'a\,ircd fetus sometimes exeeeding the smaller threefold in weight, the difference depend- ing upon the nutritive advantages enjoyed by the one at the expense of \{> Ic,. fortunate fellow. In eonsequence of this disparity it sometimes, though vciv rarelv, happens tiiat the fully-matured fetus is expelled at term, while the -till imperfeetiv developed fetus is retained for a time within the uterus until \u devck>pment has p?'ogressed farther toward completion, when it in turn is Imm, Two remarkable ea^es in which double uteri were present have been recdidcil bv Jiarker and (Jeuerali,. where intervals of forty-three and thirty days rc-pcc tivelv intervened between the births of the two fetuses. It is the occunciic, of such cases which is erroneously regarded as a fact in support of the jkiv. sibility of super fetation. Triplets may originate, it is evident, from a single ovum or from two dr three distinct eggs, a fmpiciit arrangement ijcing that one child is dirivd from a distinct ovum and tw(.> from a single ovum. U|.on the nianiK r nf their origin depend the arrangement and relations of the placenta and incm- branes, (Quadruplets may exist as double twins, or they may residt Innna combination of a single birth with triplets. Plural conceptions, on the one hand, may result from a .single coitiH, \vhcrcl)v are impregnated ova which have simultaneously been discharged tVuin the sexual glaml, ])repared for the reception of the male elements; on the other lianil, rc|)eMted impregnatiou< may occur after ditlerent, though cIuhIv following, sexual acts, tliesc resulting in the fecinidation of dill'crent ova wiiidi have been lilierated at -lightly separated 'uomcnts, but which belong to the same ovuhition. This possibility has received recognition in the term .\////(/'- j'{Viin(J<iti(in or Kttjtcriiiijx'cf/ndtioii, by which is understood the fecundatidn nf two ova, lu'longiug to the same j)eriod, by ditlerent sexual acts. Conspiciiini. examples of such occnrrcuccs arc afforded by instances where a negress oiws birth to a white and a lihuk ciiild. While the oecnrrenee of superimpregnation is nndisputed, KiijK'rfcfdtidii.nr the possibility of ova which originate from different ovulation periods, and tliciv- f(»re lii)eratc(l at ((lusideral)le intervals, being impregnated by sexual acts wiilclv separated, is nut admissible. While instances of the delayed birth of a .-('('(iini child arc adduced in sii|tp<irt nf th<' recognition of the possibility of sup"!'fct;i- tion. the obvious physical impossibilities of the as-nmed occurrence an iiniiii- swerable objcctinns to the vali<lity of such interpretation. When the rii|iiil and important changes in both the ovinn and its environment that f'nllnw fecundation are recalled, the impossibility of spermatozoa reaching ami iiii- preguating an ailditional ovinn on the one haml, and of flic (tviuii, ivm although ft'ciuidated, descending the F.-dlopian tui»c t" the uterus, n\\ ihe other hand, is manifest. The cases cited in support of superfetati((n arc all explicaidc from the well-kiK.wn fiicts attending the nueipial growth and dcvd- luains impris- aocus" (U llw; in tlie pcit'w- morc tU\ oivd Tonco lU'ji' 11(1- eiiso of it> lc>s ■;, thoiijili .crv while tlif -till torus until is in turn is I'uni, ■ bt'i'U rooordcil ty days rc~|Kr- thc OCCUl'K'lHV ort of the |l(l^- or from twd uv hihl is (liiivwl the manner (if LMita ami iiuiii- V resuh in 111! ;i a single enitiis ilischariiX'd t'lMiii enients ; oii tlif , thoupli il(i>(ly erent ova wliidi I beloujj; tn ilic the term ^"//(i- fce\uulati(Mi ni ;. C'onspielKill- a neji-ress givis siipcrjctdlinih 111' 'riotls, and lluTi- 'xual acts widely )irtli of a .-('('(mil itv of suivrfcta- •rcnee an iiikui- When tlie r:i|iiil (>nt that l(illii«- ;ichin}ij iuul ill'- tlic ovum, evtii nterus, »\\ tin' ■rfctation iHT;ill •owth anil ilevil- PIIYSIOLOGY OF PREGXANCY. 145 opnient of twin eoneeptiuns, where this disparity results in the delayed deliv- erv of tlie less favored fetus. " rinial births frequently occur before term, twins being born a few weeks before the end of gestation, (juadruplets and quintuplets in the earlier months of pregnancy. 4. Changes in the Maternal Organism Induced by Pregnancy. 1. Local Changes.— 'riie pre.senee of tlie fecundated ovum inaugurates a season of inereased nutritive energy, which not only effects changes in those organs in inimediate relations with the developing fetus, but also induces chaniies involving the entire organism of the mother during the continuance of pro'-'nanev. The clianges thus indu(;ed in the general system being discussed in a separate section (p. 153), consideration in the present place will be directed to tbcj.-e ehaiiires manifested l)y the sexual organs and the parts intimately con- nected with the processes of gestation and parturition. The iifrnifi, as may be expected from its especial relation to the developing fetu,- earlv manil'ests the profound changes which it undergoes; indeed, the preparatorv alterations affecting its nmcous lining and va.seularity preceding each menstrual epoch must be regarded as the beginning of the cycle of chan<i-es that ends only with the return of the organ to its normal condition after the expulsion of the )>ro(hu't of conception and the protecting structures. The hvperiniphy of the nmcous membrane of the uterus and the greatly i'ncrea.sed va.scidar supply which take place coincidently with the liberation of the ripe ovum from the ovary, under usual conditions, are succeeded by the destructive changes giving rise to the phenomena of men.struation. Should impregnation, on the contrary, occur, the liypertrophic proce,s.scs are continued with inereased vigor, and result in the alterations already described in con- nection with the formation of the decidua (p, 86). The most conspicuous consequence of the changes in the uterus is the not- able increase in the size and weight of this organ. From the insignilicaut dimensions of the small, rigid virgin uterus, which include a length of 7 cen- timeters {2'-l inches), a breadth of 4.5 centimeters (1|^ inches), and a thickness of 2.5 centiineters (1 inch), there is developed a huge flaccid sac which meas- ures at the elo.se of gestation from 37 to 38 centimeters (15|^ inches) in length, 26 cemimeters (lO^^ inches) in breadth, and 24.4 centimeters (0| inches) in thickness, with a circinnti'rence at the level of tiie oviducts of from 70 to 73 centimeters (2!) inches). The weiti'ht of the virgin uterus is about 40 grams n| oumx's) ; that of Ibe uterus at term, about 1000 grams (2 pounds), an increase of twenty-live llines taking place. The ca|)aeity of the uterus at the clo.se of gestation is between 4000 and 5000 cubic centimeters (from S to 10 pints), or over five hundnd times that of the virgin org.iu. The increase in the bulk of the uterus occurring during the earliest mouths ff pregnancy is attributable to the general hypertrojihy atfccting its walls, and net din'ctly to the developing ovuuu since only aticr the latter completely Mils 10 >* H!, ■ifp, i "ill-- . ' il I hi; i 140 AMKIUCAX TEXT-BOOK OF OliSTETRICS. the utcrino cavity, at tlio exj)irati()n ol" the fifth month, is the aii<;monto(l , izo of tho uterus pHxhiccd l)v tiic nicchanical distoutiou caused by the ra]>iHv p'owinii' fetus. The enhu-gement of the uterus, moreover, is not dirctlv dependent u])()u the ])reseiiee of the oviuu, hut is (hie to actual increase oi' tis- sue, as shown l)y the iiict that the liypertrojjhy of the organ ju-ogresses ujitu the fourth month in extra-uterine pregnancies, the same as if the ovum wopo present within the uterine cavity. The livpertropliy of tlie uterus at first affects cfpially all parts of the vi.cns but later the fundus and the body grow more rajiidly than the cervix. Tlio changes which atfect the uterine walls consist of thickening of the nuu'oiis membrane, increa-e of the nuiscular tissue, augmentation of the connci tivi tissue, and enlargemej-.t of the blood-vessels, the lyiuphatics, and the m ivcs, As a result of these alterations the walls for a time reach a thickness ol' 1.5 centimeters {^ inch): but this excessive growth is followed by a niiirkcd reduction resulting from the distention iucident to the later mouths of pivo. nancy, Avheu the extended uterine walls measure but 5 millimeters (y'ir inch) in thickness. The increase of the muscular trmic is etTected not only by excessive growtli of the already existing involuntary muscle-fibres, which increase from ten tn eleven times in length and from three to five times in breadth, Imt also hv tin formation of new muscular elements which likewise soon acquire the (IIiikmi- sions of .0 millimeter in length by .02 millimeter in breadth. The himinaof the uterine blood-vessels are materially increased, the artcric^ becoming wider and longer — without, however, entirely losing their tortiKi-itv — and the veins dilating into large venous chamiels, the .s'//(((.s nfcrivi, wliidi penetrate lietween the nuiscular fasciculi and v,-hich are particularly well <l(vol- oped within the placental area. The walls of the venous canals are intiiiiatciv united with the surrounding and likewise hypertroj)hied connective tissue, in consequence of which arrangeni<'ut the vails of these vessels do not cnllaiiv when mutilated, but reinaiu more or le 'ss traDinii Tl le lymphatics of tl mucosa and the muscular tunic considerably enlarge. The nerves disl to the uterus also share in the increased growth, especially the </<i)i(/li c(tlc, which more than doiiiiles its usual size. The form of the ureriis undergoes a marked series of changes durinir nancy. During the first three months the ])yrif'orm shape is retained ; nlilltri oil ('I'm- pi'( -II I M- (|uently the organ becomes more expanded in its lower segment, and livtlu fifth month ])r(sents a form iiitirnu'diate Ik tweeii the -spherical ai.d tlir |ivn- form, the longest diameter iu'Ing vertical, and the an.ero-])osferior diiiicii-i'i being greatest just below the middl(> of the body (Webster). Late in ))r(i'- nancy the pyriform or egg shape once more ])redoniinates, owing to the (loiih- lik(! distention of \hv fundus and the broadening of the lower segment. During tiie early niontii- all part< of the uterus incri'ase with ecpial rapidily: after the fiftli month, howev <'r, the cervix |)articip.".ie but slightly ill ( n!ii|ii son with the rate of growth manifested in the upiier part of the organ. Wliil' hypertrophy of t!ie cervix is admitted by all, the (>xteut to which this portim: 4 PIIYSIOLOaY OF PltEa.XANCY 147 rmontcd ;izc the rapnlly not tlirc'tly loroiiiro ol' tis- ((jrossos 11)1 t(i ic ovum were t)ftbo vi-in*. cervix. '\\w ){■ tlio mu.'.)u> the eoniK'i tivr ul the luivcs, lieknoss ol' 1.5 bv a in;irkc(l lonths ol' pivi;- letcrs {-^^; iiMli) j.(.p<5i;ivo e;ri>\vtii aSO IVoiU till tn Imt also liy the uire tho (Vhiumi- aseil.the avtoric^ I thciv tortuosity i(,s ntrr'nii, wlucli hirly well ilcvi'l- are iiiti mutely nc'ctive tissue in do IK^t ('tillu|W' tnphatics of tlic rvcs (lislriluUfil (/(nnjlioii I'lrri- ,(.es (luriii'i JMV'.;- retained ; suIk- nent, and Uvtli. a'l a..d til.' pyii- sterior diiiu'ibi"ii Late ill iivi":- vintr to tli<' iluiii'- v sejrment. th e(Hi:d raiiiility: iirlitly in rnini»;\i"- he or^an. ^^l"'' ,\l,ieh thi- l"iiW' of the uterus euiitrihiites to the formation of the excessive uterine sac present iit tlie close of ])regiiancy is a <iuestion re.irardinj,' which authorities j^reatly differ. It may be stated at once that the older view, that the cervical canal gradually unfolds itself into the uterine cavity as gestation advances, is no lon.n'r tenable, since the investigations of :\Iiiller so clearly showed that the cervical canal is but little affected, liegarding the question, however, as to what extent the ci'i'vix ])articipates in the production of the uterine sac— whether it retains its integrity throughout the entire canal or contributes a part of Its leuutli to theeularged muscular bag— the solution is less readily at hand. The ditli rcuccs of opinion concerning these points have arisen more from diflfcreiices in the iiiterpretatiim of certain anatomical details than in their variation. It is of interest, therefore, to note the structural peculiarities as repeat.'dly observed in favorable preparations of the uterus at the close of presrnancy or at the i)eginning of labor. The classical section secured by Bramic oVa woman who died during the first stage of labor (Fig. 134) shows, i/A .Silir.ti-i/i-l-'s COIlt'ttlll:'!! /!,'ii:i,hiiy ci lii.'titi-J Antcriiir T'li^'iiiiit mi attachment . and /oitu'/ itterint' srt^- jtiriits {Sr/tyordt'r s Ciftt- tniction-rin^). r..uimhxyy of dilated txtt'rnal os. Fin. l:U.— Socliiiii nf Uic imitiiriciit canal at end of the stas;c of ililatatimi, from a woman who dieil (lurini: lalior iliraiuuM. in addition to the widely dilated os externum, whose still-defined })osition indicates the juncture of the uterine and vaginal ))ortions of the parturi- ent canal, two annular markings of much interest. The uppermost of these markings is apjvirent as a distinct ridge completely encircling the uterine sac and s(>parating the thicker and more voluminous upper segment from the more dependent lower ]iart. This projection was described by Bandl as the dilated true os internum, and as defining, consequently, the upper limit of the cervical canal ; by Schrouder the same structure was r(>gai'de(l as a coitfracfion- rivg which marks the juncture of the upper contracted and the lower dilated vierinc siymcntx. Some distance lower a second ridge, slightly marked 148 AMi:iiICAS TEXT- BOOK OF OBSTETJilCS. I i II ^^1 \ •', '\ anteriorly, but more foiispicuons on the posterior wall, eonstitiitcs IMiilln's ring, wiiieli JJancU regards as indicating the upper bonier of that j)art of the cervical canal which is uiiatleeted until the dilatation of labor takes plaop, Sehroeder, on the contrary, views this ridge as the true os internum, and tlic zone included between his contraction-ring above and the one in qucMidn below as the inferior segment of the uterus. From the foregoing it is evident that the significance of the zone inclndcd bctwci'U these two rings is the principal (piestioii at issue, some authorities regarding it as a j)art of the true uterine sac, while others consider it to n piv- scnt the upper jiart of the cervical canal, that unfolds before the terminntidn ot' gestation and thereby contributes to tlie extension of the uterine sac. Ac- cording to the tirst view, the cervical canal retains its integrity tlirougliout pregnancy ; according to the second, the canal })articipatcs to a limited d(ir|.,.^, in the tbrmation of the fetal receptacle by dilatation of its upper portion toward the close of gestation. While both views claim distinguished iiMiiies in their support, the weight of evidence seems to lead to the acceptance of tlio doctrine attributing a limited jjarticipation of the cervix in the formatiuii of tiie uterine sac of pregnancy. The cervix of the uterus of the sexually mature virgin is about e(|ii;il in length to the body of the organ, and only in women who have borne childivn is the neck relatively shorter (Kussmaul). During the first three months (,f pregnancy the cervix partakes equally in the general hypertrophy afTectiiiu; tlie uterus (see Fig. 137), and reaches a length of 6 centimeters (2| inches) or iiioic, While it is only from the seventh month that the os internum exhibits a tendency to exi)and into the adjacent uterine cavity, the forces leading to this unfolding i)egin their inHiience very much earlier — in fact, as soon as tlii< portion of the uterus has readied its maximum hypertroj)hy, or from ai)iiiit the fourth month t)f gestatit)n. In addition to the effects of the presence of the fetus, the traction exerted by the muscular bands — retractor fibres nt' liayer — which pass from the outer layers of the uterus into the round and the sacro-uterine ligaments is an important fai'tor in causing the gradual uiitliM- ing of the cervical canal. The dilated, funnel-shaped cavity contributed In- the cervix for a long time retains its fiattened plicse and is covered by ciliated columnar epithelium ; its nuicosa finally undergoes conversion '\\\U\ tlie decidiia by changes identical with those taking place in other parts of the uterine mucous membrane. As a residt of these changes the cervical eiin;il shortens, and at the close of gestation measures from ?t to 4 centimeters (l||n H inches). The nnfblding of the cervical canal takes place earlier in primi- jjarse, owing to the greater resistance t)f the comparatively rigid nuiscularti- sue of the body of the uterus, until now unaffected by th:> changes of prcL'- nancy. These changes residt in a general softening and elasticitv of the IhhIv of the uterus from the begimiing of gestation, the cervix retaining its iisiial firmness during the earlier months almost unimpaired. Toward the closoul pregnancy the vaginal portion of the cervix projects less and less, the scein'Mi; shortening being probably due, in part at least, to the swelling and greater i^T* — I'llYSIOLOaV OF rilFJiXAXCY 149 ites Miiller's t part of the takes place. luin, aiul the > in qiuvtidii zone included ae authorities or it to repre- e torminatidii i-ine sac. Ae- tv throujiliout limited decree upper portion ^uisheil niiines ■eptanee of the I Ibi'uiatioii of about o([nul in borne ehihlreii bree months of iby afti'ftiii'j; tlic inebes) or more. i-num exhiliitsu 5 U'aclino; to tliis as soon as tlii< , or from alioiit tbc presence of raetor fil)rcs of round aiitl the jjnidual uiifnU- contributi'd liy ered by cifiatfil orsion int" i'"' icr parts of tlio If cervical canal nti meters (lit" earlier in \\nm- fid muscnhiv ti- ■bano;es of \mp citv of the hotly ■tainin^^ its usual •ard the closei.t less, tbc scoiio'i': liu'T and '^'renter proniinencc of the snrronnding walls of the vagina as well as to traction exerted l)v asecn<lin,ir and diverginjj: nnisele-fibres. 'I'he ciian<ie of ixtsition of the uterus is partieidarly associated witii the rapid ^rowtir of the body, hut during the early months of gestation this erosvtirrcsidts in aiigmciited autero-jtosterior and lateral diameters rather tiian in iircat increase of the longitudinal axis of the organ. In consequence of this increase tn-etiicr with tiie increased anteflexion resulting from the additional wciglit of the liypertroi)hied tissue, the fundus does not rise above the sympiiy- sis until the fourth niontii. The fimdus lies usually to the right of tlie median line, and often is so turned on its long axis that the left side is directed forward. At tlic fifth month the uterus fills the hypogastrium, from which time on the rise in the jxisition of the fimdus is so regular in its progression that under normal conditions this detail furnishes valual)le assistance in the estimation of tlie stage of i)regnancy. During the last two weeks of gestation the uterus sinks within tlie pelvis, the fundus taking a jiosition somewhnt lower than before, resting downward and forward from 7 to 8 centimeters ('2f to 31- inches) below tlic ensiform cartilage. The observations of Webster led this investif-ator to believe that the sinking of the uterus not infrequently begins long before (sometimes from the fifth month) the last two weeks, the period usually assiiinc<l. The jiosivion and relations of the full-term uterus alter with the posture of the woman. In the upright positicm the fundus bends as far forward as the tension of the distended abdominal walls permits, and rests against the anterior j)arietes. In the recund^ent position the uterus lies against the lumbar part of tlie vertebral column, the fundus approaching the dia|)hragm above, with the intestinal coils in front and at the sides. On assinning the lateral ])osture the large, flaccid uterine sac becomes dependent on the corre- sponding side. Tiie relations of the prritoneum and the uterus become disturbed in eonse- quence of the altered ])osition of the latter and the excessive tension caused by its enorinoiis proportions. The layers of the broad ligaments become gradu- ally separated and tiie entire structures shortened, in eonsecpience of which the Falhipian tubes and the ovaries are drawn toward the uterus, against which they lie at the close of gestation. The changes in the disposition of the pelvic peritoneum during pregnancy have been by no means detinitely determined, and opinions dilfer as to the forces leading to such alterations as well as to the extent of displacement. Regarding the lateral arrangement, it is evident that the increase in the trans- verse and vertical diameters of the uterus must result in the elevation of the peritoneum on each side of the pelvis to a considerable degree, as conclusively demonstrat(>d by the observations of Barbour and Polk. Tiie arrangement in front and behind, however, is not so clear, and the statements of authorities are conflicting. Polk maintains that the lowest situation of the peritoneum in front and behind the uterus, with the ex "ciition of Douglas's poneli, in the non-pregnant condition is indicated liy a line passing from the centre of the 'J ?■ I , ! ,& ■y^ '■''prM,-.; loO AMKIilCAX TEXT-IiOOk' OF OIiSTi:TliICS. k I \M svniplivsis to the jiiiu'tiirc i)t' tlic tliird anil lluirtli sacral viTtcbiu*. At iho tenniiiatioii of pregnancy, l)iit lMli>rc the usual sinking of the uterus wiiliin the pelvis has occurred. tli<' lowest limit of the peritoneum, aceonling to the .-aino observer, has ascended and is now marked by a line passing from the centie of the symphysis to the sacral promontory. These conclnsioiis arc not eontii'med i>y examinations of frozen sections n)ade bv Webster, since this author finds the inferior limit of the peritoiicul pouches during picgnancy as low as in nidlipara'. The changes in the ante- rior relations of the peritoneum of the vesico-uterine fossa, whereby the piri- toncum becomes -tripped from the bladder, are usually regarded as due ti, ili(. elevation of the uterus and to the coiise(|ncnt mechanical effect, which togi ihep are also supposed to exert an influence by which the floor of the poucli nf Pouglas is raised. Wi'bstcr attributes the stripping of the peritoneum I'ldin the bladder, on the contrary, to the drag caused by the gradual sinking of tjic pelvic floor, since the delicate subserous tissue gives way under the tra<li(iii, and the peritoneum eousiMpiently does not follow the posterior wall of tin bladder in its descent. The extent to which the stripping of the serous cover- ing fakes ])lace depends largely upon the caj)acity of the peritoneal folds < xi>t- ing in the uon-prcgnaut condition, as when these are ample less displaccniem follows than when the traction camiot be met with supplementary fi>siie. According to Webster, the central portion of the pouch of Douglas at no time during pregnauey becomes elevated ; this author further points out that the sinking of the uterus may be progressive from the middle of pregnaiuv, resulting in the marked downward displacement of the organ sonietiiiies observed before the end of gestation. The nujiiui also exhibits changes resulting from the exaggerated uutritien of i)reu:iiancv. These changes include irreativ increased vascidaritv, thickeiiiiiir and softening of its niucous membrane, whose folds become less rigid and (.'(iii- spicuous. and hypertrophy of the uuiscidar tunic with great dilatation of tin' blood-vessels. In couse(|ui'Uce of the large (piautity of blood contained within the less compact tissues, the vaginal surface presents a bluish tint in contrii-t with the bright red of its usual condition. This change of color is rcganleil bv some as a valuable objective sign of pregnancy. llic e.vfcriKi/ (/iiilldln likewise participate in the increased hyperemia uf the generative tract, the unusual development of the blood-vessels and the lyiiijili- atics inducing a condition charactcri/cd by softening and greater infiltratiim et' the tissues, hence the vulva ap|)ears particidarly prominent. The exetssive vascularity of the parts finds expression in the dusky hue and the unusual activity of the sebaccnus follicles and the sweat-glands of the labia. T/ic (trllcii/(ifli)iis of (he pclrin exhibit to a limite<l degree changes due to ])regiiancy. These changes .'U'(> manifested by an unusual softening and v;wii- larity of the iuterarticular cartilage, particidarly that of the symphysis, in consequence of which there takes j)lace a certain amount of loosening, attciidul in some cases with slight movement. Whatever temporary increase in tlie pil- vie boundary may thus be secured, the gain at best is j)robably very insignilieaiit, '■^■A* vx. At ilio Items wilhiu i>; to the i^aino n the eoiitre ;)/.en soctiiiiis he peritiiiitiil i in the antc- rehy the pciM- as (hie tn the liich to<:( ilior tlie poucli (if itotieiini 1111111 iinkin^ nl' the • the t radii III, r wall of till' ^ ."ierous I'livcr- ml loUls (■xi^t- s disphicciiicm leiitary tis.-iu'. ifhiH at no time ts ont that tin- ot" pre<riiaiuy, trail soiuctiiiiis rated nutritidii rity, tliiekciiiiis; riirid and •■nii- latatiun of tli- ontained within tint in couti'ibt Ltlur is re,<:anloil vpereniia of the and tlie lymiili- r infiUratiiiiHif The extrssive nd the unusual ic hd)ia. (•hanji;es due to niiiii: and viwii- symphysis, in iseninj:, attciidi'l rea.'^e in tlic pi- (TV insiii-niliranl, "^ .::i- riiYsioLoay of rRKaxAXcv. 151 Other ehaiiiie- atl'ecting the pch'lc floor and the parts closely connected thorewitli, snclfas the ha.^e of the bladder and the urethral orifice, result from the downward displaeeinent of the structures closing' in the outlet of the pelvis. The jH'lvie-tloor projection is pro.<rressively increa.^ed from 'l.'i centimeters (1 i„rii) ill the nullipara to !).'» centimeters (;.\} inches) at the end of pregnancy; the -kiii-distaiiec t'roin tlie .symphysis to the coccyx is almo.st doul)led. The foliowiKj: table, compiled by Web.ster, ba.sed on the olwervations of himsdf and of other observers, displays some of the more imiKirtant variations induced iiy pregnancy within the parts in relation to the pelvis: p.' vic'-lli ur Sk l.-ilislMlH I)i^ lilMCL' i>t I>i. \:\W<- ol l)i.- tllMC'l' 1.1 Th ickllr^ <; u Df |.th of lltl Dh tilllCC ot. \)\> tllllCl' ol Piftiiiici' ol Distiiiici' of iirnji'dioii • ■ •r from cnccvx losyini'liyl!* iirilhnU oriiicc liclow liriiii . ^ invllinilorilHvlii'lowsyiiiiplivMM . . . juiKiiiiM 111 liliiilil'T mill iiri'llini lirlow brim f Ilsxuc liclwciii i>ubi'S mill viif,'iiiii ,.,•,, vi-inil I'l'Uili I'i'l""' l'""> •, • ■ • • ,,< rxtii'iiuiii l"l"v\- brim posteriorly .... oscxti'rniiiu li'low brim iiiitrriorly .... o< iiitrrimm b>'low brim posteriorly .... osiuterimm belinv luimuiiteriurly .... NcL- ' Fifth Ekhith Ninth LiPAKA. Month. Month. , Month. Cm. Cm. Cm. Cm. i") 4.1 .").(l «.,5 !;)..-> 14.0 10..S •£xb fi.i 0.7 0.7 ■J..^ 0.0 U'.f) •A:l ■A:l i\.\ 7.6 o.:i 7.0 i.ii '.'.8 ;i.r. 4.4 :^.i r..'> 0.7 0.0 0.3 11.1 8.7 .H.O 0.:! 11.1 8.7 IJ.J :..7 7.1) 7.0 0.0 0.7 7.9 7.0 0.7 The (ilxlniiiiiKil lail/ff manifest the enormous distention to which they arc subiceted bv tiie formation of more or le,<s conspicuous lines — the struv f/ravi- dantm — whicii are found in over 90 per cent, of pregnant women. These lines ai)pear as reddisii or lihiisli, sometimes lighter, streaks, which are most numeroiis and well marked during the la.'st months of pregnancy over the lower part of the abdomen, particularly at the sides. They extend as curved or simioiis liiii's, and they persist for some considerable time after the termina- tion of gestation, gradually becoming whiter and more cicatricial in appearance. Thc.-;e .striio are due to displacements and partial ruiiture and atrophy of the connoetive tissue of the (lce|) layer of the greatly di.stended cutis. They are not peculiar to pregnancy, but may a])pear even in men whenever the skin is sulijccted to unusual stretching, as from tumor.s, ascites, and other causes ; furthermore, they are not limited to the abdomen, but in pregnancy are seen on the nates, the thighs, and the breasts. The linea alba also not infrequently becomes broader, and in mnltipane the recti muscles are .sometimes .-^o widely separated that the mass of the uterus appears between as a median projection. The umhU'wm is aft'eeted by the increasing bulk of the abdominal contents, and by the fifth month begins .o exhibit a diminution in its depths; bv the seventh month its dejiressioii I .^ become obliterated, and during the remaining weeks it becomes gradually everted until the umbilicus forms a rounded elevation. Tlw v)(nn)i)(trii f/lands, coineidently with the changes affecting the genera- tive organs, undergo important alterations during the preparation for their assunijition of the stage of functional activity. These changes early induce ■ i ^, V] /5 / IMAGE EVALUATION TEST TARGET (MT-3) 1.0 145 I.I 12.0 ■ 2.2 iu „^ liii ■ 40 11.25 1111.4 HiotDgraphic Sciences Corporation 21 WEST MAIN STREET Wlki^ViR t«Y MSSO (716)S/2-4503 m n \ iV \\ ^ 6^ i^.^ ,.^^ 6^ 152 AMKIffCAiY TKXT-BOOK OF OliSTETRIVS. I : 1 'i. "I 1 r greater general voliimc in the hreasts, <lei)en(ling upon an increase both of the interlobular connective tissue and fat and of the true secreting tissue of the glands. The enlargement of the breasts begins as early as the second month, but it does not become conspicuous until toward the middle of preg- Fio. IST).— VlrKin nipi)le and areola: 1, iiippk'; 'J, iin'ola ; ;i, tubercles of MorKiij,''" ; '. crevlec at base of iiip|)le. nancy. On touch the periphery of the organ presents uneven and knotty masses consisting of the enlargal acini and lobules of the rapid-growing glandular tissue inibedde<l within the areolar and adipose tissue. The ulti- mate compartments of the secreting structure become earliest enlarged ; conse- Via. 136.— Nipple and breast of proKnancy : 1, nipple with openinRS of milk-duets; 2, primary areola; 3, glands of Montgomery ; T), secondary areola ; (i, venous circle of llaller. quently the increase is first noticeable at the jjcriphery, afterward extending along the course of the larger ducts toward the centre of the organ. The dis- tention of the skin due to the augmentetl volume of the glands is especially marked over the periphery, in which location rcnldish, bluish, or whitish striae, I PHYSIOLOGV OF PREGNANCY 153 nw, similar to those seen iijm)ii the distendetl ubdoiuinal walls, ;!j>})ear c manifes- tations of tlie nnusnal tension of the integument. The veins are also enlarged, juid show through the tightly drawn skin as a network of blue lines. The nipple shares in the general hyj)ertrophy of the organ, Wcoming enlarged, more readily erwtile, and sensitive. The surrounding rosy areola of the virgin (Fig. 135) is gradually replaced by a more deeply colored area, whose tint by the middle of pregnancy varies from the slight brownish discol- oration seen in women of light complexion to the dark brown or almost black .'olor seen in bnniettes (see PI. 17). The areola by the eighth or the ninth week Ix^omes softer and more elevated than usual, and its sebaceous glanils, from one to two dozen in number, greatly enlarge, those at the periphery i)econ>ing particidarly conspicuous. These enlarged sebaceous follicles consti- tute the glands of Montgomery (Fig. 136). The mammary areola varies from 'J. 5 to 4 centimeters (1 to 1^ inclies) in diameter, although these dimensions iiiiiy greatly \w exceodwl. In the fifth or the sixth month of pregnancy an additional irregularly pigmented area, the so-called '* secondary areola," some- times appears (see PI. 17). After the third month of gestation the breasts contain a thin fluid, the colostrum, which may bo pressetl out of the newly formed glandidar tissue. This fluid consists of a thin albuminous medium containing numlH>rs of fat- drops, displaced epithelial cells, and characteristic aggregations known as "colostrum-corpuscles." 2. General Chaneres. — Pregnancy, while a purely physiological con- dition, creates great and important changes in the maternal organism. These changes pertain to the different systems and organs of the Ixxly ; to some more than to others. The general changes in the maternal organisni dcpeiul to a great extent on the alterations in the blood and in the functional modifications of the nervous system. The jiregnant woman has to provide nutriment, to breathe, to maintain blood-circulation, to secrete and to excrete tor two individuals — herself and her fetus. All this means that extensive changes in the general system must occur. If these changes are carrii'd to a reasonable extent, health is maintained and the system liecoines fortified, as it were, for the coming parturition ; but when these changes are developed to excess, disorders complic"ating the pregnancy are jiroduced. Changes in the Circnlaton/ Sydem. — Formerly it was supposed that preg- nancy was accompanied by l)lo(Kl-changes like unto ])lethora, and it was almost universally inferred that the attending symptoms — the headache, the ring- ing in tl:a ears, the flushed face, the cardiac palpitation, and the dyspnea — were the results of these alterations. Consecpiently it was a very common |)ractice with physicians many years ago to bleed pregnant women from one to many times at intervals during the latter months of pregnancy. Enormous ((uautitics of blood were thus extracted by venesection. A wonderful revolu- tion has taken place in the treatment of pregnant women during the past twenty-five years, owing to more rational ideas of the real condition of the circulatory fluid. 154 AMKIilCAX TKXT-liOOK OF OBSTETRICS. hll' ( I 111 pregnancy the composition of the bloiHl, which is increased in quantity, is profbtmiUy ahercil, as many careful analyses prove. The quantity of blood present beftn'e pregnancy would Ixi iiKuUHpiate to meet the condition of preg- nancy. Thus, the blo(Rl is increased in its watery elements and white corpus- cles, but is made deficient in the element of albumin, is increased materially in the amount of fibrin, and is diminished in the proportion of retl corpuscles — conditions of anemia, hydremia, and liyj)eriiiosis. This hyi^rinosis is also augmented after parturition, because at this time large quantities of effete materials are thrown into the circulation. Instead of a blood-change called "plethora" being present, it should be recognized as one of anemia and hydremia orof ehlorof is. If called " plethora,'' it should be named scroun plethora. Individual variations in the quantity and quality of the blood are depen<lent on many conditions of hygiene and diet ; poor hygiene raluces the blootl to marked chlorosis and hydremia. The surrender of the maternal nutritive material to a growing fetus and a devel- oping uterus, to pelvic tissue, and to glands means a great tissue-drain on the maternal circulatory fluid. As these changes in blood-quality are most marked at the close of utero-gestation, the attending phenomena must be those that are most strongly shown. Certain thrombotic affections observed in preg- nancy and after delivery are thus explainable. In place of the blood-supply at this time l)eing improved by bloodletting, it must clearly be evident that venesection is strongly contra- indicated, for it tends further to aggravate the abnormal alteration. To C'azeaux are we indebted for much of our present knowledge of the blood-changes of pregnancy. Certain viscera of the circulatory apparatus are also much modified in size and in function. The heart becomes physiologically hypertrophied — a I'act known for many years and determined by numerous observations. This liy- pertroi)liy is u wise provision of nature to meet the increasing exigencies of the blood-supply in the advancing months of pregnancy. Hypertrophy of the heart is constantly present to a considerable degree, the whole weight of this organ being one-fit th more in the pregnant than in the non-j)regnant state. The left ventricle, the profiling part of this organ, is alone att'ected. This physiological hypertrophy remains during the period of lactation in those who suckle their children, otherwise the organ quickly diminishes in size; hence in women who have borne many children the heart may remain ])ermanently large. Incident to the total blood-supply in pregnant women the maintenance of tlie cinuilation demands either greater frecjuency in the heart-contractions or an increase in the entire quantity of blood entering the left ventricle. The multiplied vascular elements of the jK'lvic organs also increase the labor thrown on the heart. Disturbances of the circulatory organs are very often seen. Thus, ])alpitation, while purely sympathetic in the earlier months of gestation, later come on from the encroachment of the enlarged and enlarging uterus j)usliing up th(! diaphnigm and embarrassing the heart's action. The blood-changes of anemia and of hydremia may be so great that edema PJIYSIOfAHiV OF PREGXAXVY 155 may be observed in the feet aiul may extend upward to the thiglis and the labia majora. Other orjians are likewise increased in size. The liver and the spleen are enlarged. The spleen norniully increases in size, owing to an in)i>ortant rela- tion to the quantitative change in the circulatory fluid. A fatty degeneration shows itself in both the liver and the spleen in women who have suddenly (lied after labor. Xuinerous small yellow spots are seen scattered through the liver — fatty deposits in the hepatic cells. The thyroid gland is increased in >izo. In women in whom there is a predisposition to this enlargement, preg- nancy may further stimulate the growth and bring about permanent structural clianges. The eidargement, of this organ is thought to sustain some relation to changes in the heart and the blood-glaiu'.idar system. Changes in liespi ration. — Pressure of the enlarging uterus, through mechanical action, causes changes in the respiratory organs. An upward movement of the diaphragm lessens the longitudinal dimensions of the thorax. Some embarrassment of the respiration follows this decrease, notwithstanding that there is some increase in the breadth of the lower thorax. In the last two weeks of utero-gestatioii, owing to the limited shortening of the cervix iitiTi and to the settling down of the fetus in utero, respiration and circulation Ixrome easier. As more blood must naturally be jM'ovided to noin-ish the woman and her child during pregnancy, this extra blood nuist not only be properly circu- liitid, but must also be duly purified. The elimination of carbonic-acid gas l>y respiration is therefore increased in pregnancy. The resj>iratory organs nmy be dcrangitl by cough and dyspnea originating tVoin nervous sympathy in the earlier months of pregnancy. In the later months of gestation the derangement is from encroachment of the gravid uterus, interfering with normal respiration. These phenomena are mostly (>l)sorved when there is twin pregnancy or dropsy of tin; amnion. ClKUi[/Cfi in the lYKjextivc Si/ntem <ni>l in Xutrition. — The pregnant woman provides the nutritive pabidum by which the growing organs are sustained and by which the fetus and its apjK'udages are built up. She must therefore digest more food, form more blocnl, and increase the activity of the secretory and exi-retory organs. Very few W(»men escape such troid)lcs of digestion as nausea and vomiting. In the earlier months the appetite is, as a rule, capri- eioiis. Further al(»ng the appetite and the digestion increase in activity, thereby assisting in improving the general nutrition. An increase of weight takes place in normal cases, irrespective of the grow- ing uterus and the ovum. The average gain anu>iu)ts to from ten to fil"teei> pniinds in the whole nine months, being greatest in the last two months. This increase is not far from one-thirteenth of the whole body-weight, and it is progressive from the beginning to the end of jtregnancy, notwithstanding the n:iiisea and vomiting. The adipose tissue increases most in bidk, especially in the latter half of gestation. These deposits are most noticeable in the mammary glands, in ' V ; 166 AMERICAN TEXT- HOOK OE OBSTETRICS. ill iM;l«, i i' i^' ! M j ! the alKlominal parietcs, in the hips, and in tlie omentum. The wliole figure becomes fuller and rounder. All this increase is but so much stored-uj) ])()ten- tial energy, to he utilize*! after delivery, when this energy, by the metabolism of the body, assists the manimary function. Rokitansky has spoken of the lamelltp of osseous material on the inner sur- face of the skull and the frontal and parietal bones external to the dura mater, called "puerperal osteophytes." Those lamellte, which are irregular in shape, consist of calcium carbonate, traces of phosphates, and organic matter. They are not jKJCuliar to pregnancy. Robert liarnes thought they sustained son)e relation to the calcareous changes found in the placenta and to the forthcoming milk. The temperature of the bmly in pregnancy is not materially changt 1, although, according to some authorities, it is slightly lower in the morning than during the day. CImnyca in the Skin, the Gait, and the Osteons Elements. — The functional activity of the sebaceous glands, the sweat-glands, and the hair-follicles of the skin is increasetl by pregnancy. It has Iwen ssiid by Robert IJarnes that the growth of the hair is invigorated during pregnancy when prior to ges- tation the hair had been falling out. Pigmentations are quite generally observal in spots over the body, the linejB albicantes being most noticeable. They are also seen about the ab<lomen, the navel, and on the face. Around the nipples these deposits may be seen in the form of areola?, primary and secondary (see PI. 17). These pigmentations vary much in extent and in intensity in different subjects, being more marked in brunettes than in blondes. Seldom do these deposits completely disapj)ear, but they are always less after parturition. It is not unlikely that they are the result of a teni])orary hypertrophy of the suprarenal cjipsules. There is also a change in the gait of a pregnant wonian. To ])reserve the centre of gravity of the body the head and shoulders must be thrown back- ward. This action produces a change in the gait most noticeable in women of low stature. Owing to the drain on the osseous elements of the blood during ])regnancy by the growing fetus, there is always a considerable delay in the union of fractured bones. Changes in the Urine. — Owing to the hydremic condition existing during [)regnancy, the urine becomes more abundant and of a lower specific gravity. It is thought that the kidneys Iwcome enlarged, which is probably the case. This change in the size of the kidneys has somewhat to do with the increase<l (juantity of urine, but more probably the more active function is attributable to the increased blo(Ml-supj)ly and to the increased arterial tension. There are also (pialitative changes in the urine. The chlorids have been found increased, while the phosphates and sulphates are decreased, due to their use in the growth of the fetus. The kiestein |u*llicle found u|M)n the urine of jm'gnant women several hours after its excretion has no necessary relation to jn-egnancy, l)ecause it is found on the urine of virgins and on that of men. The glucose found in the urine of many pregnant women in variable pifvsioLoay of preg nancy. 157 <(iiantities has been referred ti) a putlutlogiciil increase in tlie jrlycogenic func- tion of the lis'cr. Sugar is present in the nrine of almost every woman at ."(ime jwriod of hictation Ix-ing inflnenccd inneii hy the character of the diet. Its presence dejMinds on tlie (piantity and qnality of the milk, dimiui8hing as I ho lacteal secretion is snppre.ssed. Traces, more or less in quantity, of albumin are found in the urine. Authorities differ as to the frecjuency of albuminuria in pregnancy. Hchrowler siivs that the urine of all pregnant women will contain albumin in from 3 to ") jwr cent. ; other authors have contended for a much larger jwrcentage (tVom 20 to 30). Unquestionably, albumin is found in the urine of a very large number of i)rcgnant women. No regard being paid to the numl)er of iircgnancies, nor to the ])revious con(litit)n of the kidneys, the presence at Miine time of a trace of albumin will l)e found in a very large nnml>er (if cases. The writer, who instituted these examinations in a large clinical experience in hospitals, has found the frcipicncy to be at least 30 jKir cent. This frequency must Ik? inquircKl into with reference to its etiology. In the fust place, quite a nuniber of pregnant women have a physiological albumi- nuria. The trace of albumin is then small and of short duration ; there are iKt tube-casts, and no attending morbid symj)toms. Every authority must coiu- clih' with Miirickc, that all>uminuria is relatively commoner during labor than (luring pregnancy. A proh)nged labor is oflener thus accompanied than is a short and easy labor. Albuminuria is often confined exclusively to the periml i.r labor. The (Hrcnrrence of albuminuria during labor is explained by the tlieory that the reflex vaso-motor spasm of the renal arteries, resulting from uterine contractions, causes renal anemia. This theory has the support of Tvler Smith, Spiegelberg, and others. Renal albumiiuu'ia may appear early in pregnancy, before there is any possible renal venous stagnation from pressure, being the result purely of reflex irritation. Why should not this irritation at times be transferred from the uterus to the kidneys as well as to the stomach ? Such an explanation must Imhl good, if albumimiria is present early in jjregnancy, the urine having been iiurnial iM'forethat time. There is an intimate comiection between the nervous ganglia of the pelvis and the nerve-filaments of tiie kidneys. The hydremic state of the bhuKl incident to pregnancy is at times a cause of albumimu'ia. An increased arterial tension which exists in pregnancy may he productive of albuminuria. The urine of a pregnant woman may be alhntninous from causes not nephritic, yet morbid. Thus, it may be albumin- ous from blood, from mucus, or from pus in the tirine, each of which may be cystic, vaginal, or uterine in origin. The prevalence of albuminuria during ))regnaney may be classified as fol- lows: {(() Crises in which it was present when conception took place, a chronic Hright's disease of some type, with albumiiuiria, having existed before jH'eg- nancy ; (/>) Cases in which albuminuria from sub-acute or chronic Bright's disease, the result of scarlet fever, etc., ha<l existed years Ix^fore, and from which disease a recovery seemingly had taken place : at least there was uo 158 AMEJtiCAX TEXT-nOOK OF OBSrETRICS. ! I I li. trace of albiiniiii in tlic nrine at tlio time of j'oncoption ; (c) Cases in wliicli tlie existinj; ])re<rnan('y or parturition was attended hy an allunniniiria, it haviiifj never existed before. In tlie first two divisions of the above elassifieation prefjinaney aggravated or eansed a retnrn of tlie albumin. In the last division albuminuria started during, and had been clearly attributai)le to, the eonJition of pregnancy. Excepting, then, the cases in which the albuminuria has been due to physiological or pathological causes, not nej)hriti(!, and not attributable to pregnancy, the author is disposed to think that the estimate made by Sell roeder (.']-5 per cent.) is not wide of the ai^tual facts. The oldest theory is that albuminuria and kidney disease during pregnancy are due to mechanical ju'essure of the gravid uterus on the renal blood-ves- sels, especially on the veins. All admit that this mechanical ])ressure pre- disposes to, if it does not excite, the disease. This doctrine has been ably advocated by Simpson, Carl Brown, and Cazeaux. It is not so much the renal pressure alone as it is the intra-abdominal pressure that so acts. Support of this theory is obtained from the following facts : Albuminuria is more conunon in the latter half than in the fii-st half of pregnancy. More cases exist among ]»rimij)ara^, in whom there is great ab- dominal pressure from the rigid, unyielding aUlominal Malls. Albuminuria is greater in twin pregnancy ; it is also common when there is a severe pressure from large uterine fibroids or from ovarian cysts. Tight lacing and heavy skirts aggravate the disease. It is less frequent during gestation than (luring labor, when pressure is greatest ; it diminishes after labor or after the removal of the abdominal tumors. Any cause that brings about renal venous stasis pre- disposes to and excites ne])hritis. For instance, valvular defects and j)ul- monary emphysema, as well as pregnancy, may develop true parenchymatous inflammation of the kidneys. No one of all the above tlieories or facts constitutes a sufficient explanation for all cases. Each fact or theory may answer for some cases; two or more combined afford a better soluticm for most. All can recognize the influence of intra-abdominal tension with pressure on the vena cava and its branches, esi)ecially in priniiparous women. The sinking of the fetal head into the true pelvis in the last two weeks of pregnancy, while it improves the respiration and circulation in general, does not relieve the renal venous stasis. WhlK- most women feel lighter and freer during these last two weeks, owing to the settling down of the fetus from the shortening of the cervix, the intra- al)doniinal and jK'lvic ])ressure is not diminished. So great is the significance of albuminuria during pregnancy that its ])res- enc(! should always Imj watched for. Frequent physical, chemical, and niicro- scopi<'al examinations of the urine shotdd be made in the latter months of pregnancy. If the presence of allniniin is but slight, it may be physiological, or, if pathological, no noticeable symptoms may be observed ; but if it is con- siderable and pei'sistent, and if it occurs early in pregnancy, the prognosis is grave. Albuminuria is then a condition full of ill omen, although it is always PHYSIOLOGY OF PREGNANCY, 159 susceptible of anit'lioration by well-iHrw'twl treatment, ami in many eases it iiiav entirely be overcome. From a clinica' standpoint it is ordinarily presnmed that wluii there is ;ill)UMiinuria there is also nremia to a corresponding degree. Donbtiess it is true that when albumin is abnormally excreted by the kidneys there is some ii'tcntion of urea iu the blood, from defective atftion of the kidneys, but certainly these two fiuietlonal tlisorders do not hold the same proportion or Illation. There may be much albuminuria and but little uremia, and Wcc (V/'.««l. It is the tlegrce of the latter disorder that forebodes evil. The whole line of treatment should be directed toward favoring the elimination tVoni the blood of this poisonous material of urea, with its ju-oducts. To secure this result it is ineuml)ent upon us to act as potently as we can upon the bowels and the skin — compensatory organs of the kidneys — and to address our remaining treatment to controlling other symptoms that may arise. Changes in the Nefvoun Hi/ntem. — The nervous system becomes more impres- sionable in pregnancy. The emotional susceptibility is markedly increased and the whole character is altered. A woman may become fretful, peevish, irri- t:il)le, and at times unreasonable. The most amiable woman may thus be dis- posed when pregnant. She is often depressed in spirits at first, when her general nutrition is impaired from an imperfect appetite or a faulty digestion. Mania may be excited later on — easily in those who are thus predisposed by inlu^ritance or by actual melancholia. These conditions are among the most troublesome of the various comj.lieations of pregnancy. To witness a woman ill the process of child-bearing impaired in her mental functions is indeed sad. Tliere are cases, however, in which a sense of well-being takes the place of one of more or less physical debility. A conclition of want of mental and physical activity before pregnancy at times becomes changed to one of buoy- ancy and exhilaration. Physically such women are stronger, and mentally tliey are more active and energetic. Xo fSictor enters so much into the eiiiisation of this mental cheer and despondency as the psychical — the degree of the desire for an offspring. ■ 11 II. DIACIXOSIB OF PREGNANCY. 1. Symptoms and Signs of Pregnancy. 1. The Nausea and Vomiting of Pregnancy, called the "Morning- Sickness." — This symptom consists of nausea, accompanied often with vomit- ing »»r the retching of a glairy fluid, showing itself early in the morning, gen- cially before, at times only after, breakfast. The assiunption of the erect posture seemingly excites the disorder. Sometimes it begins very early, within a few days after conception, but usually not until the fourth or the fifth Aveek of pregnancy. Seldom does it pei-sist throughout pregnancv, but generally coases spontaneously within the fourth month, although it may continue b : l If i i^ 1(50 AMKIilCAX TKXT-JiOOK OF OliSTETItlCS. tliruuglioiit tlu; whole plthmI. In many or in most cases it is comparatively mild, and does not seriously imj)air the health, its presence being regarded as a lavorahle omen ; i)Ut as there is every degree of seriousness in its nature, it is at times so severe and so long continued that not only are parts of" meals vomited, but all foods, of whatever kind, variety, or (juantity, are also rtjected. Not only may the ingestion of food excite v tmiting, but the siglit or the smell of food may also give rise to this characteristic nausea. Morning sickness is a sympathetic disonler reflected from the uterus. It is aggravated i)y unpalatable food, by sexual excitement, and by emotional disturbances. It is most marked in first pregnancies, and in women of highly nervous organization — a fiict ever to l)e considered in the management of this affection. It is a suspicious or presumj»tive evidence taken by itself, but when associated with certain other symptoms and signs it l)ecomes a more prob- able symptom of pregnancy. Not necessarily in the regular order of time, but quite generally asscK-iated with this morning sickness, there are certain morbid longings for food ; for instance, foods and drink and certain vegetable acids formerly disliked are now desired ; the most unpalatable substances, such as chalk, clay, and slate-|)encils, may be craved ; or there may be a distaste for the usual articles of diet. Other stomach disorders, such as acidity, flatulency, heartburn, and unpleasant eructations, are sometimes noticed. Sdlicdfion is a very common aivompaniment of the morning sickness when the latter is severe. A constant dribbling of the saliva by day or by night occurs in the earlier months of pregnancy, and its severity and duration remain for an uncertain |»erio(l. It has Im'cu observed to continue for months after the abatement of the nausea and vomiting. Tontlnii'hc, — Under the above heading may also 1k' included tootha(;he, which at times is a purely functional disorder ; n»ore often it is a symptom of actual caries, arising from alteration of the buccal secretion, dissolving the lime-salt- of the enamel of the teeth ; t»r it may be the result of a morbid determination of the ossific elements of the teeth of the mother to the bones of the growing fetus. 2. Menstrual Suppression. — The second symptom more or less ex|)ress- ive of the existence of pregnancy is the suppression of the menses. The fniKrtion of menstruation is almost always suspended throughout the whole period of pregnancy. 80 reliable is this symptom that the <letermination of the end of gestation, or the time for the expected parturition, is best obtained by adding from two hun(lre<l and seventy-eight to two hundred and eighty days to the date of aj>pearance of the last menstrual flow. Hut not invariably is nienstruation suspended following an inipregnation. The most frequent ex- ception to the general rule is found when menstruation returns (mceonly ; then it is usually for a somewhat shorter time and in diminished quantity. The occurrence of a menstrual flow in diminished quantity and for a shorter time in a married M-oman who has had her menstrual periods regular as to time, quantity, and duration is very significjuit of a possible pregnancy, and the conception must have occurred several days before this function last appeared. DIAUXOSLS OF PREGyAWY 161 us. It lotioiml ■ highly iicut of soH; hilt re i»roh- ime, hilt 1 iiiorhid ble uc'ul-^ , Slid I as ^tuste Ihr atulency, less whon by nigl't (Ui nit ion »r mouths :oothtv<:he, syiiiptoni Llvhig tho |ji niorhul he hones AL'iiiii, hy way of cxecj»tion to the rule, there are recorded notable instances in which the peritnl of prej^naney was attended by a rejijular incnstruation. The writer recalls in his experience the case of u woman, now living and in health, wiu> never menstruated Ix-'fore marriage, nor during her married life of several years unless she l)ecanie pregnant. She had no menstruation the first two yeare ot' her married life until pregnant, and there was no return of the menstrual ilow until she was again pregnant; in other w(»rds, menstruatictn in this case wiis never present except during pregnancy, when it was normal in all regards," having thus appeared in three distinct pregnancies. Possibly the periodic lii'inorrhage in this case was of cerviral origin, but no ])athologicid lesion of tiie uterus ctndd ha detected. Menstruation ot!curring during the first three iiinnths of pregnancy may come from the decidual cavity of the uterus, not vet closed, before the decidua vera and the decidua reflexa have become ai:<rlutinate<l ; then there must have been a certain amount of chrouic decidual (lulometritis — a morbid state, of course. As many causes purely pathological — general and local, physical and psvchical — induce menstrual suppression, the exact significance or the relative value of this symptom, as an evidence of the existence of pregnancy deserves most careful consideration. For instance, menstrual supjiression following months and years of menstruation, normal in all regards, is a very strong siis- l»icion of pregnancy. Its value as evidence becomes less when it is stopped ill a woman whose previous periods have been irregular from any cause. This symptom of ntenstrual suj)pression cannot, of course, be present from preg- nancy when the menses are physiologically absent from lactation, or when the lirctriKUuy iKVurs l)efore the first menstrual apiwarance, prior to puberty or after the menopause. So much faith has the popular mind in the presence of tiiis symptom of menstrual suppression as indicative of pregnancy that no small degree of anxiety in looking forward to a pregnancy is often manifested by women. There is what is calletl " jisychical amenorrhea," in which case menstruation is suspended or is delayed from purely psychiad causes. While it ailects newly-married women who may l)e anxious to avoid pregnancy, it coiu'erns mostly unmarried women who have exposed themselves to the pos- sibility of impregnation. The fear of a possible pregnancy is doubtless suf- ficient to prevent a normal return of this function. All the exceptions above mentioned should ever be held in mind in esti- mating the actual worth of the symptom of menstrual suppression. ;5. Mammary Changes. — During pregnancy the mammary glands are in immediate sympathy with the growing reproductive organs of the i)elvis, con- st'(|uently a genuine physiological hypertrophy commences in these organs i'mm the beginning of gestation. Their glandular structures become larger, fuller, and firmer; a sensation of weight or of pricking in them is felt by the |»atient; the veins, blue in color, become enlarged and more visible. Light- colored, silvery lines are seen radiating over the prr)jecting organs in the last iiKinths of pregnancy. The nipples also become enlarged, nutre elongated, prom- inent, and somewhat erect (l*Is. 17, 18). Surrounding the nipple is noticed the 11 I i:i\n ' ' "?' Illi / ir) 1 h m\ ir,2 j.i//;a7<j.v TiLXT-nooK or onsTF/nncs. uri'ola, which Ih-coiiics darUi'i' in color, and which is most pronounced in bru- nettes (I'l. 17). Two or more cnhirgcd moist i'olliclcs, varyini; in size and con- taining sebaceous material, are seen proje* tiiig from the surface of the areola. In tiie lifth or the sixth moutli tiiere appears a secoiidarv arecthi (IMs. 17, 18) con- sisting of scattered minid spots, appearing as if tlie color had l)een dischar<"'d as a shower ol" <lrops (Montgomery). Thus every structure entering into the composition of the mannnary glands is physiologically hypertrophied. These changes begin as early as the seccuid month, an<l become more pro- ncMinced as pregnancy |)roeeeds. The two mammary glands are equally enlarged and progres.-ively (h'veloped. The secretion of colostrum in the glands eidianees the value of these mannnary changes indicative of pregnancy, especially if noticed in women who have never before been ])regnant. Milk is now and then seen to ooze from the nipples of some women before deliverv (I'l 17); in most women a drop (»r more of colostriun may be s<jueezed from the nipples after the third month. Instead of the lacteal secretion being pro- moted, its suppression in niu'sing women is very suspicious of another preg- nancy. Milk is secreted at times, though rarely, when there is no ])regiiancy. Pelvic diseases, such as chronic metritis, rapid-growing fibroids, ovarian cyst«i»- niata, and false pregnancy, at times induce milk-secretion. Cases are reconled of the j)resenee of milk in the mannnary glands of males. These character- istic physiological changes, in their uniformity and progressiveness, mark the distinguishing ditferences l)etween the mammary changes of pregnancy an<l those alterations noticed in size and shape of the glands from symj)athy Mitli certain pelvic diseases — ovarian and uterine. These mammary changes in structure, color, and func^tion are of little diag- nostic value when considered alone, but when taken in conjiniction with other symptoms they are highly probable evidi'uces, especially in first pregnancies. Owing to the fact that tiie darkening of the areola in nndtipai'ie, and tli( ei*'«tility of the nipple remain more or less prominent, while colostrum may st»»»ietimos be j)reseiit for years after the cessation of lactation, it can be ap- preciated how these signs lose their diagnostic value in v)ineu who have borne children. 4. Functional Disturbances of the Bladder. — Fiuictional disturbances ot' the bladder are ([iiite often noticeable ear'y in pregnancy. As the bladder is s(»me\\liat dragii'cd upon by the physiological prolapsus of the uterus in tlic first month (a |)ositioM rather increased in the second month), inid as it is pressed ii)Htn din'iug the third month by the increasing normal anteversion, it can lie understood why fuMctional disorders of this organ may result. The bladder- capacity is diminished, and in consequence there is an increased fre(piency ot urination. The vesical symptoms tend to diminish in the fourth montli. because of the ascent of the uterus from the pelvic to the abdominal cavity. if iH'troversiou of the uterus existed prior to pregnancy, this backward mal- position is increased, while the uterus is j)elvic in position. IJecau.sc of the increasing size of the organ, with its growing contents, there follows, at times. fViim ri^troversion, serious urinary retention. Incontinence of urine more I'Ki:<i NANCY. I'l.ATK 17. I'rimiiry iireolii, olnvaf cd iiiul cdeniiitouH 'i 1' \i, Willi |..lhi I.- liii 11 l.|uhili-i Vi'imni'y iiruulu, piKUieiUed d'A , I'ut ilai, Willi Klllllll lll|l|i|l' (III II llllllK-ltl'l. -i./| S MmitKui LT.v'Hfolliclesil'i. iiu>;iiN .li\ilii|i(il. Veins i"iii>iiii: "MT iIh' IpIvhsI iinil piiiiiiirv iiicula, Willi iiii'Kiilai' I'ipiiii'iitaliHii liii a Mnihlii Eil'eotility "l nil'I'lia'; 1 iniiuaiya la. Milk, Willi lailil ^' >oiMlai\ ali'i'la liii a liliMiilli' Secoudiiry iireoliv ui "Mia! .«i/.i' (in a iiiiin.iic). Becondnry areoln. pruiniin'iitly maiki.i iS . w iiu wi<li' |ii'iniar\ 1 1*1 areola lin a 1*1 iin>'tl<'i. Miimiiiiiiy -inns nf iiir^iiuiicy in llK'ir nnU r it»niliiiil> lilc >i/.iM. i I 1 PREGNANX'Y. KIrvaliiiii III piiiiiaiv aiinla (10) in |ii'iitiU', <'ij|ii- piiM'tl witli all art'ola wliii'h is nut t-lfvat^'il (cnni* liusitu iili>>t<<Ki'<>I'l>)- Plate 18. 1 Wi'll roniKMl, lirni lui'a^t ami iiii'pli' (in a liruiictte). Typii'iil i^i^'hA in a lnnni'lti'. inrlmlint; tnllicli'H ami |)i'inmi'.v anil Ki'Cdmlai.v ari'ula'. T}|ii('al ni^nit in tlin blniidi': K, fnllii'U'Hi I'A, |>i'i- niary aronla. i.. I:i Miminiuiy sl^ns at progniini'y. 'if i \^ m. DIAGNOSIS OF PREGNANCY. 163 rarely occure during pregnancy, from coughing or from sneezing, when the bladder is somewhat distended. Kiesteine, sometimes present in pregnant women, is a proteine substance, consisting of triple phosphates, fungi, and infusoria, that forms like a flocculent cloud on the urine kept standing for a few days at a tem- perature of 70° F. It occurs in the urine from the eighth to the thirty- second week of pregnancy, then disai)pears. It has practically no diag- nostic value, as it is found in the urine of non-pregnant women, and at times in that of men. 5. Intrapelvic Sigrns. — Certain changes in structr.re take j>lace in the uterus in the earlier mouths of pregnancy, when the organ is confined within ilie true pelvis, before it ascends within the abdominal cavity ; tliese changes, carefully studied and detectal by vaginal touch and by bimanual exami- nation, possess a significance far greater than any of the aforementioned symp- toms. Associated with some of the other symptoms, these changes become extremely probable evidences : {(i) Softening and Enlargement of the Cervix Uten. — These changes, com- ])ared with the physical conditions of the same parts in the virgin or the never-pregnant woman, will be observed to be quite characteristic — less so in women who have borne children. The cervix uteri softens and enlarges in all directions. The lips of the os uteri become patulous and puffy, a condition most noticeable in primiparse. The softening of the infravagi- nal cervix, beginning below, extends upward. The cervical secretion of nuu'us, the so-called "cervical plug," is increased. The diminished resistance to touch and the increasing width of the tissues i^oemingly shorten the cervix. These changes, while beginning in the first month, are not recognizable until the second month ; from this time they are progressive. Erroneous views as to changes in the cervix uteri during pregnancy existed ill years past. It was believed that the cervical canal was greatly shortened to form ])art of the corporeal cavity, and that toward the last of pregnancy no cervical cavity existed, it having lost one-half its length by the sixth month, and so on, until it was obliterated in the eighth and ninth months. These views, long entertained, were in 1826 called in qiiestion by Stolz, whose views most moilern obstetricians now u))hold. Post-mortem examinations made of women in advanced pregnancy — the best proofs — have established the fact that the cvrvix maintains its length of 'J. 5 centimeters (1 inch) or more to the last days of j)regnancy (Fig. 137). Digital exploration through the patulous cervix substantiates this fact. iJut during the fortnight preceding j)arturition a genuine broadening of the cer- Kui. 137.— (Vrvix nt end iif pn'Riiaiioy (Winter). i 'A\l r!!ir 1 i 1 1 1 'i 1 i j ■ j ■ i ■ i , ' 1 ) ^'1 ^ : 164 AM/:/i/('AX TEXr-BOOK OF OBSTETRTCS. vix takes plaw, when the cervical canal is merged into the upper uterine cjivity — a result, no doubt, of the incipient uterine contractions i)reparatory to labor, as pointed ont by Matthews Duncan. The broadening ot" the cervix in the last stage of pregnancy, prior to eight and one-half months, then, is, seemingly, not real until the last fort- night. More or less of these changes remain even after parturition ; in other words, tho cervix does not completely resume its pristine virgin firmness and smoothness of siu'face or its original size. While these changes are noticeable from pathological as well as from physiological causes, their value in the diagnosis of pregnancy is only to be relied upon, when associated with other signs and when taken in conjunction with certain other symptoms. {h) The Violet Color of the Vulvar and Vaginal Mucouh Membrane. — Dr. Jacquemin of Paris first discovered this sign, and Dr. Chadwick of Boston has fully dwelt upon its diagnostic significance. Insj)ection reveals its pres- ence. It is of importance in the earlier months of pregnancy, when there is seen the then pale violet color, becoming nu)re bluish as pregnancy advanc(;s. But this sign is not of positive value. While arising from a venous stag- nation in tiie vaginal vessels, it may come also from vaginal or uterine con- gestion due to disease. This sign is valuable often as early as the second month, and in the latter half of pregnancy it is highly diagnostic ; then its recognition possesses great value. ((•) Jlef/ar^s .w/», which has been given to the profession within the last decade, possesses a great advantage. In all doubtful contlitions of early preg- nancy this sign ought to be searched for. It is to be detected by vaginal touch and by bimanual exann'nation. Its presence implies a change in the consistency of the lower uterine seg- ment. The greatest changes in the uterus must and do take place in the body of this organ — the l)ed,as it were, for the growing oviun. The neck of the womb is less supplied with blood, and it receives comparatively little of the stimulus of pregnancy. The develop- ment of the cervix is largely comj)leted by the fourth month. During the first six or eight weeks of gestation Fi(i. isx.-i'roKnnnt litems cif early part of the body of the utcrus enlarges, espe- tliinl iiidiitli il)ni\iii's Croziii secliDiii, with iimb- . ,, . . ... ui)ieiM,stii...rte.nrein,vei-si.m: I., i., .kei.iua vera. <'ially HI its autero-jjosterior diameter. Bimanual, recto-vaginal, or abdomino- vaginal touch will detect some enlargement in all directions — anterior, pos- terior, and lateral. The lower uterine segment becomes soft, compressible, and pulsating; above there is the j)rojecting or bulging uterine wall, hard and i DIAGNOSIS OF PREGNAXCY. 165 resisting; diiriii}; uterine contmction, l)<)<rf;y or soft (Inrin;; relaxation. The ac- eonipanyin}^ illustrations (Figs. 138-140) best elneidates these facts. The uterus in shape has t)een likened to that of a deniijohn, to an old-fashioned fat-bellied jug, or to a sphere (corpus) resting upon a cylinder (cervix). These alter- iitions in consistency, while noticed on the jwsterior wall by rectal touch, are best detected along the anterior uterine wall, by the finger in the vagina with Ri-sl'i.'Hf Flo. 139.— Uimaiiiial sikiis of the sixth to eighth week, sliowiiig dingrnnimHticnlly the iilterntlons in consistency of cervix and corjnis uteri: A represents the vaulting or overluuiglng of the body and its rlastic feel, witli the compressibility of the lower uterine segniont and the iinyielding cervix; B shows tlie conditions during uterine contraction, when the body is hard and globular. the outer hand on the abdomen seizing the uterus. The .structures of the ciirporeal wall may become soft and yielding, and may show a contrast with the cervix below. It is true that the sign of bof/f/incas of the body is not always present, and that its presence is simulated somewhat by morbid states, but the ])eculiar compressibility of the lower segment, together witii the bogginess of the body and the ciianges in shape of the womb, is not simulated by anything else. (d) Changed Position of the Uterun. — We must not fail to bear in mind the modification in the jjositions of the uterus that pregnancy usually produces. f/rroiy. ,) Kkj. UO.— Frozen section of uterus at two and a half months (I'liiardi. sliowing relaxed and thin walls, thickened decidua ; with the clinical Ihidings of Figure l;l'J it will be seen how the bimanual signs originated. Ill the first and second months the uterus is somewhat lower, but in the third iiKtnth it undergoes an increased anteversion, for the reason that the relatively iiicrea.' lug weight of the body of the uterus with its growing contents tilts the upper end of the uterine lever downward and forward. This change in ])osi- tion will be noticed in all ca.ses except tho,se in which |)regnancy has oc- curred in a previously retroverted uterus ; the retroversion is then increased. I t ; y |.«fJ Jlfl [I "f KJO AMKlilVAN TKXT-liOOK OF OBSTETRICS. u '?] I TIlis statement is made, notwithstaiidiii^ that some of this antoversion maybe ap]>ai'eiit, not real, the aiitero-postcriin" diameter of the organ being thickened. Hegar's sign, reeognized, as it may be, so early as the seeond month, and the overhanging and softness of the eorpns, the changed position of the uterus, and the violet color of the vagina and cervix uteri, while not abso- lutely positive signs, are highly pri>bable evidences when associated with some of the rational symptoms referred to. They jwssess a diagnostic sig- niticance ever to be watched for and carefidly es'. lUated. They are a com- plexus of physical signs that gives a reasonable diagnostic certainty. (j. Abdominal Changes. — Under this head are included all those cliangcs in size, shape, and ai)pearance of the abdomen that may take i)lace. (a) EHlairfemcnt, Size, and Slutpc of the Abdomen. — At first, diu'ing the first six to eight weeks, there is somewhat of a flattening of the abdominal snrface, due, doubtless to the descent of the uterus into the pelvic cavity, thus slightly dragging the bladder downward and making traction on the tu-achns, thereby drawing the umbilicus inward. The navel in consecjuence becomes dei)ressed ; hence the conunon expression, " A blank before a bank." I^ater in the fourth month, as the growing uterns rises for proper acconnnodation in the abdominal cavity, a slight abdominal enlargement will be observed, and the umbilicus is no longer sunken. By the fourth mouth the fundus uteri has risen about 5 centimeters (2 inches) above the symphysis pubis. The vertical enlargement jiiogresses at the rate of fully two lingers' breadth each four weeks, reaching the umbilicus at the end of the sixth month, and touch- ing the ensiform cartilage at the end of thirty-eight weeks, or eight and a half lunar months (PI. 19, Fig. 1). The umbilicus for many weeks prior to that time lias been protruding. During the last two weeks of utero-gostatiou the upper portion of the abdominal walls protrudes less and the girth of the woman seems smaller (PI. 19, Fig, 2). The patient feels more comfortable. The cer- vical canal is now eflaced, the child in idem has sunken, and the pelvic liga- ments are relaxed — changes preparatory to the coming i)artm'ition. During this time it will be noticed that the enlarging pregnant womb is symmetrical, snujoth iu its contoiu", larger vertically than transversly, and by proper pal- pation it will be felt to contract spontaneously. (h) Coloration. — On inspection of the abdomen of ])regnant women there will be recognized not only the condition of the navel, but also a changed color of the abdominal surface, and the presence of stria;, due to distention of the abdomen. The pigmentation may extend from the pubis to the xiphoid cartilage — the brown lines. On the sides of the abdominal walls and dowu the thighs red, blue, or white markings, like cicatrices, may be seen. (c) Fi((d Movcmnd.'<. — Fetal movements are generally visible after the sixth month through the abdominal parietes. 7. Ballottement. — Hallottemeut is a passive motion of tlie fetus, consist- ing of the peculiar sensation felt by the examining fingers upon giving the fetus a motion //; ufcro. A'aginal ballotteme;.'^ is usually emj)l')yed, although abdomiuid ballottement is also pract .cable at times, and may be noticed for a I'HK(JXAN(Y. I'l.Air, 111. halt' ) that n the voiuan .' c'or- lijra- )m"niij :!tncal pa 1- there anjif lion o iphdiil lowii sixth pnsist- llir thi' Ihoutili ll tor a s ■« I S "3 i Ok ■--',. j f "■-■' -J_ / r II DIAGNOSIS OF PREGNANCY. 167 longer period of time, even during the Ix'ginning of labor. F«)r the ballotte- ment impulse to be perceptible there must be a mobile fetus, not too large, and a sufficient quantity of the liquor amnii to permit the entire fetal displace- ment in idem. The woman stands or reclines during its performance. In the vaginal ballottcnfient the Hnger is placed within the vagina, anterior to the cervix, the pulp of the finger being applied to the anterior vaginie fornix by a direct brisk motion. The fetus is propelled upward into the uterine cavity, and, falling back by its gravity, an impulse is imparted to the finger against which it falls. Ballottemeut distinctly noticed is a pathognomonic sign of pregnancy, there being no other condition in which a solid body is found Hoating in the uterine cavity. The absence of this body does not preclude the possibility of pregnancy, lor different conditions may prevent its being noticed, such as ex- cessive or great dinunutiou in size of the fetus, hydramnios, multiple preg- nancy, some abnormal presentation, or a faulty insertion of the placenta. Vaginal ballottemeut can sometimes be practised successfully as early as the latter part of the fourth month. It is more easily recognized in the fifth month, is most distinct in the sixth, continues in the seventh, is doubtful in the eighth, and is absent in the ninth month. 8. Intermittent Contractions. — As soon as the uterus is developed suf- ficiently to be felt by the hand through the abdominal wall, there may be perceptible intermittent uterine contractions which are constantly going on at intervals of a few minutes throughout pregnancy. Purely independent of volition, they may become valuable, in a diagnostic sense, in corroborating other signs. Uterine contractions are not positive signs, because the uterus undergoes somewhat similar contractions to free itself of clots of blood, of polypoid or fibroid tumors, and of retained secundines, or they may be simu- lated by a distended bladder. The method of procedure for detecting uterine contractions is to grasp the fundus uteri for from five to twenty minutes, with the patient recumbent on her back, the uterus meanwhile being lifted by the right finger per vaf/inam, the abdominal walls being relaxed by some flexion of the lower limbs. The characteristic hardening will then Iw felt, the contraction lasting for several minutes. To IJraxton Hicks we are indebted for the thorough elucidation of this sign, which is often referred to as " liraxton Hicks' sign of pregnancy." 9. Quickening and Fetal Movements. — Quickening is the sensation ex- perienced by the mother as the result of active fetal movements. The period when these active movements are felt is quite uncertain. Usually quickening is considered to occur about the middle of pregnancy, consequently the time of expected parturition is based on this event, but very unreliably. Certain sensations of motion, sutih as fluttering or ]>ulsating, are sometimes felt by the mother earlier than these active motions. As pregnancy advances these active motions increase in frequency and become more marked, and toward the last they are seen very generidly. When felt or seen by the physician, as can be (lone after the sixth month, fetal movements constitute a very valuable and s n ' 4 \ } / w. "K-- >iii 11 ; 1 i i I I .i. M < i ./• 168 AMKRICAX TEXT-BOOK OF OBSTETRICS. positively reliiiMe sifjjii not only of pirj^imncy, hut also of a live child in nfero. This sign slioiiM ni'vor hv iiiti'iTcd to exist from the statements of tlie patient. Supposed fetal movements are fretpiently felt by the patient, and are thought to Ih>, but are not, evidences of pregnancy ; frequently they are only illusory. These seemingly fetal motions come from the abdominal walls in false preg- nancy or fronj the intestines in tympanites. Failure to detect letal movements does not negative pregnancy, for the cliild may be dead or its motion may not be felt. To detect tlu'se movements, place the patient on her back njxm a table or a bed, with the thighs flexed and the abdominal walls relaxed. All clothing should be removed from the abdo- men. Uy palpation and renewed prt'ssure at ditlerent part.s of the alxlomen the active fetal movements may be detected ; better, .sometimes, by applying the hands to the abdomen, after fir.st wetting them with cold water to excite a refl<>x action of the fetus. 10. Uterine Souffle. — This murnuir has been called '* placental," because it was thought to be due to the movement of the blood through the placental sinuses; it has also been named the "abdominal souffle," because it was thought to result from the ])ressure of the gravid uterus on the abdominal ves.sels. Neither of these two theories is correct. This ])lacental niurmiu' is doubtless due to the movement of the maternal blood through the uterine blood-vessels ; hence it should be called " uterine .'iouftle." Heard first in the fourth month, on the sides of the upper part of the uterus, especially the left side, which lor obvious reasons is brought nearer the anterior abdominal wall, the murmur is at all times synchronous with the maternal pulsation. It is very uncertain as to its presence, tone, piti'h, duration, and locsation ; if once lieard, it soon leaves, to return at another time or at another jdace. It is thus usually heard irregularly as to time, ])lace, ])itch, and duration until the end of pregnancy. Uterine souffle is no longer regarded a.s a ct>rtain ]>roof of pregnancy. A sound exactly resembling it is not unfrequently hearil in inter- stitial fibroids of the uterus, and it may be heard when ovarian tumors are present. In the majority of cases of parturition it is heard for the first two or three days in the lying-in state. 11. Petal Heart-sounds. — These sounds are a comparatively modern dLscoverv. Maver of Genoa first heard them in 1818, in examining the abdo- men of a pregnant woman. The fetal heart-sound cjumot, as a rule, be heard earlier than the fifth month in utero-gestation. A practised ear may .sometimes detect it a i\>\v weeks earlier, as in the fourth month. As this sound becomes stronger and louder in advancing pregnancy, its detection in the last few months becomes very easy. The sound may, of course, be (|uite feeble. If normally vigorous, .some non-conducting material, as a tumor, may intervene, impeding its transmission, or there may be a ])osterior position of the child, thus making it less distinct ; hence the inability to hear the fetal heart-sound ought not to negative a pregnancy. When attempts are made for its detection, the room should be (piiet and the patient should be in the dorsal posture, with the head on a pillow and the thighs flexed lightly to '"*i. '■^'^ '-■^^■_ «>!^'.-'*' ^ i '-f DIAGNOSIS OF I'UK^^aNCY. 169 the body or extended. 'P ,e stethosroiK" ouf,'lit to l)e utilized, from motivoa of modesty, in loeii'- " ^ the .soimd of the fetal heart. This instrument should l)e applied t|\the alnlomen below a tnuisverse line passin^j^ through the umbili- cus, oeduise the head of the fetus is more often lower than the breeeh. Since the occiput in most instances points toward the left side of the maternal pelvis, the fetal heart-sound is most frequently heard with greatest distinctness upon the left lower sjmce of the abdomen (space D, Fig. 141). If not heard in Fio 141.— Locution nnd intensity of fetal heiirt-sounds in the left occiplto-anterior position (the four quttdnints nro indicated by flie reti lines ; tlie poce is from Spigelius). this space, search for it should be made over other spaces (as b, c, a). If heard well in regions c, D, the inference is that the head is the lowest part of the fetus, and that the back of the fetus is anterior; if heard best in regions A, B, it is to be inferred that there is a pelvic presentation. The mean frequency of the pulsations of the fetal heart is about from 135 to 140 to the minute; they are less frequent in large than in small children, and probably are less frequent in males than in females. A tcm]>orary variation iu their frequency and force is very common. The sound is double and i L. _<./ u 11 : ( !i/ H 1 I i »l I 170 A.VKIifCAN 7'/y{^'y-/^<''>^>A' OF OliSTETPTCfi. ! ihytlunic, tlie first soiiiul boiuj; more clonr iiiid (,'"''t>.i»'t tliuH the second ; then conies 11 hrief pause, wlien tlie secontl sound is iieard ; ^ longer pause follows before th(> double rhythniie sound is a^ain heard. The al)ove-.?iP"t'«"«^ ^«*o- queney indicates that there is no relation of the fetal heart-sound to'^^inii- sations (>f the lu'^t' .'r's heart. These two sounds are perfectly independent. lieeause of the varying frc(|uency of the fetal heart-sounds, attempts have been made to bjise some reliable predictions as to the eex of the fetus hi ulero ; but experience has proven that but little reliance can be placed on such attempts. The sound of a fetid heart well heard when the uterus is relatively small — too small to accommodate a fetus ^)f five or more months' development — should at once create suspicions of an extra-uterine pregnancy. As auscultation with the stethoscope reveals the presence of the uterine souffle and the fetal heart-sound, the practised ear may also detect the funic or umhilmd muffiv — an intermittent hissing sound synchronous with the fetal heart. It is referable to the umbilical cord. It is heard in but the smallest number of cases, and its causation is conjectural. As a sign of pregnancy it has very little value. There are also heard sounds produced by active movements of the fetus m uhro. Fetal movements, for instance, may be heard by the ear instead of being felt by the hand. Their value is significant. 12. Petal Contour. — Inspection of the shape of the alxlomen in preg- nancy is also valuable ; a careful, well-trained touch by palpation may detect the size, shape, and presentation and position of the fetus, as well as, at times, the presence of twins in ntevo. 13. Mental and Emotional Phenomena. — Pregnancy quite generally motlifics the nature — i)hysical, mentid, and emotional — of a woman. At times, she is more vigorous, buoyant, and cheerful than in the non-pregnant state. More generally, however, she is more or less irritable, excitable, and fretful. As the physical appetites for foixl in quantity, quality, and variety are fre- quently changed, so also is the moral sense sometimes seriously deranged. Classification of the Phenomena of Utero-gestation. — The symptoms and signs of pregnancy may now, for convenient study, be classified as to the time of their occurrence. For instance, the nine calendar months of utero- gestation may be divided into three periods, and a classification may be made of the aforesaid phenomena as to these three periods. Fii'd Period of rtero-r/cstafion. — This period comprises the first three calendar months — the time during which the gravid uterus is enclosed within the true pelvic cavity. The si/mptoms are — (1) Menstrual suppression; (2) gastric disorders ; (3) mammary changes ; (4) vesical irritation. The signs are — (1) Beginning jmtulousness of the os uteri ; (2) softening of the infra- vaginal cervix, gradually extending higher ; (3) uterus slightly lowere<l during the first and second months, and antevertwl in the third month ; (4) flattening of the abdomen, with increasing depression of the umbilicus, the depression gradually disappearing toward the fourth month ; (o) violet-colored vaginal / /■\ r r nr.Aaxosis of PRKaxANcv. 171 hI ; then follows )iied fre- ulciit. )t.s hnvp l(.'tijs In aced on walls iind corvix iiti-ri ; ((5) irt'>i;ar's siirn (contpivsHihility of lowi'i* iktcriiKt seg- ment), with Hot'tened and ronnded ntcrine Ixxly. Second Period of Llero-f/eddtton. — This period enii)iiu'es the fonrtli, fifth, and sixth montlis. The hh/uh and xijiiiptouiH are — (1) Menses still absent ; (2) subsidence of the gastric disturbances; (.'!) increasing and j)rogressive development of the mammary signs ; (4) vesical irritation imj)roved ; (5) the uterus higher, ascending into the alHlominal cavity ; (6) cervix higher in vagina ; navel no longer depressed ; (7) fundus uteri two fingers' breadth above pubes at the end of the fourth month ; at the und)ilicus toward the end of the sixth month ; (8) cervix more softened and patulous ; (9) fetal active motion (quickening) experienced toward the end of the fourth or in the fifth month; (10) ballottenjent detected, becoming more «listinct ; (11) intermit- tent contnietioui, also detected, increasing in force ; (12) uterine soufHe audible in the fourth or fifth month ; (1.'}) fetal heart-sounds easily detecteil, usually first in the fifth month. Third Period of Utero-gestation. — This period embraces the seventh, eighth, and ninth months. The m/m and symptomn are — (1) Menses continue absent ; (2) gastric symptoms slight > • only occasional ; (3) further progressive develop- ment of the mammary signs, colostrum sometimes present ; (4) uterus continues to rise in the abdominal cavity, reaching midway between the navel and the ensi- form cartilage at the end of the seventh month ; reaching the ensiform car- tilage in the first two weeks of the ninth montli ; after which period it grad- ually becomes lower; (6) ballottement continues until the eighth month, when it is doubtful ; it is absent in the ninth month ; (6) umbilicus commencing pro- gressively to protrude ; (7) vaginal cervix seemingly shortened, more thick- ened, soflened, and patulous, getting higher; (8) fetal movements felt or seen after the sixth month ; (9; in last two weeks the fundus uteri, having reached its maximum height and size, begins to descend, when the cervix undergoes a real shortening. Now the cervical lips become thinner. The presenting part of the fetus, having partially entered the pelvic inlet, is more easily detected by vaginal touch. Pi'essure-symj>toms of the chest and the stomach disapi)ear, though edema of the limbs and the genitals may show themselves. Relative Value of the Symptoms and Signs of Pregnancy in Point of Diagnosis. — Very properly we may classify all the symptoms and signs of pregnancy as medical evidence of the presumptive, the probable, and the positive kind. They naturally rank in value inversely in the order named. The presumptive evidences ofj-'ef/nanct/ are — (1) Menstrual suppression ; (2) morning sickness ; (2) irritable bladder ; (4) mentid and emotional phenoiuena. The probable evidences are — (1) Mammary changes ; (2) the bimanual signs ; (3) abdominal changes in size, shape, and color ; (4) changes in cer- vix uteri in size, shape, consistency, and color; (5) uterine nuirnnu'; (6) intermittent contractions. The positive signs are — (1) Active movements of the fetus ; (2) passive movements of the fetus (ballottement) ; (3) fetal heart-sounds. Differential Diagnosis of Pregnancy. — Nothing can be of greater ill rm Wf ; I! ! i 1 .1 ( ! ^i i "1! i I II. 172 AMIJRTCAX TEXT-BOOK OF OBSTETRICS. moment, on tlie one hand, than a correct diagnosis of pregnancy, and on the other of the many conditions sinuilating pregnancy. Not only does a correct estimate of the actnal condition concern the patient and her family in a physi- cal, mental, or moral sense, bnt the professional repntation of the physician is also serioHsly involved. The legal and social relations of some pregnancies possess a deep and painfnl interest; therefore let no opinion be expressed in any case nntil a reasonable certainty can be arrived at. Time niay be needed to clear np all donbts. As pregnancy im])lies a certain variable amonnt of abdominal enlarge- ment after the fourth month, its existeni'e must necessarily be differen- tiated from the many other con<litions, physiological and morbid, that are attended with the same sign. In the <litferential diagnosis not mnch diflH- cultv need exist after this eidargement is fairlv well advanced. Most mis- takes are doubtless made when the gravid uterus is still within the pelvis; there is then often much doubt. There will fii-st l)e considered the differential diagnosis of pregnancy and the morbid conditions simulating it during the first three months. Just here comes into play the diagnostic value of the sign so forcibly elucidated by Hegar. The peculiar shape of the uterus in the second and third months of pregnancy (see p. 1(54) is not simulated by anything else. While in a measure resembling subinvolution of the uterus, it is to be remembered that in this morbid condition there is an organic enlarge- ment uniform in all directions. In chronic metritis attended with hyperemia, with or without flexion, the uterus is not jug-shaped, and the elasticity and compressibility of its uterine walls are absent. Chronic metritis attended with parenchymatous hyperplasia of the uterine body, shows the uterine walls dense, hard, sensitive to touch, not elastic, doughy, or boggy. An interstitial fibroid in either uterine wall is dense, hard, and uneven. Doubt is apt to pertain to cases of ]>regiiancy associated with chronic retroversion, but then a careful analysis of the presumptive symptoms will always be helpful in dif- ferentiation. A clear study of the j)hysical signs of the cervix and the corpus uteri as to color, size, shape, and consistency are of inestimable value in the first three months. A search for Hegar's and the other bimanual signs ought never to be neglected. Pregnancy may be concealed, feigned, and imagined. These possibilities must be considered and be cleared up. When ])regnan(y has created material abdominal enlargement, the diagno- sis ought to be differentiated from all other conditions attended by the same sign, such as ascites, ovarian tumor, uterine fibroid, distended bladder, tym- panites, pseudo-cyesis (false ])regnan('y), enlarged uterus from gas (physo- metra) or from water (hydrometra), retained menses (hematometra), obesity, enlarged abdominal viscera, malignant disease, etc. In differentiating these con- ditions the three ])ositive signs of pregnancy should always be borne in mind. In ascites finctuatiou is most distinct ; the resonant note (m j>ereussi()n is always changeil in location according to the ])osition of the patient. Cardiac, hepatic, or renal disease can usually be detected as a causative factor of the ascites, and the symptoms of pregnancy are absent. \ DIAGNOSIS OF PREGNANCY. 173 Til ovarian tumor a fluctuation of the abdomen is also present, though less distinct; the aMominal enUirgcment has come on more slowly and has n peculiar shape. INIenstruatioii is ordinarily present, and the signs — iiitra- polvic and abdominal — ot" pregnancy are entirely absent. The area ofdulness jind tympanites is not essentially altered by posture. As pregnancy and an ovarian tumor quite often coexist, a constant watch ought to be made for this pt)ssibility in every case of an abdominal enlargement. The presence of two tumors of different consistency with an intervening sulcus is quite significant ; when both are present, the uterus itself by a vaginal examination shows enlargement, and there are present the presumptive symptoms of pregnancy, while there are also the signs of an ovarian cyst. A uterine fibroid creates an abdominal enlargemeiiC which is more firm, hrrd, and dense than any of the above-mentioned conditions ; it is nodular ami very often asymmetrical, is quite slow of growth, and menstruation is not only present, but, as a rule, is also increa^ied in quantity and lengthened in duration. While the uterine murmur may be very well marked, there are present no positive signs of pregnancy. A distended bladder is of comparatively short duration, is attended with much discomfort, is associated with dribbling of the urine, and is quickly relieved by the use of a catheter. Fecal accumulation is dissipated by a copius rectal enema and free catharsis. Tympanitic distention of the abdomen is always very resonant on per- cussion, is variable in size on diflerjiit days, does not fluctuate, and quickly disappears by ])roper treatment. Pseudo-cyesis, or false pregnancy, occurs oftcnest toward the menopause, and its false appearances are quickly unmasked by the administration of an anesthetic. Obesity shows the abdominal walls soft, doughy, and easily palpated between the fingers of either liand, and there are uo intrapelvic signs indicative of pregnancy. Hydronietra and physometra are extremely rare. There is always with ihem an absence of most of the probable and all the positive signs of preg- nancy. The uterus in both diseases enlarges more slowly, and never to the extent of an advanced pregii;uicv. Diagnom of Krtra-Hfcri)ic I'lrrfnnncii. — A judicious differential diagnosis of intra-uterine pre i;nancy implies a careful consideration of the possible or ])robal)le existence of extra-uterine pregnancy. This is especially the tiict wiien the gravid uterus or the extra-uterine sac is still within the true pelvis, for if the diagnosis is the best guide for treatment, now is the time of all others to know the exact condition of atlliirs. The following symptoms and signs are worthy of most reliance from a diagnostic point of view. When extra- uterine pregnancy exists, there are — 1. The general and reflex symptoms of pregnancy ; they iiavc often come on after an uncertain period t)f sterility. Nausea and vomiting appear aggravated (Winttkel). /il I I 174 AMERICAN TEXT-BOOK OF OBSTETRICS. ; 2. Then comes a disordered menstruation, especially metrorrhagia, accom- panied with gushes of blood, and with pelvic pain coincident with the above symptoms of pregnancy. Pains are often very severe, with marked tender- ness within the pelvis. Such symi)toms are highly suggestive. 3. There is the presence of a pelvic tumor characterized as a tense cyst, sensitive to touch, actively pulsating. This tumor has a steady and pro- gressive growth. In the first two months it has the size of a pigeon's egg; in the third montli it has the size of a hen's egg; in the fourth month it has the size of two fists. 4. The OS uteri is patulous ; the uterus is displaced, but is slightly enlarged and empty. 6. Symptoms No. 2 may be absent until the end of the third month, when suddenly they become severe, with spasmodic pains, followed by the general symptoms of collapse. 6. Expulsion of the decidua, in part or in whole. Numbers 1 and 2 are presumptive symptoms of extra-uterine pregnancy; Numbers 3 and 4 are probable signs of extra-uterine j>regnancy ; Numbers 5 and 6 are jjositii-e signs of extra-uterine pregnancy. Some of the above-mentioned symptoms resemble those of early abortions. In all cases with the history of a supposed abortion, when an intrapclvic mass is then or afterward felt, there should be suspicion of an extra-uterine preg- nancy. In consideration of the possibility or probability of extra-uterine pregnancy, based on the detection of a lateral extra-uterine sac, we are neces- sarily obliged also to exclude in the difi'erentiation a small ovarian tumor, an enlarged ovary, a hydrosalpinx or a pyosalpinx, and pelvic exudates (cellu- lar or peritoneal). A distinct sulcus between the sac or the tumor and the uterus may be a physical sign to guide in the diagnosis. The symptoms of a severe and overwhehning pain are quite generally manifested by the end of the third month, because most cases are tubal in some form. Tiiose symptoms are not noticed when the extra-uterine pregnancy is entirely abdominal. The possiI)ility of mistakes in diagnosis is to be considered with reference to — (a) Retroflexion of the gravid uterus ; (b) pyosalpinx with amenorrhea, or causing abortion; (c) malignant tumors of the abdomen with ascites; ((?) normal ])regnancy complicated with abdominal tumors; (r) coincident intra- and extra-uterine pregnancy ; (_/") pregnancy in a deformed uterus. Didc/noxis of MuUiph' J'ref/na))ci/, — Susj)icions of a twin pregnancy are rarely excited ; but the presence of nuiltiple ])regnan('y may be conjectured from the following data : (<i) Very large size of the abdomen ; (h) exaggera- tion of the results of a gravid uterus ; (c) irregularity of abdominal enlarge- ment ; (d) detection by palpation of the abdominal walls of two fetal heads and other parts of fetuses; (f) ballottement imperfect or impossible; (/) fetal movements distinctively felt in different j)arts of the abdomen ; (,7) recog- nition by auscultation of two fetal heart-sounds, not synchronous with each other and heard at different locations, with an intervening space where the heart-sounds are heard feebly or not at all. i DIAGNOSIS OF PREGNANCY. 175 ley lire rct\iro(l jtrgera- lilartri!- hoads f) ibtal oog- |i each ire tlu' Diagnosis of a Prior Prrf/nanci/.- — In tlie earlier months tlie diagnosis of anv previous pregnancy must always be obscure, even if search has been made for evidences of a previous pregnancy within a few days after the expul- sion of the uterine contents. Of coui"se we would expect to find the uterus more or less enlarged, some local hyperemia of it, the os uteri patulous, and tliere may be present some lochial discharge. But these distinctive differences between the uterus which has suffered an early abortion within the first three or four months and the chronically-enlarged uterus menstruating are not suf- ficient to be surely reliable. In case of doath a post-mortem examination would probably throw much light on the question of gestation. In an aborted uterus some remains of the placenta or of the decidua might be detected, the placental site would be imj)erfectly involuted, and in the ovaries the corpus luteuni of pregnancy might be found. The physical evidences of a previous pregnancy are most distinctly marked when parturition has occurred late during pregnancy or at term. The uterus by palpation in the hypogastric region is then felt much larger ; the lochial discharge is more characteristic ; a fatty degeneration can be de- tected in the uterine walls ; the placental site will be well marked ; the vagina is patulous and relaxed ; the corpus luteura of pregnancy is quite distinct. Sliould the cervix uteri or the perineum have been lacerated in the previous parturition, they will be observed either ununited or secondarily healed. The vulvar fourchette is always destroyed after the first delivery. Very often — quite generally, indeed — unmistakable proof of a previous pregnancy and delivery is noticed by vaginal touch. An iusi)ection of the cervix uteri shows tliat the OS is oval, with imperfectly-healed rents. A careful examination after death will show the same condition, and the cervical canal will be found less fusiform • the uterus is enlarged and heavier, the corporeal cavity having lost its clearly-defined triangular shape, the fundus uteri being no longer convex, as in a nullipara, but flat or concave. All general appearances of recent deliveries are very uncertj\in ; there are none which may not be produced by other conditions. Some women look perfectly well alter a delivery, and one unacquainted with the clinical history would never susjieet that parturition had occurred. Inspection of the abdo- men is more to be depended on. A soft and relaxed abdominal wall, with the skin thrown into folds, traversed by white shining lines (linea; albicantes) extending from the groin to the navel, is strong probable proof of recent delivery. The l)reasts after the first few days are fuller, are tumid, •vnd they contain the lacteal secretion. The presence of colostrum-corpuscles bespeaks :i recent delivery. The nipples show the characteristic areolic. (Chloasma uterinum usually occurs on the face of pregnant women, and lasts for many years. But the same skin affection is also met with in single women, and even in men. It is due to physiological and pathological changes in the litems and to various disorders of the menstrual functions. Diagnosis of the Life or the Death of the Fetus. — The fetus may from some cause, maternal or fetal, die in utero before its time of viability. Such ff< 176 AMERICAN TEXT-BOOK OF OBSTETRICS. \l i ■: 1 1, 1 it I li ■ ( a death generally shows itself sooner or later by certain niaternal symptoms. The patient has a feeling of languor and physical depression, with impaired appetite ; there will be noticed a furred tongue, nausea, vomiting, and a pale and sallow color of the patient. Chilliness with some fever is sometimes observed. The abdomen does not progressively enlarge ; the breasts become flaccid and diminished in size ; and a fetid discharge from the vagina, contain- ing exfoliated epidermis, is a certain but not common indication. The absence of the fetal heart-sounds, especiully if once heard, and the cessation of active motion of the child, once felt, if pregnancy has advanced beyond the sixth month, are positive proofs. Should the fetal head have presented, its scalp becomes soft and flabby; the cranial bones are loose and movable, overlapping one another. The lips of the fetal mouth in face presentations become flabby and motionless. No caput succedaneum can form in delivery, for there is no fetal circulation to assist in its production. Large quantities of meconium may be discharged, although the breech does not })resent. Should the breech present, the examining fiuger discovers that the inal sphincter of the fetus will not spontaneously contract. The umbilical crd, prolapsing in shoulder or other presentations, is cold, flaccid, and pulseless, contrary to its warm, full, and pulsating condition during fetal life. The rapidity of maternal infection from retention within the uterus of a dead fetus will depend u|K)n her vital resistance, the condition of her general health, and — the most important factor — whether or not the membranes have been ruptured and atmospheric air has entered the uterine cavity. 2. Duration op Pregnancy. Parturition or childbirth means the end of pregnancy. The end of preg- nancy, or the time of expected labor, is always important to foretell, not only for the physician's but also for the patient's sake. Cazeaux has given expres- sion to tiie statement that conception is more apt to follow when a voluptuous sensation or a general erethism occurs during or following coitus ; but this cannot be true. jNIany women are always passive in coitus, and all women are entirely j)assive in conception. The normal duration of pregnancy is nine calendar months or about ten lunar months. To be more exact, its duration is between two hundred and seventy and two hundred and eighty days, from the flrst day of the last oc- curring menstrual period, or about two hundred and seventy-five days, calcu- lated from its cessation. Various methoils have been suggested to obtain the time of the expected parturition ; the most reliable of these methods is as fol- lows : Deteniiine the exact day at which the last menstruation appeared. Count forward nine months, or, better, count backward three months, and then add seven days. Irrespective of the time of the year from which this couiil is begun, a very close approximation, from two hundred and seventy-eiglit to two hundred and eighty days, is obtained. This is the rule; but it is un- certain and excej)tions are not uncommon. Many difficulties are experienced in detern)ining the date of the expected parturition. As most pregnancies i * it DIAGNOSIS OF PREGNANCY. 177 l)ont ten Ired aiul last oc- Is, C'llU'U- [)tain tlif Is as lol- |[)poar(Hl. luul then [is count lty-('igl>i It is un- leriencotl rnaneies occur in married womeu, we canuot base any calculations on a single act of coitus. Even if there has been but one coitus, all physiologists admit that there is a variable period in different women, and in the same woman at dif- t'oreut times, between insemination and the fertilization of the ovum. When the impossibility of ascertaining the precise time of fertilization and the probable variation in the length of gestation itself are considered, the reasons for this uncertainty become apparent. Recognizing with His that the moment of fecundation marks the beginning of pregnancy, the pos- sibility of fixing this occurrence becomes of great interest. The uncertainty becomes still greater owing to our inadequate knowledge as to the length of time during which the sexual elements, the ova and the spermatozoa, retain their vitality after liberation from their respective sources. Wiiile the exact time during which the matured but unfertilized ovum retains its power of successfully receiving the male element is unknown, the obsc-rvations conducted on lower animals render it probable that the ovum is capable of impregnation at any time during its sojourn within the oviduct and l)ef"ore reaching the uterus, or, probably, for a period of about one week from its escape from the Graafian follicle. The remarkable vitality of tlie spermatozoa even under far less favorable conditions — direct observation showing that these elements retain their move- ments for over nine <lays outside the body — renders it almost certain that their powers of fertilization are maintained for a longtime after they are depositefl within the healthy female generative tract ; the assumption of His, Haus- mann, and others that the spermatoza arc capable of fertilization after their sojourn of three or more weeks within the oviduct is well foiuided. (Consideration of these facts renders apparen.t the impossibility of fixing with certainty the Uginning of pregnancy, since concej)tion may result from the union of tlie ovum liberated at the commencement of menstruation with the spermatozoa introduced toward the end of the period ; or it may result, as pointed out by His, from the meeting of the male elements already within the oviduct with an ovum discharged a day or two before the occurrence of the menstrual phenomena. The i)ossible discrepancies arising from these causes have been represente<l graphically by Marshall as follows : I., 2, .3, 4, 5, 6, 7 26, 27, 28, II. in which I. is the first day of the last actually occurring menstrual pericxl, and II. is the first day of the first omitted period. Should pregnancy, how- ever, occiu' under the conditions regarded as possible by His — that is, by the i'crtilization of an ovum precociously discharged just prior to the first omitted period, a discrepancy of over three weeks woidd appear between the actual termination of pregnancy and the esti.nated date of labor, when calculated in tlie usual manner from the first day of the last occurring menstruation. The general consensus of opinion, however, regards the time immediately following the menstrual period as that most favorable for fertilization, the upper third of the oviduct being probably the locality where fecundation most usually takes place. Should impregnation have occurred following the menstrual period, the 12 I wm III ^1 i\i ' I ■•* m 178 AMERICAN TEXT-liOOK OF OBSTETRICS. next expected period will almost certainly Im? absent ; but if it has taken place within a few days before an expected period, the expected flow may not physi- ologically be suspended, but simply be diminished in (piantity or be short- ened in duration. The prediction of the date of labor from the last menstrua- tion is likewise very unreliable in all women in whom its previous occurrences have been irregular or uncertain in time. Quickening, as a rule, is noticed by the female in the fourth month — about four and one-half months — and it is not unusual for counts to be made from this period. But as quickening (active movements of the child) is felt at un- certain times, this rule has been found to be very fallacious. At a certain time it proves to be the most reliable of any rule for adoption — namely, when men- struation has physiologically been suspended by an intercurrent lactation. Then there is no last menstrual period to count fi'oni, and we have but to add four and one-half months to this time of quickening to determine the approxi- mate time of the exjiected labor. It is no wonder that the duration of pregnancy in the human female has been such a fruitful topic for discussion among obstetricians. Not only the moral character of a woman, but also the legitimacy and the hereditary rights of a child, may depend upon a fair solution of this question. Is it j)ossible for a women to give birth to a child ten, eleven, or twelve months after the death or the continued absence of her husband? is a medico-legal question concerning which the obstetrician may be called upon to express an opinion. Experience witli some of the lower animals in whom the date of a single coitus is well fixed, and the records made by numerous distinguished obstetric authorities, make such exceptional instances as reliabh creditable. Most of such offspring are very large male children. 3. Prolongation op Pregnancy. Sir Charles Clark in 1816, when giving his evidence in the famous Gard- ner-Peerage case before the House of Connnons, said : " I have never yet seen a single instance in which the laws of nature have been changed, believing the law of nature to be that parturition should take place forty weeks after con- ception." ]\Iany jihysicians of the present day hold that the law of nature is quite fixed in this res])ect — that human pregnancy never exceeds this term. But we have now sufficitnit evidence to show that human pregnancy is not so definitely and precisely fixed as some think. The duration of pregnancy may be shorter or lonjver than 280 days. To what exteut may ])regnancy be jirolonged, and what are the evidences of its prolongation? It is easy to understand the moral and legal aspects of 1;; iiportiint question. The moral charact* r of ilie female, and the iidieritcid is and legitimacy of an ofispring may depend on a fair and just fixation dl' 1!- Duuriiity, and on the determination of the possibility of the prolongation of liitinan pregnancy, as when a woman gives birth to a child ten, eleven, or twelve months after the death, or the forced absence, of the husband. Laws ou this question vary in diffei'ent countries. In France legitimacy cannot bf ^2M Gai-d- t seen lllg tllL' r con- 11 at lire term. not so •y may kleiiccs Iccts tit' lioritcd It ion (if Igation rcii, or Laws inot be DIAGNOSIS OF PREGNANCY. 179 contested until 300 days have elapsed since the death of the husband, and in Austria and Prussia about the same time is allowed. In England and in the United States no time is fixed. Numerous cases are on record of a prolongation of pregnancy to 336, 332, "24, and 319 days, respectively, after the last menstruation. Granting that conception in these cases did not take jilace within a few days after the last menstruation, as is the rule, but w'as postponed to just before the first missed iieriod of that function, we «ui subtract about 23 days from these periods of gestation, and will then have 313, 309, 301, and 296 days, each exceeding the ordinary duration of pregnancy. Admitting that the first menstrual cessation was due to some abnormal (•■msc — a mere possibility — we will still have a prolonged duration of preg- iKincy. Hence the possibility of a variation of a conception being uncertain its to time does not account for the great variation in gestation so often (il)sorved. It is extremely uncommon in healthy young women for a men- strual period to be skij)ped for one time only without there being some notice- able change in the bodily health. Variations in the duration of pregnancy occur in cows, in which there have l)oen careful records of a single coitus. When impregnation occui*s in the human female as the result of a single coitus, the date of which is accurately recorded, as among single women or among married women whose husbands have been absent for months, possible errors of the date of conception may be avoided. If, then, pregnancy is at times prolonged, to what extent is there any pro- traction ? Meigs, Atlee, and Simpson have mentioned instances when the duration was prolonged to almost or quite a year. Dewecs records a case which was prolonged to ten calendar months. Playfair, Liisk, and Leishnian mentioned cases of considerable prolongation. Taylor and Beck in their work on ^Medical Jurisprudence record numerous instances of protracted gestation. Other physiological functions of life, such as dentition, puberty, or men- struation, may vary as to the time of occurrence. Some women appear to go uniformly beyond the usual time for parturition. The degree of uterine activity must be less with them. More frequently the sex of the forthcoming delayed cliild is male rather than female. We are forced, then, to the conclusion, by a study of the analogy of other functions of the body, by observations in the lower animals, and by accurate reliable data, from women in particular, to believe that pregnancy may be, and often is, prolonged. Gestation may be lengthened, parturition may be delayed, from a few days to several months. The causes which conduce to labor — the maturing of the dccidua vera, its preparatory disintegration, and the final detachment of the membrane of the ovum from the uterine lining — do not always occur at the same time or with the same degree of activity ; hence gestation may be jirolouged. I m i 4 ■ i I 1 i w ■ ': 1 1 1': i I r , I ! 1 1^ ' .1. M if 180 AMERICAN TEXT-BOOK OF OBSTETRICS. III. HYGIENE AND ^fANAGEAIENT OF PREGNANCY. Hygiene of Pregrnancy. — To be ciirrii'd sat'oly through the period of utero- gestatioti, tlie most critical time of her life, physiologictilly speaking, the preg- nant woman nct'ds special care. Particniar attention is to be given her in the selection oi' diet, exercise, rest, sleep, clothing, and bathing. Her mental condition is to be watched ; her attention diverted. The condition of the breasts calls for some prophylactic treatment. DU'f, — Very early in pregnancy the desire for food is diminishe<l and cer- tain unnsnal articles of food may be craved. Fair quantities of food are always needed. Kespect must be paid to her morbid longings in taste. Thus the time, j)lace, and social association in partaking of food, and its kind and variety, are always to be considered. The morning sickness is thus sometimes best abated. In the fourth month the gastric irritability usually spontaneously subsides, the ap|)etite reappears, and the digestion improves. All foods, ani- mal and vegetable, that are reasonably well digested and mitritious are best suited to her condition. In a word, the diet of a pregnant woman should be plain, simple, easy of digestion, highly nutritious, and partaken of at regular intervals, A good general supply of nitrogenous food, with vegetables and fruits, is called for. No inflexible rules can be made for all cases. As some foods do Mot agree equally well with all patients, personal likes and idiosyn- crasies must be consulted. A generous diet improves hematosis, increases func- tional activity, augments body-weight and body-heat, imparts tone and firm- ness to the blood-vessels and tissues, and diminishes the susce])tibility of the nervous system to pain and reflex irritation. That the diet must directly influence the growth and development of the fetus in utero is reasonably clear. In the latter ]>art of pregnancy the gravid uterus has risen to and presses upon the stomach, hence food has to be taken in greater moderation and at shorter intervals, A milk diet is at times especially needed. Albuminuria is a condition calling for the use of milk, as recommended by Tarnier. Its absolute use, strictly enforced, gives very good results in tliis complication. Exercise. — Moderate exercise can almost always be well borne. Violent exercise and excessive fatigue are invariably to be avoitled. Extraordinary exercise, such as riding horseback or over rough roads, dancing, or lifting heavy weights, is injurious. Long journeys by water or by land should be postponed if i)ossil)le. Is parturition made more easy by unusual physical exercise? Affirmatory ojiinions have been entertained. Doubtless, women whose habits have accus- tomed them to considerable jjliysical exercise can, all things being equal, undergo parturition easily and quickly; but those unaccustomed to any special physical exercise should undertake only what can comfortably be borne. If active exercise is not well borne, then ])assive exercise may be highly bene- ficial. Riding in the open air gives the j)regnant woman the necessary fresh air and sunlight. Crowded and ill-ventilateil rooms are to be avoided. HYGIENE AND MANAGEMENT OF PREGNANCY. 181 tirin- fuatory accus- eqiial, I special |e. If beiio- f'rcsli wided. While moderate exercise is needed in many or in most cases, its continnance is objectionable in cases where the normal relaxation of the pelvic jointK becomes excessive. The pubic joints, most often atte(!ted, are so relaxed at times that locomotion is impeded and rest is demanded. Rest. — A pregnant woman needs abundance of sleep, because of its health- tjiving, restoring influence. A portion of each day, after the mid-day meal, may well be selected for the assumption of the recumbent posture, to obtain lor an hour or two either rest or sleep. Clothing. — Great care is to be taken that the clothing is so adjusted as not to compress the alMlomen and the chest. While the quantity and the quality of the clothing are to be determined by the season of the year, the garments ))]aced around the waist are to be as light as ])racticable consilient with com- fort. The clothing is best suspended from the shoulders. The corset and tight-fitting skirts are injurious, impeding as they do the expansion of the Sii'owing uterus and its contents, and favoring the development of symptoms of a not uncommon complication of pregnancy — albuminuria with uremia. Multipara! with relaxed abdominal walls often experience comfort by giving support to these parts with an abdominal bandage, thereby maintaining the uterus in a more normal position, wherein there is better accommodation of the fetus. All possible pressure of the pelvic and renal veins is to be removed. Bathing is to be administered to the body at the usual intervals observed in health — daily in warm weather, and at least twice a week in cold weather. The baths are to be general, with an abundance of water and soap. The tem- ])erature of the bath may be either warm or cool, according to previous habits and to the season of the year. The functional activity of the skin, quite often impeded in the last weeks of pregnancy, should be maintained carefully by the free use of the bath. Vaginal injections are not required if there is no leucorrhea, vaginal or uterine. If an injection is given because of this complication, there is nothing better than a saturated solution (one quart) of boric acid given with a fountain syringe in a very gentle current. Sexual intercourse is to be regulated carefully, for very often it is found to be injurious to pregnant women. While especially enjoyetl by some pregnant women, coitus is distasteful to most women at this period, and it be(!oraes the source of nuich pelvic discomfort to not a few ; it may create an abortion. Even uncivilized nations have condemned the privilege of sexual intercourse during the period of pregnancy, and have visited ])unishment on the offender. During the first few months of pregnancy, wdien so many abortions occur, and toward the last of pregnancy, it is best for the husband and wife to occupy separate beds. May local treatment to the diseased cervix and canal be carried on during pregnancy? With proper precautions and due care, this question is answered in the affirmative. INIost of the accidents causing the induction of abortion by local interference have arisen from a neglect to investigate atid deter- mine the condition of the body of the uterus, and to ascertain whether it may 182 AMKltlCAX TKXT-nOOK OF OJiSTETRICS. :!? have boon gravid. l'rc<jiianc'y a<i<;ravatos chronic cervical endometritis in that it increases the cervical catarrh, the granuhir degeneration, the secondary vaginitis, and the vulvar pruritus. Hy the genth; use of warm vaginal injec- tions of a uiiii'orm temperature, and by the topical use of astringents and emol- lients, and in rarer cases of the nitrate of silver in solution, not only may the patient l)e made more comfortable, through an imj)rovement in the local con- dition and the arrest of reflex disorders, such as nausea and vomiting, but par- turition itself may also be made easier. The mental vondition of pregnancy is always im])ortant to consider. P^motional susceptibility is usually somewhat increased. The pregnant woman, quite excitable and irritable, readily responds to external iiiHuences by which, in the non-gravid condition, she would not be influenced. Sometimes she feels unusually well, is intellectually brightened and more active, takes greater interest in her household affairs, and says she is positively happier. At other times a certain despondency creeps over her mental state; she is unusually morose ; there is observed irritable moodishuess or ]ieevishness beyond the control of the will ; the senses of sight, hearing, smell, and taste, and the sen- sory or motor nerves, are frequently perverted without any structural changes in the nerves concerned. All these pervei-sions or exaltations of function are doubtless directly or indirectly attributable to the quantitative and qualitative changes of the blood from pregnancy, and to the physical changes going on in the sexual organs, creating reflex disorders. Structural alterations in the growing fetus may be effected, modified, or perverted by psychical influences. Certain fetal disorders may I'esult from maternal impressions. Monstrosities do at times so occur. Physiologists admit, and observations prove, that the maternal emotions do affect the development of the exterior of the fetus. Likewise may the mental ilevelopment be altered in its complex and delicate organization. Idiocy may so result. The mind influences and modifies the body in ways unexplained. In view of these facts the wise physician should aim to direct the mental condition of his patient. ^Vhiic all sudden unpleasant news, frights, and physical shocks are carefully to be avoided, those circumstances which im- properly harass the pregnant woman are to be dismissed. Kind assurances are ever holj)ful. A judicious amount of amusement is not to be forgotten. The mind is to be occupied pleasantly, and diverted into new, pleasing, surprising channels, into associations agreeable and cheerful. Around the patient should be thrown a gentle, protective care, and she should ever be treated with considerate kindness. It becomes the duty of the husband to give his wile an intelligent co-operation to bear her burden. Management of Pregnancy. — It becomes the duty of every practitioner of medicine engaged to attend a woman in an expected parturition not only to give her some general hygienic directions as to diet, dress, exercise, and the regulation of her bowels and skin, but also in a general way he should assume some professional care of her throughout her pregnancy. Many disorders and a \ f i IIYGIEXE AND MANAGEMENT OF PREGNANCY 183 complications are apt to arise during tiiis periiKl, and much depends upon prompt and well-directed advice in their judicious management. First of all, the stomacJi disorder most frequently occurring calls for some attention. Reference has been made to its dietetic management, more effi- cacious, it may be, than the medicinal. In this connection the writer has realized general good results from the administration for a time of koumiss. Failing with the retention of tlie food on the stomach, rectal administration of food is next to be utilized. For the physiological nausea and vomiting of pregnancy the writer has found the following remetlies efficient : Tincture of nux vomica, weak solutions of atropia, sodium bromid, cocain, and electricity. Faradization (secondary current) of the stomach and the doi-sal spine, and gal- vanization of the central sympathetic are worthy of a more extended use for this affi'ction than they have yet received. Next, the alvine evacuations are to be maintained daily. A good diet and regularity of habits show their good results. The mineral waters, such as Congress, Hathorn, the sulpho-saliue waters, or a solution of phosphate of sodium or Carlsbad salts or the Seidlitz powdei-s, are indicated. Purgation is seldom called for. The best laxative remedies are aloeiu, podophyllin, and cascara sagrada. Above all, it is important that careful attention be given to the renal func- tion. Once a month at least, during the latter half of pregnancy, should the ])hysical, chemical, and microscopical elements of the urine be ascertained, to detect any possible alterations in its quantity and quality. Not a few cases of puerperal eclampsia from uremia may thus be averted or be modified by a supervision of the kidney excretion. " To be forewarned is to be fore- armed " was never better illustrated than just here. Albuminuria is present in at least from 5 to 10 per cent, of the cases of pregnant women ; some claim that the proportion is larger. A careful examination of the abdomen may very properly be made after fetal viability. The external examination by palpation, together with an internal vaginal examination, is called for in all cases toward the last two weeks of pregnancy, to determine not only the fetal viability and a possible multiple pregnancy, but also to ascertain the presentation and position of the fetus in ufero, the existence of any complications, as hydramnion, and to a})preciate the cervical condition in shajie, size, and patulousness, in order more correctly to estimate the time of the approach of the expected parturi- tion. The pelvis of every woman should be examined by external and internal pelvimetry in the seventh or eighth month of pregnancy, if in her first j)regnancy or if she has had any special difficulty in a previous parturition. At the time of this examination directions may be given as to the })re])aration of the room, the bed, the garments, and as to obtaining all needed articles. The exact methods of diagnosis that prevail in maternity hospitals ought also to exist in private practice. If the labor promises to be long, difficult, or very painful from obstructions of any kind, the obstetrician ought to know it in advance, that he may elect at a proper time before parturition whether to choose jTnf ^ ill I I ll I )^ 184 AMKRICAy TEXT- BOOK OF OliSTEritlCS. the iiidiK'tiui) of a piviiiatiin! lubor, to (h^pciid on tin; use of the forceps, or to resort to a podalic version, a syinpliysiotoiny, or a ('esareau section. How many craniotomies could tlius be avoided and maternal deaths prevented ! The mammary glands need ample room for their development to prepare them for the coming function t)f hu^tation. The nipples, especially if retracted, should always he drawn out by i\w application of the index finger and the thumb for a few minutes each day during the last six weeks of pregnancy. Exposure of the glands and the nipples to the air dctubtless tends to diminish their tcsndcncy to become sore and fissured. Daily ablutions with cold water are always essential. A topical appli(^ation of the following as a jirophylactic remedy for sore and fissured nipples is to be reeouimeniled wheu it is thought desirable to use an astringent application : I^. Tannin, Glycerina?, Aqufe rosa>, Sig. Apply daily as directed. .5ss ; .?ss.— M. As no two pregnant women are alike, and as no two ])regnaneies in the same woman are alike, no absolute rule can be framed for all. The expectaut treatment is largely called for. Discretionary powei-s are necessarily given the pliysiciau in charge. Only general principles cjui be laid down for guid- ance. Special (lirections are called for when there are special disorders and complications. A very frequent danger is that an abortion or a premature delivery may be precipitated by uterine contractions. Any constitutional dis- ease, especially syphilis, nuiy require special medication. Doubtless there are remedies which often favor uterine tonicity and become prophylactic against abortions. Viburmun j)rnnifolium, aletris, and cimicifuga doubtless favor the normal completion of gestation. In all eases as little medicine as possible ought to be given. Pregnancy is a purely physiological condition, and it is best managed by an observance of the hygienic instructions. ' i TlIK PATllOLOUY OF PltKd NANCY. 185 IV. THE PATHOLOGY OF PREGNANCY.* I. Diseases op the Several Systems. Thk remarkable clianj^es occnirriii}'; in the genital organs of woman, and also tliroiigliont her entire body, as gestation advunees, occasion conditions which often transcend the bounds of health and Iwcome states of disease. As these changes are most pronounced in the uterus and its appendages, it will be appropriate to consider, first, the pathological conditions of the uterus and its appendages induced or exaggerated by the pregnant state. It will then be proper to study those geneial derangements which the condition of pregnancy invites ; next in order, to treat of the influence of the various infectious agents upon the pregnant organism ; and finally, the surgical injuries and processes observed during this period. 1. Pathological Conditions of the Uterus and Appendages. The Uterus during Pregnancy. — While the position of the jiregnant uterus is subject to frequent change, it has been found by Ferguson ' and others to be rotated to the right in 80 to 90 per cent, of all pregnant women. <Jreat distention of the bladder may temporarily lessen the degree of rotation upon its axis. Occasionally this dextro-torsion becomes excessive, as in a case reported by Wenning,'' in which the uterus at six months' pregnancy was so strongly rotate<l toward the right as to sinndate extra-uterine pregnancy upon that side. The left tube was greatly eidarged. The terni " hypertrophy " best describes the normal condition of the preg- nant uterus in the various ]>hases of gestation : its peritoneal covering, its interlacing niu.scular and elastic tissues, and its glandular lining membrane, all become enlarged by production of new elements from nuclei already exi.sting. The enormous increa.se in area and in blood-supply is especially remarkable in the ])regnant woman : although the deciduous njembranos represent the greatest development of its epithelial elements, still the eiulonietrium shares extensively in the general hypertrojihy. It is readily seen that this condition of plethora naliu-ally favors the rapid development of any neoplasm previously existing in the uterus, especially any neoplasm whose elements closely resemble normal uterine structures ; such neo})lasms are — Myomata of the uterus, sometimes termed fibro-myomata or uterine fibroids. As has been .'•hown by C'room' and others, although myomata exist frequently among childbearlng women, they do not alway* attract attention during pregnancy, and are often undetected at labor. Such tumoi-s grow, * The guperinr figures (') occurrinj; throughout tlie te.xt of this article refer to the bihli- ography given in the Kefereuce List on page 'M'.\. ! :i il V ' ^|! l' is! j If ?: g. > ■' i» p 186 AMERICAN TEXT-BOOK OF OBSTETRICS. however, with groat rapidity during pregnancy, often interfering with the circuUition in the lower extremities. Many cases in which early pregnancy is complicated by edema of the legs, and in which abortion occurs at four or five months, accom^^anied by profuse hemorrhage, are cases of fibroids complicating pregnancy : their bulk causes interference with the functions of the bladder and the rectum, while they alter the position of the uterus, causing abnormal presentations of the fetus and prolapse of the cord at labor. Their encroachment upon the uterine muscle interferes with its normal contraction and retraction ; hence the rhythmic contractions of the uterus commonly exist- ing dnring pregnancy are unusually painful, and sometimes are excessive in strength. The substance of the uterus may be so altered that rupture of this organ may occur, as in a case described by Hogan,* where a fibroid pregnant uterus ruptured spontaneously at about the fourth month of gestation. When rupture docs not take place, spontaneous I'cduction of a displacetl fibroid uterus sometimes results from the stimulus to growth and intermittent contractions furnished by pregnancy. Spontaneous reduction is frequently followed by rup- ture of the membranes and abortion, as pointed out by Loviot.* Although fibroid tumors of the uterus are often supposed to prevent conception, cases are on record where sterility persisting for some years in such patients had been replaced by pregnancy so late as forty-five years of age.® Pregnancy exerts a remarkable influence upon fibroid tumors of the uterus, not only in causing their rapid growth, but also in frequently bringing about a condition of well- marked softening and fatty degeneration : this pathological condition sometimes decides the choice of a method of treatment in these cases. The treatment of pregnancy complicated by fibroid tumors when interference is necessary is by operative procedure. Submucous tumors, if they become pedunculated and distend the lower uterine segment, frequently present before tho fetal head, and, excitiiig premature labor, may be removeil by the obstet- rician in advance of the child. Intramural tumors require no treatment during pregnancy unless the results of their pressure upon important viscera oblige the obstetrician to perform hysterectomy. Subserous fibroids in the pregnant patient may often be removed without terminating the j)regnancy, as in cases reported by FronuneF and others. Should extensive fibro-cystie changes in the uterus occur, complicating pregnancy, this condition should not be allowed to go on to term, but hysterectomy should i>romptly be performed. Routicr* reports a successful myomectomy during pregnancy, and he has collected, with his own, 15 eases in which the operation was performed, ten of which recovered. Strauch ' also reports the successful removal of a fibroid as large as a goose-egg from a pregnant uterus by abdominal section. Phillips '" gathered reports of 282 cases of fibroids complicating pregnancy : his statistics indicate a high mortality from radical jiroccdures. Pozzi, " from his collection of these cases and his personal exj)crience with them, considers simple myomectomy the preferable procedtu'e in suitable cases. The occurrence of s])ontaneous abortion sometimes necessitates immediate operation in cases of pregnancy complicated by fibn id tumors ; thus Bourcart '^ .J i, iii THE PATHOLOGY OF PREGXANCY. 187 erence ecouio before (bstct- iiring blige pliant cases cs in owed lo has \\, ton of a lotion, lincy : 1 from jidors 'diato ■art" reports t^.e case of a pregnant patient whose gestation was coniplioatcd by iiiyonia of the uterus and by excessive ;;orsion of the uterus and its append- ages. Spontaneons abortion was followed by chill and fever. Taking advan- tage of a fall in the t>^uaj)erature, liourcart performed hysterectomy. The result was successful. Attention has recently been called by Hofmeier '* to the intlu- encc which myomata exert upon pregnancy in causing abortion. He cites from the records of others 796 cases of pregnancy with this complication, and finds that aboilion occurred in 6.9 per cent, of the cases. He naturally concludes that the majority of patients who suft'ei- from myomata during pregnancy pass through gestation but slightly influenced by the tumor of the uterus. Ott reports a case of pregnancy nearly at term complicated by fibromyoma of the uterus and bronchitis.'* Amputation of the uterus was performed ; the stump was covered with peritoneum and dropped. The patient and her child made a good recovery. Gordon "' rept)rts a successful myomectomy by which a fibroid was removed from the anterior wall of the pregnant uterus : although the uterine wall was left thin and vascular, hemorrhage was controlled by stitching the peritoneum and the base of the wound with fine catgut. Recovery was rapid and pregnancy was nninterru])ted. Staveley '" collected a considerable number of cases of fibroid tumors com- plicating pregnancy, and he adds from the records of the Johns Hopkins Hos- jiital two oases in which myomectomy was performed successfully during preg- nancy without interrupting gestation. Staveley's tables embrace 33 cases with a maternal mortality of 24.25 ])er cei^t. Statistics show that in late years nivomectomy for this condition is more successful than before antiseptic sur- gery attained its present perfection in technique. During the last eight years the mortality-rate of myomectomy in these cases has fallen to 11.75 per cent.* Cancer of the uterus, complicating pregnancy, increases in oases of .•arcinoma with great rapidity during the pregnant state, and with even greater vigor during the puerperal condition. Wl-.cn pregnancy has not advanced beyontl the fourth iiionth, \ ..w dor Veer" and others practise vaginal extirpation of the uterus. In oases whore carv. noma attacks the cervix the prognosis is most uiifavorable. If delay is practised, the tissues surrounding the cervix soon become infiltrated, and delivery by abdominal section, should life persist to full term of ]irognancy, is the only alternative. The fact that caroinonm grows with greatest ra]>i(lity during tho puerperal condition obliges the obstetrician, whenever possible, to perfor.n oomploto extirpation of the uterus, either at the time when the fetus is '^"li veered or as soon as possible thoroaftor. The danger of septic infection follow i'lg Cesarean section is so groat that the majority of operators prefer hystere. ^oniy or total extirpation. Cancer ocoasioually involves the uterine tissue so ex, 'nf.vely as to result in rupture of the uterus. This extensive involv(>ment vjctMirs in cases where preg- * Tlie literature of this subject given on page 313 will iiiteitst (lK>-,e who desire to [tursue it fiu'tlier. wwwm \i 14 'I 1 i 1 i ' 1 ; \ ;i ■ i 188 AMEBIC AX TEXT- BO OK OF OBSTETBICS. nancy supervenes upon the existence of the cancerous condition. The great stimulus which pregnancy causes in malignant growths results in the rapid dissemination of malignant tissues, which gradually destroy the elasticity and the resisting power of tl»e muscular layers of the womb. Rupture occurs in these cases during abortion or during labor at term. The prognosis is exceed- ingly grave, for, even should the patient rally immediately from the rupture, the malignant growth must sooner or later end her life. Auvard repoits the case of a patient in her eleventh pregnancy who had ute- rine cancer for two years.'* Labor was exceedingly slow, the pains being very weak but persistent. When partial dilatation was present the os was incised in several directions and the fetus was found in breech presentation. Extraction by the feet was performed, and persistent hemorrhage ensued ; on exrjnination the uterus was found ruptured transversely at the upper edge of the lower uterine segment. The patient succumbal to shock. Cancerous infiltration of the tissues of the cervix often necessitates multiple incisions in any necessary manipulation during pregnancy or at labor. Von Herff " illustrates the value of free incisions in cancerous cases. Cesarean section had been decided upon, but, as a last resort, multiple incis- ions \vere freely made, and they proved efficacious. Early pregnancy compli- cated by uterine cancer invariably demands total extirpation, from which even unfavorable cases recover and the operation has prolonged life, as illustrated by Moller.^ In his patient the cancerous uterus was extirpated with great difficulty by reason of the infiltration of surrounding tissue. A rent was left in the peritoneal cavity, through which rent a loop of intestine protruded. Notwithstanding these unfavorable features, the patient made a good recovery, and some time after the operation was comparatively free from cancer. Sutu- gin reports two cases of amputation of the uterus at term for cancer, in each of which cases the life of the child was saved. Tayhtr of Jaj)an records*' a very unfavorable case of cancer in which vaginal extirpation was performed with great difficulty. A favorable result followed. In cases where the cervix only is involved the diseased tissue should at once be removed by the knife and cautery, with the ho])e that the progress of the disorder may be checked temporarily while the pregnancy advances, thus affording the child a better opportunity for life. In carcinoma of the preg- nant uterus complete extirpation is the only treatment that promises a favor- able result. If the i)atient is seen for the first time in pregnancy advanced bevond the fourth month, delav mav be advised in the interest of the child so long as the tissues about the uterus do not become involved. Under the improved methods now followed in performing total extirpation the prognosis for the nujther is no longer desperate, a fair chance for recovery from the opera- tion and the prolongation of life being thus given her.^^ In epithelioma of the cervix complicating i)r(>gnancy, Edis^ reports a ease in which an epitheliomatous mass was found involving nearly the whole cervix and extending down upon the posterior vaginal wall, rendering the pas- sage of the fetal head ini})ossible. The ch'ld was delivered by Cesarean s( „ $ THE PATHOLOGY OF PREGNANCY. 189 i tion, and seven months after the operation the epithelioma had made but little progress. The decidual lining of the uterus may occasionally become the seat of malignant disease, as observal by Sanger and Chiari.^* This form of cancer is describctl by these writers as a true sarcoma of the dccidua : its symptoms are foul discharge and hemorrhage persisting after labor, and its fatal termi- niition usually occurs within six or seven months after delivery. Metastatic deposits are not uncommon, the cells of which bear the characteristics of decidual cells. There \z an innocuous form of this growth, also described by Siingcr,^ that is not to be mistaken for decidua remaining adherent after a i'onner pregnancy. Hypertrophy of the decidua occurring during pregnancy may be non- nialignaiit and not dependent upon the existence of syphilis; thus, Hermann'^ ilcscribes cases of decidual hypertrophy in which the tissue measured one-fiftieth of an inch in thickness : microscopic examination revealed the presence of large cells, with large nuclei, five or six in number, without intercellular sub- -tance, but infiltrated and containing leucocytes. A similar condition has also I Ml described by Virchovv, ^ Strassman,^ Dohrii, ^ Gusserow, ^^ Klebs,** and Matthews Duncan.^^ Sponttineous rupture of the uterus occasionally happens during preg- nancy. Such cases are usually found to have been complicated by a fibroid tumor or by displacement of the uterus, with adhesions binding it in its dis- placed position. ^Manipulation intended to replace the uterus has sometimes hastened its rupture; thus in a case reported by Dickey^ the patient was in the third month of her fifth pregnancy: an eftbrt had been made to replace a retroverted womb, the effort causing the patient considerable distress. A few days afterward something was felt to give way, and the patient perished ill a few hours from shock. Post-mortem examination showed early p -"ancy and the ui( riis ruptured transversely from one Fallopian tube to the otiier. Spoi'hmcoiis rupture of the uterus may result from the rapid development of a largo fetiis in a uterus whose tissues have been weakened by previous disea ?. I'lio lietus may escape into the abdominal cavity, as illustrated in a case repon, '1 bv Aladurowicz,'* in which fatty degeneration of the uterine wall at tiie jn.iction of the fundus and cervix was found. The fetus had heco.ne partially encapsulated. Purulent jieritonitis ensued, and the ab- doiiinal wall opened spontaneously with the discharge of pus. The patient died of exhaustion. Endometritis during pregnancy results from an aggravation of a pre- existing inflammatory condition, and it is a familiar and frequent cause of ear! I'oortion. In patients who complete the jieriod of gestation the existence of !' . .'undition nuiy be susjiected when occasional discharges of blood or of watciy aiicus occur. While the pregnancy is not likely to go to term, still its coiitiiuiance must not be despaired of because of these discharges. An endo- metritis set up or aggravated by ])regnancy not infrerpiently causes adherence of the membranes about the cervix and the lower uterine segment, often com- m 190 AMERICAN TEXT-BOOK OF OBSTETRICS. \ ! ; I )i i I plicating labor by premature rupture of the bag of waters and protracted dila- tation of the birth-canal. It is noticed in women who conceive shortly after an abortion that an endometritis arising at the abortion may persist through- out pregnancy, becoming aggravated, and resulting finally in the firm adhe- rence of the placenta and in complicated labor; thus, Lohlein** reports a case of tills character in which the pregnancy went to term, its latter portion being complicated by intermittent pyrexia and by a very firmly adherent placenta. The treatment of this condition is entirely in the interest of the mother, as the prospect of her retaining th.e ovum to maturity is so slight that exhaust- ing hemorrhage or febrile disturbance should lead to the prompt emptying of the uterus : this should only bo done in the most thorough surgical manner and under strict antiseptic precautions. Sufficient dilatation to permit the use of the sharp curette and of draiii q;e should be secured by using the fingers or solid metal dilators. ShouL t.?ptic infection and fever be present, the blunt-edged douche-curette may I j red to great advantage, thoroughly emptying the uterus under a stream antiseptic fluid. Where sepsis and fever are absent the sharp curette followed by antiseptic irrigation will be found eflficie it. Drainage with iodoform gauze, with repeated intra-uterine irrigation, is indicated, should fever and foul discharge continue. Curetting is best performed at the time of abortion or premature labor, or, if this oppor- tunity is omitted, it should be done when the patient has recovered strength and the interior of the uterus has ceased to furnish a foul discharge. Salping-itis existing during pregnancy complicates the pregnant condi- tion largely by reason of the adhesions and the inflammatory exudates usually present with the salpingitis. As the uterus increases in size, tension upon these adhesions causes very considerable pain, and if the adhesions are firm, binding down the uterus, abortion is not infrequently the final result. A frequent cause of retroversion and retroflexion of the gravid uterus is to be found in salpingitis and in the adhesions and exudates which accompany this condition ; in such cases obstinate nausea and vomiting, and finally abortion, may bo the direct consequence of the salpingitis present.^® ^' Salpingitis is by no means a trifling complication of pregnancy, as cases are recorded in which acute sepsis, with general peritonitis developing twenty-four hours after labor, has caused death. It is certainly true that a patient suffering from salpingitis should avoid preg- nancy, and should subject herself to prompt and thorough treatment if the lia- bility to pregnancy exists. Diseased conditions of the ovary complicating pregnancy are usu- ally made worse by the gravid condition ; thus, ovarian cysts, solid tumors of these organs, and inflammatory conditions are greatly aggravated during preg- nancy. Acute oiiphoritis complicating pregnancy is of rare occurrence, and it may result from an exacerbation of a chionic process or septic infection from a previous abortion. Three cases of this affection are rejiorted by Coe ;'^ in each of two cases tubal and ovarian abscess formetl and was emptied. All three patients recovered, although convalescence was prolonged. The treat- THE PATHOLOGY OF PREGNANCY. 191 ineiit of this condition is largely expectant, abdominal section being most successful before the fifth month of pregnancy. Thomson^' has shown that while the tubes undergo a marked hyper- trophy during pregnancy, the ovary itself does not. The alterations observed in the ovaries during pregnancy are caused by foreign growths, and not by the increase of elements normally present. In addition to the danger of abortion which the size of an ovarian tumor occasions, there is possible risk tliat such a tumor may twist its pedicle, and that gangrene may be added to the complications of labor in this condition. It has repeatedly been shown that the operation of ovariotomy is safe and satisfactory during pregnancy, and this fact calls for the removal of ovarian tumors as soon as their presence is detected. In these cases adhesions are not often present, nor does the preg- nant condition predispose to their formation. The rapid development of a cystic condition of the '^vary may completely mask an early pregnancy, as in a case reportetl by Polaillon,^'^ in which preg- nancy could not positively be diagnosticated until a cystic ovary and an adherent tube were removed. This operation did not interfere with the preg- nant condition, the patient going to term and being delivered of a healthy child. Spontaneous cure of a pelvic cyst complicating pregnancy occasionally happens in the case of broad-ligament cysts, which disappear by spontaneous rupture. Rnge"*^ describes a case four months pregnant in which under anesthesia a pelvic cyst was pushed up above the brim of the pelvis, relieving pressure upon the uterus. Abortion followe<l, and after recovery the abdomen was opened ; no cyst was foiuid, and its disappearance is ascribed to spon- taneous rupture. The evidence in favor of the operative treatment of ovarian cysts complicating pregnancy is greatly in the ascendant over any other form of treatment ; this is shown by the results of Schroeder and Olshausen, Flaisclilcn^^ and Dsirne;*' the mortality of the operation ranges from 9.8 per cent, to 5.9 per cent. ^langiagalli " and Acconci *' similarly report good results from ovari- otomy during pregnancy. Tcrrillon ^^ advises against puncture of ovarian cysts during pregnancy, and urges ovariotomy not earlier than the third nor later than the fifth month. Disorders of the vulva may occur during pregnancy as the result of mechanical injury or be associated with some constitutional condition. Hema- toma of the vulv is especially likely to happen by reason of the congested condition of the parts caused by pregnancy. An illustrative case is reported by Eiirendorfer :*^ incision under antiseptic precautions and tamponing, ])ref- erably with iodoform gauze, resulted in speedy cure. Pruritus of the vulva is one of the most annoying complications of the pregnant condition. In cases where there is no reason to suspect the neglect of cleanliness, pruritus is to be considere<l as due to one of two classes of causes. The first class comprises the many diseases which alter profoundly the condition of the skin ; chief among these are disorders of the digestive and excretory systems, as diabetes 192 AMERICAN TEXT- BOOK OF OBSTETRICS. :■ i m and nephritis. The treatment of the pruritus in such cases resolves itself, first, into the treatment of the general condition, and then into such local applications as njay be found of use. The latter embraces the various antiseptics and anesthetics which are available in the ]>ractice of dermatology. The second class is those cases in which no diseased condition of the general organism can be found to account for the pruritus, and in which the disorder is purely local. This class is treated by local applications, and in obstinate cases resection of the diseased tissues may prove the only alternative, Sanger** has shown that in these cases partial or total extirpation of the vulva is thoroughly legitimate, and should include the removal of the glans clitoridis. Where the entire vulva is affected plastic operation may be necessary to cover surfaces exposed in the extirpation. In circumscribed pruritus of the vulva it may be possible to limit the extirpation to the affected part. Elephantiasis of the labia may complicate pregnancy, and prove an annoyance to the obstetrician at the time of labor. The appended illustration (Fig. 142) is taken from a case under the observation of, and described by, the writer. The patient, who wa'* pregnant for the first time, gave no history of venereal disease ; the growth persisted for several months before the occurrence of pregnancy, and increased slowly during gestation. Aside from its bulk it occasioned no suffering. During; labor it rendered thorough vaginal examina- tions difficult, and at tlie moment of delivery impeded somewhat the dilatation of the birth-canal. Especial precautions were taken to maintain the parts in an antiseptic condition at the moment of delivery. The patient's convales- \i ' I r Fi(i. 142.— Elephantiasis of the labia ((int'-fourtli liff ^izo). cence was uninterrupted, as no serious wound of the iiypertrophied tissue occurred during the labor. During tiio puerperal period the injured tissue decreased verv sliglitlv in size. I. i-:-,i THE PATHOLOGY OF PREGNANCY. 193 The presence of bacteria in the genital tract of the healthy pregnant ]):itient is an interesting qnestion which lias occasioned extensive research. The results go to show that pathogenic bacteria are not present in the healthy pregnant patient. Among the most thorongh of such investigations are those of Winter,*' made at the suggestion of Schroeder : he found that the Fallo- l)ian tubes containefl normally no micro-organisms : this is also true of the normal uterine cavity. In half the uteri examined germs were present at the internal os ; in the secretion of the cervix, antl also in the vagina, there were found abundant micro-organisms. These germs were found to be patho- genic, but not ])ossessing the virulence which characterizes them when observed ;iniid tissues in a pathological condition. It was found, however, that when pathogenic organisms were introduced from without the germs already present ill the genital canal assumed a virulent character. Diseased conditions of the vagina occasionally comjilicate the pregnant condition ; thus, Rissrnan*" reports a case in which a polypoid degeneration of the connective tissue of the vaginal wall attained such proportions as to pro- hipse before the fetal head during labor and to offer an obstat'" to delivery; in this case the condition was accompanied by gonorrheal infection. Vesico- vaginal fistula caused by pressure in a previous labor may become a serious complication at labor, by reason of the thickened condition of the tissues about the fistula and the excessive pain which pressure occasions.'* Displacements of the pregnant uterus are not infrequent, often causing great discomfort, and sometimes seriously complicating and even terminating pregnancy. If the patient has already borne children, the supports of tlie uterus are frequently so weakened that when repeatetl pregnancy ensues dis- placement readily occurs. The most frequent uterine displacement complicating pregnancy is retrover- sion of the gravid uterus : this produces the usual symptoms, pain and drag- ging sensation in tiie back, interference with the functions of the rectum and often of the bladder, and a sensation of weight and heaviness relieved only by the recumbent position upon the side or the assumption of the knee-chest posi- tion. On vaginal exaiiiination the os and cervix are found directed upward and fijrward, and the fundus of the uterus is below the promontory of the sacrum. In uncomplicated cases, where no peritoneal adhesions exist binding down the uterus, retroversion of the pregnant womb is a comparatively simple matter. As the uterus increases in size the womb gradually rises in the pelvis, until at four or five months it passes above the brim and remains permanently ill the abdominal cavity. The treatment of uncomplicated retroversion of the pregnant uterus con- sists in supporting the womb by tampons of autisejitic mooI smeared with an antiseptic ointment. A preparation containing 10 grains of powdered boraeic acid to the \ ounce each of lanolin and vaselin is most useful in these cases. Oner in four or five days such a tampon should be removed and the vagina be irrigated gently with warm water or with a saturated solution of boraeic acid. A Sims speculum should then be used, and the pelvic floor i;i J T ■ If ; Mil 1 ■ :- j 'i i 1 , i '1 III Hm 1/ i;,' ^M 1!I4 AMERICAN TEXT-BOOK OF OBSTETRICS. be (Iruwii downward nnd backward, when a tampon of antiseptic wool, rolled into a shape fitting the pelvic floor, should be introduced and carried across from side; to side, puttinj; the utoro-satTal ligaments slightly upon the stretch and raising the fundus of the uterus, Snch tampons have the great advantage over the hard-rubber pessary that they create no irritation, support the uterus comfortably, and mould themselves perfectly to the contour of the parts. Their use, however, re(iuires discrimination in fitting the tampon properly, and calls for regular supervision of the ])hysician at comparatively frecpient intervals. Cases are occasionally met with in which it is impossible for the patient to have the services of a physician except at intervals of several weeks : it is then often advantageous to fit a carefully-moulded hard-rubber pessary which shall raise the uterus to its proper level. It is often asserted that such a pessary n)ay cause abortion : the fact, however, remains that it is not a well-fitting pessary that produces abortion, but it is the displacement of the uterus resulting from a lack of such support as the jKJssary should give. Cases of habitual abortion caused by displacement of the womb are not infre- quently tnu'cd by raising the pregnant womb. ^lany cases of retroversion of the uterus are associated with chronic pelvic peritonitis, and are complicated by ])rolapse of one or both of the Fallopian tubes and of the ovaries, and the presence of adhesions binding the displaced organs in their artificial situation. With these patients the pain as the uterus increases in si/e is vei-y distressing, and residts from traction uj)on adhesions which occasionally yield, greatly adding to the patient's comfort. In other cases the separation of these peritoneal adhesions is accompanied by very considerable shock, which simulates to some extent the shock of rupture of the sac in tubal ectopic gestation. In still other cases these adhesions are so firm and tense that spontaneous separation of them is impossible, the womb remaining fixed in the position it occupied at the time of the original perito- neal infiammation. The continued growth of the uterus may so stretch these adhesions as to enable the wond) to rise into the abdominal cavity. Should the peritoneal surfaces not yield, however, a retroverted and incarcerated uterus will be tiie result, and, as the fetus increases in size, the adhesions not yielding, abortion is inevitable; and should fresh septic infection occur and the patient survive, her condition will be aggravated by fresh adhesions, and chronic invalidism will restdt. The frcf|uency of this eomi)lication may be estimated by the report of Martin,''^ who found in 24,000 women 121 cases of retroversion and retro- flexion of the titerus persisting dm'ing pregnancy. In 27 of these cases the defi>rmity was congenital, and one ease is cited in which a jiatient sufl'cred for three and a half years with congenital retroflexion and with gonorrhea, but conceived after recovery from the gonorrhea. Sterility in cases of congenital retroflexion depends upon a diseased endometrium or disease<l condition of the tube, and not upon the congenital deformity. In 94 of the eases the retro- version persisted after repeated pregnancies. Nine of these patients wore pessaries at the time when conception occurred. The most significant THE PATirOLOGY OF PREGNANCY. lOf) svinptoin which dnnv the patient's attention to the backward disphicomcnt of the uterus, and tor which she sought medical aid, was dysuria. When spon- taneous restitution fails no time shouhl be lost in accomplishing the same by instrumental means. Tiiat retroflexion and Incarceration of the pregnant uterus is a serious condition may be inferred from the report and collection by Treub of 50 cases of death from this cause."^. He found that out of the 50 ilcaths, thirteen were from uremia, eleven from rupture of the bladder (Fig. 143), six from sepsis; ten followed peritonitis and cystitis; three were caused l)y jn'cmia, two by rupture pf the peritoneum, and five cases followed acci- dents occiu'ring during an effort to replace the uterus. These statistics have recently been amplified by Gottschalk,** who col- lected G7 deaths from backward dis- ..cm" placement of the pregnant uterus, the immediate causes of which he describes as follows : Uremia and collapse, six- teen cases ; se[)ticemia arising from the bladder, four ; gangrene of the bladder, tiiree ; rupture of the bladder, eleven ; peritonitis from disease of the bladder, seventeen ; pyemia, three; ruptureof the peritoneum and vagina, two ; improper efforts at reposition, five; gangrene of the intestine and peritonitis, one ; oc- <lusion of the intestine, one ; and four eases in which the inunediate cause of death is not described. Gottschalk in his i>aper reports an interesting case imder his own observation in which the retrovertcHl pregnant uterus ]iroduced intestinal occlusion without ileus. He Fi(i. lis.— Frozen soction of retroviTted utonis of performed abdominal section, but was throo ami a half to four months. Doath from rup- m.able to save the patient. '"'^" ^'^ '•'"-'''^■■- (•"•'"-'• '••""■ '"""• "• i'"'- ^' ^- '»■ Ecto])ic gestation may be sinudated by a retroverted pregnant uterus, as in n case re|)orted by Barbour,*'' in which the physical signs of retroversion in the pregnant Jiterus were perfectly present. In the treatment of this con- dition Colin stein,'"' in treating five severe cases of incarceration of the preg. nant uterus, first emptied the bladder by a stiff catheter, and then drew down tiie cervix and vaginal wall with a tenaculum, while the cervix was pressed backward by downward pressiuv behind the symphysis. While the cervix was drawn downward and backward by a tenaculum the fundus was raised with file free hand of the operator. Retroversion of the pregnant uterus is occasitmally found complicated by the existence of disease of the pelvic bones; in these cases the pelvic^ deform- ity is often such that spontaneous restitution of the uterus is impossible. It is then necessary to relieve the patient by operative means, and, as a last I ■ 1 1 I I,; i ii f Pp '( 190 AMERICA X TEXT-nOOK OF OliSTEriUCS. resort, to extirpate the uterus per vaginam if possible. An interesting ease of osteomalacia eoni}>lieating retrofl(!xiou of the gravid uterus is reported by Jienckiser ;" efforts had previously been made to produce abortion and to puncture the fetal sac through the posterior vaginal wall. The. treatment of retroversion of the pregnant uterus when adhesions are present must be conducted with great caution. A gentle effort should be made to stretch the adhesions, gradually allowing the womb to regain its lost position : this is best accomplished by the use of the antiseptic wool tampon, combining with it an alterative api)lication which shall aid in the absorption of exudates in the pelvis and shall loosen adhesions. At present a favorite remedy fortius purpo.se is ichthyol, as follows : Ichthyol, Lanolin, Vaselin, aa 5j; .Ijss. An ointment stronger in ichthyol is occasionally employetl with good results. Once or twice weekly the patient may take, with advantage, a hot vaginal injection if this bo practised very gently. In cases of sudden and severe abdominal pain with great shock occurring in patients in the early months of pregnancy and with retroverte<l uteri prompt incision of the abdo- men, with assiduous examination of the pelvic organs, may residt in finding a small focus of infection or a ruptured adhesion, which can be dealt with successfully by surgical means. If such adhesions do not yield, abortion is inevitable, and especial precautions must be taken that septic infection is pre- ventwl in uteri so bound down. The fact that hematosalpinx or jn-osalpinx very frequently accompanies such peritoneal adhesions indicates the danger of rupture of such accumula- tions and of acute septic infection which may follow. Should such rupture occur, evidenced by pain in the abdomen and symptoms of shock, the abdomen should be opened at once, the parts be carefully inspected while the patient is in the Trendelenburg posture, and all foci of infection should thoroughly and completely be removed. With free irrigation with saline fluid and drainage it is possible that such a patient may escape general infection of the abdominal cavity. 2. General Disorders of Pregnancy. The UUETIIHA, nLADDKiJ, and t^ijetkus share during pregnancy the condi- tion of increased vascularity and irritability that characterizes the pelvic organs. The bladder in early ]ireguaucy is less capable t)f distention antcro-posteriorly, and hence enlarges laterally as gestation goes on. In the latter monthsof pregnancy the uterus rises in the abdomen, drawing the bladder with it above the pelvic brim ; this seems a conservative j)rovision to protect the bladder from injury by pressure. The bladder accompanies the uterus in the displacements frequently seen during pregnancy. The urethra becomes elongateti as the uterus rises in THE PATHOLOGY OF PREGNANCY. 197 the pelvis. The uretlira may become completely or partly oceliulecl in some of the uterine displacements observed during early pregnancy. If the dis- placement of the uterus be not eorrectal, there follow over-distcntion of the bladder, paralysis of its muscular layer, and decomposition of the retained urine, with erosion, ulceration, and final perforation. Cystitis and hematuria complicating pregnancy demand rest in the recum- iM'ut posture, and if the inflammation of the bladder be gonorrheal in character, its careful treatment is strongly indicated. Labor in such cases, by making traction upon pelvic adhesions, may comj)ress the ureters, favoring the development of uremic poisoning and eclampsia. Subinvolution of the uterus is very apt to occur in such cases, while the inflammation of the uri- nary tract may become chronic. Diphtheritic inflammation of the bladder is seen in cases where an incarcerated uterus prevents the passage of urine and where a catarrhal condition of the mucous membrane has previously been ])rescnt. In cases where during pregnancy the gernjs of gonorrhea have been retained in and about the urethra, labor, by reason of the pressure and disturbance of the parts which then o(!cur, may cause migration of these germs. Cystitis is the first result of such added infection, and later this infection travels up the ureters to the kidney, and acute parenchymatous nephritis may be the result : this whole process occupies several weeks for its full development and consummation, and its issue is usually fatal, the patient perishing from septicemia.** The Kidneys during Pregnancy. — There is abundant evidence to show that th(> kidneys share with the other viscera the congested and hypertrophietl condition common during pregnancy. This peculiar engorgement of the kidney has given rise to the term " kidney of pregnancy." Much discussion has been elicited in the effort to differentiate the "kidney of pregnancy" from beginning nephritis. It is evident that only the systematic and microscopic examination of the urine can accurately determine whether simple congestion is present, or whether the kidney is being damaged in its essential elements, the secreting cells of the tubules. When such study of the urine finds only hyaline casts, crystals of various sorts, and the slight epithelial dehrk which may be found in healthy individuals, there is no reason to believe that nephritis exists ; but when, on the other hand, '.piihelial, granular, or fatty casts are persistently present, the diagnosis of nephritis can scarcely Vr denied. It is upon such comparative examinations that a diagnosis mnfl be based, and not upon the mere presence or absence of serum-albumin. Attention has recently been called by Trantenroth ''' to a coiulition of beginning fatty d(>generation in the kidney which causes no symptom in the urine, and which may suddenly become so acute as to destroy the patient by sudden kidney failure. Infective process as present ill these cases is so flir wanting, and i)atients thus affected, if they survive pregnancy, do not become nephritic afterward. An acute inflammation of tlie kidney cannot be caused by pregnancy, and is only observed in the rare cases where infective bacteria find entrance to the genito-urinary tract 1 1 f I I ( • )l! I. 1/ «» 19H AMh:iiIC'AX TEXT-nOOK OF OliSTETIiTCS. of the pregnant. This coiulition of conjjostioii (hiring prcgimnoy is iiiciriisod (hiring hihor, and ronal all)niniii is prosont (hiring th(! progress of hibor in eonsiderable ainonnt. J'atients suffering from diseased ki(hieys and becoming pregnant have the ki«hiey disorder greatly aggravated, often to a fatal issue. The causes of this condition, known as the " kidney of pregnan(y," arc the increased intra-abdominal tension to which all tiic viscera are sid)jected ; disturbances in the nutrition of the kidney through an altered condition of the blood of the pregnant patient ; and an engorgement of the spermatic veins and ureters by mechanical pressure. It is possible for eclampsia to develop without lesion of the kidneys, although in most cases of cclamj)sia a diseased condition of the kidneys can plaiidy be discerned. Fischer, in studying the same subject,'*' found in 70 cases evidence that the " kidney of })regnancy " was present in tifty-eight ; eight cases of nephritis occurred among the 70 ])atients. Fischer found red blood-corpuscles in eonsiderable amount in cases where acute nephritis occurred. Gramdar and epithelial casts indi- (\ited chronic nephritis. Tlu^ occurrence of chronic endarteritis accompanying chronic nephritis e\])lains the rupture of blood-vessels within the uterus and the intra-uterine hemorrhage which sometimes destroys these j)atients. Schauta"' describes a typical case of fatal hemorrhage in which chronic inter- stitial nephritis and degeneration of the muscle of the heart and uterus were found. The life of the child was also sacrificed. Albmninuria is of such fre«juent occurrence during ])r(>gnaney as scarcely to rc(]uire serious consideration, except as a symptom in connection with others of ni^phritis. Among others, Meyer *^ from an elaborate study of this subject at Copenhagen found albuminuria in 5.4 per cent, of pregnant women. Casts accompanied the albumin in 2 p(M' cent. This may be taken as an indi- cation of the relative frequency of kidney involvement in cases manifesting albu- nunuria. As pregnancy advanced, albumin became more abundant until during the last thirty days but 28.9 \wy cent, of urine examined was free from albumin. Premature births occurred in 8 percent, of patients witii albiuuin, and in 21.0 per cent, of patients who had casts in the urine. He adds other clinical details which emphasize the significance of the presence of casts as indicating nephritis. Lantos ^^ in the clinic at Budapest found albumin so fivquently in pregnant l>atients that he considers it ]>hysiological during pregnancy and a diagnostic symj)tom of the condition. Herman calls attention in this" and in other l)apers presented at the Obstetrical Society of London to two conditions of renal disease in the pregnant woman : one is acute kidney failure with extreme diminution in the (piantity of urine and deficiency in the excretion of urea, which quickly ends fatally if the excretion of urea is not rc- estal)lished. The otlr-r process resi'^mblos interstitial nephritis in its shnv course and idtiniately fatal termir , 'on. The interesting fact that a patient may have uremic convtdsions din-ing pregnancy without eclampsia is illus- trated l)v Boudin,"" who d(^scribes a patient seven months pregnant admitted to the hospital unconscious with unMuic convulsions. On establishing the secre- tion of urine and purging the patient, con.sciousness returntKl, and the follow- THE PArifOLOGY OF PREC! NANCY. l!ll> iiig (lav a seven months' fetii.s was stillUoni. Syniptonis of iironiia siipcr- vc'iiod, l)iit recovery linally ensued. Tlie patient inanilested no symptom of eclampsia and had no tnlema. The very interesting^ (piestion of the proj^nosis in nephritis (hiring pregnancy has recently received consideration at the hands of Kohlaiuk.®" In a series of 77 patients, r)!).7 per cent, showed nothing pathological in the urine after their recovery from labor; KJ.H per cent, mani- fested slight involvement of the kidneys as shown by hyaline casts and leuco- cytes, with a trace of alhni-iin ; in \hA per cent, a catarrhal condition of the urinary tract was evidently present ; in (i.o j)er cent, the patients were the victims of nephritis. The presen(;e of sugar in the urine during pregnancy has l)een the subject of inv(!stigation by lierberotf c"^ his tests were thorough and ndnute, and his results were largely negative, a trace of sugar being present in some i)atieiits in early pregnancy, and disappearing as labor a|)i)roached. Polyuria may be observed in the pregnant patient without a pathological condition of the urine, as in a eas(3 reported by Voituriaz,** Among the most signiticant of the symptoms presented by pregnant patients sulfering from nephritis may be reckoned albuminuric retinitis. Abundant evidence of the signiticanee of this complicati(>n is afforded by the literature of ophthalmoloi:!v upon the subject. Tn a recent paper Randolph** reports 5 eases, with a pa ihologieal study and drawings of the tissues involved : he regards visual disturbances occurring in the first six months of pregnancy, associated with violent headache, as very significant of albuminuric retinitis. If this condition be found, to save sight pn^gnancy should at on(!e be terminated. Visual disturbance-* during the last seven weeks of pregnancy are of less grave im)>ort. The occurrencte of renal retinitis in one pregnancy does not necessarily mean its recurrence in a succeeding pregnancy. The treatment of disorders of the urinary tract occurring during pregnancy necessitates, first, a careful examination of the j)osition of the uterus, inasmu(>h as j)ressure upon the bladder, ureters, and kidneys by a disphu^ed pregnant uterus is so frequently a cause of disease. A retroverted uterus should be raised and be sup})orted in proper ])osition by tampons of antiseptic carded wool. Cystitis may be treat(Ml by douching the bladder with creolin or lysol, 30 drops to the pint or (piart of warm water, as the patient's tolerance will permit. The administrati(»n of salol, of boracic acid, or of sodium salicylate internally is also of advantage. If the ureters become involved, catheterization of these ducts, the bladder having first been rendered aseptic, is indicated to determine which kidney is affected if pyelitis is present. Should this ]>ro- c(Hlure show the presence of pus and bacteria in one kidney, the extirpation or the drainage of this organ is indicated. Such disorders, however, compli- cating pregnancy, are unfavorable and dangerous to the life of the patient. Should recovery occur, the ])atient is liable, after the birth of the child, to become the victim of some form of chronic nephritis. Suppuratingr hydatid of the abdomen is an infrequent but dangerous complication of pregnancy. The diagnosis is made by the presence of an inwr . ! il 1 ;( J 1 1 j J 1 i 2()(» AMEJilCAX TEXT-BOOK OF OBSTETRICS. abiloniiiial tumor not attacluHl to tlie uterus, aii'l by the contents of this tumor obtained through tapping. An incision, shoukl be made throiigli the abdom- inal wall, and tiie edges of the sac of the tumor be sewn to the edges of the alxlominal incision. So soon as adhesion has taken place the cyst should be opened and its contents thoroughly removcnl. Pregnancy is not necessarily interrupted by this complication. Peritonitis during pregnancy/" as has been stated, rcsidts in most cases from previous iiiftammation of the endometrium, the Fallopian tubes, or the connective tissue of the pelvis, causetl by septic germs or their spores. There remain, however, cases in which no infection can be traced, but in which sudden exposure to cold or to dampness may produce rapidly-extending and fatal peritonitis ; thus, instances are recorded where a cold bath taken while the patient was overheatetl, and accompanied by the drinking of cold fluid, was followed by rapidly-developing and fatal general peritonitis. Mechanical iiijurv or a severe strain may be followed by peritonitis in a ])regnant patient. Gow ^' reports the case of a patient advanced in preg- nancy who slipped through a hole in the floor of a building ; peritonitis supervened ; the patient was delivered by version, but ceased breathing during delivery. Abdominal incision disclosed no blood in the peritoneal cavity, but lymph was found upon the peritoneum and uterus. No evi- dence of rupture of the uterus or other organ was discovered. Xo focus from which the inflammation could have begun was found upon examination. Concealed accidental hemorrhage is among the most dangerous com- plications of pregnancy. One of the most extensive recent collections of such cases is that by Storer," who contributes an account of 46 in his own observation, and adds the collection of 84 oases by Goodell and 23 by Braxton Hicks, making a total of 16.">. 46.7 per cent, of the mothers perished, and of the chiklren 514 per cent. Of 63 cases which received no treatment, 64 per cent, died, while in 79 cases in which the contlition was detected and treated, 29 per cent. died. It is thus apparent how insidious is the danger and how difHcult is its recognition in these patients. There is contributed by Jardrin" a further series of these cases, the results of which differ in no partic- idar from those observed in the more extensive series of Storer. As so nuich importance naturally attaches to a diagnosis of this complication, it must be remend)ered that the hemorrhage is concealed, and that the i)atic:it may be thrown into a condition of danger without a])parent flow of blood : her symp- toir.s then will divid(> themselves into two classes — namely, those j)ertaining to her general condition, and those which have to do with the uterus itself; of these, the first furnishes the best indications of danger and the most rational suggestions for treatment. A rapid, weak pulse, lacking in tension ; an indifl'crent, languid attitude of mind ; respiration becoming more and more shallow; a jiale or pallid face; a clammy skin; thirst; dimness of visit)n and "air-hunger;" a restless irritability which is a very significant symptom of a certain kind of shock, — these furnish an array of symptoms which shoidd attract the attention of the physician. THE PATHOLOGY OF PREGNANCY. 201 If conc'caletl iU'cidoiital heniorrhnge occurs during labor, labor-pains may coa-^e or may grow weak, and the usual sensation of pain in the uterus may be replaced by a dull constant ache above the pubes. It is occasionally noticed tliat the os uteri is dilating without apparent labor-pains. The uterus may become enlargetl, forming an asymmetrical timior of the abdo- men which can be appreciated by palpation. As regards those symptoms which can be observed on making an examination of the genital tract, the o« liter! is usually slightly dilated, and the cervix is s(>ftened, although it may not be effaced. Slight uterine hemorrhage is generally observed. The lower uterine segment becomes distended with clot ; as the hemorrliage persists the sensation conveyed to the linger resembles that in placenta pncvia. Inetfectual and spasmodic uterine contractions and the accumulation of blood between the Ictus and the wall of the uterus will cause irregular enlargement of the womb. Concealed accidental hemorrhage from some other source than the uterus or the placenta may occur during pregnancy, the blood escaping into the abdominal cavity. An illustrative case is reported by Sutugin" of a multi- gnivida who, three days before ailmission to the hos})itaI, had fallen while carry- ing a heavy load. Two days after her fall she was seiziHl with weakness, and felt no fetal movements after this time. When examined, no dilatation of the OS and cervix was present. The fetal heart-sounds were absent. The patient complained greatly of pain in the uterus, probably caused by uterine con- tractions. Shortly after <lelivery the piitient luul clonic spasm of the extremities, and <lied in collapse. On post-mortem examination a large amount of clotted blood was found in the abdomen. The source of the hemorrhage was a torn vessel of the mesocolon. The uterus contained a fetus nearly at term an(' dead. As regards the <Ii(i(/no.si)i of this condition, it must be based ujion symp- toms of prostration and shock greatly out of proportion to the amount of licinorrhage that may be present. The dangerous character of this complica- tion of pregnancy and lal)or should lead the physician to take alarm prompt- ly and to interfere as quickly as |)ossible. The method of interference will depend somewhat upon whether the licmorrhagc occurs during labor or before tiie beginning of actual labor. One of the most plainly indicated expedients in these cases is rupture of the membranes, which will lead to a closer coaptation of the uterus upon the fetal body, thus making pressure upim its blood-vessels. Accompanying this rupture, the administration of ergot or ergotin is indicated for similar reasons. Treatment by these expr'dienis may be considered the expectant method, which, in G.'i cases reported by Storer, gave a mortality of forty. Rapid dilatation of the os and cervix and delivery by version or by the forceps give a better prognosis, as in 18 forceps deliveries four deaths are reported. Where, however, the hemorrhage is sudden and severe, and the liirth-canal is not sufliciently dilated to p(>rmit delivery, the uterus should be emptied, and the bleeding be controlled by abdominal incision and hysterec- tomy or by total extirpation of the uterus. The use of the tampon of antisep- tic gauze is indicated in cases where hemorrhage externally is considerable and 202 AMERICAN TEXT- BOOK OF OBSTETRICS. it )i 'i the OS and cervix are too tiglitly closed to permit of rapid delivery. In intro- ducing the tampon it is well to pack the end of the strip of gauze into the os and cervix, thus furthering dilatation and checking external hemorrhage. The "prognosis for the fetus in these cases is exceedingly grave and is almost necessarily hopeless. Loss of blood induces rapid asphyxia, and the rapid fetal movements accompanying the partly asphyxiated state may explain some of the obstinate uterine pains from which these patients suffer. The causal relation existing between involvement of the kidneys and intra-uterine hemorrhage has been describetl in treating of Nephritis and its consequences. In a series of clinical lect ires upon the subject of hemorrhage during pregnancy Budin ''^ describes the case of a patient suifering from hematuria with albuminous urine. Profuse intra-uterine hemorrhage com- plicated labor; the child perished. The Posture and Bearing of the Pregnant "Woman. — Accompany .; the changes in the jx'lvis peculiar to pregnancy we find certain variations in the posture and bearing of the patient as pregnancy advances. This has been the subject of study by Knhnow,^^ who found two types among patients in the latter months of pregnancy. The most frequent is a back- ward curve of the entire body, while in 20 per cent, of cases a backward bend of the trunk only was present. Tiie cervical vertebrse are straightor, the thoracic curve is greater and more projecting, the lumbo-dorsal region is straighter, its curve being lower and flatter, while the pelvic curve is often lessened in the later months of pregnancy, and is sometimes unchanged. The hip-joints are usually carried ))osteriorly, while the sternum projects at its lower extremity, increasing the diameter of the thorax. Relaxation of the Pelvic Ligaments. — Among the general changes caused by pregnancy are those affecting the joints of the pelvis. The fact that an increased secretion of synovial fluid is present in the pelvic articu- lation during pregnancy has long been recognized, and has been accurately studied by Driver:" in his examination of 300 cases he found the amount of relaxation is ])roportionate to the general strength and firmness of the patient's tissues. Age has nothing to do with it, nor does the amount of relaxation influence the patient's walking. Some of those whose joints were most relaxed could walk without difficulty ; conversely, consid- erable motion produced in some patients marked lameness. Pain at a sacro-iliac joint showed that the ilium moved upon the sacrum upon that side. This phenomenon is sometimes observed in patients who are not preg- nant. Some patients recovered spontaneously from a serious condition of lameness, while others were not benefited by prolonged and thorough treat- ment. A slight degree of relaxation may facilitate delivery and obviate the use of forceps. The most successful treatment described was an abdominal bandage of twilled cotton 5 inches wide, with padded perineal bands 1 incli wide. Where the ])atient was deficient in general strength cold baths auid massage were sometimes useful. The Toxemia of Pregnancy. — The interesting metabolism characteristic THE PATHOLOGY OF PBEGNANCY. 203 ! of pregnancy has not yet been sufficiently elucidated to explain clearly the origin of toxic material which not infrequently jeopardizes the lives of mother and i;hild. The fact that nutrition and its converse are going on in two organ- isms, each dependent upon the other for proper assimilation and excretion, explains the ease with which these processes may pass the bounds of physio- logical activity and become disease. The character of the poisons produced in the body of the mother and the fetus places them, so far as we know, in the class of animal poisons, alkaioidal in nature, denominated toxins. The symptoms they produce upon the pregnant patient are especially addressed to tlie nervous system, hence the study of toxemia in pregnancy appropriately leads to a consideration of nervous disorders during this condition. Various observers by differing methods of investigation have isolated several poisonous principles from the urine of pregnant women in whom elimination was deficient: Diihrssen^* lays great stress on the retention of creatin and creatinin in the kidneys of the pregnant patient. Actual nephritis ho rarely observed, but congestion and accumulation of urine through pressure upon the ureters and by hydronephrosis are common. Creatin and creatinin accumulating in the vessels of the cerebral cortex produce cerebral irritation. It is natural that such a condition should be commonest in patients in whom excretion is habitually deficient. Poisons absorbed from the intestinal tract stand in close relation to the toxemia of pregnancy, as shown by Budin.^' This is especially true where retr(»version of the pregnant uterus produces intestinal stasis. In many of these cases the bacterium coli communis pene- trates the wall of the bowel, causing peritonitis in adjacent tissues. Culture experiments by inoculation demonstrating the toxicity of urine in pregnancy have been performed by Ciiarpentier,*' who, following Bouchard's researches, injected such urine into rabbits, producing tetanic convulsions and speedy death. Acute congestion in the kidneys of these animals was the only lesion found to account for the fatal issue. Similar injections beneath the skin of other animals less susceptil)le than rabbits produced death after longer intervals. The condition of congestion of the kidneys in patients suffering from toxemia in jiregnancy is also described by Prutz.*" He notes a verv interesting point, that but slight structural alterations were present in many exceedingly severe cases of toxemic poisoning. In the kidneys of infants burn from mothers suffering from toxemia there were observed congestion and transudation of serum, witii the formation of casts in the tubes and great distention of the veins. A similar congestion in the livers of toxemic patients is described by Pilliet and Delansorme."^ This condition of con- gestion in the kidney of the pregnant wonian was found in two-thirds of the cases examined by Fischer during the second half of jiregnancy.*'^ The state of the blood in these patients has been studied by P»Ianc,*^ who made cultures and inoculated animals with their jjroducts, producing alinimi- nuria and siip])ression of urine. Convulsions were also caused, and intense con- gestion of the kidneys was observed. Additional testimony as to the extensive disorganization of the blood and tiie pathological condition of the liver in the '\ ;i fii l! k (1 m 204 AMERICAN TEXT- BOOK OF OBSTETRICS. I . t ! ■(■ toxemia of pregnancy is affordwl by Papillon and Audain.*'' The accumulation of ptonia'ins in sufficient quantities to produce poisoning has been observed by Koffer and Kuudrat.** Paultauf and Kundrat have also reported similar cases in the Records of the Pathological Institute of the Vienna University. Among many interesting contributions to the bacteriology of this question is that made by Gerdes.*^ In common with other observers, he is inclined to ascribe to bacteria a causal relation in these cases. As bearing upon this point we note the observations of Tarnier and Chambrelent,** who found in toxemic pregnant w^omen that the degree of intoxication present could well be estimated by observing the toxicity of the blood-scrum of these patients. It is interest- ing in this connection to note that any disorder caused by bacterial invasion predisposes to toxemia in pregnancy; thus, Lang®* finds that twice as many pregnant women who are syphilitic show symptoms of threatened toxemia in pregnancy as are observetl in non-syphilitic pregnant patients. The precise toxic agent responsible for the gradual development of toxemia with threatened eclampsia has not yet been isolated, although a number of sub- stances have been charged witii this result. The significance of a diminished quantity of urea in these cases has been brought to the attention of the pro- fession by Hermann** and Davis:" the latter in 84 cases, vitli a total of 5G4 examinations to determine the amount of urea present in the urine of pregnant and parturient women, found that the average percentage of urea in the urine of a iiealthy })atient before labor was 1.4. After delivery this percentage increased to 1.9. Considerable diminution in this quantity was first accompa- nied by symjitoms of irritation of the nervous systeru and threatened intoxica- tion, and, where the patient's excretion was not stimulated and the amount of urea brought up to nearly normal, eclampsia develojted. Davis does not ascribe to retained urea the causal role in toxemia, but he regards it as a valuable index in estimating the excretory activity of the patient. A well-marked example of ptomain-intoxication during pregnancy is the case described by Gustav Braun.'^ The patient, seven months pregnant, died from pulmonary edema after premature labor. The urine contained casts and albumin. Tiie ])()st-mortcm examination was made by Paultauf, who found fatty liver, fluid blood, nejiliritis, and cerebral edema. Multiple rupture of capillaries was found iu the viscera. The fact that the blood of patients suffering from toxemia may contain pathogenic germs has been illus- trated by Blanc,'^ who made cultures from the blood of such a patient, obtaining in forty-eight hours germs which caused albuminuria and toxemia in ral)l)its. It was foiuid on experimenting that chloral in the proportion of 4 parts to 1000 of tiie culture-liquids effectually destroy these germs. Blanc"* continued his experiments by injecting the urine of ])regnant j)atients into the bodies of rabi)its and observing tlic result. It was found that while tiie urine of some uon-j)regnant patients was poisonous when injected, the urine of pregnant patients was far more toxic, causing distinct phenomena of decided poison. Van Santvoord '"* from clinical observation ascribes toxemia during pregnancy very largely to deficient action of the THE PATHOLOGY OF PREGNANCY. 205 liver, by which an insufficient formation of urea causes the patient to retain in her blood toxic material. The imnmnity which the kidneys display in some of these cases is illustrated by Prutz's description of the condition of tiie kidneys in 22 cases of fatal toxemia. In many of these, beyond a general congestion, no pathological condition was found. Micro-organisms were absent from the kidneys, and there was no relation between the severity of the intoxication and the condition of the kidneys. The belief that peptones are among the substances causing toxemia has led observers to study the urine of pregnant patients with regard to tiie presence or absence of these substances. Thomson ^ examined the urine of 23 pregnant and puerperal women for jH'ptone ; the results of his examination were negative. Koettnitz"'^ made 140 analyses of the urine of 31 pregnant patients, but could not discover that peptone is a significant ingredient in these cases. It is often present in the urine of patients who suffer during pregnancy from any severe complication. While the entire subject of the toxicity of urine offers a vast field of inves- tigation and has produced a large literature, so far as the obstetrician is con- cerned there is abundant proof that no one substance is especially dangerous to his pregnant patient, but that the gradual accumtdation of nitrogenous waste, of potassium combinations, and of animal alkaloids produces a condition of toxemia, the symptoms of which are first observed in a disordered state of the nervous system demanding the attention of the physician. Following the line of Bouchard, additional observation is required for a more precise determi- nation of the relative toxicity of the various substances retained in the blood ill these cases. The jn-ophylaxin of the toxemia of pregnancy resolves itself into mainte- nance of excretion. Remembering the interference with the circulation to which the patient is subjected by pressure, a first and very important precau- tion is to secure suitable clothing. There can be no question of the advisability of laying aside completely the corset or any other form of support for skirts that com|)resses the abdomen and forces the viscera down upon the brim of the pelvis. The art of dress has advanced sufficiently to enable the patient to obtain comfortable and shapely clothing supported /entirely from the shoulders. Poor patients can make for themselves from cheap materials waists which fulfill the same indication. While the intelligent physician will ailvise and strongly urge that the corset be laid aside, he will remend)er that this is one of the pieces of medical advice which is expected and is rarely followed. The responsibility, however, is not his after ho has stated the case fairly and clearly t(» his patient. Constriction of the blood-vessels should also be avoided by wearing loose shoes, by dispensing with garters that encircle the legs, and by the avoidance of constipation so far as possible. In this latter difficult ])r()l)lenj it will be found that a proper mode of dress is of the utmost importance by avoiding pressure upon the large intestine. In avoiding con- stipation it is well for the patient in addition to select a diet not rich in nitrogenous elements. The heavier and less digestible meats should be omitted. Birds, lamb, mutton, fish, and oysters are best adapted for such ;i 1 l7 H 20f5 AMERICAN TEXT-BOOK OF OBSTETRICS. patients. A i abundance of raw fruit, or cooked fruit if the digestion re- quires it, is oT great importance. Whole wheat, Graham, and rye bread is of vahie. The avoidance of large amounts of sweets and stimulants of every form is also indicattKl. While vegetables are useful, they are inferior to fruits for the needs of such patients. An abundance of water is a prime necessity. If the patient cannot obtain bottled waters, ordinary drinking- water wiii(:!i has been boiled and filtered may be taken in abundance. If her means allow her to choose, she will find the lightest Vichy or any of the slightly alkaline and effervescing waters agreeable and advantageous. Milk is to be taken freely by those with whom it agrees ; many, however, cannot use it without producing obstinate constipation. The medicinal treatment of intesti- nal torpor threatening toxemia consists in the use of such laxatives as can be employal for a considerable time without violent purgation and without losing their eUcct. Compound licorice powder in small (piantities, rhubarb or colocynth in combination with extract of belladonna, small quantities of the lieavier mineral waters (such as Himvadi Janos) and cascara sagrada in com- bination with the substances mentioned, have been found efficient. Where the liver is evidently at fault, the occasional use of calomel and soda, followed by a saline, is distinctly indicated. W^here hemorrhoids complicate the patient's constipation, rectal suppositories of glycerin 1 drachm, extract of belladonna \ grain, and iodoform 5 grains will be found advantageous. In addition to avoiding constipation, the prophylaxis of toxemia embraces such care of the skin as shall promote constant and free elimination. Fre- quent bathing in tepid water, flannel (varying in weight in accordance with the climate) worn next the skin, massage of the limbs and the upper portion of the triuik, and gentle exercise are not to be neglected. Remembering the important part wiiich the lungs ploy in excretion, and the necessity for a free supply of oxygen, the patient must have an abundance of fresh air. A mild and equable climate is naturally the best for such cases, but, as this is seldom available, the patient, properly clad, should be out of doors in all weathers. It is of imjiortance that tlie amount of urine secreted be observed, lieiice tlie patient should be instructed to take such precautions that this information is availal)le for the physician. He may inform her that an amount varying within certain limits is what is expected and desired, and that any marked decrease from this should at once be reported to iiini. Examination of the urine of ])regnant patients should be an invariable cus- tom not to be omitted in any case. It should be done at least once a month through the entire pregnancy, or, l)etter, i>nce in two or three weeks. While this imposes additional labor upon the physician and inconvenience upon the j)atient, yet in all eases of primigravidie, especially in women whose nutrition and excretion are not of the best, " Paternal vigilance is the ])rice of safety." If this be reasonably explained to a patient, she will rarely object. The examination of the urine in pregnancy requires ciiemical and microscopic investigation. By the first we search for albumin, sugar, and urea in all cases. Important as this examination is, it is second in value to the microscopic THE PATHOLOGY OF PREGNANCY. 207 study of the specimen. By tliis study we derive positive and valuable infor- mation as to the condition of the parenchyma of the kidney, and this informa- tion can be obtained in no other way. Hence in pregnancy an examination of tlie urine that does not include its microscopic study is certainly superficial and deficient. In cases where a suspicion exists that toxemia is developing, in addition to the substances already mentioned we must examine chemically lor indican, acetone, peptone, pus, and blood. In complicated cases micro- scopic examination must be patient and thorough. D'uKjnoHts. — In diagnosticating the toxemia of pregnancy two clinical signs are of especial value: first in importance are the amount and character of the excretions ; second is the condition of the nervous system. The first sign is to be ascertained by careful questioning and accurate observation. The second sign must be determined by closely interrogating the various functions of the jiatient's nervous system. The presence or the absence of pain, head- ache, thirst, lassitude, disturbances of vision, of hearing, or of taste, sleep- lessness or lethargy, irritability or apathy, melancholia, and nausea and vom- iting, are all symptoms to be recognized or be eliminated. The condition of the skin, as affording evidence of the functional integrity of its excretory apparatus, is of great value. Of secondary importance are the occurrence of swelling of the feet and legs and the presence of serum-albumin only in the urine. The treatment of the toxemia of pregnancy consists in the prompt stimu- lation of all the elimiuative organs of the body. In view of the hepatic condition present there can be no question regarding the efficiency of mer- curials in a few repeated doses. The remarkable diuretic effect of calomel is also of value in these cases. In selecting saline cathartics it is best to avoid those containing potassium salts, as potassium has been shown to be ail irritative element in the urine. Those purgatives producing a free flow of watery fluid from the bowel, such as colocynth, elatcrium, and jalap, are ospe(Mally indicated. Rectal injections of glycerin, combined with sodium salts and spirits of tiu'peutine, are excellent in [)roducing copious watery evacuations. The beneficial effect of such elimiuative treatment on the ner- vous system is remarkable in many cases, the patient passing from a condition of melancholia and great restlessness to a feeling of comfort and good health. Warm and hot baths in these cases, taken befi)re retiring, are an excellent moans of treatment. If the patient's symptoms are threatening and a con- dition of hysteria is present, the hot pack will i)r()vc a most valuable resource. The diet in cases of toxemia should be restricted to milk, fruit, l)iead, and, if tiie patient requires more than this, fish, oysters, and gruel. Meats, eggs, vegetables, pastry, and all forms of stiundants, including tea and coffee, should absolutely be forbidden while symptoms of toxemia are present. In examining the urine two points are especially valuable : one is tlie smiount i)assed daily ; the second, the amount of urea excreted by the patient. If the condition of the kidney passes beyond congestion to actual nephritis, the practitioner will be aware of this through the microscopic study (I '■".■ ■ I i: 208 AMERICAX TEXT-BOOK OF OBSTETRICS. of the urine, wlieii casts, bloody, epithelial, or fatty, will be prep^iit. The presence of senun-albuinin and hyaline casts is of very little moment so long as a free amount of urea is excreted, and microscopic study of the urine finds no evidence that the parenchyma of the kidney is diseased. It is evident from what has been stated regarding the toxemia of preg- nancy that simple albuminuria is of little moment in the pregnant condition. The com])licatio'.is of pregnancy ascribed to albuminuria do not result from the presence of S!>rum-albumin in the urine, but from the circulation through the body of the mother and her placenta of blood rendered irritating by toxic material. The occurrence of thickening and induration in the walls of the placental blood-vessels, the partial separation of a placenta in fatty degeneration following this process, with the consequent hemori-liage and asphyxia of the fetus, are familiar complications of the toxemia of pregnancy and they follow the diffusion of toxic material in the placental blood. Simple albuminuria is often seen in multigravidic in whom, by reason of the large size of the fetus or by tiie relaxed condition of the uterus and the abdominal walls, the ureters are pressed upon and the kidneys are in a constant state of congestion and accunui- lation of urine. Many of the women thus affected have edema of the extremities, they remain entirely free from those disturbances of the nervous system seen in toxemia. The condition of such patients docs not demand the production of abortion, but it requires that the heart-muscle be stimulatetl, the circulation be maintained in every way, and, if possible, that the pressure of the pregnant womb upon the ureters be relieved by a supporting bandage when it can be used. In sharp distinction to these cases are those of the toxemia of pregnancy, where, notwithstanding prompt treatment addressed to the organs of elim- ination, the patient's nervous symptoms continue, while her excretory processes are plainly deficient. In such cases, in the present state of our knowledge, the prompt termination of pregnancy is the only rational and conservative treatment. If the toxemia of pregnancy be recognized and the patient will submit to her physician's advice, eclampsia should become more rare than puerperal septic infection. The tenilency which patients who suffer from toxemia of pregnancy exhibit to pass into nephritis after pregnancy or during a subsequent gestation must be borne in mind. In a woman who has once shown marked evidence of the toxemia of ])regnaney each succeeding gestation brings added risk of fatal poisoning. If her condition be undetected and her general health after parturition be neglected, she will not infrequently become the victim of nephritis. Disorders of the Nervous System ix the Pre(ixant Patient. — Neur- algia. — The ])rcgnant patient is peculiarly susceptiljle to various disorders of the nervous system. Conuuon among these affections, and occasioning great distress, are the various forms of neuralgia often observed diu'ing gestation. As is gen- erally the case, these neuralgias usually have as a starting-point some portion THE PATHOLOGY OF PREGNANCY. 209 of the nervous system in which a patliological condition is present. The decay of the teetii so often seen during pregnancy accounts for many of tiie cases of obstinate toothaclie which annoy and distress these patients. In women who sutier from habitual constipation during pregnancy, and in whom the size of the fetus is so great as to cause pressure upon tlie nerve- trunks at the brim of the pelvis, obstinate cramp and sciatic pain may occasion great distress and may seriously depress the patient's general health. Some of the worst of these cases result from the pressure of hardenetl fecal matter upon nerve-trunks above the brim of the pelvis, and upon branches of nerves so situated that they may be pressed upon in the pelvic cavity. In some of these cases the uterus will be found retroverted, thus preventing proper evacuation of the bowels and adding to the pressure which retained fecal matter causes. In other patients there is great complaint of cramp and of sudden spasmodic contraction of the muscles of the thigh, often worse at night. Where the disorder is severe an obstinate i)ain, radiating down the tliigh as far as tiic knee or even below the kuee, is often observed. In dealing with these cases the fii-st duty of the obstetrician is to ascertain accurately the position of the uterus : if it be found retrovertetl and not bound down by adhesions, it is a comparatively simple matter to raise it to or above the brim of the pelvis, and to sustain it by tampons of carded wool. If the uterus be found bound down by adhesions, the problem is much more difficult. If the patient be put at rest in bed and the bowels be thoroughly moved by salines, a very efficuent form of tampon in these cases may be found in a strip of surgeon's lint 3 or 4 inches wide thoroughly soaked with glycerin. A Sims speculum is introduced, and this strip is packed with the aid of dressing-forceps thoroughly behind the cervix, pushing the uterus up as far as possible without causing positive pain. This application is followed by a very copious discharge of watery mucus, greatly relieving congestion and softening adhesions which are not extraordinarily tenacious. The growth and development of the uterus will frequently separate such adhesions, and sur- prisingly good results are observetl in cases where the uterus has been partially bound down in the pelvis. The fact that pregnancy exists contra-indicates, naturally, uterine massage and any instrumental interference. If the uterus be in good position, the next step to be taken in relieving pelvic pain radiating down the thighs is to empty the bowel thoroughly : this should be done with the same care exercised in preparing a patient for an abdominal section. In addition to the purgatives usually employed, the colon should be flushed thoroughly by frequent and copious injections of warm water and sulphate of magnesia, or injections containing soapsuds and castor oil to which turptntine is added. If impaction of feces is present, an ounce of ox-gall dissolved in a quart of hot soapsuds should be injected through a rectal tub? as high into the bowel as possible. This injection is to be retained so ioiig as the ])atient can do so, and when an inclination to evacuate the bowels is felt a second injection of sulphate of magnesia, glycerin, and turpentine will usually result successfully. Some cases of obstinate pelvic u t ! % • ,- r li:) I! . I I'! ■> r 1/ 210 AMERICA X TEXT-BOOK OF OBSTETRICS. neuralgia occurring during pregnancy are cured by erai)tying the bowel of hard and irritating feces. Where the uterus is in proper position and the intestine is free from fecal matter, if pelvic neuralgia still persists, it will be found to depend upon anemia, depressing causes which affect the nervous system, or, possibly, upon malarial infection. Treatment appropriate for this condition will result in the gradual relief of the neuralgia. Facial neuralgia with hemi(!rania is often observed in pregnant patients in whom no exciting cause in bad teeth can be discovered. Many attacks follow exposure to cold or to damp ; others are caused by loss of sleep. The pain is often paroxysmal, and frecpiently an irregular interval may be observed between tiie attacks ; thus, some patients will sleep during the night, but are seized with violent pain in the early morning ; others suffer more in the afternoon or at night. The face and scalp are often tender to pressure in these cases, and tlie conjunctivae on the affected side are frequently reddened. Wl'.ere painful spots can be isolated local treatment may be instituted by painting the part with menthol or with iodin, or by spraying it with ether or with some other anesthetic. The constitutional treatment of this condition consists in thoroughly emptying the intestine to relieve the patient of fecal poison which may be depressing the nervous system. Absolute rest in a darkened warm room of ecpiable temperature, systematic feeding of easily- digested food, and tonics — irouj arsenous acid, and quinin — and, if the pain be severe, alcohol, at regular intervals are to be recommended. When sleep is impossible by reason of pain, jihenacetin with caffeine and sodium bicarbonate is often used to advantage. If pelvic neuralgia be present, phenacetin may be given by rectal suppositories of 10 grains each. Morphia and atropia mav be given hypodermatically when other remedies fail. Chloral and the bromids are of comparatively little value and often disappoint in these cases. It should be explained to the ])atient that the loss opium she takes the sooner she will recover ; and where her suffering is n(»t severe ever}' effort should be made to imjirove her general condition by tonic treatment rather than by narcotizing her with opium. Salivation. — Derangement of various secretory nerves is sometimes observed during gestation; the salivation of pregnancy is a faniiliar instance. Hyperse- cretion of tears is seen in patients suffering from salivation, as shown in a case reported by Xeidon.*' So abundant was the secretion as to keep the eyes con- tinually suffused and to cause an eczematous eruption of the lids. The tear secretion was weakly alkaline, the eyes W'Cre normal, and no appreciable cause was found for the condition ]iresent. The patient was finally cured by a 5 jier cent, cocain solution. Salivation of pregnancy is a most obstinate and annoy- ing condition often re])eated in subsequent pregnancies and resisting all forms of treatment. It is without apparent cause, as a rule usually affecting women of nervous tem])eraraent, especially if the general health be depressed. Treat- ment is usually palliative only, and it should consist in the free administration of tonics and in those milder sedatives which interrupt least of all the patient's THE PATHOLOGY OF PREGNANCY. 211 imti'itioii. The bromids have boeii given freely, both by the stomach ami by spray applied to the interior of the mouth. Cocain may also be sprayed into the mouth, the effort being to cocainize the mucous membrane near the opening of Steno's duct. Tliis condition rarely if ever becomes serious. Another form of al)normal secretion occurring in pregnancy is that of excessive perspiration, wliich is commonly met with in poorly-nourished and neurasthenic cases. Herpes is found among the interesting disorders of the nervous system to which tlie pregnant patient is liable. Fournier"' rejwrts a case in which the lesions were distributed irregularly over the body, especially upon the i'orearms, the anterior part of the thorax and feet, and the abdomen. Accompanying these lesions were patches of nnlness, in some instances these areas being covered with biillse as large as an olive or a small (jherry. Tiie usual j)eriod of pregnancy at which this disorder occurs is between the liiird and the fifth month, occasionally i;s late as the sixth or the eighth month. In other cases, more rare, the lesion does not show itself until the second or the third day of the puerperal period. There is a strong tendency in this disorder to recur during subsequent pregnancies, and instances are given where the patient has suffered from herpes during five successive gesta- tions. Although intolerable it(;hing and burning accompany herpes during prcirn^ncy, yet the general health remains remarkably unaff>"c!ed. The occur- rence of gestation is not influenced by this complication, anJ patients usually recover promptly when gestation terminates. Herpes in the puerperal period is often characterizetl during its onset by fever, persj)iration, and general pruritus. In from twenty to twenty-four hours after these symptoms occur the characteristic eruption appears. The remarkable tendency of herpes to recu:' is illustrated by the cases of Cottle, Wilson, Gale, and Hardy, the last of whom describes a patient who suffered in nine out of ten pregnancies with this disorder. There is no evidence that the fetus and its appendages are affected in this disease. Occasionally mixed forms of the eruj)tion, are seen, some of them resembling pemphigus and others assuming a sy])hiloid type. It is noticed that young women are oftener attacked by herpes than those older. The treabnent of herjies consists, first, in j)roperly regulating the functions of the body. Herpetic patients are generally depressed or in some manner are tlcfioient in nervous energy, and they will be found to improve under the pro- iongcd use of arsenic, hypophosphites, and iron. The great number of reme- dies which have been administered as specifics in this disorder, and their failure to influence the course of the disease, show that it is not amenable to specific treatment. When the ern])tion first begins borated vaselin, glycerol of starch, and lime-water and oil will be found soothing a])plications. When tlic eruption is fully developed bismuth and starch and starch-and-talcum powder are useful dressings. For the intolerable itching, applications of carbolic acid, hydrate of chloral, menthol, or corrosive sublimate in solution have been found useful. Wlicn a large portion of the body is involved, baths containing starch, gelatin, or bran may be employed. }'| II "PI If f 'i (^ 1/ 212 AM Kit [CAN TKXT-BOOK OF OliSTKriilCS. While the progiiortis of herpes eoiiiplicatiug gestation is f'avornhlo ho fur as the coiitimiance of pregiuuicy is eo'icenied, still this coinplieation exercises a most depressing iiiHiienee, and r,my lead to eoinplieated labor by reason of oxhuustion. Care shonld be tiiken, then, to snpport the general strength of the patient in every possible way, to promote her nntrition by a earefidly- ordere<l diet an<l tiie persistent nse of tonics, and to see to it that during lal)or her strength is conserved in every possible mumier. Sudden death duriner pregnancy may rcsnit from the entrance of flnid or of air into the enlarged sinnses of the nterns. Ilektoen ""• narrates the ease of a patient who, while taking a vaginal injwtion, fell dead : it was fonnd that she had been nsing a Davidson syringe, i he autopsy showed the tissues of the uterus fdled with air and blood and the placenta partially detached, while the riirht ventricle contained frothv blood, but no clot. Air was found in the subserous vessels and also in the vessels of the pericardial and pleural cavities. The condition of pregnancy seems to predispose to sudden heart and respiratory failure. This is especially the case where nausea and vomiting have been well markcil during the first months of pregnancy. McCabe'"' reports the case of a jjatient wlio desired relief from obstinate nausea and vomiting, and to whom morphia had been given by hypodermatic injection. As it was impossii)le for the attending physician to see her at short intervals, a hypodermatic injection was prepared by him and left for administration during his absence. She seemed relieved, but a few days after, on attempting to move, a sudden weakness developed, terminating almost immediately in death. The same observer describes tiio case of a young woman who during her second jtregnancy was nuich annoyed by intense pain over the uterus and across the lower part of the back, simidating after-pains. A hypodermatic injection of ^ grain of morphia was given, which made the patient easy. It was found that she had miscarried the night previous at about two and a half months of gestation. There was no sign of puerperal septit^ intwjtion, but a rapid and weak heart caused the patient much distress. During the night following she suddenly sprang from her bed, and almost immediately expired. As in both the above cases morphia had been given by hypodermatic injec- tion, the relation borne by this drug to the phenomena observed is of interest. It would seem from these cases that morphia hypodermatically is a dangerous drug to be administered to ]>regnant patients. Cerebral thrombosis and hemorrhage during pregnancy are illu trated in a case reported by Horroeks, '"^ in which a patient in her second preg- nancy developed stupor and drowsiness with rectal and vesical incontinence during the last month of gestation. The pupils were etpial and symptoms of palsy were wanting. The urine contained neither all)umin nor sugar. The heart seemed normal, and labor subsequently came on spontaneosly. Con- sciousness, however, was obscured, and derangement in the motor a]>paratus of the brain and nervous system was evidently present. After death many of the cerebral veins were found occludeil by thrombi. There was also recent THE PATIIOLOCY OF PliKaXANCV. 21. 'J t'xtravasutioii of bloixl al(»iij; the intornul oapsiilo. Cystitis and supimrativc iicpliritis on one Hide oxistod. Menineritis duringr preernancy is almost invariably fatal to tlio niotluT, and fro(|iit'ntly to her child. Cliund)rc'Iont "" describes 7 cases of aente meningitis dnring pregnancy, in six of which labor was terminated artificially with the birth of a living child. In one case birth was spontaneous before the mother's death. In view of the grave natiu'e of this coniplication labor should be indnceil in cases of meningitis during pregnancy where the fetus is viable, in the hope of saving the life of the infant. Spinal Irritation complicatingr Pregnancy and Labor. — The hyperemic and hyperesthetic condition eharaeteri/ing pregnancy exaggerates all forms of functional nervous disturbances or jiathological conditions in the nervous sys- tem. Spinal irritation is not infrc(iuently observed, and it is well illustratetl by cases reported by Napier."" The symptoms w(n'e great tenderness on pres- siu'c al(»ng the spines of the vertebrie, and iji one patient fatal albuminuria grad- ually developed. These cases followed an epidemic of diphtheria which pre- vailed four or five years prior to these observations : the poison of diphtheria seemed to lose its activity by attenuation. Cases of cerebro-spinal meningitis (leveloi)ed as the epidemic died away, and last of all occurred the eases of pregnancy complicated by great tenderness along the spine, which tenderness seriously impaired the patients' strength and hindered convalescence. A toxic condition following widespread diffusion of diphtheritic poisim should be con- sidered as the cause of these cases, but the phenomena of spinal irritation were predominant. Maternal impressions are familiar to all obstetricians of extensive reading and experience. It is not the writer's purpose to consiiler the matter in detail, but simply to draw attention to the fact that a pregnant patient may undoubt- edly so profoundly be influenced by nervous shock as very markedly to alter the development, the shape, the size, and the appearance of her offspring. In recent literature on the subject Mackay "" describes five cases in which fright produced distinct birth-marks nptm the fetus. The writer may add a case under his personal observation in which a ])regnant woman was informed that an intimate friend had been suddenlv killed bv being thrown from his ' trse : the immediate cause of death was fracture of the skull, produced by the corner of a dray against which the rider was thrown. The mother was ]); f'ouudly impressed by the circumstance, which was minutely described to liif l)y an eye-witness. Her child at birth i)resented a red and sensitive area upon the scalp exactly corresponding in location with the situation of the fatal injury in the rider. The child is now an adult woman, and this area upon the s('al[> remains d and sensitive to pressure, and is almost devoid of hair. Space notnl not be taken to discuss the question of maternal impressions. There is certainly more than coincidence in the fact of fright and shock and the subsequent malformation or marking of the fetus. The well-known " elephant-m;; ' " of England, and the "turtle-man" exhibited in the United States, with other instances, are familiar evidences of this statement. '■ f ; m 214 AMEIiTCAN TEXT-BOOK OF OBSTETRICS. M' m \ k 1 Hi IMP i 1 ■;■■ r i Chorea during Pregnancy. — There is no disorder of the nervous system so nianilestly aggravated by pregnancy as eliorea. The physiological plethora characteristic of normal pregnancy seems to exaggerate the functional activity of the nervous system, and it results in marked exacerbation of all pathologi- cal phenomena. The chara(;teristic choreic jnovements occasionally extend even to the uterus, as in a case reported by Braxton Hicks.*"" The patient was a young woman who had suffered from chorea in childhood : the uterus, which could be outlined distinctly in the abdomen, presented marked altera- tions of form, accompanied by very evident choreic contractions. These uterine movements became less violent as the patient was treated by rest in bed and by the administration of arsenic : she was subscfjuently delivered in normal labor, making a good recovery. In an elaborate essay upon the subject McCann'"^ divides cases of chorea occurring in pregnant patients into cases of true chorea, of hysterical chorea, and a mixed form. It is rare to find chorea occurring in patients after the eighteenth year, except during pregnancy. Primigravidte are more susceptible to chorea than are multigravida;, especially to true chorea. In ])atients free from rhemnatism it is rare for true chorea to occur in any but the first preg- nancy. When the exaggerated reflex condition which occurs in chorea is called to mind, it is natural to expect that the great majority of cases will occur in the third and fourth months of gestation. The reason for this occur- rence seems to be the irritating effect upon the nervous system of fetal move- ments which begin to be felt at about that time. So far as the etiology of chorea in pregnancy is concerned, acute rheumatism is the n^ st immediate cause, and next comes an hereditary history of distinct rheumatic taint. Epilepsy and other disorders of the nervous system predispose to chorea during pregnancy. Fright, emotion, and profound anemia also favor its occurrence. For the actual outbreak of chorea, however, there must be present an hysterical predisposition to nervous excitability, a depreciated condition of the blood, and an actively exciting cause, which is usually found in fetal movements. Post-mortem examinations of patients who have died from chorea during pregnancy show that in severe cases the motor cortex, the intel- lectual centres, and tiie spinal cord are all involved. In mild cases the motor cortex only is imj)licated, and the spinal cord least often. The effect which chorea produces upon ])regnancy depends entirely upon its severity. In mild cases am(>nable to treatment the ])regnancy is not interrupted, while in severe cases abortion occurs, sometimes followed by fatal termination from coma and high temperature. Severe cases of chorea which do not result fatally may end in mania persisting for a considerable time. Paralysis and delirium are also occasionally observed to follow this disorder. If the preg- nancy is at term when the mother is attacked by chorea, the risk to the child is but very little, if any, increased. The earlier in pregnancy that chorea occurs, the great(>r is the danger to the existence of the fetus. Although the physician natiu'ally hopes that choreic movements will cease after delivery, .such is rarely the case ; they die away very gradually, and they have been THE PATHOLOGY OF PREGXAyCY. 215 observed to continue for five months after labor, Pregnancy predisposes greatly to the recnrrence of chorea, so tliat a girl who has been choreic iu early life will almost snrely again become i-horeic should pregnancy occur. As in the non-pregnant, chorea during pregnancy is sometimes more severe than a former attack, and, again, ma\ be less violent. Chorea during child- hood is very apt to reappear in subsequent pregnancies in the same indi- vidual. It is also interesting to note that the younger the patient, the greater is her liability to u recurrence of chorea. The great liability of pregnant patients to hysterical manifestations restdts to a very per|)lexing degree in introducing this element into cases of chorea during pregnancy. The ditt'erential diagnosis is best made from tiie character of the movements, which in hysteria are more sudden and occasionally are riiythmical in character. Impairment of sensibility is noted as a prominent symptom in cases possessing a strong hysterical clement. A history of pre- vious hysteria is sometimes obtainable. In making a diiferential diagnosis imitation movements must be borne in mind, as they an; sometimes calculated to deceive skilled observers. As regards the jxirtion of the body most often iilVccted by choreic movements, (rowers"** out of 64 cases found eleven in which the right sitle oidy wiss alfcctcd, and thirteen in which the lefl side alone was artwitcxi. During ])regnancy chorea is most often bilateral, the reason for this being that as the disease is more severe than in the non-preg- nant, its manifestations are more widespread. It is usually found in these cases that in the begiiming the movements were unilateral, afterward becoming biiatcM'al as the disorder increased in severity. The physiognomy of the l)reg- nant patient suffering from chorea is characteristic, being listless and vacant iu expression, and when the facial muscles are affected peculiar grimaces result- intr. General relaxation of the muscular system often occurs earlv in the dis- ease, and in the later stages mental apathy is not infrequent. Dilated pupils are often present, and are thought to depejid upon a generally relaxed con- dition of the muscular system. In a large number of eases the face is alfcctcd ; in a few, however, it is r >t, Speech and the nKn'cments of the tongue iiecome involved in the severe case% Sighing and irregular respiration have been described by Iloniberg and others. It is interesting to note that chorea mure severely involves the memory of ]>regnant patients than of non-preg- nant. The cessation of choreic movements is promptly followed by improve- ment in memory. Patient.-' who become maniacal after chorea often give utterance to a ptrnliar cry described by Ilond)erg and others. The analogy iK'twceu the cry of chorea and that of the patient about to be seized by an (■|)il( ptie ]>aroxysm is interesting. The prognosis of mania or delusions co:m- plicating chorea in pregnancy is often unfavorable; shoidd the patient not have chorea after her delivery, she may be found the victim of delusions or of chronic mental apathy. Sijmjttomx of dmira especially referable to the pregiiant state are, first in iinportunce, tluwc produced by the (|uickening of th(> fetus. The ])resenee of II nervous temperament in a choreic patient, or its absence, will (h'tcrmine the m "hiw m 216 AMERICAN TEXT-BOOK OF OBSTETRICS. j severity of tlie symptoms. As regards the influence of chorea upon labor, choreic movements often cease when labor-pains set in ; such movements gen- erally die away during the stage of uterine contraction, often to recur so soon as the labor-pain is over. The labors themselves are often normal, and in many cases during the pains, especially when the patient endeavors to assist them, the choreic movements become more than usually pronounced. While there is a temporary lull in the choreic movements after the birth of the child, the effort to expel the placenta is usually followed by their exacerbation. It occa- sionally happens that choreic movements become more than usually increased during the puerperal state about the third or the fourth day. The irritation incident to the formation of milk has been cited to explain this fact. Abdom- inal pain, which often accompanies movements of the bowels at this time, is also thought to cause increased choreic movements. Pressure on the uterus and the abdomen sometimes increases choreic movements during the puerperal state. The irritation of luirsing their children has aggravated chorea in some patients, the convulsions becoming so violent that the nipple was jerked out of the child's mouth. In choreic cases endocarditis is sometimes observed as a complication, and it makes the prognosis much more serious. Hemic murmurs dependent upon anemia are exceedingly common in these patients. An examination of the urine shows an excess of urea and phosphates, probably the result of the increased muscular activity of the convulsive seizures. In diagnosis the chief difficulty arises in distinguishing the true chorea of pregnancy from the hysterical and mixed forms. Attention nuiv again be called to the fact that in true chorea movements are irregular and spasmodic, and are increased by motion and vol- untary effort, especially if such effort be sustained. In the hysterical form movements are sudden, isolated, and often rhythmical especially in the iugers. Hysterical chorea never becomes so intense as greatly to exhaust the patient. Delirium, acute mania, and delusions may complicate chorea during pregnancy, as illustrated in the eases described by Jones;"** one of his cases was com- ])licated by sejitic infection following jiremature birth of a decomposed fetus at seven months. In another case ])aralysis of the left arm occurred as a com- })lioation. Children born of choreic mothers sometimes show marked tendency to convulsive movements. line"" describes two cases in which the chorea of the mother reapj)eared in conv ilsive movements of the child. Maniacal cliorea is to l)e distinguished from the mania of ])regnancy and the jHier- ])eral state by a jirevious history of choreiform movements. In defaidt of such historv an <>xaet diajjuosis is often difficult. In maniacal chorea the patients are less sullen and are more garrulous than in true mania. In esti- mating the dangers of chorea in ])regnan(y the violence of choreic movements, the amount of slc(>p lost in conscciueuce, and the intercurrent com])lications must all be considered. The jirognosis of maniacal chorea is usually good as regards the menial condition. Occasionally mental defect persists for a long time after labor, and it may ultimately become permanent. Sejjticeniia and ])yemia very seriously complicate such cases. JAM; L^s.v THE PATHOLOGY OF PREGNANCY. 217 So fur as treatment is concerned, sedatives and narcotics liave been used extensively with but indifferent success. The indications for treatment are to secure bodily and mental rest, to procure sleep, and to bring about an improved condition of the patient's blood and nutrition. It is often necessary to protect the patient's skin from friction caused by the severity of the movements. A profoundly depressed mind and nervous sys^omcall for an entire change of sur- roundings. In the medicatitm of these cases arsenic, intelligent feeding, and the maintenance of proper digestion are of the greatest importance. Rest in bed, freetlom from annoyance and excitement, bathing, and gentle friction are also of value. To procure sleep, chloral in doses of 30 to 40 grains has given good results. Gairdner '" relates the case of a girl, eight years of age, who took by mistake 60 instead of 20 grains of chloral to procure sleep ; she recovered from the drug, and was permanently cured of her chorea by the dose she had taken. Trousseau and Gowers have used in these eases strychnia, ' pushed to a ])hysiological effect. Sodium salicylate, wet packing, and the appli- cation of cold to the spine have also been recommended. So far as the obstet- ric treatment of these cases goes, the obstetrician must guard against hemor- rhage, to which the anemia so generally present predisposes. Violent choreic movements also render it difficult to control the uterus during the third stage of labor. The debilitated condition of the patients exposes them to additional risk of septic infection. When chorea persists after delivery nursing should be prohibite<l, as it undoubtedly tends to aggravate the condition. If the chorea be slight or of the hysterical form, the pregnancy should not l)e inter- rupted. In all severe cases, however, labor should be induced. The follow- ing conditions may be cited as calling decidedly for the interruption of prog- nancy in a choreic ])regnant patient : tlireatened exhaustion on the part of the mother from the intensity of the movements and a deficiency of sleep ; when mania or fixed and dangerous delusions are present ; when a grave physical complication, such as endocarditis, increases the gravity of the case. Pantzer "^ reports the case of a woman, aged twenty-six years, pregnant for the fifth time and suffering severely from chorea. In a previous pregnancy her movements had been so excessive that labor was induced, after which choreic movements persisted for several weeks. During the pregnancy in question she was obliged to enter a hospital. Although easily excited, she was readily controlled by morphia, and no grave condition was found at con- finement threatening the interest of iier cliild or herself. The usual treatment for chorea was administered, with the added jirecaution of avoiding large doses of bromid, which tend to favor hemorrhage after labor. The patient's labor was normal, and she made a good recovery. Catalepsy is occasionally observed during the ]>regnaut state, as in a ease recently reported by Shoot of Ijunwarden."* The ])atient was a robust woman, aged forty-four, who had borne eleven children ; in youth slie iiad suilered from typhus, and after recovery became subject to fainting fits, but throughout her marrie<l life she remained strong and well. Tiiere was no history of a neurosis in her family. During the seventli mouth of her twelfth ill h i i '9. < 218 AMERICAN TEXT- BOOK OF OBtSTETBICS. prognancv she was seized with cataleptic fits following the loss of a child : she was found stiff' and motionless by the attending physician. The forearm could be raisetl and bent with some force, and reniainetl in the same position for about ten minutes, after which it slowly fell. The lower extremities behavcu in a similar manner. Consciousness was lost. The pulse was 64, full and regular, the temperature and respiration normal. The pupils were somewhat dilated, but reacted to light. On inhaling chloroform the rigidity of the muscles ilisapjvaicd, and the patient seemed to sleep calndy for hours. On awakening the patient remen)bered nothing that had taken place. The fetal heart-sounds, previously audible, were lost, and were not heard until fourteen days before labor. No albumin was found in the urine upon exam- ination. Cataleptic fits occurred three or four tinies daily, occasionally with an interval of several days. Atropni gave the patient a week's freedom ; the disorder contimied, however, to term, when she was safely delivered of an apparently healthy boy. On the fifth day after labor an attack recurred while the patient was nursing her child ; two days later the second took place, which was the last. Shortly after the first attack her child, who had been weaned because of the cataleptic complication, was seized with dysphagia. In the evening of the same day the child had a cataleptic fit, the symptoms being precisely those of the mother. The rigidity which deveh)ped relaxed during a warm bath, but soon afterward returned. Tonic cataleptic convul- sions recurred, and the child died after two days' duration of the cataleptic fits. Pregnant patients are exposed to those poisonings of the nervous system from lead, arsenic, dyestuffs, tobacco, and other substivnees met with in the arts, and which commonly act by producing, among other complications, multiple neuritis. In the absence of specific poisons multiple neuritis is occasionally observed, as describal by Sulowieff'."^ His patient was three months advanced in pregnancy and snifering from nausea and vomiting. No cause for the latter complication could be found in the condition of the urine or of the genital tract. Her nervous symptoms, however, were peculiar and pointed to multiple neuritis, especially well marked in the lower extremities and upon the back and neck. The organs of the special senses were in a very hyjieresthetic condition ; the blood was normal. Her history included an attack of scarlatina in childhood, and also hysteria. She was nourished, when necessary, by rectal injections, and was treated by faradization and hypnotism. A very careful study of her nervous system showed polyneuritis in very widesj)r('a(l degree. A post-mortem examination showed all the viscera free from marked i)athological change. The nerve-trunks, however, throughout the body gave evidence of varying degrees of degeneration ; this was especially true of the jihrenic nerves : it had been noticed during life that the action of the patient's diaphragm was at times very deficient. Diabetes. — Among the rare disorders ol' pregnancy in which the nervous system and the assimilation of the patient seem equally affected may be con- sidered diabetes. Its rarity may be inferred fnim the statement of Griesinger, Ik THE PATHOLOGY OF PREGNANCY. 219 who found, of 53 cases among women, two only during pregnancy. In Frerichs' large experience, in 386 cases there were 104 among women, and only one of these had diabetes during pregnancy. Matthews Duncan "'' reports the ease of a multigravida who had a suspicion of diabetes for a short time in a former pregnancy. At the eighth month her fetus perished in utero. Excessive amniotic liquid was present. The patient collapsed before labor began, and perished shortly after. During her first pregnancy she had suffered from great thirst, and passed enormous quantities of urine during the first few days after delivery. During the pregnancy which ended fatally her urine was examined two months before her confinement, and nothing abnormal was detected. It was excessive in quantity. The patient's tongue was dry and brown, her breath had a ixjculiar sweetish odor, and purplish areas were detected upon the skin. Ilcr temperature was normal, but she suffered greatly from a sensation of oppression. Reid reports a case very similar to Duncan's. The amniotic liquid was very abundant, and it possessed an abnormally great amount of albumin. The child was large and well developed, but dead before labor. Xewnmn saw diabetes in two pregnancies in the same |)atient, the mother finally perishing of the disease. liccorchi observed diabetes in an infant born of a diabetic mother. Williams reports a case, with autopsy, in which the liver and kidneys were found granular and in pale cloudy swelling. In Husband's case the liquor amnii was saccharine. Bennewitz and Winckel also rejjort cases. In Duncan's case an examination of the eyes revealed a large pear-shaped clot in the central spot of the retina. The patient was suddenly taken with intense ]>ain in the right side of the abdomen in the fifth month of pregnancy. Labor was induced, but the child was dead and decom- posed. Tlic patient died, and no cause for the fatal issue could be found on post-mortem examination. Frerichs discovered in a patient, in the eighth month of pregnancy, who suffered from diabetes and who perished after delivery, a tumor of the medulla oblongata. Diabetes may occur during pregnancy only, being absent at other times. It may cease with the termi- nation of pregnancy and may recur afterward. The ]>rognosis fi)r subsecjuent pregnancies is not invariably bad, as a patient, if cured of diabetes, may in subsequent pregnancy escape its return. The existence of dialwtes does not militate against conception. A possible explanation of the occurrence of diabetes during pregnancy is found in the results of the study made by Oddi and Vicarelli : "" these observers found that during pregnancy there is a largely increased consiuiip- tion of hydrocarbons derived from the waste of nitrogenous material resulting from fetal nutrition and growth. This was seen by analyzing the air respired by ))regnant patients. It is rational to conclude tiiat cases in which this met- abolism is seriously disturbed may furnish the complication of diabetes diu'ing pregnancy. Diabetes seems almost unifi)rmly fatal to the fetus, and that at a compara- tively earlv period of gestation. The amnion seems to be the seat of tlic diabetic process, tind dropsy of the anuiion or the formation of saccharine 1W\ i i I 1 t i ■ , ( 'I 220 AMERICAN TEXT-BOOK OF OBSTETRICS. matter in the amniotic liquid is the condition most commonly observed. Fry "^ reports the case of a patient in her second pregnancy who suffered from great thirst and who was easily fatigued. Examination of the urine showetl 9 per cent, of sugar, which was reduced by treatment to 5 per cent. The child perished during pregnancy. The mother died five days after delivery. The treatment of diabetes complicating ])regnancy is that which the prac- tice of medicine enjoins in such cases. The fact that the life of the fetus is usually lost shoidd lead the obstetrician to disregard it, and to empty the uterus promptly if the diabetic condition is pronounced. The prognosis for the mother, should she survive labor or abortion, is unfavorable, as the diabetic condition commonly persists and ultimately proves fatal. The fact that diabetes occurs in pregnancy, and that it is attended with peculiar fatality, emphasizes the necessity for the examination of the urine in pregnant ])atients. The presence of more than a trace of sugar should lead to a thorough examina- tion of the patient's processes of assimilation, when it may be possible to avert further development of diabetes, and thus save the lives of mother and child. T/ie patholof/y of diabetes mellitus complicating pregnancy is well illus- tratetl by a case reported by Hehir."* The patient, a ro.ultigravida, suifered from diabetes during pregnancy, and gave birth to a dead fetus nearly at term. Amniotic liquid was turbid, having a heavy, mawkish odor, and being very abundant. An infusion was made from the epidermis of tho fetus, and traces of sugar found in this infusion. The liquor amnii was also examined, and in it sugar was found. The patient had been greatly annoyed during her pregnancy by excessive corpulence, and had suffered from polyuria and diabetes mellitus. Hehir also describes a case of diabetes in pregnancy in which abortion occurred at the fifth month ; similar phenomena were observed in this case. Idiopathic universal pruritus as a complication of pregnancy may occa- sion great distress and may seriously interfere with a patient's rest and nutri- tion. In two cases reported by Feinberg "" the disorder became worst at the time when menstruation would have occurred had pregnancy not been present. Palliative treatment mitigatwl the patient's sufferings to some extent, but it was unsuccessful in relieving the disorder. Both patients were exceedingly nervous, easily excited, and one of them aborted under great excitement. I'ruritus limited to the vulva and vagina is frequently observed as a com- plication in patients suffering from diabetes during pregnancy. In such cases any form of treatment whidi lessens the amount of sugar in the urine decreases the ])atient's suffering from pruritus. In cases not associated with diabetes local apjilications are indicated, such as antiseptics, in strong solution, painted over the part. Tims, bichlorid of mercury (1 : 1000) followed by an application of salt-solution or ])lain water, carbolic acid, 3 to 5 per cent., tincture of iodin, glycerin, and carbolic acid, are oft(!n employed. In patients not unduly susceptible cocain is used to advantage, altiiough the extensive area to which the api)licati()n must be made renders it a dangerous one to patients readily influenced by the drug. The ai)plication of electricity by ])lacing a THE PATHOLOGY OF PREGNANCY. 221 moist electrode upon the inucoiis membrane of the vulva has been beneficial in some cases. The observance of cleanliness is of great importance, esjie- cially where a vaginal discharge amioys the pregnant patient. Douches of carbolic-a(!id solution, of crcolin and green soap, of boracic acid, of alum in solution, or of a hot soluti(m of sodium bicarbonate should be tried faithfully. Sitz-baths of a warm solution of boracic acid, of sodium bicarbonate, or bran sitz-baths are also indicated. The local application of starch and laudanum or lead-water and laudanum is another resource of service. Where extensive irritation and excoriation are present the application of an ointment contain- ing belLtdonna, opium, and iodoform is often a source of great comfort. Pen- cilling the nuicous membrane with nitrate of silver is occasionally of value. In the majority of cases, however, the best treatment for pruritus of the vulva and the vagina com])licating pregnancy is to be found in careful cleansing, etteoted by gentle irrigation of the parts with non-irritating, antiseptic fluids, and by constitutional treatment addressed to improving the condition of the patient's nervous system and assimilation. Hysteria during pregnancy furnishes an interesting illustration of the fact that the pregnant condition exaggerates any previous defect or susceptible point in the patient's mental and physical organization. The belief once entertained that pregnancy exercises a favorable influence upon women already hysterical is certainly erroneous. It occasionally hap})ens that a pregnan , greatly desired and occurring amid the most favorable circumstances, furnishes a healthy stimulus and assists a patient in cultivating self-control, but such cases are the exception and not the rule. Mild forms of hysteria during pregnancy often take the shape of melancholia and fear of approaching con- finement. Such cases require ])atient encouragement on the part of friends and physician, and should stimulate the obstetrician to take every precaution that he be surprised by no unforeseen complication during the labor. If the physician makes a thorougli study of his patient before labor, and demon- strates to her that he has exercised every precaution in her behalf, it will go far in allaying her ap])rehensions. In the experience of the writer prelimi- nary examination of pregnant patients by ))alpation, auscultation, and pel- vimetry often exercises a very favorable influence in such cases. Hysteria com- plicating pregnancy becomes dangerous when it ])asses into a condition of maniacal excitement. While the ju'ognosis in such cases is not unfavorable so far as the recovery of the mother goes, yet these patients require prolonged and careful treatment, and sh, iild labor occur during mania injury to the fetus or to the mother may result. Such cases require constant watchfulness, kind and systematic restraint, and when any obstetric manipulation is required the use of anesthetics is usually a necessity. As one of the dangers that threaten in these eases is exhaustion through a refusal to take food, feeding of such patients is a cardinal point in their treatment. As is so often seen in deal- ing with the insane, it is better to attemjit no deceit in tluir management, but to win the patient's confidence by faithful and patient attention without dis- simulation. i I : I \l m ■ if +■ f 4 222 AMERICAN TEXT- BOOK OF OBSTETllICS. Mania complicating pregnancy is of importance chiefly as influencing the course of labor and the puerperal state. Mania is observed during pregnancy in patients of very neurotic organization, in those having a heredity of insanity, in women who have been alcoholic, hysterical, or in other ways neurotic, and in women who sutter some great mental shock while in the pregnant condition. Unhappy marriages form a considerable element in the causation of mania during pregnancy. The diagnosis in these cases is to be made by eliminating hysteria, delirium tremens, hystero-epilepsy, and the temporary delusions and hallucinations whit.-h sometimes accompany toxemia from deficient excretion. In the former, observation will usually make diflerential diagnosis a matter of ready accomplishment. In cases of toxemia a study of the patient's exci'e- tions is required to arrive at a correct result. The prognosis in these cases depends upon the underlying condition which is the exciting cause of the mania. In those of highly neurotic organization, but whose physical con- dition is goo<l, the prognosis for life is good, but the outlook for mental soundness is not brilliant. In cases where mania has followed a profound shock, as by sudden bereavement, an accident, or a calamity, if the patient's physical condition is go<xl the prognosis for a complete recovery is also good ; this is especially true if the child is carrietl to terra and survives its birth. If, however, mania is grafted upon a background of serious physical disability where some well-marked pathological condition is present, it may be the fore- rinmer of a fatal issue — if not at labor, within a short time afterward. This is especially true in those cases where toxemia and interstitial nephritis are b{>ginning, and where the patient, if she escapes eclampsia, passes ii.to a con- dition of pronounced and fatal nephritis after labor. The trcdtment of mania during pregnancy varies with the condition which excites the mania. What has been said regarding the treatment of hysterical mania applies to cases where the patient is neurotic, but is physically in good condition. In women who become maniacal in the presence of calamities or of sudden bereavement the free use of narcotics for a time is often indicatcfl to se- cure sleep. If the life of the child continues, the hope of its birth and maternal affection should be used as jwwerfid mental tonics in dealing with the mother. Perfect seclusion and protection from all intrusion are absolutely essential. When tlie first sluK'k t(j the mind and the nervous system has passed, all the resources of the therapeutic art are required in promoting the nutrition of the brain and nervous system. The treatment of mania complicated by toxemia through deficient excretion calls for the avoidance of narcotics and sedatives and the prompt securing of active elimination. As soon as the patient is freed from the poisons which an; irritating the brain her condition usually is marked- ly improved. Nausea and Vomiting of Pregnancy. — On the border-line between the physiology and the pathology of pregnancy, nausea and vomiting have been con- sidered by some as an inevitable result from the irritation occasioned by the development of the pregnant uterus, and by others as purely a pathological phenomenon. Like the kidney of pregnancy, the pregnant uterus and its THE PATHOLOGY OF PREGNANCY. 22.} nervous supply are in a condition of plethora which borders upon an actual pathological change. The progress of our knowledge in the pathology of pregnancy gives good reason at present for the belief that nausea and vomiting are not a physiological, but a pathological, accompaniment of the pregnant con- dition. As many patients pass through pregnancy with no pathological lesion of the kidneys, so many women bear children without the nervous irritation and the anemia, slight or profound, that accompany nausea and vo' iting. The predisposing causes for th<! emesis of pregnancy are to bi: 'i d in a congenital irritability of the nervous system, that produces •A.,ggerated response to normal reflex stimuli. The predisposing causes for this af!'ecti(tn are anatomical lesions in the generative tract, notably congenital malforma- tion of the uterus or dislocation of the pregnant womb. The exciting causes for this complication are sudden shocks to the nervous system that power- fully exaggerate its reflex susceptibility. An infective j)rocess producing hyperemia and irritability of the cerebro-spinal axis may also be an exciting cause for the nausea and vomiting of pregnancy. A pathological process which affects the constitution of the blood is also a frequent exciting cause in these cases. Direct mechanical injury or violence to the pregnant womb often begins and maintains this condition ; thus, a patient in early ])regnancy, while straining or lifting, suddenly retroverts the uterus, and obstinate emesis follows. Metallic and irritant poisons absorbed into the system, vitiating the blood and irritating the nervous centres, produce nausea and vomiting. Among the most frequent of the exciting causes are the movements of the fetus in utero and excessive peristalsis in the mother's intestine. Distention of the bladder and the rectum is frequently present in these cases. The diagnosis of this condition must usually be made in large part from the statements of the j)atient or from those of her attendant. As such vomit- ing is most frequent in early morning, unless in severe cases the physician rarely has an opportunity actually to observe the ])henomenon. In mild cases nausea begins as soon as the patient raises her head from the j)illow. The desire is for instant emesis, which is usually accomplished without straining, and is often repeated. Following this emesis the patient may take food with appetite, and the ]>lienomenon may not recur until the next morning. In such cases the matter vomited is mucus, sometimes of strongly acid reaction, sometimes of Heutral reaction. In more severe cases the sensation of nausea begins as soon as the patient awakes ; assuming the u])right posture is followed by vomiting but little relieved by emesis. The material ejected is mucus, often burm'ng and bitter to the taste, frequently excessively sour. Although the l):itieut may succeed in retaining food, the sensation of nausea persists often iMitil mid-(l,iy or even later: the sight or the presence of certain articles of food greatly increases her distress. Perturbation of any kind exaggerates the sensation of nausea. If vomiting is repeated, it is accompanied by straining and retching. After mid-day the patient is better, and may eat heartily at evening. Such eases are accompanied by anemia and often by considerable loss of weight. A third class of cases is well characterized by the term per- W. ■ > l«. I 11 li) ^'•. m \m\ • ^h i ■■ 1 1 ^>|; 1 ili 224 AMERIVAN TEXT-BOOK OF OliSTiyTRICS. If V m nicioun ; in thorn the sensation of nansea is present at intervals during the ])atient's waking hours. Hor cravings are lor varied articles of food and drink, and they are no sooner satisfied than a new craving arises. Vomiting is accompanied by straining and ret(!iiing, by dryness of the fauces, or by pro- fuse salivation. The matter ejected is, first, mucus and the UkkI taken, bile, and, in severe cases, niiufus stained with blood or with coffee-ground material. Food is no sooner swallowed than it is ejected, although there occur surprising periods of tolerance in which the patient eats greedily, and which occasion hope in the mind of the physician that substantial improvement has taken place. As the case proceeds distress and pain are felt beneath the stermim, not located at any fixed point. The sensation is described sometimes as that of smothering, but more often as that of distress which has nothing to do with breathing. In dangerous cases it is worst at night. Emaciation is progressive — in some cases rapid, in other cases slow. A more deceptive phenomenon in these patients is acute fatty degeneration of the tissues, that gives to the pa- tient a plump ap|)earauee which may deceive the physician. As the case pro- gresses the clinical picture of pernicious anemia becomes more and more apparent. Signs are present of disintegration of the blood in the vomit, in hematogenic jaundice, in sordes, and in pur{)uric extravasations. The urine contains the debrifs of broken-down corpuscles, the feces are dark in color, the mucous membranes dark and reddish in appearance, and the nujutal condition is one of apathy or of delusion so often seen in these cases. A further explanation of the process is observed in the condition of the eyes by a necrosis of the cornea, and dimness of vision may be noted. The j)ulse and the cardiac action of the patient in severe cases of nausea and vomiting of pregnancy show the effect upon the heart and the arteries of the gradually developing anemia. The pulse is rapid, soft, and weak. Arterial tension is usually diminished, the first sound of the heart grows less and less distinct and forcible, and in fatal cases cardiac syncope develops. The temperature is subnormal at first ; later in severe cases it increases as a fatal issue a])proaches. In other cases the temperature varies slightly from the normal, and in all cases it is not an important factor in diagnosis or in prognosis. The ])ulmonary signs are usually negative : the patient occasionally complains of an irritable cough which accompanies a dry condition of the fauces, or in others of the accumulation of an excessive amount of mucus. Palpation of tiie abdomen may detect a dislocation, of the uterus, and in the early stages of the more severe cases the abdominal walls are often excessively irritable, the practice of palpatitm increasing the nausea. Liver-dulness is usually slightly increased in area as the liver becomes the seat of acute parenchymatous, fatty degeneration. The patient's reflexes are much increased, although ])aralysis or atrophy, otiicr than that attending emaciation, is seldom observed. The nutrition of the skin, except in purpuric (^ases, is usually fairly maintained ; bed-sores in cases well cared for are of rare occurrence. A clammy sweat is frequently seen, especially upon the face. The symptoms of an improvement in the condition of the patient suffering THE PAriroLoav of PUKayANVY. 225 from nausea ami vomiting of pregnancy arc a dimiiuition in the uansoa and the eniesis ; tlie ability to take anil to retain food ; a normal eondition of the excretions, especially of the urine; the absence or the diminution of excessive perspiration ; considerable periods of sleep without emesis, and the absence of substernal distress, especially at night. The pulse falls gradually to 100, and the temperature reujains normal. Symptoms of danger in these cases are the continuance of the nausea and vomiting and the gradual dev('k)pment of the signs and symptoms of pernicious anemia. Among the most important of these are a persistently rai)id, feeble pulse, substernal pain and distress, and colfee-ground vomit. The pailiohf/icdl anafomy of tliese eases may be dividi'd into — first, those of the organs of the body other than the generative organs ; and, second, tlutse of the uterus and its ai)pendages. In the first class of cases it is evident that lesions which may produce obstinate nausea and vomiting in the non-pregnant may also by coincidence be present in gravid women. Thus, cancer of the stomach ; chronic gastritis, whether gouty, alcoholic, or caused by arterio-sclerosis ; nephritis in its various forms; brain-tumor; chronic displacement of the stomach by the pathological condition of adjacent viscera ; hysteria producing emesis ; emaciation, vomiting, and acute yellow atrophy of the liver, — may be present and cause vomiting in pregnant patients. ( )f these conditions but one stands in a possible causal relationship, and is by some considered dependent upon the condition of pregnancy. It has been shown by Lomer and by Frerichs that tliis disorder nniy atfect pregnant women in fiu'ms of varying severity, and that the milder cases of acute yellow atro})hy of the liver, in which death does not occur from this complication, often show themselves through nausea and vomiting only. As regards the changes to be met with in the genital organs in these cases, they are, first, those of jiosition ; and, second, those of structure. In the former we have acute and chronic dislocations of the uterus. Couimoncst among these dislocations is retroversicm, which generally follows straining or lifting, and in which the relation be- tween the dislocation and the nausea and vomiting is that of evident cause and effect. This complication is serious in proportion to the condition of the surrounding parts : if no adhesions bind 1 11— Voiiiitinir nf preRixiiK'y- Cyst in iiuti'vinr wall (if eorvix ^Davls). • \ > 1 M, rft[7 ^ ^X^^ 1/ i ( f i I :1 p 226 j.v/;/i'/r.LV Ti:xT-Booh' of oiisrF/rnrcs. ihe utiTiis in its abiiuriiial position, tiio reduction of the dislopution is readily ellectcd and tiio excitinj; cause is at once removed. Wiierc, however, the prcjfnant womb hccomcs retroverted and bonnd down by adliesions in the process of pelvic inthunmation, the patholofjical condition is far more compli- cated and jjrave. Chronic «lislocations of the prej^nant womb are those in which that organ as a whole is forced downward in the pelvis and impacted with its fnndns against the symphysis pubis. This condition of the womb is the result of persistent wearing of tight clothing before and after the occur- rence of pregnancy, and it has been well described and its imi)ortance has been urged by (Jrailey Hewitt in a brochure entitled Severe Vomiiiitg ilitriii;/ Pre()H(tncji, published in London in 1800. This condition of impaction is not infreciuently accompanied by congenital malformatit)n of the pregnant uterus, evidenced by extreme anteHexion, with a patlutlogical condition of great importance in the cervix. It has repeatedly been observed in such cases that tlie cervical canal was tightly closed and that the tissues of the cervix were excessively dense and resistant. Attention has recently been called by Davis,'^" in a case of this sort, to a condition of excessive development of connective tissue in the cervix accomjianied by the presence of a retention- cyst of considerable size in the anterior wall of the cervix (Figs. 144, 145). Fiii. 1 l."i.— Vomitiiif,' iif pri'Kiiuiicy. Delist' coiiiRTtivi; tissuo In cervix (Diivis). In addition to these gross chaiige:^ in the uterus, tumors of the ovary and enlaro-ement of the tid)es have been observed in cases of nausea and vomiting of pregnancy. Microscopic examination of the endometrium in many oi' these cases lias demonstrated the presence of endometritis of various forms : that this of itself is a cause of the nausea and vomiting is not demonstrated ; the condition is apparently the accompaniment and the result of the congenital malformations or dislocations already described. Through the researches of Lindenmann of Moscow'-' we are in possession of the interesting restdts of microscopic examinations upon the tissues of a mother and her fetus perishing from pernicious vomiting complicated by polyneuritis. A gross examination revealed enlargement of the spleen with the appearance usual in inanition, with cirrhotic kidneys and liver. Micro- TIIK PATJIOLOaV OF PliEaXAMT. 227 s('(»pic examination rpvoaknl noiiritis of the jjlircnio, piK'nnioijastrit', inoilian, and pcronwil nerves, bcinj^ espoeially well marked in the phrenic. Tho liver siiowed fatty degeneration and elondy swelling. The blood-vessels of the spleen were dilate«l, and the bhx^l-eorpnseles could not be stained by coloring agents. The epitheliiun of the kidneys showed fatty degeneration. The organs of the fctns exhibited fatty degeneration of the liver and necrosis of the kidney. The entire pathological |)icture was that of infection by a toxine, and Tiindenmann considers the infection as anto-intoxication, In his control-experiments upon this case he describes interesting observation,' on the pathology of inanition in animals, and from these comparative studie.- he excludes simple inanition as a cause for the lesit)ns in j)ernicious nausea. The rational lirahnvnt of the nausea and vomiting of pregnancy is im- possible without a thorough knowledge of the co'idition, first, of the patient's ])roccsses of assimilation, and, second, of the condition of the genital tract. The patient nuist be examined thoroughly to exclude any cause tor the malady that lies outside the genital tract. This examination will eliminate the rarer complications of this disorder. A thorough and painstaking examination of the uterus, its si7,e, shape, consistence, position, and the condition of the pelvic tissues surrounding it, is then imperative. In cases where the sensitiveness of the j)atient is so great that an examination aggravates the vomiting, anes- thesia by chloroform or by bromid of ethyl is indicated. The i)hysician in tills examination nuist broadly ditfereutiate between two conditions: he may tind a simple dislocation of the uterus in retr('V»»rsion or prolapse of the uterus, and partial impaction anteriorly ; or he may detect a congenital mal- t'ormation manifested in sharp anteflexion with thick and resisting cervix, or a retroversion bound down by pelvic adhesions. In the first and simplest of tlieso conditions the restoration of the uterus to its normal position is indi- cated, and is almost invariably successful in relieving the condition. The explanation of this relief seems to be that the constant irritation to the reflex nervous system which pressure upon the pelvic nerves maintains is relieved by replacing the uterus, hence the pathological jihcnomenon ceases. If retrover- sion be present, the bladder and the rectum should be emi)tied thoroughly, the patient ]ilaced preferably in Sims' position, when, under anesthesia if neces- sary, the perineum shoidd be retracted and the cervix drawn downward and backward with one hand, while with the fingers of the other hand the fundus should be directed gently u]>ward and forward. Reposition having thus been elTcctcd, it is well to sustain the uterus in its position, at first by a jMicking of antiseptic gauze, then by tampons of carded wool. If the pregnancy be an (arly one and no pathological condition in the ])elvis be present, a Ilodge pessary may be worn to advantage. In prolapse and anterior imi>action of the gravid uterus a thorough cmjitying of the bowel is of great importance before attempting replacement. The uterus should then bo raised gently upon the fingers of the physician, and if difficulty and resistance be experienced, tiie knee-chest jiosition should I)e tried. It is often observed in these cases that but slight change in position is sufficient to relieve the patient, and this I UA 2-2S ^^^E^rcAN text-book of obstktrtcs. I ;- (7 gain, liowovor small, is to hv inaintaiiu'd by tamponing the vagina with anti- septic soft material. As soon as tlic patient's strength permits, it" the uterus is not in its normal position, it siionhl again be raised by gentle manipniation and the tampon be replaeed. In this manner, under thorough antiseptic ])rc- eautions, it is possible by gentle manipulation to restore vi'ry nearly to its normal position a uterus prolaj)sed and anteriorly impacted. In cases where the ])hysician detects an abnormal c«)ndition of the cervix, the result of congenital nialformatii>n anil pathological processes, the case is far more serious and the treatment is more ditlieult. It is here that dilatation of the cervix, found by (.'opeman,'" by a fortunate accident, to be cllicient, is the method of treatment to be employed. The proil'ssion is huniliar with Copeman's I'lfort to induce labor in a jiaticnt pregnant six months and almost dead from nausea and vomiting. Having dilated the cervix as much as he (H)uld with his lingei's, he attempted to rupture the nien)branes and failed. The improvement caused by the dilatation was so great that no fmllier interference was practised, and the patient recovered. Tiiere can be no (piestion but that in cases where a patlu)logit'al condition of the cervix is present, dilatation is demandeil, anil without delay. The physician shoidd not be misled by a soft lition of the external os, for oftentimes a chronically congested mucous f the o'lands of the cervix give to the casual cun( membrane and liypersecretion o d h tl (il)server tlie nnj)ress ion that tl le cervix is so ftenec w lile this mav be true of its external portion, the internal os will be found tightly contrattol and its walls in a condition of dense resistance. Dilatation should be jiraetised under anesthesia, preferably by chloroform or by bromid of ethyl. The finger is a safe instrument, but in cases where the tissue resists the linger it is necessary t(» use, first, stei'l-bladed dilators, as is done by Wiley and others, and then complete the dilatation to the j)oint of admitting the finger by solid metal bougies. This procedure of course exposes the pregnancy to danger of inter- ruption, and rupture of the membranes may occur during the dilatation. Tin; l)hysician should be prepared for this coni])lication by having ready a suitable curette and douche-tube with which to thoroughly curette and douche iIk^ uterus. Following the complete removal of the ovum by the curette and douche, the uterus should be packed with iodoform gauze and be carried well "1 ) into the pelv I n uiu lertaliing to treat a case of the nausea and voinitiii of pregnancy it is impossible for the physician to do his duty without making a thorough examination, and without |)ractising interference such as his judg- ment may dictate. If he is hampered in this examination by the pn'judiccs of his patient, he must decide whether to place the responsibility upon her and her frieiuls or to retire from the case. In milder cases, where a condition of simple irritability and hypersecretinn ill the OS and cervix are dett'cted, local applications to these parts are of great value. Where the mucous meml)rant' is angry and red, following a cleansing; douche of creolin and green soap, the ])hysiciaii may apply nitrati- of silver 1)\ jiencil with advantage. In raising a simply dislocated uterus in the pelvis anti- septic and analgesic ointments may be incorporated with the tampons employed. IS THE PATJIOLOdY OF PRFAiyAyVY 229 Irctioii kiisiiKj; [•or l)v aiili- iovi'il. TiiiKS an ointmout of" bollailoiniM, iodot'onii, and morphia is somotimos of use in tliose cast's. If oxcossivo secretion he present, io(K)fonn, belhulonna, and glycerol of tannin form a useful mixture. The. mt'dh'inal (rcdfinoit of the nausea and vomiting"; of preixnaney consists, first, in eliminatinji; hy examination the necessity for operative interference, or in promptly rcmedyinu; a pathological condition of the uterus. A strict con- trol of the patient is then an absolute necessity, and here the services of a skilled and competent attendant arc of the greatest value. The patient should he j)Ut to bed and her strength preserved in every possible way. Tlie subject of nausea and vomiting should not be dwelt upon with iier. Siie slioidd bo fed by carefully-prepared nutriment — if possible, '>y th(> mouth — at r(>gular intervals, [f the stomach is non-retentive, rectal !;),ections of nutritive sub- stances are demanded. Among these substances are various j)rcparations of beef in the form of peptonoids, peptonized beef, beef-juice combined with brandy, with milk peptonized and pancreatized. If it is desired to adminis- ter alcohol and the stomach cannot tolerate dry champagne or brandy and soda, brandy may he given by rectal injection. The list of remedies which have been employed by administration in the stomach in these cases is exces- sively great, and it shows how eomparativt'ly niiimportiuit all have been in radically relieving the disorder. Where evidence of chronic catarrh of the stomach was present, lavage of the stomach has been found of the greatest value. The soft-rid)ber stomach-tube should be ])assed, and a solution of sodium chliirid, sodium salicylate, or a dihit(> solution of bicarbonate of sodium should be employed. The administration of animal ferments In con- nection with food is also of great valiu\ Thus, ingluvin, pancreatin witii sodium bicarbonate, with nux vomica, or strychnia and pepsin, are of decided v;ilue. Solid food must not be attempted until the patient's strength has con- siderably improved and the condition of the tongue warrants its trial. It is well at times to consult tl>', j..v- nt's appetite and craving when solid food is given, if this craving does M.)t call for articles of an injurious character. When solid food is tai.< n, scraped raw-beef sandwiches, oysters, junlwt, milk with lime-water or with ' iehy, and freshly made broth in which bread is dipped, are usually of value. Prugs are of use in the tn>atment of this complication only in so far as they iissist in ])reserving the ])atient's strength. It is folly to drug a patient with narcotics while the ])hysician is ignorant of th(> position and condition !»f the pelvic organs, and the prolonged administration of iHor])hia is often sim])ly a mask <br negligence or for incompetence. It is much better to pro- cure sleep by the administration of alcohol j)er rcctinn by night, by sponging with warm water and bathing whiskey, ami by sccui'iiig for the patient perfect repose, ihan by the administration of depressing i-emedies. Where narcotics are indispensable. nu)rphia and atropia or codeia are undoubtedly the best. In exlrenu' cases prompt and vigorous stinudation nuist be brought into play til tide the patient over a collapse which may follow the dilatation of the ci'rvix or the em|)tying of" the uterus. Here the hypodermic use of strychnia, m \\\ i] ! fin .■' --if/- ■• i 1.! 1 '! I ' m )i 280 ^IJ/Ti-iJ/CliV TEXT-BOOK OF OBSTETRICS. digitalis*, atropia, and alcohol, iho transfusion of saline solution, the aj)pllcation of electricity to the spine, the aiiplieation of heat to the base of the brain and about tiie trunk of the IkkIv, are iill of value. The explanation of those eases in which spontaneous cure of this condition occurs is to be found most reasonably in spontaneous reduction of dislocations of the uterus. Experience has shown that it requires but a slij^ht change in the position of this organ to alter a state of irritant pressure to a condition in which no irritation, or but little, is produced. There is certainly no other rational ex])lanation, from our knowledge of pathology, for these cases. The folly of waiting for such a change to occur without using every effort to place the uterus in proper position is self-evident. It is remarkable that this most important point in treatment — namely, the securing of a proper jiosition of the uterus — should have been considered as a last resort. That such a change may often be produced by the posture of the jiatient only is illustrated in a case reported by (Jrant,'^ who as a last resort elevated the hips of a patient upon pillows, whereupon her vomiting ceased. The fact that curetting the uterus in urgent eases is followed by immediate relief is well illustrated bv Roland '-' and by Blanc.'-' The excellent results following the reduction of Flii. 1 liV— Air-liiill |ics-nry in |i(i»iticiii Mini rnisiim tlic uterus. dislocations of the uterus fiii<l abundant illustration in Hewitt's Jfcpnrtu, in which the nsi of tli.- Uariel air-ball pessary is (leserii)ed and fully illustrated. T' is instrument is of value when the linger has dislodge<l the anteriorly-im- pacted uterus, and under antiseptic precautions its u>ii> has been attended witli THE PATHOLOGY OF PREGNANCY. 231 excellent results. The accompanying illustration (Fig. 146) sliows the air-ball pessary in position and raising the uterus in the pelvis. Kingman '^® also describes cases in which the reduction of uterine dislocations has terminated nausea and vomiting. Ptyalism complicating this condition has been well described by Ahlfeld/^ Avho believes that these cases are primarily neurotic in origin, and treats them accordingly. With the same view of the causation of vomiting, Gunther '^ treats these cases by galvanism, the positive jiole being placed against the cer- vix, the negative between the eighth and twelfth doi'sal vertebrae. From 2i to 5 milliampcres were emi)loyed for from seven to ten minutes ; so long as the current was uninterrupteil he did not observe danger of disturbing the preg- nancy. Siinger and Hcnnig '^ describe cases in wliich the exciting cause of vomiting was a pathological condition, either in the uterus or some abdominal organ. Ascites complicating pregnancy may arise from a lesion of the abdominal viscera interfering with the return circulation and also with the lymphatic circulation of the peritoneum. l*rcgnancy itself sometimes occasions ascites through a pathological condition which atfects the peritoneum of the mother and the amnion of the fetus by a similar jirocess. An interesting case illus- tr;iti!\g this condition is reported by Florentine.'*' The patient was a young v(yn:,n married three years who had borne one living child and had one abortion. The cessat'on of menstruation was followed by obscure pain in the abdomen, increase in size, and the evident presence of fluid. Pressui'e- symptoms became so pronounced tliat suffocation was threatened and pains like those of lal)or supervened. The membranes were ruptured, when the entire fetus with a large amount of amniotic liquid was sudd 'uly expelled. Distention of the alidomen was relieved by paracentesis. The presence of an ovarian cyst was then diagnosticated and the tumor removed a month later. Recovery ensued. Tubercular peritonitis complicating pregnancy is also a cause of ascites, and it may develop gradually as gestatioii advances. The treatment of al)- (loniinal dr()])sy complicating pregnancy is, j)referably, by exploratory incision. If a tubercular process be ])reseiit, the prognosis for very great imjirovcment, if not recovery, is excellent. If a [)athol()gical condition of tlie lymphatic system of the peritoneum is the cause of tiie condition, free drainage by incision is much the safer treatment. The immunity displaytnl by jircgnant ]>aticnts to operative jirocedures when ])ropcrly conducted renders such inter- ference safe and highly appropriate. Phantom pregnancy, or pseudo-cyesis, may result from a strong desire for pregnancy in a ]>atient sutfering from ascites. An illustrative ease is reported by (May.''" Phantom jiregnniu-v without |>alliological lesion is not a rare condition. ()i)served in nervous pat'< :<ts who strongly desire preguiuicy, and wiio are usually i)ast the time of greatest reproductive activity, it- ,-ynip- tnms are the subjective symptoms of normal gestation. The diaipioxiH and Ircdiinciif of il.is condition are completed i)y a thorough examination, and m \i 1 ' vm I Ml' 2^52 AMERICAX TEXT-BOOK OF OBSTETRICS. W whenever the patient will submit to examination under an anesthetic the cure is usually complete. It is well in such cases to have a friend of the patient ])rcsent at the examination to personally witness the disajipearance of the abdominal tumor as anesthesia proceeds, Illustrativo cases are found in the literature of the subject, and among them is that of Johnston. '^^ Acute yellow atrophy of the liver in the pregnant woman is an infectious disease of uncertain origin. Out of 143 cases of this disorder Thierfelder observed thirty during pregnancy. Spteth saw it but once in 16,502 preg- nant women. Epidemics of this disorder have been reported by Kerksig, Charpentier, and Bardinet. Lonier's excellent jiaper upon the subject, and the reports of Mavthews Duncan '^•* describe this complication fully. Its s}/mptoms are those of jaundice, hematogenic and hc))atogenic, witli evidence of profound intoxication from the absorption of septic material and toxins. On palpating the abdomen the area of liver-dulnoss is diminished ; after the stage of incubation, lasting from three to five days, the ])atient has gastric and intestinal catarrh with rigor, j)ains in tlie head and back, and fever. Albu- minuria is often present ; in severe cases there is great tenderness over the liver and abdomen. Occasionally the disease results in death before delivery. As a rule, patients come into labor or abort with a fatal issue. In a case recently observed 1,'y the writer the profotuid jaundice of the mother was reproduced in the bright yellow color of the amniotic liquid and the deep orange staining of the fetus and its appendages. This patient had high fever before delivery, and died in septic coma shortly afterward. The cause of acute yellow atrophy with malignant jaundice is blood-poisoning from acute septic infection. Its pro(/no.m is exceedingly grave, and the treatment of these cases consists in the effort to terminate pregiumcy promptly, to arouse the secretions of the intestinal canal, and to support the patient's strength. Tlie milder form of jaundice diirinfj prcffnanci/ may result from impaction of feces, catarrh f)f the bile-ducts, pressure of the jiregnant womb upon the liver, and the physiological hyperemia which the liver shares in common with other abdominal viscera. Failure in excretion by the kidneys in greater or lesser degree is often noted in these cases, and the development of gall-stones is a not infrequcjit accompaniment. Where the disorder is ])romptly recog- nized, and the gastro-intestinal tract is subjected to proper and ctKcient treat- ment, it is often ])ossible to avoid fatal issue. Winter describes an illustrative case"* in which a nuiltigravida who had suflTered froui malarial intoxication was attacked with jaundice. After a violent illuess of six or eight days, with great gastric disturbance and vomiting, prematui'c labor occurred, after which the mother recovered. Tlie frcdimcnt of this coudition is the medicinal treat- ment appropriate for these cases in the noii-])reguant. Premature labor is t(» be ex})ected in well-marked cases, and in protecting the interests of the mother no effort should be made to avoid it. Gastric ulcer complicating pregnancy has been observed by Robert Koch '*' ill two j)Mticiits, each of wliom sulVcred from ])rofus<' vomiting of bIoo<l accom- jiaiiied l)y alxloiniiial distress. In one, tlic milder case, pregnancy was '\\\in'- i i THE PATHOLOGY OF PREGXANCV. 233 rtipted and a living child was born. In the other the patient collapsed after vomiting blood freelv, and, although she rallied and ultimately recovered, her child was stillborn. Appendicitis in jiregnancy has been well described by Mixter.'^^ Prema- ture labor followed the attack, and an abdominal tumor demanded operation. The appendix was found at the lower end of the kidney, its position having possibly been altered by the pregnant uterus. Fecal concretions were present. Tiie patient recovered after ojjeration. Albuminuria and peptonuria are variations in the metabolism of the pregnant i)atient, and are of interest and importance to the oi^stetrician. Tiie clinical importance of the presence of serum-albumin in the urine in ])regnancy has been greatly exaggerated, and a closer study of the excretions has demon- strated its very limited significance. In accordance with tlie preciseness and the delicacy of the tests employed serum-albumin has be(;n found to be present by Schroeder in from 3 to 5 per cent. ; Iiigersiev, 4.8 percent. ; Flaischleii, 2.6 per cent. ; Meyer, 5.4 per cent. ; while Lantos, in an interesting series of observa- tions at Budapest,'^ found albumin in 18 per cent, of pregnant women and in 60 ])er cent, of tliose recently delivered. In thirty-nine- fatal cases, in whicli tlio urine had contained albumin, the patients had suilercd neither from eclamjjsia nor from nephritis. The kidneys in these cases were very pale and anemic. Lantos is convinced that albuminuria is very common among pregnant women, that it results from reflex irritation of the vaso-motor nerves of the renal vessels, and that it has no patiiological significance; it may, however, be of value as a sign of pregnancy in making a ditt'erential diagnosis. Peptone has been found in the urine of pregnant women, and it is thought by some to be an evidence of the death of the fetus. Thomson '** could not observe that peptone was cha- racteristic of the pregnant condition, nor that it is a symptom of a macerated or a dead fetus. According to his researches, peptone appears intermittently witiiout a|)preciable cause in the urine during pregnancy and after lal)()r. Vwnn the researches of Koettnitz,'^" who examined the urine in 31 cases of pregnancy, we may believe that peptone is not a sign of fetal death. Its presence seems a |)hysiological phenomenon, only becitming jiathologieal when this su))stance is found in excess. In I'omplicated labor where maceration of the fetus and severe visceral disease of the motlier are present it has been found. Tlie treatment of albumiiuu'ia and peptonuria during pregnancy consists in interference and lational iiygieiie. As most ]tregnant ]vitients eliminate insuttieieiitly, such forms of diet as agree best with the individual case should he enjoined. The peculiarities of the individual should be stiidicvl chwly, and tile whole range of tiierapiMitie and medical art will tre(|ueiitly be taxed to aid the patient in solving the diilieult problem of nourishing herself and her unborn ehihl. Many specifi(! treatments have been urged i'or albumimwia ; among them is the benzoic-acid treatment, sometimes eond)ined with bicarbon- ate of ])otassium. Various ] \ugatives have been giv( ii in these eases, the best purgatives being those that do not introduce into the blood of the |)alieut a ^>. Ml I I M 'K 1 ' : i h' ■ i r •' lilii f^K! ' • 1 ' ■ ■ 1 1 ! j II p 2:U AMERICAN TEXT-BOOK OF OBSTETRICS. largo amount of potassium salts. In general it may be said that the presence of albumin or of peptone in the urine of a pregnant patient is not of itself a l)athologieal phenomenon, and it is only when the presence of albumin is asso- ciated with casts and deficient excretion, as indicated by deficient urea, that albumin becomes an indication of disease. Abnormal conditions of the mouth and teeth during pregnancy may occasion cousideraljle distress and inconvenience to the patient. The gums fre(piently become abnormally soft, and a condition known as " white caries" is often seen in the teeth. The edges of the gums are thin, pale, somewhat shrivelled in appearance, and retracted from about the teeth. A jirominent ridge along the free border, often of deeper tint than the surrounding mem- brane, is sometimes observed. In other cases the gums are reddish and are apparently softened, exuding a thin fluid or pus from around the neck of the tooth. Such a condition does not imply neglect of cleanliness, but it seems a passive congestion and transudation from the tissues. It has been shown by Elliott '^° and others that this condition of caries in the teeth results from the altered secretions in the oral and buccal cavities. The secretion of saliva is much increased, ptyalin being often absent. The saliva early in the day is often of acid reaction, and this is thought to have a potent influence upon the development of curies of the teetli. This disorder is sometimes known as "brown caries" when extensive discoloration of the teeth is ])rcsent. The margins of cavities in these cases are black. A line of brownish discolora- tion sometimes occurs upon the upper incisors or the canines. The enamel is opacjue. This form of caries generally begins in the region of the bicuspids of the upper or lower jaw, and is usually found among ])atients of the lower classes. Softening of the dentine of the upper bicuspids and molars is some- times observed, apparently liecause the bicuspids are those teeth against which fluid is most forcibly ejected in the emesis of pregnancy ; tli(y are also in con- tact with the tongue at rest. General softening of the teeth without actual decay, and loosening of the teeth in their sockets from jiartial absorption of tiie alveolus, are also observed. White or soft caries is often found in an inexplicable manner in patients apparently well nourished, and in its j)atIiology resembles osteomalacia. Affections of the nerves of the face and the teeth often accompany the structural conditions mentioned. I?y some, altered nervous conditions in these ])arts are referred to pathological conditions in tlie mucous nuMnbrane of the stomach. Occasionally pain in the mouth and teeth is purely reflex from the utci'us, as in a case described by Garrettson in which pain was felt about a carious tooth. Its removal brought no relief, l)iit tiie healing of an ulcerated cervix uteri caused the pain to disappear. Tlic frrcidiicitf of these conditions is to be found in a pro]U'r attention to the general condition of the patient. Ijoeally, chhcate <>l' potassium ami bromid />{' potassium arc usefid when the gums ii:e irrital)le. Powdered l)oracic acid may be brusiied upon the teetii with a soft brush, or e(|nal ])art> of charcoal and preeii)itated chalk may be used for short periods. In I'dlcv THJ-: PATHOLOGY OF I'REGXANCY. 2:50 pain, felt in sound teeth, a i)li8tei' over the fourth or Hfth dorsal vertebra has been of use. Absohite alcoht)! and eoHodion may be painted over a tooth attacked by soft caries. AVHien carious cavities require filling, this should be accomplished with as little distress to the patient as possible, and the filling should be of a non-irritating character. When a tooth occasions severe sutl'er- ing during jiregnancy there arc many reasons for advising its removal, as preg- nancy has been interrupted as the result of such distress, while the ])resence of continued pain has an undoubted influence upon the development of the child. Exophthalmic goitre and simple goitre may develop rapidly during pregnancy, and by the associated changes which occur in the circulation may result disastrously to the fetus. Thus in a case reported by Haberlin '^' the rapid develojjment of exophthalmic goitre was accompanied by premature separation of the placenta, with death to the fetus at eight months. The termination of labor was followed by immediate cessation of the development of the goitre. In severe cases such patients become excessively nervous, the hands tremble violently, palpitation of the heart and a sense of constriction about the throat are present, with considerable emaciation. Vomiting is also a symptom in well-marked cases. While palliative treatment nuiy temporarily relieve these j)atients, if the symptoms be urgent a removal of the goitre should promptly be undertaken. Abnormal conditions of the blood are not of very infrequent occurrence. The normal condition of the blood during pregnancy in ill-nourished women is that of temporary anemia, which soon gives ])lace to a development of physiological plethora and hyperemia. It has been shown by Dudner'** and others that so sooi as the balance of nutrition becomes established a steady increase in the amount of corpuscles and hemoglobin is to be observed. Narse"-* found the specific gravity of the blood during pregnancy to be 102o. The amount of fibrin increases, while the (|uantity of salts and hemoglobin diminishes. Winckclmann '" found that as pregnancy advances the quantity of hemoglobin increases. Scliroeder '^' considers anemia in pregnancy as the exception and as a pathological condition, while neither he nor Meyer '^' observed a g' at decrease in hemoglobin or corpuscles. The observations of Ingersletf,'" '^""ehling,'^'' and Meyer '^'•* upon the comparative composition of the blood in the pregnant and the non-pregnant show that in the fornu>r the mind)er of red corpuscles is slightly decreased and also the amoutit of liemoglobin during early pregnancy. Aiiriiita in tiie pregnant is produced by the same causes which influence the non-pregnant. Its recognition is effected i)y the same methods of examina- tion and diagnosis employed in the study of internal medicine. The condition of anemia complicating pregnancy was early recognized by American physi- cians, whose contributions to the literature of the subject are among the first. Cazeaux and the I'^rench school ascribe to anemia many of the disorders of ]tregnancy. A curious ;iversion to the treatment of anemia diu'ing ]M'cgnancy by methods usually employed in non-pregnancy is shown in the records of i ' > ' *: r '1 if r ^ • ilfi % i m I, 1 '/ p 2:}() AMERICA X TEXT-BOOK OF OBSTETIUCS. a malpnictice suit reported in 1871 by Woodniaii to the Obstetrical Society of IjOIuIoh, when a physician was sued for using the ainnioi)io-eitrate of iron in the treatment of this condition. It was claimed that he had thus ]iroduced abortioji. The verdict of the society was in favor of the physician. Gus- serow '•''*' reports five cases of extreme anemia in tl>e prcj^nant state. The eiglith month seemed the perio<l most favorable for the development of this complication. Bischoff and liiermcr report cases of oligemia and anemia with cachexia at about this period.'" Cameron's excellent descri])tion of leukemia during pregnancy'''^ includes a case with a marked family history of leukemia. Sanger ''^ reports the case of a leukemic mother who bore a healthy child, and also of a healthy mother who gave birth to a leukemic chihl. Davis'** rejwrts the case of a multigravida seized with hematogenic jaundice. Examination of the patient's blood showed the condition of per- nicious anemia. The blood of her fetus was found to be normal. UndcT treatment her condition greatly improved after delivery. While it is possible for these patients to bear healthy children, still preg- nant women suffering from various forms of anemia and leid<emia are subject to dangerous symptoms as pregnancy advances and as the pathological condition of the blood becomes pronounced. Important symptoms are epistaxis, hema- temesis, and melanemia, with the development of a purpuric condition. Atten- tion has been drawn by Laid)enberg "'' to the severity of this comjilication and to its almost inevitable interruption of pregnancy, and he urges the early induction of labor as the duty of the physician. The most serious condition of the blood attacking the pregnant patient is 'pur- pura luvmorrhagicd. Its occurrence and severity in pregnant women are ex- plained by the sympathy existing between the utero-ovariati and the tegument- arv systems of the bodv. This nervous connection is often observed in the skin eruptions which accompany disorders of menstruation. As has been shown by Immermann, the complication is sporadic in pregnant patients, and it occurs Avithout regard to family history or to previous condition. Phillips"^ col- lected cases illustrating the absence of previous history of hemophilia in these patients. In some of them hard work and insufficient nourishment seem to have produced the disorder. Profound mental disturbance has occasionally been fol- lowed by this condition. In Phillips' case the child showed no symptoms of ])ur])ura, and the mother recovered raj)idly after labor. Kaezmarsky ''^^ reports a case in wliich severe sacral pain during pregnancy was the first symptom. The l)irtli of a dead fetus followed speedily, and the mother perished from hemor- rhage. Dolirn reports twin pregnancy with this complication, with severe post- partum hemorrhage and death. lioth these ])atients had ])reviously been healthy. AVernicke, Recklinghausen, Ilanot, and Luzet offer evidence which seems to prove, on the one hand, that the disorder is a form of infection by bacilli ; on the other hand, the cases described by Dohru ''^^ do not point to this con- dition as causative. The immunity of the fetus in these cases is inexplicable and of interest. Microscopic study made; of the l)loo<l in this complication by (iibbon during the height of an attack of purpura showed that the red cor- THE PATHOLOGY OF PREGNANCY. 237 pn.sples contaiuod muubcrs of hlm-k granules massed togotlicr in some of the coll.s. Tlu'se bodies increased as the (hsorder became severe, and diminished in convalescence. The nnmbei' of corpuscles early in the disease was over 5,000,000 per cubic millimeter, this number being greatly diminished as the disorder made progress. The white corpuscles became excessive, and the hemoglobin fell to 30 per cent., afterward rising to 60 per cent. The irmtinvnt of anemia and Ictdcemia complicatii.;, pregnancy consists in securing thorough elimination, and in the employment of those forms of treat- ment found usefid in the non-pregnant ])ationt. Osier'*' obtained good results from the persistent use of arsenic, the free use of iron, the inhalation of oxygen, systematic and forced feeding, and, of great importance, the correc- tion of the condition of gastro-intestinal catarrh so often found in these cases. The patient's strength should be conserved in every possible manner. Should purpuric eru|)tion devclo}), with hemorrhages, antiseptic dressings must be applied over these areas, and care should be taken that bichlorid of mercury is not employed, the susceptibility of anemic pregnant j)atients to mercurial poisoning being a contra-indication to its use. Bichlorid of mercury in minute doses should be given when a possible sy])hilitic taint is suspected as a complication. The j)rompt induction of labor is required in cases where the disorder steadily increases in severity, although this procedure when the ])atient has reached a critical condition is useless and unjustifiable. If done at all, labor should be induced promptly and while there yet remains sufficient strength to justify a hope that the patient will rally. Cardiac disease complicating pregnancy is not infrequently observed. In those patients who are well nourished slight cardiac lesions are frequently undete(!ted during ])regnancy and cause no embarrassment at labor. A ])hysiological hy))ertrophy of the heart occiu'ring during pregnancy is well described by Larchcr, who found hyjiertrophy of the left ventricle in preg- nant women. Other observers assert that this hypertrophy is associated with dilatation of the right heart. Istria'^ and others maintain that preg- nancy often induces endocarditis, and other observers have noted the devel- opment of endocarditis after repeated parturition. The most fatal of these lesions in the pregnant patient is mitral stenosis. Marshall"" and Duck- worth demonstrated the remarkable ])reponderance of this form of heart disease in women. Direct cardiac symptoms are comparatively few, con- sisting of ])alpitati()n, sometimes i)ain and depression. Bronchial catarrh is generally obsei'ved. The want of concMirrcnce between the cardiac sys- tole and the impulse given by the pulse-wave is an interesting and important diagnostic point in these cases. Cases reported by Fritscli, Budin, Macdonald, and Malherbe illustrate the occurrence and fatal termi- nation of this disorder. The results of this lesion in 14 cases given bv Macdonald were death in nine. Porak saw eight fatal cases out of 13. Remy in 19 cases found el(>ven fatal. In double n\itral lesion seven out of Hart's 8 cases perished. In one-half of the cases recorded pregnancy has been inter- rupted without interference. Half of these patients died and half of them rm M \t 238 . I .}fEIf /( 'A X TKXT- li O OK OF O liSTETn K 'S. recovered. The pretloiuiiiaiiee of piilinoiiiirv syin|»t(»ms in mitral stenosis sliould l)c borne in mind in makinj^ a diagnosis and in instituting treatment. Wliile tlie mortality ol" pregnaney eomplicated by mitral stenosis is more than ')() por cent., aortic lesions give u mortality of 'J.'] per cent. Mitral insnllieieney is aci redited with 1.3 per cent., wliile in complex lesions (»f tin; heart a mortality of 50 per cent, is a conservative estimate. The prognosis for the continuance of pregnancy and for the life of the chihl is distinctly tinfavorable. Mack ness '"^ reports a case of pregnancy complicated by aortic and mitral disease in which labor was indiiccil. Partial reeoverv ensned. The patient's condition of prostration became so excessive (hiring the latter })ortion of her pregnancy as to require vigorous stiinnlation. She was greatly prostrated by ])ersistent emesis and ))aroxysnis of oppression, which were relieved by the administration of nitrite of aniyl. Mcrklen "'* reports an illustrative case in which pulmonary tuberculosis ■was associated with stenosis at the mitral orifice. Dilatation of both sides of the heart was present, with general anasarca and exaggerated pulmonary con- gestion. Venous stasis in the kidneys was well pronounced. I'ulmonary liemorrhage occurred, and it was a temporary relief to the patient. Hemoptysis complicating pregnancy may occur from simple pulmonary congestion in eases of valvular heart disease, or may result from disease of the parenchyma of the lung, most commonly tubercular. ^Cartin'®^ describes the case of a patient four months pregnant who sutt'ered from obstinate and j)ersistent hemoptysis. There were jiulmonary signs of consolidation an- teriorly below the right clavicle. Bleeding occurred at about the time when the patient would have nnnistruated had she not been pregnant. Kjjistaxis subsequently develoi)ed, and later a profuse red rash, resembling that of scarlatina, covered the body. This rash gradually faded, and was not attended by fever or any signs of other complication. I'ulmonary signs gradually improved, especially under treatment by a succession of blisters upon the ch(>st, that gave marked relief. The j)aticnt entirely recovered and went to the usual termination of pregnancy. Hemorrhage from the Uterus. — The fact that ])rofuse hemorrhage from the uterus may occur during pregnancy and still the ])atient go cm to the end of gestation is well illustrated in a case descriljcd by llobertson.'^'' His patient was a multiy-ravida who had several liemorrhaues so severe as on each occasion to cause the supposition that abortion had occurred. Her pregnancy continued to a successful termination. Internal hemorrhage is observed asacom])lication in patients sufl'ering from nephritis during ])regnancy. To such an extent may syni])toms of shock and acute anemia l)e ]>resent that placenta prfevia has been susjiccted in these cases. Schauta"'® reports the ease of a \vonian, aged forty-ibur, who had borne nine children, and in whom profuse hemorrhage caused a diagnosis of placenta pra3via. Although the jiatient was not in lalxjr, the os was sufficiently dilated to permit a diagnosis to be made that placenta i>ncvia was not present. Transfusion by normal salt-solution was iminetliately performed, and when the patient rallied. i'. THE PATHOLOGY OF PliEGNANCY. 2:50 as tho diild was (load, it was extracted by craniotomy. A larj;c amount of clotted blood was found in the uterus and vaj-ina. Tin- patient siiecuinbed from tiie hemorrhage shortly after delivery. The post-mortem examination revealed chronic nephritis as the only complication accounting for the con- dition. Winter observed three similar cases in Schroeder's clinic. 3. Acute Infections during Pregnancy. The condition of pregnancy renders the patient peculiarly liable to the rapid development of infective germs. The body of the pregnant woman presents that condition of plethora and hyperemia in the viscera that invites the growth of bacteria. It is not, then, difficult to understand why these complications of pregnancy are among the most severe. First among these disorders may be considered those in which the infection usually gains access to the body through the genital tract. Such disorders are gonorrhea, syphilis, and cancer. Gonorrhea is by no means an uncommon complication of pregnancy, and in an ignorant woman no intelligent history attracting the attention of the physician to the condition present may be afforded. The complaint, howes'cr, of difKcidty in micturition and of burning and irritant discharge should occasion an examination, when specific vaginitis may be detected. The symp- toms and treatment of this disorder in the pregnant are essentially those in the non-pregnant, but the pathology of the condition is more complex and of greater import. Not (july may the gonococci infect the nuicous membrane of the vagina, and possibly cause abscess of JJartholini's glands, with oc- casional acute inflammation of the rectum and the surrounding tissues, but the endometrium also may be attacked, and even the fetus may be infected in ntero, by the gonorrheal virus. Children have been born with gonorrheal o])hthalmia and under circumstances which precluded the possibility of in- fection during birth. Such infection, however, is of comparatively little importance when compared with the dangers arising to the mother from the development and retention of gonorrheal infection in the tissues about the uterus and in the tubes and t)varies. The entire genito-urinary tract of the mother is liabU? to such infection, the consequences of which may not become apparent until some time after delivery. Thus, in the writer's observation a patient })erished from the sudden and acute septic inf(L>ction occasioned by the spontaneous rupture of a small gonorrheal ovarian abscess occurring two weeks after delivery. This ))aticnt's puer[)eral period had apparently been nor- mal, and the infection n'ust have l)een received before or during pregnancy. The same observer witnes d death from nephritis in which the genito-urinary tract had been the cat during jircgnancy of gonorrheal infection. In this case the tubes and ovaries escaped, but the bladder and ki<]neys showed abundant infective germs. The presence of gonorrhea as a complication of pregnancy should lead to prompt antise])sis of so nuich of the genital tract as is accessible. If the bladder is invaded, it should also be subjected to the same thorough antisepsis. At the time of labor all possible precautions J '5' .^. ^. V«^. w; .O^,^^ IMAGE EVALUATION TEST TARGET (MT-3) 4' 1.0 ■i^lM 12.5 1^ l&i 12.2 2.0 I.I 1-25 IIIIII.4 IIIIII.6 P^ <^ /2 ^> »». •'-> y y^ Photographic Sciences Corporation 25 WeST MAIN STMIT WfeCiSTER.N.Y. M5S0 (716) •72-4503 ft^^ <i^ 240 AMERICAN TEXT-BOOK OF OBSTETRICS. i! •/ 1 • 41 \' h < ■ ; v, H: should be taken to avoid violence to the uterus or its appendages that may set free retained gonorrheal poison. During the puerperal period the occur- rence of septic inHaniiuation in and about the uterus should be treatetl ])r()niptly by intra-utcrine antisepsis, or so soon as possible by abdominal incision. It is folly to treat the insidious ravages of gonoi*rhea in the con- nective tissue, the peritoneum, and contents of the pelvis occurring after labor by any but prompt surgical measures. Hxploratory abdominal incision is far more conservative in these cases than delay. Syphilitic infection during pregnancy in many cases runs the usual course of this tlisorder, and in others it assumes peculiar malignancy. Patho- logically speaking, the viridence of syphilitic infection in pregnancy depends n(;t only upon the patient's powers of resistance, but also upon septic germs vvhich may be associated with the bacillus of syphilis. Some of the most malignant types of puerperal sepsis are observed in patients who become syphilitic at conception or during pregnancy. In these patients the syphilitic eruption is so masked and exaggerated by the septic element present as to occasion great difficulty in diagnosis. The writer recalls a case of this sort where close study by Kaposi was necessary to differentiate between an acute syphilitic exanthem and septic infection. Hirigoyen'*^ describes the occurrence of syphilis in 34 patients, who corajn-ised 5 per cent, of the total number of pregnancies under observation. Other statistics seem to indicate that this percentage is the usual one in pregnancy occurring in large cities. The influence which pregnancy exerts upon women already syphilitic has been described by Fournier, who laid down the maxim that a syphilitic woman who becomes pregnant is much more likely to abort than is a preg- nant woman who becomes syphilitic. The percentage also of fetal death in syphilitic women who become pregnant is much greater than among pregnant women who become syphilitic. The age of the syj>hilis exercises a very dis- tinct influence upon the prognosis of the pregnancy : the longer the woman has been syphilitic before pregnancy occurs, provided she has not been sub- jected to efficient treatment, the worse is the prognosis for the eontimiance of the pregnancy and the life of the fetus. The prognosis of pregnancy is also very serious the earlier in the pregnancy the infection occurs ; thus, the majority of pregnancies complicated by syphilitic infection occurring during the flrst four months result in the death of the fetus. When infection occurs from the fourth to the sixth month of pregnancy 50 per cent, of children are lost. During the last three months of pregnancy the comnlication of syphilis results in the death of less than half of the children. General fetal mortality in ayj)hilis is under the best circumstances 75 per cent. The mother's iiealtli in pregnancy complicatwl by syphilis is liable to rapid deterioration if tin' syphilitic process be acute. The stimulus of j^reg- nancy seems to exaggerate the sj)read of the poison and the various lesions which it causes. To l)e efficient, aiitisyphilitic treatment should begin as soon as the infection occurs, anil the earlier in the pregnancy such treatment is THE PATHOLOGY OF PBEGNANCY. 241 begun the better are the results obtaineil. Local treatment of syphilitic lesions complicating pregnancy consists in thorough cleanliness and in the maintenance so far as possible of local antisepsis. Ulcers should be dusted with calomel and iodoform ; the parts should be kei)t thoroughly clean with antiseptic douches, and the discharges from syphilitic patients should be received upon absorbent material, which is then burned. Antisyphilitic medication is to be conductetl in accordance with the therapeutics of this disorder in the non-pregnant. The biniodid of mercury, the bichlorid of mercury, calomel, gray powder, and the bichlorid hypodermatically are all of use. Inunctions with mercurial ointment are found advantageous in many cases. In those patients with whom mercury does not agree iodid of potas- sium in combination with iodin may be used to advantage. The following mixture has proved efficacious in a number of cases : Iodin, Iodid of potassium, Compound syrup sarsaparilla. Dose, one tcaspoonful after meals. gr. IV ; .^iv ; .Siv. Besnier'*® obtained good results with a pill containing ^ of a grain of bichlorid of mercury with y^ of a grain of extract of opium and ^Jj of a grain of extract of gentian, rubbed up with glycerin. Equally important with the specific treatment of syphilis in pregnancy is the tonic treatment wliich these cases demand. Well-ordere<.l feeding, in which an abundance of fat in cod-liver oil or other forms is includetl, and tiie persistent administration of iron, arsenic, nux vomica, and such substances as stimulate digestion, are of the greatest importance. The aim of the physi- (jian must be not simply to tear down diseased tissue, but to build up that which is sound. The results of such treatment are often most gratifying. The characteristic lesions of syphilis fade with great rapidity in these cases ; the l)aticnt who may have repeatedly aborted goes on nearly or quite to term, and a fairly-devoloped and healthy child is born. Neglect, however, or inadequate treatment for these patients often resjilts in sad ravages in the mother's tissues, resulting very frequently in fetal death. Oincer complicating pregnancy affects the course of gestation chiefly in its local manifestations in the genital tract. In rare instances multiple sar- comata develop with great rapidity in various portions of the body, causing (loath by constitutional infection. In otiier instances cancer of the uterus by metastasis sjieedily retluces the patient to a condition of threatened collapse, often resulting in constitutional septic infection. In such cases the interruption of pregnancy seems of very little avail for the patient, except i » so far that tlio malignancy of the cancerous process seems less acute if the uterus is emptied. Ti/phoid infection during ])regnancy seriously complicates the mother's chance of convalescence from labor, and frequently results in tiie deatii of 16 i ■■ '"I 242 AMERICAN TEXT-BOOK OF OBSTETRICS. V u the fetus. In a case clcscribcd by Findlay "' the hnsbaiul had been ill for 8otue time w'th typhoid infection. The patient's pregnancy was terminated at about the expected time, labor occurring with a temperature of 103° F. and the pulse I-IO. The uterus contracted well, although during labor intestinal jMjristalsis was active and the patient had diarrhea, M-hich subsided after delivery. The secretion of milk did not occur, the breasts remaining without signs of activity. The skin of the child was shrivelled, and after a few days it showed an eruj)tion with bullous spots, the scars of which persisted when the child had reachetl adult life. Pregnancy is interrupted in these cases by continuetl high temperature, by hemorrhage in the endometrium or in the membranes of the ovum itself, and by a depi-essed condition of the maternal circulation, with asphyxiation of the child. Kaminski, Zulzer, and Scanzoni observed in two-thirds of their cases the interruption of pregnancy. The fact that the fetus may become infccteil by the transmission of the germs of typhoid through the ])lacenta has been demonstrated by Giglio."" The latter examinwl carefully a fetus and its appendages born from a mother suffering with typhoid fever in an epiden)ic at Palermo. Pregnancy terminated forty- six days after the beginning of the fever. Although the specimen seemed normal on casual examination, cultures of the maternal blood demonstrated the presence of the typhoid germ, while cultures from the milk revealed bacteria exactly resembling those obtained from a typhoid non-i>regnant pa- tient. The fetus and its apjwndages also contained typhoid bacilli. Boyd "' reports a ease in which a week after the fever began premature labor occurred. The i)atient finally succumbed after continuetl high temperature. The fUagnosis of typhoid fever complicating pregnancy presents no especial difficulty. Should the physician see the case during the puerperal pericKl, it must not be mistaken for puerperal sepsis, nor should puerperal sepsis com- plicated by diarrhea be mistaken for typhoid fever. It will be remembered that in septic cases diarrhea is a not infrequent symptom. The treatment of typhoid fever during pregnancy should be addressed to controlling the temperature and to maintaining the patient's strength. Such cases are especially fitte<l for the treatment of pyrexia by the bath and pack. The latter is most efficacious where the very energetic application of cold has a tendency to prostrate the patient. Xo fear nee»l be felt regarding the in- duction of labor by treatment addressetl to controlling the temperature, for it will not be such treatment, but its failure to modify the fever, which will bring about a premature ending of gestation. The fact that in many pregnant patients suffering from typhoid the stomach is excessively irritable will lead the physician to abstain from the administration of drugs by the stomach s(» far as possible. TJrynipelas during pregnancy is of not infrequent occurrence, and it is grave or is slight as a complication in accordance with the accompaniment of other forms of septic germs. Facial erysipelas may occur in the pregnant patient, and even abortion may follow, without the development of puerj)cral sepsis. Such a result, however, is possible only when strict antiseptic pre- ;ial the are ho IS a in- )!• it will iiaiit cad .S(> i.« IClll unit icral nro- THE PATHOLOGY OF PUEGXANCY. 243 cautions are observed. Erysipelas of the genital tract — or of the lower extremities, where the infective germ gains ready access to the genital tract — resnlts almost invariably in puerperal septic infection. The symptoms of erysipelas complicating pregnancy do not differ essentially from those of the disorder in the non-pregnant patient. The treatment consists in supporting carefully the patient's strength, and in avoiding all unnecessary examinations and manipulations in the genital tract, as interference with this portion of the patient's body is an addetl risk of infection. Smith '" reports the case of a woman six months pregnant who injured her knee. Erysipelas develojied in the thigh eight days afterward, and it was followed by a large abscess burrow- ins: beneath the muscles. Premature labor occurretl at seven and a half months. The puerperal period was normal and the child survived. In a recent case of facial erysipelas under the observation of the writer the mother suffered but slight inconvenience from the infection, but gestation terminated prematurely, the child surviving. Erysipelas of the face and head seems to affect the fetus in many cases quite as markedly as in erysipelas of the pelvic organs. Cohn '" reports a case of facial erysijielas at eight months' pregnancy. The fetus, prematurely born, showed upon the corresponding portions of the head and face an edematous red swelling which gradually faded, followed by desquamation. Examination of the infiltrated tissues for erysipelas-germs gave negative results. The child perished from multiple abscesses in the kidneys. A similar condition of the fetus has been described by Runge, Kaltenbach, and Stratz. Measles. — Of about the same relative virulence as erysipelas is the infec- tion of measles attacking the pregnant patient. The symptomatology of this disorder occurring during gestation does not differ essentially from that ordinarily observal. If the bronchitis usually accompanying measles l)e severe, the incessant cough and movements of the abdominal walls thus occurring greatly increase the probability of abortion. The child may be born with an anomalous eruption or it may apparently escape. The prog- nosis of measles complicating pregnancy is to be based upon the severity of the infection, and especially the continuance of high temperature. The infection of measles may be transferred from mother to child, as illus- trated by a case described by Lomer;'" the child perishe<l from intestinal catarrh ; the mother recovered. The child's eruption was characteristic on the forehead and breast a few hours afler birth. Gautier "* found measles transmitted from mother to fetus in six out of 11 cases: the maternal mortal- ity of the 11 cases was two. Scarlatina is a serious com])lication of pregnancy, and its virulence is shown from the great prom|)titude with which it affects the fetus in ntero. The fact that the germ of scarlatina is morphologically held by mariy ob- servers to be identical with various forms of septic bacteria renders scarlatinal infection of grave im])ort. An illustrative case is reported by Ballantyne and Milligan,"* in which the infection occurred during the seventh month of m 244 AMERICAN TEXT-BOOK OF OBSTETRICS. n 1/ prcfjiiaiu'V. Two days later gestation ended, and the f'etn.s was found to have scarlatina. In 21 cases of scarlatina during pregnancy Meyer '" found it impossible to detwt the nicdiuin of contagion. Tiio incubation period was from three to five days. In six out of 21 cases the disease ran a mild course without com- plications. In 8 cases sepsis occurred with two deaths. The resemblance of puerperal scarlatina to diphtheritic infection of woun<ls was strikingly illus- tratetl in Meyer's complicated cases. The interruption of pregnancy by scarlatina is well illustrated by Rcmy;"* abortion occurred at five months, the patient making an uncomplicated recovery. Variola resembles scarlatina in its infective energy and in its rapid trans- mission to the fetus. It possesses, however, the fortunate distinction (>f being susceptible to modification by vaccination. While pregnancy renilcrs the mother more liable to the infection of small-pox, in those cases in which variola occurs in women who have formerly l)ecn vacc'inatcd the disease runs a com- paratively mild and favorable course. Vaccination during pregnancy is to be performed without hesitation v.henever variola is epidemic. Especial care .should be exercised in procuring pure virus, and antiseptic precautions are necessary in performing the vaccination. There is abundant reason to believe that the fetus is protected by such vaccination. Pneumonia during pregnancy is a serious complication for mother and child. The interference with respiration ocr'asionwl by the size of the preg- jiant womb, and the unfavorable conditions under which the heart labors ihiring pregnancy, account in large part for the st^verity of the couiplication. Jurgensen, among 247") women suffering from pneumonia, found 43 who were pregnant. Of this number more than half aborted. As in the other infiK;- tious, the degree of fever present is of great importance in prognosis. The symptomatology of pneumonia in the pregnant does not differ from that of the disorder in the non-pregnant. It is observed, however, in pregnant patients that embarrassment of the circulation is very often present, and that heart failure develops more rapidly than in the non-pregnant. Mann '^' reports the case of a woman aged forty-two with typical pneumonia at eight months' jiregnancy. Tiie fetal heart-sounds ceased five days after the initial chill. Shortly after the crisis of the pneumonia the child was born with the aid of forceps. During labor the patient became cyanotic, and she was allowed to bleed freely from the umbilical cord : although an unfavorable prognosis had been given, the patient made an iMiinterru])ted recovery. The writer reports in this connection the case of a young primigravida aged twenty who developed pneumonia when near the end of gestation. A temperature of lO-'i'^ F. rapidly developed, and an acute pneumonic process catarrhal in nature was found over both lungs. Although the os was partly dilated, no labor- pains v.ere present. The patient's distress and dyspnea steadily increasetl, and three days after the beginning of the ]>neumonia the child was expelled with three or four powerful labor-pains. The child was cyanosed, had fever, and after passing through an attack of pneumonia recovered (Pis. 20, 21). lMM:<iNAN( Y. I'l.Mi; Jt>. % 1 f^ •»• -r * i^ K! I". lO ► 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 < 1 1 1 1 1 1 1 1 1 1 1 1 1 1 . 1 ! 1 1 1 1 1 1 ; 1 1 5' -■i"WT""Tr-T"",i ^"TTTTTTTfT-'-iT^Tl" 2 ■""■^" r {«"4+]'Li •' ; ( ,,.>.,;:,.,..,• i t 1 i f' 1 1 ' ' 1 1 1 ■ 1 i ■ ■ ; Ml; ' ' I u ^ - 1 ^ i ' ! 1 12 1 1 1 1 , 1 M , i 1 1 1 1 OH 09 z »',9fc-'Ti u ..M^.^m li i ill! !!.: !L--j . -ill -:,.; :«'«i ^111 r i^* u J- X - -. 'K" H^Ti. -..,. ...... ...,.-, -.i. i ...1 .. , ^^^^^, 2! l'^ j nf^'?n['' u ' i"^"'''' ^^ 2 "*""""+ +^"""11- "'t:'^>^ Li -^ ^/k^'-'i^s^ ' : \'\^ • • : , qii 9»05 5 + T jz^ ri ;; -r-^+r^t 1+" ......... ^, os' ^r T "T'tt ">l/1fT-"I Jil IJ ^;' .. "'' oi; r Lrr3f'*T 1 H+^ ^^, .p^ , .. .. . . ^^^ !» u ^'^■■'^cr I.J ^' i^:,.. ;, 1 u. 3^1 9^^ 2 1 4' , 1: ^•*-. 1 j_ ;,,,,, 1 1 : ; , 1 i ,»'' £<- : u j '.■)»/ 47 ■-•4 1 I : : i I ' £11 t-»i 2 - -' jr,|,V/ l'^ : ^ t^ 'M Bc' u \ _.T $»§ lY " it ^ i' "'l'"! 2 + ^4^^ LJ 1 _ ^^ L^ 4 4-f- 4- I: ■"" J», 61 1 s -- - ---p - -- - -Tgv^ t--+- ^4-f-~ +-H --r- - «,r9vi i U "T 1 1 ■« 'a iJi ' 1 J_I___' ' _. '' 9C 2l ! ,'.'/// f, ic^ -j , - i, J ' «" y 1 i 1 III; 1 ^'■^2i:"" 1,1 j ■""■♦^ 2! (& Ul 1 X- -- ''^- ''^ , i i"' 9C 2 iTi" ?/..:" 7t r 8Z yi -T'R,r '" 4 L_.. I^._.. iL-L.4 "^ 2 '■ *' if! 1 i P u it t ■'■■T?ir II 1 1 00 ■ 2 r' > ; 1 »oi Ul 1 " ' ■■ ' '^^ III , 4-4.' ' ♦" 82 9! 81 2! :::::::::.::: -A.. tti^. 1(1 1 JOI \J^__ , _ hi_'lf!?;;^_; III 1 i_ 1 ^'' **■ 2 I . i '^'f ^t' U -^ . ^^ H^ 4lT - ^'■'^. ^ 4 ^.^ I ^ ^"^ 9J: 2I T . .. ... ... L, ... /•*•" ^" '^' t' r " .« |92; Ul ± it t^jt ^ '9ji 2{ i , '■''!' i ':;'> 11 p OG « U[ „ V. , -, :..J4 .1^.. .,._ °"'i««: 5' 1 .1 .1 y ■^ -i:"^?*^^ r " ' ; 1 ^ 96 '9J' 2 — -^ rr'i'ff '"""" --+-t--Tr-p -Vi- \o, 95 1 y^ t - "ii ---ti^^^ III 4- i 1 ' 001 9C| 1 4 'l ' «oi 8! 2 + 1 + TV-'ttTf y lEH^ t : II 1 , .901 92i 2 H"^rcvr 2 -.4- 4-iy:ji:td^: . -.-.I. 4-, 4.1 I ...fj ^. '"""^ 1 111 , ' 001 9J i y 2 y 5' 1 ■ 4-4 1" :t ,96 sr! y 2' _.. i [-1 „. -.."•" ?T"!ft^ ,4-+^---lJ4-+----+ -1 ™1'^' ■■I'^y..*"' ' i 'iiii JE I y z' -- dv'-^J^ y 2' :' "^ "" I" ilfefc :<i' ' 1 1 1 HI »t;9i u '" ' >i »<: OE: 2 ! 'if * '* ■ L _ _l_ _1_ 951 »? S- .„__ ^'' ' 5?' 11 t-\ 1 - - I'V'i 1 ■'■»P(r''TJ_ 1 11 ^>2 2 2 2 2 2 2 o o> c <?■• ^ il ^ 1 K»^ ■: ''I 1 r/ It! V i'i;i:iiNAN( Y. 'I \ 1 1; 1<M i — 1 1 — I . — I 1 L u 3 "^,i h_. W'.T.- 3' ''\> ^^■•■.'. »9-K,f ' 5' ...'*' If.- »<i Of . . , .... . . . t ••■■"*lf )> -J .4. • ...> ■■Mm k: MIK !m III. ■M </ ^ rrr • .... !i, '^xa'' 3' iqi> ttl .... Ml « . 1*"*^ 3 ' ''•'■a Slr^ Vua ,((' ,« 1 1 ' t> 1 1 fc s' 1 ■tAj» V V. ; .'* s ... 1} < t ; 'i s' 1 . . . J... ' * l»J_ •t ...!' M* , , , , 9 "TI + •■■ ,...' ')i^ t^ .... 1 i ' . . , J , .-.l- '.i\\ uU 1" w< s r'f i , ' ' ¥,'y tl'l » 1 , 5" ^ • • ■L •««>< f- ' ,c u 5, ' ' I ' 1 ' .... ilA^ «3 J:,; ' 't , ; 1 5 i.i. 1 M *^-*' tK' * M I 11"* ff" 4-^ l| 'T^«; UJj -4 -i-.+J- +tri-t ^4. -1- -14+.; -,^r^■ ....-,- H-"f "tH ' t~* ■•^ i'' S -*-H-. TwT^ *■'•'■ ' ' * ' ;)<., ■W oc ' > ',?ff 1 1 u J il! 1 * , ' ff+l jee "1 * ' 1 , ' , ' ^ ' u ' 1 ! ' ^ {],. ill J. I'M I' ■! 3| *T T'T ' Ill Ui - -H- Ill' ttl^-t i . U |- -++4-^ -. + . • '^J^ Ati^ .2i^ £4 III! ' . ■ !•' 5P- "t+t- -+-- -Ha. fv, <£X "* fit ^4^ 1 1'' i! 1 tt:;:t± 3-- ' 1 i ■ . y/< • ■--rt 1 |S: 1 !! m 1 ^"* * ' u 1 1 |>" w , > , ' 1 J . ''.T ,1 if" " 1. ' ■ i^' ^ If J ! ■ It. . ' 'si mij- ' ^ ' 'li/ •^■' it r*' , ■ ' ; 1 ^Al ■ , 1 . , ; ; ; li, '4i',| If ,hJ ^f! . i . . III oc' «[i et . ►» i U.* i\ r* -i+-j.i- i . i i ■ 1 4*1 ,1" ,'t , t 1 t 1 1 ' " ^tt ' "^ ' ' ' ' : if^l ■ 'iS-fT iir' t..,oc . * •" , ' ■ ill" !!:1 1 . 1, u 3' . ' i • illl i 1 . J,.., 1 f. 4 w'otl Ki.lC ,12 ' * ~t" V ^ j 1 3' ' Jk \m- • " 1 .- -* ... f .-;., ».' Jt' ■Tm '^ri" 3 tf--( iffl" T-rt-P ' 1 ' ^ ' '«.'»' ■' "',"1 !!'"! ! I; itii it^ '4'7i , u ■ IW 'i'l T 1 «. ,ij at >l , M U|l liil II' 4f u! III !'lr' '•' t« 1 * 1 ' , T I'lf'" .•I « i ! 1 3', ! Hlc t^ **r (4*1 1 Ml ,.5 5' I " " -r/ii R .*r-" OH K 61 **■ ,»», . *" ^ '!:' (■'ii' "^ , u ri.^ •t •»i Oi I U, . : : . ~'D 7;»- 9». M u J' ..:. .j;, i i I ! i i ! ! ,,. :/ itl ifc' .< *c- 1'^ z . •< u J' ■ . . . 1 4 . i . ; '.•< irjtyj ?*■» l(. as s' .... '1^9^ ' pti 09 «l l' tf 1.1' is' "■',''■ A'"'i ..,, ■■■■ Uf'i. p- .... 0(1 ftfl ; *;■ ■ , , ,1' 'M* --r 1 r' ttr 77 " ^"tifL /^i' w1 s ■ Ull ■j.M-Ue* lii- \Ln^ '. • . . »»' |»? 1 j' •' .... .,.. . .ii(.i 1. 1 .... tti .09 I' -i .-; . t . n ,.., .... ■•,;i W.I J ^ 1^1- ■ y^ 1 , 1 l~ ^f it fi jif 1 i '■ If 'ii -^•'i ( « t/ THE PATHOLOGY OF PREGNAyCY. 24r, Although the mother's urgent symptoms were relieveil tcnjporarily by her hihor, she i)erisho<l of heart failure soon afterward. Examination of her urine iluring the pneumonia and before her delivery showed the presenee of albumin in apprev'iable quantity, and the proportion of urea was 1.2 per cent. Epithe- lium from tiie kidneys, with abundant crystals of oxalates of lime, were found l)V microscopic examination. The urine containinl large quantities of bacteria of various kinds. The treatment of pneumonia complicating pregnancy is that of the non- pregnant. The patient is in no way improved by the induction of labor, and the occurrence of labor shoidd often l)e made the occasion for depleting the circulation through controllable post-j)artuin hemorrhage. Pneumonia com- plicating pregnancy offers more opportunities for depletion than does ])neu- monia in the non-pregnant woman, and symptoms of threatened asphyxia with profound cyanosis should be met promptly by this resource. Cupping gives great relief in these cases, while the hypo<lermatic use of strychnia and atropia has proven of comfort to the patient. The complication is serious in proportion to the extent of lung-tissue involved and the tolerance or intoler- ance displayed by the circulatory apparatus. The prognosis of pneumonia occurring during pregnancy has been made the subject of study by Wallich,'^ who found that pneumonia interrupts pregnancy in one-third of all cases before the sixth month, and from the sixth to the ninth month in two-thirds of all cases. The maternal mortality varied from 50 to 100 per cent, of recorded cases, while the fetal mortality was 80 per cent. Cholera during Pregnancy. — Cholera during pregnancy well illustrates the severity of a pronounced infection with the pregnant patient. From a series of 10 cases Klautsch '*' describes two stages of the disease — one attended by copious evacuations from the stomach an<l intestines, the second by a period of intoxication or asphyxia. The patients were usually taken ill at midnight or early in the morning, and when temporary relief from the symptoms of collapse had been obtained by the injection of saline fluids a typhoid stage frequently developed, with active delirium, followal by deepest coma. Diu'ing the coma the pulse was strong, dicrotic, and the respiration irregular. Hemorrhage into the conjunctiva; was often ])resont. The fetus usually perished in these cases during the stage of intoxication. The mothers complained that in the first stage of the disease fetal movements were exces- sively violent. It has been shown by Slaviansky, Tijyakoff", and Simmonds that the epithelium of the placenta is extensively diseased, and that liemorrhages and premature separation often occur. Whore the fetus died it was usually expelled at the end of the stage of asphyxia and in the begin- ning of the typhoid delirium. Instrumental delivery was frequently neces- sary. Post-partum hemorrhage was rarely observe<l, and where the mother survived involution often proceeded promptly. As regards the prognosis for tiie mother, it was as good as the prognosis in cholera in non-pregnant women. For the fetus the prognosis was excessively grave. The treatment of preg- 'J 111 AMKiiivAX Ti:xT-iiO()K OF onsTi'/mics. jf I I ! \V I'li tv] naut patients attaclxtnl l)y <'h(»l('ra is the trpatinciit of cliolcra in the non- pregnant. X(i attcntiun should tx* paid to the pregnant contlition, other than to complete hihor as rapidly as possil)h> wiien it begins, and to scHUiro good nterine contractions (hiring and after the lalxtr. A more unt'avorahle view of the prognosis for the mother is given by (Sallianl."^ In Ids ca^v,-. tlie hietie- acid nietiuKl of treatment was extensively employed with negative resnits. In ndid cases a nnmber of his patients recovered. Tvtnnnx in I'ra/iKinvif. — Among the acnte infections that attack with great viridence the nervons system of the pregnant patient tetaims is the most fortnidable. Onr knowledge of infection explains by the tetanns bacillns the exciting canse of this complication. A predisposing cause is to be fonnd in the snsceptibility which pregnant patients manifest dnring the first three months of this period. Indeed, the first half of gestation shows by far the greater nundx-r ut' cases of this infection. Tetanns develops usnally after some minor manipulation in the early niontlis of j)regnancy, and especially where abortion requires interference on the part of the physician. Tliiw Vinay'*" in lOG cases found but one after craniotomy and one after C'esirean section ; the infection is one ttf early pregnancy, and is not usnally cwnnectcil with parturition at ternu Patients most apt to be attacked by the tetamis bacillus are nudtipartx; above the average age anil those who have been living in damp and stpialid lodgings. The direct conveyantf of the infection has been noted by Henricins and by Anion. The latter, while treating a case of tetanus in the husband, infected the wife, who aborted, dnring the manual delivery of the placenta. Tetanus is most frecpient among pregnant patients in the tropics, where the condition of the soil is favorable to the growth of the infecting germ. An association of tetamis in pregnancy and the pueiperal period with endt)metritis has been pointed out by Markus.'*' The treatment of tetanus in pregnancy is largely prophylactic. Remem- bering the peculiar susceptibility of pregnant patients, especially during the first months, any minor operation or examination shoidd be conducted with scrupulous antisepsis. When once tetanus infecti has occurretl, but little esui be d(»ne to save the patient. Tetany is a condition which is commoner during pregnancy than is tetanus. It is characterized by tonic spasms beginning in the muscles of the extremities, especially those of the hands. In severe cases spasmodic move- ments may extend over the entire muscular system. The spasms are symmetrical wher not artificially produced. Attacks of tetany are not accompanie<I by loss of consciousness. Such seizures are intermittent and of short duration. As a rule, recovery ensues, the spasms gradually becoming less frcipient. Patients <leseribe a tingling or a numb sensation of the extremity affected as precetling the spasm, and the same phenomenon follows the cessation of convulsive move- ments. If the main artery or the nerve of the extremity in which spasmodic movements are observed be compressed, these sensations, followed by spasm, may be induced. The application of cold causes the spasms of tetany to itnise. The flexor muscles, and especially the interossei in the hands and feet. Till-: rATiioiJXfv OF j'/ii:(iXAy(y. 247 nro oftcnost iiffi'ctcil. Tlii' elect ricnl reneti(»n of the nerves in the iifr<H'te«I region is njiieli iiieroas(><l. The patient's >;i'iieral temperature is not afFiH-twl. Any nieehanieal irritation of tlie |)oripheral nerves, <>yA\ as tappin^r tlie trunk of the faeial nerve in front of the ear, results iii spasm. The disorder is generally s|H)radie and in rarely epidemic. It is most usually observetl in women during the childhearing pcritMl or during menstruation. TrousHcau foinul, of 44 cases, forty amid mu'sing women. Kussmaul found transient allniminuria present, and Stiel observed glycosuria. Dakin"** reports the cast; of a mnltigravida of nervous tem|)erament who in the third month of her fourth gestation was seized with frecjuent vomiting during the <lay. Afler this condition had persisted for eleven days she developed spasm of various mustrles, j>re<'e<UKl by numbness. The hands and feet assnuieil tlu' jjostiire seen in tetany, the flexors in crontraction, and the interossci producing exten- sion of the phalanges. The soles of the feet wen' Ivdlowitl by spasmmlic extension. The affected muscles were slightly i)ainli Tiie condition ex- tended to all the extrenuties, and vomiting was inere;"sed. On the second day of tetany the spasmodic condition bccanie so i :eessiv<- as to " luse intense sutl'ering. The temperature was s I'jnormal. '1 tie pati"nt 'K-u of asphyxia produce' b spasm of the muscles of respiration on t!ie third day of the t<'tany. Trousseau recognizes three varieties of tetany in accordance with the .-•verity of the affection. He rarely oUservwl a fatal result. Meinert saw five cases end in recovery. In one of these cases the patient suffi-red from tetany in successive pregnancies. One of Meinert's patients had her th\ i<>id gland removed. Between the attacks of tetany the patient is normal to all appearances. In non-fatal cases the pregnancy is tiot interrnptetl nor is labor influence<l, the spasms ceasing as .soon as the uterus is emptied or within a few days. In contrasting tetanus with tetany in pregnant i)atients it is well to remem- ber that in tetanus the spasm begins in the face or the r.eck, and advances cen- trifiigally with opisthotonos. In tetany the spasm begins in the extremity and advances centripetally, producing the characteristic posture of the extremities. In tetanus the spasm is constant : in tetany it is intermittent. The great fatality of tetanus and the comparative mildness of tetany are to l>c kept in mind. Tetamis is commonest among men, who by virtue of their oc<!upatlons arc exjMJsed to infection from the tetanus bacillus. Tetany is jwculiarly com- mon among pregnant women or women in a depressed and susceptible condition. The differential diagnosis between the convulsions of toxemia and those of tetany is not difficult with accurate observation. The treatment of tetany in pregnancy consists in giving the patient such sedatives and anotlynes as shall procure ; iccp. Vomiting or diarrhea requires especial attention, as it induces a condition of debility favoring a fatal issue. Abortion should not be producetl in tetany, as the disorder rarely fails to yield before intelligent medication. m i 'i t ': 248 AMERICAN TEXT-BOOK OE OBSTETRICS. 1 *■ f ^t ■fci ; 4. Accidents and Surgical Operations during Pregnancy. Although the nervous s^-stem of the pregnant woman is remarkably suscept- ible in many ways to reflexes, she sometimes exhibits a very decide<1 power of tolerance to severe injury or to surgical interference. The difference in this resisting power, as shown by some patients and as seen to be lacking in othei-s, de|>ends not only upon the condition of the nervotis system in these cases, but also upon the normal or abnormal state of the uterus and its lining membrane. In a woman in perfect health a considerable injury or a surgical shock may be received without the interruption of ]>regnancy, while if the patient is of extraordinarily susceptible nervous system or if the endometrium is in a con- dition of disease, interruption of pregnancy is almost inevitable. Accompany- ing the premature ending of gestation serious hemorrhage, shock, and greatly increased susceptibility to septic infection are observetl. Those operations most frequently demandeil during pregnancy are surgical proceilures undertaken for some condition of the uterus or of its appendages. Thus cancer of the uterus demands the complete extirpation of that organ as soon as the diagnosis is made, irrespective of the existence or tiie period of gestation. One of two methods of ojjcration may be chosen— (extirpation per vaginam when the diseased uterus is small, or the com])lete removal of that organ through the abdominal cavity when its size precludes the possibility of its removal through the vagina. In either instance the prognosis for the recovery of the mother is by no means desperate if the operation be per- formed before her strength has been reduced by the development of cancerous cachexia. It is sometimes possible to combine the two methods of operation, as in an interesting case reported by Stocker,'*** in which a multigravida was found to have cancer of the cervix. At the sixth month of pregnancy the cervix was removed per raf/innm, and the conij)lete extirpation of the uterus was accomj>lished by t>pening the abdominal cavity. The patient made a good recovery from the operation. Myomotomy and myomectomy are demanded during j)regnancy for fibroid tumors (complicating the development of the pregnant uterus. The choice of operation will depend upon the size and location of the tumor, and upon the amount of pressure which it is exercising or which it will cause upon the growing womb. Flaischlen '* found two fibroid *^umors behind the uterus in the case of a patient pregnant three months ; one tumor sprang from the cornu of the uterus, the other from the base of tiie womb. Both tumors were ligated and removed without the interruption of pregnancy. Amputation of the pregnant womb is a familiar operation for contracted pelvis. It may, however, be performed at any period of gestation when the interests of the patient demand hysterectomy. The method of procedure best adapted to such cases is abdominal incision, ligation of the ovarian and uterine arteries, and amputation of the uterus, leaving a short stump to close the vagina and stitching the peritoneum over the surface of the stump. Tumors of the ovary are justly considered serious complications of prcg- THE PATHOLOGY OF PREGNANCY. 24!) lie 1st lie lie nancy. Dsirne'" colloctcil 135 cases in which pregnancy was complicated by tnmor of the ovary. He finds that the gravity of this complication increases as pregnancy advances. There is rarely any reason in this complication for delay in removing such a tumor by abdominal incision. Puncture of an ovarian cyst and the artificial interruption of pregnancy are to be avoided : they are to be consideretl only in the light of proceilures adapted to an unforeseen emergency. The preferable time for operation in such cases is before the fourth month of gestation. The fetus is least likely to be lost when operation is performed in the third or the fourth month. No period of preg- nancy, however, contra-indicates ovariotomy, but this complication uniformly demands operative treatment. Double ovariott>my during pregnancy may be successfully performed, as exemplified by Polaillon.'** His patient, agetl twenty-three, had a good-sized ovarian cyst upon one side and a diseased ovary upon the other side. Her general condition at the time of operation was not promising, and numerous adhesions complicated the removal of the tumor. Operation was performed in the third month of gestation, and it resulted in the continuance of pregnancy, which terminated in normal delivery with a healthy child. The patient's pulse and temperature showed little reaction following operation. Kreutzman "® reports two cases in which ovarian tumors were successfully removed from pregnant patients without interrupting gestation. One of these women, who was in her second pregnancy, had gone two weeks over time. She had a large ovarian cyst in the loft ovary, the pedicle of which had recently become twisted, the contents of the tumor being tinged with blood. Affections of the Fallopian tubes may call for operative interference during pregnancy. The prognosis in these cases is equally good with that of opera- tion for the removal of ovarian tumors, and the reasons for prompt interfer- enci! are quite as cogent as in the former case. In hematosalpinx it is often impossible to make a differential diagnosis between this condition and eetojiic gestation. Tliis fact is well illustrated in the experience of Doraii,"** who re- moval both tubes and ovaries from a patient who had suftered from attacks of violent pelvic pain at various intervals. One tube had ruptured, allowing the free escape of blood ; the tube contained a structure in the midst of a clot resembling an aborted ovum. It is probable that double ectopic gestation existed. The patient made an uninterrupted recovery. Aocuh'ntu and Injuries. — As regards tolerance to general accidents and injuries during jiregnancy, American observers have noted the remarkable tolerance displayed by negro women under such circumstances. Thus, Tiffany'" reports the case of a negro woman wlio fell, striking the abdomen violently against the edge of a tub. Peritonitis with retention of urine fol- lowed. The patient, however, under faithful attendance recovered without the interruption of jiregnancy. Stab-wounds oi" the abdomen occurring durin.- the pregnant period, but without interrupting gestation, are reported by Belin,"^ in whose patient a considerable portion of tiie (>piploon protruded from the wound. Sloughing ensued, but the patient made a good recovery. m '■ '■; 250 AMA'IilCAA' TEXT-BOOK OF OBSTETRICS. Tf V / if-.' Richard "* describes the case of a pregnant woman who fell, lacerating the abdominal wall near the umbilicus. A mass of intestine protrudetl as large as a man's head. The woman was at term, and soon after normal labor ensued, from which the patient recoveretl. Harris '" describes the case of a woman pregnant six months whose abdomen was torn open by the horn of a bull. Although omentum and intestine protruded, pregnancy was uninter- rupted. The viscera were replaced and the wound was closed by suture. A similar case in which a lacerated wound of the abdominal wall 5 inches long was made is reported by Corey.'** In this case the pregnancy was at the third month. The patient went two hundretl and two days longer in ges- tation, and had a normal labor. Obstruction of the intestine calling for abdominal section is described by llydygier,"* who operated in the sixth month of gestation upon a patient who had symptoms of strangulation for seven days. Recovery without abortion ensued. In fractures retardetl union is reported by Petit "^ and others in pregnant women sustaining this accident. An interesting operation for stone in the bladder upon a patient eight months pregnant is I'cported by Keelan.'^* The calculus, which weighed 12 J ounces, was successfully removed without the interruption of pregnancy. Gunshot wounds not penetrating the uterus do not commonly inter- rupt gestation. A remarkable instance is cited by Prozowsky.'^ The patient was wounded in many places by pieces of lead pipe fired from a gun but a few feet distant. Neither she nor her child suffered, so far as gestation was concerned, from the accident. A pistol-shot wound of the lung occurring during pregnancy, followed by hemorrhage and shock, is reported by Ban- croft.^ A healthy child was born at term. A remarkable case is described by Lihotzky,^' which illustrates the fact that the changes occurring in pregnancy may bring into active irritation a foreign body that had previously been inert ; he describes the case of a patient perishing from rapid peritonitis in the eighth month of pregnancy. At the autopsy the duodenum was found perforated by a s})oon which the patient had swallowed two and a half years previously — an occurrence almost forgotten. The remarkable tolerance shown by the pregnant woman to direct injury from mechanical causes is illustrated in a case reported by JMilner.™^ The woman in the sixth month of pregnancy was accidentally shot through the abdominal cavity and the lower part of the thorax, the missile penetrating the central tendon of the diaphragm and lodging in the lung. Localized pneu- monia and peritonitis seemed to limit the injury, the wound draining through the lungs by very free expectoration. Recovery ensued, the patient giving birth to a healthy child sixteen weeks later. Direct mechanical injury may rupture the pregnant uterus, usually causing the death of the i)atient. It is interesting to observe that the membranes may remain unruptured in these cases, thus obscuring the diagnosis of rupture of the womb. Neugebauer ^'^ describes a case of suicide in which a primi- gravida threw herself from the third story of a house upon a stone pavement ; THE PATHOLOGY OF PREGNANCY. 251 the immetliate cause of death was fracture of the skull. The uterus ruptured, and the fetus in its unbroken membranes was found among the mother's intestines. The patient's pelvis also sustaine<l serious injury. That pregnant women can endure terrible injury complicatet^l by er\'sipe- las, and still go on to term, is illustrated by a case reported in the Prugcr medicinische Wochenschrift, 1881, No. 6. A woman in the eighth month of pregnancy, while working in a brickyard, was buried beneath a mass of earth and rock. A terrible gash was cut through the scalp, and many bruises and lacerated wounds were sustained. Erysipelas attacked the wounds of the scalp, and the patient was for a time very ill. She did not, however, mis- carry, but bore a healthy child at term. Fancou ^* describes the case of a woman who had an injury to the knee requiring drainage. She was attacked by erysipelas, which spread over the whole body save the genital organs and the head and neck. Her pregnancy was uninterrupted and recovery ensued. Operations upon the rectum are to be avoided if possible in pregnant patients. It has been sliown by Tiffany ^'' that such operations are an excep- tion to the rule in usually producing abortion or miscarriage. On the con- trary, a diseased kidney may be removed from a pregnant patient, as shown by Tiffany, ***" with complete success. While major operations seem well borne by pregnant women, minor surgical procedures of an irritant character are sometimes attended by disas- trous results. Thus, Fancon observed in the clinic at Strasburg a case where cauterization over the ankle-joint was practised for a neglected sprain. Abor- tion followed, complicated by septic infection, necessitating amputation. The patient finally succumbed. Pregnant women often survive burns without the interruption of gestation if the pregnancy is not far advanced and the burn is not severe. Hunt ^^ reports a case of excessive burn in the ninth month of pregnancy that seems to have affected the fetus directly, for the child was born dead and blistered over an area corresponding with the burns upon its mother's body. Curiously enough, cases are reported where preg- nant women have suffered from abscess of the breast, in which the abscess has been opened, curetted, and drained without interrupting pregnancy, although interfering with the breasts nsually results in profound disturbance of the uterus. Pregnancy is nocontra-indication to excision of the cancerous breast, as illustrated in a case reported by Pilcher.^* Parasitic growths of the abdominal cavity requiring abdominal section have been treated by surgical interference during pregnancy with success. Amputation for crushing injury and severe blows has been sustained by pregnant patients, and recovery ensued. A remarkable case is reported by Fancitn, in which a pregnant woinan jumped from a second-story window without interrupting the gesta- tion. Amputation at the hip-joint during pregnancy has been successfully performed by Keen.** The reason for operating was malignant disease of the femur. The patient, who was five months j)regnant, had been living in the tropics. She made a good recovery after the operation, without symptoms of abortion durinj; her convalescence. ! u 252 AMERICAN TEXT-BOOK OF OBSTETRICS. ififi In deciding upon operations upon pregnant patients care should be taken that the various excretory organs of the body be phiced in the best possible condition. All unnecessary shock is carefully to be avoided, as is also hemorrhage. Although a hemorrhage does not seem to produce abortion, it is dangerous, because it renders the patient more susceptible to septic infection. Fractures unite poorly in pregnant patients, and aj)plication of cauterizing agents should not be practised during pregnancy. Major operations on the abdominal contents are especially well borne. Pregnancy does not contra- indicate operation for diseased conditions of the uterus, the tubes, or the- ovaries, provided the fetal sac is not opened. A striking instance of the benefit which pregnant patients sometimes receive from operative interference is shown by those cases of osteomalacia during pregnancy greatly benefited by oophorectomy. A good example of this is the case described by Kasch : ^"' the patient, a niultigravida, aged forty- one years, suifered from osteomalacia, which continued after the birth of her twins. As the condition continued to grow worse, the tubes and ovaries were removed, when the patient began immetliately to improve, and subsequently became able to walk. The almost incredible power of resistance which the pregnant uterus dis- plays to interference is well illustrated by a case reported by Vickery : ^'' this patient was subjected to medication and operative interference to empty the uterus ; it was supposed that incomplete abortion occurred, and her physician curetted the uterus and applied tincture of iodin followed by injections of hot water. Notwithstanding this treatment pregnancy continued. The prognosis of pregnancy complicatetl by tumors in cases subjected to operation must be considerefl as decidedly favorable. Gordes ^'^ gives an interesting account of 16 cases of pregnancy complicated by abdominal tumors ; out of the 16 cases, four perished : all the cases were treated by operation, and many of them in the most radical manner. 5. Diseases of the Ovum. Under Diseases of the Ovum will be included the disorders of the mem- branes, the deciduae, the placenta, and the funis. The following syllabus presents the topicji taken up for consideration in their expressed order : Amnion Chorion Decidual endome- tritis : C Adhesions and bands, < Polyhydramnios, ( Oligohydramnios. f Vesicular mole or \ Myxoma. Placenta : ''Placentitis, Calcareous degeneration, Fatty degeneration, Apoplexy, Tiunors, Syphilis. Anomalies in position, size, weight, shape, and number. Polypoid, Hvpertrophic, j (Ystic, (^Catarrhal. Cord : r Coils, j Knots, j Torsions, (^Stenosis of its vessels. THE PATHOLOGY OF PREGNANCY. 253 A. Diseases op the Amnion. Amniotic Adhesions and Bands. — Adhesions between the fetus and the amnion, supposed to arise from an arrest of development, are occasionally met with. As the amniotic fluid increases the adhesions are elongated, forming bands. They cause certain deformities, as webbed toes and fingers. Rarely, an amputation of a fetal limb results. When the bands and adhesions are accompanied by a deficiency of the amniotic fluid (oligohydramnios), they are regarded as the cause of malformations of the lower extremities, because the fetus cannot preserve its normal attitude, and it is therefore subjected to injurious compression, residting in deformities. Polyhydramnios, or dropsy of the amnion, is an excess of the amniotic fluid. When this fluid is in marked excess of two quarts, poly- hydramnios may be said to be present. Cases are recorded whore more than twenty quarts existed. This condition is found more frequently in multiparse than in primiparse — 23 to 5 ; more frequently in twin pregnancies of the same sex than in single pregnancies. In some cases of twins one sac contains an excess of fluid, while the other sac contains less than the usual amount. This condition has been found in extra-uterine pregnancy. Two forms of polyhydramnios have been described, the acute and the chronic. In the former the accumulation of the fluid is very rapid, producing fever. In the latter the fluid increases slowly, and the uterus thereby tolerates its pressure to a greater extent. This condition is sometimes dangerous, because the centrifugal pressure conduces to a critical tensity of the uterine walls, threatening rupture. In labor the sudden free exit of the fluid favors malposition of the fetus, and especially prolapse of the umbilical cord. Pathologij. — The i)athology of polyhydramnios is most obscure. This disease has been attributed to a defective maternal cardiac action, permitting transudation of serum from the maternal blood through the fetal membranes. Inflammation of the amnion (amniotitis) has been held as a cause. To great activitv of the renal fiuiction of tiie fetus it has also been attributed. There is no settled opinion at present as to its causation. A recent author states that Miere is a frequent and an undeniable connection between polyhydramnios and the insertion of the placenta in the inferior part of the uterus. The blood- stasis resulting from such a low insertion favors osmosis into the amniotic cavity. Si/mptoinatohg!/. — The unnaturally rapid increase in the size of the uterus is the most striking symptom of polyhydramnios. The uterus at five months becomes as large as it should be at term. Fluctuation becomes a conspicuous symptom, even to the jioint of utterly obscuring the presence of pregnancy. Obstetric auscidtation and palpation are easily rendered nugatory. Pressure- symptoms relating to circulation and to respiration become especially urgent. Vaginal examination reveals a nearly or (piite obliterated cervix and a resilient mass filling entirely the pelvic inlet. Treatment. — Induction of labor is ;\'mau(led in the acute form, but in the 254 AMERICAN TEXT- BOOK OF OBSTETRICS. :l 1 im ! !• if V chronic form only when the presstire-syniptoras become urgent. It has been recommendal to cautiously draw off the cxcei^s of fluid with an aspirator. Two things must be guarded against : first, the malposition of the fetus and precipitate labor ; second, a post-i>artum hemorrhage, which is so liable to result from uterine atony after over-distcntion. Oligohydramnios means a deficiency ' f the amniotic liquid. Its pathology is unknown. Adhesions and bands are frequent in this condition. It cannot be detected prior to delivery ; it is revealed at that time only. Fetal malformations are frequently encountered in oligohydramnios. The fetus is subjected to an abnormal pressure which results in deformities. Webbed toes and fingers are alleged to arise from this condition. Amputation of a fetal extremity may follow the abnormal deficiency of fluid. Malformations of the inferior extremities are ascribed to this complication. B. Diseasp:8 of the Choriox. Vesicular Mole (CVstic mole ; Hydatidiform degeneration of the chorionic villi ; Dropsy of the villi of the chorion ; Myxoma of the placenta; Molar pregnancy). — The villi of the chorion occasionally undergo myxomatous degeneration, which produ(!es a vesicular mole. The mole is a mass of pedunculated vesicles resembling in aj)pearance grapes or gooseberries. There may be as many as five or six thousand of such vesicles. The vesicles vary in size from a millet-seed to that of a filbert, and they conUiin a fluid, usually colorless, transparent, liquid as water, holding albumin in solution. Rarely the fluid is reddish in color. If all the villi of the chorion are involved in the degeneration, the life of the ovum is always sacrificed. If only a small portion of the villi are involvetl, the life of the ovum is not necessarily destroyed and development to term may proceed. In twin preg- nancies one chorion may un-'Ugo myxomatous degeneration M'liile the other ovum may proceed to full develoj)meut and be born at term. Often in double pregnancy the development of a cystic mole in one chorion seriously compromises the life of the other ovum, resulting in a miscarriage. Vesicular mole is very rare. One author reports only one case in over twenty thousand deliveries. It is oftenest found in multiparte of from twenty-five to forty ycai's of age. Nimierous recorded cases of women who have repeatedly developed vesicular moles exist ; one case developed this condition in eleven pregnancies. PatJioloffi/. — An endometritis is generally supposed to be the factor predis- posing to the development of a molar pregnancy. The villi of tiie chorion undergo hypertrophy and myxomatous degeneration. Three cases have been reported wherein the chorionic villi grew so rapidly as to penetrate the uterine wall even to the peritoneal covering, rer.dering successful removal impossible without a fatal hemorrhage or a subsequently fatal peritonitis. Symptomntolof/y. — Three symp jms characterize molar pregnancy: first, an abnormally rapid increase in the size of the abdomen ; second, uterine hemor- rhage ; and third, the expulsion per vaginam of the vesicles of the mole. THE PATirOLOaV OF PREGNANCY. 266 It may be possible to feel the grape-like masses through the cervical canal. Exsanguiuation of the patient and septic infection are the chief dangers. As a rule the fetus dies. Rarely, a bunch of the vesicles may lie expelled without the course of the pregnancy being interruptal. Treatment. — No active interference is demanded until the hemorrhages occur. If they are small, rest and an oi)iate may suffice. If severe, the uterus must be dilated and very carefully curetted, subsequent hemorrhage being prevented by an intra-uterine tampon. The possibility of the growth hav'ng penetrated and thinned the uterine wall makes it necessary to use the curette cautiously to prevent perforation of the uterus. C. Decidual Endometritis. One of the commonest diseases of the ovum is decidual endometritin. Four varieties of this disease are described to-day : the polypoid, the hyper- trophic, the cystic, and the catarrhal. The names of the different varieties indicate the predominating characteristic of the endometritis. In catarrhal endometritis the discharge of a watery fluid is so abundant as to receive the name hydrorrhea gravidarum. It may occur as early as the third month, but usually it is not encountered until the last months of pregnancy. It is more frequently seen in multi})ar8e than in primiparfe. It is found upon close observation to be a mucous secretion rather than the yellowish amniotic fluid ; the latter is further differentiated by containing urea. The sudden appearance of the fluid in a large quantity is generally mistaken for premature rupture of the membranes. In most instances it is repeated several times before delivery occurs. Should pains follow, quietude and an opiate are indicated. The etiology of hydrorrhea gravidarum is obscure. It has been attributed to syphilis, to overwork, to an exaggeration of a pre-existing endometrial inflammation, to gonorrhea, and to an infection following the death of the o"um, to be followed sooner or later by a miscarriage. The frequency of miscarriage from an old endometritis is a well-known fiicfc in obstetric observations. The treatment of this malady during pregnancy is absolutely nil. All that can be done for it must be done in the intervals between gestations. D. Diseases of the Placenta. Placentitis, inflammation of the placenta, is a very rare disease. Its origin is very obscure, but it is supposed to start from the decidual tissue or from the larger fetal arteries. It soon terminates in induration, oftentimes resulting in strong adhesions between the placenta and the uterine wall, con- stituting the adherent placenta. Apoplectic infarcts are often found in placentitis. Calcareous Degeneration (Placental calculi ; Ossiform concretions; Pla- cental ossification). — By this term is meant the deposits of lime on the edges of the cotyledons or in their s\ibstance in the shape of particles of sand or of needles or of scales. They consist of amorphous carbonates and phosphates 1*11. m m K i I 256 AMERICAN TEXT-nOOK OF OBSTETRIVIS. w m^ of lime and inafjiiasia. The presence of these secretions is without therapeutic significance, and has no ill effect on the functions of the placenta ; so many as five hundred have been found in one placenta. Patty Degeneration. — A fil)rous, fi)llowed by a fatty, degeneration of placental villi is of very common occurrence, especially toward the margin of the placenta. When it involves a small area no serious interruption of the function of the placenta follows. When a large area is involved the death of the fetus occurs. The etiolof/t/ of this condition is unknown. A fibrous degeneration, undoubtedly the condition denominatetl by the earlier writers " aclerases," or "scirrhous" or "cartilaginous degeneration" is regarded as the precursor of fatty degeneration, because it diminishes the blood-supply, which leads directly to fatty degeneration, or, in some cases, to amyloid degeneration. The diagnosis of this condition is quite impossible during pregnancy. Apoplexy. — Blootl escapetl from a ruptureti blood-vessel and occupying circumscribed cavities formed in the tissue of the placenta is called " placental apoplexy." It is occasioned, as a rule, by the rupture of some of the maternal blood-vessels. The effused blootl rarely comes from the placental vessels. The clots vary in size from that of a millet- or a hemp- seed to that of a ]>igeon egg. Usually there are several clots, a large number being twenty or more. They are situated at various depths in the substance of the placenta, from the fetal to the uterine surface, upon which some of them have a small and irregular orifice. Owing to the spongy nature of the substance of the placenta, the normal condition of the tissue is disturbed only a few lines from the boundary of the cavities. The cffuboi.1 blood soon separates into two parts, one solid, the other liquid. The serum disappears by osmosis, while the solid part contracts, becomes denser and smaller, and loses its color. These whitish homogeneous masses have been denominated concrete pus or tuberculous matter. Cutting into the cotyledons of a placenta often reveals apoplectic clots in the various stages of chronological consecutive changes. The results of placental apoplexies depend upon the period of gestation in which the hemorrhages occur, and upon their number and the extent of territory invaded. Aboi'tion or premature labor is rarely produced. If the infarcts arc small and few in number, the gestation will be com- pleted and the fetus will continue to live, its nutrition suffering little or not at all. If, however, the effusions are large and numerous, the offspring will be born feeble, puny, and emaciated. If the apoplectic attacks recur at short intervals, there will occur a progressive diminution of fetal motions and heart- pulsations until they cease altogether. In all cases of a dead-born fetus pla- cental apoplectic infarcts shoulil l)e sought after carefully. It is by no means rare that women miscarry repeatedly from this cause, and when they do com- plete their gestations their placentas will be found to contain a number of effusions, both old and recent. Symptoms and Treatment. — The occurrence of placental apoplectic infarcts THE PATirOLOGY OF PREGNANCY. 257 varcly betrays itself by any recognized symptoms, providetl the hemorrhage is limited in amount. In some cases there may be present indications of internal hemorrhage, whose occurrence will Imj suspected, chiefly in women who have experienced this condition in previous gestations and in whom placental apoplexy was found. Should placental apoplexy be susjwctcd, especially in women predisposed to the affection, the prophylactic treatment of uterine hemorrhage is indicated. Absolute rest, small phlebotomies, and saline cathartics, repeated pro re nata, are the most rational treatments. Tumors. — Both solid and cystic tumors of the placenta have been described. They are very rare. They may originate in the meshes of the cellular tissue or in the glandular cavities of the decidua serotina. Solid tumors may cause death and expulsion of the fetus, while the placenta may remain for weeks and even months before being expelled. The presence of tumors can be determined only after delivery, for there are no known symp- toms indicating their presence. Syphilis. — Syphilis of the placenta is a well-established condition. The observations of Fninkel are classic, and comprise all that is fully settled, to- day, upon this subject. The appearances of the placenta with syj>hilis derived from the father differ from those of the placenta with syphilis derived from the mother. In the former the fetus ?8 diseased and the villi are filled with fatty granulations, their vessels are obliterated, and their epithelial coverings are thickenetl or absent. In the latter there may be present one of three conditions, which vary according to the time of infection : 1. If the mother be infected during the generative act at the same time as the fetus, syphilitic foci will often develop in the maternal placenta (placental endometritis). 2. If the mother is syphilitic before conception or becomes so shortly after, the chances of the placenta remaining healthy arc about even. 3. If the mother is not infected until after the seventh month of preg- nancy, both fetus and placenta escape entirely. A syphilitic placenta is heavier, larger, and paler than normal. Its general color is pale red, but in its diseased parts it is yellowish-white. Here and there the tissue is firmer, more resistant, compact, and friable than normal placental tissue. Anomalies of the Placenta. — The more important anomalies of the ]ila- conta arc anomalies in position, size, weight, shape, and number. At the end of pregnancy the placenta is normally situatal at the fundus of tiie uterus, anteriorly or posteriorly ; it is from 2 to 3 centimeters (1 inch) thick at its central portion and from 17 to 18 centimeters (7 inches) in diameter. It weighs about one pound. The abnormal position of the placenta of greatest clinical imjwrtance is placenta pra;via, by which is understood a situation of the placenta in any portion of the lower uterine segment — that is, in that portion of the uterine body which is dilated during the progress of labor. The size of the placenta is exceedingly variable ; sometimes it is very thin 17 I Itl i' I* 2rj8 AMK/i'/CAX TJ'L\T-li()()K' OF OliSTKTJtlCS. and correspond iiifjjly \i\r^v. This nhiiornmlity is most remarkably exhibited in the so-called " placenta meinhranaeea," a placenta forme<l by the hyper- trophy of the entire chorion, the normal atrophy of the chorion levo not occnr- r\\\^. The placenta is freqnently enlarged by edema when there is dropsy of the amnion from either local or general causes. An increase in weight of the placenta usually, although not always, accompanies an increase in size. The variations in shape are of interest, and the anomalies of number arc of great clinical importance. The shape is usually round ; it may be very irreg- ular, one or more lobes being more or less developed, when the names placenta duplex, tripartita, multiloba, etc. are applied (1*1. 22, Figs. 1-3) ; it may be oval, as is (piite frequent in the so-calletl *' battkxlore placenta" (1*1. 22, Fig. 6) ; it may have a horse-shoe or crescentic shape. The anomalies of number are of greater clinical importance than the variations in size and shape. The danger of accessory growths lies in the possibility of one or more of these growths being retained in the uterus and undergoing decompositit>n with the production of septic infection. When these accessory placental growths serve as a channel of conununication between the blootl-sinuses of the decidua and the main placental growth — in other words, when they arc finictionally active in carrying nutriment to the growing fetus — they are ciillcd " jdaccnta; succentiu'iatie " (1*1. 22, Figs. 4, 5). Placcntte spu- riie are analogous accessory formations whose villi have no direct communica- tion with the maternal blood. Ji/ \i i f t I ( ' n ■ Si E. AXOMAIJES OF THE COUD. Coils. — One or more coils of the funis may be around the botly of the child or around one or more of its members. The neck is the part most commonly encircletl. As many as eight coils around the neck have been reported. They are found more often with male than with female children. They occur more frequently in multiparae than in primipara;. Their injurious eifect is to pro- duce sufficient constriction of the vessels to result in fetal death. In cases where the coil passes over the portion of the fetus lying against the anterior wall its presence can sometimes at least be inferred by the detec- tion in it of a murmur which is synchronous with the fetal heart-sound. A positive diagnosis cannot be established before labor. Coils are found at least once in five or six deliveries. In breech presenta- tions and when around the neck they are the most dangerous to the child. Cases of amputation of the members by the pressure of the cord coils have been reported, but it is generally thought that these aniputations result from amniotic bands rather than from coils of the cord. Knots. — When the cord is abnormally long or the liquor amnii very abundant, knots in the cord are liable to be found. They may be double or be single. One case is reported where five knots were found. In recent knots the Whartonian jelly is not displaced, the cord diameter being normal. In old knots the jelly is displaced, and the diameter of the cord is decidedly lessened in the knot. Ordinarilv the circulation in the cord is not molested, rUKCNANCY. Tl.MK -J-'. ANdMAi.iKs (PF riii; I'l.Ac inta: 1. I'liiciMitii «itli iiTCLMiliir lulics i.\\iviir(11. 'J. riacttita in twn iiiiri|uiil Inhi- I Aiivimli. :i. liTi'L'Ul.'ir |.liici'iil,i (Aiivnnii. 1. Sniiill iirci'>siPTv iiliuciilii iliilx'iiioni l.fpiiL'i'i. .'i I'liuTiita Hicccntuiiiitii .Itilu'iMiiiii Lrpimri. r. '■ lliillli'ilun'" pliwiiiin, nviil lAuviiicli. 7. I'liii'i'iilii with vi'liiiiu'iiluus Itiiclllllfllt 111' cnlll I l;iln'lllnlll l.l'pil^^' I'liUrlHii Willi twofiiuiil liiln'S (Itiln'IMiiMt l.ciiil;,'!' :tl n I! I t ii ! k ai til re til ;v( ox sio iiil I'Ol liii inu sill oiii "t( iiiO( 0S|)( km: IIIOI tlioi OXC( fr('(j cut has iron liav( nil-: I'ATiKHjjdY or ritiJiXAxrv. 269 Imt twcasionnlly the knot is so tifilitly drawn as to cause fatal fotal aspliyxia. Ono case of twins is reporto<l where a hard scjnare knot tliat united both curds was found, resultinj; in the loss of both children. Torsions. — In the vast majority of cases the cord is twisted upon itself from left to right ; the cause is unknown. Torsions are likely to be very numerous when fetal death has occurred several days before delivery, are commoner in male than in female children, and are most numerous near the two extremities of the cord. In some cases the jelly of Wharton is wanting at the twiste<l points, and the lite of the infant is endangered from cini)arrassnieiit «»f circidation. Complete atresia of the cord and death of the fetus may follow. Stenosis. — Independently of knots and torsions, narrowing of the vessels nf the cord may occur, usually in the vein near the placenta. The causes of these stenoses are believinl to be syphilis and atheromatous degeneration. But one eventuation succeeds the development of such stenosis, and that is the death of the fetus. (). Abortion. Definition. — In a general sense by " abortion " is meant the interruption and termination of pregnancy by the expulsion of the ovum before the end of the twenty-eighth week, or the seventh lunar month of gestation. In a more restricted sense the term is used to denote the expulsion (»f the ovum prior to the comi)lete formation of the placenta — that is, before the end of the twelfth week, or the third lunar month — "miscarriage" being the term applied to expidsion of the ovum from the twelfth to the twenty-eighth week. Expul- sion t)f the fetus between the twenty-eighth week and a short period before full term is designated " prenuitnre labor." A goodly number of eases are recorded where fetuses have been born alive between the fourth and seventh liuiar months, the greater number living a few hours only, while several six months' fetuses lived and were successfully rearetl. Another classification of abortion sometimes used is that which divides the subject into " ovular abortion," occurring before the twentieth day, " embry- onic abortion," occurring between the twentieth and the ninetieth day, and " fotal abortion," occurring between the twelfth and the twenty-eighth week. Frequency. — Statistics as to the frequency of abortion are necessarily incomplete, and therefore unsatisfactory. A'^ery many abortions take place, especially during the first three months of pregnancy, that do not come to the knowledge of the physician, and it is fair to presume that prior to the third month an inunense number occur which are not even suspected by the patients themselves. The actual number of abortions, therefore, must largely be in excess of estimates based upon statistics of observed cases. The relative frccjuency of abortion to labor at term has been estimated varicisly by differ- ent authors as 1 : 5J and 1 : 8, while the relation based upon hospital statistics has been placal at from 1 : 75 to 1 : 80. According to some investigators, from thirty-five to forty out of one hundred mothers, to their own knowledge, have abortetl at least once before their thirtieth year. 1.-^ ^' I r! •! 260 AMERICAN TEXT-BOOK OF OBSTETRICH. il mi Time of Occurrence. — Abortions occur most frequently during the first, second, and third niontlis of pregnancy, when the ovum is usually thrown off in tofo. The throwing off' of the ovum so fre(]uently at this jK'riod is due in part to the great vascularity of the uterine mucous membrane at this time, in part to the feeble attachment of the undevelopetl chorionic villi to the decidua, in part to the space existing between the chi>rion and the deeidua reflexa (this latter allowing of the easy accumulation of blood between the membranes), as well as to the inability of the ovum at this early stage to offer sufficient resist- ance to disease-processes. The changes incidental to ])lacenta- formation is no doubt also an imjwrtant factor in the pro<luction of abortion at the third and fourth months. Abortion is more apt to take place ui)on the days correspond- ing with the menstrual periods. The disposition to abortion diminishes after the fourth month, as the placenta bci'omes more fully developed and the connec- tion between the ovum and uterus becomes stronger, and the uterus adjusts itself to the new order of things. Etiology. — Abortion is the direct result either of fetal death or of uterine contractions. The causes which result in fetal death or in uterine contractions are usually subdivided into those referable to the father, to the mother, or to the fetus, and may be either preiUsposiuc/ or exciting. Exciting causes, either alone or in connection with some j)reilisposition, act quickly and more directly upon the uterus or the ovum. Such are violent coitus, blows, falls, contusions, the jarring of railroad travel, missteps, run- ning of a sewing-machine, lifting of heavy weights, rapid stair-climbing, sea-bathing, stretching of the arms above the head, etc. Abortion produced for therapeutical purj)()ses will be treated of in another section. Exciting causes are generally only active in the presence of the predispos- ing ones, while many of the predisposing causes remain inactive except in connection with some exciting cause. We caiuiot, as a rule, say in a given case what will and what will not produce abortion, for on the one hand there are many notable instances where pregnancy has been terminated prematurely by the mildest of exciting causes in the a[)j)arent abseiuie of any i)re(iis- position, and on the other hand where the most serious traumatisms in the presence of a demonstrable i)redis])osition has failed to pn)duce abortion. Faterndl Cannes. — A syphilitic father may produce syphilis in the ovum without necessarily infecting the mother. Other causes on the part of the father are extreme youth and old age, debauchery, and feebleness. Maternal Causes. — Systemic, recurrent, or so-called " habit " abortion is jn'obably due not so much to a maternal constitutional predisposition, the result of habit, as was once t)elieved, as to a continuance of the origirud cause. 7)(bercuhsis and si/j)hi/is of the mother may destroy the fetus by transmission of these diseases either to the placenta or to the ovum, or simj)ly by lowering tlic mother's vitality. Sy])hilis is responsible for most recurrent abortions. The acute infectiouH diseases kill the fetus eitlu-r by the direct action of the poison transmitted through the placenta, by the action of high temperature, or by the tendency to placental hemorrhage jiroducetl by the disease-process. Diseases THE PATJIOLOGY OF PRKaXAXi'Y. 261 of the heart, Imh/s, lirrt; and kidnci/a destroy the fetus by producing passive congestions in tlie placenta. An excess of carbonic acid gas ; chronic lead-poisoning ; convulsive diseases, such as chorea, eclampsia, epilepsy ; excessive vomiting and cough- ing ; an irritable nervous organization and the habits associated with the extremes of social life ; excessive i)hysical exertion, fright, anxiety, and other emotional excitements, — are all more or less potent factors in the causation of abortion. Hot sitz- and loot-baths tend to produce abortion by dilating the pelvic blood-vessels, in this way causing an excessive amount of blood to be sent to the uterus. Among the local causes may specially be nv^iuIontJ subinvolution, acute and chronic inflammatory diseases of the uterus and its appendages, as well as tiunors, displacements, adhesions, and degenerations. Utidomctritis and retro- flc.vion. are particularly prone to act as inciters of uterine contractions. Adhe- sions of the uterus to adjoining organs, as well as tumors of the uterus and in its vicinity, contractinl pelvis, and tight-laciiig, occasionally cause fetal death by impeding the development of the uterus. While sun/ical operations of the most serious nature have been performed on the uterus and other pelvic organs during pregnancy without in any way influencing the ovum, operations of a minor kind upon distant organs have produced abortion. Fetal Cames. — Any morbid condition of the ovum or its appendages that endangers the life of the fetus is liable to bring about premature expulsion of the fetus. Syphilitic disease of the membranes and the placenta is a frequent cause. Among other causes may be mentioned hydrorrhea, cystic degenera- tion of the chorionic villi, placental apoplexy, and the various degenerations of the j)lacenta ; abnormal relations of placenta, especially placenta jjrjevia ; too short a cord and the knotting of the cord. Death of the fetus may be brought about by d'sease transmitted from or through the mother, such as syphilis, small-pox, and other infectious diseases, and rarely tuberculosis. Pathology. — Hemt»rrhage from rupture of the utero- placental vessels usually takes |)lace in the decidua vera, but the blood is often forced between the decidua and the chorion. Occasionally hemorrhage breaks through the decidua, and even through the amnion and into the anuiiotic cavity, filling tiie sac with blood. ITlerine contractions separate the chorionic villi from the decidua reflexa from above downward, and the detached ovum is forced into and through the dilated and thinned cervical canal. The decidua vera is usually the last to be expelled, and it is this that most fretiUfUtly remains long alter everything else has been discharged, owing to the inability of the unde- veloped Uterine musculature to entirely throw it off. The decidua reflexa may he torn, leaving the other memhranes intact, the chorion, amnion, embryo, and anuiiotic fluid being expelled first, followed by the rest. Rarely, the chorion ruptures with the decidua, leaving the amnion intact, cither entirely free from other membranes or perhaps covered at one point by chorion and decidua. Occasionally, owing to the rigidity of the external os, especially in prim- ipane, tiie ovum becomes fixed in the cervical canal, and it nuiy remain there .'I i 262 AMERICAN TEXT-BOOK OF OBSTETRICS. a long time unless relieved by incision. The term " cervical jiregnancy " has wrongly been applied to this condition. The appearance of the extruded mass (Figs. 147, 148) differs according to the causes, the time, and the duration of the abortion, but, as a rule, in tiie early months the ovum will be found imbedded in a large blood-clot, the coagnlum arranged in layers cor- responding with successive hemorrhages. When blood- cK)ts are formed at different times between the mem- branes, there results what is designated a " blood mole." If the coloring matter has been absorbed from these clots, the mass is called a " flesh mole." The fetus is usually much smaller than it would be at the same time under normal conditions, especially where the cause has been slow-acting. Sometimes the fetus can be recognized only by aid of the microscope, or it may have entirely disappeared after maceration in Fio. i47.-specimciis fnim ^^^^ liquor aumii. After partial maceration in tiie New York Hospital (iibintt, liquor anuiii the retained fetns mav dry up, and finallv sliowiiiK tho coiuiitiims in , n i • •(• i i' • i /• • ' wiiicii ova are found. bc cxijelletl ui a mummiiiea condition, or, putreiactive changes setting in, it may be exjielled piecemeal. Clinical History. — In a simple, uncomplicated case of abortion occurring before the third month of gestation the patient, with very little if any warn- ing, has a more or less profuse, generally continuous, hemorrhage from tiic uterus. After a variable period, more or less severe, regularly recurring modified labor-pains occur, due to uterine contractions. Under the influence of tiie uterine contractions the cervical canal is expanded, the external os is dilated, and the ovum is either forced out entire, imbedded in a large cU»t, Fl<i. 14K.-(ivuni iniln'<l(UMl in Ijlondclot (Alilfeld). or the embryo is first exj)elle(l, followed shortly by the already Iooscikm membranes. During the third and fourth months, owing to the more rigi< |t THE PATHOLOGY OF PREGNANCY. 263 condition of the cervix and external os, the pains bceonie niorc severe, more force being required of tiie uterus to overcome the resistance of these parts. Owing to the firmer connection of the oviihu* to tiie uterine surfaces, more force is also necessary for detaching tiie membranes, and, as the uterine muscle is still undeveloped, a greater length of time is taken to complete the abortion. The anmiotic sac in tiiese cases umally ruptures before the com))lete separation of the membranes ; the fetus is expelled, generally with a portion of the mem- branes ; and the remaining portions are finally entirely detachetl and forced out of the uterus. Afler the fifth month the process more and more resembles labor at term. The above outline of the clinical progress of simple, uncomplicated abor- tions occurring before and after placental formation probably does not repre- sent the class of cases usually coming under the physician's care. It will be well on this account to consider briefly the more common symptoms and variations in detail. Prodromal Ssmiptoms. — Reliable symptoms and signs indicative of ap- jiroaching abortion very rarely exist before the third month, and they arc not constant after that time. The occurrence of shifting pains in the back and abdomen, frequent urination, sometimes nausea and vomiting, and a mucous or watery disciiarge from the uterus sho»dd be a warning of the pos- sibility of approaching abortion, and early and appropriate treatment should 1)0 instituted. Duration of Abortion. — The duration of the abortive process varies accord- ing to the j)erio(l of gestation, the cause of the abortion, and the condition of the OS and cervix and the energy of the uterus. As a rule, abortion is slower tiian normal labor at term. Especially after a fall the ovum, in the earlier period of its development, may be thrown off and expelled instantaneously, or it may rapidly be expelled after a few gushes of blood and a single painful contraction. These cases, however, are but rarely observed. Hemorrhage and Pain. — In early abortion liemorrliage is the leading symptom, and it is the first that attracts attention in the majority of eases. It is often excessive and alarming, and may be so profuse as to endanger tiie niothci-'s life. Hemorrhage may i)reee(le pain many hours or even days and weeks, or in rare cases it may take place conjointly with pain. It may be very slight at first, cease after a variable period, and then recur, or it may l)('gin with a sudden ])rofuse discharge. Hemorrhage may take place contin- uously from the uterine surface, but it may oidy appear at intervals externally in the shape of clots, sometimes collecting in the uterus in considerable quanti- ties before being expelled. This "concealed hemorrhage" rarely happens Ijcfore the fourth or the fifth month of gestation. The amount of blood lost varies considerably with the period at which the hemorrhage occurs, being, as a rule, less the nearer the abortion is to the end of pregnancy, and it depends ((I a considerable degree uj)on the extent of separation of the ovum from the uterine wall, as well as ujH)n the activity of the uterine contractions. Gen- cnilly the hemorrhage will continue until the uterus is empty. Hemorrhage ; I i ( ? ! ( ; : I 'i i hf 1 f 1 fir f:. I, ^/ h i 264 AJfERICAN TEXT-BOOK OF OBSTETRICS. is sornetimos preceded in these cases by the passage of small quantities of dark-coloretl blowl-seriini. The pains of abortion, which resemble those of labor at term in many instances, vary considerably according to existing conditions. Many patients complain that abortion-pains are harder to bear than those of normal labor, and not so easily forgotten. In exceptional cases the pains may begin some time prior to the occnrrence of hemorrhage. Expulsion of Uterine Contaifii. — Instead of the membranes ancl the placenta being expelled with the fetns or shortly afterward, a jiortion or all of the placenta may remain behind, either only |)artially or wholly detached from the uterine wall, constitnting what is designated " incomplete abor- tion." There may be considerable delay before the remnants are entirely expelled, the process of nnaided expnlsion recpiiring days, weeks, and even months, for completion. So long as ".ny portion of the ovnin or its coverings remains in the uterns, just so long will the patient be subjected to the risk of hemorrhage and sepsis. Frequently after several days there is a return of hemorrhage and pain, with slow dilatation of the external os, and the decom- posing uterine contents come away piecemeal. Sometimes in twin pregnancies symptoms of threatened abortion will sub- side without rupture of the membranes, and the pregnancy Avill continue to term, at which period a living child will be born, and at the same time a dead fetus or "blighted ovum" will be expelled. Diagnosis. — While there is, as a rule, but little doubt as to the existence of abortion in the majority of cases coming under the physician's care, it is nevertheless true that there are cases where it is quite impossible to make a positive diagnosis, and others in which the diagnosis can only be arrived at after a searching examination into the history of the case, a careful analysis of the symptoms, and a thorough physical exploration. Where the entire ovum is expelled suddenly, as sometimes happens in early pregnancy after falls or blows, and the expelled mass is either lost or thrown away without being examined, a positive diagnosis is not possible. In dealing with a ease of iitcrine hemorrhage and pain, unless there be sufficient evidence of its cause, the first point to determine is as to the e.ri.'^tcnce of j)n'(/)i(tm'if. In the early months of gestation this determination may l)i> impossible, and in the absence of positive signs we can only presume that preg- naniy does or does not exist. It may be denie<l by those who may have an object in denying it, or it may be admitted by those who simply believe them- selves to be pregnant. Abortion may be sinuilated in the non-pregnant woman by dysmenorrhea, by pain and hemorrhage caused by the presence of submucous uterine tumors, and may even be feigned by hysterical girls at the menstrual period or l)y women with intention of blackmail. In the absence of a history of previous attacks of dysmenorrhea, and of a record " running over " two or three months, u vaginal examination should be insisted upon, which examination, with that of the napkins, would probably settle the diagnosis one way or the other. A carefid inquiry into the patient's history, together with THE PATHOLOGY OF PREGNANCY 205 physical exploration and examination of the discharges, will assist in clearing up doubts in the case of hemorrhage and pain from uterine tumors. The examination of membranes, clots, and pieces of tissue offered in evidence as to abortion will expose any attempt at malingering. Having determined that pregnancy exists in a case of suspected abortion, the next thing to be determined is whether we have to do with abortion ot with something sinudating it. Abdominal pain and uterine hemorrhage occurring at the same time in a woman supposed to be pregnant is presump- tive evidence, at least, of imi)ending abortion, but such evidence alone is not sufficient for a positive diagnosis. For instance, hemorrhage may take place from a diseased cervix in pregnant women, and at the same time there may be present intestinal colic, neuralgia, stretching of old visceral adhesions, or the discomfort of an over-distended bladder. Nor is the presence of membrane always positive evidence. In extra-uterine pregnancy the expulsion from the uterus of a deciduous membrane, together with more or less hemorrhage, may lead to a wrong diagnosis of abortion. In the latter case the absence of chorionic villi will count against the case being one of abortion. Pregnancy existing, and abortion determined upon as the cause of the symptoms, the next inquiry will be as to whether abortion is simply fhreatrn- Infj, whether it is inevitable, or whether it has been completed. Li threatening abortion the os uteri is undilated, the cervical canal is unoxpanded, the hemor- rhage is not profuse, and the ])ains are easily controlled. In inevitable abor- tion the OS is usually dilated sufficiently to admit the index finger, the cervical canal is expaniled or expanding, the angle between the upper and lower uterine segments is effiiced, the uterine contents are forced down within reach of the finger with each pain, and the hemorrhage and pains cannot be con- trolled ; or profuse hemorrhage alone, if uncontrollable, may be sufficient evi- dence of inevitable abortion. A critical examination of the discharges from the uterus by floating them in water will often determine whether or not the integ- rity of the ovum has been destroyed, and will thus assist the diagnosis. Abortion is complete when the uterus is free from ovular tissue. The continuance of pains or of hemorrhage, or both, is conclusive evidence that the abortion is incomplete. Prognosis and Sequelae. — For the child the prognosis is necessarily fiital. As a rule, the ])rognosis fi)r the mother is remarkably good, better even than after labor at term, a fatal termination rarely taking place except in badly- managed or neglected cases. The danger of general septic diseases is much less after early abortion than later. Even under conditions that would, if existing at the end of j>rcgh'Uicy, prove most disastrous, such as septic intox- ication from putrefaction of retained membranes, rapid disappearance of the symptoms is the rule in abortion under appropriate treatment. But while the immediate danger to the mother's life is less than it is at the termination of pregnancy, the pernicious consequences of neglected or badly-managed abor- tions are far more common, and not nearly so amenable to treatment. The nature and severity of the sccpielaj vary with the causes. Anenn'a, with great debility, consequent upon excessive hemorrhage at the time of 2(i6 AMERICAN TEXT- HOOK OF OBSTETIUCS. \A W -I i/ ■<r abortion or upon rocurring licniorrlKigcs, tlio result of subinvolution or of retained fetal membranes, is very fr('(|uently observed. Among the more eonnnon local results of abortion are acute and chronic inflammatory diseases of the uterus, the ovaries, and the tubes, and of adjacent structures, from a more or less marked septic infection. Such diseases are endometritis, acute cellulitis, pelvic peritonitis, ])elvi(! abscess, salpingitis, pyosalpinx, ofjphoritis, etc. Hydatidiforin moles, the result of retained chorion, and placental or decidual polypi, the result of retaine<l fragments of placenta or decidua, are often noticed. Secondary infectious are not infre(]uently encountered as a result of abortion. Suppurative arthritis may be mentioned as an ex- ample. One abortion nearly always predisposes to recurrences, giving rise to wiiat is known as "habitual abortion," indess the original cause be removed and the abortion be managed in a proper maimer. A most important sequel to abortion is its baneful effect, at times, upon the nervous system. There is scarcely a single manifestation of the so-called "functional nerve disorders," from slight irritability of temper or mental depression to actual insanity, that may not have its origin in a pathological condition the result of abortion. While local irritation alone may be respon- sible for some of these disorders, the possibility of autoinfection from the slow but continuous absorption of mildly septic material from a chronically inflamed mucou' surface should be borne in mind. Treatment. — In the treatment of abortion we have to consider — 1. Pro- phylaxis ; 2. Treatment of threatening abortion ; Ji. Management of actual abortion and treatment of its accidents ; 4. Treatment of incomplete abortion ; 5. After-management. Abortion is truly a surgical condition, and its treat- ment requires and should receive the application of the same well-known j)rin- ciples in regard to the prevention of sepsis as do other surgical affections. Surgical cleanliness is as much indicated in abortion as it is in labor at term. Prophijlaxis. — Tlie prophylaxis of abf)rtion consists in the treatment of all those general and local conditions which predispose the patient to its occur- rence, in the restoration of the patient as nearly as possible to normal health before and after conception, and in the avoidance after ])regnancy has begim of those exciting causes which are more or less prone to precipitate an abor- tion, at least in predisposed cases. T^ocal causes, such as tumors in and about the uterus, subinvolution, endometritis and other inflammations, displace- ments, etc., sliould be sought for and should appropriately be treated before conception. General pathological conditions, such as tuberculosis, syphilis, lucmii,, the neuroses, as well as diseases of the thoracic and abdominal viscera, • '>uld also receive treatment both before' and after i>regnancv has begun. As «\j)'iilis is probably resimnsible for a much larger number of abortions than aay olacr single cause, its presence in one or both parents should receive })roni[)t and thorough attention. In those instances where no other cause can be found and there is no indication of syphilis existing in either parent, father and mother should be placed under antisyphilitic remedies, as an apparently cured syphilis may still exist sutticiently to affect the ovum. During preg- ' 'I THE PATHOLOGY OF PREGNANCY. 267 nancy the jifi-oatcst care should be taken to avoid all jjossible sources of irritation, such as fatiguinj; work, too long walks, riding, dancing, lifting, reaching, stair-climbing, jumping, sea-bathing, corsets, tight clothing, conta- gious diseases, poorly-ventilated or overheated rooms, crowded theatres or crowded churches, emotional excitement, late hours, etc. The diet should be regulated carefully, in order that acute dyspepsia, fla*^«lence, colic, diarrhea, and constipation may be avoided, and the kidneys and the bowels should be r(>gidated properly. Coitus should be prohibited. The patient should, if possible, spend several days in bed at the times corresponding with the men- strual periods. A retroflexed uterus should carefully be righted and be held in position by an aj)|)ropriate pessary. In cases of habitual abortion it would be well for the patient to allow an interval of six months or a year to elapse between the last abortion and the next pregnar.cy while under treatment. In some cases confinement to bed the greater part of the time seems to be the only way in which pregnancy can be carried through to term. Treatment of Threatening Abortion. — If upon examination the os is found undilated, the cervical canal unexpanded, hemorrhage not profuse, and pains absent or moderate, the case shoidd be considered as preventible and be treated accordingly. If we knew for a certainty that the fetus was dead, there would be no reason for treating the case as preventible, but as there are no reliable signs of fetal death where abortion is only threatening, we must treat it as though the fetus were alive. Our aim is to prevent, if possible, any further separation of the ovum from the uterus, and to allow of the healing of the already injured surfaces. To this end we endeavor to control hemor- rhage and uterine coiitractionn. Absolute rest and quiet are essential to the proper treatment of threatening abortion. Tlie patient should be put to bed in the quietest, best-ventilated room in the house. She should maintain a recumbent position for sevei-al days or until all danger is past. She should not rise, even to a half-sitting ])osition, for any purpose, the bed-pan being used for defecation and urination. Everything having a tendency to produce nervous disturbance should be avoided, such as talking, visitors, and worry of any kind. Secure free move- ment of the bt)wels each day by sufficient doses of castor oil or other mild laxative, aided, if necessary, by enemata of glycerin and water or of sweet oil. The clothing should be cool and light, the diet nutritious and easily assim- ilated, but non-stimulating. In tiie way of drugs, opium in one of its forms is mostly to be relied upon as a general sedative. It should be given in full doses, and repeated often enough to preserve systemic quiet. In some cases it may be advantageous to give with the opium such nerve-sedatives as chloral hydrate, the bromids, or j>Iienacetin. These drugs should be given per rectum if the stomach is sen- sitive. The fluid extract of viburnum prunifolium in drachm doses is said to assist materially in quieting uterine contracticMis. Ergot in small doses (15 to 20 min. of the fluid extract) may be of benefit in selected cases (where there is 1' I ■ !"^ ';i^ 1 4'| ! I ■ 1^1 ; 1 , I i I 268 AMERICAN TEXT-BOOK OF OBNTETIiWS. little pain, hut much lioniorrhn<;o) in assisting in tlio control of hemorrhage by contracting the arterioles, bnt as a general thing it shonlil not be used, owing to the tendency for even small doses to excite uterine contractions. The vaf/lnal (ampnii, as a rule, should never be used in threatening abor- tion, on account of its action in exciting uterine contractions. In exceptional cases, however, where there is not much pain, but considerable hemorrhage which cannot be controlled by other means, the tampon may be useful in connection with the sedatives already mentioned. A vaginal injection of hot alum-solution (.^ss-Oj) may be used instead of the tampon. Any malposition of the uterus siiould l)e remedied by the gentlest manipulations. Treatment of Actual Abortion. — If the os is dilated and the cervical canal is expanded, or the pains and hemorrhage continue notwithstanding treatment, and there seems to be no prospect of checking the progress of the abortion," the expulsion of the ovum becomes inevitable. The main indication now will be to control hemorrliar/e and to secure complete evacuation of the uterus. If it has not been done before, the vagina and the external genitals should be placed in as nearly an aseptic condition as can be done with hot water, soap, and an antiseptic solution. The physician's hands and the instruments should also be rendered surgically clean before an examination is made. If the ovum is protruding with membranes unruptured, it may easily be dis- lodged from the cervical canal, but we should refrain from manipulations that miglu cause rupture before its complete extrusion. Before the fourth month we may best meet the indications — to control hemorrhage and to expedite delivery — by the use of a vaginal tampon. Properly applied, the tampon will surely con- trol hemorrhage ; further, it hastens the com- plete separation of the ovum by causing an accumulation of blood between the uterus and the membranes, and it is a powerful exciter of uterine contractions. The tampon may be made of a long strip of aseptic or antiseptic gauze, of pledgets of aseptic or antisejitic ab- sorbent cotton or wool, or, in the absence of these materials, of "My soft fabric, such as a silk handkerchief, a soft towel, or strips oi' pieces of sheeting, cheese-cloth, an ordinary roller bandage, etc. Whatever material is used, it is understood it nuist be stcrili/ed thor- oughly by boiling, by dry heat, or by steam, or it may be scalded thoroughly in some hot Fm.iio.-sims'simsition for tamponing autiscptic Solution. If a large number of aiulciiretlinK (.skonu). . ' .... j>ieces are used, as of antiseptic wool, they should be so secured to each other by a string as to facilitate their withdrawal. If the material has previously been prepared or if it can be sterilized by dry heat before using, it is better to use it without soaking in an antiseptic solii- -li s THE I'AriiOLoav or PiiixiXAXvY. 269 tion, as more accurate tamponade can l)o done when the tampon is dry than when it is wet. For introducing the tamjion the patient shoidd be placetl across the bed, or, better, on a table, in the dorsal or in Sims's position, with the hips at the edge of the bed or the table (Fig. 149). A very cojiioiis hot-water or hot antiseptic vaginal douche shotdd next be given, after the Fi<i. )"0.— Frozen section of the utonis, showing placenta iind partially-detached membranes (Frcund). Itladder has been emptied. The tamponing may be done with the aid of a Sims speculum if assistance is at hand ; if not, then a bivalve speculum may bo used, or, as is preferred by some, one or two fingers of (Mie hand are intro- ducetl into the vagina and there act as a guide. With dressing forceps one end of tlie strip of gauze or a pledget of the tampon material is passed into the vagina along the introduced fingers, and is accurately packed by |i^^: "Mi- ! I illfl' { ' J ijir Ail" ; I i' ill ' ' ft A k i i hi . * 1 W^'- hi "--ft. \i m: 270 AMEIUCAX TEXT-BOOK OF OBSTETRICS. them into, against, and about the os antl the cervix. The tamponing should be continued in this way until the vagina has been moderately filled. All antiseptic pad is placed over the vulva and is held in place by a T bandage. Moderate doses of fluid extract of ergot (iTtxv to oss) should be Fig. l')!,— Frozen section of the uterus, showinj; retained memliriuies (Freund). administered every two or three hours, together with quinin or strychin'a where these are indicated for debility. If there is much pain, 5 grains (tf phenacetin will give the patient comfort without interfering with uterine contractions. A second tampon and other accessories should be in readi- j; THK PATJfOLOaV OF PRKaXAXVY. 271 I108S before the removal of the first. Tlie tiunpon slioiihl Ik? remove*! earefiilly after from six to twelve hours, when, as is usual, the entire ovum or the fetus alone will he found in the vagina or adheriu}? to the tampon, ff the ovum has not been expelled or oidy a portion has been thrown oflf, we should tampon again, after emptying the bladder and douch- ing the vagina, in the same manner as before. If after the removal of the second tampon it is found that the membranes have ruptured, and oidy a portion, if any, of the ovum has been expelled, the uterine cavity shotUd be explored by the introduction of one or two thoroughly antiseptieized fingers, the vagina having first received a thorough cleansing with hot water or with antiseptic fluid. If much pain is to be fearwl or the patient is nervous and resisting, an anesthetic should be employed. If the OS is not sufficiently dilated to admit the finger, graduated metal or hard-rubber dilators should be employed. The introduction of the finger may be aided materially by })roperly applied counter-pressiu'c on the fundus through the abdominal walls. The cavity of the uterus must be explored thoroughly and the retained portions (Figs. 150, 151) be separated, if adherent, and removed. In case the use of the finger is unsuccessful, the adherent mass should be removed by the careful use of a not too sharp intra-uterine curette. The instrument devised by Carl Braun or one similar to it answers the purpose admirably, being at the same tiiiie a curette and an irrigator. Either ])lain hot water or a hot mildly antiseptic solution of creolin (1 to 2 per cent.) or of boric acid (4 per cent.) or straw-colored tincture of iodin, are recora- inendcd for irrigating the uterus, as being the fluids least liable to do harm. In the use of the curette great care shoukl be observed lest more harm be (lone than the good we seek to acconiplish. The dangers to be avoided are perforation of the uterus by careless manipulation, and in needlessly injuring, hy indiscriminate curettage, uninvolved mucous membrane. After complete emptying and irrigation of the uterus in this way an antiseptic pad should be placed against the vulva. The tampon is contra-indicated in abortion after the fourth or the fifth month, as the uterus at this period is sufficiently large to contain considerable l)lo()d. Fov the control of hemorrhage rupturing of the membranes is to be |)referred, but if tamponage is resorted to the uterus must closely be watched. The incfFectual uterine contractions usually found may be stimulated by from ')- to 10-grain doses of quinin. If after rupture of the membranes, liemorrhage continues, the uterus must be emptied as quickly as possible, the cervix being dilatetl if necessary, the fetus be extracted, preferably by turning, and the placenta be removed if detached or easily detachable. If the placenta is firndy adherent, it may safely be left for a few days to become detached by natural means, provided the uterus and the vagina can properly be irrigated antiseptically, the former twice in twenty-four hours, the latter from four to six times or continuously. The insertion into the uterus of an iodoform- nanze tampon has been used successfully in these cases. After the pla- centa has become detached, it and the remaining adherent fragments may be \ii -m irfi IF ■mr u 272 AMFJtIVAy TEXT-nOOK OF OJiSTKTIilVS, rlJ i / I (■ reruovtil in tlio niaiiner already (U'st'rihod, oitlior by moans of tlio fingers or the curette. Tiratincut of T)icnmj>frtr Abortion. — If tlioro is, after the apparent com- pletion of abortion, more or less hemorrhaj^e, either eontinuons or interrupted, with slijrhtly dihited os and flabby cervix, especially if there be pain and an odor of drcomposition, it is evident that some portion of the ovnm still remains in the ntenis. In tl>e mildet^t cases, in which there is as yet no infection of the retained j)ortion and the os is contracted, conservative measures might l)e ailvisable in tliose cases tliat could Ih' kept under observation and in those in which the treatment could properly be carried out. Such conservative treatment woidtl consist in keeping the j)atient quietly ih bed, stimulating uterine contrac- tions by repeated moderate doses of ergot and by the use of the vaginal tampon, and by keeping the vagina and the vulvu in a strictly aseptic con- dition. In neglected cases, where there is nuich hemorrhage or pain, and especially if there be even a minimum amount of fetid odor to the lochia as it comes from the uterus, the indications arc clearly to empty the uterus com])lctely and at once — with the fingers if possible, with tlu' curette if necessary ; to render the uterus and the vagina as nearly aseptic as possible by antiseptic irrigation, and to keep them so. In the treatment of incomplete abortion, whether the case is seen early or late, there should be observed the same rigid adherence to the principles of asej)tic or antiseptic surgery as is observed in any other case. After-management of Abortion. — There is no valid reason why the woman who has aborted should not require as much time for the repair of uterine lesions and for the proper involution of her eidarged uterus as does the woman who has been delivered at term. Owing to the inn)erfect develojiment of the enlarged uterus after abortion, the process of involution is even shnver than the same ))rocess after labor at term. There would be a marked decrease in the number of pelvic disorders, and there would be almost as great a falling off in the number of abortions, if wonien \ ere treated after aborting more nearly as they arc after a normal labor. Missed Abortion and Missed Labor.-- Am a child at full term may die and may remain in ntero for weeks or for months afterward, this condition is called *' missed labor." A similar conditicn — missed abortion — is observed in the earlier months of pregnancy when the fetus dies, the ovum remaining in utero for weeks or for months. The symptoms of pregnancy are then arrested ; the liquor amnii is absorbed, the abdomen becomes smaller, and milk appeals in the breasts. The child in ntero, surrounded by the placenta and the mem- branes, becomes macerated or mummiHcd. It does not necessarily become putrid, because the unbroken membranes prevent the entrance of atmospheric germs. In these cases labor does not come on at all, or, having commenced, the ])ains cease and the fetus is retained. Oldham was the first to ai)ply the term "missed labor" to cases in wliicli occurred ii the iiqiioi- to whether access to tl condition I somewhat, tion of all parts beinj; uterine wal through th( peritonitis, ,' hut convale.' and the fctu Hed product it n)ay cause results. I}es may lead to i A dead : generally ser ('onseqiiently iew weeks, an to induce lalx <';uition is safi WJien nature active efforts be emj)loyed Ijc exercised t «'mia. Lapa very thing to > Miiller of are really case.* <'-\'pulsion, bee; it may be sai( fetation of the ft'tii.- in a biloh History. — E pathology, and sions and 'las c or twenty years attention. Froi of many jiractic 'lot quite unkno 18 Tin: PATiroLoav or pjiKayAxrv 273 occurred ineffective uterine eH'orts to expel the fJ'tns ami other contents except the litpior aninii. Air does or tloe.s not enter the uterine cavity accordiii}; tis to whether tiie membranes are or are not ruptured. If atmosplicrie air lias access to th(? fetus, the hitter undergoes putrefactive ciianges, i^ivinj; rise; to a condition Iviiown as jihi/xomrtnt, or fi/inpaniltH uteri ; the soft jtarts licpjefy somewhat, then escape, k'aviii}^ tlie osseous structure. A coinph'tc evacua- tion of all the fetul structures is rarely effected l)y riture alone. Some of the parts beinijj retained, the projectiui:; hones may ))enetrate the surrounding uterine walls, and find their way into the vaji^ina, the rectum, the bladder, or through the abdominal walls. A similar action may lead to suppuratitm, peritonitis, septi(!emia, and death. Most cases, however, eventually recover, but convalescence is long and very tedious. If air is excluded from the uterus and the fetus is retain<;d, the latter may become mummified, and this mummi- fied pro(hict may remain indefinitely without creating special harm. Possibly it may Ccausc irritation, suppuration, and uterine or pelvic abscess and their results. Jk'sides maceration and mummification a prohniged fetal retention may lead to adipocerous changes. Calcification very rarely oreurs. A dead fetus within the uterine cavity, although no air has entered, generally seriously impairs ti.j health and endangers the life of th(> woman. Conserpiently, in cases of this kind it is always prudent, after the la|)se of a i'iiw weeks, and when there is no physical evidence of a commencing expulsion, to induce labor artificially — an oltstetrical procedure which under careful pre- (•aution is safe, infinitely more so than allowing the dead fetal mass to remain. When nature is successful in partially eliminating some of the fetal portions, active efforts by the hand or by instruments, after cervical dilatation, sliould be employed to aid the woman. Every known antiseptic precaution shoidd be exercised to prevent or to control hectic symptoms, peritonitis, and septi- cemia. Laparotomy, laparo-hysterectomy, or a Porro operation may be the verv thing to do under certain circumstances. ^liiller of Xancy has shown that many cas(>s of so-called " missed labor" are really cases of extra-uterine pregnancy, with ineffectual attempts at fetal expulsion, because of a certain position of the fetal body. With fair propriety it may be said that most of these cases are those of advanced extra-uterine fetation of the intramural (interstitial) or tubal Viiriety, or (>f retention of the fetu- in a bilobed uterus. 7. Extra-uterine Pregnancy. History. — Extra-uterine pregnancy from the standjioint of its etiology, pathology, and operative treatment has provoked such numerous discus- sions and 'las called forth so many valuable essays within the past fifteen or twenty years that the historical side of the subject iias received but little attention. From this one-sided view the impression has arisen in the minds of many practical men that this anomalous form of gestation was almost if not quite unknown even to our immiMliate predecessors. A research into the 18 Ml f^^ 'IP 'p ,' ; ' i:l :i ' lii ^\^- i/ 274 AMKIx'ICAN TEXT- HOOK OF OliSTF/riilCS. niodioal litoratiire of the past four ccnturios, however, brinj^s to lifjlit many clear descriplioiis of well-recoirnizcd cases of extra-uterine prejinaiiey. Israel Spacli ii his extensive fiyneeolot;ieal work, ])nl)lishe(l in 1597, figures a liiliopedion drawn m i^Ua upon a fnll-lent;th cut of a wofuan with the belly laid open. He df>di<'!ited to this ealeified fetus, which he rejjjarded as a rever- sion, the followinj:; eurio'.s i-pij^rani, in allusion to the classical niytii that after the flooil the world was re|)opulated by the two survivors, Deucalion and Pyrrlia, walking over the earth casting behind them stones which on striking the ground becaiue jieople. Roughly translated from the Tiatin, this epigram reads as follows : " Deucalion cast stones behind him and thus fashit)ned our tender race fi-oni the hard marble. How comes it that now-a-days by a reversal of things the tender bodv of a little babe has limbs nearer akin to .stone?" We find many of the earliest writers mentioning this form of fetation as a curiosity, but offering no explanation as to its cause. One of the first and most natural suggestions was that the fetus had died in idcro, and aftcrwarii had become displaced into the abdominal cavity, where it excited suppuration and thus was finally discharged. An important discussion was called forth in 1669 by the case of Benedict Vassal, a surgeon in Corrari, Italy. The great obstetrician Mauriceau's draw- ing (Fig. l'")2) of the specimen obtained shortly after the autopsy is remark- ably clear, and it well supports his judgment that this was not a tubal preg- nancy as asserted. His description of tiie case is well worth quoting even at this day ; translated freely, it is as follows : " History of a woman in whose abilomen there was found, after death, a small fetus about 2% inches long, together with a great quantity of coagulated blood. " The history of this ease deserves to be carefully considered to decide whether the fetus, as believed by many, was generatetl in tlie ejaculatory ves- sel, called the tube of the womb. On the sixth of January, 1669, in the village Corrari, I saw in the hands of a surgeon named Benalict Vassal a uterus which he had removed a short time before from the body of a woman aged thirty -two, who had died after three days of the most agonizing pains in the stomach, from which she had fallen into frequent fainting spells and th(> most violent convulsions. This woman had borne eleven children at term, but in her twelftli pregnancy, at about two and a half months, the womi) dilated in the direction of the riglit horn, and, unable to withstand this disten- tion, ruptured. The fetus was expelled into the abdomen, and was fi>und with a great quantity of coagulated blood among the intestines of the mother. Many physicians, surgeons, and naturalists betook themselves to this surgeon to see the uterus which was exhibited by him as a prodigy, as he insisted thai the fetus was formed in the ejaculatory vessel, which Fallopius calls ' the triun- pet of the womb.' They ac<'epted at once, without further investigation, that this was just as the said surgeon claimed, and that this case confirmed stories of a like nature narrated by Riolanus. However, I examined the parts of thi- TIIK PATirOLOGY OF PTiT-MXANCY. 27r> ntonis most carofully and minutoly, and it was evident to mo that those wlio aoecptod this opinion had been letl into error ; for this reason, tliat at tlie time I made a (h'awing of the womb as it tiion appeared, and this is a more faithfnl a>ul aceurato repnuhiction than that which tiiis snrjjeon had engraved npon eopper after a n;onth had ehipsed, as tlie uterus then retained ahnost nothing of its i)rimitive form, and was spoiU'd by the handling of a tliousand men or more who had seen the utcrns, pulled it, disturbed it, and tin'ned it inside out that they might examine it. " Many have addneetl this ease to prove to us that the testes " [ovaries] " of women are full of little ova which at the moment of coitus free them- selves and emerge from the body proper of the testes, and are thence borne into the uterus through the tube, to serve for the generation of the fetus. They claim that one of those so-called ova had by chance romainetl in the tube of this woman, instead of passing forward into the uterus, and that this was the cause of her death. " Regner de Graaf among others holds this opinion, for the confirmation of which he brings forward the figure of this uterus, which the surgeon of whom I have spoken had already given to the public ; as one finds it on the 260th page of his book on the ' Generative Organs of Women.' Any one .^f^^^ Km. 152.— Cast' (if I'Xtni-iili'riiU' prcnimncy liuiiviMl by Mimrici'iiu, ri'dniwii, Imt p n.'Ucnlly unrhniiKod. The Ictus is here slunvii iiltiuhiil to tlu> siic, wliich wiis not the caso in liis lii;ui . Tlic ilistiiict in'ck IwUM'i'll tile sue Mild llu' llti'lMis is ovidolll •, tlic n>illid liniiiiifiit cniiu's mil nf llii' iiiu t'l siirl'iicc (il'tl.c sue iimri' tcixviird its outor polo. Tlio roliitiiiiis of ii tioniml iitorus iirc in lii •■|<mI Py M;;iirii'i'iui in dotti'd liiio.s, who will examine, earefidly and without prei.ulicc sin ..lilowing figure, which is ino.st faithful and faultless, and at the .siiue time It kIc into our reasons, will Hiitl that we have given another demonstri'tion wli:<l; we believe to be the true explanation." ii: ! ! r \i ii ^"^'^ 1 'v.^i ii; ii-- ili'i _jr ' . 1 f i! i'\ 276 AMERICAN TEXT-BOOK OF OBSTETRTCS. r I ' <'. 4 Miiiiriccan with groat insiglit tlion oltos the anatoniioal relation of the round ligaments to the bodv of the uterus as substantiating his view of the ease. He says, " Beliokl how elearly I demonstrate that this part in which the ehild was contained was a portion of the body pro))er of the womb, and not the tuba uterina, and this because the round ligament is constantly attached directly to the lateral wall of the body of the womb, called the cornu, and at this place it becomes fused with the substance of the womb. It is therefore certain that the ])art where the ligament ended (Fig. 162); and at which it was strongly attached on the right side, where the malformation existed, was a portion of the womb its<>lf ; consequently the child was engen- dered in a ])art of the womb that was elongated." It is interesting in this connection to note that Mauriceau, in this differen- tial diagnosis, anticipated some of the results of our latest investigations con- cerning the differences between tubal and corinial interstitial pregnancy and Fiii. 153.— Koduci'd (iguro of Dciitsi'li's cn»c of iitnlomiiml prciriinnpy dm norouiit nf which was putilishiil ill ITUSt witli lifi'-si/t' cdpiior-iplati' onuraviii),'.-). pregnancy in a rudimentary horn. From the above it is evident that Maiiii- ceau was positive that impregnation had not occurred in the Fallopian tiilic, but in one cornu of tiie uterus, and that the ovum had devcl(»i)ed as a hcrni;i from the uterus. I find that liegner de Graaf, just as Mauriceau states, accepted the view of Vassal, and in his description of the Fallopiiin till' reports the case and reproduces th< figure from tlie copper plutc wh" u Man.' IsUcM THE PATHOLOGY OF PREGNANCY. 277 eoau condemns. De Graaf believed this to be a case substantiating his own tlieory regarding the function of the ovaries and the Fallopian tube. He says, " AVe Judge that the tulxs called Fallopian in women and in every kind of female arc true vasa deferentia, or, if you prefer, oviducts, inasmuch as the ova are transmitted through them to the uterus." He further says, "The tube or horn [Falloj)ian tube] of the wond) is dilated and affected by semen corrupted there and seeking an outlet ; but it is remarkable that the male semen should reach that point and that a fetus should have been conceived there, as is proved by histories." De Graaf believed that the ova were fertilized in the ovaries and that they were then carried downward into the uterus, where they remained until the full term of gestation was eomj)leted. He does not offer any explanation for the arrest and development of the ovum in the tube ; on the contrary, he dis- tinctly states that he does not know why it occurs. He recognized, however, the dangers of this anomalous pregnancy, as indicated by the following state- ment : "The ovum already fertilized is detainetl in its transit in the tubes, and by its increase in size brings death to the mother." In his critical remarks upon Vassal's case he says : " And from this our opinion it is not difficult to explain how a fetus occasionally develops in the abdominal cavity among the intestines, inasnmch as the ova already impregnated fidl from the testes" [ovaries] " outside the cavity of the tubes and are nourished by the neigh- boring parts." From these references to the earlier literature it will be seen that ectopic gestation was clearly recognizetl, its symptoms graphically described, and the theories advanced those that are accepted by many writers of the present day. Numerous other coiuributions are found in the literature of this subject, following De Graaf and Mauriceau, one of the most interesting being figured in the obstetrical work of Peter Dionis of l*aris, published in j . early part of t!>e ei$rhteenth century. Evn so early as J 741, Bianchi constructed an elaborate classification of the foi'ViS oC extra-uterine pregnancy, that was simplifietl by Boehnier in 1752, ,vlic 'K-iiibed three forms — " gestatio ovariea," " gestatio tubaria," and " ges- tatio a lop iiijlis." From the time of Boehmer a period of fi)rty-nine years intcrveucii in which this classification remained practically unchanged. In 1801, Schmidt described the interstitial fi)rm of ectopic gestation, and with this addition Boehmer's classification must practically be accepted even at the ])resent day, with the exception of a primary abdominal form. Mhlogi/. — Xo entirely satisfactory conclusions have yet been reached "e.'^iii'ding the cause of this anomalous form of pregnancy. Among many il;"ories none have been demonstrated. One great difficidty lies in the fact tii;' it has not yet been determined at what point in the female genital tract ii.'.r'ial impregnation of the ovum takes place, and until this question is settled the primary question, whether extra-uterine fetation is an abnormal ectopic impregnation or is simply a detained impregnated ovum, must remain unanswered. Many claim that the seat of coalescence of the male and the • jj mMi> |ffi|^)' 1 H^^ti u it mm M^i - ■ -ran, -VTH?-. 278 AMERICAN TEXT- BO OK OF OBSTETRICS. '1 ill \f I i| female elements is nornially in the Fallopian tube. If this claim be admitted, it can readily be seen how u variety of causes might operate to detain the ovum in the tube, where it may continue to develop extra-uterine. Chief among the causes ascribed a few years ago, at the revival of this subject, was the loss of the tubal ciliated epithelium, which would manifestly conspire to prevent the ovum from being carried on down into the uterus ; other causes cited have been flexions of the tube, dilatations and diverticula, constrictions from inflam- matory changes, and polypi in the tube, closing its Itniien like a valve. While a variety of causes may operate, it is most jirobable, from the frequency with which old inflammatory disease is found coexisting on the other side, that most cases of tubal gestation arise from ileus of the tube, resulting in an inability to transmit the contents of the tulie, due to adhesions. An imjiortant '"a''.se, operating in cases where the pregnancy is toward the outer end of tli iMue, is the })resence of a diverticulum, as pointed out by J. W. Williams. Clasfiificafion : Prhnanj Foi > -The primary forms of extra-uterine preg- nancy are classified as follows : ( Tnbo-uterineor interstitial. 1. Tubal : <^ Isthmial. 2. Ovarian. ( Ampullar. Secondary forms are derived from the primary, as follows: / X 7-. ,1 r Uterine; / \ -e ii f Tubo-ovarian ; {(t) trom the ) „ , ,.' , (c) Irom the I 41 i • , ' ^ ' .... 1 < Jiroad ngament; ^ ' u \ Alxlomnial: rstitial: .1 i .*^ 1 ' ampullar: ) ,, , ,. ' . (^ Abdoninial. ' (^Jiroad ligament. f Abdominal ; {(1) From the J Abdominal ; 1^ Broad ligament. ovarian : | Tubo-ovarian. In tubal pregnancy, when the fertilized ovum develops out near the fimbri- ated extremity of the tube it is called ampullar ; at the inner portion of tlie tube it is called idhiaial ; while in that part of the tube which tras'crses the uterine wall it is designated intrrxtitial or fnljo-uterinc. It is in the latter form that the term extra-uterine pregnancy becomes a misnomer, as the conception is not, strictly speaking, extra-uterine, being enclosed in the wall of the uterus, although outside its cavity. For this reason Mr. Tait suggested the term ectopic gestation. Many writers, more ])ractical than scientific, were mis- led by ]Mr. Tait's dicta to go so far as to hold that there is but one form of ectopic gestation — namely, the tubal — and so able a pathologist as IJIand Sutton gives them countenance by his denial of the ovarian and abdominal forms, as he considers the cases which have been reported do not sufficiently demonstrate their existence. Xo criticism, however, has yet succeeded in destroying the claims of cases of Leopold, Patenko, and ^Fartin, which wo must accept as primarily ovarian. In Ijcopold's case the j)atient was operated upon for a pelvic tumor of twenty-five years' standing that jiroved to be iu\ ovarian tumor containing a lithopedion. In the walls of the tumor ovarian stroma was clearly demonstratetl. Patenko's case is even more striking. The right ovary was the size of a hen's egg, and it contained a cvst with smootli walls in which was found a yellow body, the size of a hazel-nut, composed of niterstiti (h) From the isthmial Tin-: PATHOLOGY OF PREGXAM'Y. 279 cylin<lric<al and flat bones. These bones, which were subniitted to a careful microscopical examination, were tbniul to be fetal in origin and not the product of" a dermoid cyst. The enveloping wall contained corpora lutea and fV)llieles. The tube of the aft'ected side had no adventitious connection with the ovary, and its fimbriated extremity was entirely free, although the internal ostium was closed and some of the fimbria; were gone. Opponents of the theory of ovarian j)regnancy take exception to this case, claiming that the gestation was primarily tubal, and that a so-called "tubal abortion" had occurred into the ovary, and that later tl»e ovary and the tube had become detached from each other ! Martin of Berlin re]iorts two cases which he believes to be examples of undoubted primary ovarian pregnancy. In these cases the gestation-sac was Fig. IM.— I'rof. Aiigiist Mnrtin's cnso of oviirinn prcfiiiniicy. Tho intiict tube is st'on lying above the oviiriun siiu cuiiluiniiig tho IVtiil unvolnpi's. sitiuited entirely within the ovary, the fimbriated extremity of the tube being intact. As an explanation of ovarian pregnancy ^lartin advances the very natural suggestion that \\\c spermatozoini finds its way through the fimbriated extremity of the tube into one of the small recently-ruptured cysts so fre- ([uently found on the surface of the ovary, and that it there ct)alesces with the ovum. Too few observations have yet been made to prove the possibility of pri- mary abdominal pregnancy, although the case of Schlcctendahl is diilicult to explain upon any other hypothesis. In this case a fetus measuring 15 centi- meters (6 inches) in length was found attached to the abdominal wall near the spleen in a woman who had died of hemorrhage. The gestation-sac was sur- rounded by adherent intestines, and the uterus and appendages appeared nor- mal. For the present, however, only two primary forms of ecto]ue gestation — tubal and ovarian — can positively be accepted. Practically, tubal pregnancy is the only primary form found. I ii'iil ri ; ^i'f itf ; / ,7 1 , ' i 1 '1 1 H 280 AMERICA X TEXT-BOOK OF OBSTETRICS. Secondurii Forms. — The secondary forms of ectopic pregnancy are derived- froin the j)rinuirv. The tubo-iiteriiie or interstitial pregnancy may rupture into the uterus and be followed ii.inu'diately by expulsion of the fetus, or it may go on to full term and be delivered in the natural way. This mode of termination, unfortunately, is rarer than two other possibilities — namely, rup- ture into tiie abdominal cavity or rupture into the broad ligament. In the istlunial form of tubal pregnau«;y the rupture occurs either into the abdominal cavity, thus forming a secondary abdominal pregnancy, or into the broad ligament, forming extra-peritoneal, broad-ligament pregnancy. The ampullar form of tubal pregnancy gives rise to secondary tubo-ovarian, abdominal, or broad-ligament pregnancy. Tubal Pregnancy, — In the first week after fetuindation of the ovum the tube begins to thicken, due chiefly lo vascularization without hypertrophy of the muscular fibres. In this respect the tubal envelope differs in its develop- ment from that of the uterine nniscle in normal pregnancy. In the latter case there is hypertrophy of the individual muscle-fibres to eleven times their length in a normal non-pregnant uterus ; the connective tissue, peritoneal covering, blood-vessels, and iymi)hatics being also increased by hypertrophy and hyperplasia, so that at full term the uterus weighs two pounds instead of two ounces, the weight of u ^ rgi ..1 uterus. The thickening in the pregnant Fallopian tube is due to excessive vascularization with but slight increase in the tissue-elements. As the pregnancy progresses the wall of the tube becomes thinned and stretched until in some cases it appears as a thin transparent mem- brane composed only of an attenuated stratum of muscle covered with peritoneum. The development of the fetal membranes derived from the ovum, with the exception of the placenta, is the same as in intra-uterine pregnancy. Nor- mally, the placenta is derived about equally from the decidua serotina of the uterus and the chorion frondosum of the ovum. In tubal pregnancy Bland Sutton holds that the placenta is largely fetal in its origin. As the embryo increases in size and the walls of the tube become stretched, the plicae in the mucous membrane lose their characteristic appearance and are gradually smoothed out. During the first four to six weeks the abdominal ostium of the tube becomes hermetically sealed. Until the fetal membranes are well formed the life of the fetus is in constant jeopardy, as the chorionic villi have but a feeble hold upon their points of attachment to the tube and may easily be dislodged. This termination is most favorable from the first to the third week of the pregnancy, and it may be so harmless as to give rise to no serious discomfort. An apoplectic ovum thus detached appears as a lump of coagulum, and unless carefully examined its true character n)ay be overlooked. Such bodies, known as "tubal moles," are absolute proof of the nature of the ])athological condition. As the pregnancy advances the formation of the tubal mole is attended with much greater danger, as the accompanying hemorrhage ofi?n causes rupture of the tube, followed by rapid death of the mother. These moles, if recent in origin, will be found to contain the embryo and its mem- THE PATHOLOGY OF PREGNANCY. 281 braiies. The absolute diagnostic point Is the discovery of chorionic villi or of the embryo itself. If extruded into the abdominal cavity or into the broad ligament the mole loses its characteristic appearance and soon becomes envel- oped in a yellowish coat of fibrin, and there may be such complete disinte- gration of the fetal tissues as entirely to obliterate its embryonic characteristics. The villi, however, are most persistent, and they may be found after the other evidences of their origin have disappeared. These villi have the same appear- ance under the microscope as those of normal pregnancy. If the ovum continues to grow, the point at which the placenta is attached is of the greatest importance to the mother, as upon this largely depends her chance for life in case of rupture. If the placenta is implanted on the superior wall of the tube, the mother is in constant peril, as rupture here may be fol- lowed by frightful hemorrhage, the lacerated or detached placenta having no counter-pressure to control its bleeding, as is the case when it is attached to the floor of the tube. For this reason many surgeons claim that this termi- nation is invariably fatal. If the placenta is implanted v,' the floor of the tube, the chances of rupture are not necessarily decreased, but the dangers attending this accident are far less to the mother. In this position the pla- centa is pushed downward against the resisting pelvic floor, insimiating itself between the layers of the broad ligament. If the embryo is extruded through the upper wall of the tube, the placenta may still retain a firm attachment and only slight hemorrhage follow, and the immediate danger be escaped in this way. Occasionally the ovum is lightly attached in the ampullar extremity of the tube, and is extruded into the abdominal cavity without rupture of tne tubal walls. This extrusion is known as " tubal abortion." As evidence of this the fimbriated extremity of the tube is found enlarged and patulous, and there is free blootl in the abdominal «;avity, in which the tubal mole may be found if the abortion is recent. Tubo-uterine or Interstitial Gestation. — The history of the embryonic development in this type of ectopic gestation differs from the tubal proper on account of its difference in environment. Here the muscular fibres of the uterus undergo the same changes as in normal pregnancy. Rupture is almost inevitable, but it docs not occur so early as in the tubal variety, on account of the greater thickness of the walls surrounding the gestation-sac. Ilecker oollcctei^^l twenty-six cases in which rupture occurred before the sixth month. The fetus occasionally escapes into the uterus, and it is either expelled at once or it goes on to regular term and is born in the natural way. Rupture occurs most frequently into the abdominal cavity, and in such cases the hcm- orriiage is profuse and usually terminates the patient's life in a short time. Interstitial pregnancy is rarely recognized before rupture. Rapture of (he Sac. — The time of rupture of the sac depends u])on its lociition and, to a certain extent, upon the attachment of the ])la('enta. la tubal ])regnancv primary rupture occui's usually between the second and the fiinrtcenth week. When tiie placenta is implanted on the floor of the tube, the probability is that the rupture will not take place so early as when it is situated 5:' m *'* .t t in ! I- i\ 4 Jfi ( I i SI 282 AMERICAN TEXT-BOOK OF OJiSTETllJCS. on the superior wall. Tlio causes of rupture are tliiiuiiug of the walls of the tubes beyoud the liuiits of elasticity, heiuorrhage into the sac, traumatism, and If the patient survive the primary rup- ture, the fetus niav still contiiuio gradual enlargement of tiie embryo. to develoj), either burrow'ug down- ward between the layers of the broad ligament or growing upward into the peritoneal cavity among the intestines. The injury to the ])lacenta is nuich less when it is situated on the jielvic floor, as the displacement is not so marked, the hemorrhage is not so ])rofnse, and consequently the lives of the fetus and the mother are in less jeopardy at the time of rupture. If blood is poured into the peritoneal cav- ity, it will usually be absorbed; if the collection of blood oecin's be- tween the layers of the broad liga- ment, it constitutes pelvic hemato- cele (Fig. 155). When the fetus becomes intra-ligamentary and continues its development in that position, it is known as broad-liijiuncnt (/cshtfion. After the twelfth week the sac is liable Fui. 155. — I>iiinriiiii showing pi'lvit' lu'iniitoccU' posto- rior to tlie utorus, whicli is crowdi'd forwanl willi tlio blndcU'r bi'himl tlio symphysis imbis, wliilo tlio ri'Ctiiiu is romi)ri'ssf(i l)oliin(l n>;iiiiist tlu' siioniiu (Skenrl. 4i>\\X^ ,;f '! /-^ \o> %>«j,. *<'>■• .:m^ " '.• ?;t> -. .. Fig. irifi.— Riipturcil loft tulml prt'j;iimu'y, IVtiis still iittuclicil iiiiil lylnn within the pi'lvis. Hydnisiil- piiix and ndln'sidiis on the rinht side. I'tiTiis disphu rd towiml tlio rinht by tho sac: » is the fiuulus uteri; r, the rectum; t, the rinht closed tube; ,/', the fetus; and .-•, the ruiiturcd extra-uterine sac. to secondary rupture at any time up to term. Here again the situation of the placenta is of the same importance in the prognosis as in the primary rupture. The Fetus. — The question as to the possibility of life for the fetus is iuHu- enced by the location of the ])regnancy. In the tubal variety the most favor- THi: I'ATIIOLOGY OF PliEGNAXVY, 283 llSlll- al)lo attuclnncnt of the plucenta is on the floor of" the Fallopian tube, as there may be .sli<>l)t it" any distnrbance of the fetal circnlation if the rnpture be in the .superior wall of the tube, when the child may <;(> on to full term (Figs. 156, 157). Even, however, if the ectopic fetu.s be delivered alive, it i.s often deformed and puny and rarely lives more than a few day.s. For this reason its life should be but little regarded in the tieatnient of ectopic gestation. The <lispo.sal which nature makes of the fetus in case the mother survives the rupture is also of considerable interest. The dead en)bryo lying free in the abdominal caviiy may be completely absorbed up to the .se<!ond month ; after that period it either undergoes mummification, calcification, or is eon- verted into adipocere, or decomposes. Mummification is analogous to the change which bodies undergo in a dry atmosphere. A mummified fetus in its general appearance closely resembles bodies found in arid regions buried iu Fig. 1.')7.— ("iirimiil iiicf,'iiniK'y. In tliis cnsc ni|itnn' occiirreil in llic rislit iiniloveUipcd oorim of a bii'oriuito iitiTus i^l'rum n spucimon pri'Sfiiti'd to the writer by Dr. Wiitson of Biiltiniori'). dry soil or in sand or exposed to the air. The fluid con.stitiients of the extra- uterine gestation are tibsorbed, and the soft tissues become leathery or parch- ment like. In other eases the fatty elements are converted into adipocere or into ammoniacal soap in the pre.^ienee of ammonia formed by the decom- position of the tissues. Either the mummified or the adipocere fetus may still midergo further change and become partially or wholly calcified. This pro- cess is not entirely confined to the superficial parts, as there have been described a number of specimens which exhibited the saponaceous or the nmmmification process on the exterior while the internal organs were calcified. A fetus which has undergone calcification is known as a lUhopalion. The fetal mass may remain indefinitely in the abdominal cavity without giving rise to any discomfort to the mother. Cases are reported in which •W\ %'h^" ki* >f 'V f ■ 284 AMKItlVAN TEXT- BOOK OF OliSTETRICS. sucli bodies liave stayed for ten and fifteen years, in one instance for fifty-four years, in the pelvis without ^ivinj^ rise to serious trouble. On account of the close anatomical relation between the gestation-sac and the rectum and intestines a slight rupture of the intervening walls may occur at any time, or a diapedesis may take place and pyogeni(! organisms gain access into the sac; and induce suppuration. The fetus is then converted into a putrid mass, which may be discharged into the rectinn, the vagina, or the bladder. Occasionally the sup- piu'ating mass i-uptures at some point on the anterior abdominal wall even so high as the umbilicus. The latter termination is frequently noted in the older medical literature. Symptoim, — All the symptoms characteristic of normal pregnancy may be present. Frequently, however, the subjective symptoms are entirely absent, and the patient may be quite unconscious of her condition. The increase in the areolar circle around the nipple and other mammary changes, the gastric disturbance, pain on the affected side, associated with amenorrhea, are th.e most characteristic symptoms. Too much stress, however, ranst not be laid upon the absence of the menstrual flow, as it is subject to the greatest variations. In some cases instead of amenorrhea there will be profuse metrostaxis with the expulsion of small bits of decidua. It is of importance not to confuse the decidua of ectopic pregnancy with that of membranous dysmenorrhea. In the latter condition the decidua is usually expelled in small pieces and rarely as a cast of the interior of the uterus. When floated out in water numerous delicate velamentous processes are seen. This membrane is rarely more than one or two lines in thickness, and it is usually very friable. The decidua of ectopic pregnancy is much thicker, varying from 6 to 20 millimeters (^^g^ to | inch); it is much less fri- able, the uterine surface being covered with a thick, shaggy, villous coat, and instead of small bits it is usually expelled in large pieces or as a complete east of the interior of the uterus. Pain is variable, in some cases being almost constant, in other cases absent. The character of the pain before rupture may be sharp and lancinating, or there may be dull and heavy aching. The statement of the patient that she considers herself pregnant is of some value, as that ill-defined sense upon which she bases her opinion may be the only subjective indication of her condition. The appearance of the external geni- talia may be the same as in norn -d pregnancy. Under these circumstances the vaginal mucous membrane appears purplish in hue, the cervix is soft, the OS uteri is usually closed with a plug of mucus, and the uterus, instead of its pyriforin shape, is now globular and enlarged to the size of a one-month pregnancy. If an examination be made before rupture, the Fallopian tube of one side will be found enlarged, and if far advanced the uterus will be forced from its position in the median line by the growth of the tumor. If the pregnancy is advanced to the third or the fourth month, a circumscribed tumor, well defined as an area of dulness on the anterior abdominal wall, may be outlined by percussion. Vaginal examination reveals this tumor lateral Till-: I'ATJIOfAJGV OF I'RKGXANCy. 285 and posterior to the titcnis, with a well-marked sidoiis between it and the uterus. Unfortunately, it is only in the rarer instanees that a ])hysieiau is called before rupture occurs, when, unless he is a skilful spt'cialist, the prob- abilities are that ectopic gestation will not be suspected. The growth of the tuujor may give rise to pressure-symptoms, such as constipation and dysuria, but they are of little special significance, as any pelvic tumor may be attended with similar disturbances. Ruptui'c. — The sym])toms of rupture are very characteristic, and they usually are so definite as to cause little doubt in diagnosis. A j)aticnt pre- viously healthy or only slightly (!omi)laining is suddeidy seized M'ith severe abdominal pains, sharp or lauciiuiting, cutting or agonizing. The attack in many instances cannot be ascribed to external violence or to undue exertion on the part of the jnitient, as she may be in the midst of light household work, or walking on the street, or even be in bed when the rupture occurs. Previous to the attack she may have had no discomfort or oidy the slight disturbances of preguantiy. If the hemorrhage is extensive she may fall unconscious as if struck a blow. The pulse, at first rapid, soon becomes almost or quite imper- ceptible; the respiration is quickened, then becomes jerky, and finally the air- hunger so chara(ieristic of severe hemorrhage becomes ])ronounced ; vertigo, nausea, and vomiting are present. The symptoms soon merge into those of profound shock, the extremities being cold and clammy, the skin pale, the conjunctivae pearly, and the lines about the mouth drawn. If the patient is conscious and is able to talk, she will usually complain of intense abdominal pain. Death may follow soon after intraperitoneal rupture, or it nuiy be delayed for a day or even longer. In some instances the bleeding ceases for a short time and is followed by gradual improvement in symj^toms, but it again begins a few hours or some days later, and the patient survives only a few minutes. In extraperitoneal hemorrhage from ru])ture into the broad ligament the symptoms may not be so urgent. The initial attack in both instances is simi- lai', as the peculiar sharp pain at the onset is due to rupture of the tube. The blood as it accunndates usually checks the hemorrhage by its own pressure, and the patient may have no further troid)le. If the embryo dies at the time of primary rupture into the broad ligament, no*fnrther discomfort ' ;'^ It, as a rule, as a harmless hematocele is all that remains. Unfortunate I v, in many instances this is r jt the termination, and the fetus continues to develop, and sooner or later a secondary rupture occurs, attended by the same symptoms as the primary rupture. In the rarer cases, which go on fiir nine months, labor-like pains come on and closely simulate those of normal i)artiu'ition. These pains may continue for houT's or even for days, and then cease. The escape of blood and of por- tions of the dccidua occurs in a majority of cases at this time, and may mis- lead the attending physician into the diagnosis of abortion if the constitutional symptoms are not urgent. The subjective symptoms of pregnancy are almost always present in such advanced cases. The fetal movements may have been -ji*i '2SG A.y[Kl{l(\\N Ti:XT-lt()<)k' OF oitsTKrnics. so luiicli on OIK' side as to call tlic inotlior'M attontion to this pliononu'iion. Tlic fl'tal la'art-souiuls arc distinct, bcin^ heard w itii unusual clearness. In cases siu'vivin;; the rupture the sharp labor-like pains jrradually sub- side, the secretion in the breasts tlisappears, the tumor decreases rapidly in size, and as soon as the patient recovers I'roin the shock and loss of blood she may rej^ain her health. It is in these cases that absorption or one of the other chanfjcs that rendt'r tlu^ fetal body innocuous takes place. Infection of the incarcerated fetal mass may occur at any time, even years after the death of the end)ryo, followed by a train of symptoms similar to those attending pus- formation from other causes. J>iti(/noxiK. — 'Plu! history, if carefully reviewed, often directs attention strongly toward ectopic gestation. The pregnancy usually occiws in a mul- tipara some years after the birth of the last child, although it may follow shortly. There may have been an intervening attack of acute intlamination (»f the tube or of pelvic peritonitis. This is strongly insisted upon by those who advocate the theory that tubal gestation is diu? to an old inflammatory l)rocess which has changcHl the normal histology of the tube. A characteristic history is as follows: A woman who has borne one or more children, after an interval of from five to twenty years of sterility observes symptoms of another j)re;,nancy. Her menses, which have been regular, cease, and the mornin;^ nausea, \v,\'u\ in the breasts, darkening of the areola, and other symptoms characteristic of her former pregnancies appear. In addition to these symptoms, slie has in one ovarian region dull ])ain, at times so severe as to cause her to seek the advice of her phy- sician. This pain may continue until it culminates in the acute paroxysms caused by rupture, or it may cease, and not be noticed again until the rupture occurs. The most characteristic symptom of all is the sudden sharp pain of the rupture. If followed by a marked anemia it is still more decisive. The bimanual examination, taken in conjunction with this history, points with absolute certainty to the nature of the pregnancy, and the diagnosis is com- paratively simple. In the atypical cases, on the contrary, a positive diagnosis is often difficult or even impossible. In the normal uterine pregnancy, as the embryo develops the uterus is dis- tended equally in all directions, but occasionally the ovum develops in one corner, distending the uterus on that side, which may prove misleading. In ])regnancy occurring in the rudimentary horn of a bicornuto uterus the symp- toms are so nearly alike that a differential diagnosis is not likely to be made. Kussmaul collr;'ted thirteen cases of pregnan(\v in rudimentary cornua, the majority of wiiicli had been reported as tubal pregnancies. If an exploratory section be ])erformed in these doubtful cases, the anatomical points insisted up(m by Mauriceau are of the greatest value in making a differential diagnosis. They are as follows : In cornual pregnancy the round ligament is situated anterior to the outer side of the gestation-sac. In tubal pregnancy the round ligament is situated on the uterine side (Figs. loT, 158). Pregnancy occurring in one horn of a well-developed bieornute uterus may 77//; /M TIKH.OU V OF PltKiixWANCY. 2H7 go to term ami jjjivc riso to no untoward symptoms. A profx'iant uterus devi- ated to one side by a myoma may l)e mislalven for ectopic gestation. Tiie diag- nosis, however, can usually he made it' the examination is eonchicted under anesthesia, as it will be I'ound tiiat the tiuuor varies its position with that of the cidarged uterus, and is directly continuous with it, in addition to being densely hard. The <|ne-tion of interstitial pregnancy naturally arises in these cases, and if the character of the tumor cannot be recognized a( the (irst exam- ination, the patient's symptoms shouhl be observed carefully, and she should be examined again lat(!r to decide whether there is any inerease in the size of tlie .suspected tumor. If there is a perceptible increase, the probabilities are that it is interstitial pregnaiuiy. An adherent retroverted gravid uterus may also give rise to misleading symptoms, such as sharp pains, obstinate eonstipatiou, >•■.. .in"-- y^"- /"'f\. :>^ \v.:::. -ji.y Ve y '-T' i :--^i^^ Via. I"i8.— Dianrnmnintir sketch sliowiiiii rclaticuis of iiu unniiiturt'd siic (») to utpnis (u), nmnd lignmcnt (rl), and bladder (h). The nuiiifnms adliesloiis are .siigK^'s^tive as to the etioldtiy. pelvic pressure, dysuria, etc., but it is readily differentiated by a bimanual rectal examination, if necessary drawing the uterus down with traction for- eoj)S so that the fundus may readily bo pal|)ated. Ovarian tumors and enlargements of the Fallopian tubes, associated with intra-uterine pregnancy, may cause confusion, especially if the tumor lateral to the uterus gives rise to sharj) pain, as may occur in pyosalpinx. In such instances the question of a twin ])regnan('v, one intra-utcrine and the other extra-uterine, nuist be considered. As fever accompanies jiyosal- pinx in the majority of cases, it nuist carefully bo considered in the differ- ential diagnosis. If it be im|>ossiblo to arrive at definite conclusions con- cerning the suspected mass, and the life of the patient seems in peril, an exjiloratorv celiotomy is justifiable, otherwise expectancy is the safer coiu'se. Occasionally a pedunculated ovarian cyst becomes strangulated by axial rota- tion : such an accident is accompanied by pain, vomiting, rapid pidse, and other constitutional disturbance, at times amounting to ])rofound shock. Rup- ture of an ovarian cyst may also be difiicnlt to differentiate from the rupture I ili! I ft .l«i re " i • 288 AMKIilVAN TJ'LXT-nOOK OF OliSTETlilCS. of an ectopic g:\station sac; in such c .ses the history and the vaginal examina- tion will cl','ai' np the diagnosis. To snnunarizo briefly, it may be said that the diagnosis of ectopic gesta- tion depends npon the following cardinal points : 1. A iiistory of probable pregnancy. 2. Paroxysmal pains, usnally located on one or the other side of the pelvis. '^. Irregnhir metrostaxis. 4. The expnlsion of bits of deeidna. 5. Coincident eidargement of the nterus and softening of the cervix and discoloration of the vagina. G. Tnmor lateral or posterior to nterus and indirectly connected with it, nterus moderately or not at all enlarged. 7. Changes in the breast. 8. Anemia. Tiie diagnosis of ectopic gestation after tlie death of the fetus is largely dependent npon the clinical history ; if this be deficient, the diagnosis is fre- qnentlv impossible, especially if there has been a long interval between the rupture and the time when the patient consults the physician. If the fetus has undergone calcification, It may be felt as a hard mass, but even this is not conclusive, as a calcified myoma may present similar characteristics. Treatment. — From the operative standpoint it is best to divide ectopic pregnancy into the following periods : 1. J^efore rupture; 2, at the time of rupture; 3, after rupture; and 4, after calcification, saponiflcation, munnnification, or suppuration of the fetus has occurred. 1. lirforr Ixiipfiirc — Tlie electrical treatment, so much advocated a few years since for the destruction of the fetus, while valuable in its day as pio- neer work, has deservedly fallen into disrej)ute, because of its uncertainty in terminating the fetal life and of its dangers to th(> mother through subsecjuent inflammation. The injections of fluids into the sac for the same purpose is so utterly fonMgn to present ideas of treatment that it is oidy mentioned to be condemned. The proper course to pursue is the removal of the atfoeted tube. Precipitate operation, however, is not advisable, as the diagnosis should be as accurate as possible before resorting to radical measures. Cases with a history suggestive of ectopic gestation and a mass lateral to the uterus detected by vaginal examination should bo operated upon without hesitation. A pro- portion of such cases will prove to be pyosalpinx or hydrosalpinx, but an error is not serious, as in either instance operation is indicated. 2. At the Time of h'liptuir. — If called at the time of rupture, the siu'geon must exercise considerabh* judgment in his decision whether or not to operate immediately. Tf the patient is in collapse, the pulse weak and rapid, and the skin blanched and clammy, an immediate examination should be made to discover if ])ossiblo whether lupture has occurred into the broad liga- ment or is intraperitoneal. If the rupture has taken i)lace into the broad ligament, a lateral tumor-mass closely connected with the uterus will be THE PATHOLOGY OF PREGXAyVY 289 <lotcct«l. Tlic mass is circuniscriboil aiul fliK'tiiating, and rectal examination shows the cul-de-sac to be free of fluid. In such a ease tiie method of treat- ment is an expectant one, the possibilities being that the h(>morrhage will soon cease if it has not already done so, and that the patii'ut will recover, leaving )■ 11.. IV.l.— 1'iii^'rnni (if inlmiu'iilciiu'al viiptmc of liilml incu'iininy. I'rrc IiIiimI in Huiinliis's ciil dc sue mill iiiiiHiii; tlu' iiiti'sliin's IiickiiiMini ; S, syiiiiiliysi> ; i;, rccliiiii. a hematocele to be dealt with later if necessarv. If examination reveals free lliiid in the cul-de-sae (Fig. 159), and there are no signs of improvement in tlie patient's condition, the natural inference is tliat (he rupture is intraperi- toneal, and an immediate operation is indicated, as every moment detracts from the cliances of recovery (Fig. IGO). PrejHivation for Opcra- limi. — The chances for re- covery I'ollowing operation ill extra-uterine pregnancy depend upon the careful (it)scrvation of al' the de- tails of antiseptic and asep- tic technique. For this „,,..,,. ' _ _ 1' Hi. liid.— Dr. IVi'k s cast' O "''11-^'"" II. oluci) ot ixtni-ntiTJiu' reason a precipitate opera- lirotiiiniiiy in Ww tliinl munth; din'ration lit time of ru|iturc; tioii is always attended with ■"''•'"^ '■ > • greater danger, as of necessity care in details must be sacrificed. The surgeon should always have a com])lete set of abdominal instruments and accessories sterilized and packed ready for use. If the operation is hurritnl, select a wcU- 19 I g n ft I r F'T t ftl' 1^ . J£l :■ ■ 1 ■ ' 1.: ■ f I 290 AMERICAN TEXT-BOOK OF OBSTETRICS. lightal room or provide a portable electric light; remove all unnecessary fur- niture, dampen the floor to prevent dust rising, but do not disturb the curtains and other hangings further than is absolutely necessary. A common kitchen table can be turned into an operating-table, with a chair inclined against one end, upon which the patient's feet may rest. Cover the table with a folded blanket, lay upon this a Kelly ovariotomy pad, and place a small pillow at the head. As it may be necessary to irrigate, a douche-bag should be suspended in a convenient position near to, and ibout 4 feet above the level of, th(( table. Two smaller tables are required for the instruments and dressings, and three or four chairs for the wash-basins and sponge-dishes. A room thus hastily improvised serves admirably for an operating-room. An abundance of boiled water is necessary. Directions should given immediately after deciding to operate concerning the preparation of the water. A wash-boiler or other large tin vessel must be scalded thoroughly, and be partially filled with water which is allowed to boil for an hour if possible. It is best to let the water cool to 110° F., but if time is pressing })ure cold water from a well or a hydrant may be used for reducing it to proper tem- perature. This method of cooling the water, however, is not advisable except under stringent necessity. Great care nuist be observed by the physician in disinfecting his hands : they should be scrubbed thoroughly with a nail-brush with soap and water, followed in succession by immersion in permanganate of potassium (hot sat. sol.) and oxalic acid (hot sat. sol.). A (juart of each of these solutions is sufficient. The patient, under anesthesia, is then transferred to the operating- table and is rapidly prepared for abdominal section. The anterior and lateral surfaces of the abdomen are thoroughly washed with soap and water, followed by alcohol, then by ether, and finally by bichlorid solution (1 : 1000). As it may be necessary to open the sac through the vagina, this passage should be washed thoroughly with soap and water, followed by bichlorid solution (1 : 1000) and an iodoform pack. All dressings, towels, and gau/t; to be used in immediate proximity to the field of operation must be i)rovidcd by the surgeon, who slioidd always carry them among his accessories, as the s^teriliza- tion of these articles cannot be entrusted to an untrained person. Instruments are taken from their sterilized envelope and j)laccd on towels or in trays. During the preparation the patient should be given a stinndating enema, also strychnia (gr. ^'j^) and brandy hypodermatically. In such cases as these the infusion of normal salt-solution into the radial artery is often of the great- est service in sustaining the patient's vital forces, and occasionally it is abso- lutely necessary to save life. It is umiecessarv to carry a special infusion aj)paratiis, as an ordinary aspirator adnurably serves the purpose. To prepai-c normal salt-solution dissolve 6 grains of sodium chlorid in one liter (a quart) of boiling water and boil for some minutes. Select one of the smaller blunt- pointed aspirator needles. Fill the aspirating bottle three-fourths full of tin' solution, cork tightly, and, instead of making a vacuum in the bottle, force in aii- THE PATHOLOGY OF PREGNAXCY. 291 until the pump works with diffifulty, then turn the entrance stopcock. The radial artery is the most accessible for infusion, as it can be utilized if neces- sary for this purpose by an assistant while the abdominal operation is in prog- ress. Cut down somewhat obli(piely on the artery, and place a provisional ligature above and below the point of infusion. When ready to introduce the fluid invert the bottle, turn the exit stopcock, and insert the needle into the artery while the fluid is flowing, thus preventing the possibility of intro- ducing air. The dangers of this accident, however, are practically of no moment if the fluid is injected centrally into the artery. If the exsanguination is extreme, a liter (a (|uart) of solution at a tempera- ture of 105° F. may be infused. After the needle is withdrawn both ligatures are tied and the wound is closed with a subcutaneous stitch. It is remarkable how quickly the pulse improves under this infusion : it may grow weaker shortly after, but if the bleeding is completely checked the chances for recov- ery are far greater if infusion is emj)loyed. The fluid used must be perfectly free from dirt or bits of cotton, etc., which produce emboli and cause gangrene. The Operation. — The abdomen should be opened freely in the median line ; the clots should be turned out, exposing the ovarian and uterine arteries, which are caught either with forceps or between the fingers. If on attempting to clear the pelvis of clots fresh blood wells up, no further time should be lost in attempts to expose the bleeding points, but the operator must introduce his hand into the pelvis, grasp the arteries, and then apply hemostatic forceps. Having controlled the active hemorrhage, he can then carefully cleanse the abdomen of clots, inspecting closely the ddbris as he does so for the embryo or the tubal mole. If the pregnancy is in the first or sec- ond month, the operation consists of a simple sal pi ngo-oophoreetomy ; if, how- ever, the term is farther advanced and the placenta is extensively attached to the interior of the tube, or in ease of previous rupture to the intestiiies and pelvic walls, the operation is not so simple, and calls for good judgment to know how best to deal with the i)lacenta. It is exceedingly hazardous to attempt the removal of a placenta which is firmly attached, as the hemorrhage following its dislodgoment may be so extensive as to defy control. In such cases it is best to leave the placenta in xHn, for lo attempt its removal would take away any chance the patient has for life in her condition of shock and exsanguination. Xo means further than those necessary to save life at the time of operation sliould be undertaken, as the essential principle is first to control hemorrhage, leaving subsidiary conditions for subsequent consideration. If the placenta be attached exclusively to tlu? floor of the tube or the pelvis, its blood-supj)ly may be derived from numerous vessels, and an attempt to control these by ligation would be impossible. The best course to pursue in such cases is to cliec^k the hemorrhage, tie and cut the cord close to its placental origin, and leave the placenta undisturbed. Drainage should not be employed in these cases, because of the increased danger of sepsis. The jiroper treatment is to clos' the abdomen completely, and after the i)atient has recovered a second m mm i' 4 ill? ) r 1 1 ■t* )' ' 1 S-^lf ' V,f J I I Jr] d? 292 AMERICAN TEXT-BOOK OE OBSTETRICS. iff ' H !> r'j -^l operation may be performed for the removal of the placenta if it cause unto- ward symptoms. The greatest care in aseptic and antiseptic details should be observed, as upon the absence of infection depends the patient's chance for recovery when the placenta is not removed. If the operation is absolutely aseptic, the prognosis is good, as the placenta atrophies and gives no further trouble. If, however, the case is infected, suppuration of the placental mass occurs, terminating in general peritonitis or in a pelvic abscess. Often in the course of an operation the placenta becomes detached and may be removed with the fetus. In all cases in which the operation follows the death of the fetus by some days or weeks the placenta is only held by the slightest attach- ment or it may lie free in the gestation-sac. It is for this reason that the operation is more favorable at such a time, as the dangers of hemorrhage are much decreased. In some cases, especially those in which there is a temporary cessation of the bleeding, the slightest disturbance of the sac after the abdominal cavity is opened causes a renewal of the hemorrhage. Bold surgical measures are then demanded : the operator should sweep his hand rapidly around tiie ectopic sac, loosening the adhesions, after which the sac is delivered from its bed of adlic- sions. The points of bleeding can then be reached and controlled. Adhesions to the omentum should be tied off in small sections to prevent necrosis en masse. If the intestines crowd down into the field of operation, and if the opera- tor is unable to pack them back satisfactorily with sponges, the patient should be placed in the Trendelenburg position. In case there is extensive oozing on the floor of the pelvis after the removal of tlie ])l!icenta, that it is dif- ficult or impossible to control by ligatures, a strip of iodoform gauze should be packed down upon the bleeding points. If tliere is a large amount of debris scattered throughout the abdominal cavity, free irrigation with steril- ized normal salt-solution (6 per cent.) at a temperature of 110° F. should be employed ; 3 or 4 liters (3 or 4 (juarts) of the solution may be necessary to cleanse the cavity. There is no danger from the distribution of this material in the abdomen by irrigation, as the ectopic product is sterile except in the rarest cases. In all ectopic eases that undergo operation the ojiposite tube and ovary should closely be examined, and if normal or if only slightly adherent tlioy should not be removed ; otherwise their extirj)ation is demanded, for to allow a diseased tube and ovary to remain, which can be of little if any further func- tional value, would only subject the patient to the dangers of a subsequent ectopic pregnancy or to the discomfort and pain due to adherent appendages. 3. After liupfior. — Contrary to the natural Inference, cases are not usually submitted to operation at the time of rupture, as by the time the surgeon is called the patient is either recovering or is dead from extensive hemorrhage. In a certain proportion of cases the i)atient, although feeling the sharp pain accompanying the rupture and being compelled to keep to her bed for a day or so on account of weakness, does not call her physician, as she considers it THE PATHOLOGY OF PREGXANCY. 203 only a trifling matter associated with her pregnancy. There Is undonbtetlly a considerable number of cases like the latter In which the death of the fetus occurs at the time of rupture and no further symptoms are observed, and the patient makes a perfect recovery. It is for this reason that a statistical table compiled for the purpose of ascertaining the rate of mortality in extra-uterine pregnancies due to rupture is fallacious. If the surgeon sees the patient imme- diately after rupture, and there is a general tendency to improvement in all her symptoms, he should defer operating until a future date, to be determined by the patient's condition. If the rupture be extraperitoneal in a case in which the pregnancy has advanced only to the first or second month, an operation should not be per- formed ludess the fetus continues to develop in its new location or untoward symptoms arise from the hematocele. To subject a woman to an operation for a hematocele which is giving her no trouble is, to say the least, bad judgment. If the life of the fetus is not destroyed at the time of rupture, the operation should be performed as soon as the patient has recovered from the primary rupture. The life of the fetus must not influence the determination to operate, and under no circumstances should operation be delayed on account of senti- ment in its behalf. As the dangers of operation greatly increase as the pregnancy advances toward term, on account of the development of the placenta increasing the dangers of hemorrhage, the earliest date possible should be selected for ojjera- tion. A free incision should be made in the central line of the abdomen. If the pregnancy is in the early weeks, the operation may be no more difficult than a salpingo-oophorectomy for pyosalpinx or for hydrosalpinx. The dan- ger of hemorrhage, however, from the broad ligament is somewhat greater than in the ordinary salpiiigo-oophorectomy, on account of the increased vas- cularity of the ttibe, and great care should be exercised in placing the ligatures so that they will control all blood-vessels. The "transfixion needle should not be employed for this purpose, as the subse(juent shrinkage of tissue following the removal of the vascular tube is liable to dislodge the ligature, as more tissue Is usually included, and a larger size of silk is employed, than when the ligament is tied off in small sections. The pregnant tube when the ligatures are laid should be lifted well out of its bed with a medium-sized curved needle armed with a carrier. The medium-sized silk suture is the best In this loca- tion, as it stands sufficient strain easily to contrc)l hemorrhage, and yet does not strangidate the tissues en masse. Each suture should overlap, in an imbri- cated mamier, the one placed immediately before it ; thus no vessels can pos- sibly escape ligation. If pregnancy is further advanced and adhesions have formed between the gestation-sac and the adjacent viscera or the pelvic floor, or if it is a broad- ligament gestation with the placenta firmly implanted on the pelvic floor, the operation becomes one of the most diflicult in abdominal surgery. The adhe- sions should be dissected off carefully, all bleeding points should promptly be ligated, and the sac should be emicleated in the ordinary manner. Drainage iU ill '/ 294 AMERICAN TEXT- BOOK OF OBSTETRICS. sliuukl 1 ot lie used if it can possibly he avoided ; only persistent oozing which cannot b3 controlled by ligatures justifies its employment, as the dangers of infection are greatly increased by leaving the abdominal cavity open. The fact that particles of clots and other dfibris are scattered throughout the abdominal cavity does not indicate drainage, as such material is innocuous if the field has been kept aseptic, and it will give no trouble if the wound is hermetically sealed. It is in these densely-adherent or broad-ligament cases that enucleation of the sac is often impossible, and that other measures must be resorted to for the relief of the i)atient. The treatment of the ectopic sac then becomes a question of great imi)ortance, as the adhesions to neighboring viscera or to the pelvic floor may be so extensive as to preclude its removal, as the danger of hemorrhage following its enucleation is too great in such cases. This question should usually be decided after the abdomen is opened. The extent of adhesions and the vascularity of the sac and adjacent tissue should be noted carefully, and if of such a degree as to contra-indicate removal, the next measure, that of making an extra])eritoneal opening, nuist be resorted to. Extra peritoneal Evacuation of Gextat ion-sac. — The j)oint of opening depends entirely upon the location of the sac : if it is situated low in the pelvis and is of easy access tlu'ough the vagina, unquestionably the best method of procedure is to evacuate the contents of the sac into that canal and establish free drainage. The best method of o])ening the sac is as follows : After carefully examining the pelvic mass and deciding where the accessible point for opening is — usually in the fornix — the operator thrusts a pair of medium-sized sharp scissors, guided by the index finger of the vaginal hand, into the sac, and withdraws theiu jiartially open ; this is followed by larger scissors, which are also withdrawn in the same manner. While doing this it is usually best for the operator to have his assistant press the sac gently down- ward through the abdominal incision. After evacuating the embryonic debris with the fingers or with placental forceps, the sac should be irrigated freely with sterilized water or with a very weak bichlorid solution (1 : 20,000), fol- lowetl by warm water. After cleansing the sac thoroughly it can be nacked with iodoform gauze, care being taken to leave a free opening for subse- quent discharge. The greatest care must be observed in passing fivim the abdominal to the vaginal operation, as to niake a vaginal examination followed by the manip- ulation necessary to evacuate the sac by the vagina, and then to close the abdomen without the most careful disinfection of the hands, would be an unpardonable mistake. It is usually best for the operator to entrust the closure of the abdonien to his assistant. If the sac, instead of being in close relation with the vaginal fornix, is found to be ])ushetl up above the uterus, and is situated nearer the anterior abdominal wall, the vaginal method of treatment is not advisable, as there may be an intervening sj)ace comunuii- cating with the general j)eritoiieal cavity between the ectopic sac and the vagi- nal fornix, making it both difficult and dangerous to reach the sac. In these THE PATHOLOGY OF PREGNANCY 295 cases it may be necessary to stitch the sac to the abdominal woimd, and then to make an extraperitoneal opening into it. As a rule, however, the sac will be attaclied by close adhesions to the abdominal wall above Ponpart's liga- ment, and should be opened in this region. The sac shoidd be washed out freely as in the vaginal method, and be packed with gauze. The after-treatment in these cases is often of great importance, as the sac fills up very slowly and there is constant purulent discharge. The fistula must not be allowed to close. As a rule, the ganze which is inserted at the time of operation should be withdrawn one piecic at a time. After the removal of the last piece, usually about the second or third day, fresh gauze should be inserted, the cavity I,»ing first freely irrigated with some mild fluid, such as boracic-acid solution (semi-saturated). 4. Operation after the Fetus has undergone Mummifieittion, Calcijicatlon, Haponifieation , or Suppuration. — The fetus may remain for years in any one of these conditions, except that of suppuration, without injury to the mother's health. Soon after the death of an ectopic fetus the licjuor amnii is absorbed, the placental circulation ceases, and the vascular connection between the fetus and the mother is broken. The liquid portion of the cctoi)ic product is grad- ually absorbed, leaving in many instances the fetus isolated in its sac as an in- nocuous body. In such cases operation should not be performed so long as the patient's health remains good, but on the first indication of constitutional dis- turbance, especially if febrile in character, celiotomy fi)r the removal of the foreign body should promptly be resorted to. If suppuration occurs and the pus-sac opens into the rectum, the vagina, the bladder, or externally through the abdominal wall, the fistula should be enlarged and the fetal debris be removed. The sac should tlien be irrigated frequently until it fills with gran- ulation tissue. These sinuses heal with difficulty, and they may be persistent. 8. Diseases op the Fetus in Utero. Under this head only a r^sumi' of the diseases occurring before birth will be noticed. There are many conditions which give to the fetus immunity to disease and to injury during the pre-natal state, such as the protection given by the liquor amnii, the uterine wall and bony pelvis, etc., but there are also many predisposing causes, such as hereditary influences from the mother and from the father, nervous disturbances, high temperatures, bad nutrition, diseases of the womb and its appendages, and certain infectious diseases, which have their influence upon the growth and development of the fetus, and which are not only accountable for disease, but sometimes also for the death and expulsion of the child before it has reached its full term. Certain tendencies to disease are inherited : this pertains more particularly to abnormal conditions of the nervous system and to disorders in nutrition. Drunkenness, epilepsy, diabetes, phthisis, and cancer of either parent are unfavorable to the health and development of the child. Frequently a fetus of such parentage dies In utero. 1. Infectious Diseases. — Pregnancy does not give immunity to infec- 'V,X : ,'* I '■''"' ^ ' V\ ! I 1 ;i i ! i ' -^ 1 ■ i , ■ i 1 ■' 1 : ' I'ij 1 h 29G AMKIilCAy TEXT- BOOK OF OBSTETIIJCIS. tious diseases. If tlio niotlior is suttbring from one of the infecL'oiis diseases, the fetus may eseape iiiieetion, hut generally it suffers, either indirectly througli tiie low state of nutrition or the high degree of temperature of the mother, or directly by a transmission of the disease itself. In either event the pregnancy may be interrupted by premature death and expulsion of the fetns, or, if the fetus is born alive, it usually dies s(xm after birth. The mod'j of infection is often obscure, and the path or paths of its trans- mission are siill unsettled questions. Ziemsscn holds that the poison circulates in the blood. The transmission of disease-germs from mother to fetus has in some instances been demonstrated. Placental infection producing sepsis hi vtvro will be considered later. Pus-organisms have been found to be trans- mitted to the fetus in septic disease of the mother, and well-formed collections of pus have been t)bservcd in a fetus at the time of birth. All infections of the mother do not seem to be equally severe in their effects on the child, rrcgnancy complicated by la grippe, cholera, diphtheria, typhoid and malarial fevers in the mother is very likely to be interrupted. It seems probable that in most of these eases the death of the fetus is produced by direct transmission of the infection from the mother, and in many cases this has been demonstrated bv findino- the disease-germs in the fetus. So far as his researches into the subject have gone, the writer is not aware that there are any instances upon record of children being afflicted with diphtheria, mumps, or whooping-cough at birth; but children are born with all the patho- logical indications of malarial disease, such as enlarged spleen, etc., and Play- fair states that the agitation caused by the chill is even felt by the mother as her child in ntcro ])asses through this partictdar stage. Cases of cong(>nital recurrent fever have been reported. The fetus usually dies, and shows all the pathological changes which characterize this disease — enlarged spleen, pigment in the spleen and portal blood. Albrecht reports a case in which he found the spirilla <if recurrent fever. According to Bcmis of Xew (Orleans, the fetus of a woman who recovers from yellow fever is immune to the disease. As regards typhoid fever, while a pregnant woman is liable to take this infection, and the presence of the disease proves in many cases the cause of abortion, the writer dt)es not know that there is a case on record of a child being born with unmistakable typhoid lesions. In the case of a mother affected with cholera early abortion is the rule, but if the child is born alive it usually survives but a few days. The theory of intra-uterine transmission of the bacillus is supported by the microscopical cxaminatious of Tissom and C'attam. 2. EnuPTiVE Diseases. — Of the eruptive diseases contracted in the pre- natal state, variola, scarlatina, measles, and erysi])elas have been observed in their typical form. Eruptive diseases seem to affect the child in ntcro to a greater degree than any other diseases ; they arc very likely to })roduce abor- tion, possibly on account of infection of the endometrium. Scarlatina and Measles. — There are a considerable number of cases on record of children being born in the difl'erent stages of scarlatina and measles. THH PATHOLOGY OF PREGKANVY. 2D7 When scarlatina occurs in pregnancy the fetus is usually, but not invariably, int'ected. The prof/noKis as regards both mother and fetus is grave, especially if the maternal infection occurs at or near the time of labor. LeopoUl Meyer men- tions an epidemic in which twenty puerperal cases became infected. Variola. — In about 50 per cent, of cases of pregnancy complicated by variola abortion takes place. In the hemorrhagic form it is almost certain to do so. Manifestations in the fetus do not always occur at the same time that they do in the mother. A case is on record where the mother in appa- rently good health gave birth to a child with the small-pox eruption upon it. Vaccination of the mother will sometimes protect the fetus. Erysipelas is likely to interrupt pregnancy. Cases of intra-uterine trans- mission of ervsipelas have been cited bv several reliable authors. Lebcdeff found in the fetus of a mother suffering with the disease the erysipelas coccus. Erysipelas affecting the mother in the puerperal state may be transmitted to the new-born child. The proc/nosls is more serious than that of a case outside of the puerperal condition. Tuberculosis. — A child born of a mother suffering from tuberculosis is usually piHiy, feeble, and predisposed to pulmonary disease. The question of the possibility of direct transmission of tuberculosis to the fetus has recently been the subject of considerable investigation.* Several cases of transmission of tubercle bacillus from the human mother to the fetus in ufero have been reported by Keating, Jacobi, and others. The fact that the ])lacenta some- times contains tubercles would show that in those cases the bacilli were intro- duced through the maternal circidation. From clinical observation of cases we may also deduce — (1) tuberculosis may be transmitted by either parent, and (2) that the bacilli may gain access to the fetus through the (<t) maternal l)lood, [l>) through the areas of tuberculosis, such as the peritoneum, intestines, etc., and (c) from the outer world through the genital tract. Fetal Syphilis. — Perhaps the most important as well as the most fatal disease which affects the child in idem is syt)hilis. It is one of the chief causes of abortion. Mode of Transmission, — Syphilis may be transmitted by either parent. If a mother who is healthy becomes infected during pregnancy, the child may escape if this infection takes place in the last month, unless the chiUl again becomes infected at birth or ■while nursing. Prof/nosis. — The earlier in pregnancy infection of the mother takes place, tlie more likely is the fetus to die. If the infection occurs during the first three months and is not subjected to treatment, the fetal mortality during the iirst few days i^fler delivery reaches 100 per cent. The prognosis is a trifle better if infection occurs during the fourth or the fifth month (fitienne). As a * Tho tliodi-y of con<;enitiil tuberculosis lias foniul support in the experimental research on lower animals, also in cases of the human fetus, described by Johne (Fig. 1, Foiischritle d. MM- ii-iii, ltd. iii., No. 7) Merkel (Fig. 2, Zcilschrifi f. ktinische Medicin, 1884, Rd. viii.), Bircli- llirschfeld, and others. Iff ill!. i W-^ 298 AMFJilVAM TEXT-HOOK OF OnSTETlilCS. rule, iiifootion of tlic mother i ■ safer for the fetus than infwtioii of tlic father. Whether tlie speriiiato/oa of the iiifeeted father may infeet the mother is uii- deciiled. All authorities do not admit the possibility (»f infeetion of the fetus unless the mother is syphilitic, hut modern authorities (Tarnier, Schroeder, Charpentier, Priestley, antl others) assert positively their belief in the trans- mission of syphilis to the ovum without infection of tiie woman. Diaiinon'iH of FvUtI ISi/jihi/in. — The infection of the fetus may be inferred if either parent had accpiired syphilis at a day not too far remote from the time of i)rocreation. The limit ot" safety has not been discovered, but the more recently the father has suffered with this disease the more likely is he to trans- mit it in severe form. Often the sipis of fetal syphilis can be looked for oidy in the fetus after its expulsion from the uterus. In many cases the child is pre- maturely born, and there are traces of the disease; in other eases the child is born apparently healthy, the disease developinjjf in the course of from two to six weeks. The evidence of syphilis, whether the baby is born dead or wh(!ther the disease makes its a])pearance soon after birth, is usually charac- teristic. (I'rcmature death of the fetus, due to syphilis, is considered on page 310.) If born alive, the child is often prematurely born, and presents durin<>; the whole of its infancy, and j)erhaps during childhood, a ]>rematin'elv old look. There is usually marked general debility. Among the first manifes- tations of hereditary syphilis is snuffles. The eoryza is foUowwl by a charac- teristic rash consisting of erythema and erythematous patches about the amis, the genitals, the thighs, and the forehead. The U])per lip is likely to become excoriated and fissured. The mucous mendirane of the larynx may be affected, producing hoarseness, and there even occurs ulceration of the larynx. Pemjihigus is one of the most characteristic of syphilitic lesions. A little later roseola, the maculo-syphili<lcs, psoriasis, vesicles, and pustules may also occur. Sometimes mucous patches appear ; these may occur around the anus, the vulva, the groin, and the lips, and sometimes in the folds of the neck. Coryza may result in caries of the nasal bones. Syphilitic infants are liable to suffer from broncho-pneumonia. Congenital syphilitic pneumonia occurs in two forms — white hepatization (Virchow) and the interstitial form. The white hepatization produces eidarge- nicnt of the lungs, the cut surface presenting a mottled grayish appearance. The alveoli arc filled with fatty epithelial cells. Tlie interstitial form consists of increase of connective tissue between the alveoli ; there may also be yellow induration, due to gummata on the pleural surface or scattered through the tissues. Icterus and cyanosis are frequent symptoms of sy))hilis. The occurrence of the symptom of icterus is explained by syphilitic hepatitis, which in the new- born is of a different character from syphilis of the liver in the adult. Infant hf'patic syphilis is always hereditary (Chauffard) : the blood carrying the infection arrives in that organ, and the process is markedly profuse, rendering the organ at an early stage diffuse and massive. In the healthy infant the liver should constitute one-thirtieth part of the body-weight ; in a syphilitic chilil Till': PATimr.oav or pnEaNAxcv. 200 this proportion is much oxcccdcd, in .s(»nio caws having f'onuod ono-oijfhth of the weight of tho body. The liver presents two chanfres — the guniinata and ditl'nse infiltration of eonneetivo tissue. This form of cirrhosis is usually of the hypertrophic form. Cyanosis is dependent either upon premature hirth or upon syphilitic chanj^es in the lungs, Ibr gununa'a and white hepatization in th(! lungs are found with frecpiency. The tendency of syphilitic infants to hemorrhago will again be alluded to under tho subject of Ifnnorr/i<i(/ic ])iathvHls, This fltrin is designated by Behrend as sj/plii/is li(iinorr/i<i(/i('a. It usually attacks childn>n of premature birth who an; either born dead or live only a few hours. In these children are found all the changes which characterize congenital syphilis: numerous extravasations of blood under tho skin and in the internal organs, also at times great (piantities of blood in the stonuich and intestines, in the perito- neal cavity, and in the membranes of the bniiu. If such children live for a little while, then fmiuently new hemorrhages appear in the skin and in other organs, Ruge saw a syphilitic child present hemorrhage about the anus, at the j)oint of the tongue, and, finally, about the eighth day of lifii', severe mnbilical hemorrhage. The hemorrhage occurred tlircctly out of the skin like drops of sweat. Further, upon the ninth day severe icterus develoj)ed and the child died. Tho autopsy showed well-(levci>ped syphilitic changes in the internal organs. Edema freiiuently occurs in this hemorrhagic form. Teudorness and swelling of the long bones arc strong evidence of hereditary svphilis. Tho most characteristic change in fetal syphilis occurs in the bones. The white line which noruudly marks the junctinv of the epiphysis with the ♦liaphysis becomes broader, often irregular, and yellow from fatty changes following a i)rcmaturo attempt at ossification ; in marked cases there is also thickening of the periosteum and perichondrium. Tho diaphysis is sometimes sclerotic. Some authors (INIiiller and others) reganl these ])rocosses as quite different from those of rachitis ; others consider them idcnti<'al. Tho (pies- tion of identity between the two must be considered unsettled. The thynuis gland is often nuich enlarged, and may present multiple abscesses. The (rcdtmnd of fetal syphilis is mainly prophylactic. In parents who are svph'iitic the disease may be eradicatcMl by long-continued treatment. (Jreat benefit may bo derived from treatment of tho mother during pregnancy. If after thorough treatment for the disease, coucoptiou docs take ])lacc, tho result may bo a child free from syphilis. Etiemie, from a sttidy of thirty-two cases of pregnancy in sy])hilitic women, concludes that the mortality of the fetus in cases whore the mother has never been under treatment is enormous, reaching nr).5 per cent. If treatment be a]i])lied throughout pregnancy, wo may hope to obtain complete innnunity from this infant mortality. If a mother who has been infected recently, or who has had a number of miscarriages due to syphilitic infection, is again pregnant, antisyphilitic treatment should at once be instituted. Mercury and iodid of potassium are tho most reliable remedies. 3. CoxcKXiTAi- P'KKOUMITIKS AND MAi-FORMAxroNs. — Amniotic Bands. — One of the conditions to which manv deformities are duo is the formation of .rX\ \\<)- • 1 r I ( t n i ! i ^ .* t i liii 1 1 i 1 1 ! ^ . '■] : .'^00 AMERICAN TKXT-IiOOK OF OliSTKTRTCS. nmniotic bands. Simoimrt (lifroroiitiatos three classes of amniotic bands accord- ing^ to their origin and insertion — tlie i'eto-amniotic, the fetal, and the amniotic. Verv often the anomaly consists only in the existence of these bands, but some- times their existence is the cause of serious disturbance in the normal develop- ment of the fetus, giviufi^ rise either to cleavage or to strangulation, which in turn explains many of the malformations. Adhesions between parts of the fetus and the amnion are favored by a deficiency in the amount of the amniotic fluid. If these points of adhesion l)ecome firm(>r or vascular, they may pi'rsist, and if the process develops at an early term of fetal life, the regular dev lopment at that point will be arrested, giving rise to morphological anomalies which consist in the failure of union between two parts, such as hare-lip, extroversion of the bladder, etc. If these amniotic bands are attached to the etlge of the fetal cleavage, the cavities are j)articularly likely to remain open, giving rise to ectopia (Miiller). iStranf/u/dlioii. — Anuiiotic bands disturb the development of the extremi- ties chiefly by producing constrictions, causing at the peripheral end edema or atrophy. If this strangulati(in takes place at a very early date of fetal life, then the growth of that part will be greatly arrested, so that the periph- eral end beyond the constriction is propttrtionately small ; in other cases it produces death of the j)art and the so-called "spontaneous amputation." Intra-nierinc Amputation. — It is now generally admitted that the exist- ence of aiuniotic bands is one of the causes for intra-uterine amputation (Fig. 161). This amputation usually takes place early in fetal life. Sometimes there are a number of these bands, and they persist to the time of birth. The other causes recognized as such ^^ "" V ki^^'i^*^ are inflammatory processes and intra- Sjl^ \ [^ ' ■!►' "^ uterine fractures. Virchow attributes ^KKLla*"*-'^'*^^^^^ them to primary inf1ammati(m fol- lowed by cicatrix and disturbed nu- Fki. ir,i.-K(tn.mcUis(intra-utorinL-umputution). tritioii. Simi)son hoUls that thcrc is a causative relation between intra- uterine fra(!tnre and spontaneous amputation, the healing processes being unf;i- vorable for fractures. The bone-ends may perforate the vessels and <l. interrupt the nutrition of the extremity, causing a sequestrum. Intra-uterine fractures occur occasionally, and they are usually di to external violence, notwithstanding the protection of the fetus by the amniotic fluid and the maternal body. Abnormal nuiscular contraction of the fetus and a diseased condition of the bones are other causes. A syjihilitic osteo- chondritis may result in separation of the epiphysis and diaj)hysis of the long bones, simulating fractures. Next to external violence, advanced rachitis in the fetus undoubtedly is the commonest cause of intra-uterine fractures, which are commonly multiple. Tibial fractures are frequently associated with an imperfect development of the long bones. The intra-uterine con- TIIH PATHOLOaV OF riiKOXAXCY. 301 (litiotiH arc not lavoruhle to a good union. Union may take ]>laro before birtli, but u.sually it is a union witii bad ilctbrniity. In rachitic t'ctusort tlio conditions I'or good union arc particularly iiutavorablc. If these fractures remain ununited, or if they have healed, but have producetl markoil disloca- tions, they may cause difTicult labor. Congenital luxations occur in certain Joints, and produce such secondary changes on the surface of the joint that in some cases restoration at the time of l)irth is impossible. Various joints may thus be afleeted, but this accident occurs most frequently in the lilp-joint. In Prof LangenbecU's clinic there occurred 90 cases of luxation of the hip-joint to 5 of the humerus, 2 of the head of the radius, and 1 of the knee. According to Kriiidein, luxations arc more common on one side. Luxations are apt to be associated with otiier malfornhitions ; they are commoner in females than in males, 87.6 per cent, occurring in females. Etiolnffij of DiHlocatUmx. — As to the etiology, many theories have been advanced to account for the occurrence of dislocations, of which the Ibllow- ing four are the most plausible : 1. That it is due to true traumatic dislocation resulting from injury inflicted before birth or during delivery. 2. That it depends on a relaxed condition of the ligaments or upon hydrops of the joints. .'J. That it is a deformity caused by .spasmodic muscular contractions during fetal life. 4. That it is due to a malformation of the acetabulum characterized by the pi'oduction of deficiency of the socket in which it is normally held. Since in most cases of congenital dislocation the labor has been easy and natural, the first theory will hardly liold. It has also been demonstrated (Midler) that the same force which in an adult woidd produce a dislocation will in the fetus produce epiphyseal separation. The theory accepted by most writers as the most plausible explanation for the cases which have been examined is the fourth — congenital malformation of the acetabulinn. This theory, which was advanced by Paletta, has found adherents in Dupuytren, Hrechet, and most recent writi-rs. The deformity is not usually noticed until it is time for the child to walk. The atl'ected limb is slightly shortened. As the child grows older oblirpiity of the pelvis and compensatory lateral curvature of the spine may follow. Further discussion as to symptoms and treatment would liardly come within the scope of this work. Congenital Tumors. — Alxhtniual Tionors. — The fetus occasionally pre- sents at birth abdominal tumors of considerable size. The abdomen may bo enlarg* . on account of ascites, which is usually of syphilitic origin. Disten- tion of the bladder sometimes produces an immense enlargement. Other abdominal enlargements which have been observed are produced by hydro- iiophrosis, dilate<l ureters, ovarian tumors, and carcinoma of the liver. S(i (d Tumors. — Vario.is tumors also occur on the surface of the body, particularly in the sacral region. They may be located on the sacrum oi on the s \*\ h V \i "t\ 302 AMERICAN TEXT-BOOK OF OBSTETRICS. sacrum and coccyx, but usually on the coccyx alone. They are more frequent in the female than in the male. Out of 58 cases of sacral tumors, forty-four were females, fourteen males (Molk.) The tumors vary in size and in their general appearance. We distinguish the following forms: (1) Congenital cystic tumors; (2) Congenital fatty and fibrous tumors ; (3) Congenital tumors with fetal remains ; (4) Caudal excres- cences ; (5) Attached fetuses. The cystic tumors are usually hydrencephalocele or spina bifida. They occur chiefly in the cervical and lumbar regions. Fibrous tumors and lipoma occasionally occur. Sometimes these tumors contain a part or parts of a fetus. This inclusion results from a cleft in the medullary fold, that may give rise to a double formation resulting in a rudimentary tumor. These tumors may be simple or be multilocular; they may contain rudimentary limbs, cartilage, or loops of intestine. Sometimes one rudimentary fetus is attached to the palate of a fetus more developed. Caudal appendages occasionally occur : they may be either fibrous or bony, assuming the shape of a tail. Molk gives two such examples. Sometimes in cases of attached fetuses an extra limb is attached to the sacro-lumbar region ; sometimes it consists of two limbs fused into one (see Dystocia). In these cases the pelvis usually shows some malformation. Treatment of Congenital Tumors. — Of all these tumors the treatment is excision, but it is only indicated in cases where the attachment is not too extensive or where the growth does not to any extent encroach on the pelvic cavity or the viscera. Deformities of Special Regions and Organs of the Body. — Tlie in- fluence of amniotic bands in arresting development by preventing tlie normal fusion at an early stage of embryonic life is now generally admitted as an explanation for such deformities as hare-lip, cleft palate, fissure of the nose, etc. Often a number of malformations occur in the same individual. Deformities of the Face. — If the frontal process fails to unite with the superior maxillary process, which in the normal course of development unite in front of the mandibular tissues, a defect in the soft parts, producing hare- lip, may result ; if the inward growth of the palatine processes is arrested, cleft palate results. Ifare-lip occurs in various degrees. Sometimes there is only a slight notch in the lip, and again there may be one or two fissures extending to the nostril, and it may or may not be associated with cleft palate. The existence of hare-lip interferes more or less with nursing, especially if associated with cleft palate. Often feeding with a spoon is unsatisfactory, because the food will regurgitate through the nose. Infiuits with hare-lip, as a ride, are there- fore imperfectly nourished, and if they survive are likely to possess a low vitality. The treatment consists in sustaining the strength of the child as well as possible fi)r the first few weeks of life; after that an ()]>eration should be perfi)rmed. A consideration of the methods of operating would hardly be within the scope of this work. THE PATHOLOGY OF PREGNANCY. 303 Congenital occlusion of the posterior nares occurs, but very rarely. Con- genital cysts of the floor of the mouth sometimes manifest themselves in the form of a swelling under the tongue or the chin. Toiif/t'e-tie. — Very frequently the frenum of the tongue binds this organ to the floor of the mouth, immobilizing the tip of the tongue more or less. This condition interferes with suckling, and if not corrected will prove an inipediment to speech. The treatment consists in operating, as soon as the discovery is made, by raising the tongue either with a spatula or a finger, rendering the freiiimi tense, snipping the membrane with scissors, and making any further separation by tearing with the finger. Care must be taken not to cut too deeply, to avoid profuse hemorrhage. In the second jiart of the digestive tract strictures or pouches may occur. Malformations of the stomach arc not common. The " hour-glass " deformity sometimes occurs. Congenital obstruction of the bowel may be located in the duodenum or the jejunum, but more fre(piently in the ileum. Portions of the intestine m.-xy entirely be absent, or be represented only by a band of fibrous structure running along the free edge of the mesentery. Volvulus and hernia may cause obstruction. Couf/euital im/nitial hernia is due to a patulous condition of the inguinal canal, through which a loop of intestine protrudes. A few cases of perforation of the intestine are recorded. In these cases death occurred within the first few hours after birth. In three cases the rup- ture was found at the sigmoid flexure ; in one case in the splenic flexure ; in one case the transverse colon was perforated. The etiology is tissue-necrosis, probably accumulation of meconiiuu. Tiie large intestine, including the sigmoid flexure and the rectum, is liable to various malformations. The commonest malformation is obstruction of the bowel, due to deficient development. In an imperforate rectum there may be a well-defined exterior opening or it may bo absent ; the rectum is usually deficient to a greater or lesser degree. In imperforate anus the rectum is well developed, but the external opening is hi'-king. In some of these cases where the amis is absent the rectum passes into the anterior or genito-urinary segment. Hydrocele is a not infrequent atfection, and is dependent somewhat upon congenital defi)rmity when the processus vaginalis remains patent. Congenital defects in the generative organs of female children are not so com- mon as tliey are in the- male, and they are fre([uently not noticed until a later period in life. The defects of the internal organs are gynatresia and defect of the uterus and of the ovaries. INIalformations of tiie organs of generatit)n of the female are usually due either to absence of Midler's ducts, to failure of union or bicftnniity, complete or partial, or to persistence of tiie septum, giving rise to the double formation of uterus and vagina. Persistence of the canals of (jiirtner sometimes gives rise, later in life, to cysts of the vagina, and persist- ence of the ducts of the Wolffian body may «levelop into parovarian cysts. Nmuerous cases of cystic tumors of the ovaries existing at birth have l;een recordetl, but there are still controversies concerning the embryonic origin of 304 AMERICAN TEXT-BOOK OF OBSTETRICS. ( ! , I 11- 'f / '1 1 t these tiimoi's, some assuming that all cystic ovarian tumors are already formed in the embryo (Poz/i). This origin applies especially to the dermoid. J, Bland Sutton, who has devoted much time to the study of fetal ovaries, says : " I have never succeeded in detecting an ovarian dermoid at birth, neither can I refer the reader to a trustworthy case." Malformations of the Extremities. — Numerical excess, supernumerary digits or toes, is another variety of maltbrmations. The treatment for super- numerary digits is amputation. Congenital union of digits (syndactylism) occurs in varying tlegrees, there being sometimes a firm fusion of the two adjacent members, at other times a webbed condition. The fusions are treated by incision. Club-foot is only a modification of a ]>hysiological position in utero. Too small an amount of amniotic fluid tends to produce chilnfoot, the foot being pressed against the breech ; this long-continued pressure of the soft ])arts tends to shortening of the bones by I'ctarding the progress of growth ; thus the position becomes fi.xed (Ivanderer). This congenital malformation usually produces talipes varus or equino-varus. There is usually moi'c or less ])aresis, and sometimes paralysis of the nniscles of the aft'ected side and tonic contrac- tion of their ()j)ponents. The treatment consists in ])roper bandages, which should be applied as soon as the deformity is discovered. Malformations of the Circulatory Apparatus. — Malformations of the heart are very common, esj)ecially persistence of the foramen ovale. Fetal endocarditis, with its consequent valvular lesions and transposition of the aorta and jndmonary artery, also occurs. Sometimes there is but a rudimentary sep- tum between the ventricles. As this system resembles the arrangement of the heart of the lower forms of life, it is called " reptilian heart." Persistent cyanosis is the most marked symjitom of these malformations. Frequently the fetus is not viable. Malformations of the Brain and Cord. — Cerebral hernia, or men inr/oceJe, is a tumor varying in size from a hazel-nut to that of a child's head. It occurs usually on the occiput, occasionally at the root of the nose or on one of the fontanelles. Sj)i))a bifida, which is not uncommon, may o<'cn])y any part of the length of the spinal colunni. It is a congenital malformation in which the lainiuie fail to unite in one or more of the vertebra^ allowing protrusion of a sac com- ])osed of the spinal cord or its membranes. If the spinal membrane only protrudes, it forms spinal meningocele; if the cord and spinal nerves as well as the membranes ]>rotru<le, they form meningo-myelocele; if in the latter pro- trusion the si)inal canal is dilated, forming a sac, it firms syringti-myelocele. ExcncephaluH is a deformity in which the brain is present, but the cranial bones are not developed. Pseudeneephalux, in which the bones of the cranium are absent or arc undeveloped and <'ontain a rudimentary bi-ain, is a more common deformity than anenrep/iahm, in which there is no brain and no development of the cranium. Acep/iafia and hemiceplialia are deformities consisting in a defect of the skull ; sometimes the delect continues into the spine. The integun)ent and nerve-tissue are wanting, and are replaced by -:..^; THE PATHOLOGV OF PREGXAXC'Y 305 some granulation tissue. The etiology is unsettled, although several theories exist. A fetus with this malformation is usually not viable ; if there is lii'e at the time of birth, it soon ceases. These deformities may occur successively in several pregnancies. Mk-rovcphalla is a monstrosity with a very small skull. The forehead is flattened and receding. Monstrosities of this class may be viable; if so, they are imbecile. Tiny may live for some time, and may even attain great age. Excessive Development. — Excessive development of the whole fetus occasionally occurs, in which the fetus has weighed from fourteen to eighteen pounds (A. Martin, Beach, Meadows) ; the more freiiuent cause, when the excessive development is not very great, is prolongation of pregnancy ; other causes are multiparity and excessive size of one or both parents ; again, there are cases in which the fetus as a wliole does not exceed in weight the normal limits, but there is an excess of development in some particular member of the body, especially one of the extremities. In such hypertro- ])hies of the fingers and toes, if the de- formity is sufficiently pronounced to prove a hindrance, am])utation is indicated. Double Formations. — Authorities do not yet fully agree concerning the cause of formation of homologous twins and double monsters. It is generally accepted that both originate from one blastula of the yolk. It is still a question of dispute whether the ])lastoderm membrane presents two germ- i native areas, which later fuse more or less into one being, or one area, which becomes more or less divided. As union may take place in the cephalic, the median, or the caudal ex- tremity of the embryo, one of these forms of monstrosities may result (Miiller). They are accordingly named cephalopagus, thoracopagus, ischi- opngus, etc. Of these classes various modifications occur. Figure 162 icprcsents an interesting specimen of thoracopagus, exhibited by Dr. W. \\ . .laggard before the Gynecological Society of (Chicago. If there is an uiKHjual development of the embryos, one may seem nearly normal, while tlie other is quite rudimentary and seems to form but an appendage to the loriner. Such a rudimentary fetus may even become completely enclosed by tlic larger one (Miiller). 4. MATRRN'ATi Imphkssions. — There exists a jxipular belief, which was Itarticularly prevalent during early times, that the peculiar sensations, emo- tions, sights, etc. experienced by a ]>regiiant woman arc rre(|uontly transmit- ti'il to her child, and if these sights and imj)rcssions are particularly friglit- tul. they cause marks and defects on the child. One of the arguments 20 Kiu. KVJ -Thoracdpajjiis (douljlo foriiiu- tiiiii). v\ ft- ! : I, ; I.: -^ i ?i: 1 lilt ?^-t . i 1 v I 1 I i • i I ; \' I 1 306 AMERICAN TEXT-BOOK OF OBSTETRICS. advanced in favor of this view is that a belief so universal and adhered to through centuries is rarely entirely fallacious, especially when the subject is based upon observation. The advocates of this theory adduce one of their most reliable arguments from the Scriptures (Gen, xxx. 37-35)) : " Jacob took him rods of green poplar, and of the hazel and chestnut tree ; . . . . And he set the rods which he had pilled before the flocks in the gutters in the wator- ing-troughs, .... that they should conceive when they came to drink. Antl the flocks conceived .... and brought forth cattle ringstraked, speckled, and spotted." At the present time authors, practitioners, and teachers differ, but up to the beginning of the eighteenth century they were nearly unanimous in the belief that fetal marks, deformities, and lack of development were due to impressions received by the mother. Wherever the truth may lie, it is very evident that manj' of the cases cited have been taken from individuals whose testimony would hardly pass as conclusive in other matters. During the past forty years many articles have been written strongly opposed to the previously accepted theory of maternal impressions. It lias always been extremely difficult to demonstrate that any deformity or mark or lack of development in the child was due to an impression which the mother may have received before its birth, inasmuch as there seems to be at least one unanswerable argument in that mc Hnd no direct nerve-connection existing between mother and child. The late Fordyce IJarker has been credited with demonstrating the correct- ness of the theory of "maternal impressions" in a paper read in 1886 befoi-e the American Gynecological Society. He quotes freely from physiologists to show that the weight of authority must be conceded to be in favor of the doctrine that maternal impressions may affect the growth, form, and character of the fetus. His opinions, however, were very largely based upon references and arguments adduced from older writers. Barker, in concluding, quotes the following from the Bnt'iHU-Amerkan Journal: "When, in the early weeks, structural development is proceeding at no tardy rate, an interference to luitritiim of the mother cannot but impress the fetus detrimentally, and the organ interfered with would be that one in the condition of the most active development, or that which could less easily bear any arrest, however transient, with inq)Mnity." Again: "Then, too, although no nervous connecticm has been demonstratetl to exist between the mother and the fetus, yet the latter possesses nerves; and alterations of the nutrient ])ower of the mother cannut but act on the nerves that are governing, though it may be only to a sligiit extent, the growth of the fetus itself" As a matter of fact, only a few cases — exceedingly few — of defective or marked children are born compared witli the multitudes of perfect ones ; then, too, the testimony in many of these cases is absolutely worthless. One of the ablest articles opposing this theory is written by J. G. Fischer. A few of his conclusions, and those epitomized, will be given. Tliey arr briefly as follows : Tiiat traditional superstition has perpetuated the notion, ^ THE PATHOLOGY OF PREGNANCY. 307 and that the medical profession is in no considerable degree responsible for its continuance ; that intense emotions and apprehensions are experienced, and malformations are expected by many gestating women, yet the abnormal births arc extremely rare ; that there is no law in the alleged result, and that the occasional apparent relation of cause and effect is due to accidental coincidences. There is, in addition, against the theory, another argument, which is that the assumed causes are alleged to have operated upon the embryo subsequently to the named period for the evolution of the part which is found to be the site of the malformation, implying not otdy a formative process, but a retro- formative power. This argument, it appears to the writer, is particularly strong. For instance : a child is born with a profuse growth of hair upon a spot of the body whore it should not exist. The mother and Ik.t friends, after considerable coaching, remember that some of the impression? somewhat similar to this were received at a certain time. As a matter of fact, that time occurred a considerable ])eriod after or before the period when, according to the study of embryology, we know the hair to have been developed. Several years ago Norman Bridge wrote a strong paper against the theory. Among other things, he says : " To endow the blood with such a weird intelligence as this would n^quire is too great a load for our credulity. There is no philosophy that it so acts. There is possibly enough in this theory s(j that we should, on account of the comfort of the pregnant woman, advise her not to indulge in violent emoiions, or to see peculiar sights, or to do any- thing which is outside of the proprieties of life." It is desirable, in the writer's judgment, to give this advice to all pregnant women. Many cases have been brought forward that seem almost to prove tiie position assumed by both parties in this controversy. In the writer's judg- ment, nothing is really established, and we must continue to believe that if a pregnant woman sees a sight and gives birth to a marked baby, it is usually only a coincidence. We must still regard the relation of cause and effect as largely an accidental coincidence bearing in mind, however, the fact that, exceptionally, very profound emotion can and does in some unknown manner influence the growth and developin(>nt of the fetus. 5. Intua-itterine Diseases of the Bones. — RaohUh of the new-born occurs in two distinct forms — the fetal and tie congenital. Although rachitis as it occurs in early childhood was recognized by the ancients, it is only recently that the existence of the fetal form has been fully recognized and described. Since Bohn and Winckel described these two forms the investigations of Vir- cliow, H. Mliller, and others have given support to this classificaiion. Both i'nrnis originate in the pre-natal state, but in the fetal form the disease-process is fully develoi)ed at birth ; in the congenital form it continues to develop. Petal rachitis (Fig. KiJJ) has been characterizcci as a disease of the periosteal cartiliige, giving rise to an active growth in tiie w roiig dircctictn ; at the same time there is a deficiency in the deposit of calcareous matter. In rachitis the cartilaginous and subperiosteal cell-growth is excessive and irregular, wliilc the process of ossification itself is also irregular and sometimes wanting (?('.' ■JL.r ' . i I, *. 308 AMERICAN TEXT-BOOK OF OBSTETRICS. (Fig. 1 64). The line of ossification between the epiphyses and diaphyses is irregu- lar, likewise is the zone of calcification ; newly-formed bone- and marrow-cavities may be in the midst of cartilag , and masses of cartilage may take the place of bony tissue. At the same time there is an excessive proliferation of cells on the inner layer of the periosteum ; these various abnormal processes lead to bony deformities. The long bones develop more laterally than longitudinally ; the extremities are short, thick, and usually curved ; the skull-bones are thick ; the ribs show nodular enlargement (beaded ribs) ; deformities occur in the spinal column and pelvis, and the thorax shows the " pigeon breast." There is a general disproportion between different parts of the body. The head is often large, the neck thick and short, tiie abdomen large. Associated with these characteristics we may find hydrocephalus and enlargement of the thyroid gland. Rofei-ence has already been made (page 300) to the frequent occurrence of in- trauterine fractures in cases of con- genital rachitis. There are other conditions which affect the growth of the skeleton in ntrro, and which resemble rachitis — Schmidt's, Bidder's, and Miiller's dis- eases. Bidder's Disease. — In Bidder's disease (osteogenesis imperfecta) the lines of ossification are normal ; tlio epiphyseal cartilage is normal, but Fig. 163.— Fetal rachitis. Fig. 104.— Skvill (front view) in fotal racliitis; ubsL'iice (if frontal bone. ossification does not fully take jilaco either in the epiphysis or in the diaphysis. Tiie bono-production from the jieriostetmi is commoiu'od, but in the dia])hysis tiic ('((mpact portion is imperfectly developed ; in the marrow-cavities tiiero is no d<'j)(»sit of calcaroous sub.stancc. The bones remain short and ])liablo ; tlie sagittal suture remains broad. The bones of the face and skull are particu- larly apt to be affln'ted. Sometimes this condition affects in a slight degree tlic bones of the skulls of infants wlio are otherwi.se perfectly developed. Schmidt's disease is charMctc'rized by great ])redisposition to fracture nl' the bones. The jteriosteum and the epiphyseal cartilages are normal, but (he bony canula; do not j)resont the concentric arrangement which normally exists. THE PAT/IOLOOV OF PREGNANCY. 309 The bone-corpuscles are large, and usually remain empty. The spongy sub- stance contains much connective tissue and many undeveloped cells. Miiller's disease is a diseased condition of the cartilage. The embryonic development of cartilage, which normally extends chiefly in a longitudinal direction, expands in all directions ; at the same time the development of bony structure from the periosteum continues. This action leads to the pro- duction of thick, short bones. The skull-bones are also very thick. 6. Intra-utkrine Diseases op the Skin, Connective Tissue, and Serous Membrane. — Diseases of the skin, the connective tissue, and the soi\/US membrane that manifest themselves in the pre-natal state are usually due to fetal syphilis. Cases of congenital ichthyosis, pemphigus, and other eruptive diseases have also been observed. Pemphigrus. — Pemphigus neonatorum in its epidemic form is considered on another i)age ; it must not be confounded with the congenital form. Al- though the pemphigus is usually syphilitic when present at birth (Roeser says always), still some cases of non-syphilitic pemphigus have been observed. Erysipelas has been observed to be transmitted to the fetus in utero. Anasarca. — Under this head belong hydrothorax, ascites, and hydro- cephalus. These conditions often produce mechanical obstruction to delivery. Occasionally anasarca is seen in connection with dropsy of the mother. This condition is frequently due to obstruction of the umbilical veil accompanying syphilis. Excessive distention of the body may result from ascites and hydro- thorax. Ascites is often due to syphilis ; also to organic lesions of the heart. Tumors. — Among congenital tumors of the skin, nevus is the most com- mon. Although not always noticed at the time of birth, the nevus is prob- !il)ly always present at that time. These tumors belong to the angiomata. Hairy and pigmented moles often occur congenitally. Peritonitis. — Fetal peritonitis is usually due to syphilis. It manifests no symptoms at this period, but if not destructive to the life of the fetus, it is likely to produce some constriction of the bowel. It also occurs in infants in connection with puerperal fever, especially in lying-in hospitals. The path- (tlogieal conditions correspond with those found in similar cases in adults. Pericardial and endocardial inflammations rarely occur, and the latter is more often located in the right side of the heart, and may leave lasting val- vular changes. 7. Struma. — Struma of the thyroid gland must not be confounded with edonia of that structtu'c. While edema occurs as a traumatic injury, true struma is an hypertrophy of the thyroid. Edema results from face presenta- tion ; hypertrophy may produce the same. Struma may be complicated with ('(lonia, which, however, will only be temporary. 8. Intra-uterine i/isEASEs OF THE Xervous System. — There are of the brain a uund^er of defects which are congenital in their origin, and which Inter manifest themselves as some forms of deaf-niutism, cretinism, idiocy, and otiier forms of ])artial or complete loss of development. Hypertrophy ul" tlie brain sometimes occurs, associated with rachitis. m If r ill •" ' 310 AMERJi'AN TEXT-nOOK OF OBSTETRICS. i I r; Hydrocephalus. — Fetal hydrocephalus is not common and its etiology is not understood. According to Meigs, it is due to an inflammation of the lining of the ventricles. Jt often ])r(xluces a hideous defornuty, due to pro- trusion of the eyes and ])rojection of the Ibrehead (see page 259). Cretinism is endemic in some mountainous districts of Europe. It is often associated with eniargement of the thyroid gland. Syphilitic Idiocy. — Manifestations of syphilitica idiocy are recognized after the period of infancy. 9. Dkath iw THE Fetus. — In presenting this subject a repetition of what has been said under Abortion (page 259) can hardly be avoided. The causes resulting in death of the fetus before maturity may be consid- ered under the following heads : (1) In the father, — alterations of semen, as in phthisis, albuminuria, etc. (2) In the mother, — general diseases, excitability of the uterus, and marked lesions of the same. (3) In the fetus — or faulty development. (4) In the annexes of the fetus — membranes, placenta, cord. (5) External violence. (1) Causes resuU'my from the Father. — Conditions producing great debility in the father are liable to manfest themselves in a low degree of vitality in the oflfspring, and often before the time of birth ])roduce death in the embryo. Old age in the father, chronic poisoning, albuminuria, and phthisis are likely to be followed by this residt, but the most frequent cause from the parental side is the transmission of syphilis from the father. The embryo may show signs of this disease without the mother being infeoted. Death of the fetus is explained in various ways. The fetus itself may be of low vitality, or the membranes may become affected in a way to interrupt life. Syphilis may produce hypertrophy of the villi of the chorion (Schroedor), jiroducing sufficient pressure on the maternal vessels to render imperfect tlic interchange of nutrition between mother and fetus. The more recent the infec- tion of the parent the more likely is it to produce death of the fetus and abor- tion. Rupture of one of the viscera may cause death of the fetus. J. W. Ballantyne cites three cases in which rupture of the spleen was the immediate cause of death within two days of delivery. One case occurred during Prof. A. II. Simpson's service, and the post-mortem examination was made by tlic writer; death occurred two days after labor. The second case is one reported by Charcot (1858), in which a stillborn infant had been resuscitated and lived half an hour. The third case was reported by Kleinwiichter (1872) : a pre- maturely born infant, weighing four and a half pounds died in four honis. 2. Cmm:s reuniting from the Mother. — The influences from the mother lead- ing to death of the fetus are numerous. Acute infectious diseases of the motliei come under this head. It has been demonstrated that high temperature and anemia of the mother are liable to interrupt gestation by premature uterine otrntraetion. Tuberculosis, carcinoma, nephritis, and diabetes of the motlier often cause peculiar excitability of the embryo; the nervous system of the THE PA'nH)lA)(iY OF PRKUNANVY 311 motlier will likewise bring about this comlition, the motor nerves responding to very slight irritation and setting tip uterine contraetion. IMithisis of the mother sometimes produces premature labor, sonietimes abortion. Death of the fetus on account of tuberculosis of the mother is not usual, but frequently the child is poorly developed, and if it survives remains feeble. Wliether this feeble condition is due to lack of resistance or to intra-uterin< jr latent disease cannot now be decide<l. Conditions of the uterus and its immediate surroundings n. , uterrupt preg- nancy ; especially is this true of endometritis and all iuHammatory conditions of the parenchyma. Conditions which interfere with the expansion of the uterus, such as versions, flexions and adhesions, and neoplasms, also some- times interrupt pregnancy, but usually the uterus ov(!rcomes the resistance by degrees. The presence of uterine fibroids is more likely to interfere. 3. Causes resulting from Fault}/ Development of the Fetus. — As regards the fetus itself, anasarca sometimes results from disease of the mother, sometimes indejwndent of the same ; it may cause })remature birth and expulsion. 4. llie Anncven of the Fetus. — Membranes, placenta, and cord, degener- ations of the placental villi, extravasations and effusions of blood into the placenta and membranes, will more or less interfere with the nutrition of the embryo, causing jiartial or complete separation of the placenta. Amyloid and fatty degenerations of the placenta will ])roduee the same result ; likewise any condition which interrupts the circulation of the cord must be disastrous to the nutrition, and eventually to the life, of the fetus. Dropsy of the amnion (hydramnion), or an excessive amount of fluid in the amniotic cavity, is not uncommon. Wiicn it exists in a marked degree, it will ])roduce death of the fetus, though the latter may have advanced to maturity. Knots in the umbilical cord may produce sufficient change in the circulation to materially affect the fetus (Fig. 1G5). Lefour, who (,'xperiinented with refer- ence to knots of the umbilical cord cm the fetus, concludes tiiat " the influence of mere knots a])art from compression is slight. When the intravascular com- ])ression increases the cord becomes turgescent and tends to loosen." Fi(i. IfiS.— Knotted oiinl. AVhen death of the fetus occurs in successive pregnancies the term *' habit- ual death " is applied. Some authors apply the term only to those cases in wliich abortion occurs repeatedly at the same stage of pregnancy. Schrocder Mould apply the term only to cases occurring repeatedly at about the same ])eriod and assoeiatetl with no apparent anatomical changes in the mother, the embryo, or the membranes — that is, when the interruption is brought about '&,1 fi ilii: i I it V 1 1 ' t 312 AMTUilCAN ri'LXT-liOOK OF OliSTETRK'S. . ;»:. merely throngli excessive irritability on the part of the mother. Most authors, however, give as causes for habitual death of the fetus, lirst, syphilis, the most common, then maternal anemia and uterine disease. 5. External Violence. — The dilferential diagnosis betwceu death produced by external violence and that produced by natural causes is oi medico-legal interest, but does not properly belong to this work. 10. Post-mortem Changes of the Fetus in Utero. — The changes produced in the fetus by pre-natal death are characteristic, and usually an; markedly different from those protluced after birth. A number of post-mor- tem changes may take place ; in the main, the changes vary somewhat with the period of development. If pregnancy is interrupted during the first few weeks, the embryo is usually not much altered, is small, and is generally sur- rounded by very little fluid. If the fetus dies during the first months of gestation and the ovum is not expelled, some weeks afterward the latter may be found containing no trace of the embryo. The total absorption of the fetus assumed by many writers is doubtful ; according to Midler, it does not occur frequently, and probably is possible only at a very early period of development. He assumes that in many cases where no trace of the fetus is found it has either passed previous to the expulsion of the membranes, or has been liquefied and is passed in a state of dissolution. The membranes may show signs of decomposition or may con- tain extravasations of blood. If the vitality of the chorion has been retained for several weeks or months, it will result in a " mole pregnancy." After the fourth month of gestation the possibility of unobserved escape of the fetus or that of liquefaction no longer exists. At this period the fetus is either retained without change or it undergoes one of the following changes : 1. Maceration ; 2. Saponification ; 3. Mummification ; 4. Putrefaction ; 5. Sup- puration ; 6. Calcification. Maceration (Fretus sanguinolentus, E. Martin) is the most eonmion of the post-mortem changes of the fetus aflter the fifth month ; it rarely occurs at an earlier period of dcvelojiment. The fetus is usually discolored, brownish, and livid ; some of the epidermis shows bulla; ; these may contain a yellowish fluid, or if ruptured the red corium is exposed. The thoracic cavity is usually small, the abdomen large, containing bloody fluid, and all tissues, muscles, and bones are softened. The umbilical cord is dark, and Wharton's jelly is distributcnl irregularly. The placenta is also softened and saturated with bloody serum ; the chorion and decidua show necrosis. In some cases occur the characteristic changes of syphilis, osteo-chrondritis syphilitica being especially marked in the lower epiphysis of the femur. Associated with this may be a condition designated by Buhl " lipoid degeneration." Tjiterature contains but one case of this change, it being fully described by Buhl. In this case the muscular, adipose, and bony structures were unchanged, but the cavities were lined with a thick caseous matter, which in microscopic examination showed crystals ol' margarin. According to Buhl, this process must not be confounded with that of " saponification." I 77//; PA mo: )gy of pregnancy. 313 Saponifloation. — The process of " suponitication," describe<l in older books, comes probably iiiider the head of niuniniification. Mummification. — Tliis change may be regarded as the typical post-mortem change of the fetus when death takes place between the third and the sixth month. The fetus is shrivelletl, the tissues are dried, the skin is gray and shows the outline of the skeleton. If such a fetus has been retained for a long period and is subjected to pressure, it sometimes becomes desiccated and flattened like a sheet ; such a change is designated by the term Jdm papp'aceua. Twin pregnancy is most likely to produce such a change when one embryo dies and the other continues to live and develop. The placenta is also dehydrated, and there is no amniotic fluid. This fluid has either been drained off or has been absorbed by the chorion. Mummification is more likely to occur in cases where the cord is twisted about the neck of the fetus. If the fetus attains the age of several months before death takes plaa^, it is likely to undergo one of the two changes, putrefaction or suppuration. Both these changes are due to the entrance of germs, which is more liable to occur after the rupture of the membranes, so that germs are admitted from without. Putrefaction. — The process of putrefaction differs from that of maceration. It is characterized by the presence of a foul odor and by the production of gas — sometimes in great amount (phy.sometra or tympanites uteri). Suppuration is often associated with putrefaction. The changes which the fetus undergoes in ectopic gestation have been referral to under that head. Calcification. — A dead fetus remaining in the uterus or in e.xtra-uterine cysts for a longer period may become infiltrated with calcareous matter until it resembles a stone. Such a fetus is termed a lif/iopedion (p. 283). Cases are on record where the fetus has been retaine<l in this state for many years. Lusk cites a case in which the woman was supposed to be pregnant, and labor ceased with the expulsion of a child. Thirteen years later Lusk removetl a calcified fetus. REFERENCE LIST. 1. Ferguson : EiUnburgh Medical Journal, 18<t3, p. 1118. 2. Weiiiiing : American Journal of Obstelrics, ISilO, No. 2. 3. Crooni : Edinburgh Medical Journal, Oct., lS<t2, pp. 31(i-:522. 4. Ilogan : Transactions Southern Surgirtd So- ciety, 1892. •'). Loviot : Bidlctins et Mcnioires dc la Societe Ohxtctricalc et Gynecoloyique de Parut, 18<J2, viii. p. 17. t). Oliver James, Liverpool : Mediro-Chirur- (jical Journal, l8t)l, xi. p. 204. 7. Fromniel : Verhandlumj der Deutscher Ge- sellischuft f. Gyniikoloyie, iv. p. 325. 8. Rentier: Annales de Gynecxilogie, March, 181)0. 9. Straucli : <SV. Petersburger medicinische Woch- enxrhri/t, 1892, No. 10. 10. Pliillips: Practitioner, Dec., 1888. 11. Pozzi : Gazette Medieale de Paris, 1890, No. 21. 12. Bourcart : Annates dc Gynecologic, July, 1894. 13. Ilofmeier : Zeitschrifl f. Geburtshiilfe, 1894, B(l. 30, lift. 1. 14. Ott : Centralblatt f. Gyniikologie, 1889, No. 18. 15. Ciordoii : Boston Medical Journal, Oct. 17, 1889. , ll'l _J m ir 1 !t li I ; I I 314 AMEIilVAN TEXT- HOOK OF OltSTKTIirCS. 10. Stiivt'ley : Sew York Jounntl nf < I ijHi'.rnlixjij 4">. II ml ObMvlncn, l.S!t4, No. Ti. 1". \'im (liT Vi'LT ; Jiiiirnnl Aiiuriain MiiUcitl ,U-«iri<iliiiii, 1H!I2, 1!». 4<i. 18. Aiivard : liiilhlinn ilr In Sicieli ObMitricale ,1c /View, LSHlt, No. J-). 47. li). Von HerH": CnilmlhUiU /. (ii/niikDiogie, 1H<>1, No. .'")(). 4.S. 20. Moller : Cenlntlblalt /. Uijiiakijlixjii', 1802, No. (i. 49. 21. Taylor: M,,Ur<il liecm-d, 1891, No. 9. I 22. Taylor: .l/.v/iV.i/ /^yo,,/, 1891, No. 9. ! 50. 23. Ellis : Traimiftioim Lomlon ObMelrical So- i rivtij, 1882, xxiv. p. H04. j 61. 24. Siiiigi'r iuul Cliiari : Cinlntlblnlt f. Oymiko- loijie, June l.S, 1891. 52. 2o. SiinKcr : Cfiitralbhitt f. (iyniikiiluiii,; 1894, No. 7. ryS. 2<i. Herman : TmiimrtitmK Lnnilon Ohntetncal j SoriHy, 1891, xxxiii. p. 4')t). 54. 27. Virchow: Arrhir, Ikl. xxl. S. 118. 2>l. .StrasMinann : Munntxrhri/l f. Geburtshiilfe, ' 55. ]{(1. xix. S. 242. I 29. Dolirn : Momlxclirift /. Geburtshulfe, Rd. 56. xxi. .S. 375. 30. Giis.><ero\v : Moimtschrift f. Geburtuhiilfe, ' 57. M. xxvii. S. 321. 1 31. Kk"l)s: MoiiiilHchriJ't f. GeburtMlJe, Rd. 58. xxvli. S. 401. 32. Matthews Duncan : Resetirehen in Obntetricx, 59. p. 290. 33. Dickey : Annalx of Gi/iiecology and Pcedi- tiO. atrirx, 1891, 1892, v. p. (i. 34. Madurowicz : Wiener klinixclic Wurhcn- (51. Hchrift, 1889, No. 20. 3."). JjJlilein : (\ntmlbliitlj'. Gyniikologie, March, ()2. 1892, xix. p. 200. 3(). Nolile : I'mnmctionn Aincriran Gynecological li:!. Siirii'ly, 1S91, xvi. p. 484. 37. Nol)k' : TrmiKdrlliiiix AiiiericiinGynccolDc/ienl , t)4. Society, 1891, xvi. ]>. 484. (io. 38. Coe : Ameriran (TynecologiculJounuil,l><9l, No. 9. i liG. 39. Thomson : Deiilnrhe mecUcinische Wochen- Kelirifl, 1SS9, No. 44. Cu. 40. I'olaillon : ArrhiivH de Tocologie et de Gyne- 08. cologie, xix. p. 729. 41. Ruge : CentralbUitt f. Gymikolnc/ie, 1890, I 69. No. 30. ... I 42. Schroeder, Olshausen, and Flaischlen : 70. Zeitxchnft /. Geburtshulfe, 1894, Rd. 71. 29. 43. Dsirne : Archie f. Gyncikologie, Rd. 42, .S. 72. 41."). 44. Manj^iagalli ; Berliner klininche Wochen- i 73. xchrifi, 1894, No. 21. j .Vcconci . "I)ei cistotne ovnrici in rap- porto allc funxioni Ki'"i''''itive," Milano, Tipiiyr. Jierhiri, 181S9. Terrillon : Airhiren de Tneologie, .\pril, 18SH. Klirendorler: Archie /. Gyniikolni/ir, Rd. 34, Hit. 1. SiiUKer : ( 'enlrnlbliill f. (lyniikolni/ie, 1894, No. 7. Winter : Zeitxchri/t /. Gebiirtxhiil/e, Rd. 14, Hit. 2. Kissman : Centralblnll J. (lynaki)logie, 1892, xxiv. J). 452. Virginin Mediiol Monthly, 1888-89, xv. (!7<). Martin : Dentxehe medicinixche Wochen- xchrifl, 1889, No. 39. Trenh : yeilerlondxch tijdxvhrift rimr Ver- liixkiiiideen Gynipcolngie, Jalirfjf. iii. No. 3. (cottschalk: Archie J\ Gyniikulogie, Rd. 40, Hft. 2. Rarl)our: Edinburgh Meuicid Journal, Kept., 1894. • Cohnstein : Archie f. Gynlikologie, Rd. 33, Hft. 1. Renckiser: CentridblattJ. Gynlikologie, 1887, No. 51. Davis; InlernationnI (linicx, 1894, vol. 3, S. 4, p. 275. Trantenrotli : Zeitxchri/t f. Geburtxhiilfe mid Gynlikologie, 1894, 15(1. 30, lift. 1. Fischer : I'rager inedirinixehe Wochenxchrift, 1892, No. 17. Scluuita : Internationak klinixche Itnndxi'limi, 189-\ No. 27. Meyer : Zeitxchri/t /. Gebiirtxhid/e, Rd. Ill, lift. 2. Laiitos : Archie /, Gyniikulogie, I'l'.. 32, Hft. 3. Herman : Lancet, .Jan. 13, 1894. Roudin : Journal de Medecine de Paris, 1893, No. 22. Kol)liUick : Zeitxchri/t /. Gynlikologie, 1894, Rd. 29, S. 208. Rerlieroft': Vnich, 1893, No. 10. A'oituriaz : Archieex de Tocolngie, 1890, No. 12. Randolph : Bulletin Johnx Ilopkiux Jlns- pital, 1894, vol. v. No. 41. I'^chroeder : Lehrlmeh der Geburtxhiilfe, IS'.ll. Gow : Edinburgh Medical Journal, 18.SS, part ii. Storer : Boxton Medical and Surgical Jour- nal, 1892, cxxvii. pj). 377, 379. Jardrin : Glaxgoie Medical Journal, 1892, xxxvii. 417, 422. TITK rATHOLOaV OF PREaXANrV .315 71. Sutii)fiii : ZfilMhriJI J. (ieburtMlfr, xxiv. 103. |>. *2M(I. 75. ISiulin : Pmirh Midirtile, 1888, Nos. 2, .'<• 104. 70. Kiiliiiow ; Airhir f. (lyHahtlmjii', 15(1. ;<•'), lift. ;«. lor). 77. I)rivfr: limttm Mfrlintl iiiiil Siirfilrnl Jintr- mil, St'pt. 1"), 1887. 100. 78. DiilirsHi'ii : Archil' /. (hjudkohijii; Ikl. 43, lilt. 3. 107. 79. Budiii : Iai Neimine Mfilicnk, 1893, No. .\ix. p. 141. 108. 80. Cliiiriionticr: ArckireA ik Tornhr,i,; 181)2, lO'.l. No. 2. 81. Prutz: Zeilwhri/lf. Gehnrlshiilf,; IM. xxiii. 110. lilt. 1. 82. I'illiot and Delimsornu' : liiilhlln tie In So- | 111. rit'le Aimhmuiiiic ili- J'nri^, 1802, No. 8. ' 112. 83. Fisi'liiT ; PriKjer iin'ilieinixchf Worlifnxrhrijt, 1892, No. 17. 113. 84. IMiuic; Lnoii.1 Medicali; 18<)0, No. 38. 8"), Piipillon iiixl Aiuinin : Hiilhiin de la Sii- 114. riele Aiidinmique di' I'lirlx, 1891, vol. vi. I p. 303. I 11. -J. 80. KofltT and Ktiiulrat : Wlfiiir klinkche \ Wiirh'UHvhnfl, 18111, No. xx. 87. (ierdcs: Mihivhrner inrdifiiii.irln' Wiichen- 110. schri/l, 1892, No. xxii. I 88. Tarnier and ('liaml)rc'lont : Aiimden di- (lijiivciiliKjii', Nov., 1892. 117. 89. LauK : Arrhiivn dr Tnrohf/ie, 1892, No. xi. 90. Herman: ^lincricdii Jiiiini<il nf the Medical 118. Scicncfs, Nov., 189], p. 48."). 91. Davis: Aiin'rinin Joiirmd of tin' Mi'dical 119. Sciriic's, Feb., 1894, p. 147. 92. (tustav Hraun : Wiener mediciiiiKchf I'lrKxr, ' 120. 1888, No. 19. 93. Blanc: AiiiKdex de Gi/iieeiil(i(jie, 1891, vol. 121. 30, p. 1.'). ! 94. Blanc; /.i/-»h.s JAV/kk/c,. 1890, No. .38. 122. 9.'). Van Santvoord: Medirid Jlee„rd, 1891, vol. 40, p. 197. 9(1. Thomson : Deiilni'he iiiedieiiii.iehe Woeheii- 123. xeliri/t, 1889, No. 44. 97. Kocttnitz : Cenlridhlatt /. (Iijnlikolnfjie, 1888, 124. No. 48, p. 778. 98. Neidcn : MotinlMnll f. Aiif/enheilkunde, 125. 1891, xxix. ]). 3.")3. 120. 99. Fonrnicr ; L(i Jhillelius Midiade, vi. p. 1170. ; 127. 100. Ilektoen: Joiirmd of the Ainerirnn Mediad ' AxMtcidtinii, 1892, vol. i. No. 1, pp. 128. 0-12. ' 101. Mc('al)c: Trannactionn New York Mcdiccd 129. Sncieti/, 1892, p. 200. i 102. Horroeks : Tmnmctions London ObMetrical ^ 130. Society, 1891, xxxiii. 3, p. 201. ( Chnnihri'lent : Animlen de (iijnirnlnfiif, IVI>., I8,S1I, p. IM). NapiiT : yorth Carolina Medical Journal, March, 1888. Mackav : Lomlon Lancet, 1891, vol. ii. p. 1.388. Braxton ilicks: Tranmctinn* London Ob' Hletrirnl Sorietij, 1811], xxxiii. p. 48(), McCann: Triiiinaetionn Lomlon Obnletrical Societji, 1891, vol. xxxiii. pp. 413-48.'). ( towers : IHxeaM's of the Xernniit Si/steni. Ilandlield -Jones : TrannaetionK London ObMetrical Societij, 1889, vol. 31, p. 243. Bue : La Prenne Mi'dicale, Sejjt. 1, 1894, p. 279. ( lairdner : (llaMi/oir Medical Journal, 1870. I'antzer: Cenlralblatt f. llyniikoloijie, 1890, No. xxxii. Shoot : yederlamlKcli, tijdxchrifl voor Genees- kinide. SolowieiF: Ccntralhlalt f. Gyniikologie, 1892, No. xxvi. Matthews Unncan : Traumctionn Obxtet' rical Society, 1882, vol. xxiv. pp. 250- 285. ( )ddi and Vicarelli : Lo Sperimeutale, Fitseicolo No. 2, 1891, Memoire Origi- nali. Fry : J'ranKactioun American Gynecological Society, 1891, vol. xvi. Ilehir: Indian Medical Gazette, March, 1892. Feinl)erg : Centralblull f. G yniikolof/ie, 1890, No. vii. Davis: 7V((/i.s(/W/o».s American Gyneco- logical Society, 1S1I4, vol. 19, p. 110. Lindcnmann : ( 'entralblutt f. I'athologie, 1892, No. XV. Copeman : "A Novel Treatment of Obsti- nate Vomiting in l'ref;nancy," liritiKh Medical tlourual, May 15, 1875. (irant: Montrrid Medicid Journal, 1891, vol. xix. Koland : Xourellex Archiren d'ObKlitrique el lie (lynceoloijie, 1893, No. vi. Blanc: Archirexde Tocoloi/ie, No. vi. 193. Kinjrman : lio.slon Medical and Surgical Journal, vol. 77, p. 427. .Mdt'eld : Cenlralblatt f Gyniikologic, 1891, No. 17. (innther: Cenlralblatt f. Gyniikologic, 1888, No. 29. Siinger and Ilennina;: Miinrhencr medi- cinisehe Worlien^chrift, 1888, No. 28. Florentine: American Gynecological Jour- nal, 1892, vol. ii. p. 149. J 316 AMERICAN TEXT- BO OK OF OBSTETRICS. , ! I r 131. Clay: Chim<jo Medical Siandard, 1801, p. 29. 132. Johnston : Virriinin Mvdiad Monthh/,lSiii\ vol. XV. J). 140. See also Lomer, " Ueber die Bedeutung des Icterus (.Jravidarurn fiir Mutter und Kind," Zeitschrijt /. Gehurtslnilfe, Kd. xiii. lift. 1, 8. ICi). 133. Matthews Duncan : Lccturen on Diseases of Women, 3d edition, p. 2i)5. 134. Winter : Transactions Washington Obstet- riml Society, 1889-90, vol. iii. p. 1. 135. Robert Koch : .SV. Peterxburgcr medicirir ischc Wochcmchrift, 1893, No. x. 136. Mixter : Boston Medical and Surgical Journal, 1891, No. 27. 137. Lantos : Archiv f. Gyndkologic, Bd. 32, Hft. 3. 138. Thomson : Deutsche medicinische Wochen- schrift, 1889, No. 44. 139. Koettnitz : Deutsche medicinische Wochen- schrift, 1889, No. 44. 140. Elliott : Birmingham Medical Review, 1892, vol. 32, p. 1. 141. Haberlin : Centralblatl f. Gyndkologic, 1890, No. 26. 1 12. Dudner : Miinchcncr medicinische Woclien- schrift, 1890, Nos. 31 and 32. 143. Narse : Deutsche Archiv f. Gyndkologic, X. 315. 144. Winckelinann : Inaug. Dissert., Heidel- berg, 1888. 145. Schroeder : Archiv f. Gyniikologie, 1890, Bd. 39, Hft. 2. 146. Meyer : Archiv f. Gyndkologic, 1887, Bd. 31, lift. 1. 147. Ingersled': Ccntralblatt f. Gyndkologic, 1879, No. 26. 148. Fehling : Verhandlungcndcr DcntschcnGe- sellschaft, 18S(i, I. sitzung. 149. Meyer : lor. cit. 150. (iiisserow: Archiv f. Gyndkologic, 1871, ii. 218. 151. BischoH'and Bieriner : Corrcspondenz-blatt fiir Srhweizcr Arrztc, 1872. 152. t'anienm : American Journal nf the Med- ical Sciences, .Jan., 1888; Nov., 1890. 153. Siinger : Archie f. Gyndkologic, Bd. 33, Hft. 2. 154. Davis: IVanmetions American Gyneco- logical Society, 1891, vol. 16. 155. Lautienherg : Arrhirf. (r'y;i(7W()(/(V', 1891, Bd. 12, lift. 3. 156. PliilliiiHi Tran.taclions London ()bstetric(d Society, 1891, vol. ;):i, p. 390. 157. Kaezniarsky : Klin. Mitt, aus der f, (le- burtshillfe Klin., Budapesth, 1884, S. 178. 158. Dohrn: Archiv f. Gyndkologic, 1874, Bd. 6, p. 486. 159. Osier : Boston Medical and Surgical Jour- md, Nov. 8, 1888. 160. Istria : " l)e la grossesse considdrde eoninie cause de I'endocardite chroniciue," T/iftsc, Paris, 1876. 161. Marshall : " Du retrdcis,sement mitral, sa frequence plus grande chez la femnie que chez I'liomme, I.," Tlilse, Paris, 1879. 162. Macknesa : Edinburgh Medical Journal, 1890, p. 123. 163. Merklen : La Semaine Medicale, 1892, vol. 12, p. 274. 164. Martin : Medical Press and CirctUar, 1886, vol. ii. p. 328. 165. Robertson : London Lancet, 1891, p. 487. 166. Schauta : Internationale klinische liund- sehan, 1892, vol. 6. 167. Hirigoyen : Memoires el Bulletins de la Societe de Medecine el de Chirurgie dc Bordeaux, 1886, 15, p. 335. 168. Besnier : Journal de Medecine, Nov., 1890. 169. Findlay : Obstetrical Gazette, 1889, vol. 12. 170. Giglio: CentndblaU f Gyndkologic, 1890, No. 46. 171. Boyd : Annals of Gynecology and Pirdiat- ric", 1891, vol. V. 172. Smith : Transactions Washington Obstet- rical Society, 1889-90, vol. ii. 173. Cohn : Ccntralblatt f. Gyndkologic, 1888, No. 48. 174. Lomer : Ccntralblatt f. Gyndkologic, 1889, No. 48. 175. Gautier : Annales de Gynecologic, 187!>, p. 321. 176. BallaiityneandMilligan : Edinburgh Med- ical Journal, July, 1893. 177. Meyer : Zeitschrift f Gelmrtshiilfc. M. 14, lift. 2. 178. Remy: Archives de Torologic, 18^4, No. (!. 179. Mann; London Lancet, 1891, p. 610. 180. Wallich : Annales de Gynecologic, June, 1889, p. 439. 181. Klaiitsch : Miiuchener medicini.ichc Worh- ensehrift, 1892, No. 48. 182. \ iiiay : Archives de Toeologic, 1893, No. 3, 183. ^larkus : Prayer medicinische Wochch- schrift, 1890, No. xxi. 184. Dakin : Transactions Jjondon Obstetrical Society, vol. 33, p. 163. 18.5. Stocker: Centralblatf f Gyndkologic, \S\t2. No. .32. 186. Flaischlen : Ccntralblatt f. Gyndkologic, 1892, No. 10. THE PATHOLOGY OF PliEGXANCV. 317 187. Dsirno : Archiv f. Gyniihtlmjie, lid. 4;5, 200. lift. 3. 188. Polaillon : IhiUelin dc I'Academie ile 201. Mdecine, Paris, 1892, vol. 28, p. 14(). ISit. Kreutznuiii : Occidental Medical TiniCK, 202. Aug., 1892. 203. 190. Doran : Transacliom London Obstetrical Society, 1891, vol. 33, p. 112. 204. 191. Tiffany : Transact iom American Surgical Associntion, 1888, vol. C. 205. 192. Beliii: JMletin MMical du Nord, 1878, vol. 17. 193. Richard: BiUletin Medical du Nord, 1878, 20(). vol. 17. 207 194. Harris : American Journal of Obstetrics, vol. 20, j). t!73. 208. 195. (,'orcy : American Practitioner, ^i\\)t., 1S78. 19(). Rydygier: Proceedinys Congrens Go-vian 209. Suryeon-s, 1887, No. 12. 210. 197. Petit: Thesis, 1876. 198. Keelan: lirilish Medical Journal, 1887, 211. p. 825. I 199. Prozowsky : Vrach, St. Petersburg, 1879, 212. No. 6. I IJancroft : Medical and Surgical Reporter, 187t), vol. 34. Lihotzky : Centrnlblatt /. Gyniikologie, 1892, No. xxiv. 489. Milner : Medical Xews, Ixi. 24.3, 244. Neugebauer : Centralblatt f. Gyniikologie, 1890, p. 88. Fancoii : Journal rftvf Sciences Medicates de Lille, 1883, p. 241. Tift'auy : Transactions Medical and Chi- rurgical Faculty of Maryland, April, 1884. . Tiffany : Medical News, Ajiril l(i, 1887. Hint: American Journal of the Medical Sciences, vol. 81, p. 18(>. Pilclier : Provincial Medical Society, King's Co., 1879, vol. 3. Keen : Medical News, March 2(), 1892. Rasch : Zeitschrift f. Geburtshiilfe u. Gynii- kologie, \k\. 25, Hft. 2. Vickory : Boston Medical and Surgical Journal, 1890, p. 413. (jerilcs : Centralblatt f. Gyniikologie, 1890, No. 45. w \- l(>. Ill . I i I II m m-i ^ i I;-, 1 l^ww 1 1 1' ^! ■ ■ If III. LABOR. V \i% I. THE PHYSIOLOGY OF LABOK * Definitions. — Labor is the complex process by which the ovum is severed from its connection witli the motlier and extruded or extracted from the ma- ' ternal oriranisifi. The term normal hibor (eutocia) may be restricted to labors with normal factors that are terminated by the natural forces, or it may be narrowed down to include only vertex presentations in anterior positions under right conditions. Di/Kfocia, or ditticult labor, includes all forms of abnormal or complicated deliveries near term. Premature labor refers to the premature birth of a fetus which has reached the period of viability or of sufficient de- velopment to live independently of the mother. Mm-arr'uKjc, or inunature delivery, is usually restricted to the expulsion of the fetus from the third month until viability, although it is often used as a synonym of abortion, and is the lay term for that event, "abortion " to the layman denoting criminal intent. The word abortion is reserved for the expulsion of the ovum in the first three months. Causes of Onset of Labor. — What constitutes maturity or ripeness we do not know, and in the indetiniteness of our knowledge " we refer the matter to a law of the organism — a law the cause of which we do not know." The termination of j)regnancy is due to some combination of conditions, no one of which, singly, will account for the occurrence of labor at two hundred and eighty days after the date of appearance of the last menstrual period. Briefly stated, the chief fiictors are — 1. Increasing irritability, witli strengthening intermittent contractions. 2. Changes in the decidua — loosening, thinning, and thrombosis. 3. Excess of COo and lessened oxygen in the placental blood acting on the motor centre for the uterus in the medulla. 4. Increasing tension on fully-developed muscular walls. 0. Stronger fetal movements in more confined space. G. Partial relaxation of the cervix. 7. Menstrual periodicity (tenth period). 8. Habit and heredity. 9. Exciting cause — exercise, sM'<in, emotion. 1. A steadily increasing irritability is probably the rule during gestation. At certain menstrual epochs. >^uch as the second, third, and seventh, it is espe- cially marked, and there is evident disturbance both of the neighboring nerves and of uterine ganglia in the first and last trimesters. InteraiitteuL contractions occur regularly in the non-gravid uterus, they * The ifiiprrior fifiiires ( ' ) occurring tlirougliout the text of this section refer to the bibliog- riipliy givt'ii nil ]i;ige ;i40. .318 tht THE PHYSTOLOGY OF LABOR. 319 arc distinct from the very boginniiig of pregnancy, tliey stcatlil)' gain in strength daring its progress, and at its end hardening and prominence during contractions may always be found. The dividing-line between contractions and true labor-pains is not easily drawn, and as soon as the ovum becomes a ibreigu body by beginning separation more vigorous action is ensured. 2. The changes in the decidua arc well epitomized by Lusk:' "The re- searches of Friedliinder, Kundrat, Engelmann, and Ijcopold have demon- strated that the decidua vera of pregnancy is distiuguisiiable into an outer dense, membranous stratum, comj)oscd of large cells resembling pavement epi- thelia, probably mctainorphos(!d cylindrical cells, and an — in appearance — underlying mesliwork, ibrmed from the walls of the enlarged decidual glands. It is in this spongy layer that the separation of the decidua takes place, the fundi of the glands persisting even after the expulsion of the ovum. By many a fatty degeneration of the cells of the decidua has been observed toward the end of pregnancy, but Leopold, Dohrn, and Ijanghans have shown that this is not of constant oceuirrencc. The traljcjcuke w'hich enclose the spaces of the network diminish in size with the advance of pregnancy. Thus, while they measure at the fourth month about j,^ of an inch in thickness, they become gradually reduced in the subsetpient months to -^-^ of an inch — a change which materially facilitates the peeling off of the decidual surface. "From the fourth month onward large-sized cells make their appearance in the serotina, especially in the neighborhood of thin-walled vessels. The largest of the so-called giant-cells contain sometimes as many as forty nuclei. Though a physiological product, they resemble for the most part the so-called specific cancer-cells of the older writers. They are of special obstetrical inter- est from the fact, observed by Friedliinder and confirmed by Leopold," that they penetrate the uterine sinuses from the eighth month, and lead to coagula- tion of the blood ami to the formation of young connective tissue, by means o!" which a portion of the venous sinuses becomes obliterated before labor besrins. The subtraction of these vessels from the circulation tends to increase the amount of the venous blood in the intervillous spaces of the placenta." ;3. Brown-Se(piard found by experiment that an excess of COg circulating in the blootl of a gravid aninutl excited uterine contractions, ami he claimed that this excess of the gas was the pi-oximate cause of labor. His theory lacks conclusiveness, however, because it does not explain why the COj postpones its irritant action until the end of the ninth month. Lcopohl believes that the excess of Qi)., in the placental blood is the result of venous hyperemia of the placenta, produced by the spontaneous thrombosis in the veins of the placental site at the end of pregnancy, while Flassc credits it to certain changes in the circulation of the fetus — chiefly in the crossing blood-currents of the right auricle and shrinkage of the ducius venosus and arteriosus. Spiegclbcrg tcaciics that at maturity the fetus rc(pii:'"s some new sub.-tance not supi)lied by the ]»lacenta, and that it dies (as in extra-uterine ])regnancy) if it does not obtain it. wliile chemical substances no longer required accumulate in the l)lood and act as irritants to the spei'ial nervous centres. ' <1 : >^ IM ■:. I .i"' > \-»ii^L^ >■■■ ^Mt^ i ■ ■ 1 I m 320 AMERICAN TEXT-BOOK OF OBSTETRICS. 4. Power iu 1819 called especial attention to over-distention of the uterus as a causative factor iu labor ; it can admirably be demonstrated by analogy. As the over-loaded stomach or the rectum rejects its burden, so the over-dis- tended uterus rebels and expels its contents by the contractions of labor when the mouth of the organ begins to be distended. The occurrence of ])rematuro labor iu hydraninion aud multiple pregnancy sustains this theory, but, on the other hand, it does not account for labor-pains in extra-uterine pregnancy. The extensibility of the uterine wall has a limit, and when this is reached the ovum. in its growth presses more and more upon the iuternal os. This })ressure excites a special set of nerves and brings about uterine contractions, just as the contact of the drop of urine at the neck of the distended urinary bladder ex- cites contraction snd evacuation of that organ. A theory of this nature brings up the question of the innervation of the uterus. Through what set or sets of nerves does the uterus receive its motor impulses during labor? The nerve-supj)ly is largely from the hypogastric and ovarian plexuses of the sympathetic system. The cervical ganglion receive:-!, in addition to its extensive connections with the lympathetic, filaments from the second, third, and fourth sacral nerves. Rut Lusk and Jacquemart report cases of successful labor in patients sutf'ering with paralysis of the lower ex- tremities, retention of urine, and incontinence of feces — a state of affairs which would lead one to discount the imjjortance of the rdle ])layed by the filaments from the sacral nerves. On the other hand, the experiments of Schlesinger'^ argue against the exclusive source of motor-supply resting with the symi)a- thetic, for he was able to elicit reflex movements of the uterus by stimulation after severiiiLT all the branches of the aortic plexus. Whether he may not have overlooked some of the slender nerve-filaments in cutting the branches of the aortic plexus is a question worthy of consideration, and the possibility of such an error detracts from the value of his experiments and the weight of the conclusions to be drawn from them. The uterine ganglia have a certain independence of action, such as the cardiac ganglia possess, since rhythmic con- tractions by both may be kept up after separation.^ Brandt has shown that massage of no part of the pelvic contents will prodMc< contraction in the non- gravid uterus so rapidly as manipulation of the (supravaginal) cervix, and the writer has demou«+rated this for the early weeks of pregnancy.'^ Whatever the chainiels of nerve-force may be, there has been ])roved to ex- ist in the medulla oblongata a motor centre for contraction of the uterus that may be excited to action by COj in the blood, by anemia, and perhaps by tlic toxic substances retained in the blood of one suffering from nephritis. At full term something stimulates this centre to acdvity, with a complex, co-ordinated .set of muscular contractions as the resultant. Moreover, it is supjwsed l)v Schat/ (hat the uterus possesses an inhibitory centre which is active throughmit j)regnancy, but wliicli for some reason ceases to ad at term. G. A diminished resistnnce in (lie lower birth-canal is to be noted. The cervix is fully softened, the pelvic floor is edematous and relaxed, and (he uterus and its contents often sink low in the pelvis. THE PHYSIOLOGY OF LABOR. 321 7 Tlift tlioory udvuiioed hy Tylur Smith to the olfwt that the tenth period of ovarian excitement incites the nervous ap|)aratus of the uterus to activity is of some force, since prej^naney is often interrupted at menstrual epochs ; but it is open to the same objection as that just mentioned, for it does not make phiin wily the nintli or eleventh j)eriod iliils to effect the same result. ^lore- over, single ovariotomy has been jx-rformed many times, and double ovariotoiny a few times, during pregnancy, without perceptibly influisncing its course. 8. Many multiparie tbllow the same rule in a series of pregnancies. Tu other cases great variations are seen. 9. Filially, with all things ready, an unimportant, i)erliaps accidental, occurrence, such as slight increase in intra-abdominal [>ressure from walking, stair-climbing, coughing, or straining at stool, as well as any mental irritation (anxiety, care, anger), may be the exciting cause. We iiuve been dealing, then, with deteriiiining causes, factors in a phe- nomenon, noiK^ of which can establish a claim to be considered singly and absolutely causative. Wiiickel sums up by saying that labor is the total of several causes which may enter into different combinations to accomplish the same result. liusk takes substantially the same ground, and Barnes observes that the determining causes act synergetieally, not singly. The fetus is mature, ready to undertake the complex acts of respiration and digestion ; the imperceptible uterine contractions of several weeks have loos- ened the attachments of the decidua, whose trabecuhe have grown much thin- ner and capable of easy rupture ; the uterus by distention, pcrhaj)s by increas- ing pressure of the fetus oi> the internal os, has grown very irritable, the lusty inmate augmenting this condition by the force and frequency of its movements. The maternal blood contains an increased (juantity of C"()^; venous thromboses in the uterine wall near the serotina and in the si'rotina itself obstruct the cir- culation and cause stasis of the maternal l)lo(,(l reMirning from the ])Iacenta ; the cervix uteri becomes soft and dilatable ; the advent oi" the tenth menstrual (late, with increased congestion and irritability of all the generative organs as a conse(iuence, adds fuel to the pile ; the unknown factor deposits the spark at the centre of uterine contraction in the me(lulla, and lal)or has be juii. The Phenomena of Normal Labor. The ])hysiology of the processes concerned in the expulsion of the fetus includes a stutly of the action of the uterine walls, the uterine ligaments, the abdominal muscles, and the vagina; the changes induced by labor in the cervix, in th(> lower uterine -(•gment, and in thf IxmIv of the uterus; the viuiations in the |)resenting pouch of membranes; and the character of the li(jiior anuiii, the formation of the caput succcdanenin. and the ciianges in the |H'lvi(^ floor. Then the t-linical character of the three stages of labor will i)e ciinsidered, leaving i[iic>tions of mechanism and management for later sections. Uterine Contractions. — The uterine ciintriictions of labor go by the name III' "pains" in all language-^, including tiie speech of the scienti.st, because 111' the sulfering iiiscjiarably associated with tiicin. The <'nnxr of this sulf'criiif/ 21 I '4 ■ ':1IH1' |i >;: 'V «K Hi i; P- ''^-i rMi t w 'j 1 1 '■' : ■ (i M: 'iM »'■"■*■-■; T ' 1 I; [■ , i, ■ <>' 1 I / '1 1 I 1 3'22 AMERK'AX TEXT- HOOK OF OIIHTKTRIVS. is the coinprcssiuii of" the uterine nerves hetween the contracting nuiscular fibres, the tension of tiie external os and lower uterine segnjcnt, the stretching of" the nterino ligaments, and the pressure of" the advancing fetus on the nerves of the vagina, the vulva, and the neighboring structures. ^Moreover, hyper- emia of the lower end of the cord and its envelopes is jirobably in part respon- sible for the distress. The looaVion of the ^)nm is, at first, in the hunbo-sacral region, and later in the abdomen or down the thighs. The most severe degree of ])ain is felt at the vulva as the head passes. The onset of the contraction is more ra])i(l than the decline. The pain begins suddenly a few seconds after the beginning of the contraction — as may be seen by the bulging foi'ward of the fundus or be felt by the examining hand — reaches and retains f"or a f((w seconds its acme of intensity, and then gradually subsides. If each pain l)e divitled into ])eriods of increase, acme, and decrease, the acme will occu])y the greatest length of time of the three divisions, the total duration of a pain being about one minute. The suffering is commoidy more severe in very young or in elderly priniiparje than in those in the prime of ]>liysical life. Susceptibilitv to pain, and general vigor, have nnich to do with the anunuit of anguish experienced, it being among serene women and dull-witted and sturdy-limbed hospital patients that we oftenest see quiet labors. Painless deliveries have been reported, but they are rare. The muscular fibre of the uterus is non-striated, and the contractions, as in all organs of like histological stri'.cture, are pcrif<f>i/(i(\ invninntavy, and intrr- mitfcnt. Contractions sweep over the uterus in a peristaltic Avave, probably travelling from the opening of the Fallopian tubes down to the cervix, reaching a swift acme, and subsiding within twenty or thirty seconds. Waves in both directions have been observed in the uteri of .some of the lower animals. Though mainly controlled by the sym])athetic system of nerves, and hence inde- ])endent of the will, the pains are nevertheless influenced to some extent by the brain — a fact demonstrated by the ef!"ect of fright or of excitement in retarding or even in stopping labor. The pains last from thirty to ninety seconds, and the peristaltic action from twenty to thirty seconds ; the interval is about thirty minutes at first, whereas at the end of labor it is but two t(j three mimites, and nearly disappears as the head emerges. Symmetrical pains often occur in groups, f"ollowed by shorter or almost abortive pains. As to tho force exerted. the pressure during the height of a pain never exceeds 100 millimeters (4 inches) of mercury, the average being 60 millimeters ('JJ| inches ; Schat/), TiCaman measured the force with which the head atlvanced (r^ot the force with Mhich it was proju'lled), and found a high pressure to be five jiounds. Forcep- was required where it did not exceed two and a lialf pounds.'' The force of the pain remains about th.e same during the entire labor, or it may increase by a fourth, and this with no regard to weariness on the part of the patient. Tin force does not increase with the resistance offered, but the ]>ains sinqdy beconi" niore frequent and last longer. The type of the pains is nearly constant in \\\v same patient (Schatz). anc |i THE PHYSIOLOGY OF LABOR. 323 Fui. ICC).— Pulpntion of the cervix before la- bor. The two rintrs ure shown, with tlie tinner-ti)) toueliiiif; wlmt iiiay lie called clinieally the " iii- ternnl os " (one-lialf natural size). The amount of force exerted by the pains \s sui)p().>^o(l to riiii<re between soven- teeii and eiglity pounds. Our methods of niearfurinjr, however, are defective. Duncan and I'oppel, who studied the force rccpiired to rupture the mem- branes, found that in ea.sy cases it was hardly more than tlie weiolit of the chiM, and only in severe cases did it rise to fifty pounds. Sehatz" passed a rubber bag into the uterus during- labor and connected it with a gauge, rcgi>;ter- iiig tifty-Hve pounds as the maxinnun. An ob.stctrician knows that all the nni,<- cidar ])ower he possesses is sometimes insufficient to prevent rapid expulsion of the head. The changes in shape in the uterus during contraction are markei]. In the quiescent state it re.sts against the spinal column, ovo'd in shape, the transverse exceeding the antero-posterior diameter. During contraction these diameters be- come about e(pial, the titerus assumes an ovoid or somewhat cylindrical form, and by means of this increase of «^he antero-posterior diameter and the con- ti'actile action of the broad anil round ligaments the fundus is forced forward ay-ainst tlie abdominal wall. At the same time the uterus becomes longer at the expense of the lower uterine seg- ment and the cervix (Fig. 23(5, p. 42")). Action of the Ligaments. — The uterine ligaments — the round ligaments, the lower part of the broad ligaments, and the utero-sacral bands — contain much muscular tissue which is directly continuous with that of the uterine wall. Contraction of this muscular ti.ssne occurs with each pain, and serves to fix or to .steady the uterus in position at the brim, and to a.ssist in lifting and liolding it at an angle favorable for exi)ulsion of the fetus (Fig. 211, p. 38S). Action of the Abdominal Muscles. — Next to the uterine contractions the force of the abdominal muscles is the important expulsive agent. We include all those nuLscles that fix the thorax and pelvis or narrow the abdom- inal cavity. The resultant of the forces ofthe.se muscles lies parallel with the axis of the superior strait (Winckel ; see Fig. 211, p. 38S). The action BiX'>"">'.^' i/iiattition of intiriiiil OS, Flirt Iwr liilatation of iutt'yniil os. Conif*lcte fj^tiLCtitt'nt of inti'riuil os, iK'ith sharp t'xtt-rnal os. £-o Fifi. 1(')7.— Diagram showing; the sensation to the exaniininn linger of wiileninj.' and elliiee- iiii'nt of the internal os dnriiin dilatation of the iervi.\, and the knife-like eil^e of the external OS (one-liulf natural size). r ^&>\ .11 in ' Uii \ ■ \ ■ Hi i :| 324 AMERICAN TEXT-BOOK OF OJiSTETRIVS. \ ( 1 : I' ■ J on tlic part of the woman is V(jluntarv at first, bnt bocKMios loss so as labor advance's, as sliown by her inability to withlioUl strong prcssnro at the time when tlie pelvic floor is endangered. .i/,-(///' y. n,\iili<,t. '^ ' J^',Lf>;vrr uterine se/;ment. 'ostmor vaciutil 'vail. Fid. If*.— Secliuii ul' iiTvix at torin (Wiil- deyer). Tlii' iiTfuuliir hlutU'il lilack marks with- in till' ciTvical canal, riiiiiiiii!,' to tlii'iiii'inliraiies, (li'iKito iiiiiciiiis iiiciMliraiu' nf cervix ; llio dc- ciiliia runs in a wavy line bcnc.Uli tlic nieni- branes. Such assistance to the uterus is not absolutely necessary, for labor nuiy be accomplished in the absence of the action of these external forces, as in paralysis ; but when the head lies in the pocket Ibrmed by the curve of the sacrum and the partly stretched |)elvic floor, having to turn nearly a right angle in its course, the power brought to bear by the abdominal muscles is of very great moment. From the atrophy of the truidv-museles due to corset-wearing, failure of force at this crisis often calls tor forceps extraction. The uterus is raised by the round ligaments so that abdominal pressure acts to better advantage. The uterus is compressed from all sides, is supported by the pelvic walls, and is arrested in attempts to slip downward by the utero- saeral and brt»ad ligaments and the sacral ciu've, while its contents are j)ressed out. The increased tension on all the contents of the trunk sends blood to the extremities and flushes the face of the patient. Be- low the pelvic brim the pressure is not brought to iu'ar, and conges- tion produces edema ;ind softening of the cervix and pelvic ilonr. At times the child is expelled with considerable force by means of this added power, and the uterus may even be inverted by these ettbrts of the external nuiscular structures. Action of the Vagina. — At first the vagina opposes some obstacle to the advancing head. When, however, a large circumference has passed, any onwai'd motion may receive slight aid from contractions of the vagina. Figiue 185 (p. l)-'»()) shows how the vaginal walls are smoothly fitted to the ehikl even after the exit of the head has <>i'eatly distended the passage. Changes in the Cervix during Labor. — Although palpation of the exter- nal surfiice of the cei'vix may give the impression of a smooth ex])ause of stretched rubber around the opening, yet when the finger is passed within tli<' cervical canal as far as the membranes, is hooked forward, and then slowly withdrawn, one detects two well-defined rings with a 1- to 2-inch (.'?.5- to "i- centimetcr) pas.sage l)etween them, and fiiuls that this pa.ssage has yielding siili; Viis^lna. Kiii. liv.i.— Cervix of multipara at bcu'liiniiii.' of lal)(ir; the internal us is at llio edge of the crater (frozen section, Winter). THE PIIYSlOLOfiY OF LAIiOJi. 325 Rt-jU'i tt'ti iiitttihyaiu's. posttrior \~ V Ktxtunt, Fi(i. 170.— Cervix of five iind a hnlf months' primipara in •lilatation period, witli marliiMl irregularity in i>ro(;ress of tlilatalion ol" posteri<jr and anterior lips, the posterior lieiiiR nejirly llattened (Winter; frozen section, five-eii.'htlis natural size). Compare wideniuK funnel or crater with I'iKUre K'.h walls (Figs. 166, 1G7, 174). Whether thi.s inner ring 1k> the trne iiitornal os, or only the ui)per limit of the vaginal jjortion of the cervix, we may he allowed to call it, for dinicjil pni- poscs, the internal os, since we need to watch it.s be- havior during the dilatation .stiige. At the beginning of labor in the primipara the cervix i.>; barely pa.-<sable by the Hiiger-tip. Dilatation of the internal o.s occurs first, and it may open rather widely before the external OS begins to gape (Fig. 1G7). In this case the cervix thins out to a flat ring over the watch-glass niend)ranes, and the external os r.iay form a .sharp, parchment-like edge as the internal os merges with the lower uterine .segment and the mend)ranes or the presenting part is applied directly to the external os. At other times the two rings draw back iu less marked .sticcession (Figs. 169, 170). In nuil- tipara the more open canal ]\hit. OS. freely admits the finger dur- ing the la.st month, and the condition is suggestive of labor b(>guii. But an inner edge may u.-^ually be distin- guished (Fig. 170) until the early labor-])aius* or the threat e n i n g preliminary pains begin. The effect of such early pains in com- mencing the dilatation of the cervix in certain cases is shown in Figure 175. In multipara; labor is likely to pull back the whole cervix bodily, but with .some thinning and with a somewhat irregular edge, (iradually the circle widens until it merges imperceptibly into the uterine wall, leaving, as a rule, to represent the external os, a slightly raised encircling ring in the wall of the curved birth-tube 3 millimeters (3, inch) in thickii(>ss, located against the back of the symphysis in front and halfway up the sacrum behind (Fig. 134). The wall of the cervix is then 2 millimeters (^\ inch) in thick- ness, and the cervix is said to be ctlaccd. The anterior lip may be nipped betv een the bony ring (pelvis) and the ball of bone (fetal head) and become elongated Fin. 171.— Dilatinj; cervix of eitilit months' primipara, with Iironouneed thinninK of posterior lip (Winter ; frozen section, two-thirds natural size). ;^- i m 1 326 AMKRIVAX TKXT-IiOOK OF OBSTETRICS. aiul odt'iiiatous, even to the cxtt'iit of ivppoariui; at the vulva <liirin<; dclivory or of liantj;iii<!; without it afterward. lu paticius witli contraeted inlets the external os ofti'U remains at or ni'ar the brim after full dilatation. The dilatation is estimiUed either l)v j^uessinj; the eoin it seems to resemble in size, or by stating the inches of its diameter, or the number of fingers which the elastic ring will admit. The cervix may not be found greatly dilated, and yet may be dilatable to a large size, as determined by the introduction of four fingers or the whole hand. The eommou error of the beginner is to Fiif. 17J.— Cervix cumpresscd bi'twcpii the head nnd tlic pelvip floor, nt the hoRlnningof Inbor in a Vl-piini (Hurt, iini'-tliinl uatiiriil sizei. Tlic ciTvix exti-mls fmin the tiiherosily uji to the riKht-hiunl n ■ tile viiniiiii is shown, mill also the ureter ami the tmse of the broad litjauient ; the area on the sl<le not covered with periloiieiiiu being the shaded space (a, a, a). believe that the cervix is nuich more widely opened than it is in fact. He is sometimes deceived into thinking the cervix has gone by the exceeding thin- ness of the tissue stretched taut over the head (Figs. 167, 210; p. 385), or, again, by the softness of the yielding edges. The cervix may remain in a stationary anil partly dilated condition for hours, or, in rare cases, for days. It may close after partial dilatation — even fnmi the size of three fingers. The mechanical factors effecting dilatation are discussed on pages 424-430. The active agents are: (1) Coiu'raction of the longitudinal fibres of the uterine Till': rnv.siOLoar or laiior. 327 bmly, piilliiijT the cervix up over the ovum ; (2) liyth'ostatie pressure of the bag (»f waters ; (o) \ve(l^e-aeti(»n of the preseutin^ part ; (4) softening of tlie cervix. 'i'iiere is tension on all the other uterine vessels during a eoutraetion, hut the unsupported eervieal vessels helow the pelvic hrini l)econie engorged and the lyni[»hati(; interspaces are intiltrated with serinn and looseiujd ; thereliv the torce of cohesion is lessened. Were it not s»», the elastic cervix woidd dose down on the siioulders after the })assage of the head. " Indeed, the conditions of an elastic tube are not infre((Uently realized in versions wlu-re an attempt is made to extract tiie fetus through an i m per I'ectly dilated os ; in which ease, after the disengagement of the shoulders, the cervix is apt tt) close ui)on the neck and arrest the delivery of the after-coming head. That this complication does not hap[)en as a rule is due to the fact that in natural labors the mechan- ical expansion is associated with certain organic changes which render the; cer- vix soft and distensible, and which at the same time diminish its retractility."" To bring the cervix to a circle of a diameter of 5 centimeters (2 inches) frequently demands two-thirds of the total time recpiired for full dilatation. Irregular dilatation is not infrecpient, wherein the posterior lip is further etfaced than the anterior, or inversely, but the former is more common. From the frozen sections, the first process would seem to be constant in occurrence and most marked in character (Fig. 170). Location of the Orifice. — The internal os is foinul at the beginning of labor and in frozen sections 6.3 centimeters (2^ inches) below the brim, being a little lower than in the nullipara.'" The cervix nuiy be high and pointing backward, and, in practice, when there is much difficulty in reaching it far up toward the promontory, one may be obliged to hook tlie anteri(»r lip downward with the Hnger in successive sections until the external os can be caught (Fig. 356, page 556). A cervix at a long distance from the vulva suggests false labor- pains taking place at an early period of pregnancy, before the occurrence of "sinking" of the uterus, or a contracted pelvis. The cervix may be found low in the pelvis, near the vulva, with the head packed into it, pressing it downward against the pelvic floor and toward the vulvar opening (Fig. 172). Changes in the Lower Uteruie Segment. — The two beliefs concerning this portion of the uterus can only be summarized. Schroeder and his school teach that the lower uterine segment is that part of the wall of the body of the uterus (Fig. 173) extending from the coutr(iction-ri)i(/ i\hn\c — the level at which the peritoneum is found firmly adherent — to the internal os below ; that it is constituted of more loosely adherent nniscular layers than the wall higher up; and that it is relatively passive during labor. By its anatomical structure and l)v the epithelial C( 'cring of its nmcous mend)rane the lower uterine segment is diiferentiated fr n the cervix in both the pregnant and the puerperal uterus, hi pregnancv th • internal os may be found by its forming tlu; upper end of the closed cervical canal. With this point the denser structure, with its con- nective-tissue appearance, the character of mucous membrane and its junction with the decidua above, and the upper limit of the arbor vita>, usually coincide. The lower segment dilfers distinctly from the upper, to which it belongs f^^-^. rO^ 1^. ^ \N ».\5 i!>< % A, IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I L^12.8 |2.5 us lii |2.2 I," u 114 I lio 12.0 L25 iU lil.6 Photographic Sciences Corporation 1i WI'.T MAIN STRIBT WEBSIIR.N.Y. 145S0 (71*) «/2"*S."J ^o 6^ ■ »■ 1/ <f '., 1 iH 328 AMERICAN TEXT- HOOK OF OBSTETRICS. anatomically, in possessing loosely connected muscular layers which are easily separated, whereas the rest of the body of the uterus is made up of inseparably interlaced bundles which can only be dissected from one another, even iu tiie thinnest layers, by destroying the structure (Hofmeier)." " The physiological behavior of the lower uterine segment during labor is essentially passive, as opposed to the remaining portion of the uterus, which is sharply contrasted with it by contractions." The difference between the two is palpable, afler vigorous uterine contractions, to the hand within the cavity, the ring being occasionally detected by the hand M'ithout as well. The term " contraction- ring," though firmly seated, should yield, in the writer's opinion, to the more correct "retraction-ring," which is self-explanatory. The writer has given precedence to the views of those investigators who believe that the cervix remains unchanged until the beginning of labor. Only Pcliroeilor, llofini'ier, Miilk-r, i>t al. HODY OF UTEKl'S. LOWKIi ITKHINE \ SKO.MKNT Contract Ion ring. CEKVIX. Internal n». I (Miillor's riiij;.^ [ External on. /iriiUH, A'Ushtt-r, Buyer, et al. Iiiteriinl os (or Kiiigof Bandl). (Braun's isthmus.) ExternnX oh. Bony OF urnKus. isvHonytiti'its H'ith /,>-,ivr uterine sef- Hunt). Fi(i. 17:!. — Dingrnin illustratiiiK the two ti'BchlnKs luicnt tlio lower ulorine si'Knicnt and the cervix Oil tlie left side nil iiiteriial os has l)een added for the sake of eleariiess, althuiigh in tlic frozen sections of women with full dilatation it is rarely apparent macroscupically (one-third imtiirul size). the briefest outline, however, t)f the voluminous controversy ^^ can be given, and the opposite side stated. The older theory held that toward the end of pregnancy the upper portion of the cervix was expanded and drawn up to form part of the general uterine cavity, leaving only the small vaginal por- tion of the cervix below. Braun, whose section is given in Figure 134, l)elieves that the semicircular ledge with the large vein (Kranzvcne) is the in- ternal OS, 10 to 11 wntimeters (4 inches) above the external os; Bandl confirms this. He now believes,'^ with Kiistner, that in first labors the mucous nvm- brane of the dilated portion of the cervix — the lower uterine segment — becomes torn or stripped off, and subsequently there is formed upon the denuded surface a new membrane not distinguishable from that of the corpus, which in future pregnancies is capable of forming a tlecidua. Bayer '^ concludes that " the ex- , 'II THE PJIYSIOLOGY OF LABOR. 329 Closely iMlerwdfen \ layers. « :? Limit of firmly ail- hereHt peri- toneum. I 6; (3 RetriUtion-ring. << Easily sepa ral'le layers. cessivcly tliin decidna of the lower uterine segment pusses into eervical mucous membrane on the jiosterior wall of that segment, and that the lower uterine segment and supravaginal cervix are one and the same thing. It envelops the presenting part during labor, it is thinne<l out, distende<l, paralyzed, while the thick, contractile muscle-mass of the corpus lies above, where the phenomena of contraction oct;ur with their expul- sive effect upon the uterine contents." Practically, the lower uterine seg- ment interests us as the common seat of rupture of the uterus. During long labors, or where obstruction is asso- ciated with vigorous contractions, ex- treme thinning occurs at this level, and in such cases the retraction-ring can sometimes be felt as a baud or ridge in the vicinity of the navel to serve as a danger-signal. The thickness nf the hirer vterine seijment was measured by the writer on such of the frozeii sections as wotdd ad- mit of study. In 5 cases at the eighth and ninth months of pregnancy the average thickness of the wall was G mil- limeters (J- inch), the extremes being 5 and 10 millimeters (y^ to ^ inch). In 5 cases in the stage of dilatation the average thickness was 3.6 millimeters {\ inch), the extremes being 2 and 5 millimeters {^ to y^ inch). In 6 cases in the expulsion stage the average thickness was 3.5 millimeters {\ inch), the extremes being 2 and 7 millimeters (^ and ^ inch plus). The remarkable thing in this series is that there are so many instances where a measurement close to 2 milimeters {-^ inch) was found, in some sections of the wall, either in the first or the s(x;ond stage — namely, in seven different patients. Thus we may say that before labor the wall of the lower utei'ine segment is 6 millimeters (]- inch) thick, and durinrf labor 3.5 millimeters [\ inch). Anterior and poste- rior walls are rarely equal in thickness, but the sections are nearly equally dlvidcil on thimier anterior or thinner posterior walls. Changres in the Body of the Uterus. — Thickening of the wall of the upper uterine segment is a somewhat cttustant factor. It is especially marked in long or obstnicted labors (Figs. 134, 185, 2H8). The average thickness of the uterine wall at term is the same as during the early dilatation stage, as 'ej; 1 r^ — ^ •st ts =«^ 'n ijjk) s'^ -J Internal os. %i « ^ C 1-^ H ;^ ft t •^ 5 ;* 65 l'>v External os. V'a^itta.^ Kifi. 171.— Section (if tlie waU of tlio pregnant utiTiis (UiifnifRTi. The (HtViTonco in Icxtnre bo- twt'i-n <'L'rvix and lower uterine segment, aecortl- ing to Hofnieier, is clearly shown, as well as the loose-meshed and close-meshed muscle-layers of the vipper and lower uterine segments. ^'■1- :kn — 'i\ 330 AMERIVAy TEXT- BOOK OF OliSTF/TItlCS. measured on eight frozen sections — namely, 7 millimeters (^ inch). Toward the close of the expulsion stage it is, on five sections, from 9 to 18 millime- ters (\ to J inch), averaging 1 ,, ; , centimeter (^ inch). Bag of Waters — Pore- waters. — Through the dilating cervix the fetal envelopes are tclt, growing tense during the pains or just before the sensa- tion of suffering comes. The ovum is being peeletl off the lower uterine segment and pro- truded. We note the amount of tension, the shape of the pro- truding sac, and its volume, and, later, the location of the tear. The tension is usually intermit- tent, as above stated. At times we detect a permanent lesion and look out for hydramnion or twins. The shape of the sac depends on the shape or size of the pre- senting part, the elasticity of the membranes, and the amount of liquor anuiii. It may be (1) Flat; (2) watcii- glass — this is usual with vertex presentations (Fig. 176); (;i) hemispherical — it may bulge fidl and round (Fig. 177) ; (4) glove-finger — it may be elongated Fi*;. 17'i.— Ppotinn of primipiira of twcnty-iiiiith week, slioHliin beKiiiniiiK (liliitutiuii of the eeivix in the iit)sem'e of paiiilul oontractions ■ mi>, luiicous jiIiik; i", internal os, with attachment of membranes (Ahlfeld; burdcneil prepa- ration, une-thirU natnrul size). I"i(i. ITii.— rorm of nienihianis iluriuK ililala tliin, WHtchnhiss I Varnien tlie presenliiiti partis lari;e and tills the cervix lonesixtli natural sizei. Fl(i. 177 —Form of membranes with less elll- cieiit lillin^riif cervix and pelvis, and larger iiimii- titv of f(jre -wiiters imodifled from Varnier). in shape when the cervix is narrow and the ])resenting part does not fill it, as in knee or shoulder presentations (Fig. 178); (o) pear-shapctl (Fig. 179), as Tine riiYsioLoay of labor. 331 whore the fetus is dead and niaeoratcd ;'' (({) double, as with twins — but very rarely. The membranes are slightly permeable tnider pressure (Tarnier and Pinard), and at times the amnion will leak into the chorion, jriving a double pouch. Some of the vajrinal flow ha.-- been eredi*^e<l to this source. The cervix and lower uterine segment are drawn up over the prot»'udal ovum. The chorion often separates fron« the decidua. The attachment of Kiii. 1T.H.— filovo-tiiiBcr furni wluTO tho proscntint; (iiirt iMsniiill (iiiciililU'il fnnu Variiii'ri. Km. IT'.t.— renr-shnpi'il pourli sci'ii with some ciikl'S of iiiai'L'riiti'il fttiis (iiKHlitk'd .''r(im Vtiriiier). the membranes initil the beginning of labor is at the internal os, or upper limit of the apparent cervix. In normal eases'* the coverings of fetal origin are not se|>arated, nuUcrnal and fetal membranes parting at the level of the lower pole. In certain cases before rupture the chorion jind amnion may already be separated throughout or far up on the cord. X/tCENTA TnBRANO I"l(i. 1811.— riiicoiitii ninl iiu'iiiliniiics after ili'IiviTV, tn sliow linw tlu' rolatloii of tin.- opi'iiiiiK to the liliict'iita iiidicatt's the site of the hitter: 1., htteral iiiiphmtation : II., fiiiulal iniplaiitation; III., placenta , .aviu marginaliij. Xormally the membranes give way on full dilattition of the cervix when |ti<'ssiiig on the pelvic floor. At times rupture occurs days or hours before labor, from low implantation of the placenta.'' In PouUet's case the mem- I 'ii ^i»*ll ':^-. 'fffipH^ |ij^R'>< *',VJJ. -Kf ^ K-'v ■ ^'1 <Ik^ w^BKb^ Wl 332 AMERICAN TEXT-BOOK OF OBSTETRTCS. li l\) I 'j; M m- l)ranes gave way six days, and in that of Mattlipws Duncan forty-five days, before labor. A ('oj)ioiis diseliarge of fluid tliat has collected between the ovum and the uterus and due to a catarrhal endometritis, called " hydrorrhd'a gravidarum," may deceive one into believing that the amniotic sac is empty. A more common cause of error is the gushing of (nlorless hysterica' urine. At times rupture is delayed until the membranes btdge through the vulva. In rare instances the child is born enveloped completely in the unbroken sac ; this is the " caul." The chorion usually gives way first, having a firmer attachment, as the amnion can loosen over most of its surface and slip downward and out. The seat of rupture may not correspond with the opening of the cervix. If it is on the side wall, the waters may leak more slowly, but this slow flow of the fore-waters is not very often seen, although discharge of the hind-waters in jets, as the presenting part recedes from its tight fit in the cervix during a contraction, may simul.ate it. Frequent gushes of so-called ** liquor amnii " arc often only urine. After rupture the waters may come away with a forcible gush or may leak slowly. On examination after delivery the position of Fici. 181.— Locntton of the caput succedniioum, iiinl its liniicutiDii of the oriRinal position of a verti'x ])rfseiituti<iii. the tear in the membranes shows the location of the placenta in the uterus (Fig. 180). An opening opposite the after-birth would denote implantation in the fundus ; a tear close to the niargin of the placenta woidd indicate pla- centa prtevia ; and one of the intermediate degrees is also shown. Character of the Liquor Amnii. — Ordinarily the waters have a slightly turbid, yellowish color. At times the amniotic fluid is thick with greenish or brownish meconium, due, perhajis, to undue pressure on the child, and some- times indicative of danger, except in breech presentations. Flakes of skin THE PiivsioLoay of lab or. 333 and a niiuUly consi.stencv siig«^cst a macerated fetus. Bright blood in any quantity within tlie membranes indicates prcmatiuc separation of the placenta with leakage into the amniotit; sac, but is very rare. Formation of the Caput Succedaneum. — The caput succedanenni is an edematous swelling that clevelops on the presenting part of the child as the cervix expands. The cervix makes pressure all over the presenting part dur- ing uterine contractions, except at one spot, and here serous infiltration develops a doughy prominence. The si/e of this swelling varies with the duration of the labor. If it occurs on the face, the grotescjue disfigurement alarms the family, but the swelling subsides in a day. The scrotum may assume large dimensions in breech labors. On the scalp the position of the edema serves to indicate the position in which the head enters the pelvis, provided too long delay in the lower birth-canal has not occurre<l. The tumor is located on that end of the head and that side of the head opposite in name to the position. Thus in the left occipito-anterior position it is found to the right posteriorly ; in right occipito-postcrior, to the left and front (Fig. 181). Clinical Course of Labor. Signs of Beginning Labor. — From eight to fourteen days before labor "siidving" or " lightening" occurs in a considerable number of patients. The uterus drops lower, the fundus falls forward, the head engages or descends to lie on the pelvic floor (Fig. 172), and as a consequence the patient experiences a sense of relief, breathes more freely, digests better, and has looser waistbands. This may never occur in a given patient, or it may happen two days or four weeks before delivery. In half the primigravida; Bruhl examined he foimd the greatest circumference of the head beneath the brim at the end of preg- iianev where the inlet was roomv, whereas in onlv one-third of the nudti- gravidic was this condition seen, owing to the laxer state of the abdominal wall after first pregnancies. On the other hand, irritability of the bladiler and venous obstruction in the legs or the labia, with more difficulty in walk- ing, may result from the intrapelvic pressure. At the time of subsidence the intermittent contractions may begin t(> be painful, so that labor is supposed to be under way, the pains often being grouped in certain parts of the day or night, and being most commonly seen among multipara\ Late in pregnancy tile vagina and the vulva are relaxed, a glairy mucus lubricating them and facilitating internal pelvic measurement and examination. The only certain method of determining whether labor is under way is by digital exploration of the cervix. JJy passing the finger within the cervix and iiooking it forward we may determine whether the internal os is widening or • lisappearing (Fig. 166), and the whole tubular canal of the cervix is being thimied and drawn up ; for we must remember that in over-distention of the uterus, as in cases of hydrainnion or twins, or in the relaxed state of some iiiultiparous uteri, or where there has been wide laceration, the cervix gapes in the last month, and that a low i)osition of the fetus flattens the cervix between tile head and the pelvic floor (Fig. 172). i i 1534 AM/:/i'/(A.\ Ti:XT-li(KtK OF OllSTKTRH'S. n : Wo are warned that labor is actiiallv under wav l)v the foUowint; sijjns : 1. Irritahility ol" the bhuhh-r and the reetuni l)ee(in)in<i; more marked than before, micturition beinj; particuhu'ly affected. 2. The "show" — an escape of blood-streake«l nuicus, due to slight lacera- tions of the cervix. This sign is not constant, ?>. Expulsion of the mucus plug fntm the cervix — a sign not often detected. 4. Increased secretion. Jioth cervical and vaginal mucus is jwured out in such a manner that when the passages seem soaked and softened with free mucilaginous discharge we may expect to find cervical dilatation making good progress. 0. Rhythmical uterine pains. The most conclusive symptom of beginning labor is the occurrence of regularly recurring pains, with lessening intervals au<l increasing force, and the most conclusive sign is that stated above — namely, beginning dilatation of the cervix. Stages of Labor. — The jirsi stage, better called the dlMnWon stage, ends with the complete canalization of the utero-cervical zone. The second stage, •/ Fiii. IW.— IVlvlc 11(1(11- liofdrc (listoiitidii (iiKidiliLMl fniiu a fidzcii section by I?riuin nnil Zwcifol, (Hic third nntiinil sizf) : tlii' fdfiiin mid tliicki'iiiiit; st'uiii oxci'sslve, but Webster's iiieiisurements show that this lloor is ratlier thinner than the average. the Nt(U/e of expufnion, ends with the birth of the child. The third or placental Hhiffc ends with complete evacuation and lasting retraction of the uterus.'*' Tlie First S(a(/e, or (fie JHlatntion Star/e. — When labor is fairly started the contractions of the uterus assume a certain regidarity, characteriztnl bydecreas- Tin: I'JfVSI(J/J)GV OF LAJiOli. 335 ill}? intervals aiul by incmising furco aiid ikuiiI'iiIiu-ss. Occurring at Hrst about every half-hour and only slightly discoinforting, with sonic sense of ]>ressiire, the contractions gradually run closcrtogcther until, toward the end of dilatation, they give but momentary intervals of relief. The pain is located as a rule in the sacral region, and later extends to the lower abdomen or down the thighs. The patient is restless, standing, sitting, moving, tossing, wringing her hands, seizing on a support, calling for pressure against the sacrum, or begging for re- lief. Her outcry is invohmtary, high-pitched, or apologetic, an impatient pro- test, or a plaint. She can be persuaded with difliculty that any progress is being made by such colic, seemingly futile. Her cries are not like those of the second stage, which is marked by a transition to the groan or grinit of efl'ort as she closes the glottis and strives to expel the child. The maternal jiulse increases in fre(|uency during a uterine contraction, while the fetal pidse is Kin. I8H.~FuIly-<listondcil pclvir floor (over onotliird lifo size). retarded at the acme of the j)ain. The temperature in normal labor rarely rises 1° F. Urine is freely secreted during this stage, and attacks of shiver- ing or vomiting may occur toward its end. With each pain the cervix grows tense, the border becoming sharp and the mendiranes protruding, to retreat again as the edges relax. Gradually yielding and softening, with abundant luucus-.secretion, the retreating edges permit the mendiranes to re,<t broadly on the pelvic floor. When the opening measures 7.0 centimeters (3 inches) the bag of Avaters usually gives way and the "fore-waters" escaj)e, clear or milky, with particles of vcrnix caseosum, while the bulk of the amniotic fluid is hold back by the ball-valve action of the head. After a ])ause pains recur and the head descends, and the im of the cervix is pushed back against the pelvic walls until its edges are hardly j>erceptible, the cervix being flattened against and practically continuous with the vaginal walls. The duration of the stage of dilatation varies from two hours to several m n H -■>^^a AMKRHAX TKXT-nOOK OF OUSTETJilCS. (lavri. Ill tlu> priniipiini twenty-ioiir lunirs is not iiiicuinnion, and tlie length incroasos with the patient's ajje, avera{j;ing over thirty hours at forty years (I)octerliii). To j;ive a figure lor the student to remember, we say that tiie averanc duration in the primipara is fifteen hours, in the multipara ei<j:lit h(»urs. The Secniid Star/r, or the Stage of Ex/tutttioii. — We are not here coneerned witli the mechanism, wliieh will bo treatwl later (p. 430). The patient has a fully-<lilated cervix, ruptured membranes, and a fetal head resting on the pelvic floor. The character of the pain changes ; it is no longer teasing fUllydustended Flu. IW.— nitinniiii iif tile iiclvic tloor liofurc iiri'l (luriiit; thi- proci'ss of thiniiiiiKor strotchinn- It will bo sfoii that tlR' stnicturu is thiiiiit'd riitlKT tliiiii drivi'ii furwurd (uiio-tliinl natiiritl size). iV JsM I (^ and inefficient ; the impulse to drive out the great mass that presses toward the outlet l)rings about an effort by the diaphragm and abdominal muscles with closed glottis; steadying herself or pulling hard on sheet or assistant, she .strains to bring all her strength to bear; instinctively, as in the savage races, she takes the seini-recund)ent posture that brings the uterus upright ; and her outcry is the groan of great etfort or the moan of endetl exertion. With each pain the pelvic floor bulges and then recedes; the vulva gapes and the head appears; the parts behind the outlet grow thinner and more dangerously tense ; the acme of suffering has arrived. As the head protrudes through the opening the pains grow stormy, and, reckless of injury, the mother drives out the tortin'iug obstructi(m. The fourchette slips back over the face and is snugly a])plied to the neck or shoulder (Fig. 185). Xow occurs a pause of from one to five miinites. The child may grow dusky, or may attempt to breathe, thus drawing into the air-])assages fluids taken into the mouth. Tin: I'JiYsioLoav or i.Anoii. .•}:J7 IJsimlly the iioxt pain oxpcis the tnink, wliidi is fnllowcd l)y a jjiisli of liquor ainiiii, with s(»mc' bloctd. Tlie ihimfioii oj the r.ry>»/.s/o« .v/m/r varies from ten iiiiiiiitos t(» six hours. In priniipanu tlic avcrajjc is t\v(» lioiirs, in tniiltipanc on(> hour. Chaneres in the Pelvic Floor. — Tho polvic floor is the fleshy diaphrafrin dovetailed int() the bony outlet of the pelvis, ft is about o eentinioters(2 inehes*) Fi(i. 185.— Pelvic floor nftcr the escupe of the head (one-thinl naturitl size); eoiistruoted from the /vM'ifel frozen section to show tlie pusliinn forwiinl of tlie anterior vulvar eomniissiire also, and the rciimrl^ahle way in which llie child is paelied into tlie liirtli-eanal. Tlie passage of tliis liead tlirough 111!' pelvic cavity mi(,'ht well result in rupture of tlie uterus. ill thickness, concave above and covered with peritoneum, and convex in shape (111 its lower skin-surface. Between these surfaces lie fascia?, muscles, coinieetivo tissue, and fat, named in tho order of their physiological importance. Through tlio floor run three slits, the urethra, the vagina, and the rectum-anus. The axes of these openings are oblique (Fig. 1H4), so that direct pressure from above 22 i! 1 1' ;WH AAfKItlCAX TEXT-noOK OF OJtSTKTIilCS. teiuls to diet! tlio openings by prt'ssinij their walls tojj;etlier. Ordinarily tlieir capacity for distention is limited, but the remarkable character of the |M'lvic floor is that, whereas the chief function of this nni<|iie strnetnre is to form a Holid and luibroken support for the or<;ans above it under all conditions uf strain, at certain moments it nnist, without injury, etl'ace its<'lf, and ojm'u up to the size of its entire length and bn'adth. Wc shall consider the change- that bring about this rcsidt. Hart, studying fr»»zen sci'tions maiidy," observed that the vaginal slit <livides the structure intct an anterior part, which he named the pnh'ir styinnit, triangu- lar in shape, com|)ose<l of retropubic fat, bladder, urethra, and anterior vaginal wall, attached (loosely) to the ptibcs ; and a much larger and stronger |M>sterior part, the mivritl nq/mnit, between the rear vaginal wall and the |M»stcrior Imiuv wall, including the anus and part of the rectum. Symington'* considers flmt the rectum and bladder and the upper vagina, like the uterus, should not lie regarded as parts of the flo(»r, but as organs resting u|»on it. Webster'" hulcU that the bladder is indM>dde<l in the pelvic floor, and that the vagina and (-ervix are parts of it, together with the rectum from the coccyx down. In the illustra- tion (Kig. ^M), ibr obviotis reasons, the bladder and cervix have been ojuiitcij. Late in pregnancy the changes that belong to the j)clvic floor arc relaxation from edema, moderate increase in thickness, and a l«»w <lrtM)p or " Imlging peivic Y-iooi Ki(i. IHt').— IVlvic tliiiir si'cii ill iixial coronal section (nuxiificd from Hart). downward." All these changes favor the stretching that is to come. The main- tenance of .";s former axis by the vagina, its distance from the symphysis, tlic sliiip<' of the pelvic floor at this time, and the low j)ositi(»n before it is opcncii lip into an oblique hernial canal are shown in Figures 182, 184, and 186. During labor, in the dilatation stage the parts anterior to the vagina aiv li^' ""•■ '■"y-'oi.'xn- or ,..,„„,<. I'osfmiiicfl /n.m Im.;,,,, ,i,.:,. , . •^•^•* :;.:;■■;■ ";•■ ■; -- ™ Ti^zx:; r™' .-.:.." ^.<- .:,.. „■ , ,' '.'•/"■'■"■'■-""I l-...'l. .( |H.,i„ „. i '" ""■":"• '->■ ""• 'I."".,,,!;,,,; |„, ' Tt;^XL:ir;!:r' '"■■' '■''--'' """ " "- '"""■"' " ' ',-• '■'■ "■<•" t" 2 ,„illi„„.,,,.. ( 4 „-,"".'", ""-"""I l'.v™...i-l i, „„„„. / ''° "'■' » '"".v '"• ^ X.I :: ,;t!:!':i' '""•''"'■■xi'v. ..4, ,,, ,,, ,° Tliickiiess of die n,.!..;,, n ■ „ " " ".!" "?:"• '" '^-'X <•<• -lu- anus, in „.,,.•„,,„ ,,.. . ^ *>■.'..„..,..«. ,„,.„.. '■■■"- ■'^-'■-".";'^:;:;r'";:- ■■-■:::::::'J \ „ ■■" «'"<-'-''U's| (lislfiili,,,, .7 .), """■ ""■■«'"». « <lo,„.|„ ,„■ ,,„, '■ "'• \"y ■"'x'-ralo sti„,„li_,s„,|, ,, , * The fi,,„ros „sod in thi ■ d" • '"' '"'''' '''^f*^'"'"'. ---:^.:r':;;d?r='?"-^^^ ^ ^§n ■I 340 AMERICAN TEXT-BOOK OF OBSTETRICS. The average duration of the placental stage is from twenty to thirty min- utes. The placenta may follow the rhild at onee, or it may remain two hours. After that time the ease belongs under the head of Pathology. Duration of Labor. — The length of labor varies within very wide limits, and our definite statements of averages do not claim accuracy. The exact hour of the onset of labor is often impossible to fix. Labor is usually longer in the primipara than in the pluripara, on account of the greater I'esistance of the soft parts during the first delivery. It is longer, as a rule, in the very young and in the elderly primipara, and in the stout than in women of slighter build. Spiegelberg's 506 cases are commonly quoted, wherein the three stages in the primipara are averaged respectively at fifteen hours, two hours, and half an hour, with a total of about seventeen hours, while the multipara is listed at eight, one, and one-half, the total being given as eleven hours. Many of the text-books are non-committal. The majority, however, estimate the duration of labor in the multipara at eight hours — not varying greatly from Spiegel- berg's figures in other respects. Table of Average Duration of Stages of Labor in Iloum. Primipara Multipara Dilatation Stage. Expulsion Stage. I'lacontal Stago. 15 8 2 1 i Total. 17 9 Spiegelberg ^^ states that labor most frequently begins between 10 and 12 o'clock in the evening, and the end of labor occurs twice as often between 9 P. M. and 9 A. M. as in the other twelve hours. West^'' found, in 2019 cases, 40 per cent, delivered between 11 p.m. and 7 a.m., and the most favored time is between midnight and three in the morning. A larger lunnber of rapid labors are said to occur in summer than in winter (107 : 100). REFERENCE LIST. 1/ 1. Liisk: Midwifery, 1892, p. 124. 2. Archivfilr Gyniikologie, Bd. xi. p. 49. 3. Wiener mediciiiigeke Jahrbuch, 1872, 1873. 4. Colinstein : Archiv fUr Gyniikologie, Bd. xviii. p. 394. 5. New York Journal of Gynecology and Ob- Htetrics, June, 1892, and Asovember, 1893. 6. Parvin : ObxIetricK, 1890, p. 362. 7. Ceiifrnlblalt far Gynilknloyie, 1884, p. 648, and 1885, p. 625. 8. Winter: Zirei Medianschn., Berlin, 1889. 9. Lnsk; Midwifery, 1892, p. 138. 10. Barbour and Webster: Edinburgh Lab. Re- ports, vol. ii., 1890, p. 31. 11. Schroeder : Srhwangere und Kreissende Ute- rus, 1886. 12. A clear epitonu' with partial bibliography is given in Jaggard's section of Hirst's A merican System of Obstetrics, p. 333. 13. Arrhivfiir Gyniikologie, Band xv. 14. " Ziir Phys. u. Path, niorphol. d. ( iebfir- nuitter," Oyn. KUnik, 1885, p. 398. 15. Ribeniont-Dessaigri.-:s-Lepage: PrecLid'Oh- stetricide, 1894, p. 332. 16. Pinard and Varnier: Anatomie Obstctricuk. 17. Precis d' Obstvtricale, p. 33"). 18. Jewett: Outlines of Obstetrics, Saunders, Philadelphia, 1894, p. 109. 19. Structural Anatomy of the Pelvic Floor, Edinburgh, 1880. 20. Edinburgh Medical Journal, March, 1880. 21. Researches in Female Pelvic Anatomy, 189!i. 22. Lchrbuch, 1891, p. 147 ; Monatsschrijt fUr Giburtshiilfe, 18(18, p. 279. 23. American Medical Journal, 1854. THE CONDUCT OF NORMAL LABOR. 341 II. THE CONDUCT OF NORMAL LABOR. L'l- IlirstV Is. 1. Antisepsis. Nowhere do we find more striking proofs of the value of the antiseptic system tlian is shown in the diminished puerperal mortality and morhidity in hospitals since the introduction of antisepsis into obstetric practice. Jk'foro the advent of Listerism the usual death-rate from childbed fever in lying-in hospitals was from 2 to 10 per cent., and in so-called " epidemics" this limit was often exceeded. In the women who survived, feverless childbeds were comparatively infrequent. Under antiseptic methods the mortality from sepsis in well-managed institutions is less than 1 in 200, and the morbidity does not exceed 10 per cent. A few examples will suffice to show what is possible under the present perfected system of aseptic obstetrics. Professoi's Groth, Netzel, and Sonders of Stockholm report' 17,8(52 births under their direction (1880-89), with 1 death in 344, or .29 per cent. In Copenhagen (1888-89), in 1218 hospital deliveries the death-rate was .24 per cent. Slawiansky * tabulates the results of 176,646 deliveries in fii'ty-thres hospitals of Russia (1881-89), showing a morbidity of 8.57 and a mortality of .38 percent. Leopold^ records 3089 cases (from May, 1885, to May, 1887) without a death from septic infection. The Boston Lying-in Hospital (1891) recorded 550 deliveries with no death from septic causes. In 1892 there were 515 continements with but 1 fatal case from septicemia — a mortality of less than 0.1 per cent, for the two years.* In the Sloane Maternity, New York City, there has been thus far but 1 septic death in 3000 deliveries.' In the New York Maternity Hospital 957 women were delivered during the three years ending Oct. 1, 1893, without a death from sepsis.® While in pre-anti septic times the puerperal mortality was many times greater in public institutions than in private practice, to-day the pauper delivered in a hospital is exposed to less risk than are the well-to-do classes who are confined in tlieir own homes. Insurance reports show that of all deatlis in women between the ages of nineteen and twenty-nine more than 18 per cent., and between twenty-nine and thirty-nine years more than 13 per cent., are due to puerperal causes. From 65 to 75 per cent, of puerperal deaths are attributable to sepsis. It is fair to assume that these statistins have to do almost wholly with a class wiio are delivered outside of hospitals. This indicates a mortality that is truly ap])alling, especially when one reflects that it iidls upon women in the prime ' Verhnndlitntien <les. X. Internationakn ^ft'(^. Con;/., ]\. Ill, * Deiitschf med. H' hemchrifl, vol. xiii. No. 2o. * Comninnicntion to the writer from Dr. Charles M, Green, Sept., 1893. * Personal letter from Prof. J. W. Me Lane, Oet., IS'.tli. * Peraonnl eomnuinieation from Dr. Hohert A. Murray, Oet., 1893. Ibid. 1 i PM ! ■ \! \:\ t 342 AMERICAN TEXT-BOOK OF OBSTETRICS. r of life and tiscfulncss, aiul is tlie result of a preventable disease. Yet the disastrous effects of puerperal infection are not represented by the mortality alone. Thousands of invalid mothers owe their impaired health to the milder grades of sepsis in childbed. Xo stronger evidence could be oft'ered than is afforded by the foregoing facts of the need for improvement in the obstetric methods of the general practitioner. Obstetric antisepsis dates from 1847. To Ignatius P. Senunelweis, a young Hungarian wiio at that time held the position of assistant in the lying-in department of the Vienna General Hospital, belongs the credit of first demon- strating its efficacy. The obstetric service of the hospital was divided into two sections, in one of which instruction was given to midwives, in the other to nietlieal students. It was with the latter that SemmeUvcis was connected. The students in this department were at the same time actively engaged in the pur- suit of practical anatomy and pathology. The women were delivered by students who for a considerable portion of their time were occupied with the operations of the dead-house and the dissecting-room. They took no precau- tions to cleanse themselves except to wash tlieir hands with soap and water, and they made examinations ad libitum. The death-rate was excessive, reach- ing nearly 10 per cent, of the Momeu delivered. Horrified at this frightful mortality, Seininelweis bent his energies to find- ing the cause. He was struck with the fact that in the midwives' clinic the death-rate was little more than 3 in every 100 woujiMi confined. The records showed also that women delivered before admission nearly all escaped. It appeared, too, that prolonged labors in the students' clinic were almost invari- al)ly followed by death, while in the midwives' section the length of the labor made little difference in the mortality. Daring the time that Semmelweis was engaged in his investigations Prof Kolletschka, one of his associates, lost his life by a dissection-wound. The symptoms of his colleague's illness were entirely similar to those of the fatal malady which was raging in his own wards. Impressed with the identity of the two diseases, it dawned upon him that the cause of the deadly scourge was to be fijund in the infected iiands of the students who attended the labors. In May, 1847, he established the order that students before taking charge of a labor case should wash their hands in eidorin-water or in a solution of chlorinated lime, and he restricted the number of examinations. The result was an immediate fall in the death-rate. In six months it had dropped ihnw nine or ten to three per hundred, and in the second year of the new r6gime it did not exceed 1.5 per cent. No proof could be clearer of the correctness of his views, yet they were bitterly opposed by the profession. He struggled in vain for the acceptance of his theories. He was ridiculed and despised, and finally died insane, the victim of continued persecution.' Soon after its introduction into surgery by Sir Joseph Lister in 1866 anti- sepsis began to gain a permanent foothold in obstetrics. First adopted in ' For niuny of these facts the writer is indebtwl to an address by C T. Culllngwortli, M. D., F. R. C. P., entitled Piurpenil Fever a Preventabk Disium. THE CONDUCT OF NORMAL LABOR. 343 liti- in I), 1870 by Stadfeklt of Copoiihagen, it was taken up by the principal maternities ot'Pjiirope, and to-day, with many ini[)rovements in the technique, it is univer- sally practised in the lying-in hospitals of the world. Practical Rules for Disinfection. Indrumcntii, Utcimli^, and Drcmm/n. — The most efficient of all germicidal agents is heat. For instruments, utensils, sutures, and dressings that will not be injured by high temperatures heat attbrds the best means of disinfection. Either of three methods, dry heat, boiling, or steaming, may be employed. ])rif Heat. — For metallic instruments and f(jr most utensils exposure in an oven is a convenient and effective method of sterilizing. It is necessary, on the one hand, to make sure that the temperature reaches at least 234° F., and, on the other hand, that it docs not exceed 400° F., at which point the temper of steel instruments would begin to suffer impairment. F(»r greater accuracy in regulating the temperature a tiiermometer specially made for the purpose may be used. As some time will be require<l to bring the instru- ments to the necessary degree of heat, the exposure shordd be maintained for at least fifteen minutes to ensure proper sterilization. IloUimjf. — A ready means of sterilizing most instruments is by boiling them half an hour in water. The addition of 1.5 per cent, of washing soda to tiie water helps to remove greasy matter and prevents steel instruments from rusting. The soda should, if possible, be chemically pure. This method has the advantage tliat it is available in any household. All that is needed is a vessel large enough to hold the necessary instruments and appliances and a range fire, gas stove, or even a large alcoliol lamp. In emergency no more elaborate apparatus is requircil than a common disii-pan. Place in it the instruments, silk sutures, sponge compresses, and other materials to be steril- ized, cover thetn with water, and boil for the requisite length of time. Turn off the water, and the pan serves as an .aseptic instrument-tray. Steaminr/. — Sterilization by steam retpiires special apparatus. Numerous appliances arc to be had for the purpojic, one of the most economical of wliich is the Arnold steam-cooker. This process is available for practically all instru- ments, dressings, and utensils not too bulky to be containetl in the sterilizer. It is well to place the articles to be sterilized in a wire basket or a cloth bag in which they may be lowertnl into the steam-chamber. This facilitates handling and makes it possible to remove the instruments promptly on opening the sterilizer. If allowed to remain in tlie steam-ehamber for even a few seconds after air is admitted, the instruments become wet with condensed steam and polished steel surfaces are liable to tarnish. The time required tor sterilization is from thirty tninutes to an hour, according to the Itulk and character of the materials. Dressings need the longest exposure. In the labor ward of a hospital a steam-sterilizer may be kept in operation •luring the labor, and the instruments, compresses, sutures, and dressings may be taken direct from the Rteam-cbamber as th(>y are wanted for use. Chemical Antiseptics. — Among the chemical agents most commonly em- mv- V ' ; ■ 1 Eii- i/'i JM ' : !' 344 AMERICAN TEXT-BOOK OF OBSTETRICS. ployed for obstetric antisepsis are the mercuric chlorid dissolved in water, in .strength of from 1 : 2000 to 1 : 500, the mercuric iodid in similar proportion, the peroxid of hydr(»gen ' (lo-volume solution), the liquor sodoe ehlorinatse diluted with 9 volumes of water, a 2 ])er cent, creolin mixture (in water), a 2 to 5 per cent, solution of carbolic acid, and a 1 : 1000 solution of hydro- naphthol. The order in which they are named is substantially that of their germicidal potency. The j)ractical efficiency of mercuric chlorid (corrosive sublimate) is greatly increased by the addition to the solution of five parts of hydrochloric, tartaric, or acetic acid for each ])art of the sublimate, since in neutral solutions of that salt the mercury is preeipitatetl as an albuminate on contact with blood or with other albuminous liipiids. The acid, moreover, serves to protect the solution against impairment of strength by contact with the alkaline fluids of the tissues. The mercuric chlorid is decomposed by alkalies. The mercuric iodid (biniodid of mercury), recpiires the addition of on equal weight of the iodid of j)otassiura to render it freely soluble. With this salt no acid ia required. Neutral solutions of the mercuric i(xlid yield no precipitate M'ith albumin. The chlorinated-soda solution, the ])eroxid of hydrogen, and the creolin mixture have the advantage of being practically non-poisonous, and they are therefore more suitable to be trusted to the nurse than the mercurial preparations. The Obdeti'ician. — The obstetrician should always be clean ; especially must Jiis hands be clean, and he should wear clean clothing. It is well to avoid con- tact with ])athological material and, so far as possible, with other sources of wound-infection. Yet attendance on post-mortems and contagious diseases is not necessarily inconsistent w-ith the safe conduct of confinements, provided a rigorous antiseptic cleansing be always observed as a preliminary to the care of the obstetric patient. After a septic exposure an entire change of clotiiing and repeated and conscientious use of disinfectants nnist be practised before taking charge of a case. The writer has repeatedly attended a prolonged labor, has delivered by forceps, and has repaired perineal rupttu-es within one or two hoiu's after having the hands bathed in offensive pus, witiiout infect- ing the patient. Repeated scrubbings with hot water and soap and with dis- infectants, including the final use of the permanganate method, will, if properly executed, ensure complete asepsis of the hands within an hour after the worst exposure. When summoned to a case of labor immediately after a septic contact, besides the usual care in disinfection, in simple labor all internal examina- tions may be avoided. In addition to this, it is possible, if thought necessary, to manage the birth even without contact with the external genitals of tlio patient, tlie required manipulations being conducted through the intervention of a fresh towel well saturated with the antiseptic solution. It is impossible, however, to lay down rules which alone will make an aseptic practitioner. The obstetrician must be ])ossessed of an aseptic instinct, ' The l)e8t j)roparation of tlip jieroxid of liydrogen is pyrozone. 10 In In THE CONDUCT OF NORMAL LABOR. ,'J45 and this is a matter wliich comes of training and a keen appreciation of the ])ossible sources and modes of infection. In liospital practice the obstetrician should, during attendance upon a hibor, wear a fresh-laundered gown or a clean ai)ron large enough to prevent contact of his hands with his clothing. His hands and forearms arc to be cleansed thoroughly and disinfectetl before the first examination, and before each subse- quent contact with the genitals if they have in the mean time touched anything that is not aseptic. For the disinfection of the hands the following method, which is substanti- ally that of Fiirbringer, is reconuuenoled : 1. Clean the nails dry. 2. Scrub the hands and forearms for not less than three minutes with a hand-brush, with soaj) and water as hot as can be borne. Special care must be taken in brushing the nails and finger-tips, and the water should be changed two or three times. 3. Soak well with alcohol (not below 80 per cent.) and, before it evaj)orat('s, 4. Immerse for three minutes in a hot solution of mercuric iodid or chlorid (1 : 2000 to 1 : 500), or in a 3 })er cent, solution of carbolic acid. Undoubtedly, the most essential step in the process is the soap-and-water scrubbing. It not only removes the greater part of the offending material, but it is also indispensable to the proper action of the antiseptic solution. The latter can penetrate the skin only after the oily matter has been removed and after the skin is thoroughly wet. The use of alcohol helj)s the action of the chemical solution by dehydrating the skin and rendering it hygroscopic, thus favoring penetration of the solution. Welch, of the Johns Hopkins Hospital at Baltimore, recommends the fol- lowing procedure, which is known as the pennanr/anate method. By it tlie hands, it is claimed, may be rendered practically sterile to culture tests : 1. The nails are cut short and carefully cleaned. 2. The hands and forearms are serul)t)ed for three minutes with soap and water. The brush before using is sterilized by steam, and the water, which is as hot as can be borne, is frequently changed. The soap is rinsed off with plain walor. 3. The hands are next immersed in a warm solution of permanganate of potassium and are scrubl)ed with a sterilized swab. Distilled, or at least boiled, water should be used for the solution, w'hich should be saturated. 4. The hands are next held in a warm saturated solution of oxalic acid in boiled water until the permanganate stain is entirely discharged. 5. After rinsing in sterilized water the hands are immersed for two minutes in a 1 : -500 mercuric-chlorid solution. The Nurse. — The nurse should be no less careful than the obstetrician in the observance of all antiseptic details. The Patient — In hospital practice the patient has a bath and a change of clothing at the onset of labor. Before the fir-it internal examination the abdomen, the thighs, and the vulva are cleansed by the nurse with soap and \ ^ I I ■ ;j4() AMUR/CAN TEXT-BOOK OF OBSTETRICS. warm water. The soapy water is rinsetl off and the parts are well bathed with the antiseptic solution. It is a nseful precaution to cover the limbs of the patient, when she takes the 1)C<1, with a pair of muslin leggings fresh from the sterilizer. The leggings should be closed below, so as completely to envelop the feet. In addition to this, the patient and the entire cot may be covered with a sterilized gauze sheet. During the first tage a vulvar dress- ing saturated with Thiersch's solution may be worn. Similar precautions are not all practicable in private practice, nor are they all necessary. The clr'iij^e of clothing, the preliminary cleansing and disinfec- tion of the external genitals and adjacent surfaces, and the aseptic cleanliness of everything that comes in contact with the birth-canal nujst always be insisted upon. The utility of prophylactic vaginal douches is a question which has pro- voketl much discussion. Stetfeck ' recommends vaginal irrigation during labor with mercuric-cMorid solution at intervals of two hours, rubbing the antisep- tic well into the mucous membrane with the lingers. Doderlein ^ advises scrubbing the vagina with a preparation of creolin and mollin, followed by a ten-minutes' douching with the creolin solution. Hofmeier^ favors preliminary disinfection, especially in maternity hospitals where students are allowed to examine the patients during labor. He concludes, from a comparison of the records of the Wiirzburg clinic with the published statistics of other like institutions, that, with preliminary disinfection and the carefid observation of all possil)le antiseptic precautions, instruction by means of examinations during labor does not necessarily increase the danger of infect- ing the patient. He further contends that thorough disinfection of the birth- canal is not a source of danger to the mother, as has been claimed, but that it results in a diminished puerperal morbidity and mortality, FrommeP reports over five hundred cases in which vaginal injections of the corrosive-sublimate solution (1 : 2000) were en>i h, 'etl, and where in manv abnormal ciises from sixty to seventy examin? lL)us vere made during the patient's stay in the hospital, the clinic being oiwu to about one hundred students, and being also used for the training of midwives. In this number of patienis there were two cases of sepsis whose infection was traceable to his clinic. The morbidity-rate was from 5.5 to 7.5 per cent. In another series of cases, where external disinfection alone was praetisetl, the morbidity rose to 11.1 per cent. Mermann ^ reports the results of seven hundred cases without the employ- ment of vaginal douches for preliminary disinfection. He records a morbidity- rate of 6 per cent., with no deaths from septic infection. In the last two hun- dred births there were two cases of mild ophthalmia, and in all less than ten ' " Ueber Disinfection des Weiblichen Genital Canals," Zeitschrift /iir GeburtshiVfc, vol. xv. p. 395. '■' " Disinfection des Geburts-Canal," Archiv JUr Gyiidkologie, vol. xxxiv. 111. ' Deutiichi' mcd. Wochcmchrijt, 1S!)1, No. 49. ♦ Ibid., 1892, No. 10. » Centralblatt fiir Gyndkologie, 1892, No. 99. THE COyOCVT OF ^OIi^fAL LABOR. 347 of conjunctivitis anionjT the children. Merniann omits internal exaiiiinations whenever practicable, observing the progress ot" the labor by abdominal palpa- tion and auscultation. LeopoKl and Goldberg' publish the statistics of several thousand deliveries with and without the eniploynient of vaginal disinfection. Their tables show the best results where the vaginal douches were not used. They recommentl the employment of abdominal palpation as a means of noting the progress of labor, and th(! restriction of vaginal examinations to cases of dystocia, except when necessary to confirm a diagnosis made by the abdominal method. They advise douches in operative cases and in all others where previous infection is suspected. Fischel in an experience of 880 births at the Prague Maternity lost nine women from sepsis with the employment of preliminary disinfection. After sto|)ping the use of the irrigations, iu a scries of 933 cases there were but two deaths due to infection, and a year later, in 521 women delivered, there were no deaths from that cause. The safer course, at least for general use, is undoubtedly the restriction of internal examinations as much as practicable, and of the preliminary vaginal douche to cases in which the scd'ctions are pathological. In the presence of purulent gonorrheal discharges both the vaginal and cervical canal, as well as the vulva, ought to be cleansetl carefully with soap and water and gentle fric- tion with the fingers, and subsecpiently washed well with the antiseptic solution. In extreme cases the disinfection may be repeated at intervals of two or three hours during the labor. This is required not only in the interests of asepsis for the mother, but as a i)rophylactic against ophthalmia in the child. Mer- curials, however, are not suitable for the purpose, owing t'> the danger of mercurial intoxication, Merctuy has been found in the stools after a single vaginal irrigation. Some of the non-toxic disinfectants, such as creoliu, peroxid of hydrogen, or the chlorinated-sotla solution, are to be recomnit-nded. Doderlein has calliHl attention to the litmus-rea^'tion as a ready means of distinguishing healthy from morbid vaginal secretions. He points out that while in health they are strongly acid, in pathological conditions of the secre- tions their reaction is feebly acid, neutral, or alkaline. These observations have been confirmed by Williams ol Baltimore. The litmus-reaction of the vaginal secretions therefore affords a convenient guide to the conditions in which preliminary internal disinfection is indicated. Ant'HepHis in the Use of flie Catheter. — Should the patient require to be catheteriz(><l after labor, care will obviously be needed to prevent infection of the vaginal wounds and abrasions. But this is not all. Cystitis of the vesical neck frequently results from infectious material carried into the bladder during the use of the catheter. So common is this accident that patients who have repeatally been catheterizcd by the mirse, even with ordinary precautions, very rarely escape some degree of vesical irritation, and they often sutt'er from severe inflammation of the bladder or of the vesical neck. Pyelitis may even ' Dcutuchc mad. Wuchmachn/t, 1892, No. 13. iri ! i I ' , ■','■' II > 6.il iji iy!|i I ■ i 348 AMERICAN TEXT-BOOK' OF OBSTETRICS. result by extension of the septic process from tlie vesical mucosa through the ureters. The strictest asepsis must therefore be observed in catheterizing the bladder. The instrument should be boilitl in water for fifteen minutes imme- diately before using, and this is pctssible even with soft-rubber catheters with- out material injury to tiie instnmient. It should then be haiulled only with hands that have been previously sterilized. The patient lies \\\wn the back with the knees drawn apart. The labia are to be held apart, either by the jiatient herself or by an assistant, so as to com- pletely expose the meatiis urethra^ and so held until the instrument is passed. The meatus, the vestibule, and all the surrounding surfaces are to be cleansed with soaj) and water, and subsequently be washed with the disinfectant solu- tion. The catheter, well lubricated with sterilized vaselin, is then passed with clean hands and with the parts fidly exposed to the eye. Precautions must be used to prevent urine from trickling over the wounded surfaces or into the vagina as the instrument is withdrawn. The catheter, after using, should be cleanstMl carefully with water. Care must be taken that irritating chemical antiseptics are not carried into the urethra upon the catheter; otherwise a troublesome urethritis may result. 2. Management op Normal Labor. Essential to the proper management of childbirth is a watchful super- vision of the health and habit^ of the i)atient throughout pregnancy, and a previous knowledge, so far as possible, of the conditions to be dealt with in each case during labor. Next to Listerian cleaidiness, nothing is destined to do more for improv ■ I results in obstetrics than the practice, now happily growing with obstetricians, of studying their cases before labor. It is desirable, therefore, Miat the jiregnant woman be under the observation of her physician from an early period of gestation, and especially if the experience be her first. Much-needed information and advice may be im- parted with reference to the hygienic requirements of pregnancy. Knowledge may be gained of conditions likely to complicate the parturient or puerperal process, and much may often be done to fortify the health and strength of the ])atient. Dystocia, if it cannot be prevented, is more successfully managed with the aid derived from previous knowledge and preparation. I]ven w'hen all is normal, both jiatient and jjliysician are amply rej)aid for their pains by the increased confidence with which the result of labor is awaited. The patient should be atlvised with reference to the selection of her nurse. Instructions will be needed pertaining to the care of the nipples. Siie should be directed to cleanse them daily during the last month or two of pregnancy, and, if they are very small or suidven, to draw them out with the fingers. This manipulation also helps to inure them to nursing. Daily inunction of vaselin or of fresh cocoa-butter during the same period keej)S them supple, and is a better preparation for suckling than the use of astrin- gents so commoidy practised. THE CONDUCT OF NORMAL LABOR. 349 Especially Important is it tliat tho functions of tlic kidneys he watched. Dnrinji; the last one or two months before labor the urine should be examined weekly. An occasional examination at an earlier period is generally advisable. If albumin be found, the microscopic study of the urine will best reveal the character and extent of the structural chanfjes in the kidneys. In doubtful cases the best evidence of the manner in which these or}j;ans are performing their functions is afforded by occasional quantitative tests for urea. Obstetrical Examination. In the later months it is the duty of the jjhysician to make a preliminary obstetric examination. Tlie most suitable time is usually about the end of the eighth month. The object is to determine the position and presentation of the child, the relative size of head and pelvis, and the poi-sible presence of patho- logical conditions that may conjplicate the mechanism of labor. It is to be assumed that full information has already been obtained, at the time of engag- ing to attend the patient in confinement, with reference to her obstetric history, including the number of previous pregnancies, term labors, and miscarriages, all important facts pertaining to the character of the pregnancies, labors, and childbed period?, and particulars relating to the course of the present pregnancy. In hospitals it is the rule to make an external and an internal examination. Ill private practice an internal examination, while always desirable, need not in all cases be insisted upon. Usually all that is necessary to know may be determined by the external methods. In the presence of pelvic deformity, and in all cases in which for any reason the external examination is not satis- factory, exploration of the pelvic cavity should not be omitted. It is essential that the bladder and the rectum be empty. The patient lies upon a bed or a lounge, covered with a sheet and with the limbs outstretched. Her clothing is to be loosened and the skirts drawn above the abdomen. The necessary manipulations are conducted under the sheet or through it, without exposure of the patient. In this maimer the abdominal examination and the external measurements of the pelvis may be made without causing discomfort or giving offense. The hands of the examiner are first bathed in warm water to render the skin soft and the touch more acute. This precaution, too, helps to prevent reflex contractions of the abdominal and the uterine muscles, which are more liable to occur when the hands are applietl cold to the abdomen. The examination should be methodical. Errors of diagnosis are more fre- quently the result of carelessness than of ignorance. Success here, as in most other undertakings, depends upt)n a capacity for taking jiains. All manipula- tions are to be conducted gently, and need never cause the slightest pain, except rarely when deep ])ressure is rc«|uircd to map out the lower fetal polo. A definite order of procedure is recommended in accordance with the following scheme : ■|i"1 '•&'h^' 'til, !'i' a 3o() AMi:iiivAy Thwr-nooh' of onsTiyntics. 1. DrACNOSIS OK TMK KkTAL I'KKSKNTATION AMt POSITION. Lncftfinn of the Dnrxnl P/inic initf Suui/I Ptirfs, — Tlic sitiiatinii of the (If)rsal plane and small parts of tlie fetus may, as a rule, easily l)e made ont hy palpat- ing; tliealxlomen. The palmar surfaces of the finger-tips are applied with lij;lit iiitermittinj; touches (Fig, 1H7). Heginniiigat the lo\v(>r part of the abdomen, a narrow zon«' is palpatetl entirely across from one side of the tumor to the other. The palpation is repeated over a similar area just above the first, and so on until the entire surface of the timior has been explored. The situation of the f«'tus will usually be learned by the first t<»uclies. It presents to the examining fingers the feel of a solid body, while elsewhere over the tumor only fluid is felt. The location of the child niav more readilv be made out bv J)laei'ic: one hand flat upon the middle section of the abdomen and pressing firmly back- ward (Fig. 188). The licpior amnii is thus displaced to one side and the child to the other, where it can more easily be j>alpated. Fic. IST.— (ii'iicral palpiitiDii of iiliilomcn for Icu'iitiiif; ilcirsal plimo ami small parts of futiis (from a liliotnuraph). The child's back is identified by the length and breadth of the resisting j)lane which is offered to the examining touch, and by the absencie of a suIcmis between it and the fetal head. The side of the child presents a narrower i:it- icr. iitil ■tiis luid otic hil.l III)'. Ivcr coNnrcr ok nokmai, kahoh. I'l.Mi: "J.-l. KXA.MINATlciS lii;i()IIK I,. Midi!: llxiimilllltinll (if IdWtT I'cllll |icilf ilVolll II |illnl(,i.'ni|ill I 1 1 .'I I Iter i( lIlC 11)1 cf the ;-; '. -r «,, i™: t;;;,"" :■ -'— > '- '-> ,1,. ■'"tt'rior position of the child'- I I /' . l"j-'ituoi position '"■""'» «"' "I«.n .1,0 alKl.„„c.„ „v,. , w"""-' "'" "'""■■■'■'« fc., .0,1,,. ^ft"'nit of the iitmis(I'|.2;}). 'ill.! "|i,' ifi ' ii iil 'i 111 l8 Ii I :i: 1 o;'»-2 ami:rivax text-book of obstetrics. With tlio liaiuls irstiiij; upon the sitlos of the tumor, thoir palmar Kii; sinks (U'opiT in llic ,Sll rfacrs nearly laoiu}; each otlii-r and the tin<!;er-ti})s 1 or 2 inches ahovo Ki(i. I'.iii — Kxiiiniiiiit L'()|l(ll(ll tile level of the piibes, maintaining firm pressure, the llnger-tips are gently (OXDlCr OF X *»liMAL LAHon Vi. vn: '24. I Wf 1 tl !« 1 ii ll. 1 28i 1 m i:.\ ^'II^VIInN lt|:r,,|;|; I, »liiil:: I, I'lilii " I'll.'llir I '■ ii'i; ill, '■"inlrnni 111. I |.ll..|,,i;,;,|,h ■"■'■'liii- III.' Umul iii'n..s> II I'' Mi|ini p I MW , ' r . f ! 1 J. '? 1 / i ; i 1 ' r r t( iij Ml til if* ill I / i I > bri diK put the the ri<,Wi ci'tl tlesc men liciic / siiniil upon tiiwai I'llCOU pillar , pivs.si: l''iii(ll • '.•Itcs { "I' flio I" fill' THE COX DUCT OF XORMAL LAliOJi. 353 thrust downward into the hriin of tlie pelvi^i. Tlie pelvic excavation is then explored to learn if it contains the presentinjj; fetal part. If it is tilled before labor, the i>resenting ])art is the vertex. Xo other fetal part sinks into the lesser pelvis nntil labor begins, and even this sinking very rarely occurs except in priniipara\ In the latter the fetal head is normally always in tho j-.clvic brim. Dnriiig labor either pole, whether the woman has previously borni^ children or not, should be found in the lesser }K>lvis. The head when it lies above the lesser pelvis is not usually so accessible to palpation as when in the excavation. A useful nianeuvre for locating the liead, if it is not readily found by direct palpation, is to i)lace the hands in the usual position over the sides of the lower uterine seg- ment and proceed as for external ballottement, bringing the hands more ;ind n\ore nearly together initil the head is found. The head will be ivcognized as a solid globular body which can be tossed from one band to the other. The cephalic extremity is distinguished from the breech by its greater mobility when it lies above the excavation, by its hardness and globular shape, and by the presence of a sulcus between it and the fetal trunk. The breech alone, is smaller, with the interior extremities larger than the head. It lacks tlie hard and globular character of the head, and presents no sulcus between itself and the trunk. An imperfect ballottement of the heatl is frequently ol)tainable when it lies in the lower segment of the uterus above the pelvic inlet. C('i>haliG Promiucncc. — When the head is in the excavation one side of the brim will be found more completely tilled than the other (Fig. 189). This is due to the fact that the occiput sinks deeper into the pelvic cavitv than the sinci- put. On one side the frontal portion of the head, on the other side the najie of the neck, occupies the pelvic brim. That side of the cephalic tumor which is the more prominent, therefore, is the sinciput. Cephalic prominence to the right indicates a left, to the left indicates a right, fetal position. The situation of the greater prominence will be observed in the course of the pal|>ation above (lesiribed. It may also be made out by arching the hand across the abdo- men innnediately above the ))ubes (PI. 24; Fig. l!*.'i). The cephalic promi- iicni'c will be found most marked in <K'cipito-posterior positions. Location, of the Anterior Shonbh')' in }'erte.r J^resentotio)). — The anterior siioulder may usually be found as follows: While the bands are stiP held upon the abdomen over the sides of the fetal head, move them upwar<l toward the fundus without ri'laxing the pressure. The first obstacle they tiicounter is the anterior shoidder, which may more fidly be identitied by map- l)iiig it out with the fingers of one hand. Steadying the fetal mass by gentle pressure with the other hand over the breech facilitates the examination. I'iiidinir the anterior shoidder within 1 or 2 inches of the inediau line iiidi- tales an anterior, and several inches from tiie median line a post(>rior, position (if the fetus. In left ])ositions the shoultler lies to the left, in right positions to the right, of the median line (Fig. 15>2). 2:t lU- %i%\ 'mm. ).' : a }Sn ill liifeM: iv.:,.i:'E .'. / !r sr)4 AMEIIK'AX TEXT-BOOK OF OliSTETRIVS. Kxianinntlon of the rjt/tcr Fetal Pule. — The cxaiuiiier next faces the mother's fiioe and phu-es his hands over the sides of the fnndns (Figs. 190, IDl). The finiihil poh- of the fetus is then examined hv palpation. The head is differentiated from the breeeh by the characters ah'eady Km. I'.il.— Kxainiimtinii df uiiper Mai polo (from a photograph). mentioned and by a more pronounced ballotteinent than is usually pos- .sible when the head presents. By reason of its smooth, globular shape, and especially of its flexible attachment to the trunk, the head is very movable, rebounding distinctly under the touch when in the roomy upper uterine segment. Location of the Fetal Heart-to)ie,s. — The stethoscope may or may nol be u.'^ed, according to the usual habit of the examiner. The point at Mhich to listen first is directly over the supposed location of the upper part of the child's back. Failing here, the entire surface of the tunmi may be .searched. The hen it -.sounds are usually heard over an area of about 3 inches in diameter, but, since they are .sometimes more widely diffused, it is importaii! to locate the point of greatest intensity. The point upon the abdomen ;i! which they are mcst intense is termed the j'(tcH.s of aniicultafion. As a nil''. this point overlies the fetal heart. Exceptionally, the sounds are most di- Is vorv KT upi ay not |)int ill tumor llies in l>ortan! Lieu ill |i rill''. St (li-- THE COXDiCT OF yORMAfj LAliOli. >)i> tiiictly heard at some remote point, owing to firmer contact of the i'etus witli Fi<i. 11.12.— Mftppiiig out tho anterior shoulder (from ii photoKrnph). tlio utorino wall at that point. Their location usually serves to distinguish lelt from right, and anterior from posterior, positions. In a posterior posi- Kio. l;i;{.— .Mftliiiil of lociitiui; the eeiihiilic proiniMriiee hy iir( '.nu',' the hanil iicmss the suimipuhie reKinu tioii the heart, if heard at all, is found far hack over one side of the ahdo- iiit'ii ; frc(|uently the cariliac .sounds are (piite indistinct ; rarely they .uvj \vli(»lly inautlible. 1: I !■ 356 AMKRJCAN TEXT-nOOK OF OliSTETIilVS. For the diagnosis of prosoiitation the sitiiutioii of the fetal heart is of limited value in women who have borne ehildren. Sinee the position of the lieart is nearly midway between the extremities oi' the fetal ovoid, tlie mere inversion of the long axis of the child makes little ditlerence in the location of the heart-somids. In primiparie, in whom the presenting pole sinks into the excavation in vertex, and rides above it in breeeh, presentation, the level at which the heart-tones are heard is of some valne in determining the pres- entation. In first pregnancies this level will usually be found below the umbilicMis in cephalic, and above it in breech, presentation. The Location of the Fetal Movements must be taken on the statement of the mother, which statement as an aid to diagnosis is liable to the usual fal- lacies of subjective signs. It may have some weight, however, in deciding in what part of the uterus the feet lie. Importance of the Ahdoniinal Examination for the Diarpioniti of the Fetal Presentation and Position. — With all the facts clearly made out it will readily be seen that the abdominal examination is of nK)re value for the diagnosis of j)resentation and ])ositioi! of the fetus than the vaginal touch. Every physi- cian, therefore, shoidd familiarize himself with the techni«iiie of abdominal palpation and auscultation in its application to obstetric practice. It is within the ])ower of every obstetrician to become expert in obstetric diagnosis by tlu! abdomen. AVliile the facilities afforded by a hospital service are »*f great advantage, they are by no means indispensable if j)roper use be made of the opportunities which even the general practitioner has at his command. Patholof/ical Conditions. After detf rmining the presentation and position of the fetus, the abdomen is next to be interrogated for the ])ossiblc existence of fetal or maternal anom- alies that may complicate the labor. A pendulous abdomen in a first pregnancy should suggest the possibility of pelvic deformity. It not infrecjuently occurs, however, in multipane in whom the ])elvis is normal, and it may retard the labor by hindering tiic engagement of the jjresenting pole. Ilydramnion is recognized by the increased size and permanent tension of the uterine tumor, by preternatural mobility of the fetus, and by the pres- ence usually of suprapubic edema. The entire abdomen is exploi'cd for the possible presence of pathological growths of the itclvic or abdominal organs. The lo'-ation of the placenta may usually be made out by palpation over t bdomen, except when its implantation is mainly upon the posterior wall ■ ih' uterus. Its convex edge presents a resisting ring, and the ])alpati<iii t tdal it.'irts is partially obscured within the placental area. The diagnosi> of vicious i!!.-;ertion of the placenta is therefore sometimes ])ossible by abdomi- nal examination. A liydrocephalic head of a siz(! sufficient to give rise to dif!ieulty in delivery ought to be recognized by external palpation. Its size may be determined ksibility |)ari« ill |ing till' ision of >logioal in ov<'r n- Nvall llpat'uiii \gno!?i> j[)doini- ■ 'liven huiiu'd TIfE CONDn'T OF XORMAL LA/iO/f. i]r>7 more accurately by moasureincnts taken with calipers throujfh the abdominal walls, and by tryin}>; whether it can be crowded into the excavation. In twin pre}i;nancies, as in hydramnion, the abdominal tumor is usually large and persistently tense, and there is suprapubic edema. Indeed, multiple pregnancies are generally associate<l with exi'css of licpior amnii. Single feta- Kiii. ini.— Hfliitivc IdCHtion nf tlif |i(isl(ii(ir sii)Kri<ir iliiic spiius iind spiiic of liist liiiiiliar virti'brn. The liitttT is the second vortobral abovt' tliu luvol of the iliac spiiU'SdifttT tlio Ariaiiuc). tiou with hydramnion is distinguished from plural pregnancy by the greater inobilitv of the fetus in the former. There is a larjier numi)er of small parts than in single fetation, and they are more widely distributed. Two <lorsal planes and more than two fetal ])oles may sometimes be made out. One head in the excavation and one in tiie upper utcriiu; segment or in one iliac fossa make the diagnosis of twins. Two fetal poles njore than 12 inches a[)art cannot belong to the same child. The most conclusive evidence of double fetation is the detection at the sanu^ time of two fetal heart-beats of ditl'erent rates. Palpation in nudtiple pregnancy is generally rendered diflicult by the per- manent tension (»f the ulerine tumor. t^) / ■ 358 AMERICAX TEXT- BOOK OF OliSTETPTCS. » I I 2. EXTKKNAI- MeASUKKMKNTS OF THK Pkia'is. In primipaiw, and in niultipaiw in whom tlio prcvions obstetric liistorv gives rise to any .sn.spicion of polvic contraction, tin- external clianieter.s of tlie pelvis should be measured. Tiiree measurements are usually sufficient — namely, the external oonju<iate, the inters|)inal, and the intercristal. Of these measurements the most important is the external conjugate (1*1. 25). This diameter is measured from the depression (Fig. 19-1) just below the spine of the last lumbar vertebra to a point on the pubic surface in front of tiie upper part of the symi)hysis. As a rule, it may safely be assumed that the pelvis is ample when this diameter exceeds 7^ inches (18 centimeters), Fid. I'.i,').— Mmiunl iiR'tluKl of incasuriiiK tlio (liiigonnl rniijuRftte. and that it is contracted at the brim when the diameter falls below that limit. Occasionally the saero-pubie diameter at the brim will .a found slKjrtened with an external conjugate of Ih inches (IJ) centimeters), and it may be normal when the diameter of Haudelocipie is less than 1\ inches (18 centimeters). Contraction in other diameters must be excluded. An interspinal equal to or greater than the intercristal diameter indicate* flattening of the j)elvis ; when both are small, there is general contraction. 3. VA(a\AI> HXAMINATIOX. Before examining per viiginam the obstetrician's hands and the external genitals of the patient are to be cleansed with the same care that is observed during labor. Lt limit. led Avitli Incn'mnl liiotors). fdicatc- Ion. eternal Iservcil (ONDITT Ol' NOIJMAL 1,AI!()K. I'l.ATi: -J'). Mt'iisuriiif; tlie oxtiTiiiil Kinjugato : llio Murk ilots show tlio points from wliich tlio moiisuroinciits arc iukeu (from a photograph). ku, Bft' JM |w:Hi; Ifl it I ' v\ w r t HI jHli ri; li i ! r I I <L (ONDrcr ol" NuKMAI. I.AIiui:. I'l.ATi; 'Jti .Miiimal mi'thoil of muasuring tlie diiit;oiial conjiiiiiitc : p, promontory; r, n, periiu'iil bmly dis- pliicril luickwani. It 1 *■■ i. ' j ' i ;i^^ »"Li;;- |ii,,i If'l 1 m 1 m-:. V ;■ / I in tli| gi'( iiK IIKJ In tioi nial ( rece M'Oll exec arat( bed 1 nient apj)!! be cc with sei.sso rm: i'oxnrcr or xonmal lahoil .•{■)!) In parous woiiicii tlic pelvic Hour aiul tlic cervix are <>.\atniiu><1 for injuries iiillietod (liiriiij; previous lalxirs. In all <'ases the (lia;i;oiial eoiijiitiate and the aiitero-posterior and hisisehial diameters at the ontlet should earel'nlly ho nieasin-ed and the width and curvature of the saernin be noted. The method of measuring:; the diagonal conjugate is shown in Fij;ure lJ»r) and Plate 2<). With the patient in the lithotomy position, two Hnjiers of the exainininjjf hand are passed into the vaj^ina, and the tip of tlie second fniffcr is made to rest by its outer mari^in against the most prominent part <tf the sacro-vertebral angle. The point at which the edge of the subpubic ligament cuts the radial border of the examining han*l is marked by a finger-nail with the other hand. The distance between the points of contact is the value of the diagonal ctinjugate. To Hud the true conjugate the amount to be subtracted from the diag<(nal is usually 'S to J inch, according to the depth and inclination of the symphysis. The diameters of the cavity and the transverse diameter at the brim are esti- mated by ])al|)ating the walls of the pelvis. The examining hand is to be used wet with the antiseptic solution. If any other lubricant is required, glycerin or vaselin sterilized by heat, or glycerin biniodized or sublimated (1 : 600), may 1- > employed. The Lying-in Room. In pi'ivate practice the patient is generally confine<l in the room which she is to occupy during convalescence. The choice of room is not a matter of indifference. One of the first requisites of health at all times is pure air, aiul this should not be deniinl the patient at a time when the need of oxygen is greater than usual, owing to the severe muscular activity of labor and to the increased tissue-waste of the puerperium. If possible, therefor(\ a com- modious room, one which permits of constant ventilation, slu)uld be selected. In cold weather an o])en fire is an efficient aid to ventilation, and it adils greatly to the cheerfulness of the lying-in chamber. A sunny exposure is desirable. Dust-laden hangings are especially objec- tionable, vet it is neither necessarv nor best to so far disnuintle the room as to make it cheerless. Ordinary claanliness is usually suflKcicnt. On no condition should the confinement be conducted in an apartment recently occu])ied by a patient with erysipelas, childbed fever, siij)pu"'ating w(junds, or cMier diseases which are recognized sources of possible sepsis, except after systematic cleansing and disinfection. The management of the patient at the close of labor is simplified if a sep- arate cot be providetl for the confinement, the patient being transferred to the bed at the close of the labor. The, Nurse^s Prcpdmiions. — An orderly nurse will have ready, conve- niently near the bed, a small table (Fig. 196) properly eijuipped Viith such appliances as the doctor will need for use during the labor. The table should be covered neatly with one or two frcsh-lannderwl towels, and be supplied with a wash-basin, a hand-brush, soap and hot water, an antiseptic solution, scissors, a ligature for the navel, and a suitable aseptic lubricant for the hands. iliilil I- vv ! I ' ' ' ,b .'}(;( > AM/:iU(Ay Ti:xT-nooh' of obstetrics. ■f , ! : V^ -\r, I The iiiirso shoiiKI also provitlc j)l('iity of clean sheets and towels, one or two pieces of niihleachcd nnislin for alxlorninal hhulers a half yard in width by one and a (jnarter yards in length, one or two snrgically clean rnbber sheets large enough to cover the ent're width of the bed, plenty of nuislin sheets, a nig or oil-cloth lu protect the carpet beside the bed, safety-pins of convenient size for pinning the binder, a fountain syringe, a suitable be<l-pan, a supply of hot and of cold water, a package of salicylated or borated cotton for the navel dressing, a blanket for wrapping the child, and the child's clothing. PvcparatUm of flic Bed. — The patient should lie upon a firm mattress. It is customary to protect the bed by means of a rubber sheet, which ought to be large enough to cover the entire width of the bed and the greater part of its I: lA M ! '■■. V, ; Ml t * Ki(i. I'.Kl.— TiilMc ('(iiii|>pe(i with basins, briislies, milisoptics, etc., for the pliysiciaii's use. ! li hi length. Over this rubber covering is .spread a nni.slin sheet, the two cover- ings being pinne<l fast to the mattress. These spreads are covered with a second rubber overlaid with a bed-sheet. The latter coverings are withdrawn after labor, leaving th(> \)ed clean and protected l)y the first rubber and its mti.>^lin covering. Two or three fre.sh-Iaundered sheet.s, each folded to four thicknes.ses, may be placed upon the bed in jnisition to receive the tli.scharges. In phux* of the sheets a good absorbent dressing is a pad specially made for the purpose. It consists of a cheese-cloth sack or bag, which i,^ filled with jute, absorbent cotton, cotton waste, or other absorbent material that has j)revi- ously been prepared and sterilized. The stick rctiuires (o be from 2^ to 3 feet «<l"-e aud .3 or 4 i.u,.„o« thick Tl , ''' «" ''o.n. sI.o.,lv before use 1 ' ^''' '' ^'' ''^^'^^^'-^1 by sfon • . An oiiji.t ;:ut "JT""; "'"^'^' ^'--f^-'. " """"^'"^^''*' ^-^ «>nuiioiiIv eninlMxv. i • ^ ^' absorbent pad i* ihn t- n »l"tio„ ir,; ** "■'"''(«• A ..apfet „. 1 " "'• ''"""8 "«' firs' «ta J i ^^'J; a Jialf-dozeii iicedJes, ''"'•"•'-^<">"t«'spo.vi.„etor ••'hout 2 i„eI,o.s i„ K,„,,.. . , C:';::; ::::£-•- -k™ 2t,:r' '^v•■'"--- •' ''N>"".-i...i. ,,^ ,?;;t ;';'''''f ''-!•'■ ■■'-:., ::'?,"" -'■■■ ■■' ■^""■' U i (.; •/ i.li\ 362 AMERICAN TEXT- Ji 00 A' OF OBSTETRICS. The bag should also be supplied with two or three ouuces of chloroform, twice as much ether, a few ounces of carbolic acid, and a drachm or two of chloral. Mercurial antiseptics and also obstetric cmergeuts, such as niorphin, elaterin, digitalis, ergot, and veratrum viride, are most conveniently carried in tablet form. 3. Anesthesia. Of anesthesia in obstetrics for the usual surgical indications little need be said. The eniplovnient of anesthetics in obstetric operations is governed by the well-established usages of surgical practice. ]iy obstetric anesthesia is understood something entirely distinct and apart from the surgical use of anesthetics. It is intended to diminish, not to abol- ish, pain. Its object is merely to mitigate the severer sufferings of ordinary labor, not to cause complete insensibility. To what extent anesthetic agents may be used to advantage in a simple labor is a question that calls for the exercise of tact and judgment. That, on the one hand, obstetric analgesia accomplishes a distinct gain, in so far as it spares the {)atient the exhausting effects of severe pain and prolonged nervous tension, cainiot be doubted ; nor has the obstetrician any more pleasing duty than to save the needless sufferings of childbed. On the other hand, except in moderate doses and during the most active period of labor, anesthetics are lia- ble to impede the progress of the birth. The careless and long-contimied use of these agents, especially in excessive quantities, is fraught with serious dan- ger to the j)atient. Their abuse is doubtless at times an unrecognized factor in grave and even fatal accidents of childbed. These objections obtain more csj^cially against chloroform. With reference to the influence of anesthetics upon the strength and the frequency of the uterine contractions we have some recent observations from Ponlioff.' lie administered chloroform, in various degrees, to five parturients, studying the effect upon the pains with the aid of a tokodynamometer. Even under small doses the labor was retarded. In eight observations the muscu- lar pressure sank nearly to one-half that present before the administration, and the strength of the uterine contractions was not fully restored for several minutes after the inhalations were stopped. That the use of anesthetics during labor ])redisposes, in some degree, to relaxation of the uterus in the third stage, as claimed by Ijusk and others, is abundantly exemplified in the writer's experience. The foregoing facts, while they do not forbid the employment of obstetric anesthesia, call for the exercise of caution in its use. When rctpiircd for no other purpose then to mitigate the sufferings of the patient, anesthetics should be reserved until the latter part of the second stage, and even then they may be withheld so long as the ])ains are well borne. Tlieir employment is per- missible at an earlier period in the labor when, recpiired to subdue great ' Archil' fur Gi/n., Hai.d xlli, 12. (1 the from jionts, ^vcn luscu- lition, Ivcral ["C, to Irs, is totric Lr no konUl 1 may per- brcat THE COXDUVr OF NORMAL LABOR. 363 nervousness and excitement or to relieve pains of extreme and unusual severity. In cxeoptional oases these agents may act to accelerate the labor by counteracting the inhibitory effect of pain upon the uterine contractions. In the third stage of labor the uses of anesthetics are chiefly surgical. When anesthesia is recjuired to the surgical degree, it nnist not be assumed that the obstetric jiatient enjoys any special innniuiity from the usual dangers of anesthetics. The relative safety of obstetric anesthesia lies not in any peculiarity of the subject, but in the mode of administration, the limited dosage, the slow and gradual inhalation, and the intermittent use of the drug, during the pains only. Under complete anesthesia the parturient woman is exposed to the same dangers as are other patients. In eases in which an operation must be performed requiring anesthetics, neither disease of the heart, of the lungs, nor of the kidneys, nor the exhaus- tion of the third stage, forbids their use. These conditions, however, neces- sitate increased caution in their administration. In cardiac disease, even in lesjons of the myocardium, anesthetics lessen the danger by subduing the rt i' Kos. Choice of Anesthetics, — For mere obstetric analgesia chloroform is gen- erally preferred. It has the advantage of being pleasanter than ether and is less bulky to carry. The latter agent seems to be growing in favor, however, for obstetrical use, and it is claimed to be no less manageable than its rival, chloroform, for partial anesthesia. Hirst thinks analgesia is even more promptly produced by ether than by chloroform. The satisfactory use of ether for this purpose, however, depends ujion its jn'oper administration. It must be given very gradually in quantities of a few drops with each inspira- tion. The difference in the safety of the two agents is insignificant when .^ed in the obsteirio method. When couiplcle insensibility is required for surgical interference, chloro- form should, as ti rule, give place to ether. The general mortality of chloro- form when push(j.l to the surgical degree is four or five times greater than that of . thiM*. 0\ the two agents, chloroform is the more potent and its effects persist i -ngor r,%>r inhalation stops. Ether, since it is used in larger (piantities, is nv \^ irritant to the air-passages than is chloroform ; hence the former pgent should be replaced by chloroform in inflammation of the air- passage,', especially if it be acute. Ether is generally believed to be more dangerous in nephritis than is chloroform, but this question is not fidly set- tled. Owing to the tendency of the former agent to produce high arterial tension, it is dangerous in marked atheroma. Methi ' of AdminiKtrnfioH. — The patient is prepared for anesthesia by looseniii :• .i'^ clothing, by lowering the head, and by attention to such other l)recaution>. arc commonly observed in surgical practice. To protect the skin from the irritating effects of the chloroform vapor the lips, nose, and chin may be smeared with vaselin or with glycerin. A towel spicad in one thickness over the head, and lifted by the middle so as to form a large air- chamber about the face (Fig. 198), makes a suitable inhaler. An Esmarch w r'' I., !i ;};t ;■ ' . i 304 AMERICAN TEXT-BOOK OF OBSTETRICS. mask is also a convenient apparatus for administering the anesthetic in the lying-in room. On the first premonition of a coming pain the inhaler is placed over the face of the patient, and the anesthetic is dropped upon it opposite the mouth. With chloroform, one drop or, at the most, 2 drops should be let fall at each breath. In case ether is used, .3 or 4 droj)s with each inspiration will suffice. When sufficient effect is not obtained in this manner, the patient may be requested to breathe rapidly as the pain is coming on. For convenience in graduating the administration a bottle specially con- structed for the purpose may be used, or a dropping-bottle may be improvised by cutting a longitudinal slot in the side of the stopper (Fig. 198). The foregcing methods of administration ensure abundant dilution of the anesthetic vapors with air and a safe and gradual development of anesthesia Kio. li»8.— Mi'lliod <if Hiving cliliinifunii witli Uw tnwcl inlmlor: tliL' illustnition repivsoiUs the towel as trimsiinrciit {from a phologrupli). with the least possible quantity of the drug. The inhaler should be removed on the ap})roaeh of unconsciousness, and should always be withheld in the intervals between the pains. During the severer ])ains at the acme of ex- pulsion the inhalation may usually be pushed nearly or quite to the surgical degree. Other Anesthetic Af/cnts. — An agent of great value as a partial substitute for the anesthetic vapors is chloral. It is particularly useful for alleviating the pains of the first stage when they arc not well borne. From 4o to GO grains may be given in doses of 15 grains repeated every twenty minutes. The total quantity should not exceed a drachm. Under the full dose the L'l as zed I the lox- licnl [utc |ini>; GO tp?. itlu! THE CONDUCT OF NORMAL LABOR. 365 patient usually bears the pains with little complaint, and sleeps quietly in the intervals. Chloral in the (piantity mentioned has no inhibitory effect upon the uterine contractions. In disease of the heart, either organic or functional, the wisdom of its emj)loynient is questionable, owing to its depressant effect. It is said by some authorities to be unsafe to give chloroform to a patient who is already under the influence of chloral. The coal-tar analgesics relieve the i)ains of lab(»r, but they also tend to cause uterine inertia. The hydrochlorate of cocain applied to the cervix and vagina has proved of little service, its action being merely superficial. It is especially objection- able on the ground that it necessitates interference within the passages. From an eighth to a quarter grain of the sulphate of mor{)hin, admin- istered hypodermatically, as a rule acts kindly in unusually painful labors, but it is rarely to be recommendeil in strictly normal conditions. Examination during the Labor. The first duty of the obstetrician on reaching his patient in resjionse to her sunnnons is to satisfy himself that she is, as she assumes, actually in labor. The beginning pains, however, are not necessarily to be taken as ovidence that active labor is near at hand. Painful uterine contractions are sometimes ex])c- rienced at intervals for days before the birth. Rarely, after they are fully established, they may wholly cease for hours. Inquiry is made for the usual i)henomena of beginning labor, the time when tiie pains began, and their character, strength, and fre(juency. Most distinctive of labor is the rhythmical character of the j)ains and the contraction of the uterus during the ])ains as felt by the hand laid upon the abdomen. The first uterine contractions of childbirth frequently give rise to little more than a sense of i)ressurc in the sacral and the lumbar region. As the labor progresses they are felt in front over the lower abdomen, and finally radiate down tiie thighs. If the labor is in actual progress, a systematic external and internal examination is to be made. The general object and method arc substantially the same as in the preliminar ' examination, with the addition of certain details which pertain more especially to the labor. The abdominal examination aims to determine whether the (ihild is living, what is the presentation and position, the quality and frequency of tlie fetal pulse, how far the lir d has descended in the pelvis, the presence of anomalies that may com})licate the birth. The relative si/e of the head and pelvis can be eslimated by observing how far the head has suidv or can be made to sink into the excavation. In doubtful cases measurements of the head may be taken with calipers through the abdominal wall. Distention of the bladder is recognized by palpation over the supra])ul)ic region. The diagnosis of presentation and position by abdominal pal|)ation is not usually so readily made at this time as l)efore labor, but in most cases it offers no special difficulty. The character of the fetal heart-sounds affords im- portant information as to the prognosis for the child, and they should fre- !.i 1 . t (■ fi ''■m. ., ■ i: 366 AMERICAN TEXT- BOOK OF OBSTETRICS. \:\ II m I ■« * :,M h b: quently be Ustcned to throughout labor. A fetal pulse-rate much above or bel'^'w ^'.'.0 liornial range, or a pulse which grows progressively weaker, indi- cates danger to the child. When a systematic preliminary examination has been made, little additional information remains to be gained by examining internally after labor begins. For the detection of possible complications that may have developed at the onset of labor, such as prolapse of the cord or of a fetal member, as well as for more precise information of the stage of progress, a vaginal examination is usually desirable, even though the obstetrician be expert in abdominal palpation. Before examining internally the nurse is directed to cleanse the abdomen, the vulva, and the inner surfaces of the thighs witii soap and water, and finally Avith an antiseptic solution ; meantime the obstetrician sterilizes his hands and forearms. The object of this examination is to learn — (1), the condition of the vulva and the degree of resistance it will be likely to ofter as the liead descends; (2), whether the vagina is well lubricated by the secretions, and the presence or ab- sence of obstruction ; (.3), the condition of the cervix, how far dilated, whether dilatable as judged by the extent of softening and thinning; (4), the size and protrusion of the bag of waters; iv J {'i), the presentation and ptsition of the child in confirmation of tlie abdominal examination. Vertex presentations iire recognized by the hardness and the globular shape of the cranial portion of' the head and by tracing the sutures anil fontanelles. As the anatomical characters of the presenting j)art are often somewhat obscured by the caput succedaneum, the examination nuist be made with care, using firm pressure and searching as far as the fingers can reach. In other than vertex presentations still greater pains will generally be needed to identify the presenting part. During the vaginal examination the hardness of the child's head should be taken into account as an important element in the prognosis. The position is determined by finding in which quadrant of the pelvis the small fontanelle lies. This is best locatwl by first tracing the sagittal suture. (For diagnostic signs of other than vertex presentation the reader is referred to the (;lui])ter treating of those presentations.) The examiner will learn whether the membranes are still intact, and liow far they protrude during a pain, and will make sure that a loop of the cord has not ])r()lapscd into the bag of waters. It is perhaps unnecessary to say that in this part of the examination care will be needed lest the membranes be prematurely ruptured. To the question which is invariably asked, " How long will the labor last?'' a guarded answer must be given. Definite predictions are seldom possible at the beginning of labor. The prognosis, so far as it can be estimated, must be based on the strength and the frecpiency of the pains, the extent of dilatation and the dilatability of the cervix, the position, size, and hardness of the head, and the degree of descent. When nothing abnormal has been discovered assurance should be given accordingly. -- -— o. .on.u, ,,,„,. _ Management op thp Pr« « Duni,g the first ,st«ire nf . i . "'®'" '^^^OE. «"^^' to tl.e bed u„ti til • "' "'^ ^'•''*'*^"t o,„.J,t not . , "H'ted. Much „. 1. '''^-^'^^^''^^ room and fl "'^"""r '"ore eon,- "■<"'- being re, iJ?',™'"""" "f «>.-.«,i„ bt^ " " '; «»• ';»g break, before ,, eta 'f''" °' "«= "'^'bra,, 1, I '"«' "* be "•P"l»ive elibrt. " * ""'•'■ '» n«ma,T, ,„ b7 j ,' "' '" b" all„„.„l ova™a,«l, ''--" «b.,„l., bo el™,. ".,„ '^' ■";"/'- J--"., ..Z „ »'"■'« «"■« sfage i, ;, , „, , " """'""■ «-l'.on,l, 'bepaliejitiiiifilir , *'™™' ™le for tl,e . 1 ■. ; '!""o.. :.:!„t,r,H "■"'"'"• "- ^•- - : ^ict?, ■"" '<> ■«--, „,,b '""'H.|f f,,,,;, „,e r„.' ' '""""■'" ■•-1"b«l, be ,,■,■'''■'■"•'■■ ''=™" after ),i, """b 'be ,„a,er„a| „„, ,, ,. , " """"''' *" be left t„ 1 : I. 1 1 1 3G8 AMERICAN TEXT-BOOK OF OBSTETlilCS. Management of the Second Stage. In the second stage of labor, as in the first, so long as all is nornuil the duties of the obstetrician are few and simple. From the time dila- tation is nearly complete the patient must not, as a rule, be allowed to leave her bed, not even for evacuations of the bladder or the bowels. She is to be dressed in the usual night-clothing, which the imrse will keep well tucked under the arms, beyond the reach of soiling. A folded sheet hung like a skirt from the hips still further conduces to cleanliness. AVhen the pains are feeble, their intensity may be increased by retjuiring the patient to move about in bed or even to assume for a time a sitting or a half-sitting jiosture. The uterine expulsive efforts should be reinforced by the voluntary muscles. Direct the patient to " hold the breath and bear down with the j)aiiis," Most women during the expulsive pains instinctively brace their feet and catch the hands of the nearest bystander to assist the straining etfort by pull- ing. Except in precipitate labor this pra(!tice is to be encouraged. A sheet rolletl into a loose rope and fastened by one end to the foot of the l)ed makes a convenient and efficient sling for the purpose. An abdominal binder is frecjuently useful in helping the progress of labor during the second stage, particularly in multipara) having lax abdominal walls. The distressing sacral pains so common in the expulsive stage of labor may be relieved in some degree by pressure over the painfid region. For this pur- j)ose the nurse, taking jmsition on the bed behind the patient as she lies upon the side, supports the back by pressing firmly against the sacrum with the palms of the hands during the pains. Cramps in the lower limbs are best overcome by powerfully contracting the antagonistic muscles. In case of crami)s in the calf of the leg, for exani))lc, the patient should forcibly flex the foot and hold it so until the muscular spasm subsides. Rupture of the Membranes. — When the bag of membranes does not burst spontaneously by the time it reaches the pelvic floor, it should be ruptured by the obstetrician. Care nnist first be taken to see that a loop of the cord has not slipped down beside the head, as that condition of things would seriously be complicated by the escai>e of the waters. It is not usually difficult to tear the sac with the finger-nail during a pain. Failing by this method, a sharji- pointed scissors, previously sterilized, may be used. A convenient instrument for tl " purpose, generally to be found in the lyiiig-iu room, is a coarse hairpin. It is li. t straightene<l and then well flamed. This perforator is passed on the finger-tip as a guard and a guide, and the bag of membrane is punctured while tense during a jiain. Obstetric Position. — As a rule, the posture of the patient should be left largely to her own choice. Occasional changes relieve fatigue. In simple slow labor the pains are promoted by permitting her to move about in bed and now and then to take a sitting position. Until the head reaches the pelvic floor a half-sitting posture is the most favorable, since the '"'" ""■'-''"■■'■ -• -o,n,u. ,,,,,, a(;9 perineal stm^, ^j,^. , '"' ^^ oflcofivdy i„ tJ.e Ji„. „.■ , •'" "« ti,o xz.- '"''"'""'"'><' "f'^v'^iZt ""r''.""-<»'si. .1.0 "■"'« •■vposo 2 ^ '"*""' "'"' ••"«„ib„i,„ ," "' "'*■■' «'" "-"ally 1,0 <-«<'".l into ' • ' •"■'"^"la.-l.v i,, ,1,;,, ,1,0 1 ,;'"'■ "■T"' "'««a,tor i... to ,„„ .,„. '"" "■"* a,,., rnsei., „„;, noZ,,:':'' ^^ilt' '"'' '- """ ''avo boc°, „„l!f, ^'""''«'"«i„„ i„ t|,i, ,,. '" !'""'"'"" of ,,o,-i,„,,l .^'•''•■" wo ,,,fl« „,,, ,, "■'""■ " '"" "on „„■._ ► i; ' .- 1 IftVr: i i I >. i •''I 'v.i f Ji < ' ' w ( t/« V ■ f I Ip ^ ■ I t ■f t 'i i ^r • J |L ) |||t ' ^ f Um i '1 Wfk l-i; ,1 kM i "^i ;i IM ■f 370 ^^rI•:^iI('Ax text- hook of oustktrics. and (listc'iisibility of tlic pelvic fl(n)r, or to lessen the teiision to which it is Hubjected (hiring the birth, or both. The former object is best accomplished by the slow and gradual delivery of the head, permitting time for the tissues to stretch ; the latter, by so regulating the expulsion of the head as to keep its sujallest circumference in the grasp of the resisting girdle and the propel- ling power directed in the axis of the outlet. The rate of descent is perfectly at conunand of the obstetrician. The Kiii. I'.i'.K— lU'Kuliuiiifj; the liirlli (j1' tlio liciiil (I'nmi a iilmtoKnipli)- expulsive force of the abdominal nuisclcs may sometimes be suspended by rc([uiring the i)atient to breathe rapidly during the pains. This, however, is not always possible. The action of th(> abdominal nuiscles is at this stage frequently involuntary and wholly beyt)nd the jjatient's control. ]\Iost effect- i,l by lor, is llVect- TlIK VONDL'CT OF yoiiMAL LMiOIi. 371 ual for the regulation of tlio pxpclling ])()W('r.s is tlie use of anesthetics. Cliloroform or ether shouhl he given at this jx'riod on the a|)i»earance of tlio slightest danger of laceration. \\y the jntlieions use of the anesthotie the strength and fretjuency of the pains and the rapidity of expulsion may bo reutdated at will. The advance of the head, however, can still further be controlled by pres- sure with the thumb and Hnger held constantly upon the occiput. With the thund) a])plied to the head inunediately in front of the tense border of the perineum, and with two lingers resting upon the occiput, the rate of descent is easily watched and regulated. To keep the tension of the vulva at a niininiuni, the hmg axis of the cephalic cylinder must be kept at a right angle with the jilane of the outlet of the soft parts Too rapid extension of the head must be prevented. 1'he forehead should not be permitted to pass the j)erineum until the occiput is fully expelled and the nape of the neck rests in the subpubic arch. Moreover, to guard against too great strain upon the i)elvic Hoor, the direction of expulsion must be regulated by crowding the head well up in the pubic arch, especially at the time when the e(juator of tiie head passes the vulvar ring. The expelling force is thus directed in the axis of the outlet, and the least possible downward thrust is exerted upon the jK'lvic floor. The foregoing manipulations arc best conducted with the patient in the left lateral position. In first labors, therefore, and in others in which the ])erinouni is liable to be torn, the jnitient should, as a rule, be placed upon the left side, with the buttocks close to the edge of the bed, as soon as the head has reached the floor of the pelvis. There is rarely danger of laceration until after the occipital pole appears in the vulvar fissure. Up to this point usually the ])rogress of the perineal stage, when not over-rai)id, may be noted by the touch alone. With the finger upon the perineiun just behind the posterior vulvar comnussure the occiput can be felt through the soft parts some time before it licgins to distend the perineum, and the rate of descent can be observed as accurately as by passing the finger within the ])assages. From the moment the occiput ap])ears in the vulvar orifice the parts ought to be under ocular inspecttion. The vaginal discharges are occasionally washed away with a cloth which is kept lying in a warm antiseptic solution. 'S ! c tension of tiie resisting rinj"; may be tested by now and then passing the finger within the vaginal orifice dm-ing a pain. The head is allowed !:o a(',ance during a pain until the perineal edge becomes as tense as is deemed safe. Its further progress is then arrested by direct pressure with the fingers in the line of descent (Fig. iOO). Until about Fi„.jon K,..„i.ui„j,M.x. ° _ ... IMllsKill lit IIk' llOlKl With to be expelled, driven down with the pains, it recedes tho lini-t is of .mo iiami in the intervals, and by this to-and-fro movement the '"'"''"^' •"^' '"■'"^"'■ jiolvic floor is moulded as it were to the re(|uired degree of distention. AVhen the bregma apjM-ars at the edge of the perineum, the head no longer recedes between the pains and is on the verge of expulsion. During the Am M m^ i i! 4' I > li .']72 . I Mi:ni< \ 1 S TEXT- HOOK () /•' OliSTKTliK 'S. passaj^o of tlic ei|iiaf<ir of the licail cxtoii.sion unist be prcvt'iitnl by upward ])rcssure in tlie axis uf expulsion with tiic tluiiuli placed upon the sinciput dose to the perineum, the finu;ers restinj;' upon the occiput. The sinciput must not be jwrmitted to advance faster than thi' occiput. K reipiired for tlic bottler control, both hands may i)e used [V\\i. 201). A favorite method for mana<rint>: the expulsion of the heatl is the fol- lowing : The |)atient lyintr upon the left side close to the etlgo of the bed, the operator, >ittin<f lu-hind her, grasps the head with the fingers of the right hand placed Just in front of the fourehette, while the left hand, passed over the abdomen and between the thighs of the mother, seizes the occiput \\ Fl(i. Jill.— Prtfurri-d iiiotlind fur RKiiliitiiiK I'XpDl.sidii of tlie lu'iid. (Fig. 199). This ])rocedure gives easy command of the birth of the head, yet offers no importan*^ advantage over simj)ler methods. The writer prefers to this the manipulation shown in Figure 201. As a rule, in first labors a half iiour or more from the time the pelvic floor begins to l)e distended will be recpiired before the head can safely be allowed to pass. In subse(|Uent births a shorter time will usually suffice. While the jirocedtires just described are to be recommended to the general exclusion of other methods, there is no objection to the use of gentle pressiu'c '10 I'll! and tlio B,,, ,,„„ % '■ "" '■•Miii'»n,i, bv i|,e ,i,„„.i. ' ' "'" '«' '"""') "■«. bettor tl,„ ft' ''"'"•' "■""• "ft^'r «|.isi..to„v '■,""'-■"'"'■ T'"= I lie .success of tl ' • ' ' ^'"^'^ "'^ '" t''o •"«y fiiKl r»„m ft,, r ' "'"' '" "I'i'^l' ovc, t|,o ; ' ,.!'"' -'I'l'^iwitlv ■"-•.ai.ie„ J; ,;"'-"•;"""' '™o,.„n.', if:''"',;:,™" «' i" .1.0 ,.„„, »^"""o:;,t„, I ,^ ;:«!'■ -; "■<■ ".*i„„ ;,„iu :;:;;;'' r "'T'- °" "■« 1/ ' li: M) '1 '. . i ,4 1^ •(■ .}| 4 P' ^ »£t ' ? ^ ; 1 I J-. I >i( AMl'UilCAN TEXT-BOOK OF OBSTETJilVS. Most essential is it that the cuts be made parallel with the long- axis of the mother's hody, not with the vaginal axis. The cuts will then he found on exaujination after labor to run parallel with the outlet of the birth-eanal. If the knife be held in line with the axis of the vulvo-vaginal outlet as the latter appears at the time of incision, its point will be liable to invade the very struc- tures the operation aims to save; the ])os- terior ends of the incisions will be ibund after delivery nnich nearer the median lijie than was intended, and the trans- versus perinei and other iiuportant struc- tures will possibly be divided. This result is well shown in the accompany- ing illustrations by Dr. R. L. Dickin- son ' (Figs. •202, 20;3). If j)referred, the resisting ring may be divided with scissors. Alter labor the cuts should immediately be reunited with stitches. A running or an inter- rupted sutiu'c with fine catgut best an- swers the purpose. The wounds may generally be closed without waiting for the delivery of the placenta, thus saving the necessity for renewing the anesthesia. During the suturing the patient may lie on the buck or on the side opjiositc the one being repaired. jraiKif/ciiicnt of the Cord. — Tlie moment the head is born a finger is slipped within the passages to ascertain if the cord is coiled about the child's neck. When so fotmd, the loop or loops should be drawn down one by one over the licad. Should the coil be so taut that it cannot be brought down — an accident that nuist be extremely rare — the cord may be tied at two points, and be cut between the two ligatures and the trunk promptly delivered. Jk/ivcri/ of t/i:' Trunk. — The head should now be held in the hand to keep it in the axis of expulsion. Contrary to the usual teaching, the writer prefers to deliver the posterior shoulder first. While the anterior shoulder lies behind the symphysis the finger is passed over the dorsal aspect of the posterior shoul- dc!" and is slipped into the axilla. The j)osterior shoulder is then folded for- ward and is cautinMsly liftetl over the ))erinenin. Kxcept in emergency calling for immediate delivery in the interest of mother or child, the expulsion of the truidv is left to nature. It is not good jtractice to drag the child out of the uterus. The uterus should be compelled to expel it. The presence of the trunk and the extremities stimulates contrac- ''Tlif l)iiV('tion of tliL' Incision in lOpisintDinv," Tniiin. Am. (lyn. Sor., 1S92. Kli,. JiiJ.- Double i|ii>iiitiiniy(skctc'li, just aftor delivery, liuMi iiiilure. K 1.. Diekiiisoui : A.diree- tiiMi (if iiieisiiiii laulty. iinintinj,' tnwiinl the )mis- teriiir viiL'iniil will I ; li, enrreet line of iiieisiuu. nimihii.' ii:n-iille! willi llie iixis nl' the vulviir (ipeiiiMi,'. ^^^/^ mv/>6YT OF Js^oPU^r if ■ • * • i! , -^ ill* , 376 AMKRIVAX TEXT-BOOK OF OnSTKTJilCS. of the weight of" the cliild in the tir.<t moinent.s after birth i'vom rehixatioii of the uterus, too early ligation of the eord exposes the new-born infant to the loss not only t)f reserve blood, but also to a ])art of its own. 8iuee the ehild's heart may be endangered by forcing too much blood into the eircnlation, compression of the uterus should not be practised before the cord is tied. In certain emergencies immediate ligation nuiy be necessary, owing to con- ditions of the mother requiring the obstetrician's entire attention. In case of well-developed, vigorous infants the rule of late ligation loses nuich of its importance. The practice now usually observed is to tie the cord after notable pulsation has ceased and the respiration is fully established. If, as seems pmbable from the researches of Caviglia, the principal cause of the afflux of blood is uterine pressure, neither the child's respiration nor the funic pulse is the ti. guide to the time for tying the cord, but rather the iirst firm contraction of the uterus. In case of twins the cord should always be ligated on the maternal as well as on the fetal side, owing to the possible existence of a vascular connection between the two placentas. A suitable material for the ligature is narrow linen bobbin. For greater security against hemorrhage a rubber elastic baud may be used. It is perhai)s needless to say that the material should be surgically clean. It may be left in the antiseptic solution until wanted. The common practice is to tie from one and a half to three inches away from the umbilicus. For this rule, in the absence of a navel-cord hernia, there is apparently no better reason than custom. It is in the interest of an aseptic healing of the navel wound to reduce to a mininunu the amount of necrotic nuiterial in the stump. The ligature should therefore generally be placed not more than half an inch from the cutaneous line. It is to be tied as tightly as it can be drawn, with care to put no strain on the umbilical insertion. JJefore tying, the cord, except it be already thin, should be pinched firndy between the thumb and finger at the point to be ligated. This procedure is better than stripping, which is liable to do violence to the navel. The cord is divided within a f|uarter-incli of the ligature. It is cut with clean scissors while held in the hollow of the hand to guard against injuring the child. A bit of cheese-cloth ju'cssed a ^^'W times against the cut end of the stiunp will show whether the vessels are securely tied. It is a common practice to ))la('e a second ligature a short distance from the first to control the matermil end of the cord. This jiromotes cleaidiness and, it is gener- ally believed, favors the placental expulsion. The latter claim, however, is doubtful. Management of the Third Stage. Xot the least ini])ortant duties of tlu' obstetrician in the condiu't of natural labor fall in the third stage. Upon the skill and attention given to this period Vlu %1^ tiie iiuraecJfate safbtv of fl, ^ ' ' '' ''"" "•";•>"■•"«.( of ,1,0 „„•,,, «,,:,;'';■'''*'' •*'''-''^ "'"I -"'''im-oiuCr' -"'-< iv<it.'.s „i,..tiuHi ,,,- i TUT iTTT ^«i^..,-'r«y .« ,. . ""»" -, -•"■"•■"■M ,.„* „„„„„„„„ T'"" '■"""■"I'i"' "ill. oll,c.,. ,l„,i,. Tl , , '"'"'■ ""■'-•' '.f el . " ',';•■ '■■'■"■ '"'""'^'I -vail, „C . „ '"" -'."'"I"'-" "' ^"•'^"""•^ applied t„ ■*. r ry I I i I ^!*. -« ?■ :(:i: i m 378 AME/ilCAN TEXT-IiOOk' OF OBSTF/FIiTCS. the uterus until a vigorous contraetiou is induced. The hand is then plaeed in such position upon the al)douieu that the fundus rests in the lioUow of the hand with tlie thiinih in front and the four fingers behind (Fig. 2(J4). At tiie height of the contraction the uterus is conij)ressed and thrust downward in tiie direction of the pelvic axis. If not at once successful, the process is repeated at short intervals until the object is gained. Until recently C'red6 advocated much earlier interference. Shortlv before his death he reeoninieuded waitin<r thirty minutes. His procedure is now generally adopted. The expectant [)lau still advocated by certain authorities is open to the objection that the |)lacenta may be retained for hours, din'iug which the patient is exposed to the danger of hemorrhage and is deprived of nuich-needed repose. Traction upon the cord while the after-birth lies in the upper uterine seg- ment is inconsistent with the normal mechanisn! of placental expulsion. When the placenta has passed into the h)wer segment of the uterus or the vagina, no harm will be done by gently pulling the cord to assist the delivery. As the jilacenta is extruded the membranes are gradually detached from the uterus, care bcMug taken that no fragments are torn off and left behind. To i)revent this the placenta is caught in the hand as soon as it ])asses the vulva, and if the membranes are not already free they should be twisted into a rope by turning the placenta over, and the twisting contimied until tiie separation is complete. Should a strip of membrane accidentally be left in the passages, it may be removed, if in the vagina or hanging from the cervix, by grasping it with the fingers and gently drawing it away, or by seizing it witli sterilized catch-fbrceps and twisting it oH". Fragments of membranes remain- ing wholly in the uterine cavity above the cervix are, as a ride, better left to be expelled with the lochial discharge unless they give rise to hemorrhage. Placenta and nieud)ranes must be examined carefully to see if they are coni- ])lete. Possible anomalies of the after-birth or the cord may also be looked for. To make sure that both amnion and chorion are entire the membranes are best examined by transmitted light. The duties of the obstetrician, even in strictly normal labor, are by no means ended with the delivery of the after-birth. The third stage is not com- plete mitil uterine retraction is fully established. For at least a half-hour after the placenta comes away the uterus is to be watched with the hand upon the abdomen, using friction if necessary to provoke contraction. It is a useful precaution to give a half-drachm of the Huid extract of ergot at the close of labor if the uterus is not firmly contracted. Its use is proper only after evacuation of ])laecnta, membranes, and clots. Its action is most prompt and certain when injected subcutaueously. One or two doses may be left with the patient with instructions that they be taken in the event of flow- ing too freely. The use of a moderate dose of ergot at the close of laboi' is not only harmless, but it is also entirely in keeping with the t)bjects ol treatment at this period. It limits the danger of hemorrhage, and by dimin- ishing the blood-supply it promotes involution. It closes the gates against infection, guards against the retention of blood-clots in the uterine cavity, and Tin-: coxnucT of normal labor. •.M\) 1» tlRTofore los.-!oiis the toiuloncy to af'tor-paiiiri ami to putrid accuniulatioiis in tlie UtlTllS. IvKi'Aiu OK liAcr.KATioxs. — ( 'crclcdl facerofions .should ho sutured at the elose of lahor in case they give rise to much hemorrhage. In the absence of troublesome bhteding the advantage of the primary suture is doubtful. The method of operating is as follows. No anesthetic is rc(|uired. The cervix is most readily brought down within easy reach when the patient is on the back. She may lie across the bed with the hips close to its edge, or still better on a Krm table, [f necessary, the ])erineinn may be retracted witii a large Sims speculum. The anterior vaginal wall may be held up out of the wav with a retractor, if recpiired. The cervix is drawn well down with a volsella. The lips of the wound are most conveniently held in contact with a single volsella, one hook being caught in each lip near the lower end ol" the tear. The lirst suture should be passed just above the upper angle of the laceration and tied. This suture, if properly placed, controls tlu; bleeding. The otiier sutures are then applied as in the secoixhuy o|)eration. The mate- rial may be waxed silk or silver wire. The former is recommended as being more mauagealtle, and it has, in the writer's experience, proved entirely satis- factory when well saturated with paraffin wax. Laccrdtions of flic jnlri'' floor in general practice ])rol)ably occur in not less tlian ;}o ])er cent, of first and in about 10 per cent, of .subsequent labors. This percentage of injuries, however, is capable of considerable reduction under proper management of the i)er- ineal stage of the birtli. In skilfidly conducted labors the ])roportion of lac- erations should .scarcely exceed 1 ") per cent. In cas(> of relatively small vulvo- vaginal oritice, narrow ])ubic arch, un- usual rigidity of the pelvic floor, in breech extraction, and in other rapid (icliveries notable injuries are inevi- table in a large proportion of cases. The type of laceration most fre- i|uently encountered is one that riuis nearly in tiie median line of the super- litial structures and to one side of it in tlie vagina (Fig. 205). Sometimes the wound presents the shape of a Y with one arm to citiier side of the inctlian line. Time for Ixcjiair. — I 'nlcss the con- dition of the patient at tiie close of I;>l)or is such as to forbid — and this is vciy rarely tiic ease — lacerations of the pelvic floor shoidd innnediatoly be sutured. Vet perfect union may be obtained ¥%"'" '' ^' ' '^iMV'" "^^ -jmmmg^ B ^' .. i ^^ ^S -% WF' VJ Wk wi ik^ Mm :^^^^m*' ^i^-'^' imM w^^^^e^tm 9^K l-'|i;. JO."..— l.iici'ratinii cif tlii' [n'lvic llimp. cxIciiiHiiK liiilf wiiy tci till' rL'clnm nml runiiiiit; tDWiinl llir ritjlit v.'iL'innl siilcii-; (t'ruiii n ski'Ich ill tliu I'losu (if liilicir liy Uiilurt I.. Ilickiiisnii, M, I),). 380 AMJ:iiIC\N TEXT-BOOK OF OBSTETRICS. t 1 / 11 .! I ii •/ i»i l)y nporatinj. at any tiino within twcnty-f'our honrs. Tho j^nturing may generally be clone with ('oinplete sncceiss even after so long a period as a week if for any reason it has previonsly bi'en negleeteil. AVhen perfornieil thus late the wound-siirfaees are first to be vivitied by rubbing theiu with a told of cheese- eloth, and then made smooth by trimming with seissors. The writer has frequently repaired laeerations while waiting for the delivery of the jilaecnta. This praetiee saves time, and generally, too, the renewal of the anesthesia. It is not to be advised in extensive and complicated injuries. Siifwe Material. — For ordinary use prepared silk is recommended. Silk- worm gut or silver wire is less likely to cause suppuration along the needle- track, but neither is so easy of ai)])licatit»n nor so comfortable for the pa- tient. Catgut is best reserved for buried sutures, owing to its tendency when j)artially exjjosed to decompose and to lead septic niaterial into the needle-track. The writer's method of sterilizing silk by immersion for two hours in melted paraffin at a temperature between 240° and 260° F. has iri his hands ])roved sa«^isfactory. A thermometer specially made for the pur])ose, which can be kept immersed in the melted wax, must be used for regulating the temperature, otherwise the silk is liable to be overheated and charred. The wax employed should be soft, as the harder varieties crumble in hand- ling the thread. A No. 7 silk is a gooel size for the larger wounds ; somewhat smaller sizes mav be used for slight lacerations. Needles. — For use in the external and more accessible portion of the wound the needle should be straight or be slightly curved and about 2 inches in length. For suturing tears high up in the vagina a needle as much shorter as the depth of the wound will permit, and having a more pronounced curve, may more conveniently be used. Xeedlo.-? of ihe Hagedorn pattern will be found most satisfactory. Jfethod. — An anesthetic is usually necessary. Ether is to be preferred here, as usual for surgical anesthesia. Small tears may be repairal under coeain anesthesia if for any reason it is desirable to avoid the use of the general anesthetic. Coeain is most effective when injected at several points in the lips of the wound. Not more than a grain at most can safely be used in this manner, and the solution should be rendered sterile by boiling. Many women, however, suffer very little pain from the introduction of sutures, since the tissues have largely lost their sensitiveness by the j)ressure and contusion received during labor. If care is taken to plunge the needle quickly through the skin-margin at the mf)ment the greatest amount of pain is produced, lacerations not very extensive n>ay be sutured without anesthesia. The ])atient lies in the lithotomy position, crosswise of the bed, with the hips close to the edge of the latter, or upon a table. The knees are held by assistants or by some of the numerous appliances eonuuonly em])]oved for the purpose in gynecological practice. The sheet sling of Dr. Dickinson has the advantage of being always available. One of the chief difficulties in determining the extent and character of the ^'//A' coy DUCT OF voru,, r , ,. '"'*^ J-Ajion. no, iaceration arks f"i-,>i.. fi . "°* '■""» "P one «,■ lH„|, ,,M,„ „/-,l' '"'">■ """ "i'l', •« ,„«i,„„|,. ":'?■ -..Uy, o„.,„Vee,, „„ „„,„ ;,«■-';'■«"■. TU. aim t t'' "' flio lacerati.,,,. I, ,i,„ ,l„ ,'""■'"" '" «"fart tlir„ii»|,„Mt lli, • , '-»""' to,.,,,,, „,;,,;* "'■: J";',™'. o"e b, o„cr,b ^: :';''^'f Tir 1 1 3H2 AMI'llilCAX TEXT-BOOK OF onSTKTJtICS. 5t» ti ^1 ( 1 iniK'otis nionibi'iiiu", and the rcinainiiit; wound is sntnrod on cither Ine perineal, the vaginal, or both surfaees as may be tbnnd most expedient. When the rent <loes not extend np the reotnin too far, in addition to the last interrni)ted sutures tied in the rectum, which coapt the torn ends of the sphincter, a reinforciiiif stitch will be useful passed in the following maimer: While a tenaculiun is used to draw out one retracted end of the nmscle, tiie suture is passed through this end of the nmscle, and contiimes its course upward, buried along the edge of the rectal rent, to the apex of the rent; the needle now emerges, and is again buried along the other margin of the rectal rent, and is carefully j)assed through the other end of the torn sphincter, while a tenaculiun draws out this retracted end of the muscjle. In deep tears of any kind the tiered suture "s a good one. Beginning at one end of the wound, a layer of the torn structures at the bottom of the laceration is closed with a running catgut suture ; this is re[)eated in a plane next above the first, and so on until the wound is entirely closed. The last tier of stitches, which is partially exposed on the vaginal surface, is best made with waxed silk. It is well to dust the suture-line with some bhuul anti- sej)tic powder like boric acid, iodoforni, or a mixture of both (iodoform 1 part, boric acid 8 parts). For a few days this application may be renewed with each change of the vulvar dressing. The right and tl»e wrong methods of SHtiu'ing are shown in Figures 20(5 to 20H. After-care. — There is no necessity, as a rule, for tying the patient's knees together. The sensitive- ness of the jiarts will be a sufficient safeguard against injurious strain upon the sutures by sepa- rating the liml)s, and the patient will be much more comfortable without the leg-binder. Retention of urine frecpiently results, owing to the rcfiex distiu'banee caused by the perineal suture, es{)ecially when the latter comes close to the rectum. While injurious distention of the bladder must not be jK'rmitted, the catheter should be withheld if possible. AVhether the bladder is emptied volun- tarily or otherwise, urine must not be permitted to trickle into the vagina or over the suture-line. The bowels are to be kept open, as in other cases, after the second day. The sutures are removed on the eighth or the ninth day. Toilet of the Patient. — Tiie child is received in two or three thicknesses of flannel, is well wrapped, I'Kj. 20f..-ucorati(m iiko that ""^1 '■' 1'''<1 '» =1 wanu place. The nurse then U\v\\> .shown in FiK'uii. 'J05, with sutures jior attention to the mother: soiled portions of her jiropcrly placed I'L'tuly fur tyinj;. '■ body ar(> to l)e cleansed, best with an antiseptic .solution ; her linen, if necessary, is changed ; and all blood-stained articles are removed from the bed. For bathing the genitals a piece of fresh-boiled 10 edge "^ uanislied from fi,,, i • . '"•^''^••<' of a snoiKm u '■"•■'^•'•-"•'■t.vinB.-/, miiNcli.-,.,,,!^ . iTf, milinjr """"""-'■"»'"-- looMai ;:;;,;';3^ I^K;. 20S.— Shows fllll . "' ^-"-' '^"-^-S'^ "-■ :>St»i»S5<«-- '=" -P-ecos are attached to the J,, ,1 H' '"^''"'^■^ ^^''^'^' ='"<' 2 i.,e es th •':•« b.,rned after „sing. Tl,oso'. • " '"'^'"'"^^ ^" ^''^^ '^'-Hler T ' i " <''='tely before use F .„ ''"'""^^ «'-^" ^ct .sterilised b T ^""''''■' l\H4 AMKIilCAX TKXT-lUtOK OF onSTKTIUCS. A (Imw-slu'ot [tlacod midcr tlio pati-'iit's Iiips is a ('«mv('iiit'iit drossinj? for pru- tc'C'tiiiii; tlio 1)('(1. Till' (Iriiw-slicct consists of a coinmon iniisliii slicet folded to four tliic'Iviu'sscs, It is replaced hy a fresh one as often as soiled. Instead of tlio draw-sheet an aseptic pad siniihir to tiie hihor-pad, bnt thinner and smaller, in.iy he preferred. AbdoiiiiiKil Hinder. — The ahdoniinal hinder is usefnl to steady the uterns, and it [)roniotes thecond'ort of the patient, especially when the abdominal walls are very lax. The nsnal material is a piece of nnhleaehed nuislin 1| yards in leniith and abont 18 inches in width. 'J'liis y-ives width onony-h to reach from the ensiforni to a point below the trochanters (I'l. 27, Fig. 1). Unless the binder overreaches these bony prominences it is liable to slip up, and in a few hours is reduced to a mere ro])e around the body. Binders ready made with gores to fit the body offer no advantage. The pinning of the binder shoidd begin at the lower border, and at the first application should be fairly tight. If the uterus shows any tendency to relaxation, three folded towels, used as compresses, may be placed on the abdomen under the bandage, one on either side of the uterus and cme immediately al)ove it. The binder may be dis- pensed with aft(>r one ov two weeks. IJcfore leaving it is well for tiie piiysician to take final note of the pulse and the general condition of the mother, and the nurse should receive all ueeded instruction in regard to the general care of both patients. III. THE MECllANlt?M OF LAUOR. Labou is a natural process, and it is the province of the accoucheur to restrict himself to watciiing tiie processes of nature so long as they are normal and ctHcient, and to interfere with them only when they become disturbed or inefficient. He is at his best when he is able to compel the faulty efforts of natural labor into a normal course, and he makes a comparative failure when- ever he is obliged to sul)stitute for the acts of nature the relatively crude process of an artificial delivery. An ability to restore the normal by making trifling alterations in the mechanical conditions presiipposi's, however, a most accurate knowledge! of the details of the mechanism which governs the usual course of labor, and of the alterations in them which determine the advent of any deviation from the normal. When, moreover, it is remembered that obstetric operations are but efforts to direct an extraue<iiis force into an accu- rate imitation of the processes of nature, it becomes evident that the first essential to success in obstetrics is the ])ossession of a far-reaching knowledge of the mechanism of labor in its several varieties. Any intelligent study of obstetrical mechanism nnist, however, be preceded by a comprehension of the technical terms used in describing it, and of tiic several classifications l)y which labor is commonly subdivided into varictie-. It is further necessary that the student should possess an accurate knowledge (()MtI(T (»1' N(»I;M\I, I.Ar.nl; I'l.ATi; US- lea I'liial '(.I or lU'll- [•nuU' cing Imost llS\l!>l thiit IflCl'll- iirst It the 'tio-. 1. Al ilniiiiiiiil liiink'r ami liiriist-liiiulcr in |i1iiic din (ln>m II {>liMtnm'M|>li |ilinl(if;rii|ili). '-■ Uii'ii>t-liiMiUr ill jilnt'L' m I l^ in , 1 ' 1 ' 1 H 1 i 1 4 , i 1 j: ' ^B; i ^^■l ^^^|i 1 \ I^H i i^H ' ' :> 1 I ( ■( Tin: MHVJfAXISM O/' l.MiOli. 385 Iff tlic shape and dimensions of tlie obstetric eaiial, and (»(' the i'etiis whieh is to pass tlironffJi it. He is then in a position to a('((i:ire an int( lli<i'ent iinder- standin^f of the principles whieh nnderlie the ineelianisni of all the forms of lahor, nnder the head of a description of it8 coninionest variety, and so easily (.r^oes on to understand the niodilieations in the mechanism that follow upon ilie alterations in the conditions in the other varieties. Attitude of the Fetus. — \\y the; attitude of the fetus is meant the posi- tion its parts assume in iilrro in relation to one another, in contradLstinctiun to any relation they may bear to the luiiternal parts. During the earlier months of prcffiianey the uterine cavity is nearly »|)herical in shape, and it is then so larj^o in proportion to the fetus that its walls are rarely in contact with the embryo. The fetus hangs freely in the uterine cavity, i)eing suspended by the umbilical cord, with its head somewhat lower than its pelvis and with its limbs in a somewhat extended position (Fig. 209). As pregnancy progresses the size of the fetus increases more rapidly than that of the uterus, until in normal eases at term the adai)tatioii I'Ki. lin'.i.— licliilidii lictwi'iTi tlif sizi' (pf till' utc- Kl(i. ■-'10.— Adiiiitatidii tjitwct'ti tlic iittriis and nis mid till' I'l'tus lit lil'tli iMuiilli (iiiR'-sixtli imtiinil tho f<.'tus at ti'i'iii, in vitIux prt'suiitatiuus (11110- ^i/^■l. .sixth mitural si/fi. I)0tween the two is siitVieieutly close to make any extended movements of the f^n.il lind)s diflicult or impossible. The attitude which the ciiild then assiunes is that represented in Figure 210, which is readily seen to be the most com- pai attitude in which the child can be arranged. Presentation. — The word prcxnitatlon is used to define the relation which the long axis of the child bears to the long axis of the uterus, and the dif- t'cicnt presentations are distinguished from one another by the use of adjec- tives which rel^ to the part of the child that is to enter the pelvis first in a uiven ease. The several ])resentations which may occur are ce)>halic presen- tations — that is, presentations of the vertex, of the brow, and of the face; pres- entations of the pelvic extremity, whieh are sidxlividcd into lireeeh and foot- ling proscntati w; and transverse iircsentations, under which are included presentations of the hip, of the trunk, and of the shoidder. 25 iii ? i,5' I V. iS^- y%-% \M\ •w \n I? 5 I ^'« I 386 AMi:iiICAy TEXT-BOOK OF OBSTETRICS. Position. — 111 obstetric use the word jiosHion is restricted to a meaning in wliicli it is used to define the relation that the dorsum of the child bears to the dorsum of the mother during its passage tlirough the ])elvic canal. Kach ]>resentation is subdivided into i)ositions according as the dorsum of the child is directed anteriorly or ptisteriorly and toward the right or the left side of the mother. Thus we recognize under each presentation four positions, according to whether the part wiiich gives the name to the jiosition is directed left- anteriorly, right-anteriorly, right-posteriorly, or left-posteriorly ; for example, vertex jtresentatioii, occipito-left-anterior, breech presentation, sacro-right- posterior. Classification of Labor. Presentations. — Tlie presentations are first of all roughly divided into l())if/iiu(lin(i/ and ohli<juc presentations. The longitudinal presentations arc tiuise in which the long axis of the fetus is in correspondence with the long axis of the uterus ; the obliijne i)resentations are thos(i in which there is a considerable angle between the two axes. The lo)i(/itudin(il pn'ScnUdio)!)^ lU'o, then, those in which either the cephalic or the j)elvic end of the fetus is found at the inlet of the pelvis at the begin- ning of labor — that is, all the variations of cephalic and pelvic presentations. 'f he ohlifjuc or transverse prcsnitafions iuchule all those in which any por- tion of the fetus other than the head or the breech is found at the pelvic brim. Plead presentations are divided into those of the vertex, of the brow, and of the face. Pelvic presentations are divided into breech presentations, in which both thighs are flexed upon the abdomen when the nates of the fetus enter the mother's pelvis, and fooUhig presentations, in which one or both legs are extended and enter in advance of the infant's pelvis. Transverso presentations include presentations of the hip, of the trunk, and of the shoulder; among these presentations those of the shoulder are by far the commonest and most important. It is also convenient to classify the ]>resentations of the fetus in two other ways, ill a<'coi'danc(> with the results which may be expected to accrue from their occurrence — namely, into normal and abnormal, natural and unnatural, presentations. Normal and Abnormal Presentations. — A ])resentatit)ii of the vertex occurs in about I'T ])cr cent, of all labors, and, both from its frecjuency and from the favorable character of its results, is considered to be the only noriiKil presentation, all otliers being elassifie<l as abnormal. Natural and Unnatural Presentations. — Natural ])resentations are those in which the conditions are such that they may be exjiected to terniinate, in ;i large j)roportion of cases, in delivery by natural or unaided labor. Fnnalural pri'scMtiitioiis are those in which the shape of the presenting part of tlie fetus is so ill-adapted to the pelvic canal that the labor can ordinarily be termiiiati il only by tlie intervention of the obstetric art. natural delivery being possible only when the pelvis is exceptionally large and when the fetus is at die same ""■' -'^W-'AV*,. or 7.,B0«. time i„„„a„„o or ,.™.,„i„„„||, „„,,„ '"""" -^"^ —" " ■ - ™-=~"it':=-- Position.—,? divi^w.n r .1 FfTifo-— V f '"^^ '^t t''(" beginning a z ";t .''r"r" '->'-■■- .-""i:^: : ;;r;v r™'"-' -' '>>•"» "°Sr£S;S":^';:n::: "" - '- -» „„„. I »».'• '""• ""■" ""-"■'■■•■" i« »,, ;:;;;:,;|;:tr' ';':",""i ■■" ....... j,.ut'u to til (ioniain of i . . !l u. 1 ^flWF" ''' \\f 1 ffl^fl '!'■'• f ^ 1 ' '' 1 ■'•% 1 nm f ly ' ' •f ' ''*'■ m ^ t' 'i; i i; :f i7 !■■ I I / i ••; 388 A.VEliJCJX TEXT-BOOK OF OBSTETlilCS. Anatomy op the Pelvis. The anatomy of tlie bones and the soft parts which together make np the j)elvis is (lesc'ril)e(l in detail in another portion ot" this work, bnt for tlie com- prehension of the medianism of hibor it is necessary to add to the anatomical description a discussion of the shape and dimensions of the parturient canal as a whole, before its mechanical relation to the fetus which is to pass through it can intelligently be discussed. The porfui'icnt cannl (Fig. 211) may be divided, for purposes of descrip- tion, intt) three i)arts — the supra pe/vic, the pelvic, and the infrapelvic portions. Kl(i. ■JU— Tlie imrlurii'iit ciiiml: at. axis (it iiliriis; aI, axis iif inlet; iti!, ri'tfiictioii-riiiB ; lo, iiiU'riml (|^ . Ko, (.■xttTiml ns iciiR'-tliird imtiiriil sizcl. The xKpraptlvic or abdominal portion of the parturient canal is made up of the uterine ctivity anil the large or false pelvis. This portictn of the ju'lvi- is classified with the uterine cavity on account of the similarity of their finictions; that is, the obstetric function of the large pelvis is simply that of affording a resting-place to the lower [)ortion of the child during the whole ( r THE MECHANISM OF LABOR. 389 tlie greater portion of pregnancy, and of guiding the presenting part to the inlet at the beginning of hibor. The pdch- portion of the ])arturient canal consists of the small or true ])elvis. The infra pel I'k portion is made up of tlie soft parts lying below the pelvic bones, which jiarts, though small and inconspicuous in the non-parturient state, are stretched out during labor into a tubular canal which considerably prolongs the parturient canal, and completes the curve of its lower portion, known as the chitc, of Cams. All adequate comprehension of the shape and the mechanical functions of die parturient canal in its entirety will best be attained by postponing the description of the canal as a whole until its subdivisions and component parts have been described in detail. Suprapelvic Portions. — Fterhw Cavity. — The uterus at term is a hollow, ovate-shajwd viscus, whose cavity, although anatomically a part of the ])ar- tiu'ient canal, is, from a mechanical standpoint, less a part of the passage than the engine by which the passenger is to be propelled. The function of the uterus as the source of the propulsive jiower by which labor is accom- plished will be discussed later. Its function as a portion of the canal ictjuires no special description. ./'W/.sr Pelvis. — The false or large pelvis is that portion of the pelvis lying above the linea terminalis. It is composed of the lumbar vertebrse, the upper surfaces of the latei-al processes of the first sacral vertcbi-a, and the Hliiamous portions of the iliac bones, and functionally it is completed In- the lower portions of the anterior abdominal nuisclt's and their attachments to the horizontal rami of tlie pubic bones. The whole thus forms a I'umiel whose sloping walls terminate in the inlet of the true pelvis, and are admirably suited to their office of directing the presenting part into the ])elvis in the initial stage of labor. Apart from this point, the chief practical value of the lidse pelvis is in the light which alterations of its sha])e or of its dimensions throw upon the diagnosis of ])elvic deformities. To be in a jiosition to detect anv departure from the normal shape of the pelvis, it is especially important to be familiar with the normal shape of the iliac crests and with the normal curve of the linea terminalis. Although the crests of the ilia are classically described as presenting an S- curve, it must be remembered that only one portion of this curve — iiamelv, tiiat which possesses an anterior concavity — enters into the formation of the basin of the false pelvis; the other portion of the curve is entirely without the pelvis, and is utilized solely for the attachment of the saero-iliac ligaments ;uid the erector spiuic muscles. The shape of the anterior portion of this curve is such that the greatest distaiic(> between the crests is normally '2.5 centi- iiieters (about an inch) more than the distanci> between the anteri(»r superior spi- nous processes, the distance between the crests being normally 'J") centimeters (about 10 inches), and that between the spines 22.5 centimeters (about 9 inches).* Under normal circunistances the anterior ])ortion of the linea terminalis * TIr'sp (linu'iisions aro found to 1)0 soiiu'whiit v;\ii:ilili' iiiiinni,' dilli'ioiit nurs. Tlic lifjiiri's ijivt'H are belifvi'tl to lie !i]ii)ro.\iin;iti'ly i-orreot for Anii-riciui women. tWJ ' r If l.iSi,;-' i' ,1 hi i 390 AMKRICAX TEXT-BOOK OF OBSTETRICS. presents ii uniform curve with an internal concavity, and there is bnt little, if any, projection of the crest of tlie piibes in or about tlie niecliaii line. Pelvic Portion. — The true or small pelvis comprises all that portion of the pelvis lying- below the linea terminalis, and it is divided into three portions — the superior strait or inlet, tlie inferior strait or (Hitlet, and the excavation. It is formed by the sacrum, the coccyx, the lower portion of the ilia, the ischia, and the pubes. These bones taken together form a deep basin-shaped cavity, whose posterior wall is formed by the sacrum and coccyx and is Yk :;12.— I'l'lvis soun from above, showiiiK tho (k'crcaso in tlic trnn^iviTso ilianu'tiT from above downward (ouo-third natural size). sharply curved with an anterior concavity. The anterior wall is formed by the symphysis, and is short and nearly straight. The lateral walls, which are formed by the lower portions of the ilia, the ischia, and parts of tlie descend- ing rami of the ])ubes, are irregular in outline and slope gently inward, so that the transverse diameter of the pelvis is markedly less at their lower than at their upper extremities (Fig. 212). At its upper and lower limits, which are known as the superior and inferior nfniit.s (Fig. 213), the dimensions of the pelvis are much less than in the inter- vening space, called the "excavation." An accurate knowledge of this por- tion of the parturient canal is of the greatest importance, and on account of its complexity is most easily given by sejiaratc descriptions of the excavation and of each of the straits, after which description it will be easy to include that of the pelvis as a whole in the general description of the parturient canal that follows at the end of this section. T/ie .siij)cri(tr .stniil is bounded by the promontory and ihe anterior surface of the first sacral vertebra, the linea terminalis, and the pubic crests. The shape of the inlet or superior strait of the pelvis varies considerably in accord- ance with the point of view selected, but if the eye of the observer is placcil in (he probable position of the axis of the cliiKl at term, it will be seen that the shape of the inlet is approximately circular (Fig. 212). THE MECHANISM OF LABOR. 391 It must be remotuberod that the presence of the soft parts somewhat alters •*^''-'-5:jir<j^%v ,/ ••^'•^ it-' \ \ 7^»*s:-_->ii«ws'*'L.^_ / Fir,. Ji;!.— Lateriil viuw of the pelvis, showing superior and inferior straits (one-third natural size). tlie shape of the brim. The importance of this fact, however, is lessened by V':^>. Ittkrcristal ■ ' "' Jfansverse Intersjfmal .V^* -V, F\G. 21 1.— I't'lvis seen from aliove, sliow inn tliiinu'ters of lirini fmu'thinl natural size). the fact that the vessels, ihe connective tissues, and the rectum, as well as the 1 ( r V ^ hi Cl' IM teiiit si ii I i / i I i: ! f) I "I ,1 ) I ? 1 ' 4' -I I ! ^4 ( I 392 AMERICAN TEXT- BOOK OF OBSTETRICS. psoas-illaciis muscles, which together form the only important soft parts in the inlet, are concentrated in the sacro-iliac notches, where the space is already most abundant and where its decrease is of least importance. The dimensions of each of the straits are determined by measuring the antero-posterior, the transverse, and the two oblique diameters. The antero- posterior, or, as it is more commonly termed, the conjugate, diameter of the superior strait (Fig. 214) extends from the upper border of the symphysis pubis to the promontory of the sacrum; its normal length is 11 centimeters (4} inches). A little less than half an inch from the upper border of the sym- physis pubis is found a point which, owing to the thickness of the pubic bone, is decidedly nearer to the promontory than the uj)per border itself From the promontory to this point the distance is 10 centimeters (about 4 inches), and this is called the "obstetrical" diameter or true conjugate. The greatest transverse diameter of the superior strait averages 13 centi- meters (5^ inches) in length ; this is the diameter referred to whenever the transverse diameter of the superior strait is mentioned. This diameter lies, however, so far back in the pelvis — that is, so near the promontory (Fig. 214) — that it can never be occupied by any of the diameters of the fetal head. The transverse diameter, which could, in fact, be occuj>ied by the fetal head, lies some distance anterior to this, and is so much shorter as to be of little im])ortance, being, in fact, less than are the oblique diameters. In point of fact, the head never enters a normal pelvis transversely, and the transverse diameter is therefore measured merely as a means of comparing one pelvis with another. The oI)lique d'-uneters extentl from the ilio-pectineal eminences to the sacro- iliac articulations; their length is 12.5 centimeters (about 5 inches). Since the terms rigid and left oblique diameter are differently used by different author- ities, it seems best to distinguish these diameters as tlu; first and second oI)li(pie diameters of the inlet, in accordance with the frequency of their importance in the mechanism of labor; the first being that which extends from the left ilio-pectineal eminence to the right sacro-iliac synchondrosis. The inferior strait is bounded by the subpubic ligament, the descending rami of the pubcs, the rami, tuberosities, and spines of the iscliia, the saero- sciatic ligaments, and the coccyx. Its shape, when looked at in the direction of its axis, is that of a lOzenge whose anterior sides arc formed of the ])ubic and ischiatic rami, while the posterior are made up of the saero-sciatic liga- ments.* When looked at from a point somewhat anterior to the line of its axis, it is seen to present a roughly triangular shape ; but when we rememl)er that the sacro-sciatie ligaments become very distensible during labor, and that the softening of the sacro-iliac and sacro-coceygeal articulations that occurs * Owing to tlie projection downward of tlie tuberosities of tlie iscliia, it will be seen that tlip surfaet' of the inferior strait is bent upon itself to form an external I'onvexity (Fig. "Jl'ii. I'Or practical j)nrposes it is, however, convenient to neglect this bend, and to deal with tlu' inferior strait as though it did, in truth, lie in a plane between the tip of the coccyx and the subpubic ligament. Fl(: JAjU. / lor- 'ond their iVoin acro- otion )Ub'H' liga- )f its iuImt tluit Iccnrs |i that •21'> • 111 tli>- .1 till' T///; MECHANISM OF LABOR. 393 during pregiiaiicv ])orinits of a considerable movement of these bones upon each other, it will be seen that when the soft parts of the inferior strait are T- / / / / Kiii. 'Jlo.— I.iitiTiil vk'w (if tlu' pelvis, slidwiiiK cxtiTiinl convoxity of tlio inferior striiit. distended by the heatl, its aspect from either position will be that ut an ovate or egg-shaped orifice (Fig. 216). The antero-posterior diameter of the inferior strait extends from the lower border of the symphysis to the extremity of the coccyx. Its length in the non-parturient state is 9.5 centimeters (about 3J inches), but when the move- .'■\ ^ M ^■-'•* '^:^^'\ H Flii. 2Ui.— View of distended outlet. Tlie dotted lines sliow the possible position of the sacro-sciutic ligament and tlie eonseiiuent inerease in the transverse diameter duriiifj extreme distention. inents of distention spoken of above are fully effected, the length of this diam- eter is increased to 11.5 centimeters (4^ inches), or perhaps even to 12.7 cen- timeters (5 inches). The transverse diameter, which is drawn between the inner borders of the tuberosities, measures 10.5 centimeters (4| inches), and it is the only nnyield- wm m\ M:, Cl?/ll,i:f i;-! V I \\ \ ' J 'U. n V c ,M 394 AMERICAN TEXT- BOOK OF OBSTETRICi^. '-I iug diameter of the inferior strait. The divergent direction of tlie tuberosities makes it possible, however, for the transverse diameter of the head to corre- spond with a much wider transverse diameter of i\u\ outlet whenever the con- ditions of the case permit the parietal protuberances to occupy a position pos- terior to the tuberosities (Fig. 216). The oblique diameters are manifestly rendered unimportant by the uncer- tainty as to their length, the result of the elasticity of the sacro-sciatie ligaments. -f The excavation, which is bounded by the inferior and superior straits, com- prises all that portion of the pelvis lying between them. The backward curve of the bodies of the sacral vertebrae and the straightness and shortness of the anterior wall of the pelvis render the excavation much more roomy in an Fi(i. 217.— Iiiiigram showiiiKn (iivision of tlir liitcnil wall of tlie I'xrnvation into sections In nccordancu witli tliiir iiailiuniL'al functiiins. i -I antero-posterior direction than is either of the straits, and this increase of space is, of coiu'se, greatest in the middle j)ortion of the excavation. The oblique diameters are correspondingly increased for the same reason, and, indeed, in the middle of the excavation they are often longer than any of the diann>ters of a small fetal head — a fact which is sometimes oi' inii)ort- ance in the mechanism of posterior positions of the vertex and of presentations of the face. If the transverse diameters of the excavation were similarly ample, this portion of the pelvis would be devoid of obstetrical interest ; but this is far from true. The transverse diameter of the excavation is at one point the smallest and also one of the most rigid diameters of the whole pelvis, and the importance of the anatomy of the lateral walls of the excavation is so great that its comprehension is the key-note to the whole sid)iect of obstetrical mech- anism. The anatomy of the lateral walls is so difficult of description that it (^ ^ of he jiul, l)rt- Tin-: MECHANISM OF L Alio II. 395 IS possible to comprelieiul it only l)v means of a stilxiivisioii of the lateral walls of the excavation into three parts (Fijj;. '217) : An iipjur jtortion {A, Fijjc. 217), which is ronj^hly triangular in shape; a sccontl jioiilon (/>'), which lies hclow and in front of the first ; and a //(//•(/ portion (C), which lies below and l)chin<l the first. Portion A is composed throuj^hout of unyielding Ixme. In .'ts Vi, r part its surface is smooth and very uniformly ciu'ved. The transverse iu.=neter of the pelvis at this point is the ample transverse diameter of the superior strait. The obliipie lines drawn through the anterior edge of this portion upon one side of the pelvis and through the posterior edge of the corresponding portion jipon the other side arc likewise ample, and, indeed, vary but little from this same length (5^ inches). In its lower part portion .1 of the lateral wall inclines inward to its termination in the rigi<l ischial sj)ines, between the points of which the smallest diameter of the pelvis is found — a diameter so small as to be practically impassable by the biparietal and suboccipito-bregraatic diameters of a full-sized head. Portion, li of the lateral walls of the excavation has but little rigid bone in its compttsition. Its upper part is made up mainly of the membranous coverings of the foramen ovale, that are covered by the obturator muscle, and at the time of term, like all the other ligaments and fascial coverings of the pelvis, are mure elastic than in the non-parturient state. When these muscles and fascia) are put upon the stretch by the pressure of the pre- senting part during its descent, their recession converts portion B of the lateral wall into a shallow spiral groove, with bony edges and a soft floor, which ileepcns as it descends and turns forward. The ischio-pubic ramus, which forms the floor of the lower part of portion B, is here so curved (laterally outward) as to lend itself readily to the continuation of this groove. Portion C has a bony edge composed of the posterior bonier of the ischium and the lateral edge of the sacrum and coccyx, but it is made up maiidy of the very elastic sacro-sciatic ligaments and the pyramidal muscle. When these ligaments and muscles are put upon the stretch during the descent of the head, portion C'of the lateral wall is converted, like portion />, into a spiral groove which deepens as it descends and turns forward. When the rigidity of portion ^1 and the yielding nature of portions B and C are considered in connection with the fact that even in the bony ])i'lvis the foramen ovale and the sacro-seiatic notches ar(> regions of recession separated from each other by the projecting ischial spines, it will be seen that when distended by pressure from within, the lateral walls of the excavation may be considered as consisting, for mechanical purposes, of two deep grooves separated from each other by a prominent ridgo of unyielding bone (Fig. 218). The anterior of these grooves pursues a spiral course downward and forward from the anterior end of the oblique diameter at the brim, to end under the pubic arch at the anterior end of the conjugate diameter of the inferior strait. The posterior groove pursues a similar s[)iral course ilownward and fui ward ; ' > -J' h b' - » . 'pHiPiiJII \' n V *' f .1^' 39(J AMKIilCAX TEXT-nOOK OF OliSTKTIiK'S. from the posterior end of the <ither obIi(|ii(( (lianieter at the brim, to end in the same point at the anterior end of the conjugate at the outlet. Ki(i. '.'18.— Suctions (il'tlio i)L'lvis, showing the luteral wronvos mid llu' Imiiy ridtje wliicli separates them : A, siifiittiil soctinn. Tlio linos '', c, il. i , inciicutc the horizontal plimi's Ihrounh which tliu cross-suctions h, t; (I, i\ aru tuljcn. The shadud portions of the liKuru indicate tliu spiral grooves, tliu dui)th of the fjroovu licinn deepest wliere tlie sliadinK is darliest. H, cross-section, sliowinn tliu nearly-uniform curve of tlie uuhroken tiony ciniinifercnce of the superior strait. C, cross-section, showing the bony iseliiuni (.\, V\\i. -17) separatiiit; the distensible foramen ovale (li, Kin. -1") and sacro-sciatic notch ((', Fif?. 217). I>, cross-section through the ischial spines, which here eniphasizu dellection inwanl of the bony rid^e (.\. Ki).'. 217). K, cross-section near the inferior strait. The jiosterior half is distensible, ami in the anterior half the bony duscendins; ramus of the jiubes <'urves outwardly to contiinie the c\irve formed by the yielding tissues which cover in the foramen ovale, as seen in the sections (' and 1) The oblique diameters drawn toward the bottom of the anterior groove I ! THH MHCIIAXISM OF LAJlOIt. 397 jve upon on <i(l(' and tlir bottom of the j)o.storior {jroovo upon tlio other side arc throiif::Ii()Ut the pelvis aiiipio lor the passaj^e of any of tlie diaiiieters of the t'ctal ii<'a<i except tiie oceipito-frontal and tiie occipito-nientah Should any roiintl body be started at the upper end ol' either of these grooves, and be foreed downward by a i'ix-u-tvr(i(> under the influence of a (;onstant intraiielvic pressure, it must necessarily follow tli-' \-M\ of least resistance — that is, the course of the i;roov(( in which it started — to end its course under the pidjic arch at the outlet. The imp(»rtance of these considerations will be apparent w lien the section on the Mrc/mniHin of (lie Sccoiuf S(a(/c of Labor is reached. Infrapelvic Portion. — When the soft parts below the inferior strait are distended by the head, they inchule a hood-shaped space of considerable si/e, bounded upon its upper border by the edj^e of the pubic arch, the tuberosities of the iscliia, and the lower edj^e of the sacro-sciatic ligaments, and upon its other (»r inferior border by the (triticc of the distended vagina. Its anterior wall is from a ((uarter to half an inch in length. Its posterior wall, when fully disten<led, is from (5 to 10 centimeters {2\ to 4 inches) in length. When the head has wholly escaped from the inferior strait it occupies an elastic canal com[)osed wholly of soft parts and having but one mechanical function — an elasticitv which l<cei)S the head constantlv in contact with the edge of the pubic arch. The Parturient Canal as a Whole. — The parturient canal (Fig. 211) con- sists functionally of two portions, an ovate reservoir formed by the uterine cavity and the false pelvis, and a curved passage which extends downward and forward from the lower opening of the reservoir. This passage ])ossesses an irregularly cylindrical shape which has classically been likened to the curve of a ram's horn. The anterior wall is much shorter than tlic posterior. If both the anterior and posterior walls are divided into an equal number of c(|ual parts, and planes are drawn l>etween each pair of these points (Fig. 219), a curved line passing through the centre of each of these planes forms what is known as the axin of the pclric canal ; if this curved line is continued forward, it will reach the abdomen of the mother at about the situation of the umbilicus in the non-j)arturient state. This prolongation of the pelvic axis is known as the curve of CarHi<. The centre of any body j)assing through the pelvic canal nuist travel through a path closely approximate to this curved axis. Were the jielvic canal exactly cylindrical and the fetal head exactly spherical, the mechanism of labor would l)e limited to an observation of the abovi -related fact; but in reality the irreg- ularities in the contour of the pelvic canal and the corresponding irregularities in the shape of the fetal head are matters of the greatest importance. It will be remembered that although the transverse diameter of the superior strait is nominally the greatest, yet the ra])id convergence of the ilio-pectineal lines as they stretch forward renders the length of the practicable transverse diameter in fact less than that of the ol)li(pie diameters, so that any ovate body presented to the inlet of the pelvis will tend to enter the brim in the oblique diameter. At the inferior strait the transverse diameter is the narrowest of the whole ) Tr- ill I IIH I f i i > ^ i A / 31)S AMi:itI('AX TKXT-IiOOK OF OliSTr/mil'S. pelvis, iiiid, since the ()l)li(|no diameters at tlie moment of delivery are shorter than the distended eonjiiLrate, any ovate Ixidy which attempts to pass the ontlel will do so most readily it' its lon^- diameter corresponds with the antero-posterior diameter of the inli'rior strait. It is therefore evi«lent that the process of Klii. 21',t.— SuKittnl Sfctioii nf the iiclvis, .showing the pflvic axis "Mil tlu' ciirvi' nf Ciinis. labor will most easily he aceomjilished by the occurrence of a rotation of the longest diameter of the presenting parts from an oblique position at the supe- rior strait to an antoro-posterior position at the outlet ; in point of fact, the mechanical relations which lead up to this rotation lie at the bottom of the whole subject of the mechanism of labor. It is to be noted that when the woman is in the erect position the axis of the suj)erior strait * forms an angle of about 30° with the horizon ; that in the same ])osition of the woman the axis of the inferior strait is directed down- ward and a little forward ; and that the axis of the vaginal outlet of the par- turient canal loftks almost directly forwanl and but very slightly downward. Differences between the Male and the Female Pelvis. — It is important that the obstetrician should clearly understand the normal characteristics ol' the female pelvis in contradistinctioti to those of the masculine form, because the approaches to a masculine type — which are not uncommon and may occur in any portion of the pelvis — are not unim])ortant as a cause of dystocia and * .\ line (Innvn from tlie ct'iitre ol' tlie superior stniit in a diri'ctioii iierpeiuliciilar to ils jilane. t' J^JL the ., the \ the Ito 11- 77//; MIJIIAMSM <)l I. Mian. 3!Ji) of alterations in the nioeluinisiu ot" lalutr. Tlie (lilH-rences between the male and tlie female pelvis will be ren»lere<l most easily familiar by the use of a series ol' figures showing respectively the shapes of the superior strait, of the Fill. 'JJO.— Malo iK'lvis viewed in tlie uxis of llie l)rim. antero-posterior curve of the sacrum ami the pubic arch, and of the inferior strait in the masculine and feminine types. Superior Sfraif. — In the male the sacrum is narrow, the promontory en- croaches deeply into the brim, the iliac crests are comparatively erect, ami the interior concavity of the anterior portion of the ilio-pectineal line is but little Fill. '2.!1.— l\'mnle pelvis viewed in the nxi.s of the brim. marked (Fig. 220). Tlie shape of the inlet is tlius angular and strongly eor- ilate as compared with that of the female pelvis (Fig. 221). Antero-pontcrior Section of the J'e/cis. — In the male the sacriun is long and i:, \ I ¥ !' p^--. - l-al * , !.:■, t ■ ) er 'II '■'»/' / 400 AMERICAN TEXT-BOOK' OF OBSTETRICS. its upper ]K)rtic)n i.s nearly straight, wiiilo the K)\ver part of tliis bone and its continuation, tiie coeeyx, are bent sliarply forward. The symphysis and the ailjacent portions of tiie descending rami are long and erect (Fig. 224). In the I"i . II'.'J.— Mule pelvis seen I'niiii tlir IVinit. female (Fig. 22")) the sacrum is sliorter, its general direction is more distinctly downward anil backward, its upper portion is much more concave from above downward, and the antero- posterior curve is throughout more uniform than in Ki(i. ■Jjn.— Ki'iiiiilo iu'lvis si'fii rrciiii tlie front (oiu'lliinl iialunil size)- the male. Tlie .-ymphysis is short, and tiie wider jiubic arch, shortly to l>r spoken of, decreases the importance of the descen«ling rami in the formation of the anterior wall. Jtij'erior >Str<iit. — In the male (Fig. 222) the migle of the pubic arch mca- i'lo. i I 1 \ r '■^^ ..«„/.,.v.v.„ oi- x.„„,. "H>.s in,,,, 7/50 ^^^ g^^„ 4QJ ^^-^ ^, " ^"^^'•««'tie.s, greatly j X> / '"'■ --'•-J"'"srMni.n,-i(; . „,,,,„ "('<'t;il)iila. and tU • " *''"'' '^ ■•' iii'catcr ,.,.l.,- .'"" ''■"^ *''' wnipan i" "■"....■„ ,M„i i;„. V " '"■' '^ I".- .1 n,„ , , '.'"■."""■""" "f .1, "■'■■■' "'■■-^^^•t:^^':;:i:;;:::';";:--:n;:;/;;:r::^ '''"■''^!l!'<l /111- I •Uollc, t. 10 noos '"■ .^•"■' ••"I.I f|,a( „r The Fetus. ^. ■^" {illicJi '.-■s . , ""■'■'■'■"•'■ '■" "'■■pa-.-:. , T ',"",' ^'"'I'" ""'""d ;;;;;::■■rJ■;^M^,. H,,,:::!;r::r:,-;v':i^-' -■- ■ , y .""•''''•«-"<^><.l..rmo- I,|,„, ■ , •''" "' ""• '••'••-I lica.l an.l „• '" a (lior'diii^li illi (lie iiiiiprc- I h ■J^ f 1,, i, Ik-t' 1. T ( ■ ]'. •1 I'ii ^'ff ;ff^ 1 J i i :\ * ! i I 402 A^f/'JIUCA^' Ti:xT-ii()OK of onsrKTi^rvs. sliapo nnd <linu'ii>i(»n.s of tiu iv'tiiniiidcr of the fotiis in tlio attitiido it onli- iiarilv assiiiiios, tlnniii'li loss often of iniportaiieo, is iievortlieless essential. The Fetal Head. — The head is obstetrieally divided into two portions, the face and the cnniiiun. T/ir face is iniieh smaller in ])roportion to the cranium than that of the adult, and is of l)ut little iiuportanee in normal labors. It is, however, well to ri'meinber tiiat the i'aee is made up of the most solid and ineom])ressii)lc bones which enter into the eomjiosition oi' the head, and that its eoufiguratiou i,s altei'ed but little, if at all, by the jiroeesses of labor. I'/ic crctniiua or brdlii-atnc is to be divided for purposes of description into two ])ortions. the fxtnc and the vaitlf of the skull. The base is formed by the basilar portion of the oeeij)it;d bone, the petrous portions oi' the temporal bones, the s])heuoid and ethmoid, and the orbital processes of the I'roiUal bones. Tiiese bones, even at birth, are firmly united, and they foi'ui a coiii- ])aratively small but almost totally iueomi>ressible mass. Th(> vault is made up of the parietal bones and the scpiamous ])orti(;ns of the occipital, tempoi'al, and fi'outal bones. These bones are all wide, flat, and sliLihtly curved. The scpiamous portion of the occipital bone is attaciicd to the basilar |)ortiou liy a band of fibro-cartilaiiiuous tissue which permits of (piite free motion between the two portions. All the bones of the vault are united at their (>dtres l)y n>eud)ranous commissures formed of the dura matci' and the uuossificd exterual jK'riosteinn. Tiie vault of the cranium, thouiih much lariicr than the base of the skull, differs from the i)ase in its ]V)ssession of compressibility and of a marked capacity for alteration of shape under the mouhliuii' influences of the constant pressiu'e of labor. It nuist be remembered, however, that difl'erent lieads present very different detri"«'i''< <^1 ossification at the tinu' of birth, and, indeed, vary widely, from eases in which the flat bones are so slightly ossified as readily to ho bent by the jnrssure of the finoer, and in whiv'h the mem- branous intervals are extremely wkh. and well marked, u]) to cases in wliicli the ossification luiil union of the hone- are .><o far advanced as to reduce the compressibility of the skull to a min- imum of small practical value. T/ic Siifiircs (tml tlir Fimtdiicl/cti. — The uiend)ranous lines of union between the contii!;uons bones of the vault are known as .^iittirc^, and at the point- where more than two bones meet tlic-e sutures couniionly widen out to mem- branous spaces known :\:- j'i)iil(iii<I/(X (Fiii'. 2'J(i). The suture.- arc distinguished by the fbllowiuir names: 'I'hat between the frontal bones is the _/;'f)/(/''/ ; tlini between the frontal and parietal bones is the cdroiKi/ ; that between the parie- fals is the s'ti/Htc! ; and that which separates the s(|uamous portions of the oceijtital from the two parietal- is the /mu/xl'iido/ sutiu'c. At the point whci'c the frontal and parietal Ixmes come foocther the frontal, ^ir Fi(i. '220— DliiuTunis (if tlic foiitiim lies : .\. iiiitr- rii)r: H, postiTior; (', liilcrnl. luilir: iinii- Iwccn It ;nv lint- Itlii-'' liK'in- ll>!ii tl liafi'- ir ti l)llt'.ll LAIioH. I'l.AlK -28. ■> ^-•ti .CI c^ K vs Ocap/h* -fFoiital * ^ Occipul ^^s Biparletal S .S diparktal ^ cmspn- Ver Tex ^'nfane/Ze ^\ (brejwa) ^ Bitemporal Scmdlm-j hstprior ^ioi**^ Tontande >V* OcapiTal Prvtukruncc Biparietal 5' inciput t Bitem voral I Kktai. IIi;aii: !. Kcliil skull scon Imni tlir siilc ; j I-'itnl skull sr.n finm hIkivi': ;i. Kctal skull situ Crniii lii'hinil. I Kiliil -kull sciii I'nitn in Irmit showing sulmis, l.inlHii.llrs. iinil cliaiiifli'i-s. t i| e UT^ ^*^y- ; ' ' i ;: :ii: i,i- >', ; 1 I I THE MICHANISM OF LABOR. 403 sagittal, and coronal sutures moot in a inonibranous space or fontancllc wliicli is rliouiboidal in shape and is ordinarily of considerable extent. Tliis space; is known as the (interior or large I'ontanelle, and sometimes as the hrcr/tiui (1*1. 28, Fig. 2). Of its four sides, the two anterior are usually tlie longer, and when this diilerence is well marked the resulting fontanelle may more ])roperly be said to assume the shape of an Indian arrow-head (Fig. 22G, a). The junction of the sagittal and lamixloidal sutures at the point where the occipital and parietal bones meet forms a small triangular space, known as tiie posfrrior occipital, or small fontanelle (PI. 28, Fig. .3). In well-ossiiied heads ihis space is frequently small or wanting, and the ])osterior i'.)ntanelle is then I'cpresented only by the jiuietion of the three suturi's. It is to be remembered, moreover, that when the bones are closely crowded together by the jiressure oi' severe labor, either fontarielle, however well marked, may ]nu'tially or Avholly be ciTaccd for the time l)y an overlapping of the edges oi' the l)oncs which bound it. Fxceptionally, a locally defective ossification along tlic edges I if tiie bones may result in the ])roduction of either Wormian bones or I'alse I'liiitauelles, hoth of which are most connnon in the course of the sagittal suture, and which may result in considerable coul'iision of diagnosis if the ])ossil)ili!y of tiicir existence is not borne in mind.* Dimensions of the Fetal Head. — Tlie size of the i'ctal head at term varies greatly with the size of the individual fetus, but. iiowevcr great this variation may be, the relative proportions between the ditferent parts of the head remain approximatclv cdustanl, and for the sake of clearness it is usual, in the discussion of general principles, to ignore this variation of siz(> and to use as the basis of argument the dimensions of the average head, 'llie diam- eters that have been found most useful in the description of the head are as ^(lllo^i•s: The (iiiftro-itnsfrrlor >ll(niuii ri^ — the oecijiito-mentid, the oc>'ipito- i'lMutal. the snl)occipito-l)regmatic ; the traiixrcrxc lUamdcrs — the biparietal, the hitemporal, and the bimastoid ; the vcrliral (liaiiu'fcrN — the fronto-mental and the cervico-bregmatic. Antrrn-poHtcrior Diduicfcrs. — The occipito-niental diameter (PI. 28, Fig. 1) is drawn from tluM-hin to the most distant jiortion of the occiput. The occipito- frontal (PI. 28, Fig. 1) is drawn from th<' ]ioint of union of the supraori)ital ridges to that portion of the occiput which is most distant from them. The suboecipito-bregmatic (PI. 28. Fig. 1) is drawn from tlu' jinint of junction hctween the occi|)ut and the neck to the centre of the anterior fontanelle, Tnnii^rcrxc Diaincfrrfi. — The biparietal diam<'t(>r (PI, 28. l'"'igs. 2, 4) is drawn li'om the a]>ices of the lti|)ari(>tal protuberances — naiii ''y, throuLi'h that portion It is WL'll to Iiciir in niiiid, in luldilioii to iln' iiiitciiiir :inil ))osti'riiir tontniiollcs, tin ocia- >iniiMl I'xislctici' of ;i tiiiiil. tlu> hiliriil fontiuirlli'. Tills lontjiiu'lle is iinxMii nnly in ]ioorlv-ossi- liid Imids, nnd wlu'ii ]irt'scnt is found at tlir jmu'tion of iho c>tTi])it!ii. piirit'ial, and ltin]ionil I'oiu's, ni'ar tiio l)as(' of the mastoid j'roct'-s ;in<l luliiiul tiic lar. Tiio iatcrrd fonlaneilc may -oiiu'tiiiiis 1)1' niistaivi'ii for llic lircirnia iiidi"-s carcfiiily oIim rvid. It i-^ foMi-siiiid, Imt is iii( iru- !:ir in siiapc il'l. SS. Fijr. l!i. It may \»' >aid tlial llic mastoid iitorcs'. iWU lil<r tlir side of a l:iri;r canine toolii imiieilded in tlie tem|"in\l lione. It is nsually iceouni/.aMe, i it is some- linns a valuablo [loinl in the (iia>;nosis <>( lids region of tl skull. ' m ■ m e' ff I I fl ni'ui Hi ■ 404 AMEIUVAN TEXT-BOOK OF OBSTETRICS. of" the skull at wliicli tlic lateral .siirlht'cs arc most widely distant from eaeli other; the bitemporal (PI. 28, Fij-s. 2,4) extends transversely between the most distant ])()rtions of the coronal sutures ; the bimastoid extends between the mastoid processes at the base ot" the skull. To these diameters is some- times added a less important diameter, which is that lying between the base of the zyj^omatic ])rocesses, the bi/,yi>'omatie. Vcii'mil J)i<niictcrx. — The fronto-niental diameter (IM. 2(S, Fijjs. 1,4) extends from the chin to the upper part of the forehead ; in the absence of anv dis- tinctive point of ori<;in at its upper extremity, as well as from its small size, it is of but little importance. The cervieo-l)rc<imatic (I'l. 28, Fij>\ 1) is drawn between the junction of the neck and the chin and the centre of the anterior fontanelle. The lengths of the several diameters, as obtained by Tarnier and Clian- treuil, are given as follows: ('I'litimclcTs. Iiii'lii's. Occiiiilo-iiifiitiil (liaiiH'ter {'A oj Oc'ci|iilii-fri>iitiil " 11.5 ^ 4.] Siili()(ci]iilo-lin<,'iiiiiiii' (liaiiietcr !)..') = 3if jiipiuiutaldiaiiiftor 9,5 =: 3:} r>itciiip<ii'al (liaiiu'lor 8 =rT .'{j Itiniastiiid (liaiiH'ier 7.5 ^= 3 l'"nmtn-iiiL'iUal iliaiiu'tcr S =: 3j (.'iTvicK-ln-eginalu' dianiutor . 9.5 ^^ 3:{ These diameters may be divided into classes in two ways: (1) by their com- jiressibility, and (2) by the degree of ditticnlty with which they may be expected to pass the pelvis. The compressibility of the fetal head as a whole is not only a very variabli' factor, but the diU'crent parts of tlie same head vary witlcly in both the case and the safety with which compression can be applied to them. The biparietal an<l bitemporal diameters are safely and easily compressible. The suboecipito-bregmatic, occipito-frontal, and occi]>ito-mental diameters an; almost e(|ually compressible, but the degree of danger to tiic Ictus that com- ]>ression of these diameters involves is vastly greater than is the case with the biparietal and bitemporal iliameters ; and with obliijtie compression the degree ol' danger inci'cases as the direction of the force approaches to the antero-posterior diameters, '{'he bimastoid and bizygomatic diameters arc I'or j)ractical purposes totally incompressible. The Relative Value of the Diameters of the Head as Compared with the Diameters of the Pelvis. — It will be observed that the lengths of the suboccipitip-i)rcgm;itic and biparietal diameters are nearly equal, so that a cross- section of the head through these diameters { I'^ig. 227, A) is very nearly cinui- lar ; an<I from this fact and from tlicii' size this cross-section is capable of pass- ing ;uiv diameter of thi' pelvis when pr(>sented to it in any obstetrical position. Since this is the cross-section which is always jiresented to the jielvis by wcll- llcxcd heads, the study of position would !)e of litth' im|)ortance if the exist- oneo of Hexion could alway.s be depended upon and if the remainder of the lom- Ivitli tlic tin- n.r ath he Ircu- liiss- ruin- Icll- ;ist- iUv THE MECHAXJSM OF LAJiOIi. 405 lioad could be iu'<;locto(l ; but two factors in labor equally contribute to render this cross-section of the licad bv no means the only one which nnist be con- sidered. In the first j)lacc, we nuist be prcjiared to consider the mechanism of brow and face cases, and, in addition, those cases of vertex labor in which the Hexion of the head is, from one cause or another, imperfect ; and, moreover, even in the best vertex labor good flexion is seldom attained in the early stages A 1! Fif:. 2J7.— niiiiiu'tcrs (if tlie fotal lioiid : A, rrosssrctinn nf the fi'tnl head tlir(Hii;li tlio snlxK'ripito- l]rff,'mati<' ami hiparictiil diaiiictiTs , H.cross-scctinii of the fetal licail tliniiii;li the hiparii'lal and dccipito- fnnital diaiMctiTs; (', iTciss-si'c'iiai cif the fi'lal head llirouuli tlir liiparii'tal and ()('ci|>ili)-nic'ntal diaiu- iliTs; 1), cross-sL'ction of tlio fotal head tlir ■^^dl tlii' siibuccipilnCrnnlal and bitruipural diaincti'i-s, ol" engagement at the brim. Secondly, even when good flexion is present and this circular cross-section is in the inferior strait or excavation, the brim is occupied by the fnmtal portion of the head in combination with the neck — a by no means luiimportant factor in the mechanism of even the most normal cases. It is therefore important to renunnber the shape and dimensions of the cross-sections, which include, first, the biparietal and oceipito-frontal diameters (Fig. 227, b) ; second, the biparietal and occipito-mental diameters (Fig. 227, c); third, that which cuts th(> head and neck through wiiat might be called the " suboccipito-frontal" diameter* and the bitemporal diameter (Fig. 227, d). If the diameters of thes(> cross-sections be compared with those of the pelvis, it will be seen that all the transverse diameters are ca|iable of an easy ])assage througli any of the diameters of the pelvis. The occipito-frontal and sub- occipito-l'rontal are too large to ])ass any of the conventional f diameters except the oblique diameters at the superior strait and the dist('nsii)Ie anteni-postcrior * A|i|)r().\iinii(('lv (lie ('ci'vico-lnvfjnuUii' [iliis the tliickiu'ss of tlio lu'ck. t 'I'liost' wiiicli liavu iianu's. ;.a^ 'if-.- 1 1 ; i , 1.* ': ji u 1 ,.,„, il ^^; ■? wiit I 4()f; amehivax Ti:xT-ji(K)K of oiisrirrnns. (Iiaiiu't(M's of till' iiiCci'iur strait ; wliilc tlu' occipito-iiiciital is toit larfi'c cvt-n tin- these, and may coiiscmieiitk l»e rei;ar(Ic(l as an ini[)i'artit'al)k' ur impossiljle (liaiiieter, A careful reiiiemhraiiee of tlie relative values of tliest; diameters will he found of nfeat service in the comprehension of normal laltor, and of still more valne in mider-tandinu; ahnormal lahor. The Articulations between the Head and the Spinal Column. — The articidations hy which the head is joined to the tnmk are, it will he remem- bered, the occipito-atlantoid, the atlanto-axial, and those hetween the other cervical vertchra*. The oci'ipito-atlantoid articulation admits of hnt little motion except that of extension and llexioii, while even that motion, when carried to extremes, is lifcatly assiste(l hy a similar mov(MMent in the other cervicai arti( illations. So, too, the rotatory movement which alone is possihlo in the atlanto-axial Joint is nrcatly assisted i)y the movements in the other articulations of the iiech. The capacity tor lateral llexion resides wholly in the intervertehral articulations and is limited hy their liii;aments. iiotatioii of the heail to either side is safely possihie only tliroiii:li an are of ahoiit !)()^ ; that is, when the chin of the ll'tiis is in the jilaiie of the shoulders the limit of ^aftly ill rotation has heeii reached. ^ViitcM'o-posterior flexion is limited only hy contact hetween the chin and the hreast. Extension can he carried to a point at which the occi|nit rests airainst the hack of the neck and the chin is in a line with its anterior surface. The Fetal Body. — The compressihility of the fetal trunk renders impossihle and worthless any statement of the ahsolute len<>th of the diameters which the fetal hody presents to the ])elvis diirini;' lahor ; hnt the relative leiiuths of the transverse and aiitero-jiosterior diameters as compared with each other is of importance, and is constant in at lca<t two parts of tin; trunk — namely, in the regions of the shoulders and the hips. The transverse diameter in hoth these regions is always longer than the antero-posterior diameter. TItv Sliouldcrti. — The relation of the shoulders of the infant to the mechan- ism of lahor is somewhat altered hy their movahility. The shoulders may he ])reseiited to any portion of the pelvis in one of two positions: First, they mav enter together, with the line of the clavicles approximately at right angles to the spine — that is, in the position ordinarily assumed hy adults. Second, one shoulder may lie elevated and the other depressed, so that the one enters in advance of the other, hoth clavicles hcing still approximately in the same line, hut this line now foriuiug an ohlitpu; angle with that of the ^'crtehral column. In the second, which is the usual and normal position, the transverse diameter never loses its su|)eriority of length over the antero-posterior diametei'. When hoth siioiildcrs cuter together, this superiority of the transverse diam- eter is always somewhat less marked, and is occasionally so much diiiiinished as to lead to interruptions of the mechanism Iiy which the delivery of the shoulders is normally aci'omplished. '/'//c ///'/<N. — The pelvic hones of the infant are sunicieiitly rigid to |)revcii( anv coiisidcrahle moulding of vhe hrcech, and the transverse diameter of tin' THI-: MI'X'IIAXISM OF LMIOU. 407 hips i.s alwiiys considcnil)!}' }:;r('atf'r than the aiitci'o-postcrioi' diamctor of the sum,' portion <it' tho hody. The Trunk. — Tlic intt'rnuHliato portions of the inlant's trunk arc so soft and coinprossihle tliat its dianictcrs arc totally inconstant. The shajic of the cross- section of the trunk corresponds witli the shape of that portion of tlie [)clvis in wliich it lies, and even the prescuce of the linil)s in juxtaposition with it makes but little diircrcnee, since its softness permits the liud)s, nuder the pres- siu'o of labor, to intlent it at any point. Diagnosis, Frequency, and Prognosis op the Several Varieties OP Labor. |)lA(iN(»sis.* — In obstetric (liauiiosis we are furnished with two methods of examination of almost e(|iial importance — namely, examination of the abdomen and examination of the vatfina — which must be described separately. The abdominal examination unist be subdivided into iuspectiou, palpation, and auscultation. In the w^ii of this method of examination it is l)est for the bej;'inner to ijiuore tlu,' possibility of (). L. P. and (). D. A., on aecoimt of their <j;reat infre(piency and of the excessive complications that an ellbrt at their recognition would involve. The value which the individual obstetrician places upon an abdominal examination is generally proportionate to the experieuce he has enjoyed. The !)cgiuner should be urged to avail himself of every oj)portunity for practising this method, for, while he will find in his early practice many cases in which the obesity of the patient or the rigidity of the abdominal muscles and uterus renders abdominal palpation of no value, a large muni)er in which the exam- ination is inconclusive, and oidy a few in which he can attain a clear diagnosis In- this means, yet as his ex]ieri( nee enlarges the first class will steadily decrease in nund)cr and the latter two will increase proportionately, if he is faithful in ])ractising palpation upon every case that comes under his charge; and the value which attaches to facility in making a diagnosis by this means iu many difficult operative cases can be a|>preciatcd only by those who possess it. It is ccrtaiulv a liict that to the experienced hand abdominal pal|)ation yields rcsidts fully as valuable as those which can be obtained by digital examination per vaginam, and that ther(> are but few cases iu which rept'ated examinations during the progress of labor will fail to establish a diagnosis by palpation and auscultation alone. Abdominal Inspection. — Insjicction is mainly valuable as affordiug a hint of the existence of ti'au-^vcrsi' presentations and of nndtiplc pregnancy. Abdominal Palpation. — Palpation is the most important part of the abdominal (wamination ; it .-liould hv performed only iu the intervals between the pains, all |tressure of the hand being intermitted with the appcaraiic(,' of * Aitli(Mi<;li lilt' iiictli(i(ls wliicli iiuist ln' n-.r(l In luiikiiiL; tlir ili;i'^ii(i>is of pfi'^t'iiliitinu mihI |insitiiii\ ;irc iiidiciilod in Mimtlu'r (iMil nf tiii- wmk, siicli w ili;ii:'iiii>is is so fS'-t'iili;il tii tlie iiu'cli;iiiii"il iii;in;ii;(im'iit nf IiiImii- tli;il it si'i'iiis wisr to i\'[)i.';a tlu- tcciiniiiiu' of tin- .several ItU'llloils of rXMIllilliltiiill ill lili> svclioll. 1v a ii I I II I f. < 1 ! 1 408 AMKlilCAX TEXT-liOOK OF OJiSTKTUHS, cacli coiitrat'tioii. 'I'lic |tliysi('iiin slioiild stand l)y tlic patient's side fa<'ing toward licr litad, and slioidd apply the palm of each hand flat aL^ainst tlic cor- I'cspondini;; side of tlic nt( rns. 'riiroii<;li()iit tlio examination it is all-important tiiat the motions of tlu' haiul shoidd he slow and j>;entle, uny (puck or jerky imj)nlse heinir almost certain to result in rijiidity of the ahdondnal walls and the litems, tints frnstratini:- tli" purpose of the examination. Kvery elfort slionld l)e made to divert the attention of the |)atient, t() soothe her fears, and to assure her that the examination will not he painfnl. It not infrecpu ntly happens that the first attempt will he a total failure, while the second will yield satisfactory results owintr to the chanu'cd mental condition of the patient. D'HKjuoHix (if Prcsfnfdfioii Itj/ J'd/jxtHon. — The fiiiiicr-tips of eacii hand should l)c ])ressed with a i!;ra<lual and <i;entle motion downward behind the .syniphysis pubis in search of the fetal head (Fig. 228), which in cephalic j)res- Flii. li'JH.— Diatjiiiisis nf iirL'Si'iitiitinii liv |iiil|iiitii)n. ontations is almost always to he felt in thi< situation as a marked transverse check to the examininu' hand. In this examination care sliould he taken to note on which side the head is most plainly perceived, since with a wcll-ilcxed head the frontal extremity is nuich the more easily reached, with the pai'tialiy extended head lint little din'erence is to he noticed, and in face ])resenlation> the occi)>ut is nnich the more di>tinct. The fundus should then he pal])ated carefully as a I'urthcr means of excluding the possibility of a breech jiresentation. The head may be <lis- tinguished from the breech at the fundus by its greater si/e and mobility, bv its I'onnded contour as opposed to the tapering form of the smaller breeeh, and bv an easilv distinguished sulcus which correspon<ls with the neck of the child ; but the best evidence of the jiresencc of the breech at the fundus -MSttm mvmmammmmri^r^ •rsc I to Ixcil lilly litv. THE MHCIIAMSM OF l.AIKH!. 409 is ahvays the recogiiitiuii of a head prosi'iitatioii l»y (Iccp palpation Ix'tiiiid tlio svinpiiysis. J>i()'('rt)iti((l Diiif/noxix of I'rixcnldtionK hi/ Pii/patinn. — ('cj)hii(ic J'lrsnittt- tloiis. — Tliu most (listiiKJtivc si^ii of licad prcsoiitatioiis is to be found in tlio recognition of the licad by deep jialpation bcliind tlio symphysis. Tlic diat;- nosis should tlu'U hv clici-Ucd by asirrtainin<5 the absmcc of the signs clianu'- t('risti(! of tlic head at the fundus. J'ilrii- ]'irfifiital!<))iti. — In Iji-cccli presentations the obstetrician's attention is generally first arrested by the absence of the transverse cheek to the fnigcrs, due to the presence of the head, on ticep palpation behind the symphysis. Ho should then be able to recognize the presence of the head at the fundus by the signs just emimeratcd. 7Vo/(.N7V/'.sv Pr<x>iif(tlio)is. — In transverse presentations the long axis of the child is felt to be transverse. The din'erential <liagnosis between the head and the breech is always of importance, and is to be made by the signs emi- meratcd above as characteristic of the head. -* I)la(/iiiixiK of I*onHioii hi/ J'dlpaHoii. — The hands should be j)lace(l along the sides of the uterus and should make geiitl(> but deep pressure toward each other (Fig. 221)) — that is, with the uterus and child directly between their Kli:. JJ'.I. — |lill'_Mlnsi« nf pn<iti(ill \'\ |i:ll|iiltiiill. palms — in the elVort to es^ mate tiie relative resistance atlbnlcd l)y the right ami left sides of the uterr . the Hal, tirm back of the child usually presenting a resistance to |)ressure .iiat is mai'kedly greater than that of the yielding abdomen and the movable lindis. The diil'ering resistances having iteen estimated, the lingers should bo applicnl to the sides of the uterus, not with the lip< deepiv iudeuled into the alulomcn, but with their whole palmar surface press(>d linnly against the '^M I k Wtfi 1i>, ^ ▼^ .Q. v' C IMAGE EVALUATION TEST TARGET (MT-3) 1.0 1.1 1.25 Himm 2.5 2.2 ^ 1^ 12.0 •UUu 1.4 1^ 1.6 v3 V] / fliotographic Sciences Corporation 33 WfST MAIN STREET Wi:itST»i^ N.Y. MSSO (716) 873-4S03 '*> %^ & ^Iff 410 AMERICA y TEXT- HOOK OF OBSTETRICS. uterus ; the luuul.s slimikl then be niovctl gently up ami down along the uterine wall in an endeavor to recoirnize the irregularities due to the presence of the fetal limbs. During this search it is necessary to guard against the error of nustaking either of the round ligaments for the fetrd nicnil)ers. These ligaments, which at term are of nearly the size of the adult finger, extend obli(|uely from the coriuia of the uterus downwaril, outward, and Ibrward to the pelvic brim. They may be recoguizeil by their situation and by the pain of which the patient invariably complains when they are rolled about tnider the fingers. Tlu; existence of small subperitoneal fibroids is another jiossiblo source of error. With thin and flaccid abdominal walls it is sometimes possi- ble by this method to recognize the fetal lind)s with the utmost distinctness, but in the majority of cases an irregularity in the contour of the fetus is all that can be hoped for. liy palpation, then, we can hope to distinguish not only the presentation, but also the position, since the latter must correspond with the quarter of the pelvis in which the letal back is Ibiuid. Owing to the infrc(piency of O.I). A. and O. L. P. posititms, it is generally safe to call all cases in which the back of the child is found ttnvard the left, O. L. A., and those in which it is found toward the right of the mother, (). D. I*. Abdominal Auscultation. — Auscultation of the fetal heart givTS confirn;- atory evidence about the presentation and position, informs us of the condi- tion of the child, and is the most important sign in the recognition of nudtiple pregnancy. In vertex p;.'sentations the heart is most plainly heard over the back of the child and below the mother's umbilicus;* in breech presentations the heart is heard over the back, but its greatest intensity is generally above the mother's umbilicus ; while in presentatitms of the face it is most readily heard over that portion of the uterus which corresponds with the chest of the child, ibut is again below the umbilicus. In transverse presentations the heart is usually plainly audible when the back is anterior, but is often found with difficulty in the ])osterior varieties, and is of comparatively little value in the diagnosis of position. In interpreting the evidence of position furnished by the situation of the fetal heart it must not be forgotten that, owing to the fiict that sound is better con- ducted by solids than by li<p)ids, the exact situation of the letal heart-sounds corresponds with that portion of the back or chest which happens at the moment to be in cor.tact with the uterine wall ; the situation of the fetal heart-sounil, therefore, may vary temporarily with the position of the mother, as one or the other shoulder rests against her soft parts, or it may temporarily be absent (especially when the patient lies upon her back), owing to the intervention of tiie li(|iior amnii between the fetal chest and the physician's ear. * Owiiiff I') the <il)liiiiio pnsiliini whicli tlic slioiildcrs norninlly occnpy, tlic dividinfj-line llictwccn the rijilit iiml the U'i'f iiositioii (if the lu'iirf-souiids in lliis iind in all longitiidiniil piTs- cntitlionH slmuld \w tlint dniwii )i('t\v('t.'n tliu iindiiliciis and the right anterior Hiiperior ttpini' ol' tlie ilinin nitlii'r \.\vm\ ihi' ini-dian line of the bodv. Ictal C'Oll- Luiuls linent |)UIul, lie or l)seiit \\\ of Is-lini' luvs- THE MECHANISM OF LABOR. 411 In addition to tlio value of aiisenltation in the diagnosis of jmsition, its iMi|)ortan('e in the recognition of the eonditioti of the fetus ean hardly be over- estimated, any fatigue of iniportanee being (|ui('Uly shown by alteration of the rate and regularity of the heart-soinids. In addition to the fetal heart-sounds, the so-called "uterine" or " i)laeental souffle" is generally heard as a soft blowing sound synchronous with the mother's pulse ; this sound is of no practical value. Summary of Diagnostic Signs Aimished by the Abdominal Exami- nation. — At the conclusion of the abdominal examination its results shoidd be summed up and a diagnosis be made by some such mental process as the following : The first j>rocess of palpation, describe*! on page 409, enables one to deter- mine whether the presentation is cephalic, pelvic, or transverse, and this result is cheeked by the j)ositi(jn of the fetal heart as obtained by auscultation ; that is, in cephalic presentations the heart is found below the umbilicus, in breech presentations al)t)ve it, and in transverse presentations a little toward that side of the abdomen to which the hea«l is directed. The position is determined by the situation of the fetal back, as established by the second method of palpation, <leserii)ed on jiage 409, and by the position of tiie fetal heart, which position should correspond with that of the fetal back.* If the presentation is either breech or transverse, no further determination is neccs.' ary, or indeed possible, by the abdominal examination; but if the pres- entation is cephalic, it is both necessary and possible to determine whether it is a presentation of the vertex, the brow, or the face. In vertex presentations the end of the head that corresponds with the fetal abdomen — that is, the face — is found at a higher level than the opposite or occii)ital end, and the fetal heart is heard over the back. In face presentations the end of the child's head that (•orrespt)nds with the abdomen — that is, the face — is palpated less readily than the dorsal (occipital) end of the head, and the heart is heard over the front of the ciiild.t In brow presentations both ends of the head arc easily reached by palpation. The heart is usually heard over the back. Vaginal Examination. — Tcchtuijitc nf the E.ramhtafinu. — In obstetric work it is usually best to avail (»ue's self of the extra length of the middle finger by employing two fingers fitr all examinations, except in those cases in which the extremely narrow vulva of a primipara makes the introduction of the second finger painful to the patient. Most American obstetricians prefer to * Exivpt ill fiioi' iirescntiilions isfo p. 4591. t It will bo perceived tliiit the (listiiictioii ln't\veen vertex mul liiee presentiitions by iiiidoiu- innl extuniiintion is likely to lie ditru'iilt, since in :i left antcrioi' position nf either pr'iscntiition the most ai'ces-iible end of the lieiid will be foinid in the riij;ht ])osteri()r (jnarter, wlrle in both presentations the heart is let't anterior; the only distinction is to be t'onnd in the position of the fetal limbs us comimred with the heiirt, and in the perception of the Kroator si/.c and more rciiMided contour of the occiput as opposed fo the face; but the ^rreat infrcipiency of face pres- entations and the ease with which they are distiiifjuished on vaginal exuininutiun make liiis sonrt'e of error a matter of small importance. m !5- r ' I. v: r\. 4'^ i \ 'ii' 1.; I i '■A I WF^' % 412 A Mi: arc AX riLxr-nooK of obstetrics. examine tlic patient wlion in tlio loft lateral dooiibitiis, but it is woU to accustom one's self to exaniiniiij; in all positions, not only in the interest of the patient's comfort and convenience, but also biniause it is often possible by changing the decubitus lo reach a portion of the chilil that has before lieen unattainable. The vulva being aseptic, the hand, having been thoroughly disinfected and anointed with an aseptic lubricant, should be intUKluced under the iMnl-clothcs, which should be so held up by the other hand as to protect theni from contact with the examining fingers ; these should be placed against the genital cleft, and be swept gently forward until they find the entrance of the vidva and come in contact with the fourchette, friction against the vestibule and clitoris being carefully avoided in the process. As the examining finger enters the vagina it should note sticcessively the size of the vulvar orifice, the position of the coccyx, the shape of tlie sacrum,* and the condition of the rwtum — whether full or empty. These points having been ascertained, the finger should be pass'nl upward into the posterior fornix, and be swept forward over the sofl and yielding vault of the vagina in the effort to find the external os, which is usually situated in the median line and near the centre of the pelvis. In case of failure to find the os readily, the field of the pelvis should becpiartcred systematically by the examining finger, much after the fashion employed by a pointer dog in searching a field for game. If the cervix be not yet taken up, it is recogni/e<l as a roundinl prominence, on the summit of which is found the orifice of the os if the patient be a primipara ; in multipane the lacerated and ragged condition of the cervix frequently makes the external os indistinguishable from an early stage of .'abor, but the finger ill such cases may usually be passed into the cervical canal, and will then recognize the ])resence of the internal os. If the cervix has been wholly taken up, the os is best recognized by passing the finger through it and into the space between the cervix and the presenting part.f The physician's ability to reach the upper j)ortious of the pelvis is more dependent upon the position in which his hand is held than upon the length of his fingers. When he desires to reach the tipjier and j)osterior parts of the pelvis, his hand shouhl be held in the position indicated in Figure 230, the 2)erineum being strongly retracted by the pressure of the web between the second and third fingers. When the object sought for lies nearer the anterior wall of the pelvis, the position of the hand should be altered by rotation of the forearm into the position represented in Figure 231. The upper border of the second finger is now pi'cssed firndy against the edge of the pubic arch, and the pulp of the finger is directed anteriorly. * The writer stronjfly recoiniiien<ls tlie priictice of roiijrhly nieasiiring tlie conJuKiite diameter l)_v reiicliiiiR upward for tiie i)roiii()ntory of the siicrnni, as a routine measure, at tlie conelusion of the first examination in eacii ease, nnd he believes that many operative difliculties may lie avoided by this simph- prociMJui-e. t Unless this precaution of hooking the linger about the edge of tlie os be observed, tlie beginner is liable to mistake a fold of the vaginal wall, or in breeeh presentations the anus, for the OS uteri, both of which mistakes have been made by medical students in the presence of the writer. ^i^iii THE MECIIAXISM OF LABOR. 41S The OS liaviuj; been reached, tlio fiiij^er .slioiiM note its size, the thickness of its edffe, and its consistency, wiicthcr hard or si)t"t, and by very gentle stretch- ing shonld endeavor to ascertain its (h'grec of dihitability ; in tiiis hist luaneu- vre it is necessary to enjploy tiie greatest gentleness in order to avoid tlie inex- FlG. 'JoO.— I'dsiton (if the liiuid in digitiil cxiiiiiiimtinii of tiK' fetus along the posterior wall of the pelvis. cnsable accident of a manual hiceration of the os during exatnination. Tlie <'liaractcristicallv diiferent sensati(»ns vicldc<l to the fiii";er bv the smooth and velvety cervix, the rough but slippery niciubrancs, and the iiairv scalp is a matter with which it is important to become i'amiliar, for it is easy to recognize f.^ 7 *. Fici. 2;!1.— I'osition of the hand in digital examination of the fetus alonj; the anterior wall of the jielvis. these ditferenees if the physician has trained himself to observe them in even a comparatively small number of cases, an<l the possession of this faculty may at some time preserve him from the dangerous t»r even liital error of making an application of the forceps to the intact membranes or over an undilated cervix. If the cervix is thin, it may be possible to recognize the presenting part '''if nil V'' wM tr i. 1 !' M iPW 414 A.VKRff'A.X TEXT-noOK OF OliSTF/riilCS. throii^rli its sub.stiince ; but in ordinary cases it is nccossarv to introduce tlio fin»'er tlirous^li the os in order to distiuiruish between the difl'ercnt parts of the child. The finger should be passed up until it conies in eontaet with the pre- sentinjj; part, an^it should then seek systeniatieally for u.arks by which the character of this part can be determined. The jiresenee of the head is to be determined by the perception of one or more sutures ; that of the face, by the presence of the raouth and nose ;* that of the breech, by the rccoornition of the spinous ])rocesses of the sacrum, the j^enitals, and the anus. The tid)eros- ities of the ischia and the i)ubic arch are also easily recognizabl(\ The shoidder jiresents no very distinctive marks, and the diagnosis of a transverse jiresenta- tion is not easil\ made by vaginal examination din-ing the early stages of labor unless a hand and an arm are prolapsed, but it shoidd always have been recognized by abdominal palpation before the vaginal examination is made. The various distinctive marks of each of the presentations must be sought for. and the diagnosis is to be made in accordance with those founil to be present. Summary of Sigrns of each Presentation. — The diagnosis of presentation bvvaginal examination, though ordinarily easy, is sometimes ditficult when the j)resenting ])art is still high in the pelvis. It would be supjiosed, a priori. that the distinction between the hard head and the yielding breech could be made in all cases with the greatest ease, but a considerable experience in the superintendence of students has convinced the writer that this pt)int of consist- ency is a most unsafe and unsatisfactory gui('c, and some personal experiences Jiave le<l him to adopt the rule of never permitting himself to diagnose a head unless it is possible to recognize at least one suture, nor to commit himself to the diagnosis of a breech without inserting the examining finger into the anus and recognizing the presence of the coccyx. Vcrtc.v lWi«nt(ifinun. — In vertex j^resentations the finger shonld first recog- nize the convergence of the lambdoidal and sagittal sutures forming the small fontanelle. The finger should ^^ n pass along the sagittal sutiu'e until it reaches the large fontanel^ . . .v.gnizes the four sutures which enter it. It should next search for the ears, the mastoid processes, and the lateral fontanelles, all of which may usually be found by following the hnnbdoidal sutures to their^^w'minations. The ear is always recognizable, the mastoid and the lateral fontai»t4l«^ are less constantly conspicuous, and all these niarks are usually less easily w*ached upon the posterior than tipon the anterior side. The car, when reached, always points toward the occipital end of the head, unless, as sometimes hapjiens, it is folded forward against the scalp — a fact which is easily recognized if the finger is passed backward and forward a fi'w times across the ear. A\'ith a well-flexed head the posterior fi)ntanello is lower in the pelvis than is the bregma, and the upper and posterior part of the ear is generally the more easily accessible. When the head is somewhat extended the fi)ntanelles are upon about the same level in the pelvis, and the anterior edge of the ear is most easily reached. AV^ith extreme extension of a vertex presentation the * Care nuist be taken not to miHtnke the Ruprnorhital ridpos of a face presentation for tlie Biiboccipital ridges of a well-flexed vertex presentation. TJIi: .VFA'IIAXJSM OF LAliOIi. 41 Tr (■\ (brows are not infreciuoiitly accessible (soo //ro/r iVcsf/i/^^/oo.-*). Tlic <liag- iiii-is of ])ositioii in vertex j)reseiitations is made by ascertaining the position (it the occijMit ; this is obtained, first, by comparing tlie positions ot" the small and large fbntanelles in the pelvis, and, seconil, by observing the direction in ' which the flaps of the ears point. Brow Presentations. — When the extension is so extreme that the small fdiitanellc is reached with difficnlty and the supraorbital ridges and the bridge of the nose are Avell below the brim of the pelvis, the presentation is that of a l»row. By very high examination the mouth can occasionally be touched in binw presentations. The position is named after the position of the small i'diitanelle, but care should be taken to check the diagnosis by an independent oliservation of the root of the nose, which should, of course, be in the opposite (|ii;u"tcr of the pelvis. Face J*re.se7ifafinn.s. — When the supraorbital ridges are found upon one side of the pelvis and the point of the chin upon the other, the presentation is a face. Before the diagnosis is considered assured the fingers should recognize, in addition to the chin and the supraorbital ridges, the mouth, the nostrils, the (yes, and the root of the nose in their ])roper pi>sitions ■ and it is even well to a<lnpt the precaution of always inserting the finger intt» the mouth and ascer- taining the presence of the maxillary ])rocesses and the tongue, which can be mistaken for nothing else. The position is indicated by the position of the chill, and should be checked by an observation of the position of the frontal suture. Breech Presentations. — In breoch j)resentatio!is we must distinguish, during the vaginal examination, between presentations of the whole breech and foot- ling presentations. In presentations of the whole breech the finger should rt'Cdgnize the spinous processes of the sacrum, the anus, and *he genital cleft. In boys the scrotum often becomes eno "', "'sly distended, and this may lead tn confusion if the possibility of the f. not borne in mind. When a l)i('cch presentation is found, the finger should always be inserted into the anus, and be made to recognize the tip of the coccyx, the tulx^rosities of the ischium, and the pubic arch. The position is named, as has been said, after tilt' jiosition of the sacrum, and it is most easily determined by finding the ])()sition of the tip of the coccyx of the fetus by rectal examination. ■hHH^I ling presentations one or both ankles or feet protrude through the os. Presentation of a HamJ or a Foot. — If the membranes be rupturecT sciiting hand or a foot may easily be drawn outside the vidva and be recognized by the eye ; if this be impossible, it may easily be differentiated by ihe touch tliroiigh the membranes by observation of the following points : The foot is to be distinguished from the hand by the presence of the malleoli and of the ])niminence of the heel, and by the facts that the great toe is of equal or jrnater length than the others and is j)lac(Hl in the same plane with them ; while the hand is recognized by the absence of the heel, by the fact that it can be placed in direct continuation of the line of the lind) to which it is attached, and that the thumb is shorter than the fingers and can be opposed ndinff the "cci^^ffe- 416 AMERICA X TEXT- HOOK OF OnSTETRICS. to thoni. Tlio ini|K>rtaiice of avoidiiif; rupture of the membranes in such presentations is, however, so great that it is usually best to trust to the results of external palpation. Presaifdfious of the Kiire and the FJbnv. — The knee may sometimes be dis- tinguished from the elbow by the presenc' of the patella; but, sinee the latter is small and not always easy of recognition, it is best to distinguish between these two joints by following the course of the limb to its termination in a hand or a foot as the case nuiy be. TranHvcrse Pirfimtutioua. — The shoulder is liable to be mistaken only fur the breech, from which it may be distinguisheil by the presence of but (uic limb in place of the two which are attached to the jielvis, and by recognitidii of the smooth riilge of the scapula as opposed to the rough spines of tlic sacrum ; recognition of the clavicle and the ribs will also assist the diagnosis ; but tlio recognition of a shoulder by vaginal examination is extremely dilli- cult, and the existence of the presentation is ])ractically ascertained, in tlic majority of cases, by external palpation, without assistance from vaginal examination. In presentations of the hand it is sometimes possible to make a diagnosis of position by observation of the hand alone ; to this end it is first necessary to determine which hand of the fetus presents, this being best ascertained bv attempting to shake hands with the presenting part, the right hand of the fetus coming into position to shake hands with the right hand of the physician, and the left with tiie left. If the presenting hand be turned by rotation of the forearm into forcetl supination, the thumb points to the side on which lies tlic fetal head, and the back of th.e hand corresponds with the back of the fetus ; l)nt in actual practice the attitude of the chihl so seldom corresponds exactly to any one of the four classical positions that this evidence is of comparatively slight value, and is only to be use<l as confirmatory of the results of palpation. FuKQUENTY. — The vertex ])resents in about 97 per cent, of all labors, the breech presents in about 2 per cent., and the remaining 1 per cent, is niado up of brow, face, and transverse presentations, the latter two being the more frequent. f'jyjfijapsis. — Vertex Presentatlont^. — In vertex presentations the jn'ognosis lother and child is better than in any other variety of labor. It Jwever, to some slight degree with the position, being better in antc- rKn^nuTn in posterior positions, on account of the somewhat longer and more difficult labors which are to be expected, as will be seen, in the latter. Face Prenentntions. — In face presentations the prognosis, though not neces- sarily bad, is always worse for both mother and child than in vertex cases; for, although the majority of face labors are terminate<l with safety and rapidity by tiic efforts of nature, yet in the comparatively small number of ^ cases in which an arrest occurs, and in which art must step in, the delivery is often extremely difllicult. The prognosis for the mother is that of the opera- tion indicated, but in the operative delivery of face cases the dangers to the fetus are always, iwctiliarly great. THE MKCHANISM OF LABOR. 417 Brow PresmtationH. — In brow prpsontations the prognosis for both patients is tliat of ilio ojKiration i)y which tije case is delivcral. It is therefore neces- ,«;iriiy worse than that of vertex presentations. Breech Presentations, — In breech presentations the prognosis for the mother is only altered from the normal by the fact that the rapid extraction of the :ifter-coming head and arms that is very freqnently necessary is attended l)v a greatly increased liability to perineal and cervical lacerations. The prognosis for the child is always bad, especially among primiparse or with women who for any other reason have rigid soft parts. Transrerse Presentations. — Transverse presentations must always be termi- nated by art, and the prognosis varies with the period of labor at which inter- li'i'once is undertaken. In uncomplicated transverse jiresentations an early version is Jisually easy, and the prognosis for both patients is therefore good. In neglectal cases the operation is always difficult, and the prognosis for both ]):itients is bad. ^ t^ 1. Yertkx Presentations. Frequency of Cephalic Presentations. — At the end of pregnancy the ccplialic end of the child presents in about 97 |)er cent, of all cases. In !I7,871 births in private practice Spiegelberg found head presentations in over 97 per cent. In 23,000 tases confined in Guy's Hospital Lying-in Charity the percentage of head presentations was 9G.9. Premature delivery and stillbirth of the fetus decrease greatly the proportion of head pres- entations. Thus, Collins found that head presentations occurred in 97 per cent, of living children amitng about 16.000 deliveries at term, and in only about 80 per cent, among 500 births of putrid fetuses. Churchill found that at seven months only 83 per cent, of living and 53 per cent, of dead children are born by cephalic presentation. DuRois found 83 to be the percentage for living children and 45 for dead children at the same perio<l. It is found that (hiring the latter months of pregnancy changes in the jiresonting pole of the fetus occur once or more in from 35 to 40 per cent, of all eases. The change from a pelvic or a transverse jiresentation to a cephalic, however, is very much commoner than the loss of a cephalic presentation. The latter would therefore seem to be the position of more stable equilibrium, and it will be found that these observations — namely, the decreased percentage of head presentations among premature and stillborn children, and the greater stability of head presentation as compared with any other — have an important hearing upon the etiology of the presentations. Relative Frequency of the Four Positions. — In about 75 per cent, of all cephalic presentations the occiput is found upon the left side of the mother, and in more thf i 73 per cent, of this 75 ])cr cent, the position is anterior — that is, O. L. A. In the remaining 25 per cent, the occiput is of course (lirocted to the right side of the mother, but the determination of the relative frequency of right anterior and right posterior positions is not so easily do- tcrniined, there being great differences of opinion upon this point among 27 V"*>^_,, ...-4J 418 AMERICAN TEXT- HOOK OF OJiSTETRICS. different olwervors, the key to tliis tlifferencc of opinion beinj; probably found in their adoption of different pcrimls of labor for the deternii nation of the position. In a larj^e proportion of those cases in whieh the occiput is to the rifrh^ and somewhat anterior at the vc 'v lK«jjinninjj of labor — that is, before the head is even pressal iiito the superior strait — the position becomes right j)os- terior as soon as engagement owiu's. It is probable that some observers have classified such cases as O. I). A., and others as C). D. P. Again, the enormous majority of right posterior positions become right anterior by rotation during the sec(md stage of labor. An observer who made his diagnosis only during the latter part of the second stage would class all such cases as anterior posi- tions. It is certainly a fiict that the vast majority of right positions are right posterior positions at the time when the greatest diameter of the head occupies the sujKTior strait ; and if this peritxl of labor be selected as the time when the j)osition should be determined, it is safe to say that nearly 75 per cent, of all cases are primarily O. L. A., and almost 20 per cent, are primarily O. D. P. Of the small remainder, almost 4 per cent, are primarily O. D. A., and but a little over 1 jier cent, are O. L. P. Etiology of Presentations. — Three conditions have Iwen urged as chiefly contributing to the fre(iiiency of cephalic presentations, and it seems probable that the true cause must be found in a combination of all three conditions, which probably vary in their importance in individual cases. These three causes are — first, the effwt of gravity ; second, the easier adaptation of the fetus to the uterine cavity in head presentations; and third, the effect of active movements on the part of the fetus. In estimating the relative im|)()rtance of these factors in the etiology of head presentations, it is evident that to attain the truth it is necessary to reach a conclusion which will explain the results of clinical observation recorded aoove, and whieh will make evident not only the reasons for the great prepon- derance of cephalic presentations of the fetus, but also for its variability in accordance with the period of delivery and the condition of the fetus. The lujfuence of Gravity. — It has been found by experiment that if a re- cently-dead fetus at term be immersed in a saline fluid of the specific gravity of the liquor aninii, it tends, under the influence of gravity, to assume an obli(|ne position, with the head lower than the breech and the right side lower tliiiii the left. This fact is exj)laincd by Matthews Duncan, who has shown that the specific gravity of the fetal head is greater than that of the decapitated trunk, and that the greater specific gravity of the right side is due to the enormous relative size of the liver in the new-born child. It is evident, then, othtT conditions being equal, that we may expect, in a preponderance of cases, to find the head and right shoulder of the fetus in that portion of the uterus which is horizontally lowest in the ordinary positions of the mother. The ordinary positions of the mother may be considered in this connectidu to be three — the vertical position of the trunk, the horizontal position in a dorsal decubitus, and the horizontal position in a lateral decubitus. Wlun THE MECHANISM OF LABOR. 419 obably ion of ^ rl^lit )re th(( it JHtS- rs have ormous (luriiifr <luriii«!; or posi- 0118 arc lie head the time f 75 per riinarilv ). D. A., „s chicHy ])robal)ie lulitioiis, esc tlint' n of tlie of active ogy of to reacli reconleil prepon- )ility in us. if a re- avity of oblitiue er tluiH tliat tlie trunk, iiormoiis 1, other ases, to uterus lincctioii m in a 1 When the tnuik is erect the anterior uterine wall is inclined to the horizon at an .•in«?Ie of about 35°, and the lowest portion of the uterine cavity is to be |()und in the neighborluMxl of the pubes. Most pregnant women are in this position — that is, either standing or sitting — for about two-thirtls of the twenty- four hours, and it is consequently the most important of the three positions in this connection. In this position of the mother the child would tend to assume, iHider the influence of gravity, precisely tiie ix)8ition in which it is usually liiuiid — that is, a vertex presentation, O. L. A. — and in the absence of disturbing elements it will l)e in this relation to the mother about two-thirds of the time. When the woman lies upon her back the posterior uterine wall is inclined t(i the horizon at an angle of about 55°, and the lowest portion of the uterus is in the neighborho<Ml of the promontory. Thus, in this position also the influence of gravity tends to maintain a cephalic presentation.* When the woman lies upon her side the lowest point of the uterine cavity is usually near the fundus and toward the side upon which she reclines.f In this position, then, the influence of gravity would be exerted against the maintenance of a cephalic presentation ; and since the lateral decubitus is maintained by most pregnant women for the greater part of that third of tiic'ir time which is spent in bed, it is evident that the influence of gravity would not, by itself, be a suflicient cause for the appearance of a cephalic ])r('sentation in so large a number as ninety-seven out of every one hundretl labors ; but since, from the influence of gravity alone, it is probable that the head would maintain, other influences being excluded, a cephalic presentation (hiring the greater part of the time, it is fair to assume that this furnishes a predisposition toward the existence of a cephalic presentation in any given case. When, moreover, we investigate the relation of this factor to the varia- tion in percentages due to premature births and stillbirths, we find its influ- ence so entirely in accord with the results of clinical observation as to add still further proof of its importance. Thus, Dr. Duncan found that when a child dies in utero before labor, the specific gravity of its head is less than tliat of a living child, and the body, when uncontrolled, often actually floats head uppermost in a saline fluid. Again, it is highly probable that the rela- tive difference between the specific gravity of the head and that of the body is less among premature than among full-term children, since we know that the proportionate development of the brain and the cranial bones, in compari- son with that of the body, is much less during the early months of pregnancy than it becomes at term. It may with propriety be coneetled that the greater specific gravity of the cephalic pole of the fetus is a predisposing cause of head presentations, and it only remains to be determined whether the other causes arc sufficient to main- tain this position when once established. * Tliongli with the back of the fetus toward the back of the mother (see Etiology of Posi- tion, p. 422). t When the woman lies njion her riffht side the influence of gravity tends to tnrn the back of the child forward, and when slie lies upon her left side tends to turn it backward. rV 'is 4 i^ mM 420 AMKIilVAX rKXT-nOQK OF oustethics. Athtjdaiion between Ftinx (iiul I'teruti. — It is iisiiul to coiisiilor the ntonis as a flaccid mass which rcatlily iiiuulds itself to the sha|K' of its oontoiits or its surroundings ; hut when we renjenilK'r that during each contracrtion the uterus straightens itself and tends to a.s8unic a definite form, and tliat, moreover, there is undoid>tedly a |>r(XM;ss of slight rhythmic contraction going on through- out the whole of the latter part of pregnancy, it is evident tiiat the uterus must be regarded as a IkmIv which has, to some extent at least, a definite, in- trinsic sha]H>. It has, moreover, Ixjen determined by post-niortom examina- tions that tiiis 8ha|H< is one which alters, and alters in a definite direction, during the development of tiie uterus. At and for sonic time Ixjfore the fifth month tlie uterine cavity is nearly spherical (Fig. 232), and is very large as compared with the still small and undeveh)i)e<l fetus ; but from this time on the cavity becomes progressively i\f^ •,"f I i < Fio. 232.— Kclativf sizeipftlii' fctUMiiid tlio utiTine ciivity lit till' tillli niiiiitli. Fi(i. 2:!;t.— Adaiitmiiiii lntwH'i'ii till' uttTiis and till' feliis at tiTiii in vortix pri'sentatioii. more and more ])yriform, until toward the end ** pregnancy it assumes the ilvfinitely pyriform shajK? shown in Figure 233. The uterine cavity, at term and under normal conditions, is but little larger than the fetus. It is, moreover, evident, on comparing the shape of the fetus in its ordinary iiftitudc with the shape of tho uterus at term, that in head presentations (Fig. 233) the fetus and tiie uterus are extremely well adajited to each other, i)iil vhat in breech (Fig. 234) or in transverse ])resentations one ])ortion of tiie uterine muscle is subjected to an undue amount of tension, while other por- tions are unduly relaxed ; therefore any change from the cephalic to either :i brcHH'h or a transverse presentation will be op))osed by the contractile power of that portion of the uterine muscle that would he overstretched in the new ]>resentations ; that is, we may assume that the shape and contractility of tiie uterine walls tend to ])reserve a cei)halic presentation whqji this is once well established, and that the rhythmical contractions would probably tend to rc- eatablish it when lost. It is safe to assume, then, that the shajKi of the uterus may be considered an imjiortant factor in preserving a cephalic presentation THE MECHANISM OF LAJiO/i. 421 Fin. 2^.— Adaptation J>cfwpoii the fetus and the \itt'ru.s Hi term in breeiii prenvntHtlon. when tliis has once l)oen estnblishal by the inflnencc of gravity, and that its in.sonsil>le contractions fnrnisii an influence of ini|)o;tan(rf> in re-establishing a hcatl presentation when this has been lost. Injliient'c of the Feiul Movemenl»f, — Since the fetal movements arc accidental and independent of any volitional impulse, it is probable that their occurrence would be insufficient to effect any con- siderable change in the relation of the fetus to the uterus unless in an ex- tremely relaxinl condition of the uterine mid abdonunal walls, and that even in siurh uteri the change would Ihj likely to (K-cur oidy when the position of the mother addcnl the influence of gravity to the effect of fetal movements. It is evident tiiat even in such cases the operation of the same causes would probably tend to a spee<ly assumption of the cc;ib;>|ic presentation. Couehmonii. — It is now necessary to Oil. ider how far the ctmditions just enumerated explain the observed facts quototl at the beginning of this section . First, that cephalic presentations pre- ponderate in tiie proportion of 97 to 3 ; necond, that this preponderance is much decrease<l by both premature deliveries and stillbirths ; third, that the change from a pelvic or a transverse presentation into a wphalic is very much more common than the loss of a cephalic presentation ; and fourth, that both abnormal presentations and changes of presentation are much commoner among multiparte and when the quantity of liquor anuiii is large. X First. — The existence of a condition, the influence of gravity, that tends to establish a cephalic presentation, and that is operative for two-thirds of the time, in combination with other conditions which render any other presentation unstable, and which are operative all the time, is, in the absence of anything which favors any other presentation, sufficient to account for almost any per- centage of preponderance of cephalic presentations. Second mid Third. — In the middle of pregnancy the shape of the uterine cavity is nearly spherical and its size is greatest as compared with that of the fetus; the latter is but little developed and the presentations are totally un- certain. During the sixth and seventh months the conditions ajiproach nearer to those observed at ter ""i ; but even in the eighth and ninth months tlie differ- ence in the specific gravity t)f the cephalic and pelvic ends of the infant is less marked than at term ; the pyriform shape of the uterus is less strongly marked, and the adaptation between the uterus and the fetus is less close ; that is, all the factors which we have been considering as im])ortant in the production of the preponderance of cephalic presentations have less value than at term. We find by observation that at these periods the preponderance of •«■ i i ; 1 ; i in iii 422 AMERICAN TEXT-BOOK OF OBSTETRICS. r 1 ,! I ill I I i:'itfl ^1 I' • vm M>r V ''■>^- cephalic presentations is oorresponilingly decreased, and that spontaneous changes of presentation arc corresiM)ndingly muc'h more frequent than at the end of pregnancy ; we a'^>, then, justifietl in onr belief in the importance of these factors. Fourth. — These considerations are in fidl accord with the observed fact that both abnormal presentations and changes of presentation occur most frequently in multipara) with relaxetl uterine and abdominal walls, and are but rarely seen in the more rigid condition of the muscles that is characteristic of first pregnancies. So, too, it is fully establishe<l that these changes and abnormal presentations occur much more frequently when the quantity of liquor amnii is relatively so great that the uterus tends tlu'ough distention to acquire a more nearly spherical shape, and when the limbs of the fetus ave accordwl much greater freetlom of movement. As a result, it seems safe to assume that the influence of the relatively greater specific gravity of the cejihalic pole of the fetus is the predisposing cause, and that this, together with the intrinsic shape of the uterine cavity and the influence of the movements of the fetus, are the maintaining causes of the great preponderance of cephalic presentations. Etiology of Position. — It has already been observed (p. 419) that in the erect j)osture of the trunk, iisually assumed by the woman for two-thirds of the twenty-four hours, the influence of gravity tends to the production of an O. L. A. position, and in the remaining one-third of the twenty-four hours the influence of gravity varies with the decubitus which the woman assumes in bed. Therefore it may safely be assumed that any conservative factors which appear late and ten«l to fix the child in any position in which they find it are more likely to find it O. L. A. than in any t)ther jiosition. Sucli a factor is to be found in the shape of the suj)erior strait. The jireseuce of th(> rectun^in the left ilio-saoral notch renders the second oblique diameter of the pelvis less ample than the first, so that if the oblique cross-section of the head that is ordinarily ])resentetl to the pelvis at the inlet rests with its long diam- eter in correspondence with the second oblique diameter at the brim, the head is less easily areommodated than if it is presentetl to the first oblique diameter. It will, then, as the adaptation becomes progressively tighter and tighter, tend to remain in the first oblitpie diameter for longer periods than in the second ; that is, it will be dislodged with diffit-ulty from the first oblique diameter, and with ease from the second by any slight cause ; and since the influence of gravity tends during the greater part of the time to turn the occiput forward, a head which occupies either an O. D. A. or an O. L. P. position will tend to become (). L. A. rather than anything else. The maintenance of an O. D. P. position is, moreover, rendei-(Hl comparatively unlikely from the fact that the shape of the head is loss well adapted to that of the pelvis in this jiosition. Changes of position are, in fact, extremely I'requent until within the last few- weeks before delivery, and the position, moreover, is never finally determineil until the head engages at the brim. Diaernosis. — On abdominal examinatUm the head is found at the inlet ; the TUK MF.VIIANli^M OF LABOR. 423 fotal liiul)s ami the most nocossiblc end of tho head arc found on one side of tlie alnlonien, and the heart on the otiier. On vof/inal examhiafion the finger ^honld recognize the small fontanelle on one side of the pelvis, and bv follow- ing the sagittal sutnre should find the large fontanelle on the other. The ears should always, and the mastoids and lateral fontanelles shoidd usually, be felt at the ends of the lanibdoidal sutures. Prognosis. — The prognosis for both mother and child is better than in any other variety of labor."^ A. Mechanism of the First Stage of Labor. It is customary to divitle labor into three stages. Tlie first stage comprises the time occupied in the dilatation of the os ; the second, that expended in the descent and expulsion of the child ; while the third is occupied by the birth of the placenta. For purposes of description it is well to consider the three stages as being sharply divided from one another, but it must bo remembered that clinically tiie division between the first and second stages is often difficult and indefinite, since the final stages of dilatation are not infre<|uently accomplished only dtu'ing the descent of the head ; and for clinical ])urposes it is well to define the end of the first stage as occurring whenever the os is fully dilated or dilat- able, it being understood that the expression '' fully dilatable" refers to a con- dition in which the os, though still iii'.perfectly dilated, has become so soft and elastic as not to offer any efficient obstacle to the descent of the presenting part. To understand exactly the njcchanisni of labor it is necessary to discuss first the forces by which the process is accomplished, and next the manner in which each force acts during the different stages of labor. The forces by which labor is effectetl are those produced by the contraction of the uterine antl abdominal muscles, together with such inHucnce as can be effected by the weight of the child and the waters. The uterine muscle acts in two ways: first, by diminishing the intra-uterine urea and thus creating a general intra-uterine fluid-pressure due to ti»e contrac- tion of the uterus upon the fluid contents of the utn'uptured ovum ; second, by the fi)rce of dii'cct contact between the breech and the fimdus of the uterus whenever a rupture of the membranes and the consequent escape of the waters jiermit this contact to occur. Direct contact may also occasionally oc(!ur, as will be seen later, before the rupture of the membranes. The abdominal muscles when set into voluntary contraction reinforce both forms of action of the uterine muscle. When the uterine muscle is in direct contact with the breech, the abdominal nniscles, lying in close contact with the uterus, add their force to that which the uterus itself exerts against the child ; when the child is protected from contact with the uterine walls by the ])resencc of a quantity of liquor amnii, the contraction of the abdominal muscles again adds ii, elf to that of the uterine wall, and thus adds its incrcn)ent to the general intra-uterine fluid-pressure. The force of gravity is inactive in many positions of the mother, and is at most an increment of but small importance. ^;l I II 8' ■■ m u- :j ''i it> •i -i 'if !in- '!' |i#|il lit ' 424 AMERICAN TEXT-BOOK OF OBSTETRICS. it*^ «-«^ In considering the manner in which the above-mentionetl forces are employed in effecting the dilatation of the os during the first stage of labor, it is neces- sary to consider several variations which may occur in the mechanical con- ditions. When the waters are abundant and the membranes persist unbroken throughout the first stage, the dilatation is usually accomplished by the action of the membranes only. This may be considered the normal mechanism of dilatation, and must be describe<l first, after which it will be proper to take up the various conditions in which, from one cause or another, the membranes cease to act their proper part, and tlie dilatation must be accomplishetl by the pressure of the fetal head against the cervix. Normal Mechanism of Dilatation. — In the first instance — that is, when the waters are abundant and the menibranes are intact — the position of the fetus is unaffected by the intra-uterine fluid-pressure. It is an axiom in phys- ic-s that fluid-pressures, however pro- duced, are invariably equal and oppo- site in all directions, from which it fol- lows that, the pressures A (Fig. 235) being equal and opposite to the pres- sures B, the child will be uimioved by the uterine contraction. Similarly, the fluid-pressure upon any one portion of the uterine wall being equal to that ex- erted upon any other portion of equal area, there would be no effect, even upon the shape of the uterus, if its entire surface contracted at once and if its walls were of uniform strength throughout. The initial stages of dila- tation of the OS are in reality to be referred to the fact that the lower uterine segment possesses less muscular strength than the upper part of the uterus, and to the character of the uterine contractions. Neglecting for the moment the latter factor, and limiting the discussion to the effect of the different strengths of the upper and lower uterine segments, we shall see that the contraction of the more powerful upper part of the uterus forces the less j)owerful lower portion open, notwithstanding its efforts at contraction. The total force exerted by the uterine contractions results in the application of a uniform centrifugal pressure upon all portions of the containing wall. The amount of this pressure upon any given unit of surface — as, for example, a square inch — will, of necessity, be ecpial to the average force exerted by tiic same superficial extent of the uterine wall ; hence it follows that at any portion of the viscus where the strength of the wall is greater than the average the contracting centripetal force will tend to overcome the resulting centrifugal /.v. Fir.. 235.— Diagram illustrating the ab.sence of altLTQtion in the nttitudo of a child by the actiun of opposite and equal fluid-pressure.s. THE MECHANISM OF LABOR. 425 force, and the result will be a decrease in the extent of the uterine walls at that point. Similarly, at any point where the strength of the uterine wall is below the average the expanding centrifugal force of the fluid-pressure will be greater than the centrijwtal force of the contracting muscles, and at such points, therefore, the expanding force of the fluid-pressure will tend to over- come the contracting force of the uterine muscles, and there will be a conse- quent increase in the area of those portions of the uterine wall. Now, the lower uterine segment is by all odds weaker than any other portion of the uterus ; it therefore tends to expand during the contraction from the action of the general intra-uterine fluid-pressure. The circular portion of the uterine area, which is opposite to the lumen of tiie vagina, is, moreover, unsupporte<l by the general intra-abdominal pressure and by the force of the tonicity of the al)dominal muscles that is exerted upon all the other portions of the uterus — a fact which, by decreasing the centripetal force, still further increases the surplus of the centrifugal element at this point. As a matter of fact, at the beginning of labor the first influence of the uterine contractions is seen in the assumption by the lower uterine segment of a more expanded shape, such as shown by the (lotted outline in Figure 236. Moreover, since at one point in the lower uterine segment the cohesion of its substance is still further lessened by the existence of a solution of continuity, the lumen of the OS uteri, it is evident that there will be a still more marked tendency to expansion at this weakest spot, resulting in a tendency to dilatation of the OS. To these considerations must be added the effect of the peculiar composition of the uterine muscle and of the peculiar character of its contractions. It is essential to remember that this highly composite muscle is made up of inter- lacing fibres, whose action may mechanically be divided into one set of longitutlinal and one of circular stresses; that is, if the action of those fibres having an oblique direction be resolved, as is physically allowable and proper, into their longitudinal and transverse resultants, the action of the whole will U found precisely c(jual to that which would be exerted by two hypothetical sets of fibres, of which the first and m(»st powerful set directly encircle the ute- rus in horizontal zones, while the second and less powerful set extend upward through the margin of the os, cross the fmidus, and thence passing down to reach the margins of the os at points opposite to their origins. If a uterine muscle so composed were set into action, it will be seen that, Fin. 2.'i6.— Diagrams showing tl)e diminution of tlie iippiT uterine scKiiiont aiui tlie expansion of tlie lower segment during eaeli eontraction. s. \ k. ^■A-' ..+^1 8-^Wr "f*^? mm ll 426 AMERICAN TEXT-BOOK OF OBSTETRICS. V\ il . I t, '\ y I from a mechanical standpoint, the circular fibres surroundinj^ the os would by their contraction tend to keep it closed, while the longitudinal fibres, acting in opposition to these, would by their contraction tend to open the os by drawing its margins apart over the contained ovum. This conception, though somc^- what more simple than the actual anatomical fact, is mechanically essentially correct; but, since the circular stresses are the more powerfiil, it is evident that this arrangement cannot result in the dilatation of the os unless compli- cated by the presence of some additional factor. This factor is found in the circumstance that the contractions of the uterine muscles, like those of all the hollow viscera of the body, are peristaltic, and that the rhythmic contraction of the uterus begins at the fundus and passes gradually down to the cervix. Each contraction of a given part of the uterus is preceded and followed by a relaxation ; but since, from t!ie interlaced arrangement of the fibres of the uterus, the contraction of any portion of its surface necessarily exerts a longi- tudinal strain, it will be found that the outward stress upon the margins of the OS remains nearly constant, while its circular contraction is intermittent ; it is probable that the initial dilatation of the os is largely due to the constancy of the longitudinal and the intermittoncy of the circular strain ; that is, the first gains in dilatation are made at moments when the uterine muscles of the lower uterine segment and the cervix are relaxetl, but when the general fiuid- pressure is maintained by contractions of the unper ])ortions of the uterus. As the internal os and the upper ])ortion of the cervix dilate under the action of these forces, a new mechanism comes into play through the elasticity of the membranes, which bulge through the circle of the os and enable the intra-uterine fluid-pressure to take direct effect upon its margins. As this process continues the internal os becomes effaced, the cervix is shortened and ■m -m^ Fif!. 237.— DiiiKram illustrntiiiK the dilatntion of the OS by tlic niumbrancs. If the npplication of the lliiid-pressure to tlio os {(it riKht nntiles to the surface of tlie nieinbranes at tliis point) is repre- sented by the direction of the arrow, and the amount of the force liy the length of tlie diagonal line wliieli continues the arrow, the amount of force tliat Is api>licable to tlie dilatation of the os is represented by tlie length of the line A. Fiii. 2.18.— Diagram illustrating the dilata- tion of the OS by the membranes. All the con- ditions are identical with those of Figure 'Jl!7, ex- cept that the membranes have a greater con- vexity ; tlie direction of the arrow is therefore more obli<iue, and the force ellicient for dila- tation, represented by the line a, is greatly In- creased. disappears, and finally the external os itself is in direct contact with the mem- branes and begins to receive directly the effect of the longitudinal stresses. As the external os dilates the membranes again bulge forward into its lumen, and the force of the fluid-j)ressure becomes directly active upon its margins. The force so exerted is directly proportional to the convexity of the membranes, and increases as the convexity increases — a fact which is explainable by well- THE MECHANISM OF LABOR. 427 known physical laws as follows : The force of fluid-jiressuro, in addition to being opposite and equal at all points, is always exerted at right angles to any surface against which it is applied. If it is necessary to ascertain what portion of the force is exerted in any given direction, it is only necessary to break up the internal force into its elements by the construction of a parallelo- gram of forces, such as is described in all elementary treatises on niechanics and illustrated in Figures 237 and 238. Figure 237 exhibits the influence of the general intra-uterine fluid-pressure when the conditions of the case allow but a slight convexity to the unsupported portions of the membranes. The expan- sive element of the fluid-pressure is here represented by the line A, while in Figure 238, where the convexity of the unsu])p()rted membranes is much greater, the expansive element of the force will be represented by the length of the much longer line A : from this it follows that, other things being equal, the rapidity of dilatation will be proportional to the degree to which the mem- branes project through the os. As will be seen later, the same considerations are equally applicable to the action of the head in producing dilatation after the rupture of the membranes. The familiar clinical fact that the closing stages of dilatation are usually much more rapid than the beginning stages is fully explained by the foregoing considerations, taken in connection with the equally familiar fact that the contractions of the uterus tend normally to become stronger and stronger throughout the process of labor. In the more normal form of the mechanism of the first stage — that is, so long as the membranes remain intact — the progress of the first stage of labor is dependent maiidy upon the first form of force which the uterine muscle is capable of exerting — that is, the force of the general intra-uterine fluid-pres- sure — and the membranes are the dilating agent. The second form of force, that of the direct pressure of the uterine muscle against the child, is under these circumstances inoperative, while the fact^that the voluntary muscles of the abdominal walls are but seldom brought into j)lay by the patient^ reduces the action of the remaining or auxiliary forces, in this form of the mechanism of the first stage, to the small reinforcement of the general intra-uterine fluid-pressure, which is due to the general intra- alxlominal pressure constantly exerted by the tonicity of these muscles. Mechanism of Dilatation of the Os after Rupture of the Membranes, with Partial or Complete Escape of the Waters. — Partial Encape. — After the rupture of the membranes the liquor amnii tends to drain away until its escape is stopped by the contact of the presenting j>art with the margins of the OS (Fig. 239). In this condition the presenting i)art forms with the circle of the OS a ball-valve ; the general intra-uterine pressure is concentrated upon its upper surface, and its descent is opposed only by the comparatively feeble resistance of the cervix. When this condition occurs the portions of the fetus that correspond with arrows marked A' and li' are still affected by pres- sures whicih are opposite and exactly equal to the propelling force exerted upon the portions which correspond with the arrows A and B, but the propel- ling force represented by the arrow C is opposed only by the resistance of the mm I ■|| i^l I: M * 4," '•i'. 428 AMERICAN TEXT-BOOK OF OBSTETRICS. unsupported cervical and vaginal tissues, against which the head is pressed by a force equal to the effect of the intra-uteriue fluid-pressure upon an area c Fio. 239.— DiaRram illustratlnf; the mnnner in which the gviieral intru-utiTiiie fluid-pri'ssure lioconu's propulsive after the rupture of the memlinmes. Fig. 240.— PiaRram illustrating the dilatation of the OS by the head. The total force is again repre- sented by the oblique line, and the force which is ap- plicable for dilatation is represented by the line .rl. equal to the transverse area of that zone of the uterus whore the head Hrst conies in contact with the walls — that is, the surface R to R'. From the coni])arative rigidity of the spherical head it can exert but little direct expan.^ive force upon the margins of the OS during the early stages of dilatation (Fig. 240) — a fact which ex- plains admirably the relatively slow progress of dilatation after early rup- ture of the membranes. When, how- ever, the OS has so far dilated as nearly to admit the greatest circumference of the head, its action is that of a slightly tapering wedge, by which almost the whole power of the propelling force is transmitted into an outward pressure of the margins of the os, and which must compel an extremely rapid com- pletion of the dilatation * (Fig. 241). It will be seen that in this second form of the mechanism of the first stage the force employed i.s still that of the general intra-uterine fluid-pressure, but that the dilating agent is now the head. * It will be seen tliat this fact is an adequate explanation of the greater frequency of laceration of tlie cervix when a rupture of the membranes results in the completion of the dilatation by the direct pressure of the rigid head. Fio. 241.— PiaRram illustratinR the diliitation of the OS by the head. The total force is repre- sented by tlie obli<iue line, and the force applic- able for dilatation is represented by the line A. THE MECHANISM OF LABOR. 429 After Complete Escape* of the Waters. — The escajie of auy considerable quantity of tlie waters usually results in contruotiou of the uterus sufficient to iKjrmit of firm contact between the fundus and the breech of the child. The ibrce of this contact is then transmitted to the head through the vertebral (ioluinn of the fetus. At first sight it seems unlikely that any considerable force could be transmitted through so flexil)le a rod as the vertebral column of an unborn child. This transmission is, however, rendered possible by the ibllowing conditions: It is an observed fa(!t that during a contraction the long diameter of the uterus, far from being decreased, is actually lengthened. This l)henomenon is due to the superior strain of the circular stresses, which by tlieir greater force decrease the antero-posterior diameter of the uterus and thereby f increase its length (Figs. 242, 243) ; the lateral uterine walls, at the Fio. 242.— Diagram illustrating the alteration Fio. 213,— Diagram illustrating ttic alteration i^the shape of a oross-seetion of a uterus during in the shape of a sagittal seetion of the litems its eontraetions. The heavy line represents the during its eontraotions. The heavy line repre- non-eontracted, the dotted line the contracted, sents the non-contracted, the dotted line the con- uterus (compare Fig. 213). tracted, uterus. same time, come into strong contact with the siu'face of the fetal body, and so straighten out the child, thus increasing the violence of the contact between the breech and the fundus, and affording a firm supporting surface which pre- vents any bending of tlie vortebne, and converts the backbone for the moment into a mechanically rigid rod which is fully capable of the transmission of force. When this form of mechanism obtains, the head acts as the dilating wedge, and the second form of force, that furni.shed by direct contact between the breech and the finidus, is alone active. Mechanism of Dilatation of the Os with Originally Scanty Waters. — It occasionally happens that the waters are originally so .scanty in amount as to ])ermit direct contact between the breech and the fmidus to occur early in the first stage. Under these circumstances the head is brought into close contact with the OS at the beginning of labor. The nuH^hanical conditions are now clo.sely similar to those which obtain after the escape of the waters, with the single exception that if the membranes are tough and inelastic their tension may somewhat impede the progress of the head. * This term, though conventional, is inaccurate, tis tliere is almost always some liquor left in the uterus. t The ovum being incompressible. I m m 'W ( i iJ h t I ti\ ,4 wl i hi* I f I 430 AMERICAN TEXT-BOOK OF OBSTETRICS. m I i ;l: 'ih K t* \i H y \\ '1 ' i t 3 Mechanism of Dilatation with Undue Elasticity of the Membranes. — If the membranes are unusually elas- tic, it may sometimes happen that after the formation of a considerable pouch of membranes in advance of the head, the volume of the uterine contents may be lessened sufficiently to permit the head itself to be brought into close contact with the margins of the os, by the force of a perhaps temporary direct contact between the breech and the fundus. In this jiosition, if the head is in contact with the entire mar- gin of the OS, it forms with it a ball- valve by which the " fore-waters " are entirely cut oif from the uterine con- tents. The pressure, C (Fig. 244), is now opposed only by the elasticity of the membranes and of the vaginal tissues. The general fluid-pressure is no longer exerted against the margins of the os, and the conditions are mechanically sim- ilar to those illustrated in Figure 239. Fio. 244.— ningrain illustratiDg the formation of a biill-valve by fontact between the lieail and the edges of the os. The waters behind the head are exposed to the general intrauterine fluid- pressure, while the fluid-pressure in advaneeof the head is only created by tlie elasticity of the fetal membranes. B. Mechanism of the Second Stage of Labor in Vertex Presentations, O. L. A. The second stage of labor is commonly dividal into three sub-stages : The descent and expulsion of the head ; external restitution ; and the delivery of the trunk. The adaptation between the normal head and the pelvis is so close that for the accomplishment of the de.«icent and expulsion of the head there is retpiired the occurrence of a set of somewhat complicated movements which are, in fact, e.s.sentially one single complex motion. This motion consists of three elements : (1) The descent of the head tiirough the pelvis; (2) a change from the partially extended position which the head normally occupies at the beginning of labor to one of complete flexion ; and (3) lateral rotation of the head within the canal, from the oblique j)osition which the suboccipito-bi'egnmtic diameter occupies at the brim to the antero-posterior position in which it emerges from the outlet. Although it is necessary in discussing this motion to describe its components separately, it must not be forgotten that no one of its parts am proceal to its accomplishment without the coexistence of the others. Thus, descent can be accomplished only during the existence of flexion, while flexion is produced only by tlie act of descent. So, too, the final stage of descent, known as expulsion, is normally imj)ossible without rotation, while rotation occurs only during the descent of a fully-flexed head. The most intelligible THE MECHANISM OF LABOR. 431 wav of (loscribing these highly complex phenomena is by a chronological study of the mechanical conditions which occur and succeed each other during the stage of descent and expulsion. Descent. — It is necessary, in doscyibing the mechanism of the second stage, to iK'gin by considering tlie action of tiie forces by which the mechanism of this stage is effected. So long as the fetus is exposed on all sides to contact with the liquor amnii, the contractions of the uterine and alxlominal muscles can produce no effect upon it other than that of subjecting it to a uniform fluid-pressure, equal and opposite in all directions. In point of fact, the mech- anism of descent does not begin until the presenting part is cut off from the liquor amnii by coming into apposition with the edges of the os. As was implied in the last section, this contact may happen in cither of two ways: First : AVhen the mechanism of the fii-st stage is such that the head comes into close contact with the margins of the os before any considerable quantity of the liquor amnii has escaped from the uterus, it forms with the os a ball- valve (p. 430), by which the remaining part of the waters is retained witiiin the uterus; and the occurrence of descent is then the result of the action of tlie intra-uterine fluid-pressure. Tiiis is the nomial — that is, the most usual and the most favorable — rnechaniwi of descent. Second : AVhen close contact between the head and the os does not occur luitil after tiic complete escape of the waters, the uterine muscle contracts upon the child, and the force of the circular stresses (p. 425) is lost so far as the production of descent is concerned, but the breech and the fundus of the uterus come into contact with each other, and the force of the longitudinal stresses is thus still available. This second form of the njechanism of the second stage is commonly called a "dry labor," and such labors are, with reason, much dreaded by obstetricians, because the loss of the powerful circular stresses usually leads to a protracted second stage. Normal Mechunmn of Descent. — The portion of the head that is without the uterus (/J, R', Fig. 239) is opposed only by the resistance of the vaginal tissues. Every other portion of the fetus is exposed to the general intra-uterine fluid-pressure. If it is remembered that fluid-pressures are always equal and opposite, it will be seen that the forces A and B are directly neutralized by the forces A' and B\ and that the force C is opposed only by the comparatively trifling resistance of the vaginal tissues. This force (C) is then practically unop])osed, and is therefore efficient for descent. Mechanism of Descent in Dry Labors,— When the escape of the waters has permitted the uterus to contract upon the child, the advance of the present- ing part is opposed only by the vaginal tissues, and is favored by the force of all the longitudinal stresses of the uterine muscle;* but unless the descent progresses rapidly a localized contraction (p. 429), due to the unopposed action of the circular stresses, leads to a lessening of the calibre of the uterine canal at any point where the diameter of the child is small — for example, the neck (Fig. 245) — and the descent of the child is then further opposed by the fact * And by the auxiliary eflbrts of the abdominal muscles. 415-^ "3 ~ Hill i-f) iV. <V' 432 AM ERIC AX TKXT-JiOOK OF OliSTETRICS. that the shouklors must bo niado to dilato this riiij; — that is, to overcome the tonic contraction of tlie circMilar stresses. In dry labors, then, the force of the circuhir stresses is not only lost as a factor in the jiroduction of descent, but niay sometimes also be opposed to it. ^ Flexion. — At fii*st sight it would seem that the only result to be expected in either case would be tiie occurrence of descent, and that as the head is normally somewhat extended at the beginning of lal)or, this descent would oppose to the iielvic diameters the always ditH<'ult and frequently impossible occipito-frontal diameter. A somewhat more careful examination will demon- strate, however, that the propelling and opposing forces are already so dis- posed upon the head as to favor, from the start, the occurrence of flexion, and that the first movement of descent will, under normal circumstances, tend to bring to the brim the much smaller suboccipito-bregmatic diameter. To this end two factors contribute : first and most important, the articulation of the \^l V W\ ' ! Fi(!. 21').— Constru'tion-rinn about tho lu'ck of tlie child (oni'-.>iixtli niitiiral size). Fig. 'J4(>.— Piannnn of head lover. vertebral column to the skull at a point much nearer to the occipital than to the frontal end of the head ; second, the mechanical effects of the irregular shajjc of the skull. Unequal Lenyths of the Ends of the Hmd, — The effects of the excentric position of the occipito-atlantoid articulation iiujst be investigated separately for each of the three forms of force that may be active — that is, for the force of gravity, the general fluid-pressure, and the force of direct contact with the uterine muscle. Force of Grarlti/. — Whenever the force of gravity is active, it is evi- dent that the weight of the body will be transmitted to the skull through the occipito-atlantoid articulation. If the fetal head is supjmsed, at the begin- ning of this motion, to occupy a position midway between extension and flexion, the occipital and sincij)ital ends of the head, marked o and F resjK>ct- ively (Fig. 246), will rest against the uterine walls, while the force A is applied at the occipito-atlantoid articulation. Since the force is applied nearer to the THE MKCUANISM OF LAJiOJi. 433 occipital end of the head, it is evident that a greater nmoimt of impulse will be conuminicatetl to the occiput; and since the resistances an; of nc(!es,sity (■(pial, the occij)ut will tend to advance more rapidly ; hut advance of the occiput with relative delay of the sinffput is, in effect, flexion. The head, in fact, becomes a lever of the third class, in which tiie pressure of the resist- ances applied to tiie longer end is more effective in delaying progress than the cijual pressure applied to the shorter end of the lever. It is further to be noticed that as flexion progresses the relation between the lengths of these arms is so altered as to make them progressively more unequal, so that, as the head flexes, the point at which the pressure of the resistance is applied to the occipital end of the head becomes progressively nearer to tlie vertebral articulation. General Infra-uterine FtuUl-pressurei — If Figure 247 represents the situ- ation of the child at the end of the first stage, we see that the forces A and B are applied directly and with equal force to the ends of the head ; but it is evident that the pressure (C) exerted upcm the breech of the infant will be transmitted to the head more readily by the vertebral column than by the soft tissues of the trunk, and that a large portion of this force (C) must therefore be conceutrated on the con- dyles. So far as this force (C) is con- cerned, the argument used in ex{)lain- ing the i)roduction of flexion by the influence of gravity applies, then, with ecjUiU force to this condition. Direct Contact between the Breech (tnd the Fundus. — The whole effect of a direct pressure upon the breech by the fundus will be applied to the condyles of the occiput, and, the resistances ujion the occiput and sinciput being of neces- sity equal, w'hile the o])posing forces are concentrated at a point much nearer tiie occiput, it is evident that the occipital end of the head will tend to advance more rapidly than the frontal end ; but advance of the occiput with relative or absolute delay of the sinciput of course results in flexion. Irregidar Shape of the Fetal Skidl. — The occurrence of flexion is like- wise aided by the second factor referred to above, the irregular shape of the skull. As will be seen by analysis of the opposing forces exerted at R and B' (Fig. 248), if the effect of the equal resistances at R and B' be represented by the length of the equal lines S and S' drawn perpendicular to the surface of the skull at these points (the direction in which these resistances must, according 28 Fio. 247. —Diagram illustrutint? the upplicdtion of n prepoiidurnncL' of tlii' intra-uterini' Huid- prossnro to the occipital cml of tlio licad. It is evident from tlie condition of tlie lioad lever (see FiR. 2lti) tliat the sinciimt is exposed to Ihe force H, ])lns a small proportion of the force C, while the occiimt receives the force .1, plus the greater part of the force C. •I ;' It i' ■ .ti, i'^ m 434 A^fi:iU('AX TKXT-jiooh' OF oiisrKTiirrs. \\ to wi'll-kimwii inccliiiiiical laws, Itc i-xcrtod), the coiistnictioii of tlu; imrallcl- of^ram of fonrs sliows that tlic line T (wliose length represents the |)ortioii of the resistance! H which is exerted in direct opposition to desc<!nt) is much greater than that of the line T* (which represents the efficient proportion of the resistance A''). From this it is (;vident that the occipital end (tf the head is exposed not only to greater force from ahove, hut also to less resistance from below, while the sincipital end is opposed by greater resistance and receives u less amount of propulsive power — conditions which can only result in a more rapid advance of the iK'ciput. As soon as partial flexion has heen acconijdished a second etlect of the irregular shape of the head comes into play, and there must he accorded stich importance as is due to it, Figiu'e 241) represents a partially-flexed head t \ I; • w if/ Fki. 248.— DlnRrnm illustrntlnir the Influonco of Vw. 249.— DinKrnin illustrating thi- sccoml- the irreKiilnr shape nf the skull in imHlueiuK tlexidu, iiry etleet of the irregular shiipc of the head in hy the eonstruetion of the parallelonrani of forees. i)roniotlng ilexion after partial flexion \\i\s It i.s seen that the forre whieh dilates the siiieiput, once been produced, represented hy the line T, is greater than the foree whieh dilates theoeriput, represented by the line T, which represents tlie sinciput. engaged in the elastic canal formed by the lower uterine segment and the vagina.* The forces A and B, due to the con.striction of the ela,stic canal in which the head lies, and acting neces.sarily at right angles to the surface of contact, will then form a pair of equal but not opposite forces — in mechanical language " a couple " — the effect of which is to rotate the head upon a tnms- ver.se axis at C, thus increasing its flexion. It will be noticed that all these causes of flexion f are dependent for their existence on the presence of resistances acting in opposition to the vis-a-tcrr/o M-hich urges the head downward, and it necessarily follows from this fact that flexion occurs most rapidly and becomes most marked when the resistances are best developed — a theoretical consideration which is in thorough accord with the observed fact that there is often a temporary lo.ss of flexion in the excavation, where the space is the greatest; that i.s, that flexiolTis generally better marked while the head is experiencing the well-developed resi.stapces of * The fiict that the vaginal walls pos-ses-s at the end of pregnancy intrinsic muscles of con- siderable development, though too often wholly neglected in the consideration of the mechan- ism of labor, is, notwithstandini;, an element in the production of flexion that must not he forgotten. t Except the last and least important. 77/ A' MHCJIAXISM OJ' hMiOli. 435 tlic fdiperior stniit than in the excavation, where the nwistanees are less. So, too, Hexioii ajjaiii increases when the heail reaches the inferior strait. Flexion is, in iiict, nurnially more marked in this part of tiie pelvis than in uny other; Imt here another factor comes into play. We have previonsly seen Hexion produced by the action of the pro|)ellinj; (iirces ajj;aiiist resistances which were exerted with approximately eipial force im hoth the occij)nt and the sinciput ; but when the head reaches the inferior strait its occipital end rapidly frees itself from the pressures of the bones, and is opposed only l)y the resistances of the soft parts of the pelvic floor, while the sinciput is still exposed to the firm resistance of the l)ony sacrum. It is evident that when the greater pressure is exerted on the longer arm of the lever extreme flexion is a necessary result. The mechanical explanation is tliiis in complete agreement with the clinical fact that the deeper is the engage- ment of the head, the more marked is the tendency to flexion and the greater is the certainty ^■>i' its accomplishment. ^ Rotation.- f he movements of descent and flexion make up the whole iiK'chiuiism of the earlier part of the second stage of labor ; but another factor — rotation — is necessary to its completion. The mechanism of rotation is, unfortunately, extremely difficult of com- ])rehension ; and, as nothing is more difficult than to teach mechanical prob- lems involving the use of three dimensions without the aid of models, the student will be wise if he supplements the words and figures of any written description by a constant inspection of the dried pelvis and by the results of the iiitrapelvic touch in actual clinical work. A complete comprehension of the mechanism of rotation is seldom acquired in any other way. The student iiuist, at all events, grasp the fiuidamental flict that it does occur, and nuist (ihcuj/n occnr, before expulsion can take place. The hea<l enters obliquely because the oblicjue diameters are the largest at the superior strait, but it must emerge in an antero-posterior position — that is, with the sagittal suture opposed to the antero-posterior diameter of the outlet — because the antero-posterior diameter is the largest at the outlet. The movement by which the oblique position at the brim is converted into an antero-posterior position at the outlet is known obstetrically as rotation. To understand the mechanism of rotation it is necessary to remember, first, that with good flexion (without which rotation does not occiu') the occipital end of the head is on a lower level than the sincipital ; that is, the occiput receives the pressure of the loicev portion of the anterior part of one lateral wall, while the sinciput receives the pressure of the tipper portion of the pos- terior part of the other lateral wall. Secondly, it is necessary to remember accurately the shape, depth, and direction of the spiral grooves described on page 396 (Fig. 218). Thirdly, it must not be forgotten that whenever one end of the head executes a movement of rotation, its other end must, of course, move simultaneously in the opposite direction. As the head enters, (). L. A., in the usual position of moderate flexion at the brim, the occiput is necessarily ill contact with the upper part of the anterior groove upon the left side of the '^Jl'n w r 436 AMERICAN TKXT-liOOK OF OJiSTETRICS. pelvis ; tlioufifli the jrrodvo is Ium'o slitillow, the occiput is unable to move away from it, because the bregiuatic rej^ion lies at this time in the deep sacro- '¥/' C-rTix ,Hlat,,i. Ii.-iui , O^^'***^^ l'"iu. aw,— rositioii 111' till' lu'iid in tho iiil'iTior strait al'tiT (tiiiipli'te mtaticiii. Tlio tnl)eri)sitios of llic ischi;i )ir»^voiit any furtlicr mtiuy nuivoincnt, wliilr liirtliiT (k'M'ont is oppusoil mily l)y tlie soft |mits (one-tliiril natural si/.i'). iliac notch on the rii^ht side. As descent sjoes m\ the occiput enters the anterior ijroove more fully — that is, it reaches the j)oint at which the i:;roovc Flu. ■-'.M.— Forward motion of tln' licad diirlnn tlu' stauo of cximlsion iindiT the iiitluiMifL' of tlic forwiird thrust uf tlu' sacniin and tlic pilvic lioor (ono-slxtli natural size). is too deep to permit an easv escape of the occiput from its guidance — and l)v the time the occiput approaches the point where the groove turns forward, aii<l THE MEVIIANJSM OF LA HOP. 437 where it imi^t itself turn lorward to avoid tlie pressure of the projoeting iliac spine, the suboecipito-froutal diameter is in the brim and the sinciput is in the sacro-iliae notch. With the next movement of descent the sinciput slips below ihe promontory mid is in contact with the upper and shallow part of the pos- terior groove on the right side. The oc^cipito-frontal diameter now occupies the extremely large oblique diameter of the excavation, and the posterior tnlge of the groove in which the sinciput lies is here so ill marked that, with the great space afforded by the oblicpic diameter of the excavation, it would be au extremely easy matter for the sinciput to slip backward into the hollow of the sacrum if any forw tending in this direction were ••.pplied. This force is, in fact, applied as a result of the tendency of the occiput to turn forward along the course of the anterior groove of the lel't side,* under the impulse furnished hv the pressure of (he projecting iliac spine against the posterior surface of the occipital end of the head. JJut when the sinciput has once slipped backward in this way into the hollow of the sacrum, there is nothing left to prevent the occiput from turning still farther forward, until, as it reaches the metliaii line, it receives the thrust of the other side of the pelvis, and is steadied in its Kiii. 'J.')'.'.— Ilciut (liiriiiK (listontinii of tlii' iH'Ivic lliior iiftor nitiitiun. witli lioKinniiiK oxtonsiim (Smi'llio). median position by its reception of e(pial pressures on each side from the descending rami of the pubes and the tuberosities of the ischium. Expulsion. — The parietal bosses now lie in contact with the tuberosities of the ischium. The narrow temporal diameter corresponds with the narrow trans- verse diameter of the pelvis between the iliac spines. The sinciput is still in * It will l)c rcnicmbcrid tli:it wln-ii the (Hiiiuit lurti.s forwanl tiie sinciput must of necessity lurn backwiird. J i \ ■ toj ' u tL, .1 ii ' 438 AMERICAN TEXT-BOOK OF OBSTETRICS. :';'i r>!l;", I :i ' --^A till contact with the lower portion of the sacrum, and tlie occiput, tliough steadied on both sides by the bones, finds its descent opposed only by the yielding tissues of the vaginal outlet (Fig. 250). Under these circumstances (p. 432) the propelling force from above concentrates itself upon the occiput until the perineum is fully distended. The occipital end of the head is then freed from the resistances, while the whole bregniatic region and the sinciput form a rigid slanting surface which is opposed to the slanting surface furnished by tlio sacrum and the perineal tissues (Fig. 251). As a consequence the driving force of the uterine j^rcssure is converted by the shunt of these shelving surfaces into a forward thrust, under the influence of which the head, as a whole, moves forward until its progress is arrested by contact of the nai)e of the neck with the anterior pelvic w-all. The large fontanelle is now at the fourchette, the whole of the occipital half of the head is free from pressure, while the fore- head is still exposed to the driving force of the uterine muscle above and to the forward shunt of the posterior pelvic wall. The necessary result is a for- ward motion of the head with arrest of the neck ; that is, the head extends, the bregma, the forehead, and the face successively pass the fourchette, and the head is expelled by extension (Fig. 252). It is then a convenient nniemonic that in normal labor the hea<l descends in flexion and is expelled by extension. The time occupied by the latter stages of the expulsion of the head — that is, the time between the first appearance of the hairless forehead and the com- pletion of the expulsion — is usually very brief. This rapid motion of descent is usually followed by a period of inaction, which is due to the fact that the decrease in the volume of the uterine contents has been so great as to exhaust the contractile power of the uterine fibres, and to render progress impossible until after the occurrence of the j)eculiar phenomenon known as retraction. Retraction of the Uterus. — It is well known that the amount of shortening possible to any given muscular fibre is very definitely limited, and it is believed that the extreme shortening of the uter- ine nniscle as a whole that is observed during labor is rendered possible by a process of rearrangement of the rela- li tions of the fibres of the uterine muscle to one another, known as retraction. The way in which this process is ef- fected is not definitely and scientifically known, bi.t the conception generally ac- cepted as a working hypothesis is that the cells of the uterine muscle not only shorten, but rearrange themselves u|)(in one another in some such way as tiiat diagrammaticaily represented by Figure 253, A and B. When retraction has once taken place it is usually permanent, and the distinction between contrac- tion and retraction, whatever it may mean patiiologically, is therefore clinically Kio. 253.— Dinnrams roproscntiiiKtlio Iiypotlict- ical roliitions tjt'twci'ii llio utiTiiu' fihri's in \iiiro- tmctccl and retrartcd iitcii : A.arrantii'nu'iit nf tlie iitcrini; fibres in the unrrtractcd ntcrus; It, ar- raniifmont of tlie iiU'rinu liljpcs in iIk- rt'trai'tiMl uterus, SSM THE MECHANISM OF LABOR. 439 one which it is important to understuiul and to bear in mind. In the descrip- tion of the mechanism of hibor it is nccossarv to refer to retraction as an estab- lislied entity, notwithstanding the unestablished position of the hypothesis upon which rests its existence. When, after the expulsion of the head, retraction of the uterine fibres has becMi effected, the rhythmic contractions again set in and the process of expul- sion of the body begins. Expulnion of the Body : Rotation of the Shoulders. — The shoulders having entered the pelvis during the expulsion of the head, they are usually born with the next few succeeding pains. The liead having entered in the first oblique diameter, it is evident that the shoulders, which normally lie at right angles to the antero-posterior diameters of the head, will normally enter the pelvis in the second oblique diameter. As the shoulders are driven down by the pains, the anterior shoulder follows the curved line of least resistance, previously travelled by the occiput, while the posterior shoulder follows the ])ath of the siniiput. The anterior shoulder thus rotates to the arch, and the transverse axis of the shoulders occupies the antero-posterior diameter of the outlet. Restitution of the Head. — The head, being now free from j)ressiire, tends to retain or reassume its natural relation to the shoulders, and thus as they assume an antero-posterior diameter the already expelled head undergoes an external rotation by which the occiput is carried to a position opposite the left, and the sinciput to one opposite the right, buttock of the mother. This process is known as the e.vternal rotation or restitution of the head. The shoulders are, however, so small and soft as compared with the head that the mechanism of their rotation is not infrequently faulty or irregidar. It may, moreover, happen that at the time of their entrance the action of the intrinsic muscles of the child may have so turned the body that the transverse axis of the shoulders lies at an acute angle to the antero-posterior axis of the head. The small and soft shoulders may from this cause enter the pelvis in the transverse, or even in approximately the first oblique, diameter. The shoulder which should normally have been the posterior m-iy thus become the anterior, and in this way icad to such an excessive external rotation of the head that the occiput swings around to the right buttock of the mother. This faulty ])rocess is com- monly known as super-rotation. Expulsion of the Shoulders. — The shoulders being retained in the antero-posterior diameter by the pressure of the tuberositio , the posterior shoulder receives the forward shunt of the jjclvic floor, which, together witl» the cnrvature of the body necessary to admit of the passage of the ciu'ved pelvis, jams the anterior shoulder against the symphysis pubis in such a way (Fig. 254) that the posterior shoulder sweeps forwai'd over the perineiun and is the first to reach the vulva. As the body is urged onward the perineum retracts, the anterior shoulder a])])ears from beneath the arch, the shoulders emerge from the vulva, following tiie direction of the curve of (^u-us (Fig. 219), and the remainder of the body rapidly follows in the same path. During the l>rocess of expidsion the arms normally remain crossed upon the chest in the 11 uM fi m ;■ i :| I i i.i ■l i'rllt i; I, riiii u f I I Ml % 440 AMERICAN TEXT-BOOK OF OBSTETRICS. usual attitude of the fetus, but they are uot iufre(|ueutly helil hack by the fric- tiou of the pelvic wall, aud are thus forced iuto a position of partial exten- sion in which the forearms lie across the abdomen. The mechanism t)f the second stage in O. D. A. positions differs from that l'"lii. J.M.— Expulsidii of till' sIkiuIiUts. of O, L. A. only in the substitution of the word right for the word left throughout the description. C. Mechanism and Management of the Third Stage of Labor. Mechanism of the Third Stage of Labor. — After the expulsion of the child the uterus shuts down upon the placenta, and there is usually a period of from five to ten minutes during which little or no contraction is api)arcnt, this interval being occupied by the process of retraction of the uterine fibres. The first active contractions of the uterus after the expulsion of the child necessarily lessen the area of the uterine surface over wiiich the placenta is attached, and thus in ])art or in wlK)le separate the placenta from the uterine wall ; during the next relaxation blood escapes from the torn sinuses in the placental site, and the mechanism by which the placenta is expelled (lei)ends upon the escape or non-escape (»f this blood from the uterus. li' the first retraction is sulHcient completely to detach the placenta, but does not succeed in exi>elling it, any blood which may be effused will usually find its way to the external worhl by dissection of the membranes from tiic uterine wall ; during the next fi'W contractions the uterus will be able to shut down nj)on the placenta, and will compel it, by the force of direct contact, to pass through the os edgewise and in the most compact possible form — that is, in the shape shown in Figure 255, in which the thin caUe-like placenta is seen to have been folded upon itself in a roughly fusiform shape. When, however, the attachment of the placenta is too firm to permit an immediaie separation, or when, as probably more freipiently happens, the con- traction of the fundus is more energetic than that of the lower portion of the uterus, so that only tlie upper ])()rtion of the placenta is detached, the relaxation following each contraction will be ai'companied by an effusion of blood whicli is confined behind the placenta. The upper part of the placenta will then Ix; THE MECHANISM OF LABOR. 441 {'orct'd downward, and as the detachment proceeds the position of the phicenta will be so far altered that its fetal surface presents at tiie os, the uterine cavity heliind it being occupied by a mass of blood (Fig. 256). When this occurs, Kio. 255.— The more favorable mechanism of expulsion of the placenta (Varnier). tilt' placenta presents in so much more bulky a form that it is usually expelled so slowly and with so nuich dithciilty that the process is not completed until tiie elfuscd mass of blood attains sufficient size to redistend tlie uterus slightly. l"i(i. 250— Tlu' loss favornWe of the common mi'tliods of exp\;lsion of the placenta (Varnier). and thus permit of the occurrence of more forcible contractions. The placenta is then expelled, not by the force of direct contact, but by an intra-uterine lluid-pressure cxcrteil through the mass of ctfused blood. Tliis second form of the ii:cchanism of the third stage of labor, though OKsentially normal, is much the Ics,-! easy and favorable f(»r the patient ; although the amount of blood lost is not usually sufficient to etlect any perceptible altera- tion in her pulse. In either mechanism the elastic and collapsible nature of the membranes rciitk'rs them less likely than the ])lacenta to be thoroughly detached, and as the latter emerges through tlu; h()le in the membranes tliiit corres|)onds with the OS they, are necessarily invi'rted, and, becoming detached by the traction (hie to the advance of the placenta, follow after it in a loose mass. 1 ! IT 1 Tv '■ i i;'^' / I ■^ U: V \ ■V-.:: if t 5 %•.' M I! . H* I, ■It I :■ 442 AMfmiCAN TJ: XT- BOOK OF OBSTETRICS. Managrement of the Third Stage of Labor.* — The iii<iuiry naturally arises: How far is it within the power of the obstetrician to favor or to compel the occurrence of the mechanism first described? To this inquiry it may be answered that the maintenance of a careftd watch upon the uterus by constant touch of the fundus through the abdominal wall, and the institution of rapid but lij;ht friction with the fingers upon the fundus during the first ct»ntniction, usually so far increase its duration and force as often to effect tlie com|)l('t(' separation of the placenta. Moreover, if this friction is persisted in through- out the succeeding period of relaxation, it will usually maintain sufficient <'on- traction to prevent any considerable effusion, and secure separation during the first or the immediately succeeding pains. This most essential portion of tlie method of Crede should therefore uniformly be adopted. The second and less favorable mechanism is probably safer for the patient than any mamial method of removal of the j)lacenta, but in case a delay in the third stage, notwitiistanding the adoption of Cred6's method of expulsion, should require the introduction of the hand, a digital intra-uterine exami- nation should first be made, and if the placenta is found to present in the way ."^•'•own in Figure 256, an effort should be made to reach the edge of the pla- centa with the finger. It may then be possible to draw the edge of the after- birth into the os, and thus permit its ready expulsion without the complete introduction of the hand. D. Mechanism and Management of the Posterior Positions of Vertex Presentations. Mechanism of Right-posterior Positions. — In the right-posterior posi- tions of vertex presentations the head always enters the pelvis O, D. P. ; it .should invariably enter the inferior strait in a right-anterior position ; l)ut the process by which this rotation is accom])lished is, unfortunately, so deli- cately balanced that it is always liable to a failure, and this, if it occurs, necessarily results in a persistence of the jiosterior position, which, though not incompatible with a natural delivery, is attended by greatly increased risks to both mother and child. We have to consider, then, first, the entrance of the head into the j)elni^ in posterior position's ; secondly, the normal mechanism of the suhsequent deliver if by rotation ; and tiiirdly, the (abnormal) mechanism of the delivery of a persist- ently posterior occiput. Labor in posterior positions is usually longer and more difficult than in anterior positions, for two reasons ; first, l^ecause the entrance of the head • iito tie pelvis is more difficult; and second, l)ecause, even under the most f.'VOiTible circumstances, \x\hov is sure to be lengthened by the more extended utai.i n of the occiput that is necessary to its completion. T!ic Jijicult entrance of the head at the brim in occipito-posterior positional is due to the existence of two factors, one of which is ])hysiological, while the other is mechanical. The physiological factor is to be found in an irregular * For tlie inana^einent of the first and ssecond stages of normal labor, see page 3()7. Vi3 THE ^fK('I^AXISM OF LABOR. 443 and imperfect action of the pains, that cliaracterizcs tlio first stage of labor in a larf^e proportion of posterior positions. The exact cause of this well-marked feature of such cases is unknown. Probably it is a reflex phenomenon due to pressure, from the mechanical mal-adaptation shortly to be sj)oken of; but it is a fact that a long first staire, which is due to irregular, variable, and ineffective pains, is always sutrtrestive of a posterior position. The mechanical factor is due to the irregular shapes of the fetal liead and the pelvic brim. If ])arallel diameters ar'> drawn across the pelvic brim (Fig. 257), the cue (a) from the right side of the sacral promontory to the right ilio- Fio. 257.— Adaptation between the fotal head and the brim of the pelvis In anterior positions of the iii'cipiU. Ifel pectineal eminence, and the other (i{) from the left sacro-iliac notch to the pubes, it will be seen that when the head enters (). L. A., the wide biparietal diameter of the head corresponds with the greater space affoi'ded by H, the longer of these diameters; while the lesser bitemporal diameter is in corre- sponden(!e with A, the shorter of these parallel diameters. The entrance of the head is therefore mechanically easy in anterior posi- tions ; but, conversely, when the head enters (). D. P., its wide bij)arietal diameter is opposed to the uari-ow oblique space between the promontory and the ilio-pectineal eminence of the right side, while the narrow biparietal diameter is loosely fitted into the wiilc space afforded by the antei'ior portion of the pelvis (Fig. 258). Two factors of difficulty are tiius j)rodu(!ed : first, the widest portion of the fetal head finds itself in apposition with a nari-ow portion of the pelvis, and therefore rcipiircs a jiowerful driving impulse to force it through the brim ; second, this retarded widest ])orti()n of the head is situated on the occipital end of the head lever, while the sincipital end is almost free. This situiition, therefore, always tends toward a tt)o I'apid descent of the sinciput — that is, toward the production of extension — but the degree •;!::: A"-^ 1 ^ •fi; w 'i I 1 i<> : i \ 1¥ ii 'S'i 1' n I It iii 17 : H 444 AMERICAN TEXT-BOOK' OF OBSTZTRICS. of extension produced varies with the relative sizes of the pelvis and the head. If the disproportion between the biparietal diameter of the head aud the portion of the pelvis in which it finds itself (that is, A, Fig. 258) is not extremely great, the protliictioii of an extension sufficient to cause a light pressure of the forehead against the pubes may be enough to equalize the Fig. 208,— Adttptntiou between the fetal head and the brim of the pelvis in posterior positions of the occiput. resistances at the opposite ends of the cephalic lever, and may thus permit the greater pr()j)ulsive force applied to the occiput (sec page 433) to accom2)lish its descent wliile the sinciput is still above the brim. The head in this ease will enter the excavation in a fairly well flexed condition. If the disproportion between the occiput and the jmsterior portion of the pelvis is more extreme, the process of extension will continue until the occipito- frontal diameter occupies the first oblicpie diameter of the brim. The head may then pass the brim, after long l;d)or, in an extended position ;* it may be arrested at the brim by becoming a brow presentatit-'. or it may exceptionally be converted into a face presentation. PatonKje of the Exvandion. — After its escape frt)m the superior strait the head occupies the first oblicpie diameter of the excavation O. D. P., aud the accomplishment or non-accomplishment of tiie remainder of the labor by the normal mechanism of rotation depends wholly, and only, on the degree of flexion ju'csent. RoUdinn in Wcll-Jfc.ved RUfhl-posterio)' Pos'dlom. — When the occiput enters the excavation — that is, passes below the promontory — while the sinciput is still delayed in or above the brim, it occupies for the moment so roomy a posi- * It will l)e remembered tli.at the ocoii)ito-frontal diameter is too large to pass even the oblique diameters at the brim witii ease. n ! • THE MECHANISM OE LABOR. 445 tion that it is enabled to (lescen<l rai)iilly almost to the floor of the pelvis, while the sinciput, delayed by the pressure of the anterior pelvic wall, makes but slight progress. The occiput then lies between the sacrum and the right ischium, in the hollow made by the recession of the elastic sacro-sciatic lig- iiraents — that is, in tlie deeper jwrtion of the posterior groove of the right side of the pelvis — while the sinciput is pressed against the smooth and uniform surface of the upper part of the anterior jwrtion of the lateral wall on the left side. As descent goes on the occiput follows the posterior groove forward under the pressure of the unyielding bony edge of the sacrum, which presses against its posterior surface ; this motion is unopposed by the sinciput, which in thoroughly well flexed heads is still so high in the plvis that it is free to turn backward over the smooth bony surface of the upjjcr portion of the lateral wall (portion A, Fig. 217, a and n, Fig. 218). Rotation thus pro- gresses smoothly, and usually rapidly, until the occiput reaches the spot at which the posterior and anterior grooves of the right side join, and thus assumes an anterior position. The sinciput, which has by this time become well {)os- tcrior, now lies in the upper ])ortiou of the jiosterior groove of the left side. The head is now in an O. D. A. position in the lower portion of the pelvis, Fig. i!')9.— Diagram lUustratinR the possible rcprodiietitin of flexion in piirtly extended posterior posi- tions of tlie occiput. The force of rotation is represented by tlio arrow a; tlie portion of tliat force whicli is applicable to flexion, l)y the line h. and the remainder of the mechanism, including restitution, is exactly similar to that which would have obtained in an originally O. D. A. position (see pp. 430-440). Mechanism of Rotation when the Head enters Poorly Flexed in Biffht-pos- terior Positions. — When more marked, but not extreme, extension occurs across the brim before the passage of the occiput, the releast; of the latter, as be- fore, permits it to juake a rapid descent until it is arrested by contact with i M I ! m:\^ II / -I . >! i '! i? I- MJ >;ni- 'i. "1 11 446 AMERICAN TEXT-BOOK OF OUSTKTRH'S. the polvif Hoor; hut at the time wlieu the occiput hcgiiis to feel the forward impulse of th(! (K-ep h)\ver portion of the posterior jjroove of tiie right pelvic Mall the sinciput is not, as l)efore, in contact with the smooth surface of por- tion A of the left lateral wall, hut has, on the contrary, already entered the upper portion of the anterior groove on that side. Under these circumstances rotation may exceptit)nally be accomplished. When this does happen the mechanism is as follows: As the occiput is urged forward, the posterior side of the sinciput is j)ressed firndy against the slightly rising edge of the upper portion of the anterior groove, and under tavorahlecirciunstauces this increased pressure may residt in flexion of the heail in the manner illustrated in Figure 259, which is a horizontal section of the jjclvis through the spot where the sinciput impinges against the lateral wall. The rotation force due to the for- ward motion of the occiput urges tl»e sinciput backward in the direction (tf the force represented hy the arrow A. If upon this arrow we construct tiie parallelogram of forces, we see that by the shunt of the shelving surfaces of the sinciput and the pelvic wall there is produced a small pressure (b) upon the sinciput that tends directly to flexion, and that nuiy, under favorable cir- cumstances, actually produ(;e flexion to a degree sutticient to permit the sincij)ut to slip by on to the smooth surface of portion A (Fig. 217). The sinciput is free io then glide back into the posterior groove as the occiput moves forward, and tlie mechanism of rotation described above goes on as before. This process, however, is mechanically so extremely difficult that it can occur only under the most favorable conditions — that is, when the adaptation is easy, when the jjains are powerful, and, nu)st important of all, when the loss of flexion is so extremely slight that but a slight change is needed to restore it. Mcclumwti of Rotation vhcn the Head enfrrf* Cnfiexed in Posterior Poni- tious: the Mechmmm of the PaHnaf/e of the Hrearation in Pemident Jiight-pot<- terior Positions — When the head passes the brim so far extended that the sincijjut is as low, or nearly as low, in the pelvis as the occiput, the forehead reaches the deeper portion of the anterior groove at about the same time that the occiput reaches the deeper portion of the posterior groove. Both ends of the head are then urged to rotate forward by the forward trend of their re- spective grooves ; since neither one can rotate forward unless the other turns back, there residts a dead-lock which can be broken oidy by the intervention of art — that is, by a manual or an instrumental flexion of the head. In rare cases, however, this dead-lcK^k may be avoided by the occurrence of a second and abnormal mechanism, by which the occiput is rotated directly backward into the hollow of the saerinn. This rotation can occur only when the adaptation between the head and the pelvis is exceptionally easy, when the sacrum is exceptionally hollow, and when its lateral concavity is but little marked. The occurrence of a backward rotation is then due to the fact that the posterior edge of the anterior groove, formed by the isehiatic spine, is more prominent than the corresponding portion of the posterior groove, formed by the edge of the sacrum. W, under these circumstances, THE MKCHANISM OF LMiOR. 447 I he occiput iiMil the sinciput arc at ('([iial depths in the pelvis, it results that I he sinciput is more Hrnily fixed in the anterior groove tiuiii u the (K'cipnt ill the posterior; and if the adaptati(»n is exceptionally esv-sy or the lower portion of the sacrum is wantini; in prominence, the occiput may be able to escape from the posterior sjroove and turn backward over the sacrum as the sinciput rotates forward. This escape of tiu^ occiput into the hollow of the sacrum usually so far diminishes the pressure on the occiput as to permit of its rapid advance, while the descent of the sincij)ut is still delayed by the normal resistances of the anterior wall of the pelvis. The rapid descent of the occi- put as compared with the sinciput thus re-establishes flexion, with the head in a directly o(!(!ipito-posterior position. Expulsion of the head in a persist- ently posterior ])osition by the natural forces or by the aid of forceps is then possible, thou<!;h the conditions are much less favorable than when the occiput is rotated forward, as may be seen by reference to Figure 2G0. On comparing Fi<i. 'JOO.— P'xpulsion of thu heiul in persistontly i>ostorii>r iiositions of tho occiput; mcclianism of fuce to pubos delivery. Figure '2G0 with Figure 251 it will be seen that when the occiput is anterior the curved axis of the child's head and body corresponds with the curved axis of the pelvis, but that when the occiput is posterior these curves are reversed iipt)n each other, and that to etfect t!ie delivery in this position the uterine foi'ces must alter the shape of the child by elongating the occiput, by com- pressing the sinciput, and by imxhu^ing an exaggerated flexion uniil the normal curve of the fetal axis is reversed. Although the fetal head is surprisingly tolerant of the excessive compression necessary for this change of shape, the process always results in the stillbirth of a large proporticm of the children; while the |)rominence of the occiput, even after the most extreme moulding, always exposes the soft tissues of the pelvic floor to a degree of tension that almost invariably results in deep laceration of these structures during the stage of expulsion. The expulsion of a persistent occiput posterior, more- over, always requires, iu addition to lax adaptation, the presence of very ^'i •'■!l 1 vj 4- '*'fi ■ i '1 I 448 AMERICAN TKXT-nOOK OF OliSTKTIiTCS. j)owcrfiil uterine contractions or tlic application of powerful traction by tlic forceps; and even when tlie.se conditions are present the process is a lontr one. The head remains in ])osition nntil the |)rocesses of the change in its shape and the prcHluction of extrenie flexion are snfficiently far advanced to permit the occipnt to travel downward along the median line of the posterior wall under the influence of the pressure from above. The region of the small fbnta- nelle finally appears at the vulva, and the ])erineum retracts, or, more com- monly, tears across the (H'ciput to the base of the neck. The occipital end of the head is then free from pressure, while the sincipital end is still expost'd to the driving force of the uterine contractions. The excess of pressure upon the sincipital end of tlu^ head then causes extension, by which the fbrehea<l, the eyes, the nose, and the chin successively appear under the arch, while the occiput swings backward, and the head is born by extension (Fig. 200). licdUutlon. — During the expulsion of the head the shoulders enter in the second oblique diameter, and the rotation of the left (tiie anterior) shoulder to Fill. 261.— Ocpipito-pnstorior positinii, with the head hoRinniiiK to distend the pelvic floor (Smellie). the arch j)roduces an external restitution to the right, in accordance with the general law that external rotation or restitution restores the head to its origi- nal position. Abnormal or so-called " super-rotation" is, however, of e.sj)ecially common occurrence in these cases. Snmman/. — In reviewing the mechanism of posterior positions it is at once a|)parent that the whole key to the situation is to be found in the degree of flexion presented — that the better the flexion the more certain and the more rapid is the execution of the normal and most favorable mechanism. It is an Tilt: MKCIIANISM OF LAJlOIt. 449 cstablisiliwl liiot in pnu^tice that in the comparatively tew cases in which gcxxl llcxion is established at the start and maintained to the end, posterior labor is hardly less favorable than anterior; and that the degree of ditHculty increases as the degree and persis(en(!e of flexion decrease, nntil we reach the fact that when flexion is lost and is not promj)tly restoretl by art, posterior positions invariably yield long, difficult, and exhausting labors for tlio mother, and a liirgc proportion of stillbirths among the children. It may safely be said that there is no variety of labor in which easily-avoided ill results are so commonly incurred as in posterior positions of the vertex ; and there is certainly no sub- ject in obstetrics that better deserves the attention of the student than the means of detecting extension and of preserving or re-establishing flexion in these cases. \ Mechanism of Left-posterior Positions. — Of the mechanism of O. Ij. P. positions it is only necessary to say that it differs from that of O. D. P. posi- tions simply in the substitution of one side of the pelvis for the other, and in the fact that failun? of rotation is more <!omnu)n in left positions. Manaerement of Labor in Posterior Positions of the Vertex. — Prophy- Id.rln. — Since posterior labor is so much less favorable than anterior, it is evi- dent that every eftbrt should be made to prevent the occurrence of posterior positions, or, when they do occur, to convert them into anterior positions i)t'l'ore the occurrence of labor or during its early stages. We are, fortunately, able to effect this end in the great majority of cases, provided the position is diagnosticated before the rupture of the membranes or the engagement of the head. For this reason, if for no other, the obstetrician should in every case endeavor to ascertain the [)osition of the fetus by making an abdominal pal- pation some days before the advent of labor. If a posterior position is dis- covered at this time, it is usually possible to rectify it by postural treatment of the patient. If the patient is placed in the knee-chest position, the anterior wall and the fundus are the lowest portions of the uterus. So long as the patient remains in this position ihere is a tendency for the child to sag away from the brim under the influence of gravity ; and since the recession of the head from tlie brim leaves the child free to turn upon its own axis, while the presence of the spinal column makes the dorsal side the lieavier, there is also a tendency Iowa il a rotation of the fetus as a whole until ita dorsum is in apposition to the anterior wall of the uterus. The woman should in such cases be instructed to assume the knee-chest posture several times daily during the last few weeks of pregnancy, to remain as long in this position as is possible without fatigue, and, on relinquishing it, to recline on the right side for a short time before rising, in the hope that .as the child's head again settles down against the brim it may become fixed in an anterior position. The enlarged abdomen of the gravida at term may prevent the assumi)tion of the true genu-pectoral position and compel her to adopt the knee-elbow atti- tude ; but in either event it is essential that the abdomen should be free from 29 [V i- i ; Cl i ^. f '! « kU t'! I IB I ■ ; ' r* ; ! ig' W'i! '" •V Ci: 450 AMEIilCAN TEXT-BOOK OF OBSTETRTCS. J^ SVn Fui. 262— Correct (A^ and iiicorrt'ct (H and C) muthuds of assuming the genu-pect(>rul pusi- tion. pressure against either the bed or the thighs of the patient ; tliat is, the thighi* siiould be vertical (Fig. 2G2). The postural treatment is especially powerful when instituted before aiiv labor-pains \\w'2 occurred. If this treatment is conscientiously carried out for beveral days, the physician M'ill almost surely find the position anterior when summoned to th^ j^ntient in labor. Even if the patient is not seen until labor is present, it is still worth while to adopt a postural treatment so long as the membranes are unruptured and the head is unengaged. The patient should then be encouraged to maintain this position so long as her strength permits, or until a vaginal examination without alteration of her attitude dem- onstrates the fact that rotation has occurred. She should then be placed in the latero-prone position upon .lie side to which the occiput is directed, and should remain in that position until the head is firmly engaged in the new position. Should the head, after once becoming anterior, sliow any tendency to revert to the posterior position, it may even be wise to ruj)ture tiie membranes in order to prevent any such reversion. Should the postural treatment fail, no special treatment is necessary until after the rupture of the membranes has occiu'red ; but both before and after rupture frequent examinations are advised, in order to detect early aii\ tendency to the production of marked extension. Passage of the Superior Strait. — In the majority of cases the head in pos- terior positions passes the superior .strait by the natural efforts only after some delay, and often only after the occurrence of some extension and of considerable moulding of the iiead. The attitude of the physician should be determined by the degree of exten- sion jiresented. When the extension is not extreme, he siiould not be alarmed by a failure of progress, but should avoid interference, and expect the best results so long as the condition of both patients remains good. When extension becomes so extreme that the eyebrows are below th<' brim of the i)elvis, tliere is but little prospect that the head will pass the superior strait by the natural efforts, and unless active progress is present it is wise, after a single hoin- lias passed without alteration of the condition, to abandon the expectant method of treatment and resort at once to the oi>erative treatment of a high arrest of the posterior occiput. Operative treatment at the superior strait sidwlivides itself into the operative re-establishment of flexion and the delivery through the superior strait of tlie flex(!d but arrested head. Operative Flexion. — If, at the tiuie when operative flexion becomes neees- THE MECHANISM OF LABOR. 451 s!iry, the membranes are still intact, it may occasionally be possible to raise I lie forehead by making pressure upon it with two fingers placed within the •ervix, the woman being in the recumbent or knee-chest position, in order to all'ord the assistaiice of gravity to the efforts of the accoucheur. Since it is impossible, however, to obtain complete flexion of the head in this way, and ^ince the extension is almost certain to recur if no further change is made, it is essential that the iiead as a whole should be freed from the brim by pres- sure! upou the vertex, after flexion has been secured, in the hope that on its en- trance it may be better situated, iiud may thus be able to maintain its flexion. Shoidd extension again recur, it is best to etherize the patient, introduce tlie hand into the vagina, and dilate the os manually to a degree sufficient to permit the passage of tlie half hand within the uterus. Should the membranes 1)0 ruptured at the time when interference is decided upon, this must usually 1)0 the first maneuvre. When sufficient dilatation has been attained, the half iiand should be i)assetl within the os until the fingers cover the forehead, which should then be pressed gently upward until complete flexion lias been secured and the head has been freed from the brim. The hand should then 1)0 withdrawn, the fingers placed as high upon the forehead as possible iu order to maintain flexion, and the head forced into the brim by external pres- sure. The ether should be removed, and the fingers should maintain pressure upon the anterior portion of the head until a firm engagement in a flexed posi- tion has been effected by the efforts of the uterus. Should extension become re-established, an operative delivery of the head is necessary. Operative Belnrt'i/ of a Hiyh Arrest of the Posterior Occiput. — If extension is present, flexion should be established by the introduction of the half hand. Three methods of delivery are then possible : The child may at once l)e turned, the head may be rotatod manually and forceps applied to the anterior occiput, or forceps may be used while the occiput is still posterior. The latter method is to be recommended only when t!ie other methotls are, for one reason or another, contra-indicated or iiiipi.ssible, and the choice ordi- narily rests between the procedures or a manual rott>*:iou of the oc:iput to the front with a subsequent ap}»lication of the forceps, anu version. "« Manual rotation and the application of forceps is a difficult, and version in nor.nal pelves is an easy, operation. The head after manual rotation not infrequently returns to its original position during the manipulations incident to the application of the blades, and in any event it is necessi.ry to apply the forceps to the head when freely movable above the brim, Widch operation is always difficult. The writer believes, however, that aft' ' 'ho forceps has successfully been applied to the head in an anterior position, :k\ extraction with it is less dangerous to the sof*^ parts of the mother than is tl c extraction of an after-coming head ; the forceps operation should (l';'"'^^if'ore, in his opinion, be chosen by those who are thoroughly skilful iu tix n« of the instrument, but the primary performance of version should l)e el<'cte.l by operators of small experience. Should manual rotation and the use ot forceps '»(• d( cided upou, the whole h ^ ■ 4^. \'i. H ''d\i m. if ill t- II r/ (' ' ' ^i w 452 AMERICAN TEXT-BOOK OF OBSTETRICS. hand should be passed into the uterus and the licad be raised gently until the whole surface of the hand can be applied to the forehead, the fingers lying over the face of the child ; whereupon the hand and the forearm of the operator should be rotated with the head until the occiput is well anterior to, and even, if possible, to the left of, the median line. During the introduction of the hand careful counter-pressure must be made at the fundus by an assistant or by tlie other hand of the o])erator, and during the rotation the external hand nuist be used to promote the rotation of the trunk. The rotation should always be slow and be procural with the utmost gentleness. Unless the rotation of the trunk accompanies that of the body, the head will return to its original position as soon as it is free from pressure. In ditticult cases it may occasionally i)e per- missible to apply the internal fingers to the shoulder of the child to ])roniote this rotation. The whole nianeuvre is frequently so difticult that, unless the waters have been but recently evacuated, it should not be attempted until a fair experience in version has furnished the operator with some adroitness in intra- uterine manipulations. After rotation has been effected the head should be urged into the brim by counter-])ressure upon the fundus, and it should be maintained in position by gentle abdominal pressure upon the head itself, from the hands of an assistant, while the forceps application is made. The forcejis should be api>lied, if pos- sible, to the sides of the head, and, as in all high operations, the use of an axis-traction instrument is to be recommended. If version is decided upon, the head shoidd be flexed before it is raised, as this always requires less force thaji an attempt to raise the extended head. If version is absolutely contra-indicated and manual rotation fails, an attempt should be made to bring the head through the sui)erior strait by the application of forceps without alteration of the position ; but as a preliminary even to this operation an extended head should gently be flexed. In the use of forceps while the occiput is still posterior, it is inadvisable to make any attempt to ajiply the blades to the sides of the head, as the position of the parietal bosses in the narrow space between the ilio-pectineal eminence and the promontory makes it extremely difficult to adjust the forceps to the ends of the biparietal diameter. Even when it is so adjusted a very slight forward inclination of the line of traction may cause the forcei)s to slip forward along the head to the temporal region. In this position the forceps is extremely likely to slip from the head altogether ; even if the forceps holds its position, the sole and necessary result of tnictiou is a reproduction of the extension, which, of course, results in an arrest, or at least requires the use of increased and unnecessary force. The blades should therefore be applied to the sides of the pelvis, where they will take an oblique grip upon the head. This application is always very difficult, and the operation too frequently results in a fi-actuiv of the skull or in the birth of a stillborn child from cranial compression. A> soon as the head has passed the brim the forceps should be removed ; if neces- sary, the forceps may be reapplied in the manner shortly to be recomr i 'rded f«)r the operative treatment of the loi, head in posterior positions. )lo to ition inenco the sliglit rwanl eint'ly ition, hie!.. 1 and if tht' I'ation c'turo As licces- lulfi THE MECHANISM OF LABOR. 453 Management of the Passage of the Excavation in Posterior Positions. — Flexion. — Ais was said ia the discussion of the mechanism of posterior posi- tions, the maintenance of complete flexion is the first and most essential con- dition of the progress of the liead through the excavation. It follows that the maintenance of flexion when possible, and its re-establishment when it has been lost, must demand throughout the case the most careful attention from the obstetrician. When the adaptation is easy and good flexion is present from tho start, descent and rotation to an anterior position are sometimes so quickly performed that no assistance is needed ; but in a large proportion of cases the head enters the excavation in a condition of partial extension, and in such cases an early iidoption of certain very simple measures frequently makes the difference between difficult and easy labors. The various expedients which may be used to promote or to re-establish flexion form, then, the first and most important division of the treatment of the low head in posterior positions; but, since it not infrequently hapixjns that even a well-flexed head fails to rotate from over- tightness of adaptation, from relative inefficiency of the pains, or from minor variations in the shape of the head and the pelvis, it is necessary to add thereto a second division, which consists of the expedients that may be employed to tlivor or to produce rotation during extraction, whenever, from any cause, a well-flexed head is arrested in a posterior position in the excavation. Maintenance of Ffe.vion. — Unless progress goes on with unusual rapidiiy, the maintenance of flexion by counter-pressure should be undertaken as soon as the head has entered the excavation and the forehead is within easy reach. As soon as the degree of descent permits, the fingers should be placed against the frontal bones as far forward of the large fontanelle as the pelvic space allows, and any further descent of the sinciput should be retarded by a ntenance of pnssiirt against the forehead throughout the whole of each pain until the occur- rc'i'i' of rotation carries the frontal bones backward and out of the reach of the tii'gcrs In this process a simple retardation of the descent of the sinci[)ut is {]'. ihfii U to be aimed at or desired, since flexion is supposed to be already ])resei: . and "ts maintenance is all that is needed. This maintenance of flex- ion, w'.iv.i/ is unusually easy, is always a very much more simple matter than is an attempt to raise the forehead by pressure after extension has once occurred. If this precaution is carefully observed from the start, loss of flexion is extremely rare, and a recourse to the more heroic methods required for its re-establishment may usually be avoided. Re-cstahlishment of Flexion. — When extension occurs, it must be reduced "ifore any further })rogress is jiossible. Flexion may be re-established either in pushing the sinciput up, by drawing the occiput down, or by a combination t>i ;;o(h methods. The forehead may occasionally be made to recede by pres- sure upon the frontal l)ones with the fingers ; it should thou be held in position until the uterine efforts have effected complete flexion by descent of the occiput, and until rotation has occurred. This method, the simplest and safest, is, how- ever, possible only in very easy (lases. h* i i 454 AMERICA X TEXT-BOOK OF OBSTETRICS. ' i ; ; i: I t 1 ! ,i/ ;^ t: ': I It is occasionally possible to reinforce this niethotl by hooking the fingers of the hand around the occiput, and thus drawing down upon the occiput witli one hand while the sinciput is pressed up by the other hand. This method is possible only when the extended head is very low and the soft tissues of the outlet are very lax ; in the majority of cases in which extension has fully been established it is necessary to resort to instrumental methods. The recti's (Fig. 26.'i), which was the precursor of the forceps, was originally used to promote the descent of the head by the application of leverage motions to the sides of the head in alternation. The vectis is never used to-day except for the reduction of exten- sion, and, in the opinion of the writer, cannot be recommended even for this purpose, since, in the first pli; e, its efficiency depends on its possession of an ex cr^'eratcd cephalic curve w'hich renders its intro- du( i 'icult, and, in the second place, it can rarely be pre\ r'ed from slipping, without the use of a degree of force which exposes both the vagina of the mother and the scalp of the child to serious risks of laceration. If employed, the vectis is passed around the occiput and is used to draw it down, while the delay of the sinciput is entrusted to the friction of the j)elvic walls or to counter-pressure by the fingers. For this purpose the hand of an assist- ant must be utilized, since the employment of the vectis always requires both hands ; that is, while one hand makes traction on the handle of the vectis, the fingers of the other hand must always be placed between the vagina and the instrument to protect the tissues from laceration. Beversed Forceps. — A far better operation, when manual efforts at flexion have failed, is to be found in the application of reversed forceps. This opera- tion is in reality a mere extension of the ancient jnnnciple that the tips of the forceps should always be directed toward the leading point on the presenting part ; but when the forceps is applied to an extended head in a ])osterior posi- tion with the tips directed posteriorly, its grasp is directed so far toward the occipital end that the instrument is almost certain to slip after flexion has occurred. It is therefore important to remember that this application should be utilized only for the production of flexion, that during each traction tlic fingers of the unemployed hand should carefully note the motions of the head, and that as soon as flexion has been established the blades should be removed, if necessary being reapi)lied for the delivery of the head in the manner recommended for the delivery of a well-flexed head in posterior positions. Technique of the Application of liei'ei',se(l Forceps, — The forceps should hv placed outside the vulva, in the position in which they are to lie when applicil to the head — that is, with the transverse axis of the blades at right angles to Fig. 263.— The >ectls. THE MECHANISM OF LABOR. 455 the sagittal suture, and with the tips directed backward. If the lock is of tlie ordinary form, the handle of that blade which would be the left iu the ordinary position should be held in the right hand, and, under the guidance of two fingers of the left hand, should be inserted into the vagina and passed into position as near as possible to the occipital end of the head (Fig. 264). xion )era- )f the ntinti posi- tlio las lould n the the 11)0 the erior id be plied es to Fio. 'J64.— The iippliciition of reversed forceps. The arrow indicates the iiTect of the forceps in pro- moting the descent of the occiput while the sinciput is delayed by friction against the anterior pelvic wall. Tlie other blade should be adjusted to corroppond with its fellow, and simple traction upon the handles should be made in the direction of the handles, all leverage motions being avoided. The force of the instrument is then directed against the occipital end of the head alone ; the sinciput is delayed by the friction of the pelvic walls, while the occiput descends under the force of traction, and flexion results. As soon as the small fontanelle has been brought to the centre of the pelvis — that is, when the head has been flexed — the forceps should be removed and the process of rotation be entrusted to nature, since lacerations of the vagina are far less often |)roduced wiien rotation is ofl'ccted by the uterine force than when it is procured by instrumental means ; unless, indeed, the condition of the patient •-lectssitates an immediate delivery. Low Forceps in Wclf-ffcxcd Heads in Poftterior Positioihs. — When rotation fails notwith hmding tlie ])resence of good flexion — that is, when a well-flexed head is delayed in a posterior position until the signs of exhaustion occur — this failure is usually the result of a relative want of eis-a-terejo, which must be compensated for by the substitution of the vis-a-fi'onte of the forceps ; but it is the first essential to success in this operation that the instrument should be so applied that its ])resencc in the vagina ofl'ers no impediment to the rota- tion of the head. If in this position of the head the forceps is applied to the sides of the pelvis, its obliiiue grasp upon the forehead and the occiput will almost certainly prevent rotation ; while, even if it is applictl to the sides of the head, it is liable to cause extension and consequent delay, with laceration u 1 ll M . 456 AMERICAN TEXT-BOOK OF OBSTETRICS. \ t !' I! i W " m^ ':] of the perineum, aud frccniently the death of the fetus, unless special precau- tions are taken to ensure its grasping the occiput. So long as the occiput is dit.tinctly posterior to the transverse line of the pelvis, the forceps should he applied to the sides of the head with the concavity of the pelvic curve toward the forehead — that is, with the tijjs anterior ; but care should be taken during the aj)plication of the blades to keep the handles well raised, or, to use a better expression, to direct the tips far backward into the pelvis, in order to ensure their grasping the occiput aud thus promoting rather than retarding flexion during the tractions. The tractions should be directed as far backward as the perineum will allow, at least until rotation has occurred ; since it is sometimes difficult to secure this line of traction in the ordinary position of the hands, it is often well, in the extraction of posterior positions, to place the left hand upon the shanks of the instrument near the vulva, and with that hand draw backward while the right hand steadies the extreme end of the handles. It must not be forgotten that the maintenance of flexion and the conse- quent production of rotation are essential objects of thio tirst application, since descent is dependent on them. The production of forced rotation by a rotative movoment of the handles of the forceps is so extremr 'y (\.;igorous to the soft parts of the mother as to be permissible to none but tlie most experienced operator. The operator who has really acquired sufficient skill to justify such a maneuvre will infallil)ly have acquired so active an impression of its dangers as to use it with the most A B '^1 ' |'|:^ t Fio. 205.— Lateral motion of the handles of tlu' cnrved forcops rlurinR the rotation of a posterior posi- tion of t)ie lu'uil : A, position of tht' liuntlles when tirst upplie<l ; li, ])osition of the handles alter partial rotation has oeeurred. extreme care ; but, though an active rotation force is not permissible, it is always proper, and indeed necessary to success, that the operator should avoid preventing rotation. He should know exactly the motion the handles will make during the rotation of the head, as that occurs under the guidance of the pelvic grooves, and he should be constantly on the watch to promote and favor this motion. In this connection it must be remembered that when rotation occurs it v ill be in the axis of the blades and not in that of the handles, so that as the blades rotate their handles will move in a laterally circular direction such as is illustrated in Figure 205. If a good pair of straight forceps is at hand, it THE MECHANISM OF LABOR, 45V is much the better instriimeut for low operations in posterior positions, since with it no such lateral motion of the handles occurs, and the avoidance of the necessity of watching for it greatly simplifies the ojKjration. At the conclusion of each traction the handles of the forceps should be sep- arated slightly, since, if this is done, the head not infrequently rotates to an anterior position within the blades. This maneuvre is especially useful when the original application of the forceps has been slightly inaccurate, and the head is, in consequence, not grasped exactly on its sides. A careful digital examination should always be made at the conclusion of each traction, in order to note exactly the mechanism which is going on, to become aware of rotation as soon as it occurs, and to detect any tendency to extension which may have followed a faulty application of the forceps. As soon as the position is slightly anterior, or even when it becomes trans- verse, the forceps should be removed and reapplied to the sides of the head, but this time with the concavity of the pelvic curve toward the occiput, since any further rotation with the blades in the former position wo^''' carry them into the position of the reversed forceps, in which the grasp is unsatisfactory and the danger of laceration is great from the too close approach of the tips to the posterior wall of the vagina. The tractions should again be intermittent, rotation of the forceps with the head should be favored, and the compression should be intermitted during the intervals between the tractions, to permit the head to rotate within the blades. When the head has reached the O. D. A. position the forceps should again be removed, and reapplied in the ordinary way, unless the application is at tiuit time wholly unsatisfactory. The operation as a whole is vastly more difficult than is an extraction in an anterior position. Delivery in Persi^ienUy Posterior Positions. — When, from any cause, the proper maintenance of flexion has been neglec^ted, and the occiput has settled into the hollow of the sacrum — that is, where it has become directly posterior — a delivery " face to pubes " is all that can be hoped for. Under these circumstances delivery by the natural efforts necessarily implies the presence of an unusually powerful and active uterus. It is necessary for the pains to force the head into extreme flexion, to mould it into a much-changed shape, and to distend the soft tissues to an extreme degree ; and the vis-a-tergo of the uterus must usually be reinforced, before the process is completed, by the vis-a- f route of the forceps. The first duty of the obstetrician is to establish an extreme flexion by. pressure on the forehead with the fingers ; it will then be maintained by nature if the uterus is powerful enough to effect an unaided delivery. In this case an attempt to preserve the perineum by keeping the occiput well forward against the pubes is his only other duty ; and as the necessary change in the shape of the head is to be most safely effected by slow moulding — that is, during a long second stage — he should be patient and loath to interfere ; indeed, in these cases the use of the forceps is never warranted unless the signs of exhaustion of one or the other patient are clearly present and increasing and progress has ceased. kii ' ' , ( '\\ } l'\f r . '(' ' t ' If M1J^iiM:M i 458 AMERICAN TEXT-BOOK OF OBSTETRICS. If the forceps must be used, it should be ai)pHed to the sides of the head, aud the extraction should be effected by means of the so-called " pump-handle traction." The tractions should at first be directed well backward until the perineum distends, in order to draw the occiput downward along the posterior pelvic wall, aud then should sweep forward, in order to draw it forward over tke pelvic floor to the vulva and the arch of the pubes. These tractions should be gentle aud intermittent, in order to encourage a slow moulding of the head,* and the forward direction should be maintained until the small foutanelle appears at the fourchette and the perineum retracts along the neck. The handles of the forceps should then be moved backward, but without inter- mission of the traction, in order to favor the appearance of the face from under the pubic arch by extension as in natural labor. 2. Face Presentations. Frequency. — A face presentation is not a very common anomaly. Pinard found 320 fare cases out of 81,711 deliveries at the Paris Maternity — a fre- quency of about 1 in 250. At Guy's Hospital Lying-in Charity, London, there was a frequency of 1 in 276, or .36 per cent, out of 23,591 cases of labor. Churchill analyzed about 250,000 cases, and found that face presen- tations averaged 1 in 231. Collins at the Dublin Rotunda found the fre- quency to be 1 in 497. Spiegelberg thought that in Germany it was 1 in 324. Relative Frequency of the Positions. — M. L. A. is but very slightly more frequent than ^I. D. P. M. D. A. and M. L. P. are very rarely seen. Etiology. — Face presentations are, of course, ])r()duced by the extension of vertex presentations at or just before the beginning of labor, and every face presentation has therefore passed through the stage of brow before becoming a face presentation. Many factors may contribute to the production of this ex- tension, and it is probable that the etiology of the anomaly varies widely in different cases. It may be originated by an abnormal shape of the head, by an obliquitji or abnormality of the uterus, by small tumors in or about the pelvic brim, by a (hformiiy of the pelvis, or by an over-tight adaptation between the head and the brim in a posterior position of the vertex. Undue Lene/th of the Hind-head. — Any abnormal prominence of the occi- put necessarily lengthens the short arm of the cephalic lever, and therefore tends to the production of extension. The presence of such an anomaly would undoubtedly predispose to a face presentation, and cases have been reported in w' ' 'h it was apparently the sole cause ; but in the majority of face cases the heaw is found to be of normal shape after the moulding of labor has passed away, and was therefore probably normal at the beginning of labor. Obliquity or Abnormality of the Uterus.. — An obliquity of the uterine axis by which the fundus is inclined to the side on which lies the back of the child tends to roll the condyles to the opposite side of the pelvis by altering the * Since the chief danger in this operation is that of inhibiting the life of the fetus by com- pression of its skull against the pubes, it is well to have the fetal heart watched by an assistant, and to regulate the force of the tractions by the eflect produced upon its beat. THE MECHANISM OF LABOR. 459 Fig. 266.— Manner In which an obliquity of the uterine nxis may produce a face presentation. direction of the uterine force (Fig. 266), in wliicli the condyles are urged (in the direction of the arrow) by the uteru.s, and thus produces extension. Again, any irregularity in the contour of tne uterine wall on the side to which the occiput is directed — for example, a cicatrix or a localizetl tonic constriction — may delay its progress and so pro- duce extension. Small Tumorn in he Brim. — A tu- mor which impedes the advance of the occiput, but does not interfere with the sinciput, may be the cause of a face presentation. Pelvic . Deformities. — The minor grades of flattened ])elvis in which moderate extension at the brim is nor- mally present (see Di/stoci<i) are a fre- quent cause of face presentations. Tif/ht Adaptaticn in the Posterior Positions of Verte.v Presentations. — We have seen (p. 443) that there is a marked tendency to the production of extension at the brim in O. D. P. and O. L. P. positions. That this is a frequent cause of face presentation is shown by the fact that, although an O. D. P. occurs but about once in every four vertex labors, tlie results of its extension — that is, an M. L. A. — make up nearly one-half of all face labors. Diagnosis. — On abdominal examination the fetal limbs, the heart,* and the least accessible ])ortion of the head are found on the same side. On va/fi- nal examination with the linger, the pointed chin, the mouth with its maxillary processes and the tongue, the no.strils, the bridge of the nose, the eyes, and the supraorbital ridges should be found and recognized. The position is deter- mined by the position of the chin. Prognosis. — The prognosis in face presentations for both mother and child is always somewhat worse than in vertex labor, but it varies greatly in accord- ance with the position of the diin, the prognosis of anterior positions being vastly better than that of posterior positions. The mortality of face presenta- tions varies also between extremely wide limits, in accordance with the varia- tions in the adaptation between tlic head and the pelvis, and more especially with the degree of ossification of the fetal liead. When the chin is anterior, when the adaptation between the head and the pelvis is moderately easy, and the fetal head is so soft as to permit of an easy production of the necessary change of shape, face labor is apt to be rapid. The prognosis for the mother is then unaltered from that of good normal labor, and the prognosis for the child is but little worse; but this statement is true only when the conditions are such that there is rai)id progress throughout the * In face presentations the heart is heard over the ventral side of the chest. V ii- '*:: W. ' ifli:-H'^ 460 AMERICAN TEXT-BOOK OF OBSTETRICS. second stage : witli the supervention of any delay tlic prognosis for the child becomes decidedly poor, wiiile at the same time the mother's prospects arc rendered less good by the risks of laceration during rotation tiiat are always involved in a difficult or operative delivery of the face. In posterior positions of the chin the j)rognosis for the child is always poor, since under the most favorable circumstances it is necessarily exposed to the utmost danger, both from the marked compression of the cranium against the symphysis that invariably occurs and from the great tension upon the tissues of the neck that is implied in the extreme extension necessary to excite rotation in posterior positions of the face. With any but the most extremely favorable conditions the prognosis for the child in posterior positions of the face is almost necessarily fatal, while that for the mother is complicated by the proba- bility of extensive lacerations. In the large majority of such cases rotation fails, and the child's case is tiien practirally hopeless, since no instance has yet been I'ccorded in which the child's life was preserved during tiie extraction of a persistently posterior position of the face. ^ Mechanism and Manafirement of Face Presentations. Mechanism of Face Presentations. — In the mechanism of face presenta- tions the chin plays the same role that the occiput does in vertex labor. Rotation is as necessary to expulsion in the one case as in the other, and the occurrence of rotation depends on the fact that under normal conditions the chin enters more deeply into the pelvis tlian the most prominent point upon the other side of the head, which in this case is that portion of the forehead inmiediately anterior to the bregma. This deeper entrance of the chin is in face presenta- tion secured only by the existence of complete extension, and extension is therefore as important to progress dur- ing the second stage of face labor as is flexion during the second stage of vertex labor. Mechanism of Face Presentations, M. L. A. — Fully-developed face pres- entations at the beginning of labor are comparatively rare. The face commonly starts as a vertex, passes through the stage of a brow while still unengaged, and becomes a face presentation only during the passage of the brim. By reference to Figure 267, which represents the position of the head during the passage of the brim by a face presentation, it will be seen that after the point of the chin has passed the pelvic brim the ventral side of the head and the neck is so shaped as to offer but little opportunity for the engendering of friction against the pelvic wall, while the Fig. 267.— Presentation cif the face at the pelvic brim. THE MKCHAXISM OF LABOR, 461 sliapo t)f' the prdjec'tiug forehead and bregmatie region is such as to ensure lirni pressure between them and that part of the pelvis opposite. Tlie j)osi- tiou of tlie head brings its articulation with the spinal column tlir out to the Fio. 'J08.— Face prcsontntion nt imtlot after rotation (Smelllo). ventral side of the head, and we have then ti 9 pressure of the propelling force couceutrated far out to one side in the head, while the resisting force of friction against the jielvic walls is exerted almost wholly upon the other side ; hence good extension is the rule in face labor. The existence of complete extension, i| I '- II * ^^ ■■mm I ■mm' Fio. 269.— ConfiRuration of the tVtnl lunil after it.s Fi(i. JTO.— Configuration of tlie fetal Viead after its delivery as a face preseiitiitioii. delivery as a vertex i)resentation. however, places so groat a strain upon the tissues of the neck that its produc- tion is usually accomplished slowly ; and the diameter which must occupy the brim as the head descends — namely, the eervieo-bregmatic (Fig. 267) — is so AMKlilVAN TEXT-BOOK OF OliSTETJilCS. lurge that wiih reasonably tight adaptation the deseent of tlie faee is iisiiallv accomplished at the exj)eii.se ot" consi«lerable niouliling of tiie head (Fig. 2(Jt)j. The eervieo-breginatie diameter of tiie head is so far behind the leading point, the chin, that by the time the head is free from the superior strait — that is, when this great diameter passes it — the chin is already deep in the pelvis, and does, indeed, by this time occupy the deepest portion of the ante- rior groove of the left lateral wall. At tiiis point tiiere is often a temporary dead-loek, since the great elongation of the head may still leave the region of the sagittal suture in the sacro-iliac notch, where it is prevented by the promontory from turning backward, although the chin is being urgctl strongly forwai'd by the lower jwrtion of the anterior gntove. Ii(jtation can then occur only when the propelling force is sufficiently strong to crowtl the chin downward to the lowest possible jK)int, and may even require a further lateral moulding of the head under the pressure of the promontoiv agaiust the projecting occiput. As soon as the occiput slips under the promontory rotation i)romptly occurs. The chin swings under the pubic arch (Fig. 2(38), and the mouth, the nose, the eyes, and the forehead successively appear at the fourchette. When tlie angle of the jaw rests against the descending rami of the pubes, the chin and the face )econu' wholly freed from pressure, while the occiput is still exposed to the propelling power of the uterir^ force from above. The chin then sweeps upward, and as the occiput continues to progress, the bregma, the small fontanelle, and the occiput successively appear at the fourchette, and the head emerges by flexion. The mechanism of face labor is, then, extension, descent, rotati on, and hirtj i by fl exjo n. Restitution carries the chin to the side to which it was originally directed during the expulsion of the shoulders. The mechanism of M.D.A. labor is, of coui-se, similar to that of M. li. A. The Mechanism of Posterior Face Presentations, M. D.P. — The chin enters the posterior groove at the brim, and should ti'avel forward along its course ; but even when extension is complete the production of so extensive a rotation as is necessary to bring the chin t(t the front is rendered extremely difficult by the marked obstacle affiorded to its perfcrmance by the resistance of the very prominent bregi^iatic region, which, notwithstanding its size (Fig. 271), must be made to travel backward along the whole left lateral surface of the brim — a motion possible only when the propelling forces are sufficiently powerful and the head is sufficiently soft to permit the protluction of a very extreme degree of moulding of the head. When rotation has once carried the chin into i. i anterior position, the mechanism, of course, is that of a primary M. D. A. Xo separate description of the M. L. P. mechanism need be given. -■■. Management of Face Presentations. — Mmiarjemcnt of Face Presentatioii>< at the Brim. — The measures which must be considered in the management of face presentations when detecteil while the child is still in or above the brim are as follows : The case may be left to nature; an attempt may be made to niise the (Fig. ('(.' of -iitly verv IT i 0(1 of a 1100(1 TllK Mi:%IlA\IS.V #/•• LMi^H. chill, and «o roston- a vcrtox pnsoiitatioii l>y idiiiiikiI jiexinn »f tin' litail, aftor wliicli it may bo loft to nature <»r l)o dolivorod l»y tlio forcops ; fonrjtn may Ik; applied to (lie face as aiioli, or the rase may at once he delivered by irrni(>n. NntnrdI Labor. — The first expedient, that of leaving the case to the «'are of nature, is applioablu only under one set (tf cireiimstaiu'es. Wlieii the chiu Fi(i. '_>7I.— Posterior position of tlie faro deeply engnKed in tlie pelvis (Smellie'. is anterior ; when the woman is a multipara who has liad a succession of easy labors; if the accoucheur is able to satisfy himself by a thorough examination that the soft parts are soft and dilatable, that the ])elvis is ample, and that the child is small, the latter point having been determined not only by palpation of the abdomen, but also by palpation of the head with the half hand introduced into the vagina ; when the uterus is j)owerful and the pains are frequent ; and, finally, when no ])athol()gieal complication is present, — it is often wise to adopt a conservative policy ; but the conse(piences of delay are so serious even in anterior positions of the face, and the prediction of an easy labor is always so (litficult, that the obstetrician should feel that in making this prediction and adopting a policy of inaction he is taking a very grave responsibility. When the chin is posterior, or when, in anterior positions, the conditions are anything but the most favorable, it should bo the rule that the detection of a face pres- entation at the brim is to be followed by immediate interference. Interference at the Brim. — The choice of methods rests between manual fcvion of the head into a vertex presentation, version, and the application of forceps to the face. The choice between version and the production of a head presentation by manual flexion rests mainly on the position of the chin. If the chin is pos- terior, flexion of the head will result in the production of an anterior position ,L! -i'- iV^, r-^: ',:^ d", 1 ''!? iLiliJJJ m > i , y 1 ": ; * I ! ' III '. ' ! I ^ ji: . ; I ^^ AMERICAN TEXiP-BOOK O^ OBSTETRICS. of the vortex — the most favorable position for a subsequent delivery by nature or for an extraction by the forceps ; if the chin is anterior, flexion can produce only the unfavorable posterior position of the vertex.. In posterior positions of the chin manual flexion should ordinarily be the first expedient, and the head, when flexed, should be urged into the brim by external pressure with the hand, in the hope that it may become engaged in this position under the influence of the pains, after which the case should, of course, be left to nature ; but if an engagement does not follow promptly, it is host to apply forceps at once, since the conditions which originally produced the face presentation may usually be relied upon to reproduce it. If the manual reproduction of a vertex presentation proves difticult or impossible, the attempt should be abandoned and version be performed. If the chin is anterior, flexion of the head would result in the production of a posterior position of the vertex ; and siuce, as has been seen, posterior positions of the vertex at the brim are usually best treated, when interference is necessary, by a resort to version, it follows that in anterior positions of the chin, when interference is necessary, a primary version is the operation of choice. When in such cases a version is contra-indicated, the choice lies between an application of the forceps to the face and a manual flexion into a poste- rior position of the vortex, to be followed by an attempt at a manual rota- tion of the occiput to the front and the application of forceps. If the conditions are such as to render this latter operation possible, it is generally preferable to the use of forcoj)s to the face ; but since the conditions which contra-iiidicate version very generally render manual rotation of the head diffi- cult or impossible, it will sometimes be necessary to resoi't in such cases to the use of forceps to the face. The u„e of forcops to the face at the brim is always a difficult operation. The delivery of the child through the brim without injury to either mother or child can be accomplished only by the utmost accuracy in the adjustment of the blades ; and oven in anterior positions the prognosis is serious. The use of forceps to the face higii is, then, never permissible to any but a thoroughly skilled operator, and even in such hands it should be reserved for a last resort. In posterior positions the forcops is ncvcv permissible, and it should be forbid- den both from its inherent difficulties and because success in the passage of the brin; can (»nly result in the production of that very dangerous condition, a jwstcrior jiosition of the face within the excavation. Manaf/euicnt of Face Frcsentatlonx, Low. — Chin Anterior. — When a face presentation has been allowed to pass the brim or has not been discovered until it is within the excavation, its j)rogress should be watched with great care, and the utmost pains must be taken to maintain complete extension throjighout the second stage. A constant watch over the processes of nature must be main- tained, since any considerable delay is attended by great danger to the life of the child, from the likelihood that an interruption of its cerebral circulation may occur as a result of the extreme tension necessarily put u{)on the vessels of the neck or of their compression against the sides of the pelvis. \ y THE MECHANISM OF LABOR. i!^ by nature 1 produce ily be the 2 brim by ngaged in houlcl, of iptly, it is produced be manual le attempt )roduction , posterior iterf'erence jns of the jratiou of is between o a poste- mual rota- If the ! genemlly ions which liead diffi- ases to the operation, mother or istmeut of The use lioroughly list resort, be forbid- )assage of couditioii, leu a face ered until care, and ghout the be main- he life of irculation he vessels It follows from these dangers that even moderate delay furnishes a sufficient indication for the use of low forceps in face presentations. Complete exten- sion, as has been said, is of the utmost importance, and, fortunately, may easily be maintainetl by pressure with the fingers upon the under surface of the lower jaw. Should interference become necessary, it is absolutely important that the forceps should be applied to the sides of the cranium, and with the tips so far posterior as to be entirely clear of the neck. In anterior positions, if this necessity be borne in mind, the application of forceps is easy, and the extraction of the child ordinarily presents no great difficulties ; but it must not be foi"- gotten that pressure upon the tissues of the neck by the tips of the blades nmst almost invariably result in loss of the child. Chin Posterior. — As has been said, the face should never be allowed to enter the pelvis chin posterior. If this abnormality is not discoveral until it has occurred, the patient should at once be etherized, the hanvl be introduced, and the possibility of raising the head above the brim should be tested. If this is possible without grave risk to the mother, it should at once be done, and the face dealt with according to the principles already outlined for the operative treatment of the face high (p. 463). If elevation of the iiead proves impossible, the obstetrician should content himself with the maintenance of extreme extension by traction upon the chin in combination with a constant attempt to promote rotation by drawing the chin forward with the fingers. This process should be persisted in so long as there is, in his judgment, any possibility of rotation. When this prospect becomes hopeless, forceps may be applied and an attempt be made to extract the face as a persistently posterior chin presentation. Any atteu'pt at rotation by the forceps must be forbidden, both because of the grave danger of j)rovoking extensive lacerations of the mother that neces- sarily attends this maneuvre, and because any slipping of the blades upon the child or any oblicpie application of the forceps would necessarily involve com- pression of the vessels of the fetal neck, and therefore the loss of the fetus. A straight forwps should be used if it is at hand. It should be applied care- fully to the sides of the head and with the tips well anterior, so that the grasp of the blades may be wholly upon the cranial vault. The tractions should be directed slightly backward until the perineunj is thoroughly upon the stretch, tlion forward and upward until the chin emerges, and then well downward, that the occiput may emerge under the arch and the head be born by flexion. Since lacerations of the pelvic floor are inevitable in this operation, and since every possible advantage nmst be taken, the j)erineum should be incisal by deep lat- eral Incisions as a preliminary measure. This [)rocess has not yet been successful in the extraction of a living child ; but since it has never, so far as known, been adopted while the child was in good condition, and as it has several tisnes succeeded in extracting dead but uninjured children, it deserves a more extended trial whenever a childin this posititm is still in fairly good condition. If the child's vitality is already seri- ously compromised, its chances of life are so small that the prospect of preserv- •3; • » J s ■fi, . fit V466 AMERICAN TEXT-BOOK OF OJiSTI-yTRICS. f ! i ' I \\^^i ' i i| ;/ ing the mother's soft tissues would, in the judgment of most obstetricians, justify the choice of craniotomy.* 8. Brow Presentations. Frequency. — As face cases liave usually, if not invariably, passed through the stage of brow in the process of their conversion from a vertex presentation, temporary presentations of the brow must be at least as frequent as those of tiie face; but if only those brow presentations which remain such until altered by the obstetrician are included in the list, the freijuency becomes less — jiro- bal)ly not more than 1 in 1500 labors. Relative Frequency of the Ponitious. — Brow (). L. A. and brow (). D. P. arc almost equally freciuent. The others are much less common. Etiology. — Brow presentations are due to the same causes th produce ])rcsen tat ions of the face, but it \s of course a fact that if the process of exten- sion is arreste<l in the stage of brow, it implies a greater obstacle to the prog- ress of the head than where nature is able to develop a face ])resentation. Diagnosis. — On nInJombial examination the two ends of the head are found at about the same level, and the heart is usually heard over the back. On vaf/inal examination the small fontanelle is found at one end of the field, the large fontanelle in its centre, and the supraorbital ridges on the other side. Prognosis. — Since at term and with a normal head the spontaneous delivery of an unchanged brow presentation is possible only after a degree of prolonga- tion of labor that is disapproved by modern obstetrics, the prognosis of ju^r- sistent brow presentations for both mother and child is that of the operation chosen. It should be remembered, however, that when nature changes the brow to a face the prognosis becomes that of a face presentation. Mechanism and Management of Brow Presentations. Mechanism of Presentations of the Brow. — Anterior Ponition of the lirnir -■p"'-' T-> .. {that i,s, brow O. D. P. and brow (). J,. P.). — In the rare cases in which a jircs- entation of the brow succeeds in enter- ing the pelvis, this possibility is due to the fact that the mouhling of the liciid lias [)rogressed until the occipito-mental diameter has become sufficiently sniiili to pass the oblique at the brim, and this change is compensated for by a corre- sponding increase in the ocicipito-frontiil diameter (Fig. 272). The increase in the length of this diameter necessarily carries the forehead much deeper into the pelvis than any other part of the Fio. 272.— fonnpurntlon nf tlio fetal lii-nd nftiT its (li'livcry lis a brow pR'ni'iitatioii. * Since tlie aliove w;is writton the greiit success of syniphysiotoniy has led most ohstetriciniis to believe that a division of the symphysis shoidd jirecede all aj)i)lications of tlie forceps to a peiT^istently posterior position of the face. THE MECHANISM OF LABOR. 467 liead, so that lu auterior positions of the brow the projecting forehead engages in tlie auterior groove of the lateral pelvic wall as soon as the brim has been passed, and reaches its deeper part by the time the occiput escapes from the sacro-iliac notch and enters the shallow u|)per part of the posterior groove of the opposite pelvic wall. If the conditions are so exceptionally favorable as to permit of the expul- sion of an unchanged brow presentation, the forehead moves forward along tiie course of the anterior groove, while the occiput, being still in the shallow up])er part of the posterior groove of the opposite side, moves back into the liollow of the sacrum ; the root of the nose conies to the pubic arch, and the pntgress of the anterior portion of the head is then arrested, while the occiput travels down along the jxtsterior wall of the pelvis and across the perineum. The nose and the chin then appear beneath the pubic arch, and the head in anterior positions of the brow is thus expelled by extension. External rota- tion, of course, carries the occiput to the side to which it was originally directed. Posterior Pomtions of (he Brow {that is, brow O. L. A. and brow O. D. A.). — Should an unchanged posterior position of the brow succeed in passing the l)rim, the forehead would enter the posterior groove and the occiput would lie against the shallow portion of the anterior groove. If the case went on to delivery, the rotation of the forehead along the posterior groove would be similar to that of the occiput in occipito-posterior positions of the vertex ; but when the enormous difficulties incident to the expulsion of the brow under the most favorable circumstances are increased by the inherent difficulties always attached to rotation in posterior positions, the sum-total of the obstacle becomes so great that a delivery is almost unknown, and it may be laid down as a practi- cal rule that |)osterior positions of the brow always become arrested. Manag'eiuent of Brow Presentations : Management at the Brim. — When a brow presentation is detected at the brim, we may deal with it by any one of the four following methods : the case may be left to the care of nature ; the brow may be converted into a vertex by manual flexion ; the brow may be changed into a face by manual extension ; or the case may be delivered by innneiliate version. The choice between these methods of treatment depends primarily on the position, but in posterior positions of the brow — that is, when tiic occiput is anterior — the indications are considerably modified by the pres- iiu'c of excessive moulding of the presenting part. Anterior Positions of the Brow. — The class of cases which should be left to the care of nature is extremely limited, and includes only those few cases of auterior positions of the brow which, when detected, are raj)idly changing into anterior positions of the face, and in which the conditions of the case are such that, if the face becomes established, its progress is certain to be rapid and easy. Flexion of such a brow would jirodnce a j)osterior jiosition of the vertex, and there is then but little hope of a spontaneous delivery of the new presentation, since the marked tendency to extension which always character- izes uie posterior positions of the vertex woidd almost certainly reproduce the «•;■ t fj^T : mm 1,1 •iff let : „ 468 AMERICAN TEXT- BOOK OF OBSTETRICS. i r n 1 \i iiSiia / brow, while if an operative delivery is to he undertaken, vei-sion is the opera- tion of election in posterior positions of the vertex. It follows that vei-sion is the operation of choice in anterior positions of the brow (see Management of Face Freseutatious at the Brim, p. 462). All other anterior positions of the brow should be dealt with by iinniediato version as the o|)eration of choice, the production of a vertex by manual flex- ion being ruled out for the following reasons : In freeing a partially-engaged brow from the brim of the pelvis as a pre- liminary to version, it is essential thai the first effort at raising the head should be directed against the forehead, siiice a preliminary flexion of the head re- places the long occipito-mental diameter by the shorter occipito-frontal diam- eter, and the subsequent elevation of the head therefore exposes the tissues of the mother to far less risk than would be involved in an attempt to force the extended occipito-mental diameter bodily upward. Moderate flexion is, more- over, an important element to success in the subsequent manipulations of the version, since its production minimizes the obstacle offered by the projecting sincip.it. When in anterior positions of the brow which ]>romise a difficult delivery an attempt at version fails, a manual extension of the brow to an anterior posi- tion of the face, to be followed by forceps, is the only alternative to craniotomy, unless the condition of the child warrants a resort to one of the major cutting operations (see The I'^se of Forceps to the Face at the Brim, p. 464). When the brow presents in a posterior position — that is, with the occiput anterior and with the head unmoidded — its treatment by mainial flexion results in the production of an anterior position of the vertex, and a manual flexion is therefore in these cases the operation of choice. After the re-establishment of flexion the head should be held in position by the hands for a few pains; but, unless its engagement occurs promptly, it is usually best to resort to an imtnediate a])plication of the forceps, since it may fairly be presumed that the conditions which originally led to the loss of flexion are still present, and will probably reproduce the extension if the case is left to itself. In this position of the brow a manual extension is contra-indicated, since it could only result in the production of a posterior variety of the face, which in itself is so danger- ous that it demands an immediate version. If, therefore, in these cases a manual flexion is ruled out, version should again be selected as the o})eratioii of secoiul choice. When the brow presents in a posterior position — that is, with the occiput anterior and with the head already much moulded — the oj)eration of manual restoration of the vertex must be ruled out in the interest of the child, for the following reasons: Fii-st, if a marked change of shape is apparent at the time the presentation is detected, the restoration of a vertex presentation by ii manual flexion of the head ))resents great difHculty ; moreover, the conditions are so much altered by the change in shape of the head that its re-extension into a brow would almost certaiidy occur as soon as the pains reappear or the forceps is applied. Second, a vertex delivery involves so extensive a re- THE MECHANISM OF LABOR. 469 moulding of the head to its original shape as to expose the child to great risk of danger from cerebral hemorrhage ; while the delivery of a much-moulded brow by version — that is, by the extraction of the after-coming head — results in but little change i'l shape, and is therefore nmch the safer for the child. Version is, then, the only operation which should be considered in these oases. The operative treatment of brow presentations, high, may be summarized as follows : In anterior positions, version is the operation of choice. In the posterior positions of unmoulded brows a manual flexion to au anterior posi- tion of the vertex and a subsequent application of forceps to the head should be preferred ; this failing, version should be the second choice.* In the pos- terior positions of much-moulded heads version should be selected. A high application of forceps to the brow is ordinarily more dangerous to the mother than a craniotomy, and but little more ho{)eful for the child. The abdominal operations would be indicated only in the interests of the child, and would usually be contra-indicated by the fact that the vitality of the child is usually considerably lowered by the time the ordinary operations have become impossible. Management of Brow Presentations after their Entrance into the Pelvis. — Since the brow never enters the pelvis until after an excessive moulding has been produced, and since the adaptation is then always so close that any alteration of the presentation is impossible, it is unnecessary to discuss in this connection any other prol)lem than the delivery of the brow as such excessively moulded and closely adapted to the pelvic cavity. If the sinciput is anterior, the forceps should be applied to the sides of the head with the concavity of its pcilvic curve anterior, and the mechanism of the natural delivery of a persistent brow should be imitated. The tractions should be directed downward and backward until the root of the nose engages at the arch, and their direction should thou gradually be moved forward and upward until the occiput sweeps forward over the perineum, then downward again to permit the emergence of the face ; but the chance of extracting a living cliild in this way is so small, and the risk to the mother's tissues is so extremely great, that the application is never permissible unless the child is in fairly good condition. If its vitality is already seriously lessened, it is probably the best practice to deliver by craniotomy. Such cases are, fortunately, almost never seen during the life of the child, and perhaps never at term. If the brow has entered the pelvis with the ninciput posterior, and the child is still alive, a very cautious attempt to promote rotation by the forceps might be justifiable ; but success would be extremely unlikely, and a resort to crani- otomy would almost certainly be necessary. This condition, however, is so extremely rare that it is almost unnecessary to refer to it. * An extension to a face and a subsequent rotation of the chin to the front are occasionally possible, but this operation is always diflicult, and should not be attempted by operators of small experience. !.' M it ''I ' I if ■[ ■! i'; ! i. WM ■n 1? i'i ffl^ ' . VI ■ I-- f 470 AMERICAN TEXT-BOOK OF OBSTETRICS. 4. Pelvic Pkesentations. Pelvic presentations are commonly divided into breech, knee, and footling presentations ; but knee and footling presentations are so similar in every respect to those of the whole breech that it is convenient to treat them as sub- variations. Frequency. — Pelvic presentations occur in about 1 in 30 labors when mis- carriages and i)reniature labors are included. Among laboi"s at term, however, their frequency falls to about 1 in 60 cases. Thus, Pinard found among 100,000 cases 3301 pelvic i)rosentations, but on excluding the premature cases the proportion fell to 1 in 62. Among pelvic presentations about 60 per cent, are presentations of the breech. Etiology. — Pelvic presentations are produced by the failure of the condi- tions which ordinarily ensure the existence of cephalic presentations (see p. 418). They are, then, especially frequent among premature and macerated children, when the liquor aninii is excessive and when the uterine and abdom- inal walls ."'.e very lax. They are the rule in hydrocephalus, and one out of every four twins is a breech child. In deformed pelves, too, in which the head is unlikely to become fixed at the inlet during the last weeks of jM-eg- nancy, breech presentations become more frequent. S. D. A. and S. L. P. — that is, the two positions in which the long diameter of the breech occupies the first oblique diameter of the inlet — are much more common than S. L. A. and 8. D. P. Knee and footling presentations are probably always secondary, and are due to an active movement of the fetal limbs. Diagnosis. — On ahdommal examination the head is found at the fundus and its absence is noted at the brim; the heart is heard above the umbilicus. On v<f(/inal cramination in presentaticns of the breech the presenting part is at first high and is reached with difficulty. The finger recognizes the vulva or the scrotum and penis, as the case may be, the anus, and the sacral spines. On rectal examinaticm of the fetus the coccyx, the tuberosities of the ilia, and the pubic arch are easily recognizable. The position is best determined by the position of the coccyx as ascertained by a rectal examination. In knee and footling cases the prolapsed extremity is recognized by its anatomical characters (see p. 415). Prognosis. — The prognosis for the mother in breech presentations is only altered from the normal by the frequency with which rapid extractions are necessary, and by the fact that in such extractions there is a greatly increased risk of laceration. The ])rognosis for the child is always poor, the mortality running as high as 10 per ccht. in skilled hands. The prognosis for both patients is worse when the mother's soft parts are rigid — for example, in primiparse. Mechanism and Management of Breech Presentations. Mechanism of Breech Presentations. — Normal Mechanism. — In breech presentations the first stage is ordinarily abnormally slow. If the membranes '^^i^ifis wmm THE MECHANISM OF LABOR. 471 are intact, the dilutatiou of the os is perfcvmed by them as in head presenta- tions, and every care should be taken to preserve their integrity until the os is fully dilated. This precaution is of special importance in breech presenta- tions, since, although the small and tapering breech is not ill-adapted to the dilatation of the os, the breech, when considered as a dilating wedge, labors under the disadvantage that its small size renders its passage through the cervix an inefficient preparation of the soft parts for the passage of the larger and harder head ; extensive lacerations of the cervix are therefore frequent whenever the pre[)aration of the cervix has been entrusted to the breech. When the resistance of the cervix has been overcome, the comparatively small and soft breech naturally enters the pelvis easily, as tlie bitrochanteric diameter, the greatest diameter of the breech, is less than any of the diam- eters of the brim. The bitrochanteric diameter enters in one or the other oblique diameter, and is then crowded downward into the pelvis until the pos- terior hip impinges on the pelvic Hoor, when, under the forward shunt of this portion of the posterior wall of the pel- vis, the breech as a whole bends for- ward by a lateral inflection of the trunk (Fig. 273). This movement engages the anterior hip in the deep portion of the anterior groove of that side of the pelvis to which it is directed, and as the anterior hip rotates forward the posterior hip slips back into the groove of the sacrum. The lateral infiection becomes well marked, the anterior buttock appears at the vulva, and as the trunk is driven more dee[)ly into the pelvis by the uterine contractions tiie anterior hip becomes fixed at the pubic arch, and the posterior hip swings forward until the posterior buttock and trochanter appear successively from under the fourchette. As the posterior half of the breech emerges the perineum retracts upward Aug the child's pelvis, and, all pressure being thus removed from the pos- teupr surface of the breech, the inflection is released and the trunk of the child is permitted to straighten itself again, thus releasing the anterior hip from its position of pressure against the pubic; arch ; the whole trunk then moves downward through the j)elvis, and only such moderate lateral inflection as is necessary to accommodate the trunk to the course of the pelvic bones still persists. When the legs remain, as they should, in their normal position of flexion, the escape of the knees from the vulva releases the lower extrem- ities. At about the time the umbilicus appears at the vulva the shoulders enter the brim, their transverse axis lying in the oblique diameter. H the arms remain in their normal position — that is, crossed over the breast — the anterior Kl(i :7;i.--I,iitiTnl inflection of tlio truiili dnring oxpnlsion of tlie broei'li. i^E^ ^ \i \i '■;.■ ! 14 ill. :* V:\ k. ( a M W}i 1 ; -i i I '1, ■i I 472 AMEEICAN TEXT-BOOK OF OBHTETRICS. shoulder rotates to the arch and is delayed by fixation against its inner surface, while the posterior shoulder and elbow i)ass the vidva. The escape of the posterior shoulder so diminishes the size of that portion of the body occupy- ing the outlet as to permit the anterior shoulder to escape from the arch and emerge from beneath it. The pressure of the uterus upon the longer arm of the cephalic lever should, under uorinal conditions, preserve the flexion of the head. In this condition the chin aod the face necessarily enter the pelvis first, the suboccipito-frontal and suboccipito-bregn)atic diameters occuj)ying one of the oblique diameters of the superior strait. Since, at the time the head engages at the superior strait, the sho'ilders have already rotated into a position in which the bis- acromial diameter occujjies the antero-posterior diameter of the outlet, the head approaches the superior strait in a transverse diameter, but the recession of the j)osterior portion of the lateral wall of the pelvis at the brim, as it approaches the sacro-iliac notch, causes the face and the forehead, the first portion of the head entering the pelvis, to swing backward into a posterior position. The after-coming head thus normally enters in an occipito-anterior position. As the head eutei"s the excavation the sinciput is so much lower in the pelvis than the occipital end of the head that it swings along the course of the posterior groove until it slips into the median line upon the pelvic floor, the occiput which is still exposed to the smooth bony surface of the brim at the same time rotating to the median line in front. The face appears followed by the forehead at the vulva, the perineum retracts over the bregmatic region, and the head is born, still in a state of flexion. Afmormal Mechanwn of Breech Presentations. — The frequent occurrence of abnormalities in breech presentations is to be accounted for by the ease with which the legs, the arms, and the head may become extended l)y friction against the pelvic wall. The descent of the legs and the arms should normally be accomplished jxw! passu with that of the body through the transmission of the uterine force to their uj)per surfaces by the liquor amnii ; but in a large pro- portion of cjises the cervix has still sufficient resiliency to contract tightly upon the fetal trunk after the legs have passed the cervix. The upper surface of the legs is then cut off from the pressure of the liquor amnii, while their descent is still opposed by an undiminished friction against the pelvic walls ; agaH, they may be detained by being themselves caught in the grasp of the cervix, while the body continues to descend ; or, finally, they may have been placed in an extended position by the action of their intrinsic muscles. As a result, it not infrequently occurs that the legs become extended against the body during the descent of the breech. Under these circumstances it occasionally hapj)ens that the legs are sufficiently closely applied to the child to act as rigid splints to its trunk, thus causing arrest by preventing the lateral inflection necessary to the passage of the trunk. An arrest due to this cause usually necessitates a resort to operative interference. The re-contraction of the cervix upon the body may also result in an exten- sion of the arms upwai'd during the descent of the shoulders, until they lie along SR THE MECHANISM OF LABOR. 473 the sides of the head. The shoulders then enter the pelvis normally, but their further progress is arrested by the fact that, unless the child be small or llio pelvis be uiuisually ample, the head and the arms form too bulky a mass 10 enter the i)elvis together easily, and the interference of the obstetrician is ;igain required. Even though the legs and the arms maintain their normal relations to the trunk, the passage of the head may be arrested by extension. Under normal circumstances the sinciput is driven into the pelvis, because the pressure of the liquor amuii upon the forehead is usually sufficient to overcome the resistance of the face against the pelvic walls, and there is nothing, there- litre, to disturb the original relation of flexion of the head upon the chest ; l)iit if the attendant is injudicious enough to make traction, or if the already delivered portion of the trunk is unsupported, its weight, under the influence of gravity, is transmitted to the head through the occipito-atlantoid articulation, and a traction is thus initiated which is exerted solely against the occipital end of the head. The result is an abnormally rapid descent of the occiput. If this descent occurs before the head enters the superior strait, it may cause sufficient extension to result in the entrance of the occipito-mental or the occipito-frontal diameter into the superior strait, and thus produce an arrest of the head in this ])oi'tion of the pelvis. If the influence of gravity only becomes active after the entrance of the forehead into the pelvis, no more than a partial extension is likely to result, but this partial extension brings the occiput into the deeper portion of the anterior groove of one lateral wall, while the sinciput rests in the posterior groove of the opposite wall. Rotation of the forehead forward is thus prevented, and there results a dead-lock which can only be broken up when a rapid descent of the forehead — that is, the restoration of flexion — is secured by operative influence. Still another abnormality occasionally occurs. When the child is small or the pelvis is exceptionally ample — in other words, when the adaptation between the child and the pelvis is abnormally easy — the shoulders may enter the brim in the transverse diameter. If the back of the child is anterior, this produces no modification of the mechanism ; the shoulders become oblique, and finally antero-posterior, during their passage through the lower part of the pelvis, the head enters with the sinciput posterior, and the birth goes on normally. If, however, the shoulders enter the superior strait transversely in a posterior position of the breech, the face and the forehead usually become engaged in the anterior portion of the pelvis before rotation of the shoulders can occur. If, under these circumstances, the flexion of the head is thoroughly well marked, the forehead passes along down the course of the anterior groove, the face appears under the arch while the neck retracts the perineum, and, if the pains are of tiiC very best, the forehead may be urged down uuder the arch and the head be born in flexion. The successful conduct of this form of mechanism by the forces of nature is, however, rare. It often happens that the projecting chin, the mouth, or the nose catches upon the upper border of the pubic bones. The sincipital end of tlie head is then delayed, exteusiou results, the head jams across the brim by m i 474 AMERICAN TKXT-ROOK OF OBSTETRICS. $-- ' 'il ,1 >\-h\ the occipito-meutal or tlie occMpito-fVontal diameter, and an absolute arre t usually follows. Delivery by the efforts of nature then almost never oecurs, and is only possible when the adaptation is so easy that the uterus is able to drive the occiput through the brim, while the chin slips upward and forward over the horizontal ranuis of the pubes in order to make room for it. If this happy release of the chin happens, complete extension follows, the occiput appears under the fburchette, and the head is born in extension. This move- ment of extension is, however, usually accomplished only by traction on the body or by the application of the forceps ; even then it is likely to involve so much delay that the preservation of the life of the child is unlikely. Management of Breech Presentations. — Nothing more thoroughly tests the skill and judgment of the obstetrician than his management of a breech presentation. Upon the one hand, it is of the first importance that he should remain inactive so long as the natural processes are progressing satisfactorily. Upon the other hand, he must be prompt to foresee the appearance of danger to the child, and to interfere as soon as this danger is manifest. He cannot be warned too strongly to avoid premature interference, since the use of trac- tion instantly disarranges the delicate balance by which the normal attitude of the child is maintained. As before stated, the maintenance of flexion in natu- ral breech labor is due to the facts that the legs, arms, and forehead are driven down by the action of the intra-uterine-fiuid pressure upon their upper sur- faces, and that this pressure is more than sufficient to overcome the friction of the pelvic walls against the lower surfaces of these parts ; but when traction is made upon the breech, the additional force thus supplied is distributed to the members only through the knees, the shoulders, and the occipito-atlantoid articulation respectively, while the very fact of its application —that is, the promotion of a more rapid descent — increases the force of friction exerted against the feet, the hands, and the forehead. Traction is then almost invari- ably followed by extension of the legs, the arms, and the head, with all its inherent difficulties. When, however, interference is demanded, speed in extracting the arms and head is essential. After the scapula) appear five minutes is an average time, within which the mouth should be brought to the vulva. He who interferes in a breech delivery should feel that unless unusual good fortune attends his effi)rts he is likely to be confronted by the necessity of a manual delivery of each and every portion of the child's anatomy as these por- tions successively approach the pelvis. ICven in the most skilled hands this process is attended by much more danger to the child than is involved in a natural delivery. Since natural delivery is ordinarily possible only when complete flexion is maintained, since a single traction is likely to produce extension, and since, ■when extension has once occurred, delivery is ordinarily possible only by the immetliate adoption and subsequent prosecution of an operative extraction, it becomes evident how important it is that the obstetrician should remain abso- lutely inactive unless there arise circumstances which show him that nature is THE MECHANISM OF LABOR. 475 likely to fail — that is, that the best chances for the child have been lost, and that the second best must be taken ; for if it be true, upon the one hand, that a prompt natural delivery is i«afer for both mother and child than the best operative interference, it is equally true, upon the other hand, that when nature fails in promptness the only hope for the child and the best prospect for the mother is to be secured by the immediate performance of an o|K'rative delivery. Management of Nonnal Breech Labor. — In breech labor the obstetrician's duty, so long as progress is normally rapid, is reduced to the following details : It is wise never to <!onduct a breech labor without one skilled assistant, if such a person can be obtained. This assistant should give the ether if this is required, and should be ready to apply suprapubic pressure to the head if a rapid extraction becomes necessary When delivery is imminent the woman should be placed in the lithotomy position, since there is never any certainty that interference may not become necessary at any moment. It is also well to put the patient slightly under the influence of ether as soon as the delivery is thought to be near at hand, since, if interference is indicated, it is rendered greatly easier by anesthesia, and because a jiartial anesthesia can be raised to the surgical degree with much less loss of time than is necessary to produce unconsciousness in a totally unetherized patient. From the time the breech enters the |)elvis the fetal heart should care- fully be watched, since there is always danger of compression of the cord, and for this reason any irregularity of the fetal heart is sufficient cause for inter- ference. As soon as the cord can be reached its pulsations will keep the obstetrician informed of the condition of the child. As soon as the buttocks emerge from the vulva they should be wrapped in a warm sterilized cloth ;* the attendant should do his utmost to relieve the perineum from undue strain by pressing the hips and the pelvis of the child into close contact witii the arch ; and even after the delivery of the hips he should continue to support the breech in an elevated ])osition for the same rea- son. When the knees appear he should reduce the bulk of the })resenting part by f!>}xing out the legs. As soon as the umbilicus is within reach of the finger he should gently draw down a loop of the cord, to avoid the danger of undue tension upon the cord or up(m the umbilicus during the subsequent descent of the body. The hips and the body should still be held constantly forward toward the mother's abdomen, in the curve of Cams, in order that the rota- tion and expulsion of the head may not be interfered with by the weight of tli(! body; but no traction should be made during this process. As the elbows appear the forearms should be drawn out, and if the fetal body is sufficiently elevated the head should follow without delay. f Rapid Extraction of the Breech when Arrested High. — When a breech is arrested at the superior strait until the signs of exhaustion of one or the other * Wirm in order to lessen the danger of a jjremature resi)iration, sterile on account of its contact with the vnlva. t For the procedure of extracting tlie Ijcad and arms low, see page 480. I' )' ■X t>b. AMERICAN TKXT-liOOK OF OBSTETRICS, patient appear, or when a rapi^l delivery becomes necessary by reason of some condition which threatens tlio life of mother or child, five methods of securiiiir descent are applicable : Traction may be made npon the anterior j;roin with the finycr, the JilUt, or i\\i blunt hook ; forceps may be applied to the breech ; or the hand may be inserted into the uterns, and be made to briiKj down a f(y for use as a handle by v^jiich to make traction. Of these metliods, the use of finj^er in the groin is always preferable when its employment is possible, but in high arrest of tiie breech the finger seldom has sufficient power to secure descent ; and if the breech is but slightly engaged in the brim at the time interference becomes necessary, the introduc- tion of the hand to bringdown a leg is ordinarily the metiiod which should be chosen when the finger in the groin fails. If the breech is already so far engaged as to render this maneuvre ditficult or dangerous, the cautious employment of the blunt hook or the fillet is permissible. An ojierator of practised skill may succeed by the forceps, but the application of this instru- ment to the breech at the superior strait is not to be recommendeil to begin- ners. llie Use of the Fim/er. — In applying this metluKl the half hand should be passed into the vagina, the forefinger be hooked into the groin in any manner convenient to the operator, and traction be made downward and backward in the axis of the superior strait. Care should be taken to direct the line of traction rather toward that side of the pelvis to which the back of the child is directed, in order to lessen the dan- ger of snapping the femur (Fig. 274). The Blunt Hook.— Yioth the fillet and the blunt hook can usually be ap- plied to the groin, without s|)ecial diffi- culty, in any jjortion of the pelvis, and both furnish fairly effective means of traction ; both instruments, however, labor under the disadvantage of subjecting the tissues of the child to great risk of injury, the blunt hook, when skilfully used, being perhaps the less daneri - ous. The hook should be passed, under the guidance of the finger, betwo- anterior hip of the child and the pubic bones until it can be so rotated tl.>. its point passes between the child's thigh and alxlomen. The finger should tin ■ be passed between the thighs and be brought into contact with the point of the hook, which should then be settled downward by gentle traction until its curve fits snugly into the flexure of the groin. The shank of the hook should then be grasped by the hand to which the finger belongs (Fig. 275), and traction should be made with the other hand, the finger lying in contact with the ^' ^"^SC'f ' Fio. 'J:4.- -Proper (A) imd improper (B) directions of traction upon the thigh.* * Though represented with tlie fillet, this Figure illustrates equally the manner of employ- ing the fillet, the blunt hook, or the finger. THE MV.VHANISM OF LAIiOR. 477 point of tlie hook tlirotiglioiit tho cxtniction, in ordor to protect the soft pnrtH from injury as f'nr as |>ossil)l»'. The liiit> of traction .should iw dirertcd toward (he side on which the sacrum lies, in onler to avoid fnicture of the thigh. ■■\tl Fui. 27.').— Mf thod of gruHpIng the blunt hook. The Fillet. — The fillet may be made of a i>iece of broad tape, preferably linen on account of its greater strength, or of a wide .strip torn from a silk handkerchief; the best fillet known, however, is that made by pa.ssing a stout cord through a piece of rubber tubing about three-eighths of an inch in diameter. The fillet may occasionally be passed through the groin by the un- aided fingers, but in high arrest it is seldom possible to succeed in adjusting it l)y this method. Several instruments have been devised for the special j)urpose of placing the fillet, but their place can be filled equally well by a piece of string and a large English webbing catheter. The disinfected catheter should he threaded with a double looj) of disinfected string or of narrow bobbin, and with its stilette, should then be bent to the shape of the blunt hook (Fig. 276). The catheter shoidd be pas.sed into the groin in the manner directed for the use of the blunt hook, and the finger should dnvw down the projecting loop of string until the end of the fillet can be passed through it, when, by the removal of the catheter, the fillet is jjlaced in posi- tion in the groin. The .same precaution as to the direction of the line of trac- tion must be observed with the fillet as that recommended for the blunt hook and the finger. The Use of Forceps. — If the forcej^s is used in high arrest of the breech, its application is similar to that which is to be described under low arrest (p. 478 although it is much more difficult. The Extraction of a Leg. — In the introduction of the hand into the uterus to bring down a leg, the breech should be pres.sed back gently through the brim before any attempt is made to pass the hand. The utmo.st gentleness sh' 'Id be observetl throughout this maneuvre, and undue ten.sion on the utero- vaginal attachments should be avoided by a careful maintenance of counter- FiG. 276.— t'sc of the cfttheter as a porte-fiUet. ( * -lA, ^i.-:!- s ;i mi ■II 478 AMFJilCAN THXT-BOOK OF OBSTETRICS. prt'ssiiro against the fiiiuliis with the other liand. The operator should always be careful to ascertain the position of the cord, to avoid the production of an uiHiecessary prolapse. If the foot is within reach, it should be seized and gently drawn out fnMn the os. He should seize the anterior leg whenovcr that is accessible, as the line of traction on the anterior leg can be kept nearly in the axis of the inlet, while a pull on the rear leg brings the anterior but- tock to a sitting position on the brim, and the traction in a line running from the child's hip, located near the mother's i)romontory through the vulva. If the legs are extended across the chest, two fingers should be placed along the crest of the tibia, and be used to so flex the leg tiiat the foot passes down the median line of the child's abdomen until it reaches a position in whitii it «ui be seized and withdrawn. When the foot appears at the vulva, the h'g should be wrapped in a towel which has been dipped in a warm solution of corrosive sublimate, and traction should be made upon it in a line which shoidd at first be directed as far back- ward as the perineum allows, in order to pull, so far as possible, in the axis of the superior strait. As the breech descends the line of traction should swing fi)rward, until, when the hips clear the vulva, it is directed nearly vertically upward, the woman being in the lithotomy position. As soon as the knee is well outside the vulva the grasp should be shifted to the thigh, as any pro- longed traction on the lower leg is apt to overstrain the ligaments of the knee-joint. If there is any difficulty in bringing the breech to the vulva, its delivery may be assisted by hooking the forefinger into the other groin as soon as it is within reach ; as the breech distends the perineum it should be drawn well forward, and every effort sliould be made to prevent a laceration precisely as is done in the delivery of the fore-coming head. When the second knee appears at the vulva, it should be drawn outward along the side of the child and toward its back, until the fingers can reach the leg and release the foot by flexion of the leg ui)on the thigh ; but all pressure upon the shaft of the fenuu* nnist carefully be avoided, since fracture of the fenuir during this process is always easy. Care should be taken to bend the knee only in the natural direction. littpid Extraction of the Breech leliea Arrexfed Low. — Low arrest of the breech can usually be overcome by the use of the Ji)i(/er in the groin, which method should always be the first tried, li this method fails, the use of the Jiflety or, better, the hliail hook, is decidedly less dangerous to the child in low than in high arrest, the method of applying them being exactly the same; the Joreepx is here, however, easy and is almost invariably eflicient; moreover, if due care is exercised, this instrument is fiir less likely to injure the child than is the blunt hook. Applk'dtio)! of the Forcej)^ to the Jireedt Lojr, — If the breech lies in an antero-posterior or obli(pie position, the tip of one blade of the forceps should lie against the upper sacral vertebne, while that of its fellow should bo pressed into the flexor surlace of the most easily accessible thigh (Fig. 277). If the position of the hii)s is transverse, each tip of the forceps should THE MECIIAyLSM OF I.AJiOR. 479 of tlio wlik'h of tlio ill low 110 ; the )V('r, if tiiaii ill iiii uild 1)0 277). slioukl impinge upon a foimir just above or Itovond the trocliaiitor, whicii then furnishes a firm hold for the blades (Fig. 27<S). In making the application the forceps shonld be placed in an ai>proxi- inately correct position upon the breech, locked, and held lightly in this posi- tion. A hand should then be passed into the vagina until the tinger-tips can touch the exact spots at whicli t!ie tips of the blades should lie; an accurate adjustnieut is then easily attained by direct movements of the tijis of the blades with the internal fingers. The small size of the tapering breech, iu comparison with the diameters of any pelvis through wiiich a living child can be ex- tracteil, renders it easy to obtain an accuracy in the adjustment of the forceps that is impossible of at- tainment when the forccjis is used upon the head. It is this fact which renders the forceps valnai)le in this connection, since the avoidance of injury to the child and the attainment of a secure grasp of the breocli are to be eH'ected only by the adjustment of the tips to exactly the points to which they were directed, and the utmost care nuist be observed in verifving the position of the forceps before any traction is made. When the operator is sure that the instrument is satis- Fm. JT-.-Forcops applied to IV;. OT,-lM,r..,.ps,.pplu..l t,. lilCtOI'ilv in Ilosition the "" "I'liilUL' piisiUuii nl the u tnuisvcrso positldU ot lliL- , 111 111 I bret'uh. Ijri'i'cli liaiulles should he grasped sufliciently tight to ensure a firm pressure, which shonld then be maintained without intermission until after the (k.'livery of the child. The ordinary forceps is better adapted to this application than any special forms which have yet been devised. When the instrunient is used u|)oii the high lireeeh the advantages of axis-traction are perhaps more t'ully apparent than in juiy other obstetric operation. l\(ipi(l Krfrdcfinn of the Tridili. — As soon as the legs and the jielvis of the child have cleared the vulva, they should be grasped (througli a warm as(>ptic towel) in the manner shown in Figure 279, in which each thigh is grasped by V.I [ U .1' ' '1' : ! 'i I ■!-:g: ,'■ 1 * i'^'^i 480 AMERICAN TEXT- HOOK OF OBSTETRICS. V'i \i the fingers of one hand, the thumbs of the operator lying along the sacrum ; this grasp should he maintained tliroughout the extraction, no other grasp being so secure, and any pressure upon the crests of the ilium or upon the ab- domen of the child being dangerous to its bones and abdominal viscera. The line of traction should be directed as far backward as the perineum allows, in order to facilitate the passage of the shoulders through the superior strait, and the back of the child should bo kept steadily directed upward — that is. toward the anterior portion of tiic mother's jwlvis — to secure an anterior position of the occiput for the after- coming head. When the umbilicus a])- pears at the vulva a loop of the cord should be drawn downward, as is done during the normal delivery of the breech. liaijid Extmdlon of the AftiT-cominf/ Fio. 279.-Method of RraspinR the thighs during lJ^.^^^l ^,„,^ AnilS.—H, bv any chaUCC, tht! extraction of the breech. . . either arm remains flexed upon the in- fant's chest, it may easily be drawn out when the elbow appears at the vulva ; but in the great majority of cases both arms will be extended beside the head, and their extraction is then more difficult. The method that should be chosen for their release must depend upon the point of the pelvis at which the shoul- ders become arrested. Low Arrest of the Arms and the Head. — I.i easy extractions it is very often possible to bring the shoulders into sight outside the vulva by simple traction upon the thighs. In such cases it is frequently possible to extract the after- coming head and arms by the very easy and simple numeuvre known as DetH'titer'i^ method. In this procedure the body of the child is dropped down- ward as soon as the points of the shoulders are in sight ; the feet are grasped with one hand, the Hngers of the other hand being pressed upon the upper sur- face of the shoulders, and the child is drawn vertically downward toward the floor, the mother being in the lithotomy positicm. Under this traction the occiput appears at the vulva, and the forehead and face follow coincidently with the arms. The mechanism by which this somewhat surprising dtilivery is accomplished is as follows : The method is applicable only when the pelvii' space permits the head and the arms to enter the brim togeti)er, and both arc then contained in the excavation when the shoulders are at the vulva. The arms are tiien in contact with the elastic sacro-sciatic ligaments, which stretch before them and permit them to lie by the side of the head. The chin is arrested by the pelvic floor; the head extends, and thus brings the occiput to the vulva. The head is then delivered in extension, and the arms follow ) via ^s^rn^ THE MECHANISM OF LABOR. 481 (Fig. 280). The original advocates of this method claimed that it rarely if ever tears tho perineum, and the writer's experience with it certainly supports this claim. When t;,e conditions permit the head and the arms to enter the pelvis together — that is, when the shoulders can be brought to the vulva by traction upon tl'.e thighs — Deven- tor's method, though not the most powerful, is cer- tainly by far the most rapid and easy of all the inaneuvres for the release of the head and the arms, and it should always be given a trial. It is nec- essarily inapplicable when the head and the arms are arrested at the sui)erior strait. Trac- tion then only increases the difflcidty. If the shoulders appear at the vulva, but Deventer's method fails, the liiothod known as combined traction on the face and the shoiddcrn should be tried. Two fingers slu)uld be passed along the upper surface of the most easily accessible arm until their tips rest in the bend of the child's elbow. The elbow should then be urged backward and toward the median line by the fingers, and be swept across the child's face to the vulva, at which the elbow, forearm, and hand apjiear in the order named. This process should then be repeated with the other arm. Pressure upon the shaft of the humerus should carefully be avoided, since it is certain to snap the bone. The child is then laid astride of one of the operator's fore- arms, and the hand belonging to this forearm is passed into the vagina until its first and second fingers lie upon the canine fossie of the child. The other liand is hooked over the shoulders, the nock being between its first and second fingers, with the finger-tips upon the supraclavicular region (Fig. 281). The iiand that is hooked about the shoulders is then used to make traction upon the ciiild, while the internal hand exerts itself to preserve the flexion of the head. The direction of the first tractions should be in the line of the axis of that part of the pelvis in which the child lies, and as the head emerges the line of traction should sweep fi»rwar(l in the curve of Cams until, at tlie end of the extraction, the body of the child rests upon the other forearm and along the abdomen of the mother (Fig. 282). When the mouth appears at the vulva ai Fio. 280.— Deventer's iiicthnd of extraction of the urter-eoiiiiuK head iinU arms. \V' fM' ,t 1. 1 ,' f i'5 ' > I.' .i i:l V:i: I" i I i ^ !' i • i ';M. ■(! '■ re ^,i ; I 482 AMElilCAN TEXT-BOOK OF OBSTETRICS. and tlie moiitli and pharynx have been cleared out, all hurry ceases, and tin- Fk;. ;!81.— Delivery of the ufter-coiiiiii}? liead liy coinlnned triictiou on the lieud niid shoulders. operator's efforts should be direc^^'Hl to the preservation of the perineum. But little traction should now be used, and the hand that was apj)lied to the face should be used to shell out the head by })rcssure on the forehead through the perineum, or, if necessary, by passing two fin- gers into the rectum. Il'uih Anrd of the Art)}>< and Head. — When the adap- tation between the head and the pelvis is not sufficiently easy to permit the simulta- neous entrance of the head and the arms into the pelvis, the arrest of the shoulders at tlie superior strait may be known by the fact that the child ceases to make progress, - ^.m. ^^ under tractions of ordinai'v -s/s^ _^^^ strength, at about the time ' when the tips of the scapula' Fi(i. 282.— riisitioti n( tl't' cliiM Itnnii'diiili'ly after the eseupe , , a 1 • of the unereoiuiii),' heud from the vuivu. ap})ear at the vulva. At tlllS THE MECHANISM OF LABOR. 483 ])oint of the extraction it is therefore important to watch for a marked increase of resistance, and when this is observed the tractions shouhl immediately be intermitted, since their continuance only serves to lock the head and the arms t-ccurely in the brim, thus rendering the subsequent maneuvres for their release more difficult. The body of the child, in such an event, should be pressed slightly upward, and be rotated until t!ie back is directed to one or the other side of the mother's pelvis. The hips should then be elevated gently toward the mother's abdomen and toward the side to which the back of the child is directed, moderate traction being exerted upon them at the same time. The object of tills maneuvre is twofold: first, tiiat space may be afforded for the passage of the hand into the vulva alcmg the abdomen of the child ; secondly, that the jiostcrior shoulder, which is usually the most accessible, may be brought as deeply into the pelvis as possible. The hand of the operator that naturally faces the abdomen of the child should then be passed rapidly into the vulva, with its palm flat against the abdomen and chest, until two fingers can be passed up along the arm of tlie child and their tips placed in jwsition in the bend of the elljow. No pressure upon the arm should be made until this position is reached, but when it is attained the elbow should be drawn down across the child's face until the forearm and liand are within easy reach and can be brought to the vulva. If the hand passed along the abdomen fails to reach the elbow, the latter may sometimes be found by seizing the feet in tliat hand and drawing them gently upward and to the opposite side, so that the hand which before held the feet can be passed along the back of the child close under the pubic arch to the back of the posterior shoulder, and thence along the arm to the elbow, which, however, must, as before, be brought downward a(!ross the child's face. The hips of the child should then '■ swept downward and traction be made upon the thighs, in the hope that tlie pelvic space may permit the entrance of tiie head with the remaining arm ; if this does not occur, the body of the child should again be pressed backward into the pelvis, and the child be so rotated that the arm which was anterior becomes posterioi-, wiien it should be released by the same method that was used in tlie extraction of the first arm. During this rotation the back of the child should sweep across the front of the mother's pelvis. This rotation may be effected either by grasping and turning the thorax with both hands or by drawing the already cxtraifted arm Ibrward along the side of the pelvis, between the labium and the back of the child. In rotating the child it must always be remembered that the articulations of the neck are so arranged that if the point of tlie chin be carried beyond tlie point of the shoulder a dislocation of the atlas upon the axis is the result. l''or this reason the thorax should be ])uslie(l strongly upward whenever an attempt at rotation is made, in order to free the head iVom the superior strait ; and the hands of tiic assistant should wateli the heatl from above, that he may warn the operator if it fails to follow the shouhlers. In the extraction of the Jiead from the superior strait the method of combined traction upou face and !ililfcili-i rP 'i r [if iiil Ms f W4 ^S'^ i ' t M-i !i :■ f: ! ■ I 484 A ME RICA. Y TKXT-nOOK OF OliSTETIilVS. shoulders is usually tlio host, hut it should then he reinforced hy suprapuhic pressure applied in the axis of" the brim hy the hands of an assistant. iJiJfictilt Ki'trdction of Hie Hend and the Anns, — Arrcd of <m Arm behind the Occiput. — It sometimes happens that the head rotates with the shoulders, but the arm is detained behind the pubes by friction against its walls. In such a case the arm crosses the nape of the neck and, if traction is made, becomes jammed between the occiput and the symphysis. If this accident is discovered before traction has been made, })rompt rotation in the reverse din.'c- tion may unlock the arm, and in this case this reversed rotation should Im; continued until the arm becomes posterior — that is, throutih 180° ; l)ut unless the first attempt unlocks the jam, the child will probably be lost, and it is then, perhaps, best to make direct traction upon the arm at the risk of fracturing the humerus, after forewarning those present that this must be the result, and that it is done in the interests of the child. Closure of a Constriction-rin(/, or of (oi Imperfectly dilated Os, about the Neck. — The stricture of the canal formed by either of these conditions may embarrass the release of the arms, but it does not otherwise affect the above- descril)ed maneuvre, except that any abrupt or too forcible movements of the hand while within the uterus are even more dangerous in these cases than in others. The extraction of the head from the constricting band is, however, often a matter of great difficulty. Any attempt to overcome this obstruction by force exposes the mother to the most imminent danger of rupture of the uterus ; and though steady traction upon the mouth and the shoulders slioidd be given a fair trial, and may effect dilatation in time to save the child, it is in these cases that the application of forceps to the after-coming head is most often indicated. There can be no doubt of the truth of Lusk's observation, that " the forceps will sometimes bring the head rapidly through the cervix when traction upon the feet only serves to drag the uterus to the vulva." Care siiould be taken, however, that this rapidity be not so great as in itself to cause a serious laceration. Arrest of the Head at the Superior Strait bi/ reason of an Unusual Size of the Head. — Most (Jerman and American obstetricians believe that the use of (combined traction upon the face and the shoulders is the best method to adopt in arrest of the after-coming head at any })oint in the pelvis, and it should certaiidy be the first methotl tried in any given case; but as cases frecpiently occur in which the head can be delivered with far greater ease by a rapid alter- nation between two or more methods than by the continued use of any one alone, it is for this reason, if for no other, well to be familiar with all the methods which have been foiuid of value. The Prague Method. — This maneuvre is often of service in effecting the engagement of the head and its initial descent into the superior strait. This is especially true in certain forms of contracted pelvis atul with operators whose nuiscular strength is inade((uate to the really severe strain which is sometimes imposed upon the internal hand in the use of the combined method at tiie brim, but it is usually inferior to the combined method after the greatest diam- THE .VKC/fAXISAf OF LAliOH. 485 eter of the head has ])as.sc(l the superinf .strait. \A\w all iu(!th(Hls of inaiiiial extraction, it is greatly increased in value by the application of proper supra- pubic pressure by an assistant. In executing the Prague method the feet are seized by one hand and the body is drawn as far downward as the perineum allows; the other hand is Kiu. 283.— Delivery of the nftor-comiiit; IumkI by floxioii thnmtili si'i/.iiri' (if lower jaw, and extrusion by means of pressure in axis of lirini. then hooked over the shoulders, and traction is made by both hands simul- taneously (Fig. '284). As the head enters the excavation the body is swung rapiiUy upward, aiul the remainder of the delivery is acc()m{)li«hed by upward Fici. 28^1.— I'nifjiie nietlioil of extrac tint; tlie aftereoniiufjliead, superior strait. traction on the feet, while the hand upon the neck promotes flexion by retard- ing the descent of the occiput (Fig. 285). The chief disadvantage of the Prague method lies in the fact that all the force exerted by the operator is expended ui)ou the child's neck, and that the amount of force that can .safely be applied is therefore less than in the combined method. 1-<- K: : r-f~f. : tflMlL- -t^'i-,- ■1'i i ! ;: /' .i: r t ;:f 486 AMKRIVAX TILXT-liOOK OF OUST FT UK'S. I \ n. . Arvci^t from Ktioisian of the Haul, — This condition is rare unless in iin- H'opcrly conducted extractions, l)ut if, l)V any eiunisiuess on the part of the operator, tiie ahdonien of tlie child has been directed to the front durinjj the liberation of the anus, and the chin is therefore arrested at the symphysis, the Prague method should be used through- out. In this case the direction of the first traction should be nearly horizontal (Fig. 286), and as the occiput descends the l)ody of the child should be raised until, when the head emerges from the vulvji, the line of traction is nearly parallel with the mother's abdomen.* ForcepH to the After-coming Head at the Superior Strait. — The use of the forceps is generally believed to be the most powerful and certain means of overcoming difficult cases of high arrest of the after-coming head. This one- ration is, however, often difficult, and the time occupied in the application of the forceps may be of vital importance to the child. Moreover, there are but few cases in whicih a skilled operator, aided by efficient suprapubic pressure, fails to deliver by manual extraction ; but as such cases do occasionally occur, the forceps shou hi always be at hand before the delivery is attempted. If Fiti. i;K),— I'niKUO iiii'lliiMl of oxtnictiiin tliu aftor- I'oniiiif; lu'iid, iiifiTior strait. I'Ki. '.'SO.— Ivxtracliiiii nf arti'i-ccjiiiintr lu'a<l, cliiti arrosti'(l at syiii]iliysls. forceps be used, the body should be raised to ;i nearly vertical position, and the * If forceps is necessary, the instruinent sliuuld be aiiplieil under the eliikl'H body, and should extract by the same mechanism. \ ;i^ THE MECHANISM OF LABOR. 487 forcei).s sliould be passctl into phu'o upon th(! sides of tlio liead, beneath the abdomen of the cliild. An axis-traction model siiould be preferred, Avresl of the Hmd at the Inferior Strait or on tlic I'crincam. — Cases lit which manual extraction by the combined method fails to overcome a low arrest are extremely rare, but if forceps be required the application and extrac- tion are always easy. Arrent of the Head due to Contraction of the Pelvii^. — ^n t onlinary form ((f contraction the arrest is always at the brim, and after J . j.ad has passed tlie superior strait the subsecpient delivery is easy. A breech presentation should never be allowed to persist as such in ajmto- minor pelviti, but if it has not been corrected the inevitable arrest of the head at the superior strait should be met by extreme flexion and by the application of forceps, followed by craniotomy if not proni|)tly successful. In aUjfat pelves, and in Hat pelves oidy, the head enters the superior strait ill the transverse diameter, and the passaji;e of the strait is most easily eflf'ected in a somewhat extended position, in which the biparietal diameter is received by one of the sacro-iliac notches, while the lesser bimastoid diameter is opposed to the contracted conjugate : if, then, the hand, when it is passed into the vagina for combined traction, finds the head transverse, it should allow extension to go on until the face begins to approach the side wall of the pelvis or until the greatest diameter of the head has passed the superior strait; when this has occurred flexion should promptly be restored, and rotation and de- livery will then rapidly follow. In simple Jfat pelves the application of forceps to the after-coming head is rarely successful after manual extraction has failed, but in pelves of the _7en- erallif-contracted flat type, if the transverse diameter is markedly dimiiushed, tiie mechanism approaches that of a normal or justo-ininor pelvis, and if the breech presents and efforts at manual extraction of the head fail, the apj)li- cation of the forceps may be tried. 5. FooTi,iX(; PRr:sKXTATioNs. Mechanism and Management. — The mechanism of footling presentations is in no way different from tluit of presentations of the whole breech. The treatment varies only in that in a rapid extraction there can be no question as to the choice of oj)eration. 6. Thaxsversk Prkskxtatioxs. Under transverse presentations are included presentations of any portion of (lie trunk ; but as all transverse presentations soon change to ])resentations of the shoulder, it is only necessary to speak of the latter. Freqaenetj. — Transverse presentations occur in from 1 in 150 to 1 in 800 of all cases of labor. Thus, Spicgclbcrg made the proportion 1 in 180; Churchill, 1 in 2o2 ; and the (Juy's Hospital Reports, 1 in 297 (or .32 per cent, out of 22,980 cases of labor). The positions are of but little importance. Etiolocjy. — Transverse and breech presentations are protluced by the same i /I a 'I:! : « m, •v'.'i irfi I Ml ^]ii\m 11! :^*^ y 488 AMERIVAN TEXT-BOOK OF OJJSTETJiJCS. causes (see p. 470), but in transverse presentations tl»e influenee of pelvic de- formities is sonu'wiiat more important, since, if the head cannot enter the brim, it may slip to one side and permit the shoulder to c iter even after labor is well under way. J>ia(/uoKis, — On (thdomhml examination the longest diameter of the uterus is transverse; the head is found in one flaid\, and the breeeh in the other. On vaf/inal iwaminatiun the finger may be able to recognize the clavicle and the spinous process of the scapula, and to ascttrtain that there is but one liiiil) attached to the presenting part, but the vaginal diagnosis is ai)t to be obscure unless an arm is prolapsed. Proynosi)t. — As the termination of a transverse presentation by natural labor is extremely rare, the prognosis for both mother and child is necessarily that of the operation undertaken. AVhen the abnormality is detected and treated early, the prognosis for both patients should be fairly gt)od, but it becomes worse in j)roj)ortion to the length of time during which the case is allowed to go on untreated. Mechanism and Management of Transverse Presentations. Mechanism of Transverse Presentations. — Since natural delivery so rarely occurs in transverse j)resentations, the later stages of the mechanism by which it is effected are of small practical importance ; but, notwithstanding the rarity of its completion, its earlier stages are rendered not unimportant by the fact that success in the delivery of impacted shoulders rests upon a thorough comprehension of the processes by which the imj)action waseilected, this being, in fact, the first stage of the mechanism of natural delivery in transverse presentations. The jirocc^s is commonly known as the " spontaneous evolution of tlie fetus." Any part of the trunk may present at the beginning of labor; but as the fetus is crowded down into the brim, the shoulder inev- itably enters deepest in persi.stent transverse piesentations, and, .since the shoul- der always becomes anterior early in labor, it is only uece.s.sary to describe the anterior form. In the anterior form the supraclavicular region corresponds, at the time of the entrance of the shoulder, with the anterior end of one oblique diameter at the brim, the lower portion of the thorax lying at the posterior end of tlio same oblique diameter. The full width of the shoulder enters tin; pelvis, and this portion of the child is then fixed in position by contact of the neck with the horizontal ramus of the pubes. Under the influence of the driving power of the uterus above, the lower portion of the thorax is forced more and more deeply into the posterior half of the pelvis by a lateral inflection of the body of the child upon it.self. The trunk then dips into the excavation, the true ribs, false ribs, abdomen, and ]>elvis of the fetus entering in the order named (Fig. 287). If the child is sufficiently flexible and if the uterus is sufficiently ])owerful to complete the delivery, this process of lateral inflection of the trunlc goes on until the pelvis of the child appears at the vulva, and with its expul- sion the case is converted by spontaneous evolution iiito a presentation, or TlIK MJJCJiAAJ^M OF LABOR. 489 ri'her an expulsion, of the breieli, in which, however, one tiliouldcr is already witliin the pelvis anil (»ne arm is already delivered. A second and very nuich more rare lorni of tielivery in ju'rsistent trans- verse presentations is seen oidy with immature fetuses, and it can seldom occur unless maceration is far advanced. In it the prolapswl shoulder is driven forward throuffh the pelvi-, the head of the child beinj; crowded into the pel- vis with the body (Fig. :i88). The alioulder is the leading point, uud it should A Fi(i. 'J87.— Spontuni'ous evolution, first form of nicclinnism. rotate to the arch, but when this process is possible the body is always so small and soft that the mechanism is usually but little marked. Management of Transverse Presentations. — The prognosis of sponta- neous evolution is so bad for botli child and mother that transverse presenta- tions should never be left to nature, and the question of the treatment is sim- j)ly the question of the choice of the operation to be adopteil. Three opera- tions are applicable to the treatment of transverse presentations in its various stages — the several savxaiwa oi' version, decapitation, 'a\v\ exenteration, the choice between them depending upon the stage of labor at which the presentation is detected. Version. — If the presentation is detected before any portion of the trunk is deeply engaged, and while the membranes are still unruptured, one or the other of the external ver.sionx should be chosen. If the abdomen or the hip presents, pelvic version will usually be the easiest, and for this reason should generally be preferred ; if the conditions are such as to render cephalic version easy and if the pelvis is normal, cephalic version should be ])erformetl. If the shoulder ])resents, cephalic version should be chosen, except in a flat pelvis, where the shape of the inlet makes a breech presentation the presenta- \l^ im I . m {r^ ] % ... . I d, v--^ W^y: 490 AMj:iil('A\ TEXT-BOOK OF OliSTFTltlCS. ) , . 1 i\ tloii of clioiff. In such oases an oxternal ju'lvic version would naturally ht chosen. It, at the time an (tperation is undertaken, the shoulder has alread) entered the pelvis, but the conditions of the case are still such us to permit of version, a bipolar, C(ji/i(di<', or peteic version should he performed. If, at the time when interference is decided upon, the membranes arc already ruptured, and especially if the shoidder is already well crowded into the pelvis, the external and bipolar methods will usually he impitssible, and internal podali(! version must be chosen. Infer mil Podalic Vernion in Tr(in,s- rerne I'resenf((tion,s. — This operation ditl'ers from internal version in head presentations oidy in the choice and method of introducing; the hand, in the Kio. 'J88.-Sp(intaiico\is ovdlutloii.sot'diid and riirc Fkj. 2R0.— Krozi'u suction of shoulder prcscii- formofnu'clianisiii, known lis l)irtli \vitl\d(>iil)k' body tiitkm (Cliiara): tlie distortion and tlii' ulont;a- (one-sixtli natural size, ri'drawn from Kiistnor). tion of the nci'k are noteworthy. frequent occurrence of a prolapsed arm, and lU the method of raising an impacted shoulder. In raisinj; the shoulder it is necessary to remember the mechanism o^' the method by which nature deals with a neglected transverse presentation — that oi' spontaneous evolution. In this process, as has been said, the trunk enters the pelvis at the brim in an oblitpie diameter, bnt as it is forced farther down the shoulder rotates to the front and becomes fixed there, while the thorax and the abdomen are crowded into the posterior portion of the pelvis by flexion upon themselves (Fig. 287). Now, so long as the j)osition is still ol)li(pie, and if flexion of the trunk has not begun, the presenting part may easily l)e raised by pressure upon the shoulder in the axis of the superior strait ; but so soon as the shoulder has rotated to the front antl the thorax has entered the ju'lvis, it is essential that the process of relieving the impaction should begin by the return of tiie part which entered last — that is, of that portion of the thorax and the abdomen still lying opposite the sacro-iliat; synchondrosis. No j)ressure must be exerted upon the shoulder itself until the trunk again occupies an oblitpie position. It will be seen that the process of unlocking the impaction is by a direct reversal of the mechanism of spon- ?ii; fmmmmmm Tin: MKCIIAXISM OF LAIiOIi. 491 tiiiit'du.s evolution. Of course, (liiriiij>; tliis wliole process tlio most careful vdiiiiter-pressure must be maintaiued at the fundus. In simple eases a prolapsed arm may he used as a convenient handle hy wiiieh to jtush up the shoulder, and in all cases it is w'll to he^in the operu- A'< ;;.'('/(■ 'oot. JVt,ir foot U/t Fig. 290.— nlrcrt nirtlnxl of si'lzinp a fciot in vit- aion fiir ♦.^llIl^svL•rsl■ iiri'Sfiitations. Fi(i. '201.— Oircct ini'tlKiri of soizini; a fmit in vor- .siun I'cir transviT.si' priseiitations. tion by noosing a fillet around the prolapsed wrist. This Hllet answers a double purpo.se: First, it may be used to draw the arm out of the way of the operating liand ; second, during; the |)rocess of extraction slight tractions oa the fillet will prevent the extension of that . arm, thus greatly facilitating the delivery ; but care nuist be taken to remove the noose as soon as possible, for cases arc on record in which sloughing of a member has followed the too prolonged or violent u.se of a fillet. In the .search for u fi)()t two methods may be u.sed : The hand that corresponds with the position — that i.s, left position, left hand — may be passed along the back and over the buttocks to the thigh and leg (Fig. 292), or the hand may be pa.-^sed across the ab- domen and directly to the feet (Figs. 290, 291). The first, which is the surer way, should, as a rule, be preferred, but the latter method is often the easier, especially iu ab- domino-antorior positions. Much has been writt(!n on the advantage to be gained by se- lecting the superior foot in version for transverse presentation; but as this view has never obtained much credence outside of England, and as Galabin, one of the latest British authorities, not only di-sajiproves of this practice, but gives a very convincing mechanical proof of the fallacy of the theory which prompted it, Fiii. L".i'.'.— ^f(■tlllMl (if rcacliina tlu' fnDt by lirst passuij,' llio liaiid ainuiiil the breech. ^ ! i M : * V_ U AMERICAN TEXT-BOOK OF OBSTETRICS. the subject need only be mentioiicil here. Unless special care be taken to select the superior foot, the lower foot is almost inv'arial)ly seized. Treatment of Neglected Transverse Presentations. — Wiien ;. transverse pres- entation has been so lonjf neglected that the release of the shoulder is thoiiglit to involve more danger to the mother tiian it wotdd be justifiable to incur in the interests of the child, or wlien the child is already moribund or dead, one or the other of the appropriate destructive operations must be undertaken. If the neck is at this time within reach, devapUation should be selected. If the process of spontaneous evolution has gone so far that it would be ditti- cult or impossible to apply the decapitator to the neck, an c.venter<dion should be chosen, and after the abdomen and the thorax have been emptied of their contents the operator must use Ills judgment as to whether it is safer to break the vertebral cohunn and extract the child still doubled up ujwn itself, or to draw the fetal pelvis into that of the mother by traction with the fingers from within its cavity. 7. PUOLAPSKI) EXTUKMITIES. Presentation of the Head and a Hand. — When a hand ])rolapses and enters the pelvis with the head, it is most commonly placed at one end of the bitemporal diameter. Its presence then generally results in delay through the increased size of the presenting part, and it may occasionally interfere with rotation. If the hand is placed against the occipital end of the head, its presence may delay the descent of the occij)ut and thus produce extension at the brim. Tliis abnormality usually causes a delay sufficient to induce exhaustion on the part of one or the other patient, and thus indicates opera- tive interference ; but if such an indication does not arise, the ultimate result in most cases is that the head sli{)s by the prolapsed arm, after a greater or longer period of delay, and is thus eventually born by a natural labor. Pro(/nosis. — If the ])resentation is detected early, the prognosis is little dif- ferent from that of normal labor, and even when detected after a moderately ong second stage it is influenced by the treatment, and should never be grave. Treatment. — An attempt should be made to push back the prolapsed hand with the fingers, and, if extension has occurred, to restore flexion by pressure upon the forehead with the hand. Should this effort fail, an operative delivery nuist be resorted to, the choice of operation dej)ending upon the position of the head. If good flexion is present, the forceps should be applied, but care must be taken to introduce the blade between the hand and the head, and great care will be necessary to avoid fracture of the fingers, the hand, or the wrist. If the application fails to do injury, the prognosis of the operation is good, since the tractile force is applied to the head while the hand is still ex- posed to friction against the pelvis; the head thus always slijvs past the hand. When marked extension is present, if manual flexion fails or if tlie head is already much moulded toward ihe configuration of a brow, internal })odalic version should be performed. Presentation of a hand and a foot is decidedly more rare than the above ; its j)roguosis and treatment are, however, similar. DYSTOCIA. IV. l^YS'roCIA 4Ji;i 1. Anomalies in the Forces op Labor.* In a noi'inal labor the active forces of" expulsion (the uterine and alxloruinal muscles) and the passive forces of resistance (the fetus, the pelvis, and the iiiatcrnal sort structtu'cs) are so nicely balanced that the expulsive forces are just sufficiently resisted to ensure a slow and gradual i)assage of the fetus along the birth-canal. Tlie walls of the birth-canal and the structures around (he vulvar orifice are by this arrangement slowly and gradually dilated, and are not rudely torn apart, as they would be by a more rapid expulsion of the Ictus. This balance between the powers of labor, however, is easily disturbed. There may be anomalies by deficiency and ;'nomalies by excess in the com- ponent parts of the forces of expulsion and in all the sources of resistance. Tluis the uterine muscle may be too weak or too strong compared with the resistance it must overcome; and so also with the action of the abdominal muscles. The resistance furnished by the pelvis, the soft structures, and the fetus may be excessive or deficient. 1. Dkfu'IEXt Power of tiik Uterine Muscle; Inertia Uteri. In this condition tlie uterine muscle is unable to overcome the normal resistance offered by the weight of the fetal body, by the friction of the pelvic walls, and by that of the undilated maternal soft structures. Inertia uteri is inan'.f'ested in the vast majority of cases during the first stage of labor. The weakened uterine force therefore is almost always neutralized by the obstruc- tion of an undilated cervix. There is scarcely another condition in obstetric practice that can be traced to such a variety of causes or that deujands so many different [)lans of treatment. I'Jtiolof/}/. — Deficient jiower of the uterine muscle in labor may be due to a defect of the muscle it If, to some anomaly of innervation, or to a mechanical interfereuce with the full and effective action of the muscle. Examples of the first-named ca' .-c lu.iy be found in imperfect development of the womb or in anomalies of dec liijincnt, as in ufcrus hicornls. The uterine muscle maybe exhausted by rapitdy-succecding pregnancies. It may be over-distended by twins or by hydramnios, thus losing the power gained by cohesion of muscular bundles. The uterus may be weakened by some cause — as an adynamic fever or a wasting disease — that weakens the whole organism, but it does not neces- sarily follow that uterine weakness always accompanies a reduction of body- strength. The writer has seen women in the last stages of phiuisis or in the midst of an attack of typhoid fever or pneumonia exhibit a uterine power in labor above the noruu\l. The uterus may be weakened by profuse hemorrhage, as in placenta pra^via. It may be rendered incapable of exerting normal lorce in dry lalH»rs. The li(|Uor anuiii iiaviug drained off comjdetely (>arly in the first stage, the uterus retracts upon the child's body, thus being subjected in * Tlie miperior fijjurus ( ' ) uci'iirring thi'oiinhinit liic text of this iU'ti(Je refer to tiiu bibliog- riniiiy Kiven on pngt' ST'J. / I ;, •» -^ 'I 494 AMERICAN TEXT-BOOK OF OBSTETRICS. \ ; i cei'tain regions to sevciv and long-continued pressure, and becoming in those spots anemic and fViaMe, while in the areas free from the pressure of th( child's body the uterine wall becomes congested, swollen, and edematoir-. Above all, the uterine :,iiiscle may become fatigued. This is the commonest cause t)f uterine inertia. It is seen oftenest in primiparje, in whom inertia is more than twice as common as in multiparte on account of the diffi- culty of dilating the rigid cervical tissues. Inertia may appear in con- sequence of any serious obstruction in labor. At first the ))ains are feeble, infrequent, and inefficient, but as labor continues the uterine contractions gather force. The inertia from this cause is bkcly to be only temporary, seen at intervals between periods of stormy uterine action or of long-contimicd tonic spasms, until finally exhaustion of the whole organism threatens the patient's life or the uterus ruptures. It has been asserted that an anomaly of innervation in the anatomical sense, a deficient supply of the terminal nerves in the individual nniscK'-cells, is a cause of uterine inertia, but it is not yet clearly demonstrated to bo so. An inhibitory nervous impulse to the uterine nnisde, on the contrary, is a frequent cause of uterine inaction. It is the result of some emotion or of excessive pain. That the " doctor has frightened the pains away" on his first arrival has become proverbial in tiie lying-in I'oom. The presence of any one who is a cause of embarrassment or is disagreeable to the patient may have the same effiL>et. In hyperesthetic women the uterine contractions may be so exquisitely jiainful that their first onset is followed by an inhibitory impulse which cuts them short almost inunediately. Every clinical observer has seen the phenomenon of rajiidly-recurring, very painful uterine contractions, which are, however, of short duration, and wiiich secure no a])preeiable dilata- tion of the cervical canal. A woman may be tortured thus for hours in the early part of the first stage of labor, when this inliibitory nervous impulse is commonly observed. With the continuance of labor the individual becomes more or less indiffi'rent to her surroundings or more iinired to suffering, and the inhibitory nerves, probably derived from the spinal cord, apparently lose the power of responding to the stimulus of pain. Among the mechanical causes of incnicient uterine action during labor are fibroid tumors of the uterine walls, displacements of the womb, old peritoneal adhesions, and fresh outbreaks of periuterine* inflanunation. J)l(i(/)i()sis. — The n'cognition of uterine inertia should always be easy. The contractions of the muscle are of short dni'ation and are separated usually by long intervals, and by palpation the observer may convince himself that tluy are feeble. The uterus during the [laiii does not assume that intensely hard consisteiKy which normal vigorous action of the muscle in labor oct ;isions. Tlie ])atient's expression, action, and demeanor point to deficient force during the ])ains. The woman is more placid, the fa<'e is less contorted, and there is less outcry during the contractions than in tiie normal ])arturient patient, except in those cases 'm which excessive pain inhibits ut(>rine !;"ti()n. In these cases, however, abdominal palpation and the short duration of the jiains are sr.f- U Tlic y '•}• tlicy iiu'd idllS. iriiii; IV is ;•'('))( uses, si:!- DYSTOCIA. 495 ilcicntly plain signs of the inertia. Finally, labor is delayed. During the lirrit stage dilatation is slow or does not progress at all, and in the second stage the presenting part does not advance. One fatal error in the diagnosis of inertia uteri should be avoided : the physician shoidd be sure that labor is not (lelaved by some obstruction. It lias happened in a careless and superficial cxiiniinatiou that the observer has taken the distended and thinned lower uterine segment for an inert womb. En such a case the measures adopted to stimulate the supposedly inactive uterine muscle to overcome an obstacle lliat is insui)crablo might easily be interrupted by rupture of the womb. A methodical and careful examination will guard one from this error. The source of obstruction will be discovered. The firmly, jierhaps tctanically, contracted upper uterine segment may be contrasted with the inactive lower segment by palpation of the whole anterior surface of the womb. The con- tra(^ti()n-ring should be visible, and the whole uterus stands out with unusual prominence, from the anteversion that always accompanies prolonged and powerful uterine contraction. Treatment. — From the diversity in the causes of inertia uteri it follows that no single plan of treatment can be depended upon. If uterine action is inhib- ited by emotion, the cause of nervous disturbance should, if possible, be removed. An objectionable person should leave the room. If excessive pain prevents effective contractions, an analgesic should be admim'stered. Nothing is better for this pur])()se than chloral administered in 15-grain doses, repeated, if necessary, twice at intervals of fifteen minutes. A quarter of a grain of morphia hypodermatically comes next in order of efficiency. If the uterine nuisde is simjily apathetic, it can be aroused by some direct irri- tant. The insertion of a bougie as for the induction of labor answers the purpose well. A more effective but more troublesome measure is the dilata- tion of the cervical canal by Barnes's bags. These not only irritate the ute- rine muscle and thus bring on strong contractions, but they also artificially dilate the cervical canal, and thus relieve the uterine nniscle of a great part of its task in the first stage of labor. If tlie head should be well engaged in the pelvis, however, the insertion of the bags is difficult and they are likely to cause malpositions of the head. In such cases, if the os is dilated to the size of a silver dollar, nothing is so effective as the application of forceps — not with the idea of dragging the head through the luidilatiMl cervical canal, but to ])ull the head at intervals iirudy down upon the cervix. Tiie impact of the head upon the cervix acts as a powerful rcHex irritant, and will excite as strong contractions as any direct irritant can do. Not only so, but the ])ull of the head upon the cervix will gradually dilate the canal as effectually as coidd strong propulsion from above. As soon as effective ])ains arc established and the dilatation of the cervical ci'ual ])rogresses satisfactorily the forceps should be removed. Inertia uteri so profiuind as to (lcii;:>ud the somewhat radical measures just described is, fortunately, rare. More commoidy the pliysician sees the minor grades, in which there is simply a ilagging of uterine eiTort during the first ■U* 4''t^-i AMERICAN TEXT-BOOK OF OBSTETRICS. stage, ef^pecially in priniiparje, accompanied by every evidence of temporary physical and mental exhaustion. After a period of rest effective contractions will reappear, even if nothing whatever is done to aid the patient. The more complete the rest, the more vigorous will be the uterine action when it is resumed, and for this reason the administration of chloral and opium is often followed after a time by a satisfactory progress in labor. But these drugs necessarily retard the termination of labor by the time of rest they secure. It is ordinarily desirable, therefore, to resort to drugs of a stimulant character that shall at once revive the flagging uterus and so hasten the delivery. ^Nfanv medicaments have been recommended for this purpose, but, of them all, alco- hol, quinin, and ergot alone deserve consideration. The last was employed extensively at one time, but clinical experience forbids its use to-day. The contractions of the womb induced by ergot are likely to become tetanic. The uninterrupted contractions interfere with the fetal circulation ; they niav cause fatal intra-uterine asphyxia, and they often produce such exaggerated blood-presssure and stagnation of the current in the fetal body as to in^luco extravasations in important viscera, especially the brain. Further, the cir- cular fibres of the cervix come under the influence of the drug, and by their firm contraction neutralize the contraction of the longitudinal fibres of the uterine body, and thus retard labor almost indefinitely ; and, worst of all, should there be some obstruction to the descent of the child in the maternal pelvis or in the fetal body, the administration of ergot predisposes to rupture of the uterus. For these sufficient reasons this drug as a stinndant to the uterine muscle in the first and second stages of labor should be banished from the obstetrician's pharmacopeia, except in the single instance of the birth of the second of twins (see p. 509). Owing to the recommendations of Albert H. Smith and of Fordyce Barker, quinin has had, and still has, a great reputa- tion as a stimulant to the uterus in labor. The writer's experience with the drug, however, does not permit him to subscribe to a belief in its efficacy as a uterine stitnulaiit in labor. Quinin has the positive disadvantage, moreover, that it will occasionally in certain susceptible individuals produce a violent post-partum hemorrhage. In the minor grade of inertia under description, so often seen in j)rimipara', and almost always the result of exhaustion, the writer has found nothing so useful as alcohol, in the shape of a wineglassful of sherry, taken slowly with a cracker, and given with the positive assurance that it will bring back the pains and hasten the conclusion of labor, for the patient needs moral and mental supjutrt as nnich as she requires a physical and muscular stimulus. An impression prevails among general physicians that inertia uteri in the first stage of labor, before rupture of tlie meinl)ranes, may safely be disre- ganled. In a n\easure this view is correct. Tiie writer has seen in a number of instances a partial dilatation of the os and then an entire cessation of ute- rine contractions for many hours and even for days. In one case the cervical canal was sufficiently dilated to receive foin- fingers, and it remained so for more than a week, the patient all tli(> while going about on her feet in per- itsmmmmum' f DYSTOCTA. 497 feet comfort, without a single painful contraction of the womb. But should inefficient uterine contractions be accompanied by much pain, as happens in some cases of inertia, the long-continued first stage should not be regarded with indifference. The patient will in time show the irritant and depressant iU'eots of long-continued suffering in an elevated temjierature, an accelerated ]nilse, and a lessened resisting power of body-cells, the last playing an import- ant r/)le in the predisposition to sepsis after labor. Another consequence of delayed, painful labor may be seen in a sensitive, nervous individual, who is thrown into a state of excitement — who from gloomy foreboilings of harm to herself and to her infltnt passes into an almost maniacal condition of terror and dread. It should be a rule of practice, therefore, to watch carefully all cases of inertia uteri, and to interfere as soon as the patient's mental condition or her jMilse, tem])erature, and general vigor are demonstrably affected by the delay in labor. 2. Excessive Po^\'Eu in the Expulsive F(jrces of Lahor. An actual excess of power in the expulsive forces (the uterine and abdom- inal muscles) in labor sufficiently great to expel the fetus })recipitately is extremely rare. A relative ex'cess is not uncommon. The child's body may be so small, the pelvis so abnormally large, the maternal soft parts so relaxed, that the ordinary power exerted by the uterine and abdominal nuiscles is far in excess of that required to overcome the weak resistance offered, and the child is fairly shot out of the birth-canal. The rapid delivery may cause serious residts to both mother and child. In the woman the structures on the ])elvic floor may be lacerated severely ; the sudden evacuation of the womb ])ro(lis])oses to hemorrhage from inertia ; the placetita may be detached pre- maturely ; and the sudden evacuation of the abdominal cavity predisposes to dangerous syncope. For the child the chief danger is the possibility of unexpected delivery of the mother in tiie erect posture. The umbilical cord may rupture, and the chikl, falling to the ground, may be injured fatally. I'rccipitate and unexpected labors occur mrst frequently when women are seated U2)on the water-closet. The child i' evacuated into the waste-pipe or <lown a well, and may be destroyed. Some astonishing examples of infantile vitality, however, are furnished by such cases. In one instance a woman was unexpectedly delivered while seated upon the conimtM'e in a railway train moving at the rate of thirty miles an hour. As soon as she could connnuni- cate the startling intelligence to the conductor tlu' train was ])acked until, several miles from the place wIkm'c it was stopjxd, the infant was found u])on the railway ties alive and well I* In another ease, under the writer's obser- vation, a young woman purposely discharged her fetus at term into the well of a privy twelve ieet deep. Three bricks were thrown or fell (k)wn the well after the child and lay across it* body. Eight hours after its birth the infant * Professor AVillijim Osier told t'lo writir nf \\\\> renmrkiible nceurrence. It liappened on llie (amulian I'acilic Huilroad. 33 |i ;i: "■(■ !<: t lit- i-\ r ' ■ Ik' ■in 45)8 AMERICAN TEXT-BOOK OF OliSTETRICS. was fished out of the bed of niaiitire in wliicli it was iinniersed to the neck, unharniod and in good condition. Unfortunately, the i)hysician is usually not at hand to prevent a precip- itate delivery and to avert its consequences. Shoidd he find an infant descend- ing the birth-canal with a rapidity dangerous to itself and to its mother, he can easily retard its progress by pressure with his hand against the presenting part. 3. DEF()R>riTIES OF THE PELVIS. Comprehensive and satisfactory knowledge of deformities in the female pelvis has been gained only in the latter half of the present century, since the appearance of Miciiaelis' work in 1851.' Until the announcement bv Arantius in the last quarter of the sixteenth century that a contracted pelvis is a serious obstacle in labor, the prevailing belief had been that difficult labors from mechanical obstruction by the maternal bones were due to a failure on the part of the pelvis to expand sufficiently for tiie passage of the child. This idea continued in force for a number of years after Arantius' time. According to Litzmann, Heinrich von Dcventer (LGol-1 724) should be re- garded as the real founder of our knowledge of the pelvis and of its anomalies. He described the inclination of the pelvis, the axis of the pelvic inlet, the contracted pelvis, and the flat pelvis. Pierre Dionis was the first to point out (1718) the relationship between rachitis in childhood and a deformed ])elvis in the adult. William Smellie's contributions to the study of the female pelvis were remarkably full and clear, when one considers how little was known before his time. His description of the rachitic pelvis, his reflections on its cause, and his accounts of illustrative cases may be read with profit to-day. Roederer, Stern, Cooper, Vaughan, Denman, Haudelocque, and 1' re- mery added nuich to the stock of knowledge during the latter half of the eighteenth century. The men of the present century to whom we owe most of our present information about the pelvis and pelvimetry are Naegele, Kilian, Rokitansky, Michaelis, Robert, Litzmann, Xeugebauer, and many others to whom reference will be made in the sections devoted to the particular varieties of deformed jielvis.- Frequency of Deformed Pelves. — It is difficult to estimate the frequency in America of ])elvcs sufficiently deformed to influence decidedly the course of labor. Statistics from our lying-in hospitals affi)rd little aid to a correct conclusion, because the inmates are chiefly European immigrants and negresses. In the Boston Lying-in Hospital, however, deformed pelves wen- foiuid in 2 per cent, of native-born and in per cent, of foreign-born women (Rey- nolds).' The writer's experience in private and consulting practice convinces him that deformed pelves are by no means rare among native-born women in the densely-popidated centres of the Eastern States. Xo general practitioner, in a large city at least, can hope to avoid such I'ases, and it is likely that each year will affitrd him one or more striking exap.ple.s. It follows that an ability t(» recognize deformities of the female pelvis is a necessary c(piipment for every DYSTOCIA. 409 practitioner of medicine \vlio may be called upon to attend women in confinc- iiicnt, and that a knowledge of" pelvimetry i.s as essential to the intelligent and successful practice of obstetrics as are jjcrcussion and auscultation to till' practice of medicine. European statistics bearing on the frequency of contracted pelves give the following results: Michaelis found in 1000 partu- rient women 131 contracted pelves; Litzmann, 149. Winckel found in Ros- tock per cent., in Dresden 2.8 per cent., and in Munich 9.5 per cent, of con- tracted pelves among pregnant and parturient women. Winckel believes that 10 to 15 per cent, of childbearing women have cojitracted pelves, but that in only 5 per cent, is the obstruction serious enough to be noticed. Kaltenbach puts the frcHpiency of contracted pelvis at 14 to 20 per cent. In Marburg it was found to be 20.3 per cent., in Dottingen 22 per cent., in Prague IG per cent. Schauta estimates it at 20 per cent. Classification of Anomalies in the Female Pelvis. — All classifications are merely a convenience for the teacher and .student. It is rarely possible to draw sharply-defined lines between varying manifestations of a condition. The majority of German authors follow Ijitzmann's classification of abnormal- ities of the female pelvis, by which they are broadly divided into those of size and those of shape. Modern French authors ado})t the still less satisfactory division of over-size, under-size, and anomalies of inclination. The writer linds Schauta's classification the most convenient, and therefore utilizes it, with some slight modification.* ANOMALIES f)F THE PELVIS TJIE RESILT OF FAULTY DEVELOPMENT. Simple flat ; Generally equally-contracted ( justo-minor) ; Generally contracted flat (non-rachitic) ; Narrow funnel-shaped, fetal or undeveloped; Imperfect devehtptnent of one sacral ala (Naegele pelvis) ; Imperfect development of both sacral aUe (Robert pelvis) ; Generally cijually-eidarged ( jnsto-major) ; Split pelvis. ANOMALIES DUE TO DISEASE OF THE PELVIC I50NE.S. Rachitis ; Osteomalacia ; New growths ; Fractures ; Atrophy, caries, and necrosis. ANOMALIES IN THE ( 'ON JUNCTIONS OF THE PELVIC HONES. Abnormally firm union (syiU)stosis), which is apt to be found in elderly juMuiiparje, particularly at the sacro-coccygeal joint: Of symphysis ; Of (lue or both sacro-iliac synchondroses; Of sacrum with coccvx. k ■p.. I irrrrr 500 AMERICAN TEXT-BOOK OF OBSTETRICS. Tf Vv, ■' m ! I s 'i J i I Abnormally loose union or separation of the joints : llelaxation and rupture ; Luxation of the coccyx. AXOMALIIvS DIK TO DISEASE OF THE SUPERIMPOSED SKELETON. Spondylolisthesis ; Kyphosis ; Scoliosis; Kyplio-scoliosis ; Lordosis. ANOMALIES DUE TO DISEASE OF SUBJACENT SKELETON. Coxalgia ; Luxation of one femur ; Luxation of both femora ; Unilateral or bilateral club-foot ; Absence or bowing of one or of both lower extremities. Diagnosis of Pelvic Anomalies : Pelvimetry. — Deformities of the female pelvis may be detected by the history of the patient, by her a])pear- ance, by ])alpation of the exterior and interior of the pelvis, and by external and internal measurements of those pelvic diameters that are accessible, or of Fi(i. 293— Modem c iiiibiiiation t>{ Hiui- (li'l(ii'iiiii.''s mill (isimiiUT:- iu'lvimL'tiT. Fit!. 201.— Osinnik'r's pclviniL'tLT. Fig. 2'j:i.— Martin'.s pt'lvimetor. salient points on the woman's body corresponding as nearly as po.ssibIe with the internal measurements desired ; the relations between the two la.st haviiiiz; been a.scertained l)y many observations on dead and living bodies. For taking DYSTOCIA. 601 ])elvic measurements the examiner's fingers, a tape measure, and a modified mathematician's callipers — a pelvimeter — are usually employed. Baudeloctpie (1775) was the first to devise the pelvimeter in ordinary use. He laid the luundations of pelvimetry, and his instrument and methods are in use at the present time (Figs. 293-25)6). It is convenient to describe the measurements ot' the diameters of the pelvic iidet, pelvic cavity, and pelvic outlet separately. 3feasai'ctnent of the Antero-posterior Diameter of the Superior Strait. — This measurement, the most important in ihe pelvis, cannot be taken directly. It must be estimated by several plans. Baudelocfjue was the first to point out the relation between the measurement from the depression under tlie last spinous process of the lumbar vertebrte to the upper edge of the sym- physis pubis, and the true conjugate diameter of the pelvic inlet. To this external measurement the name "ex- ternal conjugate" was given, but it is often called " the diameter of Baude- locque " (Fig. 208). Its discoverer be- lieved the relation between the external and internal diameters to be constant — that the one exceeded the other by 8 to 8^ centimeters — but in this he was mis- Fia. 'JlU'i.— Harris-Dickinson yiortiiljle polvlmetLT. Fig. 2U7.— Measuring oxtermil conjugate. taken. The line of the e\ternal diameter does not usually coincide with the line of the internal, an<l the thickness of bones and superimposed structures differs, of course, in each individual. In 30 cases in which Litzmann had an opportunity to compare the measurement of the external conjugate taken during life with the actual measurement of the true conjugate taken after death, there was an average difterencc of 9.5 centimeters, but the maxinuini dilTerence was 12.5 centimeters and the minimum 7 centimeters — a variation of 5.5 centimeters in this small nund)er of cases. Michaelis found a ditterence of 0.6 to 3.2 centimeters, and Schroeder 11 to 3 centimeters between the external conjugate of the living body and that of the dried specimen. The ■ H at- . ;r ' . - , ■ t - ./:; *'! 'i^J ;^T'i f TTFTr ! I* I i fi ■ *1 iiii III i(i f pt li : hiir ii 502 AMERICAN TEXT-noOK OF OBSTETRICS. measureiiK'nt of the oxtcrnal coiijiigato, thoreforo, is not to be reliod upon in making an cstiniatt' of the size of tiie true conjugate. It sini|>ly serves to indicate the i)rohal)ility or tlie improbability of pelvic contraction. An exter- nal conjugate of IG centimeters or under means certainly an antero-jiosteriorlv contracted pelvis ; between 10 and 19 centimeters the ])elvic inlet will be con- traetetl in more than half tlie cases; between 19 and 21.6 centimeters there Fig. 2US.— MonsurltiK the I'xtoriml cdiijugnto (liametcr uikiii the living fcmiile. will be but 10 per cent, of contracted pelves; and above 21.5 centimeters it is almost certain that the conjugate diameter of the pelvic inlet is not contracted at all. The external conjugate cannot be measured accurately without some prac- tice. The begiimer in pelvimetry will do well to remend)er the ftdlowing rules: Have the patient dressed for bed. Place her upon her side, with the thighs slightly flexed and the clothing rolled well up out of the way, the lower part of the body being covered with a sheet. The examiner stands at the patient's back, facing her head. The de])ression below the last spinous process of the lumbar vertebrie is found l)y rubbing a finger-tip over the lumbar spines from above downward until the finger sinks into the depression sought and feels no more prominent spinous processes below.* The knob at the end of one branch of the ])elvinieter is placed firndy in this depression, and is held * Micliaelis preferred the nicisurenieiit from the tip of the hist liinibar spinous process, instead of from the depression l)eh)\v it. DYSTOCIA. 503 tlicre with ono hand wliilc the fingers of the other hand find a pouit on the .>;viiij)hy.si.s pnhis about \ of an inch lx'h)\v its nppor eilgo, on wliich j)oint tiie other l)ranfh of the ju'lvinu'ter is firmly set; tlic pelvimeter having heen so placed that the indicator is turned toward the examiner, the measurement is thcrefijrc easily read off as soon as the pelvimeter is in proper position. It i- (tn the average, in well-built women, 20\ centimeters. The best means for determining the length of the antero-posterior diameter of the pelvic inlet are the measurement taken from the lower edge of tiie symphysis pubis to the promontory of the sacrum, the diagonal conjugate diameter, and the distance between the upper outer surface of the symphysis jiubis and the pronjontory of the sacrum. The diagonal conjugate diameter is one side of a triangle the other two sides of which arc the height of the sym- pliysis and the true conjugate. The distance between the outer ujiper surface of the symphysis and the promontory of the sacrum differs from the true con- jugate by the thickness of the upper portion of the .symphysis. SnicUie was accustomed to estimate rougidy the length of the true conjugate by a digital Fi(i. 2li'J.— Stfin's iiistniiiR'nt Inr diivct iiR'asuri'inoiit of tlic ciPiijuKatt.'. examination, basing his estimate on the ease with which the ])romontory could be reached. In the latter pai't of the eighteenth century .lohnson '" proposed fi»r estimating the size of the pelvic inlet a method which consisted in inserting the fingers of one hand in the mouth of the wond) and then spreading them between the pntmontory and the sacrum. A few yeai-s later the elder Steiu devised a graduated rod for measuring the distance between the lower edge of the symphysis pubis and the division between the second and third sacral vcrtebric. This distance he believed to be \ to 1 inch greater than the true conjugate. Stein later constructed the instrument fi»r the direct measurement of the conjugate shown in Figure 299. Many instruments have since been constructed on this principle, but they are impracticable in the living female, fi)r obvious reas' .is. I>audelocqu(! was the first to propose the measurement of the diagona' conjugate and the subtraction from it of an average figure (i inch) to dett'rniine the length of the true conjugate. His method, exactly as he described it, is still in use, with the exception that two fingers instead of one are emjdoyod in measuring the distance between the symphysis and tlie promontory. To measure the diagonal conjugate correctly the examiner must have the skill that comes of practice, and he must conduct his examination in ^ ! ^. IMAGE EVALUATION TEST TARGET (MT-3) // 1.0 I.I li^lM |2.5 ja yi2 112.2 II 2.0 m. 1.25 1 1.4 1.6 ^ 6" ► % %' Photographic Sciences Corporation 23 WIST M'«H JTRSIT WEBSTH.N.Y, U:»SO (716) 873-4503 V iV 4 ■^^ <^ V ;\ ^'^^ fe ^io % r 6^ r>04 AMEIilCAX TEXT-BOOK OP OBSTETRICS. a careful anU methodical manner. The patient is put in the lithotomy posi- tion and is brought to the edge of the table or bed on which she lies, so that the buttocks project well over it. The examiner cleanses \\\i. lefl hand and anoints the first two fingers with an unguent ; he then inserts these fingers, held stiffly extendetl, inward and up- ward till the tip of the second finger finds and rests upon the promotory of the sacrum. Care must be exor- cised not to take the last lumbar for the first sacral vertebra or vice verad, nor the second for the first sacral vertebra — mistakes easily nuide in cases of so-called "double promon- tory." Witii the tip of the second finger resting firndy in place u[)(>n the middle line of the promontory the radial side of the hand is elevated until upon it is plainly felt the im- press of the arcuate ligament under the lower alge of the symphysis. With a finger-nail of the otlier hand a mark is made upon this point of the examin- ing hand, whicii is tiien withdrawn (Fig. ,'}n(i). Tiie listance between this mark and tiie tip of the middle finger held extendetl is taken by a l''iii. :!iMi.- -Mfiisurinn the iliau iliaiiiLtor. iiiiil ciinjiignte /./ Kin. I'lOl— KlTcot nf ilitrcrciil Incliimtlmis of the imliis upiiii the ri'liilioiisliiii ln'twci'ii tho trui' 1111(1 tin- iliiiK'ciiinl ('(injuKuti.' illiimcttT (Kilirlllnlltlll'SSllinnes). Fio. ;«)2.— EflVct of different thlekiicRses of the sym- physis upon tlie relationship between the true nnil tho diiigonul eotiJURUte diameter (Uibemont-UessaiKncs). pelvimeter. This distance is the diagonal conjugate. By the observation of DYSTOCIA. 505 many subjects, alive and dead, an agreement has been reached that 1 J centi- meters should be subtracted from the diagonal conjugate to obtain the true conjugate diameter. But the acceptance of this average difference depends upon a normal height of the symphysis, 4 centi- Fi(i. 303— Effect of (liffiTcnt hctpthts of the promontory upon tlio relntionship iK'tweon the (rue nnil the dingoiml conjugiito (Kibemont-Des- sniKnes), Fio. 304.— Kffect of different heights of tlie symphysis upon the relationship between the true nnd tlie ilingonal conjugate diameter (Kibeinont- Dessaigncs). motors, a normal angle between the axis of the pubis and the true con- jugate, 105°, a normal thickness of the symphysis, and a normal height of the promontory (Figs. 301-.'i05). Those factors, however, are not constant, and if they vary much from the normal the most skilful and most experienced obstetrician may be misled wofully in his estimation of the true conjtigate. The writer has had under his care a rachitic dwarf in whom there was more than 3 contimotors' dif- ference between the diagonal and true conjugates, and Pershing found among 90 pelves in the miisoiuns of Philadelphia a dif- ference varying from 0.8 centi- meter to 3.6 centimeters. It is declared that these soiu'ces of error may be eliminato<l by the following corrections : For every degree of increase in the conjugato-syniphyseal angle add half the niunber of millimeters to the sum to be subtracted from the diagonal conjugate, and vice Fiii. 30.').— Effect of the lessoned slant outward of the syniiiliysis in a nu'lUtic pelvis upon tlie relationship between the true and the conjugate diameter (K boniont- Dessttignes). f II Iffii |lliB ' mammml^^ms '■ I 'IIBH 'HH IflKHH tf Si \ 'my, 0()«) AMEltlCAX TEXT-BOOK OF OBSTETlilCS. i( revHti ; also, for evorv O.o centimeter increase in tlie height of tlie svinphysis over tlie normal add 0.3 centimeter to the snn» to be suhtractetl from the diagonal conjugate, and vice rcrml. While these rules are admirable for tin study of the dried specimen in a museum, they are not easily applied to tiic living ])regnant female. The height of the symphysis can be measured in the living subject, but an allowance for variations in this respect eliminates error in only a small proportion of cases. The variations in the angle of the syni- l>hysis, a much more important source of error, can only be surmised. The writer much prefers the measurement between the upper outer edge of tin; synij)hysis pubis and the promontory of the sacrum for the estimation of the true conjugate, having demonstrated its superior accuracy in practice.* For taking this measurement the patient is put in the dorsal position, with the Fk;. aiJii. — Hirst's ju'lvimctiT: a, fur monsiirintr tlie tnio cimjiiKiiti' iilus the tliicknoss of the symphysis; n, witli extra tip iidileil for iiieasiiriiit; the tliiciciiess of tlie syinphysis. buttocks projecting beyond the edge of the table or bed on which she lies. A mark with the point of a lead pencil is made on the skin over the sym- physis pubis, about J of an inch below the upper edge. The two fingers of the left hand are inserted in the vagina as in measuring the diagonal conju- gate. The tip of the middle finger, having found the middle line of the promontory, is moved a little to the patient's right, and tip B of the pelvi- meter, shown in Figure 30(5, is made to take its place. While the examining physician holds the shaft of the pelvimeter firndy in place an assistant adjusts tip A of the movable bar over the mark made on the symphysis. This bar is then screwed tight, the whole pelvimeter is removed, and the distance between the t'ps is found by a tape measure. This distance is the conjugate plus the 'hickness of the symphysis (Fig. 307). The latter the writer has found to be DYSTOCIA. 607 ijiliysis 2 IK'S. sv ni- l's ['OlljU )1" til bol VI- tiniiig llj lists IP tl I to be Fl<i. 307 MousuriiiK' tlu' truo (•()Ilju^'Htt' [ilus the tliick- iK'ss of tho symphysis. 1 centimeter in twenty-six dried jwlves, IJ centimeters in nine, 1^ centi- meters in thirteen, IJ centimeters in tour, and 2 centimeters in tliree sjieei- iiiens, one a high-grade rachitic l)elvis, another of the masculine type, and the third a justo-majo- pelvis. The thickness of the sym- physis is measured as shown in Figure 30H. In living subjects the index finger of the left hand must find the inner surface of the sym- physis pubis, and follow it up to within about | of an inch of the top, where it bulges to its full thickness. On this point one tip of the pelvimeter is placed, and it is then held in position between the ends of the first and second fin- gers ; the other tip of the instru- ment is adjusted over the mark made on the skin externally : the distance is read off from the indicator pro- vided for the purpose. It is not necessary to make an allowance for the thick- ness of the tissues over the sym- physis, for this is included in both measurements, and on subtracting one from the other tlu^ necessary correction i' of course made. The tissues over the inner surface of the symphysis can usually be so compressed by the kiKtb of tiie pelvimeter as to be practically eliminated. If this is impossil)lc, as may happen in some primiparie, a small allowance may be made for these tissues — say, at the most 0.5 centimeter. In taking this measurement it may be necessary to anesthetize the j)atient ; and this is well worth while if a decision between some of the more serious obstetrical operations is to be based, as it must be, upon an accurate estimation of the true conjugate.* Mmmrement of the Traimrrw Diainchr of the Sujivrlor Stndt. — The * Wi'llcnliortrh was tlie lirst to pini>loy this jirinciplo in jielvinictry. Ilis polviiiictrr was imjtrovi'il npim by Van IIiiovcl, ami in ri'cont tinius iiy Skiilscli ami t)y niilliti i Dniiscln- iiuili- clnixchf WocliciiKrhrift, No. 18, 1S!K); Aiiiiriritii Joiinial nf ObnMriri', IHW ; Miiller's Ilundbuch der CicbitrtMil/<; vol. ii. pp. 2')'), 'J(>0, 'JGl). Flo, ;j(JS.— MeiisurinB the thli'kni.'ss of thu sympliysis. !IM' L - 4 '^ i i f mmmm %9 508 AMERICAN TEXT-BOOK OF OBSTETRICS. transverse diameter of the pelvic inlet cannot be nieasnred directly, nor can it be estimated accurately. Fortunately, this is not necessary. It answers the I'equirements of practice to determine whether there is a diminution of this measurement, without determining the exact degree of lateral contraction. To do this the following measurements are relied u^wn : The di.'-tance between the anterior suj>erior spinous processes of the iliac bones, which in well-formed women is 26 centimeters ; the distance between the crests of the iliac bones, 29 centimetei*s ; the distance between the tr()chantei*s, 31 centimeters; the dis- tance between the posterior superior spinous processes of the iliac bones, 9.8 centimeters ; the distance between the subpubic ligament and the upper ante- rior angle of the great sacro-sciatic notch, which, according to Lohlein, is 2 cen- timeters less than the transverse diameter of the inlet ; finally, an estimation of the width of the pelvic inlet by a vaginal examination. In taking the external measurements the woman is placed upon her back. The salient points are easily found except in the case of the iliac crests. They are discovered by ^ ■";,.^«'j Fio. 3()9.— Skutsch's method of measuring the conjugate diameter. moving the knobs of the pelvimeter evenly along the crests of the ilia until the two opposite points most widely separated from each other are foiuid. If the crests are no farther, or even less, separated from each other than the spines, points 5 centimeters back of the latter are arbitrarily selected as the sites of the crests. The posterior superior spinous processes are t)ften marked by distinct dimples on tiie woman's back. The internal measurement of Lohlein is made by the fingers in the vagina. If all these measurements are much less than normal, a lateral contraction of the pelvis may be assumed, and the degree of contraction is roughly estimated by the amount of decrease in the measure- ments, although the relations between these measurements and the distance sought is very variable. The efforts of Skutsch and of others before him accurately to measure the transverse diameter of the pelvic inlet by combined internal and external measurements camiot be said to have vet been crowned by success. The softness of the tissues externally permits the external knob of the pelvimeter to sink into the flesh to a varying degree, and the same is true of the structures within the pelvis. It is difficult also to keep the pel- DYSTOCIA. nm vimeter in the same straight line when the internal knob is changed from one siilc to the other (Figs. 309, 310). Moreover, better results in practice luay be obtainetl by an estimate formal by a vaginal and a combinetl examination, under anesthesia if necessary, of the relative size of the transverse diameter of the pelvic inlet and the antero-posterior diameter of the child's head. Measurement of the oblique diameters of the pelvic inlet is rc<|uired only in obliquely-contracted pelves. It will be referred to in the description of these pelves. The Measurement of the Capacity of the Pelvic Cavity. — The capacity of the pelvic cavity must be estimated by vaginal examination. There is no plan by which accurate meas- urements can be made. It Is sufficient to estimate the size and the shape of the pelvic canal by palpating the lateral •;•. walls of the pelvis ; by dcter- // mining the curve, perpendicu- \l larly and laterally, of the sa- :• crura ; by noting the height ;/•■ of the sacro-sciatic notches, Kio, 310.— Skutsc'li's inothoil of iiicnsurint,' the trans- verse diiimeter of the jielvie inlet. Fig. ol!.— Munsnrcment of the nntero-iKistcrior diumeler of the pelvic outlet. the approximation of the tuljcrositics of the ischia, the depth of the pelvis, and the direction of its canal ; by detecting, pt)ssibly, the presence of an exos- tosis, an osteosarcoma, an abnormally-projecting spinous process, an old frac- ture, or asymmetry of the pelvic walls from any cause. Measurement of the Transverse Diameter of the Pelvic Outlet. — The atitoro- posterior diameter of the inferior strait is enlarged during labor by the displacement backward of the coccyx. The transverse diameter between the tul>erosities of the ischiatic bones is constant, and if there is contraction of the outlet the greatest resistance to the escape of the fetus is furnished by these firm bony eminences. The transverse diameter of the pelvic outlet can be measured directly with ease. The woman is placctl in the dorsal pt^ition with thighs and legs flexed. The distance between the tuberosities of the jcdttM*><'4^' ii' dim !■(■ 1 f# 51 AMERICAN TEXT- BOOK OF OBSTETRICS. iscliia is mcasuretl with a ix-'lvinicter, or the examining physician places his thumbs squarely on the tuberosities, and an assistant measures the (listaiu-e between the physician's thiuiib-nails. If it should be tlesire<l to measure the antero-poaterinr diameter of the pelvic outlet, this may be done as shown in Figure 311, 1.5 centimeters being sub- tractetl for the thickness of bone and superimposed structures. 4. Description of the Several Varietie.s of Abnormalities in THE Female Pelvis. The simple flat pelvis (Fig. 31 2) is the earliest recognized form of contracted pelvis — the peliu)i j)l(()ia of Deventer, who did not, however, make a distinction between the simple flat and the rachitic flat i)clvis. It is doubtful, indeed, if ho knew the difference between the two. lictschler was the first to point out the distinctive features of this form of pelvis. In I^urope it is the commonest variety of deformed pelvis. Schroedcr states that it is seen more frequently than all the other forms put together. In America it is also eonmion, but the equally general ly-contractetl pelvis is encountered here as often or perhaps oftcncr. Out of a series of 316 pelves in women of American birth the writer has found eighteen (a percentage (»f 5.6) with the measurements charac- teristic to some degree of a simple flat pelvis. Cha)'acteri,stic)<. — In the simple flat jielvis the sacrum is small and is pressetl downward and forward between the iliac bones, but is not rotated foi ivard on its transverse axis. The antero-posterior diameter is contracted, therefore, throughout the whole of the pelvic canal. The contraction, however, is not often great. It is scarcely ever below 8, and is usually not under 9.5, centimeters.* The transverse diameter is as great as, or jiossibly greater than, that of the normal pelvis. Occasionally, however, in pelves aj)proaching the type of the generally-contracted flat pelvis the transverse diameter may be found some- what diminished. There is in those pelves quite frequently a double promon- tory formed by the abnormal jirojection of the cartilaginous junction between the first and second sacral vertebric. The line drawn between the lower prom- ontory, or the second sacral vertebra;, and the symphysis is often as small as, or smaller than, the true conjugate.f Kiiologij. — The simple flat pelvis has been as(Tibe<I to heredity, to an arrested rachitis, to overwork before puberty (especially the carrying of heavy weights), to premature attempts to walk or to sit up, and to the weight of a heavy trunk upon a j>elvis ill fitted to bear it on account of weakness of its ligaments. It is probable that in the majority of these pelves the form is * Eiifrolken has descriljod a specirni'ii with a true conjugate of 4.S oentimeters, a diajional conjugate of 7.-") pcntiiut'tepi, with transverse and ohli(|ue diameters of the inlet 13.3 and 12.4 centimeters respectively. This specimen is iini(|uc. t Crfde found in nine pelves with a double promontory the conjugate from the true prom- ontory longer in four and shorter in three cases than the conjugate measured from the false promontory. In two cases the two conjugates were of equal length (Klin. Vortriige ueber Gebuiishiilft; Berlin, 1853). DYSTOCIA. 511 iiilioritci and congenital. It has been loiuul by Feliling in a number of fetuses and new-born infants. J)iaf/no8ix. — The simple flat pelvis is easily overlooked. There is nothing in the patient's appearance or history to suggest the deformity, unless she has had difticulty in previous labors. The characteristic signs are the diminished antero-posterior dianjcter, determined by internal and external measurements, and a transverse diameter as great as, or greater than, normal, or prhaps a trifle under the normal nteasurement. This last point is determined by meas- urements externally and by the internal palpation of the iielvic canal. In measuring the conjugate diameter of this pelvis one must take into account the lessened inclination of the sym- physis outward, its height, some- what below the normal, anil the low position of the promontory. Usually the average sum of 1 1 centimeters is a suflicient amount to subtract from Fl(i. 31J.— Plinpk- lliit pi'Ivis (mixk-l in Hirst Colk'ctioii, liiivLTsity nf IViiiisylvaiiiii) ; e. v., Ku;. 313,— TIk- two oonjuiintos of n (lou))k> proiiKintory 85 cm. ; tr., l;U cm. ; obi., I'.'l cm.* (Kil)cm(itit-l>cssait!iies). the diagonal conjugate. If there is a double promontory, as is frequently the case in this form of pelvis, the ccmjugate must be measured from the promon- tory nearest to the symphysis, usually the lower (Fig. SVl). Jiijfucm'c upon Lahor. — From the failure of the presenting part to enter the pelvis during the last weeks of ge.«tation there is frequently some degree of pendulous abdomen, especially in women with abdominal walls relaxed from previous pregnancies. The uterus is sometimes broader than common, and is often tiltetl to one si<le. The pre,->enting |>art, if the head, may be lo().«e al)ove the superior strait, resting on one iliac bone or on the symphysis, or it may be pressed down firmly upon the brim in a transverse position, to accom- modate its longest diameter to the longest diameter of the pelvic inlet. Mal- prcsentations are common, as is also prolapse of the cord and of the extrem- ities. The meml I'anos may protrude in a cylindrical pouch from the external OS as the liquor amnii is forced out of the uterus without obstruction from * Tlie !il)l)reviii ions ti: nnil <>lil. will be iiseil throughout to designate the transverse and oblique diameters of the iielvic inlet. .ill r)i2 AM ERIC AX TEXT- BOOK OF OliSrETlilCS. \\ ! » 111' -4 :i- . r<i the ini|)orfbctly engagcil head. From the same caii.xe an early rupture of the inenihranes is likely. Acconling to Lit/inann, natural tbrees end the labor in 79 \iGV cent, of cases, but in .50 per cent, the head is not fully engaged until the OS is completely dilatinl. The dilatation of the os proeeetls slowly, for the head does not descend low enough io press upctn the cervix. Consequently the dilatation must be effected by a retraction of the cervix over the head or by the distended menibmnes. Should these ruptiu'c, the os, although consid- erably dilated, may retract until the head at length descends and again dilates it. Alter the obstruction at the superior strait is passetl — where, of course, it is greatest — the head usually (leswnds the remainder of the birth-canal with ease and rapidity, but labor may be prolongetl by an exhaustion of the natural forces in the attempt to secure engagement. The apparent anomalies in the niei-hanism of labor characteristic of this dcfornuil pelvis are in reality the best pttssible provision for the spontaneous obviation of the obstruction. The transverse position of the head at the inlet, the increased lateral inclination, and the imperfect flexion are designed to accommo<late the size and the shape of the head to the unnatural size and shape of the pelvic inlet. An explana- tion of these peculiarities in the engagement of the head can be found in the alteretl relation of expidsive and resistant forces. The head, forcetl down upon tlie flattened brim and free to move upon the neck, rotates until its longest diameter is adjusted to the greatest diameter of the inlet — the transverse. It seeks the direction of least resistance, as any inert body will when propelled through a contracted canal. But the transverse position of the head alone is not sufficient to overcome the obstruction. The bijjarietal diameter of the head is too large to enter the conjugate of the pelvis. The occiput, the bulk- iest portion of the skull, seeks the greater space to one side of the promontory, and is pushed against the lateral brim of the pelvis, the ilio-pectineal line. Here it is arrestetl. Further propulsion of the head is secured by a movement of partial extension, which brings rather the small bitemporal than the larger biparietal diameter of the head in relation with the contracted conjugate. Still, the obstruction may not be overcome. Both sides of the head may be unable to enter the jielvis at once. One side is propelled into the j)elvic canal, the other is held back. That side which encounters the most resistance will naturally be the last to enter. Thus it is that usually the anterior parietal bone, slipping more epsily past the symphysis, enters first. To this result also the inclination of the pelvic axis to the axis of the trunk contributes. Owing to the anterior jiosition of the whole sacrum and to the diminished antero-posterior diameter of the pelvic outlet, on account, also, of the transverse position of the head and of its imperfect flexion, rotation of the head on the floor of the pelvis occurs late, and occasionally fails altogether, the head being exjiellcd froni the vulva in its original transverse or in an oblique position. The localized pressure to which the maternal structures are subjected results sometimes in necrosis of cervical tissue over the promontory and of the anterior vaginal wall behind the symphysis. On the child's head the caput succedaneum is not exaggerated, because the head, when once firmly DYSTfiClA. \\:\ F|. ■prfssliiii m the iniiiitiil iMdit- <'mis(M| by llii- pressure (il llu; imimniiinry o iiciicc, usually f|uitocl(»s(> to tlicsiiiittal f^iiturcl Fii;. WW). Sinuctiiuos a suocos- sioii of tli('S(! ilcprcssioiis or a <futU'i'-.slia|)('(l <>;roov(' uiay lu' noted in a lino nui- ning outward and iorward on the oiiild'.s. skull. More l"rc(|ii('iilly the course of Fiii. ;!1.'>.— Murks iimde liy the promontory on the child's hend mid fiiee (Fritsch nnd Kii.stner). the head and face over the promontory is marked by a red streak runninj; from the depression before noted in a line parallel with the coronal siitiu'c toward the temple if the head is well flexwl after cnjiajjjement, or to the outer corner of the posterior eye, or, in case of extreme Hexiou, to the cheek (Fig. 315, A, B, c). 33 / ^6 r'r!? 514 .1.1//v7.'/r.l.V TEXT-lKiOK OF (Hi.STirmKS. I'siiallv tlic posterior parietal hone is tlcprossc*! Iwlow tlu! anterior, wliieli over- lupH it at tlie .sagittal suture. The posterior side of the skull is also Hatteiieil t'ruiii the greater and more prolonged pressure to which it is suhjeeteil. Ordi- narily the lateral ineliuation of the child's head is in a direction front hefore backward, so that the anterior parietal l)one presents at the centre of ♦',o supe- rior strait. < )eeasionally this inclination is so exaggerated that the ear is the ])resenting part. Kxceptionally the lateral inclination takes the opposite direc- tion, the anterior parietal hone catches on the rim of the puhic bones, and the ])osterior parietal bone is the first portion of the child's hea«l to enter the pelvis. The i)resentatii»n of the posterior fontiuielle occurs even in normal ])elves as a rare exception, but is seen in about 10 per cent, of co:itractc(l pelves (Schauta), and is the residt in them very likely of firm alMlominal walls an<l an increased in<-liiiatiou of the pelvic inlet to the axis of the trunk. In these cases the anterior parietal bone is pushed under the posterior at the sagittal suture. When the posterior side of the head by descent finds romn in the hollow of the sacrum and moves backward, the anterior portion of ilic skull glides over the symphysis, and the sagittal suture UKtves from lis oriijiiial ])osition, just behind the symphysis, toward the median line of the |M'lvic<.-.«nal. In adtlition to these anomalies (»f mecli;'.nism, Hreisky de>cri!Hs what he calU an "extra-median" engagement of the head in eases of flat pelvis in which there is considerable h^rdosis of the lund)ar vertebra'. The head in extreme flexion is forced down upon half of the pelvic inlet, an<l enters the ])elvie canal on this side alone. Directly the obstnu'ting ])romontorv and lumbar vertebra are passed the head descends the pelvic; canal with rapidity and ease. This mechanism was noted nineteen times in Hreisky's clinic among 2002 labors.^ Justo-minor Pelvis. — In this ty|)e of contracted pelvis the form of the female ])elvis is preserved, but the size is diminished ( 1*1. 2i', Fig. 1). Three divisions of this pelvis are commonly made: 'V\\v jmrnilr, in which the bones are small and slen<ler ; the iiuixculitic, in which the bones are large, heavy, and thick ; and the (Iinirf, or jxlrin tiatui, in which the pelvis is very dimimitive in size and tljc pelvic hones ar(> not joined by bony union, but are separated by cartilage as in the infant. The innominat(> bones are divided inio iheii three parts, and the s;H'ral vertebra* are distinct from one another (1*1. 2J), Fig. 2). The justo- minor pelves pass by insensible gradations into the simple flat, the transversely- contracted, and the generally-contracted flat pelves. In the larger cities of the United States the justo-minor jx'ivis is very frequently encountered. It is cer- tainly !is common here as is the simple flat ])elvis, and if one were to judge ftiwn lios])ital patients, among whom there is a largo |)roporti(m of shop- and factory-girls, this variety of cimtraeted pelvis would be regarded as the commonest. ('/Kintctcristics. — While it is convenient to speak of the justo-minor pelvis jis the normal female pelvis in miniature, the description is not strictly accu- rate. There are peculiarities due to an arrest of ilevelopment which give to the e(|iially general ly-contraoted pelvis some of the features of an infantile j>elvis. The alie of the sacrum are narrower than they .should be in eompari- I DYSTOCIA. Platk 2fl. r. V. idici Tr. (irili'ti ' 4 Tr. (uutli'tl 7 em, Aiit, iKiat.iiiitlt't Ti I'lii, 1. .Iiisto-iiiinor jK'lvis iMiittiT Musi'uin, CulUw nf I'hysicinns, I'liiIacU>l|i)iiiiK inlet n pprt'frtly sjniiiu't- riciil (ivciid, ■_•. Mwiirl' pelvis. ;;. .lustniiiiiinr pilvis with nipliiri'il pelvic jniiit'^, fulldwint; I'urci'ps iippli- ciiiiiin illirst tullictiun, l'iiivir>ily ni' rinnsylviiiiini. I. Narruw, I'unMcl-slmpfil pilvi.s i^piiiiiini in tlic Hirst ((illcitinii, rniviT>ily ni rcunsylviiiiitn. ■'>. h'cttil illclrvilnpecl pelvis, pinlialily an ,irn>lii| divi-lnp- iiirnl I'niiii racliili> ( Miillci' Mii-runi, rulli'uT of I'liysii-iansi. il. Minm- uraclc ..f n,iii-.iH . im 1 .h.-ipcil pi'l- vi> uilli cunlriKli'il puliie an'li. 7. i ililic|iiclyccintnicti'cl pelvis ^^^u'gl■l('l. ,>. ( ililii|Mi'ly i-uiitni(;ii| pelvis iplintu'.'iaphed Iniii a pla.-ler ea>tj. 1: 'fi H ! i» ! ,*! :• . ' ) ' n« DYSTOCIA. 515 soil with the bodies of the vertebrte. The sacrum is short and is not pushed as far forward between the iliac bones as it usually is; it shows also a dimin- ished forward inclination, and on its anterior surface a greater lateral, and a less marked perpendicular, concavity than common. The distance between tiie posterior superior spinous processes of the iliac bones is relatively great, on account of the posterior position of the sacrum and its slight rotation forward. The conjugato-symphyseal angle is greater than normal, by reason of the lessene<l inclination outward of the symphysis and the pubic bones. The promontory la high and not prominent, and the inclination »)f the pelvic entrance to the abdominal axis as the individual stands erect makes a more obtuse angle than it does in the normal ptslvis. The bones in this form of contracted pelvis are commonly small and slender, except in that somewhat un\isual variety the masculine pelvis, in which they are firm and thick beyond the normal. Women with a justo-minor jielvis are ordinarily of slight build and below the medium height; but this pelvis may be found in individuals of ordinary stature, and sometimes actually in tall women of large frame. The true dwarf pelvis (PI. 29, Fig. 2) is very rare. It is found only in women of dwarf stature. The bones are slender and fragile, and the carti- laginous junction between the original divisions of the pelvic bones is pre- served. There is extreme contraction of the pelvic canal. In the commoner kinds of justo-minor pelvis the contraction is not often very great. The conjugate diameter is seldom below 9, and scarcely ever so low as 8, centimeters. The pelvic outlet in some cases is laterally contracted ; in others it is comparatively roomy. Etiolofjrj. — The justo-minor pelvis is the result of arrested development ; it may be foiuid in women descended from a stock that has deteriorated physically, or in women subjected during childhood, infancy, or intra-uterine existen* e to unfavorable hygienic surroundings or conditions. Diafpioxh. — The justo-minor pelvis is easily confused with a rachitic pelvis, but the distinction is readily made by careful j)elvimctrv. All the measure- ments, while equally reduced, bear their normal proportion to one another, except in the case of the external conjugate diameter, which is apt to be longer than would be expected, on aeeoimt of the posterior position of the sacrum antl its lessened inclination forward. In estimating the true conjugate diameter from the diagonal conjugate one must take account often of the increase in the conjugato-symphyseal angle, and must remember that the sum to be subtracted from the diagonal conjugate is not infrequently greater than common. The symphysis is less in height than in the normal pelvis, but the error of compu- tation from this source may be disregarded. Ij()hlein lays special stress upon the importance of measuring the pelvic circumference in making the diagnosis of this form of contracted pelvis. It is always far below the normal, 90 cen- timeters. An internal examination of the pelvic cavity and inlet should Imj made carefully, to determine approximately their capacity, with a special regard to the approximate length of the transverse diameters. Influence on Labor. — The mechanism of labor shows far fewer anomalies 11^ AMERICAN TEXT-BOOK OF OBSTETRICS. ill this than in any of the other forms of contracted pelvis. The head, from the greater resjistance encountered, is strongly flexed. It may be placed trans- versely, but is quite commonly oblique, and may even be antero-posterior in position if there is a tendency to lateral contraction of the pelvic canal. By the [)erfect flexit>n of the head the obstruction to the progress of labor is in great part obviated. If anything interferes with this movement of the head, as a faidty application of the forceps, engagement and descent may become impos- sible. Pelvic presentations in labor are a great disadvantage by reason of the difficulty experiencetl in freeing the arms and in bringing the head last through the generally-contracted pelvic canal. To secure its rapiil passage, the child's head must be flexed strongly by the operator's finger in its mouth before an attempt is made to secure engagement in the superior strait. While the woman escapes localized necroses of the soft tissues following labor in the justo-minor pelvis, there is greater likelihood of rupturing pelvic joints in this than in any other variety of contracted pelvis, and there is also an extraordi- nary liability to eclampsia (PI. 29, Fig. 3). Tiie caput succedaneum, which is very large on account of the early fixation of the head and the long labor, is situated directly over the smaller fontanelle. There is an overlapping of the cranial bones both laterally and antero-posteriorly. The generally-contracted, flat, non-rachitic pelvis presents the com- binetl features of the flat and the generally-contracted pelvis. Characteristics. — All the diameters are below normal, but the conjugate is less in proportion than any of the others. This pelvis has many of the feat- ures of a rachitic pelvis, but the anterior half of the pelvic circumference is not markedly broadened ; indeetl, it is often the reverse. The sacrum is small and is not rotate<l on its transverse axis ; it is placed farther back between the innominate bones than in the normal pelvis, and very much fiirther back than in the rachitic pelvis. The promontory is high and is not prominent. The influence of this deformity of the jwlvis upon labor is that of a flat pelvis, but the difficulties are greater than in the case of the simple flat pelvis, for tliere is less compensatory room in a transverse direction. The generally-contracted non-ra''hitic flat pelvis is comparatively rare. The flattening, according to Litzmann, is due to a shortening of the innominate bones, especially at the ilio-pectineal line. In estimating the true conjugate diameter of the generally- contracted flat pelvis it is safer to subtract 2 instead of If centimeters from the diagonal conjugate, on account of an increase in the conjugato-symphyseal angle, the result of the high position of the promontory and the diminished slant outward of the symphysis. Etiology. — This generally-contracted type of pelvis is due to hereditary influence or to an arrest of development in the embryo, fetus, or infant. It is claimetl, however, that it may be j)roduced by premature attempts to walk anil by long standing upon the feet in very early life. Diagnosis. — The recognition of a generally-contracted flat pelvis is diffi- cult. The measurements usually resemble those of a generally equally-con- tracted pelvis, but the conjugate diameter is less than one expects in that form DYSTOCIA. 517 is (lifti- lly-cf)ii- at Ibriii of contracted pelvis, and the mechanism of labor is that of a flat pelvis. The diagnosis can be made by finding tlie reduced conjugate diameter and by the ease with which one can reach the lateral pelvic wall in the palpation of the interior of the pelvic canal. A certainty of diagnosis can be obtained during life only by the direct measurement, not only of the conjugate diameter, but also of the transverse, by the methods of Liihlein and of Skutsch. The Narrow, Funnel-shaped Pelvis ; Petal or Undeveloped Pelvis. — This variety of pelvis is contracted transversely at the pelvic outlet, or both in the transverse and antero-posterior diameters, without abnormalities in the spinal colura. The depth of the pelvic canal is much increased by the length of the sacrum, of the symphysis, and of the lateral pelvic walls. The sacrum is narrow, has little perpendicular curve, and is placed far back between the ilia (PI. 29, Figs. 4, 5). Schauta ascribes this form of contraction to an anom- iilv of development by which the pelvic walls are lengthened downward and the weight of the body is thrown backward upon the sacrum. It is said to be very rare, but it has been found quite frequently in those hospitals where the outlet of the pelvis is regularly measured. It comprises from 5 to 9 per cent, of all contracted pelves, according to Breisky, and Fleischmann found twenty-four examples in 2700 parturient women.^ A slight manifestation of tiie deformity is often called a ''masculine" pelvis by reason of the diminu- tion in the breadth of the pubic arch. Tin's degree of the funnel-shaped pelvis is frequently encountered (PI. 29, Fig. 6). Diagnosis. — The diagnosis of a narrow, funnel-shaped pelvis is made by a comparison of the measurements of the pelvic inlet with those of the outlet. The former are found to be normal or even greater than normal, while the measurements of the outlet are diminished. If, as is the rule in extreme degrees of this deformity, the inlet and cavity are contracted, the outlet is still smaller in proportion. A careful palpation of the pelvic canal is an important aid to a correct diagnosis. The pelvic walls are felt to converge as they ajiproach the outlet ; the narrowness of the pelvic arch is appreciated, and the approximation of the tuberosities and spines of the ischiac bones is noticeable. Influence xqwn, Labor. — The peculiarities of mechanism in labor are mal- positions of the head at the outlet (as backward rotation of the occiput), ob- lique and transverse position of the head, and imperfect flexion. There is also an insufficiency of the expulsive forces, the greater part of the fetal botly being contained in the lower iiterine segment, cervix, and vagina, while the upper muscular segment of the uterus is in great part emptied and therefore powerless. By the approximation of the pubic rami the presenting part is forced backward, and serious lacerations of the perineum are to be feared. Tiip pressure of the head upon the lower birth-canal may result in necrosis of soft structures or lacerations along the descending rami of the pubis and the ascending branches of the ischium. The tissues over the projecting spines of the ischiac bones are also the seat of tears or of necroses. The narrowing of the jiubic arch may lead to serious injuries if the forcejis be applied. The writer has seen long clean cuts in the anterior vaginal walls, and profuse hem- is / :i ' \ -^ W I I * a •\ it a.. 1-, fi :■ i r ■ r i Mil fl 'H f I I I i: .1' ! 518 AMERICAN TEXT-BOOK OF OBSTETRICS. orrhage, following the use of instruments. In well-niarketl examples of the narrow, funnel-shapetl pelvis, with a transverse diameter at the outlet not much below 3 inches, symphysiotomy gives the best chance of a successful termination for mother and child. Higher grades of contraction with a diam- eter of 2 inches and under demand Cesarean section. In lesser grades the woman may be delivered spontaneously or by forceps. Obliquely-contracted Pelvis froza Imperfect Development of the Ala on one Side of the Sacrum (Naegele Pelvis). — This pelvis was first describetl in 1834 by Franz Carl Naegele,^ but had been noticed as early as 1779 without a full understanding of its significance (PI. 29, Figs. 7, 8). Chantderistics. — The pelvic inlet has an oval shape, with the small point of the oval directed to the atrophied side of the sacrum. The sacral ala is atrophied or is absent, not only in that portion of the bone entering the sacro-iliac joint, but also in the transverse process along its whole length. The sacro-iliac joint on this side is ankylosetl in the vast majority of cases, but not invariably. The sacrum is narrow, asymmetrical, and turned with its anterior face toward the deformed side of the pelvis. The promontory is not only turned in this direction, but is also pulled over to the diseased side. The innominate bone on this side is pushed as a whole upward, backward, and inward, and its anterior face is pushed inward and backward. The tuberosity of the ischium, as a necessary consequence of the displacement of the innom- inate bone, is higher than its fellow, projects into the pelvic canal, and is so turne<l that it looks rather antero-posteriorly than laterally. The spine of the ischium is brought quite close to the corresponding edge of the sacral bone and juts prominently forward into the pelvic canal. The whole innominate bone on the diseased side lacks its normal curvature at the ilio-pectineal line, and may run almost straight from the sacro-iliac junction to the symphysis pubis. The opposite innominate bone has a greater curvature than common, especially in its anterior half; otherwise it is practically normal in structure, position, and inclination. The symphysis pubis is pushed toward the healthy side of the pelvis, and its outer surface, instead of looking directly forward, is inclined to the diseased side. The pubic arch likewise faces somewhat in this direction ; its aperture is asymmetrical and irregularly contracted, as the ischiac and pubic rami on the diseased side are pushed inward upon the pelvic canal and over toward the healthy side (PI. 29, Figs. 7, 8). Etiology. — The cause of the obliquely-contracted pelvis under description is an absence of the bony nuclei in the ala or lateral process on one side of the sacrum. The lateral process consequently fails to develop, and the in- nominate bone is brought in relation with the bodies of the sacral vertebrae. As a result there must be some distortion of the innominate bone even in fetal and infantile life, but this is increased to an exaggeratetl degree when the indi- vidual begins to walk. Instead of receiving the pressure from the lower extremity approximately on the keystone of an arch, as does a normally- curved innominate bone, the defornial bone in a Naegele pelvis transmits the pressure in almost a straight line upward and backward, so that the extremity DYSTOCIA. 519 of the posterior arm of the arch slides past the sacro-iliac joint instead of resting firmly on it as an arch does on its abutments. The irritation and strain of this nnnatural movement bring about in time the atrophy and ankylosis of the joint. That the deformity in this kind of oblique pelvis does not follow a primary ankylosis of the sacro-iliac joint is proven by the fact that the innominate bone is pushed backward and upward on the sacrum — a movement that would be impossible were this joint first ankylosed. As a further proof of primary lack of development and secondary ankylosis, there is no trace of inflammation in or about the ankylosed joint, and the alse or transverse processes of the sacrum are atrophied or are absent along the v/hole length of the sacrum, and not only in that portion of it which enters into the composition of the sacro-iliac joint. Diagnosis. — The recognition of an obliquely-contracted pelvis from arrested development of the sacral alse may be very difficult. There is nothing to direct the attention of the physician to the possibility of this deformity. There is no history of previous disease or of accident, no scar of an old fistula over the joint, and the patient does not limp. The diagnosis can be made only by a methodical external and internal palpation of the pelvis and by careful me'^s- ureraents. If the outspread hands are laid over the innominate bones, it will be noticed that the dorsal surfaces are directed obliquely forward and back- ward as they lie upon the diseased and healthy sides. An internal palpation of the pelvis will detect one lateral wall much nearer the metlian line than the other, and the diagonal conjugate will be found to run not antero-posteriorly in direction, but from before backward and from the healthy to the diseased side of the pelvis. There are a number of points from which measurements may be taken that will show inequalities where in the normal pelvis the dis- tances should be the same or should differ by a very small sum. Naegele recommended the following measurements : (1) The distance of the tuber ischii on one side from the posterior superior spinous process of the ilium on the other ; (2) from the anterior superior spinous process of one ilium to the posterior superior spinous process of the other ; (3) from the spinous process of the last lumbar vertebrse to the anterior superior spines of both ilia ; (4) from the trochanter major of one side to the posterior superior spinous process of the opposite iliac bone ; (5) from the lower edge of the symphysis pubis to the posterior sujierior spinous processes of the iliac bones. In addition to these measurements, others of value have been suggestal by Michaelis and by Ritgen. These are the distances from the middle line of the spinal column to the posterior suj)erior spinous processes of the iliac bones, and the distance from the lower edge of the symphysis to the ischiac spines, and from these spines to the nearest point on the edges of the sacrum. In this latter measure- ment it will be found that the distance from the symphysis to the ischiac spine is longest on the diseased and shortest on the healthy side, while the distance from the ischiac spine to the edge of the sacrum is very much shorter on the diseased than on the healthy side. This last, which is a very important meas- i AMinUCAX TEXT-BOOK OF OJiSTETIilCS. urenient, can easily be taken by laying finger-broailtlis between the points to be measured. Infiucnce on Labor. — The mechanism of labor in an ol)li(|nely-eontraeto(l pelvis is in the main that (tf labor in a generally-eontractcHl pelvis. The shape of the pelvic entrance and canal is symmetrically ovoid, and the head can enter the contracted space only by extreme flexion. There are none of" those anomalies of position, flexion, and inclination o. the head which are seen in the flat pelvis. As the head descends the birth-canal anomalies of mechanism may appear resembling those described in the narrow, fnnnel-sha])ed ])elvis — namely, abnormal and imperfect rotation and anomalies of flexion. Depend- ing npon the degree of deformity, there is more or less interference with the progress of labor to (!ompIcte obstruction. The head can almost invariably be found entering the ])clvis and passing through the canal with its longest diameter in coincidence with the longest obliipie diameter of the pelvis, from the diseased sacro-i Mac joint to the op])osite ilio-pectineal eminence. Prnr/noxia. — In the recorded cases the results of labor in the Xaegele pelvis have been bad. Of 28 women reportctl by Lit/maiui, twenty-two died in their first labor, five of them undelivered. Three of these women died in consequence of their second labor, and two after the sixth. Out of 41 cases, six were delivered spontaneously, twelve by the forceps, fourteen by craniotomy, five by version and extraction, four by premature labor, and two by Cesarean section. The following accidents were noted in the course of labor or shortly afterward : Ilupture of the uterus or vagina, vesico-vaginal fistula, fracture of the horizontal ramus of the pubis, rupture of the sacro-iliac joint and of the syin])hysis. In another series of cases, 28 women furnished 42 labors witii the following results : twenty-one died as the result of the first labor, three of the second, and one after the sixth. These women were delivered seven times by craniotomy, once by Cesarean section, four times by premature labor. and in a number of instances by forceps. Out of 41 children in Litzmann's statistics there were only ten delivered alive, two of these by Cesai'can section and two by premature labor. The six other living children were all born of the same mother.* Treatment. — Force])s and version are not, as a rule, successful in the treat- ment of labor obstructed by an oblicjuely-contracted pelvis unless the degree of deformity is slight. The induction of jH'emature labor and the perform- ance of Cesarean section are the most successful means of delivery, but the former should be resorted to only when the distance between the lower edge of the symphysis pubis and the sacro-iliao joint of the healthy side is not under 8.5 centimeters. In 20 forcejis operations thirteen women died. The proposition of Pinard to do what he calls ischio-pubiotomy will not meet with much favor. The room trained bv the movement outward of the innominate bone on the healthy side, the other being, of course, immovable, will be suf- ficient only in pelves so slightly contracted o^ to allow a delivery perhaps by much simpler means. * The writer is indi'litcd for tiiese statisties to Schauta Hoc. cit.). DYST(XIA. 1'I.ATE 30. •'. V. ''i 1111 v:\Wi\ II'. iihiiii n I'lii. i. Tr.itisviTSfly-contriictt'il prlvis (Unln'it ; iiiiulcl in MiittiT MllscMini.t'iiiliK'"'" I'liysiciiLiis, riiiliii|rl|.liiii). 'J. TniMsvrrsi'lycimtniitcil pelvis, slmwiiij,' <-iriilniclioii nl iiiillct (iiumIcI in llic Hirst Cnllci'iidii, t'liivcrsily <if I'L'iiii-ylvimiiil. ;l. Triilisvcrscly ciintniclcil pelvis, u itii nlpseiiee nl'sneniiii ( llolil). I. Split pelvis iSeliinitiil. f). (ielie rally eiilliilly-ciiiitnictecl nieliitie pelvis i Hirst Ciilleelinii, riiiversily df I'eiiiisylviiniii), 0. lieiieriilly- oiinlriieleil raeliilie i n'l vis i Hirst ('iilleetinii, t'liivi'isity iit' reiiiisylvii'iiiii. 7. 'I'ypieiil Hat raeliilie pelvis > .M lit- ter Miiseuiu, Ciilletje iif I'tiysieiaiisi. 'I'lie pruiiiiiiitnry nl' the saeniiii pruji'ets sn I'ar Inrwanl tluit the tnio traiisv'.Tso diaiueter is hiseeled liy it. s. I'lat raeliilie pelvis, with uim^ual ciesceut of lliu itroiuulitury, riitu- tion (if the saeniiii, and lordosis (Miitler Mu.seiiiii, ColleKi' of I'hysieiaiis). vj'r ''5' I ,!/■ .Wl i . ^ '«• I i IF DYSTOCIA. 521 Transversely-contracted Pelvis the Result of Imperfect Develop- ment of both Sacral Alse. — This pelvis was first described in 1842 by Hubert, and is generally known as the "Robert i)elvis" (PI. 30, Fijjs. 1,2). It is the rarest of all contracted pelves. Schauta was able to find but six examples recorded in childbearing women. Ferruta has recently rejwrted another case.'" Herman gives eight as the number of recorded cases. The anatomical conditions are the same as in the Naegele pelvis, except that both sides of the sacrum are aft'ected instead of one. Other parts of the sacrum besides the alse may show imperfect development. There is a case reportwl in which the whole lower portion of the bone was absent (PI. 30, Fig. 3). The sacnnn in this pelvis is extremely narrow, and the posterior superior spinous processes of the iliac bones are brought close together. The degree of con- traction in the transverse diameter is so extreme that natural labor is out of the question. An asymmetry of the Robert pelvis has been observed, one side showing a greater degree of the deformity than the other, and thus approaching the type of an obliquely-contracted pelvis. The cause of this deformity is an absence of the bony nuclei in the sacral aloe of both sides. Secondarily, as in the Xaegcle pelvis, there is apt to be an ankylosis of the sacro-iliac joints. That this ankylosis is secondary and not primary is demonstrated by the same condition which proves that anky- losis is not a primary cause of the oblique contraction and ill-development of one side in the Naegele pelvis — namely, a displacement of the ilia on the sacrum necessarily occurring before the ankylosis. The treatment of labor obstructed by a transversely-contracted pelvis of this kind simply resolves itself into the performance of Cesarean section. Justo-major Pelvis. — A generally equally-enlarged pelvis nuiy be found in women of gigantic stature, but it may also be demonstrated in a woman of medium height. The pelvis of the Nova Scotian giantess was large enough to give passage to a child weighing 28f pounds. The largest pelvis that has ever come under the writer's notice was found in a woman somewhat below the average height, without an abnormally great development of any other portion of her frame. Diar/nosis. — The diagnosis of a justo-major pelvis is made mainly by exter- nal measurements. If all of them are found far in excess of the normal while preserving their normal relative proportion, the diagnosis of a justo-major pelvis is justifiable. The internal examination, if considered necessary, will show that the promontory is quite inaccessible, and that it is much more dif- ficult than common to reach the lateral pelvic walls. This anomaly of the pelvis does not, of course, obstruct labor ; on the contrary, it predisposes to precipitate deliver^-, although the resistance of the soft parts may be quite sufficient to delay the process considerably, even though the pelvis present no obstacle whatever. During pregnancy it is noted that the uterus has a tend- ency to sink deep within the pelvic canal, so that pressure-symptoms of the pelvic viscera and blood-vessels are common in the latter weeks of gestation, and these symptoms may become so exaggerated as to make locomotion diffi- kl Kr yr it f / l-:i) 522 AMERICAN TILXT-UOOK OF OliSTKTliJVii. cult. In l!il)(»r tliorc may be noted anomalies in the mechani.sm (lo|>enileiit ujHtn insiilHcient resistance to tlie enj^af^cmeiit of tlui liead. Thus imperiecl flexion at tiie superior strait may be observed, and there may be a tardv rotation of the head on the pelvic floor. Split Pelvis. — The split pelvis, which is due to a defect in the develop- ment of the hnver portion of the trunk in front, is almost invariably associated with exstrophy of the bhulder. This pelvis has very rarely been observed in tiie childbearinj; woman ; there are on record but seven examples complicating^ labor. This form of pelvis presents n<» obstacle in parturition. There are the same peculiarities in labor as in the justo-major j)elvis — namely, a tendency to precipitate birth, and anomalies in the mechanism the result of imperfect resistance. After labor it is almost certain that there will be a prolapse of the uterus. The didf/iiositi of this detbrmity j)resents no difHcultie^, and no obstetric treatment is called for in labor (PI. 30, Fig. 4). The Rachitic Pelvis. — In the healthy life and growth of bones two opposed processes are found : on the j)erif»hery there is an active proliferation of cells to form the bone-structure, while in the interior, l)one-substance is being constantly ab.sorbed by the marrow. In rachitis the absorption of hone- substance goes on more rapidly than it does in healthy bone, and at the same time there is in the perij)herv a very mu« h more rapid proliferation of cells, which do not, however, develop normal bone-structure. Their growth and multiplication result in the formation of an osteoid material poor in lime-salts and much more jtliable than healthy bone. The result of this pathological process in the pelvic bones is to make the pelvis more sensitive than it should be to the mechanical forces that are brought to bear upon it. In the rachitic pelvis the size and shape of the pelvic canal are modified by three factors : the pressure from the trunk above and the counter-pressure from the extremities below ; the pull on the pelvic bones by ligaments and muscles ; and an arrested development the conseciuence of an interference with normal growth that this disease occasions. ChavaderiMics — The effect upon the shape and size of the pelvic canal of rachitis in the pelvic boiK's is not unif()rm. Several varieties of contracted pelvis may result. The commonest is the fiat pelvis with .some contraction of all the diameters, but a most marked diminution in the antero-posterior diameter (PI. .'!(). Fig. 7). There may, in addition to this conmion form, be found a simple flat rachitic pelvis without alteration of the transvcr.se diam- eters, a generally e(pially-contractcd rachitic pelvis (PI. 30, Figs. 5, 6), and a so-called " pseudo-osteomalacic " pelvis, in which the effect .seen in osteomalacia is jiroduccd by pressure upon the bones .softened by rachitis. There are other rare forms of asymmetrical development, in connection usually with spinal disease of racihitie origin, that will be described elsewhere. CliaracteriNticfi of (he Fltif, ( h'HVi'aUii-cnntraded Rdcliitic Pelvis. — The sacrum is |)resscd forward and downward between the iliac bones, and is rotated on its transverse axis, mainly by the pressure of the trunk upon it, but partly by the pull downward of the psoas muscles upon the spinal column i; ■ i' DYSTOCIA. Plate 31. ('. V, .'i riu. Tr. liiiliti 11 cm Tr, l"iiil.-ti llj .ni. 1. Fliit riichitic pelvis, sin iwinu' tititcTior pnsitinii df ncctiilnila iMillliT Musiiiin, ( •nlh'i.'c i.f riivviiiaiis, I'liilinK'lphiiii. ■_'. I'liit railiitic pelvis, slmwiiiir reltitive iiieasiircnieiils df iiiiieni-pnsteiidr ami tniiisverse iliuiiieti'i-s lit inlet (Miitler Museiiiii. Ciillei:!' nf riiysicMiiiisi. :i. Kliil riiehitie |ielvi< willi Imueil I'eiiinni i Miit- ter Museum. Cullene of riiysieiiiiisi. I. l-'l.-it racliitic pelvis, slinwiiit; reliilive iMeii-iireiiieiit- ..f inlet Mini (unlet ^.Miitter Museum, Culletie nf i'li.vsieiansi. .V7. I'seiiilo-dstenmalaeiii. ur.i Ma DYHTOCIA, o2.J and the p''ll upward u|K)n the ixjsterior surface of the saertun by the ereotores spime miiscli's (PI. 30, Fijj. 8). Tlie effect of tins movement would naturally be to throw the tip of the sacrum and the coccyx directly backward, so that the pos- terior surface of the sacral bone would rim an almost horizontal course lus the woman stood upon her feet. The attachments of the sacro-sciatic ligaments and muscles to the lower sacrum and coccyx, however, prevent this backward movement of the bone us a whole, and, pulling the lower portion of the bone forward, cause a sharp bend in it, usually at the junction of the fourth and fifth sacral vcrtebrse. The sacrum is narrowed in its transverse diameter, and the lateral concavity of the anterior siu-fact; is ctJaced, by the forward movement of the bodies of the vertebrte between the alte. The anterior surface of the sacrum, indeed, may be convex from side to side. By the pull of the strong sacro-iliac ligaments running from the sacrum to the ])osterior superior spinous processes of the iliac bones the latter are pulled downward and forward by the descent of the sacral promontory, and are consequently made to apjjroach one another bel. !nd, but they do not keep pace with the movements of the sacrum, and co: .iccpiently project more prominently than common on either side. The natural result of this movement forward and inward on the part of the posterior superior portions of the ilia would be to throw the anterior half of the innominate bones outward, but this movement is opposed by their junction at the symphysis, and to a less degree by the attachment of Poupart's ligament to their anterior superior spinous j>rocesses. The ilia, however, restrained by a somewhat yielding force, are thrown to a certain degree out- ward and backward, so that their upper edges run almost horizontally outward, and the distance between their anterior spines becomes little less than, the same as, or even greater than, the distance between their crests (PI. 30, Fig. 7). A further result of these combinetl forces pulling the innominate bones inward and forward behind and holding them in place in front is to produce in them an abnormal curvature, as in the case of the sacrum, or as in a bow bent between one's hand and the ground (PI. 31, Figs. 3, 4). The point of angulation or greatest curvature is found on the ilio-pectineal line, back of the median transverse line of the pelvic inlet, near the sacro-iliac joints. On account of the flexion of the innominate bones the transverse diameter of the rachitic pelvis is relatively increased, but as the whole pelvis is com- monly below the normal in size, this diameter rarely exceeds, if, indeed, it equals, the normal transverse measurement. A further consequence of the exaggerated curvature of the innominate bones is to throw the ace- tabula forward, so that the counter-pressure of the lower extremities is exerted more antero-posteriorly than in the normal pelvis (PI. 31, Fig. 1). The pubic rami and the symphysis are diminished in height and show a lessened slant outward. The cartilage at the junction of the symphysis projects inward upon the pelvic canal, standing out above the level of the bones to such a degree that it is sometimes a source of injury to the head or to the maternal structures. The force of resistance at the symphyses to the out- ward movement of the innominate bones sometimes bends the ends of the , \s^A .11., i \i: 'm :¥m pwm ifpllite , , , If- ' 'i ■'■;:. "' i— fM' .■ vm \l 524 AMEIifCAX TEXT- BOOK OF OJiSTETRICS. H pu])ic bones inward upon the pelvic pjinal, Jijivinji; to the pelvic inlet the shape of a Hiiiire S. From the traction of tlu' adductor and rotator muscles of the thi<ih upon the tidierosities of the ischiac bones (inereased in rachitis bv the p(isitit)ns of the acetubula and tlie bowin*;" of the femora), the latter are ])ulled outward and forward so that the pubic arch is <;reatly widened and tlie transverse diameter of the pelvic outlet is increased (I'l. 31, Fijj. 4). The antcro-posterior diameter of the outlet is somewhat diminished by the excess- ive jierpcndicular ciu'vatiire of the sacrum, but lh(> contraction is relativeiv much less than in the conjugate of the inlet. The whole ])clvis is lilted forward on its transverse axis, so that the inclination of the superior strait is increased and the external genitalia are displaced backward. The bones of a rachitic pelvis arc usually slighter and more brittle than conunon. They may, pcrhaj)s, show no peculiarities iik structure, or in rare cases they may be tbund much thicker and heavier than normal. In the generally etpially-contractcd rachitic ])elvis — a rare +ype — is seen mainly an arrest of development, the consequence of rachitis in very early lii'e, Avhieh retarded growth without much atfecting the shape of the pelvic inlet and canal, from the fact that the pelvis had not been subjected to the pressure of the tnmk diu'ing the active stage of the disease, because it ran its course to complete recovery before the child attempted to sit up or to walk. Possihiv also the disease in some of these cases is not severe and lasts but a short time. As the detbrmity is the result of arrested development, we find a transverse contraoiion as in th(> fetal ill-developed ])elvis (PI. .'JO, Figs. 5, G). The ilidfpiosifi of the rachitic origin of this type of pelvis is made by the relations of iliac spines to crests, by the history of rachitis in early iid'ancy perhaps, and ]K)ssil)ly by the signs of the disease in other portions of the body. In the psci((fo-of<ti'0))i(il(ii'ic pclris the rachitis has been severe in character and long contimied. Etforts to walk have been made while the disease was in active progress, and possibly the weight of the trindi has been exaggerated by attempts to carry heavy burdens. As a consetpience of the pressure of the trunk and the countcr-])ressure of the lower extremities the pelvis bends to an extreme degree under the forces imposed u])on it. The sacrum siidvs far down into the j)clvic canal and is sharply curved or bent from above downward ; the innominate bones are bent at a sharp angle laterally, and the acetabula are j)ressed inward upon the pelvic canal. Wh«>n at length the bone disease has riui its course the pelvis is firndy set, by the hardening of the bones, in its unnatural position and shape. The dilfcrential diagnosis between this ju'lvis and the true osteomalacic ])elvis is made by the direction of the iliac crests, by the tb'in constitution of the boi.cs after the disease has been arrested, and by the signs ol' rachitis in other portions of the body. Osteomalacia, besides, has certain peculiarities of its own that enable one to recognize it without ditlieulty (IM, :M, Fig^. 5, (J, 7; Pi. ;52, Fig. 1). Diaf/uosiK. — The diagnosis of a rachitic ])elvis is made by external and internal measurements, by ])alpation of the exterior and interic. of the pelvis, by the woman's history, and by her appearance. An individual who has had t the shape ninsck's df rachitis hv I hUtor arc iileuod and ^4). Tiic the cxccss- i rehitivcly is is tihcd I'l'ior strait irittle tiiaii or in rare )c — is seen early liic, e inh't and ressure of s eonrse to Possihly short time. transverse ade by tlie •ly infancy 'the body. 1 cliaracter isease was iggeratcd lire of tiie nds to an far down Dwnward ; ihnhi are sease has les, in its lis pelvis ei'csts, by I, and by sides, has ilifliciilty I'lial and lie pelvis, has had DYSTOCIA. Pi .n: 32. e. V. lioni 1st mill tiiiiii 4 2il mil', vi'i't. Ill rm. Ti-, IJi iiii. 1. I'si'udii-iislCdinnliiciii. 'J. Kiicliilii' lu'lvis with I'nntriicti'il liiiti'i-ii-iiostcfionliiiiiiilii' llniiiiu'liiiiil llic |n'l- vie I'll Mill I M lit If r MllM'Mlll. Cnllri^r of l'll\siriillis, l'llil;|i|i'l|illill '. "., I'rilcllllnll- lirl 1) nl' lilillil h , ( 'h.-i T'lu'M- lirll. 1, Uiirliilir Iu'lvi^ with il.Mililr |ironiniiiiiry i Mullrr Miim'Uiu. i 'nil rL:r .■!' I'li> -iii.iii^ ■. :•.>'' Miii 'i' miiilrs uf usll'iUMUllU'il' Iil'lvrs. 7. 0.-|i'"lllu!lli'ill, ^Imw ilii; , »\ linin;lriri,l rMllU'ilrlinll Ml .illlirt / DYSTOCIA. 525 rachitis in childhood '.?, usually of ^niall stature, with short, thick, curved extremities, a low broad brow, a large square head, a flat nose, a "chicken breast,' and enlarged joints. The lumbar lordosis and the rotation of the sicruni produce a sway-back, most noticeable when the woman lies on her back upon a hard surface. When she stands erect the pregnant uterus near term falls abnormally forward and downward, on account of the short abdo- men and lack of engagement of the presenting \vAvt (PI. 32, Fig. .i). riie most characteristic facts in her history arc that she walked first at three or four vcars of age and was late in getting her teeth. By the pelvimeter the normal relation between the iliac spines and crests is found disturbed. Tlie ditfcrcnce in distances between the former and between tlie latter is much reduced. The posterior superior spinous pmcesses arc apprdxiiiKUcd, and the Kk;. :Ui; — Afipcnr.'iiiii' iliiriiv.: liO' of tli(> liicrh- Fn;. :U7. -'^K-i'lrtnn nf m rncliitic duinr M.iliriil csl ;;r.iili' nl" ^ll(■llili^; iiscUiln(i>liiiiiiiiliiriii (I'il'- Milsiinii, 1 ni\ri>iiy nf IViiii^\ l\ aiii;n. |piii^>h jiilili. depression luider the last spinous process of the lumbar V('rtel)ra approaches or is actually in the line drawn between them. The external antcro-posterior diameter of Baudelocque is below the normal. Internally, the diagonal con- jugate is found considerably reduced. The symphysis has less of a slant out- ward than it should have, the promontory is found low an^i prominent, tli(( sacral bone is sharply bent upon itself, and the pelvic canal is remarkably shallow. On account of the increase in the conjugate-syinphyseal angle due to the lessened slant outward of the symphysis, at least 2 centimeters should be subtracted from the diagonal conjugate. The difference between the two would be greater were it not for tlie low situation of the j)romontory, which compensates to a certain extent for the lessened slant of the symphysis, but does not entirely neutrali/.e it. A double promontory in these pelves is not F»>»i ►! J6 ^^f^ 1 Si V J?: : r ■' :?i'S f'^i 526 ylJ/^72/C^l.A^ TEXT-BOOK OF OBSTETRICS. uncommon (PI. 32, Figs. 2, 4). If found, the mtasurement should be taken from the promontory nearest the symphysis. Occasionally the lordosis of the lum- bar vertebra;, the result of spinal rachitis, is so great as to constitute itself an obstruction above the pelvic inlet. In such a case the effective conjugate must be taken from a j)oint above the sacrum to the symphysispubis(Pl. 30, Fig. 8). Injiuence on Labor. — The influence on labor of a flat rachitic pelvis is mudi the same as the influence of a simple flat pelvis, except that the contraction, and consequently the obstruction to labor, is greater in the rachitic form, and that the promontory of the sacrum is more prominent and more '^barplv defined. The anomalies of mechanism at the inlet are the same in both forms of pelvis, but they are exaggerated in the flat rachitic pelvis. As soon as the obstruction at the inlet is overcome the descent of the head and its esca]ie is more rapid in the raciiitic pelvis, because of the shallow canal and the expanded Fiii. 318.— I'ressuru of tliu iiruinoutory \ipon the hcftJ in a contniotod pelvis (Sraellic). outlet. Injuries to the child's head and to tlie maternal tissues from pressure are common. In the former a sharp indentation may be seen on that portion pressed against the promontory in tlie efforts to secure engagement (the so- called " sjxKJU-shaped " depression, witli fracture of the parietal bone; Figs. 314, 318, 3I9j. lA)cali/ed Jiecroses are not infrequently seen in the mater- nal structures where they have been nipped between the child's head and prominent portions of the ])elvic bones — namely, in the cervical tissues over the j)romontory, or very rarely in the ])osterior vaginal vatdt, and in the ante- rior vaginal wall behind the symphysis and the ridge of the piibie bones. AA'hen the slough sej)arates openings may be established between the birtii- canal and the peritoneal cavity, the bowel, the bladder, and a uretcir. Osteomalacic Pelvis. — Osteomalacia, a soft condition i>f tlie bones in consequence of an osteomyelitis and an osteitis, is exceedingly rare in DYSTOCIA. o27 America. There are certain jiarts of the world where it is frequently seen, notably Italy, Germany, ami Austria, but in America there are but three !)!■ i'oiir examples on record. The bones of the pelvis in this disease become ,~() soft that they yield to every force imposed upon them. They bend before llio pressure of the trunk from above, tlu; extremities from below, and the |)iill of the muscles attached to the pelvic bones. The flexibility of the pi'lvis in extreme cases of osteomalacia can bo appreciated when it is stated that the superior iliac spines may be bent backward until they touch the spinal column; the horizontal rami of the pubis maybe jjushcd inward imtil they almost obliterate the pelvic inlet ; and the tuberosities of the ischium mav be approximated until they nearly close the pelvic outlet. Xot only are the pelvic walls so compressed that they almost obliterate the pelvic canal, but tlu> spinal column also, sinking under the weight of the trunk, bends liir forward ih I'lu. 319.— Ovfrlapping of the criiiiiul bDiios in a futile attempt to engage in the superior strait of a rachitie pelvis (Smellie). and descends low into the pelvis, occupying the little remaining room in the inlet and canal, and becoming itself a serious obstruction to the engagement of the i)resenting part. From the lateral pressure of the thigh-bones the ischia and ])iibcs are pushed inward and backward, making by the former movement a sharp beak-like projection of the pelvic inlet between the jjubic rami, and by the latter much diminishing the s-ize of the pelvic canal (PI. 32, Figs. 5, (i, 7). Tile sacrum is rotated on its transverse axis and is driven low into the pidvic canal — an exaggeration of the nioveinont seen in a rachitic pelvis. The lower portion of the sacrum and the coccyx are pulled sharply forward by the mus- cles attached to them, so that the sacrum is bent at a sharp angle in its lower third. The innominate boucs are bent laterally at a jioint slightly anterior to the sacro-iliac junction, and the iliac bones may be folded upon themselves horizontally. The inclination of the pelvis as a whole is much increased. t ,i •i-^: !; r m \ AMi:ni<'A\ TEXT- nook' or oustktrics. The (luifpi()Ni.s may Itc based ii|)(iii tlir flillnw inu- symj)tuiiis : Tlic (IImmt bc'jrins usually (liirini"' prcoiiaMcy or l:icl;iti<.ii. w itii dull ai'liiii;: pain- in ii„. extroniitics, tlii' back, (he li!uil>ar rcuion, and over tlic ante rinr iidrtiiai nf il,,. jK'lvis, Every umveineMt incica-cs iIksc pains. As ijic di>ea>e pi'(ii;if>., . the bones of the spinal eolunin are -o iicnt and eoni|nvs<ed thai llie Individn,, is dinnni-licil in >talnre to an exiraordinarv decree. She nia\ lo>e a> nnicji ,i~ Fli.. HJiJ.— ll:i>l .s (use nl' u^icdiimliiciii ilmiit iiinl prnlilo vii^ws in (lill'trfiil |>i'rs|icctivc!. ;. I and a half in hci<iht (Fig. 320). The gait of an osteomalacic patient i.> il: u". In order to compensate for the approximation of the thighs brought aUoUi i)y t'.ie collapso of the ]>elvis the imhvidual nuist turn almost through a half circle in order to bring one foot in front of the other. Upon examination of the pelvis tenderness upon presiiure is discovered over its anterior wall. The flexibility of the pelvic bones may bo denutustrateii by direct pros.sure, antl an DYSTOCIA. Pl,ATK 33. I- ill li, II III' III. I'dLlI'"'-- iili\li|i| lllllcli :i- iclll |> •dlliillt illli'll :i Cltioll TIlc tul nil 1. ExoRtosi's nt tho sacro-iliai' juiictliiiis. 'J. KiiDblikf oxnstosis on the promontory (SohiuitiO. 3. Ai'nn- tlicipi'lys. t. Kiichitic jii'lvis with "Imormiil bill hhiiit proji'i I'i'lion of iU'ii-pi'i'tincal riiiliicin'cs iMiittcr Mu- lliii'linriilnniiii Ot<'hnn. il. Knictuii' nl' tlic ju'lvis (Otto). 7. iri' of tlii^ acotabuhi in coiisoiiik'Iku of coxalnia (Ottoi. S. Fracture of tlie ri(,'ht ahi of the sacrum (Kritscli). '0 m scum, Cnllou'c of rhysiciuiis, I'liiliic '.oliii Kractu DYSTOCIA. o2{) internal oxaminatioii discovers in the early stage of the disease the peculiar licak-like space behind the symphysis, and later the almost entire obliteration of the pelvic outlet and canal by the sinking in of the pelvic walls. Jf it is possible to make a satistiictory internal examination of the pelvis, the low po-ition and tiie projection of the promontory at once attract attention, and tlie sharp angulation on the anterior face of the sacrnm can be felt. On account of the exaggerated inclination of the pelvis it may be necessary to iriakc an examination with the patient upon her side. An osteomalacic pelvis lias been taken for a kyphotic, a Robert, a pseudo-osteomalacic, a cancerous, or a fractured pelvis, but a careful, methodical examination of the patient will always lead to a correct diagnosis. liiffuciice upon Labor. — The results of labor in osteomalacic pelves show ;H. I' irt m\ fC- ''X\i-\y I'm. oL'l.— Cystic enchondrnma (Zweifel). Fi(i. S22.— Button-like exnstdsis on tho promontory (Sphiiuta). that the obstruction is a serious one in spite of the flexibility of the pelvic liones, by rcascm of which flexibility in some cases the head can distend the pelvic canal sufliciently to pass through. In 80 cases collected by Lit/maun forty-seven ended fatally. In another series of 128 cases the labor had a spontaneous termination in twenty-seven cases, in four there was premature delivery, and in five abortion ; four times the labor was naturally terminated ; ill eight cases version was ])erformed, in four the child was extracted by the feet, in twenty-five forceps was employed, in eleven craniotomy was performed, and in thirty-six Cesarean section ; rupttu'e of the uterus occurred in five women before any operation was undertaken. In still another series of cases reported from ^lilan the flexibility of the pelvis was so great that the child was delivered in only two instances by Cesarean section. The most successful 530 AMElilVAX TEXT-BOOK OF OJiSTETRIVS. Flo. ;>j;!.— Exostosis on the symphysis (Sclmutn). treatment in modern times fur this obstriietion in labor ninst be the perlbrin- ance of Cesarean seetion, and the oi)erat<)r should at the same time remove the ovaries, or, what is better, do a eoniplete Porro operation. It is bewjnd dispute that tlie eessation of sexual funetions favorably modifies or aetuallv cures the tliscase. Tumors of the Pelvis. — The commonest ])elvie tumors are bony excros- cences, usually Ibund over one of the pelvic joints. The excrescences are oriji- inally cartilaj^inous projections which become ossified by an extension of bonv tissue from the two bones between wliich they lie. These exostoses mav be found over the saero-iliac joints, over the symphysis pubis, and over the prom- ontory of the sacrum (Figs. 322, 32."i ; ri.33,Fijrs.l,2). They may reach t lie size of a pigeon's egg, though they aic nstially not larger than a pea or a nut. In the exostoses occupying the seat of the pubo-iliac junction, <lirectly above the acetabula, the bony growth is iipt to assume a sharp, thorny shaj)e, i)ro- jecting with its point into the pelvic inlet. Kilian was the first to direct attention to this fact; he called a pelvis thus deformed ^' acanthopcli/s" {V\. .'>3, Fig. 3), or a "yWm npinom." Another possible seat for a bony projec- tion is along the crests of the pubic bones, the exostosis taking here the form of a long, sharji edge, and j)robal)ly owing its origin to an ossification of the attachment of the iliac fascia, a transformation of tissue analogous to the ossi- fication sometimes seen in (Jimijernat's ligament. These bony outgrowths con- stitute a serious form of obstruction in labor, not so nuich fron; their encroach- ment uj)on the room of the pelvic inlet as from the sharply-locali/od pressure which they exercise ujiou the maternal structures and upon the fetal head. In the four cases repcjrted by Kilian, death, it was claimed, resulted in each case from a i)erforate(l uterus. Other tumors of the pelvis offering an obstruction in labor are enchondromata, fibromata, sarcomata, carcinomata, and cysts (Fig. 321 ; PI. 33, Fig. 5). These tumors are rare, and their importance as an obstacle in labor depends, of course, upon their size. Cysts of the ju'lvis are formed usually in sarcomata and in enchondromata, or are hydatid cysts. Cancer of the pelvic bones is always a secondary growth or is metastatic. It may result in a number of small tumors in the bony pelvic walls, or may take on the form of cancerous infiltration with a consequent softening of the bones like that of osteomalacia. The treatment of labor obstructed by tumors of the pelvis is ordinarily the performance of Cesarean section. There is one case on record (Abernethy's) in which the tumor, an enchondroma, was removed by an incis- ion in the j)osterior vaginal wall, but in the vast majority of cases these growths cannot be reached or cannot safely be excised. In 49 cases of labor obstructed by a pelvic tumor 50 per cent, of the women and 90 per cent, of the children lost their lives (Winckel). DYSTOCIA. r>;n Fractures of the Pelvis. — Out of 13,200 fniotiircs roportcd from nine lar.ii;e hospitals in America and in Kuropo, but 0.8 of one por cent, were i'racttn'os of the pelvis. When one considers that almost all grave injuries of tlie pelvis end fatally, the rarity of a pelvic deformity dependent upon a united fracture of a pelvic bone in a woman of childi)earin<i: age may be appreoiatctl. Most frcfjuently the fracture is found in the pubes, next in the ilium, next in the ischium, next in the acetabulum, and least frequently (if all in the sacriun. The effect of a fracture of the pelvis upon the shape anil size of its canal depends on the situation of the fracture, and may be due to distortion of the pelvic walls, ti> excessive callus-formation, or to ossification of the pelvic joints near- est the seat of fracture. In a fracture of the acetabulum the result of hip- joint disease the head of the fenuu" may project into the pelvic canal (PI. .'{;}, Fig. 7). Fracture of the pubes results in an irregular distortion of the pelvic inlet, most marked, of course, on the injured side (PI. 33, Fig. 6). A fracture of the upper portion of the sacrum mav residt in Fk;. ;i24.-Trnn8Vfrsi' fracture nC thf sacrum with ,,,.,. 1 ,. * . /T-i. .siioiidylolisthctic (lefiiruiitv iNcUKcbaiRT). a spondylolistlietic deiormity (r ig. 324). Fracture of the lower portion of the sacrinn is followed by a dislo- cation of the lower fragment inward. In a case seen by the writer the lower half of the sacral bone was turned in at right angles to the rest of the bone by the pull of the pelvic muscles attached to it. A fracture of the sacral aKT may cause an oblique contraction of the jielvic inlet like that of the Xaegele pelvis Pi. 33, Fig. 8). Neugebauer" reported an extraordinary case of bilateral fracture of the pubic rami in which there was union with callus-formation on one side and an ununited fracture on the other, the fragments moving on one another 2 or 3 centimeters when the woman walked. Caries and Necrosis. — The only effect of this disease of the pelvic bones is the production, in rare cases of tid)erculosis of a sacro-iliac joint, of an oblique contraction of the jielvis. When the sacro-iliac joint is affected the idtimate result is the same as that produced by imperfect development of the sacral ala^ in a true Xaegele pelvis. There is loss of tissue, ankylosis of the joint, and an arrest of development in the affected part if the disease occurs in early childhood. Ankylosis and Relaxation of the Pelvic Joints. — Synostosis may develop iu any of the pelvic joints ; in the symphysis it occurs not infrequently, and often at an early age. A number of operators have encountered this dif- mf r 'J' • f 1 f I ih:\ ^. I I: m> 1.^1 r-ii i}:\'2 AMEJtICAX TKXT-liOOK OF OliSTKTIilCS. ficiilty in jittriiipts rcci'iitly to jx'rform symphysiotomy. In otliiTwisc iiiuili- stnictcd labor synostosis of the piil)ic symphysis is not a serious comlitioi*, aUhoiijfh it limits the slij^lit c'xpan>ion wliioli every nurmul j)elvis .shoiiUI exhihit preparatory to and ihn'iiifjf labor. If synostosis of the saero-iliac joint deveh)ps in tlie individual's early ehildhood, it is followed by ill development of the sacral alio on the alTeelcd side, and of that portion of the imiominate bone eoneerned in the formation of the joint, an oblicpiely-eontraeted ju'lvis of the Xae<;ele type beiiiir the result; but suHi eases are rarer than those in which lack of development in the sacral alie is the primary oeeurrence. If the synostosis of the joint occius after puberty, the etfect upon the pelvis and upon the eoiu'se of labor is prae- ticallv nil. If both joints are early ankvlosed, a form of laterallv-contractcd pelvis like the Robert pelvis is the result. This kinii of contracted pelvis is rarer than the transversely-contracted pelvis due primarily to lack of develop- ment in the sacral ala>. The sacro-coccvjieal joint becomes ankvlosed, as a rule, between the thir- tieth and fortieth years, but as the joint between the first and second coccyfr(!al vertebra; is ordinarily nnatlected, the pelvic outlet is capable of expansion dnrin<f labor in its antero-posterior diameter nearly as well as if the sacro- coccygeal joint were normal. Karely there is an ankylosis of all the coccyfieal joints along with that between the sacrum and the coccyx. In these cases labor can be terminated only by a fracture of the coccyx or a laceration of the pacro-coeeygeal joint. The expulsive forces of labor may be sntticient to cause this fracture, and the bone has been heard to give way with a loud crack as the head was passing through the pelvic outlet. This accident, however, is more likely to be caused by the artificial extraction of the head. An abnormal relaxation of the pelvic joints may be a simple exaggeration of that natural ])rocess by which the pelvic canal is made somewhat expansil)!e pre]>aratorv to labor. It is more likely, however, to be due to some patho- logical condition within the ])elvic joints, as an inflammatory process follow(Hl, perhaps, by suppuration, the eollecticm of fluid witli'n the joint, osteomalacia, caries, or new growths. In pregnancy the patl;oloi:;eal relaxation of the ])elvic joints may occasion some difficulty in locomiilion. During labor an exaggerated relaxation of the joints predisposes to their rupture. The Spondylolisthetic Pelvis. — The spondylolisthetic pelvis was first described in 1839 by Kokitansky, who reported two cases; Kiwisch and Kilian followed with a description each of a specimen ; bnt we owe our knowledge of the condition mainly to the indefatigable researches of Neu- gebauer, '- who collected more than ninety cases and specimens, and to the discoveries of Lane, who has done much to clear up the etiology. The name "spondylolisthesis" * indicates the condition — a slipping down or dislocation of the vertebrje. To affect the ])elvis the spondylolisthesis must be in the luni bo-sacral region (Figs. 325-327). Charactcristir.^ — As the name denotes, there is a dislocation of the last * a-6v(h'?.nCj vertebra, and uXiafii/air^ a slipiiing out or down. DYSTOCIA. Mil liuiibur vortclini ir. front of tlio siuu'iiin, the body of the formor sli|)|)in^ down ill front of the first .sacral vertebra, so that its inferior border, or in advanecil eases its anterior surface, comes in contact with tlie anterior fiice of tiie sacrnni, to which it becomes united by bony union, Tlicre is also, of necessity, an cxairirerated lordosis of the lumbar vertel)ra and a descent into the nclvic inlet of at least the fourth and third, and even of the second, lumbar vertebra*, which diminish by their bulk and anterior projection the antero-posterior diameter of the pelvic canal. Ft is only the body of the last Inniliar ver- tebra that is displaced, and not the arch, held fast by the lower posterior articular surfaces, nor the lamime surrounding; the spinal cord, so that the latter does not necessarily suffer compression by the displacement of the ver- tebra, although this result has been noted in a few cases (Fig. 320). To allow the displacement of tlu! body of the last linnbar vertebra the inter- Kk!. "Jti,— Spondylolisthesis, beginning (Schautn). Flu. :'.'J7.— Last Inmhnr viTti'hni of sjioiKlylo- listlu'sis Ml) ciiiitriisttil with a normal ti.th lum- l''i(i. :i'23.— Spondylolistlu'sis, woll markoil (Scliauta). , bar viTti'bra iNcug.baut'r). articular segment of the spinal arch and the jwdieles are enormously lengthened from behind forward and are bent at an angle ilownward (Fig. .'527). After a time this segment may exhibit a transverse fracture or a solution of continuity from i)ressnre and attrition. The deformity is always gradual in development. If it develops during the childbearing period, successive labors become increasingly difficult. As the vertebra descends it pushes the sacrnin backward and downward, and with it depresses the pos- terior portion of the jjclvie brim. To compensate for this movement the anterior half of the pelvic brim rises and the height of the symphysis is increased. This movement of the pelvis diminishes very markedly its inclina- ■.¥ ;.4 V- i r4iiJ m ,»■>, ff,< •'n' B*: ^k' ;'> ■ f 1"^ ^ ^ 'X' i^ ■ "* ■ ti^j ' '■*■ :•<■ ■;i. j;.;-f i.: ' Mi '• 'I'l Hi"* ' r 1 f " h ryM AMERICAN TEXT-BOOK OF OBSTETRICS. tion, and disturbs tlie normal relationship between the bones and the soft structures tliat overlie them. The base of the triangle formed by the jiubic hair in women is well below the upper edge of the symphysis, and the exter- nal s'enitalia are so pulled forward that the vulvar orifice is directed anteriorlv as the patient sits or stands. There are, moreover, the same displacements of the pelvic bones that are seen in kyphosis — a rotation backward of the sacrum on its transverse axis, and a rotation outward of the upper portions, and inward of the lower portions, of the innominate bones on their antero-pos- Fi(i. 328.— Wini'lii'l's lase of spondylolisthesis of modornte degroe. terior axes. The descent of the lumbar vertebra) drags the large arteries of the lower trunk into the pelvic iidet, so that the iliac vessels and the bifurca- tion of the aorta can be felt in the vaginal examination. The degree of con- traction in the conjugate diameter of the iidet depends upon the descent of the last lumbar vertebra and the degree of the lordosis. The contraction is usually not excessive, but it may be so great as to preclude the possibility of the engage- ment of the fetal head. Miolof/u. — The etiology of spondylolisthesis at the lurubo-sacral junction is still involved in considerable obscurity. It has been attributed to ilireet injuries of, and to faults of development or ossification in, the interarticular segments of the spinal arch. It is certain that these are predisposing causes, but the observations of Lane appear to demonstrate that the commonest cause of this deformity is an exaggerated pressure from the truidv above exerted often upon healthy bone. As the result of this pressure a joint is formed in the intervertebral ilisk, and the interarticular segments of the last lumbar DYSTOCIA. 535 tU..J VPi't'bra undergo stretching, pressure, angulation, and atrophy until the hone is actually severed. Following or accompanying these changes in the arch, the body of the last lumbar vertebra is displaced farther and farther down- >\ard and forward. Dkujnosis. — The di:»gnosis of a spondylolisthetic pelvis is not easy, and can be made only by close attention to the patient's history, by u careful observation of her appearance, by an internal and external examination of the pelvis, and by pelvimetry. In the history of the case it may appear that the individual was the subject of a serious accident, such as a fall from a lioight or a fracture of the pelvis by the passage over it of a heavy weight, or it may be learned that she has carried excessively heavy burdens for a long time. The woman's height is diminished and the length of the abdomen is short- ened. Viewing the patient from behind, there appears what is called the sad- dle-shaped or "sway " back, the lumbar vertebne projecting visibly far forward Fl<;. 3'J9.— Ahlfi'Ul's ciiso i)f spdiidylnlistlK'sis. l"l(i. 3oO.— Broisky's case of spondylolisthesis. and being displacetl downward, throwing into bold ^'elief the posterior superior spinous processes and the rims of the iliac bones, ai.d producing quite a dee]> furrow along the course of the spinous processes of the lumbar vertebrje. The apposed articular proce> <es of the first sacral and the last lumbar vertebraj stand out as button-shaped prominences on the inner surface of the posterior rims of the ilia. The buttocks are flat and are pointed bel.)W, giving to the region a cordiform appearance. Tn front there is a pendti.ouj belly ; a deep crease is observed running across the lower abdomen a 'u rl distance above tlie symphysis. Ijaterally, the floating ribs are seen alii'ost to rest upon the ci'ests of the ilia or actually to siidc between them, and th( soft structures of the flanks are thrown outward in prominent fold;, '''''•e trunk is shortened, and the limbs appear relatively too long (Fiijjs. .'L'*^- oGO). The patient's body bcinji; thrown forward bv the def'ormitv (if the sr.ini', an elfort to maintain an equilibrium is nuide by carrying the sh(>ulders fai back; as the individual walks 'I.- ^! imp- , nil. • A\ / i . \ jflt J J 11'' \ "i ft i v. M: i^^ms^:% i : I M I r,:]U A.}n'JIi'I('AX TEXT-BOOK OF OJiSTL'Th'ICS. a disposition to fall forward may !)o noted, and showill state |)erliaj)s that slic i- nnable to earry any load npon her arms in front of her hody, for fear of to])pliiit; over upon her face. She may also complain ot' a <i:ratint;; sensation and somikI in the small of the back (erepitns). The j>ait is |)ecnliar; the toes are nm tnrned ontward, and the feet are swnnjj aronnd one another so that the foot- ])rints fall in a straij^ht line. Upon an internal examination of the pelvis — best condneted, aeeordinj; to Ncnu'chaner, in an nprijfht or lateral position — the lordosis of the Inmhar vertebra* is at once discovered. The an<>;le formed bv the attacliment of the last hnubar vertebra to the saernm may be detected with ease, and it is noted that the body of this vertebra does not possess lateral ])roj<'etions, transverse processes, or ahv. J{y their absence one i> snre that he is not feelinj^ a projectin<j; i»roinontorv. J'nlsatinji: iliac arteries can ))(' felt, and it is ])ossible even to reach the bifin'cation of the aorta — a symptom first j)ointed ont by Olshansen. l?nt the symptom is not pathoiino- monic. The same sign is exhibited in the extreme lordosis of some' rachitic jM'lves and of the osteomalacic pelvis, also in himbo-sacral kyphosis and in some cases of dorso-hunbar kypiiosis. The external })aIpation of the pelvis reveals its decreased inclination. A measurement of the pelvis will show a marked diminntion in the external conjugate diameter, an increased height in tiie symj)hysis pubis, an increased ilistancft between the posterior superior iliac spines, and a diminished distance between the anterior iliac spines and the crests. There is also some diminu- tion ill the diameters of tli(> outlit. The internal conjngat*' diameter must be measured I'rom the lumbar vertebra nearest the symphysis pubis — usually the fourth. This is called the " false" or "elTcctive" coii)ugate diameter of the spondylolisthetic! pelvis. On account of the decreased inclination of tiic pelvis it is not necessary to subtract more than the ordinary sum from the diagonal conjugate. In liict, tlu; diagonal conjugate may approach very neaily the length of tli(> true, or may actually measure less than it. Jiijfitcticc iijxiii Ij(l)t)i\ — The iulliience of a spondylolisthetic pelvis upon lal)or is that of a fiat pelvis. The obstruction in the former may be over<'(iine iuor(> easily mi account of the l)ow-Iike shape of the projecting vertebra and tiie coincidence of the uterine and ]»elvic axes. The obstruction to labor depends entirely upon the ]>rojectiou of the liuubar vertebra". This projec- tion may be so slight as scarcely to intluence the progress at all, or it may be so great as to make delivery by the natural channel (piite im])ossible. There is noticed in labor something of the same mechanism that is seen in the flat pelvis llir the purpose of overcoming the obstruction — namely, deerea.-ed flexion, transverse position, and exaggerated lateral inclination of the head. < )n account of the forward dislocation of the external genitalia aiul of the jM'Ivic floor, lacerations of the latter are the rule, and the tears arc often com- plete into the r(>ctum. This liability to injury is explained by the fact that the presenting ])art impinges directly upon the middle of the pelvic floor as it <lescends the l)irtli-canal. instead of being directed forward to the vnlv."r orifice. Fistuhe of the anti'rior vaginal \all are likewise eoiiimon, fV"M tli r)YST()('IA. Pl.ATF. ^4. 1. ("niitri\rti'i\ uiitU't of ii kypliotic iiclvis (HiirlHnin. J, Kyplintlc luMvis I'rniu iilmvc i Hiirliiiiiri. ;!, I. I.iiniliiisiicral kyplidsis iprlvis (ililectiii. ■<. AsyiiiiiU'ti'ii'iil (.•inilriirtii'ii "f ilu' nulht Irciin ky|iliosi(.linsis. tl-N. 'I'yiH's iif scnlliitic nicliitii' pflvi's. .*?/ ••» }pm. ■]< ii h.f ■ '-' '■. ■ * , " / y^^.d\ rA ii. ( ' . { A V0 n ft iK f ■ J •■ 1 •! • i J t . 1 1 H 1 DYSTOCIA. 537 localized pressure to which this region is subjected while the head is passing the obstruction at the inlet. The presenting part is thrown forward by the ])rojccting vertebne, and is received upon the prominent ridge of the pubic l»(tne, greater in height an<l higiier in situation than in the normal pelvis. Tiratmcnt of Labor Ohdrui-fcd by SjtoniIi//o/iiitli<'fii' Pclris. — The maiiage- meiit of hibor in these cases is governed by the same principles that obtain in the management of labor in a fiat pelvis. If the effective conjugate is over 9.5 centimeters, the woman can be deliv- ered spontaneously, by forceps, or by version. With an effective conjugate of between 7 and 9.5 continieters the induction of premature labor and the performance of sym- ])livsiotomy must be considered ; or craniotomy should be (lone if the child is dead. If the effective conjugate is well under 7 centimeters, delivery must be effect'd by a Cesarean section. These rules presuppose, of course, a child of average size. Kyphosis. — The ky|>hotic pelvis was first adequately described in 18G5 by Breisky, although its ju'culiarities had been recognized before by [jitzmann iri 1861 and by Neugebauer in 1863. The condition was called by Herr- gott " s]iondyl-izema," a name adopted by Neugebauer and others (Fig. 331 ; PI. 34, Figs. 1, 2). Characteristics. — The degree of deformity in a kyphotic j)('lvis depends upon the situatiim of the hump: the nearer this is to the sacrum, as a ru\o, the greater is the deformity in the pelvis. Ordinarily the kyphosis will be near the (lorso-luiid)ar junction. There is a compensating lordosis of the lumbar spine, but not enough to' keep the centre of gravity of the tnnik from being too far forward. In con- s('(pience the weight of the trunk is transmitted in a direc- tion from before backward, so that the sacrum is rotated on its transverse axis in a direction the reverse of that seen in rachitis — namely, backward and downward. The result of this movement is to Uiake the sacrum straighter, narrower, more curved from side to side, and longer (1*1. 34, Fig. 2), to jndl the posterior superior spinous processes of the iliac bones closer togetlu^r, and to separate the anterior spines more wide' The diminished width l)etween the posterior superior spinous ])rocesses is caused partly by the pull of the sacro-iliac; ligaments. The sacrum cannot move in any directi(m without dragging the ilium on each side by these ligaments, thus approximating their up])er pitsterior surface's. It depends also upon the narrowness of the sacrum. To compensate for the movenuMit of the upj)er portion of the sacrum backward, the lower portion of the bone |)rojects forward into the pelvic outlet. To preserve the bo«ly from falling forward, the knees and thighs are slightly flexed and tiie pelvic inclination is almost entirely lost. This posture puts on a stretch the ilio-femoral liga- K|(i. :i;il.— Kypliosis; (iri'iiti'st tniiisviTsc di- aiiU'tiT lit outli't, 7 cm. (MiittiT Museum, <'iil- Iffrc of I'hysicimis, I'liiliiili'lpliiiil. I I ! iKr. ■ 'I ; t '■" i' ■ '):}>< AMERICAN TEXT-BOOK OE OBSTETRICS. iiK'nt.-', whicli pull oiitwanl the upper portions of the innominate bones. To for.iponsate for the movement outward of the iliae bones, the lower segments of the innominate bones move iin -ard upon the pelvic inlet ; in other words, /i'/d/ /wad Spini' (*/ Isc/nttm. hchiutit . Kiii. ;a2.— Uiiiil iir"''stf(l tiy spiius nf iscliia in a kyphotic \iv\\ s (Hurtiii). there is a rotation of the innominate bones upon their iiLtero-jiosterior axes. The result of these movements in the pelvic bones is to enlarge somewhat the pelvic inlet, espeer.ily in its antero-posterior diameter, but to contract the h\tal I'u'iii/. Intersfthwus liiantt'lt-y- ■-^ ^-' Fiii. :i;;;!.— ViTtlcHl soction rif kyiihotio ja'lvis, slidwiiin \\w licaii nrrcstod liy the pjiini's (if tlic iscliia (Itiiilin). canal toward the outlet, where the diminution of the diameters is most marked, especijdly in the transverse (I'l. 34, Fig. 1). In the rare cases of lumbo-sacral kyphosis the upper portion of the sacral bone may be involved in the necrotic process, and the sacrum may exhibit deformities by destruction of its tissues (PI. 34, Figs. 3, 4). The other cha- racteristic deformities of the kyphotic ])elvis are most marked in this type, unless, as in one instance, the boily is bent almost double, and it is necessary ■ 11 . I u ones. Tu r sogiuciits lier words, terior axes, newliat the [)iitract the if the isrliia :'S is incst the sacral lay exhibit other eha- this type, ^ necessarv DYSTOCIA. I'l.ATK 3"). 1. I.uxiitioii 111" rijjlit ('(■iimr. 2. ('miixfiiitiil liixiilinn nt' Imih I'finuru. H. l-uxatiim i if left ffiiuir mi ddr- sum iif iliiiui, with liilsc joint iilmvi' iicrliilnihim. I. ('niiticiiiliil hixiilimi nf hdth Irnioni tiihiitii^'niph nf UKiiU'll. .'). t'dXiilKii' pi'lvis I Miltlcr Miisnim, t'ollocf "'' l'lijsiciiin>. riiiliuli'lpliiii). li. Aiiti'iidi- ili>lo(iiti(m nf fi'innr. 7. Coiigoiiitiil dislociitioii of the fciuurii. S. IVlvic ilcl'oniiity, Iho r'jsult uf ilouhk' I'Uib-tout (Mi'.viT). ft*- I ^ !, 'rX ^ w ; ■ i ; w'' ' i! ffijji; '\ sii \ ; J ii] w. ah, ■ ■:! J'il'ii J'S!): tJ!'!J' Si -1;J DYSTOCIA. ;■):«» to rest the anterior portion npon an artificial snpport, as a cane. In this case tiie pelvis, althongh relieved of the weight of the trunk, is obstructed by the overhanging Inrnbar vertebraj to such a degree perhaj>s that the inlet is practi- cally obliterated (pelvis obtecta). In all cases except the slightest of lurabo- .^acral kyphosis the projecting lumbar spine blocks the pelvic inlet and seriously obstructs labor. In 21 labors complicated by this deformity of the j)elvis (JG per cent, of the mothers and 75 per cent, of the children were lost (Winckel). Influence on Labor.— TXw influence of the kyphotic pelvis upon labor is usually not felt until tiio presenting part has descended to tiie pelvic floor. In consequence of the shortened perpendicular diameter of the abdominal cavity there is a tenilency always to transverse position of the fetus in utero, but this position is ordinarily corrected by the first few labor-pains. When the head arrives at the pelvic floor, if the occiput is directed backward, anterior rotation will very likely be prevented and there v.'ill be a persistent posterior position. If the occiput is directed anteriorly, the transverse diameter of the head may be caught between the approximated tul)erosities of the ischiac bones, and labor be brought to an indefinite standstill (Figs. 332, 333). Occasionally spontaneous delivery is possible on account of the extreme mobility of the pel- vic joints in the kyphotic pelvis; in any case, as the progreas of the head is retarded only when it reaches the pelvic ontlet, the labor ordinarily is easily managed. The application of forceps may be sufficient to overcome the obstruc- tion, but if it is not, a symphysiotomy will pretty surely do so unless the con- traction is extreme or asymmetrical. Should the child be dead, craniotomy is readily performed with the head so accessible as it is on the pelvic floor. DiagtiOKiii. — The diagnosis of a kyphotic pelvis presents no difficulties. The hump-back is obvious, and the history is easily obtained that the spinal deformity was developed early in life. The pelvic measurements diagnostic of this deformity show an increased separation of the iliac crests and the ante- rior spines, a diminished distance between the posterior superior spines, an approximation of the tuberosities of the ischiac bones, and some diminution in the antero-posterior diameter of the pelvic outlet. Care should always be exercised to detect asymmetry in these pelves, to discover an arrested develop- ment with general contraction, and to diagnosticate lateral contraction at the pelvic inlet. These complicating deformities constitute often insuperable obstacles in labor. Frequency. — The kyphotic pelvis is said to be somewhat infrequent, but the practitioner in active practice will surely encounter several examj)les in the course of his career. The writer has had under his care four well-marked cases of kyphotic pelvis, in one of which Cesarean section was necessary. In the other three delivery was spontaneous. Scoliosis. — In the scoliotic pelvis there is some degree of oblique contrac- tion. The innominate bone toward which the lumbar vertebra arc bent, receiving the greater part of the weight of the trnnk, is pushed upward, inward, and backward by the extra ]>ressure exerted npon it by the head of the femur. The acetabulum on this side is displaced anteriorly and upward ; '\ti n fe :^H:^!'v. i ?- V ,:: vfi'm^^^^m- ■:'■■» f , 'Htm''"- '" ' I m 'mm* ^ ;VK) AMI.IUCAy TEXT-liiiOK O/' OIISTKTIUVS. tho syinpliysis is ])nsli('(I over on tli(> opposite side. Tlio dcfrrcf of asyniinotrv is nirt'ly stillicieiit to constitute an ol)strnetion in laltor. The scoliotic pdvi- is, however, most often rachitic, and in addition to tlie asymmetry of scoliosis there may he the contraction of a racliitic pelvis (IM. .'54, Ki;;s. 6-S). • — — •; - , - ~ - ; Kyphoscoliosis. — In a combination i of kyphosis and scoliosis of tho spinal colnmn tiie pelvis will show, pcrhap-, the cond)ined featnres of both, hnt thi' kyphosis, heinj; of rachitic, not of carious orij::in, will not he antrnlar, and will lie situated hiirh in the dorsal rojiion, where it may he compensated for entirely l>v Ininhar lordosis (Fij;. 3.")4 ; 1*1. .'5(), Fi^. 1). Tho kyphoscoliotic pelvis is nsuallv an asynnnetrically-contractod rachitic jk'I- vis(iM. 35, Fijr.l). Lordosis. — Primary lonlosis, not the rostdt of pelvic deformity or of spinal disease, is very rare. Aside from some illustrations ^f it in an article by Xeu- ijobanor (/oc. e/V.), the writer knows of no reference to the subject except his own (Fl. 36, Fij;. '1]}^ ft may readily 1)0 seen what an influence this deformity would have upon coition and ])artnrition, and how it mii;Iit bo an insu])orable obstacle to natural completion of the latter. Anomalies due to Diseases of the Subjacent Skeleton : Coxalgia. — The deformity of the jtelvis due to coxaliiia in early childhood is of two tyj)os. In one there is an oblicjuc contraction by a dis))laceinent of the innominate bone on the hc'.thy side U])ward, backward, and inward, on account of the i)ressiu'e of the femur, the weiixht of tho body boinu- re- ceived mainly ujwn the sound leji. This form of coxalgic pelvis, as a rule, pre- sents no serious obstacle to delivery unless it is associate*! with a rachitic dei'ormity (PI. 35, Fiu". '); IM. 3<), Fi<r. 3). Special attention, however, should always be paid to the leuixth of the conjuiiate diameter of the inlet and to the transverse diameter of tho outlet. In tho other variety of coxaliric ju'lvis the deformity is also an obli(iuo contraction, but it is the bono on the diseased side Kii;. :'.;!t.— Ky|ili(iscciliipsis i I.rdimliii DYSTOCIA. Pl.ATK 3rt. 1. I-iimhn-dorsnl kyphoscoliosis (Sclinutn). 2. Lordosis from imrnlysis of s]>iiii\1 muscles illirst). ;>. Skil- cton of 11 \!\r\ with coxiiljiiii iMiMlicnl Muscmn, t'liiver.sity of l'fiiii~ylvuiii;ii. 1. liriii- viru. ■"•. Siiir view, of lui (il]lii|iicly-c(iiilnicti'rl pelvis, Hk' resiill nf tiiliereilliius UjsvU.H.' ill ulie knee jniut illiist). (i. Seiiliosis frcini uiiiliitenil Mti'npliy nf Ihe spiiiiil iiiusele.s (Hirst). iC : I i ^l 1 I 1' r' I 1 H 'p.i DYSTOCIA. 641 wliicli is (Irivci) inwnni upon the pelvic canal. Tlii.s (lisplaeonietit of the iiiiioiiiinatc boiif is tlic result of an arrested (levelnpment on the correspond- iiiir side of the pelvis, and is very likely associated with an atrophy of tiie siiTuI alii and an ankylosis (tf the saero-iliac! j(iint. The contraction of the pelvic <'anal is nuieh more serious in this form, and there may be all the ditliciilties in labor onconntercd in the true \ae>;ele pelvic. Luxation of the Femora. — Dislocation of the thi<;h-bones, if congenital or oeciirrint; early in childlinod and n<»t corrected, has some elfect npon the hize and shape of the pelvis, bnt usnally not onoiifjh serionslv to oi)strnct lalior. If t»ne tliijjjh is dislocated, the weight of the IxMly may be thrown r— - I'Ki. ;!;!.'). — CimKenitiil liixiitinii 111' liiitli I'l'miini : c, crest of ilium ; F, tnicliiintur of ft'inur (Henry). Kid. ;!;!fi.— ( 'use of t'onRenltal lii.\iitioii of tliu foinorii. maiidy njmn the other leg, and this may prodnce an oblique contraction of the pelvis of the kind already described (PI. 34, Fig. (j). If the thigh-bone i.s displaced forward, the anterior half of the pelvis may be driven in a little npon the pelvic canal, and the head of the thigh-bone, as in one case re])ortc(l, may project over the horizontal ramus of the pubis into the pelvic iidct{ 1*1.. 'Jo, Fig. G). In the congenital lu.xatiou of both femora backward npon the iliac boiics there is an exces.sive rotation forward of the sacrum, an increased width of the pelvic canal, and from tlu; drag of the attached nni.scles and ligaments between the thighs and the pelvis the ischiac tuberosities are ])ulle<l outward, upward, and backward, so that the pelvic canal is made shallow and its outlet very wide. The heads of the lemora move up antl down on the iliu when the k ':' \m > ■!. •r 642 AMERICAN TEXT-BOOK OF OBSTETRICS. patient walks, and the distanoo between the lower edge of the symphvsis and the inner <jondvle.s of the femora i. shortenetl (Figs. 335-337; PI ;]:, Figs. 2-4, 7). " In the absence of one lower extremity the pelvis may be contracted obliquely to a serious degree, as in La Chapelle's case,* by the pressure on one side of the remaining leg. Any condition which throws the weight of tli(> body mainly on one leg may produce the same effect, as is shown in a case of the writer's (PI. 36, Figs. 4, 5), in which there was tuberculous disease of a knee-joiiit early in infancy, followed by marked shortening and atroj)hy of the leg. The weight of the body fall- ing maiidy on the sound leg, the cor- responding innominate bone is pushed upward, backward, and inward, dimin- ishing the area of intrapelvic space on Fl(i. :i:)7.— Alilfcld's (iisi' uf luxatioii nf Imtli fcmorii. Flc. ":w.— l.uxiitiiiii unci )uiriily>i.s of the ri^ilil lower liml) (Wiiii'ki'l). its own side (Fig. 33S). Torggler reports an interesting case i>f this kind in which the disability of one leg was due to scleroderma.'^ Iji the absence of both lower extremities there is the characteristic " sitz-pelvis," in which tlio innominate bones are usually rotated on an antero-posterior axis, so that the crests of the ilia are aj^proximated and the tuberosities of the ischia are sepa- rated. Minor deformities of little ])ractical importance may be the result of unilateral or bilateral chd)-foot or of the bowing of one or both lower extrciu- itios. In the former there is an increased inclination of the pelvis, an approxi- mation of the acetabula and of the ischiac tuberosities, and a narrow pubic arch (PI. 35, Fig. 8). * Pratique des Accouchemenia, iii. p. 413; according to .Scliauta, the only case on record. DYSTOCIA. 54;^ .). The Management of Labor Obstructed by the Commonest Forms OF Contracted Pelvis : a Simple Flat, a Rachitic Flat, and A Generally-contracted Pelvis. There is no situation in medicine where experience and good judgment count for more than in the management of labor obstructed by a contracted pelvis. It is extreniely difficult to formulate hard-and-fast rules for tiie ('•nidance of the inexperienced where so many factors must be taken into account. The rules given below govern the writer's practice in the average case, but due attention must be i)aid to the history of past labors, the size of the child, the age of the woman, the build of both parents, and the probable strength of the expulsive forces, greatest in the primipara and less with successive labors. If tlie diagnosis of a conjugate diameter of 9.5 centimeters or less is made (luring pregnancy, the physician must choose either inui.ction of premature labor, or forceps, version, symphysiotomy, or Cesarean section at term. If the conjugate diameter measures as low as 9.5 centimeters, it is a safe plan to induce labor four weeks before the expected termination of i)rcgnancy. This entails no additional risk upon the child if its parents are in a jiosition to afford it the best care and nursing, and it is much the safest plan for the mother, the induc- tion of labor, done properly, having no maternal mortality.* It is true that many women with a conjugate of 9.5 centimeters can deliver themselves with- out difficulty at term. Spontaneous delivery with a measurement as low as 8 centimeters and under has been recorded. But the majority of women with a conjugate of 9.5 centimeters will experience abnormal delay and difficulty in labor, with added risk to themselves and to tiieir children; and in a certain proportion oi' cases a conjugate of 9.5 centimeters proves an insuperable obstruc- tion in labor, and is the cause of ru])tured uterus or death from exhaustion in the mother or of injin-y to the child's brain. These results aii. t<» be feared especially if the child is overgrown or if the mother's expulsive powers are weak — two conditions impossible to predict with absolute certainty. For these reasons, then, the rule to induce premature labor when the conjugate is at or below 9.5 centimeters is a safe one. If the conjugate measures 8 centime- ters or under, the most successful treatment is the induction of premature labor at the thirty-sixth week, and then, if necessary, the performance of svm- ])liysiot()my when it appears that natural forces, aided, perhaps, by forceps, are not sufficient to secure the engagement of the head. By this plan the majority of women with a conjugate of 8 centimctci's or a trifle less will be delivered spontaneously or with no more serious o|)eration than the application of forceps. The conil)ination of prematin-e labor and symphysiotomy will usually be suc- cessful with a conjugate diameter at or above G. 5 centimeters. If the conjugate measures 7.5 centimeters or less, the induction of premature labor four weeks before term cannot be exjiec^ted of itself to secure a spontaneous delivery. Symphysiotomy also will be required in the majority of instances. \n such *Tlii8 statement is based upon tlio writer's exptirieiice in private pnict ice, and not upon hospital statistics. It does not liold good for labors induced before tlie tiiirly-sixtli weelt. ^.k^: W'W i? *' m Ifl-^fi 'i ^ ' h- F ' * 1 * ^^ ir" ^■' '^! C' C'l ii 544 AMERICAN TEXT-BOOK OF OBSTETRICS. In ' ' ' 'I 'i, h f ■ !l t^i I ' If cases, therefore, tlie operator may wait until term before he operates. But it the ohiUl may exj)ect good care, the writer prefers tlie induction of prematuK; hibor in addition to tlie symphysiotomy, for the following reasons : The extraction of the child after the division of the symphysis will be easier, quicker, and attended with less risk to the maternal soft structures ; the i)o.ssi- bility of an overgrown child and of a failure to extract it after the symphysis is divided is avoided ; and by inducing labor the operator may set the time iw the operation, and may consequently make his preparations without hurry or inconvenience. With a conjugate diameter of the superior strait below (J.o centimeters the woman should be allowetl to go to term and shoidd be deliv- ered by Cesarean section. If the physician sees the patient for the first time in labor, or only discovers the deformity after labor has begun, he must choose out' tlic following modes of delivery : A waiting policy to allow the cngaj,oU!ent of the head by natural forces ; the a[)plication of forceps ; the performance of version; symj)hysiotomy ; or Cesarean section. So long as the child is alive craniotomy shoidd not be considered. The selection of the best mode of delivery in contracted pelves is one of the most difficult problems in obstetrics. If the patient is a primipara and the conjugate is above 9 centi- meters, natural ibrces will in the majority of cases, provided the child be not overgrown, secure the engagement of the head,* although it may be by the expenditure of considerable force, after long delay, and oidy after prolonged moulding and an adaptation of the size of the head to the size of the con- tracted inlet by apparent anomalies in the position and flexion of the former. It is wonderfid liow successfully an obstruction may be overcome even in cases of contracted ju'ivcs with a conjugate of 8 centimeters or less. But while waiting for spontaneous <lclivery the physician may see the uterus suddenly rui)ture or may lind the child's head after birth seriously injured. It is permissible in most cases to wait for the full, or almost full, dilatation of the OS, keeping careful watch upon the woman's pulse, temperature, and general condition, pooh the situation of the contraction-ring and the disten- tion of th(! lower ..ierine segment, and taking whatever operative measures may be require<l in plenty of time to forestall the possibility of uterine rup- ture. The application of forceps to the head above the superior strait for the purpose of securing its engagement by forcil)le traction should in general be condemned, but it nnist l)e admitted that there are important exceptions to this ride. If one is skilled in the application of the forceps, bears in mind tilt' transverse position of the liead, and can gauge the degree of traction which may be exerted without injury to the child's skull or to the maternal * From IHSl to 1,SH7 there was sjiontdiicoiis dflivery in one hundred nnd sixty three out of 444 eiises of eontraeted pelvis in the N'ieinm Hospitiil, and in forty-seven women the coiijuKnte was not alxive S.") eentimeters ( Hrinni n. Iler/fehl, l>i'r KaiacmchniU it. seine Stdhini/ zur kinittt- lirlii'ii Friihiji'lmrl, Wi'iiihutij, iihijiiKrhin /iDiiiiiiiiiirrdlioiirn, KraiiiitUnnir l)fi ii. zu deti nininldinii (lihurli'H, Wien, ISSS, ii. p. 144). In the Musrow Maternity there were 84 eontraeted iielves anion^r 40(10 hirtiis in lsi)4, 71 per eent. of these ciises were spontaneously delivered iKiister, Vaifntlhl. /. (,'yii., No. 10, ISflo). 1 t DYSTOCIA. 545 soft structures, he will occasionally succcctl in securing an engagement with the instrument that would otherwise, perhaps, be impossible. As a rule, how- over, it is safe to say that the choice lies between inaction and the performance of version. By the latter operation the smaller end of the wedge represented bv the child's head is engaged in the contracted inlet, and there can be exerted upon the head ciomiug last, both by traction on the body from below and by in-cssuro on the head through the abdominal walls above, a degree of force that is impossible with forceps. It is well, however, to bear in mind the dan- ixer entailed upon fetal life when version is performed in a contracted pelvis, '{'hero is a considerable risk * that the head will be retained long enough above the superior strait, or in it, to asphyxiate the child beyond revival. f Or the pressure upon the head by the pelvic walls may fracture the skull and crush the l)rain, and the force employed in extraction may break the neck. If in the judgment of the operator the danger entailed upon the fetus by version is too groat, natiu'al forces having faileil to secure engagement, and if he has tried tlic forceps cautiously without success, his choice nuist rest between symphys- iotomy and Cesarean section.;): The ibrmer must be the operation of election if the conjugato is above 7 centimeters ; the latter, in eases of greater contrac- tion. These rules for the treatment of labor obstructed by a contracted pelvis pr('sup])ose, of course, a fetal body and head of average size. This point must always be investigated carefully by abdominal palpation, although, it is most (litHcult to determine. § If the physician has reason to believe that the child is over-size, he must allow himself sufficient latitude to ensure delivery. This advice applies particularly to cases in which the operator is in doubt whether fo select syuiphysiotomy or Cesarean section. \{\ on the one hand, there is good reason to fear that the child cannot with safety to itself be extracted through the birth-canal after the former, his choice should rest upon Cesarean section. On the other iiaud, if the child is under-size (a condition easier to detect by palpation than is overgrowth), spontaneous delivery may be expected through a pelvis that would not permit the passage of a child of normal size. *Tlie infantile deatli-viUe will be at least 25 per cent., or more likely higher (Nagel, "Die Wcnihing bui engiu J5e('ken," Arch. f. iliju., I'd. xxxiv.) t Nagel reports 60 cases of version for contracted pelvis, with a fetal mortality of 25 per rent. ^ //)/</., J). KiS.) X Klein and Walcher declare that by raising the bnttocks and letting the liinlis hang down as nnieh as possible the conjnaate diameter is lenglhcncd by almost a centimeter, ('linical tests of the method are described, attended, apparently, witli snccess (Zfilarhr. f. Oiburh. n. Gipi., I'd. xxi., II. I, and .1/if/. Konrsji. HI. (/..s Wiii-lcmli. Arrzll. I'., I!d. Ix. 5). The Walcher postnro has alrciidy been endorsed by quite a number of ol)servei's in (iermany. The plan i.s worth a trial at least. ? The relative size of bead and pelvis may be determined approximately by the method of Miiller and Schatz: The fetal head is gras]ied Itetwcen the extended lingers of the physician, and is pressed down steadily and for some time upon the pelvic brim (see p. 563 1, the direction of the force coinciding with the axis of the sii|ierior strait. If this manenvre succeeds in pressing the head within the pelvis, then natural forces will surely secure engagement. If it fails, the converse by no means necessarily follows. It' . ? t. i ^^ If'i 1 I ,^, W-l fmt 54G AMERICAN TEXT-BOOK OF OBSTETRICS. 6. Obstruction to Labor ox the Part of the Soft Maternal Structures in the Parturient Canal. Congrenital Anomalies of Development in the Uterus. — A cloul>le or septate uterus may complicate labor in several ways. The bulk of the i i M '1 I X 'i i.|(r Fig. 339.— rterus septus (Cruvoilhier). Fi(i. 340.— rtcTus sujitus ((irouzL'l r. tlilv MB It Fig. 341.— rtorus bicuiiiis (WiiickL'l). Fio. 342.— I'tenis didclphys. Fig. .343— Vagina si'pta (uterus liiforis). unirapregnatetl half may obstruct delivery, especially if this half is retrovortod and is increased considerably in size in sympathy with the development of the impregnated side and is hardened iu consistency by sympathetic contracti(ni DYSTOCIA. 547 tliiring the labor-pains. Tlie septum itself may prove an obstacle in labor, and sometimes labor is obstruete<l by the strong vesico-rectal ligament that runs between the horns of a bieornate uterus. If the plaeenta is attached to the septum, alarming hemorrhage may occur from imperfect contraction of the sj)arsely-supplied muscular fibres in it : malpresentations and a faulty direction and insufficient power of the expulsive force are common. Rupture of the uterus is to be feared on account of the ill-developed uterine walls. Laceration of the septum frequently occurs. It has been noted that a decidual membrane mav be retained within the non-pregnant half of the r.terus, where, undergoing j)utrefaction after delivery, it may give rise to septic infection. There seems also to be a disposition to the retention of membranes in the pregnant side of (lu> womb. Retention of tiie placenta is not unconunon, partly because of insufficient expulsive force, partly on account of its situation, perhaps attached in both divisions of the uterine cavity. Tlievard" reports the retention of the i)lacenta in a double uterus for fifty days, when it was spontaneously dis- charged. It has happened in cases of double uterus and vagina that the jiiivsician examined the wrong side, an<l was ignorant of the progress of labor until the child was about to be born ; also that he examined first one side and thou the other, finding first a dilated and then a contracted external os. In one woman with a double uterus there was noted a disposition to become pregnant in regular alternation first on one side and then upon the other.'* Closure and Contraction of the Cervix. — The cervix may obstruct labor by reason of atresia, cicatricial infiltration, contraction, and rigidity, or there may be longitudinal or transverse septa in the canal. Atresia of the cervix in a pregnant woman must, of course, be acquired after impregnation (con- ghitinatio orificii uteri externi) ; it is rarely, however, complete. There is always an indication at least of the external os in a dimple evident to the sense of sight, if not to that of touch. By pressing upon this point with a finger- nail or with the tip of a uterine sound a small artificial ojjcning may be made. Directly this is secured the dilatation of the external os proceeds in a remark- ably rapid manner, although hours of vigorous labor-pains before had been insufficient to begin it. If this plan fails, a crucial incision must be made in the cervical tissues at the site of the external os. The dilatation of the small open- ing thus made is then left to nature. If hemorrhage follows the incisions, the bleeding points should be secured by sutures. An active treatment is always called for. Without it the uterus may rupture, the vaginal portion of the cervix mav be torn oft' from the womb, or the head '^ mav emerge com- pletely covered by the enormously distended cervix as by a caul. Cicntririal contnicfion or ivfiUrathm of the cervix is the result of old unrepaired tears, of operations upon the cervix, of cauterization, of syphilis, or of cancer. In ' the first instance the resistance to dilatation is scarcely ever great, and what there is may be overcome almost always by hydrostatic dilators, by the appli- cation of forcej)s and fi)rcible delivery of the head through the cervical canal, or by the performance of version followed by rapid extraction. If the cica- trices are of syphilitic or of cancerous origin, the obstruction is more serious. mm. I f*j<?'5'fi3 X ^) •^^ rAH A}fi:ixICAX TEXT-BOOK OF OJJ.ST/JTJilCS. ', ' I i I It may bcovortHmie bv radiating incisions with scissors or with a probe-pointed bistoury, )iit it is not unliUoly to demand the portbrnianco of Cesarean section. Rigidity of the cervix is seen normally in all primipara), and to an exaj;- gerated degree in elderly primipane. It yields t)ften to copious donches uC warm water directed against the anterior wall of the cervix and fnujuentlv rep(>ated —as often as once every fifteen minutes if necessary. Chloral inter- nally and belladonna ointment applied directly to the cervix have been rocoiii- niciided, but these remedies arc not to be depended upon except in the slight rigidity characteristic of all primipara'. If there is delay in such cases, 10 grains of chloral evi'ry fifteen miimtes for three doses may advantageously Ix; given. An anesthetic, after all, is the most valuable medicinal agent that we possess for the relaxation of" this as well as of other rigid tissues. The rigid cervix yields at length to the steady pressure of the presenting part, and it is rarely necessary on account of rigidity alone to resort to artificial dilatation or to incisions. In the course of a slow tlilatation of the cervical canal and external os the anterior lip of the cervix may become incarcerated between the head and the ])elvic walls. In conseciuence of tlu^ pressure and the disturbance of circu- lation in the part the cervical tissues I'apidly become edematous, and the bulk of the anterior lip becomes so great as actually to <'onstitute a me- chanical obstruction to the descent of the head. It is usually possible in such cases to push up the anterior lip over the head and above the sym- physis in the intervals between the pains. If there is hypertrophy of the anterior lip in consequence of an old laceration and eversiou, or, all the more, should there be hypertrophy of the whole infravaginal portion of the cervix, the obstruction may become (piite serious, and it may be impossible to ])ush the ci'rvix above the head. In such cases forcible traction on the forceps or radiating incisions in the cervix may be necessary. Longitudinal septa in the cervical canal are usually seen with duplicity of the uterine cavity from failure of the jMiillerian duets to fuse completely. Occasionally the lack of fusion is confined to the cervical canal alone (uterus biforis). Rarely transverse septa have been found in the cervical canal.* It may be necessary to cut these before the child can pass into the vagina. * Cases are reported liy Miiller, IJreisky, Budin, Henry, Bidder, and Bliinc (Pozzi's Gyiw- eolixjy, vol. ii. p. •loG). Fiii. oil.— Dimlilc viiKiiin. y jzzi's Gim- DYSTOCIA. 54!) Closure and Contraction of the V .gina or Vulva. — Tlicrc may be ()l)stnu;tioii of the lower birth-canal by hjiigitiuliiial and tran.svcrso septa, by cicatrieert, by heniatoniata, by partial atresia, especially at the upper third of liie vairina, by uiiniptured hymen, by amis va<j;inalis, by vajfinal tumoi-s and (;vsts, bv eystie and soli«l tumors of tlu^ vulva, l)y enlarged earuueula) myrti- formes, by varices, by vaginismus, by congenital narrowness of the vagina and vulva, and by rigidity of the tissues, especially in eld(;rly j)rimipane. LoiH/itii(liii(d and Traiisvrrne Septa. — These uxw not ordinarily v(M'v dense in structure, and they give way commonly ijefore the advanc(M)f the presenting part. If they do not yield, it is easy to cut them in one or more places, the liemorrhage being controlled, if necessary, by sutures afterward, or in the case ()[■ transverse septa by a double ligature applied first, the septum being out between, though then^ is not much tendency to bleeding even in those as thick as one's finger (Fig. .'{45). Hcmatomatn. — Hematomata of the parturient tract usually occur at the vaginal orifice, and most often between the birth of twins. They are con- sidered here oidy as mechanical obstacles to ]al)or (see p. 680). If the blood-tumor is large enough to constitute an obstruction to th(! escape of the child, its walls must be incised and its contents be turned otit, and Flii. 345.— Transverse septum of the vatiiim (Ileyilor). Flfi.aiCi.— Aims vestibularis: (lotted lines show the limit of nnieous niemlirane; thieki'neil skin marks the normal site of the an. is (Diekinson). if heniorrhage follow it nuist be checked by a firm tampon, preferably of iodoform gauze, in the cavity of the tumor. Exteimvc cicatrices in the vagina from syphilitic, malignant, or other ulcer- ation, or from former injuries, may be stretched siitficiently by hydrostatic dilators or may be severed by multiple incisions, followed by the application of forcej)s if the head is presenting; but they may be too den.'^e and extensive to yield to the.se measures, and a Ccsiirean section may be required. Unruptured Hymen. — An unruptured hymen is not neces.sarily a bar to conception. There are a nund)er of cases on record in which :i persi.stent hymen with a small orifice has ob.«ti*ucted to .some degree the e.<cape of the child's head in labor. In two cases under the writer's notice the advance of i t I't fl '•S:'> m'<:i i.. t-^i' ; pr I ! |i M TmO AMi:iiIVAy Ti:XT-li()OK OF OliSTETltlCS. tlio present iii<;; part ruptured the liymeneal inenibrane without diftieultv, but it has been found necessary by othjrs to incise it.'" Atresia (if till' Vafjina. — This anomaly of developnient has its scat usualK at the upper third of the canal, where the vagina may be contracted to a nar- row trat't barely ailmittin<>; the uterine probe, or the canal may be obstructed b\ an annular membrane like the hymen. Although Cesarean section has been done for thi:< condition, the majority of eases on record have not re<piired it. The advance of the presenting part has dilated the narrowed vaginal canal with little more difficulty than it experiences in dilating the cervical canal. At the worst the obstruction should be overc<»me by digital, instrumental, or hydro.static dilatation. In complete or almost complete acquired atresia of the lower portion of the vagina, in which in.scmination has taken place by way of a dilated nriJthra and a vcsico- vaginal fistula, the imperforate portion of the vagina may be opened by a transverse incision, the rectum and bladder being guarded by a finger in the one and a sound in the other. Anus V(((jUi((Uh or Vvstibular'iK. — This condition may complicate labor bv the accumulation of feces in the rectum, due to the unnatural position of the anus (Fig. -'{46). In one case in which this anomaly was as.soeiated with par- tial atr(>sia of the vulvar orifice it was necessary to cut the perineal structures upward from the rectum toward the pubis in order to permit the escape of the child's head. Cydio and Solid Tumors of the Vagina and Vulva, Edema, Suppuration, and Gangrene. — In the ease of solid tunior.s excision may be neees,sary, by transfixing the palicle if they have one, and ligating it to prevent hemorrhage, or by i.n incision of the vaginal wall over them and their enucleation, followed by the immediate extraction of the child, and the control of hemorrhage by the needle and thread or by direct pressure. In the case of large cystic tumors a puncture is sufficient to remove the obstruction, (iiider" collected 60 ca.ses of vaginal tumors complicating labor — 23 cysts and echinococcus sacs, 18 fibroids, fibromyomata, and jwlyps, 14 carcinomata, 1 sarcoma, and 4 henia- tomata. Delivery was accomplished by the following diverse methods : s])on- taneously, 14; l)y forcej)s, 18 ; by version and extraction, 2; by traction on the feet, 1 ; by removal or puncture of the tumor, 16; by Cesarean section, 7 ; by induction of premature labor an<l craniotomy, 2 ; by premature labor, 3; by laparo-elytrotomy, 1 ; by craniotomy, 1 ; by pushing back the tumor and extracting the child past it, 2. Among the niothvrs thcjo were 15 deaths; among the children, 13. In 11 of the mothers and in 22 of the children the result was not reported. Kdrma of flic vulra may be the result of kidney insufficiency or of pressure in a prolonged labor. The increased bulk of the dropsical lal i'l may u'terfcre with the escape of the presenting part, or, what is more likely the edemitons tissues lose their elasticity, obstruct labor by their rigidity, and are prone to Iccp tears at the time of birth and to gangrene afterward. Punctures or incisio'is in the labia may be necessary to escape more serious injury, but it is well t(> avcjid them if possible, for they are apt to be Ibllowed by infi'ction and gangrene. DYSTOCIA. .5.51 An abscess of liurtliulin's gluiul is seldom large enough to retard labor, though it has done so (Miiller), bnt it is likely to canse trouble afterward. It should be opened freely in the early part of the first stage of labor, ciu'etted, swabbed out with earbolie aeid and glycerin, and packed with iothj- lonn gau/e. (langrene of the vulva is very rare before the termination of labor. Should it exist, it might determine an operator in favor of Cesarean section Fi(i. ;547.— Kdi-mn Hiul bc'Binning gangrene of the vulvn from prolonged pressure in an obstructed lubor (Hirst). in a doubtful case, on account of the rigidity of the vulvar tissues, the cer- tainty of laceration, amK the likelihood of grave infection. Enlarged Carimculiv Myiilformcs and Varicoxe Veins. — These tumors do not possess sufficient bulk, as a rule, seriously to obstruct the last stage of labor. They may, however, be so bruised by the j)assage of the head as to slough after- ward, or the veins in them may be rupturetl, giving rise to subcutaneous or fraidv bleed- ing of an alarming character. VaginisniUH may be overcome by an anes- thetic. Congenital narroxcness of the vagina and vulva is usually overcome by the ad- vance of the presenting jiart, though often at the expense of vaginal and perineal lacera- tions. It may be necessary to resort to hydrostatic dilatation, or even, in rare in- stances, to Diihrssen's plan of multij)le incis- i(>ns. In the case of extreme narrowness of the vulva there may be a central teor of the perineum, through which the presenting part begins to emerge. To avoid a rectal tear in such a case the perineum should he cut from the anterior border of the perforatiim to the posterior commissure of the vulva (Fig. .348). Rigidity of the tissues in the cervix, the vaginal wall, and at the outlet Fl(i. 348.— Central tear in the peri- neum, with CDtitraetv'il vulvar orlliee (Ivilieuiiint-Hessaignes). > ">ii ;' ^ ..\s 'h\ /\ m 1^. .•< t ] ■'.■:• .552 AMKRICAX TEXT-nOOK OF OBSTETRICS. ooeasioiis delay in the majority of all priniipara), but especially in the case of elderly priinipane — those over thirty years of age. Kokluird found the infantile mortality in such eases to he 19.81 per cent., the maternal niortalitv to be three times as great as in younger primiparje ; and the necessity for operative interference increases steadily with the age of the primipane until, in those ])ast forty, alnjost two-thirds are delivered by some operative pro- cedure, usually forcejis. Craniotomy should be done if the child is dead. A^'ersion is the least successfid ojjcration in tlii'se cases. Displacements of the Uterus. — The uterus in labor may be displaced forward; to either side ; downward; or backward, by the so-called "saccula- tion " of the womb. It may b(! twisted on its ])etlicle, the cervix, or it mav form part of the contents of a hernial sac in inguinal or ventral hernia. Anterior Dkplaccment of the Uterus in Labor; PetuJiUous Belly, — This is a Fit;. :M'J.— Hernia of the t,'riivi(l womb through tlie liiieii alba common anomaly in labor, seen to some degree in all cases of obstructed labor, as in deformed pelvis, and in all cases in which the length of the abdominal cavity is decreased, as in kyphosis. A peculiar example of forward displace- ment is seen in those rare instances of hernia of the parturient womb between the recti muscles or to one side of the median line during the second stage of labor (Fig. 345)). The pregnant wond) may fall forward also into an umbil- ical hernia or into a ventral hernia following celiotomy. The removal of the obstruction to labor in the first class of cases will or- dinarily obviate the anterior displacement. If the displacement depends not upon obstruction, but upon flaccid abdominal walls, the application of an abdominal binder surely corret^ts the anteversion. In cases of hernia of the uterus through the anterior abdominal wall artificial delivery with forceps or by version may be necessary ; when the uterus is evacuated it can easily be returned into the abdominal cavity. A tight abdominal binder and the dim- DYSTOCTA. 653 inntion of intra-alKlomiiml pressure after delivery will proinoto the a|>|)r()xima- tiou of the .scjiaratod recti museles. In iiifjninal hernia the pre<;naiit womb in the hernial sac is ustially unicorn «>r hicorn (Fij^. .".oO). Delivery may ho eH'ccted hv version, anil this may he followed by a reduction of the hernia, l)ut it is hest to lay open the sac, incise the womb, extract its contents, and then amputate it.* Lateral Dlxplacemeni, — A tilting of the uterus to the right side is a phys- iological occurrence in pregnant and parturient woiuen. The lateral inclination is sometimes exaggerated to such a degree that a great ])art of the expulsive lurce is lost by the propulsion of the ])resenting part agan'st the lateral wall Fiii. ;!5(l.— Innuiiiiil luTiiia coiitiiiiuiig a gniviil womb (Wiiii'kol). Flu. ;i')I.— Saci'ulatinii of tlie uterus (Oldham). of the pelvis. The displacement can be corrected by turning the woman on her side — usually the right — toward which the fundus uteri is inclined, and placing under her flank a rolled blanket or a pillow. Sacculation of the Uterux. — A baiikward displacement of the gravid womb in rare cases goes on to full development by what is called '' posterior saccula- tion," the di.stention of the uterus to accommodate the full-grown fetus being accom[»r.shed by stretching the anterior uterine wall, the posterior wall and the fundus remaining fixed within the pelvis (Fig. 351). In these ca.ses the cervix is high above the jielvic inlet and is pressed close against the anterior abdom- inal wall, the posterior vaginal wall bulges outward and downward, and fetal parts can be felt through it with a distinctness that suggests abdominal preg- nancy. Cesarean section has in one instance at least been performed on account of this anomaly, but a study of recorded cases .shows it to be unneces.sarv. By the artificial dilatation of the cervical canal and the perfi)rmance of podalic version delivery can be effected without difficulty. Partial Prolapse vith Hjipertrophic Elongation of the Cercix. — Tt is irapos- * Adams'"' lias collected 10 cases of ineniiial hernia of the fri"iviil wonili, iiicliiding Dor- ingiiis', >vhicl) iie calls "trural." In eight Cesarean section was done. In one the delivery was spontaneous. -^l-- isl N( i If |i. I- " ! I '1 P, H :!'!*;■ 564 AMrJilCAX Ti:A"r-JiO()h' or OliSTKTliirS. sil)l<' for projiiiaiicv tn uroccod tc toriii with coinplcti' j)n»Inj)si' of the woiiil), although the size of tlu' iitcriiic tiiiuor projci'tiiij,^ from th(; vulva in some cases Fi(!. 3')2.— Prolapse <if a double uterus In a pregnant woman (Maygrier). has given rise to a belief in this possibility (Fig. 353). A careful examina- tion has always shown the major portion of the uterine body to be within the pelvic and abdominal cavities. Com- monly the fundus is at a normal level, and the descent of the cervix has been Ki(i. S.")!).— I'lirtiiil prolapse of the wonili in liihor (Wagner). Fl(t. 354.— Partial prolapse of the wonil) ami hypertrophy of the eervix (Kaivre). accomplished by stretching the lower uterine segment and by hypertroi)hic elongation of the cervix itself. When the contraction of the uterine muscle DYSTOCIA. 655 licgiiis ill labor a partial prolapse of the womb i.s nsnally spontanoonsly corroeted by the rotractinn of the cervix within the vagina. This the writer has seen in several instances. In exceptional cases, however — usually nil at'count of a rigid cervix — the prolapse beconies aggravated or suddenly Km. I!')"!.— I'lirtliil prDlnpso of \.\w woinli iiiul hy|ii'rtro|ihy of the rcrvix : A, Inteml position ; B, Uoraal position (Kaivrr). makes its appearance, and the cervical tissues, growing edematous and becom- ing enormously swollen, constitute by their bidk and increased rigidity a seri- ous obstruction to the delivery of the child. Tliis difficulty was overcome in an ingenious manner in a case reportcil by Faivre.*' The woman was placed Fi(i. ;&;.— Displacouu'nt of tlio furvix. in the dorsal position across the bed, a forceps was api)lied to the child's head, and an assistant, standing astride the woman's body, hooked his fingers into the ( rvix and pulled upward to counteract the traction of the forceps upon the child's head and the incarcerateil cervical tissues. It might be necessary 'U El m *' ■■«.■■ ' III',- I % M. »' li'^ "• ' '\- ■ i' \ ! '»i 1^ \.i 656 AMERICAN TEXT-BOOK OF OBSTETRICS. ill sucli a case to enlarge the eervioal canal by radiating incisions. The liem- orrliago following might be controlled temporarily by clamjiing sutures ov( r the wounded surfaces without uniting them (Figs. .'}o4, .355). Displacement of the Cervix. — It is not uncommon in primiparte with a nar- row cervical canal for the (;ervix to be displaced backward, so that the external OS, almost inaccessible to the examining finger, points directly backward or even backward and upward. The anterior lower uterine .segment is much dis- tended by the presenting part and occupies the whole vaginal vault. The ex- pulsive force in labor is exerted against the lower uterine segment, and tlie cervical canal remains inidilated. The difficulty can be overcome by aj)plyiiig an abdominal binder and by hooking the cervix forward with the linger dur- ing two or three pains (Fig. .'55G). Tumors of the Genital Canal. — Carcmoma of the Cervix. — In a large ])roportion of cases cancer of the cervix will interrupt gestation at various Fid. 3r)7.— Liirf-'O fit)roi(l lilockiiiK tlu' jit'lvi.s (S|iio);i'llii'i%') stages, but in a certain jiercentage ((50, according to Midler) the pregnancy goes to term. If the disease is not too far advance<l, if it is confined to one lip of the cervix, and that the anterior, and if there is not too nuicli cicatricial infiltration around its jjcripliery and up the cervical walls, the labor may be terminated spontaneously, but this is rather the exception. The performance^ of Cesarean section is commonly the proper tr(>atment for labor obstructed by carcinoma of the cervix, and this operation should be selected if there is guod reason to doubt the j)ossil)ility of spontaneous or artificially-assisted delivery by the natural passage-way. The woman's life is surely doomed in the near DYSTOCIA. 557 future, and the child at any rate should be saved, even at considerable risk to the mother. It may be desirable to operate before the fetus has reached maturity if the disease is making such rapid progress that the maternal life ia not likely to endure until the natural end of pregnancy. Fibromata. — Fibroids of the uterus and cervix low enough in situation to l)ooonie incarcerated in the pelvis are likely to constitute insuperable obstruc- tions in labor, besides complicating parturition by favoring abnormal positions of the child, by predisposing to adherence of the placenta, to prolapse of the oxtremities and cord, and to hemorrhage during and after labor. If the tumor srows on the anterior wall of the uterus, the first few labor-pains and the con- traction of the longitudinal fibres of the cervix may dislodge it above the pel- vic brim, though it had been impossible to do this before by manipulation. The writer has seen one such case. It is also possible for tumors on the ante- rior wall of the cervix to be pushed out of the vulva in front of the presenting ])art, thus making room for the escape of the latter. \\\ however, the tumor is situated laterally or posteriorly, its artificial displacement upward into the abdominal cavity, so that the child may escape jiast it, is often imprac- ticable (Kig. 357). On the contrary, the attempt at descent of the present- ing part in labor must fix it more firmly in tlie pelvic cavity.* In this case, if attempts under anesthesia to dislodge the tumor and to push it above the pelvic brim fail, a Porro- Cesareau t)peration should be per- formed, even though the tumor is not of such great size as absolutely to |trevent the delivery of the (ihild. The physician nuist consider ti-.c etfeet upon it, owing to its low vit.ility, of the pressure to whicii it will l)c sub- jected l)v dragging the child past it (Fig. .■J5S). Sloughing, gangrene, and fiital infection are likely to follow. This was the history of the case illus- trated in Figure .'55S, communicated to the writer by J)r. J. P. iSii;ipsoii of South Carolina. If tlic fibroid is submucous and grows from the cervix, it may be eimcleated when labor begins. The bed of the tumor shoidd be packed with gauze after labor, f * It is !i:iivly possible tliat ii tumor low down on tlie posterior wall of the eervix, tlie most 'iiifiivoriible of all positions, may lie siiildenly elevatetl after many hours of lalior, and thus allcnv a spontaiieons delivery; lint this I'vent is not to he counted (>n in ]wactiee. tSulnf;in is an cntiuisiastie advoeaie of vauinal (i|ierations for all cases of liliroids impacted in tlie small pelvis. For intraniura! tnniors the cervix is split until the tmnor is reached. For suhseroiis tnniors the vaginal vault is opened. Nine such o|)eralions,<((fc partn are rejiortcd, with only one death {Jahvenb. ii. d. (•'oi-I.'-tIi. a. li (iihicle drr Gehitituh., lic, vol. v. p. 17')). Vu;. Ij.'is.— Small liliniid past which the child was cxtracteil. The tiiiiKH' l)ecMiiie jj;angreiiuus and the woman died (Simpsdu). ' 1} J 't'j t .' 1 r : m * • :■;:;■ w ^''•<m "Y,. : t ^ \ 558 AMERICAN TEXT-BOOK OF OBSTETRICS. '■ \ , H i 'I i \ *, ,* \ f »J I ' It is, unfortunately, a common error to overlook a fibroid tumor obstruct- ing the pelvis in labor or to mistake it for the fetal head. The woman is allowed to die of ruptured uterus, exhaustion, or hemorrhage while the phy- sician is waiting for the descent of the presenting part or is endeavoring t(. apply the forceps to what he takes to be the head. Ordinary care and sonic little experience in making obstetrical examinations should guard a practitioner against such an egregious mistake. The proffnotiis of labor complicated by a fibroid tumor depends upon the early recognition of the growth and upon the treatment. In general practice the results have hitherto been bad. Xauss found a maternal mortality of i)4 per cent, among 225 women, and an infantile mortality of 57 ])er cent, in 117 cases. Siisserott found in 147 cases a maternal mortality of 50 jier cent, and an infantile mortality of 66 per cent.'*^ A fibroid tumor may prolapse into the pelvis after the birth of the child and ])revent tiie delivery of the ))lacenta. In Lefour's statistics of 300 cases of fibroids complicating labor the mor- tality of delivery by the natural passage was 25 to 55 per cent, for the mothers, 77 ]>er cent, for the children.^^ Poljipi. — Polypoid tumors obstructing labor usually spring from the cervi- cal canal or the anterior lip, and are mncous in character. They may, however, be fibromyomatous, fibrous, or sarcomatous, and may have a situation high in the uterine cavity or in its wall. They may increase very markedly in size during pregnancy. Their pedicle is usually small, and in the case of cervical poly])s their removal is easy. The operation should be postponed, however, until the woman falls into labor, for any operative interference in this region would very likely interrupt gestation. When the dilatation of the os begins the pedicle can be transfixed and ligated and the tumor be cut awiiv. Even if these growths are not sufficient in bulk to obstruct parturition mechanically, they have been known to give rise to jirofuse hemorrhage in the first few days of the puorperium, and their removal is desirable, therefore, even though they be small in size. In the case of fibromyomatous polyps of the uterine body, the tumor has on rare occasions been torn from its pedicle during labor and expelled in front of the child. Tumors of Neighboring- Organs. — Ovarian OyMs. — An ovarian cyst is a rare complication in labor. In 17,832 births in the lierlin Frauenklinik an ovarian cyst was fi)und only five times. Tiie number of abortions in preu- nancies complicated by ovarian cy^ts is somewhat larger than common, but still a large proi)ortion of these cases proceed to term. Of 321 jiregnancies complicated by the ])resence of ovarian cysts, there was premature interruption in fifty-five (Ucmy). If the cyst is discovered during pregnancy, its removal should be attempted. Ovariotomy during gestation is not necessarily a dif- ficult or dangerous oju'ration, nor does it, as a rule, interrupt pregnancy.* It' * Dsirnc has collected statistics of IS.") operations with a niorfality of ").() per cent. I'roK'- naiicy is interruptwl hy the operation in about 20 per cent, of cases (Flaischlen, ZfitachriJ't /iir Geburlshillj'e, xxix. p. 49). DYSTOCIA. 559 tlie tumor is first discovered after the woman has fallen into labor, and if it lias become displaced downward into the pelvic cavity and is incarcerated, resisting all efforts to displace it upward even under anesthesia, its puncture through the vaginal vault, after a thorough cleansing of the vaginal mucous membrane and with a thoroughly aseptic technique, is said to give the best results. It is a matter for serious consideration, however, whether Cesarean section followed by the removal of tne tumor is not better. It is the writer's conviction that it is. By this plan many dangers in the pucrperium are escajjcd. Twisted pedicle, intracystic bleeding and shock, occlusion of the bowels, rupture of the cyst, suppuration of the cyst-contents and consequent ])eritonitis, are all surely avoided. A number of cases treated thus should give a better mortality record than has hitherto been secured. In Heiberg's statistics of 271 cases there was a maternal mortality in pregnancy of more than 25 per cent, and a fetal mortality of more than G() per cent. In deliv- eries by forceps without puncture of the cyst the maternal death-rate has been 50 per cent. ; with puncture almost as great ; and after version without punc- ture more than 50 per cent. Flaischlen recommends the vaginal puncture, or if necessary a vaginal incision and thorough evacuation of the tumor, then the delivery of the child, and on the ft)llowing day at the latest an abdominal sec- tion for the removal of the tumor. This procedure does not seem to the writer so good a ]>lan as the coincident Cesarean section and ovariectomy. Should the physician prefer vaginal punctuie — which requires, of course, no .'ipocial surgical skill — he should remember that if the tumor be densely adhe- rent, possess thick walls, and possibly be a dermoid cyst, puncture through the vaginal vault is likely to be folk)wed by gangrene of the tumor-contents and walls and by general infection. This will necessitate a hurried abdominal section in the pucrperium, with the patient in a bad condition to endure it. Moreover, if the cyst is multilocular, it may be impossible to reduce its size sufficiently by vaginal puncture to permit the delivery of a living infant. The writer has experienced both the disadvantages of this plan of treatment. Spontaneous delivery in spite of an ovarian cyst incarcerated in the pelvis lias been noted after the cyst ruptured, after it had been spontaneously dis- lodged upward above the brim, or had perforated the vaginal vault or the rectum. As an ovarian cyst must be impacted in the pelvis to obstruct the delivery of the child, it is easily understood that there is more difficulty and danger in labor from a small than from a large tumor (Fig. 350). After the child is born a cyst that had before been above the brim may descend into the pelvis and obstruct the delivery of the jilacenta. Vdc/iiKil Entevocdc, — Vaginal hernia is a very rare obstruction in labor. The writer has been able to collect but 27 cases from medical literature. Of tliese, only two were anterior enteroceles ; the others were lateral and ])osterior. The distention of the hernial sac in labor is apt to become excessive, and to tlu'caten its rupture with protrusion of intestinal loops. An effi)rt should bo made to nMluce the hernia as soon a:* it is discovered. The reduction may be facilitated by placing the woman in the knee-breast posture and by inserting ajl iwJ, f 4» : t aT iti 560 AMERICAN TEXT-BOOK OF OBSTETRICS. the wliole hand into the vagina. If this treatment is instituted in pregnancy, it should be followed by the insertion of a large tampon or a globe pessary and by prolonged rest in bed ; in labor the presenting part should immediately be brought down past tlie hci'nial ring. If there are adhesions about the latter, preventing the reduction of the hernia, the tumor should be supported and held to one side by assistants while the child is artificially extracted by forceps or after version. Should the sac rupture and the intestines i)rotrude, the child must be delivered hastily, the intestines be cleansed thoroughly and re])laee(], and the opening be sewed up. In the case of a very large irreducible vaginal hernia the writer's preference would be for Cesarean section in a labor at term. Other growths or tumors in the lelvic inlet and cavity obstructing labor have been fibrocystic tumors o^ the ovarian ligament, requiring an abdom- Fic. ;5,jt).— Oviiiiiiii tiiMiiir iiiciiictTiitc'cl in tlio pelvis (liiriiiK liilior. Fio. SfiO.— Cysldcc'lo (ibstruc'tinf; Inliiir. inal section ; fibroma of the ovary ; sarcoma of the ovary ; a displaced adherent kidney at the pelvic iidet, nocossitafing version and forcible extraction;* hydatid cysts of the pelvis, demanding Cesarean section; a displaced and enlarged spleen ; masses of exudate ; and an aneurysm of tlic gluteal artery. Cvstocolpocele and I'ectocele should be re]>lac('d if they protrude to a great extent in front of the head, and i)e held back until a forcej)s is applied and the head is brought past them with the iiistriunent (Fig. 3G0). Version and extrac- tion have occasionally been found necessary. T^arge fecal masses in the rectum must be removed by an enema or must be dug out.f Calculi in the bhi'ltler should, if possil)Ie, be discovered and removed by the urethra or by vaginal lithotomy before the second stage of labor. They may become nipped between the head and the pubic bones, and pinch a hole through the anterior vaginal * Kiinpe reports fdiir ciises ( Arrhir fiir Gjiniikrilo./li; xli. p. 'J9). Tlie writer liiis liiid «iih'. All)ers Sclioenberg reports aiiotlier in wliieli the uterus ruptured {Ci-iitrnlblnll fiir Giiiiiiknloiiii, Dec. 1, 1S94). t Corradi tells of a ease in wiiieh seven jiounds of iiardened feces were removed i)efore the woman was delivered, DYSTOCIA. 561 gnancy, it »sury and (liately he the hitter, )()rte(l and by forceps , the child rephiocd, le vaginal I hibor at ting labor lU abdoni- ip labor. displaced I forcible section ; a ,sm of the to a great h1 and the nd extrae- he rectum u! bladder )y vaginal d between or vaginal las liiid villi". (IjliiiUcohti/ii', (I hefoiH' the wall and bladder if they are overlooked or neglected.* The diagnosis of vesical calculus in the jiarturient woman appears to be somewhat diflicnlt : it has been taken for a pelvic exostosis or some other pelvic tumor, and in one ease at least Cesarean section was performed on account of this mistake. For- tunately, vesical calculus in the female is rare. In 10,000 women examined by Winckel in fifteen years it was found only once. The following conditions in and about the rectum may present mechanical obstacles to delivery : Cancer, anus vestibularis or vaginalis, foreign bodies, eoiitractioii of the levator ani muscles, benignant tumors such as cysts of the rectum, ovarian cysts which have perforated the rectum, and retro-rectal dermoid cysts. Each of these conditicnis must be treated according to the individual indications. Incisions in the perineum may be reciiiircd, foreign bodies must be removed, resisting muscles on the j)elvic floor may be over- come by an anesthetic and by the application of forceps, and cystic tumors siiould be punctured or removed after ligation of their pedicles. Cancer of the rectum may demand the performance of Cesarean section by reason of the size of the tumor and the cicatricial infiltration of the birth-canal, as in KrcHuid's case. 7. ()nsTuu(;TioN in Lauou on thk Part of thk Fktus. Overgrowth of the Fetus. — Excessive overgrowth of the fetus is rare. The writer searched the records of more than 1000 children in the Maternity Hospital of Philadelphia before he found one that weighed more than twelve pounds; weights, however, of fifteen, sixteen, eighteen, twenty-three and a half, and twenty-eight and three-quarters pounds have been recorded. The causes of overgrowth in the fetus are prolongation of pregnancy, over-size and ad- vanced age of one or both parents, and multiparity. Rarely it may be inex- plicable. The first named is in the writer's experience the most common cause. In 6 per cent, of women pregnancy may be expected to bo prolonged beyond the three-hundredth day, and for every day that the fetus is retained in the womb beyond the usual time there is commonly some little increase in its size and weight above the normal. So much diffi(ndty and danger may be expe- rienced from tbis cause that it is a good rule in practice to allow no woman to exceed the normal duration of pregnancy bv more than two weeks. By induc- ing labor at that time one will occasionally interfere unnecessarily, but he will often avoid complications and difficulties of the most serious nature. Over-size and advanced age of oiu; or both parents may be a cause of over- growth in the fetus — the latter usually because it jiredisposes to a prolonga- tion of pregnancy. It is commoidy asserted that the size of children increases in successive pregnancies up to the fourth or fifth, and then remains stationary * Kotschurowii has reported a case in which labor lasted three dins. .\t the end of that time a Ki'iik^rcnmis tumor protruded from the vulva, which tumor proved lo he the bladder and anterior vaginal wall. Tiie midwife in atteniiiiiiee iif^rforated the tnrnor with her linger, where- upon a calculus eighty-five grains in weight wiis discharged (JdhresbcrichI it, d. Forlschr. n. d. G.hietc ikr 'leburtxh., etc., vi. 225). If I i- ! 1 1 ii s *, I !: Ii I • ! , I i 562 AMFJilVAN TEXT-BOOK OF OBSTETRICfi. or even (lecroa.scs ; but theiv arc important exceptions to tliis rule. The writer has seen the teulii child va.stly exceed in size the nine preceding; it weighed Kiu. ;!(')l.— Dlcc'plialus Flu. Sfi;!.— rioi'plmliis. ^I'^f'^^^^^^^ Klu. ;'>(;4.— Cninio|iiiKi'^ Kiu. ;it)5.— Isdiioim.mis. fifteen pounds, and it was necessary to deliver it by Cesarean section. The other children had been born naturally through a flat pelvis with a conjugate Kici. ::i;ri.— lii|iyiriis iWrlls). Ku;. ai". — Diiiygus imrasitlods. diameter of i) centimeters, 'flic increase in size of successive children mu-t bi' bonic in mind in cases of coutractcd ju'lvis. The first two or three inhuii> I ! feJ DYSTOCIA. I'l.ATK ■HI " ■' ■^''- M ■HI I I. lii|>niso|iiis (IIii>l mill rirrsnlV ■_'. |ii|.rciMi|iii- i I'lr Hirrl.lulhl-, I. I. Ilur I'S-lir kii|ll(V> il''ilssrlli. :>. l.iirui' nu'MiiiLMccli' niul >|iiiiii Mllilti illirsi .iiliI I'IiTmiIi. h. ( ■..ii'jmil.il i\ ^lir ili|!liiiiiiiiisi> iWilsmi). 7. riiiirii<'(i|iiiyiis illii'st ami l'ii;i-siili. s. |ii>toiiil(il liliuMiT (Alillclili. I i i. .[ MIMI IWldll ■ ! 1 . i y J H^^^^^^^^BJPIWgi .,1 I I .11 M • tV- t^ 'f |! i m >f J-i 1 g I I f! y DYSTOCIA. 663 niav be delivered spontaneously, bnt the larger size of the fourth or fifth may make natural delivery impossible.* Overgrowth of the fetus is the most difficult condition in obstetric practice to diagnosticate with precision. A careful palpation of the head and body and an attempt to pusii the former into the pelvic inlet may give one an approximate idea of the relative size of fetal body and pelvic (jaiial, but as a matter of fact the large size of the fetus is usually discovered .. practice only ^'f^^-. Fill. 3C8.— Prosopothoracopagus. l''i(i. 3G9.— Xiphopagus. Fi(i. 370.-Janicops. after prolonged delay when attempts at artificial delivery^ especially by version, have failed. By this time the fetus is commonly dead, and should be deliv- ered by embryotomy. But the ])raotitioner nuist be on his guard again.st futile attempts to deliver an infant too large, even when mutilated, to pass through the pelvis. The writer has seen in consultation practice several maternal deaths due to this cause. Prcmafure Omfieation of Cranium; Wormian 7?onps;t Larr/e Heads; Mal- formations and Tumors of the Fetus. — No single rule of treatment can be laid down for the management of these ca.«es. Forceps, version, or some form of emljryotomy is usually demanded. Spontaneous labor, however, is jw.ssible even in ea.ses of monstrous bulk in which delivery through the birtli-eanal woidd seem out of the question. Thus in double monsters Joinoil loosely by the front or back (xiphopagus, the Siamese twins ; pygopagus, the Hungarian sisters), one child will be born by the head, the other afterward by the breech, or tnce nrsa. In dicepluili one head may be pressed into the neck of the other or may rest upon the iliac bone till the first head makes its escape from the vulva. Even in thoracopagus, the commonest double monstrosity, in which two trunks * I.rliiiiiinn in 712 Inbors tlinuiKli I'JS contracted pelves foinul increasing difliciilty in de- livery with eiich siiceeedina; lal)or. In first lalinrs 50 per cent, ended spontancc)iisly ; in second, 4li.S ; in fimrti), 3iS.4 ; in fifth, '•i'ih'j ""il in labors after the fifth only '••.S per cent, (fiitiitri. />)'.<., Berlin, 1S91). t Or. (trace Pcckani (AVic Yark- Mi'dknl liimnl, April 14, 1SS8) has reported three still- hirths, attrilinted in each instance to the development of Wormian hones in the smaller fonta- nelle, and to the conse(|ueiit interference with overlapping of the cranial bones at the sutures. This ob.scrvation ha.s not vet been verified bv others. i*^iK-': !'t 1 ^ f lilt ^, i f i , 1 I li' i .5(54 AMKRICAN TEXT- HOOK OF OJiSTETIilCS. arc iiitimatJ'ly joined front to front (IM. ;}7), spontaneous labor is possible by the inechanisin siiown in Fij!;ure.s .'>74 and 875. On the other hand, the {great- est dillieuity may be eneountered in hibor, and the most sei 'oiis operation may be demanded to deliver the woman.* Fetal tumors obstrueting delivery may be hydreneephaloeeles, lymphan- giomata, myxomata, saeral teratomata. Cystie tumors should be ptmeturcd. Solid tumors may call for version or for embryotomy. C'ranioton)y may be re- <|uired in monstrous eidargement of the eephalie extremity, as in syncephalus or in diprt)sopus. Decapitation may be neees- sary in duplicity of the cephalic extrem- Fk;. 371.— Myxoma of Fif;. 37'J.-Siicnil tumor (Miittcr neck (l.oiiKuktT). ilus., CuUfgc iif I'lijsiciiiiis). Fui. 371.!.— Annsiirca. ity, as in dicephalus or in thoracopagus. In Keina's case of tricephalus the first head was perforated and then amputated, the second was perforated, crushed, and amputated, and the third was amputated. /^- 5n Fui. 374.— .Meclianism of labor with dicophalus (Kiistner). Ki(i. 375.— Mi'i'hanisni of labor in thora- copafius ^Kiistnl'r). Diseases and Death of the Fetus. — All diseases of the fetus that increase * Tlieri" are two recorded deliveries of thorucopagi by Cesarean section (Hirst and Piersol, Human Monstroaitks). I)YST(MIA. I'l.AiK :iK. lossiblt' by tlu' <>;r('iit- ratiun may lyniphan- j)unctur((l. rc'ii ( pliaUis till' perlbrated, in tliora- hat increase :st ami I'iersol, t. Ski'Ii'tiiii (if lijilroi't')ilmliis (tlirsl ('(illcrtiim, I'liiviTsity nf ri'iiiisylviiiiitii. 'J. HyclincciilmUis illirsti. :i. Uyilrciici'iiliiildrclc pDstcrinr illirst iiMil I'iorsiili. I. llydrci pliiilni>ilr Mi|iciiur. :,. llyilni- ci'liliiiliis ilisti'iiiliiiK IdWor utcriiio sokiiumiI ( Viiniicri. ti. Tti|i|iiii'^' ti liy(lriiccpliiilii> iIhuiil'Ii the spiiml ciiiiiil. i- 'M iff. •'., . li !■ (, "/■•. ,, 1 !'^ I f m'iJ 1 I t i-, ■; t'^'-' i' •H I ■'. :.i't i'i' li, -I J 41 -I a 1 r - y. "^^ \ U: i ■ .1 ; 1. 1^ DYSTOCIA. 505 its bulk may constitute thcrohy an obstrut-tioii in labor. Cystic tumors, ctTu- sions in tlic serous cavities, anasarca, an enlarged liver, polycystic disease of the kidneys,'" and distended blad<ler from atresia of tliu urethra* are exam- j)Ies. Li(|uid accumulations should b(( evacuated by pinictiu'e or by incisions. /[i/(lroi'rj)li(tlnx (IM. IW) is tiie most important condition under this head. It is not very raro,t is often overlooked, and is a tmiuent cause of ruptured uterua. Fig. 37(i.— TappInK n liydroceplmlus tlirout,'h the spiiml ciiniil (Vnrnior). The diagnosis can be made by a vaginal examination, by abdominal palpation, and by a combined examination, or, if necessary, by anesthetizing the woman, introducing the whole hand into the vagina, and thoroughly palpating the enlarged head resting above the pelvic brim. The wide-open fontanelles, the great width of the sutures, the fluctuation to be felt perhaps in these regions, *Sch\vyzer {Arrh.f. Gyn., Bd. 43) lias collected 13 cases of dilatation of the fetal bladder from atresia of the urethra, stenosis of the urethra, and obstruction of the urethra b_v a valve- like formation of mucous membrane. Miiller re))orts a case and quotes another {Arch./, (hjn., I!d. 47, II. 1). tSi4iuchard found it sixteen times in r2,0->") births; I.achapelle and l)uu;es, fifteen times in 43,555; ilerriman, once in 000. In 159 cases tiiere were 38 maternal deaths, twenty of which were from rupture of the uterus. V»;fr TTTV Si *!f1^-»' ! • ■■ If ,-' nw I Hi .5()() AJfJ'JJilCAA TEXT-BOOK OF OliSTETRICS. llio largo sizo of tlio head appreciated hy biiuauiial exaniiiiatioii, and possihlv tile abnormal mobility of the cranial bones, and in some cases their extreme temiity, indicate the ct)niliti()n. irydrocej)halns is very oltcn overlooked in jM'actice as the resnlt nsnally of a careless, snperficial examination. A pains- taking and methodical investigation of a suspected case shonld avoid this error. There are cases, however, in which there is no increased width of the sntnres, no enlargement of the Ibntanelles, and such slight enlargement of the head that it cannot be appreciated; and yet the Hnid contents of the cranium j)revent coinj)rcssion of the skull and make the engagenu'ut of the head impos- sible. The writer has seen one such case. Hydrocephalus should always be suspe<'ted if the head in labor remains above the brim, although the j)elvis is nt»rnuil in si/e and no good reason can be found for the failure of engagement. The traitiiK lit of labor obstructed by hydrocephalus 's puncture of the cranium with a perforator and evacuation of its fluid contents. A child with this disease deserves no consideration. Alter the reduction in the size of the head the labor n)ay be left to the natural forces. If these prove insulllcient, a cranioclast may be fastened to the skull and the child be extracted artifi- cially. A cardinal rnle in the treatment of these eases is to avoid attempts to deliver with forceps — a common error in practice, and one that has cost many a woman her lile from ruptured uterus, from tleep tears when the instrument slips, as it will, and from extensive sloughs after delivery. If the pelvic extremity of the hydrocephalic fetus |)reseuts — as it does in almost a third oi" all cases — and if the head remains inaccessible above the superior strait, so that it cannot easily be piuictured, the spinal canal may be ojx'iied, a catlu'ter be passed throngh it into the cranial cavity (Van Iluevers methoil). and the fluid thus l)e evacuated (I'^ig. ;}7()). Tsually, howev<'r, then- is no special dillicidty or danger in tlie delivery of the afler-coming head of a hvdrocephalic infant. The force n^piired tor its extraction not infre(piently ruptures the walls of the ventricles and converts the case into one of exlci-nal hydroce])liahis, or possibly drives the lliiid out of the foramen magnum into th(- tissues of the neck and back, so riMlucing the bulk of the head as to per- mit its extraction. At any rat<', the condition can scarcely escape the notice ot' the medical attendant, and a diagnosis is made before the lower ntei'ine segment is dangerously stretched or ruptured. The diilicnlty in the delivei-y of a hydrocephalic fetus is not in direct pi'o- portion to the (piantity oi' lluid in the ventricles ;;nd the si/e ol" the head. In eases of extreme distention (he cranial vault is likely to rupture, while in moderate grades of hytlrocephalns the (piantity of brain-substance surronndii\g the ventricles and the strength of (he brain-membranes forbid (his means of spontaneous delivery. M(i/jirifti'iiltifiniis inul Jitiilhi posilions (1*1. .")!>) include shoulder, face, brow, deviated vertex, and compound presentations. All but the last are considered elsewhere. \>y compound presentation is meant, the presentation of two or more parts at the same time, as a head and a hand, a head and a foot, a hand and a fool, nuchal position of the arm, or the head and all four ex(remi(ies. DYSTOCIA. I'l.ATi: ;?!). iiiraircMiicnt. , lace, hniw, (> coiisidcrcil 1 ol' two or Coot, a liaiid ti-ciniti('s. m I If: I 1 K'' li if'i H" ; a-. j 1 r ■ i ■ i i'-. - I. J Nile l|,-|l |.nsi|i |- iin ■'i. l''illl|PUUIIi| l.liM'lllluicill. 'I'M 11.1 |ilVvrllljlinlM.Mll|iMi I (' |..ilni.| |.lrMlll,lli,.|| l|||t>l) ; t ! ."! ( ' 'i M m DYSTorlA. I'l.ATK 10. I.'J. 'I'wiiis, triiiisvcisf iiml liirr<-li. :',. 'I'h iti.-. \",[U (i;iii^\rr.-v. 1, Tuiii-^, In a. I an<l I'lrnli. liulli trau-viTsc. I'l, 7. 'rwiii^. \h,:\\ linuls inr^i-iiliiii;. T«ilii<, «i_ '■ H. I ff. < i iB«i |l :ji. DYSTOCIA. 567 A compt)iind presentation is met with abont once in 250 labors. It is usually a head and a hand. Tlie following table is fiu'nished by I'erniee from 2891 births in the elinie at Halle: Jliind aiui lu'iul 20 Arm aiul Iioiul 8 Hand and unibilicul cord h Botli liands 4 Foot and liund '2 Two lianils, ninbilical cord, and foot 1 Face, hand, and cord 1 Kietz found in 7555 labors the foot and head presenting in twenty-three.'^' The eause of eompound presentations is usually a laek of eonformity in the presenting part with tin; pelvic inlet (as in !nal|)osition of tiie tetus), ahead of abnormal size, a displaced uterus, twins, hytlramnios, contracted pelvis, and anomalous shape of the uterus, etc. In the trcdtuwnt of compotnid presentations before rupture of the mem- branes an attenipt should be made to overcome the difficulty by postural treat- ment. The woman should be placed on that side opposite the j)rolapsed extremity. After rupture of the membranes an attempt should be made to dislodge the prolapsed extremity and to restore it to its natural ])osition. Version may, however, be re(|uired if this att(Mnpt fails, or even craniotomy if the child is dead, ff the head and extremities present, and if the former is engagctl, it is usually best to ajiply forceps and to disregard the j)rolapsed extremities. In the case of nuchal position of the arm an ellbrt should be made to dislodge the latter, but it may be necessary to I'racture it before the delivery of the child can be secured. Miillipli' JiirfliK. — Twin labors are usually easy and uncomplicated (75 per cent.), but complications are more frecpient than in single labors. ^lalpresen- tations are common (IM. 40). The following tal>le from Spiegelberg, based on 1 1;!<S labors, gives the citmbined presentations in the order of their frecpiency : Both luads incsciitiiif? 49 per cent. IIi:id :in.l liiwcli 31.70 " " Itdlli pi'lvic presentations 8.(i0 " " Head nnd transverse 6.18 " " Urcccli and transviTse 4.14 " " Both transverse ;{5 " " Ft may be noted that ii transv(>r.se position is found in 1().G7 per cent, of cases. .Mcchauiciil dillit'idties in hibor are fre(|uent, the uterine muscle is usually weakened by overstretching, ;ind there m;i, le trouble in the third stiige of lai)or in the <lelivery of the placentii. Some form of openitive interference is demtmded in about '25 per cent, of ;dl ciises. In the majority of ctises (7!* per cent.) the int<'rv;d between the delivery of twins is less than an hour. A longer delay tlnm this indictitcs the liUelihood of .some obstruction to the birth of the second infant or a failure of expulsive forces. Serious dinieidts' in twin lahtn's iiiav tirise in one of three wtivs : Both '*- ' ii -f . / :l U- r ! 'r;r <w S ! ■■. 568 AMERICAN TEXT- BOOK OF OliSTETRIVS. heads present at once, Diie a little in advance of tlie other, the second impacted ii the neck of the first (Fii^. 877); the first child descends by the breech, and tli Fk;. 'M'i. — Iiii|iac'ti()n of heads in twin labor. Vu-. :>7.s.— l.dcliiiig of lu'.-iils in twin liibor. head of the second diild is cautj;ht by the chin of the first and pushed into the pelvis (Fioj. 378) ; one child sits astride of the other, which is transverse. If both children should be found atteniptinoj to en>z;a<>;e ity the head in the superior ^ strait at one time, one child should be retarded while the other is artificially extracted. If this is impossible, the first head should be extracted by forceps, the second be treated in like manner, and then the trunks should be delivered one after the other. Embryotomy is a last resort, but is scarcely ever necessary. A eoilint; of the cords (Fi^. 379) and their eii- tano;lemeut may be a source of difficulty and delay in iniioval twins. It may be necessary to cut one or both cords between ligatures before the children can i)e delivered. In cas(> one child pres(>nts by the head and the other by the feet, both may come down together, and the two hea<ls become locked in the pelvic entrance and canal. An ctVorr iiiay be made tn push back the child presenting l)y the head. If this su<'c<M>ds, the child presenting by the breech should be extracted immedi.atcly, for it is in immi- nent <langer from asphyxia. It may Ix; possible with forceps to pull the child j)rcsenting i)y the licati |»ast the body of its fellow presenting by the breech. Failino- ii) these attempts, the <'liild presenting by tli^' breech will almost surely have died and there will be no pulsation in its cord. It should then be decapitated, whereupon the infant presenting by the licad can be extracted without difficulty by forccj)s. '■*<i^^»^^gjjjjf*^ V\ii. :i7l».— I'.nliui^'li'inriit of in tw ins ( Wine kcli. inl> DYSTOCIA. 669 111 any case of twin labor, as soon as the first cliild is born, and the oord, liirated with a double ligature, is cut, the attendant should ininiediatily inves- tiirate the position and presentation of the second eliild. A negleet of this rule loads very often to the inipaetion of an unreeogni/ed shoulder presentation in the mcond child, and its eonsecjuent death. If an abnormality is discovered in the presentation of the second child, it should at once be corrected. Then, after wait- ing perhaps half an hour, the anuiiotie sac should be ruptured, and ergot may be administered in a full dose to secure a speedy delivery, or, if the stomach will not retain it, the hypodermatic svringe should be used, for, the birth- canal having been dilated thoroughly, there is no obstacle to the birth of the soc(md infant in twin lab(»rs, and con- sequently no objection to the employ- ment of ergot, which not only hastens the conclusion of labor, but j)romotcs subserpient contraction of the much- distended uterus, and so prevents ])ost- ])artum hemorrhage. As a further ])recaution against this accident the fundus shoidd be compressed for a long time after birth by the nurse. There may be difficulty in the delivery of the placentte in twin labors. Commonly the children are horn first and the placenta; .'ifterwavd. Their bulk may make expression dif- ficult, and it is oflen necessary to make some traction upon the cords — first upon one and then upon the other — to determine which j)lacenta will come first and to assist in its expul- sion. Occasionally one and rarely both placciuje may be expelled after the birth of the first child. Tn a case of the writer's the ])laccnta of the first child, prolapsing in front of the second, necessitated a dillicuU forceps operation titr the extraction of the second. On account of the frequent and extensive anas- tomoses between the vessels of the placenta* in unioval twins it is a necessary precaution to tie the cord of the first child with a double ligature and to cut it between the ligatures; otherwise the second infant might bleed to death. The prof/)ioNi,s of twin labors is always doubtful. There are so many possible dangers for both mother and childnMi that nudtiple labors nnist be regarded as distinctly pathological. Albuminuria in the mother is the rule in multiple pregnancies, and eclampsia is ten times more frequent than in single births.* There is a disposition to inertia uteri during and after birth from distention * Of 027 cases (if cnlatii|isi:i, sixty-iiino were multiiile iin'jjiiiuicies (Wiiu'kel). iNi.— Twins, linid iiiiil hrci'cli. if M ! . t ' if U' 570 AMEBICAN TKXT-liOOK OF OB:STETRICS. ^■:\. I III of the cavity, aiul ('oiiso(|iioiitly a likelihood ot" post-partiim hoinorrhago. Some operative interference or iiitra-iiteriiie iiianipiilatioii i.s called tor in about 25 per cent, of cases, and this, in addition to tiie frecpicncy of kidney insufficiency, pre- disposes to sej)sis. Finally, there may he insiij)eral)le obstruction in labor if locked twins are not nianau;cd properly, and the woman may die of ruptured uterus or of exhaustion. The maternal mortality in the Budapest iNIater- nity was foiu' times as <rreat as in the sinu'le births, and Klein wiichter's statis- tics ji'ivc; a mortality of ]."j per cent. For the children then; is greater danger than Ibr the mother. Twin [)regnancy is almost always j)rematurely inter- ruj)tcd, and even if it is not the children are, as a rule, under the normal size and weight. There is always the possibility that the development of one child at least will be seriously intertered with by the lack of room in the uterine cavity. Ilydranniios of one sac and oligohydramnios of the other are not uncommon. Jn labor there are the frc<picnt complications from malposi- tion, operative interference, entanglement of or pressure upon the cords, and more rarely the engagement of both bodies at once in the pelvic canal. In Kleinwiichter's and Ke/marszky's statistics the fetal mortality was nearly 40 j)cr cent. Of 38 children in cases of locked twins, only six survived — a mor- tality of 84 per cent. Cases arc on record in which an extra-uterine fetus has obstructed the deliv- ery of the intra-uterinc twin. It has been necessu'v to mak(( a vaginal incision through which the former was extracted betbre the latter could be born. Death of the fetus during or before labor, followed by rigor mortis, has proven a source of obstruction in labor by the rigidity of the child and the con- scfpient intcrtl'rence with the normal mec'lianism of its delivery, and cspeciallv of the shoidders and trunk.-'" Ankylosis of the large joints of the extremities may have the same etfect to a less degree. Labor Complicated by Abnormalities in the Fetal Appendages. — Mciiihrdiiis. — if th(! membranes are too thin, they may rupture prematurely, and thus give rise to what is calletl a "dry labor," in which the birth-canal must be dilated by the hard, unyielding presenting part instead of by that con- servative hydrostatic dilator, the bag of waters. Such lai)ors are longer and inoi'e painfid than the average, and there is a greater likelihood in them of lacerations in the cervix and a more fre(|uent demand titr an artificial termina- tion with I'oi'ceps. If tli(! membranes are too thick, they rupture late, being preserved ])erhaps until the child's head presents at the vulvar orifice, or even until the complete escape of the head from the mother's body. In these cases the head and face are covered by the mend)ranes as though by a veil, and care must be taken to ih'v the mouth and nose (piickly, that respiration nuiy be instituted without interference. The membranes thus covering the head and face are spoken of as a "caul." It is possible for the whole ovum to lie extruded uid)roken at term. The writer has seen this occur as late as the sev- enth month, and, as stated, it is actually recorded at the full period of gestation. Dilliculties in labor may be encountered in eonse(|uence of an abnormality in the (piantity of liquor aninii. If there is too little, the labor has the same 't i' DYNTOCIA. 0/1 ;liiiif'al foatiircs as tlioiijijh tliorc had Iktii a preniaturo laceration of the lucin- Ijihik's. IC there is too iiiiieh Ii(|Uor ainnii, there may be inertia as the result (if overstretehinjj of the uterine niiisele-fibres. ['iiihi/ic<i/ (,hr(L — If the unihilieal cord is too sliort, it may cause jirema- iiirc (letaehment of the ])laeenta or may ])reven' the advance of the eliild. flic (llaj/iioHis of a short cord in labor is always ditTicult. It may bo sus- pected, however, if there is exai!;<>;erated pain at the jjlacental site, marked r('<'cssion of the head after each pain, and an obvious retardation of labor I'lii. .Jxl.— rinliilical imuiI. cuu'-.'lit in llio iixillii, (■iH'ii'cliiiu' llu' shnuMiT iiiul iimlupscMl. without otiier ascertainable cause. Forceps sliould be applied in such a case it' the prcsentati(»n is cephalic. If the cord is too lonu', it may possibly prn- liipse slioidd there be other conditions in the labor I'avorablc to stich an ai'ci- ilctit ; or it may l)e coiled about the child's neck, tnud<, or extremities, and may cousecpieiitly be fatally com|)ressed duriiiti' labor ( Fi>i'. 381 ). Obstruction of a mechanical character in labor on the part of tln^ placenta i-^ seen only in placenta pnevia and in jirohqwe of the placenta. The placenta may be adherent as the result of syphilitic or other inflammation of the cikId- iiH'triuni durinti' |)re<j;nancy, and, becoming- partially detached in the third >taij;e, i -:|; im iv I a~. 'St' r i B*; I i>h nm \'' '^'jw' ' ^m ii: i I fW, r,72 AMKRIVAN TEXT- HOOK OF OBSTETRICS. may cause alarming liemorrliago. It i.s very commonly .simply retained in tlic lower uterine .segment or in the vagina, whence it may be cxpresised by the proper application ot'Cre(le'.s method. In .some cases the atmospheric pre.ssiiir obstructs tiie delivery of a retained placenta .so ett'ectually that it is necessarv to hook one's finger over the edge of it, to allow the a(!cess of air behind it. before its expre.ssiitn is possible. Retention of the placenta may be due to its great bidk, as in twin placenta;, or to tumors increasing its size. In such cases it may be necessary to extract the placenta manually. REFERENCE LIST. 10. 11. 12. 'I: /)((.'( rn(\e Urrkrii. Lit/niann ; " Drei VortriiKe iiber die (iesi'liiohte von der Lclire der (lehiirt bt'i I'liffi'in lic'fken," in Iiis Ueburt bei ('iit/nii Jicrkrii, tic, 1884. Tr(innactioiii< of the American Gynecological Sodrti/, 181)0, p. 8()7. Miilli'r'.s llunilhnck. Robert Wallace John.son : ^1 AVic Si/nlem of Midu'iferij, etc., London, 17(1!). Hirst : I'niirrsit;/ M,<lintl Mu<inzine. "Die Hecken Anomaiien," by Friedrich Schauta, in .Miilk-r's llandhnch der llc- burt.'iliiilj'r, I!(l. ii. ; Ik'tschler, Aniialcn der UlniKchen Anstalteii, i. pji. 24, (iO ; ii. p. !U ; Engi'lkcn, />/.«. liKutf/., Miincbcn, 1878 ; " Ziir Kentniss der extra-median Einstellinii; de.s Kopl'es," Kobn, Vraijer ZeitKehrij} flir Hrilhtnde, Bd. ix. rrai/er Ziitichriftfiir Heilkumle, I5d. ix. II. 4 and •"). Die ILiftelherf/er kliiti^chen Annalen, I5d. x. ]). 44i). .More elaborately described in his folio atlas, Jhis Selirii;/ reretii/te Jieckeii, tiebM eineni Anhaiuj iiber die irich- ti;/nte)i Fehler des Weibl, liee/cetin l^eber- liaupt, mit IC) Tallen, Mainz, 18;}.7. Stiiilil di (Mefriria e (;iiuTi,l., .Milan, 18<,I0, Jahrc.fherirht iiber d, Furtnehr. <i. d. Gebiete der (t'eburlfili., ele., vol. iv. |). 188. Franz Lndwisj NeUKebauer : " Hericlit iiber die neueste Kasuistik nnd Litteratur der Spondylolisthesis," etc., Zeltnehrlj't J'iir (lebtirt.-fliiilfe iind Gjpilikolor/ie, Hd. xxvii. II. ii. 1808; "Spondylolisthesis et Spondylizenio," Rcitiimv dex lieclierrliex litternires et permtiellc depitin /<W0 jimju'en 1S!)J, I'aris, (i, .Stt-inheil, 1892; "Contribution a la I'athogenie 18. 14. If). 16. 17. 18. 1<). 20. 21. 22. 28. 24. 2(!. et an f)ia,i!;nosti(iue du Hassin vicie par le ()lis,senient vertebral," Auiudex </.■ Gijneedlnijie, Feb., 1884; Zur Enlwieke- hnKjMienehiehte ties Spondijbilixlheli.-'nhin Jieekcns und .winer Diaf/uone, Halle and Dorpat, 1882, p. 294; see also Areldr J'iir (ri/niik<>b)<iie, Hd. xx. II. i. and ltd. xxi. II. ii. Ilii-st: "The Influence of the Ili.biluiil Inclination of the I'elvis in the Ereci Posture u|>on the Shape and Size of the Pelvic Canal," UiiieerKitj/ Medic(d Mmju- zine. Centr(dbhitt fiir Gi/niikohfiie, 1889, [i. ()12. XouvelleK ArchircK d' Obxtctriiine et de Gijw'- coloi/ie, 1890, p. C40. Soutbermann : lierliner medicinixche W'url,- ensrhrijl, 1879, 41. Jeutzen : Archives de Tocologie, Paris, 189it, If. 8. Ablfeld : ZeituchriJ't fiir (leburtahiilfe uml Gijniiknlogie, Bd. xxi. p. 160; ibid., Hd. xiv. p. 14. " Ueber (icscbwiilstc der Vagina i\\> Schwangei-schaft nnd (ieburts-konipli- kationen," Disn. Innng., Bern, 1889. Adams: "Ilerniji of the Pregnant I'tc- rus," Amerirnn Jimrmd of Obslelrle.<. vol. xxii. p. 22."). Xouvelles A rehires d'OhMeiri<iue, 1890. Sutugin : loc. eif. Phillips: liritixh Medical Journal, 188S, j. p. 881. Fussell : Medical Xetr.t, Philadelphia, 1891, p. 40. Dm. Lmug., Berlin, 1890. Feis : " I'cber intrauterine Leichenstarre," Archie fiir Gyniikologie, Bd. 4(), II. 2. DYSTOCIA. 673 2. Dystocia due to Accidents and Diseases.* 1. ACCIDKNTH TO I'lIK UmHILICAK CoUI>. Tli(> cord iLsimlly meusuros about 20 inches, but it may have twice or thrice that length, or may even be lonj^cr. In v'onse(|neuce of this Increased len<rth jti'olapse is liable to occur. (Jreat lenj>'th of the cord at least permits more or less iHMiierous coils or "circulars" of the finils about the fetus or its members. In consequence of these circulars the cord may i)e shortened, or there nuiy be a natural shortness of the cord. The cord has been known not to exceed 10 centimeters (4 inches) in leni>;th, but most generally iUs shortness results from its coiling around the fetal parts. This brevity, whether natural or accidental, interferes with labor, and may cause conditions more or less grave to the child and to the mother, for a ruptured cord, a detached placenta, or even an inverted uterus, may be among the accmlents resulting from the anomaly, t'ompleti' absence of the cord has been observed, the vessels pass- ing directly from tlu^ abdomen of the child to the adjoined placenta. The reason is therefore plain for including in a single group anomalies oi", and accidents to, the (H)rd. Prolapse of the Cord. — By prolapse is meant descent of the cord with, or in advance of, the presenting part of the fetus. The prolapsed loop may be ielt mobile in the waters when the membranes are unrnptiu'ed ; or, the amnial liquor having been discharged, the loop may be in the vagina ; or, finally, it may be external to the vulva (Fig. 381). Thus there are threef varieties of pro- lapse, thnugli some authorities describe the first variety as presentation of the cord. The second variety of prolapse may be met with though the first was not observed or even did not occur, the loop having suddenly been carried into the vagina by a free discharge of anmial licjuor. In most eases the two liaK'es of the loop are in a))position, but in some cases the i)resenting part may intervene. Thus in presentation of the head one half of the loop may be on one side and the other half on the other side of the presenting i)art; or in presentation of the pelvis the cord may be between the thighs. The frequency of j)rolapse of the cord is variously statcil. According to Winckel, clinics give from 1 in 65 to 1 in 500; this accident is oftener observed in hospital practice than in private practice. Etiolopy. — The essential cause of prolajise of the cord is want of corre- spondence between the presenting part and the lower portion of the uterus, for if the former 'illy occupies the space, there will be no room for the cord. Among causes :.iat contribute to this accident are great length of the cord ; the woman starding or sitting when the membranes rupture ; an excessive quantity of amnial liquor; smallness of the fetus; multiparity ; implantation * The superior figures (M occurring throiighoiit tlie text of this .irticle refer to the hiliIiogra|ihy given on jiage 644. t The elussificution nutdu hy Jucquemier, Manud ilea Accoitrhement.-i, 184t), has been adopted. Bii :> f, -i ■; i .ff^. V] yl / IMAGE EVALUATION TEST TARGET (MT-3) Photographic Sdences Corporation 4^^ 1.0 ^Bi 1^ 1.1 l^^ ^ "" nm 1.25 II 1.4 1.6 ^ ,#/ kJ ^— V 1 23 WEST MAIN STRUT WEBS^iiH.Nt 14StiO (716) 872-4503 7.^ ^ 6^ w 574 AMERICA y^ TKXT-BOOK OF OBSTETRICS. of tho placonta in tlic lower portion of the nteriis ; marginal attac-luncnt of the cord ; pendulous abdomen ; plural proffnancy ; the birth of a male ; a com- plex presentation — as, for example, descent of a hand w'th tho head ; present- ation other than of the vertex or the face ; and, more important than any of these, narrowing of the pelvis. Kaltenbach ' remarks that prolapse of the cord in presentation of the head occurring in a primipara should alwavs excite suspicion of a narrow ])elvis. Predisposition has also been mentioned as a cause, the accident having been observed in suc<;essive pregnancies ; but. of course, to admit i)redisposition as a cause no other obvious cause must be present. Roper ^ has given a case in which the accident occurred in three suc- cessive pregnancies, but there was notable lessening of the conjugate. The prolapsed loop usually descends in front of one of the sacro-iliac joints or in front of the cotyloid cavity, and rarely directly anterior or posterior. The (Ikuinos'iH of prolapse of the cord can immediately be made if the membranes have ruptured and the loop is in tho vagina, and still more readily if the cord is external to the vulva. A mistake in either case woidd seem impossible ; but with the membranes intact and with the pulsation absent the diagnosis is more difiicidt. The obstetrician feels with his fingers, in tho in- terval of uterine contraction, a soft, floating body, the thickness of a finger ; he can define it as the cord by hooking his finger in the loop and pressing it against the i)rosenting part or against the uterine wall : if pulsation is detected, there is no possibility of doubt. Winekei ' called attention to the fact that if, in auscultating '^he fetal heart, the sounds become slower, there is probable pressure upon the cord, and an examination may leail to the discovery of prolai)se of the cord. PrognoHix. — Danger to the mother is exceptional in prolapsed coid. In eonse([uence of the cord being stretche<l tightly over the head of the child, or, in pelvic presentation, of tho child being astride of the cord, there may be su<'li an accidental shortening of tho cord that dotachmont of tho placenta witli Ijomorrhago results. Moreover, the operations which the prolapse may re(|iiirc in its treatment — mainial or instrumental reposition, iiodalic version, or ex- traction with the fitrceps — are not to bo regardtnl as trivial matters and with- out peril to tho mother, although that peril is slight. The danger to the child, however, is very great. Probably it is correct to give the mortality as not less than 40 per cent. The danger to the fetus is comj)ression of tho cord, death resnltinir from asphyxia. The danger varies also with the |)resentation, being great- est in that of tho head, but much loss in shoulder or breech presentation. Karly prolapse is nioro unfiivorable than late prolapse. If tho cord is im- planted upon tho margin of the placenta and the placenta occujiies a low position in tho uterus, or if tho insertion is volamentous, or tho pelvic con- traction (a fiictor in causing the disorder) is great, tho prognosis is more unfavorable than when opposite eonditions arc |)resent. Finally, the anioinit of tho ])rolapsed portion and the part of the pelvis in which it descends should be considered. DYSTOCIA. 575 ittaolunent of male ; a coin- ead ; present- tlian any of olapse of tlic lionld always ?n mentioned nancies; but, aiise mn.st bo in tbrec suc- jngate. The J joints or in (sterior. made if the more read! I v ! wotdd seem Dn absent tiie rs, in the in- f a fin<;;er ; he iing it against eteeted, there et that if, in is probal)le liseovery of 1 cord. Ill die ehihl, or, may be sueli hieenta with may re(|iiire rsion, or cx- rs and with- to the child, tab'ty as not di resnltinjr being great- )resentation. cord is im- iipies a h)\v pelvic con- sis is more the amount ends slioidd Treatment. — If it is certain that tlie child is dead, a purely expectant plan of treatment is indicated in prolapse of the cord. The diagnosis of death, however, should be made, not solely from finding the cord pulseless, for ])ulsation may l)e absent in it for several minutes and yet the child be alive, but by careful and repeated abdominal auscultation. Again, if the prolapse is simply a compli- eati(»n of placenta prievia or of shoidiler presentation, the treatment of the essential disorder is first in importance, and it may prove best, too, for the complication. In ordinary cases restoration of the prolapsed cord, if this be possible, is the ol)stetrician's first duty. In the first variety or degree of prolapse, f'rerjuently called " |)resentation of the cord," the patient should be recunnbent anil great care should be taken to avert early rupture of the mendiranes. It will ha l)etter for the patient to lie upon the side opposite to that (tn which the prolapse o<«urs, and her head should be low. Ilicks advises that the patient assume the knee-elbow position and that entrance of air into the vagina be se<.'ured. In the second degree of ])rolapsc — namely, a loop of the coid in the vagina — if the pulsation is good, the (^ord being at the side of the head, in front of one of the sacro-iliac joints, and the descent of the head being rapid, so that spontaneous delivery will sjwedily ocinir, it is better to wait, interference with forceps, for example, being determined by the ptdsations in the cord becoming feebler or ceasing. La Motte, whose rule in cases of prolapsed cord was podalic version,^ gives a graphic account of one of his cases ending favorably for both mother and child. lie did not discover that the cord had descended until he found it in the vagina, and the uterine action was so great and con- stant that he could not attempt to turn. In his Rcflix'Um he observes that probably his " ignorance was the safety of the child." If speedy delivery, either spontaneous or instrumental, is im|)ossiblc, repo- sition of the cord is indicated. This replacement is postural, manual, or the two combined. Instrumental reposition nn'ght have been included, but there is no instrument equal to the hand for this purpose, hence reference to the various repositors will be omitted. If the postural method is employed, the patient is put in the knee-ell)ow position. The hand niay also be used at the same time, as advised by Kaltenbach, but it is preferable, if mamnd assistance be required, that the patient should be upon the side, for then oidy can anesthesia fully and satisfactorily be cinj)loyed. IJraxton Ilicks gives the folhtwing directions : " The anesthetic having been given, the patient remain- ing in the ordinary lateral obstetric ])osture, one hand is placed over the abdo- men and the position of the child's head is made out. This may be done by separating the thighs and passing the hand, preferably the right, between them. The left hand, having its back greased, is passed into the vagina, and, gather- ing the funis together, carries it past the head, which is at the same time pressed sufficiently aside. When the funis is restort><l the external hand presses the head down, and the fingers inside receive it and adjust it in the OS. Six or more labor-pains having occurred, the internal hand may be re- moved, although it might have earlier been removed, and rein*:rotluceil to feel 11 .e ■: . "^ -'■;■ 57<5 AMERICAN TEXT-BOOK OF OBSTETRICS. if the funis is still up. The patient can then be plaeetl on her hack, while the outer hand is kept a little lon-^er to seeure the adaptation of the lower uterine zone to the heatl." * The writer has two remarks to make in regard to the metlio*! suggested by Hieks. The use of the left hand tor replaeinj^ the cord, the patient being upon her left side, is suitable if the prolapse<l loop of cord bt* upon the right side of the pelvis, but if the funis has tleseendiHl upon the left side, then the woman should In* in the right lateral position, and the right hand is the pref- erable one for introduetion, while the left hand is used externally. Further, when the cord is restored it is well to hook it over some part of the child, the knee, for example, or pass it above the chin : the method of placing tli(> cord over one of the lower limbs to prevent its again falling was probably first recommended in 1786 by Croft." By whatever method the cord has been replaced, pn)lapse is very liable to recur. So great, iudee<l, is this liability that some classic writers on obstetrics have compared its restoration with the task of the Danaides and with that of Sisyphus. Manual reposition having failed, podalic version best meets the emergencv of prolapsed cord. Spicgdberg^ takes the grounil that it is not well to spend too much time in trying to replace the cord, such ettbrts in themselves disturb- ing the umbilical circulation, and perhaps injuriously alfecting the subseciuent course of the uterine contractions. After version the question of immediate delivery will be determined bv the condition of the fetal circulation, for if this remains good it is better to leave the expulsion of the child to the forces of nature. Winekel advises, in shoulder presentation complicated by prolapsed cord, immediate extraction after version, because the latter can hardly be etfected without great pressure upon the cord. If in pelvic presentation the child is astride of the cord, an etlbrt should be maile to draw down enough of the loop to permit its being passed over one thigh : if the loop does not permit this lengthening or if there is dangerous stretching, it is better to divide the cord. Coils or Circulars of the Cord. — The cord encircles the fetus once in about every six cases of delivery. These coils or circulars — adopting the ecpiivalent of the French circulabrx as applied to this condition — are nnieh more frequently about the neck of the fetus, but they may be around the body or around the members. There may lx> one or several circulars ; for example, the cord, while usually around the neck once or twice only, may encircle it six, seven, or even eight times. The optimism of Jacquemier led him to believe that cii'culaires were a wise provision against prolapse of the cord. This anomaly is generally associated with great length of the cord, but in some cases the length is normal, and in a very few it is less than normal. Etiolorjif. — Winekel ' mentions as causes of circulars a long cord, a largo quantity of amnial liquor, the yielding uterine walls of multiparae, marginal and velamentous insertion of the funis, and smallness of the child. Of cours<' the movements of the fetus are the immediate cause of the anomaly. Chan- treuil observes* that experience does not confirm the opinions of Michgorius, nvsToru. 677 Mine. Boivin, ami others, who attribute ciiciUarH to the excessive raoveiiK'nta ot' tlie mother. The injurious results of circuhirs, so far as hihor is concerned, usually arise {yam brevity of the cord — a Iv-evity which is then called "accidental," tliouj^h l)v njany the adje«'tive "relative" is applied to the condition to distinguish it Iroin "absolute" brevity. The accidents resulting from shortness of the cord will be considered in the next secition. Natural or Accidental Shortness of the Cord.* — By natural short- i)(>s of the cord is meant that the length measured fntm the uml)ili(;us to ilic placental insertion is insutli(;ici:t lo permit expidsion of the child without rupture of the cord, placental devaehment, or uterine inversion. Accidental slmrtness, usually arising from coils alwut the neck of the child, is similarly (Icliucd, cxce|)t that the pctiiit of the fetus from which the measurement is liikcn is no longer the umbilicus, but is the neck. It is evident that the length (»f the cord will vary, in case of absolute lircvitv, with the degret? to which it can be stretched, and in aci'idental brevity uitii this elasticity, and also with the tightness of the coils caused by the strain. Fiu'thcr, the point of placental attachment, either in the upper or the lower part of the uterus, and the insertion of the cord, whether marginal or (•out ral, must also Ix' taken into consideration. Matihews Dinican* assumed (iiat " it is impossible to make a (piite exact statement of the length of any mrd while i>roving itself a cause of difficult labor." Lamare says, accepting the statement of Xegrier that the length of the genital canal at the time of expulsion of the fetus is '22 centimeters (8j inches),'" that true brevity begins at 2") centimetei-s (10 inches), and that only belo\. this length does the cord inevitably cause accidents.f Shortness of the c(»ril does occur, notwithstanding the scepticism of DeweeSjJ though the instances of it arc infrc(pient. The consequences of this condition are painful, protracted labor; in)possibility of spontaneous deliv- ery ; there may be fatal pressure upon the cord, or it may be torn and there may be hemorrhage from <letachment of the i>lacenta, and even invei'sion of th(> uterus. Rigby gives an instance of a cord which was only 2 inches long l)cing torn at its placental insertion, the delivery being spontaneous. Kales" delivered with the forceps in a case in which there provetl to be accidental sliorteiiing of the cord. On making traction during a pain he foiuid there then occurred a notable depression at the fundus of the uterus, the depression disappearing when the traction ceasetl — one of the signs of this anomaly, according to some authorities, although denied by others. Werder'* reports * Most authors use the terms uhsnliile imd relalhv, but the writer tliinks thiit tlie adjectives wliicli lie licre employs are preferable. t Kalteuhach { Li-lirhiich <ler Gi-hitrhhiil/f, 1803) Mates that if the placent.il insertior of the cord is at tiie fundus 3") centimeters is too short, while in deeper insertion 20 centimeters is sulllcient. t " I shall not positively deny the existence of such a condition ; hut I nnist say I have never seen an instance, and also that I entertain strong doubts of its possibility." — C'umpendiuua *j/.t(?Hi of Midififcnj, 8th ed., I'hilada., 1837. 37 hk t i( ! ■ ;'l «»i '^,"] il s' !i'^'^'''^^. ,<-, I , I " i Si ' iMIa ii 678 AMF.RK'AN TKXT-JiOOK OF OliSTETltirS. a oaso ill wliidi, the diild iH'iiij; di'livorc*! with foreops, tiie cord was found torn at the uiid)ilinis, and with it a largo cin-nlar Hap of skin : the cord wa- Icss tlian 4 int'lios lonj*;. Fclkiii '"' nari'atos a case of spontaneous delivery in wliieh the cord, oj inches in lenjith, was torn and the placenta was cxjM'lled with the ehihl, severe heniorrha<;e occurring. In a second case of accidental sliortness of the cord, there being five coils about the ueck and one around tlic body, the delivery was spontaneous and inversion of the uterus .M-currrd. Dyrcnfurth of Jircslau,'* in a case of hydrocephalus, punctunMl the head ami delivereil it with the crauioclast ; there was then delay in extracting the shouhlers, and when this dilficulty was overcome and the labor was ended it was found that the cord, which measured but 3 centimeters, was torn halt' a centimeter from the umbilicus. Malgoiiyre had a patient in labor at term, and immediately after the rupture of the mend>ranes the child and placenta were expelled, the cord being tbund to be 2 inches and 8 or 1) lines in length. In a case reported by Leroux '" the umbilical cord was so short after tlu- escape of the fetus that the umbilicis was closely applied to the vidva, and the child could not be taken away until the ])laceuta was cxjiclled. It has been establishtnl by Xegrier '^ that if there be accidental shortening of the cord because of a loop around the neck, ]>artial delivery may occur, the child breathing, and then, unless suitable assistance be rentiered, the child will be strangled from constriction by the «)rd. Maekness,'^ in a ease of placenta pnevia, after iwrforming j)odalic version, bringing down one foot, and finding the hemorrhage not arrested, brt)Ught down the other foot ; after extracting the boily further i)rogress was arrestwl because of the cord passing between the child's leijs. It was necessarv to cut the conl before the head could be delivered. DUignonlii, — The signs usually given of brevity of the cord are severe pain at the place of the supposed placental attachment ; depression of this part during a uterine contraction or when traction is made with the forceps; marked recession of the head in the interval of contractions, this recession beintr yrreater than can be attributcnl to the resistance and elasticitv of the lower part of the birth-canal; irregular discharges of blood; and arrest of pains. Napier '* regards uterine inertia as a more important diagnostic sign than retraction of the head. Dr. King," who has made several important con- tributions on the subject, states as a characteristic sign that the patient has ii persistent desire to .sit up. Coils about the body niay be known in some eases by auscultation, in still rarer cases by abdominal palpation. Ilaake was the first (in IHGo) to discover coils around the neck by rectal touch. But the only certain way to ascertain that there is shortness of the cord is to feel it and actually to know that it is tight and stretched. This niay be done in breech presentations, when the child is astride of the cord or after the breech is born, by j)assing one or twn fingers up to the umbilicus, and finding, by judling toward the placental end. the cord so taut that it is impossible to draw any ])art of it down. In \>\\'<- entation of the head, after expulsion as far as the umbilicus, a similar method 3 '■ DYSTOCIA. 579 nul could 1)0 of oxaiuination may also be employwl. Hicks " narrates a case in which he iiiiulc the diagnosis of short cord ; after the delivery of the breech he luul to tliviile the cord before the rest of the child could Iw born. The cord proved to l)e Init 4 inches long. Treat menl. — In regard to the treatment of shortness of the cord but little can l)e said. Koederer, and many obstetricians since his day, urged the importance of pressing the uterus downward, the obvious benefit of which, of coiu'se, is to bring the placental attachment nearer the fetus. King" seeks to iiccoinplish the same object indirectly by having the woman " take a kneeling, sitting, or sfjuatting ))osition, or by so elevating the shoulders that she is placed midway between lying upon her back and sitting." Jn comicction with J)r. King's method the following citation from Dcnman* is of interest: " If the child shoidd not be born, when we have wait(!il as long as we be- lieve to be proper or consistent with its safety or with that of the parent it will be riHpiisite to change her position, and, instead of sufl'ering her to remain in a recumbent one, to take her out of bed and raise her upright to permit her to bear her pains in that situation ; or, according to the ancient custom of this country, to let her kneel before the bed and lean forward upon the edge of it ; or, as is now ])ractised in many places, to set her upon the lap of cue of her assistants." It is better that the child should be delivered by ]>resstn'e, fetal expression, than with the forceps. Instrumental delivery is the last resort. Of course, when a short cord is discovere<l, which will usually be only af\er jiartial expul- sion of the fetus, the cord shoiiM be dividetl. When, in accidental brevity of ihe cord, the strain is not relieveii by cutting the cord or by removing one or more of the coils over the head, the child is usually delivered by what Duncan*' terms a movement of spontnneous evolution : "in consequence of the strain upon the i-ord the fetus so revolves that its anterior surface is brought to look forward." Duncan adds that in cases of ct)ils about the neck this revolution is in a diiection to undo partially the encircling, and thus to lessen the strain upon the cord, and that this part of the evolution may artificially be perft)rmed to aid the delivery. Rupture of the Cord and of its Vessels. — The cord may be torn or there may be rupture of one or more of its blood-vessels ; in other words, there may be cdinplete or partial rupture. Some illustrations of rujjtures of the coril have been given in the pnveding section. This accident occurs most frecjiiemly in ('()nse(|uence of absolute or accidental shortness, omitting those cases in which the obstetrician tears the cord in an effort to extract the placenta. The strength (if the funis has been the subject of experimental study. The experiments of Duncan and TurnbulP' show that the average resistance of the cord to a strain on it is eight and a (piarter poiuids, the weakest cord yielding to five aiul a half pounds, and the strongest to fifteen. The experiments of Lamare" prove that in order to ru])ture a cord of 50 centimeters by a weight falling 25 cen- timeters, it is sufficient that this weight may in the mean e(pial lotK) or 2UU0 grams, and it may even be as small as GtIO grams. He has shown also t drt 4 Jlf' ' is t -IV ^ i 1-3 1 ' ' r WT^" .*)«(> AMKIiK'Ay TEXT- HOOK OF OliSTKTHJCS. that tlio liviiij; cord — that is, tlip cord liaviiij; its vessels filled with warm water — breaks with a slightly less force than the dead cortl. It is evident that, as has repeatedly Iwen provcnl, the cord may Ix* torn simply hy the weigiit of the child, expulsion taking place while the nutther is erect or even semi-erect. Moreover, there are instances of the cord giving wav in childbirth while the woman was lying in bed. Spaeth's ease* illustrates this : In a primipara, the first stage of labor being tedious and the second stage lasting btit half an hour, a violent contra<'tioii m-curred while the mid- wife was placing a cushion under the patient's hips, and the child was driven out a distance of ')0 centimeters from the genital organs. The cord, thick, gelat- inous, and friable, was broken : it was 30 centimeters l<»ng, and the rupture was in its middle. liudin "■" has given a similar case : The patient, a secundip- ara, made violent expulsive efforts, and the child was rapidly expelled. The cord, which encircle<l one of the thighs of the child, was torn 10 centimeters from the umbilicus: its entire length was 42 centimeters, liudin '^ has also given a ease in which the weight of the phu-enta, which was suddenly expelled and fell to the floor, ruptured the cord near the umbilicus. The attendant, while waiting for the pulsations in the ftuiis to cease before ligating, was sur- prisinl by the abrupt discharge of the placenta from the genital canal. In several instances the i-ord has been rui)tured at the umbilicus by the attempt to remove circulars from the neck. Cases are rworded of partial rupture, the tear involving only the vein or the vein and one of the arteries : the tear being also in the sheath of the cord, the hemorrhage is external, but when the sheath is entire the blood may form a hematoma of the cord. McDongall ^ found in the cord, 2 inches from the umbilicus, a collection of blood the si/e of a hen's egg. Kirkpatrick ^'* recorded a very remarkable case of thrombus in the cord : " The I'unis formed a loop the sides of which weie adherent to one another, and in conse(|iience of the pressure on the curve of the loop during labor a clot formed and the circula- tion stopped in the funis." Hamill ^ reported a case of fatal hemorrhage from a large branch of the mnbilical vein running across the fetal surface of the ])la- centa, a considerable mass of coagulated blood being found beneath the annjioii. Velpeau'^ attributes ruptures of the blood-vessels to disease causing dilatation, *' small aneurysmal or varicose pouches," and he states that he has " seen these dilatations torn at term, and communicating with a large clot which covered a part of the placenta and which had not ruptured the amnion." In velamentous insertion of the cord, while, according to Winekel, 18 per cent, of the children jwrish from asphyxia resulting from compression of the vessels of the cord, a still larger proportion die from rupture of these vessels, Spiegelbcrg states that occasionally the obstetrician ruptiu'es the cord while performing version, and even oftener during extraction. It i.s established that the cord ruptures more frequently at the fetal than at the placental end, and also that " .spirals and va.seidar anomalies are weak parts, and the cord is pecu- liarly liable to tear at those points." Hemorrhage is much less likely to occur * Quoted by Laniiirc : Klinik der Geburtshiilfe mid Gyiiiikol., 1885. Cliiari, IJraim, and Spaetli. DYSTOCIA. 681 iVorn a torn than from a cut coril. In 183 cast's of torn cord collected by Klein there were twenty-one in wliich the cord was rupture<l at the umbilicus, and in none of them was there bleedinp. Xeverthehws, in exceptional cases ot" rupturetl funis there may be considerable bleeding both from the fetal and from the placental end. Trcalmvnt. — The treatment of ruptures of the cord is chieHy prophylactic. HoniemlK'ring the causes of this accident, the obstetrician will endeavor to avert them, anil he will thus prevent the patient from being delivered in other tlian a recuml)ent position, unless in quite exceptional cases, and he will not permit too rapid escai)e of the fetus. When the coiil is accessible to touch and is so tense that tearing is threatened, he will divide it ; furthermore, he will prefer to sever the; coils about the neck of the child, rather than to use force for the removal of one or more of the coils. In velamentous insertion of the cord he will delay rupture of the membranes as long as possible, and if one or more of the vessels should Imj torn, he will deliver the child as soon as possible. In case the child is born and the cord is found torn, ligation is advisable even though no hemorrhage be present. As has been statetl, almost all tears at the umbilicus do not bleed, but should they do so, the vessels are to 1k' drawn out with a tenaculum and tied. This methwl was successfully employed by Hraxton Hicks. 2. Dystocia on-: to Hp:MoHHnA(iR. Placenta Prsevia. — If the placenta, in whole or in part, be implanted in that ])ortion of the uterus which must be dilat(Hl Ibr the passing of the child, it is called " pnevia." The lower seg- niout of the uterus in pregnancy is halt of a spheroid ; in labor this hemi- sphcroid must be changed into a canal or hollow cylinder having a diameter of about 11 centimeters (4^ inches). 15y the lower segment of the uterus is meant that portion bounded below by the internal os; its upper boundary is from '2ii to 3 inches above, measuring along tile uterine wall. In this lower segment occur the pathological phe- nomena of placenta prajvia. Hegar^ in 1863 stated that too extensive formation of the serotina ....... »o..c» ^1 - .>1..„„..4-.. *„ ^..^i^^i^ :.,*« Fio. 382.— Partial placontii prcDVia, The uterus is may cause tl placenta to project into ^5,;,,^.^ j^^^ ^^^^^, ,„„^,, . ^^^J , , j^ j,,^. ,4,,^. ^^.,,.,,„ the area of expansion of the uterus, marks the boundaiybetwuens.z, the .superior zone, I 1 onr\ TT i> • w 1 1 1 J- anil E.z,thee(iuntorial zone ; 3,4, is tlie line (" lUirnes' hi 1890, Hotmeier'™ COncludal trom boundary-line") which murks the limit between the the examination of the uterus of a eq'mtorial zone, K.z.imd the inferior zone, i.z. A- is , . . 1 /. /. 1 1 /> *''^' ITievial Map of tlie plaeenta, upon which the woman dying 111 the hftli month ot a head rests lUames). '■it i> tf ' S:;'iiP 5:f : km A is m i ffrrr .^. I" 682 AMHIilVAX TEXT-HOOK OF OUSTKTR/CS. twill j)ivj;nnii<'_v that in "most if not all caHt's" placenta |>rii«via ori<rinattMl frmn tlu' il(!Vt'l<ijnn('nt of the placenta within the reflexa ofthe lower pole of the ovum. Figure 383 represent^ admirably this view. U|H)n examining tlic illustration it will Iw noticed that a part of the reHexa upon whiili the placenta has foriiuil is not yet tniiteil witli the vera. Kaltenhaeh^' states that " by prepa- rations from early pe- riods of prej;naney Hi d'- mcier and the autiior have proved that in placenta pnevia the de- velopment of the pla- centa takes j>lace with- in the reHexa of the inferior pole of the ovum." The under surface of the present- in}; placenta is c<»ver(Ml with smooth reflexa which later is united with the opposite vera. The explanation of the orijjin of placenta pnevia |i;iven by Hofmeier and Kaltenbach has been aceeptetl by many ob.stetricians, among whom may bo mentioned Olshausen and Martin ; but there are some who dissent — for ex- ample, Ahlfold, Winckel,* Berry Hart, and Gottschalk.^' Hart, in expressing his dissent, gave the following statement : " I must now state the view I advocate for the occurrence of placenta prsevia. It is that of primary iniplaii- tation ofthe impregnattnl ovum low down, or even over theos internum. The forcible objection that Kaltenbach urges against this view seems to me not quite valid. He hoUls that the small ovum wotdd pass into the wrvieal canal and be lost. \Vc must rememl)er, however, that the hypertrophied and foldeil decidua there will practically obliterate the os internum, and thus implantatinii over it may (jccur. But why should such a l(tw implantation happen? Wo * Winckel remarks, referring to the views of Ilofnieier and Kaltenbach : " Ahlfeltl liii.< justly disputed the correctness of this explanation, and from a case in which the placenta w:is entirely situated in the lower uterine segment lias given ground for the old ojiinion of tlw primary grafting of the ovum in the inferior third of the uterine cavity " ( Lehrbuch der Gebwis- hulfe, '2d ed., 189:i). Fio. 383.— riiicenta pntvia in pregnancy with twins (Hoftncier). :ij. nVSTOC/A. 583 iiiilv know that it is niorc apt to iHt'iir in cases where the nuieons nienibrunu has been nnliealtliy. The iiyintthesis 1 would advance', but merely as an livpothesis, is that the human ovum can graft only on a surface denudcil oC epithelium, and that thus it docs not graft in the Fallopian tube, but in nonie piirt of the uterine cavity where the epithelium has been removed by menstru- ation. If, then, the ovum does i,ot meet with the eon ncctive-t issue surface until it has passed low down in the uterine cavity, some form of placenta prievia will hapiM'U." Dr. Robert Harnes first announced in 1847 his theory of placenta prievia, ;md ho has made several contributions to the sidtject since, the most recent of tlicse being a paper road by him in 1892 before the International Congress of Diseases of Women and Obstetrics, in Hrussels. In justice to one of the most eminent anil able obstetric writers and teachers, as well as in justice to the theory itself, which certainly was an important advance, and from the fact that the |)nu'tice founded upon that theory is upheld by some obstetricians, {u-om- incnt among whom is Murphy of Simderland, — the latest public exposition of his views is hero presented. The paper referred to being in French, a trans- lation of a part is here presentetl. Dr. Barnes, after having stated that his theory is represented in Figure .'J82, proceeds as follows: "It is seen from the illustration that the uterus is divided into three /ones : (1) The superior or fundal zone; (2) The equatorial or middle zone ; (3) The inferior zone. The superior zone is separated from the e((uatorial by an imaginary line (1, 2) which may be called the ' superior polar circle.' This line, it is true, has not been anatomically demonstrated. IJut it serves to mark a distinction, which I be- lieve real, between the characters of the superior and eipiatorial zones in their relations to the placental attachments and to hemorrhage. "The equatorial zone is separated fn^m the inferior zone, otherwise called the inferior uterine segment, by the line .'], 4. This line is the line of demar- cation of Barnes, Barnes' boundary-line (1847-1 8;")7). This line was called ' the internal os of Branne ' in 1 872 ; it became the ' ring of Bandl ' in 1876 ; and later, the * contraction-ring ' of Schroeder. It may also be called the ' inferior polar circle.' " The superior zone (s. z.) is the seat of fundal placenta ; it is the safest region of attachment. The equatorial zone (e. z.) is the seat of lateral or ('(|natorial placenta. The lateral placenta may give place to that form of liomorrhage called 'accidental ;' nevertheless, the equatorial zone may be con- sidered as site of attachment normal and safe. This security is still greater when the placenta is attached in part in the superior zone and in })art in the ef|uatorial zone. The danger begins when the placenta is attached in part in the inferior zone — that is, when there is partial placenta praivia. The portion of the placenta which encroaches upon the interior zone (r. z.) is liable to nsi AMi:iii<'Ay Ti:\"r-ii(K)h' or onsTirmics. prcinatiiro s<'|)!iratii)ii. ('i)iii|)l(>t<' placenta pru'via, calKKl also phicetitd pniiia fcnfrii/in, is t'oiiixl wlini the ciitirc plarcnta or tlie greater part of it is attaclicti ill tlu' inferior zone ainl covers the internal os. •' In the last case the jfcstation would Ix-, justly s|H'akinjr, an •• ^.pioficstation (or out of place), for the ovtiiii, or an iinportani part of it, is (levelo|MHl in the inferior /one 4»f the uterus, a part which is not (lesijfiie<l l>y nature tor tiii> function. The eurve<l line tracni in the inferior zone marks the jwtsition ol the total head. The line of demarcation (3, 4) corresjMinds alinofit exactly fUNDAL Kin. ."Wl.— Vnrietii's of iiliiccntn pra'vin : in A there arc seen tlu' imrninl, latcriil, iniil iiiarKiiml iiii|iliiii (Rtioii: ill It tlieri' are reiircsentLMl tlie iiiipluiitatioii of the placenta at the fnmliis, whieli is rare, and Imiihintatloii over tlie internal on, in (' lateralini|iIaiitatioii and that of a eotyledon iinineiliately over the internal os ; an<l in |l partial Implantation. sM^ t With the efjuator of the fetal head, and often it nearly corresponds with the entrance of the pelvis." Vark'lU'H of JHacvnln Pnevla. — The accompanyiiif; illustration (Fig. 384) shows different forms of placental implantation in the lower portion of the uterus, and the names applied to them, and also implantation at the fundus and at the fundus and side. Some confusion has arisen from jjiving so many varieties, and from diflTerences in the application of terms desi}rnating them. Thus, one author calls that "partial" which another names "lateral," illii.<- trating the ambiguity which comes from what Lord liacon spoke of as " the unsteady use of words." The writer thinks it better, as Schroedcr, Budin, iimrniiml iiiii'liin- I l\ich is ran', nml iiniiR'(liuti.'ly nvir Diids with tiie DYSTOCIA. :.S;) unil sonio others Imvc done, tn liinkc hut two varieties, I'omjtlcti and laUraL IJy complete phieeiita prii'via is meant that eoiiditii>ii in wiiicii (he internal o> is entirely covoreil hy placenta. It corresponds with what many others have (ill le<l "central implantation of the jdacenta ;" that is, the (jcntre of the pla- centa is supposed to 1m' directly over the internal os. Pinard''- statcsl tiiat in 10,000 acconehements he never met with tlu; insertion centr;' I'or cent r«', <"<>»- seqiiently he has the right to say that this vnriety is excci-^lingly rare. Liileial implantation of the phurnta includes those cases in which the great mass of tlie placenta is at the &ideof the uterus, a margin more or less near the interiitd /'CTiijf vnp ant Os aUrn ^~^ Vrtlhrft Cor/i cavtrrX'- diior.-^ ■ — ^Sis Pmc/iiU cUtor-^^ CUUns. --- ^'-^H Ifii mm (ttxt "' ^__^ laimydext — ' I'J Fio. 385.— Placenta pracvia : child removed, placcr'n remaining (Winter). OS ; indeed, in some eases the margin may partially extend over the os. The lateral variety is much the more frequent. Figure 385 shows a not infrequent c r.idition, a single cotyledon over the os, while the great ma.ss of the placenta is at the side : the fir.st is known as j)la- centa suceenturiata. Authorities generally agree that lateral is much more frequent than comj)letc or central placenta. Nevertheless, Trask ** gives 169 of the complete to 88 of the lateral, and Mi'iller's statistics, which include tho.se of Trask, show a slight prcKlominance in favor of the complete variety. Read's statistics^* show a ?:i.^: i^K' H*. ^ 586 AMERICAN TEXT- BOOK OF OBSTETRICS. l\ :i ■I f similar result. UnfortiUiritely, in many of the cases given by Read there is a failure to state the placental presentation, and some others are described as "almost complete" or "nearly complete," and hence nncertain conclusions onlv can be made. Miiller has shown that in complete placenta praevia the smaller lobnle was situatwl at the left in thirtv-seven out of 56 cases. In Via. 386— Partial placenta priiviti (Alilf'cld). lateral placenta pnevia the placenta is in 50 cases at the right side to 31 at the left side. As will be seen, there is a correspondence between these results. Frajucnci/. — The proportion of cases of placenta pra;via to the entire number of deliveries is usually given as 1 to 1000, 1 to 1500 (Winckel), and 1 to 1500 or 1600 (Kaltenbaeh). I'azzi*'' gives the proportion of 1 in 748. As illustrating how misleading limited statistics may be, we quote the statement of Townsend'* as to cases of placenta pnevia in the Boston Ijying-in Hospital : In the last twenty years there were 28 cases of placenta prajvia in DYSTOCIA. 587 Road there is doscribetl as I conclusions II prievia the >6 cases. In side to .31 at these resuhs. to the entire no (Winckel), ortion of 1 in we quote the )ston Lyinjjj-iii nta proovia in (1700 deliveries. Thus there was 1 case of placenta praevia in 239 labors, or more than 4 in 1000. Of course, as Townsend remarks, tiiere are more cases of this anomaly in hospital than in private practice, but still such a liu'lie proportion as he found is not the expression of a general trutii. No iiije is exempt, for placenta pra?via has occurred in a girl of thirteen years and in a woman of fifty. It is most frequent from thirty to forty years, tor out of 248 cases 127 of tiie subjects were in that ten years (Miillcr). A uoma/ica of the Placenta when it is Pnvvia. — The placenta is not oval, hilt is irregular in form ; tiie prajvial placenta extends over a larger surface, hut is thiimer, than the placenta having a normal site. • A placenta succcntu- riata is not infrequent, or, again, the placenta nuiy be composetl of twt) lobes, and the bridge of tissue connecting these lobes may be directly over the os ; lionce an error in diagnosis is possible. Tiie form of the placenta presents otlier varieties.''^ Thus it lias been found in the shape of a half-mpon or a horseshoe, or it is pyriform or cordiform ; Gilroy ^ described one as lozenge- sliapcd, the cord being attached to one of the angles. In placenta prtevia there are frequently abnormal adhesions between the placenta and the uterine wall. Miillcr found such adhesions in fifty-four out of 142 cases, and Sabarth of Reichenbach in seven out of 14 cases. This condition may cause more or less serious delay and difficulty in the third stage of labor, and of course it gives a certain liability to infection. The insertion of the cord in numy cases is marginal and sometimes is velamentous. DepanP" directetl attention to the fact that the membranes in placenta prrovia seem thickened as if infil- trated, and, further, that the chorion presents externally (juite characteristic rugosities which alone suffice, even when the placenta cannot l)c felt either by its surface or at its border, to authorize one in affirming that the j)la- ccnta is near. (hitscK. — Spicgelberg^ states that pre- vious abortions predispose to placenta \)rie- via, and that it is more frequent in the poorer classes, }H)ssib]y owing to hard work at the beginning of pregnancy, and still more to the subinvolution of the uterus which is so common in this class. So far as tlie first statement is concerned, it seems to ., ,„,„..,, , ,, ' _ Kio. 3«7.— Purtiiil pliu'i'nta imrviii, wr- the writer that both abortions and prrovial tox iiresoniution : the os biKimiint,' to j)lacenta should be attributed to a common ""t^' (■'"*'■ cau>e, a diseased condition of the endonu^truim. The accident is more fre- (pu'iit in nuilti))ar!e than in primipane — two- or three-fold (Winckel) — and according to Miillcr" 85 per cent, are multipara?. Anomalies of the uterus, such as uterus bicomis and unicornii*, cancer anil myoma of the uterus, relax- U 'Ai l> hi < < (if > », ,y i. <■{■ i^iiS^': ' ii ■ri nnrr Ih'h mm U !; I! :4 ■' '3 588 AMERICAN TEXT-BOOK OF OBSTETRICS. atioii of the uterine walls, opening of the oviducts in the lower part of the uterus, as in two cases reiK)rte(l by Ingleby, and, more important than most and more frequent than any of these, endometritis with hypersecretion, aiv causes of placenta prajvia. Osiander^" believes that lying on the back favors insertion of the ])laconta at the fundus, lying upon one side lavors a lateral attadunent, and standing Fig. 388.— Central placenta proDvJa, the os partly tlilntcd (Hunter). or sitting favors implantation over the os ; hence ho considered lying on the back or on one side, continueti some time after copulation, as necessary for a fortunate situation of tlie ovum. Stein and others attribute the origin of placenta prsevia to the sjwcific gravity of the ovum. Miillcr .states that others accu.se conception during menstruation or while the uterus has a more vertical position, thus coitus while standing, as a chief ground. DYSTOCIA. 589 '%%^. In 1874, Angus Macclonald *' reported a case of twin pregnancy, the ti'tnses being transverse and each j)h»centa presenting at the internal os. He regarded phicenta prtevia with twins as a very rare anomaly, and assortal that " the expectation of the concurrence of twins with placenta pran-ia is only 1 in 44,500 cases of labor," and that, of course, the prob- ability would be much less with both placentse presenting. Miiller found it YWiv in plural pregnancy, but Barnes has spoken of it as not uncommon, and \Vinckel states that plural pregnancy pretlisposcs to placenta prrevia, the acci- (li'iit in his experience beinj; relatively four times more frequent in plural than ill single pregnancy.* Roamy ^^ suggests that placenta prasvia may originate in sexual intercourse being deferred until fifleen or sixteen days after menstruation for the purpose of avoiding conception. If this delay were a cause, probably the number of cases would be much greater. Pinard has asketl if travelling early in preg- nancy, with conse(juent jolting in I'ailroad cars or in carriages, may not cause placenta pnevia. The retnirrence of placenta pra}via in the same subject has been observed. The cases recorded by Ingleby are explaine<l by the abnormal ))oint of entrance of the tubes into the uterus. Fitzpatrick ^ reports the case of a woman tiiirty-six years old who had nine pregnancies, the first four normal and ending in the birth of living children at term ; in five successive preg- nancies she had placenta pnevia. Siimptoms and I)l<(r)noH'ix. — The most characteristic symptom of placenta prrevia is hemorrhage occurring in the latter part of pregnancy or at the l)('ginning of labor without obvious cause. The hemorrhage frequently begins when the patient is sitting quietly or even when lying asleep in bed. FiOmer found in only thirty of 136 cases that the first hemorrhage w.as caused by some bodily exertion, such as liftingj straining, or coughing. Miiller mentions coition as a cause. Winckel states that in lateral placenta prievia the first hemorrhage generally occurs after the thirty-second week, and in the central variety between the twenty-eighth and the thirty-sixth week. In rare cases not only of lateral but also of central implanta- tion of the placenta there is no bleeding until a few days before labor, and in still rarer cases not until labor begins. Since Rigby's admirable essay" the hemorrhage occurring in placenta pra'via has been calletl *' unavoidable," while that which may happen when the placenta occupies its normal site is known as "accidental." In 1873, Matthews Duncan" took the position that the hemorrhages occurring during pregnancy on account of placenta pra;via were not unav(jidable, but accidental, their occurrence being promoted by the unusual conditions present, and especially by increased blood-pressure result- ing from the lower position (X'cupied by the placenta. Yet those who have read the essay of Rigby will remember that he referral only to the hemor- rliagos of labor, in case of i)lacenta prsevia, as being unavoidable. While not many years distant some authorities regardcnl the hemorrhage as * One of the most renmiknble cnses of jdncenta prii'via is that \i\\cn by W. J. Harris (Lancet, 18()3). A woman was twice i>regnant with twins, and in eacii pregnancy iiad placenta prnpvia. Ui m A M l.'5 3 • 1^ I I PL .vj. ^ '' V >\ ■ » i ' ::! .. I? ,' 590 AMERICAN TEXT-BOOK OF OBSTETRICS. w J. placental, it is now usually conceded that it is uterine, and should the child die its death would be not from loss of blood, but from asphyxia. From tlie fetal circulation may come a small quantity of blooil in case the chorionic villi are torn. Why the blealing occurs in the latter part of pregnancy is a (juestioii that has had different answers. Jacquemier held, on the one hand — and his view, with qualifications, was accepted by Depaul — that the development of the lower part of the uterus was more rapid than that of the placenta, henco detachment of the latter; on the other hand, Legioux assertetl that the pla- centa grew more rapidly than the uterus, that is, grew away from the uterus. Barnes has been especially prominent in upholding the latter view. Spiegel* berg, first referring to placenta prsevia predisposing to abortion, said : " Owing to the loose vascular connections of the placenta and to the higher blood-pressure in the placenta when inserted low, any shock is liable to cause rupture of its vessels and detachment ; perhaps, also, shocks affect the lower portion of the uterus oftener than the upper during the first months of pregnancy (coitus, especially straining at stool). For the same reasons premature labor, too, is relatively common ; indeed, I am convincal that even the hemorrhages which occur during the latter months of pregnancy depend upon commencing labor — that it is not the hemorrhages which induce premature labor, as is generally su])posed, but that the converse relation is the true one." The hemorriiage is not only abrupt and apparently causeless in occiu'rence — though this first hemorrhage may be fatal — but usually it ceases after lasting a few hours, or even in less time, and often spontaneously. The hemorrhage returns at irregular intervals, and is greater, occurs earlier, and is more frequent in those cases in which the placenta completely covers the os7> Auvard *® mentions as symptoms unfavorable presentation of the fetus — presentations other than those of the head * are found in from 20 to nearly 50 per cent, of cases, according to different authorities — the occurrence of prem- ature labor, and premature rupture of the membranes, Winckel remarks that in the relaticjn of the funis in ]>lacenta prsevia there is also offered a certain predisposition to bleeding. He states that Scanzoni, Hugenberger, and the author found marginal and velamentous insertion of the c<ir(l frequent. Hemorrhage occurring in the last two or three months of pregnancy with- out obvious cause, and especially if the patient has not albumiinu'ia, would at once suggest the strong probability that it resulted from ]ilacenta ])nevia. Spencer" claims that it is jKissible by abdominal palpation to determine tlic site of the placenta when it is situated in the upj)er part of the uterus, and also by tliis means, on finding it absent from its usual site, it may be discovered in the lower jiortion of the uterus. Tn examining the patient she lies u])on her back, the bladder being jirc- viously emptied. The examination should be gentle and be made in tlio absence of pains, and should be prolonged over several minutes or be repeateil * Of rourse the frcqiicnev of abnormal presentations is in part to be attributed to the fact that in many cases labor is pri'iuature. I !! DYSTOCIA. -591 if necossarv. Spencer gives the following additional directions: In an ordi- nary vertex presentation (placenta in the iipjwr segment) the occiput, forehead (at a higher level), and side of the head may under favorable circumstances be lolt distinctly in the lower segment of the uterus by means of abdominal pal- pation. In a case of placenta prtevia in which the head presents the head is not felt where the placenta is situateil ; it is distinctly felt where the placenta is absent. In cases where the placenta is in front the organ is felt as an elastic mass, of the consistence of a wetted bath-sponge, that kecj)s the examining iiiiger oft' the head. The edge of the placenta may be felt, and has the shape of a segment of a circle. Within the circle all is obscure to the touch ; out- side the circle the head or other part of the child is i)iainly felt. Impulses to the head are not clearly felt through the placenta ; impulses to the head through the ])lacenta are distinctly felt at the spot from which the placenta is absent. The same api)lies to combined vaginal and abdominal examination. Vaginal examination shows great softening of the cervix, and the bluish discoloration is well marked, extending to the external genitals. The pulsa- tion of vessels in the lower j)art of the uterus and vagina is distinct. The presenting partof tlie child camiot be recognized distinctly through the nterine wall and the overlying placenta. Probability becomes certainty * only when the finger can enter the os or penetrate the cervical canal, and the sponge-like structure of the placenta can be felt. We distinguish complete from lateral placenta praivia by the finger touching in the former jjlacental tissue at all parts sur- rounding the internal os, while in the latter the membranes can be felt, and j)()ssibly only placenta reached, by passing the introduced finger toward one or the other side. It should be remembered that complete is much less frequent than lateral placenta praivia, and that in the latter the bleeding may not occur until labor begins. ProejnoHifi. — The prognosis is graver the earlier hemorrhage occurs and the more completely the placenta covers the os. Not only is there danger from bleed- ing before birth, but also afterward, fi)r the relaxed lower segment does not com- pletely close the vessels opened by detachment of the placenta. There is danger, also, especially in the so-called aeconcheincnt force, of fatal tearing of the cervix and of the lower uterine segment. Finally, the examinations and manipula- tions and the means used for the arrest of bleeding may lead to infection, so that, according to Kaltenbach, almost as many women die from sepsis and ])yen»ia as from bleeding. ^Maygrier^^ narrates fom* cases of fatal syncope in patients with placenta prtevia, showing that severe hemorrhage from this anomaly can cause such grave anemia that death may come suddenly after the arrest of all bleeding. INIiiller gives the maternal mortality as 23 per cent, and the fetal as 64 per cent. King's^" statistics show a maternal mortality of 22.5 jier cent, and a fetal mortality of 57.2 per cent. Winckel believes the mortality from placenta ])rievia should not exceed 5 to 10 ])er cent. Such a low mortality as 5 per cent. * Niuiche I'liiimed that l)y liis inctroscono pulsation in placental vessels could be recog- nized; but the claim was not veritied, and the metroscope is now almost unknown. mm 1 1' Is r y 'V i ^^i <i 1 1 .1 r ftjs- Lhii-' ! ,' I e ijj 502 AMERICAN TEXT-BOOK OF OBSTETRICS. may be secured in hospital but hardly in private practice. According to Lomer, GO per cent, of the children die during labor; Barnes states that by his method he has hail 33 per cent, of living children born ; and Winckel says that the mor- tality of children is seldom less than 50 per cent., and in some statistics is as high as from 70 to 75 per cent. If spontaneous labor occurs, the mortality of children, accortling to Midler's statistics, is only 50 per cent. The chances of the child surviving in placenta pra?via appear so small that some writers seem to take the ground that its life is not to be considered in determining the treat- ment. But this is wrontj, and we fullv endorse the words of Dr. Barnes:''" " However, in admitting frankly that it is our first duly to save the mother, I insist upon the correlative law whicii does not permit us to sacrifice the child to this end without conclusive proof that it is only at this price the mother can be saved." Trcdhiivnt. — There is no single method of treatment in placenta prajvia apjdicable in all cases and at all times ; therefore the obstetrician will act most wisely who chooses means corresjwnding with the special features of the case in hand and with the emergencies that arise. If the bleeding occurs in pregnancy, is not great, and uterine contractions are absent, rest in bed only may be advisable. Should the hemorrhage bo severe, Winckel directs vaginal injections of hot water or of vinegar and hot water, and also the colpeurynter. Martin advises that there be provided aseptic balls of cotton-wool, with which the midwife or nurse should tampon the vagina after the use of an antiseptic injection, so that the hemorrhage may be arrested at once while awaiting the arrival of the physician. The induc- tion of i)remature labor in placenta jn'sevia was advocated in England several years ago, chiefly by Greenhalgh, and in America mainly by Thomas. For some years past Murphy of Sunderland has followed this practice, and his results, so far as saving mothers is concerned, have been remarkably good. His method of treatment will be referred to again. We believe that in many cases Spiegelberg is correct in saying that the hemorrhage in the latter months is caJisetl by commencing labor. The obstetrician will simply then accept Nature's plan and facilitate her action. Should there be hemorrhage in labor, the os dilatable, and lateral placenta pnevia with presentati(m of the head, let the membranes be ruptured, for, as Martin states, we may expect the inferior pole of the fetus to occupy entirely the lower portion of the uterus, and the presenting part to press upon the bleeding ])laeental site and to excite uterine contractions. In most cases of this variety of jmevial placenta no other interference will be recpiired ; if, however, delay demands active interference, the forceps may be used. If the pelvis presents, the same i)lan of treatment is to be ]>iu'sued, except that it is advisable to bring down a foot. In transverse presentation, of course, podalic version is indicated. But now supp.,. o the physician is called to a ease of placenta pra?via in which the Meeding is severe, whether in pregnancy or in labor, and the os barely admits the finger and is rigid, or the cervical canal is not readily penetrable : most obstetric authorities agree in advising a tampon. f •! DYSTOCIA. 593 W'iiickol uses for this purpose iodoform cotton, and others advise iotloforn) "iiuize (Fig. 389);creoIin j^aiize would be just as useful and has no unpleasant <tilor. Auvard * recoinnionds cotton or charpie. 1500 frrams being needed: this niaterinl is made into balls the size of a walnut, which are place<l in a 2 per cent, solution of carbolic acid, or in a 4 per cent, solution of boric acid, or in a 1 : 1000 solution of corrosive sublimate, until thoroughly saturated. Before being used the fluid absorbwl bv these balls is squeezed out, and to facilitate their introduction and to secure thorough packing an antiseptic cerate is used. Fifty or sixty ol" the balls will be needed. A Sims speculum greatly facilitates the introduction of a tampon. Winckel Fi(i. 389.— I'liu't'iita prii'via : vtifjiim tiiiiipdnod witii tiniize. states that a tamj)on may be applied so thoroughly that not a drop of blocxl can escape from the vulva. He leaves the tampon in place in central and lateral placenta pra}via until the os is completely dilated, so that either the ])n'senting part of the child can enter the os, thus itself making a tampon, or, by the introduction of the hand, the hi])s are brought down, thus accomplish- ing the same end. Barnes f would not leave a tampon in the vagina longer * Piijot has said tliat a liatfiil of the material will be required. t The following pas.sige is taken, not from his jiaper at the IJrnssels ("oiigress, but from liis Ohshlrir ^f^•(^i(•iln• ami SiinnTi/ : "Vaginal plugs are treacherous aids, ivquiring the most vigor- ous watching. The plug, introd'ieed with so much pain to the patient, soon becomes com- pressed, blood runs past it or aceunndates aliove or around it, and the tide of life ebbs away unsuspected. Never leave the patient trusting to vaginal plugs. Feel her pidse fre(|uently, \v;ilch her face closely, examine to see if any blood or tinged serum is oozing externally. Hciiiove the plug in an hour at furthest, and feel if the os is dilating." 38 ' /^S ;i ■ ) Hi.i 'I ^!l 'i H ■Plf: 4' i^hM 11 ^pl jBM '4 B' ' !r5 I*.vv1|«( ( ; 1 1 rm AMERICAN TEXT-BOOK OF OBSTETMICS. tlian an lioiir, but Bailly lots it remain for twenty-four hours, and Tarnior {uv twelve hours : the last praetice is probably the best. Some — I'ajot, for instaniv — let the tampon be expelled with the ehild. The praetice which has in reeent years been received with most favor bv the profession is, when the os can be entered by two fingers, the performance of bimanual version according to the method of Braxton Hicks, and bringiiin down a foot, so that tamponing is etfec^ted first by the leg, then by the thigli. and finally by the hips, of the ehild (Fig. 390). The labor is not hastened unless there is some special demand for its prompt ending, but gradual dila- tation of the OS is made. In ease it In? impossible to reach the membranes in complete placenta pnevia, the placenta is perforated. It appears that Martin, at a meeting of the Naturforseher at Hamburjr (1876), and then in his Guide to Obdetric Operations (1877)," made a definite projjosal for the suceessfid treatment of the majority of c;\ses of placenta prajvia, which treatment has later ueen established by Bchm, lIoC- nieier, Schiilein, and others. The chief point in this treatment is bringinir <lown the hips, so that by their pressure bleeding from the loosened placenta may be stopped and at the same time uterine action may be developed. If hemorrhage contimies after the birth of the child, manual removal of the placenta is performed. If hemorrhage still continues, the injection of hot water, compression of the uterus, the administration of ergot, compression of the aorta, autotransfusion, injection into the rectum at frequent intervals of nor- mal salt-solution, such as will be mentioned in the treatment of post-j)artiiiii hemorrhage, and also the hypodermatic injecticm of the salt-solution, are among the important means to l)e employed. A bleeding tear in the cervix may be stitcheei. Broths and milk may be given as freely as they can be taken, and there may be required alcohol stimulants as well as the hypodermatic use of etlM?r. Winck.'l commends the method of Breisky and of Klotz, of compressing the bleeding lower part of the uterus with one hand in the vagina and tlic other upon the abdomen, the compression being continued for half or three- quarters of an hour. Dr. Barnes, in the paper already referred to, gives the following rdsume of his metliod of treating placenta pnevia : " 1. IJupture the mend)rancs ; this disposes the uterus to contract. " 2. Apply a firm bandage over the abdomen. "3. A. tampon may be introduced to gain time, but it is not necessary to do it. Watch, observe with vigilance. "4. Detach all the placenta adhering within the inferior zone, and always watch. If there is no hemorrhage, wait a little. Tiie uterus may perhaps do what is necessary. If this fails, dilate the cervix with the hydrostatic dilator. Wait and watch. If the natural forces fail, employ the forceps which gives the best chance to the child, or as a last resort perform version. " 5. Avoid as far as possible everything which disposes to septicemia. There are four factoi-s which dispose to it : (a) The bruising and other lesions of tlic uterus ; (h) the retention in the uterus of fragments of placenta or membranes necessarv to DYSTOCIA. o95 or of clots J (e) deficient contraction of the uterus; {(}) activity of absorption, iiicrcaseil by loss of blood. All these causes are reducefl to a niininium in t'dllowing the precetling thcra|ieutic principles. But there are still other I'li^. :!'Jii.— One k'K bus htM'ii flrawti down, so Uiat the os is tampiined and tlio |)lai'i.'ntu diroctly compressed by the liips of the child (Miller). . special precautions. After the placenta is expelled examine it carefully to <oo if it is entire. If the uterus does not contract well and if blood flows, inject hot water, temperature of 45° C, adding a little iodin or carbolic acid, or else, if the hemorrhage persists, the perchlorid of iron. It would be more ^'1 1 . n^ s f fi , SI ' h m - ■1 P' .': ;l M^ 9^ AJM) AMK/ilCA.X TJJXT-HOOh' OF OIiSTi:TIiI('S. < .'4' nsi'f'iil to repeat tlie utcrino injections dnily for n week. The activity of absorp- tion indicates the nse of a jj;eneronH diet." In connection with the nictluMl of J)r. liarnos, as above jriven, n'ferencc niav be made to the phm pursued by another celebrated liritish obstetrician (Radfoni) in 1826 : "A multipara in tiic seventh month of pregnancy luu I severe hemorrha<rt% f«>r which a tiunpou was used ; a montii after this there was slitjht flooding, whicii yielded to rest, etc. ; labor came on two w(M'ks siih- 80(piently, and there was considerable hemorrhage. Upon examination the os was the size of a crown. As the pains were now frecpicnt and strong and the «lischarge eontimied, after placing a regulating bandage — one end l)eing fa-t- ened to the be«l and the other held by the mirse and tighteniHl as required — I passcnl my hand, and first detached a considerable portion of the placenta, and then ruptured the membranes. The bandage was drawn so as eiiuaily and firndy to supi>ort and compress the uterus as its si/e lessene<l by contrac- tion and the escajK? of the waters." The result was favorable for Inith mother and child. Radford gave the reason f(»r detaching the placenta thus : " I de- tached the placenta as freely as I thought necessary for the passage of tlie child, as it is better svstematicallv to do this rather than run the risk of the tearing of the structure of tiiis organ by th(> force it nuist sustain at each pain, when the os uteri has to be dilatetl by the head of the child after the membranes have been rupturetl." The ])oint of interest in c(»mparing these methods is that each obstetrician <letached jiartially the placenta, though for a diflferent reason. Murphy, who has for years advocated antl i)ractised the induction of labui- in placenta prsevia, recently made the following statement:''^ "In every case where i)lacenta ])ra)via is evident after the seventh month, or even before then, 1 bring on premature labor and remain with the patient until she is delivered, treating her on the lines laid down by Barnes." ^furphy has now had (Jl cases with oidy two deaths, and one of the two was moribund when first seen. Instead of the fiddle-bag dilators of Barnes some liave usctl, for tlie indu(!tion of labor and at the same time to prevent hemorrhage, the bixUon of Champetior de Ribes. Harris*' recently recorded very successful results from dilating the os uteri with his fingers in placenta praivia. Parks Ritchie" narrate^ two cases of placenta prsevia in which the mothers and children were .saval by uccoucheiiient fonu'.* Accidental Hemorrhag'e. — The hemorrhage resulting from premature separation of the placenta occupying its normal site is called " accidental " (Fig. .■j91). This detachment may occur in pregnancy or in labor, but is much ntorc frequent in the former ; it may be (XJinplete or partial ; the latter l]a])|u'ns much oftener than the former. Premature detachment of the ])lacenta is * AVlien tlie placenta was in advance of the child, or jUim ante pnfrem, as Par*? said it \v,is called, accouchement force was held hy the old accoucheurs as the essential method of deliverv. (luillemeau (l()4!>i, accordiuj; to Dunal, was the true inventor, or rather promoter, of this obstetric operation ; hut in recent years many of the cases reported us necnnchement Jarre aiv instances simply of rapid delivery, no violence heinjj employed, and the term has thus lutii changed in its signilicntion. [y of absiM-jt- cn, n'f"»'rcnc( I obstt'tru'iaii cgiiaiu-y had •r this there o \v(H*ks suli- iKition the us roiifj iuhI the 1(1 boitij; i"a-t- is rcHiuiretl — the phicoiita. so as c(|ually h1 1)V coiitrae- r botli mother thus : " I «le- Kissago of the he risk of th<> \ at each ])aiii. the nieiubraiies ch obstetrician u'tion of labor II every case m before then, le is delivered. s now had 01 w\ when iirst used, for the the ballon nf 1 results from tehie** narrates were saved by i)ni premature •idental " (Fi.ii'. is much niore latter bai)pens he placenta is s Vht(- saiil it w:'-* thod i)f (lelivt ly. promoter, of tlii- iiclivmriil J'oiri :ni' in lias thus Ikch DYsTOrlA. nWl lint a common event, for Goodell in 1H7() collected only 105 cases of the iieeidont. J'!llol(t(/if. — Amoiifx the causes of accidental hcmorrhaf^o some of the acute infectious diseases, such as variola and scarlatina, have been assertcil ; but more obvious and more jicncraily accepted are traumatisms, as from falls, blows, concussion, joltiuj;, etc; so, too, direct pressure upon the* abdomen, violent sneezinj;, couj;hin<;, strainin<;, or V(»mitin<;. Hut in how many him- dnnls of eases many of these may occur without the placenta bcinj^ separated I'rom the uterine wall ! lirevity of the cord, <rreat distention of the uterus, as from plural prc<:;nancy or excess of amnial lifiuor, and simply the normal contractions of the titerus in prct^nancy, have been included among the causes. Kaltenbach states that if the placenta is detached by the contractions, it must be Upper end nfctot /lembr. rtTrrrfJu Fici. 3'Jl.— Accidi'iitiil iK'morrliHKt'. RIiukI ciil- Iccti'd bctwi't'ii pliici'iitu mul part nf lucmbriiiK's anil till' utiTiiH' wall (I'lnanl and Varnler\ ■■•V;5iV< Kui. 392.— Premature rtotachment of the pla- ci'iita (icciiipyiiit; its iiorinal site. I'roziMi socticm (if an midi'livcriMl woman dt'adi>fi'i'laiii)isla (aftiT l>r. Winter). A blood mass undor the placenta. assumetl that changes in the inner portion of the serotina have made the tissue friable and readily torn. The importance of nephritis as a cause for prema- ture separation of the placenta has been established by Winter; but, as Veit has said,'"'' we cannot explain the origin of the bleeding in renal maladies without the medium of endometritis ; he maintains that the chief cau,*ie of premature detaehnunt is disease of the decidua\ That the plai-euta in these cases is diseased has been ]iroved by .several ob.scrvers; infarcts have been found, also indammation, and, in the case reported by Coe,"* fatty degeneration. Of 81 cases of accidental hemorrhage recorded by Johnston and Sinclair (/'/Y»'//m^ J/Zf/HvYf'/v/), no cause could be foimd for its occiuM-ence in forty-six. Uiaefe''^ has recently published a case of premature |)Iacental detachment in if*, ■ I" ■ i ^^,. { / a'%. '1 nns AMHliK'Ay TKXr-IiOOh' OF OliSTKTItlCS. 'i: which shortncHH of tho cord wiis the (juuhc of the accident ; the lonnth wa.s only .'! I centimeters. The patient was a priniij^ravithi, and th(' first l)le(Hlinj; (MX'iirred about the time of the descent of tiie head into the pelvit; cavity — that is, al)oiit four or five weelis i)efore the mtrmal end of prej;nancy, btil in this case ten days before hii)or. It was believeil tliat partial detachnient resulted from the strain upon tiie cord in tiie th'scent, th«! primary separation l)ein^ in tlie loltc t(t whicii the cord was attaciied ; after birtli tlie navel was immediately in front of the vulva. Underhill"* has published a case in which severe pressure upon the abdomen was the innnediato cause of the d<;tachment : A large, powerliil woman, quite heavy, in the ninth month of pregnancy, was engaged hanging clothes out of a window to dry, the greater part of her weight being siip- portetl by the window-sill, upon which her alxlomen pressetl. Violent uterine lieniorrhagj^ at once occiu'red, and the loss of bUxtd was so great that she fainted. The writer had a case in which partial separation of the placenta was caused by a fall, the woman being at the end of the seventh ujonth ; nearly a quart of blood was almost immediately dischargetl, and then the flow ceased. This patient went to term, being then deliverctl of a living, well-developed child. Si/mpfomt*. — The bleeding is internal (that is, latent) or external. The illustration (Fig. 392), from Winter, shows a partially detached placenta with a mass of blood effused l)etween the placenta and the uterine wall and also penetrating between the membranes and the uterus. In some instances the central portion of the placenta is first detached, and then the adjacent part, until tlu; entire organ is separated except at the margin, whi(;li remains firm ; there is thus formed a large ciq)-shaj)0(l cavity filUnl with blood. Dr. Coe gives the following as the signs of latent accidental hemorrhage: Irreg- ularity and feebleness of uterine "pains," the fundus only contracting; the uterus is excessively .sensitive; the .sounds of the fetal heart are irregidar and feeble; af\er a time increase in the si^-o of the uterus, ami the patient coin- j)lains of its excessive distention ; palpation of the fetus is diflficidt or inipos- sible, and in some cases there is a notable proininei. -o at that part of the uterus in which pain has been felt ; finally, there are the constitutional mani- festations of great loss of blood.* Graefc, in considering the diflf'erential diagnosis of this accident, refers to the possibility of confounding the condition with rupture of the (itern.s, or with hemorrhage into the sac of the ovum or into the abdominal cavity in ectopic ])regnancy. The cases in which there is no external bleeding are rare. Usually after a longer or shorter time blood escaj)es externally, and then the diagnosis can- not be doubtfid. The accompanying illustrations (Fig. 393, A, b) show the blood escaping externally in accidental hemorrhage. * Kritsch in the dia^nn.sis states that the l)aK of waters remain.s tense and resistant dnriiiL' tlie intervals of uterine contractions, and tliat it is impossible by touch to reach the placenta (Klinik der GebuHnhuljlichen Opemlioneii). DYSTOCIA. r)!i«) I'luxjunHiH. — The |>n));nosi.H in iicMtlciital li(iii<)i'rliii^i> is had for tlio niotlu r, or at least very j^ravc, and still worse for tlu' cliild. (JckmIcH's statistics in- clude 1()<) eases, and the maternal mortality was tit'ty->oi:r, while of 107 chil- dren only six lived ; ninetiHMi mothers were saved ont of .'$"2 reetyrdwl hy Hrnn- ton. (ialal)in in the statistien of (iny's Hospital fonnd .>1 casen of aeeidental hemorrhage, twenty-one of them heinj; severe ; five of the mothers and (56 ])er cent, of the <-hildren |M>rished. Johnston and Sinclair in HI cases had ordy |i)Mr deaths of mothers; and in (Jraefc's 14 eases only two mothers died. As Schidt/e has pointed out, the death of the child in premature detachment dl" the placenta is to he attril)Ute<1 not to loss of blomi, hut to tlie failure in (lie elimination of carhonic acid. The i)ro<;no8is is more favorable in external than in internal hleedinjj;, and more favorable, too, if the condition of the os uteri permits prompt delivery. Fl(i. 3911.— SliouinKHopnnitioii of tin' |iltu'oiitii witli fxtoriml lilfcdini;. Treatment. — If external hemorriiage should occur durinj; pregnancy, and if the fjuantity of blcuMl discharged ;,hould not be great, the obstetrician will l»e content with enjoining the recumbent posture, cold drinks, the body lightly covered, and giving an opiate ; in short, he will pursue a course similar to that re(]uire<l in threatened abortion. Even if th(>re has been a copious dis- ciiarge of blood, but bleeding has ceased, his (^hief efforts will be to relieve the patient from her prostration, no dirt>ct interference with the uterus being indicated. Possibly, as in the case under the care of the writer that has been previously mentioned, the pregnancy will not be interrupted and a living child will 1k' born at term. Nevertheless, such a patient uMist be carefidly watched, and the practitioner be jirepared to act promj)tly should serious bleed- ing return; in brief, his state will be that of armed expectation. Shoidd there be continuous and considerable flow in pregnancy or in labor, and the os not be in a condition to admit innualiate or speedy delivery, 8pie- i! J I I ' i 'I I' ft" S> I I ^ : i i': ' ) ()f)0 AMERICAN TEXT-BOOK OF OliSTETlilCS. {^olberg regards tlie tampon as the best treatment. It should, however, l)c borno in niiiul that thereby an open may be eonverted into a eoneeale<l hem- orrhage ; and, tiioiigh the pressure of a tampon in the vagina iiastens dihitation of tlio OS and evt»kes uterine eontraetions, tiiese results are not constant. I'lic internal bleeding may be very great, for, as William Hunter, in referring to the eapaeity of the pregnant uterus, said, " We are apt to consider the uterus, when containing the Ictus and mend)ranes, as being tight and distended, so as to preserve its shape when taken out of the body ; sometimes it may be so, but in the state it generally is at the ninth month it will hold a pint, a (juart, (u- now and then two ipiarts, or even more. It is in rather a loose state, not quite tight, and only about three jmrts full." The tampon will be employed in oidy exceptional cases and but tempoi-a- rily. ypiegclberg's injunction must be remembered: ''The onset of internal liemorrhage must be looked for, and be prevented by carefully supervising the body of the uterus with the hand." It may be well to add that after the rupture of tiie membranes the tampon is positively forbidden. If the labor can be ended promptly, rupture of the membranes is indi- cated, for discharge of the anniial licjuor is generally followed by stronger pains and arrest of the bleeding. This rupture is usually delayed until the os is half dilated, and then, should the hemorrhage continue, artificial delivery may be elfecteil in a comparatively short time. Coe advises stimulants by the month, by the rectum, and hypodermatically, niaiuial dilatation of the os fol- lowed by ru])ture of the membranes, and delivery by podalic version ; if delay occurs from insufficient dilatation for the extraction of the head, crani- otomy is done ; ergot is also used. (tockIcU in his classic monograph '* advi<ed early rupture of the membranes, immediately followed by the application cif a very tight binder and c(im[)resses to the abdomen, ti»e free administration of ergot, and promi)t delivery by the forceps or by version. The Cesarean section, which has recently been recommended, is of (piestion- able propriety, even in grave cases of accidental hemorrhage. Of course the usual means for securing contraction of the uterus when the labor is ended will be employed. So, too, those remedies that will compensate the loss of blood and hasten its restoration are indicated. Hemorrhage after the Birth of the Child. — Severe bleeding after the child is born may have dift'erent sources. It may be causeil by tears of the vagina, of the external sexual organs, or of the cervix ; it may l)e a result ol" rupture or inversion of the uterus. Rut the ju'cscnt discussion includes only liemorrhage from the uterus occurring independently of lesions or displace- ment of that organ. Great loss of blood may occur before or after the delivery of the ])lacent:i, but in the former case the placenta must be i)artially or coiiiplctely detached, for while it is completely adhen^nt to the uterine wall it is jilain there can be no hemorrhage. (Jrave hemorrhage during or after (he third stage of lalmr is rare, and many a careful and intelligent obstetrician will pass his professioii.il life without witnessing a ease, at least in his own practice. Herman'"' says DYSTOVIA. 601 lienniin ^' sav. that the statistics of Guy's Hospital furnish but one case of dangerous post- partiini h('nu)nhati;o in 2()4() hihors ; of St. Tlionias's Hospital, one in 2172; in I'rnssia, acconhujij tn II (•u;ar, one in o i;5i. II ennan fmtl ler states, ai ultl le profcssittn will a<;r('e in the statement, that when so large a number of eases have recently been reportcnl in winch the i(Hk>iorm-j>;auze tampon ot tlie uterus was claimed to have arrested bleeding, the presumption is tiiat many of these were cases in which tiie hemorrhage was slight. It might be added that in so large a nnmbiT of eases some were proofs of careless obstetrics, for, as Spie- o-elberg has said, "I certainly do not exaggerate when I say that severe post- partum hemorrhage is almost without exeej)tioi> ;'..> fault of the attendant." h'tio(o(/i/. — Atony of the uterus is the most fre(ptent eau'^e of liemorrhage alter the child's being «lelivered ; this hemorrhage, indeed, is frecpiently calUH 1 "at onic hleedniir. The ciMises of this failure of the uterine muscle to Th contract j)roperIy, eiosnig the moutiis or bleeding vessels, are many. 1 he con- dition has been observed after a brief as well as after a long labor; it may follow a ease of great distention of the uterus, as from plural preguaney or from ainuial dropsy ; prolonged and profound anesthesia predisposes to it. The bleeding may be in consecpience of albuminuria or of hemophilia, in still other cases from delicient imis»'ular development of the uterus. Veit" refers, under atony of the uterus, to paralysis of that portion of the uterus to which the placenta has been attaclied — a c<»ndition which has been described by Kiigel, Rokitansky, JJurchardt, Kiwiseh, Chiari, and others. In this local uterine atony there is found upon abdominal examination of the uterus a depression, while internally, corresponding with the external depression, is a |)r()iecting mass. Fritsch "^ observed a ease of local atony in which he found on se(!tion a ('oinplete varicose degeneration of a part of the uterus ; the paralytic portion was composed almost entirely of wide veins. The same author mentions a very dangerous f )rm of uterine atony the eonsequenee of i'lfection occurring early in labor, stating that it is not wonderful, when we observe that paralysis of the infected muscular coat of the bowels leads to meteorism, that the eon- tiv'i'tile activity of the uterus should fail from a similar cause. Penrose.*^ in his paper upon the treatment of post-j)artum hemorrhage, remarks: "A cause sometimes of dreadful post-partum hemorrhage is the ]>iiitial morbid adhesion of the placenta to the uterus ; here there is often the reverse of uterine inertia; the uterus may be in a condition of firm contrac- tion, but the adherent placental mass, occupying no little space in the cavity of the organ, j)reveuts and renders impossible that degree of shrinkage in si/e indispensable to the complete obliteration of the uterine blood-vessels, and hemorrhage is the inevitable result. To this cinss of causes might be achlcd those eases where the hemorrhage is caused by the presence of fibroids in the wall of the uterus or of a jxdypus in the cavity." Placenta privvia may cause post-partum hemorrhage, for the lower segment of the uterus has not the contractile power which belongs to that portion of the uterus in which the placenta has its normal site, hence the closure of torn "i .. // il .<r «il'' |i! it,,\iM: AMERICAN TEXT-BOOK OF OBSTETRICS. 1 i L'.i ,^M I < blood-vessels is not so prompt and complete, if the placenta be attached, in the former as in the latter. In concluding this topic we believe the prevention of post-partniu hemorrhage is in most cases secured by proper management ol' the third stage of labor. Si/mptoms. — Frequency of the jmlse is often a herald of bleeding. Whether before or after the expulsion of the placenta, the obstetrician finds the pulse rising instead of falling, and, though the patient's general condition may appear favorable and the uterus appear well contracted, he will redouble his watchful- ness, seeking to avert the threatened ])eril or to be prepared promptly to meet its coming. Possibly the patient herself may give the first danger-signal by asking if she is not " wasting too much " or " flooding," though frequently this expression of fear may be groundless. Oftener the physician is advertised of the dangerous condition by the expression of the patient's face — so deep a pallor upon it; probably she cimiplains of some disorder of sense, such as " ringing in her ears" or obscurity of vision, saying that ''the room is gettiui: dark." H(!r face is not only pale, but also expresses anxiety ; the pulse is feeble and frequent ; the resj)irations are shallow, difficult, it may be gasping ; the skin is cold and bathed in sweat ; in the hunger for air she wants to have the window open and to be fanned ; she may in her great restlessness move this way or that and toss her arms about restlessly and pui'posely. Possibly convulsions occur, and woe to the patient whose attendant mistakes them for an eclamptic attack ! Sometimes the loss of blood may be so great that syncope occurs. Fortunately, however, this is not in the majority of cases immediately fatal. The hemorrhage is either open or concealed — that is, external or ifiternal. The Princess Charlotte died five and a half hoiu's after a labor that had lasted fifty hours, the child being stillborn. The hemorrhage was internal. The autopsy proved a healthy condition of the organs, but the ut(>rus, filled with blood, reached above the umbilicus. Of course an external hemorrhage reveals itself, and an internal bleeding will be readily recognized by the hand of the obstetrician placed upon the patient's abdomen, for thereby lie finds the uterus greatly enlarged, relaxed, and probably its boundaries not easily defined. It ought to be noted that a bladder distended with urine may simulate an enlarged uterus, and, even if it does not, causes great ascension of that organ. To mention the possil>ility of the error is to avert it. Post-partinn hemorrhage has been divided into ])rimarv and secondary. Unfortunately, authors differ as to the boundary-line between the two, some including imder the latter a bleeding that begins a few hours after labor, while others advance the limit to twenty-four hours or even some days. In the present di.scussion all hemorrhages occtu'ring within the first twenty- four hours will be regarded as primary, and these oidy will now be considered, secondary hemorrhage being subsequently di.scussed. Prof/uoNht. — The prognosis is graver the earlier the bleeding occurs, and. of course, graver, too, the greater the loss of blood. The character of the dis- charge is also of prognostic significance, for if the blood is thin, serum-like, tat'hed, in the lie prevention anagemeut ol' I)YST<H lA. I'l.ATK 41. X, Mrllii"! Ill' nKiiii{iiilMlii>ii fur nililiciiil ^riiiinitimi nl' thr .■ulliriTiil \,]i iilil. u ■ ¥■ « r i i L i. ,1a i.::p: I: If . -.^ !. .j}^,rp i I 1 , 1 1 ? ; 1 ■ ' '/ HMbik.., L. ^ Lmt DYSTOCIA. 603 niul without clots, the fluid itself is at fault and the danger of death is imminent. .S(;vere pain in the back is regarded as testifying to uterine activity, and there- fore as ground for encouragement. Hippocrates made iiiccough and spasms (iininous in hemorriiage, and Lachapelle counted dilatation of the pupils a s;rave prognostic sign. Treatment. — It is of immediate importance to lessen the flow of blood and to excite uterine contraction. One step in the accom])lishment of the first is to lower the patient's head, taking away pillow and bolster, and to raise the toot of the bed. Let tlie obstetrician by his words and acts prevent panic on the j)art of those present and inspire confidence and hope. Instant compres- sion of the uterus is made, and the effort is exerted to promote its contraction liy this pressure and by friction. The introduction of one hand into the uterus with the other upon the patient's abdomen may be necessary to remove the pla- centa or a part c»i" it or coagula or membranes (PI. 41 ). It is important before this nianiindation that the genital canal be disinfected, which may be done by carbolic acid, creolin, or lysol, washing it out with hot water containing one of these antiseptics ; furthermore, the hot water has this advantage, it stimulates the uterus to contract. Disinfection of the operator's hand and tbrcarm is still more important, and this may be accomplished, Fehling states," in five minutes by Fiirbringer's method. This precaution is esj)e- cially necessary if a partially free ])lacenta is to be detached, for, as Stumpf lias said, the manual detachment of the i)lacenta is the most dangerous obstetric operation. The introduced hand by its contact with the uterine walls may evoke the action of the organ, and the removal of the uterine contents permits n^iactiou. Tn the removal of the separated placenta it is usually better that both hand and placenta be expelled rather than withdrawn. Meantime ergot niav be used hypodermatically with the hope of stimidating the uterus to con- tract. If the patient is very much exhausted by hemorrhage, stdphuric ether, as originally advised by Hecker — 20 drops, for example — should be injected deeply in the thigh, three such injections being made. Among the older means of evoking uterine contraction are striking the exposed abilomen with a wet towel, and the introduction of a lump of ice into the uterus. The obstetrician now generally prefers to the use of cold the iiijeeting of hot water into the uterus. Penrt)se has for many years warndy iidvoeated vinegar as an invaluable help in jiost-partum hemorrhage. He lias given the following as his method of using it ;•" "I pour a few tablespoon fills into a s'essel, and dip into it some clean rag or a clean pocket-handkerchief. 1 tlieii carry the saturated rag with my hand into the cavity of the ntenis and s(|ueoze it ; the effect of the vinegor flowing over the sides of the uterus and tiiroiigli the vagina is magical. Tiie relaxed and flabby uterine muscle in- stantly responds. The organ at once assiunes what I will term its giz/ard- like feel, shrinking down and compressing the oj)erating hand, and in the vast majority of cases all hemorrhage ceases instantly ; should one application of vinegar fail to secure sufficient contraction, the hand can be withdrawn, and a second or even a third application can be made, until the uterus shall con- ' ' •: 1 •'% l; ii IK' r,\ I ' I n 1 t H ^1i f 604 AMERICAN TEXT-BOOK OF OBSTETRICS. tract .sufficiently to stop the flow of blood." Contaniin in his monograph'''^ states that " irritant substances placed in the uterine cavity act in the same manner as ice, and are more readily eni[)loyetl. In the time of Hippocrates a pomegranate from which the bark had been removed was introduced into the uterine cavity. In our days a lemon has been employed (Evrat, jNIoreau), or a sponge saturated with vinegar (liigest, Desgrange). iVll these agents reailiK excite uterine contractions when they are immediately in contact with the walls of the womb." Uterine injections are as old as the time of Hippocrates, but prol?ibIy Pasta in 1750 first advised the introduction of a solution of "calcined vitriol " for the arrest of hemorrhage. Dr. Robert Barnes in 1857 strongly advocatcil injection of a solution of perchlorid of iron. The formula recommended by him is 1 J ounces of the liquor ferri j)erchIori(li (British Pharmacopoeia) and 8^ ounces of water. The following are liis directions for the use of this solu- tion :®^ (1) "Be sure that the titerus is empty of placenta, blood, and clots; (2) com])ress the body of the uterus during the injection ; (3) have two basins at hand, one containing hot water, the other the ferric solution ; pump water well through the syringe (a good Higginson's will do), so as to ex])el air, then pass the uterine tube into the uterus, and inject first hot water, so as to wash out the cavitv and give a last op|)ortunity for evoking diastaliic contraction ; then shift the receiving end of the syringe into the ferric solution, and slowly, gently inject abont seven or eight ounces, earef illy keeping up steady pressure on the uterus throughout and afterward." Spiegelberg®^ objects to the strength of the solution advised by Barnes, and suggests that half an ounce of the liquor ferri perchloridi be added to a pint of water, stating that "a high degree of concentration would undoubtedly corrode the internal surface of the uterus, and might thus lead to extensive and deep thnmibosis of the uterine wall and to its setpielse ; it njight also produce gangrenous endometritis and secondary infection, or cause the thrombi to be broken down and carried away by the veins." Some have advised, instead of injecting the uterus with an iron-salt solution, swabbing the bleeding surface with a sponge that has been dipped in the solution. In recent years, however, the employment of the Barnes method has had few advocates, not only because some fatal cases have followed it, but also because of the prompt hemostasis usually resulting from injections of hot water. Dr. Attliill,*" in December, 1877, in reporting to the Dublin Obstetrical Society some cases of post-partum hemorrhage in which he successfully use<l h( t-water injections, stated that he w.s leci to their em|)lovment because of a private letter from Dr. Whitwell of San Francisco. Dr. Whitwell's state- in;>nt was to the following effect : When house-surgeon at the New York State Women's Hospital in 1874 he saw the uterus contract firmly and instantly upon being washed out with hot water after an operation by T)r. Marion Sims ui)on a sarcomatous growth of the fimdiis uteri. The result led him to try the same treatment in ])ost-]KU'tum hemorrhage, and he met with perfect success. He afterward succeeded in having the treatment tried in the '\ "'^ ! 'A- ' V 1 /^ c I'' DYSTOCIA. 605 Lyiii{?-in Hospital at Prague, and the luethod was so successful that it was adopted as a regular routine treatment. Windelband,™ in January, 1875, stated that by the recommendation of an American physician living in New l'\)iuidland he had for a year employed hot-water inje(!tions, vhieh were advised hy this physician for the hemorrhage of abortion. Windelband used them not (inly in the hemorrhage in miscarriage, but also in that occurring in two cases of ])r8evial placenta, in hemorrhage from uterine fibroids and other growths t'rom the uterine walls, in bleeding after birth when the uterus was relaxed, and in profuse menstruation — in fact, in all cases of uterine hemorrhage. The water should have a temperature of 112° F., and an irrigator or a fountain syringe is preferable to the ordinary instrument. A little vaselin or cosmolin should be applieil to those parts of the external sexual organs with which the fhiid comes in contact as it escapes from the vagina, for without this precaution the patient will com])lain of severe burning. The nozzle of the syringe or inigator should not be passed into the uterus until the stream has begun, thus guarding against the possible introduction of air; it is gradually carried as high in the uterine cavity as desired, the escaping stream making a way, as it were, and facilitating this movement. Another method of arresting uterine hemorrhage is bimanual compression (Fig. 394). The patient lies upon her back with the lower limbs drawn up ; Fi(i. ;!iM.— Bimanual comprossidn of tlie uterus. tlio obstetrician introduces one hand into tiie vagina, both hand and vagina having been carefully disinfected, and passes two or three fingers up to the pos- terior vaginal vault, so that he can exert a firm pressure upon the posterior |)art of the cervix ; the other hand, placed upon the ])atient's abdomen, grasps tiio fundus and the posterior M-all of the uterus, drawing them forward, the vaginal fingers at the same time pushing the cervix in the same direction ; tliiis the uterus is anteflexed and firndy held, so that hemorrhage for the time is impossible. The vaginal fingers may be ap])lied to the cervix anteriorly, and the external hand to the fundus and the anterior surface of the uterus, and thus the organ may be retroflexed and arrest of bleeding be accomplished. Fritsch" speaks favorably of what he calls tlie " rational bandaging " of the P''v^?llli->^il ,i':!; «^ , ?; -If. I I 1 ;! i.. « } 1t- \ \ i5V< lit! f.^ t i! I i ' 1 - th I r ^'} I I 1 60(5 AMERICAN TEXT-BOOK OF OBSTETRICS. abdomen, saying : " Long prior to my injection of iron, and before Diihrsson recommended the tain|>on, had I applicil bandaging the abdomen in snitabic cases, and with the best results. It is especially to be recommended in those cases in which, some time post-partum, the uterus is again distended with blood and the anemia has reache<l the border-line of imminent danger to life, as shown bv great frequency or entire absence of the pidse. In such a case it requires con- siderable self-confidence to apply Diihrssen's tampon, as during its application some blo<Ml is lost — at least that which saturates the tampon. In these cases I recommend and employ the following method : The uterus is pressed for- ward and antevertetl ; behind the uterus there is placetl a large mass of cotton (one or two packages, amounting to 250 grams) or large pieces of muslin, ov even a big book carefully and uniformly wrappetl. Now a roller bandage is applied tightly, which not only compresses the abdomen, but acts upon the l)osterior wall of the uterus so that the organ is pushed toward the pelvic inlet. Additional turns of the bandage are made, passing above the fundus, and the uterus is fixed in its anterior position. The uterus is thus compressed in front and behind, lying against the pubic symphysis. By the abdominal compress pressure is also made upon the aorta. The blood is pressed, as it were, out of the abdomen and kept in the upper part of the body. This method, old as it is, still calls for occasional use, for it ensiires prompt safety against bleeding, raj)id recovery of consciousness, and an improvetl condition of the pulse. After such severe hemorrhage patients are not very sensitive. I have often let the bandage or compress remain twenty-four hours or longer with- out its removal being requesteil. At all events, we can in this way arrest the bleeding much more quickly than by the tampon, and at the same time we have the advantage of compression of the aorta. / would especially adviw this method of compremon for those cases to which ice are called in the final star/cs — the severest decree of hemorrhaf/e. Jf seeing a case in the beginning, such great anemia may be averted by the prophylaxis of Diihrssen's tampon,'' Compression of the abdominal aorta has been successfully employed in post-partum bleeding. One of the recent arguments in its behalf is that it prevents cerebral anemia. Kaltenbach,^^ while admitting the iisefulness of this compression, regards it as doubtful whether the favorable action is to be attributed to a lessened l)lo()d-suj)ply or to a meohanical irritation of the ute- rine plexus. The method Msually pursued is as follows : Suj)posing the obstet- rician to be upon the patient's right side, the abdominal wall is depressed with his left hand until the pulsation of the aorta is felt just above the uterus, and then slight pressure is made upon the vessel with three fingers, arresting the flow. An assistant is needed, for the fingers become too tired after twenty or thirty minutes to eontimie efficient pressure. Rudiger of Tubingen was prob- ably the first to advise this treatment, and he exerted pressure on the vessel through the jiosterior wall of the uterus. This method was rejected, and Ulsamer's method, first advised in 1825, and previously given, is that gene- rally employed. The tampon is by no means a new way of treating uterine hemorrhage, but DYSTOCIA. 607 its recent recoiniueiulation by Diilirssen has revived its use. Tiie vagiual tampon is now never used except possibly in tears of the cervix, and then Imt exceptionally, and tamponinjij the uterus will theretbre only be presented. Lcroux of Dijon and Chevreul of Anj^iers had numerous successes with the tampon ; but, as IJaudelocqiic has said, the tampon which they employed was a sponge satiu'ated with vinegar, usually introtluced into the uterus, and it was till' action of the vinegar upon the walls of the uterus which was beneficial, and not the barrier which they supposed the sponge offered to the escape of 1)1(10(1. Other means of tamponing the uterus that have been recommended are an animal bladder or a rubber sac, either being introduced empty, and alter the introduction filled with air or with a li(iuid. Zweitei reconimende<l as a final resort, other suitable means having failed, tamponing the uterine cavity with cotton that had been dippwl in a solution of chlorid of iron. He preferred this method to injecting the uterus with the solution, for a patient of his perished after such injection, while another recovered when this tampon was applied. In recent years the preference for gauze (usually iodoform gauze is selected, though some advise that which has been made antiseptic with cre- olin) has been decided. In tamponing the uterus three strips of gauze about the width of three fingers, each strip nearly 10 feet long, will be provided.* The strips have been dipped in a 20 i)er cent, solution of iodoform, and iodo- form is sprinkled upon them just before they are used. The patient lies upon her back across the bed, and two tenaculum forceps are used, one to seize the anterior, the other the posterior, lip of the uterus, and by them the organ is tlrawn toward the vulva. An assistant holds these forceps. A long uterine dressing-forceps grasps one end of a strip of gauze, and is used to carry this up to the fundus of the uterus ; at the same time the oj)erator has his hand upon the patient's abdomen over the uterus. One fold after another is laid upon that first introduced, and thus successive layers are disposed like the folds of a closed fan until the strips are all in.troduced and the cavity is cora- |)letoly filled. The uterus contracts, it is claimed, because of the contact of a foreign body with its walls. The tampon does not cause suffering, and it is removed at the end of twenty-four hours, and the uterus is washed otit with an antiseptic solution. No matter what tampon is used, it caiuiot succeed if fragments of placenta are left in the uterus ; they therefore must be removed before its introduction. Schauta, in his paper, Die Behandhmg der Blutunf/cv post-partum , after referring to his own successfid employment of the gauze tampon, states that failures have been reported by Diilirssen himself and by Fritsch and OIs- liausen, and advises, if the hemorrhage continues after the tampon has been introduced, that the strips be removed and fresh tamponing made after washing out the uterus, the gauze being packed more thoroughly. The tiim- pon will be a failure, he says, in case the bleeding results from large arterial vessels that have undergone atheromatous degeneration, or even a single such * Playfair l>as said that the puerperal uterus will hold two ball-dresses I This being true, one need not be astonished at the quantity of gauze required. 1 w W^\:: - P^^v' 1 ■ fir ' I'il^i^ L f\ ()()8 AMEIilCAy TEXT-BOOK OF OJiSTETlUCS. < A I. >i mi ] ^ ^ « ' ,1 vossc'l at tlic jdiKTiital ssitc. He adds tiiat in such cases the removal of tin uterus by supravaginal amputation may be considered in a well-c(»n(hiet((l clinic, but in private practice wouhl not as a rule be thought of. The prop.,- siti(m of Kocks he rcf^awls as worthy of consideration. This sugjicstion i- to invert the uterus, anil after thi> orjian has been brouj^ht down it is to !»• encircled by a piece of rubber tubing or by a firm bandage, best of a strip of iodoform gauze, so placed that the placental site shall be below it. Ncco- sarily the bleeding will be thus immediately arrested, and at the end of six hours the bandage is removed, and, the hemorrhage not reappearing, the uteni> is restored, this restoration, according to the communication of Kocks, being accomplishetl without difficulty. Kaltenbach states that the introduction of a gauze tampon is very difficult in case of a flaccid uterus, and often it is incompletely done, and thus tlic bleeding remains internal. He fiu'ther states, after referring to the dangerous embolism which may result from injecting an iron solution, that the gaii/c tamp(m is especially applicable in eases of deficient coagulability of the blo(Ml. Herman," in criticising the gauze treatment, remarks that we must judge the effi^ct of treatment of post-partum hemorrhage rather by the fewness of the failures than by the number of apparent successes. Fritsch has reeord((d a case in which death occurred from atonic hemorrhage notwithstatiding the tampon • and other cases, in which the cause of death was not clear, have been published. One ease of fatal air-embolism, occiu-ring while the tampon was being introduced, has been reported. To the assertion that the treatment is neither certain nor eafe he adds that it is imphysiological, for the uterus camiot bo completely contracted while the gauze is in it. (.'ertaiidy the eases are very rare in which this treatment will be required. (iuite exceptional, too, are those cases in which a departure from the rule, long established and almost universally held, that the uterus must be emptied of clots, is justifiable. " Tiu'u out that clot!" has been the injunction of obstetric teachers for a century or more ; yet it may be that in some very rare instances the direction shoidd be, " Do not turn out that clot." In Containiu's paper the following case is narrated : " There are, nevertheless, cases in which clots seem to oppose a barrier to the flow of blood. In one of his patients Professor Bouehacourt three times emptied the uterus of clots. After each evacuation the hemorrhage rectu'red and clots were again formed in the uterine cavity. The patient was exhausted and syncope was imminent. As the si/.c of the uterus was not very great and did not seem to increase, this fact indi- cating that the hemorrhage was suspended, the clots were left in the uterus. " The hemorrhage did not recur, and the following day the clots were spon- taneously expelled. In this case the clots had the fvle of an obstacle to tlic flow of blood, and it might be asked. What woidd have happened if the nh- sti^trician had determined at all hazards to empty the uterus? In exceptional cases only can this practice be followed. Xcvertheless, we are justified in tem- porizing when the hemorrhage seems arrested, and especially if the firmness of the uterus indicates return of its contractions." To this case mav be addcil DYSTOCIA. 000 (die recorded hy Dr. James F. Ilibbertl/* in whicii a similar practice was siiccessrully followed. There was this ditferencc, however : Dr. Ilibberd's patient fainte<l twice from the loss of blood. The means Ibr compensating the loss of blocnl are transfnsion, atitotransfu- .-ion, subcutaneons and intravenous infusion of a sterilize<l solution of ddorid of sodium — the so-called "normal salt-solution'' — and rectal injections of this xthition. Transfusion, in which the blood from another person is introduced into the venous circulation, is now scarcely ever employctl. In autotransfiision tlic limbs are bandaged so that the great mass of bhxxl which they contain is t'orccd toward vital organs, especially the heart. In this operation flannel baiidtigcs are used, those of rubber being objected to because by their great compression thromboses, and later embolism, may be produced. For hypo- dermatic or intravenous use, and also for injections in the rectum, the physio- logical or normal salt-solntion is prepared by adding 6 grams of chlorid of sodium to 1 liter of water free iVoni germs. Winckel advises 1 drop of caus- tic solution of sodium to be added to the mixture. The hypodermatic appli- cation is made with Minichmeyer's apj)aratus, which consists of a fumiel, a rubber tube, three needles, and a thermometer. Some select the upper portion of the thigh for the introduction of the fluid, and the quantity used in a case reported by Ziemssen was 1 liter : usually a much smaller amount will be sutKcient. The method is fully presented in the treatment of Eclampsia (page 637), and therefore further details are not here given. Before describing intravenous introduction of normal salt-solution it should be mentioned that much may be accomplished to prevent the injurious conse- ([iiences of loss of blood by having the patient drink the fluid as freely as she can without catising irritabil- ity of the stomach, and also by in- jecting as much of it in the rectum from time to time as will be toler- ated. Intravenous injection of normal salt-solution, approximately one tea- s|VK)nftd of salt to a pint of water that has been boiled and has a tem- perature of 100° F., may be made with a glass funnel, a rubber tnhe, and a cannula. Horrocks," from whose paper the accompanying illus- tration (Fig. 395) is taken, describes the operation as follows : " Make an incision about one inch long and expose the median basilic or any other vein of not less calibre. In some cases it is found useful to cause filling of the vein by tying a pocket-handker- chief or bandage round the arm. With a needle pass a silk, gut, or other ligature under the vein, cutting it so as to leave two ligatures. Draw one to ;<9 Fio. 395.— Intravenous injection. f '• :d ^ ,■; / i r' I i. *i^i.f y r 1:1 r, •rw^"*" 610 AMEIilCAX TEXT-noOK OF OBSTETRICS. i I li- ■V>:" \K ' ' ! lI' i .;Ul ' I the lower angle of tlu; wound, and tie it round the vein by a double knol, cutting the ends short. With the disseeting-fbreeps pineh up the vein and make a small nick in 't with scissors, taking care not to sever tlic vein com- pletely. Introduce the cannula (silver or glas.s) into the vein, and tie it in by means of the upper ligature, leaving the ends long as in the Figure. Tli. blood will How down the camuda, and when it is full the rublK«r tubing, pre- viously attached to the glass funnel and tilled with the saline solution, is tixcd on the end. The funnel is now raised, and as the water flows it ia replaccij by pouring in more of the saline solution from a jug (pitcher) held close to the rim to prevent air-bubbles being formed. As long as the funnel is kept above the level of the camuda, air-bubbles will always rise to the surface and escape. Another method of introduction, and one recommended in severe cases, is to fix the funnel and the cannula in the tubing, fill the apparatus with salt-solution till it runs out warm, and then to introduce tiie cannula into the vein, the funnel being held by an assistant slightly higher than the cannula, so as to keep up a gentle flow which washes away the oozing blood and ensures the absence of air. The speed at wliich the fluid is injected can be regulated bv raisintr or lowering the funnel. In most cases a distance of about .'{ feet is sutticient, and the flow is found to be about a pint every four minutes. When enough has been injected, remove the canntda from the vein. Cut the latter completely across, and tie the upper end with the long ends of the ligii- ture. Sew up the wound with a continuous or interrupted fine silk or other suture, and fix a clean pad with a bandage." Horroeks states that enough fluid should be injected to cause the pulse to be perceptible at the wrist, and that the worst cases require about six pints. Further, in the treatment of the ))rostratc condition Kaltenbach commends a rectal injection of red wine and the whites of two eggs with from 20 to 30 drops of tincture of opium. lie also sjieaks favorably of an injection once or oftener, in the up])er ])art of the thigh, of ether, tincture of musk, or cani- ])horated oil (1 : 9). Convalescence from the anemia resulting from severe bleeding will he best prouKjted by keeping the patient in a horizontal position, not even permitting her to sit up to nurse her child or to urinate. Milk, eggs, and animal broths should constitute the thief part of the diet, and alcoholic .stimulants may be advisable in some eases. If the hemorrhage has been from the placental site, and esi)ecially if the flow is profuse and its bloody character is prolonged, ergot or fluid extract of hydrastis is indicated. The first getting out of bed will be delayed several days after the usual time in patients who have suflered from post-partum bleeding. Many patients will require the early administration of tonics — quinin and iron, for exani- ])Ie, or the elixir of phosphate of iron, quinin, and strychnin, or the eoiii- jiound of ** beef, wine, and iron." Lacerations and Rupture of the Uterus. — These lesions are found almost exclusively in the lower segment of the uterus; most of them con- sist in tears of the uterine wall that run more or less transversely (Fig. DVSTOC/A. Gil .?9G). Tlioy nro callod " complete " rnptnroa of the utoruH wlion tlir wouimI |>('iiotrnte.s all throt- fonts of that organ, and " incomplete " when cither the serous or the nmcoiis lining of the womb remains nnimpaired. Laccrutions in the upper portion of the uterus are exceeilingly rare. CdHncs. — Sliarp ridges projecting from the pcjlvic hones have sometimes Iteen known to sever the vails of the uterus. These projections are most likely (c> be found at the promontory and along the ilio-pectineal line, ff there is any mechanical disproportion between the inlet of the pelvis and the fetal I'lc. 3%.— Trnnsverso rupture of lower set;- Fii!.;i>J7.—IrapeniliiiK rupture of utcnis in iishoul- iiicut of uterus (Spiejjelbern) : a, probe inserted der iiresentiition (niueli ruoililieil from Scliroeiier): or, external os; oi, internul os ; r,\ eontraetion- ring. miller the peritoneum. head, the latter in its descent will press the lower segment of the womb against these sharp ridges with so mucli force that they may grind their way into the uterine tissues. Any attempt to pull the head into the j)elvis with forceps will under these conditions only help to increase the amount of injury to the uterus. Incomplete rupture of the uterus, with the inner portion of the wall entire, can have originated only in this manner. By far the greatest number of ruptures of the uterus, however, are caused ill an entirely different way. They are the direct result of the uterine con- tractions and of over-distention of the lower segnjent of the uterus. This mode of origin \\as first jwinted out in 1875 by Bandl, and since then his statements have generally been accepted as correct. During labor the upper |i(ii-tion only of the uterus contracts, while the entire cervix and that portion of tlie body immediately above the inner os are subjected to a stretching process until they form one wide cylindrical canal. While this dilatation is going on we find that the wall of the lower segment gets thinner during each labor- |)aiii, whereas the wall of the contracting portion of the uterus thickens and iiardons. The border-line between the upper and the lower segment of the womb is marked by a ring-shaped projection of the contracting portion, the so-called "contraction-ring," which is found at a variable distance above the inner os. During the contractions the uterus has a tendency to move upward . ' 1 1! j ' 1.- ' : > i ijl ! J.! ..Ai -:;r*ir 612 AMERICAN TEXT-nOOK OE OBSTETRICS. toward tho diaphragm and to pull the dilated lower segment upward and awa\ from the presenting part, the latter usually deseending at the same time, thi- partial evacuation of the iiterus preventing an undue stretehing of the lowoi- segment. If, however, a malpresentation or some other mechanical impcdinieni ])revents the fetus from descending, tlie stretching of the lower segment con- tinues. The uterus, as a rule, tries to overcome the obstacle by an increase iii the intensity and duration of the contractions, thereby augmenting the chances for a ru|)ture. When there is unequal dilatation — as, for instance, in shoulder prescntalion, in which the greatest stretching of the lower uterus takes jihuc on that side to which the fetal head has escaped — the rupture becomes still more imminent (Fig. .'J97). The administration of ergot during labor is at times directly responsible for uterine ruptures. The writer remembers a case of a multipara with eentril placenta pra>via in which the attending physician had plugged the vagina very effectively, and at the same time had given the patient a teasp^onful of ergotol. The tampons together with the mass of the placenta nuulc it impossible for the presenting head to enter the pelvis; it escaped to the left iliac fossa, ami when the writer saw the patient two hours later he found a transverse laceration on the left side of the uterus a little above the inner os, through which the head had entered the abdominal cavity. From what has been said above it is evident that these ruptures nnist always originate in the lower segsiient of the uterus; which fact, however, does not preclude the possibility of the tear extending upwanl into and above the contraction-ring. Si/mpfoinx. — In a minor number of cases the rupture takes place without premonitory symptoms, but usually these symptoms are well marked. The parturient wt>man does not rest between the uterine contractions ; she complains of constant and severe pain in the lower abdomen on account of the intense stretching to which the lower segment of the uterus and the uterine ligaments is being sul)jecte<l. The rupture itself always takes place during a uterine contraction, and it is usually accompanied by an intense penetrating pain. At the same moment the parturient woman feels that the child has turned or lias shifted its position. The labor-pains suddenly cease ; there may be a free hemorrhage; the patient's skin gets cold and clammy; the pulse becomes very frequent and thread-like in volume. Some or all of these symj>toms may bo missing, with the exception of a change in the character of the pulse. The abrupt cessation of the uterine activity is also very constant. On examination the presenting part will ije found to have receded, or it may have entirely disappeared. Part or all of the chihl has escaped throuiili the rent, and it can (Nearly be outlined through the abdominal wall. If the tear does not extend through the peritoneum, then this membrane is detacheil so as to form a large cavity which contains the escaped fetus and a greater or lesser quantity of blood. Frcqunu'i/ of the Accidait. — No reliable statistics as to the frequency »l' rupture of tlie uterus can be procured, as in maternity hospitals, to which com- ho tVeqiioncv of , to which coin- BYSTOCIA. |)licat(xl oas^os arc constantly forwarded, there will naturally he found a greater [icrcentagc of sncli accidents than if all labor cases from a large territory were collected for statistical purposes. In countries in which osteomalacia ;ind rickets are common the frequency of pelvic contractions must necessarily increase the number of ruptures of the uterus. The ireijuency of this awi- (lont will vary also with tlie greater or lesser ability of the obstetrician. IJandl found one case of rupttn-cd uterus among 1200 continements, while (Jarrigucs states the frequenev as 1 in from 3000 to 5000; the latter statement seems to be apj)roximately correct for the Uniteil States Frog)WHis. — Rupture of the uterus is one of the gravest complications of l;il)(>r. Over 90 per cent, of the children are born dead, and of the mothers liiliy 60 per cent, succumb to the accident. Many women bleed to death before help can reach them ; others die within the next few days from septic infection or from secondary hemorrhage. Before antiseptic times the outlook was even more gloomy, but it has greatly iini)rovcd within recent years, and we may hope that in the future a still greater percentage of mothers will be saved. According to statistics published by Sciiultz and quoted by Winckel in his text-book, the following percentage of cures was effected in the 11)3 cases collected from modern literature: Complete ruptures without treatment, 20.2 jier cent. Complete ruptures treated with drainage oidy, 36 per cent. Complete rupuires treated by laparotomy, 44.7 per cent. Treat incut. — Whenever during labor the over-distention of the lower seg- ment of the uterus can be diagnosticated, an attempt must be nuule to deliver at once and to accomplish this without increasing the distention of the parts. Tlie patient should be anesthetized, as the narcosis will lessen the intensity ol' the uterine C()ntra<'tions. The mode of delivery nuist be clu)sen according to the nature of the case. Tn shoulder presentations version carefully executed is the proper procedure, providing the child 's living. IShould the child be (lead, then embryotomy would bo itrefoiablc, as i' does not increase the tension of the uterine walls, an<l consequently the danger .f a ruptur<>, while version, no matter how skilfuUy performed, will cause some additional distention. In licail presentations a gentle attempt with the forceps should be made, always taking it for granted I'lat the child is living. Failing with the forceps, the onlv choice lies between Cesarean section and craniotomv ol' he livins; child. N'ersion in these cases is out of the question, because t'le stretching of the uterus in a transverse direction is very nuieh greater ^\hon the operation is |i('rformed in head presentation than when it is resorteil to in shouhh'r pres- ciilation, where the child lies already with its long axii more or less trans- versely in the uterus. U«ider favorable surroimdini^s Cesarean section should always be the operation for treating this emcr}^ .ic; \ and craniotomy should be performed in those eases in which the «. hild has censed to live. After the rupture has taken ])lace a spoci^ delivery is also called for. 1 1' a part of the child '"■^ retained in ! le . ^^nis, delivery through the natural passages shoidd at once be attempted. Usually w. are able to extract the child ;.v| i. .Z . •l^J" ij, * I ■' 1m ^' ' I' ', >u . • ! ^ ,, ' i I ; 31' 614 AMEBICAN TEXT-liOOK OF OBSTETRICS. by the feet. The placenta is removed next, and the parts are then cleaned and examined. Hemorrhage may not be very great, as the uterus gcnoi- ally contracts well as soon as it is completely emptied. The patient should lie allowed to rest, and she may be stimulated with hypodermatic injections ol' ether, brandy, and like agents. If she rallies, the further treatment must lie decided upon. The question will be : Shall the abdomen be opened, the rupture be closed by sutures, and the peritoneal cavity be cleansed of the blood ami meconium that have entered it, or shall the treatment be confined simply to cleansing the vagina with disinfecting irrigations and introducing a glass tuho or a roll of iodoform gauze into the rent in the uterine wall to provide drain- age for the infected peritoneum ? When the accident has happened amid sur- roundings that would not be objectionable to laparotomies for other causes, there is no good reason why the patient, provided she has rallied, should nut be given the full benefit of the modern advance in abdominal surgery. Laparotomy performed under these conditions cannot expose the patient to any additional danger, but it can greatly improve her chances fur recovery. AVhen the child has entirely escaped from the uterus or when it cannot be extracted through the v'las naturales without greatly increasing the laceration, there is no choice in the mode of treatment. The abdomen must be opened and the child be taken away after ligating the umbilical cord ; the placenta is best removed by compressing the uterus, when the after-birth usually glides down into the vagina, whence it can be extracted by the hand. The tear is now repaired by suturing, care being first taken to unite the muscular coat of the uterus, and then to close the peritoneum separately with the edges folded in, so as to ensure a good and speedy union. Incomplete ruptures, with the peritoneum detached from the uterus, do not necessitate laparotomy. The newly-formed cavity is washed out through the rent and a drainage-tube or a roll of iodoform gauze is inserted to give escape to the secretions. The same treatment is pursued in complete ruptures, as already stated, whenever laparotomy is decided against. In the latter ease no attempt should be made to wash out the abdominal cavity through such a tube : the tube should serve only for drainage. Iryuries to the Infra vaginal Portion of the Uterus. — Physiologically there is a laceration of the vaginal portion of the cervix in all primipane and also in some nuiltipara;. This laceration, wliich is usually bilateral, runs in a transverse direction, so that in women who have borne children the external OH is no longer a small round opening surrounded by a perfect ring of tissue, but is a more or less funnel-shaped aperture placed transversely between two well-marked lips. It is only when these tears arc excessive that they gain pathological im- portance. This is the case when the laceration extends upward to the vaginul vault and above it, or when it is accompanied by considerable li'> iior»!i!i^";'. In some cases the anterior lip oi the cervix is wedged in bet^i een the tU'-' head and the pubic arch, and it may be torn off more or less ccnplLtely, By DYSTOCTA. 615 aiiiuilar lacerations of the cervix (Figs. 398-408^ are meant those very rare cases iu which the external os is unyielding and in which the whole lower sec- tion of the vaginal portion has by the descending head been forced off in the >liape of a circular flap containing the external os in its centre (Fig. 404). Cuuses. — The nioie extensive lacerations of the cervix arc almost always caused by obstetrical operations at a time when the cervix uteri is not suf- liciently dilated to allow an easy passage of the fetus. In some few instances ))athological ciianges in the tissues of the cervix are to blame for these injuries. Fici. ;>1)8.— Cervix of virgin (Keitzmann). Fig. 399.— Another form of exteriiul os in tlie virf,'in (Ueitz- mann). Kl<;.-1(K).— Cervix iifler niiseiir- riuge (Ueitzmiinn). At limes the uterine contractions are so severe and frequent that they force tlie presenting ])art through the cervix before the latter has had time to dilate. Not unfrequently the administration of ergot during the first stage of labor, or rupture of the bag of waters before the os is fully dilated, has provoked these dangerous labor-pains. It is stated that prolonged labors are more K'' . .1.-- Cervix of mnltipara Via. WJ.— HllHteral Iiieeration Vm. -103.— Kxtensivelnecrnticpu (Heitzmunn). to vaginnl walls with eversion involvinfj sii)ira-vaKinal cervix (Heitzmann). and vaginal wall (Ueitzmaun). Klj fertile ciiuses of cervical injury than rapid labors, ou account of the long- continued compression of the cervical tissues. iSipnptoms. — It is only in a minority of cases that there are symptoms ])resent of sufficient gravity to lead to immediate discovery of the excessive laceration of the cervix at the time of its occurrence. Intcnst; pain is somc- iiues present, more particularly in those cases in which the rent extends uj)- ward through the vault of tiie vagina to the neigliboriiood of the peritoneum. TIk^ hoMiorrhage, usually trifling, is now and then so sevens as directly to endanger the life of the patient. When a post-])artum hemorrhage is noticed while the uterus is firmly contracted a close examination nmst l)e made of the .^ . H i.; ' .! vm:,\/fil I' 'i-i ill \h 1 !■ ( < 1^ I i, I ^ I I i ' 616 AM/'JIilCAiV TEXT-BOOK OF OBSTETRICS. lower portion of the genital canal ; if it is foiind that there is no lesion of tlir vulva or of the vagina that could cause the bleeding, it will l)e an eas\ matter to trace its origin to an injury of the cervix. If needs be the cervix- may be pulled down into the vaginal orifice to allow of inspection. During- the puerperal state an extensive lacera- tion of the cervix increases the danger of ])uerpt'ral septicemia and, at a lat(!i' period, it may lead to chronic uteriuf disease. Treatment. — The prophylactic treat- ment necessitates deferring all obstetric operations until the cervix is fully dilated. This waiting is not always practicable, and we often have lo choose the lesser to anticipate the greater evil, but we should never ope- rate under these conditions without tlie most urgent indications. The administration of ergot dui'ing labor at any time before the birth of the child is accompanied by so many dangers to both mother and offspring that no terms are too strong to denounce this nefarious practice. Profuse hemorrhage from a tear in tiie cervix will sometimes be arrested by hot-water injections or by direct compression of the parts either by the Fui. 404.— External os aiul a |)i.' rorvix liiulitT ii|>, which have been (luring delivery (Winekel). i)f the irn oil' Fl(i. lO.'i.— l.iici'nitiDU throuiih the left side of the cervix intcitlie hroad lijranienl to the ischial Rjiine and along the vagina through the perineal pyramid. Fiii. 4fX'i.— The two lower corners of the latciiil laceration of the cervix seized hy a double teiiiu - nlnni and drawn down to make ready forsuturini,' (Dickinson). finger or by a tampon ])laced against the bleeding surface. In most cases, however, it is j)referable to unite the torn ti.ssuos by sutiu'cs. The vagina is held open l)y vaginal specula or holders and the cervix is ])ulled down with a volsella or with a pair of Muzeaux forceps until it appears in the vulva, when the sutures can usually be applied without nuich difficulty (Figs. 405, 400). Inversion of the Uterus. — Wy complete inversion of the uterus is meant that cliange of position and form in which the fundus is the lowest and the cervix the highest i)art of the organ, and the external surface is the internal ; DYSTOCIA. (317 *! , I el osion of tlic be au easy e the cervix the vaginal jn. Duriii- nsive laceni- s the (hui<;( r lul, at a lat(!r ronic uterine lylactic troat- r all obstetric •vix is fully i not always ten have in nticipate the Id never opc- is without till' labor at any anirers to both this nefarious es be arrested either by the liriicrsol'tlif liiUval l)y 11 (Imililc toiim- : ready iDrsuturiiij; [n most oases, I The vagina is II down with a [e vulva, wilt 11 405, 400). Items is nionnt lowest and tlic the internal ; the shortest definition of uterine inversion is, the uterus upside down and inside out. Varieties. — We have here to consider only what is known as puerperal inversion, and of it there are two or three varieties, according to the degree of the displacement of the organ. The first degree, constituting one of the I'orins of incomplete inversion, consists in cupping or depression of the fundus (if the uterus. Should the fundus descend so that it is at, or partially projects tVoin, the OS, the inversion is still incomplete ; but if the fundus and the body of the uterus have passetl through the os, the inversion is complete. If the inverted organ is external, the vagina also being inverted, the greatest displace- ment is present, and it is complete inversion with prolapse. Into the funnel- slia])ed cavity formed by the organ internally, and lined with peritoneum, the Falloj)ian tubes, the ovarian ligaments, rouuu and broad, the ovaries in part, or a portion of intestine or of omentum, may enter (Figs. 407, 408). Kic. 40" iviTsiim "f utoriis : (liiiwiiiK from an nlil [ipi'cimi'ii in alciiliol. Tlio iitonic cliief site of |iliic( iitiil iittiiclnnoiit ((') is slirunkcn liy the alco- liol.anil llms its lessenint; is explained ; li.eoiitrue- linii-riu);; ((.external os nteri (alter .1. Veit). Flfi. 40«.— Inversion of tlie nteriis. The Ininen of the reetuni is seen, and also the inversion fun- nel in whieh are the tubes and an ovary (after J. Veit). Frequcnci/, — We have no conclusive stati.stics as to the frequency of this accident. Winckel ^^ in more than 20,000 labors has not seen a case of com- plete inversion, nor had Braun one in '200,000. Denham in 100,000 cases of labor in the Rotunda Hospital, Dublin, found one ca.se of inversion. Kehrer" states that the accident is thought to occur once in 2000 labors. Probablv uterine inversion is more frequent than published reports of cases would lead f^^m^^ 1 % ■fiw I ; \ ! If ' ' > <' ,«•' i 618 AMERICAN TEXT-BOOK OF OBSTETRICS. one to believe. It may be that in some cases if the displacement was recog- nized the fact was concealed ; in other instances the accident was not dis- co veretl. Etiology. — Relaxation of the nterus necessarily precedes inversion. Mat- thews Duncan has stated : ^* ** Four kinds of uterine inversion occur after delivery : 1. Spontaneous passive uterine inversion ; 2. Artificial passive uterine inversion; 3. Spontaneous active uterine inversion ; 4. Artificial active uterine inversion. The only uterine condition essential to the production of all these kinds is paralysis or inertia or complete inaction." Without entering into the various explanations of uterine inversion given by Duncan, this accident may originate in three ways : 1. There may be spontaneous inversion. Paralysis of the uterus at the placental site existing, simply the weight of the placenta may cause sinking of that portion of thd uterus in the cavity. Such ot<3urrence is more liable to happen if the placenta is attached at the fundus; then, the remaining portion of the uterus being a( tivo, t' > introcedent part becoties a foreign body, and by peristaltic action is forced farther down, just as happens in intussusception of the bowels. So, too, in complete paralysis of the uterus the organ may be inverted by the \veight of the placenta. Each of these forms of spontaneous inversion is rare : some, indeed, regard them as doubtful. 2. The inversion may be caused by abdominal pressure or by the pressure of the hand upon the uterus. Kaltenbach states that he saw an inversion produced by the practitioner, in endeavoring to express the placenta, con- tinuing to press after the uterine contraction had ceased.* Denuce^' quotes a passage from Galen showing that this great physician knew uterine inversion could be caused by spontaneous abdominal pressure. 3. Inversion is most frequently produced by pulling upon the cord, and this may occur in spontaneous expulsion or in extraction of the child, there being absolute or relative shortening of the funis. Again, it may hapi^en if the child is expelle<l when the mother is standing, the sudden strain of the child's weight in falling, acting upon the attached placenta through the cord, producing inversion. Much oftener, however, the uterus is inverted by improper or untimely traction upon the cord in an effort to remove the placenta, this traction being made soon after the birth of the child. The uterus may then be in a relaxed condition, and especially at this time its lower segment and the os, having been recently stretched to the utmost in the passage of the child, can oppose only slight resistance to the descent of the inverted part. It has been asserted that if jiulling upon the cord was liable to cause such result, the accident would be very much more frequent, because so many obstetric attendants, ■* A (liiniliircnse has been previously reported by Johnston (Johnston and Sinclair's Practicul Midwifery). i ;- ersion given DYSTOCIA. fcl9 liclair's Praciiod especially midwives, resort to it for the removal of the placenta. But the •answer to this is that such employment of traction is not usually made almost immediately after birth, and therefore the condition of the uterus, contractions Iiaving returned, cannot promote the accident. There are too many histories of inversion being caused by untimely or excessive pulling upon the co d for one to doubt that this is the most frequent cause of the accident. "\niile in the great majority of cases inversion occurs during the third stage of labor, it may exceptionally happen hours or days after delivery. Pcnuce, in describing tardy inversions, inversions tardives, assumes a semi- ])aralysis of the placental portion of the uterine wall, which becomes there- i'ore depressed, and the depression furnishes a receptacle inviting intestinal pressure. He observes : " Such pressure, acting as in hernias, increases the cxtc!it and depth of the inverted portion and thus causes true secondary inversion." Again : ** These late inversions may happen in different ways. Sometimes the intestinal pressure, acting in a continuous i;^!Uiner, gradually produces the inversion ; sometimes, on the other hand, suddenly nnd under tlie influence of an abrupt and accidental effort or successive efforts the inver- sion results." We have thus explained the fact that in rare instances competent obstetri- cians have met with cases of inversion when the labor was properly conducted, and at its end the uterus occupied its normal position, the displacement occur- ring hours or even days after. Of course in such cases no blame can be attached to the practitioner. TV,it an inversion may begin at the ce. vix, as has been taught by some celebrated obstetricians, this part becoming everted and then drawing down the rest of the uterus, is in the highest degree improb- able ; especially is the apparent improbability great since we have learned in recent years more of the passive character in labor of the lower uterine segment. Symptoms. — The most important symptoms of this accident are shock and hemorrhage. The hemorrhage is inevitable if the placenta be partially or completely detached. There may be vomiting in consequence of the stretch- ing of the nerves in the lower part of the abdomen and of the pelvis, and syncope ; there may be reflex paralysis of the heart ; anemia of the brain from the sudden decrease in the intra-abdominal pressure may occur. Kehrer speaks of the collapse as being anemic-nervous. If there be complete inver- sion with prolapse, there is in front of the vulva a large ovoidal body as ropresentetl in the illustration (Fig. 409). In quite exceptional cases inversion may occur, as asserted by Reeve,*' " without sufficient symptoms to attract attention or to indicate that anything has gone wrong." In support of this statement Reeve, unsurpassed in obstetric knowledge and learning, adduced only two cases, both in the practice of the same obstetrician ; therefore the accident thus occurring must be exceedingly rare. J>i<ig)iosis. — If the obstetrician is ])resent at the time of the accident, and if the placenta is still attached, wholly or partially, to the inverted organ, a mistake is impossible. In other cases the history points to inversion, and the ||h M m % ■ '^l^l:■ 620 AMERICAN TEXT-BOOK OF OBSTETRICS. f symptoms presented assist the diagnosis, wliieh finally must rest upon a direct examination. This examination must be made with the greatest care, for, though in the nuijority of cases a correct conclusion can be reached with abso- lute certaintv, vet mistakes have been made even bv men illustrious in the profession, though these errors have usually been in the diagnosis of chronic inversion. One of the fii-st things for the examiner to do is to pass a catheter in the bladder, for this organ distended with urine — as it probably will be if some hours have elapsed since the accident — may be mistaken for the uterus. Fi(i. 409.— Complete inversion with prolapse (Boivin and DurOs): A, raons veneris; li, laliia majorn; r, labia miimra ; P, clitoris; K, urinary meatus ; /', exteriuil anterior border of the vagina; G, external bonier of tlie os uteri ; //, the internal surface of the uterus, now external. il 1 I Moreover, the bladder must be e^iipty in order that abdominal palpation I . be made. No matter, then, what oral information may be given that the patient has recently urinated freely, let the physician know for himsell', and this knowle<lge can be best obtainetl by the catheter. If the uterus is extra-vaginal, its general appearance is fairly given in the illustration (Fijr. 409). More frequently, especially if the examination is made some hours or a day or two after the inversion occurretl, the uterus is intra-vaginal, and by no means the size represented in the illustration. If the vagina is of normal dimensions, the hand can bo readily introduced, notwithstanding the presence of the uterus. Thereby the examiner feels a soft, probably sensitive, DYSTOCIA. 621 possibly contracting, pear-shaped tumor, the larger end below. By means of line or two fingers introduced into the rectum and directed forward the funnel- sliapcd o{)ening of the uterus is felt. If a sound should be passed into the bladder while two fingers are in the rectum, the ends of the latter may be lirought in close approximation with the knob of the sound above the vaginal tumor. By abdominal examination the body of the uterus cannot be felt, but il" the abdominal wall is not very thick and not sensitive — and the rule is that ill great loss of \> lod sensibility to pain is much lessened — the depression tormetl by the entrance to the new uterine cavity can be recognizetl. Denuce gives the following diagnostic marks of inversion and polypus : 1. The circular, not lateral, implantation of the pedicle; 2. The openings of the tubes upon the inferior portion of the tumor ; 3. The special sensibility, sometimes acconpanied by special contractility, that it otters to pressure and to acupuncture • 4. The half reduction which can always be made in inversions, never with polypi ; 5. The absence of the uterus from its ordinary place, ascertained by rectal and vesical examination. Now, we have to say as to these diagnostic marks, first, that finding the ojionings of the oviducts is not always easy under the circumstances, and that we know that an invertetl uterus may reveal no contractility, and that it may be insensitive, possibly in consequence of the utter prostration of the subject, to pressure and to acupuncture, so that the absence of these ])articular signs does not prove that the suspected tumor is other than an invertetl uterus. Prognoms. — x4ccording to Crosse,*' one-third of the women with puerperal inversion of the uterus die either immediately or within a month. In seventy- two of 109 fatal cases collected by him death occurral within seventy-two hours, usually within half an hour. Crampton*'^ in 1885 collected 120 cases; there were eighty-seven recoveries, thirty-two deaths, and one remained unre- lieved. Winckel, after quoting Crosse's statistics, states that in 54 recent cases only twelve died. But even this comparatively low mortality proves that in- version of the uterus is one of the gravest accidents of labor. Patients may die from shock or from bleeding; the death may not be immediate, and then it may occur from incarceration of a loop of intestine in the inverted uterus, from jieritonitis, from puerperal infection, or from gangrenous inflammation of the uterus. In very rare instances recovery has followetl the separation by sloughing of this organ. Spontaneous restoration of the uterus has occasion- ally taken place. Schiitz '^ states that ten such cases are known. Sometimes this has occurred after the failure of artificial means. Treatment. — Of course the prophylaxis is of primary importance. Ijct the rooiimbeut position be insisted upon in delivery. If brevity of the funis be ivcognizwl, promptly dividing the cord is indicated. In removing the placenta let no traction be made upon the cord, or at least no traction except during a pain. If compression of the uterus is made in efforts to express the placenta, S- ,**«7 •i: I > .'I i I i! ■I ^^M InKi''.^ p 1. I ei 11 ■liki 622 AMERICAN TEXT-BOOK OF OBSTETRICS. let the obstetrician be assiirod that his hand is so applied to the organ that im depression of a part of its wall is possible. The accident having occurred, restoration of the inverted organ is to Ijo made : this restoration will be more readily effected the sooner it follows the accident. If the ])lacenta is undetache<l, and especially if partially attached, it should be removed. The opinion of the majority of obstetric authorities is in favor of first removing the placenta before attempting reposition. Craniptoti remarks: " Firm and continued pressure upon any part of the inverteil organ, the patient, if possible, under the influence of ether, will suffice in the great majority of csises to reposit a recently-invertetl uterus. Thus in 92 instances of recent inversion retluction was eflf'ected in from five minutes to eight and a half hours." He gives the mortality as 20 per cent., whatever the treatment. The restoration of the inverted uterus is best made with the hands. Of course the hands, as well as the vagina and the projecting uterus, must fii-st he carefully disinfected. Then one hand is placed in the vagina, grasping, com- pressing, and pushing the organ upward, while the other hand is placetl upon thealxlomen, in part to make counter-pressure and in part to dilate the ring at the mouth of "the inversion funnel." In this effort the operator seeks to restore first that part of the uterus which cnrae out last. According to Kaltcn- bach, the restoration is, as a rule, easily accomplished, even without narcosis. The objection to beginning the reduction at the fundus, depressing it, and thus restoring first that which came out first, is that thereby a greater thick- ness of uterine walls must be passed through the constriction-ring. M'CMin- tock ** has said, in criticism of this method : " By proceeding after this manner we should give the uterine walls a second inflection, and we should necessarily require a greater dilatation of the constriction to admit of reposition. The accompanying diagram (Fig. 410) will help to bring out my meaning. Here a is the angle of inflection caused by the inversion ; b indicates the position of the OS uteri ; and c shows how the second angle of inflection would be produced by depressing the fundus, which the dotted line represents. It would ajipear, there- fore, that in the attempt to re-invert the uterus we should aim at replao''^g the part that has last come down, and so changing the angle of inflection according as each suc- cessive circle of the cervix and body is pushed uj)." TIio Fio. 4io.-invorsion of same objection holds if the indentation be made at one uterus: improper method ^,f j,,p ^,,1,^^ [nsiaSiA of at the fuudus. of restoration. After the reduction uterine retraction is .sought by irrigating the cavity with hot water and by the administration of ergot ; pack- ing the uterus with iodoform gauze, as some have reconmiended, is unnecessarv. If reduction be impossible without too prolonged or violent manipulation, it is better to wait until the puerperal period has passed. A restoration immediately followed by the death of the patient can hardly be counted an ob.stetric triumpli. Delay, too, is advisable if the patient is not seen until a few days after the DYSTOCIA. 623 acoidont : iniuiediate peril has passed, and new peril may arise from active efforts at reduction made during the lochial flow. After tliis flow has ceased reposition may be attempted by continuetl elastic pressure — as, for example, i)y a colpeurynter filled with warm water. li returning the uterus is impossible — and the reduction of an inversion is literally rc-turning — it is generally advised to control hemorrhage by ergot and by local application of astringents and refrigerants. Denuce commends lacta- tion if the patient's strength permits, stating that the hemorrhages are almost completely suppressed wliile she nurses. 3. Dystocia due to Diseases of the Mother. Eclampsia. — Eclampsia {exXa/jtrrai:;, a shining forth, from exXa/mo, to flash) is now commonly used as a synonym for puerj)eral convulsions. It may occur in pregnancy, in labor, or in childbed. It is characterized by a series of convulsive nu)vements and loss of consciousness, and coma fol- lows. Martin's definition is, " Convulsions of the entire body with loss of consciousness." ^ Desormeaux ** stated that Hippocrates and the ancient physicians employed the word exlan-at;: metaphoricidly to ex|)ress the exaltation of tiie vital proj)- ertics, the scintillation of the fire of life, according to the expression of com- inontators, that occurs at the epoch of puberty. " Some modern writers have called eclampsia the epileptiform convulsions which are transiently developed, aiul as the effect of an appreciable cause, in certain individuals, and more espe- cially the convulsions that occur in infants during dentition and in women in ])regnancy or labor. It is this last variet\ , designated by Sauvages eclampsia pariurientium, to which the term eclampsia is now usually restricted." The disease presents a strong resemblance to epilepsy, with which it has sometimes been confounded. Eclampsia is not rare ; its danger to the mother, and especially to her unborn child, is great, and even if the former should escape imme<liate death, she is liable to septic infection or to chronic nephritis, and sequelae involving the psycho-motor or psycho-sensorial centres are not uncommon. Moreover, its essential etiology is not settled beyond all controversy, nor is there j)erfect professional agreement in all things concern- ing the medical and obstetrical treatment. For these reasons ^h refore, the subjoct is of great in^portance, and it demands careful consideration. Frequency. — T'.e statements of authorities differ in regard to the ])roportion of those attacked. Auvard^" gives 3 in 1000; Martin and Kaltenbach,*^ 1 in 500 ; Vinay,** 1 in 250 or 260 : the last statement we believe is at least approximately correct. The reports of the Philadelphia Board of Health show that in the five years beginning with 1868 and ending with 1872 there wore 47,191 children born, and in that period 132 women died from eclampsia. Assuming that the disease was mortal in 25 per cent, of cases, that is, three recovered for one that died — we believe that this is a fair estimate of the mortality — the entire number of cases of eclampsia occurring in the five years was 525, or 1 in 170 labors. From 1888 to 1892, inclusive, there were ■'« ¥,. ^^ ()2i AMNIill'Ay TKXr-IUKtK OF OliSTKTniCS. 141,2;i5 births, and 99 cases of deatlis from cflanipsia. Ap|)roximatcl\, then, tlicn; wtMV WMy cases of tlic diseast; in tliat period, or 1 to .'581 labors. It appears, therefore, tliat \.\w disease was more than twice as frecpieiit in the first period as it was in the second : the partial interpretation of tliis Ijut will appear in a moment. Absolute accuracy is not clainie<l for these statistics, for some of the births were plural ; hence the entire nundwr of children born must be jj;reater than the actual mnnber of labors. Further, errors may arise as to the cause oi death jfiven by the physician, and thus the patient sut!'erin<i^ from eclampsia may have perished from sej)tic or from renal disease, and the death have been thus reported. It cannot justly bo asserted that there has been such advamc in the treatment of the disease that the mortality has been lessened more tliiiii one-half. A [)artial explanation of the ditt'ereuce is j^iveu by the fact that eclaujpsia is more fretiuent at certain times than at others. Kaltcnbadi directs attention not oidy to this fact, but also to these : the disease occurs more frcnpiently in certain places, and likewise varies in its severity. In illustration of the variation in frccpiency of eclampsia at, certain times, the statistics from whi«'h we have (piot(Hl show, estimatiuj; the actual number from the number that died, that in 1891 there were l.'JG cases, or 1 in 213 labors; but in 1890 and 18*^ .i the proportion was only 1 in 49G labors — not half so many in the two years as in the interveninjij year. Periods and T'uiw when J'Jehnnpnia most Frequenfli/ Occurs, — We have not merely to consider the several periods in which the disease is manifested, but also the time in each of those periods. Kalteubach's statement is that while the disease may apjiear toward the end of pregnancy, it is most frequent in labor, most seldom after it. Pajot has given the following: During labor, 100; before, 60 ; and after, 40. The recent studies of Goldberg,^^ includintr 1120 cases, show that in 21.07 |)er cent, the disease appeared in pregnancy ; in labor, o(].34 per cent.; and after, in 22.59 per cent. Bailly,*^ in his admirable article upon EcUunjtsia, has taken the ])osition that the order in frequency is pregnancy, labor, and the lying-in, and he has attributed, as wo believe justly, the discrepancy so common among authorities in part to the fact that, as the disease so generally induces labor, cases that really begin in pregnancy have been included in those that belong to labor, sufficient care not having been taken to observe the actual time when the attacks commeucal. N(!vertheless, the statistics of Goldberg cannot be .set aside, and wo accept the results as at least approxinuitiug the truth, though doubting the absolute correctness as to the very It.rgc percentag- of cases occurring during and after labor, while we believe that the percentage of those that happen before labor is too small.* If eclampsia occurs in labor, it is usually in the first stage. If after labor, in the great majority of ca.ses within a few hours, though a few or several days may intervene in others : even twenty-eight days have passed in a patient ob- served by Bailly, and fifty-eight in a case of Sir James Y. Simpson's. Wv * In IIe^nl!ln'^s 12 cases, nine be)j;an before labor, two during, and one after labor {London Obstetrical Sociely'n I'ranmctioni!, vol. xxxiii, 18'J2). Iter labor (loii''')!' DYSTOVIA. 625 limy, with Viiiay, qiieHtioii wlicthcr attacks (irst oa-iirriiij; niorotlian two nvpoUh alter lal)or should jii>tly he iiichuh'd imdcr puerperal eehimpsia. In the ^reat majority of eases in which the disease iiappens in prej^nancy the time (Votu Hcvon to nine inontiis oilers tiu! jjjreatest liability ; nevertheless, eases have been observed at the sixth, the tifth, or the fourth month, even at the sixth week, and Tissier re|M»rted a case at the seventeenth day, and Prestiit one in the se(!ond week. I'reinonilori/ Si/inp(ovi». — The first atta(tk may oeenr without warninj;, the patient appanaitly having been up to the seizure in good health. IVit usually there are precursory phenomena, lasting only a few hours or begimiing a few (lays before. These phenomena are nausea iuul vomiting, restlessness, weariness upon exertion, mental irritability, headache, disturbance of vision, dizziness, iiiiiscular tremors, ringing in the ears, and severe epigastric pain. Delore calls attention to lumbago as a premonitory sym|)tom observed in some eases, this symptom being the expression of renal changes. Special importance is, prob- ably with justice, to be attached to three of these — namely, the epigastric^ pain, tlie headache, and the disturbance of vision — and therefore fidler consideration must 1)C given them. The cpif/dntric suffering is I'v no means a constant nuin- ili-tation ; but if it occurs, it is (piite significant : according to liailly, it rarely lasts more than a few hours, and when it becomes very severe and continuous one may almost be certain that the convulsive attack is imminent. Dyspnea is connected with epigastric pain, antl is attributed to the poison in the blotxl, which, as will presently be seen, seems the essential cause of eclampsia. The hcadaclm is usually frontal, occupying the entire forehead, or it may be upon the one or the other side; rarely is it occipital. The dixturbatice of vixixm may be simply asthenopia or amblyopia or diplopia, or even absolute blind- ness ; in one case we have seen loss of vision twenty-four hours before fatal eclampsia at the fourth month of pregnancy, and v/v have had a patient who became amaurotic during labor — it was a plural pregnancy, and she had had for some weeks albuminuria; the amaurosis continued several days after the delivery of living twins, and then spontaneously disappeared. According to Vinay, if headache is accomj>anied by flashes of light, by ringing in the ears, by tingling and numbness of the lower limbs, the attack is at hand. In some cases, rare, however, ati aura immediately precedes eclampsia. A patient of Olshausen's uttered her husband's name, and in- stantly the convulsions came. Another may have the sensation of falling, still another may utter a cry of terror, and others have been known to raise the arm before the face as if to protect it from a threatened blow. If some of the premonitory symptoms that have been mentional, such as disturbance of stomach, of vision or hearing, headache, numbness of the lower limbs, be observed in a woman who is edematous, if she has scanty urine, and, above all, if this contains albumin and casts, convulsions will surely come unless proper means arc promptly usetl to avert them. Phenomena of Eclampsia. — The patient lies fixed in position, while her eyes are apparently directed to some distant object ; she has become nncon- 40 ! ] llsw 626 AMERICAX TEXT-BOOK OF OBSTETRICS. I <l \m ,. -i iy^ I !" I « %,\ f iw ' Ir I ' scions, and gives no attention to what may be said or done; in a few seconds the eyeballs move in various directions, soon become still, generally turned upward and to the left; the head, changing from side to side, finally remains directed to the right ; the eyelids open and shut, the muscles of the nostrils and of the face move spasmodically, then the mouth is drawn toward one side; the trembling tongue maybe thrust between the teeth; brief jerkiiii; movements of the lind)s (jccur, the arms are pronated, the forearm flexed, the thumb firmly applied to the palm, and the fingers over it ; the jaw; becoiiio rigid, and if the tongue has protruded, it is bitten; resj)iration is arrested liv tonic contractions of the muscles of the chest, and rigidity of the entire bodv and limbs is present. In from a third to half a second clonic convulsions ensue, the rigid state ceases, these convulsions involving the muscles of aniintil life, wave of disordered movetiient swiftly following wave ; respiration returns, but it is stertorous, and moist bi'onchial rd/cs are heard ; tlu? swollen face, which became " violet, livid, even black" (Jacquemier) din'ing the tonic stage, gradu- ally takes a less unnatiu'al color; the noisy expirations drive out frothy saliva, often tinged or deej)ly colored with blood. The clonic convulsions, after lasting from one to five minutes, cease, their cessation being nuirked by an unusually deep inspiration. Coma concludes the drama, the patient remaining imcmi- scious, and also iur^onsible. The coma is the consequence of cerebral conges- tion, and the congestion is caused by jn'cssure on the jugular veins by the con- vulsed muscles of the neck, and especially by the arrest of respiration diu'ing the tonic stage. The comatose condition may last from ten to twenty mimites, or even a longer time. i During the onvulsions ex])ulsion of feces sometimes occurs — more rarelv of urine and of the contents of the stomach. The body is covered with :iii abundant viscid persj)iration. The pulse, which at the beginning of tin attack was jirobably full and strong, is feeble and frequent during it, but be- comes more natural in the coma. The clonic convidsions, while rarely lasting so long as five mimites, continued in a pati(>nt observed by Tarnier for twenty mimites. The return of the patient to consciousness is only gradual, and the time intervening between the first onset of the convulsions and the end of the coma is a complete blank in her memory. Very rarely there is but a single attack, and the jiatient is restored to ))er- feet health. Still more rarely death results from this attack ; such a case li:i< been recently reported :"' the ])atient was delivered just at the beginning of a broncho-pneumonia ; at the end of nine days she had eclampsia, and died in fortv-eijiht hours after the attack. In almost all cases after an interval of half an hour, or even of several hours, the eclampsia recurs, and attack may follow attack with no restoni- tion to consciousness — indeed, in grave cases the consciousness may imt return after the first attack. The number of seizures may be very great ; Kaltenbach refers to eighty in some cases, and A'^inay says there may l>r more than a hundred. Winckcl has seen but one ease of recovery al'ti i' eighteen attacks; but \ inay states that a patient recovered after twenty-six, If ^ -.I^f erally tvinud niilly remains )f tlie nostril> II toward oiu' brief jerkiiii: nil Hexed, the ■i jaw; beeoinc is arrested hy he entire body ie eonvnlsioii- seles ot'aniiiiiil iration returns, lien faee, wliidi ic stage, gradn- it frothy saliva, ns, after lastiii;j; )v an nnusnally naining uncon- [•erebral conges- cins by the con- spiration during twenty minutes, rs — more rarely •overed with an ■ginning of tlic iring it, but bc- ie rarely lastinir [nier for twenty radual, and the |l the end of tlii' restored to per- sueh a ease lia* I' beginning of a [iia, and died in even of several ,'itli no restor:i- lisness may n^t be very gre:ii ; |s there may !"' recovery al'ti i' ifter twenty-i^i-^, DYSTOCIA. ^627 and Olshaiisen had six patients, having from twenty-two to thirty-six, who irot well. It is rare for the attacks to continue longer than forty-eight hours ; indeed, the fate of the j)atient is usually determined within the tirst twenty-four iK)urs, for if there are several attacks during this time, unmitigated in severity ;ind undiminished in frequency, a fatal result is almost inevitable. Winckel lii'st called attention to the progressive elevation of temperature with suceessive attacks, so that it may reach 102° or 10-4° F., and after death the thermom- oter marks a still higher degree. Investigations by others, especially by Bom-- neville, followed those of Winckel. Bourneville claimed that not only did the thermometer lurnish important ground for prognosis, but by it only could puerperal eclampsia be dilferentiated from uremia. If the temperature of till' eclamptic continued to increase, reaching a high degree,* the prognosis would be unfavorable, while a {)rogressive diminution pointed in an opposite direction. The results of experience do not give absolute contirmation of this view, for though usually the temperature increases during the continuance of the eclamptic attacks, yet in some instances the danger may be imminent, (liaili at hand, witiiout such increase,! or the temperature may even be sub- normal. So too in regard to the diagnosis between eclampsia and uremia : wliile it is true that there is in the latter a lessened temperature, there are exceptions % to the rule. The urine of the eclamjitic is usually scanty, contains albumin in large |)i'(t|)oftion, various casts, epithelium from the urinary tract, and blood-eel h; : ill somc^ cases there is com])lete anitria. Nevertheless, all albuminurics are not (■('huii])tics ; Hubert makes the number only 2G per cent., and Charpentier has collected 141 cases of eclampsia without albuminuria. The writer, a few years ago, had under his care a primipara who was attacked with eclamjisia a lew hours after labor, and the quantity of urine was not lessened, and showeil only a faint trace of albumin. The Iiijfuence of Ju'/((iii}tsia upon the IIcvuh and ujion the Fctut^. — In case eclamptic; attacks occur in pregnancy, more especially in the latter weeks, in tlie majority of cas(>s action of the uterus is excited and its contents are <\pelled after the fetus is death The death of the fetus may be followed by a disappearance of the eclampsia, and in case no uterine action has Ix'gnii, the pregnancy may continue for a time, or even until term ; meantime, if alijumiiiuria has been jiresent, this gradually ceases. In still other cases, by IK! ineanv numerous, the fetus lives, the patient recovers, and the preg- lUack stall's thiit in <nw cuso, untreated until tiie ])atient was inoriiiund, lie had IouikI tlie U'iii|n'iature as liigli as 110° F. ( TntiiKdfliinis Luiidnii < lliMttrical Soriitji, vol. xxxii.l. t Kiviere, referring to ISourneville's statement, remarks: "In several of our ohservatious llii" teinjierature, earel'ully taken either duriiiu' the attacks or in the intervals, was not elevated alinve the normal, or so slightly that it should not he considered" ( f'tllnKiniii' 'I Intili'infiit de I'liiiliiiiidxriciilinn fcl<impti(iiii; 1 SSS ). t Hiviere {op. ril.), ret'errini; to this view, states that Honehard ascertained tlial while uremia cinises, in the majority of cases, slowiny; of calorilication sutlicieiil to iiroduce ii suhno'.-mnl temperature, this sometimes tails, luid there may he increase of teiiiporatiiro. Ji ; ■■ V 'K'' M i' 'I ' \ k'.JiJ i^: d» 628 AMERICAN TEXT-BOOK OF OBSTETBICS. nancy is completed. Should eclampsia appear in labor, this is accelerated, and delivery may occur without the patient being conscious of it. The attacks are frequently excited by uterine contractions ; the escape of the amnial liquor may be followcfl by at least a temporary cessation of the paroxysms. The death of the fetus probably occurs in about 50 per cent, of cases as the consequence of maternal eclampsia. This death may result from the fact that the pregnancy ends before the child is viable, or be caused by placental hemorrhages, peculiarly liable to occur in albuminurics, or from asphyxia resulting from the deficient oxygenation of the mother's blood, or from the same poison that causes the convulsions of the mother. In several cases the child has been expelled dead and rigid : the writer met with a»' example of this kind more than thirty years ago, the mother attacked witi jlampsia at the end of her pregnancy, and dying twenty-four hours after delivery ; tiie rigidity was well marked ; it seemed almost as if the chief joints of the fetal members were ankylosed. Some of the children are born hemiplegic ; others, apparently in good condition at birth, are soon attacked with convulsions similar to those of the mother, and (juickly perish, and the lesions arc- often those of eclamptic women (Vinay). A case of fatal encephalitis in the infant of an eclamptic woman, coming on soon after birth, has recently been reported.'^ Terminations of Eclampsia. — Eclampsia may end in death or in partial or complete recovery. A fatal result rarely occurs during the eclamptic attack from the long arrest of breathing — an acute asphyxia— caused l)y tetanic contractioii of the respiratory mus(;les. More frequently the patient dies from gradual asphyxia, caused by pulmonary edema or congestion. Cerebral apoplexy is the cause of death in some cases : Olshausen's statis- tics,** embracing 200 cases, the general mortality being 25 per cent., include five deaths from this cause, while there were two other fatal cases presenting hematomata of the pia mater, and five with notable hyperemia of the brain and its membranes. Pneumonia is not an infrequent cause of death ; and so, too, puerperal infection. It has been suggested that tlic occurrence of the latter is to be attributed to " a special receptivity for infectious germs ;" but it seems to the writer more rational to regard this frequency as explained by the interference on the part of the obstetriciau with the labor, either to induce or hasten it, and the local treatment employed for the arrest of post-partum hemorrhage, an accident to which the albu- minuric eclamptic is peculiarly liable. Another cause of death is acute yel- low atrophy of the liver. Finally, the profound toxemia, regardless of ectni- plications or consequences of the eclampsia, is the cause of death in some cases. Mental defect and disorder may appear as consequences of eclampsia, making the recovery incomplete : anniesia represents the former, and insanity the latter. The amnesia may be temporary, or last for many weeks or months, and in some cases it relates only to recent events; in others the knowledge of years may be blotted out. Insanity occurred in 6 per cent. DYSTOCIA. 629 of Olshausen's cases. In the majority of cases the albuniinuria disappears ill a few weeks, especially if it resulted from the kidney of pregnancy, but in others grave renal disease is manifested. Hemiplegia sometimes follows eclampsia, and is usually incurable. Disorders of vision may I'cmain for pome weeks, but, as a rule, are not permanent. Fortunately, comj)lete recov- ery is the rule in eclampsia. The signs which indicate this happy result will !)(' considered under the head of Prognosis. Diagnosis. — Epilepsy presents the most striking resemblance to eclamp- sia — the same loss of consciousness and of sensation, the same series of tonic and clonic convulsions, succeeded by coma. But then the fact of preg- nancy, the prodromata of eclampsia, the number of attacks, the condition of tlio urine, not albuminous ®r only slightly so in the case wf the epileptic, abundant and not containing casts, and above all the previous history, would prevent doubt or confusion in diagnosis. The thermometer, too, may assist in the diagnosis, for the epileptic does not present a constantly rising tempera- tni'o, while the eclamptic generally does. Winckel states that a confusion of eclamptic convulsions with those caused by meningitis occurred to him once in a pregnant woman. He states that in the latter disease the attacks are seldom so general, do not return so regidarly; they constitute gradually increasing irregular contractions of some groups of muscles. Moreover, fever usually precedes the attacks for some time ; the ])!»lients have i)reviously been forgetful and sonuiolent ; yet the difference is by no means always marked. Hysteria belongs to one who has an hysterical history, and can only momentarily counterfeit eclampsia,* for there is often to be discovered " a method in the madness," the evidence of feigning ; no pro- fi)iind loss of consciousness, if loss at all ; there may be grotesque attitudes ant' expressions, but not the horrible grimaces of eclampsia ; coma does not come, and the secretion of urine is not scanty nor does this fluid contain albumin. Prognosis. — In general the eclamptic attacks that occur before labor are attended with the greatest, those after labor, the least, mortality. So, too, if the uterus can be emptied without violence and soon, the prognosis is improved. Diihrssen '* claims that if the uterus is relievetl of its contents during pro- fntind narcosis, in 93.75 per cent, the eclampsia ceases. Charpentier, taking tile statistics of German authors,^' has shown that the mortality in 171 cases of eelarapsia coming on after labor was 12.5 per cent. These facts will be osjieeially considered in presenting the treatment. Referring to an individual case, if the attacks have been less than fifteen, if neither violent nor close together, if the coma is brief, if the temperature is not high, the pulso not fVefjuent, if the secretion of urine be not greatly lessened, only slightly or not at all albuminous, there are good grounds for expecting a favorable issue. Opposite conditions indicate a doubtful or fatal result. " Of very unfavor- al)le prognostic significance are complete anuria, profound stupor, loss of * One of the nciite obscrviitions of ColeridKe was ; " Hysteria may well be called viimoaa^ from Its counterfeiting so many diseases— even death itself." I I 1 :) ' ( ; I 630 AMERICAN TEXT-BOOK OF OBSTETRICS. reflex irritability, paralysis, small frequent pulse, great elevation (»f tempera- ture, jaundice" (Kaltenbaeh). The mortality is certainly less than that given by Pajot, 50 per cent., but even Bailly has made it 42 per cent., and in some recent statistics the lowest percentage given is 19.38, and the highest 36.50: Kaltenbaeh gives 30 pi r cent, of deaths. Post-mortem Appearances. — The brain in many cases presents no material lesion, but in other instances there is great anemia with edema, and flattening of the cerebral convolutions ; less frcciuent is hyperemia, though sometimes this may be so great that rupture of the vessels occurs and apoplectic clots are found. In rare cases the kidneys have been found absolutely normal, but oftener present those changes characteristic of the kidney of pregnancy, and next of parenchymatous nephritis. Kaltenbaeh observes, on the one hand, that frequently the changes in the kidney are not significant, and are not at all in ])roportion to the gravity of the disease, as has recently been pointed out by Virchow ; and, on the other hand, there may be grave alterations, chronic pa- renchymatous and interstitial nephritis, without eclampsia having occurred. But it would not be rational to conclude, from the fact that the kidneys show slight or no changes, that their function may not be seriously disturbed. Edema of the lungs is frequently found, less often congestion, with apoplec- tic centres, and finally the evidences of j)neumonia — deglutition-pneumonia — mav occur. Vinay regards lesions of the liver as presenting as great an import- ance as those of the kidney, and considers them as more frequent and mo'-e churacteristic. The liver may be completely disorganized, and present the lesions of acute yellow atrophy in some cases, while in others it is increased in size. It presents, under these circumstances, capillary ectasije and hemor- rhagic centres at the jieriphery ; sometimes necrosis is found, and, again, hemorrhages beneath the capsule. It is quite rational to admit, as several authors have done, that in some cases the eclampsia should be recognized as cholemic rather than renal.* Etiology. — It is proper to divide the causes of eclampsia into (1) Predis- posing, (2) Exciting, and (3) Essential. 1. Predisposing Causes. — Primiparity holds an important ])lace among pre- disposing causes. The statistics of the Philadelphia Hospital from 1874 to 1889 include 2G55 deliveries with nine cases of eclampsia, and all the nine were primipanc. Other statistics make the disease from three to seven times more frequent in primipara? than in multipara\ This increased liability has been attributed to the more frequent occurrence of albuminuria in a first pregnancy, the greater intra-abdominal pressure, and excessive nervous exci- * Massen makes the following statement as to post-mortem ajipearances in women (lend of eclampsia: In 19 cases there was acute interstitial or parenchymatous nepliritis, sotiic- times with destruction of the ej)itlielium of the tubes in the cortical substances; in 5 cases interstitial hepatitis; in 3 necrosis centres in the hepatic parenchyma; the uterus and tubes jiresented interstitial lesions; the brain, dilatation of capillaries; the heart, a parenchymatous myocarditis (" Proceedings of the St. Petersburg Obstetrical Society," Annules de Gynccottyit; 1893). of tcnipcra- )oi' cent., but H the lowest gives 30 jKT s no material nd flatteniiit;' ;h soinetiiiKs oplcctic clots r normal, but eguancy, aud ne hand, that not at all in tinted out by s, chronic j>a- ing occurred, kidneys show iturbed. with apople(>- umonia — may ?at an import- lent and mo>-e d present the it is increased e and hemor- , and, again, [lit, as several recognized as ko (1) Predis- |ce among pre- Ifrom 1874 to all the nine to seven tini(>s Id liability has n'ia in a first nervous exei- in women ili'inl I nephritis, soiiu'- Inces; in 5 eiisis Biterus and tiiln's I jiarenchynu\t(uis Is rfe GynecoUxjie, DYSTOCIA. ()3I tability : the longer labor is also a cause. If the priniipara be old, the liability is increased. Plnri[)arity predisposes to eclampsia. In Olshausen's statistics sixteen out lit" two hundred gave birth to twins. Here, again, we have similar or rather the same factors which are present in primipanc and have been mentioned. Tliere must also be borne in mind that in plural i)regnancy additional work is thrown upon the eliminating organs of the mother, but this will be pre- sented in considering the essential etiology of the disorder. When the pelvis is narrow or the child's head of unusual size, the eclamptic attacks are more likely to occiu" than in oj)posite conditions. Eclampsia is more frequent, too, i)etween the ages of twenty and thirty : here, probably, the true factor is priniiparity. Hereditary influence has rarely been observed. One of the most striking eases of this influence has been recorded by the late Dr. George T. Elliot:^* The jjatient's mother had given birth to four daughters, and then died of ei'lam])sia at the birth of a son. Of these daughters one died of eclampsia at the sixth month of her first pregnancy, a second, after having two miscar- riages, died of eclampsia in her third pregnancy, the tliird had eclampsia about the sixth month, and recovered ; while the foiu'th was attacked in the (Mglith month, and perished after artificial delivery. Lohlcin states that a jxitient in Schroeder's clinic died of eclampsia, and her two sisters had con- vulsions in their first labors. Independently of heredity, as manifested in the cases quoted from Elliot, and also independently of the mental distress referred to, as predisposing causes, it will readily be admitted that the susceptibility of the nervous system jrreatly varies in diflcn-nt subjects, and that some from excessive irritability may have an eclampsia liability. Of course such condition alone cannot pro- duce the disease, but it may greatly assist in 'ts production. Kaltcnbach has said that a generally-contracted pelvis corresponds usually with an infantile liobifux, which is shown in an increased irritability of the nervous centres; yet, according to Wiedow, such pelvis must sometimes be looked upon as indicating degeneration. Thus predisposing causes may be combined in action. The mental condition may be a predisposing cause, and thus unmarried women, sutFering with shame and anxiety, are more liable. What shall be said of the opinion expressed some years ago by Johns of Dublin, tiiat indcss the vertex presented there was little liability to eclampsia? When it is proved that there is in proportion to the entire nund)er of the various presentations an undue predominance of eclamptic cases in which the vertex descends first, the action of this alleged cause would be Justly considered. It may be of interest, in comicction with this view of Johns as to the etiology uf eclampsia, to quote a sentence from Denman's "Introduction to Midwifery," as showing the possible first inspiration of the view : " I was for many years persuaded that convulsions oidy happened when the head presented ; but experience has proved that they sometimes occur in preternatural presentation of the chihl." .^ . ;j'rl! i1 •&/, ' I.J ^1 s ' t.M ! ai f:f.;y.5 ■/i. 632 AMERICAN TEXT-BOOK OF OBSTETRICS. 2. ExcMlng CauHcu. — When essential and predisposing causes combine, tlie exciting cause of the convulsive paroxysm may be in itself a very slight one, just as the electric spark or a lighted match causes explosion of a powder magazine, or careless handling that of dynamite. Thus the outbreak ol" eclampsia may occur from touching the os uteri, from pressure of the hand upon the abdomen, from distended rectum or bladder, from a uterine con- traction, or from movements of the child. 3. Essential Etiology. — Various theories as to eclampsia which once pre- vailed — the nervous theory, that which made the disease the result of cerebro- spinal congestion, the uremic theory and its derivatives — have passed away. True, Herff *^ contends for the disease resulting from the physiological irritations of pregnancy, but this is given by him as oidy one of the causes. True, too, that the term uremic is still applied by some to these convulsions, but no intelligent physician now claims, as was done by Wilson and others, that urea retained in the blood is the cause of spasms : it is probably unfortunate that any continue the use of the word in this connection, for etymological ly and as originally employed it is now misleading. The theory which makes the essential cause toxemia — not one, but several different poisons, it may be, concerned — is now generally upheld. So, too, the toxemia, while usually associated with renal failure, and dependent uj)tm it, does not in all cases have such association and dependence, for the disease caused by the toxemia may occur without renal disorder ; moreover, it is a question in some cases whether this disorder is not the consequence ratlior than the cause of the toxic condition. Admitting the microbian theory of the origin of the disease, now Jiei(i by a few — a most improbable supposition — it could only explain the toxic condition of the blood, and could not invalidate the opinion that the innnediatc cause of the convulsions is such condition. As stated by Kaltenbach, the theory of blood-poisoning is sustained by tiio clinical history ofthe disease and by post-mortem appearances. " The prodro- mata — gastric and cerebral symptoms — the rapid occurrence of serious disturb- ances in the action of the brain, the post-mortal increase of temperature, tlio nature and frequency of nervous disorders that follow, and which find their analogy in the neuroses consequent upon typhus and diphtheria, probably causetl by toxalbiuuins, are scarcely to be oxi)lained unless by the theory of blood- poisoning. The nature as well as the extent of the anatomical lesions also corresponds with such theory." Admitting the toxemia, the (juestion naturally arises. What is the source of the toxic agent or agents ? Are we to concede the truth of the position taken by Riviere, for example, that autointoxication is the true answer ? Bouchard has said ^ that man is constantly menaced by poisoning ; he labors each instant for his own destruction, makes incessant attempts at suicide; nevertheless, this intoxication is not realized, for the organism has multiple resources to escape it. The liver plays an important part in the destruction of poisons, and elimination by the skin, by the lungs, by the kidneys, and by the intestines assists in the protection of life from poisoning : the most important agents in elimination are the kidneys. DYSTOCIA. 033 The urine, according to Bouchard's investigation, contains several toxic ]irincij)les. Further, it has been found by experiment that tlie toxicity of tills secretion is greatly lessened in the eclamptic, while that of the blood- serum of the ^ame subject is notably increased. It is not the failure of the kidneys to eliminate urea that determines the convulsions, for the non-jjregnant woman may have anuria for several days without eclampsia, and while the nmount of urea eliminated by the woman in gestation each twenty-four hours is increased nearly one-third, there must be arrest of elimination for more than ten days in order that intoxication become j)ossible. We can readily under- stand that if the poison or poisons which jiroduce eclampsia are retained in tiie blood, renal inefficiency or failure may add to the gravity of the condition, in tiiat were the kidneys healthy they would cast out the offending matter. Ac- cording to Bouchard, the kidneys are ca})al)le, when sound, of eliminating infinitely more toxic material than they habitually do ; nevertheless, there are limits, and if the quantity of poison is such, notwithstanding their integrity, that they cannot accomplish their task, accumulation is produced and intoxi- cation results. Thus in the etiology of eclampsia the non-elimination by the several emunctories mentioned must be placed at the very beginning of the trouble — and the toxic matter may l)e maternal in origin. Yet may not the fetus, and even the placenta, have a part in the etiology of the poisoning? Tiie non-pregnant woman may have her abdomen as greatly distended by an ovarian tumor as from plural pregnancy at terra, and she does not suffer from eclampsia. Often if the fetus dies the eclauipsia ends. So, too, the eclamptic attacks are more frequent as the labor occurs and progresses ; uterine contrac- tions may cause now poison to pass into the maternal blood from the fetus and placenta. It seems, therefore, at least not improbable that from the latter source a part of the poison ])roducing eclampsia is derived. The microbian theory recognizes infection, attributing, however, the poison- ing, not to maternal life-processes, pois m-producing, and failure of poison- eiiinination, but to the action of microbes, toxins being formed by these. This theory was first suggested * by Delore ten years ago. A few have, from experimental studies, sustained the theory, but the majority of investigators liavc rejected it. Moreover, in order to explain the entrance of microbes, the hypothesis of a previous endometritis has been assumed. But as the eclamptics are, in the great majority of cases, primiparse, who rarely are subjects of endo- metritis, while multiparse, in whom the disease is not infrequent, are compar- atively seldom eclamptic, the microbian theory must be regarde<l as very improbable. It may readily be admitted, as Kaltenbach has said, that the ))athogenesis of eclampsia is by no means perfectly clear. Winckel, while accepting the toxemic theory, remarks that there are different degrees of this condition, j)robal)ly different poisons, or a ])oison originating from different causes. * Corre, when the hypothesis was first presented, pleasantly remarked (Manuel (rnceouchcment rl (h pdlhologic pnerpiralc ) : " We have the niicrnhe of tetanus, that of eclampsia, and soon, doubtless, will have those of hysteria, of epilepsy, of meningitis, etc." i " '^ ';■■': (l i' ^•■;i u< '-'*■ m(> ^iW' m Ijt ■iU 1 .W "!"' V:> .15 i i' I ■Pi ■■''■'! i " '■ ■ 1' 1 \v : ... ' 1 m 034 AMIJIilCAX TEXr-nOOK OF OliSTETRTCS. M 'ir A-i. I \l ^4 ihf ' i m 1 ,;,<'■;■, Halbcrtsma attributes the eeiampsia chiefly to K'ssened excretion of uriiK resulting from eompresi<ion of the ureters. Stunipf*'^ believes that in sonic cases juuler abnormal decomposition u non-nitrogenous substance, probablv acetone, is produced, and this in its elimination causes irritation ; intlannuatioii of the Ividneys has a destructive effect upon the coloring matter of the blood ; diabetes mellitus and acute yellow atrophy of the liver, with the formation of tyrosin and leucin, follow, and coma and convulsions. Herrgott '•'"•' hiis recently contributed an elaborate paper upholding the microbian theory. C'hambrelent '"*' observes that eclam})sia appears to be due to a poisoning by a toxin, but investigations so far fail to prove the presence of a really path- ogenic bacillus. Von Herff regards eclampsia as a complex of symptoms which may be produced by various causes, but the origin is especially in the; ])sycho-!notor cerebral centre and in the subcortical gangliou-cu'lls : a change f)l" irritability of this cerebral centre is assantln], ^' cklamtii^c/u' Ldbilitdt," and is either inherited or is acquired through intoxication, infection, pathological conditions etc., or, finally, it is the consequence of physiological gestation- irritation. Diihrssen finds the cause of eclampsia in retention of creatin and croatinin in the kidneys ; sometimes there is a nephritis resulting from accu- midation of urine residting from pressure upon ureters. The ereatiu and creatinin accumulate in the vessels of the cerebral cortex, causing (convulsions and coma. The disease may alst) be caused by bacterial products, and in a few cases it is purely reflex, resulting from great distention of the uterus or other violent irritation of nerves of the genital tract. In regard to some of these views one is tempted to repeat tlie remark of Pr. Samuel Johnson : In the arena of conjecture all men are equal whose ojiportunitios for information are equal. Treatment. — Vinay justly observes that there are malignant cases of eclampsia in which death is inevitable, all means of cure failing. This fact should be borne in mind in considering not oidy the value of therapeutic agents, but also the results of personal experience. There are no specific remedies in this disease, and no one plan of treatment to be constantly pursued. Prophi/la.ris. — The first points in prophylactic treatment are the avoidance of constipation and securing free action of the skin and kidneys. The tir>t is accomplished, as advised by Winckcl when there is any notable albumi- nuria, by the administration each morning of a pill composed of extract nf aloes and extract of colocynth, in sufficient cpiatitity to cause free, watery evacuations. The hot bath is the best means for producing activity of the skin ; this bath should have a temperature of 100° F., the patient to remain in it at least fifteen minutes, and upon coming out of it be wrapped in warm blankets, drink a glass of hot milk, and remain in a warm room for two hours : abundant perspiration will thus result. If an absolute milk diet is not directed, at least milk should be the chief food ; Winckel allows the spar- ing use of meat and vegetables. The diuretic action of the milk may be pni- moted bv alkaline mineral waters. For the albuniimiria Duff"" recommends 1 DYSTOCIA. G35 one drop of nitrof^Iyoerin tliroe times daily, and Vinay speaks hiplily of cliloral. The latter refers to a patient, a primigravida, haviiif]f at the end of the eighth month 22 j^rams of dried albumin in the iirine in twenty-four liours, who took duriiij!; the ninth month 120 grams of chloral, or 4 grams per day, and was delivered at term of a living ehild, no eonvulsions oceur- ling: in most eases he advises 3 grams daily, or 4o grains, lie also states that when the albumin is al)un(lant, and headaehe, irritability, restlessness, vertigo, disturbance of vision, etc. are present, chlorali/ation of parturients is (if the greatest value; from the beginning of the pains from 4 to G grams (if chloral arc given by the mouth, and the patient soon sinks into a profound sleep, uninterrupted but at the moment of contractions. In grave and persistent albuminuria, no benefit having been obtained by hygienic and medical means, and eclampsia threatened, the artificial interrup- tion of the pregnancy may be clearly indicated. In case the convidsive attack occurs, the immediate duty of the ])ractitioner is to prevent the patient from injuring herself; the greatest liability is that she may bite her partially prdtruded tongue, which, therefore, should be held back by means of a napkin stretched between i\w teeth and grasped on each side. Kaltenbach advises, for this purpose, inserting between the jaws the handle of a spoon wrai>ped with gauze. Of course the patient is jireventcd from injuring herself by striking against hard objects, or even falling out of bed during clonic convulsions — a possibility, but not a probability. If after a convulsion the tongue falls back, iirrcsting respiration, it must be drawn forward. Kaltenbach emphasizes the imiiortance of cleansing the pharynx by means of small sponges with a handle, t(i prevent the entrance of the secretions from the mouth and pharynx, mixed with bloody slime, into the lungs, stating that many patients die, after recovery fioin the convtdsions, in consequence of SvhluckpnvHmonicn, or deglutition- pneumonia. Is she to be bled? Doubtless oiu* fathers were wrong in making vene- section the common remedy in eclampsia, but their sons are equally wrong in entirely rejecting it. Though Winckel and jNIartin condemn it, though indeed it has little professional support from great authorities in general, yet we find Kaltenbach wisely, as we believe, saying that in strong, plethoric women, with great cyanosis, bleeding has undoubtedly a favorable effect. Tills bleeding removes a certain amount of poison from the circulation ; the removal, too, is instant, and it further removes from the convidsive centres tlio [loisoned blood by restoring contraction of the small vessels as claimetl l)y Peter. We believe, therefore, that bleeding in some cases of eclampsia is rational, and rests upon a sound clinical basis. (See especially the st;itistics of Charpentier upon this jioint.) Of course it is only in exceptional cases that this treatment is indicated. The administration of chloral by the rectum is generally adopted ; Winckel oinploys 1 to 2 grams of chloral thus, repeating the dose after each attack until 12 grams or more are administered in twenty-four hours; Plant suc- .^•■^'■ i 't ' .i-S' ^^'': ! . ■ i ■ ) ' 636 AMERICAN TEXT-BOOK OF OBSTETRICS. ■r, 1 ! I f''l 'A I >m!« cessfully used 150 grains, or about 15 grams, in the same period. Clark ill America (Oswego, N. Y.) and G. Veit in (Jermany arc the most promi- nent advocates of morphia hypmlennatically, and each uses what many would regard as heroic doses. Olshausen employs one-third of a grain, increasing to nine-tenths, and only resorts to chloral when morphia cannot be emj)l(tye(l : he has given 11 to 12 grains of morphia in four days. But all have not been as successful in using the morphia treatment as Veit, only two deaths in sixty cases ; and moreover a fatal narcosis of the infant, if not of the mothei-, has sometimes been observed. Anesthetic inhalation, chiefly of chloroform, is generally recommended, though Olshausen reserves it for exceptional cases, and Kaltenbach objects t«i the protracted narcosis with chloroform, for, on the one hand, it readily leads to fatty degeneration of the heart and other organs, and, on the other hand, impairs the activity of the kidneys; on the contrary, Vinay refers to patients having Ix^n kept under its influence six, ten, or even twenty-four hours. The potassic bromid may be rejectetl because requiring large doses, slow, uncertain, and feeble in its action ; moreover, according to Bouchard, the potash is the most toxic of mineral salts. Pilocar]>in is a remedy condemned by Braun, Fordyce Barker, and, more recently, by Winckel, Kaltenbach, and Vinay. Purgatives are generally recognized both from theoretical reasons and from experience as important. In addition to those previously mentioned, el:i- teriuin and croton oil, administered by the mouth, and infusion of senna, witii the sulphate of soda or of magnesia, by the rectum, are frequently employed. Professional evidence seems conclusive as to the great value of tinctiu'c of veratrum viride, first used in 1859 by Dr. Baker '"^ of Eufaula, Alabama, and long a favorite remedy with practitioners of the South and West of the United States. The method of administering is hypodermatic, and the dose, accord- ing to Jewett,"^ is from 10 to 20 minims ; the smaller dose rejieated in half an hour will doubtless suffice in the majority of cases. Dr. Jewett asserts that experience seems to justify the statement that no convulsion will occur while the i)atient is sufficiently under veratrum to hold the cardiac pulsations below sixty to the minute. If the pulse is not sufficiently reduced by the first injection, a second is given in thirty minutes : five-minim doses at longer intervals are used to keep up this lessened frequency of the pulse. The Cesarean operation performed after the mother's death has in a very few instances saved the life of the child, but Halbertsma"" has proposed, and several times done the operation, to save not only the life of the child, but also that of the mother, in grave cases of eclampsia. The entire number of operations by him and by others is 14, but as two of the patients wen- dying, the number is reduced to twelve ; of these four dietl ; that is, the operation gives a mortality of a little more than 36 per cent. Recogniziui: that the subjects operated upon were in imminent danger of death, the result does not seem discouraging. Maygrier^ has reported the case of a primipara who had eighteen attacks of convulsions; she was treated by venesection, and then, by a sound passed DYSTOCIA. 637 into the stomach throii}]fh the nose, 150 firams of milk were introduced every hour ; anuria, whi<'h was present, was almost irametliately relieved, and tlic patient recovered. Porak and Bernheim '"* advise in every case in which the urine is sup- ])rossed or is scanty and dark colored that salt water shoidd he used hypoder- iiiatically, to promote diuresis and thus elimination. A liter of sterilized warm water containiiifr 7 to 7.-5 grams of chlorid of sodium is introduced into one of the huttocks, the skin hih'ing been first disinfetJted, and either a needle or a siphon employed : twenty minutes is required for the operation ; the fluid injected has a tenijKjrature of 88° to 90° F. ; the results have been (piite satis- iiu'tory. There is a general agreeni'^nt of the profession that if eclampsia occur in labor or labor come on during it, delivery should be effected as soon as possi- ble without violence. So, too, the majority agree that eclamptic attacks that do not yield to appropriate treatment furnish an indication for ending the ])reg- iiancy. Diihrssen ®* has gone further, reviving accouchement force, which in tiiis day of antiseptics and anesthetics is by no means the perilous proceeding it once was ; he does not shrink from ending the pregnancy, even when the child is not viable, in eclampsia and in the pri.nigravida when no efforts at labor are made, overcoming obstacles presentetl by the cervix or by the peri- neum and vulva with incisions, so as to ensure rapid delivery. This method has not met with the approval of Olshausen, for example ; it has received from Oliarpentier a searching and severe criti(;ism,"'* and he declares it dangerous and that it ought to be absolutely proscribed. In his conclusions Charpentier states that the induction of premature labor should be reserved for some exceptional oases in which the medical treatment has entirely failed. He also gives the following statistics of mortality in eclampsia : After spontaneous labor, 18.96 ; after artificial labor, 30.04 ; and after accouchement force, 40.74. Goldberg gives the following statistics in eclampsia : 5 times labor was induced, 4 deaths ; 6 dilatations of os by incisions, 4 deaths. Haultain'"^ reported three cases of eclampsia successfully treated by the iiKhiction of premature labor; he dilatetl the cervix with the fingers, dilatation sufficient to apply the forceps being accomplished in from sixty-five minutes to an hour and a half, and then the gentlest traction is sufficient to cause the head to act as a most efficient dilator. All the patients recovered, and two of the children lived. Should eclampsia come on after labor, chloral is the most important remedy ; in many cases, however, veratrum viride has proved suc- cessful. Milk diet is important in all cases during convalescence. Hyperemesis. — Excessive vomiting in labor is very rarely seen. Should it occur, however, its injurious effect is shown by weakened uterine contrac- tions and by early exhaustion of the patient. Etiology. — Naegele and Grenser,'^^ who find the immediate cause of hyper- emesis in extraordinary sympathetic excitement of the nerves of the stomach, state that it is most likely to occur in nervous, feeble persons, in the chlorotic, and in those who have previously been subject to gastralgia and to hyperesthesia *;' ■V- i' 638 A.VKIt/rAX TF.XT-IiOOK OF OliSTKTlilCS. \ •'! .1 ? I I Ji I e '! I ■ of the gustric norvos. Ilypt'roniortis may rosult from excessive distention nt the stomneh by fo(Ml o'- by tlnids. Tliesc observers refer also to a nioi-al impression as sometimes a cause. Treat iiii'iit. — Usual means slionld be employed to arrest the vomitinj? : if it results i'rom irritatinji; matter in the ttomach, whether foinl or secretions, cojiiuiis draughts of warm water should be given. Sinapisnis or the application of etlifi- spray to the epigastrium, and the hypodennatic injection of morphia, will lie employed; carbonic-acid water or champagne may be useful. But it is ol" the greatest importance that the delivery, whether manual or instrumental, shall take place as soon as practicable. Hemorrhagres. — Discharge of blood outside the genital sphere, such as epistaxis, hematamesis, hemoptysis, is occasionally seen in labor. Epistaxis, unless excessive, is to be regarded not as a conipiication of labor, but ratiicr as a salutary condition relieving congestit)n of the head. If pulmonary Dr gastric hemorrhage occurs, it has been recomnjcndcd that the jiaticut should sit rather than lie upon the betl. Ice, cold acid drinks, muriated tincture of iron, and in pulmonary hemorrhage small doses of ipecacuanha, as advised by Graves, may be useful. In either form of the disease, if grave, ])ronipt delivery is indicated. If the os is not sufficiently dilated to permit delivery with the forceps or by podalic version, acconcheinoU forcC has been recom- mended. A ease of rapidly fiital pulmonary hemorrhage in a woman at term has been reportctl by Budin.'"" The labor had not begun, and soon after death the Cesarean operation was performetl and a child extracted that lived a few hours, and then perished with trismus. Hernia. — Several instances of hernia causing dystocia are recorded. For example, Smellie's*" case. No. G3, was one of crural hernia on the left side, the patient suffering from it during her entire pregnancy. In labor the hernia was forcwl down during every pain and gave her great uneasiness. Smellie says: " The labor being pretty far advanced when I arrived, I took the opportunity of reducing the hernia upon the cessation of the pain, pressing my fingers upon the part, and directing her to lie on her left side with her left tliigli close up to the abdomen — a position which favored its keeping up ami prevented the anguish which I'ctarded the labor. She was accordingly saf< 'y delivered." Winckel published a case in which there was a left labial ho ■ size of a man's fist. In the second stage of labor, while an assistan lil l)ack the mass, the forceps was applied. Reposition was madj after the lai <\\ iwA retention was secured by a truss. He also saw a congenital left ovari ,11 hernia in a parturient. The ovary, the size of a walnut, was irreducible, was not especially painfid, and presented no obstacle to birth. Smellie narrates two cases of perineal hernia. Of the one of these (:i?es seen during labor he states : " The hernia was, however, reduced by opening the OS externum, introducing my hand into the vagina, and i)ushing the intes- tine above the os sacrum." Spiegelborg, in describing vaginal enterocclo, states that the hernia is almost always found at the posterior vaginal wall, and its DYSrOVJA. (j.jy cdiitcuts are iiHiinlly formed In* loops of small intestine, rarely hy loops of the l;irfj;e intestine. Smellie reporteil a case, oectirring in the practice of Mr. Stiibhs, in which tiie vaj^ina and the pelvis were filknl by a tnmor which probably procetHUnl from the intestines beinjj; pnshed down at the back part of tlic vagina. The tnmor was rednced by pressnro, and the head immediately descended into the ju'lvis, the forceps then being applied. Dr. Hirst" col- lected 27 cases of vaginal enterocele complicating prcgnainy and labor. The lieriiia was posterior in all except two cases. Such a hernia existing, uterine contractions niay cause it to descend so lo\v that it partially protrudes from the vnlva and presents a serious hin<1erancc to birth. The tumor is soft and (•(impressible at the beginning of labor, and the percussion sound, according to iNriillcr,'^ plainly indicates its character. Heposition, as successfidly performed ill the case reported by Smellie, is still the essential in treatment, the labor being ended by the forceps or, in case of pelvic presentation, by manual extraction. Eventration. — ^^hen diastasis of the recti muscles occurs in an abdomen greatly distended by pregnancy, ])art of the uterus protrudes in the interval. This condition gives rise to inefficiency in the action of the abdominal muscles in the second stage of labor. The remedy will be found in a )iroperly-ap])lie<l bandage and in keeping the ])atient upon her back during the expidsive period. Displaced Kidney. — Winckel "■ collected six cases of displaced kidney in pnrtiu'ient women. He refers to the fact that in this condition hinderance to lal)()r may result from the organ entering the pelvis, thus materially lessening the size of the pelvic cavity. He advises, after replacement, as the best means of retention, having the ])atient lie up(m the opposite side. Tumors of the Rectum. — Jacijuemier "' states that in some cases hard- ened feces, resulting from long constipatit)n or from foreign bodies such as the seeds of cherries, have been an obstacle to expulsion of the fetus. AViiickel says that hard fecal masses presseil into a small pelvis may hinder tiie entrance of the head, cause an unfavorable jMisition or ])rolapse of a member, render the examination difficult, and produce anomalies of the pains. He quotes the case of Madurowicz-Rosner, in which, the child being trans- verse, the examination, because of the fecal mass, was very difficult and turn- ing was impossible, decapitation being employed. Such an accumulation should be washed out, its removal being assisted by mechanical means such as the handle of a spoon. McClintock, in one of his notes to the Sydenham edition of Smellie's Midirifcrjf, says: "I have seen the rectum distended with such a mass of hardened feces that supjiositories and e; iiata were utterly useless to effect their renioval, the anus being dilated to the size of a florin by the fecal accumulation within. Here direct mechanical means must be employed to dislodge and extract the scybala with which the gnt is blocked up. This having been accomplished, then enemata of turpcn- ne, soap, and water may advantageously be employed to clear out the lower portion of the colon and to stimulate its peristaltic action." Cruveilhier, according to Jacquemicr, publishwl a case in which the expulsion of the fetus '1: ■^r:'-!. H ! j i ' mi . h I \ I 1 \ # #l"f' .■ 640 AMERICAN TEXT- BO OK OF OBSTETRICS. was prevented by a cancerous tumor of the rectum. He successfully ended the hibor by the forceps. Relaxation and Rupture of the Pelvic Articulations. — In pregnancy the pelvic symphyses are swelled and softened, especially in the latter months of gestation. Budin has shown that at this time motion may be detected between the pubic bones. The physiological condition of softening may bv excess become what is known as "relaxation of the joints," manifesting itself by pain at the articulation concerned and by more or less interference witli locomotion. In rare instances occurring in labor there is an actual separation of the bones, a diastasis known as "rupture of the joint," the previous relaxa- tion predisposing to this accident. Vinay '" believes that in cases of great re- laxation of these articulations articular or periarticular inflammations (arthritos) complicate the condition. Schauta '"^ quotes the case observed by Gmelin, in which the autopsy showed (death having followed Cesarean section) that the pubic bones were separatetl 1.5 centimeters by an accumulation of yellowish serum at the place of the .synovial cavity. In some cases there has been found inflammation of the cartilage, causing abnormal softening of the joint. Osteo- malacia predisposes to rupture of the joints, this accident being very rare in the rachitic pelvis. Trousseau,"^ who met with several cases of this disorder, and who has admirably described it, refers to one patient in whom the separa- tion of the pubic bones was so great that the end of the index finger could bo interposed. The late Fordyce Barker "'^ presented the subject in his usual clear and scholarly manner. Snelling's monograph "** is oi course valuable. In the American edition of Denman,'" edited by Francis, two cases of this accident are reported by its author and two by its editor. Pelvic contraction, great size and solidity of the fetal head, and unfavor- able position have been mentioned as causes of rupture of the pelvic articula- tions. In one instance this accident seems to have resulted from the I'emarkable development of the trunk of the child, thus preventing its entering the pelvis, the forceps being required for delivery. In many cases the lesion has been attributed to the forceps, but it would seem more rational to regard the con- dition requiring instrumental deliveiy as the more important factor. Havaje- wicz '^' found that in 23 cases of separation of the symphysis forceps had been used in sixteen. In one of three cases reported by Remy '^' the forceps was used, but in the other two the delivery was spontaneous. The direction in which traction is made with the forceps may be a cause, as when a part of the force is exerted in the axis of the birth-canal, while the rest of the force acts upon the pelvic girdle, especially at the pubic joint : nevertheless, tlie accident has occurred when Tarnier's axis-traction forceps was employed. Ulsamer '^^ believed that rupture of the pelvic articulations from the for- ceps was much more frequent than was reported. He states that sometimes these ruptures are undiscovered, and sometimes they are ke})t secret, for tlie public is disposal to attribute the injury to the exercise of great force, althoti^Ii it has been proved that separation of the pelvic joints has followc<l the skilful use of the instrument, moderate force oidy being exerted ; it may occur also DYSTOCIA. 641 ill spontaneous dolivorv. Alilfekl in 1875 colloctcd 100 cases of lesions of the )){'lvic joints, and in 1888 Schauta'" added 13 cases. Diihrssen '-'' has given 3.'} casts in which suppuration in the joint foUowed the injury. The 23 cases of Havajewicz and the 3 cases of lleniy have been mentioned above. When rupture of a pelvic joint occurs in labor, it is accompanied by sudden and violent pain in the joint, tlic patient being conscious, it may be, of a serious tear at the painful part, and the instant yielding of resistance, so that the pre- senting part rapidly advances. Moreover, a "crack" is heard not seldom by those near the patient. Sometimes, as in a case (jf Remy's, the labor ends with- out any indication of the injury, which is made known in some movements of the patient a short time afterward, there having been a silent rupture. Accord- ing to Schauta, the accident most frequently involves the pubic and the right sacro-iliac articulation ; then the pubic and the left sacro-iliac articulation. Rarely are the two sacro-iliac articulations affected without the })iibic. Direct examination of the pubic joint with two fingers or with the thumb and finger, one external and the other internal, will detect the injury. Further, the lower limbs, the patient being recumbent, will be everted. Trousseau called atten- tion to the fact that " loosening of the pelvic symphyses " may be mistaken for disease of the spinal cord ; and Remy remarks that " relaxation of the symphyses may involve functional impotence of the inferior members so ]>ro- noiiiiced that it may be believed there is a real paraplegia." Should the injury not be detected at the time of its occurrence or while the patient is in bed, it is recognized when she gets up and attempts to walk ; if she succeeds, she, as Trousseau states, waddles, dragging one leg after the other and leaning greatly to the right or the left according to the foot she advances. Barker found that one of his patients could stand with comparative ease rest- ing iipon either leg, but could not balance herself upon both legs at once. If this accident occurs in labor, it is imjiortant to redouble antiseptic precautions, so that all danger of infection shall be averted so far as possible. Tf suppu- ration follows the injury, it is essential, as urged by Diihrssen, that the purulent (•ullcction shall promptly be evacuated. In one of the 13 cases given by Schauta the urethra was torn, and in lotiier the bladder and the vagina. Four of the women died, but perfect recovery occurred in the others, save one who was bedridden, at the end of twelve months. The period of recovery varied from a few weeks to several iiKiiiths. In the case occurring to Havajewicz deatii followed on the nine- teenth (h\y, delivery having been made with forceps. The child, which was iiiiiisiially large, perished half an hour after birth. In Diihrssen 's 33 cases of suppuration following rupture only seven recovered of twenty-four treated without incision, while of nine in which tiiis treatment was employed all recovered. 'flic essential treatment of rupture or o'' great relaxation of the pelvic artieiilations is a Hrin]y-a])plied bandage encircling the pelvis. " A girdle re(niires to be placed around a pelvis which has its staves separated. It is iKHossary to supply the temporary deficiency of intrinsic contention by an 41 fTT^IfW 642 AMERICAN TEXT-BOOK OF OBSTETRICS. \l\ ^f ,•! i .."i i< \ . • /' extrinsic contention — tiiat is to say, by the tight a])i)lication of a bandage in such a way as to bring into contact the separated surfaces of the symphyses" (Trousseau). Most authorities* agree that a towel answers well for a pelvic girdle. Tho union of the joint may take place in from ten to fourteen davs, but sometimes several weeks or even months are required. Diseases of the Heart. — Cardiac disease is not uncommon in pregnant women, the most frequent form being valvular, the mitral valve being often- est involved. The longer the lesion has existed and the more incomplete \\\c compensation, the greater tlie liability to premature arrest of the pregnancy. This accident was observed (Vinay) in ninety-two of 220 eases, according to the statistics of Courrejol united with those of Porak. The question of the interruption of pregnancy is determinetl by the con- dition of the patient. Fehling"'' includes among the indications for inducing premature labor chronic bronchitis with great pulmonary emphysema and insufficiently compensated cardiac disease. Kaltenbach, too, makes uncompen- sated valvular disease of the heart an indication. Vinay '" states that in the severe forms marked by gravido-eardiac accidents, when bronchitis is united with pulmonary congestion and edema, and there often supervene visceral con- gestions, anasarca, and ascites, and the dyspnea is constant, ]>reventing nourish- ment and sleep, energetic intervention becomes necessary. " Peter insists upon the good effects of bleeding, whicli is immediately useful in calming the dis- tress and dyspnea. There may be added inhalations of oxygen, subcutaneous injections of caffeine and ether, infusion of digitalis or digitalin. But it often happens that the disorders of compensation camiot bo ameliorated l)y medical treatment, and the life of the patient is in peril from increasing dyspnea and the cardiac astiienia; it is then necessary to induce labor." In a recent valuable monograph by Allyn '^* the author states that labor should be induced when dangerous pulmonary symptoms j)ersist in spite of suitable treatment; he further advises bleeding before labor is induced. Winekel regards induction of labor as uncertain in its effect upon the diseaso of the mother, and says that it ouglit to be restricted to the severest cases. When labtn* occurs it is agreed that anesthesia may properly be employed, chloroform being preferable to ether, and that the travail should be ended with as little exertion on tlie ])art of the mother as possible. If the forcejis is used, it is advised that extraction be made slowly, to avoid sudden lowering of tlic^ intra-abdominal pressure. To compensate for this lessened pressure foUowinL^ birth, Lahs and Fritsch '" recommend bags of sand upon the alxlomen. Dr. AVebster '"'' advocates chloroform as //«^ anesthetic in labor; he stato that occasional lii/podcnnicn of ether may be required, and especially recom- mends nitrite of amyl as first tried by Frascr Wright, capsules eontaim'ng 4 or 5 minims being broken and the drug being held to the ])atient's nose. " It *It is rt-markiible tli.it Meigs should liave fi)uii(l "every iiltenji-.t iit l):ini1aKii)g a I'liliire. "ii acromit (if the impossibility of well adjiistiiiLr aii<l imiperly retaininir ii hauiluK'' in jilaoe in ilii< particular part of the hoily, so that I am ohlimed to concliule that the best tiling that cnii lie done is to go to a protracted rest in bed." DYSTOCIA. 643 etrnaiK'v. is also useful in opposing the tendency to cliloroform syncope." " As the child is delivered the nitrite of amyl is of great value in neutralizing the increasing strain on the heart <lue to the additional blood thrown out of the uterine circu- lation as a result of the uterine retraction which follows delivery." He further advises that during the third stag, of labor artificial detachment of the i)la- cciita be made by a hand passed into the uterus, securing a certain amount of hemorrhage, and warns against the delivery of the placenta by the Cred6 method, and also against the administration of ergot. Diseases of the Brain. — Winckel states, referring to meningitis in preg- nauev, that when labor begins the condition is aggravated and the severe headaches may end in convulsions, but the lu'ine is free from albumin. He refers to Hecker's case of tubercular meningitis, the restlessness of the uncon- scious patient bccoining so great with the occurrence of labor-pains that the labor was artificially ended. Of the 35 eases of paralysis collecte<l by Clnn-chill,'^" in twenty-three the attack occurred during pregnancy, and in twelve eitlier during or after labor. In this inunber there were thirteen cases of hemiplegia, partial or complete, occurring before or during labor: those cases were obtained from Lever Stokes, Crosse, Simpson, and M'Clintock. linbert-Gourbeyre in his well-known monograph reports several cases of hemiplegia occurring in pregnancy, and he states that in more than half the cases des paralyses obstrtricales the paralyses are nianifested during pregnancy, and that in two-thirds the patients are hemlplegic. In 1872, Charpentier '^ collected 172 cases of puerperal paralysis, and of these there were fifty-seven lieiniplegias to forty-five paraplegias. The causes of hemiplegia were chiefly cerebral lesions and failure of renal action. In quite a large ])roportion of eases, if the hemijilegia occurs during ju'eg- nancy, either premature labor or, in some cases, abortion occurs. In these patients there is usuallv albuminuria. In verv manv of the cases a fatal result occurs, tw^enty t>ut of fifty-seven dying, according to Charpentier's sta- tistics. It is only exceptionally that the labor is protracted in the hemiplegic. La Motte (Observation CCXIX.)'^'' gives, in his usual graphic manner, the history of a woman attacked with convulsive movements three days befi)re laltor; they were followe<l by loss of speech and almost entire loss of eon- scioiisiiess. Wiien the labor began he recjognized it by some contractions of the lips and slight movements of the pelvis during a pain. Tiie woman was siit'ciy delivered, but there was complete paralysis of the right side; the j)atiei)t slowly convalesced, so that at the end of six months she was able to go to the waters of liourbon, where the cure was completed. The chief argUMient of La Motte that the j)atient had not true convulsions, though she iiad convulsive movements, was the fact that the child lived, whereas in true ciinviilsions it would have been d(>ad when so long a time passed before labor. He regarded the disease simply as apoplexy. I lemiplegia occiu'ring during labor will most probably result from cerebral hemorrhage in connection with eclam|)- sia, and it then presents an additional argument for ))rompt artificial delivery. Paraplegia. — In paraplegic women the anesthesia of the abdominal wall *■■■ I,; 644 AMERICAN TEXT-BOOK OE OBSTETlilCS. 11? ',< rl h,4g I s'S M %\ may bo so complete that the subject is never conscious of the movements of the fetus and does not fool any pain in labor (Vinay). " In a patient of Beni- luird's atfeoted with progressive locomotor ataxia labor passed almost entinlv without the j)atient's knowledge, suffering being felt only when the head win disengaged. In a case published by F. Benicke the patient had Pott's disease wilh compression of the cord. The accouchement took place at term withtnit suffering, and so unexpected was it that the woman was first advised of the labor by the crying of the child." A patient of Bernays,'^" a victim of syphilis, was *' totally paralyzed in her lower limbs and in all the muscles of her trunk which are supplied by nerves originating from the cord below tlic seventh cervical vertebra." The entire labor lasted only about thirty minutes, and its "peculiarity was, that in place of the usual interrupted labor-pains, there was but one continued contraction of the uterus, which resulted in the expulsion of a large, well-formed, healthy child." In Epley's patient"" delivery was effected by forceps after labor had lasted a day. In the case reported by I^itsckus,''^' the woman suffering from progressive locomotor ataxia, the labor was very slow, lasting five days. Garnet, quoted by Vinay, states that the final period in lal)or may be long in overcoming the resistance of the ])erineum — not from the muscles which are paralyzed, but of the aponeurotic and fibrous paits. Shock. — If sliock occurs to a woman in labor, it is most frequently the result of a grave accident — for example, rupture of the uterus. Apart fVoin the causal treatment of the condition, tiie practitioner should seek to obviate the tendency to death and to bring about reaction as soon as possible. Among the means he may employ are the external apjdication of heat, alcoholic stim- ulants, ammonia, camphor, and the hypodermatic use of sulphuric ether and of strychnia. Labor in Pneumonia. — By most obstetricians the occurrence of labor in a patient suffering with pneumonia is regarded as very unfavorable, and tluy therefore seek to avert any threatening of this event ; but if parturition is inevitable, the latter is facilitated as much as ])ossible. Great encroacluncnt upon the chest-cavity by tiie uterus may be lessened by early rupture of the membranes, and the injury to the already overtaxed heart by labor-pains is avoided as soon as possible by artificial delivery. Sudden Death in Labor . Delivery of the Child. — The chief causes of sudden death of the ])arturitiit are apoplexy, eclampsia, rupture of (he uterus, of the li(>art, or of the aorta, exhaustion from protracted labor, uterine hemor- rhage, pulmonary embolism, and, quite rarely, rupture of the spleen. In sudden death in labor it is important that the child be delivered promptly. If the dilatation of the os is sufficient, the application of tlic forceps is indicated in vertex presentation ; in that of the pelvis, the immediate bringing down of one or both feet, and extracting. Accordiiii: to Kaltenbaeh, not even one-tenth of the children delivered after the deatii nf the mother live. He quotes Pnech's statistics showing that in 453 operations one hundred and one children gave signs of life, but only forty-five survival. iJ DYSTOCIA. G4o Nevertheless, though the child be dead, its delivery should be made, " out of lonsideration for the relatives and friends of the woman and for the profession to Avhich we belong, especially if the accoucheur has been in charge of the labor for some time and has already made attempts at delivery " (Spiegel berg). Some advise that when the mother is dying from pulmonary tuberculosis, (Voin severe apoplexy, or other hopeless disease, delivery be made while she is vot alive, if consciousness and sensibility are lost. If the mother die from slow asphyxia or from hemorrhage (either uterine or from rupture of the heart or of a large blood-vessel), the probability of saving the child is very slight, but if her death be from a sudden injury, from embolism, or from apoplexy, the chance of the child's living is greatly iinjiroved. It is usually held that if more than ten minutes intervene between tlio death of the mother and the extraction of the child, its living is doubtful ; vet there are a few eases in which this period was considerably passed and the oliild was extracted alive. As proving that in some cases a much longer period than ten or fifteen minutes may intervene between the death of the mother and the removal of a living child, the following facts are of value : '^^ During the Connnune of Paris, Tarnier one night at the Maternity was called to an inmate who, while lying in bed near the end of pregnancy, had been killed by a ball which fractured the base of the skull and entered the brain. He removed the child by the Cesarean operation, and it lived for several days. He states that the delivery may have taken place three-quarters of an hour, or even an hour, after the death of the mother. In another case a j)regiiant woman fell to the pavement from a window a distance of more than 30 feet, instant death resulting ; thirty min- ute's at least after the death of the mother an infatit was retnovcd, which after some (lifHculty was resuscitated, and which lived for thirteen years. Tarnier also quotes the case, recorded by Hubert, of a successfid Cesarean operation two hours after the mother's death : the woman, who was eight months preg- nant, was instantly killed by a locomotive while crossing a railroad track. In case the os bo not sufficiently dilated for immediate delivery, Depaul stated that he could not too nmch insist, with almost all those wiio have studied this question, upon the advantages ofliered by extraction of the infant pn- vids naturalcs. One need not fear multiple incisions of the cervix by a bistoiny ; there can thus be obtained in a few seconds dilatation sufficient to iiiai<e version or to apply the forceps. Thevenot''^' states that the advice to <lcliver the child, in case the mother dies in advanced pregnancy, by the natural passage was first given in 16G5 by Schenk. He cjuotes Baudelocque, (lardien, and Velpeau as having approved of this method. One advantage of it is that there need be no delay in case the evidence of the mother's death is not conclusive, and such delay in the Cesarean operation may bo fatal to the cliild. It should be remembered that in several cases — not, however, occur- ring in recent years — the operator was startled by finding his subject oidy apparently dead. In case the Cesarean operation is selected, the same precau- tions are to '.c employed as if operating upon the living subject. ■AiL !ri fij' / t : I { h'f- ,'! I I t i 646 AMEIirCAN TEXT-BOOK OF OBSTETRICS. Aveling'^^ collected 44 cases in which spontaneous expulsion of the child occurred after the death of the mother. The force concerned in such expul- sion is usually the gases arising from decomposition accumulated in the ah- dominal cavity, causing pressure upon the uterus, or such gases in the uterus itself. It has, lu)\vever, been claimed that in some cases expulsion of the fetus was caused by contractility of the uterus continuing after the death ot" the mother, while the resistance of the pelvic floor was lessened. Post-mortotn inversion of the uterus may occur from gases resulting from decomposition in the intestines, the organ protruding from the vulva. Kaltenbach mentions a case in which a woman died from hemorrhage, the cause charged being tlio midwife's pulling upon the cord. Four weeks after death the body was ex- humed and the inverted uterus was found in front of the vulva. Kaltenbach explained the inversion as post-mortem, and the midwife was acquitted. REFERENCE LIST. /. 8. 9. 10. n. 12. IH. 14. Ki. 17. 18. 10. 20. 21. 22. Lehrluich dcr GebnrlMfe, 18!t3. 2.S. Tmn.<(tclioni* of llic London Ohifktriml Sn- 24. cii'tij, vol. xviii. 25. Lehrbueh (hr Gi-huiixhiilfe, 2(1 edition, 1893. Traitc dcst AcconchcmentH, 172(). McdimI r,rK.« niid Cirndar, .June 0, 1892. 20. London JfrdimI Jonrnid, vol. 2, 178G. 27. Text-book of Mkhvifenj. 28. /)('.« Dispoxilions du Cordon, rtr. 29. Transactions of the London Obstetrical So- 30. cietji, vol. xxiii. 31. Paris Thesis, " De la Teniioitd et de la Cordon oniliilical." 32. American ,Tournal of Obstetrics, 1SS6. 33. Ibid., 1SS9. Transactions of the Tuli)ibnr(ih Obstetrical 34. Sofietji, vol. xiii. CliantriMiil : Cenlralblatt fiir Giimikoloriie, 35. ISS."). Observations sur les f'ertes de Sane/, 177t>. 3(i. Annedcs il' Ifjir/ieue publiqne ct de Meilecinc 3/. (cfialc, 1S41. 3S. Transactions of the Edinbnr^/h Obstetrical 39. Societji, vol. xvii. 40. Transactions of the I-Jdinbiirr/h Obstetrical ' Societii, vol. viii. American Jonrnal tf Obstetrics, 1881 ; ibid., ISSd; Transactions of the American Gi/nc- 41. coloejieid Societii. Dennian's Introduction to the Practice of 42. Midwifenj. 43. Transactions of the London C)bstetrica! So. 44. cieti/, vol. xxiii. ProijrI's Medical, 1888. i 45. Pro(,ris Medical, 1887. London Lancet, 1S44. I'roeeedln(/s of Dublin Obstetrical Socirti/ ; The Ob.ttetrical Journal of Great lirilain and Lreland, 1880. Philadelphia Obstetrical Swietij, 18S8. Traitc Complet des Accouchcments, 1835. Monatsschrift fiir Gebnrt.ihiilfe, 18()3. Die Menschliche Placenta, 1890. Lehrbueh dcr Geburtshiilfe, 1893. Conffres periodiijnc de Gipiecologie et d'Oh- stetriipie, Brussels, 1892. Proi/res Medical, ISltO. Transact ioii.'< of the American Medical Asm- ciation, 1855. Placenta Pran-ia; its Ilistort/ and Tnul- ment, 18(11. Annali di Olistetricia e Ginecolor/ia, No. 5, 1894. Poslon Medie(d anil Suri/iral Jonrn<d, IS'.i;!. Miiller's nionojri'apli upon Placenta Prurio. Lancet, May, 1S92. Lecons de ('Unique obstetricale. De r Jfemorrha(/ie prodnite jxir l' fuserlinn dn Placenta sur le Serpnent ct le Cul d, ri'terns. par I5eiijaniiii Dunal, Moiii- pellier, 1S.55. Transactions <f the Edinhuri/h Ohstrtriinl Societji, vol. iii. American , Ion rnal ef Obstetrics, 1889. Lonilon Lancet, .\pril (i, 1SS9. An L'ssaji on the Cterine Ifemorrhai/e, etc., 4lli edition, 17S9. F.dinbnrtjh Medical Jonrnal, Nov., 1873. REFERENCE LIST. G47 i^tetricdl Sorirli/ ; )/ Great liritain Medical .l.<.-')- rji mid Triiil- ccolmiiit, No. ■">, Journal, lS'.i:>. ''Idccntd I'rirrin. jiiir P fii/'i'i'liiiii ml rt Ir ('"I 'I' Diiiiid, Mtiiit- -IC). 17. 48. •lit. r.d. r.i. :■,•> .VI. .")t;. 58. r)it. f.(). fii. (iii. o:!. G4. 05. (Jt). 07. 08. Oil. 70. 71. I M. ~t> I >>. 71. 7'). 70. Trnite pratique iP Aecoueheuienix, TrauiiactionK nf the Lomhii Obntetrical So- eiety, vol. .\x.\i. Le(;i)iin de Cliniijue obnltiricale, Brussels, 181)2. AmericHii JnuriKil of Obatetricn, 1880. CiiiH/rtu periodiqtie Inlcrmilional, Brus.sels, 1802. Lehrbuch dcr Geburtxhiilfe, 1891. .\(]ilress on " ( Jbstetriiw iiiid Disejuscs of Women," Britixh Medieid Anftociation, I8U3. American Journal of Obstetric.t, 1894. I'mnmrtidnn of the Auie.ricari Gynecotogiad Socictij, vol. xvii. Miilk'i-'.s JLindbuch. Tnumictionx of the American Qynecoloyical Societi/, vol. xvl. "I'eber Vorzeilifre Losnnff der Placenta bei Normalon Sitz," Zeitachrift far Gc- burlMUfe und Gjindkoloi/ic, 1892. ObMetrical Journal of Great Britain and Ireland, 1878. American Jouruid of ObstetricD, 1870. liriti-^h Medical Journal, 1892. Klinik der Geburti>hiilliichen Operationen, 1894. Ifaudbuch der GeburtMlfe (Miiller). Transactions of the .Imerican G t/necoloyical Societij, vol. iii. Verliandlun;/ der Gescllschaft file Gebtirtii- hiilfe und Gyniikoloiiic zu Berlin, July 13, 1894. J/'{(H.s'(«'/ ('«;(.< (//" the ^Imerican Gynecological Society, vol. iii. Etude liurlcK lleniorrhayien (pii xurvcnicnnent pcmlant lex unites de Couches, 1876. System of Obstetric Medicine and Surgery, London, 1885. Text-book of Midwifery, Sydenham Society's translation, 1888. (Jhstetricid Journal of Great Britain and Ireland, 1878. Allijemcine meilicini.^che Central-Zrituny, .Jan. 27, 1875. Klinik der Geburtshiilllichen Operationen. Lehrbuch der Gehnrtshiilfe. Ilritish Medical Jcurnol, 1892. Trausactions of Jie St(de Medical Society of Indiana, 1884. Tea nxaet ions if the Londiox OhMetrieid So- ciety, vol. XXXV. Lehrbuch der Geburtshiilfe, zweitc .Vullafii'. 1893. Hundbuch der Geburt^hi'ilfe, iii. Band, 1889. liCKcarches in ObMetrics. 79. 80. 81. 82. 83. 84. 85. 80. 87. 88. 89. 90. 91. 92. 93. 94. 95. 9(). 97. 98. 99. 100. 101. 102. 103. 104. 105. 10(i. 107. 108. 109. 110. 111. 112. 113. 114. 115. 110. Traitc clinique de F Inversion utirinc, 188,3. Transactions if the American Gyneeuloi/ical Society, vol. ix. " Es.-<ay upon I'terine Invci-sion," Trans- actions of the Provincial Medical and SurgiuU Association, London, 1844 and 1847. American Journal of Obstetrics, 1885. Centralblidt file Gyniikoloyie, 1892. Clinical Memoirs on Diseases if Women, Lehrbuch der Geburtshiilfe, 1891. Diclionnaire de Medeeine, tome xi. Grundriss der Geburtshiilfe, 1881. Traite des Maladies de la Grossesse, etc., I'aris, 1894. Centralblatt fur Gyniikoloyie, 1891. Nourean Diclionnaire de Medccine el de Chiruri/ie pratique, tome xii. Oui and SabrazJr: Anndesde Gynecolixjie, 1893. Centralblatt file Gyniikoloyie, 1893. " I'eber P^kiamjisie," Sammlung klinischer Vortriifie, No. 39. Archie fiir Gyni'-' ilogie, 1892. Annales de Gyu^ ^iluijie, 1893. Obstetric Clinic, p. 291. Legons sur les Antointoxicatioiis dans les Maladies. Winckel's Geburtshiilfe, 2d edition, 1893. Annales de Gynecologic, 1893. Xonvelles Archives d'Obalelriipie el de Gynecologic, April, 1S93. Medical Times and llegisler, 1890. Southern Medical and Surgical Journal, 18.59. Tran.mctions of the American Gynecological Society, 1887, vol. xii. Transactions of the Berlin Congress. Lancet, 1893. youvelles Archives d' Obstetrique el de Gyue- cologie, February, March, and April, 1893. Transactions of the Edinburgh Obstelrical Society, 1890-91. Obstelriquc el Gynecologic. Trintise on the Theory and Practice if Mid- ivifery, edited by M'Clintock. American .loiirnal of ()l).<lelrics, 1893. Ilandbuch dee Gebiielshiilfe. Lehrbuch der Geburtshiilfe. Manuel des Accoiichements, Traiti' lies .]fiiladies de la Grnssestie. Miiller's lluudbuch der Geburtshiilfe. Cliuicid Meilieiue, Sydenliain Society's translation, vol. v., " Loosen iuK ol" t lie I'elvic i^ymphyses." \\i AMERICAN TEXT-HOOK OF OBSTETRICS. 648 117. The Piirrpeml DlHefMes. 118. Amfi-inui Joiirmil oj' ObnMric-i, February, 1870. lilt. IiitnuliKiiim to tlw I'ri'ctice of Midwifery, 120. W'iviirr iimliziimfhe Bliiltcr, 181)1. 121. Airl,iir.'< (le TurohKjie, 1881) und 1890. 122. XiK'ffole and (Jrensor. 12.'{. (.'eiitntlhhll fill- (ii/iiiikotDf/ie, 181)0. 124. Unirermli/ Mcdiail Mui/dzine, 181)4. 12r). "Observations regarding Chronic Heart Disease eoniplicatinu Pre^jnanev and LalK)r," IlnspiUd, 181)4. 12G. Dixeunen of Wumfii, iMIi edition, 1804. 127. 128. 121). 130. 131. 132. 133. 134. />('.i PnrnhjdvH pwrper(deK, 18(il ; I'rnili pnitiijiir dex Aecoiirlteme.ntx. Tniile diK Aecoitrlinnrnln. St. Louis Medical und Snr<jic(d Jmmiol, Dee., 188.3. Sew York Medieid Jimrmd, March, l88o. Ventralhlalt fUr (liiiuikolof/ie, 1885. Second I'art of Tarnier's Truife prntifjin dcK AceourhementH. De AccouchemeiU arlijieiel par lea VoiiA imUirellen Hubxtilne a ropiration C'eaiu-i- eiiiie ixist-iiiiirlein. Tranmc.tioim London Obstelrical Societi/, vol. xiv. 'J / I. mjicdl Jnnriiiil, iletflcal Socii-tii, IV. THE PUERPERIUM. I. PHYSIOLOGY OF THE PUEF^^ERIUM. The piierperiiim is the period of convalescence fVoi.- ■' ./irtli. It hopns with the close of the third stage of iab(jr, and ends with the regressive changes which take place in the uterus and other genital organs after parturition. This process usually occupies six weeks; in exceptional cases it is not complete until the eighth or tenth week. The condition of the puerperal woman has been aptly compared to that of a w<nuided patient. While not sick, she is " eminently predisposed to disease." The exhaustion following labor, the wounds and contusions of the birth-canal, the presence of putrescible fluids in the passages, together with the resorption activity of the utero-vaginal tract, are conditions which border closely upon tlie pathological, and are an ever-present menace to the safety of the post- partum state. The exalted irritability of the nervous system, too, contributes to the unstable equilibrium which characterizes the childbed condition. The puerperal process, therefore, though a physiological one, demands the constant exercise of care and skill in its management to prevent the invasion of disease. Post-partum Chill. — A sense of chilliness, or even a distinct rigor, is fre- quently experienced at the close of labor or during the third stage. It is of siiort duration, rarely exceeding ten minutes, and is not attended with rise of temperature. The j)robable cause of the chill is the lessened heat-j)roduction due to the abrupt cessation of nuis(!ular effort after the expulsion of the child, and the rapid loss of heat by evaporation from tlie lungs and skin. It has no pathological sigiiifi(;ance, and requires no treatment except warm coverings and ])()ssibly a hot drink. The Pulse. — Soon after delivery the pidse-rate, which lias been somewhat increased diu'ing labor, falls, as a rule, below the usual normal standard. This retardation of the pulse generally begins within from eight to forty-eight lionrs after labor, and in exceptional cases continues until the end of the sec- ond week. Usually it lasts for a period of not more than three or four days ill primiparaj, somewhat longer after subsequent births. The duration of the rcdnced pulse-rate is generally prolonged in j)roportion as the reduction is more marked. The frequency most commonly observed is from fifty to seventy per minute; rarely a minimum of forty or less has been noted. This alteration in the pulse is not attended with a corresponding variation of temperature. The cause of this phenomenon is doulitless connected with tlic mental and physical rest which follows delivery, and the suddi'ii diminu- tion in the amount of labor put upon the heart in consequence of the inter- ruption of the utero-placental circulation. For several days after childbirth tlic frequency of the pulse is variable under slight disturbing influences. The Temperature. — At the close of labor the temiierature ranges from one CM mi as 660 AMKlilVAX TEXT-JiOOK OF OJiSTETlUCS. to throo (Icgroi's above tlie normal, according to the lencth and severity of tlio labor. Witiiiri twelve hours it falls again nearly or (\-.hr> to the usual stand- ard. In twenty strictly normal cases selected from the writer's hospiud service the average temperature at the close of labor was 99.67° F., the maximum being 100.5° and the minimum 98.4° ; at the end of twelve hours the average temperature was 99.18°; twenty-four hours after labor it was 98.()5°, the maximum being 99.5° and the niinimum 98° F. For the first four or five days of the puerperium 99.5° F., and for the balance of the period 99° F., should be regarded as the physiological upper limit of thermometrieal range. Transient elevations of temperature, however, may occur from comparatively unimportant causes, such as emotional excite- ment, digestive disturbances, or ccmstipation. A slight rise is sometimes observed on the establishment of lactation if the breasts are much engorged and painfid. This rise is most likely to occur in debilitated and weakly women and in those unable to nurse. A temperature persistently above the foregoing limits must be regarded as evidence of some comj)lication. Secretions and Exartioiht. — The general effect of labor upon both secre- tions and excretions is to increase the activity of these functions. The skin acts freely. If the body is kept warm, perspiration is usually profuse. Hyperemia of the skin and consequent exudation into the hair-follicles sometimes result in partial loss of hair. There is a notable increase in the volume of urine during the first week. Its specific gravity is a little lower than usual, the amount of water elimi- nated being greater than during pregnancy, while the total excretion of uri- nary solids per diem remains nearly or quite unchanged. This superabundant secretion of urine is one of the causes of over-distent ion of the bladder to which the patient is exposed after labor (Fig. 411). Other contributing causes of retention in the first few days are the posture of the patient, the lessened intra-abdominal pressure, urethral spasm, and the dread of pain during micturition owing to the bruised and fissured condition of the vesical neck, the urethra, and the vulva. Glycosiu'ia is observed in a considerable proportion of instances for a short time after as well as before labor. This is due to resorption of lactose, and the ])roportion of sugar in the urine fluctuates with the fulness of the breasts. It disa])i)ears as soon as the balance is established between secretion and con- sumption. Peptoiuu'ia exists for several days, jieptone being a product of uterine involution. Zoss of Weir/ht. — It is stated that during the first puerperal week there is a loss of weight, variously estimated by different observers at from one-twelftli to one-eighth the body-weight at the close of labor. This loss is attributed to the increased activity of the secretions and excretions and the small amount of food ingested during this period, together with the retrograde changes wliicii normally take place in the pelvic organs. Under the present practice of allowing the patient a moderately full diet after labor the loss is generally confined to the first few days post-partum, and is soon made good. riiYsioLOdV OF Tin: Pi'i:iirKi{ir}f. (Ml Uterine Contructiom. — Rliytlimical utorino contractions, .similar to those of labor, continue tor a variable Iciij^tli of time after the delivery of the placenta. X.-:., ^., •nitiliiji>i<S &' ^ Kiii. 411.— Kxtreme over-dlstentlon of the bladder during labor (from a skotcli by K. L. l>ickinson, M. 1).). Tiie contractions t»f tiie nteriis tend to exclude blood-clots from its cavity, to establish complete retraction, and thus to accomplish the permanent ligation of its vessels: by diminishing the blood-supply they promote in the uterus the retrograde changes which normally take place in the j)uerperal period. In primipara) they are seldom painful. In mnltiparje, in whom there is greater relaxation of the uterus and gi-eater tendency to the retentiun of clols, they arc more intense and are freijuently accomj)anied with pain. After-pains in exceptional cases may continue for two or three days. Usu- ally they cease after a few hours. They are intensified when the child nurses by the reflex influence of the mammary irritation. Even in women who have borne children they are, to a great extent, i)reventcd by the use of measures to secure full and persistent retraction of the uterus immediately after the expulsion of the placenta. Sometimes uterine contractions of a painful character occur, without the retention of clots, from jnirely neurotic causes. Pains of unusual severity, unduly prolonged and accompanied with great sensitiveness to pressure, may suggest the possible jiresence of beginning peritonitis. Thv Digestive Orr/ans. — Usually the ai)petite is diminished for the first few •lays after labor and the digestive j)owers are enfeebled. Owing to the rapid (■liMiination of fluids by the skin and the kidneys, thirst is increased. The bowels act sluggishly in consequence of the small quantity of food ingested, the increased secretory activity of the skin, the diminished peristalsis, the lessened tonicity of the abdominal muscles, and the complete rest in bed. Gknital Ougaxs. — Cumlition of the Fartavient Tract. — By palpation over the lower portion of the abdomen at the close of labor the uterus may be felt as a hard, irregularly rounded mass reaching about halfway from the pubic bones to the umbilicus. Owing to the relaxation of the abdominal If': 4 fmr ■ I ■' u ■} "I 1' .1 1 A rV'i A :) V : i [M» iV :!=' -■ ' IBP <;:)i AMKIiKWX TEXT-HOOK OF OtlSTETRirS. walls, tlio fundus may be jjrasjuHl in tlio hand, and evon the round lij^ainonts and ovaries ean generally be mapped out. Within a few iiours the uterus will be found somewhat relaxed, with the fundus at the level of the navel or a little above it. Usually it is slightly anteflexed, and its position is one of partial dextroversion and dextrotorsion. It is somewhat larger in nudtipane than after the first eonfinement. 'V\w placental area is somewhat elevated ; its surfiiee is uneven, and is studded with thrombi lying in the mouths of the utero-plaeental vessels. The outer layer of the decidua and fragments of the inner layer remain for a time, to be gradually east off with the lochia! dis- charge. A layer of blood or bloody mneus covers the entire wall of the uterine cavity. The cervix remains soil and relaxed for several lionrs after labor, having an almost gelatinous consistence. Its length is 2| inches or little more. The os internum presents the feci of a resisting ring, and in the intervals between uterine contractions it is suflfieicntly open to admit two or three fingers. The lower border of the cervix is always bruisetl and fissured, sometimes deeply torn. After twelve hours the neck of the tjterus begins to regain its former shape. Even in the absence of notable lacerations the vagina and vulva are swollen, abrade<l, fissured, bruised, and sensitive to the touch. For two or three days there is fre(piently more or less edematous swelling of the labia. The hymen in primiparu; is torn at numerous points, its fragments skirting the vaginal orifice as small projections which ultimately form the earunculjB myrtiformes. The vulvar orifii-e gapes more or less according to the extent to which the soft structures have been overstretched or torn diu'ing the birth (Pis. 42, 43). Involution. — In all the pelvic organs which have undergone hypertrophy during j)regnancy a corresponding atroph} of the tissue-elements takes ])hice during the puerperium. This prr'-'css affects the ovaries, the Fallopian tubes, the uterine ligaments, the vagina, the external genitals, and especially luo uterus. Except in primipane the pelvic structures are in normal conditions fully restored to the pre-gravid state. After the first labor the return to the virgin condition is never complete, particularly in the uterus and the vagina. The enlargement of these organs remains in some degree permanent. 'The Uterus. — The uterus, as the principal seat of tlie building-up process during gestation, undergoes the most imjwrtant retrograde changes in course of the lying-in jwriod. The rate of uterine involution is shown in the folluw- ing tables. According to Ileschl, the weight of the uterus is — At the close of labor, 770 to 80") grams. " end of the first week, 665 to 73o " " two months, 45 to 75 " According to Kaltenbach, the organ immediately after labor weighs abonf 1000 grams (2 pounds). The uterus measures at the close of labor from 11) to 21 centimeters (7;j in 83 inches) in length, and 11 centimeters (4| inches) in width at the level i<\' rn;i!i'KKHM. Vi.xn: r. ■c(l, somotiinos IS to regain its c vagina and ic toneli. For .veiling of the , its tVagnionts ately form the IS according to or torn during /'« Hl/u. C/l'St'ii Si'l ulcrhif l^ttrn-fesii,!/ /,.«,/; Kiliiutioii I iii^ I.iiwcr ut,i ill.' .\, XIII, lit Aiitcriiii- joriiix l.OU'i'l /i.lll 11/ VtiX'iiti I'm iiuiim iL f^ii^M^i ''lolltiilttnly. I'/meiilii/ silt l-'uihiii.< iilcii. B!,i,td,r. Symphysis pubis. l'i'illii\il oi-ifue. (\iTily of iilffiis ul'niv iiii'i.r. • (V(77>. / •'III ii ,'/ nuiix/iis. J'li'iiit'iitory. Cil-'i/y of lit,- 1 ' iu\ tlllll . _L_ I'dll, ll of i'fllghis. ri,-l,>-7;si\.l/ pollJl. Os t-Ait'r/iitiii. mm^ ll I / - 1 i 1 lit the level nf 1. V,.rti,.„l „u.si„l M.,.ti„„ ,„■ ut,.,us Mt rlns.. nf lal.nr. (iv.. xniuntr. niu;- .Mn;-n .MthT W.hM.n ■> Vvrti.,.! musial s,.,n,,i, ,,1 iitiTus sfc,,i„i ,l,i.v .,(■ i.iK-ii„Tiiiiii ,jUUt UVliMcn. I \ w l( * ) 1 "■ i IM i*ii:Hi*KHir>F. I'l.ATi; 43. I 'I,- 1 II!. - - H/a,/,/,-, . — S_\in/itiysis />u/-ii — Kt-tr,>/>ii/'ii- //.\sitt'.\ — L'l't-tlntilofif'ue - — - — rroinoutory. I — Uteiim- iUTit). I'tero-vi'ihiil /(>«i/(. I'oiich of />ciut;/iti. Reiliim !('il/i /'lii's. S\in/>liysis I'uhh ( 'i i-.lfi'rUHiil. ' Vi.tht.il oiifice. ^r* .'fuontoiy. h'tiiuius r/ ittt nts. Onily i<J iiUiiis. _r('>tiini ,1/ ii/;ht Kill I .wji III/ /i[t;iim,iit . r>'ii(L'i i:'y /,'yni.v. -A\\ tunt .w. V.rtU'Ml III, •Mill M'Ctinll nf lilrrilv, -ixtll .ImV n|- flUTlHTlUIM Uld.T W.'I.Mofl. J. Wl'lirlll lllrsilll s<Tli.,|l «il' ri'tiuvcili-.l uluni>, lilirniili iliiy ,,r piiiTiPiTiuiii ^nltor WrhsU'r). PIIYSIOLOCY OF TllK PUKRPKRHJM. (jr):5 the Fallopian tubes, and its npper 8ep;ment is from 3 to 4 centimeters (1^ to \\ iiu'lu's) in tliii/kness. The cavity is from 15 to 18 centimeters (6 to 1\ inches) in depth. The following sonnd measnrements are from Hansen: Tenth dav, 8. to 13.5 cm. Fifteenth day, 8.3 to 11. o Third week, 7.5 to 10.5 Fonrth Fifth 7. to 9.3 G.5 to y. Sixth week, 6.2 to 9.1 em. Seventh " 6. to 8.5 " Eighth " 5.6 to 8.5 " Tenth " 5.4 to 7.5 " The fnndns nteri lies ahont midway between the lunbiliens and the pnbic hones at the close of labor. Within a few honrs it is jnst above the nmbili- ( lis, and is at the level of the pnbic bones by the tenth day. The elevation of the fnndns, however, varies with the fnlness of the bladder and the rectum. The nterns is pnshed nj) bodily when these viscera are distended. Involution is retarded in non-nursing women, after twin births, much hemorrhage, retention of secundines, sepsis of the endometrium, or getting up too soon. Utvrhw Mui^cnlnrh. — Various theories have obtained with reference to the nature of the changes in the uterine nmscnlar structure during involution, some authorities holding that a part, others that all, the muscle-fibres are destroyed by a process of acute fatty degeneration, and that there is partial or total re-formation of muscle-elements. Sanger has shown by a large num- Ikt of observations that the regressive process is one of atrophy, by which the muscle-fibres are reduced to their primitive dimensions. The nuiscle- fibres are not destroyed by complete fatty degeneration : they undergo a true involution initil they have reached their earlier size and form. Similar con- clusions have been reached by Dietrich. The nutritive activity in the uterus is greatly diminished by the lessened blood-supply conse(iuent upon uterine retraction after labor, and atrophy ensues, fat-globules appearing only in the interior of the muscle-cells and never externally to the fibrilla\ The fat- lilobnles " do not enter as such into the circulation, but are oxidized in the place where they occur. The intermuscular connective tissue experiences a similar involution in its cellular and fibrillar elements." />Voof/-jr.swAs' of the llcnix. — Thrombosis takes place in some of the siinises at tiic placental site during the ninth month of pregnancy. The remaining (UK'S ai'c ))romptly closed by compression and by the formation of coagula after labor. A portion of the blood-vessels become atrophied as the icsult of pressure. Fatty dcgenera'iou takes place in the media. Th(> larger arteries Mi'c partially or wholly obliterated by connective-tissue ])rolifcration of the iiitima. In women who have borne children the coats of the uterine arteries ninain permanentlv thickened ar.d the arteries larger than in the nidliparous uterus. The walls of the venous sinuses are thickened and (Convoluted for sc\i!'al weeks after delivery; the location of the placental site is disi'crnible many months after labor. The nuieous membrane is studded with pigmentary deposits, an unfailing sign of recent childbirth. / I ] .'U. E ff^^TWUHMJW ii II, 1 m r I m.m ii III '! "m 654 AMERICAN TKXT-BOOK OF OliSrETRICS. lieconstnidion of the Uterine Mueomt. — Tiie deep glandular layer of the decidiia, together with IVagments of the snpi'rticial layer, remains attached to the uterus after the expulsion of the placenta. From the glandular layer the regeneration of the mucous membrane takes place. All the remaining decidual structure not concerned in the development of the new nuicous membrane suf- fers factv degeneration and is gradually thrown (tif in the lochial discharyre. The glands are crowded close together by the uterine retraction. About the mouths of the glands islands of new epithelium are formed, developed from the gland fundi. These coalesce until the surface of the uterine wall, includ- ing, last of all, the placental area, is ciovered. By the end of the fifth week, as a rule, the new mucous membrane is complete. Loc/tia. — The genital discharges of the puerperium are termed the lochia. They have their origin in the cavity of the uterus, and continue during the greater part of the period of involution. They consist at first of blood with clots and decidual shreds, and usually are of a distinctly bloody character for three or four days — lochia rubra or cruenta. During the next two or three days they are pale in color, are thinner, and consist mainly of scrum — lochia serona ; they contain blood-corpuscles, epithelial cells, and shreds of decidua. Finally, after about seven days, the discharges assume a grayish or a yellowish color and are of a creamy consistency — lochia alba. The microscopic elements are chiefly leucocytes, new epithelial cells, connective-tissue cells, fat-globules, and cholestevin crystals. The reaction of the lochia is neutral or alkaline duriii"- the first week; later it is acid. The discharge gradually diminishes in quan- tity, ceasing altogether by the end of from two to six weeks. The average amount for the fii'st eight days is about three and a quarter pounds ; the quantity, however, varies. It is greater in multiparaB than after first labors ; it is more abundant and lasts longer in non-nursing women and in those wiio menstruate profusely. There is frc(]uently complete or partial sujipression of the flow on the establishment of the milk-secretion. The lochia rubra persists longer in retroversion of the uterus and after getting up too soon. Normally, tlic lochial discharge has oidy a faint odor and is never fetid. J^ven in normal conditions micro-organisms are i'ound in the genital dis- charges after the first two or three days. Their abundance varies in difl'ereiit cases and increases with the progress of the fl(tw. The principal varieties ;irc single cocci, staphylococci, and bacilli. Tlicir occurrence in the lochia is explained partly by th<' ju'cscnce of bacteria |)rimin'ily in the vagina, pni'llv by entrance from williout. The uterine lochia, as a rule, are free from bactci'ia in normal cases. Lactation. — Important changes in the mammary glan<ls take place durin<: pregnancy in preparation for lactation. They Ih'comic enlarged by growth nl' the acini, by interlobular deposit of fat, antl by swelling and prolilcration of connective tissue. In the later months of gestation a milky scrmn miiv lie expressed from the nipples. The mammary seci'iiion of the first 'iays of the puerperium is similar to that of the latter part of pregnancy, and is tcrnnd coloHtrma. It is a viscid fluid of a fiiint lemon-yellow color, and is richer in PHySIOLOUY OF THE PUEJtPERIUM. isr^h fat, sugar, and the inorganic waits than the fully-<levehipeil ni ilk-secretion. At this early period, before the function of the gland-cells is established, it is little more than a transudation from the bhjod. A^^Bngly, there is a pi-eponderance of albumin and a deficiency of casein. I^^hief microscopic elements are fat-globules, mucous ctM'puscles, pavement ej)itlielium, occasional milk-corpuscles, and large round granular ei)ithelial cells, known as colodrum- corprndes. The latter do not wholly disajjpear for several days after the true milk-secretion is established. The laxative property of colostrum is attributed l)y Winckel and others to the abundance of phosphate of calcium, chlorids of sodium, potassium, and magnesium in its compositic^i. The large j)roportion of fat and of milk-sugar doubtless contributes to the cathartic action. De Sindty ascribes the laxative effect of colostrum to its indigestibility. The true milk-secretion begins usually on the second day in multiparoe, on the third day in primipane. The mammary glands become swollen and more or less painful, the veins are prominent over the breasts, and the axillary glands are freqnently enlarged and sensitive. Some general disturbance is experienced in the presence of great tension and pain in the breasts, particu- larly in nervous women. Thirst, loss of appetite, malaise, and, in exceptional cases, a slight elevation of temperature, may be observed on the developinent of the milk-secretion. True milk fever, it is generally conceded, does not exist. That painful engorgement of the breasts, however, may give rise to transient fever in the condition of unstable e(pii!ibrium which characterizes the puerperal woman camiot be doubted. Yet it must not be forgotten that a rise of temperature at this time may be, and most Impiently is, due to septic absorption from the genital wounds. Human milk contains on an average l.o per cent, of albuminoids, 4 per cent, of fat, 7 per cent, of sugar, 1.4 per cent, of inorganic salts, and 86 to 87 ]t('r cent, of water. Tli(>se proportions, however, arc subject to con.sidcrable fluctuation. They are affected by the health and habits of the woman, and even by emotional disturbance^, and they vary, too, with the period of lacta- tion. There is an increase in casein until the second month ; thereafter it (limiiiishcs until the ninth month. Similar variations occur in the ])ercentage (if fat. The sugar increases after the first month. Authorities, however, are not agreed on the nature and the extent of the changes which take place in ilie composition of breast-milk from month to i;:"nth. Tlu! composition of the lacteal secretion dc|)arts soi lewhat from the n>ual normal standard on the return of the menstruation. These chauges arc gcn- ei'iilly of short duration, lasting but a few days after the menstrual period. In exceptional cases tiiey I'cmain to a greater or lesser extent perniaMeiit. Fre- i|iieiitly no harm comes to the mother or the child from the continuance of nursing even when the menstrual functicma is resumed in the early weeks of lactation ; in exceptional instances it may l»e necessary in the interests of the child, and possibly of the mother, to discoiitir'ie nursing. The liquid })ortion of milk is derived, with some modification, from the .u nPT .i/,- '^^ I '12 -B. • I i ) : 1'. 1 1 1 ' ' .'I +■ ( 1 1 6')G AMERICAN TEXT- HOOK OF OJiSTETIilCS. blood ; the fat, sugar, and casein are i)rodiicts of the metabolic changes in tlio protoplasm of the secrctorv cells of the mammary glands. Thc^ fat or butter is held in suspension in the liquid portion in niimite globules of variable size, forming a fine emulsion. The average normal period of lactation is about one year. In most mu's- ing wohien, however, the milk begins to fall otf in both quality and quan- tity after the seventh or eighth month. Both the abundance and the diu'ation of the secretion vary greatly in different cases according to the health and vigor of the woman. \\\ normal conditions the (juantity increases during ;it least the first six months proportionately to the needs of the child's nutrition. In non-nursing women the secretion continues for a few days, then rapidly declines, and soon ceases altogether, the parenchyma of the gland undergoing involution. II. DIACJXOSIH OF THE PUEIIPERAL STATE. The puerperal condition can usually be recognized with little difficult v within the first one or two weeks ; later the diagnosis is not so readily estab- lished. The evidence of recent delivery is to be sought ]n'incipally in the condition of the breasts, the abdomen, and the genital tract. After the first two days the breasts are enlarged and tense. The mammary glands are firm and nodular and milk is freely secreted. The abdominal walls are lax, and the skin can be taken up in folds over the underlying muscles ; ntrice gravidarum and the pigmentary changes are evidence that advanced pregnancy has at somi; time existed, other causes of abdominal enlargement sufficient to explain the presence of strite being excluded. The external genitals are gaping, swollen, bruised, and fissured for several days after childbirth, and for at least two weeks they present the marks of recent injury of greater or lesser degree. The vagina is enlarged and relaxed ; the rugre are ef!aced and the introitus stretched and torn. Tlio uterus is enlarged, the (;ervix is notched or deeply fissured by recent tea^s, and its canal admits one or more fingers. The size of the uterus in normal conditions diminishes daily. The lochial discharges are found flowing from the cervix, and the placental site presents to the examining finger the nodular surface and fresh thrombi characteristic of recent delivery. The lochial dis- charges are distinguished from hemorrhage of non-puerperal origin by their microscopic constituents. When the importance of the question justifies it, conclusive evidence may sometimes be obtained by curetting the uterine cavity. The ])resence of decidual shreds or chorial villosities in the scrapings aifurils in(lul)itai)le proof of recent jiregnancy. The length of tim<' that has elapsed since confinement may during the first two weeks be estimated approximately by t!ie condition of the breasts, the si/c of the uterus, and the character of the lochia. For the first two or three days the mammary secretion is colostrum ; for several days subsequently the glands are swollen and hard and milk is abundantly secreted. The fundus uteri is MAXAdKMKXT OF TUK JTKni'Klil I'M. 657 just alnn'o tlio umbilicus on the day fbllowiiij^ dolivery, and it gradually sinks t(i tiie synipiiysis by tlio tcntli. Tho cliangcs in the lucliia indicate roughly the jiiogross of" tlie puor|KM'al jicriod. The vulvar wounds arc in a stage of repair [iidportionate to the number of days that have passed since the birth. in folds over 111. MANAGEMENT OF THE PUERPERIUM. PoHlmr. — During tiie first few hours after labor the best jiosition for the patient is the dorsal decubitus, ff she turns u{)ou the side, owing to the lax (•(iiulition of the abdominal parietes the uterus I'alls forward, and air may be drawn into the passages, exposing the patient to the jntssible danger of air- iboli After the uterus has bee itlv retracted and th ■1. I'onie perni! al tlic i)lacental site are firndy closed by thrond^i, the posture of the patient may be left to her own choice. Rixt. — A sound sleep of several hours after delivery is a favorable prog- nostic. It not oidy sj)caks well for the condition of the patient, but is a |)iitciit restorer. Care slioidd be t;d<en, therefore, to procure rest and sleep as -(1(111 as possible aftor the necessary attentions to mother and child have Ircii (•(iMiplotod. The room should be (piiet, and the light be subdued by drawing the curtains. The U;m' of hypnotic drugs is, if j)ossible, to be avoided. It is c-)xc!ally important that the child be not permitted to disturb the mother's rest. It ought not to sleep iii the same bed with the mother, and if it cries -houhl be removed to another room. Plit/.sieiftn^'i Vlsit.'i. — It is generally desirable that the first visit be made witliin twelve hours after confinement. This, however, is not always necessary wlicii a conn)et(!nt graduate nurse is in charge. It is the duty of the physician to make a systematic examination of botii mother and child at each visit. The principal points to be oljserved during the first days after delivery are — the general aj)pearance of the woman, whether she has rested sutticiently ; what and how much nourishment slu; has taken ; the amount and character of tiie flow; whether the bladder has been emptied, and the (piantity of urine passed ; if the liowels move daily after the first twenty-four hours; tiie presence or ab>ciice of after-pains, and how severe they are. Tin; ])ulse and temperature ill!' to be noted. The binder should be loosened at each visit, and the uterus (xainincd through tiie abdondnal walls for the rate of involution as indicated l»y flic height and widtii of tiie fundus ; the degree of tenderness over the iil( rns and broad ligaments should be noted. It is especially important at the lii-t visits to examine tiie suprapiil)ic region by palpation to learn whether tlie lilaildcr is distended. The urinary secretion is, as a rule, greatly increased liming the first few hours after delivery. Injurious distention of tlie bladder iVcijiieiitly results. The assurance that the ])atieut has passed water freely is not t(» be taken as ])roof that there is no retention. When overfilled the Madder may easily be made out as a fiiiid tumor between the ut<'rus and the alnloiniiial walls. Pressure with the hand over this region, too, will cause a ile-ire to urinate. Marked fulness of the bladder fre(pieiitly presents a visible [■2 \ i-fe larj II flfnpT" ! I: m ■ -fK'^ ! :» : ll ■ W'i 1 1 i .''.'l i ' 1 ' ' ! ■■!■■ •! I .111 I Uo8 AMKIiJCAX TEXT-HOOK OF OliSTF/fniVS. tumor alxivo tlio pulios (Fiir. 41 1). Tlio foiiditioii of tlio broasts and ni|)j)l(v and the aiuouiit of milk secreted should be watched, especially diirinj; the first week. Daily inquiry should bo made with reference to the child — wiiether it nurses properly and shows sif^ns of tlirivinj;; the condition of th'; eyes, mouth, skin, the stump of the navel cord, or the und)ilical woiuid should lie learned, and whetiier the bladder and bowels are properly evacuated. It i: well for the first few days to know the rectal temperature. The nurse, if slic be capable, will keep a systematic record of the foregoing and other facts f<ir the doctor's insjiection at liis daily visits. Her observations ought to be taken at stated hours two or three times during the day, and recorded on suital)lc blanks. This is particularly important during the first week. After that time if all is normal a simpler record will suffice. After-pahis, if severe enough to de})rive the ])atient of sleep or to be exhausting, must b(! relieved. A grain or two of opium or an equivalent dose of morphin may be given, and be repeated once or twice subsequently if required. Since many women do not bear opium well, and as it is especial! v liable to injure the appetite and digestion, the object may usually be better accomplished by the use of chloral in doses of 20 or 30 grains. It may be given in water or in milk, by the mouth or by the rectum. Tiie coal- tar analgesics are effective, but their repeated use is open to the objection that they lessen the strength of the uterine contractions and consequently retard involution. Little harm will be done when but one or two doses nw required. Of these drugs, phenacetin, in doses of 5 grains, is to be prefei-red to acetanilid or to antii)yrin, as it has a less depressant effect. A.sep,sis. — ]\[()st imj)ortant is a rigid cleanliness of the external genitals of the patient, her linen, and the bed-linen. The vulvar dressings should be changed every three to six liotu's during the first two or three days, and at all times as often as much soiled. Each time the dressing is renewed the external genitals and their immediate surroundings are to be carefully (ileansed with soaj) and water, and finally washed with an antiseptic solution. A. convenient method of cleansing the vulva is by irrigation with a fountain syringe, the stream being projected against the })arts to be cleaned and its action assisted by gentle friction with ase|)tic fingers. A bed-pan in position beneath the buttocks receives the washings. If any fetor is perceptible, it nnist be assumed, as a rule, that the toilet of the ])atient has not been pro])erly cared for. If the passages have not been infected during the labor, external measures will be sufficient to keep the dis- charges sweet. Douching and all other interference within the passages are U> Ije strictly avoided in normal cases. If the discharges become fetid notwilli- standing proper external precautions, an antiseptic vaginal douche should lie given two or three times daily or often enough to suppress all ])utrid odor. The approaches must first be rendered aseptic: the douche-tube, sterilized l>y boiling, is introduced for only 1 or 2 inches, with care to avoid abradin*; the mucous surfaces. ^Mercurials shoidd not be used for the purj)ose, owiiiu^ J/AXAChMhWT OF TIIK IT EL'I'FJil LM. (JO!) to the (laiififer of inoroiirial iiitoxifjitiijii. A 1.5-voliiino solution of liydrogen •lioxiil, in full .strength or diluted with tiircc or four volumes of water, or Labarraque's solution in water (1 : 0), is suitable. It is unneeessarv to say that otlier soiled portions of the body should be cleansed as often as soiled, and no blood-stained linen should be permitted to remain about the ])atient or the bed. The lying-in woman perspires actively , hence her .skin ought to be frequently cleansed by sponging with tepid water or with water and alcohol. This bath should be followed by gentle frietii)n with a towel until a warm glow is j)ro- duced. Cleanliness of the bed is pmmoted by the use t)f a draw-sheet, which consists of a common bed-sheet folded to foiu' thicknesses, it is placed upon the bed beneath the patient's hips, and is changed as often as soiled. Vnitihttion. — The atmosphere of the lying-in room nnist as nearly as pos- ible be Air should be admitted as freelv b d. Slide oe pure. Air snould l)e admitteil as ireely Dy open windows as is con- sistent with a proper temperature of the apartment. As the air is constantly vitiated, so the ventilation, to be effective, must be continuous. Light is essen- tial to the healthfulness and cheerfulness of the lying-in chamber. The practice of darkening the room, exce[)t when temporarily necessary to promote sleep, is irrational and has justly become obsolete. Even the full sunlight may be admitted, provided the child's eyes are properly protected. For the first few weeks the eyes of the new-born infant should be shielded from strong light from whatever source. Diet. — The diet for the first twenty-four hours is to be restricted, as a rule, to liquids. In most cases even liquid food is to be withheld until the patient has had a few hours' rest. After the use of anesthetics no nourishment will 1)0 borne until she has recovered from the effect of the anesthetic. Excep- tionally, when the labor has been an easy one without anesthesia, a little warm liquid nourishment, such as clear soup, bouillon, gruel, or cocoa and milk, may be allowed, if the patient requests it, directly after the close of lal)or. On the second day soft-boiled eggs, boiled custards, panadas, and similar easily-digested semi-solid foods are suitable. From this time on a moderately full diet is generally to be recommended. The dietary, however, must be varied to suit the needs of the individual case. As liberal a diet as tiio ])atient can digest is essential to the normal progress of convalescence and to tlic proper quantity and quality of the inilk-secretion in ntirsing women. Retention of Urine. — The enfeebled control dver the bladder in the first lidiirs after delivery frequently leads to retention of urine. Tiiis is esj)ecially liable to occur from the added effect of refiex disturbance when the jierincum Ikis been sutured. Owing to the copious secretion of urine, which is common at this time, painful and injurious distention of the bladder often results. Xot only may serious injury thus be done to the bladder, l)Ut uterine hem- iirrliage after delivery is liable also to occur from ovcr-distcntion of this vise us. The patient must be warned, therefore, of the importance of passing lur urine within six or eight hours following the close of labor and at similar intervals thereafter. The difficulty of urination dei)ends partly upon the rrcuiiilx'nt position, and it may frecjuently i>e overcome, therefore, by allowing 1 ^ p sip 1 y ■'■.J( 1^ ■rrfT ji ,' 1 1 If 'iH I ■■•' <;<)(> A.v/:/i'f('A\ Ti:xT-iiooK or onsTF/nucs. the jiatit'iit to assiiini! a sittiiij^ or lialt-sittiiif^ posture (liirin<^ attempts at niietiiritioii. Tlie soiiiul of rimnin<^ water, warm fomentations over tlic meatus urctlirju, and moderate pressure ap{)lied with tiie hand over the supnt- puhie rej^'ion are iisetul aids, and are frecpiently eil'eetive even in tlie reelininjj; ])osition. The eatheter should l)e withheld as a last resort, owinj:; to the dan^^cr ol' settiiij^ up a more or less intense eatarrh of the vesieal neek from infeetidiis material earried on the instrument. The nmeosa of the lower portion of the bladder is liable to lu; bruised and fissured duriuj^ labor, and its resistiiii:; power thereby imjjaired. In rare cases the ureters and the ])elvis of liic kidneys may b(! invaded by tiie septic process which frequently takes its orijfin from catheterization. Unc of the Catheter. — When catheterization is unavoidable, every iirc- caution nuist be used to prevent inlection of the bladder. The soft-rubbci' instrument, which is least liable to do nieclianical violence to the vesicnl mucous membrane, is generally the most suitable catheter for use by the mu'se. The Kelly or other glass catheter, which consists of a short glass tube with a foot or two of rubber tubing attached, has the advantage that it ]>rcsents a perfectly smooth ])olislied surface, and causes, therefore, a mininniiu amount of urethral irritation, lioiling in water for ten minutes inunediatciv belbre using the instrument renders it aseptic. It is jierhaps needless to say that after boiling the catheter is to be handled only with hands that have been carefully sterilized. The instrument must never be ]>asscd blindly by the sense of touch alone. AVith the i)atient in the dorsal position and the thighs separated, the labia •should l)e held well apart, either by the patient herself or by an assistant, so as to exj)ose fidly the meatus urethrte to view until the eatheter is introduced. The vestibule and labia are then to be cleansed with soap and water and washed with a suitabU; antiseptic. The catheter, well lubricated with vaselin previously sterilized by heat, is then passed — only far enough barely to enter the bladder — until the urine begins to flow. Care should be taken on with- drawing the instrinnent that no urine be permitted to trickle into the vagina or ov(>r the vulvar wounds. If the ))arts accid(.'iitally become soiled, tiny should l)e cleansed by ])ressing them with a clean damp cloth. The catheter is to be washed carefully with soaj) and water and rinsed with clear water after using. The bladder should be emptied at the same intervals as in vol- mitary urination. Ju-((ci((if!(»i of the Jioirelti. — It is a long-established custom to open the bowels on the third day. There an; good reasons for adopting the practice, now so generally followed after abdominal section, of evacuating the bowt'ls soon after labor, not later than thirty-six hours. The most suitable measure is a mild saline laxative. An eligible saline for the purpose is the solution of citrate of magnesiinu (lifiuor magnesii citratis). The action of the bowcis may, if necessary, be assisted by a rectal injection of warm water or of sweet oil. llsefid stimidating enemata, if required, arc salt water, soap and wali r, a drachm or two of undiluted glycerin, or one or two oimees of a satiu'atrii ittcmiits !it s over till' • tlio supra- ic nH'liiiiii;j; • tlio (liui<ii'r 11 infoctiim-; rtioii of tilt' its resist i I iii; 'Ivis ut' till' Iv takes its cvorv prc- ! solt-nilihi'i' - tlio vesical use by tlic I short ^-lass uitage that it , a niiniiiiiim immediately edless to say lat have been - toueh ah)iie. ted, the labia 1 assistant, >o is introduced, id water and with vaselin [irely to enter Ikeii on with- u the vaji;in!i soiled, they The catheter 1 clear water als as in vol- to open the the practice, lo- the bowels lable measuiv tin; sohitiiiii pr the bowels Ir or of sweet Ip and water. If a siiturated .i/.i.v.u//;.i//;.V7' o/' the I'Veiu'ERhm. oui ihition of Kpsom salts. Tiie bowels should l)o oiH.'iied daily after the first day. Lacfatimi. — In the interests of i)oth herself and her infant the mother niijrlit, as a rule, to nurse her own child. In certain conditions, however, this may be inadvi.sd)lo or even impossible. Syphilis contracted late in pre;riiaiicy and tuberculosis are coiitra-iiidications to maternal nursinjr, owinj; to thedanjijer of infectinj; the child. Rarely, suel<lin<r may be impracticable by reason of inversion of the nipples, or may have to be discontinued in consctpicnce of (■\eoriation and j)ersistent sensitiveness of these organs. Sometimes the mother's milk is deficient in quality or in (piantity. In marked jieneral debility from whatever cause niu'sing would be injurious to both mother and child. The early application of the child to the breast promotes tlu; uterine con- tractions; it is particularly advi.sable when the uterus remains relaxed after labor. As a I'ule, the child is put to the breast only after the mother has rested, after six or eight hours. It should be nursed once in four hours during the first few days until the mammary function is established. Usually the child will thus have learned to nurse before the onset of the true milk-secretion, and the danger of painful engorgement of the breasts will be diminished. Uejrnlaritv in nursing is as essential to the interests of the mother as to tlio.se of the child. The nipple is injured by prohttiged and fre(|uent macera- tion. The milk becomes concentrated by ()ver-fre([uent suckling, thin and dilute when the intervals are too prolonged. For this reason the child should not be permitted to sleej) in the same bed with its mother : it should lie in a crib by itself. The healthy condition of the nipples will he promoted by carefully cleansing and drying them after the child has ninsed. A .sitnrated solution of boric acid is a simple and efrective lotion fiir the purpose. If they are ilisposcd to crack, it is usefid to anoint the nipples with fresh cacao-butter after cleansing. During the fir.st few days of lactation the breasts frequently become painfully swollen. Painful iiidura- tidii of the glands in the absence of inflammation is relieved by gentle nia.s- saii'e, stroking the breasts outward from the base toward the ni|)pl( . This manipulation is best practi.sed immediately before putting the child to the breast. Distention from over-free secretion is relieved by saline cathartics, liv abstention from litpiids, and by the use of a compression breast-bandage. .All easily improvised binder is the ]\Iur|)liy binder. It is made of a straight piece of muslin, with a shallow notch cut in one edge for the neck and a deep iiotcii for each arm ( Fig. 412). The bandage is closely applied over the breasts, the ends being pinned in front (I'l. 27, Fig. 2). Not infrc' ".ently, especially in debilitated women, the supply of milk is iiisiillieient. Phe most reliable evidence of defective lactation is alforde<l by tlie signs Oi" inanition in the child. If the infant ceases to gain in weight or if the weeklv gain falls short of the normal, in the absence of disease it is to be as-;iinied that the (piantity or the (piality of the mother's milk is at fiiiilt. In iiuiny cases it is ])ossil»le to do soiiiethiiig to improve the character and to increase the quantity of the l)n>ast-milk by attention to hygienic measures. IP w / ^ -O^- A u -,%. ^, ^^^''^-^k o .*'*^.^« IMAGE EVALUATION TEST TARGET (MT-3) 1.0 ^1^ 1^ ^ lii |2.2 I.I I us Hi m 1.25 III 1.4 1.6 < 6" ► ss / Photographic Sciences Corporation 23 WIST MAIN STRtET WEK&VeK, i^i V MS SO (716)872-4503 <^ '^ ^ o^ I 6()2 AMERICAN TEXT-nOOK OE OHSTETRICS. rii lif^n )' tl The l)est galacta^o^iies are tonics, a generous diet, including the use of ni!'k, and attention to the habits and liygienie surroundings of the mother. Precaii- Fi<i. 412.— MndllU'd Mur|)liy hreast-binder (cut on the dotted lines). tions must be taken, however, again.'it over-foe<ling and consequent derange- ment of tlie digestive organs. Tiie chiily a])])lication of a mild faradic current through the breast.s, it is claimeil, acts to stimulate the mammary function,^. In the writer's exjierience tiie sulphate of strychnin in doses of from -^^f to -^(^ of a grain, three times daily, has apparently done good service, probably more by its general tonic effect than by any specific influence. When, owing to the death of the child or for other reasons, it becomes necessary to dry up the milk, a purely expectant treatment usually answers. The patient, however, generally suffers more or less pain in the breasts for two or three days. Her comfort is promoted and the disap|)earance of lactation is more rapid with the use of tlic compression binder. Daily applications of the oleate of atropia are of groat value for the relief of pain and for their specific effect in drying up the secre- tions. Restriction of liquids and the use of a saline cathartic also help. The iodid of potassium in 15-grain doses repeated two or three times daily exer- cises a remarkable influence in diminishing the flow of milk. Tardy Involution. — When in the daily examination of the uterus it is found that involution is not ])rogressing normally, measures should be used to accel- erate the j)rocess. Friction applied two or three times daily is useful for thi.s purpose. The nurse lays the hand flat upon the alxlomen over the uterus, and moves the abdominal walls in a circular direction over the anterior surface of the uterus, precisely as is done for stimulating uterine contractions in tlic third stage of labor. This procedure should Ik) conducted gently, so as to give no pain, and it may l)e continued for ten minutes at each sitting. Fara- dism or galvanism is useful for hastening involution. A mild faradic cur- rent may be used ten or fifteen minutes daily, or a smooth galvanic current of ten to twenty milliam|)6res may l)e employed for the same length of tiinc. One electrode is placed over the upper part of the sar uni and the other on the abdomen over the uterus. A hot vaginal douche once or twice daily is an agent of value for ])romoting involution. The temperature of the water should be about 115° F., and the quantity useil not less than two or tliicc gallons. Ergot in doses of a grain of the solid extract or its equivalent three times daily may be given with benefit. Sometimes the cause of the retardul involution is a septic condition of the endometrium. The remedy in siieli MANAGEMENT OF THE PUEPPEJi/UM. em use oi ni'.'U ler. Prwau 4' 1 '•. ^ \ \ * cases is a thorough currotting of the uterine cavity. An iodoform-gauze drain may be left in the uterus after curretting. The gauze should be reiuove<l in three or four days, sooner in case of fetid lochial discharges. Special Directions. — Few women, particularly of the better classes, ap- |)roach labor in the full vigor of health. The pressure-effects of the later weeks of pregnancy, the impaired nutrition, the loss of exercise, and the mental anxiety which are common at this period, all conduce to enfeeble the physical powers. When to these conditions are added the exhausting effects of lal)(»r, it is not surprising that childbirth is frefpicntly followed by more or less debility, even in the absence of complications. Restorative measures, there- fore, usually constitute an important part of the management of convalescf nee. Tiie necessity for plenty of sleep and a proper diet has already been alluded to. In addition to this the use of tonics is often of signal service. In anemia one of the proto-salts of iron may he given for several weeks. The- ]{laud pill is a popular and valuable hematinic. The arsenate of iron is especially efficacious in the treatment of anemia in puerperal women. Atten- tion shoidd be paid to the condition of the digestive organs, and the amount and character of the patient's food should be regulated. If the apjietite is poor, a bitter tonic may be prescribetl. An eligible mixture for the purpose is the elixir of calisaya with strychnin ; sij of the former and gr. ^ of the latter may be given three times daily. A good general tonic is citrate of iron and quinin with strychnin or nux vomica. A drachm of the double citrate with a grain of strychnin may be prescribed in a four-ounce mixture, with directions to take a teaspoonful three times a day ; or 2 grains of the citrate with one-third grain of extractum nucis vomica; may he administered in pill form with the same frequency. Special attention should be given to the condition of the pelvic organs during the post-partum month. For the first ten days the daily examination of the uterus by the alxlominal touch Avill enable the physician to observe the progress of involution. After that time the position and size of the uterus c'liinot readily be determined by abdominal examination. It is generally advisable, even in private practice, to make a bimanual examination during the third or fourth week with si>ecial reference to the shaj)e and position of till' uterus. In hospitals it is the rule to explore the pelvic contents shortly iK'fore the patient's discharge. If the uterus be retrovertetl, it should be rcposited, and be held in place by a suitable pessary. Often persistent retro- version may thus be preventetl. The pessary may be disusetl after two (»r tlu-oc months. Undue persistence of the ret! flow or an abnormally open cervix is generally to be taken as evidence of endometritis. For the treat- iiu'iit of this condition applications within the uterus of tincture of iodin or iodized phenol (carbolic acid and tincture of iodin equal parts) at intervals of a few days are useful. Most effectual is a currettage with drainage of the uterine cavity with iotloform gauze. This procedure should be conductetl with strict antiseptic precautions. The gauze is to be removed in from three to five days. 7i ( V-.-i^.i-r i '• ^^^Kt f ■■'■ ■, . , ' 1 1 ' ' ] 11 'i .' 3 i!!l i; • i I C(>4 AMKItlCAX TEXT- BOOK OF OliSTETRICS. litynlutioti of the Lyiufi-in. — Tlic loiigth of time which it is desirable that the wotnaii shoiihl ho kept at rest after hibor will obviously vary with tlio rate of uterine involution and with the general progress of eonvaleseence. During the first week she ought not to leave her bed. Ordinarily she may be all()\ve<l to rise partly or fidly into a sitting posture during micturition. This often obviates the necessity for using the catheter in patients who have difficulty in passing water in the reclining posture. It also favors the expul- sion of vaginal blood-clots, and alter the first six or eight hours does not, as some writers have asserted, expose the patient to displacement of thrombi or to hemorrhage. Tliroughout the second week the patient ought to maintain for the most part the recumbent position, though she need not be confined iu bed. She may for a ]>art of the day be removed to a lounge or may lie upon the outside of the bed, and may sit erect when taking her meals. During the third week a large portion of each day may be spent in a chair. The ])afient, however, shoidd not, as a rule, be allowed on her feet. In the fourth week she can have the liberty of the room, and at the end of the j)uer- pcral month, if all goes well, may be permitted to leave her room. It is advisable, however, that she should not fully resume her usual duties for two or three weeks. Caim-; ok Tin-; Nkw-uoux Infant. Innnediately after birth of the head the child's face should, when opportun- ity permits, be bathed with warm water, the eyes cleansed and carefully dried. Tliis is done as a ])rophylacti(! against ophthalmia. As a still further preven- tive, within an hoiu' after birth a drop of ('rede's solution (a 2 per cent, soln- tion of nitrate of silver) should be instilled into the conjunctival .sacs of eaeli eye. The latter precaution, when properly exetuited, is absolutely protective. No permanent injury is d(»ne to the delicate structures, and the serous oozino wliicii fre(|uently results subsides within a few days. Should it be excessive, it may be promptly controlled l>y a single application of a drop or two of a | per cent, solution of the sulphate of atropin. The ligation of the fiuiis and the dressing of the stump have been already cousideretl. Usually respiration is promptly established at birth, partly l»y the air-hunger developed by interruption of the utero-plaeental eirculatinii. and partly by the reflex effect of the contact of cool air with the moist sni- laces of the body. When the new-born infant does not breathe properly soim after birth, means should be employed to seciu'e the full expansion of the lungs. Useful measures for this purpose are blowing forcibly upon the face, dashing a few drops of cold water up(,u the chest or the face, or gently slap- ping the buttocks with the hand or with the end of a wet towel. These elforts shoidd be continued until the child cries lustily. When respiration is obstructed by mucus in the throat, the offending material may be removed by the finger wrapped with a soft rag. Still better for the purpose is a soft-rubber tube with a bidb attached. The tube is passed deeply in the j)harynx and suctimi applied by means of the bidb. Two or three repetitions of this process will MAXAf:i:}fi:xT of the prKUi'F.imwf. GC,-) usually serve to clear the throat of the ohstructiiig niucus. Susix'ndiii}? the child by the ieet facilitates drainage of liquids Irom the air-passages. The tieatineiit of asphyxia does not fall within the seojw of this section. Care must be used to protect the child against injurious chilling. It must not be forgotten that an abrupt transition has taken place from a temj)erature of about 100° F. to one nearly or (piitc thirty degrees lower, and harm wa\ be (lone by prolonged exposure. The child, therefore, is to be wrappctl carefully ill flannels, and as soon as the cord is cut it should Ik* laid in a warm place until the necessary attentions to the mother are compIctcMl. The head while moist should be covere<l as well as the trunk and limbs. The stump of the navel cord ought to be inspected occasionally, to see that it does not bleeil Irom loosening of the ligature as the stiunp shrinks. After the principal duties to the mother have been disposed of, the obstetrician examines the child tor possible faults of development and for injuries during birth. The weight and length of tlu* new-born child and the ]>riucipal measurements of the head are niattei-s of scientiflc interest : the weight especially ought to be noted for comparison with the results of subsetpient weighings as a means of (leterinining whether mitrition is going cm properly. A small and awurate spring balance, therefore, may well be a part ol' tlu; obstetrician's outfit. A ^^(•hidtze pelvimeter or other simple calipers is a suitable instrument for meas- uring the head. It is well to direct the nurse to administer to the child, within a few hours alter birth, a rectal injection of a tablespoonful of warm water ibr the ])iu'])ose of determining the ])resence or the absence of atresia ani. If the rectum be impervious, the water retiwns as last as injected. Should no incconimn be passal within a few hoiu's, the physician must ex|)lore the lower bowel for possible occiusion. The nurse is also to observe whether tlic child urinates as evidence that the urethra is pervious. Failure to pass urine for several hoiu's, however, need not excit(! alarm. The bhuhler is usually emptied in course of the birth, and but little in'ine is secreted until the child begins to nurse. Atresia of the urethra is much los i"re(|uently met with than that of the rectum; it is, in fact, extremely rare. Usefid informa- tion may sometimes be attbrdod by taking the temperature per rectum. The notion that the new-born infant should be placed upon its right side to favor the closiu'c of the foramen ovale has no foundation in fact. It may lie iiidif- Icrcntly upon the back or upon either side, changing its position occasionally. Bnlh'inf). — The first bath, if the child be robust, may be given soon after it is separated from its mother. Jji case of feeble children the ftdl bath should he ])ostponed for several days. In the latter, iinuu'tions of sweet oil, vaselin, or fresh cacao-butter are to be substituted for the general bathing. As a pre- liminary to the first cleansing the skin is to be well rubbed with sweet oil or similar fatty material to facilitate the subsequent removal of the vernix oiseosa. TJK! temperature of the water should be !)H° F. The regidation of the tein- |)(raturc nnist not be trusted to the hand. A bath-tliernKinieter should be used. While the temperature ought not to I'all below 'J8° F., it must not I t/1 i^iri '^V-'^jS^ '^rt. m GGG A.yrKiiicAX TExr-iiOOK OF oiisiKrnics. nuu^h excoofl that |K)int, owing to the danger that too high a temperature iii:u- inthice trismus. As a safeguard against injurious chilling the nurse should U- taught to bathe the child by inunersion. An infant's bath-tub is the most convenient vessel. The head is first to be wet, and the Ixnly is then gradually lowercnl into the water to the neck. The head is supported above the water hv the ntu'se's hand. Sea-sponges should Im) replaced by soft cheese-cloth servi- ettes, which can Im; destroyed after once using, or if usetl again should first lie boiled. Care njust be taken that the soap used is bland and non-irritatiiio. Most suitable is white castile or a glycerin soap; nor should even this he usi^d too freely. The skin, too, of the new-born infant is easily injured by much friction. More harm than go(Hl will often l)e done by too great thoroughness in the first bathings. The duration of the bath ought not to exceed five minutes. On rem()val from the water the child's bcwly is quickly dritnl by wrapping in a large soft towel. Little or no friction is permissible for the first week or more. The scalp and the ears must be dried ciu'cfully. The full bath may be re|)eated daily in warm weather, and three times weekly in the colder m«)nths. Soiled portions of the IxMly, however, should be cleansed as often as soiled. Especial attention is to be direetetl to keeping the scalp clean. The l)est time for the bath is a morning hour, midway between fee<lings. If the bath is repeatetl before the renniant of the cord falls oif, care must i)c taken to dry thoroughly and to re-dress the stunij) with dry borated cotton aft<'r each bath. It is usually better to omit the daily immersion of the child in water until the funic stump separates. Daily sponging with water or inunc- tions of sweet oil may be praciised instead. After the navel stump conies away the umbilical wound is to ho drie<l with care after each bath to prevent abrasions, and then to be sprinkled with boric acid, bismuth powder, or finely- powdered oxid of zinc. Should any fetor develop before the cord separates or while the wound is healing, the parts after bathing should be disinfected with the peroxid of hydrogen or other suitable disinfectant and dried befoio re-<hvssing. After one or two weeks genth? friction with the hand may In- used to promote reaction after bathing. For vigorous and healthy infants tlic temperature of the bath may be lowered gradually to 90° F. by the age dt' six months. Infant jwwders are not, as a rule, to be advised. Shoidd any irritation develop in the folds of the skin, a finely-powderetl talc or a powder eonsistiiiij of equal parts of oxid of zinc and lycopodium may be employed. It is well to cleanse the mouth gently with pure water after each nui-sing. Oofliinf/. — It is desirable that the infant's clothing be loose, with few or no pins or buttons, and capable of being easily changed. The clothing should also permit reasonable freedom of motion for the limbs. It is unnecessarv to say that all parts of the body except the head ought to be proteetcti equally. The outfit describetl below is a simple and suitable method ol' dress for the first six months. The belly-band, which should be of the lightest material, is to be discarcicHl after the umbilical wound has healed. It is used merely for the retention ot' MAXAUEMKXT OF THE PCKIiPKIilUM. 6r,7 I lie navel dressing, luul it serves no useful |>urp()so alter the navel has healed. It is a mistake to suppose that a tight abdominal bandage helps to prevent Hinbilieal protrusion. On the contrary, by increasing the iutra-ab<lominal jjfcssure, it has the opposite; efi'eet. The belly-binder, therefore, like the rest lit" tlie child's clothing, ought to be loose enough to admit easily two or three lingers underneath it. The customary triangular napkin may be of muslin or of linen diaper. A single safety-})in here is all that need he used in the ell. tiling. Napkin-covers of rubber, wiiich are obviously insanitary, should never be tolerated. The clothing proper consists of an undersiiirt and two (bosses. The undershirt sixmld 1m' made of the softest Hamiel, without sleeves ;m<l opening in front. Next is a fine flannel dress with high neck and long sleeves, cut (\ la prhiceHHc, and about 25 inches in length ; tiiis, too, opens in front. Over all is a muslin slip of a pattern similar to tiie flannel dress. The l('(>t and legs are to be prottx-ted with woollen socks reaching to the knees. Tlie undershirt and dresses may be fastened with tapes. All clothing shoidd he laundered before using, and should be changed daily. At night the muslin .111(1 flannel slips may be replaced by a suitable night-dress. The weight of these garments is to be adjusted to the reijuirements of the season. XitrKiuf/. — As a rule, when the mother's nipples are of normal size and wc^ll formed the fully-developed and healthy child instinctively suckles wIumi first placed to the breast. Not infrequently the new-born infant does not take the nipple willingly, particularly if the nipples are small or nn'sshapcn or the cliild is jiuny or feeble. Much trouble nuiy be saveil by teaching the child to nurse before the breasts become engorged. Patience and tact will usually ensure success. Wetting the nip])le with a few drops of milk squeezed from the breast, or with a little sugar and water, before aj)plying the child may be tried if necessary to induce it to nurse. The infant should be put to the breast as soon as the mother has rested, usually within six or eight hours after birth, and should nurse once in four hours until the milk-secretion is established. Subsecpiently the average interval is once in two hours. The intervals should be lengthened, as a rule, to three hours by the end of the third month, and thus continued until the sixth. About six hours shoidd be allowed, however, between the last nursing at night and the flrst in the morning. From ten to twenty minutes is enough for each nursing. As the child usually falls asleep easily after its meal, it is well, if necessary, to wake it on the hour. Regidarity of feeding is of the utmost importance in the interest of good digestion and ])roper nutrition, and the habit should be established early. It is generally best to apply the child to b(jth breasts at each nursing. Regurgitation of food soon after feeding is usually to be taken as evidence that the stomach is overfllled. For the first two or three days after birth the child gets but little nourishment from the breasts, but it nee<ls little. Should it become restless and fretfid from hiujger during this time, an occasional teaspoonful of plain water, |)reviously boiled, will often serve to quiet its cravings. Cow's milk diluted with two volumes of water, and prepared in the maimer usually practistnl for infant feeding, 'i / i I, Id !!■ ^ I 1 608 AMFJilCAX TKXT-UOOK OF OliSTKTIilCS. may he jrivcii in qiiantitios aiuountiiig to oiio or two ounces daily ; but a cliild that is f'ttl (Iocs nctt so roailily take the breast, an<l hand-feeiling is tiierednv not, as a rule, advisable if the child is to 1k' nursed. The b<'st evidence dl' proper nutrition is a projjjressive gain in weight. It is a gcKnl practice to weigh the child weekly. Since a loss of several ounces usually takes place during the tirst few days after birth, the child docs well if at the end of tlic wc'k it has regaincil its birth-weight. After the tirst week, in normal condi- tions, its weekly gain tor the first five months shouUl not fall below five ounces. \Vet-)iu)'ttivff. — When for any reason maternal nursing fails or must be dis- continued, the best substitute for the mother's breast is that of a suitable wi t- nurse. The greatest care nnist Imj exercised in her selection. The best age is between twenty and thirty-five years. A multipara, or at least a woman wIk* has had some experience in nursing, is to be preferred. It is desirable that the nurse's child be of about the same age as that to be nui-sed. A difference of a month, however, is unimportant, especially if the foster-child be tlic younger. A menstruating woman is sometimes undesirable, particularly if the flow be proltmged or be copious. Her breasts should be well formed, and should promptly refill after nursing. The nipples should be sound and bo well developed. Women whose breasts are of a conical sha|)e and not too large usually make the best nurses. The best evidence of the amount and quality of the nurse's milk is to be f(»und in the way her own child thrives. In case of doubt a chemical examination of the nulk may be made. It is nnneccssarv to say that sound health is indispensable. In addition to the direct examina- tion, useful information may be gained on this point by consulting the ])hysi- cian who attended the woman in her confinement. Any serious impairment of her general health will usually disqualify — tuberculosis or syphilis always. Even after she is established in her new office her health and habits must ho looked to and the child be watched to see that it thrives. Artificial Fccdinr/. — While there is no substitute which fully equals the natural food of the new-born infant, yet many children thrive on artificial foods : success in most cases is possible, however, only at the expense of nnicli care and skill in the management of the feeding. The first requisite in a substitute food is the closest possible approximation to breast-milk — 1. In its physical and chemical properties; and 2. In its freedom from bacterial organisms and the effects and products of bacterial life. The first condition is approximately fulfilled by preparations of cow's milk with such modifications as are indicated by analyses of human milk ; tlio second, by proper supervision of the primal milk-supply and by the further aid of sterilization. A defect in substitute foods prepared from cow's milk that cannot easily be obviated lies in the difference between the chemical character of its ca^'iii and that of breast-milk. The casein is somewhat more difficult of digostimi than that of the human milk. The former coagulates in hard masses, while jrAXAa/:Mi:xT or the pvi:iii*i:iiirM. GGi) tlic latter forms fine soft ciirils. This tlillicnlty is partially overcome by simple dilution. But the addition of water to the point necessary to render tlie casein easily dij^cstible results in a food very deficient in fat and snji;ar. riidiluted cow's milk, predifjested, is open to the objection that it docs not ivpresent the proportions of albuminoids, fat, and sujjar tbund in breast-milk. Moreover, feeiling with predijjjcsted food is unfavorable' to die development of the child's dijjestivc powers, and its uses are therefore limited. Human milk contains from 1 to 2 per cent, of albuminoids, from 3 to 4 per cent, of fat, and from (5 to 7 per cent, of sujjar. In cow's milk the pro- |)iirtion of each of these ingredients is, in round numbers, 4 per cent. It will be seen by these figures that the reconstruction of the; animal product r('(|uires a slight increase in the prtiportion of milk-sugar and a reduction in that of the albuminoids. Simple dilution is clearly not enough, since the addition of water to the point necessary to re<luce the allniminoids to the n'(iiiired proportion yields a jmiduct which is extremely poor in fat and sugar, and entirely inadequate, therefore, for the proper nutrition of the infant. Of tlic various preparations of cow's milk, none more nearly meets the require- niciits than the Meigs mixture as modified by llotch. The analysis of this mixture when properly ]>repared yields the prt)portions of albumin, fat, and sugar found in breast-milk. The formula for the Kotch-Meigs mixture is as follows : Cow's milk, mixed-herd milk, Cream, Water, previously boiled, Milk-sugar, Lime-water, 51.). 5>'j- 3vi gr. xlv, 5j.— M. To ensure the correct percentage of fat in the mixture it is necessary that the cream used in its preparation contain 20 per cent, of fat. Such a cream will 1)1' moderately thin. Ft is scarcely necessary to emphasize the importance of attention to the jjrimal milk-supply. For obvious reasons mixed milk from a Ik rd of cows is more likely to be of uniform quality than that of one cow. Much impurity is preventable by scrupulous cleanliness in milking and in tlic subsequent handling of the jiroduct. Attention to the health of the ani- mals is ((f ])riniary importance, and the sooner the milk is fed after milk- iiiir the i)etter is its condition, other things being equal. The milk-sugar ill the market is frequently unsuitable for use by reason of gross impurities, ("arc must be used to procure an article which has been fully purified by rccrystallization. Cream obtaineil bv the ordinary method of allowinir the milk to stand until th cream has risen has necessarily suiiered some degree of decomposition, fo be liad fresh, it must be separated from milk directly after milking by means of the centrifugal machine. Unfortunately, cream by the centrifugal process is in most localities not obtainable. For a i\'\\ years ])ast a milk lahoratory for the preparation of infant foo<l has been in successful operation ,:j Hi. , '•'-i-X^xWk II ')-\ «" l)^-tk » 4 1 n iU .if ivMf fcf! Kl ) 1. (J7() J.V/;/.7r.LV TKXTliOOK OF OBSTKTlilCS. ill Boston under tlio dircctioii «)f' I'rof. llotrli. llocontly a brunch laboratniv lias boc'ii cstablisluHl in New York. The iiiilk is obtained I'roin selected ani- mals, with sj)eeial eare in colleeting and handling:, and is delivere<l at the laboratory within a few hours after milking;. The ereani is obtained by the centrifugal separator. Milk mixtures are compounded on the physieian's prescription, with proportions of albuminoids, fat, and sugar to suit the needs of individual eases. This plan, which has l)een attended with signal succe>s, marks an im])ortaiit advance in the scientific feetling of infants. But these refinements in infant feeding are not always practicable, nor aic they in all cases indispensable to successful nutrition. In exceptional instances the new-born child thrives on cow's milk simply diluted with one volume ol" water to one or two volumes of milk. A lairly goo<l formula for a robust child is the following : Cow's milk, 5x. Water, previously boilefl, .?v. Milk-sugar, recrystallized and perfectly pure, 3vi, gr. xlv. Common salt, gr. viij. Lime-water, .?j. — M. Tiie defect in this mixture is that the proportion of the albumoids is too larce and that of fat too small. It usually requires further dilution for new-boni infants. If not well borne, a ])artial pretligestion may be practised fi)r tlio first two or three months by the addition to the foo<l, immediately before fcc*!- iiig, of \ grain of pancreatic extract and ^ grain of bicarbonate of sodium to each ounce of the mixture. The use of artificial aids to digestion, however, should be limited to such exigencies as cannot otherwise be met. The digestive powers, like other functions, suffer impairment by disuse. The addition of barley-water or oatmeal-water, gum-water, or similar admix- ture is adviscfl by some writers to promote the coagulation of the casein into soft fine curds. According t<i Ilotcli, carefully-conducted experiments show- that these attenuants act solely by reason of the water they contain. As Professor Rotch remarks, the natural food of the infant in the first twelve months of its life is a ]>urely animal food. This fact would seem a sui- ficient reason for excluding also all farinaceous materials from substitute foods during the first year. Condensed milks, like ordinary cow's milk, when diluted sufficiently to reduce the proportion of albumin to the required standard, must obviously yield a result which is deficient in fat, and, in the case of unsweetened prejia- rations, must be poor also in sugar. JJut this is not all. Analyses have sh(»\\ ii that nearly all brands of condensed milk lack primarily the due proportion ot' fat. With one or two exceptions they are made from milk from which a jxn- tion of the cream has first been removed. Moreover, the sweet brands are sweetened with cane-sugar, which is not an ingredient of natural milk, and is, furthermore, open to the objection that it is more likely than milk-sugar to favor butyric-acid fermentation. A condensed milk, however, to which no MAXAf{j:.vj:xr of the puEitPKituM. 671 h laboratniy selccttHl ani- ivcnnl at tlic aiiic<l by tlu' physician's <nit the uocils igiial sut'cc.-s, ['able, nor arc oiial instances ne volume nf for a robust r. xlv. 'J- \\. ids is too larjje for new-born ictised for tlio ly before fi'ctl- ? of sodium to ition, however, The digestive similar admix- Ithe casein into iriments show !ontain. it in the first Id seem a suf- iibstitute foods Isufficiently to Ust obviously ectene<l prepa- Ics have shown [proportion of which a jxn- tct brands arc milk, and is, |milk-sugar to to which no cine-sugar lias been atldetl, and which has been evajwrated at a low tcnipcr- atiirc, provided the pcr(!(>ntages of its nutritive constituents arc known, nu»y M rve as the basis from which to construct a pr(»pcr flxHl for infant feeding. Water, cream, and sugar-of-milk are to be adde<l in proportions which must l)(' d(!termined by the analysis of the particular brand of condenscil milk niiployed. In view of the progress that has Immmi made in the knowknlge of infant- l( eding, the use of proprietary fotnls for infants ought long since to have been aliiUidoncd. No less important than the proper adjustment of the principal nutritive iiigre<lients is freedom from disease-germs and the bacteria of putrefaction. Complete stcrilizatitm is possible by prolonged boiling. Milk boiletl for half an hour, and reboiled for the same length of time on the following day, will keep unchange<l for several weeks. E.\j)erience, however, has shown that under prolonged exposure to temperatures near the boiling-point certain clianges take place in the albuminoids of the milk by which its digestibility is greatly impairwi. To so great an extent is this true that many infants arc totally unable to subsist upon milk thus treated. Full sterilization of milk for infant feeding has, therefore, Ix'en |)ractically abandone<1. It is found that milk heated to 167° F. for twenty mini'.tes and promptly chilled by placing on ice remains practically sterile for twenty-four hours, and it is spared the injurious changes which take place at higher temperatures. This process is known as Padeurization. The Arnold steam-sterilizer affords a convenient means of Pasteurizing. If used with the cover removed, the st('ani-ehand)er being o|kmi, the temjwrature of the steam-chamber does not cxcwhI 170° F. The writer has found by experiments in the use of the Arnold steam- storilizer with a suitable gas stove that the water l)egins to boil at the end of two minutes after the gas is lighted. A four-ounce bottle of milk at an initial temperature of 70° F. in the open steam-chamber attains a temperature of 170° in just one hour. An exposure of about an hour and twenty mimitcs in tlic steam-chamber is therefore requiretl for Pasteurization. It is taken fi)r granted that further details of the ju'ocess require no description here. A simple substitute for Pasteurizing consists in rapidly raising the temperature of the milk for an instant to the boiling-point, then promptly chilling the milk. The capacity of the stomach in the infant at birth is approximately Y,Vir ♦''*' body-weight. The average quantity of food at each meal for the new-born child is, therefore, about one ounce. The average rate of increase is 1^ drachms per week for the first six months, subsequently somewhat less. The intervals between feedings should be about two hours at birth, and shoidd he increasetl gradually to three hours by the end of the third month. Thcs(! rules, however, will serve oidy for general guidance, and they must be ni(xli- fied to suit the needs of individual cases. Tiie food should be fed at a tempcr- atim; of 100° F. and directly from the sterilizing bottle. iin ■t'^^^i G72 AMHIUCAS Th\\'T-Ji(JOh' OF nliSTF/rii ICS. -f-U IV. PATIIOLOCJY OF THE PrERPK'UUM.* I. Injuries to the External Genital Organs following Labor. Tlio dilatation of the parturient canal an<l tlic pxpiilsion of the fetus ami tile plaeenta are almost always associated with nutre or less injury to the iii,i- ternid tissues. These injuries are usually in direct proportion to the resistance which tlic parts in question oiler to the passage of the fetus. They arc therefore, as a rule, greatest in priiniparte, and they may be absent in women that have rcpe;il- edly given birth. They are smallest in natural confinements — that is, in cases in which the forces of nature are sufficient to effect safe expulsion of the fetus iff; the proper time and manner — and they are greatest when a meclianical dispiw- portion between the fetal parts and the parts of the mother, or a iual|»<i>itiiiM of the fetus, or any of the lunnerous complications of lalnir, endangers <'itlicr the nu>thcr or the child, and calls for (vperativc interference ( instrumental «»r manual I on the part of the obstetrician. They are iiUcly to be especially great wlicn this ojH'rative interference bect)mes imperative at a time when the parturient canal is only incomi)letcly dilated. The most common of these injuries .ousist in contusions and tears of the vulva, the perineum, the vagina, and the neck of the uterus ; some of the rater accidents, such as lacerations of the body of the womb, inversion of the uterus, and injuries to the pelvic bones, have been described under Dysfocid. Injuries to the Vulva. — At times we find transverse lacerations of the vidva that involve the deeper tissues, perforating the nymplue and leaving them fenestrated for the rest of the patient's lite, or going completely through either labia minora or majora or both, and causing these structurv's to hang in shreds. Ti\e most frecpient accident to the vulva, however, consists in tcai- of the nuicous membrane, which are most numerous in the vestibulum and (ni the inner surfaces of the labia minora. Sometimes the tears are near the urethral orifice or they extend into it, and under these conditions will cause a burning pain during urination or will lead to retention of urine on account nt' the accompanying swelling. These injuries do not, as a rule, cause miieli hemorriiage, but at times they will do so, especially if one of the eonvolutinns of blood-vessels known as the hxfbs of the trxfibufe is involved. Trvaimcnt. — Superficial tears of the mucous mend)rane of the vulva will heal without much treatment. They should be kept clean and may be dusted with iodoform. All deeper lacerations and those followed by henu>rrhage are best closetl by fine silk sutures. Union by first intention takes place aliiidst invariably, and the stitches may be removed on the fourth or the fifth d:iy. When there is retention of urine it may become necessary to use the catheter * Tlie sup'rior fifjuros ( ' ) occurring througliout the text of this section refer to the bililinj,'- rapiiy given on page SO-1. ■'^.U, r H PATiioLoav OF Tin: I'ri'Jx'i'HmiM. ♦I7;l nil til th II ir swollllij; liiis siihsKlct ( )tt('ii I, liowcvcr, tilt' iKitii'iit will lu' t'lia l)l.-(l V\n. li;i.- I'rriiKiil Imcralidiis: A, liiciriit'oii I'XicncliiiK tllrlHl^;ll the siihimliT i. > iiitu tli" riM'tuiii, siilclics iMtnKliiciil tlimiiyli t<irii iimrnins "I' ri'<luin mid tlnniiHli ends uf s|iliiiiiti'r (m, icmly In \n- liid with till' knots in tlic rcctiini. 11, sutures in rccliil tear tied : rcinfnrci'i;,' stitch i;i piivsccl ilin.iinli cinls i.r s|ihiiii trr iiml iipin'iiriiiK at njiux nf rectal tear, ready tn he tied ; vaniniil Kutiircs also |iliiee(l. to iiriiiatt' s|)(»ntaiuM)iisly it' tlic vulva is wrll clcanffd with sonic warm antiseptic solution, and a bed-pan half filled with hot water or with hot ehanioinile tea is plaeed under the pelvis in siieh a niannei* that the vapor eoines in coiitaet with the swollen parts. Iryuries to the Perineum. — liiiptnres of the perineum eonstitiite the eoinnutnest injuries of lalior. In primipariK tlu! freniilnin tears almost always, and more extensive lacerations will oc- cur in at least one-third of the cases. In nnd- tipane the lacerations arc less frc(|iient and arc usually less forinidahlc ; they may he .ivoiiutl altoL:etlier in nine cases ont of ten. For practical purposes lacerations of the peri- neum are divided into lacerations ■ f the first, the second, and .!:c third dej^rce, accordinij to their extent. Whenever one-half of the peri- ueuiii is left uniiiinrcti, the laceration is one of the /(V.s7 dej^ree. When the tear extends farther back, even as far as the sphincter ani, but with- out iuvolvinj; that strnctiire, then there is a lac- eration of tlie nccond ile<free. The lacerations of the t/iird deforce, also called 43 riii. 11 1.- Vayinal and rectal su- tures tied: sutures pluied to rejiuir perineal hody. 674 AMEllIVAN TEXT-BOOK OF OBSTETRICS. "complete niptuns of the perineum," extend through the sphincter ani into tlie reetuni (Figs. 4i;j, 414). At times we meet with a hiceration of the peri- nenm that cannot be brought under either of these lieadings. We refer to the .so-called "central rupture," in which the anterior and the posterior boiuidarifs of the perineum remain uninjured, while the central portion becomes torn and j)erforated and may even afford passage to the fetus. In addition to the perineal lacerations Just enumerated, tears extending up one or both lateral sulci of the vagina (Fig. 415) are of very frequent occur- KJ f ':1'ii A B ■i- / W Jl 1 J^^^^Hfti. S^^^^^v' .. , '1- t! % 1 p J ^ S' J^ nJ %' 'iM M > \i If > 1 K m^ ^^^^^ ^■' ^ w^ , "*i mimL..^^^^ i M 0^ ^ : .j- ^m liP'j"aWPiiBifc\^M ■ ^mmmn^^m^ mm- '■^'■'^y'^M ^Im "IT- ^^kq f^i f C. V-'" ■ ' :.^ ^ W* L^ m '''M Fig. ■115.— Perineal liicerution.s : A, luceratiDii I'.xti'iKlint; up riKlit Ititerul sulcus. H, lucoratidii involviiin both lateral sulci. rencc, and the resulting injury to the levatores ani muscles destroys in varyiajj; <legree the subsequent usefulness of these structures as supports to the |)clvi(' viscera. Indeed, this typo of so-called "perineal laceration" is jjerhajjs of greatest importance, since it is the factor which more than any other deteriuines sul)se(pient relaxation and (consequent displacement of the pelvic organs. It should also be remembered that the integrity of the levatores ani mii.-iilc< may be destroyed by being over-stretched without a})parcnt laceration of tlit' Huperimposed vaginal tissues. (huscH. — In ])rimi])ar.'e with the best of can; and under perfectly noniKil conditions ruj)tures of the |)erineum cannot altogether be avoided. No matter how much softened an<l how yielding the parts become, the passage of the fetal head forces the vulvar ring so far open that in most cases there will be a giving way of tissue at the moment when the greatest diameter of the ciiild's head pa.sses this ring. Jn vertex presentations, v/ith rotation of the occiiml forward, this moment arrives after the greater fontanelle has appeared in Iroiit of the frenulum, the fetal head going through the pelvic outlet with its lesser I'ATHOLOaV OF THE PIIERPERIUM. (J75 lutoratitpu involvini; (il)liqiie (liamctcr. In iill other presentations the chances for rupture are very niiKth increased. They are greatest in face presentations, in whicli the chin has tu rotate forward and the head leaves the vulva in its greatest diameter, the trieater oblique. The causes of the rupture are also frequently found in the peculiarity of the maternal tissues. Small women with narrow vaginal open- iiiirs may give birth to good-sizetl children and escape with scarcely a scratch, till' parts possessing a wonderful elasticity ; while in other women perfectly liciiltliy, and having the parts of good dimensions and apparently quite clastic, the parts tear easily and extensively when the test comes. In still other cases the cimditions are such that we know beforehand that the elasticity of the parts is hc'low the average. This abseiujc of elasticity is usually found in elderly piiinipane, especially when they are above thirty-five years of age. Moreover, a protracted labor will make the perineum dry and unyielding, or it may cause ail edematous or inflammatory swelling, which in turn frustrates all efforts (111 the part of the obstetrician to avoid a ruptiu-e. A proper guarding of the perineum and a slow transit of the fetus through the pelvic outlet tend to avoid liieerations. Precipitate labors and labors without skilled assistance must there- tore increase the chances for such injuries. Si/ii)})fom,'f. — A burning pain is usually the only symptom that a lacerated perineum causes at the time of its occurrence. In some few eases there is free hemorrhage from torn blood-vessels, but these eases are exceptions, and the lileeding generally does not amount to more- than a free oozing of blood from tlu' raw surfaces. If left to themselves, most ruptures of the first and second (legnie will heal spontaneously ; the more extensive ones will heal by granula- tion and cicatrization, leaving the parts in an unyielding condition for subse- quent laliors. The ruptures of the third degree extending into the rectum and I'lii. 111!.— Cmnpletu proliiiisi' nf tliu uterus iiiiil viiniiial walls I'liUowiUK oxlousivo ami uiuiiiilt'il pi'riiu'al lacL-ratioii. those involving the levatores ani muscles seldom heal spontaneously. Tli(> later <niisequences of an ununited perinea, hueration are a gradual descension of the v:i<j,iiia and uterus, starting with [mdapsus of the anterior vaginal wall, and ulteii ending with complete inversion of the vagina and complete prolapsus of .:!a5!:i,li»K'-' m ■ \ '■■ i%: in| 1 ■: 1 'IK* ' i ' 676 AMERICAN TEXT-BOOK OF OBSTETRICS. the uterus, so that there is found in front of the pelvic outlet a large tumor, tl.,' covering of which is forniecl by the vaginal mucous membrane except at tln' apex, where the os uteri externum is visible. The body of the uterus is found inside this tumor (Fig. 416). In complete ruptures the impairment di" the sphincter ani makes it impossible for the patient to control the passage of gases and of litpiid fecal matter, and it renders her condition so miserable that she usually applies for a surgical restoration of the injured parts long bclinc a prolapsus has had time to develop. The principal danger, however, fnun lacerations of the perineum of any degree is found in the great liability they offer to septic infections of all kinds during the lying-in state. The lacerations form large raw surfaces which are ready to absorb and t(t carry into the system any infectious material that may be brought near them. Tims, infection from outside sources, such as may be communicatal by the hands or the instruments of physicians and nurses, will take place with greater facility and surety when the perineum is torn than if the materia peccans would have to reach the cervix uteri before it could find an easy entrance into tlio lymphatic and vascular systems. The experiments of Kehrer of Heidelberg have demonstrated that the lochial discharge of healthy puerperse contains pyrogenic and phlogogenic elements ; thus we find that lying-in women with perineal rupture have fever from absorption of the normal lochial discharge while passing over the raw wounds. This fever subsides as soon as healthy granulations spring up to form a living barrier against further absorption. It' the lochial flow becomes offensive from any cause, then its absorption will not produce simple elevation of temperature, but will be followed by puerperal septicemia with more or less local manifestations. Treatment. — The first object of the treatment of lacerations of the perineum must consist in trying to avert them, or where this not practicable at least to limit their extent so far as possible. Supporting the perineum at the time the head passes, securing the proper mechanism at the moment of its delivery, and, most important of all, resisting too rapid expulsion by forcibly retarding the expulsion of the head and by crowding the latter well against the under sur- face of the symphysis, will often avoid extensive laceration. The details of managing the birth of the head and the methods to be employed to avert serious injury to the pelvic floor have been described and illustrated on page 369. During the passage of the shoulders the support must be continued, for often the passage of the head causes just the smallest tear, perhaps extendiiiif (<nly through the frenulum, and, if the shoulders are carelessly allowed to pass, this tear may be increased to great dimensions. When the uterine contractions are so violent that they tend to force the fetal head out with great rapidity, they should be regulated by a hypodermatic injection of morphin, or, still better, by inhalations of chloroform. If a rup- ture of the perineum is apprehended, it is advisable to deliver in the lateral position (see illustration, p. 372). The passage of the head will be slower than in the dorsal jwsition, and the parturient woman can use less force in bearing down. The perineum can be more closely observal, and, in suitable eases, an ge tumor, tl.^' except at the the uterus is npairment of lie passage ut' luiserable tluit s long bei'orc liowever, IVoin great liability n state. T\w il to carry into them. Tims, V the hanils in- greater facility ins would have ranee into the of Heidelberg irperje contains in women with ichial discharge soon as healthy absorption. It' jrption will not d by puerperal if the perineum iable at least to at the time the ;s delivery, and, y retarding the the under siir- The details of ployed to avert istrated on page continued, lor •haps exten(lin;j; iUowed tt) pass, [id to force the la hypoderniiitic Irm. If a '"ip- |r in the lattMul be slower tlmn lirce in bcurins: liitable cases, an PATHOLOGY OF THE PLERPERIIM. 677 impending laceration may be avoided by the so-called "bilateral incisions" or ( |)isi()toniy, an operation described and illustrated on page 373 (see Fig. 202). Many a laceration of the perineum may tiuis be avoided, and a clean incised wound, which can easily be united by one or two sutures, is substituted for a torn wound, whose extent could not be foreseen. In eases in which the perineum appears rigid, warm moist applications (luring labor will help to soften the parts ; chloroform-inhalations carrieil to (oinplete anesthesia seem also to render the tissues more yielding. Where the delivery is accomplished by the aid of forceps, an impending rupture of the perineum may be avoided by taking off the instrument just before the greatest (liaineter of the child's head passes the pelvic outlet ; otherwise the instrument will lielp to augment the distention of the vulvar ring and will make a lacera- tidii more probable. If the forceps, however, is not removed, it should be used t(i hold the head back during expulsive efforts and thus permit gradual dilata- tion of the vaginal outlet. When these prophylactic measures fail to prevent a rupture of the perineum, it becomes the duty of the obstetrician to see that the injury is repaired in the manner previously described (page 379) and immediately after the completion ot' labor. No physician should attend a case of labor without carrying in his siitehel the necessary imjilements for suturing perineal lacerations. Complete lacerations are the only cases in which a good obstetrician may defer repairing the injury until he can obtain skilled assistance, yet it is desir- able that they should be attended to within twenty-four hours after delivery. The after-treatment is very simjile, and is usually limited to irrigations of the wound with an antiseptic wash and to keejiing the parts covered witii proper dressings, being caretiil, if the syringe-nozzle is introduced into the vagina, to avoid separating the surfaces of the wound that the sutures have a|)pntximated. The external or perineal sutures are removed between the fifth and tiie seventh day, while the vaginal and rectal sutiu'cs may be left in place a little longer. Treated in tlie way previously described, about 75 per eeiit. of lacerations of the perineum will heal by first intention. In some cases the union will be incomplete, and part of the defect will have to be made good by granulation. Sometimes the tissues of the vtdva are in such a bruised, swollen, and un- healthy condition that a union of the parts cannot be expected ; it is better in these cases not to attempt closing up by sutures. At other times, the parts having been sewed up, there develop symptoms of puerperal infection which make it necessary to reopen the wound ; as, for instance, when the lochial dis- ehar<;e has found its wav between the wound-edyres and is cnterinu: the svstem tlinmgh pockets which cannot be disinfected without laying the i)arts well open. Ill the latter cases the wound has to be frequently irrigated with antiseptic solutions, and the formatitm of granulations must be assisted as much as pos- siiile by the lavish use of powdered iodoform. Whenever the wound-surface looks unhealthy and is covered with a grayish coating (diphtheritic plaques), applications of the following dressing will be found of the greatest service : \ tl? v-A-m, / '■) ..'■ i- '%^U. 678 AMKRICAN TEXT- BOOK OF OBSTETRICS. ISf, Olci tcrcbinthiiiffi, Olei oliviB, Sig. Locally. 3iij. — M. Not only does the spirit of turpentine act as a good antiseptic agent and as a powerfnl ])romoter of granulations, bnt it also acts as a stimulant to thegoncral system, and its use is therefore perfectly safe even in those low conditions in which the free application of some one of the other antiseptic remedies mioht be fraught with danger. The mode of aj)plying the turpentine is simple. After the wound has been cleansed by irrigations, its edges are well separated by the hand and a flat layer of absorbent cotton soaked in the turpentine mix- ture is introduced between them. The dressing is renewed three or four times a day imtil the surface of the woimd is entirely covereil by granulations, when the ordinary treatment may be resumed. Iiyuries to the Vagina. — With deep perineal ruptures there is always more or less laceration of the posterior vaginal wall (see page 674), but tlieic are also found tears of the vagina ihat are not so connected. These injuries may be superficial, involving the mucous membrane only, or they may extend through the muscular coat of the vagina, laying open the pelvic cellular tissue or penetrating into the surrounding viscera. If the injury is located at llie upper portion of the posterior vaginal wall, the peritoneum may be exposed or the abdominal cavity may be opened. After protracted labors, especially when there is a narrow pelvis or a dis- proportionately large child, we sometimes find contusions of the vagina that later on cause sloughing of the raucous membrane, followeil by cicatrization and constriction of the entire vaginal canal. At other times circumscrihcd portions of the upper vagina have been contused to such a degree that in a very few days they become necrotic and lead to perforations of the wall. These injuries are particularly likely to happen when in a flat pelvis the letal head has for hours been wedged in between the symphysis pubis and the prom- ontory. The pressure-marks in the vagina correspond in such cases with sim- ilar marks on the fetal head (see Fig. 315, p. 513) ; they are of round or oval form, measuring from 1 to 2 centimeters (-| to f inch) in diameter, and, becom- ing gangrenous, ultimately produce vesico- vaginal or recto-vaginal fistuhe, as the case may be. At times we meet with submucous lacerations of the vaginal wall, resulting in the formation of more or less extensive hematoma. Causes. — A narrow and unyielding vagina, especiaii/ in primiparaj of ad- vanced age, will often be the cause of these injuries. A ra|)id passage of tlio fetal head, an over-distention of the parts by abnormal positions of the fetus, will also work in the same direction. Sometimes the vagina is rij)ped open hy undue sharpness and projection of the spines of the ischium or by abnormal excrescences of the pelvic bones. At other times the injury has been bromrlit about by splinters of fetal bones present during craniotomy or embryotomy. The most extensive laceration of the vagina ever observed by the writer was caused by the use of the forceps in unskilled hands. An elderly prim i|)ara was PArilOLOGY OF THE PUEIirKlillM. 679 (Iclivorecl by a midwife, who liad not only applied foreeps, but liad also sewed tip in the rudest manner an extensive perineal laeeration. The writer saw the patient four days after the operation, and found in the middle portion of the vagina, backward and to the left, a longitudinal gap through which could be ])assed the entire hand into a cavity filled with coagulated blood. Symptoms. — Injuries of the vagina do not at first cause nuich disturbance uidess there be a free hemorrhage ; in the rare cases in which the peritoneum has been injured, the symptoms of peritoneal irritation, such as pain and nausea, will not be missing. Frof/nosis. — Deep lacerations of the vagina are of grave importance. They allow the direct entrance of the lochial discharge into the cellular tissue, and are therefore very often followed by pelvic inflammation and by pelvic abscess. The contused wounds often cause extensive sloughing of the vaginal mucous mend)rane, and lead later on, by cicatrization, to a stricture of the vagina that may approach an occlusion. Necrosis of circumscribed regions of the vaginal wall lead, as already mentioned, to the formation of vaginal fistulse. A hematoma usually disappears without leaving bad effects, but at times its contents decompose and threaten the general system with septic infection. Superficial lacerations may heal spontaneously without causing any symp- toms, but more frequently they become infected by the lochial flow, and are changed into puerperal ulcers which cause more or less disturbance, and which finally heal by granulation, leaving in the vaginal wall a scar which in siibse- (|uont labors may prove the source of further trouble. Treatment. — Lacerations of the vaginal mucous membrane, if in any degree oxfcnsive, should always be united by sutures if recognized soon after their occiHTence, and they will usually heal by first intention. Penetrating wounds with escape of blood or of secretions into the cellular tissue are kept clean by frequent irrigations with antiseptic solutions, followed by packing the wound cavity with iodoform gauze. After severe contusions with unavoidable sloughing of the mucous membrane the patient can often be kept free from ■septic infection by the use of permanent irrigations. For this purpose a large tank or irrigator is filled with sterilizeil water and placed near the bed, at a height not exceeding 60 centimeters (2 feet) above the patient's genitalia ; a vaginal tube, which is best made of glass, is connected with the tank by rubber tubijig, and the flow is controlled by a faucet. The patient is placed on an air- cushion over a bed-pan (or a tin box made for the purpose), which in turn has a waste-tube leading to a larger vessel on the floor. The faucet is so set as to allow the water to flow very slowly or merely to trickle ; the tube is inserted into the vagina and is kept In position by tapes tied around the thigh or the waist of the patient ; the vulva is covered with antiseptic dressings. In this way a little stream of sterilized water is kept running over the contused parts, washing away the lochial flow and every particle of d(!'bris as soon as formed. Several times a day an antiseptic wash is plactnl in the tank and a fidl stream is turned on, to give the parts r. thorough disinfection. Most patients can stand this treatment for twenty-four hours and longer ; they pass the urine ■( \ \ / \' ^''', It- .111: :| I] il i 1:f .,^ li KMi- i 1( !^ ■; I ■^' it ? 680 AMERICAN TEXT-BOOK OF OBSTETRICS. without iiocoKsitatiiig a stop in the irrigation, and they rest quite comfortably. Others complain so mueh of discomfort that the irrigation cainiot he continued for more than three or four hours at a time, but even in this imi)erfect appli- cation it will do a great deal of good. Hematoma. — Subcutaneojis and interstitial bleeding, forming a circimi- scribed blood-tumor, is a rare complication of the puerj)erium that may Itc attended with considerable danger. Hince the monograj)h of Deneux, all sy.s- tematic writers on obstetrics have distuissed these blood-formations, and the only new feature that modern obstetrics has added to the subject is a lowered mortality under the newer antiseptic methods of treatment. 'J'his accident, which is rare, occurring once in about 1600 labors, is commonly caused by jircs- sure-laceration or necrosis of one or more veins which have not been able lo withstand the strain of the increased venous pressure occurring during labor. Exceptionally the rupture has occnirrcd in the latter part of pregnancy, and very rarely the torn ve.s.sel may be an artery, as in a case reported by Himon. Etiolof/y. — Several conditions have been reported as predisposing causes, the most important, doubtless, being weakening of the vessel-wall by disease. Varico.se veins of the vulva and vagina are of common occurrence, and, a priori, they would seem to predispose to this accident, yet the rarity of hematomata and the fact that most cases have not been jjreceded by markedly varicose veins force the conclusion that in thcm.sclves they are not a factor of first im])ortancc. Croom has asserted that anterior displacement of the uterus, producing a pendulous abdomen, is a factor by stretching the posterior vaginal wall and tearing its vessels before the head descends into the jielvic canal. Hypertrophy of the cervix, the use of instruments, excessive si/e of the head, undue length of the labor, and jirolonged and powerful expulsive efforts have been .said to favor the occurrence of hematomata. >Si/tnptonis and Sif/)is. — The swelling formed by the extrava.sated blood usually does not appear until labor is ended, and in some cases even .several days later, the time of its appearance depending upon the kind of injury tlie veins have received. When the vessel has been ru|)tured early and the |)re- senting part has not advanced sufficiently to exert direct pressure upon the injured veins, the tumor appears at once, and, immediately reaching its fid! size, may seriously obstruct labor ; if, however, the presenting ])art exerts sufficient prcssjire to control the bleeding temporarily, tiie tumor may be vdv small or may not be noticed until after labor. When the vein which is sid)- jected to prolonged compression is only contused, and which later gives w;i\ either s]>ontaneously or after sudden exertion, as coughins;, straining at stool. or (luring micturition, the tumor first appears in the ])uerperium, usually within a day or two, but very rarely so late as the twenty-first day, as in ;i case reported by Heifer. The situation of the tumor varies ; anatomically it is determined by the d' itribution of the fascia, either of the pelvis or of tlio perineum. Usually the blood is ettused below the pelvic fascia, and the tniiior appears in the labium, or beneath the vagina, or in the perineum, extcndiiij: exceptionally to the anus, to the gluteal region, and in front to the abdominal PATHOLOGY OF THE PIERPERIUM. 681 (rf v" :!onifortal)ly. 1)0 continucil (crf'ect appli- iir a oircuni- tliat may \w KHix, all sys- oiis, and llio : is a lowered riiis accidont, used by pi'«"^- been able to during labor, rcgnancy, and teil by Hinion. posing causes, all by disease. , and, a priori, )t' lieniatonialu kodly varicose factor of first of the uterus, )sterior vaginal } pelvic canal, ze of the head, e ett'orts have iv asated blood ■s even several of injury tlie and the pre- isure upon the whing its full ig part exert> )r may be vfiV which is sub- Hater gives w:iy Lining at stool. leriuni, usually [st day, as in :i lanatonueally it lelvis or of the and the tumor kitn, extendiii;-' the abdominal walLs. If the bleeding has occurred above the pelvic fascia, the effused blood may be situated in the broad ligaments or the periuterine connective tis,sue, and it may extend even to the diaphragm. Very rarely the tinnor may be found in the cervix. Clinically, the commonest site of the swelling is at the side of tlic vagina near the vulva. The size of the tumor also varies. Usually not larger than an egg or one's fist, the tumor may be as large as a cocoanut, or, widely distributed, it may contain a very large (juantity of blood. A hematoma, polypoid in shape, has been observed hanging from the vagina. The formation of a hematoma is generally accompanied by pain in the region affected, this pain being very severe when a large tumor is formed. There are at the same time constitutional evidences of hemorrhage that also vary in their severity in direct jirojjortion to the volume of the timior. Should tiie swelling reach its fidl volume at once, and burst — an unusual complication — the loss of blood may rapidly be fatal. In some instances the tumor con- tinues to enlarge for twenty-lour hours. Soon after its formation it assumes a livid or mottled appearance, at first giving tense fluctuation, but later a dot- Hke firmness. IJy pressing upon the bowel or the bladder the functions of these organs may seriously be interfered with, and when the swelling reaches a considerable size during labor it may impede the birth of the child or the pla- centa, and later may obstruct the lochial flow. The synn)toms being practi- cally characteristic, tiie (liaguo,si,s, therefore, is generally easy when the tumor is visible or is easily accessible in the lower parturient tract. The tumor might he mistaken for prolapse or inversion of the uterus or the vagina, for varicose veins, or for vaginal enterocele. AVhen the eff'usion has taken ])lace within the jjclvis, the diagnosis will be made by a bimanual examination, together with the mode of onset and the constitutional signs of internal hemorrhage. The (erminafion of a hematoma may be any one of the following : (u) Ab- sorption ; (b) recovery after evacuation of its contents ; (c) septic infection Ijefore or after ruptiu'e ; (d) hemorrhage, wiiich may prove rapidly fatal before rupture or at the time of rupture. Rupture niay be the result of undue or sudden eflbrt, or, at a later jieriod, it may occur spontaneously from slougliing. The idtimate result, which in any case will depend ujion the size and situation of the tumor, is also largely influenced by the treatment pursued. Small tinnors not larger than an orange are usually absorbed, while those of larger si/e fre- (|iiently burst spontaneously and thus add to their gravity. Of 30 cases col- lected by Winckel, twenty-three spontaneous ruptures occurred within eight days. If, on the one hand, the larger tumors are opened before necrotic eliiuiges or renewed hemorrhages have occurred, the prognosis is favorable, and with rigid antiseptic treatment death should be oxce])tional ; if, on the other hand, delay permits such changes, the mortality is 12 jn-r cent. (Winckel). The situation of the tumor influences the prognosis to the extent of its being accessible, and thus being more readily dealt with. Intrapelvic tumors, therefore, are more dangerous, the hemorrhage being less readily controlled and the danger of suppuration being greater. Tumors appearing during labor have had a higher mortality than those occurring after delivery. ^vr.f I 1r i1 1 'M? * I 4 11 n .: !* •S'i.;,!! It- '■. It. '-tiivn iiii I m, 682 AMERICAN TEXT-BOOK OF OBSTETRICS. The treatment of a hematoma varies with the time of its appearance, its size, and its situation. Should the swelling occur before or during labor, and offer a serious obstruc- tion to the passage of the child, the tumor should be laid open in its dejwndent portion, to favor subsequent drainage, preparations having previously been made to control the free hemorrhage almost certain to follow evacuation at this time. Manual compression by an intelligent assistant can be utilized to control free bleeding while the bleeding vessels are being searched for and ligated. If this cannot be done readily, forceps should be used to draw the head into the vagina until by the pressure of the head the bleeding is con- trolled. Even when the tumor is not large enough to impede the passage of the child, it is best to anesthetize the patient to prevent excessive straining on her part, and to apply the forceps and to employ cautions extraction to pre- vent further bleeding and increase in the size of the swelling. If the forceps is not employed, or in case the swelling first appears after labor, an attempt should be made to control the hemorrhage by the application of cold and by pressure, both of which can conveniently, and usually effectually be applied by means of the largest Barnes' bag or by a colpeurynter placed in the vagina and filled with ice-water, ice poultices being placed against the labium. If the swell- ing ceases to enlarge — an indication that bleeding has been controlled — and if the tumor is not larger than one's fist, efforts should be made to promote its absorption by cooling applications, such as compresses wet with lead-and-opium wash or with diluted alcohol. Meanwhile the vagina must be kept clean by frequent antiseptic douches, and the patient should be cautioned to avoid all ei;urts at straining. It is therefore desirable to use the catheter and to keep the stools soluble. After waiting a few days, if there are no signs of absorption, and if the tumor, which had been hard, now becomes soft, and the overlying skin or mucous membrane is tense, discolored, or vesicated, indicating, as these changes do, beginning suppuration or threatening spontaneous rupture, the time has arrived for prompt evacuation of the tumor. An incision 5 to 7.5 centimeters (2 to 3 inches) in length should be made along the inner surface of the labium, the clots turned out, bleeding vessels ligated, and the cavity daily cleansed and packed with antiseptic gauze. When symptoms of internal bleeding and physical examination point to the occurrence of a heniatoma within the pelvis, care must be taken to exclude free hemorrhage in the peritoneal cavity from a ruptured broad ligament or other vein, since the latter condition would necessitate opening the ab- domen, while in the former, if the hemorrhage is confined within the con- nective tissue, the shock and collapse should be combated, and effort be made to limit the hemorrhage by cold and by the internal administration of hemo- statics. Subsequently the tumor should be watched, and, if not absorbed, it is best to evacuate it through the vagina. If not extensive, and if there an' no marked constitutional evidences of internal bleeding, the condition will probably go unrecognized until spontaneous evacuation occura or until incision ,M-; M' PATiioLoay OF riiK pverpeuivm. 683 learance, its is made after several weeks or months, as in a case of" Terfj^rif^oriantz, in wliicli ease a broad-ligament hematoma through pressure-necrosis comnuini- (•at«l with the posterior vaginal vault, and was emptied of stinking, blootly fluid after four months. n. Diseases of the Sexual Organs. 1. PlKRl'KItAI. InKKCTIOX. By "puerperal iuf'eetion " is here understood all the manifold diseases conditions in a puerperal woman caused by microbes except eruptive fevers ; iion-inflammatorv diseases of the nervous system, sucli as tetanus, tetany, and insanity ; and inflammation of the breasts, — all of which are discussed in otlicr parts of this work. Puerperal infection in almost all cases is a wound-infection, and, just as this may be slight or be serious, puerperal infection may be a local affection of the external genitals of little importance; or it may be a more serious affection (if the internal genitals, especially the uterus; or the whole system may be drawn into the morbid process. In most books this condition is treated of iMider the name " puerperal fever," a denomination from which the writer entirely abstains, for the reason that it is absolutely impossible to draw a distinct line anywhere on this field as a limit for something worthy of that name. The old idea of puerperal fever as an essential fever, a nosological entity mi generis, is given up by all. It is impossible to define puerperal fever, and it ought to follow the terms dropsy, lung fever, and brain fever, which have long ago been relegated to the scientific lumber-room for terms fiillen into desuetude and given way for definite and correct expressions. The term " puerperal fever" ought the less to remain in scientific language as in some of the worst cases there is no fever at all. Of late years, instead of " puerperal fever," the term " puerperal septi- cemia" is used by many, which is certaiidy an improvement, in so far as it reminds us of the identity of puerperal infection with wound-infection ; but the expression is both too wide and too narrow for our purposes — too wide, l)ecause the same word has a more restricted sense of a certain form of puer- peral infection in contradistinction to other forms ; too narrow, because the word by its etymology means a condition where septic material circulates with the blood through the whole body, and because the term cannot projicrly he made to encompass many diseased cond!tit)ns foutid in the puerperal woman, wliich conditions in most cases never lead to a general infection of the whole system. The term " puerperal infection " is open to the criticism that it means a cause, and not the effect producal by this cause, but this is not without analogy in common parlance. The word " cold " meant originally a low ti'in])erature, but by extension it has been made to comprise as well the disturbance in the human body caused by ex])osiire. Hy using the expression "puerperal infection" to designate the diseased H K'- i < I'M t V / ! 'I l^w mnm " i! ; „ ' n'x % 'im'^': i -'1 '■ ii t. (iS-l AMEIill'AX TEXT-noOK OF OliSTF/riilVS. coiKlitioiis produced \>\ infection diiriiij; jn'c^niincv, childbirth, and the pncrpcrid state \vc have tlie advantage of liavin^ a general term whieli covers tlic whoh- groinul, iniM and serions ca>es, local and general distnrli- anccs in the ct|iiilil)rinni of health. We are furthermore reminded of the |>os- siltilitv of jfuardin^r otn- patients a<>ainst a |)est that not lonjr aii'o was thouuht to he due to a deterioration of the atmosphere, or even to a direct retrihution of an irate deity ; an<l we are turned in the right direction for fmdiui; thera- jH'Utieal relief for evils already existin<r. We stand also on |)urc scientific fjround, since all modern n'scarch proves that in the mildest and in the severest cases the morbific element is the same — namely, the presence of tlic diflcrcnt species of stdfj/ii/lococcus j)iio(/ciK'f< {V'u^. All) and the slrcjitiH'niTiin pi/nffciir,^ (Fig. 418). FlH. 117.— StaiiliyliiiMMcus iiycifiiius lUl^l■ll^ in |iiis (X UKK)) (Kriiiikol ami riiillirl. I'll llx— Strtiitnccicc'.is iiynnciifs in |ius (< KHKli (I'riinkt'l lunl I'fci fieri. The celebrated French micnwopist C'ornil' states that the streptococci found inpatients affected witii s(»-called "puerperal fever" arc the same as those first described by Fehleisen as the cause of erysipelas. He fbimd the .same coccus in all the different forms of |»uerperal infection — pyemia, septi- cemia, the diphtheritic and thi' ])lilebitic form. Only once did he find a rod- shaped bacillus. Clivio and Monti of I'avia' found in five cases of ])ucrpcral peritonitis in the fluid contained in the abdomen a strepto<'oceus which was identical willi Fehleisen's streptococcus of erysi|)elas au<l with Hosenbach's streptococcus of suppuration, and similar streptococci were found in phlej>'monons abscesses in other diseases. Lust ii>- of Turin ^ found this same streptococcus in the blond of the spleens and the hearts of women who died from puerperal endouu'tritis and peritonitis. Jiumm,^ who made extensive researches with ample material, likcwi-e arrives at the <'oiielusioii that the streptococci found in ])uer])eral infection an' identical with those found in inflrted wounds. Mironow'^ also identified tin' streptococcus of erysipelas with that jrathered from the uterus of sick puerperal women. Doyen, rnshini>:, Hunim, and others" found that puerperal infection iiiny be (bie to other cocci. J)oderlein ^ found the streptococcus ])vo<i;enes to be the most important, but, besides, that the pyogenic staphylococci are active >!i-- I 'mli'rtidii ini\y I'lKIM'KltAI. INri:rTI(>N. I'l All II. > iviii-'i'iu's in I'lis ml I'lcifU'D. .^ Spi'i'iiiifii fniiii a inLtii'lit wlm ilU'il soiitic, sIkiwi'iiil: tin- mntcriiil tliiil wmilil !»• loimil In !»' iriimviil liy till Tiinttf (ir the liiiixiT mi the " nniiilu'iu'il iiliHoiiliil silo." "fldts in tlii' \Ut'iinr ^.inn^o^ " Aiiiiy Micliciil Mii^ciini, \Vii.sliiiii.'tnii, II. C. .No. 10,(ily.i. W ■ '-:■<:''' I 1 MkMm k.ul^ P li t ;l s? PATIlOUKiV OF Till': I'l'h'h'/'h'If/f'M. <>85 I'licriMTiil fovor, HO cjillrd, is tlicrcforc not a nosolojjjioul entity, but is a c'onipU'X plicnoineiioii (Ino to (litrcrciit niiot'olirs. lHjf'n'nit Fonm of Jtifcclinn. — First oi' all, we must distin^iiisii hctwt'cu iiKM'c local atlrctions and a (jinvt'dl infection nactiin^ tlio whole sy.''tfin. Tlio Hiriiicr arc, of Conrsc, niiicli less danjjcrons than the latter. Next, we must separate the y>»^vV/ I'roni the jien nine N<'y>//c' inf'eetion, hotii oC which may he local i>r he jjcneral. (Jcneral putrid iiitection is! calknl Mprcmid, and general M'ptic inteetion is called xrittitrmia. I'ntrcf'action and sapremia are due to many dillerent sehizoinycetes, the so- called xdpropliiftcs — minute organisms which are allied to algie, and are found all over the world in streams, plants, animals, etc. By their growth and multiplication these organisms produce certain cijcmieal suhstanecs, the so- called (oxiiiH, a kind of ptoma'ins wiiich give rise to fever. Ptoma'inx are alkaloids produced in dead vegetable and animal tissues during putrefaction ; /i'iicor"i"niii arc similar alkaloids producotl in living animal tissues as a result (if their activity. Pt(»mains are only pniduced by microbes. Leueomai'ns arc harmless unless their excretion is interfered with. The changes occurring in puerperal infection may be produced by ptouiains or by leueomai'ns alone, without the presence of microbes, but in the vast inajority of cases the microbes are present. The saprophytes are generally brought into the interior of the uterus mechanically. 8ej)ticemia is due to a few well-known micrctbes that actively enter the tissues, which they injure through their growth, and by their distribution thronihout the body may so change the chemical processes anil normal {'imctions that death ensues. These microbes are, as we have stated, almost exclusively streptococci, and are idcnti<!al with those that cause wound- diseases; and in the second line come staphylococci. The latter two varie- ties of microbes are therefore also called pafkof/oiic microbes, which give rise to so-called specific puerperal diseases, and which are dilferent from the so- called non-patliof/enic microbes, that only cause putrefaction and non-apecific puerperal disease. The infection starts, in the vast majority of cases, from the endometrium, liuinm* distinguishes, in accordance with what has just been said, a putrid iVom a nrptic rndometrifis, but he admits that in some cases the two forms are blended. In putrid endometritis there is found in the uterus a super- ficial layer of necrotic tissue, under which is a layer of granulation-tissue filled with leucocytes, those formerly ninch-raaligned colorless blood-cor- puscles that have since the advent of bacteriological studies ])rove(l to be our truest friends, forming a bodyguard that protects us against the constant attacks of our enemies, the miert>bes, whom their miiMite bodies engulf and ai)sorb. Hence they have received the name of " phagocytes ;" that is, "devouring cells," a species of giant-killers on a small scale. While the nccr()bioti(! layer is covered with all kinds of saproi)hytic bacilli and cocci, these never enter the granulation layer. Septic endometritis differs according to its being a local affection or an r II <- ' '. < I i- 680 AMERICAN TKXT-nOOK OF OBSTKTIilCS. inflainination I'ollowod bv gt'iirnil iiifoctioii. In loml .^cpllc ('H(lometritii< the oii(I()iiu'ti'iuiu is miicli liko tliat in putrid eiuloinetriti.s, except that, besides iiu)rc or less nimierons germs oi' putref'aetioii, streptoeoeei are tbimd. (uiicral septic endoinctrififi appears under two (lillerent I'ornis — the /////;- plutth' and the l/iroiiiho-jiltlchitic. In the /ipiiplidtic form tiiere is a mixture nl' sapro[)liytes and streptoeoeei on the necrotic surface, but the granuhition-wall is much thimier than in putrid endometritis, and in the worst form of sepsi> it is altogether absent. On the placental site the veins are well closed, their walls being in contact and without thrond)!. In the severest cases the infec- tion-carriers go through the finest lymph-spaces between the tissue-element-. In less rapid cases they generally follow the larger lymph-vessels. From the wall of the lymph-vessels they enter the surrounding tissue, causing necrosis. The lymphatic form often starts from injuries of the cervix. Ill the ihvombo-plilchitic form of general intection the endometrium is like that of localized endometritis, the germs never entering the layer of granula- tion tissue filled with leucocytes except at the placental site. Here the veins have not been closed by collapse and apposition of their walls — the normal process — but are ])lugge(l with thrond)i. In some of these thrombi we find, superficially, saprophytes and streptococci, but the latter, finding a favoraltle .soil in the thrombi, enter into their interior, while the saprophytes remain near the surface. The invaded thrombus soon forms a detritus, a process that extends into the broad ligament. The thrombo-phlebitic is a more rapid and a more dangerous form. In septic peritonitis the infection is not propagated through the Fallopian tubes, but it takes place through the lymphatics of the walls of the uterus. The <llj)htli('riti(' form of ])uerperal infection begins in the nuieous mem- brane of the vulva, vagina, or uterus, or in a tear extending into the sur- roimding connective or muscular tissue, and patches, like those found in a diphtheritic wound or in the throat of a patient affected with diphtheria, arc formed. Ft is again tlu; same streptococcus that is at work, and the affection passes into one of the above-<lescribed forms. The difference in symptoms and in th(> danger in different cases of puer- peral infection may be accounted for in many ways. The different power of resistance may coiuit for something, one organism succumbing to an attack which a stronger constitution successfidly resists. The mere nund)nr of microbes seems to be of importance in all infections, the invaded body beiiii:' capable of neutral./ing a small munber, but losing in the battle with the many. Tli(> anatomical structure and eonneetions of the part invaded explain maii\ peculiarities in the result produced. An infection attacking one lymph-vesM'l leading to a gland may be cut short there, while if the infecting material enter- ai\other lymph-vessel it is carried to the peritoneu'n, thence, perhaps, throu'jli the stomata of the diaphragm to the pericanlium and the plenr;'. ( )r a throm- bus in !i vein breaks down, and part of the detritus is carried away with tip blood-eurrent through the vena cava, the right aui'icle, the right ventricle, anil IMKKrKHAI, INTKCTION. ri.Aii: to. Hhvm'tritiK tlic t that, bosiiU's tbuiul. rms — the ///'"- s u luixtmv ol i-iumlnti()ii-\v;iU form of scepsis L'll flosod, tlioir oases tlio infi'c- tissiuM'UMncnts. ;els. From tin- causing noorosis. )niotriiim is \\\<v lyer of gramila- llerc the veins ^Hh — the normal hrombi we iiml, iliiig a favorable vtes remain near i, a proecss tiiat X more rapi<l aii<l s not propajrateil lym| iliatief of til le nnieous mem- ig into the sur- fhose found in :i h diphtheria. arc am 1 tlie atVection lit eases t^i' pni'i- litVerent po\v(>r of linir to an attack licre mnnbiM- <>l ided body beiii'j battle with tlu' od explain manv |)ne lyniph-vesM'l material eulcr- [•rhaps, throu'ji . Or a throiii- jd away with the Iht ventriele, aii'l I ..4- I'liTii-. Willi slin ilily tMiilriiiil iM, Ml Ml 1 ^IciU'jliiii'^ ~lri|i " I'liiiirliii'j iiiliiti;il ii-"i-,m; linm <i uirl d' iiiin lirii «lin iliiil cii;!!! iliiy^ |io«| |.,ii linn v (III puniK lal |.ii il.inli i^ , \riii> MnliiMl Mu-ciiiii. \\ii>liiiit;iii|i I' I'., Nn. y.i.'iTi. i-Uh ■I i.V, ■'> ■ 1 i ■ 1 ,'" , J % >£■;?■? riKIM'KliAL INKKCTloN. I'l.ATi: 4t), 1 •fH-!li!i Iff 1 IJff r ((• l'i>l'li r |il.lirlll;l .n t'llllllilliM'^ '" "'' '■"■■ illlllll IVnlll v,.|,vi^ livi' iImJ^ II I'll I ilrliMiy ill II l\ l.hiiiil cnll- ililiuii. I'nlurcil uirl. niiii'li'1'11 \ciii> nl.l. ^^ iilnlitic. u iili iliinl Ulu- iii u-.ii i ,\riii\ Mr.linil Mu>.iMn, \\a>li- iii'JI'ili. li. ('., No. TTMl. r-f ij'. '' e J> ! PATHOLOGY OF THE PUERPKRIUM. 687 is deposited in a fine brancli of the pulmonary artery, torniing an abscess, from which the microbes are carried to other parts of" the body to form new foci of suppuration. Most important of all seem to be the different degrees of virulence of the microbes themselves. Virulence is a property of the protoplasm that shows itself in energetic proliferation and increased { ower of resisting the influence of the cells in the organism invaded. This virulence is diminished by artificial culture, and is increased in the anin\al body, but in what way is unknown. The virulent streptococcus rapidly invatles the tissues. Infection starting from the genitals takes place through a wound, many niii'robes being found in the genital tract of every puerpera, besides the placental site, which has been compared to the stump left after the amputation of a limb. It is not so in animals. AVith animals, as a rule, the process of expelling their offspring is not more difficult than the act of defecation, and tlioir placental site either regains its epithelium before the loosening of the placenta, or recovers it in a very short time after delivery, almost in minutes. This fact explains why puerperal infection is not produced in an animal by tlio injection of septic fluid into its vagina and uterus. As soon, however, as the same fluid is injectetl under the mucous membrane infection follows.® In the opinion of the writer the so-called " puerperal fever " is nothing but the most serious form of puerperal infection. Localized is less dangerous tiiiui general infection ; putrid infection is not so important as septic infection ; but any local infection may become a general infection, and putrid infection may end in death. S.j/tk'cmia in Children. — Identically the same disease above described in puerperte is often found in new-born children. The mother of the child may or may not have the disease. Infection in the child generally takes ]>lace tiu'ough the navel, but it may enter through sores in the mouth or through an accidental wound, or it may be aspiretl into the lungs in the putrid liquor amnii or be inhaled through the air, or it may even pass from mother to child through the placenta. If not acquired from the mother before birth, the poi- son may be carrieil to the child by doctors or by nurses, or may cling to any object with which it comes in contact, or niay float in the air. The sources of the j)(>ison ill children are the same as those we shall now describe in regard to the mothers. ExroiiOGY. — Experience shows that a ])uerpera is more lial)le to disease tiian is a woman in other conditions, and it is not difficult to give many good reasons why this must be so. The causes of puerperal infection arc prcditi- jiDfiinii or ex('iti)u/. I'lrditijio-sin;/ Cuuncs. — During pregnancy the chemical composition of the lilood undergoes considerable change ; the total amount of blood circulating in the body increases, but it is more watery than in the non-pregnant con- dition. In other words, the woman suffers from plethora and hydremia. Tlie red blood-corpuscles diminish, while the colorless corpuscles increase in number. Hemoglobin, albumin, fat, ])hosphorus, and iron are found in too small amount, whereas thequautity of fibrin is considerably greater than in the :».•. ■.P::] ,r >S 688 AJMERICAN TEXT-BOOK OF OBSTETRICS. ini f \ non-prcgnaut woman. The plethora, liyperiiiosis, and leneocytheniia predis- pose to intlainmation. The heart, especially the left ventricle, becomes hypertrophic. The walls of the blood-vessels become thicker and their calibre larger, esi)ecially those in the uterus and the breasts. The lymphatics of the pelvis become so dilated that they look like veins. This dilatation of blood- and lynii)h-vessels pre- disposes to the formation of thrombi, which not only constitute a fertile soil for the pathogenic microbes, but also may break down and be carried away by the circulation to remote parts that become new centres of infecfion. The nniseular tissue of the uterus grows enormously in order to afford room fur sheltering, and force enough to expel, the fetus. The nervous system is in a high state of irritation, as may be concluded from the headache, toothache, neuralgia, vertigo, and longings and aversions so common in the j)regnant condition. Parturient and puerperal women are highly emotional. The ])resence of a disliked or dreade<l person in the lying- in room may arrest labor-pains. A letter containing unpleasant news may cause a rise of several degrees in temperature. Shame in those who have " loved not wisely, but too well," fear of destituticm in the poor, indignation at a husband's cruelty, are all factors that lower the vitality and diminish the power ')f resistance. Since every muscular contraction and all secretory func- tions are controlled by nervous action, we can imagine that even the propaga- tion of microbes, their distribution in tlie body, and their expulsion from it may be influenced by the condition of the nervous system. At the end of labor the patient is exhausted by pain and loss of blood, and the genital canal is full of tears and abrasions, which open for microbes free access to the tissues. If this is true of even the most normal delivery, it applies with still greater force to tedious deliveries and to those in which the accoucheur nnist resort to operative interference, necessitating the introduction of fingers, hands, or instruments into the genital canal. Xormally, the muscular tissue should contract forcibly during the ex])ulsion of the child, and should remain contracted until all veins on the placental site are closed by simple agglutination. But if the muscular contractions are defective, the woman may cither bleed to death, or the veins may be i)luggwl nj) by the formation of clots, which are an excellent soil for streptococci and sti'phylococci, and into the depths of which they therefore rapidly ])euetr;it('. The separation of mother an<l child outside the placental site, wliidi separation ought to take place between the superficial and the deep layer of tlic decidua, may be defective, so th.at lari^er or smaller pieces of membranes are left behind, and at the placental site a cotyledon may be torn off and remain in the uterus. Such remnants of the secundines soon become covered with saprophytes, and they undergo a putrefaction which may lead to more or Ic-^s serious consequences. The entirely normal lochial discharge is in itself ;iti excellent medium for the cultivation of all sorts of microbes. After the birth of the child a retrograde process begins. The hyperplastic and hypertrophic tissues have to be li(piefied and be reabsorbed, the intii- PATHOLOGY OF THE PUERPERIUM. 689 ,;> ■ ' , ! mediate stage being fatty degeneration. While before delivery there is a .-strong current of plastic material toward the uterus and the child, after (k'livery the direction is reversed, and a strong current carries ett'ete material tVom the genitals, especially the uterus, to the rest of the body. Primiparffi are still more exposed to infection than those who have before hcrne children, labor being longer, the canal to be traversed being narrower, iiiid the parts composing it being softer. Delivery in general hospitals exposes the patients to greater dangers than delivery in special lying-in institutions or in their own homes. Parturient women ought not to be in the same room with pnerperte, the discharges from tlio latter being particularly dangerous to the former. The crowding of too many puerperie into one room is in itself dangerous. The less the space the greater becomes the difficulty of obtaining absolute cleanliness, and the greater is tlio danger of noxious substances being carried from one patient to another. The exciting cause of puerperal infection is, as we have seen, the introduc- tion of certain microbes into the body of the woman, as a rule into her genital tract. Sources of the Poison. — The infection may come from a woman similarly affected, from suppurating or decaying tissues, from putrefying substances within or without the body, and from zymotic diseases, especially erysipelas and diphtheria. Contarjion. — That the disease may be brought from one patient to another was discovered by British physicians, and, while in America it was denial by the leading obstetricians of the day, Hodge and Meigs, nevertheless it was ])roved to be contagious by the masterly essay of Oliver Wendell Holmes, wlio so distinguished himself in another line that his merit as a physician is apt to be overlooked.'" N'ow-a-days the contagiousness of puerperal infection is universally admit- t(Hl, and the only mooted point is whether it is essential that the microbes be carried from one patient to another on solid objects or whether they may float tliroiigh the air — a point to which we shall presently return. Siipjmration. — That the source of puerperal infection may be suppuration was pointed out as early as 1847 by Semmelweis." Students who had examined a patient with a cancerous ulcer of the uterus caused puerperal fever in and (leatii to fourteen women. Ill America was the celebratal case of Dr. Rutter of Philadelphia, who in 184!^ had forty-three cases of puerperal sejjticemia in his practice, while neighboring practitioners had none. He bathed, changed his clothes, shaved off his hair and wore a wig, stayed ten days away from the city, and did not take with him to his next patient anything he had before worn or carried. She had an easy confinement, yet she died from puerperal fever. The groat Meigs taught his students that such a fatality was God's providence.'^ It remained for the present generation to find the solution of the riddle in the taet revealed by a contemporary of Dr. Rutter, that he suffered from an obstinate muco-purul nt coryza." It is easy to understand now how by 44 :i^i !,'i|5 H' 1 « • i 1 m m ■ ft m 1 ff T m 1 1 . i kT j. li - I ( 1 I & 690 AMERICAN TEXT- HOOK OF OBSTETRICS. toudiiiig his nose with his fingers Dr. lluttor hronglit staphylococei aiKi streptococci into the vagina or the uterus of his unfortunate patients. A French i)hysician who had delivered eight hundred women without accident was seized with suppiu'ative adenitis, for which he wore a draiuago- tube. Witliin three weeks he had three cases of ))uerperal septicemia." During the time of the great morbidity and mortality in the New York Maternity Hospital immediately preceding the new era an assistant suffend frequently from pustulous eczema of the hands. A dentist, Dr. Pedlcv, called attention to decayed teeth in doctors and nurses as a jiossible source of puerperal infection.'* In 1889 there was in the Xew York Maternity Hosjiital a paralytic patient liaving a carbuncle in the sacral region. There were two puerperte in the same ward, and all were in the hands of the same nurse. One of the two puerjjenc, who had been perfectly well up to the eighth day after her confinement, got a chill and her temperature rose to 105.6° F. On the cervix was found a di|)li- tlieritic infiltration. The patient with the carbuncle had no puerperal affection of any kind. Pat refaction. — Semmelweis showed conclusively that the enormous mor- tality prevalent in the lying-in hospital of Vienna was due to cadaver-poison brought by the students from the dissecting-room to the wards in which women were examinetl and delivered. Tiie hospital has tw'o departments, one for students and one for niidwives, admission taking place to eaci; department on alternate days. Nevertheless, the mortality in the students' department was three times higher than that in the midwives' department. A similar instance is reported from private practice. A Scotch physioinn, Dr. Renton, and a friend practised in the same place. During a so-called "epidemic" of puerperal fever all Renton's patients remained healthy, while all those of his friend were taken sick. The difference between the (wo was owing to the fact that Renton did not, while his friend did, perinnn autopsies.'^ The infection may originate also from a decomposing part of a liviiiif body. Thus, frequently pieces of placenta or of membranes, left behind in the uterus, become the starting-point of ,.uerperal infection. The writer once had a patient who gave birth to a macerated fetus, and from whose uterus a decomposed plai'cnta was removed without doing the least harm to tlie parturient, but it gave rise in another patient to one of the worst cases of puerperal infection in the writer's experience. The assistant who delivered the first woman was allowed bv his colleague in charge of the second to examine her, and, although he disinfected his hands with bichlorid, lio doubtless brought on his fingers the germs that came near costing the woman her life. Some years prior to the date of the writer's coimection with the New Ymk Maternity Hospital there was erected on Blackwell's Island, N. Y., a new- building designed as a maternity hospital. The building had scarcely Ikih opened before such a so-called "epidemic" of puerperal fever broke out in it k:f m vlocncci aiiti ients. men without ■e a ilraina«r('- septiceniiii." a New York ■itant sutli'icd Dr. Pedlcy, osrsible source ralytic patient •aj in the same two pucrperie, inement, j^ot a found a dipli- rperal affeetion mormons mor- eadaver-poison ards in whicli o departments, phice to eacl-. n the students' es' department, oteh physieian, 'insr a so-ealled healthy, while 'tween the two did, peril inn \rt of a living; left behind in The writer once whose nterns a harm to tlio worst cases of who delivered th(! seeond to biehlorid, 1k> ting the woniau the New Y"il< N. Y., a nrw Id searcely l^'cn 1 broke out in it PATIIOLOaV OF Tin-: PCERPKniUM. 4!' that it had to be vaeated. The cause of tins epidemic was probably dnc to the iriiano w^ith which the surrounding grounds had been covereil in order to make a garden. Feliling" observed an epidemic of pue-; ^ral fever, diphtheria, and ciysipelas as the consecjuencc of a bursted waste-pipe, the dirty water soak- ing into the ground on which stood the hospital. Gustav Braun'* in 1889 had so serious an epidemic in the Vienna lying-in liospital that during one month nearly 18 per cent, of the puerjiera; were taken sick, and nearly 9 per cent. died. He attributed the troid)le to the fecal matter from the hospital and that of a neighboring barrack being evacuated into a canal flowing past the hospital. The immediate contiguity of a churchyard, a dunghill, a privy, a stable, a slaughter-house, a cess-pool, a sewer, a pool of dirty stagnant water, or similar jilaees where organic substances are imdergoing decomposition, is therefore dangerous to a parturient woman. Zi/inotie Diseases. — The exact relations between puerperal infection and zymotic diseases are not definitely settled. Since it is now known that it is tlie same streptococcus which gives rise to both diseases, there can hardly longer be entertained any donbl of the jjossibility of puerperal infection being (hie to the poison brought from a jierson affected with erysipelas to a jiuer- pera. The same observation applies probably to diphtheria, since a diphthe- riti(! local affection entirely like that which occasionally develops in a woiuid, and which commoidy appears in the n])per air-passages in diphtheria, is one of the commonest forms of puerperal infection. Scarlet fever may attack a puerpera, but it remains scarlet fever and follows a similar course to that in other patients. Typhoid fever is so well cliaracterized by the intestinal ulcers, and is so ditferent from puerperal infec- tion, that the two must be distinct diseases, but this fact does not prevent one disease from leading to the other. \V(ti/s by v'hich the Poison enters the Bodi/. — In the vast majority of cases tlic ]ioison causing puerperal infection is brought mechanically into the genital tra(!t by the fingers or by the instruments of doctors, midwives, or nurses. It may lurk in a lubricant or may adhere to a sponge, a rag, or to any other substance coming in contact with the genitals. ]\[any think that this mode of entrance is the only one, and deny inteclion through the air — a view which, in the writer's ojiinion, is contrary to many well-authenticated facts. There have already been quoted on the precetling page instances where e])idemics in hospitals could only hv traced to the ground, tlio walls of a building, or the air near it being infected by fecal matter and otlier refuse. Now, it does not seem at all likely that the doctors and luirses hronght the microbes from the guano lying on the ground outside the new hospital on Blackwell's Island referred to, nor from the feces floating in tlie canal flowing past the Vienna hospital, nor from the wet ground that was soaked by the bursted waste-pipe described by Fehling. It is certainly more probable that the streptococci were carrietl through the air into the hospitals I ■1 ■.■ ■h f1 (\\)2 AMimrcAx Thxr-nooh' or oitsTF/nurs. aiul woiH! doportitt^l on clothing, instnimciits, drcssiiij^-inatcrials, or oven on the lianda of the pliysii'ians and nni-scs. Soino years aj;o tlu'iv was in tlio Now York Infant Asylnm <i locul epidoinic of puerperal infiH'tion, the eaiise of wliicli was found to he a dead nn in the eeUar. The diM-tors and nnrses never visitinl the eelhir, and the fin - man who attended to tlie fnrnaee there never entered tlie wards, fs it mil, then, a h>p,'ieal eonehision that the niierohes (h'vehiped in tlie dead ho<ly of tli< rat were earried hy the air of the eeUar from t!t»or t«> floor through the whnl,' bnihlinn? This methtxl of dissemination is so nmeh tiie more likely, in!i>- mueh as we have exaet observations showinjj the existence of the streptoeoci i in the air. Humm '" fonnd the eoeei in the dust floating in the air. Depaul*' roportisi the ease of a pupil-midwife who, while wiishiufr di,. genitals of a patient alfcH'tiHl with puerperal fever, felt an nnpleasant seiisi- tion, was taken siek in the evening;, and died on the third day "with all the symptoms of the most eharaeteristie puerperal fevr." The diajj;nosis of |)M( r- peral fever was eontirmed by the autopsy ; she was found also to be a vir^;in and not menstruatiuir. The natural inference is that she inhahnl through the huigs the poison that eaustnl her death, ('reik'-' has shown that puerperal iidectidii in children may start from the mouth. The theory t)f air-infv'ction in a limitinl space is also borne out by the <'l1l(t of sanitary measures. Before the present syst«'m of antiseptic midwifery in the New York Maternity Hospital was practised, patients were always free frmn fever during the first week after a ward had been fumigated with sulpiuir. Jiusch ■" fouuil that he prevented puerperal fever in the Herlin lying-in hos- pital by heating the wards before using them to (10° Reaumur (— 1<!7" V.). In many iiospitals a great im|)rovement was obtained in the rate of mortality simply by introducing a better system of ventilation. The writer firmly believes, therefore, in the possibility of the transmission of the morbific agent in puerperal infection through the air,, but this applies only to closed rooms or to short distances. The atmosphere in general is not wtntaminatcHl, and epidemics, in the old sense of the word, do not cxi>(. They can always be traced to an individual carrier or to the ncighborhdiHl of a focus from which the di.scase spreads. Att(oiiif<vtio)i. — Some divide puerperal infW'tion, in regard to its orifriii, into two classes, called (iKfo-f/eiuiic and lirtcro-ffrnctic In the first class tlio puerpera is suppose*! to infect herself; in the second the infection is broimht to her from without. According to some of the most modern bacteriologists, atitoinfcvtion is only possible as sapremia.'^^ They maintain that the pallm- genic cocci are never found in the healthy vagina nor in the healthy cervix.-' Diulerlcin thinks that streptococci brought into the vagina soon disappear, just as he proved it experimentally for staphylococci. lint other authorities"' cliiim to have found both streptococci and staphylococci in the vagin.T of healthy pregnant and puorjx^ral women. When we take into consideration that at least staphylococcus pyogenes abounds on human liands,'^* it can hardly he doubtal that it is found also on the skin of the penis. Since, now, women j'AT/K )/.<)(,')' or Till-: j'rrnrKitirM. i\\y,\ », or ovou on ylma a l<"':il bo a tloiul nil imd (lio I'm - S. Is it Iln(, (I body of till' llilll tlio wlloli- likely, iiiM- iic strcplot'ot'ii the air. L> wiishin^; tlic )loasiu)t sciisii- ' "with all \\w rnosis of pill r- Ih' a virjiin and t)U^h tilt! 1 lilies •jHTal infcctitiii ho transmission but this api>ru's n jfonoral is imt , do not oxi>t. > noinhborlitinil oOon hiivo Hoxual intoroonrso up to tlio day of thoir oonfnioniont, tlu're is no liirticidty in supposing that fhoy iiavo, at (ho (iino of thoir oonfnioinont, suoh cocoi in tho vagina, and that, in a oortain sonso, tln'V may infoot th«'insolvo«, not oidy with saprophytos, hut also with patho^onic oo(xm. Fnrthornioro, |iiiorporal iiifootion may Ih', duo to disoascHl ntorino appondagos, or since a woman always has innnorous sapro])hytes, and s(»inetimes pathogenic; eoooi, in Ik r vajjina, these orfjanisms may Ix' earried honoo by a perfectly disinfected liiiircr into the uterus and cause infection, which in a certain sonso is also an Mil toinfection. Wo must also remember that few vafjinio are absolutely healthy. It is <l,iimed^ that normal va^;iiial secretion contains only lUifillnH V(i(/hi<i/!n auA if'iilium (i/hi('(tns, hut as soon as the soeretion boiMimes alkaline — which it easily (iocs by atlmixturo of cervical secretion — saprophytes, ])yojr(>iii<; staphylococci, and streptococci find a favorable soil, and autoinfection boc(»mes possible. Time of Infection. — Infeetion <'ommonly takes place durin<j delivery, but it may occur both before and after. iMoK'rAlilTY. — I'uerperal infection is one of the most important of diseases. I')(li>rc the introduction of antiseptic treatment puerperal infection often prevailed in so-oallod "epidemics," of which, accordinj; to Fordyce IJarker,"** iiinre than two hundred had been described since 1740 ; independently of suoh periods of a conj;lomeration of fatalities tho number of those carried olf by the disease was and is very lar^o. Fn the nia<j;iiilieent Lariboisii'^ro Hospital in Paris tho mctrtality used to be almost 8 per cent, of all tho won ion (!.-•• h th (leiivered." in <me ol the services or tho iarfjjo lyuifj-in hospital ni V K^nna tlie mortality for six years (1841-40) was almost 10 per cent.'" In tho Maternity Hospital of I'aris it avorajjed during five years (1800-64) 11 per oont." l)iirin<!; seventeen years (18(51-77) there was in Berlin one death from "puer- peral fever" in every 178 <'onfinoments, or 0.57 per cent., and a total mortal- ity in childbed of 1 in 152, or 0.(55 per cent. Outside tho capital the mortality was nnich p;roator. In all Prussia there <lie(l durinj^ sixty years (lSlO-75) 0.8 per oont. of all confined women, or, more exactly, 8322 out of ev(>ry 1,000,00().'*2 Injfiioiee of Antisepsin on Mnrta/ifi/. — The above very important and con- villeins'; statistical researches have boon eontinued, and they show an im))rove- iiient, whieh generally is attributed to the oblijiatory use of antisoptit! druf^s in the manajijoment of conlinemont oases. Thus tho puerperal mortality from all ciuises was in Prussia during; the eleven years followinj; 1875 (1S7(J-8G) 0.0833 per cent., an improvement of 27.5 per oont.'^^ Jjimitinj^ the investiga- tion to the child-bearing age (fifteen to forty-five), tho mortality from "puer- peral fever" was in the first period (1816-75) 12.01 per cent., and in the second (1876-8(5) 9.97 per cent., an improvement of 16.9 per cent. Similar investigations in Demnark load almost exactly to tli(> same results, both as to the groat mortality and to tho improvomont since tlu; introduction of antiseptic precautions.^* Still, with the sole exeeption of tuberculosis, "l»uerperal fever" is the most fiital disease for women between fifteen and ■i" ./<V (lilt AMKIiU'AX TKXT-IKiOK nl' OIlSTr/miCS. M ■ ■•■i forty-five years of ii<j:e, and if we tai\e (lie period of ten years l)et\veiii twenty-live and tliirty-five yeai-s of age, in wliieli most eliildren are i)oni, one death in every six is dne to "puerperal fever." In the jjrand-diiehv of IJaden, liKWever, tiie pnerperal mortality has remained the same during the last forty years — a eireiimstanee which is aeeoimted for l>y the inetlicieni v of the midwives, wiio do as much harm as good by their way of using ann- sepsis.'** I'a I iroi,(MiY. — A peenliar feature of puerperal infeetion is the great diver- sity of the pathological changes — a circumstance that has given rise to nuirh perplexity, hut which can easily he accounted fnr, since it is known that the true agents at W(»rk are living organisujs or a poison prodn<'ed by them. Vulvitis and Vaerinitis. — The external genitals may he the seat of ;i vdtdrrhdl or of a diphihcritii' inflammation. In th<' catarrhal form the mucous UHMuhrane is swollen and red, and it secretes a n»uco-purulent fluid. In the diphtheritic l()rm small whitish or yellowish false mend>raiies appear, spread, and join one another until there is formed a more or less thick ami large patch intiuKitely coiuKvtod with the sm-rouuding tissue, which is sw»»lleii, infiltrattHi with serum, and of a dirty greenish or a brownish color. Endometritis. — The endometrium is the chief point from which iul('<'- tion spreads throughout the body. The endouulrium may be the seat nf a catarrhal inHammation, when it is red, swollen, covered with a purideiit fluid, and sometimes studded with small roimd pustules. The lips of the os are swollen and covered with gramdatious that easily l)le<'d. Other forms nl' endometritis soon implicate the deeper layers of the uterus, and need no speciiil description apart from that to bo given under MvtrUk. Metritis. — INfetritis may assume four (litfereut forms — the .simple, the diph- theritic, the dissecting, and the putrescent. Siuijifc JfttrHiK. — In the simple form the ntorns is much enlarged, its walls are thick, the tissue is soft and friable, and near the inner surface almost dilllii- cnt, cherry-colored, and bathed in a dirty greenish-brown fluid. The cervix is often torn or bruised. Dijihthrrific iiK'frids is characterized bv a condition similar to that just de- scribed in the external genitals. A- ;i rule, the process begins in the cervix. It may, however, begin als(» at the uterine ostium of the tube, and spread through the wall as a yellow layer out to the peritoneal coat of the uterus, Diiisectinf/ nirlrHis (Fig. 41i>) is a form that has been little heeded.* In this form a large piece of the uniscular tissue of the uterus is severed from its surroundings, and is expelled sometimes so long as seven wwks after confmc- ment. Putrescent Mrtritis. — In the putrescent form the walls of the uterus are so *Tlie writer has personally observed and describwl eiglit cases. He lias given the aHiMtimi its name, ami was iliL' first to point out its relation to the puerperal state (AVic York Mt'il'md Jnuniiil, 188'2, vol. xxxvi. p. i)X~ ; Arrhinv iif Mi<Hcini\ .\pril, 1883 ; Medical liirord, Deo., Hs:!, vol. xxiv. p. 6C4). A few eases have been added in (Jerniany (see Iloechstenbach, Arvhiifiir Gynakologii; vol. xxxvii. p. 175). PATHOLOdV O/' Tin: I'rHltl'KlilCM. 68ft ihii) that thoy show irnprcssioiirt of the iiitcstinc. The iitcriis is lar^c. Tlio iiiiU'oiiH iiicinlti'iiiir of \\\\' iiit«>i'ioi' Iimii^s in discolorctl shrctls, or i( is casilv iiioviil)l(' over the subjacent tissue. Tlie submucous eonneetive tissue may Ik; clian^'ed to a wliitisli mass, and tlu^ nuiseiilar tissue may Im! red and llal)l»y ; lull sometimes the (k'struetion extends deep into tlie mus- iidar tissue, forming irre^idar cavities tilled with a choco- l.ite-coh)red or a l)hicl\ pulp, or with a more ichorous or I'lU'idcnt fluid. It is particidarly the phutental site wiiieli i-allected hy this deep lanM'owinj;, the pathojieniv" niierohes lindinj^ a favorahh; soil in th<> thromWi <-losin^ the veins. In oth«'r eases the infection follows tho lymphatic vessels. Salpineritis. — The Fallopian tubes are more rarely llic road followed hy tho infcctinj^ microbes, but we may iiave lioth catarrhal and diphtheritic inflammation ex- lending from the endometrium to this locality. Oophoritis. — The ovaries very frecpiently are affect<'d. We may find u.snperfi(Mal inflammation, the so-calle<l jtcri- I'ni iiu.^ssiMtiin,MMr- o<;/(/(oy///.s, cond)ined wiMi peritonitis, or pdirnrlniiiKifotiH "•His((iiirriKins);siK(iiri( n ' . . . ,. , ,' .,11 1 "•''l"'ll<'lli.v II. II ntlh.. uoplioritis, in which the deeper parts an; inrlamed, and n,» v.nk Mni.niiiy iic.s wiiidi mav end as an ornrian (ihm;%'t. '•""' "" '"' ;-^'. '^•'. "'"' Cellulitis. — The connective tissue of tho pelvis and liiMMunt. tiiIn whs iii^ !■ . i !■ ■! 1 I • I 11 I III I'iulilli t'lisr ipC the rriKirl iKljacent parts ot tlie ahdoiuinai wall may be swollen, bo ^ iisi„.,i h, iho \iw Vark iiililtrated with serous fluid, and bo the seat of liemor- ""'"■"' av'(„v/, vi.i, xxiv. rli;i;;ic thrombi, lliis intlammatioii may end in resolu- iv,,!,, ,i,,ii,,i(,nrniiii, is iwd- tion or in suppuration, the abscess opening:; into the rec- thirds niiuirai size.) tiiiii, the va}!;ina, and tho bladder, or breakinjf thi'oiij:;h the skin, often after lonjj; wanderings, espaiially at Poiiparf's lij;ament or above the crest of the ilium. Lymphangitis. — The lymphatic; spaces and vessels are the chief roads by which puerperal infection reaches the deeiier parts. Those of the vulva and the lower fourth of the vajrina lead to the superficial inguinal glands, from wliirli others go to the (h'op inguinal glands, which again are in connection with tlic external iliac glands. Thus a neglected wound on the labium may bccoiiK! the starting-point of a general peritonitis. From the upper three-fourths of the vagina and tiio cervix the lymphatics go to the internal iliac and the sacral glands. TIk; uterus itself is a network iif lymph-spaces and lymph-vessels, which finally lead to the lumbar glands ( l''ig. 4"J()). While the lym)»h-ves.sels, normally, are so small as to be invisible wiien not injected, in puerperal lymphangitis they become as thick as a goo.><e- (liiill, and they may form prominences (»n the surface of the uterus as large as clieiTios and tilletl with a purulent fluid. From the finer lymph-vessels the iiiliction extends to the surroiindinj>: connective tissue. Peritonitis. — Peritonitis is the commonest atVection in the graver cases of puerperal infection. The abdomen is swollen, the intestines being distended with gases. The inflammation may be local — that is, limited to the pelvis — m swrs- 696 AMERICAN TEXT- BOOK OF OBSTETRICS. or ho general, exttnuliiig over the whole abdomen; or it may ho adhesive or l)c jmt'ulent. The peritoneum is injected ; its opitlielium is thrown oif', and it i> in places covered with plastic lymph, which binds the knuckles of the intostiiios together or to the other pelvic and alxlominal organs. In the peritoneal cavitv % i Fin. 420.— Lyniplmtics of the ntorus : 1, lymphatics I'nmi the hody and fundus of the uterus; 2, ovnrv; 3, vatfinii ; 1, Kalloiiiaii tube; '>, lymphatics I'roiii the cervix ; li, lymphatic vessels from the cervix Koiiii! til tlie iliac Kaniilia ; ". lyiuphatii' vessels from the hody and fundus Koiiid to the lunitiar KaiiKl'a ; s, aiuis- tonioses of cervical and uterine vessels ; '.i, small lymphatic vessel in the round ligament Roins; to the iMi;iii nal glands ; Kt, 11, lymphatic vessels of the tubes which empty into the large lymphatic vessels from llie body of the titerus; I'J, ovarian lis;unient d'oirier). is found a fluid that may be serous, fibrinous, or jiurulent. Often this fluid very much resembles milk, and contains large clots like curdled milk. The inflammation starts in most cases from the endometrium and spreads through the lymphatics. Pleurisy and Pericarditis. — From the peritoneum the microbes find o:i<v access, through the stomatu of the diaphragm, into the lymphatics of tlic pleura and the pericardiinn, which become red, swollen, and injected, are i'i>\- on'<l with false membranes, and contain a sero-purulent fluid. Phlebitis. — The veins also often ofl'er, as has been noted, roads for tin' microbes to enter the system, although less frequently than do the lymph- vessels. Phlebitis occurs in the uterus t»r in the lower extremity. Uterine Phlebitis. — As we have stated, the thrombi (Fig. 421) that form in the uterine sinuses, where the contraction and retraction are imperfect, arc :i fertile soil for pathogenic germs. From the sinuses of the uterus the throiiilio- sis may extend more or less into the uterine and other veins. The thronilnis may become tunnelled, so that the vessel regains its lumen, or it may become organized into connective tissue and form a permanent plug. A piece of tlic PATHOLOGY OF THE PUERPERIUM. 697 thrombus may l)C torn off and he carried llir away by the blood-current, fonn- inj^ an ombohis, or the thrombus may become disintej^rated and be liquefie<l to :i ])uriform fluid which mixes with the blood and causes the condition known as pyemia. In this way the microbes may be carried throughout the bodv, Ibrming new foci of disease in all organs. Thus infarctions appear in the hings and lead to pneumonia and to pulmonary abscesses. The posterior part of the lungs is often the seat of hypo- static pneumonia. The spleen, which is large and soft, may contain infarctions, but these rarely suppurate. The kidneys are the seat of hyperemia and infarctions, llie latter often forming abscesses. In cases with a more clironic course amyloid degeneration niay set in. Some- times the loose connective tissue around the kidneys is inflamed, and there may form a perincphritic abscess. The liver may become the seat of hepatitis and hepatic abscesses. The nuicous membrane of the intestines is swollen, but no ulcers form. The heart is frequently affected by endocar- ditis, often of the ulcerous variety, by myocarditis, or by |K'ricarditis. The eyes may be destroyed. The brain and its meninges are rarely inflamed. The breasts, the parotid, the tonsil, and the thyroid body may become inflame<l and suppu- rate. On the skin appear erythematous, erysipelatous, ves- icular, or pustular eruptions. The articulations are often art'octed, and they may fall a prey to pyavthrosis, ending kki. i2i.-(iuts in si- iii ankvlosis. The subcutaneous and intermuscular coi,- "l'*""* ""^ '"••'■i'l'' "»"« noctive tissue may be infiltrated extensively with ])us, and Army Modicni Museum, form large shreds of mortified tissue. ' w,.siuu,'t..u, i...m. IVilchitis of tilt' Ler/. — The dise-ise kno\ n as ph/ci/mrifia alha (loloitf may be due either to phlebitis or to cellulitis. ( 'ffen both conditions are c(mil)in('<l. The phlebitis may begin primarily in the leg, or it may come on as a second- ary afl'ection alter the iliac and ovarian veins have become inflamed. In some cases the inflamrtiation of the vein may be secondary to thrombosis, and may again lead to pen{)hlebitis and cellulitis. In other cfses the process takes an inverse course, the inflammation of the connective tissue leading to phlebitis and thrombosis. The thrombi are subject to the san.e 'hanges as stated above. In the ])hlebitic form one or more veins form ,.!.d strings, and below the ol)struction the extremity becomes edematous an<' swollen. In tlie cellulitic lurni the skin is w' ite or pink, tense, and hard ; one or both legs swell, and the epidermis may be liftinl l)y a seron- .\ ad, tbrming large vesicles. The inguinal glands swell. Suppuration ml i..,)rtifieation may spread destruction ill the coimective tissue mulor the ,s'k'u or between the muscles. This pernicious form, howev(>r, is rnre. Acutest Septicemia. — In the sevcie ^ .-ases of puerperal infection the ahove-menti»med inflammations hardly find time to develop before tiie patient 698 AMERICAN TEXT-BOOK OF OBSTETRICS. Ufl i| I ' r if m iii succumbs. Still, there are traces of lymphangitis or phlebitis of the uterus, swelling of the connective tissue, and a little blootly fluid in different cavities ; the glandular organs of the abdomen are large, sofl, and friable, the micro- scope showing their cells to be in the condition called " cloudy swelling;" the blood is dark, thin, and only slightly coagulable. SYMPTO>ts, Diagnosis, and Procjnosis. — In treating a case of puerperal infection one would first like to know if he has to deal with pathogenic or with non-pathogenic bacteria. In some particularly well-appointed clinics an expert bacteriologist makes daily microscopical examinations and pure cultures, but most physicians have to form an opinion by the phenomena ob- servetl in the patient herself. In this respect three points are of great import- ance, namely : If the infection is caused by pathogenic microbes, the disease begins earlier, perhaps within a few hours after delivery, and certainly within a few days; the general condition of the patient suffers much more, and sh ' soon becomes somnolent; and, finally, the frequent, weak pulse and the l!it>li temperature bear witness to the presence of higher fever. But even an infec- tion that begins as non-pathogenic, or a condition that originally is not lausod by infection at all — for instance, a marantic thrombosis — may later change in character and end in sepsis. Some groups of cases arc so well marked in many respects that it facilitates the description to point them out. Thus there are localized cases, where the dis- turbances are limited tt) the genital canal and hardly affect the system in genernl. There is a lyiaphatlc form, in which the invasion takes place through tlio lymph-vessels, and which begins early and implicates the serous !i,embrancs, causing j)eritonitis, pleurisy, and pericarditis. There is a phlehiflc form, in which the microbes enter through the thrombi in the uterine sinuses. Tlic latter form begins later, progresses more slowly than the preceding form, and it is characterized by repeated chills and metastases in remote organs. Finally, there are cases of <ici(f('-'<f scptiectiiin, in which the ])atient succumbs before tlic usual inrtammations are well developed. But all cases cannot be divided into these groups: sometimes two forms are combin(Hl, such as lymphangitis and phlebitis; and often one passes into the other, as when an affection seemin<ilv local in the course of its development ends by becoming generalized. The writer prefers, therefore, to follow the anatomical distribution, and to describe the symptoms observcnl in each organ, adding remarks in regard to diagnosis and prognosis as he progresses from one to another. Vulvitis and Vaginitis. — Si/mptoms. — In the cahurhal form of vulvitis and vaginitis smarting occurs during micturition. The nlceratlve form is accompanied by slight rise in temperature, tlic labia being swollen and tender, and the ulcers being slow to heal, the process of reparation recpiiring so long as three weeks. The lochia are ot"ten fetid ; the patient complains of smarting when she urinates, and sorif times she sutlers from retention of urine. The fliphfhcrltic form is much more serious. It t»ejiiiis ofKr, with a chill, followed by high temperature, which may reach 107° F. This fevii' B PATHOLOGY OF THE PUERPERHM. G99 the uterus, mt cavities ; , the micro- 2l!ing;" the of puerperal athogenic or inted elinics ;is and pure lenomena oh- great iniport- s, the disease •tainly within more, and sli ^ and the l.ii''' even an iiit'et - ' is not caused iter change in at it facihtatos where the dis- tem in general, •c througli the IS hiembranes, (ebitie form, in sinuses. The ing form, and rans. Finally, nbs before tlu' ic divided into iphangitis and ti(m seemingly icralized. 'V\w luid to doseribc rd to diagnosis Irm of vulvitis iperature, tlic cal, the procerus often fetid ; he sutl'cr-' im^H s Olltl. with ii This fev.r l)egins generally from two to four days after delivery. It has no typical temperature-curve, except that there is a rise every evening. The pulse is rapid and weak, and the resj)iration is accelerated. The i)atient has iK^ appetite, the tongue is coated, the bowels are often loose, and she is fre- ijnently troubKnl with nausea and vonuting, .\s a rule, the uterus is implicated. It is large and tender, and the lochia i»ocome scanty, grayish, and offensive. The secretion of milk does not begin or the secretion ceases. The patient complains of pain in the hypogastric region, sometimes extending down to the legs. She has severe headache, and soon becomes stupid and delirious. These signs of general affection may pre- cede the appearance of the diphtheritic exudation For several days new ])atches form and the old ulcers spread. Fi'om the time the infiltration ceases '.uitil the scabs produced by the treatment recommendetl below are cast off and the sores healed about a week elapses. The labia are swollen and are coveral with the above-described patches. Erythema or erysipelas may start from them and spread more or less over the body. Sometimes the tissues become gangrenous. Cicatrices may cause considerable shortening and narrowing of the vagina. Diagnosis. — With a little care diphtheritic ulcers cannot be confounded with pus-covered tears in healthy tissue. These tears give rise to no general or local disturbance. Prognosis. — In the catarrhal and ulcerative forms of vulvitis the prognosis is good. The diphtheritic form, however, shows considerable mortality.* Endometritis and Metritis. — Symptoms. — The simple form of metritis is characterized by moderate fever, often begimiing with a chilly sensation ; some pain, espet^ially severe after-pains; headache, anorexia r\d a coated tongue. The lochial discharge is fetid, continues red longer than usual, or becomes so lisain after having been yellow. Tiie uterus is enlarged and tender. In regard to the (Jiplitheritic form the reader is referral to what has been said above under Viilritis. JJissccting metritis (Fig. 419) gives rise, as a rule, to a protracted (Mirnlent discharge. The jnitrcsccnt form shows symptoms similar to those I' ina in the most severe diphtheritic cases, and it is accompanied by a par- ticularly offensive discharge. J'rognosis. — In the simple form of metritis the prognosis is good. The disease lasts a week or two. In the di])htheritic form the prognosis is doubt- t'lil. the disease often ending fatally. The dissecting form has a better prog- nesis.t The putrescent form is nearly always fatal. Salpingitis and Oophoritis. — These affections apj)ear only together witii emlonietritis or peritonitis, and their symptoms are merged in those of the ivilanunation of the uterus or of the peritoneiuu. Cellulitis, or Parametritis. — The inflammation of the pelvic connective tissue in general begins with a chill or a chilly sensation, followed by fever, * 0{ 27 oases of puerperal diplitlieria, forming the base of a |ia|ier'" l)y tiie writer, five died, t Of 14 cases known, tiiree ended fatally. Of the writer's 8 cases oidy one died, wiiieh (Uatli was due to rupture of the uterus in consequence of an error committed by an assistant. :^i| i^i. ■P '% \. '^i 700 AMERICAN TEXT-BOOK OF OBSTETRICS. 'r -' 1 m anorexia, weakness, and headache. The temperature rises, the pulse and tlio respiration become more frequent, tlie patient complains of pain at the side ol' the uterus, and by bimanual examination we find the fornix of the vagina tendci' and a swelling extending from it in the direction of the iliac fossa. When the swelling increases, it pushes the uterus over to the opposite side. As a rule, onlv one side is affected, but sometimes a similar condition is found on both sides. The uterus is hardly movable. Severe neuralgic pains may extend down tlic lower extremities or up to the lumbar region, which condition nuiy be due to simple pressure on the nerve-trunks in the pelvis or to an implication of tlic nerves in the inflammation. If the inflammation attacks the connective tissiio of the iliac fossa, the corresponding extremity is drawn up and adducted, so that the affected kneo 'xsts on the other extremity. The extremity swells and Ix^- comes edematoi. Sometimes thrombi may be felt in the veins of Scarpa's triangle, of the \ j ' space, or of the calf. Usually the inti. , .ntion ends in resolution. If pus forms, the patient has repeated chills, the swelling becomes softer, and, finally, fluctuation may bo felt. The pus may be evacuated through one of the hollow organs — vagina, rectum, or bladder — or may break through the skin in more or less reniiito places, especially near Poupart's liganaent or at the crest of the ilium. Tlio abscess may now close, but often suppuration goes on, es])ecially if the abscess- cavity conununicatcs with the intestine, and, finally, the patient may die from exhaustion. In very rare cases the abscess ruptures into the peritoneal cavitv, causing general and speedily fatal |KM*itonitis. DiuffnoHls. — It maybe difficult to decide whether an exudation begins in tlic coiuiective tissue or in the jieritoneal cavity. Cellulitis nearly always starts from a torn cervix. The swelling is found on the side of the uterus, not behind, or, if so found, then only as a comparatively thin projection or bridixe. When it reaches the pelvic wall it follows the latter closely, while in perito- nitis the fingers may be inserted between the swelling and the bones. If the inflammation spreads in cellulitis, it often goes down on the side of the vaghia to the vulva ; a peritonitic exudation can only increase in the direction of the other side or upward, and it implicates, as a rule, Douglas's pouch, pushing the uterus forward. Pi'ognoiilH, — As a rule, the jirognosis is good. Generally, the process ends in resolution within two weeks. IJut it may be very protracted, even witiioiit suppuration. If an abscess is formed, the prognosis as to life and duration is less good, but even then with ]>ro])er treatment the patient generally re- covers. Rupture into the peritoneal cavity is fatal, unless laparotomy is per- formed. If cellulitis appears as part of the general infection, the result is very doubtful. Lymphangitis. — livmphangitis may start from the vulva and the lower part of the vagina or from the uterus. Vufvar lipnf)ha)i(jith is of little importance if it is arrested at the superlieial inguinal glands. The patient presents the usiud fever-symjUoms, and rod lines may be seen on the skin extending from the vulva to the groin. Tlio t .3 '■ •Tf" ■ ■ ion beo-ins in tlu> a and tho lower PATHOLOGY OF THE PUFAIPERIUM. 701 labia swell and smart. The glands very rarely snppuratc. If the inflamma- tion implicates the deeper inguinal glands, it may lead to peritonitis. Uterine lymphangitis (Fig. 420) is the most common beginning of general puerperal infection, but it may also continue as a local process. The patient -liows the usual fever-symptoms. The uterus is enlargetl and tender, cspe- rially near the cornua. The pulse is full. There may be a little vomiting and some tympanitis. Diagnosis. — Uterine lymphangitis differs from cellulitis and local perito- nitis in the absence of swelling at the vaginal roof; from general peritonitis ill the limitation to the lower part of the abdomen, the full pulse, and the absence of green vomit. Peritonitis. — On account of the diffp'-enoe in the severity of the symptoms and the prognosis it is expedient to consider local and general peritonitis s('|)arately. Local peritonitis, like tiie other localizations hitherto described, begins with a cliill, but this is much more protracted, lasting from ten to twenty minutes, and it is accompanied or is followed by a peculiarly intense pain in the lower part of the abdomen, which is extremely tender to the touch. The tempera- ture rises suddenly to 103° or 104° F. The pulse beats from 100 to 120 times per minute, and it is small and hard. The respiration is rapid. The t'over is continuous, with an exacerbation toward night. The patier.t has no appetite, but has an umiuenchable thirst. The tongue is coated. The bowels, at first constipated, later become loose. There is usually some vomiting of food, nniciis, and bile, and sometimes moderate hiccough. Tiie lower half of the abdomen is distended, and in order to lessen the tension the patient lies on licr back and draws up her knees. The secretion of milk is normal or is <('ant. The lochial discharge is diminished, is of a dirty color, and often is of utVensive odor. In the coui-se of a week or two a distinct tumor is felt in the pelvis and the lower part of the abdomen, which tumor is composed of the uterus, the append- ages, the intestine, the omentum, — all mattetl together with exudation and new- t( iined adhesioi.s. Below, the exudation is usually situated in Douglas's jwuch, jMisliing the uterus forward, but it may also be plai'tnl more laterally, pressing the uterus over to the other side, and at the same time canting it forward. The I'xndation pushes the fornix of the vagina in front of it, so that the cervix seems to disappear, and together with the corpus uteri it forms a pear-shaped body, witliout distinction between the two. The abdominal siu'tiice of the swelling is iMU'ven, and it offers a different degree of resistance in different parts. Often a peculiar sensation, much like that experienced in pressing a snowball, is felt on slight pressure, due to fresh adhesions being torn, as can be inferred from what we find in laparotomies performed after this crepitation has been i\'h. The swelling usually ends in resolution in the course of two or three weeks. Pain, fever, and swelling subside and the patient gradually regains her health. But the swelling may end also in suppuration, in which event ^if' -.^i; *' :'»■ 702 AJflJIilCAiY TEXT-BOOK OF OBSTETRTCS. W. the fever increases; tlu- patient lias repeated chills; the swelling softens and b(Hx)nies boggy, and sometimes fluctuating. If the alxscess tends toward the vagina, fluctuation may here be felt. If it progresses to the bladder, tlic patient feels a frequent desire to emjity this organ, and the act of niicturifiou is more or less painful. If the rectum is being imjjlicated, the patient com- plains of tenesmus. Wherever the abscess breaks a large amount of offensive pus, mixed with grumous masses, is evacuated. The most common, and at the same time the most fortunate, place of evacuation is through the vagina. In some cases after breaking the abscess may close at once, but in other cases, especially if there is a communication with the rectum, it may refill, or, if the pus is found in separate foci, the ]>rocess of elimination may be very protraetetl and exhaust the patient's strength. The pus may also follow tiw; vagina downward and oi)en in the ischio-rectal fossa. Enteritis, cystitis, or pyelo-nephritis may develop. PrngnoHis. — As a rule, local peritonitis ends in recovery, but it may become general and speetlily end the patient's life, or it may take so pro- traete<l a ..'ourse that she succumbs to exhaus^tion. As to complete restoration to health, the \>vi ino tlcation should be guard k1. Peritonitis leaves a ]>redis- positioii to new attacks. It often causes chronic oophoritis and salpingitis, makin*;" the patient more or less an invalid, and it is a frequent cause of sterility ; or, if she again conceives, she is more apt to have trouble in subse- quent confinements. General periton if is has symptoms similar to those of local peritonitis, but nuu'h intensified. It appears, as a ride, from two to four days after delivery, but it may also begin immediately after parturition. The chill lasts from half an hour to several hours. The pain is excruciating, and it sjireads over the entire abdomen. The pulse beats from 120 to 160 per minute. The temperature is 104° F. or higher. The respiration ranges from 26 to 56 per minute, and it is shallow on account of the pain produced by the movements of the diaphragm and on account of the compression of the lungs by the inflated intestine. The patient lies on her back, with the knees drawn up. Siie shuns every movement and dreads every approach. Even the weight of the bed- clothes may be intolerable. Her face expresses tiie greatest anxiety and pain. Her features are pinched, the corners of her mouth drawn down ; the eyes sink deep into their sockets, a black streak showing under each lower lid. The skin is ])ale ; the tongue is dry, red at the point and the edges, and brown in the middle. The thirst is Jinquenchable. The patient vomits continuously, and the vomit soon has the peculiar appearance of chopped spinach. Com- monly the patient has diarrhea, and is often racketl by hiccoughs. The urine, which is scant and often contains albumin, must frequently Ih' drawn with a catheter. The milk-secretion soon ceases. The lochia are scant, often fetid, or disappear altogether. The abdomen is enormously di>^- tended ; the percussion sound is tympanitic in front, dull at the dependent parts ; and the pectoral organs are |iMs!ied up and compressed. The patient often suffers from insomnia, and at the same time, as a rule, PATHOLOGY OF THE PUEllPERIVM. 703 g softens and s toward the hUuWor, the )t' micturitiim patient coin- it of offensive iiinion, and at srh the vagina. in other eases. may refill, or, 1 may be very ilso follow the tis, cystitis, or y, but it may ,y take so pro- )lete restoration leaves a pre<lis- and salpingitis, [■qnent cause of rouble in subso- she is in a somnolent condition, is slow to answer questions, or is completely delirious. From her li.stless lethargy she sutldeidy starts up as if scared by ;i))palling dreams and visions, and looks around with a pitiful expression of dismay and horror. In some cases the intellect remains clear "^o the last. Pror/nosis. — General peritonitis is one of the most dangcioi.3 forms of puerperal infection, but the patient may recover. Favorable signs are the ileercase in the frecjucncy of ihe pulse and the respiration, the fall in tempera- tnrc, the disappearance of j)ain, tiie cessation of tympanitis and vomiting, the return of the appetite, the increase in strength, the return of mental clearness, and a cheerful disposition. Unfavorable signs are an irregular pulse or one beating more than 140; a temperature above 104° F. ; a laboriotjs respiration, over 40 ; a copious diarrhea ; cold, clammy extremities ; the appearance of red blotches on the skin ; a profuse perspiration ; the subsidence of ])ain, while the distention of the abdomen remains the same or increases. Death ol;„, ""s usually in nine or ten days, except where an abscess ruptures into the peritoneal cavity, when life becomes extinct in a day or two. What has been said above about the doubtful return to perfect health applies still more to general peritonitis. Pleurisy. — Pleurisy, as a rule, is secondary to peritonitis or to phlebitis, but it may be a primary lesion. The fluid is sero-purulent, like that in peri- tonitis, except when it is due to an infected embolus. In such cases the fluid is ])in'ident. When pleurisv supervenes in the course of periton 'is it is easily overlooked — so much more so as, on account of the patient's sufferings, we often cannot make a ])hysical examination. Its advent may be marked by a now chill, by increased fever, and by still more embarrassed respiration. Prof/noHis. — Pleurisy is a very serious complication in childbed. Pneumonia. — Pneumonia appears as hypostatic jmeumonia in the most dependent part of the lungs or in disseminated I'oci due to embolism in any jiiirt of the organs. It is generally combined with pleurisy. The usual syni])toms of the disease — pain, cough, bloody expectoration, and dyspnea — may be missing, when it can only be diagnosticated by the stethoscopic signs — ere]>itant rales, bronchial respiration, and dull or flat j)ercussion-sound. l*rof/nnsiK. — Pneumonia is a dangerous affection in a puerpera. Pericarditis. — Pericarditis may be pro]>agated through the lymph-vessels of the diaphragm from peritonitis, or may be due to emboli from a venous thrombus. Tlie Kj/mpfoms generally become merged into those of other inflammations. Siiinetime,s, however, a friction-sound or an increased dull area reveals the presence of false membranes cm* of exudation aroinid the heart. Phlegmasia Alba Dolens. — Tlie thromho-ph/chitic form of phlegmasia may begin during ]>regnancy, and is accomjianied by fever and a sensation of heaviness in the limb. Commonly the inflanunation begins in the .second week after confinement. Sometimes the local affection is preceded by anorexia, a l>a(l taste, a coated tongue, constipation, and eructations. The phlegmasia begins with fever and, perhaps, a chill. The urine is concentrated. If the 704 AMERICAN TEXT- HOOK OF OBSTETUICS. fi li. !, thrombosis begins in tlie leg, tlie latter swells from the foot upward ; but if the leg is seeondarily att'ected after tlie pelvic veins, the swelling spreads in tli(! opposite direction. The extremity is painful ; the skin is white, tense, hard, sometimes covered with blisters, or it may become red and be perforated l)v an abscess. The Jift'ecttHl veins may be felt as hard strings. Both extremities may be atl'ecteil, the thrombosis passing from one side to the other through the vena cava, or beginning independently in cither extremity. The phlegmasia usually runs its course in from three to six weeks, and ends in resolution. It may pass into suppuration and the patient still ret^over. Sometimes gan- grene sets in anil leads to death, or sejjtici'mia may develop. Varicose veins are more lial)le to the formation of thrombi than healtiiv veins. If the deeper veins are affected, the skin luis a peculiar purple color, which variety has been distinguished under the name of phlegnmsia ccemlva dolena. As a rule, the thrombus is reabsorbed, and the swelling subsides. In other cases there ibrms a periphlebitic al)scess that breaks on the skin ; and in still others the thrombus may become infectetl and give rise to metastases just like those which will ]>resently be described under Uterine Phlebitis. The celluUtiG form of phlegmasia is characterized by high fever, by con- siderable pain, by redness of the skin, by the appearance of bullae, and by extensive suppuration and mortification of the subcutaneous and intranuis- cular connective tissue. Large shreds of connot'Jve tissue may be expelled and the sores heal, but there is great danger of the patient falling a ])rev to gangrene or to septicemia, or of being exhausted by the protracttnl suppuration. Uterine Phlebitis. — The veins of the uterus may be blocked by simple thrombosis, which may extend more or less into the pelvis. If the iliac vein becomes implicated, j)hlegmasia alba dolens supervenes. If pathogenic microbes find their way into the uterine simises, there develops infectious uterine phlebitis — one of the severest forms of puerperal infection. Uterine phlebitis begins with a long and severe chill, followed by similar attacks at irregular intervals, and it is characterized by metastases in one or more organs. The chills are due to the entrance into the blood of microbes or of their chemical products. During the chills the temperature rises to from 104° to 108° F., the pulse beats from 140 to 160 per minute, the res- piration becomes as frcfpient as from 36 to o6. Rarely the patient, instead of real chills, has oidy chilly sensations. In the interval between the chills, especially after the first chill, she feels great relief, the temperature sinking to 100° or 101° F., and the pulse and respiration betHMuing less frequent, in this form of puerperal infection there is no pain, little tenderness, and no tympanitis. After the lull of the first interval new chills follow, and the more meta- stases are developed the more the fever becomes contiimous. The skin turns yellowish, and sometimes complete jaundice develops. The nose becomes pinched; the eyes lie deep ; the cheeks are hollow; the tongue is dry and coated. The patient has no appetite, but has great thirst, headache, insonmia, PATIlOlJHi V OF THE PI ERPERIL'M. 705 ard ; but it' jreuilrt ill th(i tense, hanl, ortbratal l)y li extremities [•through the c phlegmasia in resohitiuu. iiuetimes gau- than heaUliy r purple color, rnuisJrt ccendca subsides. In c skin ; and in metastases just bit'iH. lever, by con- l)»dl«, and by and intramus- lay be expelled foiling a prey the protracted ,eke<l by simp'" f the iliac vein If pathogenic relops infections 'ection. )wed by similar istases in one or )od of microbes leratnre rises to minute, the res- tient, instead of ,vcen the chilis, ature sinking to 3, frequent. In derness, and no the more meta- The skin turns |e nose becomes Lgue is dry aii»l [lache, insonmia, sometimes diarrhea, and less fre(|U('ntly von>iting. Frequently the breath has ;i peculiarly disagreeable smell, designated as "sweet." The urine is scant, iiiul it almost always contains albumin. The secondary infection appears first in the lungs, then in the pleura, tlie heart, the liver, the kidneys, the spleen, the intestine, the meninges, the brain, the eyes, the articulations, the skin, and the connective tissue. Pneu- monia, pleui Isy, and pericarditis have already been describetl, and the other !(l(•alizatitnl^ will presently be noticetl. J)i(i(/nosL'i. — Uterine phlebitis in the beginning is somewhat like malarial J'cvcr, but the chills are repeatetl at irregular intervals and the fever soon becomes continuous. Swollen veins may be felt in the pelvis, and phlegma- sia alba dolens may supervene. There is often metrorrliagia. The appearance of metastases is characteristic. If adynamic and ataxic symptoms develop, the disease may be mistaken for fiiphoid fever. First of all, we must know if the patient is or is not a piu'i'pera. If she denies having recently given birth to a child, it can easily be proved by the presence of milk in the breasts, by the flaccidity of the abdominal wall and the presence on it of purple-colored strioe, by the large size of the uterus, by tears in the cervix, in the vagina, or in the vulva, and l»y the presence of lochia. Typhoid fever may develop in the puerperal state, but that is a very rare occurrence. It is ciiaracterized by the continuous fever, by ochre-eolortnl stools, by tenderness on pressure in the right iliac fossa, and by the appear- ance of a few discrete, small pink spots on the abdomen. Visceral complica- tions are rare, and at the end of the third week a decided change takes place for the better or the worse. In uterine phlebitis there may be gargouillement, but no tenderness, in the right iliac fossa. There may be cutaneous eruptions, but they are spread over larger surfaces as erysipelas, general erythema, large blotches, papules, or pctc'chite. There is no regular fever- curve. The disease begins with very high temperature and a pronounced chill. The temperature then falls sud- denly nearly to normal, to rise again with the next chill. Complications in ditterent organs are a chief feature of the disease. The distinction between iiter'nia lipnphauf/itis and phlebitis is more of scien- tific than of ])ractical interest, and frequently the two are combined. Lym- phangitis usually begins from two to five days after delivery ; phlebitis usually begins at the end of the first week. In lynqihangitis there is pain in the lower ]>art of the abdomen ; in phlebitis there is hardly any pain. In lym- phangitis there is great tenderness on pressure ; in phlebitis there is none of the abdomen and little in the pelvis. In lymphangitis the uterus is large ; phlebitis has less influence on the involution. Ijymphangitis spreads rapidly upward, and may cause peritonitis, pericarditis, pleurisy, hypostatic pneumo- nia, but it does not affect the head or the limbs nor cause pyemia with infarc- tion and abscesses in the viscera. Lymphangitis may begin with a chill, but this is not so severe as in phlebitis, and it is not repeated. In lymphangitis 45 U.'!, 1 i' TOO AMKIiJVAX TEXT-BOOK OF OBSTETRfCS. 'm l;i I; »» I , 'il tlio fever is more coiitinuoiis; in phlelntis there are very niarketl fever intcr- luissions or r('inis.si()iis. Endocarditis. — Eiulooarditis appears late in the piiorperiuin — from ten u> fifteen days after delivery. It is ac(;ompanie(l by an inerease in fever ainl somnolence, and jjives rise to a rasping sound, especially at the apex, more rarely at the base. This nun'inur is jjenerally synch rolious with the fii>t heart-sound, but it may also be heard with the second. It shows a peculiiir mobility, beiiifj heard one day at the apex, the next at the base, or vice irrmi. Endocarditis iscommoidy ulcerons. When the small abscesses in the cndo- cardinm break, they empty their contents — pus, microbes, and their cheniicil products — into the blood-current, which carries them throuj^h the entiic system, causing new localizations of the infection ; but the symptoms of (licsc abscesses are so merged into those already |)resent that they camiot be distin- guished. The supervention of endocanlitis in uterine phlebitis makes the pro(/)wsix still more unfavorable. The (dlmentdrij cantil does not suffer much in uterine ]>hlebitis. We have, however, mentioned the complete anorexia, the unquenchable thirst, the pro- fuse diarrhea, and the occasional vcmiting. Sometimes thrush appears on tlie dry tongue. In rare cases abscesses are formed in the parotid, the tonsil, or the thyroid body, the appearance of which abscesses makes the prognosis more unfavorable. Hepatitis. — The liver is very frequently implicated in puerperal metro- phlebitis. There is pain in the right hypochondriura. The organ is eidargcd, as can be found by percussion and ]>alpation, and it is tender on pressure. The skin has a yellow tint, and often real jaundice develops. The serous coat is often implicated in peritonitis, and then sometimes, on slight pressure, tliero can be felt the crepitation characteristic of new-formed adhesions. Nephritis. — Intlamination of the kidneys, which is a very frequent occin-- rence, is characteri/ed by the presence of albumin and casts in the tu-itie, whereas the other symj)toms, such as headache, somnolence, disturbed eye- sight, vomiting, and ])ain in the lumbar region, are so covered by the general condition that they lose their diagnostic importance. An inflammation of tlip loose coimective tissue in which the kidtiey is imbedded may cause constant tenderness on ]>ressure in the lumbar region. Splenitis. — An inflammation of the sj)leen may sometimes be diagnosti- cated by palpation and an increase in the normal dull area in the left liypo- chondrium. The patient may com])lain of pain and tenderness in this locality. If an abscess ruptures into the peritoneal cavity, she collapses and dies. Generally the symptoms due to localization in the spleen are, however, so blended with those due to other localizations and the general condition that they are not recognizable. Nervous Disturbances. — Manifold distiu'bances occur in the nervous system during the puerperal state, such as neuralgia, paralysis, convulsions, tetanus, tetany, insomnia, delirium, etc., and need not be due to infection, but to anemia or hyperemia of the brain, hysteria, pressure on a nerve-trunk, or a nrn, /'AT/lO/J)(,'y or Till': PVEItPKHltM. 707 li ii-^ I fever intci- — from ton tn in fovcr iiixl nc aiH>x, move with the tiiM ,()ws a pcculiiir ? or t'KV cccs". ort in the ciulu- tlioir ehcmitiil ujvli the entire iptoms of these uuiot he (hstin- Ditis makes the hitis. We have, ; thirst, the i)ro- \\ appears on tlie id, the tonsil, or es the prognosis puerperal nietro- DVgan is enlar>r;e»l, uler on pressure. The serous ooat it pressure, there ions. k- frequent oecnr- ists in the urine, :e, disturbed eye- •ed by the general flammation of the lay cause constant ,iics be diagnosti- in the left hype- .ss in this loeulity. Dllapses and dies. are, however, so L-al condition tbut Ir in the nervous Ilvsii*, convulsions, |,e to infection, but , nerve-trunk, or a reflex action. Severe affcH'tions of the nervous svsteni niav be due. however. » • 7 / to tlirond)osis of the cerebral veins or to purulent meningitis, produced l)y metastasis from an infected endometrium. Arthritis. — Sometin.es the infecting agents in metro-phlebitis are carried lo the joints. At the beginning nuuiy articulations may be allectod, but wliilp I lie inflammation subsides in most of them, it may remain in one or two, i'-|)e('ially tlioise of the knee and shoulder. Of the articidations of the trunk, the symphysis pubis, the sacro-iliac, and the .steru»)-clavicidar are most fre- quently affected. Puerperal articidar inflammation differs from rheumatic inflammation by its .stability, and from both this and the gonorrheal type by its pronounced tendency to suppuration. The aflected joints become ])ainful, the j)ain being ninch increa.sed by movements or by pressure. The skin becomes red and hot, and if there is an abscess in the artietdation, the joint may i)e perforated. All tlic tissues composing tlie joint, even the cartilage and bone, may be destroyed. If the patient survives, the afTected joint may remain ankylosed. Abscess and DiflFuse Cellulitis of the Limbs. — lioth the subcutaneous and the intenuuscular connective tisstie may become the seat of localization of puerperal infection. The lind) swells and is painfid. The skin be<;omes nnl and hot. Cireinuscribed ab.scesses may form, or, especially in the sid)fascial form, a diffuse phlegmon may extend over a large area — a form which is very tiangerous, and which may cost the patient her life or it may leave her in a crippled condition. Skin Diseases. — A puerpera may, as well as another per.son, be attacked l)y eruptive fevers, such as measles, .scarlet fever, small-pox, or erysipelas, as an accidental complication. She may likewise have .some kind of eruj)tion in consequence of the use of certain drugs — for example, copaiva, quiniu salicylic acid, or iodoform. A milUwy eruption, consisting of small white vesicles, sometimes each sur- rounded by a red ring or springing front a red skin, is often found in an otherwise well woman, and is only due to increased perspiration. This eru])- tion is generally found on the trunk. Sometimes an eruption of red macula) or papuhe, or a general erythema, accompanied by more or ''■>■ s 'ever, appears on the skin in pue-pera? who present no other sign of disea.se. Ihit in othe»' cases the skin-eruption accompanies other symptoms of severe puerperal infection, and it must then be regarded as ])art of the infection. An erythema may spread more or less far from the genitals, or large erythema- tous blotches may apjiear on any part of the body. Small dark hyperemic spots of the size of a hempseed — so-called "petechite" — that do not vanish on jtressure, may appear in very severe, generally fatal, ca.ses. Sometimes there is a pemphigu.s-like eruption, the epidermis being rai.sed by a serous exudation, forming large vesicles. In other cases, again, bullte fillet! with pus develop, rupture, and leave sores. Finally, infected puerperre are very liable to have bed-sores, especially on the sacrum and the heels. In all those cutaneous aflections that appear as 7(W AMinni'AX riLXT-nnoK of oiisTirntics. part ul" a griiiTal iiil'wtit»ii the syiuptorns <(t' the latter cover thoae (»1' tin Ibrmcr. Acutest Septicemia. — Tlii.s form, the iiutst (laiij^erourt of all forms ul Ijiierperal infection, lias, fortunately, become very rare, and lias entirely (li>. appeared from well-conducted lyiiifj-in hospitals, institutions where it formerly raged in the so-called ''epidemics" of puerperal Jvrcr. It l)e<iin.s soon after ilelivery with a long and severe chill. The pi 1 the respiration are rapid. The temperature in some cases may be hi^n, ami may remain so without the remissions characteristic of puerperal phlebitis, but in other cases it is normal or even sidmormal. The features are pinched, the skin pale or purplish, and the tongue dry and brown. The patient is in a somnolent, comatose, or delirious condition. She has fre(pient involuntarv, copious, dark, and offensive evacuations from the bowels. The urine is scant, nnd it contains nnich albumin. The course of this form is rapid and ends in «leath in a day or two. Tkkatmkntuf Pikui'KRAL Infection. — Puerperal infection being a biic- terial disease, its treatment, preventive as well as curative, must chieflyj)e germi- cidal. Asepsis and antisepsis are the watchwords in the warfare against it. It is an interestip,:.^ historical fact that the great discoveries which form tlio base of all antisi-ptic surgery were made by obstetricians long befor tin y were independently made by surgeons, but that the obstetrical discov lid not succeed in changing the treatment of puerperal disetise by oth^. ^.ac- titioners until the surgeons stirred up the entire world by their wondeil'iil achievements by means of antiseptic measures. The father of antiseptic midwifery was Senn.solweis of Vienna, who as early as 1847 understood that so-called "puerperal fever" was due to infec- tion, and who used chlorin, one of the best germicides, in the sha|)e of chlo- rinated lime as a disinfectant. But his g;'eat discovery remained an uncut diamond, lying despised in a corner, for a whole generation, the discoviTur meanwhile dying in a mad-house. It was when the Scotchman Lister, apply- ing the discoveries of the French chemist, Pasteur, to surgery, had laid tliu foundation of antiseptic surgery (1866), that the Danish obstetrician, Stad- feldt, and the Swiss obstetrician, Bischoff, simultaneously (1870) introdiiml the use of carbolic acid in midwifery.^^ In 1881 the French obstetrician, Tarnier, read a paper before the Iiitor- national Medical Congress assembled in London on his use of biehlorid of i.ercury as a local remedy for puerperal fever, but no one seems to have paid any attention to it until the German bacteriologist, Robert Koch, published his experiments with this drug, and the German surgeon, Schede, introdiicod its use in surgery. The biehlorid of mercury, as a preventive and curative agent, was then (in 1883) introduced in many lying-in hospitals. In America it was first introduced in the New York Maternity Hospital by the writer on the 1st day of October, 1883. While the revolution in the residts as to morbidity and mortality iVom puerperal infection dates from the introduction of biehlorid of mercury, it PATiiouxn' o/' Till-: rrHni'iinnM. im thtwo of till' all tonus 111 ^ I'lttiivly <li" ero it tuni»oily The \Y 1 y be l»i^", »'>'l i>onil phlebitis I'Orf are {)ii»el>i<l, e pntient is in ii nt involuntiuy, le urine is seant, ipiil and ends in stion being a bm- chiefly.be genui- are against it. s which t'onu the long betbr they al discov h'l ic by otl.-- .■■•"■- J their wonderful Vienna, who as was due to infk- |je shape of cliVi- l.iuainetl an uncut ,n, the discoverer lan Lister, apply- gery, had laid tlie |obstetrician, Stad- 1(1870) introiluml before the Inter- ne of bichlorid of seems to have vaid It Koch, publisluHl Ischede, introduood Intive and (nuativo Lin hospitals. 1" Irnity Hospital l>y nd mortality fn"" [rid of mercury, it lia^s, however, been proved that tlic true <'anso of the improved result-; i:« not 1) be .sought in the drug, but in its application ; that is, the xtfift disinf«>etion i)f hands, instruments, dressing-material, etc. Some large clinics, such as those of Copenhagen and \'icuna, yet cling to the use of carbolic acid,'*^ and obtain just as goo«l results as tluwe in which this drug has been supplanted by liiehlorid of nwreury. If ever a medical fact has been proved by figures, the latter have proved ti»e value of the antiseptic trciUment in midwifery. The testimony from over the entire world, inde|)endently of geographical position or climatic ditt'erenccs, is unanimous. Counting by thousands, hundreds of thousands, and millions, the liiiures are too large to be vitiated, the new treatment l)eing now in the elev- enth year of its probation. It would be tiresome and unprofitable to enter deeply into statistics, but the writer can hardly begin the discussion of the treatment of puerperal in- t'retious diseases in a better way than by showing, in a few lines, what the mortality formerly was and what it now is in the institution to which he iiail the honor of being a visiting obistetric surgeon for a period of over ten years (1881-02), and with which he is yet connected as consulting obstetric surgeon. The records of the New York Maternity Hospital .show the following mortality before and after the introduction of strict antiseptic treatment with bichlorid of mercury : Year. Dt'UviTli's. Deaths. I'cr t'lMil. IST.'i 570 5S6 480 255 254 149 ,S82 431 447 15 20 32 7 11 8 9 14 30* 2fi3 1876 1S77 3.73 6.67 2 75 1878 1870 4.33 1880 1881 5.37 2 3(5 1882 1883 3.25 6.71 Total 3504 14G 4.17 * All during the first nine months of the year. During the last six months before the change in treatment was made there wore delivered 237 women, nineteen of whom, or 8 per cent., die<l, and of those seventeen, or 7.17 per cent., succtimbed to sojisis. During the last month the total mortality reached even ten out of fifty, or 20 per cent., and tiiat from sepsis 15.69 per cent. During the first three months after changing the treatment there were 102 (lolivories, without a single death — a circumstance which then apjjcared almost miraculous, but which lias become quite a common event, and has later been oxtoudcd over much longer periods. The following list shows the mortal- ity in the Xew York Maternity Hospital since the introduction of strict anti- sepsis : 710 AMERICAX TEXT- BOOK OF OBSTETRICS. ■\l\ l'< W. m Delivcrifs. Mortiility. Per cent. Yonr. Total. From Hi'psi.s. Total Mortiility. 1.53 0.5t> 1.12 1.30 0.79 0.32 1.13 0.42 0.32 O.OG 0.87 From St-psis. 1884 522 537 44ti 389 377 314 345 240 314 305 3789 8 3 5 5 3 1 4 1 1 2 33 4 1 1 1 0.70 1885 0.0 188() 0.22 1887 1888 ... 1889 0.2(j 0.0 0.0 1890 18<ll 0.29 0.0 1892 1893 0.0 0.0 Total 7 0.18 uu ^. I Thus, dwimj the last {lure i/earx, out of 10o9 padiwient ivomen, only four dial, or O.o7 per cent., and not one of them from injection. By comparino; the jiroccdiiij;!; lists, awh ctjiuprising nine years, we find a decrease in mortality from 4.17 to 0.87 per cent.; that is, the mortality has been reduced nearly to one-fifth of what it used to be. In regard to morbidity a .similar change lias taken place, but the writer has no exact statistical material to otl'cr as proof He must, therefore, contiiie himself tc an e.xample. During the six months from October 1, 1882, to April 1, 188."), a period for whicii ho ha.s exact notes respecting tlie whole service, 192 women were delivered, forty-six of whom, or nearly o)ie out of ft-ir, tvere fierious/y ill, and thirty-nine, or nearly one in five, sutfered from puerperal inflammation, wliich now-a-days is looked upon as due to infection. A sick puerpera has now become a rare sight in the wards of the Maternity Hospital. A certain class of ca,ses is particularly interesting, because all the symptoms of cellulitis — namely, pain, tenderness, and swelling in one of the iliac fo.ssa^ — were present, and still there was no rise in temperature — a phenomenon which can be accounted for oidy in this way : that the condition was due to bruis- ing of the tissues, and that our antiseptic treatment prevented the infection which so easily develops under such circum.stances. Passing to an exposition of the treatment of puerperal infection, we nuist distinguisii between (1) hospital practice and (2) private practice, (3) lU'cvciit- ive and curative treatment, and (4) surgical treatment. 1. Prevention of Pferperai. iNFFirnoN in H()spit.\i,s. — Parturient women ought to be provided for in institutions exclusively designed for ob.stetiic purposes, and not in general hospitals. Before the introduction of antisepsis the mortality was much greater in the wards of general hospitals devoted to obstetric cases than in special lying-in asylums ; even after the introduction of anti.septic j)rophylaxis it exposes parturient women to increa.stHl risks to l)o treated by the same doctors and nui'ses who have charge of the sick, A lying-in hospital ought to have a fi'ce .supply of pure air, which onulit to circulate freely under the building, whether there be a cellar or thebniM- ing be erected on pillars. If possible, there ought to be in the wards artilirial U' t <! i PATHOLOUY OF THE PUERPERIUM. 711 1M ; I'or cent. itnl \ From ality. Si'l)'<'S- 53 0.7 1) .51) 0.0 .12 0.22 .30 0.2G .79 0.0 ).32 0.0 .13 0.29 ).42 1 0.0 1.32 0.0 \iXS'iS 0.0 0.87 0.18 n, only four dial, years, we find u he mortality has )ut the writer has therefore, conlino tober 1, 1882, to leetitij? the wholo rlij one ouf ofjo'ir, ed tVoiu puerpi ral infection. A sick )f the Maternity all the symptoms if the iliac fossio— henomenon whicli ivas due to briiis- uted the infection liiifection, we nuist jctice, (3) prcNout- L^,,s. — Parturient liirned for obstet ric lotion of antisepsis kspitals devoted to (he introduction o( K'ased risks to l)o of the sick, air, which ouiilit tellar or the bnilil- Ihc wards artili'ii»l ventilation, which can only bo obtained in the hij^hest degree of perfection by large fan.s revolving under the building and throwing pure air into the wards. During the season of cold the air is heated before being forced into the wards liy the fans. Where there is no artificial ventilation the windows must be kept more or less open at the top day and night the year round. Although this proc lure iiitcrteres souujwhat with the normal persj)iration in childbed, the writer has never observed any harm arise from it in the Maternity Hospital : this inuuu- uity probably is due to the habitual exposure of the special class of women there confined, for in private practice the writer has seen coryza, bronchitis, ;iiid pneumonia originate from a similar procedure. The building should preferably be so situated that the patients may get the morning and evening sun ; at all events, a northern exposure should be avoided ill the tcniperate zone, and a southern exposure in very hot climates. EvcJi tlie smallest lying-in hospital sliould have one or more special rooms for isola- ting sick |)atients from the other puerpera). There ought to be a regidar and rapid rotation in the use of wards. Ju tlic fraternity there are nine beds in each ward, and as soon as th<} last patient has becii there nine days the ward is temporally abandoned and disinfected, tli(> same bed never being used by more than one and the same patient before liciug throughly disinfected. On the ninth day the patient is transterred to the convalescent ward, where she .stays until well enough to leave the hospital. Pregnant women ought to be kept in special waiting wards apart from partu- rient and puerperal patients. The former often stay for months in the Maternity lli.spital, and it is more difiicult to keep discipline among them. Pregnant women need other food and regimen ; they are less clean and less (piiet ; they would be exposed to mniecessary anxiety by witnessing the suHerings of the ]>artin"ient or sick puerperal women ; and they might, perhaps, even become iiifccteil before their delivery. The parturient woman ought to be delivered in a spe(;ial delivery-room, a so-called " j)ony-room." * As the infection most tmpieutly takes place dur- ing parturition, the woman shoidd be delivere<l in a room where everything is kept strictly a.^eptic, and by all means not in a room where there are sick pncrpene. riiere should be an easy eomnnmication between the d(>liverv-room and the wards, so that patients need not be carried far or be expo.sed to inclement weather; yet there shonhl be no direct eomnnmication. In the Maternity Hospital this condition is obtained by having small covere<l corridors, open on one side, between the delivery-room and the wards. The wards shoidd likewise be separated from one another. They should liavc plenty of light, preferably from two opposite sides. Light from above is only needed in an operating-room. .\11 cross-bea'us and projections should *'riie writer bclit'Vi's this singular I'-xpreasion comes from a small luni, a kindof ont, wliicli was (mIIciI a "pony," and wliiiii wius useil for (lelivories in olden times, as it yet is in some countries - lor example, Belgium. .■r*T. I':.' P V " 12 AM E It I VAX TEXT-BOOK OF OJiSTETRIVS. bo avoiclod, as tlioy hocome reccptaclo!; for dust, which may become a oarriin- of germs. Tlie floor and walls should be hard, smooth, and not porons, so tliat they can easily be kept clean by scrubbing and be disinfected with fluids or with vapors. It is well to have separate rooms provided for patients who have undergone serious operations. The (piestion of heating is important. It is best to have a combination of different systems. Warm air may be thrown into the wards by fans ; steam may circulate in pipes: both these methods ensure a steady supply of heat, and prevent the water from freezing in the supply-pipes in cold weather. 0|)en fires are cheerful ; they give a very pleasant radiating heat, contribnt(> to ventilation, and offer an easy way of disposing of small unclean substances, which otherwise mav accumulate and vitiate the air in tlr a1. Stoves com- bine to some extent the (pialities of a radiator and an op. ii flrc, and they are more economical. IJy the evaporation of water the air should be prevent(>(l from becoming too dry. The isolating department should be separated entirely from the eomtnoii wards, and each patient should exclusively cMxnipy a room. This departnunt should have a special doctor and special mirses, who are not allowed to enter the wards. The physician-in-chief alone shotdd see the whole service. Water-closets should be of the very best kind, and never be situated in the wards or in the rooms. They should not even comnHuiicate directly witii the wards or the rooms, but should hv separated from them by vestibules with two doors. In the space between the doors a window should constantly Ix' open, and tlie doors should close automatically, There shoidd be a place where all linen and bed-clothes used by sick puerperse can be disinfected by immersion for an hour in bichlorid solution (1 : 1000) before they are washed ; if mattresses are used, there should be a room where they, as well as the blankets, can be fumigated with sulphurous acid by burning sidphur or be disinfected in' exjxtsure to sujx'rheated stcaii). No visitors should be admitted to the wards, as they often come fnnii crowded tenement-houses in which there \\\i\\ be cases of measles, scarlet f'cvd', small-j)ox, or diphtheria. The members of the house-staff shoidd not be allowed to enter the wards occupied by otlier patients, the isolating-rooms, the dead-house, and still Ic^s be permitted to make autopsies or to handle anatomical or pathological specimens. DlsiXKrxTlON. — To niake the all-important point, disinfection, as clear as possible, the writer will first simply describe how it is carried out in the Ma- ternity Hospital, and postjione for the time being all the mooted points that are being discussed in tlie medical journals. The principle upon which the disinfection is based is the belief that puer- peral infection is due to bacteria foinid on the patient, on doctors and muses. on all surrounding objects, on everything brought in contact with the genitals, and in the air of the room. We will, therefore, have to consider the disiiil'ic- tion of the wartl with its furniture, of the patient and of those who minister iiiiJ IMP' PATIIOUXIV OF THE Pf!i:iil'i:iiJ(M. 71;^ to hor, of all instruments and materials that come in contact with her, and of the air that reaches her genitals. Ward Dmufccfiou. — When the last patient has been nine days in a ward it is not used again until thoroughly disinfected. The bed-clothes are taken oil" the beds, the linens are sent to the laundry, and the blankets are s[)read nver the ends of the bedsteads. All windows and doors are closed. Thirty jxHuids of sulphur are placed in an iron utensil composed of an upper and lower pan connected by three uprights. The sulphur is ])ut in the upper pan and is moistened with alcohol. The lower pan is filled with water, which would cxtitiguish the fire in case the upper pan was burnt through. After lighting the alcohol the ward is left closed for at least six hours. Afler that time all doors and windows are opened, and, if the ward is not needed immediately, they are left open for several days. The walls, the floors, and the furniture are scrubbed with soap and water, and thereafter with a solution of bichlorid ol" mercury (1 : 1000). So long as straw mattresses were used the straw was burned ; the patients now lie on woollen blankets spnuid over a woven-wire mattress. All iKHl-clothcs used by sick puerpene an; first immersed for an hour in the solution of bichlorid of mercury, and are then preliminarily washed before sending them to the hospital laundry, where they are mixed witii the other iMMl-linen. Patients and nurses wear only such clothes as can be washed. The clothing of the doctors, when required to be disinfected, is suspended ill a small room and fumigated with sidphur. Dwnfcsthif/ the Patient. — When a patient is taken in labor she is given a lull bath of tepid water, being thoroughly scrubbed witii soap, and dressed ii! clean clothes. She is next place<l on the delivery-bed on a riil)ber blanket tliat has iK'en disinfected with bichlorid (1 : 1000), and the lower half of her hixly is washed with bichlorid of inen^ury (1 : 2000), taking particular can; to (lean every furrow at and near the genitals and the umbilicus. The vagina is irrigated with two quarts of an emulsion of creolin (1 : 100), using metal irri- ixators. In case bichlorid is used, the irrigators are painted with an incor- rodible substance. Disinfection of the Docfom and NurxeN. — The accoucheur takes off his coat, vest, necktie, collar, and cuffs, rolls up the sleeves of his shirt and iiiider-wcar til tlie middle of the arm above the elbow, and covers himself with a large nihlter apron reaching from the shoulders to a little above the ankles. He next anoints his hands and arms with soft potassa soap, and scrubs them tliin'oiighly witli warm water and a stiff nail-brush, taking particular care to clean the sj)aees under the nails and at their roots. He (hen wii)es his hands and arms, and scrapes his finger-nails with a stecil nail-sciaper, and, finally, he scrubs all these parts while holding them for at least three minutes in a solu- tion of bichlorid of mercury (1 : 2000). He is now ready for work, and must iKit wipe his hands or arms. JJut, as it is next to impossii)le to avoid touching (lill'cront objects from which new disease-germs may be transferred to the hands of the physician, a basin with a warm solution of creolin (1 per cent.) is kept .■r^ I ] ! < 1 y i K f^ '■• ■ i ! 714 AMERICAN TEXT-BOOK OF OBSTETRICS. at the bedside, and with this sohitioii he rinses his hands at the moment before touching the patient. Tiie nurses disinfect themselves witli the same care and in the same manner as the doctor. If the accoucheur has had a patient affected with puerperal infection, ery- sipelas, scarlet fever, suppuration, or other tlisease likely to cause puerperal infection, he must take special precautions. If possible, he should stay a quarter of an hour in a full warm bath containing two drachms of biehlorid of mercury, washing the hair and beard carefully while in the water. At all events, he should scrub his hands with greater care than under ordinary circiuu- stanees, and should inunerse them a longer time, say five mimites, in a stronger solution (1 : 1000), or, what is claimed to be still more efficacious, in alcohol. Dmnfvctimi the Mnteriah. — All materials coming in contact with the gen- itals, such as absorbent cotton, lint, etc., are thoroughly soaked in the creolin solution. Dmnfedhuj the Imtruments. — All instruments are disinfected by means of immersion for at least five minutes in a 5 per cent, solution of carbolic acid, or by boiling them in a solution of washing-soda (a tablespoonfid to each quart of water), and they are cleaned very carefully after having been used. All instruments composed of several parts are taken apart, the tubular oiks being l)oiled. For axis-traction forceps it is necessary to have a key, so as to be able to take off the traction-rods every time the instrument has been used. Sajxtlio used with a brusii is excellent for scrubbing instruments. Xd sponges are used. They have been replaced by absorbent cotton, absorbent lint, or sterilized gau/e. Sutures and ligatures arc of course carefully disinfected. Silkworm ;)iit stands boiling in water and is kejit in alcohol. The writer disinfects catgut by boiling it in alcoiiol in a closed vessel.* Silk is boiled for iialf an hour in water, immersed for half an hoiu' in biehlorid (I : 1000), and is kept in alcohol. If a sterilizer is available, it suffices to expose the silk to the eU'cd of circulating steam for an hour. Aiifisfptic t'oHitnct of fjdfjor. — Very few r(t(/iu(f/ examhmtiom are ma<l(' at the Maternity Hospital, and the person making them disinfects his hands immediately before tlie procedure. In ordinary cases the examining finger should not be brought beyond the external os. We know that pathogenic nn'crobes may be found in the vagina, and even in the cervix, and they are hy no means sure to be removed l)y the preliminary douche. If, therefore, the finger is brought from the vagina into the cervix, or, still worse, into the uterine cavity, it may carry disease-germs into the uterus. No /«/>/'/can/.s are used. Tlie creolin a<lhering to the finger or the forceps is all that is needed. The only exception made by the writer is when, in tlio operation of version, the whole hand is introduced into the womb, in which ease the dorsal surface of the hand is smeared with mollin containing o |»i r *This iiu'tliod (if (icorKc H. FowUt has liceii inade easy and ocmiomical hy tlie inliinliic- tidti of Charles N. D(nv(f's ooiidensci'. In liospitals it siilllcos to Iniil the calgiit iinnu'di.ilcly liefore the oiieration in a casserole with cover at the same time instruments "re lieing Imilcil. ml J'ATIIOlJX.y OF THI-: PrERPERIUM. i 10 cent, of carbolic acid. In protracted cases the vajfiiial douche is repeated every three hours. When the head bcfjins to open the vulva the latter is covered with a piece it" lint wruu}^ out ot" bichlorid solution. This is done partly to prevent the I iitrance of microbes from the air in the room, and jiartly because it facilitates all manipulations calculated to protect the perineum by obviating slipperiness. C^reolin would, therefore, not be so appropriate for this purjiosc. Tlic placenta is removed by Cirde\^ ccprcsKion method (Fi^. 204); that is, ill ordinary cases not even a Hngcr is introduced into the genital canal after the itirth of the child, the placenta being s(|ueezed out by compressing the uterus through the abdominal wall. The writer docs not, however, remove the placenta so soon as recommended by Crede, rarely removing it earlier than fifteen miinites after the birth. The membranes should be removed very slowly and cautiously, as they adhere to the iimer surface of the uterus ; other- wise they would be torn off and remain in the uterus, thus giving rise to puerperal infection. If on inspection any part of the placenta is missing, the well-disinfected hand of the j)hysician should be introduced into the uterine cavity and the missing part scraped off with the nails. As a ndc, the writer does the same I'll.. l'JJ.-(iiin-if.'iH's's liiiiiilatif^. 'limrlii'-cini, aii.l iiiua-utci-iiif luln': 1, (lnuclif-can ; '.', iutra-ulrriiR' lulir; ;!. pffitiriil piul ; I, hcUy-liiiiiliT ; ."., ktu'c-liiiuU'r ; f., mis|icH(Kts in'i'ViMiliiiK kiU'c-liiiiiUT Iimih sliiliim' ilnwii ; 7. hicast-liiiiiltT (from a iihotonriililO. t'nr larger portions of mcn»brancs. If, however, the rope formed by tiie inciiibranes breaks and the uterine end is witiiin reach, the writer sometimes tics a silk thread to il, since the retained piece, as a rule, can easily be reni<»ved the following day by pulling on this ligature. Iidrn-utcrinc injcctioitx are used if the fingers, the hands, or the instruments /" 1 „iv ii 716 AMERICAN TEXT-BOOK OF OBSTETRICS. liavc been introduced into tlio litems. The fluid injected is a 1 per cent, emul- sion of creolin at a temperature of from 110° to 115° F. Tlie apparatus used for the injection ccMisists of a douclie-can (Fig. 422/), and a ghiss tube (Fii;. 422,^), having a iiole at the end and several on the sides near the end. Before introducing the tube into the uterus the vagina is irrigated. Great care should be taken in introducing the tube. The distance from the fundus uteri to the rima pudendi should be mej'o.iiod by holding the tube over the abdomen and noting how far the tube is to be inserted. The left index and middle fingers are introduced into the cervical canal and the tube is inserted between tlKtm. It should be ascertained if the tube goes in the direction of and reaches the fundus ; this can be done by feeling the resistance offered by the latter, or frequently by feeling the end of the tube through the abdominal wall. If any difficulty is met with, the tube should be withdrawn a little and reintro- duced in another direction. The douche-can should be held not higher than a foot above the uterus. At the end of the injection the fluid remaining in the uterus should be pressed out. Dressing. — After the removal of the placenta the patient is again washed with bichlorid and the coagula removed from the pubic hairs, or, if the latter are long and matted together, they should be cut ofl*. It is the routine prac- tice in the Maternity Hospital to hold the uterus compressed for half an hour after delivery. At the end of this time an occlusion bandage (Fig. 422,^) is laid over the genitals and fastened to the binder (Fig. 422/). Tliis bandage consists of a piece of absorbent lint (12 by 8 inches, folded twice, so as to be 3 inches wide) reaching from the genito-femoral furrow on one side to that on the other side and covering the vulva and the anus. Tliis pad is first wrung out of the creolin emulsion, and after being applied is covered with a piece of oiled muslin measuring an inch more than the pad in both directions. This oiled muslin is washed with creolin and is turned forward on the inner side of the thighs. Outside of the muslin is placed a somewhat larger pad of dry cotton batting, which is held in place by a piece of unbleached muslin half a yard square and foldetl like a cravat (5 inches wide), which in front closes a A-shaped opening left at the lower end of the binder, and which is fastened to the binder with four pins. Behind only two pins are needed. This dressing is changed every six hours and every time the patient urinates or has a movement from the bowels. On making the change a bed-pan is pushed in under the patient, and the outer surface of the genitals is irrigated witli creolin. No vaginal injection is usetl. The genitals are not even touched. Erc/nt. — Contraction and involution being great preventatives of puerperal infection, a drachm of fluid extract of ergot is given three times a day until an ounce has been used. Pirincnrrhaphy. — All lacerations of the perineum are repaired immediately, the best material for suture being silkworm gut. Catheterization. — AVhen the jiatient is unable to urinate, the vestibule is washed with creolin emulsion and a well-disinfected catheter is introduced. The common flexible catheters, made of some woven fabric covered with varnish, are ■' ,i\ [• cent, eiunl- paratus used is tube (Fig. ?nd. Before t care should IS uteri to tlic abdomen and iiiddle fingers letween th(!ni. ;■ and reaches the latter, or nal wall. It" e and reintro- higher than a uaining in the ! again washed )r, if the latter e routine prac- r half an hour (Fig. 422,^) is This bandage ice, so as to be le side to that is pad is first covered with a )oth directions, ■d on the inner Ihat larger pail lleached muslin livhich in front ler, and whieh lins are needed, lent urinates or ll-pan is pushed irrigated with even touched, es of puerpeial jnes a day until (d immediately, Ihe vestibule is Itroduced. TIh' lith varnish, are PArilOLOGY OF THE PrEnrEIilVM. 717 strictly prohibited, as they cannot be kej)t clean. The best catheters are of metal or of glass, which can be boiled and be kept aseptic in a solution of ctu'bolic acid (5 per cent.). If, exceptionally, a flexible catheter is neetled, it should be of soft rubber, which is disinfecteil with the 5 per cent, solution (if carbolic acid. Si/riiiff('.s. — If injections are used, great care should be taken to disi'ifect the syringe nozzle by boiling and immersing it in a solution of corrosive sublimate. Nozzles employed in a serious case should preferably be destroyed, as glass nozzles only arc used, and they are quite inexpensive. Very much has been written during the last ten years respecting preven- tion of puerperal infection, and opinions concerning it differ greatly among leading obstetricians ; for instance, regarding the use of ergot, which some extol and others look upon as a direct promoter of infection ; vaginal injec- tions, which in the eyes of some are superfluous or harmful ; and vaginal examinations, which some fanatics would abolish altogether. Bnt since none have had better results than the Xew York Maternity Hospital, with a total mortality of 4 in 1059 cases, and few as good, the writer does not recognize any reason for changing a treatment that has .served so well for over ten years. The only change made by the writer is to substitute creolin (1 jier cent.) for corrosive sublimate for vaginal and intra-uterine douches, on account of its greater safety,^' and, so far as known, some of his colleagues yet use biehlorid (1 : 4000). II. Pkeventiox of Pierperat. Infection in Private Practice. — The benefit of the antiseptic treatment in hospitals has been so enormous that all criticism has been silenced and every doubt has vanished. From one end of the civilized world to the other the treatment is essentially the same. But how ditterent is it when we come to private practice ! So recently as 1875 the International Congress of Physicians and Surgeons assembled at Brussels, Helgium, adopted resolutions to the effect that, on account of the great mor- tality in Ivintj-in asvlums, all such institutions should be abolished. Since that time the tide has turned. The hospital is now the safe place for a woman to be delivered in ; it is in private dwellings that the danger lurks. The poor- est, the dirtiest, and the most dissolute women are safely confined in a lying-in asyhun ; the richest, the youngest, the purest, and the loveliest sometimes suc- cumb in giving birth to a child in their own homes. In the private obstetric practice of the writer there is neither death nor sickness referable to infection, wiiile in consultation practice he frequently sees death follow childbirth or abortion. What is the cause of the difTcrence? It is only that the writer n<es strict antisepsis, and that many general practitioners do not. Some smile henigidy at the mere thought of using such superfluous measures in private praetice ; others have a little mercuric chlorid or carbolic acid around the house, but use it without system or jierseverance. Still, there is nuich greater danger of the ]>atient being infected by the doctor or the nurse in private practice than in a well-appointed lying-in asylum. The young men composing the house-staff of a Iving-in asvlum are strictlv forbiilden to enter the wards ,'; fli !?;:■ '.1 I ' /"" ■■! 718 AMFJilVA.y TKXT-nOOK OF OliSTETlilCii. mi of a hospital ; tlicy lia^'c no ])rivat(' practicT ; tliov do not .see an antojisy ; and if, nnt'ortunatcly, the asylum is a dt'|)iirtnK'nt of a jfcni'ral hospital, the elothcs and the bodios of tiie nurses before goinj; from one ilepartnient to another arc subjected to thorough disinfection under the supervision of their superiors. In private practice, on the contrary, the physician nuiy have treated a case of diphtheria or of erysipelas a n\oinent before being called to a continenient ; and nearly all private inirses take prouiiscnonsly medical, surgical, and obstet- rical cases, disinfecting themselves as best they know how or according as (he combat between innate laziness and acquired conscientiousness ])rompts them. As a matter of fact, the mortality in ])rivate |)raetice is twice as large as that in hospital |)ractice, or larger. Out of cvcri/ hiimlird, viiivti/-Jin', or crrn ei(//iti/-iii)U' ii'oincn (Itlirtird i>i \cw York or other hirr/e ciflcs in j>rivatc })raf- ticc, one tliea; that is, up to 1.12 per cent, against O.G, O.o, or even 0.4 per cent, in the best lying-in establishments. Country practitioners are still greater opponents of antiseptic midwiferv than their jjrofessional brethren in the cities, the country practitioner relying on the purity of the atmosphere in which he works and on the robust constitu- tions of his patients. If, however, these conditions niay help the women to get well, they cannot to any great extent prevent thenj from being taken ill. In many respects country |>ractice exposes the patient even more to infection than does city life. In most places there is no drainage. Manure is spread over the fieltls or the garden close to the house in which live the fanner and his wife. The village butcher kills his cattle, lets the blood soak into the ground, and nails the skins to the barn-doors, whence their odor can be smelt far awav. The country practitioner cannot go home and change clothes and bathe : lie must make his round or he would never get through with his work ; and thus it happens that the same hand that was thrust into a ju'rineal abscess, that per- formed tracheotomy on a child sutl'ering from diphtheria, or that dressed a patient attacked by bullous erysipelas, at the next house is brought up to the fundus of the uterus in order to take away an adherent placenta. The same antiseptic precautions that have revolutionized lying-in asylums should be used as well in ])rivatc practice, be it in the city or in the coimtry. On October 27, 1892, the Obstetric Section of the New York Academy of Medicine unanimously passed the following resolution : " W/inrcui, Experience both in this country and abroad shows that by strict antisej)tic measures the total mortality in lying-in hosj)itals may be reduced to a few per thousand ; " ]yhere<(s, Deaths due to childbirth or to abortion are yet common in private practice ; " Bemlred, That in the opinion of the Obstetric Section of the New York Academy of Mwlicinc it is the duty of every physician practising niidwitcry to surround such cases in private practice with the same safeguards that :ire being used in hospitals." In practice in well-to-do families we should choose a large, airy, sunny room, situated as far as possible from the water-closet. Should, howevtr, \^ PATlIOIAUiV OF THE VVKUPElilVM. 719 finion in private tlio lyiiig-in room bo close to the watc'r-(!lo.st't with a door leading direc-tly from the one totiie otiier, this door shoidd he locked, and some of Piatt's chlo- lid or other powerful disinfectant should be poured frequently into the basin. Instead of lint, the writer uses for the pad in private practice absorbent cittton, and instead of oiled iiuislin he uses gutta-perclia tissue. The pad is not changed in tiie middle of the night. The patient is directed to have two liasins, two pitchers, and a Ibuntain syring(!, which articles are personally cleanseil by the writer before bringing them intt) use. In the dwellings of the poor tiie antiseptic precautions may bo nnich sim- pliHcd and yet be (juite elective. Tiic perineal pad may be made of common <()tton batting, and the gutta-j)ercha tissue may be disj)enscd with. A tin basin may be nswl instead of a bed-pan. Tiie do(!tor can easily carry in his satchel some tablets of corrosive; sid)limate and a couple of ounces of creolin, and thus be prepared to disinfect himself and his patient at slight expens<! to Iiiniself and none to his patient. Intra-uterine douches can be made with a soft-metal catiieter costing fifty cents, or with a nvw flexible catlieter costing twenty cents. The uterine sound used as a stylet greatly facilitates the intro- duction of a flexible catheter. No one can ftyresee — the average general practitioner least of all — whi'*^ ci)m- plications may arise during labor. Where an easy delivery has been ]iromise<l the iicalthy primipara, it may become necessary to perform version, symphvsiot- oniy, or craniotomy, the result of either of which oj)erations depends almost entirely on the aseptic or septic condition of the patient at the time of its performance, taking for granted that tlie operator uses all antiseptic precau- tions. The (h)cfor and the imrxc should k)iow (hat thci/ jrojuirdize their patieiit'a life by Introdumng into her vmjina (t fiiu/er fh<tf /.s not dmiifeeted. During labor dangerous microbes will not be destroyed by phagocytes or by the chemical composition of the secretions, as wo arc told they are under other circumstances. Upon the whole, labor in private practice should be conducted essentially in the same way as that described for lying-in hospitals. III. ClTUATIVK TUKATMENT OF PlTElJPKIlAL Im'KCTIOX. — Thc CUrativo is much less effective than the preventive treatment. Since infection, in the vast majority of cases, takes place in the genital canal, the first indicated procedure is the removal of the microbes that have not yet entered the tissues, which removal is effected by ablution and injection with antiseptic fluids. The second procedure is to seal the entrances, which is done by means of cauteri- zation. A third procedure is to clean the intestinal canal by an aj)ericnt or by enemas. A fourth procedure is to sustain the strength of the patient in oid(>r to give her a chance to throw off the poison that already has entered her tissuos or that circulates in her blood. Stimulants are therefore usc<l freely ; as much food is given as it is possible for the patient to digest ; and tonic urngs are administered. A fifth procedure is to cond)at pain, which indication is met by narcotics and ice. The sixth and final procedure is to redu<!e the l)aticnt's temperature if it becomes dangerously high, which is done by ice-bags, by an ice-water coil, by refreshing ablutions, or by cooling baths. ' 1j !' { \ 720 AM/CRIt'AX TEXT- no OK OF OBSTETRICS. In describing the details of tlie treatment followed in combating puerperal infection the same anatomical categories will be used as in the preceding pages, but the reader must bear in mind that what is described under ditl'erent head- ings is really one and the same disease, modified only by tiie intensity of liic affection or by the nature of the tissue affected. To avoid endless repetitions, a mode of treatment will, as a rule, only be mentioned under that organ in the alfeetions of which it is chiefly employetl, but with the understanding that a similar condition in another organ calls for similar measures. Thus the means of reducing the temperature are discussed under Peritonitis, but what is saitl there applies as well to eases in which there is a high temperature with- out peritonitis. Sometimes the lochial discharge becomes fetid, there is a moderate rise in the temperature not exceetling 102°, some acceleration of the pulse, but no tenderness, no swelling, and no ulceration. This condition is probably due to a veri/ mild degree of infection with saprophytes. Often a blootl-clot hidden in the deep pouch at the posterior fornix or in the interior of the uterus is the cause of such a condition. Health is, as a rule, soon restored bj- using dis- infectant vaginal injections of creolin or of carbolic acid every three hours, by moving the bowels, and by administering 5 grains of quinin three or four times a dav. Vulvitis and Vaginitis. — The catarrhal inflamniation of the external gen- itals calls only for the above-mentioned vaginal douches three times a day. Simple ulcers may besides advantageously be dusted with iodoform, with der- matol, or with stearate of zinc, or be covered with iodoform ointment : ^. Iodoform!, Balsami peruviani, Vaselini, 3j; 3ij; 5i).— M. If the sores become diphtheritic, it is the practice of the writer to touch thcin with a solution of chlorid of zinc : I^. Zinci chloridi, Aqufe destillatse, ad 3j, which is applied by means of a stick wound with absorbent cotton. The caustic should be applied very thoroughly, and be held in contact for a minute. The vagina is then syringed with creolin or with carbolic acid. If the perineum has been stitched, the sutures should be removed, as the torn surface is already or will be infected, and it must be treated in the ubovi'- mentioued way. Tears in the deeper part of the vagina are exposed by means of a speculum. The application of zinc being very painful, the parts should be made insensible with a 10 per cent, solution of cocain, or general anesthesia must be produced. The vaginal injections are repeated every three hours. Once in twenty-four hours the parts are inspected, and if new patches have formed the same procedure is repeated. h PATlIOIJKiV OF THE VVEUPKUUM, 721 ng puerperal w'tling pagf>, itVcrent hcad- teii!*ity of tlif srt rcpetiticnis, t organ in tlu' Hiding that a •s. Thus tlu- mii», but what iperature with- loderate rise in pulse, but no )rol)ably due to l-clot hidden in e uterns is the I bj- using dis- ?ry three hours, lin three or four he external geu- •ee times a day. otbrm, with dor- intraent : y; kij.— M. ler to touch thcin tnt cotton. The gn contact for a carbolic acid. I removed, as the led in the ahnvc- Ixposed by means Ithe parts should leneral anestlu^sia [cry three hniu's. liew patches have The application of chlorid of zinc brings out the diphtlicritic infiltration lauch more distinctly, the atlccted part l)econiing milk-white. Fiatcr, there is lormed a grayish slough wiiich is very nuich like a diphthcriti(! patch. To listinguish old slouglis from iicn* patches the physician must remember where lie has cauterized the preceding day, and pay attention to the contour (»f the iill'ected place. A slough produccil by cauterization has a plain curved outline, while that of a new diphtheritic patch has a scalloped outline, the infiltration -preading more rapidly at one point than at ^Mother. The object to be attaiue<l by cauterization is both to kill the nucrobes (iiimd in and near the woiuul, and to seal lymphatics and veins leading from tlic ulcer to the deeper parts. The writer has found chlorid of zinc nnich niore eflectivc fi»r this {)i;rpose than tincture of iodin, iodofi)rm, licpior ferri subsulphatis, or li(pior fcrri chloridi. The general treatment consists in giving an aperient if the bowels have not moved freely, 5 grains of quiniu every four hours, half an ounce of l)i'andy or of whiskey with e(pial parts of milk or water every two hours. For a change egg-nog may be substituted two or three times a day. If strong li(luor is not well borne, it may be replacf! by a corresponding amount of port, sherry, tokay, or angelica wine, but, :»s a rule, alcohol can be taken in large amounts without producing intoxication. rf there is (/aur/rene of the vulva or of the vagina, the stimulant treatment should be pushed still more, the dead tissue should be removed with knife and scissors as soon as feasible after the formation of a line of demarcation, and healing be promoted with iodoform or with camphor emulsion (see under Bed-mrrs). Endometritis and Metritis. — If the large size of the uterus, its tenderness, anil the discharge of a dirty and offensive Huid show that the uterus itself is tiic scat of inflammation, the (piestion to be decmled is whether it is emj)ty or whether it contains parts of the secundines. If there is the slightest doubt in tills respect, the first thing to be done is to anesthetize the jiatient, place her on a table, in the dorsal posture with elevated bent knees. The physician then lubricates his hand and introduces it into the vagina, thrusting one or two fingers into the interior of the womb. If necessary, the whole hand may be introduced. In either case the operator should examine systematically the whole endometrium, and especially be sure to reach both ostia uterina of tlu; Fallopian tubes, where often a piece of placenta is retained. The finger-nails are used as scrapers. The other hand of the physician is laid fiat on the fnndns, steadies the uterus, and brings the fundus within easier reach. If possible, it is of great advantage to enter the finger at one edge of the part to be rc.iioved and to take away the part in one piece. Often, however, we nuist remove the part piecemeal. It is not necessary to withdraw the hand. By pressing the loosened part between the fingers and the palm of the hand the ii.'-siie to be removed is made to follow the inner surface of the arm down to the OS. If the uterus has contracted too much to allow the hand to be introduced^ 46 'k : if J^ 722 .lJ//;/.'/r.LV THXT-liOOK or <)l{STi:Tlil(\S. and the ohstotriciaii caMiiot reach tlio fiiiuliis witli (lii> (iiipTs, (>v(>ii hv prcssin'^' well on it fVoiii tlic outside, lie may oiiiploy instead a lar^c didl wire eiiredf. This instnunent is 14 iiieiies lon^, lias a shank a <|n:irtei' of an in<;h thick, and an eve lar^c enou;j;h to admit the tip «)t' the thnmb. In nsing the eurettc the writer as a ride prei'ers to place the patient in the Sims position, lie has iisetl the wire curette as early as the end of the sihioiuI month ol' prcif- nancy ip abortion eases, alter having dilated the cervix with IlanUs's and lii> own dilators. At a still earlier period the writer uses the Simon sharp spoon. Whenever it is possible ilie let't Ibrelinfier should be introduced beside the large curette, so as to be able to teel the part to be r(>inove<l and to s<'i/c it between the linker-tip and the eye of the curette, which is safer than any kind of placental forceps. The curette is not only used to remove swiindiiies, bin may also be used to scrape away sponjiy tissu(> beloiij;inji to the uterus itself. Many obstetricians are ojiposed to the use of the curette in obstetrit; cases, n)aintainiii}r as an arffiimcnt that new wounds are produced by it, and that blood accumulates and forms a fertile soil for bacteria.^" In the writer's experience the cnrett*' is of j;rcat value — nay, indispensable — in abortion cases, but after ct)iilinement he always uses the hand if possible, f f the instrunieiit i.s first uswl after the poison is no lonjier localized and iXw. ])atient is pru- foiindly septic, the cuiette can accomplish very little. When the internal surface is smooth tli(> uterus is washed out with two or three pints of ereolin (1 per cent.) or of carbolic acid (2 per cent.), the patient beinjif in the dorsal decubitus. If there is much bleediii};, this intra-iiteriiie douche sluMild be }>;iven (piite hot (11')° F.). If an anesthetic is not adiiiin- istered, hot water is very painful, and lukewarm water is preferred, except to check liemorrhaije. St)me obstetricians pack the uterine cavity with iodoform jjau/e. In obstetric cases, which alone concern us here, the writer prefers the introduc- tion of an iodoform suppository : I^ Todoibrmi, Amyli, (ilycerini, Acaciie, Ft. siippositoria Xo. iij, of the .size and shape of t .'5ss; f.^s^ : tintrer. The use of such a suppository renders fre(|iient repetitimi of ilie iiitia- uterino douches siiperHuous. As a rule, the suppositories are usini only (Hiic in twenty-four hours. The suppository is introduced through a bivalve speculum by means df a forceps having a curvature like that of the uterine sound. A coiiiiiion dressing forceps is unsuitable for this purpose, as it does not penetrate liir enough and it is apt to wound the uterus. Sometimes it is iinneeessaiy to repeat the intra-uterine treatment, the condition of the patient being satisfac- tory. Vaginal douches are usetl instead, and they are also einj)loye(l as j'ATj/o /.()(,)' or Tin: i'ri:ix'i'i:iii(M. T'J.l n by prcssiiv^ win' <'Uirtti . m inch thitk, Hjr tll«' i'UlVtti |)(»s\tit>n. Hi loiith of prc^j;- anUs's iuul hi> I) sliiirp spoon. rd lu'sidi" till' ami to seize it than any kiiul secundini'Si l>'it lie uterus itself, obstetrics eases, l)y it, and tliat In the writer's 1 ab«)rtion oases, ' tlio instnuiieiit I patient is pm- ont with two or out.), the patient his intra-utcM-iiie ic is not admin- -ferred, exeepl to form puize. In L'rt the introdnc- ,r tiuiier. ,,„ of the intr;»- Jir ust'd only uiiiv Itn by moans ol' u id. A eoiniiioii Lot penetrate I'm' lis unntH-'Ossary to Int boinjj; satisliu'- ilso cmphiyed a^^ ;i supplement to the intra-nterino injeetioii.s. They are jjivon every three hiiiirs, Moforo omptyinj; the nterns it Is a j;«m)<1 plan first to wash it out with several liters of boiled water, which washinj^ removes a ^jreal many microbes I lial otherwise ini};ht be carried into the ti.ssnes with the nails or the <'iirette, (aiisMifjj a chill lidlowed i)y I'evor. The elTcct Is merely mechanical, and the ivsidt in preventing? chills ami fever is just as ^o(»d with plain Hterlllzed water a.- with solntions of bichlorid ol" niercnrv, carbolic acid, or lysol." If .several days have elapsed since the Ini'cction took |)laco, Unmm recom- mends the use of the <'nrotto. Under snch circumstances he stales that pack- in}; with lod(»form gauze is nnich to be preferred to injoetionH. The gauze keeps the uterus dry and proviMits the propagation of putrefaction. In .septu; infection — that is, when the microbes at work are of the pathogenic; k I ntl — these measnros become much more unr(>llable. The Intra-uterlne Injections reached their acme when junndiinif irri(/<ifi<»i. was reconunench'd. The uterus was first washed out with a 5 per cent, .solu- tion of carbolic add, after which wa.shing a <u)ntlinu)us .stream of INIInnich's .stilntlon — that is, water containing K) per cent, of sulphite of .sodium and h per cent, of glycerin — was kept circulating through the uterus by means of two ruliber ttdx's introduced up to the fundus. This treatment has, however, heen abandonetl, even In (Jermany, where it orlgliuited, as it does no good, but, on the contrary, does a great <leal of harm.^'' Even in regard toconunon intra-uterino injections opinions vary very nuich among leading obstetricians, and upon the whole the tendencry is rather to re,>;trict their u.se considerably. Pippingskold of Ilelsingfors, Finland — who has, or at least diu'ing four years from 1884 to 1887 had, the smallest mor- tality the writer ev(>r saw mentioned, namely, O.'Ji) per cent. — uses them only once or twice a year in a service varying from five hundred to eight liinidred patients jwr annum.''' Sehrader condemns them altogether, because tliey provoke Jiterlne contractions, and thereby a rapid circulation of lymph, wliieh ])romote,s general infection.'* According to Humm, the intra-uterlne injections are good In putrid endometritis, and even in the septic form if the iiiierobes have a low degree of virulenc(>, in which (!asc the process remains Ideal ; but in other cases they do more harm than good. The virulent microbes rapidly invade the ti.ssnes. Jn cases of infection from another pnerpera or from a patient atTeeted with erysipelas, diphtheria, ]ilil('irmon, etc., the local treatment comes too late. When there are clinical -ii;ns of abs()r])tion — pelvic ]»eritonitis or metastases — local treatment is use- less, and it may do haruj by inflicting new wounds, by tearing open aggluti- nated ones, by disturbing beginning encapsulation of septic foci, by causing tluMlisplaeement of infected thrombi, etc.'''' Fraidv uses G to 8 liters to wash lint a utern.s.*'' Kroenig found that in septic Infection there were as many stre|)ti)coeei a few hours after Intra-uterlne anti.septic Injections as before, and that their virulence, te.«ted on rabbits, was undiminished."^ 'Painj)onage with Iodoform gauze may occaslomdly be valuable. Thus a I 724 AMERICAN TEXT-BOOK OF OBSTETRICS. case is reported in wiiich the placenta had been retained for eight days. When the doctor found lie could not remove it he tainponetl the uterus. The fol- lowing day he removed a part of the placenta with the curette, tamponed again, and the next day removed the remainder of the placenta with tho curette/" The gauze ought to be removed soon, but not all at once, since the uterus cannot contract in proportion.^" Involution is promoted by the administration of ergot and the application of the faradic current, both poles being api)lied externally, one at the fundus, the other alternately at botli sides just above the pelvic brim. Inflammation, and es})ecially pain, are combated by means of an ice-bay; placed on the abdomen just above the symphysis. To avoid local free/iiii;- four layers of muslin should be laid between the bag ami the skin. Instead of the ice-bag there may be used a rubber coil through which ice-water is made to circulate. The ice-bag or the coil is to be kept on continually day and night. Cold is j)referable to heat, as it is more soothing, abridges the course of the disease, and perhaps even has some direct antiseptic value, certain microbes being restrained from developing,'^" while a moist warm application offers the very best chances for the development of all lower life. If, however, cold is contra-indicated, as in diarrhea, low vitality, puerperal diphtheria, etc., warm flaxseed-meal poultices should be placed on the abdomen. When the disease enters on a more subacute stage, the writer uses a Priess- nitz compress ; that is, a towel wrimg out of coid water, placed on the abdomen, and covered with some waterproof material. The pad becomes warm in a quarter of an hour, and is renewed four times a day. This transition from cold to heat is a very powerful absorbent, and it is well liked by patients. Internally there arc given 5 grains of quinin four or six times a dav, small doses of an opiate pro re nata, and a moderate amount of stimulants. If inspection of the cervix shows diphtheritic patches, the treatment is much more energetic ; then the whole cervix up to the os internum is cauter- ized with the above-mentioned solution of ehlorid of zinc, the uterus is washed out with antiseptic Huid, and there is left in it an iodoform siq)posit()rv. These injections are repeated once in twenty-foiu" hours, and a new supposi- tory is introduced. This treatment is continued until all sloughs are thrown off and fever has ceased. A warm jxjidtice is applied over the abdonicn. liarge and fre([tient doses of strong stimulants should be given — at least IimH' an ounce of whiskey or of brandy every two hours. Digitalis may be needed as a heart tonic, preferably in the form of tlir officinal infusion (.^ss, four times a day) ; but if the patient cannot swallow or vomits the medicine, the tincture may be injected hypodermatically in doses of from 5 to 10 minims, r(>peate(l according to circumstances. Tincittire of strophanthus in do.ses of 5 or 6 minims is also an excellent heart tonic, <^li- nin is given in moderate doses, not with a view of reducing the temperature, but as a tonic and antiphlogistic, one of the ])roperties of this drug beinii to prevent the migration of the leucocytes from the blood-vessels.''' m PATHOLOGY OF THE PVEllPEItlUM. 725 t diivs. WluMi riis.' The lol- ■otto, tanipoiu'd L-enta with the once, since the the application ; at the tinulus. m. s of an ice-hati 1 local freeziiii; 3 skin. Instead lioh ice-water is t'ontinually day res the course of certain microlx's lication otVers the however, cold is Lheria, etc., warm iter uses a Priess- 1 on the abdonuMi, jeconies warm in s transition tVoin iUeil by patients, six times a day, nt of stimulants. the treatment is iternum is canter- uterus is waslicd form suppository. \(\ a new supposi- louj^hs are thrown the abdomen. — at least half ,-er ren the form of the •annot swallow or naticallv in dosi's Tinctur (■ III (Jni- Ices. lieart tonic. the temperatmv, this druj; beiivi to In dmccthif/ mctrititi the process of elimination is often .so protracted tljat the use of poisonous anti.septics, such as corrosive sublimate and carbolic acid, becomes dangerous. Under such circumstances the writer has foinid a satu- rated solution of boric acid suitable. All intra-uterine injections should be warm, as a cold Huid sometimes causes collapse. Piitri'ficcnce of (he litems is a condition that has disappeared from all well- (n-dered lying-in institutions since strict a-scptic or antiseptic treatment has been introduced. If a case shoidd come under the observation of the writer, he woidd treat it with creolin injections, iodoform suppositories, alcohol, quinin, and albuminoid food. If possible, dead tissue should be removed with the large didl-wire curette, but the operation is dangerous, and it should be per- iormed with the utmost care, as there is considerable danger of perforating the solt uterine wall, and infection of the new wounds might aggravate the patient's condition. Cellulitis and Adenitis are treatetl with the ice-bag, and later with the I'riessnitz compress. If the resolution is unduly slow, the abdominal wall over the swelling .should be painted once a day with tinctiu'c of iodin. After this application has been repeated for a few days, and the e})idermis has become hard, the writer covers the abdominal wall with a piece of lint soaked in the following wash : I^. Acidi carbolici, (ilycerini, A(pi!C, Si); M. .siij. Bse This preparation softens the epitlerniis, prevents cracking, and promotes alisorption of the iodin. When the tenderness has been so much reduced that a specidum nuty be used, it is well to combine the external painting with that of the vaginal vaidt, and thus bring the 'odin more in direct contact with the aifected part. This ii|)|)lication is repeated every three days. Care shoidd be observed to take so little of the tincliu-e on the brush or applicator that it does not trickle down to the vulva, where it burns, while it is not felt at all on the i()rnix. In and)nlant ])atients it is well to wii)e off the redundant tincture with ab.sorbent cotton befori ibey rise from the table. If sup])uration sets in, it shotdd be hastened by means of warm llaxseed- iiical poultices ; when the ab,sce,ss is formed it should be opened vith the knili' through the skin or the vagina, or both. If there is any doid)t as to the presence of ])us, it maybe settled by using a hypodermic syringe or an asjjiratiug needle. The common hypodermic .syringe is too short, but one may lie made having an attachment to the ca.se and the pi.ston.* If there is pu.s, the needle may be u.sed as a guide for the knife. Some surgeons u.se a trocar. Dr. Hache Enunet con.structed a trocar that at the .same time carries a drainage- tniie.^- Some canulas iiave holes through which they may be fastened to the * X very satisfactory instrument of this kind has been made for the writer. / i; 72G AMERICAN TEXT-BOOK OF OBSTETRICS. I ! vagina with silver wire. Both in puncturing and in cutting, the wound must be made behind a line drawn transversely through the cervical canal, in order to keep clear of the ureter and of the uterine artery. The surgeon should likewise feel for and avoid vaginal arteries. Often one or more drainage- tubes are inserted. These operations should be performed with full antiseptic precautions. The best way of disinfecting the vagina is to rub it with tinctura saponis viri- dis carried on absorbent cotton or on gauze held in a long forceps, and to irri- gate with corrosive-sublimate solution (1 : 2000). If an abscess communicates with the intestine and does not close, a countor- opening should be made in the abdominal wall or in the vagina, and thorough drainage be established. If a fistulous tract remains leading from the pelvis to the vagina or the skin, and the patient's life is in danger from exhaustion, a cure may yet be ac(!omplislied by vaginal hysterectomy, with or without salpingo-oophorectomy, but the operation may be a very difficult undertaking. The internal treatment is the same as stated before. Lymphangitis. — Lymphangitis of the vulva and the groin is treated with compresses soaked in a lead-and-opium wash : I^. Tincturae opii, Li(pioris plnmbi subacetatis diluti, Sig. For external use. .5SS ; q. s. ad 5viij. — M. r 'i1! \i\ If the inflannnation runs into suppuration, the treatment is the same as tliat above described for suppurative cellulitis. Lymphangitis of the uterus is treated with ice-bags, opiates, saline aperi nts, quinin, and .dcohol. Peritonitis, — Opinions are much divided as to the advisability of using antiseptic intra-uterine injections in peritonitis. Personally, the writer gives one injection, on the assumption that besides the microbes which already have found their way from the uterus to the peritoneal cavity, and which are beyond reach, there may be others in the uterine cavity that it may be advantageons to remove. The writer has never seen any bad effect from this practice, while sometimes it seemed to do good. The abdomen is covered with two large ice-bags, whose weight is dinun- ished by suspending them from a cradle. Instead of the ice-bags, a rubber inil \, ith circulating ice-water may be employed. It is only when the above-named counter-indications against ice are present that a warm flaxseed-meal poultice should be substituted. A remedy of the greatest value in ])uerj)eral peritonitis is opium, given in ;is large doses as the patients can stand — and they can stand enormous doses — tlie only indication to stop being the ecmdition of the respiration. It is perlcctiy safe to give the drug in doses repeated at short intervals until the respiratdiy movement sinks to 14, or even to 12, per minute. The best opiate for this pur- pose is morphin. To relieve pain as promptly as possible it is well to txirin with a hypodermatic injection of a quarter of a grain of the drug. Afterwiwd PATHOLOGY OF THE PUERPERIUM. 127 '■' it,;<s|: n r j; ft ^ n is treated with the same as tlint uterus is troatcd it is better to give the medicine by tlie mouth, because too many injections would be needed ; because they ouglit only to be given by the doctor; because the medicine is brought directly to the affected i)art ; and because hypodermatic injections, if not given with the greatest care, disinfecting both the instrument ami the skin, are apt to can!-« abscesses which may prove a serions, even fatal, loinplication. In this way ^ to J grain is given every half hour until the patient is fully under the iiiHuence of the drug — that is to say, is free from pain, and yet not in a deeper narcosis than that from which she can easily bo aroused. Lawson Talt pointed out the danger of using opiates after laparotomies, and the advantages of moving the bowels. This treatment, which undoubtedly is a great advance in gynecology, should, in the writer's opinion, not be applied to puerperal peritonitis. In the writer's younger years the treatment with aperients was in vogue, and he is still harassed by the memory of the poor tortured women who were plied with senna and were given insignificant doses of opium; with that plan the mortality was much greater. With the "opiimi plan " he has saved one-half of the cases affected with general jjcritonitis.'*^ Others have, however, diametrically opposite views on this sidyect. Gott- sc'halk, for instance, keeps the bowels open and rarely uses opiates.^' If morphin has too depressing an effect, especially if the heart is weak, atropin may be added to the morphin. By adding 1 part of atropin to 1000 of Magendie's solution the latter may be given according to the above rule : 1^. Atropina; sidphatis, Solutionis morphina3 (Magendie), Sig. Four to eight minims as prescribed. Alcohol should likewise be given in very largo doses, from half an ounce to one oimce every two hours or oftener. The writer gives ((iiinin in the inod- (Mute dose of 5 grains every foin- hours, which periods of administration keep up the iuHuence of the drug continually. No aperient medicine is given. An evacuation takes place from time to time spontaneously, and if it does not an enema is given. Pure glycerin (lij-li) ""•.V be used. The hygroscopic ])roperty of the glycerin attracts iiuich fluid, softens scybala, and lubricates the passage. Another good rectal injection is composed of a (piart of fiaxseed-meal tea with a tablespoon fid of castor oil and a teaspoonful of oil of turpentine. A still more powerful enema is made of inspissated ox-gall (a teaspoonful) or fresh gall (a tablespoonful), glycerin and castor oil (a tablespoonfid of each), table salt (a heaping teaspoon- fnl), and flaxseed-meal infusion (a tabl(>spoonful to a (piart of water). Frank has seen (>xcellent residts from the subcutaneous injection of pure creasotc .'{ grams (45 minims) pro dh; or from an emulsion of creasote and oleum camphoratum, Tm. half a gram (8 minims), beginning with 0.5 ^i'lam morning and evening, and increasing the dose gradually. The injection is nuule deeply into the gluteal region or into the muscles of the spiiie.'''' .^ij.-M. iM mm mm '' I ! •• ^:\ 728 AMERICAN TEXT-BOOK OF OBSTETRICS. Occasionally digitalis or stropliantluis may be used as a heart tonic, and strychnin is employed as a general tonic, especially as a tonic for the res- piratory organs. When used as a respiratory stimulant the hypodermatic method is preferable. For vomiting cocain and hydrocyanic acid are the best remedies. The hydrochlorate of cocain may be given by the mouth or hypodermatically (gr. \, repeated every two hours). The hydrocyanic acid the writer gives by the mouth in the following mixture: I^. Acidi hydrocyanici diluti, Acidi citrici, Sodii bicarbonatis, Syrupi rubi Idaei, Aquae destillatse. 3ss; aa. gij; Iss; ad 5vj. — M. Sig. A tablespoonful every one, two, or three hours. An ice-bag placed over the pit of the stomach is also useful in restraining vomiting. The diet consists of milk, beef-tea, and oatmeal gruel. The beef-tea may be made of fresh mi'iced meat, which is put into a bottle with just water enough to touch all the meat, the water being acidulated by adding a little dilute hydrochloric^ acid. The bottle is corked and boiled for an hour in a pot of water. This beef-tea makes a very strong, nourishing, and stinuila- ting food, which is taken with a teaspoon. If more bulk is desired, the beef-toa is prepared by taking a pound of minced beef, a teaspoonful of dilute hych'o- chloric acid, and a pint of cold water. This mixture is left for an hour or more, and is stirred every quarter of an hour ; it is then placed over the fire, and is taken off as soon as it reaches the boiling-point. It is strained through a cloth, and salt is added to taste. The beef-tea may also be made witii the different j)repared extracts, such as those of Valentine, Armour, or Moiis- (juera. Liebig's meat extract is less suited for this purpose. Max Kuntfo and his followers give even solid food — eggs, veal cutlet, and ham.*** To give an idea of the amount of morphin, alcohol, and food that may be administered, the writer may mention that one of his patients who recovered took in twenty-three days 21(5 grains of morphin, 228 ounces of whiskey, 1078 ounces of milk, and 418 ounces of beef-tea, making an average of 'J grains of morphin, 9| ounces of whiskey, 45 ounces of milk, and 7^ ounces of beef-tea in twenty-four hours. The greatest amount of morphin given in one day was 13f grains. jNIany obstetricians make extensive use of antipyretic remedies — large doses of quinin, salicylate of sodium, antipyrin, antifebrin, phenacetin ; others arc strenuously opposed to their use, and the writer belongs to the latter ealegoiy. These drugs rather mask than cure the disease. Some of them — salicylate of sodium and antipyrui — are particularly objectionable, because they weaken the patient. The best is phenacetin (gr. v every four hours), since it lowers art tonic, and 3 for the res- hypodermatic medies. Tlu^ -matically {p: r gives by tlic in restraniiuff lie beef-tea may with just water adding a little jr an hour in a ig, and stimuhi- rcd, the beet-tea of dilute hydro- for an hour or )ver the fire, and ■ained througli a made with tlie inour, or M«>iis- Max Kuii^'o A ham.*" food that niiiy ;s who recovered ices of whiskey, m average of 1) , and Ih ounees liorphiu given in lies— large doses |etin ; others are latter categitry. L — salicylate of Ise they weaken since it lowers PATHOLOGY OF THE PUERPEItlUM. 729 the temperature, combats pain, and does not to the same degree weaken the heart. In this class may be reckoned carbolic acid, which the writer has given with good effect in cases of offensive diarrhea : I^. Acidi carbolici purissimi, Liquoris iodi compositi, Mucilaginis acaeite, Syrupi aurantii, Aquffi destillatae, Sig. A tablespoonful every hour. M. TTlxvj; fl-5ij ; .Sss; q. 8. ad Sviij. — M. The best way of reducing the high temperature is the external application of cold. In addition to the ice-bags on the abdomen an ice-cap may be placed on the head, for which purpose some are made in the shape of a helmet. It is grateful to the patient to be washed over the whole body with equal parts of alcohol and cold water, but this has a more refreshing than a really an- tipyretic effect. The latter is obtained by a Kibbee fever-cot, the cold pack, or the cold bath. The fever-cot consists of a wooden frame havino; a net- work of cord, under which is a rubber sheet forming an inclined plane toward one end of the oot, where a water-pail is placed. A folded blanket is laid over the netting to protect the patient against being cut by the cords, and a rubber-covered pillow is laid at the head of the cot. A folded sheet is laid across the middle two-thirds of the cot, the patient being so placed that tliis sheet reaches from her armpits to the trochanters. Her clothes are drawn up, and her legs are covered with woollen stockings and a blanket. Bottles containing hot water may be placed against the soles of her feet. The sheet is folded over the patient's chest and abdomen, and water is poured gently from a pitcher over the sheet, beginning with water at a tem- jK'rature of from 85° to 90° F., and gradually diminishing it to from 75° to 80° F. This aj)plication is continued for a quarter of an hour, when the ])atient is covered up. At the end of each hour the procedure is repeated if the temperature again rises. Where the fever-cot is not ojtainable the cold pack may be substituted in the following way : Two beds are each covered witii a rubber or an oil-eloth sheet, over which is placed a blanket, and over the blanket is laid a nuislin slieet wrung out of cold water. The patient is placed on the wet sheet, which is wrapped around her except at the feet. If the circulation is bad, hot-water bottles or hot-water bags may be i)laccd against the soles, one or two l)Iaiikets being laid over the patient. At the end of ten minutes she is re- moved to the second bed, where the same procedtu-e is repeated. Foiu" )r six siieh packs may be needed to reduce the temjM'rature as nnich as is wanted, and the handling of the patient may cause her pain and necessitates the help of three nurses. The patient is less disturbed by the cold batli, which is a powerful refrig- erant, cU'id which should be given in the following manner : A bath-tub is 1 ■.^ i 780 AMERICAN TEXT- BOOK OF OBSTETRICS. I filled with water slightly below blood-teraperatiirc, into which bath the patient is gently let down, carrying her on the sheet of the bed upon which she has been lying. The water is then gradually cooletl by withdrawing warm and sul)- stituting cold water, until it reaches 80° F. It is well to give the patient a tablespoonful of brandy before the bath, and she must be watched carefully by the physician while she is in the bath ; at any sign of collapse she should be removed from the bath ; otherwise she may remain in it for fifleen or twenty minutes. In local peritonitis laparotomy is indicated if milder remedies have not the desired effect; and since it is often difficult to decide whether the peritoni- tis is general or is localized, it is better to give the patient the benefit of the doubt. Several cures under such circumstances have been reportetl.'*' By turning out the large curdled masses and the sero-fibrinous or the puru- lent fluid, washing out the peritoneal cavity with peroxid of hydrogen, and leaving a glass drainage-tid)e for further escape of the fluid or gas, it would seem that we increase the chances of the patient ; but if we want to operate at all, we should not wait until her whole system is poisoned and death is inuni- nent. The condition is not totally different from cases of rupture or of gunshot wounds of the intestine or of the bladder, in which early operation yields very fair results, and certainly much better than the expectant method.* Still, as some patients recover by medical treatment, and since in fatal cases the operation may seem to have caused the death of the patient, recourse to laparotomy has so far been rather limited during the acute stage of the disease. If the i)atient gets over this stage and there are left encystetl peritonic exuda- tions, the operation ought to be })erformed. Pleurisy. — If the infection locates in the ])leura, producing pleuritis, there should be applied to the chest an ice-bag, which is not only very effective* in soothing the pleuritic pain, but also abbreviates the course of the disease. If, however, the affected part caiujot be reached, warm applications should be pre- ferred, either flaxseed-meal poultices or spongiopiline — that is, a piece of gutta- percha-covered felt which only needs dipping into hot water. In the exudative form of j)leurisy tincture of icnlin may be painted on tlio skin. Internally, the iodid of potassium and diuretics are given, for exami)lo: I^. Tritici repentis radicis decoctionis, 5ss-oviij ; Potassii acetatis, Potassii bitartratis, Potassii citratis, da. .^j. — M. Sig. A tablespoonful from four to six times a day. The amount of fluid in the ))leural cavity is rarely large enough to call for thoracentesis by aspiration. If the fluid becomes purulent, the empyema should be operated on by resection of a jiiece of a rib. Pneumonia. — When the lungs become inflametl, the chest should be mv- * T. H. Rurchard collected 39 eases with 23 recoveries ; that is, 60 per ccnt.^ PATHOrAHiV OF THE PUERPERIUM. 731 ered with large warm flaxseed-mcal poultices well protected with oiled mus- lin, and a flannel binder with sshoulder-straps of flannel. These poultices need not be changed more than four or six times in twenty-four hours. Stim- ulants and tonics are highly indicated. A favorite j)rescription of the writer is citrate of ammonia, obtained by mixing the carbonate with citric acid : I^. Animonii earbonatis, gij. Div. in chart. No. xij. Sig. No. 1, one powder four times a day. I^. Acidi eitrici, Sacchari, aa. gij. — M. Div. in chart. No. xij. Sig. No. 2, one powder four times a day, mixed with No. 1. Perhaps this preparation serves to dissolve the fibrinous exudation, or perhaps it only acts as a stimulant. Care should be taken to change the position of the patient to prevent stagnation of blood by gravitation. If edema supervenes, dry cupping is valuable. Endocarditis and Pericarditis. — If the pericardium is inflamed, the treat- iiiont consists in the same external apjilications am .liureties as those recom- mended for pleuritis. The inflannnation of the endocardium is hardly within roach of therapeutic measures. Ice-bags, digitalis, and strophanthus may, how- ever, be tried. Enteritis. — Offensive diarrhea is best combated with internal antiseptics — a ininiin of carbolic acid in a mucilaginous menstruum, repeated every hour, (Hiinbiiu'd or not with the same amount of liquor iodi composita ; naphthalin (n''- '.)~^''.) every two hours) ; or salol (gr. v every two hours). Enemas with a t('asj)oonfnl of starch and 25 drops of laudamnn give great relief when the patient suffers from tenesmus. A heaping teaspoonful of subnitrate of bis- muth may be added to advantage. Hepatitis. — Pain in the right hypoehondrium may be relieved with an iee- biig or with a Haxseed-meal poultice. If the bowels are constipated, calomel (t;'r. v-x) is preferred as an aperient on account of its cholagogue properties. Nephritis. — A warm flaxseed-meal poultice, or a bag with digitalis leaves (lipped in hot water, is placed under the loins. Diuretics are given (see I'lcnnxjl). Small doses of chloral hydrate (gr. xv-xx one to three times a (lay) diminish the albumin in the urine. Chlorid of iron may be given in the following form: I^. Tincturne ferri chloridi, .^ss ; Syrupi simplieis, .^j ; Aqute, <|. s. ad .^viij. Sig. One tablespoonful four times a day. To j)rotect the patient's teeth she should be directed to gargle with a solution Lh 732 AMERICAN TEXT- BOOK OF OBSTETRICS. >r r-ii 1:1 ' of sodium bicarbonate (3ij-3viij) after taking the medicine. Warm baths are useful. If uremic symptoms appear, elimination through the skin and the intestiiir must be attempted. To accomplish elimination through the skin the most powerful means is a hot-air bath, which may be obtained by placing an alco- hol lamp under a chair beside the bed, an open umbrella over the abdomen of the patient, and then covering both with a waterproof. Perspiration, how- ever, is weakening, and it ought not to be prolonged over two hours. Free evacuation of the bowels should be obtained by the most powerful drastic purgatives, such as croton oil (| drop every half hour) administered in pill form or in castor oil or in almond oil, or, if the patient cannot swallow, mixed with butter and rubbed on the tongue ; common elaterium (gr. \-\ every hour) ; Clutterbuck's elaterium (gr. \), elaterin (gr. tVtV)> ^^' gamboge (gr. 1 every half hour). The diet should consist exclusively of milk, either in its natural state, or peptonized, or as koumiss, or as matzoon. These preparations of milk should be given only in small quantities (tablespoonful or even teaspoonful doses), and if even they cannot be retained recourse should l)e had to rectal alimentation with Leube-Roscnthal's solution, Rudisch's becf-peptonoids, or an egg with half an ounce of brandy and 3J ounces of milk. Vomiting is combated by hydrocyanic acid, cocain (see Pe)'itonitis), bismuth, strychnin, tincture of iodin, carbolic acid, croasote, or lumps of ice, and an ice- bag or a turpentine stupe applied to the pit of the stomach. Encephalitis and Meningitis. — If localization takes place in the brain or its envelopes, little is to be expected of therapeutical measures. The head should be covered with the above-mentioned ice-cap or an ice-water coil. The bowels should be kept loose. Ergot and liquor barii chloridi (TTtv q. 4 h.) may be given, besides quinin, with a hope of causing contraction of the cerebral blood-vessels and checking the migration of white blood-corpuscles. Delirium, restlessness, <tnd insomnia are quieted by bromids, chloral, cannabis indica, opiates, sulphonal, or trional. Abscesses in the subcuta- neous or subfascial connective tissue are opened and treated according to tlio rules of antiseptic surgery. Arthritis. — If localization takes place in a joint, it should first of all he immobilized by proper splints and bandages, but in such a way as not to in- terfere with other treatment. In the beginning an ice-bag applied around the inflamed joint has often an excellent effect. Later, tincture of iodin or lly- blisters may serve as counter-irritants. If the effusion becomes purulent, the joint should be em])tied with the aspirator-needle and be injected with a solu- tion of carbolic acid (3 to 5 per cent.), creoliu (2 per cent.), or peroxid ot' liydrogen. If this treatment does not suffice, the joint should be laid oj)en i)y a free incision. Skin. — Puer])eral cutaneous eruptions hardly call for special treatment. If they itch, considerable relief may be obtained from bathing the skin with the following solution of carbolic acid : PATIIOIAJdV OF Till': rCEIU'EllUM. 733 f > Warm baths I^. Acidi carbolici, Alooholis, (jilycerini, Aqiui', 3.SS ; ful. oSS ; q. s. ad .5vj. Bed-Hores should be treated very carefully. A; >( as the skin becomes rod over the sacrum, the trochanters, the heels, oi uuier places exposed to pres- sure, the |)atient should be |Maced on suital)le rubber air-cushions, and so far lis possible be shifted so as not to press on the att'ectcd spot. Under the heels are placed rubber rings filled with air, or a similar contrivance is improvised hy winding a strip of nuislin in a spiral line along a wad of oakum, thus lurming an elastic ring into the opening of which the heel fits. The red spot is bathed frequently with lead-water. If there is an excoriation, it should be dressed with glycerite of tannin (sj to 5J) or with the following ointment : I^. lodoformi, Balsami peruviani, Vaselini, 5j. If gangrene has developed, the dead tissue should be removed with knife or with scissors as soon as a line of demarcation has formed, and the sore should he dressed with lint or cotton dipped in a 10 per cent, camphor emulsion or a 2 per cent, creolin emulsion : !^. Camphorje, .^ss ; Mucilaginis acaciie, .^j ; Aquae, q. s. ad 5v. — M. Sig. Shake well. For external use. When once the hole is filled by granulation the above-mentioned milder remedies may be substituted. In severe cases much benefit is derived ncm plating tlie patient on a water- iiiattress, which adapts itself very evenly to the whole lower surface, and facil- itates changes in position by the ease with which the water flows from one part of the mattress to another. Phlebitis. — 1. Phlcf/masia Alba Bolcns. — The affected limb should be l)aii)ted once a day with tincture of iodin along the swollen veins, and be sur- rounded by cotton batting, slightly compressed with roller bandages, and elevated oil cushions, so as to favor reflux of venous blood and lymph and to prevent stagnation and congestion. In protracted eases blue ointment may be substi- tuted for the tincture of iodin, but to prevent tearing off a piece of a throm- bus, which would form an embolus, the ointment should be smeared carefully on the skin, avoiding deej) pressure. As there is great tendency to relajtse, the patient should be kept quietly on a lounge or in an easy -chair with rai;«?d extremity for a fortnight after the swelling has subsided. Circumscribed V m 7;i4 AMEIilVAN TEXT-BOOK OF OliSTKTliJVS. abscesses must be opened and be dressed antiseptically, and in eases of <liff'iisc snbf'aseial phlegmon several long ineisions slioi.'d be made at an early date to limit tlie destrnetion in the deeper |)arts. 2. Tujldinmafion of Vdricoxc \Ynix. — It' varicose veins become inflamed, the limb is immobilized, and covered with cloths dipped in a lead-i>nd- opinm wash. The cloths are kept cool by evaporation and addition of ."<"■. iliiid or by changing them. If the cool application meets with objection, flaxseed- nieal jionltices may be sid)stitnted. After the acnte stage has passed the limit is slightly compressed with a roller bandage, and when the patient begins to walk abont the bandage is replactnl by an clastic stocking. 3. Utrrlm' PIMuUh calls for all the general and local treatment described in the preceding Images, esjiecially quinin, alcohol, ice-bags or warm ])onltices, and hot vaginal donches. Acutest Septicemia. — In those cases in which the infection takes snch a rapid course that no local inflammations find time to develop there is scant hope of saving the patient's life. We should, however, try to better her chances by following the principles laid down above. High temperature should be lowered by cold baths and local refrigerating aj)])lications. The patient's strength should be kei)t up by the administration of alcolutl, quinin, strychnin, atropin, digitalis, and strophanthus. Pain and restlessness should be subdued with hyi)odermatic injecti(ms of small doses of nior])hin, Frank's injections of creasote may be trie<I. Thierry of Rouen claims to have obtained recovery in ten cases of the most severe septicemia without localization, after having failed with everything else, by means of oil of turpentine injected sub- cutaneously in gram doses. It forms an abscess, and in one case he produceil even so manv as three abscesses."' ! 'n t 11 .>■ IB >' 1 2. SinUNVOLUTlOX. By subinvolution is meant the retardation or arrest of the processes by which the uterus is returned to its normal dimensions, position, and anatomical structure after premature termination of pregnancy or subsequent to delivery at term. This anomaly may also be present in varying degree in the ligaments of the uterus, the vagina, and the abdcjuiinal walls. Usually in from six to ten weeks the ])hysiological changes known as lin-ohdion have been complcteil. Et/ohf/j/, — Since the physiological changes in the uterus after delivery uw brought about by a diminution in its blood-supply, resulting from contraction and retraction of the uterine ujuscle-fibres, it is obvious that the causes of failiu'o in involution must be sought for in any factor or factors modifying tiio amount of blood going to the organ or interfering with its firm contraction. Several conditions may obtain in an individual that operate in either the mic or the other manner; indeed, not infrequently the one condition will cini- tribute to retard involution both by increasing the amount of blood in the uterus and by interfering with its contraction. The most frequent condition interfering with normal involution by dctci- mining an excess of blood is a change in the endometrium, which change is !f f fisos of (litViiso 1 early dato to nine inflaiucd, n a load-iMid- >n of ."<"■. Ilniil c'tion, flaxsocd- lassed tlio liinli ticiit begins to moiit described k-arni poultices, on takes such a ) tiicre is scant ' to better her gli temperature dicatious. Tlic alcohol, quiuiu. tlcssness should rphin. Fraid<'s :o have obtained Dcalization, after ine injected sub- •ase he produced [he ju'occsses by and anatomical iieut to delivery in the liganu'ut< in from six to [been complete 1. Ifter delivery :nv Vom contract ii 111 lit the causes of •s modifyirir the hrin contractimi. in either the one Idition will cmi- of blood in the llution by dcti r- Lvhich chanp' is PATHOLOGY OF THE PlJEIiPEIUCM. 735 either hypertrophy occurring in the latter months of pregnancy, or an inflam- ination developing after delivery, the result of septic infection. Very fre- i|uently associated with infection is la(u>ration of the cervix or of the ))erineinn with uterine displacement, together with uterine and peri-uterine inflammatory |)ro(lucts. Other causes, miieh less frerpient, are polypoid and interstitial or -nbnuicous fd)roid tnu'nr.' and cardiac and hepatic diseases producing engorge- ment of the pelvic viscera. Later in the process of involution chronic consti- |)ation, assuming the erect posture and engaging in exercise or laborious work, and the resumptiim of sexual intercourse too sunn after abortion or after de- livery at term, are causes very likely not only to retard, but even to arrest, involution. The conditions that may cause subinvolution by interference with the con- traction of the womb arc usually operative shortly after labor, and therefore (heir early recognition is important. Of these conditions the most important are large masses of hyi)ertrophied de(;idua, placental polyps, placent.'c succen- tiiriatje, large blood-clots, and displacement of the uterus. The latter, when it occurs within a few days after labor, is commonly due to a misplaced compres.s and an injudiciously firm abdominal binder, to an over-distended bladder, or to dragging adhesions. In rare cases an extra-uterine tumor may be discovered. Women who fnmi necessity or desire do not nurse their children are more likely to develop subinvolution — a fact which supports the belief of the close nervous connecti(m between the uterus and the mammary glands. That constitutional disturbances, independent of any local disorder, may in- fluence the course and progress of involution is by no means certain. The older writers were willingto attribute subinvolution very largely to defccti\ c nutrition and to the enervating ett'ects of acute and chronic diseases. That such influence is exceptional the writer is forced to believe. At the present writing tlun-e is under his care, in the last stages of phthisis, a jjatient whose physical force is at a minimum, yet involution of the uterus has |)rogressed in a ])erfeetly unin- terrupted manner. Analogous cases are repeatedly observed. There are indi- viduals, however, in whoiu there seems to be a general lack of tone : their muscles are flabby ; they are indisposed to take any active exercise, and are trcqiiently of gouty or of rheumatic antecedents. Women of this class some- times have subinvolution assocnated later with uterine displacement without a distinct local cause. Nevertheless, it is certainly wiser for the obstetrician to search for a local cause in every case than to be content with attributing a failing involution to any constitutional disorder that may complicate the puer- )i('ral period. Diaguims. — As subinvolution is the starting-point of numerous intrapelvic disorders, it is important that the obstetrician should recognize its presence, and at an early date begin measures to correct the abnormality, since deferred treat- ment ])ermits an aggravation oi" the local changes which occur in the early stages, exposes the patient not infrequently to great danger of infection, and, it' the latter is safely pass(>d, renders !ier very liable to subsequent ill health from intrapelvic disordei-s. n\ u .^r If' IS;-, I Svl " U r «■/■ I' •< i ') Nil 736 AMJ'JJiJCA.y TKXT-IiOOK OF OJiSTETJtlCS. In tlio early stiifjcs of the proeess of involution abdominal palpation prae- ti.sed at tlie daily visit will disclose any eessation in the (;radnal diminution in the size and height of the womb. For practical purposes it may be stated that the fundus uteri on the ihiy Ibllowing delivery will be found a finger's breadth above the lunbilieus ; on the third and fourth days, a trifle below the und)ilicus ; on the lifth and sixth days, two tingers' breadth below the umbil- icus; on the seventh, eighth, and ninth days, three or four fingers' l>rea(hli above the symphysis; and on the tenth, eleventh, and twelfth days the fundus is usually slightly above, on a level with, or a little below, the symphysis.'" This process of involution continues throughout the puerperal period, and earefid intra-utcrine measurements taken at varying intervals up to the tentli and twelfth weeks show a steady dimiiuition up to a point when the dimen- sions of the involuting wond) are really less than those of the unimpregnated uterus. Later, the size of the organ by subse(|uent engorgement of the uterine vessels is permanently increased to a slight degree. Associated with the failure »)f the uterus to decrease steadily in size there are apt to bean increase in and a prolongation of the bloody lochia, a coated tongue, and constipation. It is thus not a dilHcidt matter to make an early diagnosis of sid>involution; and an early recognition of the condition is of the greatest practical importance. The diagnosis of subinvolution in its later stage is, unfortunately, too often left to the gynecologist. At this time the uterus is larger than normal and is freijuently displaced, usually backward, the os is more patulous than it should be, •■\vs\ the crvix very probably is lacerated. The walls of the uterus an; considerably thickened, its vessels and lymphatics are enlarged, and its endometrium has undergone interstitial and glandular hypertrophy. If invo- lution is permanently arrested, connective-tissue development in the muscle- walls soon follows, the changes in ilic mucous membrane are permanent, and chronic metritis and endciictritis are established, to be followed perhaps hy periuterine inflammatory disease. Treatment. — From the foregoing enumeration of the most imjiortant causes of subinvolution it is aj)parent that the i)roper treatment of each patient will be governed by the cause or causes that may be present retarding normal invo- lution. While the patient is in bed the cause will usually arise from retention within i\\(\ wond) of decidual or jdacental masses and blood-clots, or of shnds of the membranes which may or may not be undergoing })utrefactive change, but which are always a source of danger and usually require removal. Tlic blood-clots accumulated within the womb can often be removed by stimulating the uterus to contract by gently rubbing the fundus of the uterus several times each day through the abdominal wall, followed by snug application of the pad and binder. When this maneuvre is not followed by proiujit reduction in the size of the wond) aiid by dinunution of the loss of blood, the cavity of the uterus nmst be explored with the finger ; then, if required, the <;urette and placental forcejis should be used, followed by irrigation with creolin or biehlorid solutions and with boiled water, and the introduction of a strip of sterilized iodoform gauze, which should be removed and may be rc- .■; I* fU"! PATHOLOGY OF Till': I'lFJtl'KliirM. 737 •alpiition pnic- dimimitutn in may l)*' s^tiitctl omul a fiuj>;<'r's tvillf below tlic low tlic uml)il- (iii^crs' broatltli lays the liindns \w syinpliysis.'" i-al pentxl, and iij) to tlio U'utli \\m\ tlie (Vinicii- uniinpri'jjiiiatcd nt of tlic uterine with the tailuie increase in and a ition. It is tluis ion ; and an early imce. ntbrtnnately, too i-jTor than normal ; patnlous than it ,alls of the ntenis jenlarged, and its [rophy. If h»vo- it in the muscle- permanent, and )wed perhaps !)>■ placed at the end of forty-eight hours. When putrefactive chanj;e has hejjun to take place, which is ann(»unced by fetid discharfje, rapid pidsc, and fever, the necessity for enrettaj^e is al)solute. Kven when fetid discharjic is aitsent the pulse and temperature may be such as to re(piire cnrrettagc. The temperature chart (Fig. 42.'5) illustrates the advantage of removing hypcrtrophied decidna. In ^^^ ^^^ "^ 1 "~~" DIMM* I 3 3 4 5 e 7 R 10 11 la 13 14 IS 10 17 18 10 ao ai - " ; 106° 106"" ■i- f 4- - -r IfMft A 10t° 103° f \i fj 1<H« 109^ i : !■ i VOP 100° -!- V r\ : : '■■\ : - f A A / - \ / '^ !■ V > k' if s ■l ^ -^ \- -H 000 -j\ If r ^ 1 J s / ^ |- 08" 07° 'if"- (5U. — 1 ^ - . . . — - T Sb ^ xl — \ s < - - — — - - — 980 970 • 1 '2" •A 17 II 1 l! •i 6 • A 4 1 2 7() J A A 1 LI 30 .1 1 28 20 1 ll r2| i ye 90 iff 1 11081 1 -■ Fiu. 1'23.— Uypcrtrophied duciduu removed with curette and placental forceps on the iiintli ilay ; lochia not ollViisive. this case the odor of the discharges was not offensive. In the absence of signs of decomposition the dangers of removing foreign material from the interior of tiic womb are in direct proportion to the obstetrician's ignorance of antiseptic details. It should be remembered that curettage employed against puerperal infection accomplishes the most good when it is resorted to early, and especially aftci- abortion. When infection has spread from the decomposing d6bris to the uterine wall the operation is less effective, and sometimes does harm by destroy- ing the barrier of exudate which nature supplies to limit septic absorption. If the womb is displaced, it should be rej>laced, and attempts should be ina<le to keep it in position by the application of a lateral compress if the dis- piac.'cnient is lateral, which is not very rare ; by the Sims or the prone jiosi- tioii for .several hours each day if the displacement is backward ; and in all cases by regular evacuation of the bladder and bowel. When the above treatment has been instituted, or even when there has been no occasion for it, the duty of the obstetrician is always to make a vaginal examination before ceasing his attendance, noting tlie size and position of the uterus, the condition of the adnexse, and determining the nature and degree of injuries of the cervix and vagina. If he now finds the uterus displaced, a j)ro|)erly fitted pessary should be applied and carefully watched, smaller sizes being substituted as the involution of the genitalia advances. At the same time it is desirable to deplete the i)elvi(^ viscera by copious hot injections, by irlycerin tampons, and by free catharsis. Septic processes in or about 47 AMFJiJCAX TEXT- HOOK OF OJi.ST/:T/iJC<S. the uterus should receive' ;ij)|>ni|)riate ticatuieiit. Advice may be iieedeil as to tlie subsequent necessity lor reparative oiteratioii. The rarer causes of sub- iuvohitioii — canh'ac or hepatic (hseases produeini;- venous stasis in tlie pdvic organs — sliouM not be ovcrhioked. Tlie value of the rc<::;ular adniinistratioM of ergot as a means for promoting more rapid involution of the uterus is doubtful. The writer has reserved the use of ergot for those rare cases whid seem to be (K'pendent upon either a general lack of muscle-tonus or iqxtn th presence of snuill and nuiltiph' fil)roids, in \vhi<'li eases u pill composed of ergotin (gr. J), (piinin (gr. ij), and strychnia (gr, ^'o), administered thrice daily in conjunction with the application of the faradic current, has seemed beneficial. Should, however, the use of ergot impair to any extent the diges- tion or the milk-secreting functions of the indivitlual, it is best to discon- tinue its use. IVpletion of the pelvic viscera by the employment of copious hot injections, of glycerin tampons, and of free catharsis is also usefid in this class of cases. Fibroid and polypt)id tumors should bo treated as directed in the discussion of Puerperal J[> iiorrli<t(/cs (p. ()04). When the treatment of subinvolution is first instituted, several weeks after the patient has left her bed, and if she complains of innpient bleeding, leucor- rheal discharges, dragging sensations, a feeling of weight antl distress in the back and loins, and, finally, is overtaken by the digestive, (fireulatory, and reflex nervous disturbances of subacute and chronic inflanunatory changes in and about the uterus, the case demands most careful gynecological examination and treatment, involving the repair, perhaps, of a lacerated cervix and peri- neum, the correction of a backward displacement, or treatment directed to the endometrium or to the periuterine structures. 3. llKM()ui:nA(!i;s in thk Pi'kiu'EIUI'm. Excessive bleeding from the uterus within twenty-four hours after delivery is called " post-]>artum " hemorrhage. Its causes and treatment have been (li>- cusswl under Dt/xtocia (p. 600). Hemorrhage occurring later than twenty-four hours after tleliverv is called " puerperal " or " secondary " hemorrhage. I" he (juantity of blood lost during the first eight days of the puerperium has been stated (p. 654) to be three and a cpuirter pounds. Any excess of this amount should be looked upon as abnormal. The bleeding nuiy vary from a sliglilly excessive discharge, which is the more common, to a sudden and alarming hem- orrhage, which can as (piiekly be fatal or alarming in its atter-efl'ects as tin hemorrhage that sometimes occurs immediately after labor. The bloody lochia continuing furnishes a favorable soil for the development and mtdtiplicalioii of micro-organisms, and thus is an additional risk to the puerpera. When it is noted that the bloody lochia are excessive and jjro'onged beyniul the third day, or when, having ceased at the usual time, there is a return,* investigation should be instituted at once to determine the cause, since the proper treatment of the case usually depends altogether upon accurate deter- * A rettini of the liioody loeliiii for ii day or two wlion tlie iiiitient first rises from her I" il is of common oecurreiu'i' iii\il of no jintholoKieal signiticancu. l'ATII()Lf)(jy OF THE I'V ERPEniVM. 7;5<> bc! nei'cU'tl as {•iiusos ol" sul)- i ill the pi'lvic luliuinistration r tlu' ulonis is iri' cases whii'li IS or »ip"» til"' 1 composi'd ol inistcml thricf .'lit, lias siviiu'tl xteiit the (Hti;os- bcst to cVisc'oii- iiont of copious ^,) useful in this at 0(1 as clirc'tctl ^roral weeks alter \)leecling, leiicor- nl distress in the (•irculatory, and natory changes in gical examination cervix and peri- !nt directed to the )urri after delivei y ent have been di>- than twenty-four icmorrhage. 'fhc rperium has hcc" s of this aninuut ,' from a sVn^htly nd ahirming luni- atU-r-etVects as the rhe Woody hichiii nd nudtipliciiti"" lerpej'a. prolonged lioycMi.l lero is li return,* lie eanse, since tho ion accurate det'i- it rises from lier I" '1 '* niiiiation of the cause. A careful inquiry will necessitate an exaiuiiiation of tiie uterus, its contents, its position, and of the adjacent structures. Tlie causes of puerperal secondary heinorrbage, arranged as nearly as may he in tho order of their fre(pioney, are : 1. Retained sociindiiies and bhiod-ch)ts; 2. Displaceiuent of the uterus; .'5. Displaceuienl of tiiroiul»i in the uterine sinuses ; 4. Relaxation of tho uterus ; "). Fibroid or polyjioid tumors; (>. Ilomatoniata ; 7. Pelvic engorgement ; 5. Secondary bh'cding; i). Malignant disease. In a series of ."JOOO deliveries seven eases of severe puerperal heniorrliago were observed. Tlie cause in two cases was over-distentioii of the bladder, protlucing uterine displacement; in one, retained portions of placenta; in two, the kidney of pregnancy ; and in two eases no cause could be found. Retained Secundines. — Tho most l"ro((U(>nt cause of hemorrhage in the piierporiuin is retention of a portion of the secundines, coinnionlv fragments Fi<:. r.'l.- Ki'tiiiiioil liypiTtrcipliiLd dccidu;!'. of placenta, more rarely portions of the membranes. Cases of profuse bleeding IVoni retained secundines an^ far more freiitiently observed after aliorlioii or miscarriage than after labor at term, 'i'lie writer recently rcmovcil a piece of licaltliy placenta from an almost moril)und patient who, after a miscarriage, had lii'i'U [)lecdi!ig contimiously and profiix'ly tlir(.ughout a period of sixteen weeks, flic frccpiency of retained j)ortioiis of placenta causing hemorrhage after deliv- ery at term, compared with retention not foljnwcd by excessive bleeding, indi- <';itt'< that not infrequently nature succcsst'ully disposes of the remnant, in tho i 'I « III < f ! i. li 740 AMERICAN TEXT- BOOK OF OBSTETRICS. nhst'iice of infection, by disintegration and drainage, Martin*' reiwrts nine cases of retained po''tions of placenta in 2'JGO births; in six of the nine cases there was not even an excess of the locliia, and in but two was the hemorrhage severe. The frecjuency of retained membranes is much greater, analysis of various statistics giving a proportion of about 5 per cent, JJut the frequency and probability of hemorrhage produced thereby are by no means so certain, clin- ical testimony on this point being at variance. It is reasonable to believe that retention of considerable portions of the membranes favors the accumulation in the uterus of blood-dots which may be of sufficient size to prevent firm con- traction, and thus indirectly the retained memljranes may be responsible for bleeding, which, however, is seldom profuse enough to endanger life. When considerable portions of the decidua are retained, whether hyjiortro- phied during pregnancy or after labor, and when to these are added, as is verv common, clot-formations of fibrin and blood, an excessive and prolonged locliial discharge is almost certain to result (Fig. 424). Syphilitic endometritis, occur- ring either during pregnancy or after labor, is a frequent cause of liypertrophiod decidua.*^ Should a large blood-clot be retained in the iiterus, the bloody flow may almost cease, and be replaced by a watery discharge ; within a few days tlieic may be a sudden discharge of disintegrated, followed by bright, blood in such large quantity as to cause the patient's death within an hour, A case of this kind has been reported by Parvin. The so-called "placental and decidual polypoid tumors," having their origin in the puerperium and causing hemorrhage, are really layers of clotted blood or fibrin deposited upon fragments of the secundines or upon a rough- ened placental site, ThesQ til)rin-formations*^ may in very rai*e cases become malignant, as will be pointed, out later, Remy ''Mias recorded an interesting case of inversion of the uterus in,the third week due to the eflbrts of the uterus to expel retained fragments of the'placcnta, Dkifinos'iH (ind Treatment. — Carefid management of the third stage of labor always includes an insp,ectiou of the placenta and of the membranes, to deter- mine whether any portions of either have been retained in the uterus, AVh( ii there has been an accessory placental growth — either succenturiata, which h;is blood-vessel communications with the main placental growth and is therei'dre functionally active, or sj)uria, which has no such cimncction — the diagnosis \<, of course, very difficult, and in the latter case is practically impossible. The succenturiate ])Iacenta can l)e diagnosticated by examining the membranes with transmitted light, and observing large vessels passing from tiie circund'creiiee of the main placenta through the membranes and terminating in torn extrem- ities where they have been (l(>tached from the accessory growth. So connnouly is puerperal hemorrhage due to retained secundines that it is visually justiliable at once to explore the uterine cavity when tiie bleediiii; is jirofuse ; vaginal and abdominal examination will disclose a failure in tlie imr- inal diminution in size of the uterine body. If the cervix is retracted, which is umisual when the uterus contains material that should have been thrown oil'. PATHOLOGY OF THE PUlJIiPlJliirM. 741 i-ts nine cases scs there was •hage severe, is of various •cquency and certain, elin- o believe that cunuiUition in ent firm con- esponsible tor life. ther hypertro- aed, as is very [)longed lochial metritis, oocur- :' hypertrophic*! lootly flow may , few days there t, blood in su(l\ A case of this ," having their layers of clotted upon a rough- re cases beeoiuc I'd an interesting rts of the uterus Id stage of lai»tv Ibranes, to detcr- uterus. ^V1"" Iriata, whieh has and is therefnro [the diagnosis w, Inpossible. 'fli'' Ineuibranes with Le circumfereiuc liu torn exlniu- ludines that it is Ithe bleeding is llure in the uoi- Iretracted, whi'li ])een thrown "11, Hegar's or branched dilators may be employed to open it sufficiently for the introduction of the finger, and by biiiianual examination the interior of the uterus should be explored. Fragments of retained secundines may thus be removed, followed by thorough curettage, removal of dislodged particles by placental forceps, and an intra-uterine douche of sublimate solution (1 : 4000), followed by boiled water, or of creolin (2 per cent, solution). When treatment is undertaken after involution has advanced, and the size of the uterus renders the introduction of the finger difficult, the curette and forceps cautiously but thoroughly used will suffice. Uterine Displaceraents. — The puerperal uterus may become displaced backward, forward, upward, downward, laterally, or more rarely it may bo inverted. From a clinical standpoint it is desirable to consider abnormalities in the position of the uterus according as the symptoms occur early or late in the puerperium. The normal position of the uterus immediately after labor is marked ante- vorsion with prolapse, especially of its lower segment. During the first twenty-four hours its retraction elevates the body of the womb to its natural position of anteversion, and the fundus, from the large size of the organ, moves freely about from side to side, rendering a displacement likely of occurrence if tlie woman is kept lying in one position, or when the bowel or the bladder is permitted to become over-distended, or when a compress and binder have improperly been applied. The result of such displacement is occlusion of the uterine canal by angulation-stenosis, with consequent retention of the lochial discharge and the accumulation of blood-dots, which, if they do not undergo putrefactive changes and expose the patient to tl e dangers of infection, lead to snhinvolution of the womb by mechanically preventing contraction and pro- moting a passive congestion of the organ. The lochial flow, which at first may have been diminished and very watery, finally, after a few days, reappears, at first very dark, then bright red, and usually profuse, and in I'are instances there may be alarming hemorrhage. Tile angulation produced by a flexion of the womb either forward, back- ward, or lateral while the patient is yet in bod diminishes the lochial How until it may almost wholly cease, the blood being retained in the uterine cavity. Very commonly under these circumstances there occur putrefactive clianges accompanied by elevated temperature;, rapid pulse, and other signs of putrid absorption. Such cases are rejieatedly observed, and when, as should always be done, an intra-uterine douche is given, the first introduction of the syringe-nozzle corrects the angulation, and is at once followed by a sudden i;nsii of ortensive fluiv' containing shreds of necrotic decidna and blood -clots. The displacement inten'"res also with inv(4ution, as previously stated, and favors the retention and hypertrophy of deci<lua ; lience tlie irrigation should nlwiiys be followed by curettage. Cases which escape infection, but ultinuitely lend to engorgement of i\\G pelvic and uterine vessels, are f()IU)wed by bleed- iiig more or less profuse. Usually the How is moderate but persistent, and after a time the patient is rcihiced in strengtii. Occasionally a snddeu and /" ■( .:v~: t I' ri 742 AM Eli IVAN TEXT-BOOK OF OBSTETRICS. alarming loss of blood will occur. In addition to exploration of the uterine cavity, the condition of the bowel and the bladder should receive attention, and by the careful adjustment of a properly-placed pad and binder the dis- placement can often be corrected. The displacement caused by an over- distended bladder is almost invariably upward and to the right. The nurse should receive minute instructions as to the manner of adjusting the pad, and when the displacement is lateral she should be taught to press the uterus toward the median line and to reapply the pad several times each day. Inversion of the puerperal uterus usually occurs immediately or soon after labor, but it may occur during the puerperium, even so late as the third week, as happened in the case reported by Il6my.®* The cause of this rare accident may be severe straining at stool, or efforts of the womb to expel a foreign body, such as a polypoid tumor or a largo piece of placenta. The diagnosis and treatment of inversion of the uterus have been discussed (pp. 619-623). It remains only to be stated hero that when this accident first occurs several days after delivery, it should be borne in mind that the inverted uterus is especially likely to be mistaken for a polypoid tumor, from which it is readily diagnosticated by bimanual and rectal exam- ination and by an attempt to pass a uterine sound. Other conditions to he remembered, which under some circumstances sinuilate an inverted uterus, aro hematoma of the vulva, of the vagina, or of the cervix, prolapse of the uterus, and possibly vaginal enterocele. Displacement of the uterus at a later period of the puerperium is usually retroflexion or retroversion (PI. 43), with varying degrees of prolapse. The cause of the displacement is almost invariably subinvolution, not only of the titerus, but also of its ligaments and of the vagina. The injury of tlic vagina which contributes to the displacement is a neglected laceration of tlio ])elvic fascia and the levatores ani muscles. In very rare cases, when those injuries have been very severe and the entire attachment of the vagina liiis boon severed, premature getting up and prolonged straining at stool or the lifting of heavy weights have caused w.'iplete y)ro/a/;sc of the puerperal uterus. The treatment of such displacements belongs to gynecology and comprisos curetting and packing the uterus with gauze, followed by plastic operations on tlio vagina, or one of the operations devised for suspending or fixing tlio uterus in its normal position. Separation or Disintegration of Thrombi in the Sinuses at the Pla- cental Site. — Ah'riiiiMir hemorrha<»:(' tnav follow cither of these accidents ovcii so kite as two or three weeks after delivery. .S>paration may occur when the ])atient is permitted to assume an upright posture or is allowed to get out of bed soon after labf)r. After the third day this danger would appear vcrv slight, since in several thousand cases at the Preston Petreat, Piiilack Iplii.i, where it has born customary for the nurse to lielp the patient to the cotiiinndc rolled to the bedside, no ''\A\ acci.Ii'Ut has Ix'oii reconled. Disintegration of clots leading to <laiig<M'ous hemorrha|,'e sometimes ac< iiii- panics puerperal infection which has produced necrotic changes in the thnirnlii. PATHOLOGY OF THE PUERPEItlL'M. 743 ' the uterine ;e attention, der the dis- by an over- The nurse the pad, and ss the uterus each day. or soon after le third week, itool, or efforts lor or a largo he uterus have that when this borne in niiiul for a polypoid d rectal exam- onditions to bo n-ted uterus, are se of the uterus, crium is usually [' prolapse. )lution, not only le injury of tl>o aceration of the ases, when these ' the vagina has at stool or the uerperal uterus. and comprises tic operations i>ii or fixing the ises at the Pla- Le accidents even L occur when the jved to get out of \\\A appear very [it, riiihuhlphin, to the coniuiotlc Lmetimes aeeoiii- Is in the thronii'i. Hemorrhage may occur spontaneously in these cases, and it has been observed in the course of treatment when the cavity of the womb is curetted. When alarming bleeding occurs soon after delivery and the uterus is found empty, dislodgement of thrombi should be susjKicted, and the bleeding should be con- trolled by an intra-uterine tampon of iodoform gauze. The same treatment is applicable to hemorrhage from disintegration of thrombi. Relaxation of the Uterus. — Hemorrhage from this cause, and of severe tvpe, may rarely occur within the first three days after labor. It may be a sudden outpouring of blood, or, the cervix being obstructed by a clot, the blood may accumulate in the uterus, in which case the patient's condition of faintness !uid the pain caused by the over-distention of the uterus may be the only signs of the accident until the size of the uterus is ascertained by pali)ation. Bleed- lug so sudden and alarming as this is invariably due to relaxation of the uterus. 'I'his accident, which is of rare occurrence, is usually found in women of lowered vitality and muscular weakness. One case of the writer's, occurring forty-eight hours after labor, was doubtless due to the exhaustion and relaxa- tiou following vigorous purgation and the free use of chloral and vcratriun in the treatment of violent eclamptic attacks chiring labor. In two other cases the hemorrhage occurred ten and twelve hours respectively after the delivery of twins. Sudden and profound emotion lias been followed by profuse hemor- rhage, probably the result of relaxation, although alteration in blood-pressure has been claimed to produce it. Hemorrhage due to relaxation of the womb sliould be treated promptly by emptying the womb by expression or by the introduction of the hand, followed by the usual means of controlling bleeding inunediately after labor, resorting, if need be, to the employment of an intra- uterine iodoform-gauze tampon. Fibroids. — Tiie dangers of uterine fibroid tumors complicating the puer- perium are twofohl. The greater danger is the possibility of the tumor under- goiug necrotic change and sojitic absorption from the sudden diminution of its blood-supply during the proces,ses of involution of the uterus. Tiie lesser ilauixor, yet one of great importance, is the hemorrhage it may occasion, rarely profuse, but usually sufficiently prolonged to impair seriously the patient's streugtli and health. Hemorrhage is very prone to occur when the tumor is suhnuicous or podunculated. Interstitial and subperitoneal tumors may not he productive of hemorrluigo, but they may undergo the sloughing change ju-t referred to, and, besides, may so thin the uterine wall as to add the risk of perforation when the uterine cavity is being explored by the curette or other instrument. Till' <li(i(/nosif< of fibroid tumors in the puerperal uterus can he made by iutra-utorine and Ititnainial (>xamin!ition. If, when a tumor is discovenHl, Ikmu- orrliage is the only complication present, it may be coiitroned temporarily, if iint profuse, by the daily use of ergot, strychnia, hydrastis, and the faradic eurreut. Sluaild tiio tumor be polypoid, it is l)est to remove it l>y the wire ecia-cur and scissors. If slougiiing has ocetirred, wliieh is annouueed by a foul ilischarge, this troatment, or removal of the tumor by the blunt curette, care WIMi .:.^ 744 AMERICAN TEXT-BOOK OF OBSTETRICS. beinjij tak((ii not to porforatc the uterine wall, or hysterectomy, is imperative. Should interstitial or subperitoneal tumors become necrotic and threaten sepsis, liysterectomy is indicated. Hematoma. — I fcmatonia in the puerperium has been discussed on page 680. Pelvic Congestion. — Pelvic congestion from any cause may occasion hemorrhage of varying severity in the puerperium. The increased blood- supply to the pelvic organs and the return for a few days of the blocnly lochia when the puerperal woman first rises from her bed constitute a frequent and physiological example of the occurrence of pelvic congestion. When the bleeding is prolonged beyond a few days, a j>athological i'ondition should he looked for in subinvolution with uterine displacement, in periuterine inflam- mation, or in a too early resumption of, or desire for, sexual intercourse. Occasionally other causes may be discovered, such as an accumulation of fecal masses in the rectum, an intrapelvic tumor, or disease of the liver, kidneys, or heart. Secondary Bleeding. — Rare cases have been recorded of rupture of an artery or a vein by erosion, and of hematomata and secondary hemorrhage following lacerations, in which cases the bleeding was controlled teniporarilv by the pressure of the child's head during labor. In such cases the bleed- ing vessel should, if possible, be found and ligated ; otherwise a firm antiscj)- tic tampon is the t)nly recourse. Hemorrhage from malignant disease is of rare occurrence, since malig- nant diseases of the uterus, cither carcinoma or sarcoma, usually prevent con- ception. Digital examination will at once make the diagnosis of malignant disease of the cervix, and the hemorrhage may be controlled by a vaginal tampon frecpiently renewed until the advisability of hysterectomy has been considered. Cancer within the body of the womb complicating the puerperium is also rare. Whether in most cases the disease exists prior to impregnation, as insisted npon by Veit, or whether it develops after labor, either at the placental site or in the decidua, is not by any means certain. In either case death ensues within a few weeks or months. IVriiller "* found, in an analysis of 577 cases of carcinoma of the uterus treated in Gusserow's clinic, that in 8.14 per cent, tiie disease developed during pregnancy or the puerperium. Cases of malignant disease develojied at the ])lacental site have been reported by Chiari,®' Kuchcr,''^ and others. Von Kahlden®' described n case of malignant degeneration of a placental polyp in which case death occurred eleven weeks after •.elivery. Ciottschalk^" reviews 10 cases of malignant deciduoma, of which eight had j^reviously been reported, and he records a case (a vi-para set. forty-two) in which, the recurring heniorrhages not being relieved by repeated curettage, he dilated the cervix and examined microscopically the scrapings from tlie j)lacental site. Sarcomatous new growths of the fiml)ria3 of the placenta were found. Although the patient's g(>neral condition was bad and her temperatnre was 104^ F., tin uterus and ovaries were rem')ved eight weeks after delivcrv, and recovery folio ved. Paeon ^' described in detail a case of deciduoma malig- i imperative, vcateii sepsis, I on page 680. may occasion rcased blootl- bloody locliiii frequent aiul ,. When the ion shonUl ho itcrine inflani- lal intercourse. Illation of fecal liver, kidneys, ' rupture of an ary heniorrliaso led temporarily tiases the blccd- e a firm antiscp- nce, since mali,u;- dly prevent coli- tis of malignant ,1 by a va};inal ectomy has been PATIIOLOUY OF THE PUERPERIUM. ^/^. 745 luun, and gives a table of all the cases reported, fifteen in number, of tumors composed of elements derived from decidual cells, and five cases of tumors com- posed of elements derived from chorionic villi. He points out the important clinical fact that half of the cases followed molar pregnancy, and in support of the notion that the tumors began during pregnancy he states that in twelve out of 18 cases the hemorrhage was known to have ap])eared almost innue- (liately after labor or abortion. As to prognosis, he says, " All cases have ter- minated fatally except two which have l)cen reported this year. In one of tiiese cases, that of Novd-Josscrand, the uterus has been removed. In three previous cases this operation was done; in vain. The other non-tiital case was Menge's patient, who received a simple curettement of the uterus. The fur- tlier report of this case will be of special interest." When continued hemorrhages are not relieved by the curette and are not tiai'cable to constitutional disturbances or to other evident local causes, the possibility of malignant disease shoidd be thought of, and the scrapings should Itc subjected to critical microscopical analysis. The result of malignant disease ol" the puerperal uterus in the reported cases has, with one exception, been a rapidly fatal termination, except when the uterus was wholly removed. This fact pt)ints to extirpation as being the only rational treatment when a positive diagnosis of malignancy has been made sufficiently early. Should the hemor- rliage meanwluiu be profuse and alarming, the intra-uterine gauze-tampon may he employed, ^Vmong other condiii<nis very rarely causing puerperal hemorrhage should 1)(' included profound emotion, syphilis, chlorosis, scurvy, nephritis, and malaria. Hemorrhage due to either of the blood-dyscrasije is probably the result of changes in the blood preventing the formation of obliterating coagula (( 'azeaux). There is yet some difference of opinion as to malaria being a factor in puerperal bleeding. Billon in his inaugural thesis (Paris, 1883) denic's any such influence after carefully analyzing 90 cases. Lifegeois, however," de- scribes such a case, and the writer recently observed a case of free bleeding a|)})arently due to this cause. It has been pointed out by Winckel" that free i)l('e(ling often fi)llows the determination of blood to the internal organs by a clilll, which fact may explain the hemorrhage observed in some cases of iiwilaria. 4. Anomalies of tiik Nipples and the Breasts. The anomalies of the nipples are of clinical importance by reason of their relation to inflammation of the breast during lactation. In ninety-seven cases (if puerperal mastitis Birket''* found imperfect development of the nipples in fiirty-eiglit, Athelia, or absence of the nipple, is sometimes congenital ; it may In; the result of traumatism or of suppuration of the breast in the nc w-born infant. Microthelia is the name given to .small, ill-developed, or sunken nipples. Mlrnithelia is by no means unconmion ; it may be the result of a congenital WM .u. . ^1 746 AMEIilCAN TKXT-nOOK OF OBSTKTllWS. defect, or the condition may he acquired fVotu the wearinj; of faulty clothing or of corsets compressing tiic breasts and flattening or even invaginating tlu.' nipples. The accompanying illustration (Fig. 425) shows diagrammatically Flo. 4t!r>.— Faulty development of the nii>i)le. several varieties of l)adly-slia])ed and ill-dcveloju'd nip])lcs which interfere witii suckling. The sunken or invaginatcd nipple cannot readily he grasjwd by the infant's mouth, and the insufficient flow of milk aggravates the child and loads to vigorous biting and tugging, which are soon followed by erosion or fissures of the nipple. When the infant takes the mushroom-shaped nipple into its mouth the narrow base of the attachment of the nipple tf) the breast is further occluded and thus a free flow of milk is prevented, and traumatism of the nipple follows the increased efforts of the child. The treatment of microtlielia will be referred to later. Polythelia. — In polythelia — supernumerary nipples — the multiple nipples are usually found in a line running downward and inward or upward and out- ward, analogous to the situatio^i of the nipples in the lower animals. Bruce"' found supenuimerary nipples relatively frequent among women — 4.8 per cent. in 104 women. Amazia, or congenital ab.sence of one or of both breasts, is an extreiiicly rare anomaly. According to Delbert, the absence of otie breast has been observed only in women, and the absence of both breasts occurs only in mon- sters having usually other deformities incompatible with life. Mioromazia, or small breast, which is a defect very much more irequent than amazia, is sometimes associated with an infantile uterus. Polymazia, or supernumerary mammary glands, is an anomaly more fre- quent than ama/ia. The multiple breasts may vary from a small nodule ol' glandular tissue to a fully-developed breast capable of nouri.shing an iiilaiit. Although sometimes situated in the axilla, on the back, or on the thigli, l!ie glands are commonly seated upon the anterior wall of the chest. DISKASKS OF TIIK r.liKAST. I'l.ATi: 17. nmltiplo nippl'"' upward ami oiit- nimals. Bnicr"'' en — 4.8 per n'lit. is an pxtiTincly breast has Ix-'H urs only in nmii- '^■,i.'. 'h more iVeqin'iit W til lionialv more u l.ll.^l.A-l.^ nl nil Niii'i I : lji.-i..iMi| ihr iiii'i'lf liMiii a I'huU^raiili; .1 .. V. I m :-ii PATHOLOGY OF THE PVERPElilUM. 747 |l 5. DiSKASE OF TIIK NlPPLES. Sore Nipples. — Under the term "sore nipples" is usually described u afroiij) of inflammatory conditions of the nipple varyinf]^ in severity from a simple yet painful erythema to erosions, ulcers, and fissures that may occasion so great distress as absolutely to contra-indicate nursing. Clinically, sore nip- ples are of the greatest importance on account of their close relation to mastitis and mammary abscess. When the irritation of the nipple passes beyond simple erythema, the epithelium is denuded at one or more points, leaving the under- lying papillie unprotected. Within a few hours there is likely to appear an erosion (PI. 47) situated most often upon the apex of the nipple, next in frc- (juency upon the sides, and least frequently at the base of the nipple. If at this time proper curative treatment is neglected, the erosions are often con- verted into fissures. When the natural divisions between the papilhe at the summit of the nipple are deeper, broader, and larger than normal, the removal of the overlying e|)ithelium by the lips and tongue of the child in the act of sucking leaves deep fissures which are very troublesome, cause intense pain, and often bleed at each nursing. Fissures situated at the base of the nipjile, at the junction of the nipple and the areola, are usually semilunar in shape; tlioy are often the most dillicult to heal, because the act of sucking almost always separates their edges, and thus at each repeated nursing they grow deeper and extend more and more around the nipple, sometimes even penetrating a milk-duct and leaving a milk- fistula. Rarely the nipple is thus partially, or even wholly, amputated. The frequency of fissures of the nipple is estimated by Kehrer as 44 per (•out. in primiparre, in whom sore nipples are certainly (uore frequent than in inultipane. Hiibner states that 51 per cent, of ntn-sing mothers between the tiiird and the fifth day will have fissured nipples. Winckel found seventy-two among 150 nurses. Dluski^* found one hundred and eighty-one cases, ninetv- nine being slight, in 433 recently-confined women in Baudelneque's clinic. Women with delicate skin, particularly blondes, are more liable to have sore nipples. The frequency, certainly of severe cases, is doubtless in some measure (l('])ondent upon the degree of cleanliness and care of the nipples in the early (lays of lactation. Ktiolnrii). — The anatomical structure of the nipple, jvirticularly wlieti there are dovelopmental defects, predisposes the organ to inflammation, on account of the injury it is likely to ret^eive during the act of sucking. The delicate ppitiiolir' covering of the nipple, being softened and macerated in the child's mouth. •; then readily removed at various points, leaving the ])a])illie unpro- tected and bathed with milk and often with blood, both of which are excellent iiH^dia for the growth and development of micro-organisms. When the nipples are misshapen, short, or inverted (Fig. 425), the infant is unable readily to gnis]) the nipjde with its mouth, and efllbrts at sucking are consequently more violent and the traumatisms to the nipple are thereby correspondingly iiKToased. While some authors consider the traumatism of sucking the i ■:^T. ^, IMAGE EVALUATION TEST TARGET (MT-S) 1.0 I.I 1.25 ■ 2.2 •u 136 mm Mi ■ 40 12.0 uut V] 'i>' / Photographic Sciences Corporation ■n WS?T MAIN STRUT WiBST^R.N.Y. MSSO (716) •72-4S03 it o^ ■■■t 'l ; I- t I III h, IP 748 AMERICAN TEXT-BOOK OF OBSTETllICS. most important, elpmont in tiie etiology of sore nipples, others lay most stress upon hat'terial invasion from tlie nurse's or the mother's fingers, from soiled eloths, and olten from the child's mouth. The truth doubtless lies, as is so oflen the wise, in the middle ground. The trauma lessens the resistance ol" the nipple-structures to invasion by micro-organisms, and when scrupulous cleanliness of Ixith the nipple and the infant's mouth is neglettol a slight irri- tation becomes un infected wound. Bumm" fre(|uently found in fissured niii- })les bacilli and cocci, and even the staphylococcus aureus and albus, when there was no adjacent inflammation. Symplotm. — From the third to the fifth day of the puerperium the ulceration at some point of the nipple usually aj)pears, accompanied by very severe pain, and in nervous individuals easily responding to reflex irritation, or when tiio sore is infectwl, the temperature may rise as high as 104° F. or higher, and may even be accompanied by convulsive movements. The nervous irritation and the api)rehension of the excruciating pain occasioned by nursing some- times prevents sleep and seriously interferes with the appetite and digestion. Treutmeut. — The prophylaxis should begin in the latter months of prejj- nancy. Pressure upon the nipples by corsets and by clothing must be avoided. The nipples should be washed morning and evening with a bland soap and water, followe<l by inunction with cacao-butter, lanolin, or sweet oil, and onee each day they should be treated with a saturated solution of alum or with a aO per cent, solution of glycerol of taimin. When the latter is used the patient's underclothing slu)uld be protecttnl from being soiled by the tamiin. If tiie 7iipplc is invaginateil, attempts may be made to draw it out with the fingers, or, what is more effective, by bu<!cal suction or by the application over the nipple of the mouth of a bottle just emptied of hot water. These mani|)nla- tions are to be employed only in the last months of pregnancy, since they can cause premature termination of pregnancy. Layers of adhesive plaster around the nipple, 4 centimeters (l^ inches) in width and 13 millimeters (| inch) thick, may be worn some months before labor. When these measures fail, if the in;il- formation and shortness of the nipple are not too great, and if it is espeeiaily urgent that the mother should nurse her child, the operation of mammillaplasty, first suggesteil by Kehrer, will improve the defect. Williams" thus deserihes the ojH'ratiou : "A circular strip of skin, together with the subjacent fibro-f'atty tissue, is excised from the prominent cutaneous fold surrounding the depressed nipple; or, instead of a circular strip, two crescentic pieces may be removed (Kehrer). Care should be taken to avoid injuring the subjacent ducts ; this will be retidercil almost impossible by keeping the incisions external to the areola. On suturing together the opposite cut edges of the manimillary ;md mammary skin the nipple will be pulled into its proper position. In a ea<e reported by Herman^' the operation residted in a permanent cure. Of course, not much good can be expectetl from this proceeding when the nipph' is congenitally stuntetl and malformed." From the earliest periotl of lactation close attention to cleanliness of tiic nipple and of the child's mouth is of the greatest importance. At least onee a lay most stro.-s rs, from soik'd « lies, as is so B I'esistancfi of leii scriipuloiis il a sliglit irri- n fissured nip- )us, when tin ih- I the ulccratiun ry severe pain, in, or when tlio or higher, and rvous irritatiiiii nursing somc- nd digestion, iionths of preg- uist be avoided. Idand soap and !et oil, and once mi or with a AO ied the patient's tannin. If the vith the fingers, eation over llic iiesc manipula- since they can plaster aronnd |s (J inch) thick, fail,if thenii.l- it is espeeiaily [lammillaplasty, I' thus descrilies ,eent fihro-fatty g the depressed ay be removed lent ducts ; tliis external to tlio ammillary and on. Ill a c:i<c Ire. Of eunrsc, the nipple is lanliness of tlio At least once a PATIIOLOaV OF TirE PUERPKRIUM. (49 day, preferably oftener, the child's mouth should be washetl with a saturated solution of boric acid or of borax. Before and after each nursing, which shoidd be at regular intervals, the nipples are to be washed gently but thoroughly with absorbent cotton and the boric-acid solution and carefully dried. If the epi- thelium is at all inflamed, the nipples, after nursing, should be covcretl with a protective ointment. For this purpose either of the following ointments, spread upon a clean piece of lint or waxed paper, will be useful : ^. Acidi borici, gr. xx ; Olei ricini, Bismuth! subnitratis, aa 5ij. Or, 'S^. Tincturae benzoini compositse, Olei olivse. Lanolin, 3u; 3vj 80 Or the nipple may be covered with lint wet with dilute lead-water — a plan having the disadvantage of necessitating thorough washing from the nipple of every trace of the lead lotion before the child nurses. The distilled extract of witch-hazel diluted with three or four parts of water the writer has found especially useful, alternating this lotion with the bisnuith paste. When the epithelium is eroded at several points or in one large area, fol- lowing the same precautionary cleansing before and after nursing, the oint- ments above referred to, or either of the following, may be used : Iodoform, gr. x; oxide-of-zinc ointment, 5ss; or, Ichthyol, .^j ; lancdin and glycerin, aa siss ; olive oil, siiss. The compound tincture of benzoin, or a lO-grain solution of silver nitrate, painted on with a brush, will sometimes be useful. Powdered tannic acid dusted over the raw surface, and kept in place by a small circular piece of lint smeared with eosmolin, is highly ])ralsed by Garrigucs."' For a distinct and deep fissure, whether situated at the apex or the base of the nipple, the solid stick of nitrate of silver, applied carefully and only to the fissure, is perhaps the most efficient treatment. This application may often with advantage be followed a day later by careful coaptation of the surfaces of tiie fissure by pressure with the fingers, the coaptation being thus main- tained until the fissure is permanently held together by a few drops of col- lodion and a thin film of absorbent cotton. While one or more of these local applications are being carried out it is always desirable to resort to a mammary binder (see Fig. 429, j). 75."}) and to relieve somewhat the mother's pain and prevent further injury to the nipple by using a nipple-shield. Of the numerous varieties of shields, that figured in the illus- tration (Fig. 427) — a glass bell with a soft-rubber nipple — is most useful. The siiicld should always be taken apart after nursiiifr, be ''leansed thoroughly, and bo kept immersed in a tumbler containing boric-acid solution. It is desirable also occasionally to wash the shield in a 5 per cent, carlxjlic solution or to boil tii<' glass bell for twenty minutes. Persistence on the part of both mirsc and mother will often overcome the child's aversion to a shield, particularly if the 1 •'; .-if . 760 AMERICAN TEXT-BOOK OF OBSTETRICS. glass bell of the shield is tightly applied to the areola and partially filled witli milk by stroking the breast before the rubber nipple is placed in the child's Fui. 42t;.— The Y-bandage (Bostdii I.jinn-in IloKpitiil). mouth. If the shield can be used, much has been gained toward the preven- tion of more serious trouble in the breasts by thus avoiding congestion and engorgement of the glands — an accident not uidikely to occur if the extreme pain of suckling makes it necessary to give up nursing, and if at the same time the nurse is not skilled in preventing mammary engorgement by massage (PI. 48), a measure, when the manipulations are skilfully performed, vastly superior to the breast-pump. The nipple-shield, however, should not be used in case the fissure is so situated that the action of the shield is observed to aggravate the condi- tion by pulling open the fissure, thus failing to relieve the mother's pain each time the child sucks. Fissures located at the base of the nipple will sometimes be aggra- vated by the shield. The shield should be given up at the earliest possible moment after the nipple has healed. Sometimes it will be necessary for a few days to remove the child wholly from the nursing breast. Usually twenty-four hours will be sufficient to allow the fissures to heal under appropriate treatment, but in severe cases, when mammary inflammation is threatened, three or four days may be requiretl. Meanwhile massage and other means to prevent mastitis are to be employed. In very exceptional cases nothing short of artificial feeding and drying up of the breasts will give permanent relief — a defeat not to be permitted except in the presence of an imminent mammary abscess or when the epithelium oi' tlic patient's mammary glands and the nipples have proved, on the one hand, un- equal to a sufficient supply of milk, and thereby, on the other hand, incajiaMe of tolerating the more active biting and tugging of the infant at the nijiplc, which effi)rts continue to destroy its epithelial covering. Fio. 427.-Nipplc-shIel(J. ■(■!■■ PATHOLOGY OF THE PUERPERIUM. 751 Uy filled witli in the child's vard the prcvcii- r congestion and r if the extreme I if at the same enting mammary easnre, when the astly superior to [however, should situated that the •avate the condi- failing to relieve sucks. Fissures Lctimes be afrjira- d 1)6 given up at ipple has healed, the child wholly lufficient to allow ere cases, when lay be recpiircd. to be employed. nd drying up itf ■mitted except in pitheliura of tlic Ihe one hand, un- hand, ineap:d)le mt at the nippK', Abscess of the Nipple. — Tiiere has been described ^^ a deep inflammation of the nipples that undergoes resolution or, more often, results in the forma- tion of a small abscess either in the lactiferous ducts or in the connective tissue of tiiO nipple. This affection is a very rare («nc. If pus forms in the ducts, it is evacuated spontaneously through the apertures of the duets ; if the abscess is confined to the connective tissue, the nipple enlarges, and becomes very red and tender, which changes are often soon followed by a spontaneous opening ; when the opening is delayed an incision should be made on the circumference of the nipple, after which there is rapid healing. Lactation should be inter- rupted for a few days until there is no longer a trace of pus. Eczema. — Eczeinatous affections of the nipple and the areola sometimes spread to the adjaccut integument of the breast ; these affections arc often dif- ficult to cure, weaning being necessary in some stubborn cases. Stumpf,** who has thrown the light of bacteriology upon the clinical fact that eczema of the nipple sometimes leads to mammary abscess, demonstrated the presence in eczema of the breast and nipple of a staphylococcus, probably pyogenes aureus ; he found the same micro-organism in the milk of those affected, and he believes that the reinfection thus occurring explains the stubborn character of the disease. Treatment. — Protective ointments containing zinc, salicylic acid, or carbolic acid are useful in some cases ; in other cases more active remeilies, such as resorcin, nitrate of silver, or corrosive sublimate, should be employed, care being taken always to wash the nipple thoroughly before nursing. The breast is sometimes affected with scabies, and occasionally with herpes zoster. Syphilitic ulcers should be recognized promptly, and should receive local and constitutional specific treatment. When the child presents no evi- dence of syphilis weaning is imperative. 6. Diseases op the Breasts. Conerestion and Engorgement of the Mammary Olands. — At the first appearance of the flow of milk, and thereafter throughout the lactation period, especially during the first two weeks, it is not uncommon suddenly to find the Flii. 128.— Kreast-piimp. '^j 51 .'if' . breaf?ts engorged with milk, accompanied sometimes by pain and tenderness and a .slight rise in temperature ; or the reaction may be so slight as to occasion 7r>'j AMi:itlVAy TKXT-IKHiK Or' iHiSTETHICH. >>.: w ■tm .;l' I •■.?fi ■ •'! r .;■:, ' II \i only <li.strcss aiul a sense <»(' fulness of the niatnniary jjlamls. Ilypersorretion olinilk and ex|t(>snn' to cold are eomnionly the eanses of lliis (condition, wlileli is |trorn|itly i'eliev«'d hy reniovintr the ex«'essive atnonnt of milk iti tln^ hrea^t and hy |)reventin<; fnrther enjrorj^enient. The over-distent ion f)f tlu' jflanrl i~ relieved l)y more fre(|nent application of the infant to tlu; breast, hy massa^i or hy the hreast-piimp. Of the vjirions hreast-pnmps offered in the shop- that called the " Kti},dish " (V\<r. 428) is the mt.st. desirable and enieieni, l"'nrther enjrorj^einent will he picvented by th(( administration of one or twu fidl doses of a saline pnrjje to obtain free catharsis, and by comjjrcHsion of iii< l>r<'asts with a mammary binder. Siijtport anil ('<»n/nr.'ixiini. off/ic /Irraufs. — Various means have l)ren devixil for obtainitif^ compression of the breasts. Strappinji; with strips of adhe.-ivc plaster, th(! roller bandaj^e, paintinj^ the breasts with contractile collodion, ami the various types of mammary bin<lers an; means each of which has its chain- pions. As a matter of fact, with the ex(!eption of adhesive; plaster, with which it is not easy to obtain persistent uniform <'ompression, and which is tronlijc- sonie on account of the painful excoriiitions of the skin produced, each n!' these m(!ans is sjiecially useful under c«'rtain circumstanc(;s, and each, fhcref'ori', lias its s|»ecial indications. It is the; writer's custom in both hospital and pri- vate practice to apply a mammary binder to every puerperal patient when th.' milk-flow is bejrinninj; to be established. At this time support, not coniprc— .-ion, of the breasts is desired. I'\»r this purpose the Murphy binder (see Kiu. \1'2, and description, pajrc fii\'2) is ordinarily nscfl, bccausf; of its simplicitv, elliciency, an<l ready i •.anufactiire. When, however, the nipples an; stunted or olhi'rwis(! ill-developcfl, the Murphy l)inder has the disadvantajfe of a^ro^n;- vatin^ the def<!(;t l)y firndy compressing!; the nipple af^ainst the breast, and liv increasintr the heat and moisture of the nipples, both of which elf(!cts remlcr sore nipph's more liable of occurrence. To escape these disadvantajfcs the wrilcr has some of tlies<' banda<res made with an opeiiiufr about the size of a silver liiiH- ilollar ov('r each nipple f l''ij;. I2!>j. TIk; marj^ins of the openinjrs are luilinii- hole stitched. This modified bandage is used when the nipples an; stunted or arc inverted or when it is necessary to make a|)plii'ations to er(»ded nipples — >iicli, for example, as the bi.-muth paste <»r the witch-ha/el lotion. The nipple, afl(r bcin<; clcinscd, is smeared with the paste, an<l a disk of chnin waxf-d paper with a film of the paste at its centre is placed over the nipple, after which the baml- nj;(! is applied. TIk; infant may now be nursed, or repeated ap|)lications ul' a loti«)n may be made, without Ioos(!nin^ the banda<>;e. Should the nipple ami the areola show any eviclences of «'dcnia, which will sonjetimes happen win n the bandajfc is too tightly applied, the swellinjf will be relieved by looscmiiLr the bandajfc and, if necessary, by pinning over each openin;.j a strip of iiiii-liii only sli^rhtly compressing; the nipple. When it is desired to compress the; breasts flnnly, as in threatened ina-titis and alter massajre, a strai<;ht strip of uid)lcached muslin tii^htly «'ncinliiiLf th(! chest over the breasts, or the Y-banda^'^e (F'oston Lyinfr-in Hospital/, i- |)refcrr(»l (Kij^. 42<»). The latter is applied as indi(;ate<l in Fijfiire l.'JO. I'ATinnjKiY <u' Tin: ri'iiurEiuiM. I •)■> ■■**'» ii'i ' mm\'^ vixsrsorrctii)!! (lition, wIikIi ill tilt' l)r(!i-t i" the j^laiiil i- t, by massiitrc, ill the slioii- iiiid «'iVKiiiii. f»f OIK! <»r IW" lircHsion ol" iIm' ,•(> hcc'H »l('vi-' il ips of iidlioivc . collodion, aii'l •h lias its cliniii- st(!r, willi wlii< li liicli is trouhli- )(liic('<l, cadi m!" I (wli, tli« n'tori', Hospital and Jtri- piiticiit when lli" irt, not coinprf" l»indcr (s,«'<' Fi'J. of its siinplidly. Ics are stnntcd or iitajro of -.v^ixri- hrcust, and l)V 1 (ittcM'ts rcmli T inta}f('s tin- writiT ol" a silver liall- linj^s arc l)iitt"n- [irc stunted or mv ■.1 nipples— >ii<li, The nipple, iil't'T ,vax(!d paper Willi which the Iminl- applieatioiis »\' ;i Id the nippl*' and ^les happen wlien Ivcd hy looseiiiiiil a strip oi" nni^lin Ireatened niii-titi« lijrhtly cneinliiiL' t-iii Hospital). I'll., l.li.- Moililiiil Miir|iliy Nrcii.st IiIikIit. Klii. i:]ll.—T\if Y-l)lilii|ii(.'r' (lii.slnij I.yiiii; in llLspitiilj I I: i , (<^ in Ki^nn :{(). I'm. I ;1 — Kipllcr liiiiicliii.'i' iipplii'il In liotli Ijrrii'-ls IK Kl'.. i:U.- I!iilli-r liiiiiiliiL'i- M|i|ilii'il Id diic' lircM^l. ■v-(' I ( .1 754 AMKlilCAA TKXT-JiOOK OF OliSTE'riiW^. After (Instill}; the siirliu-c of tlic hrcast with powdonnl starch or other hhinii (luHtiiijf-powdor, the Imsc of the Y is <h'awii iM'iieath tlic patient's haek nntil the apex of the fork is external t(t the outer edj^e of the breast. The paticni now lifts upward and toward each otiier the two breasts, un*l the h>wer arin of the fork is sinngly (h'awn across the chest l>eneath tlie breasts, the inferior border of this arm extendin*; at h'ast an inch behtw the niar^fin of tiif glanihilar tissue. The free end of the ann is now pinned to tlie free end nl the strip that has passe<l beneath the back, and the inferior border is pn . vented from slipping upward bv two safety-pins attaching it to the abdoniiii;il binder. The npj)er arm of the fork is then drawn across the chest above the breasts, the up|K'r border of this arm extending an inch iH-yond the glandnl.ir tissue of the breast, and the free end of the arm is pinned to the en«l of tlic strip passing behind the back. The upi)er border of this arm is prevenl((l from slipping by pinning it to the shoulder-straps. To secure smoothness nf the bandage and unit<)rm jurssure of the breasts, safety-pins are now applied where the two arms of the bandage join each other uiwh'r the axilhe; the pinning slioidd be from the axilla toward the areola in order to decrease the j)ressnre of the bandage gradually as the nipple is approached. A foldtd towel covered with a layer of absorbent cotton is now placed between the breasts to exert ])ressure upon their inner surfaces, and the two arn>s of tlii' bandage are brought together and iijstened between the breasts by means nl' ;i safety-pin. This bandage, when properly applied, slptuld exert so niiuli C()mj)ression of the breasts that milk soon begins to How from the ni|i|ili. The bandage will therefore occasion considerable pain, making it necessai\ tn loosen it after a few hours. It should be worn for several days, with a degree of compression oidy short of producing pain. After all signs of iuHanuniitiun have subsided the Murphy binder may be substituted. Ordinarily the two bandages just described will serve the pin-pose ot' sup- port or of couipression of the breasts. When, however, it is desired permaneiitiv to discontinue lactation, and to dry up the breasts when abscess is tlireafeiKd, the degree of compression needed is best obtained by a tight roller baiidairc (Figs. 431, 4;}2) or, what is even more eflicieiit, though very paiiifiii. hy a dressing of c()ntractile collodion. A circidar piece of material sold id the shops inuler the nanu' of "silk illusion " is appli(><l to the breast, and sliniild extend 2 or 3 inches beyond its periphery, with a central openini: t''i' the nipple and areola. To prevent puckering and to secure close adiiptnlinii to the contour of the breast, the material is cut at intervals of an inch or hhmc from the periphery toward and halfway to the c(>ntral opening. The liiiM-t is smoothly covered with the circular |)iece of illusion thus ])repareil. ;iiid ;i thin layer of coll(»dion is applied and allowed to dry. Successive lavci- nf collodion will give any amount of compression desired. Xotwithstaiidiiisr every precaution a circle of blisters around the j)eriphery of the dressing' i< likely to occur. This disadvantage, a»'d the possible necessity of releasiii;: iIk' breast temporarily for practising massage when compression fails tn drain the breast, make the collodion dressing of doubtful utility. A very ImimK' '■ I t"P f. IHSKASKS OK TIIK liKKAST. I'l.ATK IS. or other Ulaii'i iitV back uiitii t. Tli«! patitiit tho lower arm ists, the iiil'eri'i nlal'^;ill ••* <'"' the tree eml "i : border is jtn - (» the abdoiniiiiil chest above tlic 11(1 the f;lanthil:ir lo the end of the »nn is prevent! (1 e smoothness fl' i are now a|»|»lii<l • the axilUe; tlir •r to decrease tlic lehed. A lol.l.'d iced l>etwci>n tlic two arms of tlic its by means of a ,1 exert so niiitli tVoni the nij'i'l'. n^ it neeessarv tn ays, with a dci-nc s of iiiHannnatiiiii •iired jM'rnKUiciitlv cess is tlireatcin'il. [ht roller biiiulaL'i' verv painful, liy iterial sol.l in tin' Ibreast, and ^li'.uM ntral oi)eniiiu ''"' )•(• close adaptati"!! ,f an inch or in<nv Nutwith>taii.r:iiir )f the dressiiiL' i'' tv of reloasiii',' tl»' in Miissii^i' (iT llic limi>t irniin plmioLTnplisl. i! I n t ■ t ,■: 1|H !» ■" (■' [ 9 ^1 ra^ff' t- 1 If im PATHOLOaV OF TIIK PrERPKlUVM, 755 iipplitnl Y-baiulafjo or the rolli>r bandaj^o is almost as offioieiit and cortainly is loss ti'oiiblosoinc aiul less paintiil. MuHsage of the Jhv(i»t». — To achifve the best results IVoni nianipulatioii of tiio breasts it is nei'essary to know its liruitatioiis as well as its iiulicatiotis, and more important tlian all is an intimate knowledge of its teeliniqne. The pliysieian shoidd give the matter his personal attention when there is not at hand a nnrse upon whom he ean rely for its projx^r i)erformaiu'c. The im- portant eontra-indication to breast-massage is interstitial inflammation of the l>reasts. It is n method of treatment of great value for the relief of pain and t(<nsion in the breasts, due to engorgement with milk when the infant iails to <iiipty the breast properly, esjHscially when the nipple is sore, lireast-massage is also useful in mastitis to empty the gland-aeini of their contents, and even ol'pus in the early stage of parenchymatous abscess; thus it has otlen saved the anxiety, pain, and sequelte of lancing such an abscess. Technique of BreaHt-moHHuge. — After cleansing the breast the entire skin- surface of the breast is anointed with a lubricant, preferably with camphorated or carbolized oil. It is the writer's practice either himself to perform or to teach his nurse four distinct manipulations. The first manipulation is one of gentle and quick ly-rei>eated strokes of the finger-tips (PI. 48, Fig. 1). Til'' breast can conveniently be supjun'tetl during the manipulation by the patient placing her forearm under the breast, drawing the breast uj)ward, and supporting it. Starting s.t the periphery of the gland, the fingers are separate<l, and are brought together as the tips of the fingers terminate the stroke at the ni|)ple. Each segment of the gland should thus be rapidly stroked in succes- sion, paying particular attention to the region of the nipple, and, short of producing much pain, the pressure of the finger-tips shoidd gradually be increased. After this manipulation has been practisetl for about five minutes and pain is no longer experienced, the ojierator supports the breast in the palm of one hand placed tmder the indurated spot, and with the fingers of the other hand this spot is again stroked toward the nipple, using deeper and firmer pressure (PI. 48, Fig. 2), Each nodule of induration is thus treate<l in succession. The palm of the hand is next placed flat u])on the inflamed j)ortion of the breast (PI. 48, Fig. 3), and is then slightly inclined toward the periphery of the breast ; steady and gentle pressure is now made downward against the chest- wall, the pressure being greater under the outer margin of the hand — that is, at the periphery of the gland. After a few moments of steady pressure irentle rotary movements of the hand are practised over the lump. Pressure and rotation of the hand are thus alternated for a few minutes or until the ])ationt complains of pain, when the stroking movements (PI. 48, Fig. 1) are renewed for a short time. Finally, the breast is grasped firmly with both hands in such a manner as to encircle the breast com]>letely (PI. 48, Fig. 4) ; the whole gland is gently raised from the chest and compressed, especially over and at the base of the in- durated nodule, and at the same time the two index fingers are quickly stroked :i| :^'- . '.:. '^ 756 AMERICAN Ti:XT-liOOK OF OliSTKTRICS. toward the iiipplo, wlioii milk is usually hccii to flow iVotu the duds tliut empty tliat portion of the ^laud. The pressure is not relaxeil, so long as the milk flows, until the patient complains of the pain it eommonly oeeasions in u few minute^. After a few moments of rest and reassurance to th" patient the manipulations are re|>eated in the order above described until the whole gland is soil and flaccid, when a |)ressu re-bandage, preferably the Y-banilage, is snugly applied. Mastitis. — Frcquem'if. — It has been estimated that about one-fourth of all fertile marrie<l women have snfl'ered from inflammation of the breast at muimc peritnl of their reproductive activity, and in 1000 (tonsecutive deliveries Win(!kel** obscrvwl mastitis in 6 per cent, of the patients. This iwrcentap.' undoubtedly cxece<ls the number of eases observetl under the more rigid att«'ii- tion in recent years to antisepsis of the nipples and breasts. Dciss** records a frerpiency of JJ.G iM'r cent, in 1600 consecutive confinements. The disease is more frequent in primiparie. It is said to be observed oftenest in blondes ami in lymphatic subjects. It is rare after the fourth pregr.ancy (Delber^j. Tlicn- are four periods of the puerperium in which mastitis is mo«t likely t<» occur. These peri(Rls are : {a) the flrst month of the puerperium ^^^•s|H•^•ially the first two weeks), while both the mother's nipples and breasts and the infant are adapting themselves to the mammary function ; (/>) when suckling is suddenly given up, thus favoring stasis and its ill cfteets ; (c) the jieriod of appearanri- of the fii-st teeth, at which time the nii)ple is again exposed to injury ; {d) and the time of weaning, when cither engorgement of the gland is likely to (ncur because the regular emptying v>f the breast is not attended to, or, as happens especially in hyperlactation, the child, not being satisfietl with the quality and quantity of milk secreted, shows its dissatisfaction by biting and tugging at the nipple. Varieties. — It is customary to describe three varieties of mastitis, according to the location of the inflamed area. The first and most frequent variety is the puren- chi/mafous or r/landiilar, in which the acini of the gland or the adjacent con- nective tissue is primarily attacl-"«l by inflammation (Fig. 433). In either case the destructive inflammation, as it progresses, may end by involvement of both the acini and the connective tissue. A second variety is the mbcutaneoris, in which the connective tissue lying immediately beneath the skin is attacked. The third variety is the rare and insidious inflammation of the post-mammary or xith- glandular connective tissue between the gland and the chest-wall. This divi>i()n of mastitis should not obscure the fact that clinically two or all three varieties may be combined, especially in cases which do not receive prompt treatment in the beginning, since either variety may end in a combination of all three. Mastitis commonly begins as the parenchymatous variety and approaches the skin-surface of the gland. Etiology and Patholoyy. — The etiology of puerperal inflanmiations of the breast has actively been discussed in recent years, and, although the investi<ra- ticnis of bacteriologists have wrought a change in our notions of the patliolotry of mastitis, the subject is not wholly free from uncertainty. Formerly it was believed that engorgement (»f the gland with stasis of the milk was invariably PATUOLOaV (tF THE IHEIil^KltllM. 767 !trt that empty the milk Hows, a few minutes. iuuiiil>»l"tiuii> ml irt «*»1^ ""'1 mngly appru^l. u!-tburth of all ! breast at soiiic utivc dt'livorics This iKjrceiitam' lore rigiJ attcn- Oeiss** rcfonlsii The disease is t in l)h>ndes ati<l DeUwn J. 'ri»it' ,t likely to otnir. .»Hrially tlie liisl ul the infant are kling is smUlenly iml of appearaiicf o injury ; ((?) :""! , is iikoly to occur to, or, as hapitciis th tlie quality ami g and tuggiuj? at istitis, accordiiitr to ariety is the p((/« li- the adjacent coii- ;3). In either c^-^ iveraent of both tlie xdmu'oxm, in wliicli stacked. Thethinl .mamviary or «"''- [vail. This division all three varieties rompt treatment in ition of all tl.reo. ind approaehes tlie lammations of the ^ugh the investitra- is of the patholo^n- Formerly it was Ulk was invariably tlie cause uf all inamniury intlannnation ; but tliis idea lias disappeared largely, "iiKHj most pathologists consider iiiHaiumatioii, wherever found, of niiembic origin. Kecent exi)eriinents have shown tiiat stJisis of the milk will not pro- duce mastitis except when the milk contains bacteria. Ligation or stoppage ol' the milk-ducts l)y colltnlion (Kehrer) fiiilcd lo produce iiitlamiiiation of the lireast in animals. The CMrcme rarity of mastitis in supernumerarv breasts, and the fact that tiie frccpiency of the disease lias been lessened so greativ since antisepsis has l)een extendeil to the care ol' the breasts, have also been advanced as arguments in favor of the unimport- ance of stagnation of the milk. There • is, however, a clinical side to this qiics- the belief that milk- ri(i. 4;tS.— Miiiiiiimry kI'iihI : 1, liictriil ducts; gluniluliir ui'inus (I'luyl'air). tion, wluch lorccs the l)eiiet mat mil stasis continues at least a predisposing I'aetor in mastitis, es|)ecially in the very important parenchymatous variety. Sta- sis cert4tinly is a frequrat precursor .p^ mastitis, whether the accumulation of .iiilk in the gland rei'dts from hy- persecretion, from failure lo nurse at pro])er intervals, or from insnfhcient emptying of the gland when there is anatomical defect in the shape of the nipples or narrowing of their milk-ducts, — all of which conditions are known to bear an intimate relation to breast-in- flammation. Honigman** disproved the statement that human milk has bactericidal properties as regards the micro- organisms commonly found in mastitis ; further, it is believed that a pent- up milk-secretion not only lessens the resistance of the breast-tissues against luicrobc activity, but that it also otl'ers a very favorable medium for the rapid miiitiplicatiim of bacteria. The experiments of Colin and Xeumann, before rct'erred to,*^ demonstrate the fact that the micro-organisms ordinarily found in the milk are more numerous the longer the time since the removal of the milk. Although we must admit that stasis of the milk predisposes to mastitis, the eviiU'iiee is overwhelming that the 'inportant element in etiology is inlt'ction. Siiiee the invostiiiations in 1884 of liumm,'** bacteriological studies of mas- titis and mammary abscess have proved that these diseases are the result of the irritant action of micro-organi; ins, and that the infection is usually due to fttdjilii/- /ococc/, eiti. " mtreus ov (ilbxs ; someti mes. s//ry;^ococci arc found; and Moiinier^' liiis shown that in some cases staph t/lococci are associat(>d with other miero- oi'iraiiisnis, such as micrococcus tctntffeus, stirptococcus, or micrncoccHN sii/jfldrus. Tims it will be seen that the disease, like infection of the parturient tract, may oritrinate from several different pathogenic organisms. The nipples, especially when erodeil or fissured, are commonly the point of entrance of the infecting .u i i , I i"1:;r '• ;- .i' 758 AMERICAN TEXT- BOOK OF OBSTETRICS. agent, anil the soiiiros of" inl'cction are either the chiUl's month, which is know n to be the habitat of several micro-organisms some of whi(rh are pathogenic, or the patient's or nnrse's fingers, or unclean appliances used about the nipple and breast, such as soiled cloths or an unclean nipple-shield or breast-pump. Tiic exact manner of entrauce into the breast of the infecting agent in all cases is notdefinitely settled, and the question is one about which there has been, and is, considerable controversy. It seems certain that the poison may, under varyiiiir circumstances, enter the gland either from the cutaneous surface through tiie milk-ducts, which path many pathologists believe to be most frequent, or through the lymphatics ; or, circulating in the blood, the infecting poison may be ex- creted by the nulk. The frequency of involvement of the lower segment of the gland, and the fact that in the early stage of mammary abscess pus and milk are so often coincidently expressed tiirough the nipple by massage, are thoughi to be evidences of the more frequent early involvement of the milk- ducts (Delbert). When cracks or fissures of the nipple are present, Pingat believes the poison is likely to enter the lymph-channels ; and when the epi- thelium of the nipples is intact, the microbes may follow the milk-ducts to the acini, there multiply, and find their way into tiie cellular tissue. Orth thinks it probable that atreptovocci enter the lyn)ph-channels and that staphylomcd enter the milk-ducts. Williams remarks :** "As to the respective parts played by the lymphatics and ducts it is not easy to decide. It seems certain, however, that each has its rule. In superficial inflammations of the breast, especially those of erysipelatous origin, most pathologists are agreed that the lymphatics are chiefly concerned in the spread of the disease. In other cases it sceius probable that infection takes place chiefly by the ducts." The relative import- ance of the ducts and the lymphatics as pathways for the entrance of infection at first thought would seem to be a problem more of scientific interest than of practical value, since it is enough for prophylaxis to know that infection almost always occurs through the nipple, usually when the integument is broken, hut possibly when the latter is intact. It will, however, be pointed out later, when the treatment of mastitis is considered, that for one means of treatment — namely, massage — it is of importance to learn, if possible, through wliicli channel the infection has occurral. The rarest and perhaps the least important channel of infection of the breast is by micro-organisms circulating in the mother's blood-current. It has been shown by Escherich" that micro-organisms in the blood-current are often eliminated by the secretions, notably in the milk as well as in the urine. It is possible also that secondary to puerperal phlebitic infection of the genitalia a metastatic abscess of the breast can occur. Beyond these two facts little is known of mastitis and mammary abscess originating from infection of the mother's blood. The actual pathological changes resulting from infection in and about the parenchyma of the gland are such as would be expected from micro-organisms rapidly nndtiplying and finding their way into the adjacent tissues. Aceonlinir to Bumm,*^ the milk is fermented, its sugar converted into lactic and biit\ ric i PATHOLOGY OF THE rVEIiPETiU'M. 759 acids, and coagula of casein are fbrruetl containing innumerable bacteria. The epithelium lining the gland becomes swollen, desquamates, and disappears. At the same time leucocytes and micro-organisms infiltrate the periglandular tissues. Small tbci of suppuration soon become numerous, coalesce, and form larger purulent collections. The cavities thus forme<l are traversed by shreds of partially destroyed tissues, and are surrounded by a protecting wall of leuco- cytes to prevent the further progress of microbe invasion and suppuration, JSymptoms. — All varieties of mastitis are accompanied by the signs of inflam- mation. The patient complains of chilly sensations or has a distinct rigor, followed by elevation of the temperature and by pain and tenderness in the afiected breast. Each variety, however, has a train of symptoms more or less distinct. It will therefore be of clinical value to describe first the parench.ym- atous variety, which is the most frequent. Subcutaneous and subglandular mastitis are so commonly followed by suppuration that their description seems more appropriate in the section upon Mammary Abscess. When the inflammation begins in the glandular structures of the breast there will be found one or more hard, localized, tender nodides due to stasis of the milk in these portions of the gland. Tiie overlying skin is either not red- dened or there may be only a faint tinge of redness. The })ain ])roduced by liandling the breast is not severe. The temperature promptly rises to a great jieight — often to 104° F. or higher. The infection which has taken place through the lactiferous ducts is at this time producing those changes in the milk and the epithelium of the acini that have been described, and when prompt abortive treatment is not employed the more extensive inflammatory changes extending into the comiective tissue are likely to occur. Should the connective tissue surrounding the acini of the gland fii-st become inflamed, an enlarged nodule is at this time not so apparent. The patient com- plains of an ill-defined painful s|)ot, the temperature rises more gradually, and chilly sensations are complained of oftener than a rigor. The nipple has either recently been sore or will be found eroded or fissured, or upon close inspec- tion a crack or an abrasion is observed at some portion of the areola. There is early ralness of the skin that is soon loUowed by edema. It will frequently bo noted that the location of the inflammation corresponds with the situation of tlio fissure of the nipple. Notwithstanding early treatment, this variety is more likely to resist resolution, the inflammation slowly progressing to abscess- formation, a termination especially liable to follow when the nipj)le is angrily inflamed and resists treatment. The clinical signs above described are often clearly distinguishable. There arc cases, however, in which both the acini and the surrounding connective tissue are apparently almost coincidently aftected, and the difrerentiating symp- toms are correspondingly obscure. When there is doubt as to the exact vari- ety of inflammation, it is a safe clinical rule to institute the treatment to be described for infection of the gland-acini. Treatment: I*roph}//a.riH. — The prophylactic treatment of mastitis shoidd begin in the last months of pregnancy. rro{)er attention to the nipples, as r%:^ •i-.:!!. ,.f :'fr 760 AMERICAN TEXT- HOOK OF OBSTETRICS. \ previously describal, to get tlicni in the best possible condition for suckling, will ilo much to prevent inHuniniation of the broasts. From the first appli(;a- tion of the child to the breast three important means of jirophylaxis arc always to be borne in mind, and are to be impressed upon the mother or the nurse; they arc: (1) The strictest cleanliness of the l)reasts and nipples througli- out the entire period of lactation; (2) limitation of injury to the nipples by prompt measures to maintain their epithelium intact ; (3) prevention of stasis of the nailk secreted. Curative Treatinent. — When, notwithstanding all these precautions, inflam- mation of the gland actually exists, the indications are to put the gland absolutely at rest, to relieve it from tension and from the accumulated products of inflammation, to prevent further engorgement with milk and, finally, to lessen its blood-supply. The first and always essential step in treatment, especially when the nipple is sore, is the immediate removal of the infant from the breast, to secure rest from j)ain and from functional activity of the gland, to promote healing of the ni])plc when eroded by avoiding traumatism and fresh infection, and, further, to avoid the danger to the child, slight though it may sometimes be, of absorb- ing milk changed in quality by the products of inflammation or even containing pus. This l)eing effected, much has been done to prevent abscess-formation ; the oidy advantage of suckling — removal of the milk — can be accomplished more safely and less violently by other means. The next step in the treatment will be to decide whether or not the inflammation is situated in the gland- acini, and whether the inflammation has so far advanced that efforts to prevent suppuration will likely fail. If these two problems could readily be solved, the seU'Ction of treatment to be followed in individual cases would not be difficult. As has been stated above, the manner of onset, the condition of the nipple, the temperature, the character of the pain, the appearance and feel of the breast, an«l the relative frequency of ])arenchymato»is and interstitial inflammatiuii will often help a decision. When there is doubt, it is best to consider the case, at least temporarily, as one of parenchymatous inflammation. It is per- haps more ditticult to determine whether or not the inflammation has advanced bevouil the usefulness of abortive measures — in other words, whether or not pus-formation has occnrRnl. When early improvement does not follow prouipt and vigorous treatujent, but, on the contrary, the case gets steadily worse ami presents some of the signs to be described as evidences of abscess-formatinii. curative treatment short of surgical measures is not to be employed. Having decided that the inflammation is largely parcnchynnitous, accoiii- panitnl and aggravated by inspissation of milk, evacuaticm of the milk is to be obtained by skilfully a|)plie<l massage, assisted by the proper use of tin' breast-pump, bearing in mind the fact that as the breast-pump only withdiaws the milk from the large ducts near the nipple, too vigorous ap})lieation of (lie pump should not be employed. Short of jM'oducing |)ain, the breast-pnni|i i« a valuable adjunct to massage, and the two, skilfully combined, will often nmic 11 for sucklinji, \e first applii-i- )roi)hylaxis »'*' e inotlior or tlio ipples throiij^h- tlio nipplfs l)y .•oution of stasis •autions, inflain- put the gland iiulated products and, finally, to when the nipple st, to socnre rost )to healing of the ion, and, further, nes he, of absorh- ir even containiiit;; bsecss-forniation ; be aeeoniplislu'd p in the treatment ted in the glanil- . efforts to prevent readily be solvi'd, ses would not he tion of the nipple, feel of the breast, itial inflanunatiiiii -t to eonsider tlie liation. It is per- Ition has advanced s, whether or not ]not follow prompt steadily worse aii'l labscess-forinatinii. eniployeil. I'liymatous, accoiu- lof the milk is i" [proper use of the lip only withdraw- lapplieation of il"' Ihe breast-pumi' '- Id, will often more I'ATIIOLOaV OF THE PVKRPEItnM. 761 readily empty the bieast than will massage alone. Evacuation of the milk and relief of the tension in the breasts liaving been aecomplished, further aecumu- lation shoidd be prevented by firm eorui)ression of the breasts. The lessening of blood-supply to the gland and the prevention of hypersecretion are also indicated, aiul are obtained by the derivative action of saline cathartics, which, to accomplish most good, should Ik? given freely in the earliest stage. After this time their value in large doses progressively diminishes in cases seriously threatened, since an advantage is lost if the flow of milk is thereby almost wholly stopped, for the outflow of milk at the same time relieves the gland of the products of microbe activity. After the employment of massage and compression of tlie breast the applica- tion of an ice-bag^ to the binder over the painfid lobe of the gland will further lessen the blood-supply and relieve the pain, and will have the well-known beneficial effect of cold upon the inflamed area, whether or not this effect is gained, as has been asserted, through its inhibitory power over the activities of micro-organisms. The ice-bag may be kept in place continuously for from twelve to twenty-four hours, the time being determined by the disappearance (if pain and a fall in temperature. Thereafter it may be used intermittently (Uu'ing from three to six hours, until all tenderness of the breast disappears and the normal milk-flow is re-established. In addition to employing the ice-bag, or when, as rarely happens, it is dis- agreeable to and not well borne by the patient, the ap{)lication under the binder of compresses wet with lead-water and laudaninn and covered with waxed jKiper is a most valuable means of allaying inflammation and relieving pain. When the inflammation of the breast is thought to have had its origin in tlie connective tissues about the acini of the gland, the plan of treatment to be fctllowed is somewhat different from the preceding treatment. In the first place, moderate support of the breasts, best obtained by the Murphy binder, should be employed, and not the firm compression of the breasts so useful in parenchym- atous inflammation. Again, massage of the breasts can only be jiroductive of Iiiinu in the interstitial inflammation, since the relief of milk-stasis is not so urgent and the tissues are further damaged by tlie manipulation. It is the I'ailnre to recognize this class of cases, in which expression is contraindicatcd, that has helped to make some authors condemn massage of the breasts. Wiien the operator is in doubt as to the variety of inflammation present, or when the ease presents evidence of both varieties of mastitis, as sometimes liappens. and, it is to be confessed, makes a differential diagnosis difficult, it is best to resort to inassage tentatively, giving it up and deciding that interstitial mastitis is present wiien by its use pain is not diminished and the temperature fails to fall, Aliaiidoning firm (iompression and all efforts at expression, attempts may be made to conduit the inflammation by the use of saline cathartics and I)y apply- iiitr under the binder lead-water and lau<laiuim or, which is of doubtful utility, I'elladonna, either the extract or the plaster. Should belladonna be used, its lihysiojogical action upon the pupils, the skin, and the throat must always be looked for, and the drug must be tliscontinued l)cfore a poisonous amoiuit is Pi 762 AMERICAN TEXT-BOOK OF OBSTETRICS. m absorbed. The erosion or fissure of the nipple should promptly be treated, and be cured as speedily as possible. Notwithstanding active treainient, suppuration of the breast is very likely to be the outcome of interstitial mastitis. Mammary Abscesses. — Following the classification of mastitis, abscesses in the mammary gland may be located superficially under the skin or deeply under the gland ; or most frequently the abscess follows mastitis, involvinjr primarily, as has been pointed out, either the secreting structures of the gUuul or the connective tissue adjacent to the acini, and gradually approaches the skin. Two or even all three varieties may be associated. The parenchym- atous variety, approaching and finally involving areas of the subcutaneous connective tissue, where pointing occurs, is most frequently seen. Deep-seated abscesses not vigorously treated by early and thorough opening may burrow in all directions and destroy the gland, or several portions of the breast may suc- cessively be attacked when incision and drainage have not been efficient. Parenchymatous Abscess. — When the inflammation, aggravated by inspis- sation of the milk, originates in and is limited to the acini of the gland, active and persistent treatment by massage and compression will usually be followed by resolution ; or sometimes the pain, induration, and fever will disappear, and after three or four days caseous milk and a small amount of pus will be expressed with the milk. The appearance of the latter is evidence that the inflammation has not wholly been aborted. If, on the contrary, the signs of inflammation do not disappear notwithstanding active treatment, it may ho concluded that the interstitial tissues of the breast are either primarily or secondarily involved, and that we have to deal with the most frequent type of mammary abscess and one of the most painful and distressing compli- cations of the puerperium. At the earliest possible moment the formation of pus should be discovered. Symptoms. — There are, unfortunately, no absolute signs of suppuration short of fluctuation, yet in deep-seated or in slowly progressing cases it is dangerous to delay treatment until fluctuation is apparent. Left to itself, the pus will require about two weeks, or longer Avhen deeply seated, to reach tiie surface. Frequently the abscesses are multiple and form in succession, and wiu n neglected may recur for months. Velpeau observed 46 abscesses in one breast within a period of two or three months. The signs suggestive of abscess-forma- tion are recurrence of a chill or a chilly sensation ; greater rapidity of pulse; ])ersistently high temperature ; increasing dull pain in the breast ; pain upon moving the arm, sometimes with enlargement and tenderness of the axillary glands ; diminution in the flow of milk ; bluish-red discoloration, with boiijfi- ness, adherence, and marked edema of the skin. Of these signs, rapid piilso, bluish discoloration and edema of the skin, and marked diminution in the H<iw of the milk are most important, and are enough to warrant an exploratory incision. It should be remembered that some fortunately rare cases of mam- mary abscess develop subacutely, without the ordinary signs of suppuratimi, or even of inflammation. The use of an aspirator-needle has been rocdin- mcnde<l for the detection of pus, although it is often of doubtful utility. Since, PATHOLOGY OF THE PLERPERILM. 7G3 be treated, and nt, suppuration ititis. stitis, abscesses skin or deeply ititis, involving!; js of the gland approaches tlu; "he parenchyni- le sulxjutaneoiis 11. Deep-seated ; may burrow in breast may suo- n efficient. avate<l by inspis- the gland, active lally be followed ' will disappour, it of pus will be vidcnce that the ary, the signs of ment, it may he her primarily or )st frequent type stressing com ph- ut the formation of suppuration ussing cases it is ,eft to itself, the ited, to reach the [cession, and when [sses in one breast of abscess-fonna- •apidity of pul'^i' ; reast; pain upon iS of the axillary ition, with boji-iri- ligns, rapid ptdsc, [lution in the How it an exploratory ire cases of niani- of suppuration, has been recom- [ul utility. Since, to be effective, the needle always requires the preliminary use of au anesthetic, and since it may not find pus-collections which can be found by the finger through an incision, tiie aspirator-needle shouKl be discardcH.1 for the more intelligent and less uncertain exploration with the finger. Treabnent. — The patient shoidd always be anesthetized to open and treat a mammary abscess properly, except wiien the abscess is superficial or is about to point, in which cases a chlorid-of-ethyl spray or freezing with an ice-and- salt mixture will usually be sufficient. After rendering the skin thoroughly aseptic the breast is grasped, and by careful palpation the collection of pus .should, if possible, be localized, and at its most dependent portion there is made, in a direction radiating from the nipple to avoid the milk-ducts, an incision sufficiently large to admit the finger and deep enough to incise only the skin and the subcutaneous tissues (about J to $ of an inch). Through this opening a grooved director is gently passed in all directions until the abscess-cavity is found, when a dressing-forceps is introduced, by which the tissues are sufficiently dilated to admit the index finger into the abscess-cavity. With the finger all communicating and adjacent cavities are searched for and are freely opened and all friable tissue is broken down. The dressing-forceps or a probe is introduced, is pushed through the cavity to the skin-surface and is cut down upon to make additional openings in order to secure free drainage. Several such openings should be made in the skin at the different portions of the gland where pus or induration has been detected by the finger. After thoroughly dilating all entrances to the pus-cavities, thorough irriga- tion is made with an antiseptic solution. Peroxid of hydrogen, full strength, fol- lowed by a 2 per cent, solution of creolin, will be found efficacious. Weak solu- tions of carbolic acid or of bichlorid of mercury may be used. The subsequent treatment may be one of the following : The cavities and all openings may be packed firmly with sterilized gauze moistened by an antiseptic solution (1 per cent, carbolic or 2 per cent, creolin), followed by an antiseptic dressing vinder a firm bandage. After from twenty-four to thirty-six hours the gauze packing is gently removed, the cavities are irrigated with the peroxid of hydrogen diluted with three volumes of boiled water, followed by creolin (1 per cent, solution) ; strips of gauze are lightly placed in the drainage-tracts, and a compression hinder is comfi)rtably applied. The next day, if the discharge has almost dis- a|)peared, an antiseptic dressing is applied, and firm compression is secured hy carefully-adjusted compresses placed under the bandage. A large aseptic hatli-s])onge,®* slightly hollowed to fit the breast and wrung out in a bichlorid or creolin solution, will provide firm and equable pressure under a very tight roller bandage ; or the Y-binder may be employed, supplemented by a strip of nuislin drawn tightly across both breasts to compress the summits of the breasts. Care should be taken to lift the breasts slightly toward the clavicles when the hinder is applied. The antiseptic solution is poin-ed under the edge of the hinder often enough to keep the sponge moist. The sponge dressing is re- moved each day thereafter and the breast externally is gently washed. On the eighth or the tenth dav the cavities and the tracts leading to them will usually f R h ill H ■;i r hir r.^.: ! 764 AMERICAN TEXT-liOOK OF OBSTETRICS. he closcil, when the sponge conijiressioii may be discoiitiniicd. If the opeiiinjis have not united, their edges may be brought together witli adhesive strips or with collodion. If drainage is desired by means of drainage-tubes, jierforated rubber tubes at least one-fourth of an inch in diameter should be drawn through the open- ings after irrigation, and a i.jm binder should be applied over an antiseptic dressing. The next day the dressings should be renewed after irrigating the cavities, and the dressing may now be left undisturbed for four days ; then tiic tubes should Im; shortened one-half their length, the cavities be irrigated, and the dressing be reapplied. So long as the pus is thick and tenacious the tubes will afford better drainage than strips of gauze, but if the i)rogress of the case will jwrmit, gauze should be substituted, otherwise the tubes should gradually be shortened, and they may be removed entirely i)y the end of at least ten days or two weeks. The disadvantage of the drainage-tubes is the tendency on the part of the physician to allow them to remain in the breast too long, and thus to cause fistula?. The amount and character of the discharge and the dis- appearance of the cavities in the breast will indicate how soon the tubes may safely be removed. The diild, of course, must not be nursed from the diseased breast, but may be aj)plie(^l to the sound breast in order to keep up the milk secretion, provided the mother's general health docs not indicate the desirability of weaning. Convalescence is promoted by the administration internally of tonics, par- ticularly quinin, strychnia, and iron. Subcutaneous Abscess. — Subcutaneous inflammationofthe breast is usually followed by the formation of an abscess, and it always results from infection through the superficial lymphatics, the septic material finding entrance into the lymphatics through erosions of the nipple or through a breach in the con- tinuity of the areola or the adjacent skin. Usually the inflame<l area is cir- cumscribe<l ; the overlying skin raj)idly becomes very red, the temperature is elevated, and within a few days fluctuation is discovered, announcing the prompt occurrence of suppuration. The prevention of this form of inflamma- tion is obtained by cleanliness of the breasts and nipples. In the beginniiiir of the inflammation the administration of a saline cathartic and the application of compresses saturated with lead-water and laudanum, with or without nn ice-bag, and held in place by a mammary binder without compression, will affoi'd relief. At the first appearance of suppuration an incision should lie made, either wholly within or outside the jiigmented areola, to avoid ;iii unsightly scar; the abscess-cavity sliould be irrigated with hydrogen peroxid, full strength or one-half diluted, followed by a creolin or a bichlorid solu- tion, and after introducing a gauze drain a firm binder should be applied. A diffuse inflammation of the subcutaneous connective tissue sometimes occurs, which conditi'^n is much more ferious, but fortiuiately, is now very rare. It is usu .dy, but not always, ])receded by erysipelatous inflammation of the overlying skin, and is aceompanie<l by chills, high fever, and severe bnrii- ing pain. The axillary glands are often tender and swollen. The subcutaiie- PATHOLOGY OF THE PUERPERIUM. 765 f the openings esive strips or 1 rnbber tubes nigh the opon- r an antiseptio • irrigating the days ; then the L' irrigated, and icious the tubes ;ress of the case lould gradually it least ten days :he tendency on st too long, and rsre and the dis- I the tubes may breast, but may jretion, provided if weaning, y of tonics, par- ous connective tissue quickly suppurates, and when not promptly treated by incision, drainage, and thorough antisepsis, extensive sloughing occurs, which may be followed by general pyemia and death. In the earliest stage the appli- cation of compresses wet with creolin solution (10 per cent.) or with lead- water and laudanum will be useful, but these compresses must not interfere with early recognition and evacuation of subcutaneous collections of pus. Submammary Abscess. — In rare instances empyema or suppuration result- ing from disease of the ribs may perforate the tissue under the mammary gland and produce an abscess situated beneath the mammary gland ; but in the puerpe- rium submammary abscesses practically always result from burrowing toward the chest-wall of a parenchymatous abscess. Several pockets of pus may thus be formed beneath the gland and at its periphery ; the pus-cavities con>municate after a few days, and the breast is lifted from the chest, the gland feeling as if it rested upon a fluid base, its overlying skin becoming tense, but usually not red. This variety of mammary abscess, the rarest, is of very great importance, because if overlooked most serious consequences may follow before spontaneous evacuation of the pus occurs. The inflammation of the connective tissue, which almost never undergoes resolution, may spread to the abdomen, to the other breast, and to the axilla, and pus may burrow in all directions, sometimes even attacking the ribs and perforating into the pleural cavity. The symptoms are not characteristic, since the deep-seated pain, the high fever, the edema of the overlying and adjacent skin, the restricted motion of the arm on account of the pain, and the involvement of the lymphatics in the axilla may be present in parenchymatous abscess, although these symptoms are usually less marked in the latter variety. The absence of marked redness of the skin and the pecu- liar sensation imparted to the gland by the underlying fluid collection are the most characteristic signs. Treatment. — When this variety of abscess is suspected, the location of the pus-collections may be searched for with a sterilized aspirator-needle. After thoroughly disinfecting the skin, the patient ovdinarily being etherized, the breast should be pushed toward the clavicle and the needle held parallel with the chest-wall, and, entering the skin on a level with the lower margin of the pectoral muscle in the infra-axillary region, should be thrust deeply beneath the gland. When the pus is located there is passed into the cavity a grooved director, which will serve to guide a pair of scissors or dressing-forceps, the blades of which, after being introduced, are separated and forcibly withdrawn. The cavity is then explored with the finger and adjacent pockets of pus are opened, especial care being taken to find and enlarge the opening or openings between the submammary and parenchymatous abscesses. Irrigation, drainage, and antiseptic dressings should then be employed as in other varieties of mammary abscess. Abscesses in the Areola. — The glands of Montgomery and the connective tissue beneath the areola sometimes become infected, and the result is the forma- t ion of small and usually superficial abscesses. The abscesses are most frequently observed when the nipple is inverted or stunted, thus compelling the infant to " '1 1 fW ■ ■ [ . 1 ■i'M'i Il^ 766 AMERICAN TEXT-BOOK OF OBSTETRICS. l- > m take into its nioiith a portion of the areola in order to got a b(>tter grasp of the nipple. The skin at first reddens ; the ghinds ba'oine hard and more prominent, and, pointing at yellow spots in tiieir centres, finally jwrforate the skin at one or more places, leaving excavated nieers snrronnded by an indurate<l wall of lymph. These no<lnles may remain for several weeks, or, receiving fresh in- fection, they may break down, the ulceration being followed by an ngly scar. Treatment. — Care of the nip|)les will usually prevent infection of the glands. Each gland when infiamed shoidd be incised and touched with a strong bichlorid solution, after which the edges of the incision are approx- imated, covered with a narrow strip of gauze, and held together by a collodion dressing. Nursing need not be discontimied. Prognosis and SEQUEi.iE of Mammary iNFiiAMMATioN. — Mammary ab- scess is rarely directly dangerous to life. Fatal termination has been recorded from hemorrhage due to erosion of blood-vessels (Jacobus) and from septi- cemia (Gross). General sepsis, short of a fatal termination, may occur, se- riously impairing the patient's health. In an interesting case of the writer's infection of the breast occurred when the patient washed her nipples with the same oloth and water used for cleansing the child's buttocks after a bowel evacuation ; systemic infection followed, during the course of which there developed a serious albuminuria pei*sisting for several months. When treat- ment by early removal of the pus and thorough antisepsis is neglected, a large portion of the gland, sometimes the entire gland, is destroyed. Even when the suppuration has not been very extensive, the firm cicatrices loft behind frequently interfere with proper emptying of the breast in subsequent lactations, and thus jiredispose to tlie recurrence of mastitis. Milk-nodes and fistulous tracts may also remain, occasioning distress and inconvenience. Milk-nodes. — Sometimes the exudate about the abscess-cavity is not wholly absorbed, and connective tissue thus formed may constrict one or more lacteal canals, giving rise to indurated nodular masses which contain the remains of inspissated milk and which n>ay remain for an indefinite period. Effort should be made to promote the absorption of these masses by rubbing them with resolvent ointments, such as the ointment of merciny or of potassium iodid, and by th*^ use of the galvanic current. Cold or Chronic Abscess. — Very rarely the symptoms of acute inflamniii- tion of the breast subside, and after a long period severe inflammatory symp- toms may occur. The purulent collection is often found under the gland, and it requires thorough evacuation, antisepsis, and compression. FistulsB of the Breasts. — A sinuous tract leading to the abscess-cavity may refuse to close and may discharge indefinitely a small amount of pus. A more important variety of fistula is that due to injury of a lactiferous duct, eitlicr wounded by the knife when the breast has not been lanced careftdly or wlicn perforated by extension of an absceas. Such a fistula may for months or lor years discharge either milk alone or a mixture of milk and pus, which dischaiLre may be a serious drain upon the woman's health. As a rule, little can be accom- plished in the treatment of these fistulse until the lacteal secretion has been .1 I- PATHOLOGY OF THE PUERPERIVM. 767 ?r grasp of the ore pronilnont. he skin at one u rated wall of 'iving fresh in- aii ngly scar, ifeetion of th«' ouchetl with a )n are approx- • by a colloilion -Mammary ah- is been rcconlod md from septi- may occur, sc- > of the writer's nipples with tiie s after a bowel of which tlurc s. When treat - is neglected, a estroyed. Even ni cicatrices left ist in subsequent MilU-nodes an<l convenience. ity is not wholly or more lacteiil the remains of , Effort should bing them with potassium iodid, 1 acute inflaniina- immatory syinp- Inder the gland, l)n. Iscess-cavity may lof pus. A more Vus duct, cither irefuUy or wlieii Ir months or fur which dischiuire tie can be accoiii- 3retion has l)e«ii arrested, following which they often heal spontaneously. They will sometimes dose under persistent compression and attempts to obtain granulation by injecting, twice weekly, irritative fluids, such as tincture of iodin, a 2 per cent, solution of nitrate of silver, or chlorid of zinc (gr. xx-xl to f.^j). Thorough curettement and gradually shortened drainage-tul)es have also been successfid. These methods of treatment, es|K?cially in intractable cases, have been dis- carded in recent years for excision of the fistulous tracts and immediate closure by deep and sui)erficial sutures. Qalactocele. — Sometimes one of the lactiferous du(!ts happens to be occluded permanently, and in consequence the milk accunudates and forms a cystic tumor which is usually of no pathological or clinical importance indess it should, as rarely happens, attain an extreme size, when it may be tapped and drained and cicatrization of the cyst-wall be promoted. 7. AuuKST OF Lactation. There are in practice three periods during which it may be desired to arrest the secretion of milk : {n) immediately after delivery when the child has not survived birth, or when the constitutional condition of the mother is such as to preclude the possibility of successful lactation ; {!>) at any stage of lactation when weaning has been determined upon in the interest of either the infant or the mother ; (c) at the end of the lactation ])eriod. It should be remem- hered that the danger of drying up the breasts varies with these periods, being greatest when the functional activity of the glands is at its height, and least dangerous at the end of lactation, when nature is about prepared for the cessa- tion of this function. Whenever the prevention of activity of the mammary glands is desired in the first peri(Kl, diminution of the flow of milk can be accomplished by using before the first ai)pearance of breast-engorgement a firm compression binder, a roller bandage, or for very threatening cases a dressing of contractile col- lodion may be employed, and also by forestalling the milk-flow by the early administration of salines to the extent of free purgation when the patient's strength will permit. In addition to compression and purgation, it will usually be necessary to resort once or twice daily to gentle massage of the breasts or to the use of the breast-pump to prevent dangerous engorgement — a clanger usually passed by the fourth or fifth day, certaiidy by the end of the week. The emj)loyment of potassium iodid to arrest the secretion of milk is of <loubtful utility : used in safe doses, this drug is without eff'ect ; in a large dose (30 grains) it sometimes is apparently effective, but is often followed by serious symptoms of poisoning. To arrest the milk-flow in the second period, after lactation is well estab- lislied, the compression bandage and free i)urgation will be sufficient when ihe milk flows readily under the pressure and there is no disposition of the breasts to l)ecome engorged and caked. Under these conditions it is an advantage to omit massage or the use of the ])nmp, since this omission renders the treatment less painftd to the patient and of shorter duration, for after massage or suction ■ -'!^ 1 ,; 1 „ /[m *i i 1 V :ft ,.v . .^3:!; 'I. •n 'i i ' )■.'. I A i w 768 AMEIiJCAN TEXT-BOOK OF OBSTETRICS. m \ I ' ^f'H of the milk by the pump the breasts rapidly refill. When, however, the breast fails to drain under tiie bandage and n(xlular manses are felt, it is imperative! to relieve the tension by massage, on account of the danger of mastitis. The management in the third [ku'IikI is usually a simple matter. As the child is gnulually taken from the breast the slight tension of the breasts observed when a nursing has lieen omittetl should be relieved by gently stroking the breast or by the use of the breast-pump. Within a few days the flow of milk usually disapiMiars. Should a small amount of secretion |)ersist, it may be necessary to employ compression ; atropia administenMl internally will sometimes assist in further drying up the secretion (see page 773). 8. Anomalies in tiik Milk-hkcuktion. In this section will Ixj considered the following abnormalities associated with the mammary function : (a) secretion of milk abnormal in quality or in quantity, and the effect of either of these changes upon the health of the mother or t)f the chihl ; {h) conditions interfering with the performance of the mammary function ; (r) weaning; and {d) the ill effects of prolonged lactation. Abnoumalitiks in (iuALiTY. — The quality of the milk of the nursing mother is influenced by many conditions ; and while variations may be observed in the proportion t)f any or of all of its constituent elements, or even in the presence of foreign elements, the proportion of fat and albuminoids under ordinary circumstances shows the greatest and most important variations. The proportion of sugar is remarkably constant under all circumstances, and there is very little variation in the percentage of salts. A very conmiou cause of impairment in the quality of the milk-secretion is a failure to give proper attention to the time of putting the infant to the breast. Nursing at too fre- quent, prolonged, or irregular intervals materially alters the condition of the milk, and renders it either difficult of digestion or of poor nutritional value, A very common mistalie made by inex|)erieuced mothers is the frequent appli- cation of the child to the breast when it is restless, under the mistaken idea that the infant requires more food, when, as a matter of fact, an excess of food, with consequent indigestion, or thirst, is the real cause of the child's discom- fort. When the breast is given to the child at shorter intervals than two or three hours, the milk rapidly becomes more concentrated, and therefore is digested with great difficulty. On the contrary, when a longer interval between nursings is permitted, the solids of the milk are so reduced as seri- ously to diminish its value for nutrition. Perhaps the most important factor influencing the quality of the milk is the diet of the nursing mother. A diet largely vegetable will increase the pro- portion of sugar and diminish that of fat and caseinogen, while an excess of albuminous food will increase the fat and caseinogen and diminish the proportion of sugar. In each case the infant receives food ill adapted to its needs, and will either be poorly nourished or, when the fat and caseinogen are in excess, there will soon appear digestive disturbances with their associated dangers. The employment of alcoholic and malt liquors will also lead to an excess of Itil PAT//()U)(.y i)F TIIK PVKliPEIillM. rr.o ^rer, the breast is imperative astitis. itter. As the jt" tlie breast H 'ed by gently in a few «hiys it of seeretion , administered Btion (see page lities associated 1 in quality or I health of the 'ormance of the onged laetation. of the nursing iiay be observed 1, or even in the uminoids under rtant variations, •cunistances, and [y common cause to give proper jrsing at too fre- condition of the jutritional value. e frequent appli- e mistaken idea In excess of food, child's discoin- 'als than two or and therefore is longer interval reduced as seri- If the milk is the Increase the pro- lile an excess ot Ih the proportion its needs, and len are in excess, |ociated dangers. to an excess ot fat and caseinogen. There is a wides])i-cad Inflief, not only among the laity but also among the profession, that tiie nursing mother should add to iier diet some preparatiou of malt to improve the quality of her milk. While it is true that in exceptional ca-ses distinct l>eneHt is thus to l)e obtained, the indiseriminat)! use of such i)reparations certainly does ntore harm than good. Zaieski** lound that not only were fat and albumin increased in the milk of mothers taking malt, but that the milk .sometimes actually contained alcohol and the micro-organisms peculiar to malt licpiors. Klingeman"' learned Trom iiis investigations that when the nursing mother took alcohol in moderat(> ijuantity there was no evidence of its presence in the nulk. When the (pian- tity ingested was increased, a small amount (»f alcohol passed into the milk, which amount he thought was usually insutticient to have an ill effect iq)on the suckling. The changes produced in the constituents of the milk, how- ever, were quite noticeable, and Strumpf is (juoted as authority for the statement that alcohol Uiken by the mother so changes the fatty and albu- minoid contents as to dinunish the nutritional value of the n»ilk. The milk should lx> known to contain too little fat and caseinogen before reconunend- ing the use of malt; and when malt is taken, the first api^arance of digestive disturbance in the infant calls for either a reduction in the amonnt ingested or for complete abstinence. As a matter of experience it is in the latter half of the lactation jieriod that the mother's milk is more likely to be deficient in the constituents for whose increase a malt preparation is indicated, and the eom- inon practice of advising mothers to drink stout or other malt liquors shortly after labor is certainly reprehensible in a very large nund)er of cases. Care- ful analyses of the milk may be made at intervals, to determine the j)roportion of fat and albumin, and these analyses will indicate the desirability of admin- istering or withholding malt, and will often indicate other desirable changes in the diet. The diet of the nursing woman should ordinarily not differ materially from that to which she has previously been accustomed. It should consist of plain mixed food with a moderate excess of fluids. Of the latter, milk taken between meals is useful ; tea and coffee are best withheld or taken in mode- ration and largely diluted ; cocoa is sometimes useful. When the child does not thrive upon its mother's milk, or when it ])resents serious digestive derangements, a chemical analysis of the milk should be made. Having decided upon a chemical examination of the milk, it should be borne in mind that the relative proportion of the constituents of the milk varies with the time of its withdrawal from the breast. The first jiortion re- moved contains a smaller, while the last will show a larger, portion of solids, hence the specimen should be taken after the infant has about half-emptied the breast. Since each mammary gland may yield a different quality of milk,"^ and since the quality of the milk al.-jo varies at different intervals, several specimens from both glands should be subjected to analysis to obtain an abso- lutely accurate estimate of the quality of the milk.* "^ If it is impossible to obtain an analysis by an expert ciieniist, the following method, siig- 49 770 AMFJtli'AX rr.XT-nOitK OF (HiSTF/rilTCS. Microscopical oxntiiiimtion of the milk to count tlic nunilM>r of milk- ^lohiilcs, as proposed by Hoiiclicrc and r«'coniincn<lcd hy KIcinwiiclitcr, Ih no lon^jcr c(»nsidcr('d of practical value. This nu-thod of analysis <'annot take tiic place of careful chenncal analysis. The niicrosco|)0, however, is sonietinits useful — for example, to rocojriii/e the presence of colostrum-corpusclos and foreifjM matters, such as pus, blood, und epithelial cells. The later and most reliable analyses of human milk show an average com- |M)sition x\» follows : Wult-r 87-SS. Tc.lal solids Vl-VA. l-'i.t :m. AllxiiniiKiiilH 1-2. Sii){ar 7. Ash 0.2. Ki'iu-lion Fiiintly iilkiiline. S|H'(ir.c Kravity 1(I2H-1(«4."» If the proportion of fat is below the normal amount (.'5.1") per cent. — Temesvilry),"" the diet should be moditii-d by rednciii}^ slitrlitly the fatty timd and incrcasiiij; the proteids. If, on the (contrary, the milk is too rich in lat and albumin, less meat and more vegetables should be given, and at the same tim(! the employment of additional muscular exercise with daily baths is important. A change in diet alone will not reduce the proportion of caseinoncii, which is commonly in excess in the upper class of women, without reducing' at the same time tlic other constituents ; hence the resort to systematic muscular exercise is essential. Much can ofts'U be acc(»mplished by these means to adjust a proper (piality and (juantity of njilk for the child ; but not infrequently, despite all eilbrts, the child's condition fails to imj)rove, and it becomes nec- essary for its welfare to resort to artificial feeding. Sudden fright or joy, great anxiety, and other emotions in the mother have a pecidiar effect upon tiie quality of her milk. We have no intimate knowledge of the changes thus brought about, beyond the clinical fact that indigestion and colic are of frequent occurrence in infants nursetl by emotional mothers, whose nulk, it is asserted, is likely to contain more water, less fat, and more caseinogen than normal. The nursing mother should be made aware of this fact, and be cautioned to lead a life as free as possible from emotional exciti- gcstcd by Niiis, ** and considered by him sufficiently accurate for clinical i)urposes, may lie t'ln- ployed to estimate the amount of fat and albuminoids: Add enough liquor potiissa to the sample of milk to render it distinctly alkaline ; place in a test tube, boil, and set aside in a warm niinii for a lew boiu's. The fat will rise to the surface, and the amount may be estimated by a jtradiMicd rule placed at the side of the tube. To <leterinine the atnoimt of albuminoids, remove the Iiivit of fat with a pipette, add sufficient acetic acid to the remainder to render it acid, boil, and :iyaiii set aside in a warm room. All the albimiinoiils will be precipitated, and may Xte esfiiiinlcil in the same manner as the fat. There may be used with a(lvanfa{?e a test-tube graduated in liiiii- drcdths, in which a sample of milk known to be normal has been tested by this exaniin:iiii>n, and thus offers a standard for comparison. With this modification the writer has foiiiid iliis method useful for approximate analysis. The method of Holt"* may also be used for tlic <-ti- mation of the percentage of fat and for detecting wide variations in the percentage of pmicids. ■•t^s-u 1 PATIIOLOf.V OF THE Pf'h'/fJ'h'JiJf.y. 771 iiImt of inilK iwiiclitiT, is 111. •uiiiiot take tlif r, irt sonu'tlmt> (•(irpurtcles ami ill avt-raj^c t'<»iii- «7-S«. :»-». l-'-J. 7. 0.2. ilkalitie. l();54."» ;{.l') JHT Cl'llt. — tlv the fatty lond is too rich in I'at , aiul at tlu' same th daily baths is :ion of ('asoiun<>,(ii. without mliicin<r stoinatic musc\ilar e nu'aiis to a<ljii>t not infroqueiitly. 1 it beconK's luf- \\ the inothor have itiuKito kiiowlnli:'' [t that indiiic^tinii motional iiiothi-rs, [loss fat, ami more liado awaro of this omotioual cxcitc- , purposes, may lie ei»- ppotassatotlu'sainpk' lae in a warm room I'T Imatea by a urailuaicl loiils, remove the !:'>'''' lit aeiil, l>oil, awA ^I'-^'i" ll may l>e estiniatcil i» |ibe pradtiateil in 1>'>"- by this oxamiiKiiioii, [writer has fouii.l il>is L lie used for tlu' '■■li- lercentage of piot/ul''. inoiit. Fn cxtrome c«a«o« of emotion tho milk can 1)0 so fhangcd as to IxHtomc actually a fatal poison to th(> child. The aj^o of the mother and the period of lactation modify the qnality of the nulk. As the njj;e advances the pn>portioii of albuminoids j^radnally diminishes, and, bc^innini; with the sixth nmnth, as lactation advances the pcnvntaj^e of proteids becomes somewhat less (Kolesiiisky). An excessive (piantity of fat, according; t(» Monti,'™ will appear in the milk when the mother is att'ectwl by serious acute ])athol()gical pnursses, as mastitis or any other extensive febrile process. The same observer has sometimes noticed a (gradual diininuti<m in the proportion of fat in the presence of pathological prow'sses of lonj; duration. The qualitative chans^es in the milk produced by acute febrile diseases, by blood-chanj^es in the mother, by the presence in the nnik of micro-organisms, and by tht; rea|)pearance of eolos- tnim-corpuscles will be referred to in a subsequent sc»'tion. AnNOiiMALlTiES IN Qttantity. — Abnormalities in the quantity of the . lilk may vary from an entire absence of secretion to an i^normonsly ex- cessive supply, which may even continue after the child has been weaned. The normal amount of milk secreted by the mammary glands is very dif- licidt to determine, since there are wide individual variations within the limits of health. Temesvikry,'"'^ in a long series of examinations after lactation had fully been established, found the average amount of milk from one breast to l)c 59 cubic centimeters (2 ounces), the variations being between 30 and 70 cubic centimeters (1 to 2^ ounces). Ordinarily the total (juantity of milk secreted in twenty-four horn's is 414 cubic centimeters (14 ounces) at the end of the seventh day ; this amount steadily increases for a month, when the ([iinutity has reached about 2 pints, after which time, to meet the demands ol" the growing infant, it has increased to .'i pints at the seventh month, and alter the eighth month the quantity gradually decreases. Agalactia. — Complete absen(;e of the n» ilk-secretion is of such very rare occurrence that its existence has fretpiently been doid>ted. Usually there is (inly a deficiency which may occur at the beginning and continue throughout the whole ])eriod of lactation ; or more commonly the secretion, at first suf- ticicnt, gradually diminishes in amount or from some intercurrent atlection suddenly disappears. The secretion of an abnormally small amoimt of milk may be due to an anomaly in the formation of the mammary glands, cither congenital or acquired from faulty clothing compressing the glands ; it is oljscrved also in the very feeble, in women of advanced age, after premature births or stillbirths, and iu women who carry an excessive amount of adii^se tissue. Diminution in amount of a secretion previously abundant is a most im- l)i)rtant and very frequent anomaly of the man.mary function. It is often oI)served in women of the working-classes, who shortly after confinement are eoin])clled to perform an excessive amount of work iu the management of their lioiisohold affairs, and commonly are deprived of nourishment suitable to the formation of a sufficient quantity of milk. "When it is remembered that ' ) i '■}■ li 'J. ';■■'' , !.»■ M : i im ; I I, ih \ -,'»•:■) 772 AJUJIilCAX TEXT-JiOOK OF OBSTETRICS. niilk-secrctioii is a pliysiological function depending, as do other functioniil activities of the organism, upon the condition of the woman's heahh, it will readily be seen that any condition unfavorable to the mother's general healtli will interrupt the activity of the mammary glands. Thus, diminution of the milk is observed when there are unfavorable hygienic surroundings and when vitality is loweretl from frequently recurring j)regnancies or from inter- current diseases, especially .such as are accompanied by profuse discharges, as diarrhea or excessive menstruation. Temporary diminution or disappearance of the milk occurs when there is high fever and when iuHanuuation of tiie breast is present. Trentmcnf. — Insufficient milk (hie to defective development of the mam- mary gland ])ractiadly cannot be iricreased. In such cases the only recou>.se is artificial feeding. In very exceptional instances electricity and massage have contributed to awaken a torpid glaml to increased activity, but wIk ii there exists extensive actual anatomical defects even these agents accomplisli little or nothing. Mensinga, however, recorded "** an interesting case in which j)ersisteiit massage for a week succeeded in establishing a flow of milk when in six successive pregnancies there had been an absence of milk. In other cases much may bo done; to increase the (piantity and improve the quality of tiie milk by criti<!ally studying the mother's general condition and by giving especial attention to her diet. Her hygienic surroundings should be im- proved. If there is dej)ressed vitality or ill health from any cause, this nuist be removed. Benefit often follows a change of air and scene with frceddin from care and overwork. The diet should be modiJied by the addition of milk, farinaceous food, and a proper (juantity of malt, and particular attention must be given to the patient's stomach-digestion, to ensure the proper assimila- tion of her modified and increased diet. Bitter tonics, particularly nux vomica with pepsin and a mineral acid, will often be of value in promoting digestion. More can be accom])lished by these means than by any of the so-called " galactagogues," all of which are of doubtful value. Polygralactia. — A supply of milk greatly exceeding the neefl of the infant is of rare occiuTcnce. Sometimes at the beginning of lactation the milk is formed in larger quantity than the child requires, but this excess soon disip- ])ears and supply and demand are finally equalized. At times, however, in vigorous, plethoric women the milk-secretion is so abundant and is accompanied by so much discomfort to the patient that means must be employed todimiiiisli the flow, '^r'his diminution can be brought about by restricting the diet iind the amount of fluids ingested, by the administration of salines, by em|tloyini;' compression of the breasts, and by advising longer intervals in putting (lie child to the breast. Galactorrhea. — Very excessive secretion of milk of poor quality townrd the end of a prolonged lactation, and the continuation of the secretion after llic child has been weaned, are included Ui.uer the term "galactorrhea." .\-a rule, both breasts are at fault. The quantity of milk secreted is usually >\\'(- ficiently large seriously to impair the j)aticnt's health; in some cases the PATHOLOGY OF THE PrKliPFAilVM. 773 m er functiotiiil liealth, it will rcnenil hoallli limimition of miuulings ami or tVoin intiT- (lischarjic's, as aisai>poaraii<'t' imation of the t of the nian\- e only re('oi>'^e V and massaiio vity, but wlicn ents accoiui>lisli ig case in \vhitl» jf milk when in In other eases e quality of the and by },'iv ''>!-,' ; should be in\- cause, this must .110 with freedom the addition of •ticular attentit)n proper assimila- arly nux vomica nioting digestion. of the so-ealled leed of the infant ition the milk is jxcess soon (li>^:>i)- inies, however, m id is accomi>aiiie(l loved to diminish ting the diet aiul i.jfjj by emi>loyin;j; His in putting the or quality towmd secretion after t lie lictorrhea." -^^ •' ed is usually miI'- |i some cases the r (juantity secreted may Ik; enormous. The cause of galactorrhea is unknown, lielaxation or paralysis of the circular muscular fibres surroii iding the milk- diicts has been considered a cause by some anthors ; by otiicrs the condition has been considered to be an effect of extreme j)liysical exiiaustion. Si/inj)fomx. — The symptoms, aside from the almost constant flow of milk, are those to he expected when so constant a drain is made on the individ- nal's strength. Nutrition is interfered with ; extreme anemia and emaciation are ])resent, and are soon followed by some of the nervous disturbances ;<> be described as accompanying hyperlactation. Traitmvut. — Pronounced galactoi-rhea is a very stubborn affection, often continuing for a very long tinie despite treatment. Vigorous com])ression of tlie breasts, free action of the bowels, and the administration of iodid of potassium are generally useful. Electricity is often disapjiointing. forgot has given good results in some cases, and atropia is said to be satisfactory some- times, particularly in those luiable to stand free purgation. The treatment directed to the patient's general ill health — inm and other tonics and nutritious diet — has doubtless been a large factor in accomplishing the good results claimed I'or various spe(nal agents, as occurred in a case under the care of the writer, who, from the patient's general condition, was imj)ressed with the belief tiiat galactorrhea is perhajis only ime ex])ression of a neurosis. Conditions Interfering with Suckling. — Ordinarily, the condition ol'the mother that interferes with the ])crformance of the mammary function is one of simple loss of strength and flesh. Tiiore are, however, several more definite conditions that may be present at the outset of the lactation period, or tiiat later mav dciveloj) at any stage of this period. The more important of these com- plications will be considered briefly in the order of their relative imjjortanee. Faulti/ Development of the Mnminary (r/antls. — The anatomical structure of the mammary glands may in some individuals be very deficient in the di'vi'iopment of tin; glandular elenjent, connective tissue having replaced the giand-structtu'es to sudi an extent as to ])reclude the possibility of the mother s!i])|>lving sufliciont milk for lie child. This defect is a])parently inherited in rare cases. It is observed in women of ill-developed physicpie, and may be !i('(|Mire(l through undue conipression of tiie manunary glands by faulty dotiiing, or where the mother in each recurring pei'iod of lactation refuses to nnrse her eliiid. Little can be done for this condition, and, as a rule, artificial A'eding is necessary. Where atrophy of the glandular elements is only partial, elec- tricity, by stimulating the secretory function of the epithelial cells, accomplishes Ml times some improvement, although it is a measure more often disappointing, 'f he same may be said of massage of the breasts. /W(/.sr,s'. — At any time throughout the period of lactation temporary ces- sation of breast-feeding may be necessary by reason of intercurrent disease of the mother. Tims a fissured nipple often requires tiie witliholding of one breast for twenty-four or forty-eight hours, and a mammary abscess will inter- diet mu'sing from the diseased breast until complete convalescence is reached. Likewise, the child nuist be weaned temporarily in any acute disease danger- 774 AMERICAN TEXT-BOOK OF OliSTETIlICS. 11 t ■'f ' -' ously depressing the mother's strength or exposing the cliild to infeetion, such as tlie exanthemata, erysipelas, diphtheria, typhoid fever, malaria, and grave j)uerperal sepsis. When convalescence has been established the milk will usually reappear, and the 'jcliild should be returned to the breast. The presence, from any cause, of persistently high fever in the mother is in itself an indication for removal of the child from the breast. Fortunately, Nature usually takes tliis matter in her own hands, for it is a clinical fact that the milk-secretion soon disappears when the temperature is high and when the milk has thereby become injurious to the child. Schling'"' confirmed the experiments of Fehling, who has shown that within certain limits milk from a fevered mother has no ill effect upon the child. When the temperature is very high and persists near 104° F., a corresponding fever-curve soon a])pears in the child — a phenomenon not to be wondered at in the light of investiga- tions which find, as in mastitis, the same micro-orgauisms in the mother's milk and in the child's intestinal canal. The experiments of many bacteriologists, notably those of Konigman '"* and of Cohn and Xeumann,'"' disprove the notion, formerly so widespread, that a healthy mother's milk comes from the breast absolutely sterile. On the con- trary, they have found that the milk of healthy nurses contains micro-organ- isms in the vast majority of cases. The micro-organism commonly found is the staph ifiococcus pyogenes alhiis ; next in frequency, the aureus; and other microbes very seldom and in small number. The microbes find their way into the milk usually from without — probably from the skin into the ducts through their orifices on the nipple. Occasionally, however, the blood-current of the mother afflicted with septic disease is the medium of their entrance into the milk (Escherich, Longard, and Karlinski)."** Ordinarily the milk con- taining the cocci commoidy found in breast-milk produces no ill effect upon the infant. The investigations above referred to demonstrated that the chilli's intestines are capable of bactericidal action. The stools of children taking milk known to contain cocci were examined, and it was found that the cocci luid been destroyed in the intestine. Cohn and Neumann further remark, however, that we must admit the possibility of infection in weak children, to which infection is to be attributed some of the cases occasionally recorded of abscess-formation in the new-born infant. When the milk happens to cairv micro-organisms of more virulent character, as in some cases of mastitis, serious disease in the child may appear. Cases of gastro-intestinal disorders, of diph- theroid stomatitis, and of retropharyngeal and submaxillary abscesses are not uncommon, and even otitis media, dacryocystitis, and purulent ophtlialinia have thus originated (Damourette)."" The reappearance of the colostrum-corpuscles in the motlier's milk, ])ei'li:i|»s the most valuable result to be obtained by microscopical examination of ilic milk, is not only a phenomenon of medico-legal interest, but is also of practical value in determining the quality of the milk, since the presence of these coi- puscles after the eighth or the tenth day indicates (jualitative changes in the milk which disagrees with the child. ^\'e have uo intimate knowledge of iIk'^o PATHOLOGY OF THE PUERPERILM. 775 ifection, such a, and grave le milk will jast. the mother is Fortunately, uical fact that gh and when confirmed the lits milk from temperature is e soon appears t of investiga- j the mother's jiiigmau^"® and lespread, that a ;. On the con- tis micro-orgau- monly found is •ms; and other find their way 1 into the ducts \w. blood-curront oil- entrance into y the milk oon- 10 ill effect upon |\ that the child's children taking 1(1 that the cocci further remarl;, iveak children, to lially recorded of Ihappens to carry mastitis, serious lisorders, of dipl>- abscesses are not Llont ophthalmia r's milk, pi-rluips laminatitm of tlic Isalsoof practi.'iil Luce of those cov- langes in the milk [owledgc of these changes, nor do we know why the corpuscles reappear. During the first week of lactation these corpuscles are numerous, and their presence at this time is physiological. At various periods tliroughout lactation they reappear, when the milk is found deficient in nutritive value. They have been observed to reappear when the mother has been affected by some jn-ofound nervous im- pression, such as excessive grief, fright, fatigue, or sexual excitement. Inter- current diseases, ])articularly anemia, are often accompanied by their reappear- ance. Occasionally tl.ey are observed during a return of menstruation. It is also a curious fact that drugs administered to a nursing mother more readily pass into the milk during a colostrum |)eriod. The reappearance, therefore, of colostrum-corpuscles in large numbers after the second week of lactation is an indication to at least temporarily discontinue nursing. The diseases which make permanent weaning necessary are not numerous. Phthisis, either incipient or developed, endangers the mother by rapid advance of the disease, and not only exposes the child to infection by the transfer of the tubercle bacillus in the milk, as in a case clearly demonstrated by Steigen- herger,"" but also adds a risk of ill development on account of tlie imjjaired nutritive quality of the milk. A mother known to have syphilis may be allowed to suckle lier infant, provided the child bears unmistakable evidences of the disease, and provided also her general condition is such as to furnish a supply of milk of suitable quality and quantity. The testimony of the changes in the ingredients of the milk of syphilitic women, apart from its capability of transmitting the disease, is contradictory, and is doubtless due to the vary- ing condition of general health in those afflicted with syphilis. When, how- ever, the infant has apparently escaped infection, the mother should not be permitted to risk infecting the child by her breast-milk. In this connection it is desirable to remind the student of Colles's well-known law that a mother may suckle her evidently syphilitic child without fear of being herself infected. A syphilitic child should never be given in charge of a wet-nurse without informing the nurse of her danger of infection — a danger and risk so great us to induce Fournier"' to make the statement that the practice of wet-nursing syphilitic infants should be prohibited by law. It will often be necessary to (lisoontinue nursing when the temperament of the mother is so highly emo- tional as repeatedly to produce serious qualitative changes in her milk. The existence of or predisposition to goitre contra-indicates suckling, since this disease is thereby aggravated ; in some cases goitre has first appeared during the lactation period. Anemia. — An impoverished condition of tlie blood after labor renders the piierpera incapable of supplying a proper quality of milk, atid fiu'ther depletes lier vitality to such an extent that nursing must be omitted both for her own uiul for the child's best interests. It is therefore inadvisable to permit suckling to he continued when a profuse hemorrhage has occurred at the time of deliv- ery, or when a condition of advanced anemia has developed dnriiig pregnancv, with or without albuminuria, in which case the frequent tardy involution of the blood will be even more delayed. It is, moreover, certainly rational to U... 1 'Eia '■ ||mf-T 776 AMERICAN TEXT-BOOK OF OBSTETRICS. 3 \ n^ ■! ;i V > I, i ; ti \w \ I! li' believe that the blood of an albiirnimiric woman cannot supply the material for a perfectly healthy milk-secretion. Return of MenHtruation. — Among the laity the notion is very widespread that a return of the menstrual function makes it imperative to discontinue nuri<- ing. When the amount of blood lost is sufficient to produce anemia, it will always be desirable to wean the child. Ordinarily the flow is not excessive and may be very irregular, and the impairment of the milk is only temporary, as shown by the transient digestive disturbance in the child. Under such con- ditions it would certainly be unwise to resort to artificial feeding unless the child's condition clearly indicated that it was not thriving, which sometimes will be the case when the menses return regularly and profusely. Schlichter'.s"' observations, during a period of five and a half months, of 52 children suckled by women in whom menstruation had appeared, found that only one child became dyspeptic, and that this child showed a normal gain in weiglii. Thirty-three m 'iv-analyses were made, and they showed on an average less difference between the milk of a non-menstruating and a menstruating woman than betweon the specimens of milk taken from an individual at mornini.% noon, and evening. The advisability of discontinuing nursing when tlie mensem return should always be decided in individual cases by a critical study of the health of both mother and child. Pregnancy. — The experience is universal that a mother cannot continue to supply nutriment for botii her unborn and her living child; and, leaving out of consideration the possibility of the occurrence of miscarriage througii the intimate reflex association of the uterus and the mannnary glands, lactation and pregnancy are incompatible, and are not to be sanctioned except when scu'ioiis illness in the suckling makes a supply of breast-milk specially urgent for a short time. Dntg,s. — It is recognized as a clinical as well as an experimental fact tlmt various drugs are in part eliminated by the mammary gland, not only wlicn the milk is in a poar condition, but also when the nursing mother is apparently perfectly healthy. Alcohol, quinin, salicylic acid, arsenic, lead, iodoform, potas- sium iodid, mercury, the poisonous alkaloids, narcotics, belladonna, and a few other drugs have been found in the milk of nursing women. Knowledge (tf this subject has largely been gathered from accidents occurring to the infant when the nursing mother has been treateil for intercurrent diseases. Burdel '" reported fatal illness in an infant whose mother had been cin- chonized, and he advises withholding the breast until the milk containing the quinin is withdrawn. V^inay"* observed a distinct odor of nicotin, though chemically it was not shown to be present, in the milk of mothers exposed to the vapors of nicdtin in tobacco-factories, and he noted the aj)pearance of serious illness in the child upon the mother's return to the factory, which illness disappeared wlnii the milk was given up. Doses of the poisonous alkaloids physiological for the mother may at times ])ass through the milk in quantity sufficient to be poism- ous to the child. This is especially true of atropia. PATHOLOGY OF THE PUERPERIVM. Ill the material [•y widespread jontinue luui^- memia, it will not excessive aly temporary, nder such con- ing unless the liich sometimes Sehlichter's"= liildren suckled only one child ;ain in weighi. an average less truating woman iial at mornintr, rsing when the on bv a critical mnot continue to and, leaving out iage through the Inds, hictation and pt wdien serious urgent for a short 'ini iiental fact that , not only when ler is apparently iodoform, potas- idonna, and a few Knowledge of ing to the i"f:mt seases. er had been ein- milk containing' Diically it was not vapors of nieotin Ins illness in the Jdisappeared wli<n lysiological fortlu' tent to be poison- Fehling '" and Schling "' have experimentally studied the action uj)on the infant of various drugs in;>;ested through the mother's milk, and they point out the fact that the time required for partial elimination by the mammary glands varies with different drugs. The frequently observed laxative action upon the child of salines or of com])Ound licorice powder administered to the mother is sometimes utilized for the benefit of the infant, but beyond this the writer is acquainted with no exact experimental or clinical studies of the medicinal treatment of infants through the breast-milk. According to Barnes, syphilis in the infant may thus be cured. Weaning. — As the normal period of lactation is relative, often depending upon individual capacity for the production of milk and for enduring tlie strain of lactaticm, it is difficult to name a period throughout which the child should be fed exclusively from the breast. Ordinarily nine numths is the limit, hut in some individuals lactation may be extended throughout a year without detriment to mother or child. After twelve months the changes in the quality and quantity of the milk, the appearance of teeth in the child, indicating nature's preparation for other food, and the beginning ill effects upon the mother of prolonged lactation, make it imperative to remove the infant from the breast. There are, of course, a few conditions which will allow a continu- ation of lactation for a brief period beyond twelve months. It would, for example, be unwise to wean a child at the approach of midsummer, or when it had r.ecently recovered from a serious illness, or when in the midst of a dentiil period. Whenever weaning is decided upon, it is best, as a rule, though not always necessary, to give artificial food gradually, substituting at first one or two bottle-feedings daily, and gradually increasing the mnnber until finally, in the course of several weeks, the breast-milk is no longer used. At the end of the sixth month it is a good rule to investigate the quantity and quality of the mother's milk and the condition of the child, and to observe the effect of lactation upon the mother's health. If, as is quite common, this investigation indicates the desirability of weaning, this should be begun, and by the end of tiie ninth month the breiust-milk may be omitted. Hyperlactation. — Prolongation of the lactation period beyond the usual time for weaning — from the ninth to the twelfth month — is not at all tuicom- nmn among the ])oorer classes. The ill effects upon the mother and the child arc numerous, and the consequences to both are frequently very grave. These offccts are more frequently seen in women of weakly or strumous constitutions whose vitality has been depressed further by the strain of pregnancy and lacta- tion. The sipnpfoms of the condition, to which has been given the name fabes htclcd, are unmistakable. The quantity and quality of the blood are impaired ; the patient is pale, emaciated, and complains of aching pain in the back and loini-;, and in the breast when the child is suckled. Tiiere is loss of appetite, and muscular and nervous weakness with insomnia, headache, and vertigo. In niany cases, further neglected, hysteria or more serious changes in the nervous system may be followed by insanity. Cramps and contractions of various 778 AMERICAN TEXT-BOOK OF OBSTETRICS. muscles, beginuiiig with tingling, are frequently observed ; even speechlessness, dysphagia, orthopnea, and atta(;ks of" syncope have been noted. Serious derangements of the eyes have also been observed as a result of the extreme reduction ol' the vital powers and the impoverished condition of the blood, varying from a mild conjunctivitis to ulceration of the cornea or retinitis with total loss of sight. In those predisposed to phthisis this disease frequently develops at this time. Ilyperlactation, on account of the associated debility, sometimes is an etiological factor in the development or aggravation of skin affections, particularly psoriasis. The treatment of hyperlactation is the prompt weaning of the child and the use of tonics, nutritious food, and a temporary change in the patient's sur- roundings. Usually mpiil improvement follows. in. Diseases op the Non-sexual Organs. 1. Fevf:r due to Causes other than Puerperal Infection, While it is true that sometimes a rise of temperature in the puerperium occurs wholly independent of infection, it is also true that from a clinical stand- point the safest rule is to believe that fever occurring during the puerperal period always has an infectious origin until indubitably proven to be due to some other cause. There are, however, several conditions which not infrequently are observed to produce non-infectious fever in the puerperium. One of the most important causes of fever having a non-infectious origin in the pucr- pera is, for want of a better explanation, called " reflex irritation." Wiien it is remembered that during the puerperal period the patient's nervous system has not fairly begun to recover from the nervous irritability which was so pronounced throughout pregnancy, it is easy to imderstand that causes which in health would have little if any effect upon the patient's nerve- equilibrium will, out of all proportion to their magnitude, produce marked effects upon the peculiarly nervous susceptibility of the puerpera. The sud- den rise in temperature so commonly observed associated with congested and engorged mammary glands (Fig. 434) or with a sore nipple is certainly in large measure due to reflex irritation, although the element of infection in some cases is partly responsible for the fever, especially if the latter continues, in which event mastitis should be suspected. Exposure to cold, with consequent internal congestion, especially of tlic; breasts and of the abdomen, is also a cause of transient fever in puerporid patients who have beer, careless about jiroper protection with clothing or who indiscreetly expose themselves soon after labor. The chart (Fig. 4.');")) illustrates such effect u])()n a woman who left her bed eight days after licr delivery and walked through an unprotected corridor to the closet. Suoii after her return she was taken with a chill and her temperature rose as indi- cated in the chart. After the administration of a hot punch and the prottr- tion of an extra blanket the fever disappeared. Emotion is recognized as a cause of fever independent of the puerperimii. PATHOLOGY OF THE PUKRPERIUM. 779 IWI )eechlessness, twl. Serious the extreme of the blood, retiuitis with use frequently iated debility, nation of skiu the child and i patient's sur- ^NFECTION. the puerperiuiu a clinical stand- g the puerperal ,o be due to some lot infrequently im. One of the pin in the pucr- tation." When atient's nervous •ritability whioli ;tand that causes patient's nerve- produce niark<Hl i-pera. The sud- fh congested ami le is certainly in It of infection in latter continues, especially of the Iver in puerperal Isvith clothinji or chart (Fi[?. 4:55) lit days after licr ke closet. S<»i«i\ lure rose as indi- li and the proti'c- the puerperiuni. That profound emotion markedly influences the temperature in the early puer- perium is well known, but the exact mechanism of the production of fever by this cause is unknown. The appended charts are of two cases recently observed by the writer. The rapid rise of temperature observed in one (Fig. 136, A) followetl the thoughtless announcement to the patient that her husband ""*" ^^^ ^^^ DlMM* I 2 3 4 5 e 7 fl e 10 107^ i : : i • : : ; 204° 103° ^ I t : -:• ' i 101° 100^ i : : \ i 'S i : V] s ■ V ; ■ ^ -*. ; *% ,* • v; >! . , . ! C ^ '. J ! . . VP ; : ; : i \ : : 1 i i i 1 1 I •>/. ! 78 I 7G ' 62 I 60 ; (18 64 I 60 76 7H 78 ' 6 ( .V.. 64 72 : 68 I 60 [ 64 70 78 ' 74 1 100 72 I 60 tVJ fill "li 'Ml ■ Ktl c! I .t/J 78 I 76 ' 62 ! 66 : 68 64 ' 60 76 78 78 ' 6 ( .V.. 64 72 : 68 (2 (A', i no : 72 11(1 (10 (id i (16 (1(1 : m us 7(i i £ t /■;. 70 ' 72 76 Flu. 4;!4.— FfVLT IblldWiliK L'xposurf to colli. I'di. !;!.'>.— KlfViitioii of toiMpiTUtiiru (liic to t'ligorgomi'iit of till' iimiiiiiiary k'hikIs. had been killed in a railroad accident. The secondary rise of teiiijicrature was due to the i)ati(!nt's anxiety about her inability to provide for herself and cliild, which anxiety was relievetl by prcini.seil assistance. Figure 43G, B is the diart of a patient who occupied a bed adjacent to a companion who manifested .signs of mild puerjM'ral insanity. The insane patient declared that during the A B Darot I 3 3 4 5 e 7 R e to 1 1 8 4 B « 7 8 e 10 n la IS 14 107° : : : ; : • ; 104° ■■ ■ li • ■ ; ^ ■ 103° i t 1 i • t \l \ ■ "i i ■ : : '■■ '■■ A /*■ Jf A 100° : ; f. ■i-' i \ ^ Jl / J i ,^ > '^ V ^ N V ■ s S; ~r i: -: il T ■;; ^ ^^ ^ ■ ■ . Jm — _ T T" T- T ' V T ~r "T T ~ >< ( 6 4 1 ( 3 7 4 7 8 4 8 138 04 1 70 72 9 i 2 8 2 ■ > ( s 72 70 73 80 1 80; i 7.'> ' 72 1 •fi 2 ■4 (4 80 72 _i 72 » 84 "81 =! 1 88 00 1 ,1 00 02 1)0 1)2 Fl(i. 436.— Fever due to I'lnotion. niojit hor infant had been exchanged for the .sane patient's cliild, and insistefl thiit the latter patient should surrender her child, wliicli the insane woman claiined as hers. The anxiety and trepidation of the patient whose chart is here exhibited was .so great, and the rise of temperature was so coincident and i 780 AMKIilVAN TI'LXT-IiOi^K OF OliSTKTUICS. pronotincctl, that tlic n-lution of ciiiisc and dU'ct could not ho mistaken. Upon romoviiig the insaiu' patient to anotlicr room the ahirni of" thf anxious niotlui- (h'sa|)iu'ar('d and licr tcnipcratiii'i' fMl at once to \\w nonnah Acute constipation in the pnt-rpcrinn) is a frccpicnt nniso of fcvor, whicli is doid)tU>s,s (hie to the irritation of retained animal all\ah)ids. This plic- nomenon is anotlier example of the snseeptihility of tiie nervous system to various forms of irritation that at times other tlian the puerperium proihicc litth* or no effect. When a patient, before or durinji; prejjjnancy, is the subject of a disease neeompanied by fever, tlie elevation of temperature will usually be increased din'ing the puerperium, since an exacerbation of the disease is likely to occur. The fever-curves of phthisis, of j)neiunonia, of typhoid fever, and of other serious diseases are thus modified. Very hif;;h fever is often observed when serious disturbances of the brain complicate the puerperium, such as cerebral heniorrhaf^e or embolism or eclamp- sia. It is possible for a puerperal patient to be stricken with thermic fever, and the essential fever of syphilis is sometimes observed in the puerperium. 2. IiNTKIM^lKUKNT Dl.SKASKH. The puerperal patient may, of course, be attacked by any acute disease. There are, however, a few diseases which it is desirable to mention briefly, since their relation to the puerperal period is of more than ordinary importance. Exanthemata. — In recent years the important relation of the exan- themata to puerperal infection has been better understood, and there is now- little doubt that the germs of the virulent infectious diseases may effect an entrance into the puerperal j)atient either throuj^h their ordinary and peculiar modes of entrance, or throus^h wounds of the jienitalia, which latter channel is relatively far more frequent, more dangerou.s, and therefore more import- ant. When any of the exanthematous diseases occur as complications of the puerperium without symptoms or signs of infection of the genital organs — a very infrequent occurrence — the prof/noKin is more grave and the treatment is the same as under other circiunstauces, with rigid antisej)tic precautions added to prevent invasion through the partiirient canal. Scarfd J'h'ci: — When scarlet fever is contracted by the puerperal jwtieiit the j)oisoM having been introduced through wounds in the genital canal, the clinical course of the disease is greatly modified. The incubation period is shortened to twenty-four or forty-t^ght hours. The <//Vr7«o.s'/.s is usually ob.«cure(l by the fact that other forms of sej)tic infection are frequently accompanied liy skin eruptions which are similar in appearance to that of scarlatina (see p. 707). This fact doubtless explains the erroneous idea, formerly so widespread, that scarlatina very frequently attacked puerperal patients,* in whom it was thoutrlit there existed a pectiliar susceptibility to this disease, and for whom a previous attack in early life is said not to be protective to the same degree. * Martin found only tlirce cases of scsirlot fever in 10,000 patients in the Berlin clinii's. (Sjiiegelberg, Leitrbuc/i der Geburtshulfe, 3d edition, 1891). K stakon. Upon mxious inotlii 1 of i'l'vor, wliich vons systoiu In [K'l-iuin piothuc (H't of a tli^oiisc illy be iiKTcastd ^ likely to oeciir. LH", iukI of other COS of the hraiii M)lirttn or ec'laiiij)- [h thennie fever, le puerperium. my acute disensp. iition briefly, since ary iiiiportanee. on of the exan- land there is now ses may efleet an inary and peonliar ieh latter ehanncl ore more import- mplieations of the geiiital organs— n id the treatmnif is precautions ailded puerperal patient the genital «'anal, Jicubation period is lis usually obscured Jy accompanied hy (latina (see p. 707), h widespread, tliat Um it was tlionijlit whom a previous pgree. I in the Berlin I'li"'"'^' PATJIOLoaV OF THE PrEIirKRirM. 781 When it is known that the patient lias been exposwl to the germs of sei.. .<t I'cjver, and wlien the poison has entered tiie genital eanal, the vagina may show the redness, swelling, and })seudo-(liphtheritie patiiiies ordinarily observed in the throat, and the rash may be most apparent in tlu! region of the vulva. The later <K'currenc(! of (l(>s(|uamation wiien the patient survives will some- times help to verify the diagnosis. Tho profj/noxis is, (»f course, grave, being very nmch worse ac(!ording to the extent of invasion of the pelvic or other organs. The tredtmcnt. is that for the iXrave forms of puerperal iid'ection. Erysipelas. — The relation of erysipelas to ])uerperal iid'ection is even n\ore striking than that of scarlet fever. IJarnes "^ has said that erysipelas "will jierhaps aeeoimt for more epidemics of puerperal fever than any other external poison." The channel of infection is usually the partiu'ient canal. Of l.'i cases observed by Ilugeidwrger, eleven were of the genitalia, two of the nates, two of the face. Winekel saw 86 ease« — twenty-eight of the genitalia, two (if the breasts, six of tin; face and scalp. Of Fehling's 5 cases, three wen; of the iiice. It is doubtless true that very many cases of puerperal inli'ction are of erysipelatous origin, which, in the absence of the usual synipt<trns of this disease, cannot In; recognized without bacteriological examination. The disease develops mora frequently in the first than in the second week after delivery, and death occurs oftener in the second than in the fourth week. The y>/vv//((W« (if facial erysipelas in the jHierperium is comparatively favorable. When the disease attacks the parturient canal the mortality is high; twelve of Winckel's cases ended fatally. The frcdtincnf is that for grave puerperal infi'ction. Diphtheria. — The relation of diphtheria and of other infectious diseases to ])nerperal infection is similar to that of erysipelas, and the sanu; antise2)ti(j precautions against all infectious diseases are urgently demanded. Pneumonia ; Rheumatism. — It has been asserted that (he pu(>rperal pa- tient is especially predisposed to ])neunu)nia and to rheinuatism. These dis- eases may occur as intercurrent affections, but it is a flict that a septic pneu- monia or a se|)tic arthritis, to both of which diseases referiiuee has been made (pp. 708, 707), will account for the relative fre(iuency of the former diseases in the ])uerperal peritMl. Pneumonia, not of septic origin, occurring in the puerperal peri(xl requires no consideration in this work beyond the statement that the course of the disease is more serious than pneumonia in non-puerperal women, the fever being especially high, and the prognosis is distinctly more }irave. When secondary to infection of the parturient canal, pneumonia is often of embolic origin, and is frequently observed as a complication of uterine pldebitis or ])hlegmasia alba dolens. The course and treatment of septic pneu- monia are described in the section on Purrpcral Infection. A sejitic arthritis can be differentiated from true rheumatism by the history of the case; by the absence of a(!id sweats, of cardiac; complications, and of niinked febrile reaction ; and by the fact that one of the large joints, often the knee, is affected ; that other joints are very rarely affected in succession ; that it lias a longer duration and a tendency to ankylosis or to suppuration in the !■' < i vi ' mm' i'iiln IR- i'T ' 782 AMEIUCAS TEXT- BO OK OF OBSTETUJCS. joint, with geiioral septic iut'cftion ; aiul that arthritis is more apt to ooeiir in women who liave had jjonorrhea before labor. The cause of this so-ejil led "puerperal rheumatism" is probably a specific variety of niicro-orgaiiisni having a predilection for the joints. Trmtnient consists in a careful disinfec- tion of tiie parturient tract and in keeping tiie joint at rest, in the application of iodin or ointment of belladonna and mercury to the joint, and, after acuti; inHammaiory symptoms sul)si<Ie, in the employment of cautious passive motion. Malaria. — Malaria is one of the most imjKJrtant intercurrent diseases o|' the puerperium, not only because women recently contined have an increascii liability to this disease — a fact generally admitted — but especially because this disease so often sinudates sepsis, from which it is of the utmost imj)ortaiice tluit malaria be differentiated. Cliniwdly, women subject to the malarial poison almost always, as the result of the traumatism of labor, manifest this discasf after delivery, at which time the type of malaria ordinarily is mild, but excep- tionally it may be very severe. The disease usually appears on or about tlic third day after delivery, and often modifies the course of the ]nicrj)eral period. While malaria, according to Abelin,"* does not modify the involution of the womb, acute types of the disea.se, to .some extent, ])redi.spose to puerperal henioi-- rhage and to profuse and j)rolonged bloody hx'hia. The influence of malaria upon the nu Ik-secretion is shown by a diminution in the amount of milk secretetl, especially when the fever is highest. WhetJK r the germs of the disease are transmitted in the milk to the nursing infant is by no means certain. In some cases it has been asserted that such trans- mission has been observetl. IHagncms. — The diagnosis of malaria occurring in the puerperiiun is often very difficult, and, as stated above, the close resemblance of this disease to some forms of begimiing sepsis renders the difllerential diagnosis the most important feature of malaria complicating the puerperium. A safe clinical rule is to reserve a diagnosis until the parturient tract is known to be uninfected. Mliile frequently the date of api)earance is the third day after labor, wide variations are observed. The duration and marked remissions of the fever, its freciiieiit but not invariable periodicity, and especially a morning elevation of tempera- ture; the character of the pulse and the more evident relation of its rapidity to the degree of fever ; the blood-examination for the malarial plasmodinni; the enlargement of the spleen and of the liver; the quantity and (|uality of the lochia; and, finally, the efficacy of quinin, — will often assist the diagnosis between malaria and puerperal sepsis. Treatment. — An early diagnosis is usually difficult, and, in order tlmt begimiing .septic infection of the parturient canal may not meanwhile iiain headway, it is a safe rule to disinfect the vagina, or even the uterus, and to administer a calomel, and later a saline, purge, followed by one or two iVeo doses of quinin (gr. x, administered morning and evening). This course of treatment may further obscure the diagnosis for a time, but it has the ad- vantage of promjitly detecting and treating beginning infection, thus avoid- ing delay in stopping its further progress. If the disease is malaria, the } apt to occur f this so-call*'i jiicro-organisii\ iroful ilisint'ci- tho applit-itidii and, after aciitr passive motinn. rent diseases of ve an increase I illy because tlii- inipovtance that malarial poison ifest this iliseasf niiUl, hut exccp- on or about tlic puerperal perind. involution of tlu' jnierperal heniuv- , by a (liniinutiun ligiiest. ^Vhetllcl• i nursing infanl is that such traiis- iierperiuni is ofton [lis disease to some lie most iniportimt ■linical rule is to ininfected. Wli'd^' n-, wide variations jfcver, its frccjiuiit ation of tempi r:i- ion of its rapidity .rial Plasmodium ; ity and (jnaUty of assist the diagiinsis Ind, in order thiit It meanwhile siivi" Ithe uterus, and to [r one or two iVue This course of tut it has the lul- ectiou, thus avoid- se is malaria, tlie PAT/roLoav OF THE pri':iiri:nii\yr. 783 fever will likelv rccm-, hut usuallv it will rcadilv he controlled hv nninin, wliicii ordinarily should he adniinistcr<!d in daily doses (»f from lo to ,'JO gi-ains throughout a period of ten days or two weeks. 'I'lie chart (Fig. 4.'J7) ' r- "^^ " ^" ' - 1 a » 4 ft fl 7 R 10 11 la 13 14 15 10 17 )H 10 •M ai 1 - 108» lOS" ■ - Y Y 1 107« iar> ~> ; ■ ; 10*° 103° \ '■ -i- 101° 103° / j 1 102° I / XQt2P 101° ■ ■| f / u is 101" 100° • ■ / / ■^ ^ \ f 80° » k^ 4- : J. •^ >. ^ ). - I '> SL ^ r I ■\ 'i V /^ y ■•> V \ s >« '; 00° r I > s. ;Wv 06° . . - . ■ . . ■ . ■ ■ ■ — T" '- ~ - 08° 97° -J -i- - -- 07° : 7(1 1 7a' -,1 ',^\ . Ni 1 \-l Mi Ml liio' IIKJ ,M Ui; 8-1 S(j , ^l HG M , H) 82 70 ! i I : I I i I I i I I CO I fiQ S(i 7C. 711 102 ins 1(18 SO ' STi i 72| 89 I 8:1 ' 81 ! 82 7!) 84 . 80 ! Fl(i. -llw.— Maluriii in tlii' iiiicrjurimu. illustrates this jdan of treatment. The notes of the case arc as follows: Sixth (i;iy : Tongue coated, conitmctivie yellow ; uterus enlary;ed, reaching more than liidfway to umhilicus; bloody lochia j)ersistent and not otfcnsive; a very large [ST. \Wi \A\ "U IIHJ iiH (S.; m l-l 7ti '.KI in NI 7ll 7U 71 71 nn 7S 71 S4 Ht) 71 wi x-1 ':> im JS l2 I. /■-'. IOC, 108 KKI W 91 S-l 80 74 70 78 100 122: 80 7'J SI 72 SJ 80 80 SO 74 80 70^^84 ; 70 70 JO ; Fig. 4ii8.— Malaria in tlio |>iu'ri>irium. iimount of healthy decidua; and blood-clots removed with curette and placental forceps, followed by douche and gauze-packing; calomel (gr. iij) ; quinine (gr. x), at night and on the following morning. Ninth day : Temperature again elevated; uterine involution progressing; bloody lochia diminished; quinin, gr. X thrice daily. This dose of quinin was given until the seventeenth day, when cinehonisin first appeared, and, as i.s shown by the chart, the fever disap- lieiired and did not return. The writer has repeatedly observed a fact recorded by others — namely, that 784 AMI':RI('AN TKXT-JiOOK <>/• OliSrHTlilCi!}. i_L ii Ut some puerperal cases of rnalariu recpiire exeeptionully larj^e doses of nuiiiin. The eliurt (Kif;. 4.'J8) illustrates this fact. In this case, from the thinl to the tentli ilay a daily dose of 16 jrraiiis was jj^ivoii, and, the temperature iiaviiiif ~ - ~ ■^ "~ ^" TT- T- ~* "^ "•^ H r— ^ gOA 1 1 • 4 « II 7 n • 10 11 It 1> 14 It IS 17 III 1 IS 1 90 1 91 ■It ;:i n n n 11 V - - " ■^" : - - lot* IOC IM' ■ ^- A i '4 ■ / \ : ^ 1 \ M ' I i v l I \ ' 1 ; 101° lOV > f; I 1 ■ ' k \, ■ " s ^ - - - ^-^i*.. w l^ ^ V f s 4i > 1^ i^ / ■ L \. !% i - - 1 -V l^ ^rfb V k '■ 9tP ' - *— - ■. - [ ti : - - ■^- , 07* rr : \ . IKl 80 imi <jti 82106 <M DO 72 86 8 88 '.11 im iiHi I'JII KS N 1111 N H8 ' 7( 71 in !H'. 80 m ILK) 1(K) 88 INI h8 88 nil 108 Imi Tl r. 711 ■-1 78 71 Fio. ■I'.iO.— Mnliiria in the puorpcrlum. ceased to rise, the drug was about to he discontinued. Two days later — on the twelfth day — the temperature rose to 103f° F. notwilhstandinj; tiie (piiniii ; the daily dose was then doubled, .'50 j^rains beinjj^ j'iven daily until the Kfteeiitli day, when, the fever apparently being controlled, the amount was reduced to ^^^ "^^'" -- ^^^ DlHua I 2 3 4 6 e 7 8 e 10 » 13 13 14 15 16 17 18 19 20 31 107° 106° : 107° 100° 106^ 104° 'i IW^ 103P 103^ i • i ioa° ! i '. A A f L. ^ 101^ 100° \ ^ ■■I '.' ■ 1: '' V V 100° 09° -i- ^ s t 4 I V i • -^ ■\ /^ k* ■ \- X -S A A ^ /^ A I* 09° y : y, \ y N / y V V ■J V ^ ^ ^ . . • . . . • . . T* . . ^■ , . . 07° : ■\ i' ; . ; 07° ; : ■■{ s 1 •''• ! •_> ^ ('. t* 4 \ 8 h 8 II Nl ;i H U )2 y - ii JO '. 1 8 t 8 4 8 ) 8 4 k 1 IW yo 84 b - ( t) S, (K. 70^80 _!J0 , !KiJ04_]O8 100j_86^; 94 [m : 84j 82 JWJ 8« i 88 88 , 70 92 ■ 8 | M j 80 , Fig. 440.— Malaria in tiie puerpurlum. lo grains. On the seventeenth day a chill occurred and the tem])erature rose to 101i° F., whereupon 30 grains were given daily until the twenty-tliird day, when cinchonism occurred and the temperature became normal ; the amount of the drug was then reduced to a very small daily dose. The chai't (Fig. 439) also illustrates the necessity of administering l;ir<ic doses of quinin in some jiuerperal cases of malaria. Whenever attempt was made to reduce the dose from 10 grains thrice daily the temperature invarialiiy -^.I l 4 „ _ - wr J. _ i lor L_ - 1 Uf __ J. _ 10»' L 100° : ' lOV i_ - 1 UKP _ --Q»» - -»■■ "^ - V »r Lh 1 71 1 10T> 108° 106° 101' losr flioa° i4ioi» 100^ ^' 90" 97° •jituro rose xMity-thinl rmal; tlie rinp; l;i''S'' [tempt \v:\s linvariiiltly rAT/i()/j)(;y or rni: rvKiiPKiiiryt. (85 was elevated, ami the fever was filially c(»iitr(»lle«l liy adiiiinifitering 20 jfrains tliiice daily (20th, 21«t, 22d, and 2:}d days). The chart (Fig. 440) exemplifies a milder type of puerperal malaria eon- trolled by a (hiily d<»se of grains of (piiiiiii. When it is necessary to resort to large doses of (|uiiiin to control malarial lever in the piierperiiim, tiie writi-r's experii'iice agrees witii that of IJiirdel, that (lie infant is likely to sutfer and should he taken from the breast. A dailvdoso of from 16 to 20 grains has, however, produced no apparent elfect. In eases of chronii! malarial cachexia with an acute exacerl)atioii after labor, arsonie coin- liiiied with (piinin will often be more etfieient than (piinin a«lmiiiisteied alone. Hemorrhoids. — The interference with the venous eireulatioii of the rectum (luring the last months of pregnancy very often leaves the rectal veins in u liemorrhoi<lal condition, which fre(pieiitly occasions great discomfort during (•(invalescence. Relief may l)e obtained by 'ivw action of the bowels, bv the iipplication of hot-water compresses, or, if more agreeabh; to the patieiit, bv liic use of an ice-bag. A piece of cotton saturated with the distilled extract y\'( witch-hazel and inserted partially through the anus, or the use of an oint- iiieiit composed of ecpial parts of the ointments of galls, belladonna, and stra- iiioiiiiim, will further relieve the pain. Puerperal Anemia. — According to the investigations of Ingerslev, Feh- liiig, ami jNIeyer,"" the average numlu'r of blood-corpuscles and the heuKtglobiu value of the blood are lessened during the first four or five days of the puerpe- riiim, but by the fifteenth day the number of corpuscles and the quantity of hemoglobin have practically returned to normal. It very frecpijutly happens, however, especially among the poor and ill-fed, that the ])hysiological changes occurring in the blood during pregnancv not only fail to disai)pear, but even become aggravated under the strain of lac- tation, and a very marked anemia appears. This impoverished condition of the blood is especially liable to occur when the patient is the subject of any wasting or depressing disease, such as phthisis, chorea, insanity, or when at the time of, or subseciuent to, labor hemorrhage or sepsis has occurred. The anemia in such cases may progress, if neglected, to a pernicious form. Careful lilood-examinations may be made to observe the effect of treatment, which is usually efficient if not too long neglected. The administration of iron and of arsenic combined with hygienic and dietetic treatment should be kept up for a long period. .*?. Diseases of the TTrtxakv Oiujaxs. Functional disturbances of the bladder, such as inability to urinate and uiinaiy incontinence, are of frequent occurrence after labor, and are some- times very troublesome affections, especially incontinence. The loss of power to evacuate the bladder may be due to tlie inability of the patient to empty the bladder while lying in bed, or to injury of the urethra and the anterior vaginal wall, the resulting edema diiiiinishing the calibre of the urethra and making its course tortuous. Cases of the latter class are usually 50 1 \S f ^ •/ 1 .»'( •3 J('. ^ m^ 786 AMERICAN TEXT-BOOK OF OBSTETRICS. permanently relieved by a single pas^sage of a catheter, which straightens the tortiions canal, and when infection of the nrethra and bladder does nut occur the swelling rapidly subsides and there is no further diflficulty. The diminution of intra-abdominal pressure and the relaxed condition of tlio abdominal walls also prevent the operation of this pressure and the action ol" the abdominal walls in emptying the bladder; and, further, it is asserted that after labor the bladder-walls admit of greater distention by accumulated n\'\\u\ than can occur during pregnancy. The walls are thus slower to contract in response to the stimulus of the urine in the bladder, and the physiological increase in the amount of urine excreted early in the pueriwrium soon over- distends the organ. The dangers of over-distention are not only the imme- diate injury to the bladder — a catarrhal cystitis — but a further and great-r danger lies in the fact that the bladder-tissues are thereby rendered loss capable of resisting the destructive action of micro-organisms, should the latter effect an entrance. A simple catarrhal cystitis may thus be converted into a serious infective cystitis. The means to be employed for emptying the bladder, and the necessity for chemical cleanliness of the catheter when it is used, have been referred to (p. 660). Incontinence of urine in the puerpera is often the incontinence of retention. The contimial dribbling, however, may be the result of paresis of the sphincter nnisde from prolongetl labor in head presentation, or it may result from fistuhu. '£\\Q treatment will be governed by the cause. Paresis of the bladder-sphincter very often disaj)pears s|M)ntaneously, and recovery can be hastened by the admin- istration of tonics, especially strychnia, and by applications of electricity to (lie base of the bladder. If a fistula catmot be healed by stimulating applications, such as nitric acid or nitrate of silver, a plastic operation is necessary a tew weeks after the patient leaves her bed. Cystitis and Pyelitis. — The most importiint organic affection of tiie urin- ary organs after labor is cystitis. This disease commoidy is mild and of short duration, but it may be a very grave complication when it is due to infection of the bladder. Some cases of septic cystitis assume a most malig- nant type. Etiolofiy. — A simply catarrhal cystitis is frequently observed to follow injury to the bladder, either from pressure of the child's head or from over-distention of the bladder. The symi)toms in these cases usually disappear in a few diiys, either spontaneously or after mild treatment. The great danger ';f the disease is an added infection, for, as ])ointed out by Bumm, Dubelt, Rovsing, and others, a healthy iminjured bladder car. resist the action of micro-organisms; when, on the contrary, a catarrhal cystitis is present, the subsequent introduction oi' micro-organisms rapidly converts the catarrhal into a suppurative iuHainnia- tion, which may .spread along the urinary tract and finally involve the kidneys, producing pyelitis, pyelo-nephrosis, or nephritis. Ascending infection of the urinary tract usually begins in the bladder, the infecting })oi.son gaining aeeess within this viscus in one of several ways. Commonly the catheter carries (lie infecting agent into the bladder, either itself not being chemically clean, or, it' % i m PATIIOLOdY OF THE PLEIiPKIU CM. •87 n ;h straightens Ider (loos not fficulty. The idition of tl\o I the action of s assertwl that imuUitod urine to contract in e physiological mn soon over- )nly the inunc- cr and grcat-r ' rendered less ns, should the us be convertt'd )!• emptying the leter when it is nee of retention, of the sphincter suit from fistula;. daddcr-sphindcr edbytheadmin- olectricity to the ing applications, necessary a i'cw [tion of the urin- is mild and of Ihen it is due to ne a most nialig- [ito follow inj my m over-distent ion ar in a few iluys, r(>i- . ;f the disease sing, and otlu'i's, ■sranisms ; whi'ii, introduction ot Irative inflainnui- olve the kidneys, infection of the )n gaining a(cess theter carries tin' ally clean, or, it properly sterilized, but improperly introduced, it may, at the time of its intro- (hiction into the bhidder, become contaminated by decomposing lochia. Escap- ing these dangers, there is yet another danger of carrying into the bladder, on the catheter, micro-organisms commoidy found in the otiierwisc normal urethra. Garonsky,'^ Uovsing,'^' and otliers have shown from tiicir investigations that pathogenic bacteria are commonly found in the urethra. Exceptionallv infec- tion of the bladder may occur independent of the use of the catheter. Recent cHuical and exi)crimental studies of cystitis, particularly by Dogen, Clado, ITalle, Albarran, Kovsing, ISIorelle, Denys, Schnitzler, and Krogius, apparently prove that micro-organisms located in any of the pelvic visc(>ra may find their way into and infect the bladder. The observations of Reymond '^^ are especially interesting. In two cases of cystitis, where the micro-organisms in the uterus and bladder were identical, treatment of the bladder was without result, but after curetting and disinfecting the uterus the cystitis rapidly disai>peared. In seven other cases a cure of long-standing cystitis followed removal of the dis- eased pelvic organs. His four experiments upon animals showed that the introduction of bacteria into the pelvis outside the bladder-walls gave rise to cystitis with the micro-organisms in the bladder, and not in the blood-current of the pelvis. In Wreden's'^ experiments, intestinal micro-organisms, or those intentionally placed in the bowel, were found in the bladder. Very exceptionally the bladder may escape serious inflammation, but injury to the ureters, with sul)se(picnt infection, may be followed by inflammatory changes in the pelvis of the kidney or in the kidneys. Labor may also be followed by perinephritic abscesses due either to infection of the pelvic connec- tive tissue, and extension of iuHammation by continuity of tissue, or to infection from rupture of a kidney-abscess into the surrounding cellular and fatty tissue. Dioffuosis. — The symptoms of catarrhal cy? titis in a pu(>rpera are the ordi- nary symptoms of irritation and acute inflanunation of the bladder. In septic cases the early sym]>toms are simi!:;'" ; later they are very violent, when exfolia- tion of the mucous mmub'Tiiic or ever of the bladder-walls may occur, and occa- sion severe tenesmus or retention of ' ine by obstructing the urethra. Fever is usually moderate so long as the inflammation is confined to the bladder, and gradually ilisappears after from three to six days. Should this gi'adual defer- vescence br followed for ten days or two weeks by an almost afebrile cure, and should the t.'Muperature th(>n rise rapidly to a ;v,pater height than had ])revi- ously existed, and be accompanied by pain aid tenderness in the region of the kidney, it may be assumed that the pelvis oi tlie parenchyma of the kidney lias been invaded. When the teniperatnro t'coui the b(>giimiiig of cystitis is very high — above 103° — rapid infection o the kidneys has likely occurred. Examina ion of the urine will also help to deter'. line the extent of the inflammation by the presence ol' i.- ge amount of albumin, of renal ei»tlie- limii, and of easts; and bacter'; logical examination of the urine will be of iiirther assistance in recognizi'<!>; tl: vo very rare inst;mccs of infi-ction of the urinary tract unaccompan'vd bv pc'iiiont urine and without marke ' bladder symptoms. I ' ^.' . _i> : ■ in 788 AMEltlCAN TEXT-BOOK OF OBSTETRICS. 'U' Tlie time required for the spread of the inflammation from the bladder or adjat'oiit striietures along the ureters to the kidneys varies. The usual time is about ten tlays or two weeks after the appearanee of a very mild or severe cystitis. It ean, however, in rare eases oeeur almost from the outset, before or coineident with marked bladder-symptoms and in srme cases pyelitis, pyclo-nephrosis, or nephritis becomes apparent oidy after a long-standing and persistent cystitis or ureteritis. I-'ro(/uuiiix. — The danger of cystitis occurring after labor depends largelv upon the promptness and the care exercised in treatment. Neglected cases with ulceration and exfoliation of the bladder will have a mortality of 38 per cent., and of those who recover greater or less permanent damage is done to the urinary organs, from which damage the patient may ultimately die. Pyelitis persisting for months is a not unconnnon sequel. Treatment. — Prevention is of first importance. Catheterization should nut be resorted tt) uidess all other means to secure urination fail, such as ro})eatedly placing under the patient a bed-pan filled with hot water ; the sound of •. niiDiii!^' water; assisting the patient into an upright position upon her knf:es, an(i [ vs- sure over the bladder. While avoiding the catheter, however, ihe dai ger ')f ovcr-distention must not be forgotten, and the catheter must be used, if other means have failed, at intervals of at least twelve hours, but always with strict- est antiseptic care. At the earliest appearance of cystitis the bladder should carefully be irrigated every four hours through a two-way catheter with a ^ per cent, creolin solution, or, if this causes much pain, a solution of boric acid (gr. XV to fl5j) may be substituted. Warm applications over the bladder and diluent drinks are also to be used. Five- or ten-grain dosct of salol three times a day will be of service so long as the parenchyma of the kidneys is n^t invaded. When constant dribbling from the bladder is replaced by retention of urine, occlusion of tiie urethra by an exfoliated portion of the bladiler shoukl be suspected, and the separated portion shoidd be removed, dilating the urethra for this purpose if necessary. Large doses of iron, iidudations of oxygen, and the free use of stimulants constitute the general treatment en which most reliance can be placed when the patient is profoundly septic. The treatment of pi/clifiH following labor will depend upon the chaniet( r of the disease. In mild cases it may be sufticient to obtain drainage by uw administration of diuretics that act niechaiucallv, such as large drausj-ht nf water, and to attempt disinfection of the urinary tract by the administnitidn of salol or boric acid in doses of 5 or 10 grains every four hours. For sub- acute or chronic cases alterative and stimulating diuretics will be u.seful. ( 'uses that do not respond promptly to these milder measures .shoidd be treateu 'v surgical means to obtain free drainage. When a distinct collection of j-i i the region of the kidney is detected by palpation, the most efficient trcatin- n' is incision in the loin and the introduction of a drainage-tid)e, which siiould be removed when disappearance of the purident dis'.'havgc and shrinkage nf the cavity indicu ■• that active inflannnation I::' .sulisidrd. When palpation fails to detect swelling in the region of the kidney, waeu ii.ei'e is doubt as to PATHOLOGY OF THE I'i'EnPERlVM. 789 :lie bladilor or 2 usual time is mild or sevorc : outset, before cases pyelitis, g-staudiug and lepends largely eeted cases with of 38 per cent., is done to the y die. Pyelitis ition should not ch as ropentcdly ound of iunniu!: knees, ant*. ^ 'is- •, ihe duiiger 'if be used, if other ways with strict- • bladder should ■athetcr with a .\ iun of boric acid ■ the bladder ami I salol three times kidneys is not iced by retention of tlie bladder removctl, dilating iron, inhalations •al treatment rn iidly septic. )on the character drainage by tiic [U'ge draught ot 10 adndnistration lours. For sub- be useful. Cases uld be treated ' v lection of I'l' 'I ffieient treatiu' »' be, which sliould ind shrinkage nt When palpal i'lu n'e is di)ul)t as to which kidney is affected, or especially when vaginal examination finds a thick- ened, tender ureter, catheterization of the luvters will be useful for both diag- nosis and treatment. Jiy means of the ureteral catheter and an aspirating syringe tiie pus should be drawn from tlie pelvis of the kidney at intervals of a few days, the quantity withdrawn should be noted, and the same quan- tity of a weak antiseptic solution should repeatedly be forced throu*di the catheter and withdrawn. Tlie treatment by incision in the loin is less tedious, and does not require the special appliances and skill necessary for catheteriza- tion of the ureters; moreover, should the fever and the albuminous and puru- lent urine be due to small multiiile abscesses in the parenchyma of the kid- ney, the opening in the loin is more favorable for diagnosis and treatment. Albuminuria. — Albumin is very frequently found in the urine during the first forty-eight hours of the jiuerperium, its occurrence at this time being considered jihysiological. Trautenroth '** asserts that during labor albuminuria is the rule, its absence the exception, and that in from one-fourth to one-third of the cases casts are present. Both casts and albiunin promptly disappear early in the puerperium, and their presence after the first week usually means catarrh of the urinary tract or more serious disease. Etiology. — Various explanations have been offered for the occurrence of albuminuria at a later period of the puerperium. The most plausible theory is that in cases apparently passing through a physiological jtuerjieral period the presence of albumin in small quantity indicates a continuation of the kidney condition which was }n*esent diu-ing the latter months of pregnancy. To those who consider the kidney of pregnancy due to the excessive amoiuit of work thrown upo:i the kitlneys throughout the jteriod of gestation, the similar demands upon tlie excretory organs during the lying-in period readily explain the continuance of small amounts of I'bumin in the urine of the puerpera. The frequency of albuminuria duo to a continuation of the kidney of pregnancy has frequently been demonstrated by autojjsy, the kid- neys presenting the same condition of anemia without inflammatory changes. Albuminuria in the jiucrperium is very often a concomitant symptom of infi'ction arising from the genitalia. There may be either a simple catarrhal inflammation, or, when infection is at its height, true parenchynuitous nephritis may be present, caused by the excu'etion of micro-organisms or tiieir toxins, tile toxins acting upon the tissue of the kidney practically as mineral poisons. In even more advanced cases of puerperal sejisis metastatic abscesses in the kidneys may occur. It has been asserted that the albuminuria increases and (lindnishes with the pelvic lesions of septic infection. Sircdey considers puer- peral nephritis a constant complication of puerperal uterine jihlebitisor lymph- angitis. The author has observed nephritis with albmninuria and casts develoii on the fourteenth day of the puerperium in a jiatient with a very virulent mammary abscess. The prognosk of puerperal albuminuria is determined by the cause. AVhen due t(» the persistence of the kidney of pregiuincy, the small amoiuit of albu- min slowly but completely disappears. The symptoms of the kidney-lesion in m'\ 790 AMERICAN TEXT-BOOK OF OBSTETltlCS. *, > ?1 Iq I •:'* 1;' , I \i\ septic cases are usually obscure, and are often overshadowed by, and disappear more slowly than, the uterine symptoms. The possibility of thus expluiniii<r the very rare occurrence of eclampsia so late as two weeks or longer after labor should not be forgotten. Whether the kidney disease persists in kidneys pre- viously normal is also determined by the cause and by the extent of injury done to the tissues of these organs. The occurrence of albuminuritic retinitis and blindness in the puerporium would indicate an old nephritis antedatini; the pregnancy. It should be remembered, however, that loss of vision may occur after labor wholly independent of kidney disease. Very rarely tempo- rary blindness may occur from vaso-motor disturbance of the vessels of tlio retina. The loss of vision may also follow severe hemorrhage, and permanent blindness may result from septic panophthalmitis. Hemai Tia. — Bloody urine is sometimes observed soon after labor. Serious contusior > i\(^ bladder during labor, either by the child's head or by forceps, will occasij' <e followed by this symptom. Ordinarily the blood in tiio urine is due to o persistence of vesical hemorrhoids which developed duriiio; pregnancy. The differential diagnosis is made by the history. The hemor- rhoidal condition, as a rule, disappears spontaneously and usually requires wo treatment, although exceptionally it may be necessary to employ astringent in- jections into the bladder. When bloody urine from injury to the bladder is present, especial antiseptic care should be observed should the use of the catheter be required. The possibility of the occurrence of fistulae should not be overlooked. 4. Diseases of the Nervous System. Cerebral Hemorrhage and Embolism in the Puerperium. — Intra- cranial accidents so serious as hemorrhage or embolism are fortunately very rare, and often are only incidental complications of the puerperium. A woman predisposed to cerebral hemorrhage would a priori be more likely to bo stricken with this accident either during pregnancy or at the time of labor. Throughout the period of gestation the changes in the blood, the physiological hypertrophy of the heart, and the accelerated destructive changes of any pre- existing kidney-lesion all combine to offer a favorable opportunity for cerebral apoplexy. Or, having passed through pregnancy safely, the physical strain of labor would tax to their utmost the cerebral blood-vessels. Hemiplegi'^ after an eclamptic attack is a fiuniliar illustration of diseased blood-vessels givintr way under sudden and extraordinary pressure. In the puerperium, on the contrary, the circulation at once becomes more quiet, arterial tension decrease*, and the danger of cerebral apoplexy correspondingly diminishes. This explan- ation of the relative frequency of apoplexy occurring during the child-bearing period is borne out by statistics. The increased relative frequency of cerebral embolism in the puerperiiun is to be found in the fact that sepsis, either as endocarditis or as phlebitis, is a factor of great importance in the etiology of cerebral embolism in ]>uerperie. The clinical features and prognosis of cerebral hemorrhage are in uorespdt If PATTTOLOnY OF riTE rrEliPEUHM. 791 ^ md disappear LIS explain inii; Tcr after labm- kidneys pre- tent of injury luritic retinitis lis antedatini: i)f vision may rarely tempo- vessels of tlie ind permanent labor. Serious I or by forceps, e blood in the iveloped duriuji . The liemor- dly requires no y astringent iu- the bladder is the use of the tulJB should not lerium. — Intra- fortuuately vory lium, A woman Ire likely to be time of labor. |he physiological iges of any prc- lity for cerel)ral liysical strain of ^emiplegi'^ after ■vessels givini: terium, on tlic msion deoroasi"*, ;. This explaii- lie child-beariiit!; le puerperium is |s phlebitis, is ii in puerpera'. Ivre in no resptct different from the disease as it appears apart from child-bearing, and therefore need no further consideration here beyond the statement that a paralyzed preg- nant woman can pass through her labor without her uterus sharing this loss of power. Cerebral embolism also has the sjime clinical manifestations in the puerpera as in others, its symptoms depending upon the size and distribution of the vessel involved, hemii)legia, monoplegia, or aphasia developing according to the trunk or branch of the vessel receiving the embolus. It should be borne in mind that paralysis in a pregnant or puerperal patient is sometimes, although rarely, hysterical, and a critical diagnosis should therefore always eliminate hysteria. Within a year the writer lias seen a case of hysterical aphonia in a pregnant woman whose mother was similarly affected. Immediately after laljor the difficulty at once disappeared. It is suggestive, as I^loj'd remarks,'" that a large proportion of reported cases of paralysis in pregnant women appear to be cases of aphasia. The diagnosis of hysterical paralysis is usually not diffi- cult when the inconsis^tency of some of the physical signs and the characteristic mental and moral symptoms are recognized. Hemianesthesia, more or less involvement of the special senses, the loss of voice rather than the inability to use words properly or to comprehend them, the presence in only slight degree of exaggerated knee-jerk and contractures, the absence generally of marked involvement of the face, of ankle-clonus, and of bed-sores, will at once arouse suspicion of the hysterical origin of the disease. Neural and Spinal Aflfections Following' Labor. — Various forms of l)aralysis are sometimes observed to follow labt»r. Frequently a transient loss of power in one of the lower extremities either is overlooked or is attributed to rheumatism or to unimportant pressure on a nerve-trunk ; the inconve- nience, it is thought, will soon disappear, and no further attention or treat- ment is directed to a condition that is by no means trifling, and one that in some cases proves a most disastrous sequel to childbirth. The etiology of neural affections following labor may be grouped conveni- ently in two general classes : {a) Nerve-injuries due to pressiu-e by the child's head or by forceps ; (6) Disease of the nerves due to septic infection. Of the first class, there is a type of cases, due to slight injury, with only l)artial and temporary loss of power accomijanied by some pain and discomfort, all of which symptoms disappear before the ])atieut leaves her bed, the enforced rest t)f the puerperium being sufficient for nature's recuperative power to effect a complete cure. This grade of injury is of not very great clinical importance. A very important nerve-injury following labor is one producing paralysis from traumatism of the sacral or hunbar plexus, this type of paralysis, as pointed out by Mills'^® and by Hiinermann,'^ being usually peroneal, and conunonly associated with severe neuritis. The great frequency of involvement of tiie peroneal nerve is explained by tlie anatomical situation of its origin. Tlie roots of the sacral plexus lie upon a cushion of muscle, but the lumbo-sacral nerve, arising from a portion of the fourth and from the fifth hunbar nerve, soon passes over the bony pelvic wall at the liuea innominata, where it is i *"^ w m # ■i f 792 AMERICAN TEXT- BOOK OF OBSTETRICS. exposed to injury by the cliild's licnd (Miloring the ])elvic inlet. Tiiis liiniho- sacral nerve is maiidy the root for the peroneal nerve, and clinically it iins been found that the paralysis of motion due to trauniatisin during labor is often a loss of power of the muscles supplied by this nerve. In other words, the type of paralysis in these cases is commonly an inability to dorsal-flex the foot, extend the toes, and evert and rotate the foot outward. Sometimes there is also inability to rotate the thigh inward and draw it forward — movements controlled by the superior gluteal nerve. This additional loss of power will lie understood when it is remembered that the superior gluteal nerve arises from the posterior part of the hnnbo-sacral cord, and is therefore sometimes atfecldl coinciidently with the lumbo-sacral cord or is secondarily involved by the sjjread of inflammation. In other cases the loss of power Ix^eomes more general, the inflammation in the nerves extending throughout the entire extremity, and even to the other limb, or along the nerve-trunks to the cord, attacking the ganglion-cells of the cord, with the development of trophic changes. The class of cases most likely to be followed by serious nerve-injuries from pressure are usually cases of jjelvic deformity, in which the injury is produced by direct pressure of the child's head. Ilimermami has shown that injuries jiiore f;e( len'.y follow labor delayed by a generally-contracted pelvis. In the simple flat and flat rachitic pelves then is more space in the oblicjue diameters, and the nerve-truidv is thus less exposed to pressure, the jn'ominent ])romontorv of the sacrum giving the pelvic inlet a j)ronounced cordiform shape, the hollow or bay to the sides of the j)romontory ofl'ering greater protection to the iierve- truidvs. Exceptionally these injuries may Ibllow labor when the pelvis is normal, but the j)resentation is abnormal — as a face or a brow ])rescntation — the abnormal prepentatii>n offering larger diameters and thereby increasing the area of pressure. Nerve-injuries are also sometimes to be attributed to forceps. On the one hand, failure to use the instrument in ])roper cases when labor luis been unduly j)rolonged, and on the other hand pivssure upon the nerve-trunks during extraction or by pendidum movement of the blades, are factors in the ])roduction of the injury to the nerve that sometimes follows a difficult forceps delivery. It is usually not easy to determine which is more to be blamed lor the injury received — the child's head or the forceps. To assist in determining this question Mills "^* has called attention to an important fact — namely, that the ])ressnre caused by forceps is more often followed by injuries of the second and third, and even lower, sacral nerves, and therefore the mus(;les supplied by the internal popliteal — the posterior muscles of the calf — are paralyzed, rather than the muscles supplied by the jieroninil nerve. Neuritis due to septic infection may manifest itself in protean types, just as is observed in neuritis due to any toxic agent: it may be multiple or diilused, or a single nerve may be involved; it may be partly or vhieHy in the upper ex- tremities. When the upper extremities are affected, the terminal branches of the median or ulnar nerves, or of both, are commonly involved, and both motor and sensory fibres are affected. In a case recorded by !^^(■)l)ius,""' in which the neuritis attackeil the legs as well as the arms, the tendon-reflexes were rios of the ^cooitd ■tin types, just as in tlio upper ex- linal bnuiolies of lived, aiul b'li'i lion-reflexes wi re I'Ar/ioLor.v OF the prERpKiin :,r. 793 aetivc, tlie interosseous muscles were atropliiwl, and both liaixls were the soat of a burning, priek in jr sensation. The cranial nerves were not aifected. Fever and other signs of infection were present. Not infrecjueiitly the predisposing causes of neuritis under other circumstances, such as alcoholism, svphilis, and exhaustion, are jn-edisposing factors in the development of se])tic neuritis fol- lowing childbirth. The lowered vitality and the depres,> .. nei'vous force of the puerpera render her nervous system an easy avenue for the inroads of sepsis. The symptoms of septic multiple, diffused, or isolated neuritis are not dif- ferent from the symptoms of neuritis from other causes. Pain, hyjieresthesia, paresthesia, and paralysis or pseudo-paralysis are commonly ])resent. Soine- tiines there is anesthesia, and often there are changes in the reflexes with cramps and contractures. Atrophies and the reactions of degeneration are occasionally present. As a means of differentiating traumatic from septic cases ii is noteworthv that the symjitoms of sejitic; cases usually appear in il. > first, second, or third week after labor, although they may occnir earlier or later. A form of neuritis following labor, of considerable importance and involving ])rimarily the nerves in the pelvis, is that sometimes recognized by the gyne- cologist a long time, it may be, after a labor that was followed by traumatism or by mild infection. In such cases there has been left in the jx'lvis inflam- matory exudate in which a nerve-trunk or nerve-filaments are iiid)edded ; bv reason of either the spread of infection to the nerve-slu'uhs or the constant ]»iessure of the exudate and the displaced pelvic viscera more or less pelvi<! pain and even loss of power are produced. Neuritis and paresis of septic origin are not infre(piently associated with septic phlebitis. The intense pain and the loss of power sometimes observed to accompany and to be a sequel of ])hleginasia alba dolens have been consid- ered due to the accompanying neuritis. The occurrence of gangrene in ])hlegmasia has also been attributed in part to neurotro])hic changes, and has i)eon thought to be not wholly the result of an occluded circulation. Septic myelitis has been observed to complicate or follow jihlegmasia and to give rise to a ])arai)legia. Paralysis of a greater or lesser degree following phlegmasia has been recorded by Mtuiriceau, Boer, Casper, an<l (Jittermann (quoted by Winckel). When the spinal cord is attacked by the ravages of general septic infection, tlie clinical and ])athological evidences of the myelitis commonly shv w very numerous and disseminated foci of infection. Paralysis of reflex and hysterical origin in the pnerperiiuu has been described by most authors. Ikrnes refers to the shock of lal)or, exhausting the spinal centres, as a cause of reflex ])aralysis, and (piotes nrown-Seciuard's belief that retroversion may also cause reflex paraplegia. It is probable that many of the cases thought to be reflex are in reality due to the extension of the iiifliunmation to the cord or are to be attributed to sepsis, the toxic agent reach- ing the nerve-centres and nerve-tracts through the circulation. • '''If ," ' ' M'lW: '■'■r'^; ^W ■ I «r . II IM WM mm 11 9i 11 , «i> |n 1 W[ /rl ^^H: 11 il: 794 A3IERICAN TEXT-BOOK OF OBSTETRICS. Altliongh liysterioul paralysis may readily occur in a puerpera, the profound norve-changes throughout pregnancy and in the puerperitim being sufficient t(i awaken functional disturbances in individuals previously predisposed tonervou> disorders, it should never be forgotten that organic disease may be present, and that a careful and scrutinizing examination may bring to light something more than hysteria. Treatment. — Rest in bed is of the greatest importance in the treatment of neural affections following labor, when, as is frequently the case, a greater or lesser degree of neuritis accompanies the loss of power. The pain should first be relieved by the appropriate treatment for neuritis — absolute i*est, alternat(> hot and cold applications, ointments of mercury and atropin, the interiiiil administration of sodium salicylate or salol ; the further relief of pain by phenacetin or, if necessary, by opium. Later, the iodids, and, after the pain has been relieved entirely, active electrical treatment and massage, should bo employed. Pelvic inflammation should be treated systematically over a suffi- ciently long period in intrapelvic cases. In all cases appropriate general treat- ment, including strychnia and quiniu, must not be neglected. Insanity in the Child-beariner Woman. — Frequency. — The statistics of asylums in which mental derangements have l)een classified as following repro- duction show considerable variation, due to a diversity of factors, such as nationality, social condition, reliability of history, etc., that cannot be analyzed here. It is sufficient to say that in from 8 to 10 per cent, of all insane females the disease develojied in the child-bearing process, and that, on an average, one woman of four hundred confined becomes insane. The disease declares itself most frequently in the puerperium, usually within the first two weeks (Esquirol 66 j)cr cent., Toulouse 75 per cent., within the first ten days), and in many cases prodromic symptoms have been present at some time during ])ivg- nancy. Next in frequency is the ]>eriod of lactation, at any time of wliich period insanity may appear, although it is usually manifested ton-ard the latter half. The insanity of lactation is more common in raultiparfe. The insanity of pregnancy, the least frequent of all, usually begins after the fourth month, and is of about equal frequency in multiparje and in primiparae. Ettoloffi/. — It is customary to classify the causes of insanity in its relation to reproduction as predisposing and exciting, and very many conditions have been arrayed as belonging either to the one or the other class. It should he borne in mind that in each individual case many factors are indissolubly asso- ciated, the patient's mental break-dowu being the resultant of several complex conditions, each reacting upon and intensifying the other". Of predisposing elements common to the three varieties of alienation under consideration, the most important is hereditary predisposition, which is funnd in from 25 to 30 per cent. Since this is about the proportion found in insanity generally, it is evident that heredity is not of greater importance in the puerperal forms ; indeed, some statistics show it to be of less importance. Of importance also are other neuroses, such as chorea, epilepsy, and hysteria. Alco- holism and the pre-existence of insanity are also frequently predisposing facturs. PATIIOLOay OF THE PrKRPERH'M. 795 .V woman with an iiiistuMe ntTvous py.stcm from any canse is haiulicapiiocl in her passage tlu'ongh the nerve-exaltations and storms that await her tlirough- oiit the eonrse of pregi'-.-ncv, lahor, and laetation. Individnal inhibitory power will have much to do with the Hnal issue, and if this power is not sufficient tf) withstand the varied determining factors of mental disease, insanity is to be expected. During pregnancy the most important exciting cause is probably tox- emia, y which is meant a condition of the blood st» surcharged with and changetl by toxic organic principles, the result of faulty metabolism and ex- cretion, as to render the bhxtd incapable of proper nutrition. In the pathol- ogy of pregnancy the great importance of tliese changes has been insisted upon (see ]). 202). The effect o*" faulty elimination of secretions altered in <|iiality and quantity plays an important rC)lc in the production of the unsta- l)le nervous system of pregnant women, and we are not, tlierefore, surprised almost invariably to find, i)receding an outbreak of insanity, constipation, inca- pacity of the liver to perform the work thrust upon it, and failure of the skin and the kidneys, with or without albumiimria, all of which certainly can and do induce faulty nutrition of the brain. Of less importance, but contributory more especially to the insanity of pregnancy, are moral factors, such as mental anxiety from domestic worry, desertion, or seduction. The exciting causes of insanity in the puerperal period have variously been stated to be sepsis, anemia, dystocia, post-partum hemorrhage, eclampsia, great exhaustion, and profound emotion, and in individual cases one or more of these causes is usually discov- erable. The employment of instruments and anesthetics during labor has not been included as a cause, for the reason that their more general employment without a proportionate increase in mental derangements, and their capacity to relieve the suffering which otherwise must react unfavorably upon the individ- ual's nervous force, seem sufficiently plain to consider them prophylactic rather than exciting factors. The relative importance of the causes just enumerated is difficult to deter- mine, a study of statistics furnishing but little light on the subject. The opinions of various authors are apt to reflect the class of cases they have indi- vidually seen, and as insanity, after all, is not so very frequent, an individ- ual's experience must be too small to warrant general conclusions. In recent years, however, the conviction has steadily been growing that sepsis bears a f:u* more frequent and important relation to the insanity of the child-bearing woman than has hitherto been thought. This statement, if true, is of greater significance to, and calls for closer attention on the part of, obstetricians than alienists, since to the former the immediate or remote results of infwition must aud should always have a deeper interest. If the toxemia of pregnancy is, as it appears to be, an important element in the insanity of pregnancy, how much greater ^vill be the tendency of an unstable nervous system to lose its equilibrium when, overtaxed by faulty excretion during pregnancy, there is tiu'ountered the additional strain of the puerperium, when the organs of excre- tion for a time have new demands upon them, aud when opportunities for septic Wm f-' m "'■■ i I *-"•-' ii^.'ia ttet 796 AMFJirVAX TEXT-nOOK OF OBSTETRICS. lui ^3. alworptioii, in size of'tlio doso and in tiic viruKjnce and intensity of the poJMiii, arc without parallel in the whole period of the ri'[)rodnctive function ! There are many faets to support the belief that sepsis is by far the niu>t important cause of the puerpei-al forms of insanity. First, let us study tlio statistics of recent years. In 58 cases Holm noted severe puerperal processes in thirteen ; Hansen attributed forty-two of 49 cases to infection ;'^" in 40 cass Clark observed eight with septicemia and eleven others with inflanniiatniv disease of the uterus and appendages."' Hansen places the proportion of toxin cases at 86 per cent.; Idanof, at 66 per cent.; Lallier,"- at 70 per cent. Olshausen in his classification of puerperal psychoses assigns the first place td the infectious types.'^ Menzeis remarks that most alienists allow that some jinerperal cases are of septic origin, and he furtiier says tiiat it is strange im one has ventured to assert that all puerperal cases are due to intoxication fioni either bacteria or toxemic organic compounds. Roiie''^^ asserted his belief that few cases of puerperal insanity occur without preceding or coincident puerperal infection. A close analysis of the symptoms and course of the affection gives addi- tional support to Robe's notion. From the fifth to the tenth day — the usual time of a])pearance after labor — is commonly the period in which sepsis is manifested. In unquestionable septic cases the simultaneous appearance of the mental and local disorders and the aggravation of mental symptoms that may have ])!•(■- existed are surely significant. Again, the largest proportion of cases are maniacal with elevated temperature. Clark '^' says : " Rarely was a case ad- mitted that did not exhibit uterine or allied symptoms of abnormal character, the most frequent being pain on ])ressnre in the hypogastrium, and scanty, extremely offensive lochia." ^Menzeis remarks that the improvement which follows when the lochia, having ceased, return ; the invariably delayed invohi- tion of the womb; the (piick production of anemia and profound blood-alter- ations with wasting; the benefit from purges; the widespread objection to o])ium ; and the imi)rovement from local uterine treatment, — all testify to the septic character of the disease and jioint to a primary blood-condition rather than a cerebro-cortical condition. He further believes that this poisoned blood can cause, in certain individuals of low compensation, changes in the chemical constitution of cells, by which changes nerve-energy is disordered and insanity is produced, the type and result being dependent upon the ])roducts of infiani- mation and the degree of their absorption. Pathological evidence is not wanting to substantiate further the septic oriuiii of the insanity of the pnerperium. As will be pointed out later, no distinctive pathological changes in the brain have yet been found to demonstrate satisliic- torily the etiology of the affection ; whereas, on the contrary, the pathological findings in the i)elvic organs of acute cases are almost invariably those of in- fection, and in chronic cases the remote results of sepsis are often apparent in old inflammatory pelvic disease. Autopsy-records for which the most scrnti- iiizing anatomical and microscopical investigations of the brain and the spina! cord have been made are frequently summarized, as in the case most minntily fl '.V. y of the poison, net ion ! by far the iiio~l let nrt t^tntly the I'penil processes n ;"" in 40 cums h infltunniivtoiy oportionot'to.\i(! at 70 per cent. :\ni first place to allow that sonic it is strange no ntoxication from lhI his belief that icident puerperal ction gives addi- v — the usual time psis is manifested. »f the mental and vt may have \)\v- tiou of cases arc jly was a case ad- Lnormal character, rium, and scanty, provemcnt which Iv delayed invohi- x)und blood-altcr- iread objection to all testify to the ll-condition rather his poisoned blood es in the chemicil hered and insanity Toducts of intlam- U' the septic orii:in liter, no distinctivi' luonstrate satisfac- }, the patholoiiical [•iably those of in- often apparent in )i the most scrnti- lain and the spinal ise most minut.'ly PATirOLOaV OF THE PVKRPFAilVM. t97 and carefully studied by Feist,''" in which case the brain-examination was neg- ative, while tlie spinal cord showed in the posterior columns the lesions pro- duced in this location by toxic agents. The writer is not aware of any extensive chemical or micro-chenucal investigations with the view of shedding more light on this subject, but recent advances in bacteriology warrant the belief that some (lay proof will be abundant of the universal belief that either toxenua or septic infection is a primary factor in all the psychoses of childbirth. As determining elements of lactation cases, anemia, prolonged lactation, repeated child-bearing, or other bodily ccmditions productive of exhaustion are most important ; and among these the remote effects of sej)sis also should have a i)lace. Patholofiy, — Numerous pathological changes have been found in the bodies of those dying with puerperal insanity, but, as has previously been stated, none ot" these changes offers a wholly satisfactory explanation for the morbid pro- cesses of the brain. Congestion of the brain and its membranes is usually found in the more active types, and in evident septic cases inflammatory cliangos with capillary eniboli have been observed. In other cases the brain- substance has been pale, and in some chronic cases its convolutions were shrunken. The evidences of anenna throughout the body were widespread. Si/mptoms. — The forms of psychical disturbance met with are mania with or without delirimn, melancholia, and dementia, the latter being the final stage of cases that become chronic. Mania and melancholia are the prevailing types, mania being the most fre(iuent type and occurring oftenest in the puerperiinn, and more often in lactation than in pregnancy. Melancholia is more connuon in pregnancy, at which jieriod active delirium is very rare. ImanUji of Pre(/nan('i/. — In a large proportion of cases of insanity of preg- nancv the alienation is of a mild type and is preceded by prodromal symptoms. The physiological changes in the nervous system characteristic of pregnancy are heightened. The alterations in disposition, the irritability of temper, the pecidiar whims, and the depression are often followed by a condition of high nci'voiis tension with loss of memory and of self-control, and after a period of insomnia the coiulition gradually merges through sadniss, distrust, and appre- lunsion into established melancholia. The patient becomes reserved and indis- ])osed to nnngle with her friends or her family, and i- 'li ;trustful of all around her. Reliir'jus or erotic impulses may develop, auvi : [I'trts at self-destruction may be made on account of an imagined unpardonable sin. This tendency to commit suicide calls for constant watchfulness. The patient may indulge in lewd and obscene language or may make improper overtures to male aciiuaintances. Active delirium occurs in rare cases. ItmniUy of Labor. — Every obstetrician has observed the varied capacity of ills patients to endure the agonies of childbirth, and there are but few who liave not witnessed, in individuals practically maddened by their supreme suf- fering, acts of nervous exaltation, which force the conviction that for the time mental inhibition is lost and that the ])atient is no longer responsible for her uds. Without previous indication for the use of an anesthetic the writer has m 798 AMKIUi'AX Tl':XT-It<)i>K ()/' OliSTiynilCS, ^ {< jlj (■ : olxsiTvcd, JIM (lid Ilcrvii'nx, a pationt rise siiddcnly from her hod, and witli wild screams attempt to jump from her hedroom window. In another ea.«i' the patient's lond cries of " Help!" " Mnrder!" hrou^ht to hand two otlireiN whose protection the writer was compelled to claim aijainst the fnry of ;iii ignorant hnshand. Usually anil fortunately, the insanity of labor (lisappe;irs after <lelivery. Its treatment should be the termination of labor by forceps or by version under anesthesia when labor is unduly delayed. Insunii}! of the Pucrpcniuii. — When the disease develops at tl k, delir- ium is common, particularly in the ca-sm occurring; early — before the four- teenth (lav. Here also there are in at least half the cases doselv observed prodromal symptonis during pregnancy. These symptoms may have l)etii overlooked, or the onset may arise with startling snddenness iiceompanied by sui- cidal or homicidal tendencies. Fever, which is commoidy present, may l)e viry high in severe septic cases. If the patient is maniacal, which is the most cmn- mon type, she is sleepless and violent and attempts to destroy those around licr. There are delusions and hallucinations. The ideas and language of the paticni flash from her with remarkable rapidity and incessant change. Now sensuous, oI)S(^one, profane, and making attempts at self-exposure, in an instant she in.iy revert to religions ideas, to indulge in prayer and the singing of hymns. In one case, that a an illegitimately pregnant colored girl of nineteen, the writer Wiis thought to be the Almighty, from whom the girl piteously bes lit i)ar(l(iii for her sins. The next moment, while counting her pulse, he w led upon with a frenzy from which he barely escaped, the patient, now terroi i/ed by iiis presence, believing him to be Satan himself, upon whom .she spat with fury. Within a very short time he left her singing a Sunday-school song, which was soon followed by word-pictures of obscene situations mingled M'ith revoltiiiij profanity. Melancholia in the puerperium occurs less fr(>quently than mania — usually after the fourteenth day — and it is very apt to be accompunied liy jiersistent attempts at suicide, re(iniring unremitting watchfulness on the part of attendants. Delusions involving freipiently the husband's fidelity, and hal- lucinations of sight and hearing, are commonly present. Insanity of Lactation. — Mania and maniacal deliriunj are c()mj>arativ('ly rare in this type of insanity. The patient is usually melancholic, (piiet, list- less, and depressed, with frequent delusions of persecution. In the later stagis the mental faculties are at a low ebb, dementia supervenes, and the patient can with difficulty be aroused from her listless, almost lethargic, condition. It should be borne in mind that any type of childbirth insanity may occur at any period of the child-bearing process. In the j)receding description an attempt has been made to give a brief outline of the .symptoms of the type most frequently met with in each period. A classification of the type iiidi- pendent of the periods of occurrence, very convenient and practical for closely studying the progress of symptoms in individual cases, is that made by Mcn- zeis,'''^ based upon the fact that any given case may pass through six stage- — namely: (1) Prodromal disturbance; (2) early delirium; (3) melancholia; (4) stupor ; (5) mania ; (6) dementia. & ! V. bed, iiml witli H unotlu'r CUM' lul two otVu'ti> 111" t'liry «)t' :iii ilmr (lis!»i)|M'iirs )!• by t'orcL'p.s or tl !>., (U'lir- M'tbrc the i'niii- •losi'ly obsirvrtl miiy liavi! been mipaiiii'd by ^iii- nit, iniiy lu- vny IS the most i-niii- hose iinmiul In r. iro of the patient Now sensuous, instant she lu.iy r of hymns. In iieteen, the writer bes lit pardon w: led npon terroiizcd by liis e spat whh fury. 1 sonj;, wliii'li was d with revolting: ently than mania \ aeeonipanied Il- lness on the part fidelity, and lial- ire comparatively |eh(die, (piiet, list- n the hiter sta,u;e?* hd the jiatient ean Icondition. isanity may oeeiir |i<>; deseriptioii an ^toms of the type »f the type inde- kietical for eUisely it made by >b'n- )Ugh six staiTc-— (3) melancholia ; j'A'n/()ij)(,y or riit: rrKumurM. •})!» IHot/noniH. — Usually tiiere is no ditticiilty in re<'oj;nizinjf tiie various w^wh of in.sanity in the chihl-lM'arinf^ woman. The deiirinm of fever or delirium iremensi'omplicatinjj the pnerperium mip;ht otter some diflicidty at the onset <if the symptoms. In the former ease it will sometimes be necessary to wait for the decline of the fever before rt'achine; a definite conclusion, and in the latt«'r the history will go far towarti clearinj^ away any doubt. I'votjtwH'm, — As a ).M'neral statement, it may be said that alH)nt two-thirds of all eases recover within five or six months; of the other third, from 2 to it) per cent, die from septic; inlirtion, exhaustion, or intercurrent diseases ; the rest remain permanently insane. Viewed with reference to the period of oc- currence, the in.sanity of the pnerperium, particularly the nearer to labor it oanirs, shows the largest perc^eutage of recoveries, while that of jircguancy is least favorable, excluding from the latter the very mild cases of early |»regnancv in which the symptoms are merely an aggravation of the ordinarily considered physiological changes of gestation. In Mcnzeis' cases the recoveries were as follows: In pregnancy, 4.'i..'J j)er cent. ; during the pnerperium, 75 per cent.; during lactation, 50.5 ])cr cent. Melancholia is more favorable than mania in pregnancy, while the reverse is true in the jxierperiuni. The type of the disease, however, i of as great importance as the ju-riod of its oc(;urrence. The life of the patient is in greater danger fmm mania, while lier mental faculties are more likely to be disabled or ])ermancntly lost from melancholia, in which type there is also a longer duration. Again, the older the patient, the greater the number of pregnancies, and the more depression with extreme rapidity of pulse and persistent eleviition of tem- perature, the graver is the prognosis. Intemperance also adds a risk to the dis- ease. In cases clearly dtie to infection and in those in which hereditary predis- jKisition to nervous disease i> largely absent the duration is shortest and the outcome is most favorable (Toidonse). When eclampsia bears a causal relation to the puerperal form the prognosis is distiiuitly more favorable, the patient recovering sooner than in any other variety (Hop])c)."^^ The causes of death in fatal cases, apart from sepsis, which certainly is found in a large propor- tion, may be intercurrent or pre-existing disease, esiiecially of the lungs, the kidneys, and the heart. Acccu'ding to iMenzeis, tubercle is found in one-third (if the cases, not so much arising from family predisposition as from Ibllow- ing a traumatic pneuinoina due to fi)rced feeding and stupor. Trcatmciif. — It is generally agreed that practically all cases of puerperal insanity should be asylum patients ; that as such even the milder cases are hotter cared for, and that convalescence! is more raj)id and complete, is the helief of most alienists. An additional reason for asylum treatment is finnid in the fact that even these milder forms may develop into graver ones with nnexpected suddenness. When delirium and suicidal t)r homicidal tendencies are present there is no adecjuate security to the patient, her fanuly, or her attendants outside the walls of an asylum. Contrary to the bestadvice, the family and friends often insist upon keeping tile patient at home, and are unwilling to be instrumental, as they say, iu en- ii'l, wk l! Hi -.p m mm'- i I:. I'c' 800 AMinucAX Ti'LYT-itooK o/' oiisriyriiics. S '(|. Wi .\l graftinf:; upon (he piiticnt's t'litiiri! existence tlu; popular and unlortunate sti<;iii;i tliat attaches to the briefest sojourn in a hinaticasyhini. Therefore it has been thougiit appropriate to outline briefly the in<lications in inanagin<r these case-. Skilled attendants with experience in carina; for insane patients shoidd al\\a\ s be secured. Absolute rest, (piiet, and isolation must be obtained, and even MUMubers of the ininicdiate family should not be pennitted access to tiic patient. As the treatment of insanity ffenerally is larifely symptomatic, so in tin' cliildldrth form measures directed to the improvement of the {)atient's ticncr.il condition Jire to be i'mpl(»yed, ton'cther witii special treatment for symploins and complications tiiat may be ))resent in individual cases. The j;cncrai tnni- ment is all-important. Its aim shoidd be, first, to correct disordered s.atcs n| the hepatic! and •^astro-intestinal functions, so connnoidy present, in older lo ensure the proper di<;estion and assimilation of fotHl. An opcniniij enema, ful- lowed by courses of a mercurial with a subsecpicnt saline, is <;enerally the I'oiiiiiic beginniuii- in asylum practice. I'roper and snHi<'ienl food, usually liipiid and often predin'csted, (on'cther with moderate stimidation, is of paramount impcut- ance. The (juanlity of stinudants to be employed in individual cases is \n-\ determined l»y principles similar to those which jiovern their use in "typlidid" states. Forced feedini;' by the esophageal tube shoidd be resorted toonly wIkm al).-<olutely necessary, and it may be replaced at intervals by nutritive eneinaia. The almost constantly associated dei»raved condition of the blood clearly call^ for the use of iron and arsenic, which may Ik' given in the form of iJlaml's pills and Fowler's solution. The C(Mnbination oi the "four chlorids" is a particularly valuable pre|)ara)ion. Often there must be selected preparations of iran that are least likely to disorder the gastro-intestinal secretions, sncli as the all)iinnnates, Nerv(!-sedatives are not to be used indiscriminately. Xiiiri- tion is the indication, not sedation. Hromiils are of little value exce[)t in casc^ in which liysteiia of sthenic type is pronnnent. ( )pitiiii in any forni is generally not to be employed, ♦■specially on account ot" its action upon the se; reiinn^. Wiieii it is necessary to j»rocure sleep, alcohol, chloral, or |)araKlehyd is pntrr- able. To reduce high temperature, (|innin and cold, the latter either as a pack or as a bath, are to be employed. In view of the growing belief that pelvic iidlammations of septic oiigin arc of greatest importance in the etiology of the puerperal forms of the diseax', a earelid study of the uterus and its appendages should always be made in this class of cases, and usually local antiseptic treatment is to be employed, (lark remarks: "In no class of e;ises is gyneccdogical investigation of more ini|Hiit- ance tiian in the study of puerperal i?isanity." "" In many cases opcraiivr means will aiford relief and even cure — a (act urgently insist(<l upon by luilir."" Sucii radical treatment, to accomplish its best result, nmst not be delaycil imi long. Tiiat it is pnu'tically futile to remove old diseased appendages for llir permanent ri'lief of long-standing nervous alVections is an axiom begoldu >A' desperate struggle between gynecologists and alienists. When tlu' milk-secretion has not disappeared spontaneously, mcasiiics S'. irtiuuito stigma ore it lias httii inn tlu'sc rase-. should always iiicd, ami cvrii access ti» tlif uatic, si» ill tlir Kitioiil's liciicral L fur syiuplniii- lio jicncral trcul- )r(lcro(l slates <it ^t'llt, ill order lo "iiinsj; ciuMua, l'"!- cndly till- niiiiiiii' sually liquid and ininiouiit iiiipcrt- Uial cases is luM use in " tyi»li«>i«r' rtcd to only wluii lutritivc ciicmata. )lood dearly ealU > iorni oi" lUaiulV nr dilorids" is a led |>irparatioiis di' rcrelioiis, siidi -.1^ iniiiately. NnH'i- cxcept in ea-c- "onu is jrcniMally on the secretions. ■aldehyd is pivlrr- atter either as a >t" septic oi'i;j;iii aiv IS oi' the disea-r. a vs he made in llu< Mnployetl. t'liii'li n of more inii«nit- nv cases operaiivc 1 i> 1 • 11' «l upon by Ivolu'. not he delaye.1 t^" ippciida;j;es for tlio axiom heootf" el" PATHOLOdY or Tin-: /'('/■: /{/>/■: /{KM. KOI h lineoui dv, iiieasnir: should at onco ho taken to accuniplisli this end, and watchful care must he exercised to prevent the occurrence of mammary ahscess. While the patient is kept in bed the j^jreat liahilily to the formation of hed- -ores siiould he home in mind, and ell'ort.s shoidd l)e made to prevent tiieir (leeurrence. In chronic; crises, and in acute cases after the suhsidence of urjrent symptoms, out-door exercise in the company of a watchful attendant should he insisted upon and he jjraduated to the patient's streiiffth. Acute Tympanites. — In neuroti<i women enormous accumulation of ilatiis is sometimes ol).served in the puerperium. The distention ^>i' the ahdomen may not only occasion preat distress, hut, wdien it is actiompanicd hy complete l>aralysis of the mr.scular coat of the howel, with persi.stent vomitinji; and obstinate (foiistipation, such as are seen in intestinal obstruction, there is also imminent danfjer to tin; patient's life, a ermination of which beiiij; avoided l>y most active treatment of the condition. It should bo remembered that this acute paralysis of the intestines occurs without any sifijns of peritonitis or other evidences of iidection, tlu; symptom apparently beintii; due to a purely nervous influence. Fiarfje doses of strychnia administered hypodermatically are indi- cated, and, should the |)atient's distress not promptly be relieved hv rectal injections of asafetida or hy the introduction of a rectal tube and by the ap|)licatiou of a firm abdominal hinder from the trochanters to the; ribs, llie larf;(! howel may he punctured thronjfh the abdominal wall, or the al)domeu may be opened and the intestines Ik; incised and .stitched at several point.«. IV. Rapid or Sudden Death in the Puerperium. No accident can hajtpen to a woman that carries with it so much horror as rapid or sudden death at any period "f the jinerpcrium, nnd no physician, however p'oat his reputation, can c.scajM' the criticism which invariably follows oven when this accident is absolulelv bevond his control, ile should always know the causes of rapid or sudden deatii in the puerperium, and by explain- intj the utter impossibility in most ca.ses of foroseeiiifr or eonibatiii}i; the; <lealh he can partially avert unju.st and unkind criticism. It is desirable in this work to omit the detailed histories of cases of sudden d«'ath that have been recorded in the literature of obstetrics, the most important causes of this accident oidy heiiiff hero eniunerated. The eau.ses of ra|>id death may properly be .separated from tho,so of .sudden death, since nipid death will usually be preceded by an accident or j<;ravo di.seasc; which will tiuible the physician to foretell the probable c. currence of death, while sudden death conies with a lij;htninji-like stroke and without a moment's waruiu}; to a patient often previously enjoying apparent health. The eau.ses of rapid dcaih in the puerperium may be any of th<' follow- ing : Accidents of labor, such as hemorrha^t! and shock Ibllowiiifj placenta [inevia, accidental or |)ost-|)artum hemorrhaffc, rupture or inversion of the uterus; rupture of a hematoma situate<l either externally on l!ie vulva or within the pelvic cavity; rupture of peritoneal adhesions or of a broad li<:;ament or an in ii| i:-| J H' ;) ,!■ 802 AMERICAN TKXT-JiOOK OF OBSTETRICS, ovarian vein ; acute i)urj)uni liieniorrliagica ; ecrcbral embolism or apoploxv ; liomoptyj^i'^ ; i)re-exi,sting diseases of the respiratory or circulatory system sd grave as not to withstand the strain of labor, which is followed by extrciiif exhaustion and rapid death. Analyses of the recorded cases oi' touJdoi (Jcntli include the following causes : Heart failiu'e which has residted from rupture of the heart due to fatty degen- eration, to a patch of Hbroid degeneration, to ai'Ute myocarditis. kSuddcn arrest «)f the heart's action has followed a primary thrombosis in the right side oC the heart, the thrombus extending into the ptdm(»nary artery, or more fre- quently the cause of death has been embolism of the pidmonary artery. Rupture of a cyst in the auricular septum of the heart, of an aneurysm, of the auria itself, and an attack of angina pectoris have can; lunediate death. Mental emotion, such as a [)rofound impression of sorrt. ^ of joy, of anger, of exag- gerated shame, of excessive pain, or of fear, has caused sudden death by pro- ducing syncope, tiie heart's action being interrupted by energetic and persistent excitation of the inhibitory nerves of the heart. Sudden death has followed the entrance of air into the uterine sinuses; a faUil ease has been recorded from embolus of fat from the pelvic connective tissue, and <li'ath in the piier- ]>eriinn has followed rupture of a giistric ulcer and of a liver-abscess. Tlie most fre<i|uent causes of sudden death in the |)uerj)erium, arranged in the order of their relative freepiency, are embolism, entrance of air into the uterine veins, and heart failure, due usually to organic disease. Embolism and Thrombosis of the Pulmonary Artery. — Some authors — notably Playfair and Jiarker — insist that primary and spontaneous coagulatietii of the blowl in the jndmonary artery occurs, and they attribute this accident in the puerperium to the excess of fibrin and water in the blood, to hemorrhage, to syncope and the diminished ibrceof the blood-current, and to the quality of the bhxxl changed by ettete materials, by sepsis, or by blood-dyscrasia. On the contrary, other writers favor the notion that embolism usually, if not alwiiys, j)recedes the occurrence of throndwsis, and they support this belief by the uncer- tainty of the pathologist's knowledge of a primary throndiosis in the right side of the heart and in the pulmonary artery, and by the iacts that in aiM.iit luilf of the eases a pcripiieral thrombus has been demonstrated ; that the accident commonly occurs after dislodgement of a peripheral thrombus in either a fcinoriil, an iliac, or a uterine vein following a sudden etlbrt,such as assuming an uprigiit posture, laughing, straining at stool, the administration of a vaginal itr an intra- uterine douche, etc., any of which ciforts do not cause thrombosis, but niiiy hxisen a thrombus; and, finally, that thrombosis of the pulmonary artery simnld occur more freepiently, since the asserted predis|)osing causes are so conirnonly observed in the jHierperiuni. It is certaiidy true that in many recorded antdp- sies, when thrond)osis has been found in the pidmonary artery a scriitini/Ini: .search for a peripheral thrombus has not been mentioned. Whenever iiii autopsy is made, as should always be done upon a woman dying suddeidy in the jnierperium with symptoms of pulmonary obstruction, a most careful search for a peripheral thrombus should never be neglected. PATHOLOGY OF THE PUERPERIUM. ':o3 lUv, if not al\\lly^ 1 tluit in uUuut halt' tliilt tlio accident liiicitliorarciiKMai, jsnminii; an u|)ri,Ldit laiiinal <»r an iiitra- mibosis, l)nt may ary artery siioiiM HIT so conmioiily V recorded aiitdp- I'terv a serntiiii/injj; d. Whenever an Idvin"" suddenly in Prognosis and Diagnonis. — When a larji;e-size(l thronilms ohstniets the pulmonary artery, death may be instantaneous, or it may he preceded by pre- rordial oppression, great fear of impending death, extrenie dyspnea, cyanosis, and a raj)id loss of body-heat. The iieart's action is violent ; the pulse is small, rajjid, and irregular. Sometimes a niurmin- is heaid over the orifice of die pulmonary artery, and in one case the patient was able to breathe belter lying prone; in another case respiration was easier in the supine posture. In other eases, if the end)olus is small the onset oi' symptoms is not so sudden, and the symj)toms are similar but not so severe, in which «'ases death mav occm* alter several days, or V(!ry rarely recovery may follow. From a study of twenty-five cases IMayfair conchuh'd that when the accident occurs before the nineteenth day of the puerp(M-ium the obstruction of the pidmoiiary artery is most likely due to a ])rimary throndxjsis; after the nineteenth day, to end)olism. Treatment. — Little can be done for an accident so grave as obstruction of tiu; piduKmary artery. The patient should be kept absolutely at rest, and stim- ulants, including the carbonate of ammonium, shoidd be administered. Pro- phylaxis is of far greater value. Early exertion on the ])art of the puerperal patient nmst always be avoided, especially during and after intra-uterine manip- ulations, and especially when phlegmasia exists; and massage for the latter disease, as frequently advised during the stage of convalescence, nmst be under- taken with the greatest caution. Entrance of Air into the Uterine Sinuses. — Although exp(>riments upon animals have shown that the direct injection ol' large quantities of air into the circulation is not fatal (Hare), the clinical evidence of deaths from this cause in ()l)stetricai and surgical practice is incontestable. liaiilVs'^' collected 43 cases (if death following air-embolism in the uterine veins. In seventeen cases the entrance of the air was caused by injections into the birth-canal ; in eighteen the entrance of air into the uterus was sjjontaneous ; in eight gas was formed ill the uterus. Post-mortem examinations proved the i>resence ol air in thirty- ()ii(! of the 39 fatal cases. In the reported cases of sudden death from a large quantity of air entering the veins of the uterus death occurred immediately or within twenty-four hours after delivery. J'Jtiolof/i/. — From experiments and from observation of cases it is believed that air very rarely enters spontaneously into the veins of the uterus, and that to cause speedy death the quantity of air must be (!onsiderable and the air nmst inter the eireulation with fierce, as may happen during uterine contraction when the air has entered and the cervix is obstructed by the placenta or by a clot. The entrance of air into the uterus is elfected during intra-uterine manipulations, siieli as the introduction of the hand; the giving of an intra-utcrinc douche ; by aspiration following a change in the posture of the patient. It has been !issert(;d that air may be aspirated into the uterus by the movements of ordinary respiration (.\niussat), or that its presence in the uterus may be due to decom- piwitiiMi (Churchill) or to alternate contractions and relaxations of the uterus following delivery (Simpson), Winekcl '^- mentions a case uf air-embolism and sudden death due to carcinoma complicating labor. 804 AMERICAN TEXT-BOOK OF OBSTETRICS. ;.t. m I Symptoms. — There may be difficulty in breathing and a temporary loss <if consciousness when the quantity of air entering the veins is small ; whoii a large amount rapidly enters the veins, respiration and circulation are immedi- ately and desperately embarrassed ; the patient may utter a cry of alarm, anil at once becomes unconscious with or without convulsions. The cause of doatli is probably mechanical interference with the circulation. Ti'catment. — Very little can be done for the patient even when assistaino is close at hand. The cervix should be cleared of clots; artificial respiratidii and the hypodermatic administration of stimulants should promptly be em- ployed. Tracheotomy and the inhalation of oxygen gas in order to inflate tlie lungs and to expel the air-emboli have been suggested. REFERENCE LIST. f'i '.•'< 1. Cornil : Cenlralblatt fiir Gynukoloyie, 1889, 21. p. 223. ' 2. Clivio and Monti : ibid., 1889, p. 245. ' 22. 3. Liistig: ibid., 1889, p. 246. 4. Biimm : ibid., 1889, p. 723. 5. Mironow: ibid., 1890, p. (J79. 23. 6. Doyen, C'ushing : ibid., 1889, p. 246. 7. Doderlein : ibid., 1891, p. 39. 24. 8. Bumm: il)id., 1891, p. 1036. 25. 9. Harold C. Ernst : American Si/stem of Ob- 26. stetricH, Phila., 1889, vol. ii. p. 427. 10. Oliver Wendell Holmes : Easay on Puer- per<d Fever n.s a Private Pestilenee, Bos- 27. ton, 1855, originally printed its an article on the "Contagiousness of Pner- 28. peral Fever," in the New Eiigtaitd Quar- terUj .Jourmd, 1843. 29. 11. Semmelweiss : Wiener ZeitKchrift, Dec, 30. 1847 ; Sclimidt's Jahrbiicher, 1848, vol. Iviii. p. 196. 12. Cliius. I). Meigs : Woman, her /)(Vo.sc<s and 31. ItemedieK, 2d ed., I'liiladelphia, 1851, p. 608. 13. R. P. H(arris) : American Journal of the 32. Medical iScienre.i, April, 1875, )>. 474. | 14. Sir^dey : Leu Maladie-i puerperulc^, Paris, 1884, p. 99. 33. 15. Cenlralblatt fiir (ij/niikolof/ie, 1891, p. 797. 16. Sir^dey : Leu Maladies pnerperalex, p. 98. 34. 17. Archiv fiir Gynlikologie, 1888, vol. xxii. p. 433. 18. Carl Braun : Centralblatt fiir (hjniikologie, 1889, vol. xiii. p. 636. 35. 19. Bumm : Centralblatt fiir Gyncikulogie, 1889, p. 723. 36. 20. Depaul : De la Fihre puerperale, Paris, 1858, p. 31. C. S. Credd : Archiv fiir Gymikologie, 1S,S4, vol. xxiii., No. 1, p. 77. Buscil : Netie Zeilachrift fiir Geburl-ikiinde, vol. xxxii.. No. 3; Schmidt's Jalir- bilcher, 1853, vol. Ixxvii. p. 40. Bunmi : Centralblatt fur Gyniikoloyle, Iss',), p. 724; Doderlein: ibid., 1891, p. tl',1. Doderlein : ibid., 1891, p. 1020. Mironow: ibid., 1890, p. 678. H. A. Kelly: "Hand Disinfection," .limr- lean Joanud of Obstetrics, 1891, vdl. xxiv.. No. 12, p. 1415. Doderlein : Centralblatt fiir Gyniiknlniiu-^ 1892, p. 214. Barker : The Puerperal Diseases, 4tli edi- tion, 1878, p. 476. Gazette de.'< Ilopitaur, 1866, p. 151. Semmelweiss : Die, yEliolocjie, der liciiriif, und die Prophylaxis des Kiiulbeltliilniy, Wien, 1861, p. 3. Billet : De la Fitfvre puerperale el il,- h Eeforme des Maternites, Paris, \f<li, p. 59. Die Arbeiten der Puerperallivber-('niiiin!i'- sion in Berlin, Stuttgart, 187s, pp. 28, 81. Ehlers : Zeitschrift fiir Gebiirtsliiil/r mul Gyndkologie, 1889, vol. xvi. p. I')!. E. Ingerslev : Comple remlu des Tivntit/ de la Section d' Ohstetriipie et de (iijiii- cologie de la Huitihiu; Sessuin dii ('(iii<iii.< tnteriMtiomd, 1884, p. 106 et .vc*/. A. Hcgar: Centralblatt fiir Gyiiiil.ulniili', 1890, p. 629. Garrigues . Transartion.t of the .{iinrmiii Gynecological Society, 1885, vol. x. pp. 96-116. REFERENCE LIST. 805 iiporary loss (if small ; when a ion are immcdi- y of alarm, and e cause of death when assistance ficial respiration >romptly bo cni- der to inflate the nd Diseasen, 4tli eili- 18()fi, p. l-')!- JEtuibvjii', (kr Ih'ill w des Kimlhetlliiliirf, re puerpemle <( ''> I" ternilh, Paris, If^T'J, ''nerperalfifber-Cdinini.-'- Stuttgart, IKTS, pj.. fur r,eburtshiilf<- ""<' 1), vol. xvi. p. -l''!- l)(,. rendu (/ex TraMiu ^hxtctriqite it <li' '.'i/"t'- fhiie Srmiiii ''" ' "".'/'■'■•' 4, p. lOli el .■"■'/. tb/(i« /iJi- fli/'i'f /."'"'/'■'•. LoH,s «/ Me .lm.nV(r« lely, 188.J, v.-l. ^. !'!'■ 'M. A. Stadfeldt: Des MalernileH, Copenhof^en, 1 187ti, p. 12; IJischoH': Znr I'rophi/kuin • des I'uerpendjiebers, JSusul, 1870 ; lliind- scliin : C'enlndblutt fiir (ii/ndkotogie, 1889, vol. xiii. p. 828. :i8. Stadfeldt: loc. cit. ; Eiirendorfer : Areldv fiir (ijjndknIiH/if, 188(i, vol. xxviii. p. 193 ;19. II. J. Garrigues: "Corrosive Sublimate and Creolin in Obstetric Practice," ylmmcan Jourmd of the Medieid Sciences, Aug., 1889, vol. xviii. pp. 109-128. ■10. Abegg and Menge : Ventralblatt fiir Gyna- k-olui/ie, 189.S, vol. xvii. p. 980. U. Bumm : ibid., 1893, vol. vii.. No. 42, p. 975. 42. Adrian Schucking; ibid., 1877, vol. i. p. 33; Sclirader: ibid., 1893, vol. xvii. p. 379. 43. Pippingskjold : ibid., 1891, p. 680. 44. Schrader : ibid., 1893, p. 379. 4.}. Bumm : ibid., 1893, No. 42, p. 975. 4(1. Frank: ibid., 1893, p. 978. 47. Kroenig : Md., p. 979. 45. Koland: Md., 1891, p. 30. 411. Frank: ibid., 1893, p. 978. 50, Zweifel : Archiv fiir Gyndkologie, 1885, vol. xxvii. p. 315. ol. Binz : Grundziige der ArzneimiUellehre, ^t- lin, 1874, p. 109. .")2. Baclie McE. Emmet : New York Medical Record, March 19, 1892. 53. II. J. Garrigues : "The Opium Plan in Puerperal Peritonitia," New York Med- ical Journal, Jan. 24, 1885, vol. xli. p. 98. 54. liottschalk : Centralblalt fiir Gyniiknlogie, 1889, p. 554. 55. Frank : ibid., 1893, vol. xvi., No. 42, p. 979. 5ti. Knnge : Archiv fiir Gyniikolngie, 1888, vol. xxxiii.. No. 1, p. 39. 57. Maury : Medical News, Oct. 3, 1891 ; Outer- bridge : New York Jouriud of Gynecology and ObMetries, April, 1892. 58. Bnrchard : New York Medical Journal, Aug. 15, 1885. 51t, Thierry : Centralblalt fiir Gynakologie, 1893, vol. xvii. p. 1518, from Lyon Medical, June 26, 1892. 60. Parvin'B Science and Art of Obstetric.^, 1886, p. 532. (JI, .Miinchener medicinitche Wochenschrift, 1888, p. 653. 0'.', Zeihehrifl fiir Gelmrt.'<hiilfe, Bd. ii. p. 225. tin. Siinger: GeA.fiir Gyndkologie zu Bonn, Bd. iv., 1891, p. 333. •14. Archiren de Tocologie, 1891, p. 81. 05, Loc. cit. 66, Ceutralblatt fiir Gyniiknlogie, 1894, No, 21. 67. Mediciiiiache JahrbUch, iii. 887. 68. Puerperal Convalescence and Diseusen of thi Puerperium, New York, 1886, p. 79. 69. Centralblalt fiir Allgenieine Pathologic u. patliologische Anutoniie, Bd. ii.. No. 1, 1891. 70. Berliner klinische Woehenschrift, No. vi. 71. American Journal of Obstetrics and Disea.'(ei of Homed and Children, May, 1895. 72. Archives de Tocologie el de Gynecologic, 1891, xviii. p. 28. 73. Pathologic u. Therapie des Wochensbell. 74. Holmes: System of Surgery, vol. iii., 1883, p. 435. 75. Journal of Anatomy and Physiology, Lon- don, 1890 and 1891, p. 304. 76. Thise de Paris, 1894; Contributions A V Elude de I' Allaitment maternal, 77. Miiller: Handbuch der GeburlshiUfe. 78. Diseases of the Breasts, London, 1894, p. 544. 79. London Lancet, vol. ii., 1889, p. 12. 80. Davis: "The Preventive Treatment of Mastitis," Ajnerican Journal of Obstetrics, vol. XXV p. 476. 81. American System of Obstetrics, vol. ii. p. 380. 82. Velpeau : Traite des Maladies du Sein, Paris, 1854, pp. 15, 16. 83. Munchener medicinische Woehenschrift, No, 25, 1888. 84. Pathologien, Therapie des Wochenshetl, 1878. 85. Inaugural Dissertation, Heidelberg, 1889. 86. Zeitschrifl fiir Hygiene und Infeclionskrank- heilen, Bd, xiv., 1893. 87. Loc. eil. 88. Archiv fiir Gyndkologie, Bd. xxiv., 1884, S. 262. 89. Tliise de Paris, 1891. 90. Ijoc. cit. 91. Fortschritte der Medicin, Band iii. S. 231. 92. Satnmlung klinischer Vorlrlige, No. 282, 1886. 93. C'orscn: "The Trealment of Miimtnary Abscess," American Journal of ObHlelric", Jan., 1881. 94. American Journal of Obstetrics, vol. xxvii. p|). 58, 414. 95. Berliner klinische Woehenschrift, 1888. 96. Virchou's Archie, Bd. cxxvi., Oct., 1801. 97. Ilamniarsten: Physinlogienl Chemistry, translated by Mandel, New York, 1893. 98. Lnneet, Nov. 15, 1800. 99. Archives of Pediatries, vol. i., 1803, p. 199. 100. Koating's Cyelopa-dia of the Diseases of Children, arti(4e by T. M. Uotcb, vol. i. p. 275. t, i* '^ fi li • AAflJllICAN TEXT- HOOK OF OliSfETUIC^'. 80G 101. Gy6(t>/iszut, 1892, Xo«. 48,40. | 122. 102. Atrhiv /. Kinda-hiilkundc, M. xiii. II. 1 mid 2. 123. 103. />()<•. <(V. 124. 104. I'hiiinKinl, 1S92, M. vii. ji. 491. 10"). (iitzrtle lie Gi/iicciihxjii; I'siris, Fi-b. 15, 125. 1S91. lOli. Zt'ihchrifl fiir Ifuf/inic and fnfniuiiinkmnk- 120. hcilni, 1S93, li(i. xiv. pp. 207-249. 127. 107. riVc/ioicV vlir/iiV, No. 12ti, 1.S9I. 108. I'mr/er mcdieitiiiiirhe Wnchcmrlirifl, KS90, p. 128. 279. 129. 109. lirritf dfs Sciiiices mrilical, July, 1894. 110. l\'!<lir mrdlriiiiKchc chintrgiselw PrexKe, Bii- | 130. (lapust, 1890. ' 131. 111. Kditorial in Indian Medical lieroid, ,]n\y, 1890. j 132. 112. ll'iViKT klinischr Wochennchrift, Xos. 51 and 52, 1888. I 133. 113. Aiivard: Accoiirhcmentx, y>. ^iu. 114. Tniifr (/(' Midddien dc la GromteMC ct dc ' 134. Siiilen de Couclny, Paris, 1894. 115. Mi'dical /V(W and Circular, May 9, 1888. 13,5. lit). Gaztllc de Gynirnloyic, Paris, Fel). 15, 130. 1891. 137. 117. Olmlilrir Medicine and Siiri/rnj, vol. ii. p. 138. 470, 18S.5. 118. Archives dc TocoUxjie ct de Gijnecoloyic, 139. sviii., 1891. 140. 119. Miiller, Ilandbuch dcr GcburUhiUfe, vol. iii. p. 533. 141. 120. Miinchc'r. ,.:■■>. Wochenschrift, March 13, 1894, p. 204. 121. CiMilis: fis Htioloi/ij, PatholiH/n, and Treat- 142. meni, liorlin, 1890. | Anmdcx des Maladlcx des Orijanes f)cnilii- urinaircti, .\pril, 1H93. Ccntralhlatt filr Vhirunjie, No. 27, 1893. Zeituchrift f. Gehnrl. uml GyniilKolofiie, I!;iiii| .\.\x. Holt 1, 1894. American Syntem of Ob.-iletrici', vol. ii. |. (i28. Unirernity Medical Mayazine, 1893. Archie /lie (lyniikolayie, vol. .xiii,, IS'.i'J, jiart .3. /,()('. cil. Miinchener mtdicinische WochenKchrij'l, Nd. 14, 1890. MiilU'r's llandbnch. American dimrnal itf Medical Science, Vdl. xxxiii., 1893. Nourcllcs ArchiecK d' Obstctriqnc et de (iijnf. coleiyie, 1893. Zeituchrift filr Gebnrtnliiiljc and Gyniikaldiiie, 1891, p. 371. Jimrnal of the American Medical Ai'.-'nei- ((//()», .Inly 19, 1892. IjOC. cil. Vin-iiow's Archie, Hd. cxxx. p. 453. American Journal of Iniianily, Oot., ISIt:!, Archie fiir PKychialric nnd Acrrcnkninh- heiten, xxv., 1893. Loc. cil. Journal of the American ^fe(lic(d As^ioci- atwn, July, 1892, xix. p. 59. Ueber Kintritt ron Luff in die I'eueii iln- Gebiirmutler bei und nach der Gehnrl, Bonn, 1885. Text-Hook of Midwifery, AnuT. id., IS'iO, p. 543. a Oryitne.i (j!'n\li>- tMfli-iiv, vol. ii. I' V. THE NEWBORN INFANT. T. PHY8I(^L(XiY OF THE NEW-P.ORN INFANT. W 1 mi Wor.hemchi-ij't, Ni rii, AnitT. id., ISIHI, TliK pliysiolojjy of the now-born infant diil'ors in many ossontial rtspocts iVoni tliat of" tlio adnlt. A bt'ttei' nn(i»'ivtan<lin<>; of" tlicso (liH'LToncc's than we now possess wonUl no donbt aid ns greatly in (iu; proper interpretation of" the ,-iiffns of" approaching and of" exi.'^ting di.seasc, as well as in the nianagenient and treatment of" the disorilers of infancy. In the pre.sent articile only those physiological differences between the new-born and the adult will be con- sidercil that are of special importance. Growth: Wc'Kjht, — Tlu; new-born child weighs, upon the average, seven lutnnds (.'548.'} grains), boys weighing, as a rnle, about half a pound more than girls. A considerably less weight than this is frccpiently observed in |)('rf"eetly .sound, woll-develo|)ed babies, pi^rticularly in the case of twins, while ten- and tw(!lve-pound babies are not uncommon. Tho.se weighing over twelve poinids are occasionally seen, and if published records are to bo trii.sted (liildren have been born weighing* as much as twenty-four pounds. It has been shown that the weight of tlu; child is greatly influenced by — 1, the length of gestation and the nourishment of the f"etus ; 2, the age of the mother (very young mothers giving birth, as a rule, to small babies); .'{, the size of tli(! mother (the weight of the child being 5.23 per cent, of that of the iiiotlier) ; 4, the inunber of previous pregnancies (the weight often progress- ively increasing up to the fourth or fifth pregnancy) ; and o, the intluenco of nice and climate. For two or three days after birth there is usually a lo.><s in weight of from three to six (»iuices, which lo.<s is probably <luc to an ab.sence of imtritive material from the maternal manuuary secretion during this time, as well as to the increased ti.ssue-change con.<e(|uont upon the cireidatory changes and upon the establishment of respiration. The l(».><s is greater in small than in large children, and they do not so (piicUly recover. After the establishment of the flow of milk the child begins to gain, and u.sually by the end of the first week it weighs about as much as it did at birth. The gain is somewhat .slower in those babies fed on artificial f"ood or oven upon (!ow's milk. TJio increa.se after the first week varies considerably, and it is dependent upon a ninnber of conditions, such as sex, race, nutrition, etc. The increase may be very irregular, an interval in which there may bo neither loss nor gain follow- ing or preceding a ([uite rapid increase in weight. Approximately, however, it has been computed that an average-sized healthy child will gain about .78 ounces daily for the first throe months, .Go ounces daily for the second throe iiKinths, .45 ounces daily for the third three months, and ..")() ounces daily f"()r the fourth three months. The total weight would therefore be, at the end H(I7 I ■i=:r \ 1 [ fe'i ' ' r, 1 \.-i Kl' ** ; ;■: 'V f' m : n "M i:' i\m 8()H AMKJilCAN TKXT-nOOh' OF OBSTETRICS. of throe months, ten ])oiin(ls ; at the end of six montlis, from tliirteen to four- teen pounds; at nine niontlis, from .sixteen to seventeen pounds; and at twelve months from nineteen to twenty poiuids, the inerease in weiglit being doubiud in tiie first six months and trebled in the seeond six months. Li'U()th. — At birth the average healthy child measures between nineteen and twenty inehes (oO (!m.) in length, the male being slightly longer than tlic female. ]Jy the end of the first month the ehild will show a length of 'I'D, inehes; at the third month, 25J inches; at the sixth month, 281 inehes; at tlie tenth month, .'Ml inehes ; at the fifteenth month, 34^ inches, etc., thus showiiicf an inerease in length of 3 inches during these periods. During the first year there is generally a gain in length of from G to 10 inehes. There may »• times be a rapid increase in weight with no inerease in length, and at other times an inerease in length with no corresponding gain in weight. In making accurate observations the growth in weight and in length should be compared and due allowance l)e made for the jiassage of feces and urine. Size and Gnmfh of the. Head, Thorax, etc. — The oeeipito-frontal circumf(!r- enee of the head of an average-sized new-born infant is about 13f inehes for males and \'^\ inches for females (34.5 cm.). At the end of twenty-one months the circumference has increased to about 19^ inches. The anterior fontanelle continues to increase in size until the ninth month ; then it gradually closes, finally becoming completely closed in, ossification taking place from the borders in from sixteen to eighteen months. The average circumference of the chest at birth is about 12^ inches; tlii^ increases to 16|- inches in twenty-one months. The rate of chest-growth is more rajiid than that of the head. The body is proportionately wider in tlie infant than in the adult. The antero-posterior measurements of the head and the pelvis are the same at birth in males and females. Respiration. — In response to stinndation of the respiratory centres tlie child iminediately after birth, sometimes before and sometimes aller the cessa- tion of pulsation in the cord, makes its first inspiratory effort. After one or more such efforts many of the collapsed vesicles are distended and filled witli air. Generally the eom])lete unfolding of the alveoli does not take place until the second day. This first inspiration is followed immediately by exjiiration, and the mechanism of pidmonary respiration is established. The new-born child breathes about forty times a minute. Its respirations are, however, irregular, and they may be influencetl considerably by slight causes; ilir instance, there may be a suspension for eomj)aratively long intervals by atten- tion, by nuiscular effort of various kinds, by fright, etc. Respiration is most regular during sleep, and this is the only time in which it may accurately he observed. A much larger pereentage of the respired air is exchanged in infancy than in adult life, the amount being one-fourth in the former to one- tenth in the latter. The exchange is generally feeble at first, being a third more at the end of the first week than on the first day. In respiration the thorax is elevated progressively from above downward, the work being done largely by the diaphragm. { < PHYSIOLOGY OF THE NEW-HORN INFANT. SO!) lirtecn to four- ; and at twolvc being douljltil s, twecn ninotccii longer than tin' length of 22 i \ inches ; at llic ;., thus showiiiii g the first yt'iir There may a* h, and at other ht. In niakini!; lid be compared 'ontal circumfer- t 13f inches for I of t^venty-0IU' ^. The anterior month ; then it isification taking 12^ inches ; this f chest-growth is tely wider in tlie of the head and itory centres tlie s after the cessii- rt. After one or d and filled witli t take place until ily by expiration, The new-born lis are, however, light causes; for tervals by att(>n- spiration is must nay accurately Ix' is exchanged in le former to one- st, being a tliinl n respiration the work being done Circulatory System. — With the first inspiration of the new-born child there is a complete alteration of the circidation of the blood. The pulmonary arteries, until now containing oidy sufficient blood to supply the pulmonary nutrient vessels, become fully distended with blood to be carrii'tl to the lungs for ae'ration. The flow of blood being diverted from the ductus arteriosus to the pulmonary arteries, largely by the enlargement of the thorax in the first act of inspiration, the duet partially colla|)ses, thrombi fi)rm within it, and it rapidly becomes obliterated. When the umbilical cord is tie<l or the circula- tion through it ceases spontaneously, the umbilical arteries and vein and the ductus venosus become at once greatly nKluced in size, fill with thrombi, and finally become converted into fibrous cords. The foramen ovale is more gradually closed, the edge of the Eustachian valve remaining free for some time, but at the saine time affording complete protection to the foramen. (3wing to the niore rapid growth of the upper part of the body and to the ])roj)ortionatelv large atnount of work thrown upon the lungs, the carotid, subclavian, and pulmonary arteries are comparatively large. At the same time the heart is small, so that the systemic blood-pressure in the new-born is low. The pulnionary artery is much wider than the aorta in iniancy — more so than in later life — so that the pulmonary blood-pressure is greater in the infant's than in the adult's lungs. The size of the heart is to the width of the ascending aorta as 25 : 20 in the new-born ; in the adult, 290 : 61. The systemic blood-jjressurc is raised as the heart increases in size and the aorta becomes relatively smaller. The blood of the new-born is comparatively less in amount than that in the adult, but after a few months the proportion of blood to body-weight is more than in the adult, but with a low specific gravity (1045-1049). At birth the amount of hemoglobin is large (22 per cent.), but the amount of fibrin is small. The hemoglobin begins at (mce to diminish in amount, reaching its minimum at the sixth month. The fibrin rapidly increases in amount. The infant's blood contains more white corpuscles than does that of the adult, less salts, and less soluble albumin. The pulse for a few weeks after birth is very feeble and rapid, and it is easily disturbed and accelerated by slight causes. During sleep in the first week it averages about 120 beats to the minute; while awake, 120 ; and under excitement, 148 to 150. I^ater the number of pulsations diminish during sleep, while the number under excitement increase. Posture has but little effect upon the fre(]uency of the pulse. Digestive System. — Saliva is secreted immediately after birili, but in very small quantities and of weak diastatie action. The salivary glands arc poorly developed, and fi)r a few weeks at least the saliva is furnished almost wholly by the parotid gland. After two months the amount secreted is considerably increased, and it shows much greater diastatie jjower. At eleven months the diastatie ])ower of the salivary secretion is nearly equal to that of the adult. Tlie stomach is relatively smaller, more cylindrical, and more vertically I i 1 I ^M «■ 1 ■ 810 AMERICAN TEXT-BOOK OF OBSTETItrCS. situated than in tiie adult, and its nuiHoular structure is poorly developed. At birth tiie capacity of the stomach is about one ounce, and there is an increase of one ounce per month up to the sixth ni<mth, after which the increase is not so rapid. The healthy stomach contains saliva, mucus, iiematin, and blo(xl-cor- j)uscles. During the first two months of life the normal acid for the stomacii is hydrochloric acid. The (piantity of food in the stonuich diminishes rapidly during the first hour, and in from two to two and a half hours the bahuico entirely disappears. The contents of the stomach are not so decidedly acid ;is in that of adults. Albinnin is seldom found in the stomach, and only during the first hour of digestion. Water assists in the digestion of casein. The pancreuti remains in an undeveloped condition for five or six months after birth, and the action, therefore, of its secretion is very feeble indeed. The livri' is of very large relative size at birth, occupying more than half of the entire abdominal cavity. Bife, light brown in color, is secreted early, and gives to the feces their orange-yellow color. The Hmall infedine is comparatively long, being at birth about 9 feet .5 inches in length, and it grows at the rate of 2 feet per month for two months. Tiie intestinal villi are numerous, are as large as those in adults, and arc supplied with very large capillaries, through which absorption is quite rapid. The glands of Lieberkiihn and Peyer's glands are few in number and arc poorly developed. There is a very copious secretion of mucus, which readily undergoes acid fermentation, especially in the presence of particles of undigested food, the feebly alkaline secretions of the liver, pancreas, and intestines being easily neutralized. The large ititentine is also of relatively great length, measuring 1 foot 30 inches at birth. The ascending and transverse colons are short compared with the descending colon, especially the sigmoid flexure. This structure is bent upon itself from one to three times, and it is the cause of congenital constipation. Later readjustment takes place, the ascending and transverse portions increasing in length at the expense of the descending colon. The feces of the new-born consist, during the first two or three days, of meconium. The meconium, which has been accumulating in the intestines during fetal life, is a thick, tarry, greenish-black substance resembliDsr thick poppy-juice. It consists of bile and mucus, together with epitlieliiil cells, fine hairs, and fat-globules from swallowed amniotic fluid. On the third or the fourth day the feces consist of a mixture of meconium and digested milk. After the fourth day the feces are light orange-yellow in color and they consist of the residue of digested milk. They are passed from two to four times a day. Urinary System. — At birth the kidneys are lobulated, fully developed, and functionally active, the secretion of urine taking place before birth. A gradual change takes jilace in the form of the kidney, so that in about two vears it loses its lobulated form and resembles the adult kidney, being rela- tively somewhat larger. The Skin. — Owing to more or less obstruction of the fetal circulation PIIYSIOLOiiY OF THE NFAV-ItOltX INFANT. Hll I l^F ' • 1 ; f 11 ;< letal circulation (luring delivery the child's skiu is at first of a livid hue. Hpou the cstahlisii- uient of respiration this hue is changed to a deep red, due to the irritant action of the air. In a few days the color is changed from red to a yellowish or icteric tint, which is said to l»c caused l>y the deposit of l)lood-j)igtnont during the preceding (longested condition of the skin. The yellowish color gradually fades, the skin becomes paler, and finally, within three weeks, the normal rosy tint is established. More or less des(iuamation takes place during this time as a result of the early congestion. The 8H<forii)(iroHs gldiidn, on the one hand, are almost if not quite inacitive at birth ; the ttclxurom glands, on the other hand, are very active during fetal life and up to the end of the first year. The body of the infant at birth is covered with the vernix caseosa, which is com|)osod of the secn-etion from the sebaceous glands. The hair of the scalp is strong and from 1 to 2 inches long; it falls out later, and is replaced i)y hair finer in texture and generally lighter in color. The short, fine, downy hair with which the whole body is covered at birth drops out in about three weeks, and is not re|>laced. Lymphatic System. — The lymphatic system is relatively better developed and more active, and the glands larger and more niunerous, at birth than in adult life. The relation between the lymphatics and the other tissues and organs of the body is very close, ;Mid absorption is very raj)id. The temperature falls directly after birth, but by the end of the second day it rises to the maxinumi again (97.5° to 98° F.), where it remains stationary. Pat is generally absent from the interior of the body, but it is abundantly present in the subcutaneous tissues. The muscles at birth are small and soft, but they become better de- veloped, firmer, and more resisting by the sixth month. They contain more water and l(!ss myosin than do the muscles of adults, and more extractive matters, fats, and inorganic constituents. The bones are less brittle than later in life, containing a large percentage of organic matter. The Nervous System. — The rate and degree of development of the nervous system and of its various functions are largely influenced by heredity, environment, and by the health of the child. The faculties and senses are more or less dependent upon each other for their perfect development, as is so clearly shown in the slow, tardy, and incomplete development of the mental faculties when hearing is absent or defective, and in the non-appearance of articulate speech when the sense of hearing is absent. Not until the first month after birth does the gray matter appear on the brain convolutions ; before this the cerebrum is soft and of a uniform color. The niedulla and cord-centres are much better developed at birth than those of the bruin, and they remain more active throughout infancy. The inotor centres in the anterior cornua are more highly developed than are the sensory centres in the posterior portions of the cord. The extreme reflex excitability in the new-born is thus a physiological process. i ,' "1 f^. ■' ■ "If" •■J l.[ ii' !i: 812 AMKIIICAN TEXT-nOOK OF OnSTi:TJiICS. Special Senses. — The spcfial soiisos all rospoiid to stiinuli at biitli or shortly after, but to a liiiiit(><l oxtoiit, and to briiijr out these reflexes to aiiv inarkcd degree the stiiiudi must be more intense or nuist be applied over a larj^er area than is required later. The nenxe of xiiwll responds to strong stimuli very soon after birth, and the ability to distinguish between agreeable and <lisagreeable <Mlors is aecpiiriMl early. Tantc exists even at an earlier period than does smell, and the response to sweet and bitter substances is different immediately after birth, the child being .soon able to judge between the difl'erent forms of food offered. Hearing is very imperfect at first, and at least several hours elapse before even very loud or sharp noises are capable of exciting responsive movements. The horizontal position of the tympanum, the as yet closed Eustachian tube, and the absentie of air in the middle ear are offered as reasons for the imper- fection of this sense. In two or three months the infant is able to determine from which direction a sound conus. The projwr development of the mentiil faculties depends more uj)on the sense of hearing than upon any of the other special senses. SigJd is only developed at birth to the extent of a feeble response to very strong lights. Up to the sixth week there is inability at co-ordination of tlio ocular muscles. After this time the eyes begin to move in an orderly manner, and they will follow a bright object moved slowly in front of them. At about the second month rapid movements are perceived, as is evidenced by the child closing its eyes quickly on an object suddenly approaching it. At three months the development of sight goes on more rapidly and tlio child begins to separate colors. The first colors recognized are yellow, nul, pure white, gray, and black. The recognition of green and blue comes later. The faculty of distinguishing between the various colors, however, is not perfected until after the third year. The estimation of size and distance is gradually developed after the sixth month. The mother is recognized about the third month. TItc senxe of feeling or touch reacts very feebly to stimuli, owing to the imperfect development of the brain and the skin, uidess aj)pli<'d over a relatively large area. Pleasurable sensations existing 'liirii' the m>i thn>t> months are those created by the taking of food wlier ' the act of suck- ing, the sweet taste of the milk, and the staying igcr, each bi "j; in itself a i)leasurable sensation. A little later the 1. thy ba'*' who is not hinigry enjoys the warm bath, the stimulation of attention b- bright objects, and in having its limbs unconfined by clothing. The developing ability for grasping after three months gives the infant additional pleasure. Muscular action in the new-born is entirely involuntary, there being no voluntary act until about the end of the third month. Sucking and licking arc not dependent entirely upon reflex action, but are largely instinctive. The stretching and bending of the extremities are impulsive acts, and occur during sleep, as they did during intra-uterine life. Straightening of the legs .^fS J'ATI/O/JXn' OF Till': XEW'-liOltN INFANT. 8i:i after awakinj; is noticed during the seeoiid week. Vocal sounds are also inipidsive. KeHex movements arc not so strongly marked at l)irtli as they are a little later on. These involnntary movements are purposeless and show lack of co-ordination. The act of raising the head, which is attempted toward the fourth m.)nth in healthy children, is volitional, recpiiring not so much added strength of nniscle as power of co-ordimttion. As volition de- velops the power of co-ordination gradually increases, and the child learns to jwrform voluntary or purpttseful acts, V^oluntary grasping is done after the fourth month. As the child learns to halancjc its head it attempts to sit up. This act is not suceessftilly accomplished until about the fortieth week ; the chihl sits firmly alone when ten or eleven months old. Those children that creep do so at about the ninth month. Standing, which is attempted at about the ninth month, is usually successftd at the end of the first year or a little earlier. Some children walk as early as the eighth month, many by the twelfth mouth, while some do not walk until much later. Most children will walk alone by the sixteenth month. Speech is very gradiudly developed, distinct words not being uttered nuich before the end of the first year, often considerably later. The use of vowels and of inarticulate sounds, together with gestures, answer the child's purpose of making its wishes known. As the will develops and the power of mimicry is established vocal sounds and gestures become more and more intelligible, and finally articulate words are added. Single words are used for some time to express several ideas, then two words are put together, and finally short sentences are formed. '' W'M p t ^^^ II. PATHOLOGY OF THE NEW-BORN INFANT. 1. Medical and Surgical Diseases Incident to the Birth op the Child. Asphyxia op the New-born. — The respiration of a child immediately after birth is usually somewhat irregular, but it soon beconujs rhythmic, and within a short time inspiration and expiration take ])lace in a normal manner. Any deviations from this, as indicated by slight difiieuity in breathing on account of a large amount of mucus in the trachea or the bronchial ttdjes, to absolute apnea, in which there is no attempt on the part of the child to respire, represent the dit!'erent grades of what is called "asphyxia of the new-born." The phenomenon dcscribe<l is entirely due to imperfect aeration of the blood. It is because there has not been proper interchange of oxygen and carbonic acid gas in the blood of the new-born — a condition which may arise from causes that have been operating for some time in the uterus or on acx'ount of some delay or unavoidable process in the birth of the child. It is hardly necessary to speak of the physiology of the circulation in the placenta, that wonderful and perfect arrangement by which oxygen is received by the fetus and carbonic acid is thrown off by the mother. i'r 814 AJIKRJCA.X TEXT-BOOK OF OBSTETRICS. \ The {loiieral stihjoct of nspliyxia of the new-born may bo divided into twn subdivisions: first, intra-utcrinc (iKpln/xid ; secoiul, (•xti'a-H(t'ri)U' (tup/n/.via, iw tiiat form wliieh jn'esonts itself immediately or a short time after birth. Three divisions or three different jjrades of asphyxia of the new-born will be made, and they will be named in the order of their severity : Firxf, sijoht diflicnlty in breathing:; from the eolleefion of nmeus or any foreign substaiui' in any part of the respiratory appartns ; xccomlli/, an asphyxia which is pic-,- ent in the ehild, who when born is strong and robust and full-blooded; iliinl/i/. a ehild born asphyxiated, pale, limp, and apparently lifeless. The seeond and third elassifieations have by some of the older authors been spoken of respec- tively as "sthenie" and " asthenic," or the apoplectic and anenjic varieties. The first class is quite insignificant, and usually respiration is established with- out any treatment whatever. The exposure to the irritation <»f the atmosplieie or occasionally a smart slap on the buttocks is all that is neetleil in the simple variety. The other two classes, which are exceedingly imj)ortant, and n-:iiiv times very dangerous, will now b(> considered in their proper order. Intra-uterine Asphyxia. — Efio/iu/i/. — The causes of the intra-titeriiic liirni of asphyxia arise from two soiu'ces — those originating from the mother and those originating from the fetus. The causes present in the mother that mav pni- duce this dangerous diHieulty in her child are maiidy disturbances of j)laceiital eirculation, either from ju'culiarity of pain or from diseases which lead to a small supply of oxygen to her child. The causes which originate in the fetus are interferences with the cord and the placenta, ])ressure upon the head, and a natural or an accpiired feebleness which n .y be producnl because the parents are either inniuiture or aged, or because the delivery is j)re!nature. T/w p<ith()/i)(/ii'(i/ ch(in(/cf< in intra-uterine asphyxia are about the same :is those that follow when suffocation takes place from other causes. Tlie l)l(i(Mi is thin, the sinuses of the brain are filled with bhod, with some edema of the membranes, and extravasations and slight ecchymoses are found in dill'ereiit parts of the several organs. The lungs are dark in color, are somewhat iimre firm than usual, and appear to be filled with blood. The air-passages ;ire quite uniforndy filled with mucus, meeonium. and amniotic fluid. This condition suggests the (piestion which is fri'»piently asked as to whet her the child inspires //; xfcro. In some obstetrical operations, or when the hand is iutrodueed into the uterus to perforui version, air enters the cavity and pin- duees its reflex irritation, and the ehild makes an effort to inspire, and in this manner draws meconium and amniotic fluid into its respiratory passages. Sj/iiipfoiiiK of the intra-uterin(> form of as])hyxia, of eours(>, are diflieult tu be observed, and they can be det<'rmin(Hl oidy by xcry close observation of tJM ehild //) litem. A very slow or a very rapid pulse, a synqitom to wliieli we oil Ml' attach the <>'reatest i mportanc(\ intimates either pneumogastric irntati paralysis Tlu>n follows iiicr(>ase(l intestinal peristalsis, and finally miixiihir spasm, to which, it appears to the writer, should be added umisiial iiove- ments of the child. In all prolonged labors and before prolonged obstctrieni operations it is always well to examine carefully the heart-beat of the cliild, 1 I i '■ii PATIIOLOCiY OF THE NFAV-liOIiX IXFANT. 815 mcwliiit iiKnv ) WilCtluM- till' •(' iuitl 111 tin- irnt:iti(»ii nr liUv iiiiiM'iilar l)w;ause in cjusos of asphyxia it is iinportaiit to know wliether any symptoms existed })rovions to the birth of a ciiihl. or whi'thiT the condition obtainwl is tho result «)f its passaj;e thi'ou>>;h tlie parturient oanal. DUuiuoxix. — It will be I'rom sueli examinations as above sufxgosled tliat we shall be able to anticipate danger to the child, so that in all tedious and particularly dilHcnlt labors these «)bservations should be instituted. W the iieart-beat is either unusually slow or fast, we shoidd conclude that there is commencing danger to the child. The appearance of meconium, it seems to the writer, has been over-estimated, as in a mnnber of cases he has seen this discharge before the delivery of (he child, and yet there has been born a per- fectly healthy and non-asphyxiatinl child. In breech labors it is certainly not to be regarded as a sign of threatened asphxyia. Any mnisnal hemorrhage beibre birth, indicating ])artial d(tachment of the placenta, is a very significant symptom and deserves earnest attention. l*ro</noKit<. — The prognosis will also depend u])on the condition of (he child and the possibilities of an easy and rapid delivery. Tiratmvut. — In threatened asphyxia of the child the indication is to delivei with all pt)ssible rapidity consistent with the safety of the mother. Extra-uterine Asphyxia. — I'Jfiolof/i/. — In a vast majority of cases of extra- uterine asphyxia there is no interference with the placental circidatioii ; the watchfulness with which the child in nfero has b(>en «ibserved has revealed nothing, yet upon the birth of the child breathing does not take place. As- phyxia has developed from causes o|»erativo while the child is passing through the parturient canal or from diseases which interfere with the original process of respiration. Those causes are malformations of the respiratory or circu- latory organs, intra-uterine (liscase of the fetus, or premature birth. Among the (liseases which operate more frcciueiitly in the production of extra-uterine asphyxia may be mentioned particularly (he diseases ot" (he lungs, such as ate- lectasis, j)neumonia, syphilitic <liseases of the lungs, large ])leural exudates, compression of the air-passages by large glands, and injuries to the respiratory centres f.om ddlicult labors. Path(>lo;i;i. — Kxternal marks and conditions that have operateil to produce asphyxia wil'. readily be seen. The iiead also shows signs of com|>ression and perhaps unnatural moulding. The lungs are frc(|ueiitly not I'ully expau<lc<l ; indeed, in some instances large areas are Ibtmd in the condition known as dclccf'ixix. Sii)nj)fomn. — When a child is boi-n na(urally it begins to breathe, and usually to cry (piite lustily. It opens its eyes, makes a face as if disgusted with the surroundings, moves its extremiti(>s, and (he intcgunieut assumes a rosy line. .\ child born asphyxiated pnseuts one (>f two conditions altogether dii- t'crent I'rom those above described. The child is either large and robust, the skin is of a livid color, and without doubt it is a strong child (sthenic), or it it is pale, wan, and anemic (astluMiii-). There is but little U" any attempt at respiration. To all intents am, pur|)oses th(> child is deail. In many cases there is no heart-beat percepdble. In (he lirst grad(> the child is deeply cya- if 1 t ?i I 'i 816 AMERICAN TEXT-BOOK OF OBNTETIilCS. ii I i^ Mw/ 11080(1; tlio cord is piil.satiiig violently ; tiie roHexos arc not wholly aholisiitMl. In the second, an atlvanced staii;e ot'asj)hyxia, the pulsation may not he disiii:- giiishahle; the surface of the hody is extremely pallid; the extremities arc motionless ; rcHexes and muscular tone are absent. J)i(i(/iioi:iis. — It is of great importance to know whether the asphyxia took place from causes intra-uterine or later, and it is also important to know wiiich of the two forms of asphyxia, the mild or the grave, is present in each indi- vidual case. If very great pressure has been made upon the head of thecliild, either because the labor has been long and tedious or because instruments )kivc been used for a long time, or if a visible hemorrhage is present, the asphyxia is in all probability due to causes operating during the })assage through the pai-- turient canal. Observations which have been made during labor, then, are very important in deternu'ning the probable cause of asphyxia. If, however, we know that there has been partial separation of the placenta before biitli, and if we find the air-passages of the child filled with inspired foreign mate- rial, the asphyxiated condition of the child is in all probability due to intra- uterine causes. Prof/no.six. — In the first form — that is, where the child is strong and tlie muscidar tone and nervous irritability are not lost — if there are no other com- plications, the prognosis is generally good. In the second form it is alwavs doid)tfid. If pressure on the head has been long and severe, and hemorrliage takes place at the l)as(.' of the brain, the prognosis is bad. If the hemorrhage takes place on tiie convexity of the brain, the child may live longer, but tiie mental condition is usually bad. How to Determine the (irade of Afijihi/.ri((. — The grade of asphyxia can he determined by irritation of the palate. If upon the introduction of the fiiinvr to remove the nnicus there art choking and convulsive movements, and conse- ([iiently attempts to breathe, and the ]iresence of the reflexes is shown, it is asphyxia of the first grade, and the prognosis is good. If this irritation of the ])alate produces no action, but the palate remains soft, then the asj)li\xia is of the second grade, and the ])ri)gnosis is bad. Ti'fdtiiu'nf. — In every case of labor where it is known to be serious or tedious, ])reparations for the reception of an asphyxiated child should be made before its birth. A table should be ])laecd in the lying-in chamber, and upon it a pillow and a waterproof sheet should be in readiness; hot and euld water in proper receptacles should be at hand, and also a soft catiieter nv some other a])pliance for the withdrawal of mucus and other substances t'luni the respiratory passages ; an electric battery may be of use. Treatment of the Fird (h-(ule of Axphji.ria. — The chief indications in the treatment of the first grade of aspiiyxia are — remove all obstruction from the air-passages, and by the application of reflex stimuli excite res])iratory elluit-:. Remove mucus from the throat and month of the child ; irritate the skin hy slapping the buttocks and rubbing; pass before the respiratory organs snme of tlu! dilVusive stimulants, such as camphor or preparations of ammonia. To remove foreign material from the trachea and the bronchial tubes grsisp the rATHOLOGY OF THE NEW-BORN INFANT. 817 f abdlisln'ii, )t be disiiii- roniitiis luc [)hyxi;i tudk know which n oai'h iiitli- ofthocliild, ninoMts luivc e iis|)hyxia i< ugh tho jtar- )or, then, are If, however, before birtli, tbreijin inatc- lUie to iiitni- rong and tlie no other cuiu- 1 it is always id hemorrhiijie lie hemorrhaire longer, bnt tlie kphyxia can lie 1 of the fniiicr its, and eonse- s shown, it is irritation of the as])hyxia be serions or lioiild be made |ehanib(>r, and I; liot and I'tild Ift eathetcr or ibstanees fnmi jcations in the Iction from the tratory etlbrt-;, i(> the skin by |v organs smiie Inunonia. I'* Ibcs grasp iln' iliild by its feet, the head hanging downward ; pass the little finger into the throat and wipe out the niiicus. Care should be taken not to produce trautna- tisni in the post-pharyngeal space, and so ojien an entrance for infection, l-'urther to remove the nineus from the trachea, press upon the trachea with ihe finger as low down as the bifurcation, and gently s(pieeze the trachea toward the larynx. This forces the mucus into the back part of the pharynx or post- iKisal space, and it can now be forced through the nose of tin; chikl bv blow- ing into its mouth ; the obstetrician should protect his mouth with a haiid- Fkj. 111.— Schultze's method of nrtilicial ri'spirntion : A, inspiration ; 15, expiration. kerchief. If now the child does not begin to breathe, give it a warm bath or jtossibly alternate between a warm and a cool bath. Repeat all these iiicasiircs, and watch the child carefully until respiration is fully and per- I'lrtly established. Trcdtiiinif nf t/ic Scc())nl (ri'dde nf ANp/ij/ria. — If it is found by irritatifm of the throat that the rcHexes are aUsent and tliat the child is in this .severe and (hingerous form of asphyxia, our treatment must be more heroic from the fir.st. Of course the air-passages .should be cleared of mucus. It is n.seiess. how- over, with a child in this grade of asphyxia to attempt to make it breathe by irritation of the skin, and, while many of the procedures suggested in the first grade may be u.sed, artificial respiration, by means of which air may be forced intd the che.st, mu.st very soon be resorted to; while the method of jMarslial Ilall or of Sylvester may be used, the proceeding as laid down by Schultzo, 62 f I ( ■ \.n I 818 AMERICAN TEXT-BOOK OF OBSTETRICS. and briefly described below, has, tlie writer believes, been followed by the bc-t results (Fig. 441). The p!:ysician seizes the child's shoulders by putting an index finger in the axillary space and his thumbs so curved forward and over the shoulders as to strike the end of the finger, so that the entire weight of the child's body is rest- ing upon or within the circles made by the thumb and the first finger of cadi hand. "While the child's body is hanging perpendicularly the ribs are being lil'tid out, the chest is expanded, and mechanical inspiration is produced. To ])ro- duce, now, a mechanical expiration, the body of the child is swung forward with some little force at arm's length until the operator's arms are a little ahovo a horizontal line. A somewhat abrupt termination of this motion causes tlio thorax of the child to become stationary, while the lower limbs topple over upward and forward upon the child's abdomen. The abdominal viscera, in the position in which the chest is at this moment, press against the diaphragm and produce expiration. The child's body is now returned to its orignal ])osi- tion by nearly reverse motions ; the entire manenvre occupies from seven to eight seconds and is repeated eight or ten times each minute. After pi'aotisiii<r this method for two or three minutes it is desirable to place the child in a warm bath to restore the body-heat lost during the swinging movements. Mouth-to-niouth insufflation is also a valuable method to seouro tlio entrance of air into the child's lungs. A towel is placed over the cliild's mouth, and the operator, after taking a deep inspiration, quickly but gcntiv blows into the mouth of the child, and then gently compresses its chest. In this manner the child's lungs should alternately be inflated and emptied ten or fifteen times a minute. To prevent injury to the air-vesicles the inntrs should be inflated gently, and the nasal passages shoidd not, as sonietiincs advised, be dosed by pressure with the fingers. Sometimes insufflation through a catheter passed into the larynx is of service. In the severe form of asphyxia and in ])rematurely born children most remarkable results are sometimes obtained by keeping these children in some kind of a warming apparatus or incubator (see Figs. 444-448, \i. 863). Caput Succedaneum. — In quite a luunber of cases there are seen iiiunc- diately or very soon after birth enlargements, contusions, or ecchymoses on tlie head or the presenting part of the ciiild. It is not difficult to nnderstaml why or how those afteetions are ])rodMC(>d, but one does have some troid)lo in dctcr- miiiing whether they should be arranged under medical or under surgical mIVcc- tious. It is quite possii)le, then, that the present arrangement may not lio absolutely correct, but this, it ap])ears to the writer, is not jiarticularly iin])oit- ant if the main facts are presented, inasnnich as a description of these diseases or affections will be quite as instructive whether they are or are not arranged under their |)roper headings. One of the most frequent enlargements noticed is named capxf xucci'ildiicinii. This phenomenon, which is rather constant, consists of a swelling, of varviiiL' sliape and size, noticed upon the ])resenting part, especially the iiead. I'lic swelling is produced usually by pressure of the dilating os uteri, but the .-aiiic PATHOLOGY OF THE NEW-BORN INFANT. 819 k1 by the Ijc^t c finger in tho houklers as to s body is nst- finger of each ire being li It cil iced. To pro- wling forward e a little above ion causes the lbs topple over inal viscera, in the diapliragm ts orignal ])osi- froni seven to rVfter practising c the child in a lovenients. to secure tho 3ver the child's -kly but gently s its chest. In md emptied ton sides the lungs •t, as sonietinios nies insutflatiou II children most hildrcn in some p. 8G3). nre seen innno- chvinoses on the understand wliy rouble in dotcr- er surgical alVec- ent may not lie icularly inipnrt- |of these diseases re not arranged lliug, of varviii^r Ithe head. Th" l>ri, but the ^ainc Idnd of a swelling has been noticed upon the breech or the shoulder. The phenomena produced vary somewhat with the differences of position and extent and severity of the pressure. Eliolofjif. — The cause, as remarked above, has always been ascribal to pres- sure upon tlie unyielding os uteri, causing an infiltration of bloody serum in the tissues of the scalp below the constricting ring of the cervix ; but inas- much as this enlargement and the blood-tumor which will presently be described have been found on other than the presenting ]>art, we must at this time confess that the cause is not always clear. It is jiossible that difficult labors with jirolonged pressure by different parts of tlie uterus may be an etiological factor. The pathology consists of a localized edematous condition of tho soft parts of the scalp i.nd the connective tissue with some extravasations of blood. Diagnosis. — The diagnosis is not always easy, for there are found upon the head of a child several other enlargements from which the swelling must be differentiated. Chief among these enlargements are cei)halhcmatoma, hernise cerebri, vascular tumors, meningocele, encephalocelo, and hydrencephalocele. A full description of cephalhematoma is given below, and hernia; of the brain and vascidar tumors are treated on page 304. A brief description oi' the remaining tlirce is as follows : Meningocde is a tumor of the scalp into which the meninges protrude ; an cneephaloccle contains in addition to the meninges a small amount of brain-substanee; and a hydrencephalocele contains a small amount of liquid in addition to brain-sid)stancc and the membrane. Prognosis. — In caput succedaneuni the prognosis is always good. If left alone, it almost entirely disappears within a short time. Treatment. — Caput succedanoum will in every instance disappear without interference. In a case, however, where there is very extensive ecchymosis, which makes this the vulnerable point of the baby's body, care shotdd be taken against infection. In this case an antiseptic dressing should be used as a protection. Cephalhematoma. — Cephalhematoma is a soft, elastic, fluctuating tumor, generally ])ainless and situated upon one of the cranial bones (Fig. 4 12). It is stated by some writers that the tumor ooeurs more frequently upon the right parietal hone, but of the six cases seen during the first twelve years of the writer's practice five were upon the left ])arietal bone. The tumors are usually single, although a few observers, among them the writer's eminent ju'cceptor, the late I'lof. William II. Ikford, noticed one upon each side of the heail. Hol'mohl oi)served 2(5 bilateral cases, each with fbiitanelle Ijctwcen as a deep ('.epression. This variety of tuunn', it seems to the writer, shonld be confined to those cjMs where the collection of blood is upon the outside of the cranial bone, I'm. If.'.— I'l'iiliiinn'iiiiitcimii. ■ i" ■.1 - m '~i- I 820 AMERICAN TEXT-BOOK OF OBSTETRICS. I J i , / ii ' Ui ." while those upon the inside between the brain and the dura mater should l.e spoken of as "intracranial" hemorrhage and should be considered uiidt r a ditierent heading. There must at least be a very wide difference in the clin- ical history of an external and an internal cephalhematoma. The first is rather insignificant, while the second would in many cases prove fatal. Frequency. — Cephalhematoma occurs with greater frequency than writers would lead us to suppose. When first writing upon this subject, at the end of twelve years' practice, the writer had seen six cases, and in the first 1000 lalxirs which he attendetl twenty cases of cephalhematoma occurred. Henning had 230 out of 53,606 cases, or 0.43 per cent., and Hofmohl 371 in 59,885 cases, or 0.6 per cent. The percentage was about 2 in the writer's cases. The disease is said to be more frequent in males. Etiology. — This difficulty has in almost all instances been ascribed to jiros- sure upon the cranial surface by the cervix uteri. Without doubt a great major- ity of cases are caused by this pressure, but from the fact that cephalhematoiiiata have been observed in breech births, it must be admitted that in every case the rigidity of the os uteri does not produce the tumor. It has appeared to the writer that, in addition to the pressure exertetl either by an unyielding os or l)y forceps, there may exist a tendency on the part of the blood-vessels to rupture; there is an undue thinness, which makes this difficulty more likely to occur. Symptoms. — This form of head tumor is not present usually at the birth of a child ; indeed, from one to four days elapse before attention is called to this difficulty. When first noticed it is usually a sofl, painless enlargement, situated upon a parietal bone, varying from the size of a hazelnut to that of an apple. It may so extend as to include the surface of the entire cranial bone, but it never crosses a suture or a fontanelle. There is no discoloration of the skin in cases observed by the writer, and neither the pulse nor the circulation of the child is accelerated to an extent that would denote any disease or com- plication. The greatest size of the tumor is usually reachetl at the end of a week ; it then remains stationary for a few days, and then begins the subsi- dence and diminution by which nature perfe<'ts a cure. In a large number of cases in from four to ten weeks there is nothing to indicate that tlioro has been a tunjor or a growth of any character. Diagnosis. — The diagnosis is a very important question, and one not easily made out by many physicians. Not many years ago the writer was called to see what was supposed to be a hernia cerebri, which proved to be a cephalhe- matoma. The principal affections with which a cephalhematoma may be con- founded are caput succedaneum, hernia cerebri, erectile tumors or angioinata of the scalp, and the different forms of soft tumor that have been enunuTatwl in the consideration of caput succedaneum, to which should be added, in the writer's judgment, the condition known as eraniotabes. The means of diflor- entiation may briefly be stated. Caput succedaneum is an edematous condition of the tissue of the scalp that is present at birth, and it disappears nipidly without any accompanying symptoms. It has a boggy feel, while in ccplial- hematoma there is always some fluid. The position, process of repair, and PATHOLOGY OF THE NEW-BORN INFANT. 821 \\ ater should lie derccl luuUr a ice in the cliii- The first is rove fatal. !y than wiitors , at the end of rst 1000 lal.uis •ed. Heuniiig 371 in 5y,«S5 ;r's cases. I'lio iscribed to pres- )t a great niajoi'- ihalliematoiuata II every case the appeared to the ielding os or hv ssels to rupture ; kely to occur, ally at the birth ition is called to e.ss enlargement, tint to that of ail ire cranial bone, ■oloration of the r the circulation disease or coni- at the end of u )egins the subsi- a large number licate that there duration are also quite different. It should be remarked here that caput suc- ecdaneum may hide a cephalhematoma for three or lour days. From hernia cerebri the differentiation should not be difficult. The hernia occurs along Hie line of a suture or in the vicinity of a fontanelle; there is no fluctuation, hut usually there is a pulsation which is synchronous with the heart-beat. ( 'ries and agitation of the child cause a hernia cerebri to enlarge ; not .so with a cephalhematoma. A vascular tumor on the scalp has the .same boggy feel noticed in caput succedaneum, but it never fluctuates, and usually there is a discoloration of the skin that is not pi-esent in a cephalhematoma. By craniotabes is meant the soft places found upon the cranial bones in rickety children. It has appeared to the writer that a layer of bone in .some rickety children can be so thin that a softness and fluctuation could almost be made out, thus giving rise to the suspicion that a blood-tumor of the scalp existed at that point. Such a case as this has never occurred in the writer's jiraetice, but it always appeared po.ssible, and in his teachings he has cautioned his students in this respect. Tiie enlargements on the scalp causal by protrusion of the meninges alone, or those containing fluid or brain-substance, will need no further consideration than that given on pages 304 and 818. Complications, — When the hemorrhage is ex "ual complications are very rare. In a very few cases suppuration has taken i)lace, or there has been such tension with i)ain as to interfere with the nutrition of the child. Of course, if pus is formed next to the brain, necrosis may take ])lace or a menin- gitis might be effected. The danger is reduced almost to nil if maltreatment is not inaugurated by some surgical process. A cephalhematoma caused by forceps delivery may make a fracture obscure, and is a dangerous complication. Process of Repair. — At the end of four or five days (it is stated by one author after a single day) where the swelling joins the cranial bone a very small, hard ridge will be felt. This ridge is the beginning of a hyperostosis, or a tlirowing out of bony material by which the bone and periosteum are Fl( 44».— I.onRitiuUniil soction through n oopliallii'iiintdmn : n, (liirn mntcr ; I', criiiiimn ; c, ptTiorniiiuiii ; rV, iK'KinninK hyporustosis ; r, scalp (l)iivis). re|)aired, a resorption of blood having now begun to take ])lace. There is not only a ridge of bony material, but there are also Ibriuiiig forward, toward the central jiart of the tumor, little projections, so that after a time a thin crust or shell of bone is absolutely formed over the swelling. This crust will some- m h i! I? N .. 'ii H ^ t 3t_ 1. 1 ! n J r^l Ui. n ■ 822 AMERICAN TEXT-BOOK OF OBSTETRICS. times crackle like parchment. During this time the blootl and sernm arc hcinc resorbed, and while this course of repair is slow, in all cases to which the writci'-s attention has been called a complete restoration has taken place witiiont aiiv induration or thickening. It has been stated that sometimes a hyperostosis remains at the seat of swelling, bnt this has not been true in the writer's oases. Pathology. — A section through the blood-turaor (Fig. 443) reveals tlio i'act that an extravasation of blood has taken place between the bone and the |i(ii. cranium. The bone-surface is roughened, and the ])ericranium is attaclicd only to the margin of the bone, wiiere inflammatory irritation produas a perceptible thickening. Prognom. — If, as remarketl above, a cephalhematoma is left alono, the prognosis, almost without exception, is excellent. If there is ])rcsent a geniTal systemic disease, the probability of resolution is not so good. Treatment. — Interference, except in cases which will be mentioned, with tiie pretence that something is necessary deserves censure. Any deviation from this course, in the writer's judgment, is always fraught with danger. In regard to the advisability of surgical interference, there is in this oj)erativo era a difference of opinion. Winckel and Olshausen advise opening the tumor at about the sixth or eighth day, yet a case was lost by one of these gentle- men following this procedure. Among those who advise against operation are Henoch, Baginsky, Zweifel, Biedert, and especially the surgeon F. Koenig. The weight of authority is certainly against operative measiu'cs so long as there are no signs of inflammatory reaction or of suppurution. Apoplexy of the New-born. — The ctiologi/ of cerebral hemorrhasie of early life differs from that in the adult. While in the latter it usual iv results from a diseased condition of the arteries, rendering them liable to rupture, or from hypertrophy of the heart, in the infant it is often dn(> to venous congestion, the hemorrhage occiu'ring in the capillary vessels of tlie pia mater or in the choroid i)lexus. The pia mater in early iufaney is very delicate. Apoplexy may also occur as a complication of cephalliema- toma ; it may be due to compression of the umbilical coi'd, producing asphyxia ; it may be associated with atelectasis. There is usually a history of diffieiilt labor, impaired circulation, perhaps convulsions, but it also occiu's without the existence of other injuries where labor has been of long diu'ation. C. Kim<re has found collections of bloixl the s^ize of a pigeon's egg in the dtn'a mater. These collections have been observed in normal labors. Laceration of the sinuses may produce very extensive hemorrhage wliieli will prove fatal. Interference with the circidation during labor, or pressm-e produced l)v the cord about the neck of the fetus, or the jiresencc of stiinna, is sometimes followed by cerebral hemorrhage. These cases are usually asjiliyx- iated. If respiration can be established, paralysis is likely to follow. Paraly- sis is not always marked at first, but may be noticed in the course of nioiitlis; it may be followed by contractures. Sj)eech is generally impaired, and intel- ligence is usually somewhat affected. Congenital Atelectasis. — By atelectasis is meant a condition in wliicli the PATHOLOGY OF THE NEW-BORN INFANT. 82;j "i' f? n 1 \i ;riiin are I)('iii<; ich the writer's e without any a hyperostosis ! writer's ca.-cs, eveals the tact e and tlie |t('ii- iim is attached ion proehices a left alone, tlie resent a general itioncd, with the deviation from th danj;er. In his operative era minf? the tnmor of these irentle- igainst operation rceon F. Kncniu. ■jiires so long as heniorrhasie of latter it usnih y them liahle to is often due to V vessels of tlie early infancy is of cephalhenia- ;lncing asphyxia; listory of diihcnlt ■curs without tiie tion. C. KiMiire the dura mater. lemorrhage which labor, or pressure :>sence of strnma, usually asi>hyx- foUow. Tmi-iIv- )ursc of months ; {paired, and intel- Ition in which the lung-tissue remains nnexpanded, or, having heen tilled with air, collapses and returns to its condition before birth. Thus atelectasis may be either con- genital or acquired. In the congenital variety the ciiild evinces some difHculty in breathing at birth. Sotnetimes it is asphyxiatetl, and at other times the trouble is made manifest by rapid breathing and the want of expansion of one or both sides of the chest. Etioloyy. — Atelectasis does not seem to be luc c ngenital difficidties with the respiratory apparatus, for in many cases t.r ungs can be expanded post- mortem without difficulty, nor is it due to an enlarged thymus gland. The majority of those who have investigate<l the cause of this difficulty believe that it is due to natural weakness of the infant or to some debilitated condition of tiic mother, premature birth, etc., rendering the respiratory muscles too feeble to elevate the thorax during respiration. Asphyxia and pressure on the brain from any cause, producing paralysis of the respiratory centre, is also considered a cause. Frctjuency. — Congenital atelectasis is not fre(iuent. The writer has seen hut three or four cases of this condition — that is to say, where the condition lasted long enough to become very apparent. Symj)toms. — There is usually a cyanotic condition of the body of the child in congenital atelectasis ; very soon the infant commences to cry, but respira- tion is exceedingly rapid and short. If a small portion of the lung is affected, tiie difficulty will be so temporary as hardly to be notic-eable. It' a consider- ahle portion of the lung is congenitally collapsed, the difficulty in breathing will be more marked. Occasionally convulsions precede death. Didf/noHis. — The diagnosis, which is usually difficult, (»ften not made during life, must be founded upon the rapid and irregidar breathing, upon the cyano- sis, and upon physical examination. The walls of the chest upon the affected side do not expand, and there is dulness on percussion. Proynofiifs. — The prognosis depends on the extent and cause of the difficulty. If a large area is involved and the condition is accompanied by cerebral lesions, the prognosis will be unfavorable; if the area involved is small and unattended by cerebral lesions, the prognosis will be good. Treatment. — The first object in treating congenital atelectasis must be to induce a deep inspiration. For this purpose an effort may be made to stimu- late the respiratory muscles. Usually the only effective treatment is very gentle inflation of the lung through a sofl catheter introduced into the larynx. Diffusible stimulants shotdd be administered, the child must be surrounded by artificial heat, and everything must be clone to support nutrition. 2. Traumatic Injuries of the New-born. The principal factors in the production of injuries of the new-born are anomalies of the pelvis, deviations from the normal mechanism of labor, and tlie necessity for instrumental delivery ; in addition, wounds of the presenting part arc sometimes produced by the attendants either through ignorance or by rough handling. I I f %i i \x t 824 AMintlCAN TKXT-nOOK OF OliSTETRJCS. m A. Ir^juries to the Scalp, Pace, Neck, Limbs, Trunk, and Bowels.— Wouiuls of tlio Hcalp and J( ice are froqiicntly produced when artificial deliv- ery is found neces.sary. Pressure by tin blades of the forceps may prodihc, lacerations of the scalp and forehead, contusions of the face, and injury to t In- facial plexus of nerves. These wounds are fretpiently bilateral, correspond ii,.; with the points where the i'oreeps was applied, and where there is unusual re.>i>i- ance either from the parturient canal of tin; mother or from the Ixxvs of tin. skull of the child. Injuries to the presenting part are sometimes also piu- duced even in normal labor. Thus the scalp has been injured in the atteiii|.t to rupture what was supposed to be the bag of M-aters. Caput sueeedam nm has likewise been thus mistaken and punctured, and even eyes and evrJiiU have thus been injured. Injuries to the head are frequently indicative of pelvic deformities in ilic mother; especially is this true of the contracted pelvis. If the eonjnjrntc diameter is diminished, the promontory of the sacrum usually produces pres- sure on a limited spot or on two or three spots near each other. A spiiim- 8ha])ed depression of the ))!irietal bone may thus be produced. The neck ot' the fetus sometimes shows the effects of traction produced by long-contiiiiicd extension. These effects are usually manifested by transverse stria) at the point where the strain of the integument was the greatest (Miiller.) Sonii'. times subcutaneous lacerations occur, giving rise to more or less extensive extravasations of blood. In the attempt to assist the after-coming head, especially if this is done In- unskilful hands, a blood-tumor may form from a hemorrhage into the slieatli of one of the sterno-eleido-mastoid nuiscles. This condition is known ns hematoma of the sterno-madoid. There is usually some laceration of tlic fibres of the muscles as well as injury to the vessels. This accident is more common in breech jiresentations, but it also occurs in head presentations, and has been observed after spontaneous delivery ; in the latter case, however, the tumor is very small. The swelling is not always observed immediately aiier birth ; it is generally irregular, somewhat elongated, situated usually in tlic upper i)art of the right stei-no-cleido-mastoid, becoming harder, and disappear- ing in the course? of from four to eight weeks. The profjnosis is favorable as to the life of the child. Paralysis of the arm corresponding with the side on which the injury existed sometimes occtu's, but this usually disappears with the tumor. This injury sometimes causes torticollis. Fracture of the clavicle, in extracting the after-coming head, may result in puncture of the lung by the broken end of the bone. In transverse presentations the upper extremities of the child arc sometimes injured, the presenting arm being covered with excoriations, or the meinltcr may be considerably swollen. The large bowel may rupture from jire-exi-^t- ing ulceration, which is usually at the sigmoid flexure. Effusions of blood in the i)leural and peritoneal cavities have been observed after difllicult lahur, and extraction of the feet or the breech is sometimes followed by iiijinios and lacerations of the abdominal viscera of the fetus. ■li- i Bowels. -- tificial (Icliv- may pniiluici injury to llic correspond i 1 114 musual r('.>i-i- I Uoi'.oH of tin- linos also pio- n the attcinjit t succodancuiii L'S and cydids )rniities in the the conjiij;:!!!' produces pres- icr. A spooii- Tlio neck of long-eontiiiiicd iQ stria) at liie Liiller.) Sdiiu'- less extensive this is done hy into the slieiitli u is known as ceration of tlie ccident is more jcsentations, and e, however, the mediately afler usually in the and disappear- is favoral)le as Ivith the side nii disappears with ll, may result ii> id arc sometimes lor the memlicr from pre-exist- lons of blood in difficult hilM'i', Ived by injuries PATHOLOGY OF THE NFAV-hORN INFANT. 825 B. Irxjuries to the Skull and Other Bones. — 'I'he head of the now-born infant is eoniinoidy distorted by the pressure of liie iM'lvic walls in norn)al labors, each |)re.sentation and position eausinj; its cliarai^teristit! chanjre in the shape of tho infant's head, the distortion di.sappearinfjj a few iiours after deliv- iry. Injiu'ios of tiie fetus ail'eetinj; tiie bones of the head and extremities may iiecur from tlie pressure of instruments, from tho hand of tho obstetrician, and also spontan('(»usly f»« a result of very rapid labor, especially if i)irth takes place while the mother is .standing'. Fractures and lacerations of the sutures are likely to result from a contracted pelvis. Injuries to the cranial bones may be complete or incomplete fractin-os or simjdy doj)re.xsions ; any of them are fro(pi(iitly a.ss(K'iated with cephalhem- atoimi and intcrcranial hemorrhaj>;e. ('ranial fractures when at all nuirked are usually accompanied by an extracranial or intracranial hematoma. Pe- ripheral fractures may sometimes be extensive, and yet not be followed by serious consequences. Injuries of tho occipital bone sometimes prove very serious, on account of compression of the occipital foramen. Occasionally injury to the medulla results. Injuries to the .spinal column sometimes result from traction on tho child's feet or the breech in difficult labors. The injury consists usiudly in the separa- tion of one or more of the epiphyses ; tho ligaments are usiujlly unimpaired. Hemorrhages into the membranes nuiy occur. Fractures of the clavicle and the hiuuerus are likely to occur in bre<'eh presentations during the delivery of an arm. Separation of the epiphyses of the humerus may also occur, and it is liable to be mistaken for fracture of the neck of the scapula or for luxation of the humerus. This injury is always accomi)aniod by an inward rotation of the humerus. The treatment of these traumatic injuries, both of the soft parts and of the bones, will consist in observing the .same rules as for corresptrnding injuries in older patientKj. V. Iiy'uries to the Brain and the Peripheral Nerves : Obstetrical Paralysis. — In some labors which have been terminated by the use of for- ceps, as well as some where maniutl interference is necessary, either from pres- siu'c by the forceps or by twisting or stretching or direct press\u'e of the hand, there is simietimes noticed slight paralysis either upon one side of tho face or ill one of the oxtreuiities. The.se lesions may be of peripheral or of central origin, the latter being usually the result of cerebral or of sj)inal hemorrhage. These hemorrhages have already been de.seribed (p. 822). Injuries to the nerves are usually an aeeompaniment of severe injuries of the bones, the frac- tured ends pressing upon the peripheral nerves or on some plexus. One ft)rin of paralysis is frequently produced in the attom])t at delivering the arm : this form is known as Duchenno's obstetrical paralysis. Sometimes there will be slight bruises or ecchymosos of the face, and, where manual interference has taken place, of the arms and legs. The first sym])tom noticed is generally the want of jiropor action of the nuiscles of the face. In some cases there will be retraction of the eveball and contraction of • 71 1 t f 1 ■ & ^ If f , 4 \-\ V I «?:•" ' Ft . ■ " u. :; 1 ,'f; )^ 820 AMKlilCAN TEXT- nan K OF OIlSTKTItU'S. tlio pupil, n slipht droopiiifj; of tlic cyolid, tiHiially some irrojjiilaritv (if tli.^ mouth, iiiul want of expression of the side of the faee involved. Wiiore the paralysis involves an arm or a limb (Dnehenne's paralysis) the muscles will api>oar 8ofl and Hahby and the usual motions will !>(> absent. The (lidf/noKix of obstetrioal paralysis can be made without diffieultv, us it is hardly possible that anything else could pntduce the Hymptoms in a new- born infant. J'rdf/noniH, — Paralysis of the faee, the result (»f injury, usually disappears in the course of a few weeks. Paralysis involving larger trunks of nerves, :ni(i in eases where the injury has been considerable, will be longer in disappcir- ing, and in (piite a percentage of these cases some permanent deformity will remain. Tirdliiicnf. — In paralysis of the faee little more is necessary than to pnittri the parts which are bruised and ecchymosed by an antiseptic dressing, !iih| after a time to tise massage and electricity. Where the injury is to one of the extremities, the lind) should be very carefully protected by wool or ciittdn, proper support being made so that no dragging shall take place, and at the end of two or three weeks the use of oleetricity and massage, with the admin- istration of such internal remedies as are usually employed in such injiu'ios, such as small doses of nux vomica with general tonics to improve nutrition. When all acute symptoms disappear and contractions begin to be noticed, special attention should be given to the preventicm of detbrmities. o. Deviations from Some of the Physiological Processes which Characterize the Early Life of the Infant. Thrrk arc a number of conditions and processes peculiar to the earlv life of the infant that are especially liable to produce pathological conditions. Exfoliation of the Epidermis. — It is a fact that nearly all the organs and mucous membrauos of the new-born are predisposed to congestion and to a catarrhal condition which is accompanied by exfoliation of the superficial layer of cells. The great delicacy of the skin and nuicous membranes at this period is a decided predisposing cause to hemorrhage, and the great tendency to exfoliation readily affords entrance to the various forms of niicro-organisiiis which ])roduce (b'sease. Epstein pointed out that during the first days of life, as a rule, considerable exfoliation of epithelium takes place in the mucous mem- brane of the oral cavity. In this cavity there are t'vo points on either side of the posterior angle of the hard jialate that in a great number of chiklreii pre- sent e|)itlielial defects during the first days of life. Here the mucous niein- brane is very thin and anemic from the stretching of the pterygoid ligament in sucking and in opening the mouth. In these parts the superficial and deeper loss of epithelium occurs, especially if on attem|>ting to Avash the mouth of tlio new-born it is roughly handled. This shedding of epithelium is also particu- larly marked in the epithelium of the genital tract of female children. Icterus Neonatorum. — Icterus of the new-born can hardly be s|)()k<ii of as a disease, but rather as a phenomenon depending in many cases on natural I'ATJIOLOaY OF THE NHW-liOlty INFANT. 827 |troco.s.st's of th« first tlays of life It occurs in from 79 to 84 per coiit. of all infants (I'orak, Cruse), anil is most likely to m-cur in children prematurely l)orn or when lij^ation of the conl has been delayed. The yellow skin-diseol- uration occurs usually several days after hirtli, hut occasionally it exists in the pre-natal state. The discolorati<»n of the skin is usually not accompanied hy liny symptoms of disease, and is not very markinl, appearing first on the face, later on the trunk. In mild cases the sclerotics remain unatlected. This usual form of icterus neonatorum is physioloj^ical and is without serious symptoms; it usually disappears spontaneously within a week. If the howels arc slu>;^ish, small doses of rhubarb or hydrarfjjyrum cum ereta may be ^iven. The " symp- tomatic" form is more serious, on account of the patholo>rical conditions with which it is associated, and from which it must be ditferentiated. It is consid- ered on another l>age. There have Ik-cu many hypotheses as to the cause t>f the usual (the pliysio- loijical) form of jaundice, but no explanation has been oll'ercd that is entirely sntisfa(!tory. The two theories more jjenerally considered are — first, that of IhiiKitoi/cnic oritjin (Virchow's and others) — that is, the bil('-pi<iment is sup- |M).sed to oriffinatc in a rapid destruction of blotxl-corpnscles — and, second, the li<lt(ito(/etiie orijijin, in which the small common biliary duct liiils to carrv off excess of bile : these theories are fully described in the recent text-books on diseases of children. Mastitis. — The mammary <:;lands of infants, both male and female, often assume during the first two weeks a fun<'tion similar to lactation in the adult woman. The milky fluid secreted closely resend)les colostrum. This func- tional activity, being accompanied by con<^estion, is very likely to assume the form of inflammation, producinjf swelling:;, redness, and pain. External irritation, such as pressure, attempts on the part of the atten<linfj midwife or nurse to sepieczi! out the milk, etc., increase the tendency toward iiillammation. If ])roperly cared for, this physiolo<rical swellinjij will soon subside ; if irritated and perhaps sul))cctcd to much handlinix, producinj; abrasions of the epithelial covering, suppuration may occur. Infection of this gland is described on another page. P)'0(jnoHis and Tvcdtincnt. — The prognosis is generally good. Prophy- laxis occupies the first place in treatment. In cases accompanied by much swelling of the gland the latter may be dressed with vaseiin anil boratcd cot- ton. If swelling and redness of the skin occur, then the gland should be covered with an antiseptic wet dressing. Diseases of the Navel. — Under this head we may consider — (1) Anatom- ical and physiological considerations, and dressing of the navel ; (2) umbil- ical hemorrhage ; (3) slight disturbances of healing of navel wounds ; ulcera- tions and umbilical fungus; (4) umbilical hernia; umbilical fecal fistula; (•')) diseases of the umbilical vessels; (6) omphalitis; (7) gangrene of the navel. 1. AnATOMICAT. and PtlYSIOLOaiCAT. CoNSrOKRATinXS, AND DUKSSIXf} OF THE Navel. — Under normal conditions the umbilical cord desiccates ; i f I 'if' I ' J I :('! li ! f'i I 828 A3fEIiI('A.\ TEXT-BOOK OF OBSTETRICS. and drops off i'roin about the fourth to the i^'xtli day after the birth ol" the cliild. The cieatrix should then look clean, but it will remain moist ;iiii! rather soft until the tenth or the twelfth day. The dressing of the ei.iil should be such as to assist this normal process and to j)rcvent the formatinn of moist putrel'action. As will appear in this discussion, the umbilical wound is the eomnioiK-t atrium for infection which befalls the new-born, often with most disnstidi^ results. To prevent this accident the most explicit tlirections in regard in the antiseptic treatment of the umbilicus should be given to the attendant-. It is not sufficient to give the nurse verbal instructions simjjly to dress ihc cord as she thinks best, but it is the duty of the obstetrician to see not onlv that the cord is dressed in an antiseptic manner, but that it is also kept ])('i-- fectiy clean until the atrium for infection at this place is closed. Some such method as the following for treating the stump should he adopted : After cleansing the child, the abdomen and the cord should lie washed with an antiseptic Huid — bichlorid solution (1 : 10(H)) — and the cdid should be tied with a ligature that has previously been sterilized. The ((nd is now thoroughly washed with the same antiseptic liquid, and turned up a little to the left upon a ]>iece of sterilized gauze. Both the gauze and the cdid should be dusted over with boric acid, and then be covered by a compi(>ss nl' borated cotton. The cord should be thoroughly washed each day with steiil- ized water, and be dressed in the same manner each time. Particular atten- tion should be paid to the stump after the cord has fallen off; it should he dressed with .some antiseptic lotion, and the room in which the child is placed should carefully be guarded against all septic influences. kShould decomposi- tion of the cord take jilace jirevious to its .'separation, Kross advises a dressuig of bichlorid of mercury (1 : 1000). 2. O.MPHAi.ORKn.\<ii.v (UMnii.iCAi. IIkmouuhaok). — ITmbilical heinor- rhage is no disease, but ralher is a symptom of one of various pathological conditions. We distinguish two classes of omjihalorrhagia : First, hemoriliaiio from the vessels of the und)ili('al cord; second, hemorrhage from the iinihil- ical wound. Hemorrhage from the Umbilical Vessels. — Of this class there an> two varieties — one occurring before, and one after, the sei)aration of tin' cord. A. Jlemorrhagc before the sepantfion of the mnbUleal cord may occur if the ligature is not properly tied. The ligature may be loo loo^' , or it may have cut into the tissue of the cord, thus opening a blood-vessel, whereujioii liie hemorrhage takes jdace. I?ut it does not follow that in every ease of iiii|iei- fect ligattu'o of the cord a hemorrhage occurs. That this statement is true we know from numerous cases where, although no ligaliu'c had been used, im hemorrhage followed. At the birth of a living child, if it has cried lii>tily, a small amount of blood flows from the fetid end of the divided cord ten "V fifteen minutes after the cord is cut through. This blood is never tiie bliiilit red oxygenated blood. After a short time this slight hemorrhage stops. '" 'fnH'if I* PATHOLOGY OF THE XEW-BOUN INFANT. 829 isosi :i (Irossiii'j; The anatomical and patliolcigical investi}:;ations made by B, F. Schultze will assist to understand fully tlio above faots, as well as others relatinif to diseases of the unibilieal eord. With the lirst respiration of the new-born ( hild the expansion of the lungs leads to distention of the blood-vessels of the thorax ; thus the blood-pressure sinks in all the large vessels of the bodv. 'I "he greatest fall of the pressm-e occurs in the pulmonary artery, then in the aorta, then in the other large vessels, including the uml)ilieal artery. Thus the jiulse in the umbilical cord after a deep respiration is weakened and the arteries contain little blood. At the time the arterial pressure falls one (ihserves in the umbilical vessels an exceedingly niarke<l nuiscular contraction, and notices that the lumen of I'u vessels is rapidly reduced. Strawinski, who studied tiif peculiar arrangement of the muscles of the umbilical arteries, found in them an internal longitudinal and an external circular layer of the vessels, lie and Von Hasch also demonstrated, by measurement made in the lower animals, the actual reduction in l)lood-pressiu'e. 'i'he umbilical cord no longer receives blood from the ])lacenta ; the blood it already held has been aspirated into the thorax, so that the vein becomes empty and its walls contracted, although less energetically than the walls of the arterv. Kxpansion of the lungs and contraction of the inuscidar coat of the umbil- ical vessels are the two important factors which usually make severe hemor- rhages from the umbilical cord of the new-born child impossible. It nuist be stated, also, that in many of the lower animals the tendency to hemorrhage is lessened by various conditions, such as traction i»f ihe cord and by its being bitten off. But even in the human ott'spring a great tendency to hemorrhage (Iocs not exist, even though the (Ujature be not applied. This tiict has abun- dantly been corroborated by medico-legal experience, since in eases of illegiti- mate birth the cord is often cut by scissors and left untied, yet death by licmorrhai. > rarely occurs, if, however, in the new-bo':i child the respiration is imperfect, causing oidy partial expansion of the lungs, then the und)ilical Vi -iseis remain tilled with blood and pulsate strongly. Ji' asphyxia of the first degree bo the cause of imperfect respiration, the blood- pressure rises and the pulse becomes strong. In such a case, should the eord be severed and not ligated, ])rofuse hemorrhage would usually follow. This fact explains most hemorrhages following imperfect ligation of the cord. When, hipwever, such hemorrhages occur in matin-e and well-developed children, they must be due to insufficiency of the muscidaris. Hoffman fbinid that after iiirth the umbilical arteries do not contract evcidy tliroiighdut their extra- and intia-abdominal extent, but that the contraction takes place in a centripetal direction. The pulsation is first weakened in the portion nearest (he placenta, this weakening taking place progressively toward the umbilicns. For several niiiMites after the first respiration of the child there is still a full pulse-wave felt near the abdominal entrance, while the peripheral portion is i)Ioo(llc>s and eontracted. Ft caiuiot yet be decided what causes the iin|)crfect or only temporary con- traction of the blood-vessels. It is jnissible that increase of arterial pressure — f mm- 1 ' ' I ' I 830 AMERICAN TEXT-BOOK OF OBSTETRICS. as, for instance, in asphyxia — dinunishcs tlic rosistanoc of the musciilaii.; some authors believe that ])rotrac'tcd warm baths may produce rohixatimi of the niuscularis. For tlie prevention of hemorrhage a few ihiijs after birth desiccation of iho umbilical stump plays an important part. If the cord dries up noriimllv. then the dry, hard portions eifect a positive protection against the eveiiinal occurrence of hemorrhage; if, however, the cord should become gan<''i('ii(iii.- its vessels will become distended and may again become pervious. SdiiH' authors think that any obstruction to the return of venous blood to the licait may ])r()duce hemorrhage. Inasmuch as various conditions mav arise that would ])revent a physiologically bloodless condition of the umbiliciil cord and the obliteration of the tnnbilical vessels, it is to be urged in everv case that the cord be carefidly ligated. ProplniUuvix and Treatment: LUjatlon of the i'orit. — The ligature sliuuld be placed about two or three fingers' width from the navel. Particular caie must be taken with asphyxiated or premature children that the ligatuic is firm and that it does not cut into the tissues; for this reason a moist tape increases the security. If the cord is very thick, a second ligature may he applied after the cord is somewhat collapsed. The tape should be from lo to 2 centimeters (| inch) wide ; in case of hemorrhage a second ligature wuM K- a])plied. If the und)ilical end is too short or has been thrown off, a c()iii|in - sion bandage must be applied or the individual vessels nuist be secured hv encircling stitches. If the infant is anemic, stimulants must be administered and artificial heat must be applied to prevent collapse. For very gelatiiKnis cords Hudin advises the use of the elastic ligature: he found that in these cases a slight blood-pressure may suffice to j)roduce hemorrhage, even thuuuh the cord be ligated with a linen tape. Rough handling of the stump dniiiiir desiccation must of course be avoided. J}. JLinorrhaf/efrnm the Vnibi/ieal Wonnd. — (Omphalorrhagia ; also ealh'd " Idio])atliic" or "Spontaneous Hemorrhage.") — The appearance of a lew- drops of blood on the dressing immediately after the separation of the ediii, even though this occur for several days, is not uncommon, and generallv is of no importance. The ])atliol()gical condition to be here described is the one usually associated with grave constitutional disturbance, generally termi- nating in death. Fortunately, this form of hemorrhage is very rare; Wiiiekel found one ease in oOOO births, male children being attacked more fre(|ueiitlv than females, and strong, healthy children more fnupKMitly than the t'eelile. It is of interest to note the great numbei- of cases of und)ili('al liemcinliai;(' that have l)een re|)orted in America in contrast with thos(; in Europe. The condition occurs in the negro and the nudatto as well as in the white race. (iraudidier, to whom the writer is indebted for uuich information, colleeted a siunmary of 220 cases. T/ie etiolor/if of umbilical hemorrhage is still imperfectly understood. Imt it is evident that hemojdiilia is not the oidy cause. In "bleeders" uini)ilieMl hemorrhage is very rare; among 185 liunilies of bleeders, with 576 individiiMl.-- & ■ musculari . c rt'laxutimi catiim (if tile i|> nonutdly. tho cvoiilnul I gangn'iiiiii>, ^•ious. S(iint> , to tho lu'iiit ay arise lliat Ileal eortl ninl • ease that iln' gatiire slmiild 'artieular eaie the ligature is II a moist tape mature may lie bo IVoiii 1 h til raturc iri!st \h off, a ooiii|iii-.>- be seetireil hy le administi'ml v'crv gelatinous I that in thesi' even though sttimp (luriiiiT la ; also ealled iiiee ol' a few )n of th<' eonl, 11(1 generally is cperibed is the piicrally teriui- rare ; Winekel tro fre(iueiitly Kin the feelile. nl heinnriliagc Europe. Tlie the white race, ation, eoUeeted (h'fstood. I nit it (M-s " umiiilieiil 575 individual PATHOLOGY OF THE NEW-BORN INFANT. 831 who wci*e bleeilers, spontaneoii.s umbilioal hemorrhage occurred only in nine laniilies iu twelve individuals, and in the latter it i.s a question wiiether in all uf thera it occurred without the bleeding of large blood-vessels. Moreover, in the cases of spontaneous hemorrhage that have reooven'd it has not been (il)served that there was a tendency to bleeding in later life, while in hemo- iiliilia the disposition to hemorrhage usually remains through life. Grandidier offers the explanation of "transitory hemorrhagic diathesis" which has developed on account of changes in the respiration of the iiew- liorn ; but this is only a suggestion as to a cause. The (juestion is of inter- est whether the health of the parents, especially the mother, bears any rela- tion to the disease. In Grandidier's cases syphilitic disease was present six times in the mother and twice in the father. American physicians .state that the excessive use of alkaline remedi(\s during pregnancy is the cause of this difficulty. Others consider the depressing iiiHueiices, severe vomiting, and excessive thirst during ])regnancy as possible causes. If the results of post-mortem examination are examined, it will be found that the idiopathic umbilical hemorrhage is usually associated with one of the following con- ditions: (1) congenital syphilis; (2) sepsis; (3) acute fatty degeneration; (1) hemophilia. Si/p/ii(i.s is a cause of umbilical hemorrhage. Not alone (irandidier, but other authors liave found syphilis of the parents present in many cases of umbilical hemorrhage in children. The description of the syphilitic changes which the child showed during life, and which were found post-mortem, is siillicicnt to establish syphilis as an etiological factor. This oiiiuion is ren- dered .still more certain by the general t(.'iuleiicy to liemorrliag(> iu cinigenital syphilis. In cases of marked hemorrhagic diathesis it may happen that the lieinorrhage takes jilacc from the umbilical wound as well as from other organs. (SV'yw/,s'. — The observations of Weber, Hitter, and I^pstein leave little doubt that sepsis of the new-born may give rise to idiojiathic umbilical liemorrhage. It is known that capillary hemorrhages are of iVecpieiit oeeiir- ri'iiee in sepsis, but severe hemorrhages in various organs are also observed. Most of these cases were observed in orphan asylums. Epstein found among 51 children with this form of hemorrhage that 24 were suH'ering iVom acute .-rpticemia. Extensive gangnme of various parts of the surtiiee of the body i; frequently associated with this form of hemorrhage. KIcbs and his follower, Eppinger, attribiit'- the heinori-hages to the inva- sion of a micrococeiis, the motinK li(riiiorrli(i(/ici(iii. Often the blood-vessels ill the iiei<>;lil)oi|iood of the hemorrhajre were filled with the>e mierocoeei, which were also found constantly in th( blood. According to Colin and Wcigert, many cases of hemorrhage have been observed in which bacterial thrombus and emboli^::' are the cause of the extravasations. Th(> occurrence of umbilical heiuorrhage in (ifntij'iittt/ ili'i/ciicr/iflon will !»• tninid fully considere(l on another |»age. f ' i^ I Siiinj)t()m.'< (iiiil P/ij/sicdl Si(/iis of <iU llii'Kc I' (ll'll\X tl f If, fiiiorr/im/ 'i-.lt 832 AMERICAN TEXT-BOOK OF OBSTETRICS. l.ji 'm. hemorrhage generally manifests itself about the fifth day, usually just aii.i- occasionally before, the separation of the cord. According to Minot it inav occur as late as the second or the third week ; the subject mav be vx il developed and apparently healthy. The hemorrhage does not arise fr-jiii one or two distinct vessels, but oozes freely, like a fluid from a sponge. 'Ciie bleeding may at first be so slight as to be mistaken for the phvsiol()'ri(aI process above referred to, but its real signiticance will be manifested by tli(. persistent oozing or in a hemorrhage so severe at first as rai)iil]v to cxliaii-r the strength of the little patient. There is often slight icterus, sonictinus vomiting and colic, clay-colored stools, sometimes bloody discharge from tlic stomach and bowels ; in severe cases cyanosis and somnolence are pri .-(ni, showing that there is a marked and grave constitutional disturbance, in the neighborhood of the umbilicus occur spots of ecchymosis, that also uniMar in other parts of the body, so that the whole child appears mottled with bhii>li- red spots. Edema of the ankles and the hands frequently occurs, and it iii;i\ extend to other parts of the subcutaneous connective tissue. Death may f )llu\v in several hours, but the patient may live for two or three weeks. Graiididicr's statistics show a mortality of 8;'> per cent. Death is preceded by symptoms of collapse, coma, and occasionally convulsions. Differential Diagnosis. — The diagnosis of this form of umbilical hemor- rhage from the more common form first described is based on the grave constitutional disturbance which soon follows, and on the great difficiiUv, usually the impossibility, of checking the hemorrhage. TJierapeutics. — Since omphalorrhagia is a symptom of a number of con- stitutional diseases marked by a tendency to hemorrhage, the treatnuiit directed solely toward the arrest of hemorrhage will scarcely suffice. Usually all attempts at arresting the hemorrhage are futile. The employment of a styptic is only a temporary measure; it may be combined with firm pressure upon the wound. The most successful treatment consists in ligature ol" tlio navel according to Dubois' method. A hare-lip pin is passed along the (HJtro of the umbilical wound from ]:^t to right in such a way that the skin, l)iit not the whole thickness of the abdominal wall, is included. By means of a thread passed beneath the pin the navel is now raised, and a second pin is passed under the first pin, and at right angles to it, through the abdoiiiiiial wall. A figure-of-8 ligature is passed around the second pin, and, finally, cir- cularly around the base of the navel. This method is said to have arrotcd the hemorrhage in a few cases. A plaster-of-Paris bandage has been advised. The attempt to search for tlu^ vessels with a view to ligating them is almost never successfid. Hemorrhages occurring in other parts of the body are to he treated in a similar maimer. The internal treatment should be directeil (u the cause, but thus far promises very little. 3. Stjoht Disturhance in Hkalino of Navim, Woinds. — Occasion- ally when the process of desiccation of the cord has been incomplete, or wlicn there has been some irritation of (he navel by friction, espe(!ially wluii n(jt kept pcrtei'tly clean, excoriation and even ulceration may occur. In tlii> pf^-TUl'ilJ PATHOLOGY OF THE NEW-BORX IXFAXT. 833 jus-t Uil.'l', lot, it ni:iy ay 1)0 \v( il se tr'jm (jiic oiige. '["he liysiolo^ical *itcd by tlic V to oxhiuist ;, sonu'tiint's ge tVmn the arc |)r(\-('nt, U'baiK'o. I II t also apiifiir with bhiisli- s, and it iivay h may toltnw Graiulidicr's symptoms of jilical hcMimr- oii the ^nivc ■eat difficulty, .unbcr of vm- the tiviitiiuiit ffice. Usually pluymcnt of a firm pressure ligature of the [long the otljie the skin, hut By means of second pin is I the abdominal lul, finally, cir- havc arre -ted been ai hem is Ivised. almost body are to be Idireoted to the ll)S. — (Krasi'in- Iplete, or when vlly when lint r. Ill thi- leen event the treatment consists in cleansing the wound with an antiseptic; solution (;> per cent, boric acid) and in apjdying a mild astringent. Ilunge advises sali- (vlic acid and starch (1 : o to 1 : 3). The stump in those cases should be dressed twice a day. Umbilical Fungus. — If the woimd heals slowly and secretes for a lonsr time sero-purulent fluid, there sometimes then develops a red granular growth which bleeds readily, and from which there is more or less oozing of serous or soro-jiurulent fluid. This growth in some cases has a broad base; in other cases one or more of the growths ar(> pedunculated, soft, and not sensitive. In the early weeks these growths may be visible only on retracting the surround- ing integument, but later, if not arrested, they may form an elevation of con- siderable extent surrounded by excoriatious. Usiudly the health of the child d(ies not suffer. The fuutjus itself is not sensitive, but the surroundinsr exco- riation may become painful. Histologically, this fungus is a granulation tumor. The wound in the navel, as a rule, cannot heal while the fungus exists, although in very exceptional cases the growth may become covered with epidermis. This disease must be difl'erentiated from the adenoma de- scribed by Kustner. Tlie trcdtment consists in cauterizing the growth with nitrate of silver and applying a salicylic-acid bandage. Removal by scissors is likely to produce considerable hemorrhage. Diseases of the umbilical vessels, omphalitis, and gangrene of the cord are considered on other pages of this work. 4. Umbilicaf.-cokd IlKHXt.K (lleruito Funiculi Uiid)ilicalis). — Und)ilical- coi'd hernia depends upon the arrest of developmiMit of the abdominal wall in the first stages of fetal life. Frequently other malformations are present, st'.eh as hare-lip, club-foot, hydrocephalus, and spina Itifida. Lange found from a study of 21 cases collected in literature that in seventeen of them other malformations were also present. There will be considered in this discussion only such cases of umbilical-cord hernia as are not associatcfl with other mal- forniations which interfere with life. Anatomi/. — The umbilical-oord hernia is a round or an oval swelling in the uinhilical region, varying in size from a nut to that of an orange; occasiou- ;illv larger. The tumor may occupy the greater part of the abdominal wall. The hernial sac consists of peritoneum, covered by the amnion which originates fi'oiu the umbilical cord and reaches the base of the swelling. The base of the swelling is continuous with defi'ctive integiunent. Sometimes a small part iif the skin reaches a little over the tunmr. Between the external covering ;i!i(l the iHMMtoneunt is a thin layer of Wharton's jelly, 'fln^ amnion and peri- toneum may be firmly united. The sac usually contains some intestine, at times also the liver, stomach, spleen, and other viscera, such as the kidneys anil |)ane-eas. Two or more of these viscera may be ixmnd together by adhe- MoiH. The implantation of the umbilical coi'd is sometimes on the summit of the swelling, more often somewhat deeper. The umbilical vessels jiass from the e(inl between the amnion and the pei'itoneiim over the swelling to 'ii Hi! I':'Hi 834 AMEniCAN TEXT- BOOK OF OBSTETRICS. 'mm it, tlie alxlominal defect, the veins ])as.sing to the liver and the arteries towaid the bladder. CUnkal Appearance. — Immediately after birth the thin amniotic eovcrini^r of the und)ilical-eord hernia presents a grayi.sh-wliite, translucent appearance; the presence of meconium in the intestines gives the swelling a dark green colur. On palpation one may detect peristaltic motion of the intestine; the presence of a part or of the entire liver renders the contents of tlie tumor fniiK r. During the process of desiccation in the innbilical cord in the next I'vw dnvs the appearance of the hernia is nuich clianged. The circular edge of skin at the base is reddened, and suppuration often takes place. After separation df the amnion active granuhition may build up tlie edge of the nk-cr. The wound-surface grows less, the edges contract, and finally the hernia may cinse by cicatricial contraction. Death often I'csults. By rough handling tlie hernia may become gangrenous ; in this case the gangrene is liable to extend into the contents of the sac, and the child dies of sepsis. In other cases suppuraiion extends along the umbilical arteries or directly to the peritoneum, and death is due to arteritis umbilicalis or to peritonitis. Diarpiotiis, — A case of large und)ilical-cord hernia can scarcely be niistakeii for anything else. Small hernite of cylindrical form are more a])t to lead to error in diagnosis. In all cases of marked swelling of the umbilical cunl at its fetal insertion one should thiidc of the possibility of hernia of the cord. Pi'ofptosis. — Formerly the prognosis was considered always bad. In 1S.S4, liindfors taught that healing without operative measures might be procured hv suitable retention. Previous to his time cases of healing by j)rotection and compression had been reported. More recently the jjrognosis has become some- what more favorable, but the mortality still remains high. Treatment. — The treatment has already been indicaied. It consists of two methods: first, favoring natural tendency to obliteration; and, second, the radical operation. The first method consists in favoring desiccation by applv- ing careful antiseptic dressing of iodoform, aristol, zinc, or bisnnitli. The hernia shoidd be protected by a cotton compress, and when the cord and anmieii have dropped off granulation of the edges must be favored by the application of solutions of nitrate of silver. As soon as reduction .seems )H)ssible it nuisl very carefully be performed, and a compression pad be apj)lied and held in place by adhesive sti'Mps. Riidical Operation. — If this method is clutscn, the operation should be per- formed soon after birth. In this case all efl'orts at reposition are omitted. Twenty-four hours previous vo the operation iodoform dressings are applied. The o})eration consists in u'.aking a circular incision into the skin at the ha«i of the swelling, .2 to .5 centimeter {\ inch) outside of the sac, cutting down close to the peritoneum. After examination ttf the contents and separation el' adhesions the abdominal wall is closed by interrupted sutures, taking care to bring the e<lges of the skin into ])crfcct ap|)osition. In liS8,'i to 188J), Lindfors in his collection of 10 oi)erative cases had seven recoveries. Hiiicc iheii he has added to the number. MacDonald in 1S"J0 had I M' I'ATIIOLOdY OF Tin: XKW'-JiORX JXFAXT. 8:5") ;t consists of two and, sLH'ona, the -cation by iipply- bisniuth. TIk- [.(ird and amnion V the appli^'ation Ition arc oniiltfil. Isings arc applifi. f^kin at tlio l)!i-' sac, cnttinii- '1"^^" and separation ot ]i) cases with seventeen recoveries. Since then other operators liave met with hai)py results. 4. Infectious Diseases of the New-born. It has long hoon observed that occasionally a child born in ap])arentlv por- f'trt health, with good family history and with excellent hygienic snrronnd- iiigs, has developed during the lirst days of its life a disease characterized bv high temperature, exhaustion, collapse, and death. Sometimes there has been found a local trouble which explained the cause of these phenomena, but fre- (|ii(ntly nothing could be noticed. FrctjKcnci/. — The occurrence of infection of the new-born is probably ijivater in private practice than is generally recognized. It is tiiir to suj)pose that in many infants attacked with fever and i)rostration, accompanied possibly witli some jaundice and continued exhaustion, a fatal result takes place from septic infection. In hospitals a high percentage has always been acknowledged. Miller found that 700 or 800 deaths occurred yearly from diilerent foiiiis of sepsis of the new-born. FJioliHjy. — In considering the etiology of sepsis of the new-born we cannot iivoid some reference to the subject of sepsis in ntcro. After an extensive .-wirch through medical literature Von Holtz positively asserted that although septicemia tn iitero was rare, it undoubtedly occurred. For this earlv l()rm of sepsis the two modes of genesis which have been assumed, and which have given rise to consid'M'able debate and experimental research, are iihiwnldl infection and infection f :/ <tsj)ii'(ition of the (imniotic, Jinid. Although the jila- cental transmission of se])tic micr»j-organisms from the mother to the fetus lias not i'ully been demonstrated, either clinically or experimentally, this pos- sibility can hardly be denied. Several cases accurately described bv A\'eber, Biild, and Orth leave little doubt as to this mode of infection. The theory of fetal sepsis produced by the aspiration of either jMitrid anniiotic fluid or iftMiital secretions seems probable from a case described by Kiistner; experi- ments made by Hohenhausen and (tcyl are cited in sujjport of this theorv, hut the evidences are not conclusive. Many other theories have been advanced on the means by which tiie oi-gan- ism of the new-born may be invaded by intectious matter. P. Miillcr iiiade exper'ments to prove that disease-germs are transmitted from mother to child by means of the mother's milk. There has be(>n demonstrated, on the one hand, the i)resence of sta]>hylococci in the milk of septic pu(>rperal women, but, on the other hand, since staphylococci have lu'cn tliund in the milk of healthy w(mien, and since such nn'lk has not been injurious to the ehililren who were nourished by it, since also children inu'sing fron; Wdinen with septic diseases hav<^ remained healthv, the (piestiou of sepsis being trans- mitted throuixh mother's milk nuist still be considered unsolved. Air-infection is another theory, according to which tlic fetus th.nt has aspinitcd amniotic fluid will contain a favorable culture-medium in its lungs tor pathogenic germs that may exist in the sick-room. t I wP^ |iF & > I n •*; 836 AMERIVAN TEXT-BOOK OF OliSTETIiH'S. Pdthohxjii. — I'atliolojfit'al coiulitioiis will diifcr accord iii<^ to the cause ul'ilu. infoctiuii. Ill sonic cases tlic iiifcctioii-atriiiin cannot be tbuiul : if it i.«, ||„, navel, diseases ol' hlood-vcssels will be tbiiiid, with evidences of stiitic uvy]. tonitis and iiiHaniiiiation of other abdoiniiial orpins. If the infectidn i,;,^ taken place through the mucous nietnbranes, we find the patholoijieal <'<)niii- tioiis present in the month, the larynx, and the upper aii>passaj;-es, as well ;i< in the intestinal mucous meiiibraiie. Evidences of septic piieiinKniia \\li|i bloody exudate into the pleura and pericardium have been found. SdnieliuK •< hemorrha<!;e.s have taken place into the brain, the lunu;s, and the kidiu \^ This result is due partly to diseases of the liver and partly to intlaniniatinn of the veins of the umbilicus. Sipnptoins. — The manifestations of infection of the new-born nec(»aiilv vary as different organs are inv(jlved or as the entire system is invadcij. ISIaiiy of these cases of infectious disease are characterized by a rapitl Iiks di' weight and by restlessness and insomnia. There is usually a rapiil and shal- low respiration, attended with vomiting and diarrhea. The temperatinc is frc- (piently 105° F., l)Ut in some cases where the infection is profound coilanx' will early occur. Some of these attacks, with symptoms that are exceedinolv severe for a short time, are aborted. In other cases nothing is observed until about the fifth or the seventh day, when usually there will be found in tlif region of the umbilicus some evidences of suppuration, or at least some redness, with possibly a bad odor. These symptoms are st)metimes followed bv (li|)li- theritic exudates in different parts of the body. The child is fretful, its tem- })eraturc rises to 102° F. or higher, very frequently the abdomen is hard and tender, and septic peritonitis and death iiillow. Other symptoms, such as icterus and melena, may be associated with sepsis. They are not invariably present, and are sometimes described as special dis- eases. Icterus, in its general application, is considered on another page, lait its special relation to sepsis will be considered under Icterus Si/niptomaliciix, also under (iddro-intentinal Ilemorrfiaf/e. In other cases the symptoms are those which would come under one of the ((ni- ditions presently to be described — infection of the umbilicus, erysipelas, mastitis. Wound-infection. — The atrium for infection in the great majority ot' cases is doubtless through some wound, such as traumatic injuries due to delivery, or lesions of the mucous membranes due to physiological i)riK('sses of desquamation, but, most frequently of all, through the umbilical woniul. Prof. J. licwis iSmith makes the following classification: 1. Uinbiliial phlegmon, or local sepsis; 2. Sepsis following the introduction o\' poison through the umbilical s'cin ; and 3. Sepsis received in other ways or tliroiigh channels other than the umbilicus. A. iNKKrrrox tmuough the Umhilict'S. — This condition includes many of the abnormal conditions of the navel. The milder forms of infection inter- fering slightly with a normal healing process or producing ulceration arc con- sidered on page 832. The graver forms of infection of the umbilicus aro diseases of the umbilical vessels, omphalitis, and gangrene. jr^vf 1111. PATiioLoav or the nfav-houx ixfaxt. h;j7 if il i.- tin' septic iHii- nl'fi'tiiin !i;i- [yArA ('(inili- s, as wfll iis iimonia \mi1i tlu' Ividiii V-. iiillammatiiiu n\ nct't'-^arily 111 is iuvailnl. , vi\])'\(\ 1^>-^^ "' lipid and shal- pcraturc is tVc- ifouiul collapse ivo oxcocdiii>j;ly observed until )e ibimd in the ii some redness, llowed by diph- IVctful, its teia- uen is hard anil ,\ted with ^epsis. d as special dis- l)iit its ler pa;j;e, aticH!<, alstj iiptoni evoneoftheeon- 'sipelas, mastitis, rcat majority ol inpiries due to Uogical processes (imbilieal wound. 1. rnibilical Letion of itoisoit ways orihrou'^di |,n includes many If infection intev- llceration arc coii- Ihe umbilieii- are Diseases of the Umbilical Vessels — Arteritis and Phlebitis. — A<'eor(l- iiifr to lliiiigo, arteritis and phlebitis of the umbilious are of septic orit^in, the iormer occurring more frequently than the latter. The infection first attacks the perivascular connective tissue, extends t(i the advontitia, and ])rodnces dila- tation and thronibo.sis, after which the disintegration of the thrombus may induce general .sepsis, the infection being conveyed through the lymphatics. ( )ceasi()nally localized disea.se of the vessels may produce death. S]imptoin.s. — There are no sym])toms which would indicate with certainty the existence of arteritis or of phlebitis of the navel, but w(! can infer that these condition.s exist where local ulcerative or su])])nrativc jirocesses are associated with much constitutional disturbance. The course of the diseases is often acute. A child who is ap])arently well may suddenly manifest restlessness, followed by collapse and death. At other times there arc the usual symptoms of general sepsis. I)i(i(/nosis, Pro(/no,^is, and Treat iiwiif. — The diagnosis usually cannot be made definitely until after death. Cases of the milder form, occurring in children who are well develo])ed, usually recover. For children ])rematurely horn the prognosis is grave. The treatment consists in the use of antisej)tic dressings, and in adopting all jwssible means to support the strength by nourishment and alcoholic stimulants. Omphalitis, — This aifetttion is an infiammation of the navel with phleg- mon of the surrounding tissues. In the region of the navel there is a red swelling, at the apex of which the navel may be observed. Usually the healing of the wound is incomplete. The redness and inflammation extend in a circle around the .stump, the skin is tense, without wrinkles, and glisten- ing, and the abdominal wall is hard, infiltrated, and very sensitive. This infiltration may involve the greater part of the abdominal wall, and may even extend to the deeper tissues down to the peritoneum. The child is restless, has fever, pain upon every motion, even on respiration, and consequently assumes a fixed attitude ; respiration becomes costal, the lower extremities are drawn up toward the abdomen and are held immovably in that position. On the siu'face of the abdomen dilated veins may be seen. The (lisea.se may last (lavs or weeks. It nsuallv begins in the second or the third week. The ter- inination is favorable if the disease is not too extensive, but if inflammation involves the abdominal wall, peritonitis is likely to follow, li' the navel ves- sels become diseased, gangrene may result. Prognosis and Treatment. — The younger the child the more favorable is the prognosis. The treatment consi.sts in the use of antisejitic dressings, of which salicylic acid and iodoform are the best. If suppiu'ation takes pla(.'e, the pus nmst be evacuated early. The constitutional treatment is the same a.s thiit for arteritis and phlebitis. Gangrene of the Navel. — Gangrene arises from idcers of the umbilicus, from general inflammation due to sepsis, and from cholera infantum. As a local infection of the navel it is not infrequent, especially when the patient is iieirlected. t 838 A.VKh'fCAX TEXT- HOOK OF OIISTETRIVS. Si/iitj)h)iiiK. — The iiiarjjin ot" tlio wuund of the navel hocnmcs discolnnMl aiiil there is mure or less ooziii*^ (if a muddy fluid, or, in oin|)lialitis, a vesicK' nmv form eontainiiijf tiirl)id fluid. When this vesicle hursts it leaves a raw surface. The spreading; of the moist «i:aiif;rene may he rapid, may larjrelv he on the surface of or deep in the navel ; the latter condition is the most (lanucr- ous. There is always fetid odor. If the child is stron<i, tlien the process niav become arrested and the defect may heal hy gramdation, hut usuallv there is rapid loss of streiij^th, terminating^ the second or the thinl dav in deatli. Gan«frene follo\vin<i: cholera infantum usually terminates rapidlv in <;eii(ral sepsis and death, hut this fatal termination has occurred as late as the twcutv- third day. Peritonitis sometimes occurs in which perforation of the intotiiics may take j)lace, leaving a fecal fistida. Profuse hemorrhage is one of tlic probable complications. Treatment. — A 3 per cent, solution of acetum aluminum, applied wiili a compress covered with rubber cloth, acts antb^eptically and hastens the separa- tion of the slough ; after that the indications for treatment are to su))port tlie strength by nourishment and alcoholic stimulants. B. In'I'Kctiox of Otiikii WoI'XDs. — Various injuries upon the bodv of the child may lead to wound-infection tiie same as occurs in the navel wound. In i)re-antiseptic times frcfpiently small, insignificant injuries of the skin of the child from pressure of the forceps were followed by phlegmonous iiitl;iiii- mation about the injury, and sometimes by general sepsis. The infection in such eases was transmitted by unclean instruments or hands (hiring lalxu' or after the birth of the child. In a similar manner various infections iiiav follow if operations are done upon the child and asepsis and antisepsis arc iidt observed, as in opening a ce])haliu'matoma, in operating for umbilical in rnia or spina bifida, in opening a mammary abscess, etc. It may occur in tlut cutting of the band in a tongue-tied child or through the ritual of circum- cision. The most fretpient entrance of infection is through the defects in the epidermis and mucosa pnxlueed by the tendency to exfoliation referred to on page 826. The infection may also take place about the buttocks if the bed or tlio clothing be impregnated with septic material. Infections about the inoiitli and the buttocks may lead to severe intestinal inflammation. Through the mucous mend)rane of the genital tract of the female child infection may alsd take ])lace on account of the shedding of epithelium, and the infection may take on a di]ihtheritic nature and lead to gangrene of the external genital organs, terminating in the deatli of the child. Gonorrheal infection from the parturient canal of the mother is doubtless often transmitted to the giiiital tract of the female child, leading to obstinate leiicorrheal discharges which occur in early life. Erysipelas. — Upon taking up a work on Diseases of CJiildren, written in 1800 by Mi(>liael Underwood, the writer found under the head of " Infan- tile Erysipelas" a description of unquestionably septic processes which to-day would be charged to bacterial infection. The writer is tempted to (juotc freely II i rATllOLOUY OF THE XEW-llonX IXFAXT. 8;}9 f colorcil ;nul vcsicU' may avcs ;i raw V l:ir;i'<'ly lie iKist ilimi^cr- nmccss uuiv lally tlnMc i- ay ill tlcatli. V in p'licval ■; tlic twcnty- the intestines s one (il the )plieil witli a ns the separa- to suitp"!'* the \ the bo'ly *'t" tiavol woiiinl. ;)t' the skin of iionous iiitlam- "he infection in nrinpj lnhor tn- infections may itisepsis are not [nhilieal hernia y occur in the tual of cirenm- iC defects in the vcforrecl to en I the bed or tlio Unit the month Throniih tlie Ifection may also |e infection may external livnital fection from tlio h to the iienital lischaro'cs wliieh \mh-cn, wi'i'"'" Ics which tn-(1ay h to (luote freely from this old work, hotli from tlio fijciieral interest in a voice from the past and from its particular aptness and historical value. Tiio author says: "This ilispase does not appear to ho distinctly noticed by any j)reeedinjr \vrit('r. The i'ronoh have, indeed, spoken lately of a somewhat simihir alfection, combined with other con>j)hiints infesting crowded hospitals, but the disease does not appear to have been anywhere noticed in its simple and ifemnne form. I think it may with propriety be termed the Intimtile Erysipelas. It is a very dangerous species of that spurious inHammation, and it is not very often met with outside of lying-in hospitals. The ordinary time of its attacks is a ll.'w (lays after birth, but it is sometimes mot with much later. It seizes upon the most robust as well as delicate children, and in an instantaneous manner; the progress is rapid ; the skin turns of a purj)lish hue, and soon becomes exceed- ingly hard. '* The milder species of it appears often on the fingers and hands or the feet and ankles, and sometimes upon or near the joints, forming matter in a very short time. The more violent kind is generally seated about the share-l)one (or pelvis), and extends upward on tiie belly and down the tlilghs and legs, though sometimes it begins in the neck, and is ctpially fatal." (The author i)elieved it more dangerous as it atl'ects the central part of the body.) " In a few instances the disease has been attended by some varieties. Infants have not only come into the world with several hard and inflammatory patches and ichorous blisters about the belly and thighs, but with other spots already actually in a state of mortification." Since the time of Underwood it has been noticed that epidemics of puer- peral infection have been followed by deaths of a considerable ninnber of chil- dren from erysipelas or local phlegmon or from diseases of the internal organs not so easily differentiated. It has remained, however, for the new pathology of the present generation to give a fair explanation of its etiology. It has been found, on the one hand, that no micro-organisms are present in vessels of the stump of the navel cord which has been removed under the strictest antiseptic precautions; on the other hand, it has been demonstrated that germs of various diseases exist in the cord and blood-vessels of eiiildren wlio suffer from symptoms which have been named al)ove. The following is the history of a case of erysipelas vulva? : C. B., age three months, twin, female. Four days after the boy twin was circmncised hy a iabl)i the baby girl was taken sick. The preputial wound of the boy healed nicely after iiaving a slight )>nrident secretion for a fi'w days. Diajx-rs were used in common for botii babies. Tiio temperattu'o of the female twin was sod) 105° F., pulse 140, and there were swelling and redness of the lai)ia, in a ' ,v hours extending to the thighs and lower ]>art of the i>aek. Tiie redness '.IS shiny, and clearly defined with slightly raised margin. On the second day tice process had extended over the entire bat'k. On the evening of the second (lay the temperature was 10")° and the )>ulse 1(50, and the ciiild was restless. There was typical Cheyne-Stokes respiration. During the next tliree days the procx'ss abated over the back, but extended downward, involving thighs, legs, ^IfPP' IMAGE EVALUATION TEST TARGET (MT-3) // ^^ >^fe. /./ yJ^ i.O I.I 1.25 ■ 50 "^^ M^^ us Iii2 |2.2 6" PhotDgraphic Sciences Corporation 23 W*'T M^IN STRUT WEBSTIR.N.V. 14590 (716)872-4S03 V iV a>^ c\ \ ^ 6^ 4^0 l/.A I 840 AMERICAN TEXT-BOOK OF OBSTETRICS. m- a!id feot. At the end of twelve days the swelling and ralness had all !is- appeared. As soon as the process began to lessen on the trunk and extend to the lower extremities the condition of the patient began to iniprov*.-. Peritonitis. — Acute peritonitis in the new-bi.rn is always septic, ami it usually results from the absorption of septic material at the und)ilical woiind or from umbilical phlebitis or arteritis. It is almost unknown in niivatc practice. Runge found only four cases of peritonitis among 55 post-iiior- tenis in infants dying of umbilical arteritis and of septicemia the result of puerperal infection. In puerperal peritonitis death most commonly occins within a week. Pleuro-pneumonia occasionally exists in these cases of septic infection. Syiuptomi* and Treaiment. — The early symptoms are usually those of crv- sijielas around the base of the cord. There may be vomiting, diarrhea, jaun- dice, distention of the abdomen, fever, and wasting. The treabnenf of Ixitli pritonitis and pleuro-pneumonia at this early period of life consists oliicHy of prophylactic measures. When the diseases have appeared, notwithstanding prophylaxis, the main reliance is free stimulation. Phlegrmasia. — This disease, which takes place in a considerable iiunil)or of infants, is analogous to phlegmasia in adults, except in certjiin moditiciitions with respect to the special anatomy of the first days after birth. It is un- doubtedly a septic infection, usually associated with septic disease of the blood- vessels of the cord. Parotitis. — A case of suppurative parotitis with a fatal result, and septic infection through the umbilicus, producing endocarditis, and resulting talallv at the eighth week, has been placed on record. Mastitis. — The milder form of mastitis has been described on page S'27. The mammary gland often gives entrance to infwtion, either by way (jf the milk-duets or through slight injuries to the nipple, owing to improper manipu- lation or from pressure or bruising of the gland. If, in case of slight inlec- tion, the little gland is carefully guarded against new invasions, and is dressed with boric acid or with a solution of the bichlorid of mercury, the hardness and pain usually disa])pear, and the restdt will be all that one could desire. If, however, the breast is mechanically irritatetl, and thus made more vulnei- able, and if attention to cleanliness be neglected, pus in all probability w ill form. Symptoms. — The infection begins usually in the second week of life, with marked redness of the overlying skin and increased tenderness upon pres- sure. If at this point the disease is not averted, then there is an increase in the swelling, I'cdness, and tenderness. The diseased gland becomes inereased in size, tisually in circumscribetl portions. With the developing redness of the skin there arc formed in the gland absceases which finally rupture and dis- charge one or two teaspoonfuls of pus. During the abscess-formation the child is restless and its temperature high. After the discharge of the pus eou- valescence is usually uninterrupted and the cavity ra])idly heals. Socondaiy abscesses are seldom formed; the disease usually involves but one of the i It. PATHOLOGY OF THE XFAi-JiOnX jyFAXT. 841 ii;laiuls. Ill other cases the disease does not roniaiii liinite<l to the gland, hnt extends to the surrounding tissne ; it then hwomos pcniiKtutllis. In tiiis ease tlio extension of the infiltration may he very great, reaching to the axillary space. Then the temperature rises very high and there is rapid loss of weight. As soon as the ahscess is opentxl the symptoms ahate. The contents of these al)scesses may be very fetid and contain sloughs of tissue. In such cases death from sepsis has been recorded. Dr. Bush narrates the following extremely interesting case of sepsis of the now-born : A healthy child, born at full term, weighing nine poiuids. In soven days the cord fell off, leaving a granulating surface. On the fifth day of life the mammary glands were swollen and some fluid exuded. In two days tiiere was greater swelling in the left, but not in the right, side. Five days: later (twelfth day) the entire right side, half of the thorax from the middle of the sternum to the axillary line, were hot, swollen, hard, dusky-retl in color, with fluctuation about the breast. Green stools and fever were present. Open- ing of the abscess evacuated 30 cubic centimetei's (1 ounce) of sero-sanguinolent fliiid with some tissue. There was a constant discharge of bloody, foui-smell- iiig matter, but for the time the child improved. Two days later there was a second opening, and ultimately large ulcers formed, which extended to the ribs, so that the pleura lay naked at the bottom of the wound, death taking place at tlio end of ten weeks. lite prognosis is generally good, but in the development of the glandular function at a later period of life atrophy of the diseased gland may follow. In female children this atrophy may interfere with the function of lactation later in life ; it may also lead to retraction of the nipples. Treatment. — The prophylactic treatment for mild forms of mastitis has been indicated on page 827. If swelling and redness of the skin occur, then tlio gland should be covered with a wet antiseptic dressing. If suppuration occurs, the abscess should be opened early. The incision is made in the direc- tion radiating from the nipple ; the after-treatment is according to general surgical principles. If the tissues outside the gland are involved, then early incision is indicated. Carbolic preparations in the treatment of these wounds sliould be avoided. The little patient's strength must be supportetl by appro- priate food and stimulants. Tetanus Neonatorum. — This disease consists of tonic spasms of the niasseters, extending rapidly to the voluntary muscles. The disease usually begins at the time of the separation of the stump of the cord — that is, from tin- fifth to the ninth day after birth. It is now much loss frofpicnt than in former years. An examination of early literature on ])o«liatrics shows that in oldon times death from this disease very frequently occurred. Etiology. — Formerly the cause of this disease was assigne<l to various con- ditions; dense population was thought to be a predisposing cause, locality another (Keating). It is particularly common in tlio tropics. In East India and in Africa the disease is ])articnlarly fatal ; in Jamaica 25 per cent, of the iio<;ro children die each vear. In New Orleans and in IJaltimore the mortality ^ n I *l 1'^ 842 AMERIVAN TEXT-HOOK OF OBHTETRICS. ^ % ii'i' from this source was formerly very j^rcat. Pressure upon tl>o brain and neglect of ordinary care of the infimt were also considered special caii^o • npon closer study, however, it seems that one cause, common to all, !< filth. According to the recent teachings of Pathology, tetanus is a wound-in Icc- tion (Briegcr) produceil by the tetanus bacilli, inoculating, as a rule, the navel wound and there producing ptomai'ns (described by Bricger), of which tifmiia is the most characteristic. Any wound of the new-born may thus be inncii- latcd. It has been proven that these bacilli occur upon the surface oi" tli" earth, particularly in the dust that accumulates upon the floors of houses, it is easily understood how in this way the bacilli may l)e introduced into a wound, especially under conditions unfavorable to asepsis. It is also appan nr why in tropical regions, in crowded cities, and among the p(Kir this disease lias been of such frightful prevalence. Hartigan and Hirsch describe the disease as occurring very frequently among the negroes, with whom it is a practice to apply to the navel the roots of certain plants. Pathological Anatomy. — Autopsies have thus far shown nothing character- istic of the disease. There are usually exudates of bloody serimi in tli(! spinal meninges, and some extravasations of blood which may be the result of flic violent spasms. Similar changes are found in strychnin tetanus. Tiie other organs show nothing characteristic or constant. The navel wound niav seem perfectly normal ; occasionally there is suppuration of the wound and some disease of the vessels. Symptoms, — The most marketl symptoms are those pertaining to the mus- cular system. Premonitory symptoms are usually present for many hours, and sometimes days : restlessness, sudden cries during sleep, ditticiilty in nursing, rigidity of the muscles of masticaticm, these muscles being as hard as wood. The mouth cainiot be opened, the lips are pressed togeth.er, sometimes protruding; the brow is corrugatetl ; at times there is an extreme sensitive- ness of the entire surface of the body. Later there is ditficulty in swallow- ing, which frcfiuently becomes impossible. Pidse and respiration are fre(juent, and there are sometimes diarrhea and urinary disturbances. When the mnseles of mastication are involved, this condition is called " trismus ;" when there is general rigidity of all the muscles, we speak of it as " tetanus." The opis- thotonos by this time is particularly noticeable, and the abdomen is alsd hard ; the arms and hands are flexed. As a general thing, however, tlie uuiscles of the body are less involved than those of mastication ; the eoM- vulsions are at first clonic, becoming after awliile contiimous. The respi- rat(»ry nuiscles are only slightly att'ected. Spasms of the laryngeal muscles may cause sudden death. Laceration of muscles and fracture of bones have occurred as complications of the disease ; paralysis of grotips of muscles may remain. DlagnoxiH and Prognoi^iH. — The diagnosis is based on spasm of the masseter muscles, followed by opisthotonos and general hyperesthesia. Unless treatment is commenced early the outlook is unfavorable. The attacks become more tVe- f.Ml: f! PATIIOLOaY OF THE XKW'-BORX IXFAXT. 843 (|iient and more intcnso, tlic pntiont loses flesh, liyporestliosia of llic skin jicconi- panios rigidity of the tnnseidar system, and finally death takes plaw. The proplii/fnctic trcatinrnt coufi'xHtfi in observing ahsohiti; <'leanliness on the part of the attenihuits. The antiseptie treatment of the nmhilieal woinul mnst lie insiste<l npon. Long befon; the nature of tetanus was understood cauter- i/ation of the nmhilieal wound was employed. When the disease is fully (Icveloptnl, its management eonsists in making the symptoms as light as pos- sible and in supporting the strength of the ehild. The little patient shoidd he isolated. The first indieation is usually met by means of narcotics, among which chloral is useful : 1^ grains may be given by the mouth, and twice that amount by the rectum ; 15 to 30 grains may be given per diem. Opium does iKit meet with nnieh favor. C'ldoroform inhalations are also useful. The action of the narcotics is increased by the use of hot baths every one to three jninrs. A great many other narcotics have been recommended, such as the hromids, extract of Calabar bean, atropin, etc. Icterus Symptomaticus. — The icterus which is often associated with infections disease is designated the "symptomatic form of icterus." It occurs ill septicemia, in syphilis, in Winckel's disease, and in Buhl's disease. It is tiiis association with grave constitutional disturbances that distinguishes it from the mild form described on pag(! 826. In this grave form the dis- coloration is more marked, the sclerotic is usually deeply tinte«l, and there is rapid loss of body-weight. Tliere is also marked increase of urea and uric acid in the urine. Tlir jKilhohf/ical cnndidnni* at this time of life that are most commoidy met with in icterus are — obliteration of the hepati'- duct, due either to congenital stricture or to syphilitic perihepatitis, stipticemia, Buhl's disease, and Winckel's disease. Treat incut. — The treatment for icterus is indicated by the condition on which it depends. Buhl's Disease (Acute Patty Degeneration). — Pathof/cnmH and Eti- oln(/tj. — In 18(50, Buhl described a disease whose anatomical characteristics were parenchymatous inflammation and fatty degeneration and hemorrhages in the heart, the liver, and the kidneys. The cause of this disease is not yet known. Some authors deny, while others accept, a septic infection (Miiller). l>igclow found micro-organisms in the organs in cases of acute fatty degen- eration. J'atholof/ical Anatomif. — The body is cyanotic, and it usually shows icterus and edema ; not seldom ecchymosis is foinid in the skin. The undjilical wound and vessels are normal. In almost all the internal organs hemorrhages the si/e iif a pin-head or larger arc found ; they are also found in the meninges, the pli'iu'a, pericardium, peritoneum, thymus gland, and muscles. In the lungs ii('ii\orrhagi(! infarcts occur, and bloody mucus or clear blood is found in the bronchi. In the heart-muscle, the liver, and the kidneys fatty degeneration is present. In the stomach and intestines much blood is found ; the kidney parenchyma presents many hemorrhagic foci ; the spleen-pulp is very soft. !l--| ]\ k i 844 AMEHTCAN TEXT-BOOK OF OBS f ETHICS. IK'! ' ■:v, i Spnpfomn. — Most of tlio cliildron with Biihrs disoaso arc Im>i'h asphyxintiii. altlioiifrh tho labor is easy and rapid. Tlio asphyxia is hut partially, or nut at all, overcome. Deep inspiration and lusty <'ryin}f do not (xx'ur, and soon :,■- vore cyanosis supervenes, at which time many ot'tliese chihlren die. IfMcith d(M\s not (KHJur, there follows up<»n the evacuation of the meconium a diarrlirn, with some blood, and later entirely l)loo<ly stools and the vomitinj^ of liloiui. With the separation of the cord there fre<]uently ensues parenchymatous Ik m- orrhajje from the umbilical wound. At the same time hemorrlia<je fnuii ilii> nuicous membrane of the mouth, the lutse, the conjunctivic, and from the cxli r- nal ear and skin, takes place, whereupon icterus develops, >\liich in Innt'-cnii- tintied cases becomes extreme. Tiater, tnlema of the skin (H'curs, and dcalli from collapse follows, without any marked elevation of temperature, usnallv about the end of the swond week. Death may be preceded by only one uf the al)ove symptoms, such as cyanosis or heniorrhafje. Buhl's disease is rare. and has only l)een seen in lying-in hospitals. Diof/noxis, Prof/noxix, and Treatment. — The diar/nosin has rarely been made during life, and only positively post-mortem after microscopic examinalidii ot' the fatty organs. The prof/nosin in this affwtion is always fatal. Tlic as- phyxia is treattHJ on general principles, and every et!'ort inust be made to support the strength of the patient. Winckel's Disease. — Sifinptonus. — In 1879, Winckel described a disease, observed in the Dresden lying-in h )spital, that was characterized by cyanosis, icterus, hemoglobinuria, somnolence, and rapid collapse without fever. Twcntv- four cases were observed, only one of which ended in recovery. The sickness began with restlessness and cyanotic discolorations, atler which there occurred icterus, vomiting, and diarrhea, and later convtdsions, collapse, and death. The urine was pale brown, oNving to the prest>nce of hemoglobin. The lu'ine con- tained also renal epithelium, graiudar casts with blood-corpuscles, mi»!roeoeei, detritus, and some* albumin. The urine was of a syrupy consistence^ dark- brown, and coidd be expresse<l on the cut surface of the kidney only on (iini pressure. The mothers of the sick children all remaincxl well. I'athn/nf/ica/ Anatomi/. — The condition of the kidneys was characteristit.'. The cortex was of a brown color and was l)osct with hemorrhagic spots. The pyramids were cli.rk red, with infarcts of hemctgloblin in the apices. In the bladder there was dark urine. In almost all the organs and in the serous njembranes pnnctiform hemorrhages were found. Moreover, there was, as a rule, swelling of Peyer's patches and of the mesenteric lymph-glands. In the blotxl the white corpuscles were increased and the retl ones enlarged, and fine granular bodies in rapid motion were seen in the plasma. The liver, and at times the heart, showe<l fiitty degeneration.s. The liver and the kiihuys in some cases jiresentetl collections of bacteria. Cyanosis and jaundice ol' the external skin and internal organs were observetl. Two similar cases were previously observetl by Parrot (1873); fnitlier, Bigelow saw ten epidemic cases, and several sporadic cases were noted l»y Epstein in the foundling hospital of Prague. Two such cases have been [dv- ],'SaiWm^^^'^ w^^l PATiioLoav or the NKW-iionx infant. 81.) (k'ScrilxHl by Horz. In all the cases licinoglubiiiiiria was absont or not looked lor. Ktiolof/;/. — Tli(i last-named two authors elaini a septit; (»ri{i;iii of the disease. Winekel eoiild not discover the exact canseot'the disease. Poisoning by plios- plionis, potassium chlorate, carbolic acid, and arsenii; could surely be cxchidcHl. Helena Neonatorum. — Meleiia means, literally, " black disease," on iurount of the black (bloody) masses which arc vomited or passed in the stools. According to our present knowknlge, it is ditficnlt to elassily this con- (liti(tn, inasmuch as it must be regarded as a symptom of one of several dis- cMses. It (K'curs in general sepsis, in syphilis, and in liuhl's disease. Some authors speak of it in connection with hemophilia. The condition is fully (l('scribe<l under (lasfro-iiidxiinnl Hcmorrhaye (p. Ho.'J). Pemphigus. — Pemphigus neonatorum, apart from syphilis, is rare in infants, and is characterized by tlu^ ajjpearance up<tu the skin of numerous vesicles, which develop rapidly, then rupture, and soon dry up. There then remains a moist surface, which heals after a few «lays without the formation of a cicatrix. Vaw\\ V(!sicle is placed upon a reddened base. The vesicles (Minsist of a raised superficial portion of the epidermis with exudates beneath. Tlie vesicles are round or oval, and vary in size from that of a pea to that (»f u pigeon's or a hen's egg, and have considerable rescnd>Iance to !)urn-blisters. Tlieir nund)er is variable; there may be a single vesicle or a gn^at part of the l)u(ly may l)c eoverwl with them. The vesicles contain a yellowish serum, which may later become more turbid and of a ])<n'ul<!nt appearance. The vesicles appear by preference on the abdon)en, around the navel, or on any part of the trunk, or the head, and less fre(piently on the extremities, rarely oil the palms of the hands and soles of tii(! feet, a fact of considerable value ill tlifferentiating syphilit'c ju'inphigus. The eruption on the extremities is usually not marked. The vesicles generally develop suddenly, occasionally overnight; previous to the eruption the child may, but ordinarily does not, manifest irritability and disturbance of health; the eruption is prone to occur in successive attacks. The disease begins from the fourth to the ninth day of life; after the fourteenth day up to the third week its course, as a rule, is ended. Usually fever is absent. In very severe cases high tempcratun.' may occur, followe<l by exhaustion and death. As complications and se(|iiel!e there may occur furunctdosis and other ulcerative processes leaving scars. IJmbil- ii'iil suppuration and disease of the umbilical vessels are described as compli- cations in fatal cases. AV/o/of/y. — There seenis to be no doubt that pemphigus rtf the new-born is an infectious disease. It occurs in well-dcscril)c<l epidemics and endemics, partly in cities and partly in asylums, sometimes in the practice of a single iiiiilwife. Many epidemics have been observed since l.S;U in maternities in cities and in the practice of midwives. The first cause of such epidemics still remains undecided. Often these epidemics may be tra«v<l to a single pci'son. The disease has been transmitted from the nursing infant to the mother or the wet-nurse, manifesting itself on the mammary gland, but, as a rule, the infco f. i 1' 1 i^ m^ if 846 A ME II K VI .V TEXT-n O OK OF OJiS TE TliJi 'S. m '! V ft. it ;fi I wmm w *>.;; tion <»f ndiilts is raro. It is probably of l)act('ri()logical «)ngin, but the sporiiir genu has not Ix't'ii tlcnioiistratctl. This cniptioii imist not be confoiiiKK'd with that of eongonital syphilis, although there is s(nne resoniblaiK-e between tliem. Tlie treatment of pemphigus consists in protwting the blisters from iujiiiics; in case of rupture of the vesicles starcii or pulverized salicylic acid and simvli shoidd be applie<l. Where the eruption is excessive warm baths give hiik li comfort. After the bath the patient is wrapj)ed up in cotton. In cax' of ulceration this shoidd be treated on general principles. Syphilis. — Syphilis in early infancy naturally conjes under two heads, the acquired and the here<litary form. The hereditary form is considered imdcr DificdSffi of the FitHH In Vtero (p. 297). J'Jti()/o(/j/. — According to Fournicr, children acquire syphilis more uftoii than is usually supposed. The causes for contagion after birth are usuallv the following : 1. Nursing, by which a syphilitic nui-se infects the child, or in whicii tlic niu'se, being herself uninfwtiHl, nurses at the same time a second child wliidi is syphilitic. Infants not only contract syphilis from mend)ers of the Caniilv and the nurses, but, as Keating says, "syphilitic infants are sources of dainrcr to non-syphilitic nuanbers of the family, and numerous cases are seen in wliicli the baby has infected its grandparents, nurses, and other infants." In these cases the infection is transmittctl by means of patches dcvelopwl about or in the infant's mouth ; sometimes papules are the medium of contagion. 2. Infection may take place through the mother subsetiuently infirtwl or through attendants, especially by kissing. 3. The poison may be inoculateil by the midwife's or the physieiim's instruments or by the hands. The question whether syphilis is ever transmitted through the milk of the mother or that of the wet-nurse is important. We have no cvideni-e to show that this is done. Discharges from i)rimary sores are liable to inoculate ; also discharges from various secondary lesions, whether these are ac(|uired (ir are hereditary. Infants suffering from sy])hilitic coryza or specific ulceration may inoculate the breast of a wet-nurse, but probably never that of tlic mother. Vaccination has been the means of introducing syphilis. \"a('('ina syphilis manifests itself not earlier than a month or six weeks after vac- cination ; it does so by the formation of a chancre at the seat of the vaccination (Hutchinson). The t<i/mjjto»!s of syphilis in early infancy will be found on page 208. Treatment. — The treatment of infantile syphilis, like that of the adult, con- sists chiefly in the use of mercurials. Mucous patches may bo dusteil w itii calomel. For syphilitic coryza J. Lewis Smith advises Squibb's oleatc of mercury, 2 per cent. For the general treatment the use of mercury by inunc- tion has always given satisfactory results in the writer's experience. I'^t iininction the oleate of mercury or the mercurial ointment should be used, tlic oleate in the strength of 2 per cent. ; of the ointment, gr. v-x may be ap- plied to a healthy part of the skin and be covered with a flannel binder. For \'^ t: b vaccnitituiu PATHOLOGY OF THE yi:W-IlOItX IXFAXT. H['i iiitornal medication caloniol may be given in doses of gr. -^--^fj two or three times a day. When these mercurials pr<Mluee diarrhea they may Ik? comhinetl witii opium and aromatic powder or Iw omittcil for a short peri<Ml and again Ik* resorted to. Tiie chihl should, if possible, ix' nursed by its mother; if this caunot be carried out, it should be fed on artificial foinl. A wet-nurse should pot be engaged. Tuberculosis. — Aequiretl tuberculosis at the ])eri{xl of early infanev is verv rare. Most authors, however, admit the jK)ssibility of transmission of the disease at this period of life. As producing causes arc mentioned all those wliicli lower vitality, especially syphilis and tulx'rculosis in the parent. Dinxit transmission from parent to child is possible, though perhaps not fre«pieiit. A tuberculous mother should not nurse her infant, kissing shoidd be pro- hibited, and the child should sleep in a separate room (Jacobi). Exj)eriments on the lower animals have demonstratefl that tuberculosis may be traiismitte<l by the ingestion of milk from tuberculous cows ; this applies also to the use for the fee<ling of infants of milk thus afUx^ted that has not l)een boiled. Ca- tarrhal conditions of the air-passages doubtless favor the invasion of the bacillus. 77ie diofpiosis of tuberculosis in the very young eaimot readily be made: if the disease is limited to the lungs, there is evidence of brontthial trouble. In these cases Epstein recommends passing a catheter into the larynx ; this will produce a cough, during which suHicient mucus nuiy adhere to the instrument for microscopical examination. The treatment is chiefly pro]»hylaetic, as indicate<l above. When the disease is established in early infancy the same methods of treatment should be applied as those for older children. Ophthalmia Neonatorum. — Ophthalmia of the new-born is a local affec- tion contractetl during birth, liefbre prophylactic measures were adojited tiiis disease occurred in lying-in hospitals with alarming frequency. During 1SG8-69 in the lying-in hospital of the University of Herlin bleiuiorrhea (R'ourred in 5.6 per cent, of the births. In the Charit6 at Berlin from 12 to 14 per cent, were noted. Kilian gives the percentage at the maternity hospi- tal of Berlin from 1820 to 1834 as being nearly 50 per cent. Since the intro- (liu'tion of Cred6's prophylactic measures the percentage has been reduced almost to nil. Etiohf/y, — Some authorities assign different causes, stich as irritating dis- charges of the i)artiu'ient canal, wiiether s]>ecific or non-specifie, exposure to bright light, cold, etc. — others (Unger, Bumm) pronounce all cases of opiithalmia neonatorum to be due to gonorrheal infection, the gonococcus of Noisser being alone the exciting cause. There is no doubt that the secretions of the parturient canal of the mother are usually the medium of conveying ]n'ogenic frerms. These secretions, coming in contact with the cornea of the iiitint, remain fixed tor some time, giving rise to a purulent conjunctivitis which manifests itself on the third or the fifth day afler birth. The eye may become infected previous to birth by the amniotic fluid, or later through the infectious material on the hands of attendants, etc. (Runge). Frecpiently the cornea '^U n 1 'if f f I :|! 848 AMKIilCAN TEXT- BOOK OF OliSTETIilClS. i w Im If! . i\ becomes iiivolvcnl in tliis process, in which case extensive ulcerution inav octnir resulting in loss of siglit. Indirectly the disease may be transmitted ln»in tlic eyes of one child thns alfi-cttHl to those of another; it may also be transmitti i| through unclean hands of attendants, unclean sponges, towels, and tluoiiuli water used for the bath. l'<itliolo(/ic(il Aiiatoini/. — The changes produce excessive liypereiniu and swelling of the palpebral nuicosa, rendering it thick and uneven. Later (Ik iv is proliferation of the epithelium, and beneath it is a diffuse iiiHitratioii df lymphoid cells. According to Hunnn, the gonococci contained in tlic secre- tions invade the upper epithelial layer and find their way down to the paiiil- lary bodies, where this invasion excites marked hyperemia, producing later the profuse discharge. Tlu; cornea may remain clear, but it is liai»lc tu become invaded, showing points (»f ulceration ; or a general infiltration iiiav take place, resulting in an extensive destructive process. Si/mptoniK — The first numifestations of this disease ocjcur on the third or the fifth day after birth, ami consist of rwlness and swelling of the palpelnal and ocular conjunctiva. One or lK)tli eyes may be affectetl ; sometimes the lids are glued together. The secretion is at first watery, containing flakes d' fibrin ; later it is purulent and very profuse. In the course of several davs the swretion diminishes in quantity, and after six or eight weeks the disease assumes the form of chronic conjunctivitis. The protpimiH becomes unfavorable in cases in which the cornea is in- volved ; 20 or 30 per cent, of the cases of blindness in children is due to corneal ulceration thus induced. Great care must be given to the cleansiii),^ (tf the vaginal canal in suspected cases of gonorrhea by the use of antiseptie douches previous to birth. The treatment consists chiefly in ])rophylaxis. The duty of preventing tiie occurrence of this serious disease devolves upon every obstetrician. Iiiinie- diately after birth, before the child has opened its eyes, all secretions u])on and about the lids shoidd carefully be washed away with sterilize<l water or with a 1 or 2 per cent, solution of boric acid. In many hospitals Credo's method is that usually adopted — that is, after cleansing the eyes with water 1 drop of a 2 per cent, solution of nitrate of" silver is dropped into each eye. At the first manifestation of the «liseas(! active measures should be adopted. Usually but one eye is alfecte<l ; in that case the other eye should be protected by placing over it absorbent cottoii, covering the cotton with a watch-crystal, and sealing this with collodion or with adhesive plaster ; but the eye should be examined daily to be assured of its healthy state. When the disease has been developed two forms are distinguished, the mild and the severe, each having two stages, the congestive and the purulent. In the mild form the treatment in the first stage consists of the application of cold compresses. In the second stage the eye is cleansetl every two lionrs with a saturated solution of boric acid, and a \ per cent, solution of nitrate of silver is applietl to the cul-de-sac. 1 VATlIOLOay OF THE XFAV-noltX IXFAXT. 849 In the .severe form cold coin presses are applii-d ; the eye is cleansed by a solution of bichlorid of ntercnry (1 ;8()0()) and a saturated horic-acid solution ii-cd alternately every hour. As soon as suppuration is established the solu- tion of nitrate of silver is applied to the cnl-<le-sac of the cornea. While iiiiikin^j these applications to the upper everted lid the cornea nuist be pro- tcded by the lower lid, and vice vvrnd (Mettnian). It is best to la-gin with a '1 per cent, solution, but shonhl this fail to control the suppurative priK-ess a \ percent, solution may Imj employed, and should immediately be neutralizetl l)y a solution of salt. Should un ulcer of the cornea f(»rm, it is the practice dl' ophthalmologists to employ cautiously weak solutions of eserin (| to \ irniiu to the ounce). When iritis or a central ulceration of the cornea is pres- I'lit atropin (gr. ij-iv to the ounce) is preferred. The first signs ol' poisoning bv this drug shoidd carefidly be observed. When the swelling subsides and the discharge decreases, and espwially when there is corneal haze, hot applica- tidiis may be made. For the treatment of further complications the reader is ictlrred to works on ophthalmology. La Grippe.* — The testimony that very yoinig infants may be sid/jcct ti> tliis disease is increasing. Dr. Townsend of Hoston has place<l on record a (•as(> where the mother had an attack of intluenzu either before or shortly after luT confinement, anil the child very soon after its birth began to sneeze, had riipitl respiration, followed by a tentpcratnre of 104°, and passed through an attiick of la (ji'lppe. It is fair to presume that this child was infected before (ir within a short time after its birth. The liritisk Joiinutl narrates another case in which the infant died on the third day, having had a high temperature, iai)id respiration, and pulmonary catarrh. The mother of this child had influ- t'liza four days after her delivery. The following casef was observetl in 1890: A healthy woman was delivered of a healthy child ; both mother and chikl appeannl perfectly well during the tii'st week, after which the husband was taken with in i/i'ipjie of the gastro- intestinal form. Two days later the wife was taken, and on the following day tlic infant manifestwl characteristic.' symptoms of the disease — restlessness, rise of temperature, icterus, loss of appetite, and diarrhea. The stools were fre- (|ii(iit and of a putrescent odor. In all three njend)ers of the family the in- testinal catarrh was accompanied by catarrh of the respiratory tract. In the moflier this attack was followed by prolonged and great nervous exhaustion, for which no other cause could be assigned. I >i(upio.si'< and Treatment. — It is difficult to diagnosticate la. f/rippe in very young patients, but when the infection is present in the house and the parents or the nurse arc nnder its infinence, if an infant within a very few hours after biitli presents the usual symptoms of fever, exhaustion, and great prostration associated with the involvement of one of the three systems that is usually selected by this infection, the disease is most probably due to the poison of * Most of the material for this subject is talieu from Dr. Karle's article, '• Manifestations of LaOriiipe in Children," Areluven nf Pediatric^!, 1892. — M. .J. Merp;ler. t'l'lie case described occurred in my own practice, but has nes'cr been reported.— M. J. M. 54 ^H p «')(» AMHJilCAy Ti:XT-I\()(iK O/' OIlSTE'rUlVS. I f If- kj It iiifliicii/a. Ill trcatiii;: tlicse chscs wv slioiild he M;ni,l,.(l l)y tlic siimc priiicii.lr- as for adults — that is, disiiift't'tiiij; tlio intestinal tract, su|HM)rtiiifr the strfii;:ili. and nioctin^ complications. ('. Ixi'Kc HON OK iiii-: ni(ii;sTivi: AM) I{i;si'ii{.\T».uv TitAcis. — Septic Oastro-intestinal Catarrh. — Infection thron<ih the inncons nu'iiii)iinie of tiir month is characterized hy a catarrhal state involvinj; the intestinal tract. |;|,- stein descril)e<l the difl'ereiit decrees of invasion as septic catarrh, seplic cidui.. and sc|»lie diphtiieritis. This form of catarrh <litlers from the ordinary dv-- jM'ptic form in that it occurs in nursinjj children, and that it is more linlilc to occur in winter than in summer. This ditrerence is ascribed to the fact iliai durinj; the winter ventilation is not so j;ood as durinji warm weather. Thrush (s^itre ov noor) is a local disease of the nnicons memhrane ul' tin mouth due to the jirowth of a vcfretablc jtarasite, (»ften desijrnated (iiiliinii <i//tit'(inn. Althoujrh the parasitic character of the disease has ion;; Ih^-h |<,|,,u u^ no definite hotanical place has been assiiiiu vl t»» the fuiiiruv. The pn-vcncc ^4' .soor is very common amonj; infants, and it occasionally oi^iirs in the virv yoinifj. It is of frequent occurrence in foundlinji homes. Artilicial tuod iind inipaire<l nutrition favor its develo|mient. The disease manifests itself in ilii' formation of white points resembling; curdled milk ; these patches eoalesiv :iii<l adhere to the mucosa, which becomes very tender. Xursinj; becomes dilHiiilt. and diarrhea often residts from the disonleriHl .state of nutrition. DuKpumii and Treulnuut. — The diai^nosis is based on the occurrence of the white patches above described. In donbtfid cases a microscopical cxanniiiitiun will reveal the nature of the disease. The treatment consists in removal of the patches, cleansin«>: the imico.sa, and supporting; the stren<;th of the patient. After each mirsin<; the little patient's mouth should be washed carcftdly with a mild antiseptic fluid — boric acid, 5 per cent., or chlorate of potash, 2 yw cent. The a|)plieation should be made very <;ently to prevent nmiecessiirv desfiuamation of the nuicosa. If the child mu'ses from the breast, the nip|il(s slu)nld be washed off carefully with a sin. r solution before and after nur-inti, Gonorrheal infection will also produce an acute catarrhal inflammatii)n ol' the mouth. The treatment is similar to that of thrush. Stomatitis Aphthosa. — We are indebted to Holm for jiivinj; this term ;i definite meanini^, as there have been a number of varied i)athological (cmli- tions of the mouth that were termed " ajdithie." Bolin limits the term t<i :i patholoij;ical lesion of the mucous mend)rane of the month, whicli lesion i- characterized by the formation of distinct discolored spots from which tiic epithelium denudes, leavinj^ shallow nlcers. As to the anatomical nature nf these spots, there is still considerable discussion, some holding that it is a true vesicidar eruption, others that it is due to a solid exudation between the ciiti? and the epithelium. The etinlofjy is not settled. Although the disease is more likely to oc< nr after the tenth month, it may occur in the yoJing. Aphthse are found in the mouths of many children in asylums, maternity hospitals, etc. Sometimes tlmv seem to be conveyed from child to child by wet-nurses whom the childirii W \\ j'ATi/()Lf)(,'y OF Tin: st:\\-noii\ /.wrAxr. Sol stvciiuili. — Septic me of lilr act. l.|>- )tic <'r(iii|i. ii\iiry ilv-- lorc li;il>lc 10 fuel tlial r. nnc «il till' itrd (iiiliiiiii )n'M'iicc "I n tlic vi'iv ul I>mh1 iind itself ill ilic malt'si c iiiid ncs tlitliciih. •rcnco (if till' oxaiuiiiatinii renu)val of tlio ]>aticiit. ircfiilly with Ix.tasli, 2 1><T tuuicccssarv , the iiiliplcs lifter mirsin;!'. nmiatioii of !«• this term a ogical cciiili- Ihe term to a liieh lesion i- |m which till' pal nature of Itit it is a true }en the ciiti.- [koly to occur Ibnml in the Inictinu's they the child I'cii I |i;iv(> ill coiiiiiioii, Itiit the l)a<'terial ori^riii of the disease has not hcon deiiion- ^i rated. This eruption rrei|iieiitly nceiirs in |t(M»riv-»>',.".irished children. 77/c trcdiiiiciif consists of antiseptic iiieasiii'es as rej;ards iuiisin<;-l)ottles. care (il liie hreast of tlie wet-nurses, etc. The child's nioiith should he washed fiv(|uciitly with a solution of Itctrie acid, .'} per cent.; the ulcerated portions iiiiv he touched with a solution of nitrate of silver. Diphtheria. — Lit<i'atur<! «loes not cite iiiaiy cases of di))htheria in the iiew- iioni ; characteristic! cases, however, have Iteeii observed. J. Lewis Smith iiclieves the new-horn to be siisceptil)le to this infection, and he reports several ca-cs. In two of these cases umbilical phlegmon was also prcM-nt. Diphtheria ill th(! mother does not, as a rule, greatly endaiiirer the chihl (Miillcr), althoiijrh casts ar(! on record in which the disease was tran-mittcd directly from mother to child. The treat iiwnt is the same as that in older t liildreii. Rhinitis. — TIh; oeciirrence of persistent coryza in very yoniitr infants is fre- (|iiriitly due to hereditary syphilis. This sympttsni usually docs imt manif<'st itself before the second month, but it may (M;cr arlier. Xoii yphilitio siip- pniiitive rhinitis may t)c(nir dnrin>^ the first few days oi lile, and may be due to iiif' '• ••; from the discliarjfcs in the parturient canal. T/n' treatment of the simple eatanlial and suppiinuive rhinitis consists in ieansin^ the nasal passaj^e with mild disinfectiii<; solut'.iiis, as in older chil- dren ; a small syrinjie or medicine-dropper may be used for this piapose. 5. General and Unclassified Diseases. Sclerema neonatorum is a disease consistinji; of an induration of the skin mid the subcutaneous cellular tissues, associated with rapid lowering of the biiily-temperatiire. The disease is hardly known outside of foundling homes anil Miaternity hospitals. Kflohf/i/. — The etiology is imperfectly understood. Haginsky suggests infectious agents. It has also been asserted that the disease is due to an (XK'ss in the tissues of the infant of palmytic acid, which solidities at the low temperature accompanying the <lisease. There seems to be some rc- liitiiin between imjierfect develo])ineiit of the fetal heart and sclerema (Di'inme), It occurs in eases of premature birth and in infants who are piiorly nourished, Si/mptom.s. — The premonitory symjUoms are slight : the skin is first red anil then has a mottled appearance; these changes manifest themselves first U|iiin the calves of the legs, on the dorsum of the feet, then upward, involving the thighs, the abdomen, the upper extremities, the face, and the head. The roital temperature f d|,s from the norir.al to 86° or even 83° F. ; the pulse is \voak,the excretions and secretions sluggish, and the edema which now forms iviiilers the skin pale and hard ; gradually the whole body becomes cold and risrid, and eventnally sensibility is lost. Death occurs without convulsions. Occasionally the patient recovers ; in these cases the infiltration subsides, the ilorsiim and soles of the feet ])eing longest affectiHl, I'dthologkal Anntomy. — The portions of the skin affected are either yel- i I f rii i ^52 AMERICAN TEXT-BOOK OF OBSTETRICS. !> i: i li'n lowisli-whitc or prcsont a mottled, bluish appearance. Incision throiii'-li tlic infiltrated skin is Ibllowetl by discharge of" a yellowish or a reddish Huid iVdii; the cellular tissue. This fluid usually coagulates upon exposure to the air. The brain is edematous, rarely showing hemorrhagic spots. In the lun-Ts tlicic is usually atelectasis, occasionally eviilence of lobar pneumonia. In sonic u[' the other organs there frequently are ecchymoses. This disease mav bo lum- plicated by pneiunonia, septic disease of the umbilicus, pemphigus, and synliili^. Diofpwsis ami Prof/nonifs. — The diagnosis is based chiefly on the infiitnitinn of the skin and the falling of temj)erature. This edematous form of sclcicniu must be diflerentiated from the adipose form in older children; also from the usual forms of edema that are characterized by "pitting" on pressure. Tlic prognosis is unfavorable. Treatment. — The treatment consists chiefly in the api)lication of artili(i;il heat and massage and the administration of stimulants. Artificial heat is siiii- plied both dry and by means of the bath. An incubator will be of service to maintain the temperature. Massage is given with the view to improving tlic circulation and favoring the absorption of the serum. A. jMoney reports a case of sclerema neonatorum successfully treated l»v friction over the indurated areas with sweet oil, together with daily inniictiim of blue ointment into the skin of the abdomen. This autiior excludes anv evidence of syphilis in this case. Alfred liarrs also reports a case in wliieli tlic induration entirely disappeared in two months on mercurial treatment. One-half grain of gray powder was administered night and morning. Stiimi- lants must be administered frequently — whiskey, il to 5 drops every hali'lnnir. Aqua camphor and tincture of digitalis may be added with ailvantagc. In all cases special care must bo given to favor the nutrition of the cliild. tur which purpose ^arar/r will be of service. Hemorrhagic Diathesis. — It will be noticed in a few cases that an infant exhibits within a short time after birth a tendency to bleed, at first perliaps from the umbilical region, then from mucous mend)ranes of the difleieiit open- ings of the body, from the conjunctiva?, and finally from the integinnent. In other cases this tendency will be noticed upon a slight local injury wliieli under ordinary circumstances would be insignificant. Etiolof/y. — Our knowledge in regird to the cause of the disease is i;itliei' indefinite, but in a majority of cases it may be traced to some constitutional nr septic influence. The symptoms have already been stated, above. Anemia naturally results. 7>/V«7»io«/,s'. — If there is a family history of a tendency to heinorrli;iuc. if the hemorrhage is persistent, producing prostration, anemia, and collapse, ilie diaurnosis is easilv made. Prof/unsiK. — Except in very young infants the patient rarely dies dnrinu the first hemorrhage. The longer a "bleeder" suivives, the greater is liis chance of outliving the tendency to bleed. In the very young when tlieiv are symptoms which suggest continuous bleeding, anemia, and a tendency to col- lapse, the prognosis is very bad. t,, % ^iuiiji PATHOLOGY OF THE NEW-BORN INFANT. 853 M> iroiiiili tlif fluid iVdui to the air. lungs tllrlC in SOUK' (if lay 1)0 c'uiii- inl sypliill-. i inliltnitiiiM ot" sclfrfiiia Iso from till' ssure. '11 10 of ai'tilicial boat is siip- of sorvioo to aprovinji' tlio V troatotl l»y ilv inunction cxclndos any *asc in which 111 ti'oatincnt. inij. Stimu- 'i-y half hour, vantaoo. In tho ohild. tnr hat an infant first iicriiaps ill'oront i^yvw- 'iXiiinont. In injury wliich 'aso is lather stitntinnal it )V(.'. AiuMiia oinorrhauc i' collaiisc, tlio ,- dies dnviiiiT' rroator is his shon thciv arc idonov t«i <'(il- I Patholoyy. — Nothing except tho anemic condition is found in the viscera upon post-mortem examination. An unusual thinness of the blooil-vessels lias been noticetl. Trealmcnt. — The principal indications are to check the hemorrhage and to support the strength of the child : to this end the extremities of the child should 1(0 kept warm, and if ice is used as a local hemostatic, it should cover but a sn:all surface, for the tendency to reduced temperature and collapse is very gioat. Among the remedies which promise the best results are ergot, prepa- rations of iron, gallic acid, and aromatic sulj)liuric acid. Hemorrhage from the Female Genital Organs. — It happens, veiy rarely, that there is a slight oozing of blood from the vagina during the first low days of the infant's life. Ktioloyi/. — In all probability this slight hemorrhage is due to the congested condition of the pelvic organs. The sudden cessation of the How of bloo<l tlirough the umbilical arteries may also contribute to this result. It is claimed by some authors that menstruation may occur in the new-born. CuUingworth ciillocted 32 cases of menstruation in young infants. Symptoms and Treatment. — The symptoms are simply a slight oozing of blood, which can be ditferentiated by an examination of the parts. A rwl stain, often produced during the first days of infancy by the escape of uric acid or urates, must not be mistaken for this form of hemorrhage. If the hemor- rhage is slight and unassociated with the hemorrhagic diathesis, no treatment will 1)0 required. Gastro-intestinal Hemorrhage (Helena). — IJy this term is meant an osoape of a variable amount of blood, usually from the bowels, but occasion- ally vomited, during the first few days of infant life. The amount of blood lost and the symptoms that follow in this disease range all tho way from a slight and harmless hemorrhage with no general symptoms to a loss of blood so great that the death of the child is imniineut. This form has been spoken of by some authorities as tho " black disease," and by others as " niolona.'' Wo recoixnize thi'oe classes or varieties of {jastro-intostinal homorrhaijo : First, tho unimportant class duo to very slight congestion or abrasion in tli(> integrity of the lower bowel. Thrombosis of the umbilical blood-vessels has been thought to increase the congested and hyjioroinic condition of the iiastro-intostinal canal, which condition always exists immediately after birth. Asphyxia Is another predisposing cause. Rlood in considerable (piantities may flow from a fissured or excoriated nipple of tho mother and bo swallowed by tlio nursing child, and make its appearance either as moderately l)right, fresh blond in the vomited niaterial or very much changed in color and consistence if it is mixwl with excreted matter from tho bowel. This discharge must not 1)0 mistaken for hemorrhage coming from tho ohild. Tho second class is somewhat more grave : it is caused by deep erosions or iilcoration in tho gastro-intestinal tract or by the porfi)rating round ulcer of tlio stomach. The third variety is caused by constitutional iliseases present in the new- I 854 AMERICAN TEXT-BOOK OF OBSTETRICS. ■i m u 1 lil ,;i i\ *Pf *"li .ir It p boni, such as lieniorrhagic diathesis, syphilis, various fonns of sepsis, the hitn- orrhagie eruptive diseases, and tatty degenerations. The second and third classes constitute inelcna proper, which is laic According to Buhl and Hecker, 8 cases occnir in 4000 births; accordiiiix to Spiegelberg, 2 in 5000; according to Genrich, 1 in 2800(Ungcr). The unim- portant or simple variety of hemorrhage occurs somewhat more frcqucntlv. Symptoms. — The blood usually begins to flow about the second day ; sdinc- times it is vomited, at other times it comes from the bowel. If the blood i> vomited, its color may not perceptibly be changed, but if it is discharged fiom the bowel, it is usually dark, mixed with meconium, which is apparentiv nidiv profuse than usual. In the course of twenty-four hours, if tlie hemorriiai'-c continues, the child begins to fail and becomes pale, cold, and indiflercnt • the pulse is small and rapid; respiration is very frequent; the child is in collapse, and death occurs in a few hours. Proynos'iH. — The prognosis depends largely upon the etiology. In the first variety of gastro-intestinal vomiting the prognosis is good ; in the second and third varieties it is always grave. The mortality of true melena, as stated l)v difl^erent authors, is from 30 to 70 per cent. The prognosis becomes especiallv grave if the hemorrhage lasts more than forty-eight hours. Diacfnosis. — Look carefidly for local causes, and then for some constitu- tional defect. Slight hemorrhage with trismus should cause one to look Inr intussusception. If the blood is vomited and fresh and the child has no svnip- toms of depression, it may have come from the mother's nipple, from the child's tongue, or from some part of the upj)er digestive tract or respiratory ajiparatiis. If it is from the bowel, and evidences of cyanosis or jaundice or de})ressioii soon follow, in all probability some general disease is the cause. The pathohf/j/ varies with th.c cause. In true melena the tissues are ustialiv pale and anenjic. Ecchymoses upon the different membranes, and occasion- ally eroded blood-vessels, may be seen, or there may be found evidences of tlio severe general diseases referred to on the previous page. Treatment. — About the same line of treatment is indicated here as that for the hemorrhagic diathesis. In the first variety of hemorrhage the treatment consists in giving attention to the existing hx'al cause. In true melena, if mild, the internal use of astringents may be of value; in addition to this, tlic treatment is directed to the supposed cause, while every effort is made to sup- port the strength of the child. In severe cases all therapeutic measures are powerless. Colic and Diarrhea. — Colic is a very frequent cause of sufferinir jn infants ; even during the first days of life intestinal colic will be liroiidit about by an irritation of the sensory nerves of the alimentary canal : this irritation nuiy be due cither to the abnormal properties of the digestive prfxlucts or to imperfect processes of fermentation, leading to excessive formation of intestinal gas; also to the irritation produced by accumulation of fecal matter and to the delayed expulsion of ineconiiun. In other words, the irritation mav be either chemical or mechanical. In both instances the PATHOLOGY OF THE NEW-BORN INFANT. 855 s, the licm- it'll is YWYV. iccortliiijj: to The iiiiiiii- quontly. day ; soiuc- lio hldorl is liargod iVoiii iroutly more hc!m(irrlia|j;c indill'orciit ; '. child is ill In tho first 3 second and as stated hy les especially irae constitii- e to look for has no syniji- »in the child's ry apparatus, jr de])ressiou ss are usually uid occasiuii- ences of the 'c as that for le trcatineiit le inelciia, if to this, the made to siip- ineasures are sufteriuir in be hroiiirlit canal : this ;lie dii>;e-tive to excessive aceunuiliitiim other words, instances the first cause is usually due to improper food. In the young, reflexes are espe- lially easily excited. An infant nursed at the breast will sull'er from imperfect iligestion and from abnormal formation of gas if the breast-milk contains a considerable amount of colostrum, and also if nursetl by a wet-nurse whose milk is unsuitable because of disparity in age between her own and the child she is nursing. All artificial foods, especially the amylaceous group, predis- pose to flatulence. Constipation, whether due to imperfect diet or to some stenosis in the alimentary tract, will give rise to distention and irritation, pro- ducing severe forms of colic. The symptoms of colic are sudden attacks of pain, manifested by the infant refusing to nurse, by its restlessness, and by contraction of the limbs atid of the abdominal muscles. After the expulsion of gas the symi)toms will dis- appear as suddenly as they came. The treatment during the attack consists of the application of dry heat and irentle friction in the course of the colon. Should the attack be severe, a warm bath will afford the greatest relief. The introduction of a soft catheter into the rectum will favor exj)ulsion of the gas, and may l)e followed by an enema of oil or of warm water. The food must carefully be investigated, and if found at fault it must be changed for one more suitable. In acidity of the vomited matter or of the stools small doses of calomel conibined with alkalies will be of benefit ; aro- matic teas will relieve by favoring the expulsion of gas. Among medicines nsiially found efficient are grain doses of pepsin, 2 to 5 drops of gin or whiskey ill hot water, drachm doses of hot so<la-mint, or the milk of asafetida adminis- tered by the mouth (10 to 20 drops) or by the bowel. The habitual use of paregoric for this trouble is to be condemned. Diarrhea. — During the first few days after the birth the stools of the infant are a dark brown or greenish mass called " meconium." This substance is very tenacious, consisting of fatty matters, epithelial cells, biliary pigments, and cholesterin. It is really an accumulation in the small intestines of bile which collected during fetal life. After the third day the meconium has passed, and is substituted by yellowish, semi-liquid stools. Tender normal coiiditioiis the new-born infant has three or four stools a day. In infiuits, on tu'count of the pasty condition of the intestinal matter, more or less excremen- titioiis material will colle(!t in the rectum, which fact explains in some degree the number of daily evacuations from the bowel of infants in health. What, then, constitutes diarrhea in infants^ This (luestion can only be decided by (il)serving the character of the passages and noting the growth of the child. One evacuation each day in some cases may be suflicient, but fre<iuently where this is the habit some of the deleterious results of constipation will be observed. Nevertheless, we have frequently noted three or four movements each day, and have found by actual weight of the child a normal increase from week to week, with every indication of good development. From one to four jiassages each ilay, then, would be regarded as normal. Deviations from the normal number occur, such as evacuation every time the napkin is changed. Idio])atliic diar- r >'J ii^i ("fill 856 AMERICAN TEXT-BOOK OF ODSTETRTCS. m-^ ?>t , ■;!♦ rlioa may occur during tlic first week. It is usually due to bad hygienic sur- roundings, to foul air, and to improper food. Sudden changes of tLi.ipi'iatiiii' are very apt to produce diarrhea. The treatment of diarrhea, like that of colic, i.s based on the same princiiilis as that for the same derangement in older children, the selection of j)ropcr I'.mmI being the principal element of treatment. Small doses of calomel (gr. ^^^ to tq-. ' ) two or three times a day will correct the fermentation. If this drug dots umi correct the trouble, from 1 to 3 grains of subnitrate of bisnnith and 2 to 4 drops ol' aromatic sulphuric acid may be added to check too frequent st(iol>. Constipation. — Constipation is very common even in the veiy yo'ing ; it may be a symptom of various pathological conditions. In children the iiito- tine is relatively longer and its calibre smaller than in adults ; the walls aiv thimier and weaker. The ascending and transverse colon is shorter, and possibly flcxiu'es are formed be<!ause of ))ressure from above by the liver, which is rela- tively larger in a child; also by the relatively contracted condition of the jielvis. These anatomical peculiarities give less space to the intestinal tract, and in some cases they represent etiological factors in causing constipation. Tlie peristaltic movement in babies is slight because of imperfectly developed nniscular structure. As the child develops peristaltic action and nuiscular tone are increase<l. Another anatomical peculiarity in the lower bowel is the deep cul-de-sac which the sigmoid tlexiu'e »orms before it joins the rectum. This pouch predisposes to fecal accunudations. Gerhardt denies the existence of so marked a curve in the sigmoid flexure. In the healthy child the mother's milk is mostly absorbed and assimilated, leaving but a small amount of residue; the amount of material evacuated has some relation to the amount taken into the system. The albiunin of the milk is nearly all digested in the stomach and bowels of the child, and i'lom this very jirocess we have a physiological cause for constipation, fecal matter existing in such small amount that intestinal peristalsis is not excited. Habitual consti])ation in the mother may be a predisposing cause of constipa- tion in the infant. Other causes are deficient intestinal secretion, excessive perspiration, medicines, hernic'c, intestinal obstruction, congenital nialfonna- tions, chronic peritonitis. Constipation occurs also in meningitis, in myelitis, in hydrocephalus, and in microcephalic conditions and other diseases of llic cerebro-spinal system. What has been said above under the head of Diarrhea concerninii the number of normal passages in an infant applies also to constipation, i'^roiii one to four passages a day may be considered normal, providing the child docs not suffer. A steady increase in the weight and the general good condition of nutrition will aid one to decide whether the number of passages is suflii'ieiit. Constipation is undoubtedly more fmjuent in adtdts than in children. In all ])rol)ability, what are called "family peculiarities" are due more to the neglect of the ])roper attention to the wants and habits of children. Treatmevt. — In the mn'sling the use of drtigs should usually be discaided. After excluding congenital defects, we shoidd look to the mother for the canse ; !! n V 'ik PATHOLOGY OF THE NEW-BORN INFANT. 867 also to the child's diet. Artificial foods, including condensed milk, in many instances produce diarrhea, but in other cases they give rise to constipation ; any food which is absorbed quickly, leaving little or no residue, will produce tliis condition. To obviate this effect, if water has been used as the diluent, (latmeal-water should be substituted. The effect of local stimulants, such as introducing soap or glycerin suppositories into the rectum, should be tried. Whenever the colon is blocked up it must be cleared by tiie use of an enema, (ilycerin may be administered in the form of an enema (."iO to 60 drops, diluted w ith a little water). Large injections of fluitl (more than 2 to 4 ounces) should 1)0 avoided ; they produce ovor-distention and paresis. Intestinal Obstruction. — Most cases of intestinal obstruction in the young infant are due to congenital malformations, either from arrest of development or from the effects of fetal j)eritonitis. Volvulus or intussusception may cause obstruction. 'The sipnptovis of obstruction are constipation, colic, intense pain, often dis- tention of the bowel. There is no escape of flatus ; sometimes there is a discharge from the rectum of mucus and blood. In volvulus the symptoms usually occur suddenly. The diagnosis is not always easy. In cases of complete obstruction the cliild does not pass meconium. Soon after being put to the breast it begins to vomit, first the contents of the stomach, then bile, later meconium. The ab- domen soon becomes distended. Death occurs in a few hours (jr days. In some cases the anus is absent. If the external opening is present, a mal- formation of the rectum is apt to be overlooked and the case diagnosed as simple constipation. In these cases purgatives oidy increase the difficulty. The child sutlers much pain, cries almost constantly, the alxlomen is greatly distended, vomiting and symptoms of collapse appear, and death from exhaus- tion finally occurs. If digital examination is made, the finger will pass Init a sliort distance. If there be only a membranous septum, the bulging of the jrnt from above can distinctly be felt. When the amis is absent and the rec- tum ends just above it (which is the commonest condition), bulging of the lower entl of the rcctiun may be felt, but if the rectum ends higher up, this will not be observed. Treatment. — Many infants with obstruction of the bowel are either stillborn or they live but a short time. Surgical measures must be resorted to soon after hirth. When there is only a thin septum between the rectum and the gut, a crucial incision and dilatation with the finger will be all that is recpiired. The mucous membrane should be stitched to the skin. If the separation between the rectum and the surface is greater, the bulging of the distended gut must carefully be looked for, and if it is found incision should be made in front of the coccyx and be carried down until the bowel is reached. The bowel should then be opened, drawn down, and stitched to the skin. If the gut cannot be found below by dissection, then an operation from above should be under- taken. Littre's operation of opening the colon through the groin, or Amus- sat's lumbar operation, must be performed. The ojuniing of the peritoneal 858 AMERICAN TEXT-BOOK OF OBSTETRICS. II' H %\. 'n ps III cavity shoiiltl be atteuded witli the usual aseptic precautions. The stop; the operation are practically the same as those in the case of an adult, Laniphear reports a case of absence of the upper rectum in which tiic following operation was performed, apparently with success : "An incision was made through the sphincter to the coccyx, and dissection was made through the connective tissue to near the promontory of the sacrum. A small sound was inserted into the bladder as a guide. After dissecting upward for alxmt an inch and a half, the peritoneum was reached. This was cut into, the sitr- moid flexure of the colon easily pulled down and stitcheil to the ujjpcr cud u\' the rectum, an opening three-quarters of an inch being made in the side ot tho bowel, with the discharge of an immense amount of fwes. There has been no fever and no peritonitis, and the child is well and growing nicely.'' In cases where fecal matter has been passed l)v the rectum and there arc suddenly-developed symptoms of obstruction, volvulus is likely to be the cause. If the administration of laxatives (castor oil) and enemas has failed, tlicii it is necessary to resort to abdominal section both for diagnosis and for relief. Sometimes during infancy (most frequently between the ages of four and six months) a portion of an intestine passes into another. Inguinal and Umbilical Hernia. — In infants the inguinal canal is strai}j;ht and short, and in delicate male children a hernial protrusion including a 1()()|) of intestine is not uncommon. Most of these cases may be cured by tlio Mcar- ing by the child of a properly-fitting truss for several months or years. I 'm- bilical hernia may be acquired in poorly-develope<l children when there is a large cord; the hernial sac will sometimes contain small intestine and perito- neum. A compress or a disk of metal or hard rublK>r larger than the pi-d- trusion should be made, and held in position by means of a bandage ; knitted bandages are most comfortable and useful. Peritoneal abscess rarely occurs in early infancy. One case is reported in which the abscess was due to caseous mesenteric glands (Ashby and Wright). Disturbances of the Urinary Organs. — Infants frequently pass witii the urine considerable uric acid, which forms a visible deposit on the najjUin. This passage of uric acid may be unaccompanied by any discomfort ; again, it may cause disturbance in micturition, or even convulsive seizures and |)aiii. The treatment consists in administering small doses of citrate of potash and sweet spirits of nitre. The malformations described on page 303 are also accompanied by varimis disturbances of the urinary function. Opening of the rectum into the iintlira or the bladder is evidenced by the passing of fluid feces and gas through tlio urethra, or in the female it may i)ass through the vestibule. Later, vesical irrit'ition caused by the decomposing urine may take ])lace. The health of the jKitient is not always interfered with. Contraction of the urethra may uivo rise to incontinence or •"cteuiion of urine. In these cases catheterization will give temporary relief. Dilatation may become necessary. Phimosis, or elongation and contraction of the prepuce, often gives ri>o to nervous disturbance and to painful micturition, or even to convulsidiis. ff''fff'1 PATHOLOGY OF THE NEW-BORN INFANT. 859 A U Treatment for Phimosis. — If ])hiniosis occurs only in a slijrht do<froe, dailv retraction and cleanliness for a week or two usually ovcrcoino the difficulty. ICvon when the prepuce is very tij^lit and adherent to the glans penis, it is usually sutficient inunediately or soon after birth to separate the adherent sur- iliccs with the flat end of a probe, followed by thorouf:;h dilatation of the ))re- puce with dressing-forceps. The foreskin should thereafter daily be retracted, cleansixl, and a fllni of cotton covered with borated vaselin should be laid over the glans penis before allowing the prepuce to recover the glans. If the phi- mosis gives rise to secondary derangements, such as irritation, incontinence, or retention of urine, hernia, prolapse of the rectum, and more severe reflex nervous troubles, circumcision should be performed early should the above- mentioned plan of treatment fail. lli/pospadias, cpi.'^padids, i\nd e.rtrorerKion of the bhidder wiW cause incon- tinence of urine and excoriation. Operations for these conditions are the only moans of relief; they are usually delayed until after the child is one year old, and are not always successful. 6. Hygiene and Therapeutics soon after Birth. 1. Hygienk. — Care immediately after Birth. — The air-passages should be cleared of mucus by inverting the child and brushing away the mucus with the Hnger. When the infant has cried lustily and the cord has been severwl, the little one should be wrapped in a warm flannel rec(Mving-blanket. The eyes and navel should iinme<liately be deanseil with sterilized water and be washed by a 3 per cent, solution of boric acid ; after that the nurse may pro- ceed at once to cleanse its body. For this piu'pose the bath is not always advisable. Very feeble children are easily chilled, and in these the water-bath at first is to be avoidetl ; instead of the bath the body may be anointed with olive oil or with plain vaselin, which is removed with absorbent cotton. Vig- orous rubbing of the skin should be prohibitetl. The room shoidd be warm. The child should be bathcnl every day with oil or with water. The dressing of the cord has been fully described on page 828. Before clothing the child a careful examination must be made to detect any existing malformation or defect, and finally the cord mnst be examined to see that there is no bleeding. From the first the infant is to have its own crib, which may be placed near the mother's bed or in the adjoining room if a special nurse can be pro- vided. This room should be aired regularly night and morning. During tlie first few days laying the baby on its right side will favor closure of the fi»ramen ovale. Food. — As soon as the baby has been cleansed and the mother has been eared for and rested, the child should be placed to the mother's breast ; this being done both to satisfy the natural instinct of the child and for the benefit iler'ved by the mother fr<mi the reflex contraetion produced in the uterus. Tiic first secretions of the breast will usually sup])ly sufficient nourishment, and their laxative quality is beneficial to the chikl. In the course of from M .( H: MB I 1^' » ff *u I .'4 I 860 AMERICAN TEXT-BOOK OF OBSTETRICS. thirty-.six to seventy hours the secretion of milk should be established. It j.; essential that from the iMJginning the child shonld acquire re<;ular haljjts u\ feeding, and for this reason it should be applied to the breast at rcguliir in- tervals — for the first month every two hours during the day and two or tlncc times during the night. Before placing the child to the breast the nipiilc shonld be washed with sterilizal water, and again after nursing. The im- portance of giving proper attention to leeding babies cannot be over-estiinatcil. Infant mortality is very great; up to the fifth year about 25 per cent, df babies die. One author shows that out of 1940 deaths of infants, onlv >ixt\- one were nursing at the breast. The rapid development of infants involves rapid tissue-change and iicccs- sitatcs constant and sufficient supply to all the structures. Well-fed baljics are usually quiet and give comparatively little trouble, and they are usuallv exempt from disease ; while poorly-no"rished babies are fretful and are par- ticularly liable to have convulsions. No artificial food can take the place of the mother's milk ; nursing infants usually thrive well ; but, unfortunately, many mothers, especially in the favored class of society, are unable to provide this milk. Again, many who can' arc unwilling to do so. A wet-nurse is the best substitute next to that of prdj)- erly prepared cow's milk. Mixed food is likely to cause diarrhea. The details of artificial feeding have been discussed on page 668. 2. TiiKitAPEiTTlcs AND DosA(JE. — The following are some of the rem- edies most commonly requirefl in early infancy : A. External Remedies. — Antiseptics. — The stronger remedies in this ji,.'onp must be used with caution, as infants arc very susceptible to their toxic effects; this is especially true of iodoform and of carbolic acid. Salicylic acid and bt^racic acid are to be preferred. The former may be diluted with starch (1 : 8 or 1 : 5). Bichlorid of mercury is used in solution of 1 : oGOO U> 1 : 10,000. Protecfives. — Boric acid and lycopodium or borated talcum jiowder consti- tute an excellent baby powder. If there is much chafing, subnitrate of l)is- muth and starch (1 : o) may be substituted. Simple cerate is also efficient for chafing. Oiled silk is used to protect the skin from cold, to favor perspira- tion, and as a protective in swelling. Astringents. — The formulae of salicylic acid and boric acid, referred Ut above, are excellent astringents. Coitnter-iiritants in early infancy must be used with care. Babies do mit bear blisters well. In colic a spice poultice is a good counter-irritant. Heat and Cold. — Care must be observed in ai)plying heat and cold. A warm bath is a good nerve-sedative and often reduces temperatui'e. Warm fomentations may be used on the chest and the abdomen, but they are often dangerous when applied to the head. Ice applied to the head must be used with caution. B. Internal Remedies. — Xntvients and Tonics. — When additional nutri- tion is required, pcptonoids, beef extracts, and cod-liver oil are beneficial ; PATIIOLOaV OF THE NFAV-liORN INFANT. 861 the latter may be used by imuictioii. Amoiif? tonies, the synip of the itKlid (tf iron may be given in drop doses, two or three times a day. Digestives, antifermoits, and antacids are usually required only by babies who are fed artificially. Administeriu}^ these agents in hot water adds to their efHcieney. Pepsin given in grain doses will aid digestion. Aromatics, sueh as |(oppermint and anise, are given in the form of an infusion. Salicylate? of bis- muth, calcined magnesia, and charcoal are also etticient antacids. Calomel, j'ly to \ of a grain, is very efficient in fermentation of food. Laxatives. — Constipation usually depends on dietetic errors which should l)c corrected before drugs arc given. The addition of sodium, of sugar, or of l)t)th, to the food will often correct the trouble. Among drugs, castor oil, from 15 to 30 drops, is the best laxative. Calcined magnesia, from 8 to 10 ij;rains, is excellent where there is acidity or flatulence. For chronic constipa- tion the fluid extract of caseara sagrada (5 to 30 drops) or compound licorice powder (J teaspoonful) may be used occasionally. Stimulants are especially indicated in the prematurely born and in any con- (lititm in which the circulation is impaired and the vitality is low. Amousr alcoholic stimulants whiskey is the best : 1, 2, or 3 drops may be given every liour. Alcohol is especially indicated in septic diseases, in which it is borne in much larger doses. Carbonate of ammonia, ^ to 1 grain, and tincture of digitalis, h minim, every hour, are excellent cardiac stimulants. Antijn/n'tics are not often indicated ; when the temperature is high, it is best to reduce it bv the use of the bath. Antispasmodics in early infancy are re(|uired usually for colic, in which case the antiferments may be given ; in addition the milk of asafctida in from 1")- to 30-drop doses is excellent. Nerre-sedidires are not often recpiired, and should, as a rule, be avoided. Tiie irritation and pain may usually be relieved by removing the cause; this applies especially to faulty diet and its sequences. When opiates are unavoid- able, paregoric may be given in from 2- to o-droj) doses. Alteratives are especially indicated in hereditary syphilitic disease, and in tills case thev should be continued for a long time. If the babv nurses from its mother, both should l)e under treatment. Mercurials are well borne in early infancy. Calomel J grain, or gray powder J grain, may be given by the month, or the oleate of mercury may be used by imuiction. Mercurial ointment, i drachm, mixed with ecpial ])arts of vaselin if aj)plied to the body of the child from axilla to pubes, and covered by an armless, simg-fitting flannel jacket, makes a good ()ermanent medicating medium. Tills binder may be retained day and night until it becomes soiled or worn, when it should be replaced by a new one similarly medicated. For onychia, biillaj, or fissures due to syphilis, the protiodid of mercury may be used. Diuretics. — Before administering a diuretic a careful examination should be made to exclude the existence of congenital obstruction. Diuretics are oirasionally required diu'ing the first days, when the lu'ine is deficient and whore there is much deposit of urates or of uric acid. Sweet spirits of nitre, 1 m'l i 1 ill if 1 r' t 1 f^^^ r' Bi If'; 802 A mi: UK AN TExr-nooK OF niisTF/nurs. 5 drops, conihiiipd with citnitc of potiisli, j to \ trrniii, mav Im' <riv(>n two np three times a <lay. Jfctitoxttilii's are reqiiivetl with the heniorrhafrie diatliesis and in sin-i^, niek'iia, et(!. Fhiid extract of erj^ot, Croin 1 to ,'J drops, gallic acid, 1 i,, •_> jrraiiis, and cracked i<'e are the nxwt usefid ; hut ice nuist he used with cautinn when tlie vitality is hiw. 7. Premature Infants. By a "premature infant " is meant one that is born between the period nl' viability and the natural end of ])regnaney, whether the interruption of pivtr- nancy l>e spontaneous or be induced. The exact period <tf viability cannot be fixed upon accurately in any ^fiven ease, for the period may vary williin relatively wide limits. In this respect nuieh depends upon the nom-islini( m of the fetus prior to its birth, the condition of the mother durinj; preirnancv the conditions neeessitatin*; or leadin<r up to the interruption of prejrnancv, the duration of, and complications and diiliculties attendant upon, labor, a< well as upon the natin-e of the surroundings ami the ability of those intcit^iid properly to care for the child. It has l)eeii customary to fix the period of viability at twenty-eight weeks. As a mnnber of premature iidimts of twenty-four weeks have successfully been raised, the suggestion that any child that breathes at birth be treated as viable should be adopted in place of aiiv fixed rule based upon the age of the Ictus or upon its size. To preserve the life of the ])remature infant to a time corresponding td what would have been the normal completion of jiregnaney it is important that there be observed certain essentials in its care and management. riii> necessitates that we pjiy especial attention to — First, the maintenance of the bodily temperature. Second, the prevention of exhaustion. Third, the administration of the proper amount and kind of nourishniciit. The nearer to the end of fidl term the child is born, other things being equal, the more favorable are the chances for preserving its life, under proper care, to what woidd be the natural time. If it has been thus preserved and it has increased suflfieiently in weight and strength, its chances for life then are the same as that of a child born at fidl term. The Maintenance of the Bodily Temperature. — The vital organs ol" the ])rematnre infant have not develope<l sufTiciently to maintain a uniform body- heat independently of other means. During intra-uterine life the Utiis is surrounded by a fluid of a uniform temperature, and the heat of the blood is regulated by means of the placental circulation. We can best imitate tlu-e methods of natiu'e by surrounding the child's body with a suitable non-c( in- ducting material kept constantly at an even temperature, and by furnishing to the child a jdentiful sii|)ply of j)ure air that is also of a certain definite and uniform temperature. This condition, the maintenance of the bodily temperature, is best met by the use of an incubator or comruse. There are several patterns of incid)at()i's, II tW'U nr il. 1 \<> 2 h caiitiiiii peril i< I ul' 1 of ]»r(if- ity caiiiHit iry witliiii urisliiiicut ir('jj;n!iiii'y, )r('triiiiiicy, )()r, !l- well intcn'Miil ]u'ri(»l tit' infants ul' t any cliilil lace (tl' any ion(lin<: t(. iniiuirlaiit lont. 'riiin Hirisliincnt. liin^s l)i'in<r ulor proiuT rvcd anil it ill' tliL'ii an' "i>ans ul' till' llorni l)i)il\ jlio i'l'tns is Itlic blonil is Initato tlii-^c llo non-riwi- jrnisliini:' tu lloHniti' anil Ihost nu't l)y incnlKitni's, J'ATJ/OLOaV OF TIIK XFU-JlOhW /.V/'^LV'/'. mG;{ l''lii. 111.— Auviiril liiciiliatnr (ir coiivi'iise. iii»tal)ly those of Tarnier, of Anvard (Fi^s. 444. 44")), and of ('rede, wliieli kive l)een used witli es|)eeial Mieeess in the maternity hospitals of Frame and (iernnuiy. They are more ,ir Ie.s.s complicated and ^ < rr'''''''*^"'xir ixpcnsivc structures, and, ^^.'^sja-J*" "-<*if uiiile of tht'ijjreatest utility in hospitals and ainonir tilt' wealthy, they would often 1)0 impraeticahle in [irivato practii-e, especially anioni; the poor and in tnwns remote from a metropolis. A modiiied Anvard incubator can he made by any carpenter at a tritlini; expense, and will fjive satisfaction. The acconipanyinif illus- tiations explain its niechanisni (Fijjs. 44(3-44cS). ("rede's iucnhator and iiiodificatiou of it consist essentially of u double-walled copper tub. The space between the walls is filled every four hours with water at a tempera- ture of 122° F. The tub is half filled with cotton-wool, u])on which the child is ])laeed. ini- dresst'd, with absorbent cotton about its jjenitals. The tub is then filled with cotton-wool, with the exception of a space fi)r the child's fiiee. An extemporized incubator may l)e made in any home with easily procured materials that will answer the purpose of the more i'lai)orate manufactured article very well. A lar^e-si/ed market basket, a small-sized clothes basket, or an ordinary wooden box is first lined witii heavy wrapping paper, and is then thorouirhly ])ad(k'd with blankets or cotton bat- tiiiir or both. Half of the basket or the box is then filled with some soft, non- conilucting material, such as cotton-wool or cotton batting. Hot-water bottles or hot-water bags are to be so arranged about tiie sides of this receptacle that one or more may be removed or exchanged without exposing or in any way disturbing the child. The child, having been thoroughly anointed with warm sweet oil, is placed in this receptacle undi'essed, with an absorbent i)ad arranged Flii. 415.— Intcriiir view iif tlio .Viivnrd inriibatDr (\'b^. 4111. » m f i f "i ;i H(J4 AMKUICAN rEXT-liOOK (tF OliSTETUIVS. (11 II I i "-' ■;s f IS s %\ 1 P t-, * i '< *ft i' ,:t gj ji It S'S fcfr^ for the collection of Iwes and urine. The incubator i.s then filled with cotton- wool or cotton battinj^, the chilil, with the exception of its hea<l, being (din. pletely (jovered. i f necessary, an ad- ditional shawl (II blanket may be thrown over the in- cubator, care beinj; taken that niinr nf the weight be Itoinc by the infant. A thernionieter .^hoiild J be put alongside tlic child, and the teni- Kl.i. llf..-M<Klino.l Auviir.1 inciil>iitor: a, uliiss pliitc of the m..vnl.lc lid h; j'^''*' "'^' «llOlll(l he c, vi'TitMiitiiiK' tiilH' <(iiitiiiiiinK siiuill rotiiry; Inn : A', vi'iitilHtiiiK slide ; .»/, kept between 87"^ hiit-wiltiT cans; O, slldi' I'lnsiiitJ hiit-iiir cIiiiiiiIhT. mill Q9° l<^ Tl air of the room in which the incubator is to remain should be kept pure and at a uniform temperature of about 71° F. Constant attention by day and hv night is essential to the proper regulation of the temperature '• of the incubator. The Prevention of Ex- haustion. — After the child is placed in the incubator it shouhl be disturbed as little as pos- sible, as all movement, whether j)assive or active, requires on the part of the infant more or less expenditure of vital force. For tliis reason, and for the additional reason that exposure will rob it of body-heat, the Fk;. in.-nitorior vlewof nmddifiod Auvurd iiiciiliuior child shoidd be bathed not oftener "'''^ '""• than once a (hiy, and then with warm sweet oil, and this bath should be given with as little exposure and handling as possible. The absorbent pads arranged about the genitals should be changed sufficiently often to ensure cleanliness, but this change shoidd also be made gently and without exi)osure. Another source of exhaustion would be the nniscular effort re({uired in sucking if the child were put to the breast or fw. hk— iint-waurcun for modiiiedAuvimi if it were required to nurse from a mcubutor. bottle, so that some other method of nourishing the infant should be adoj)te(i. \. fMI I COttnli- 11^; I'uiii- ml. If nil a<l- lawl or nay 1m' r tin; ill- re lH'iii<j,' llOlIf 111' Ih! I)nriit' liuit. A cr :-ll(iIllil ijjfsidc the tli«' tcm- (lioiild Im' vccn 87^ F. Tlir jMirc ;m<l lav ami l)v III iiii'iitiiiiui- 1(1 l»o trivcii rbeiit I mds liilied Aiiviinl PATi/oLOdV OF Tilt: yi:\\'-ii(>iix ixiant. «or) l>c adopt (■(I The Administration of Nourishment. — Tiic prcniatnro infant sliould receive at stated intervals a deliiiite amount of nonrisliinent, tiie )|iiantity and rre(|ucncy of its administration de|H>nding soiiu;\vliat npoii its a^e and npon tlie indications arising from time t() time. If for tny reason the mother's milk cannot be used and a siiitablo wet nnrse cannot be obtained, the child's nourishment should consist of cow's milk, |)ro|)erly sterilized an*l diluted and otliorwisc modified to suit tlu; age and coiulition of tlu' infant. The greatest cure shonid 1hi observed in the preparation of the noiirishiiieiit, whether it bo taken from the breast or be prepared from cow's milk, and in its administra- tion, so that the child will receive it free from germs. Milk may be given from the beginning, or the child may receive (hiring the first day frctin 10 to 20 minims of warm water, containing 2 minims of whisky, every one or two lioiirs. From 1 to 2 drachms of warm nonrishmont should be giv(Mi every hour at first, the amount and the interval being very gradually increased after the child shows evidence of increasing weight and strength. In the admin- i.<itration o' tlic nourishment one of the following methods may be chosen. The simpler procedure, and the one most practicable for ordinary cases in private practic(>, consists in introducing the food, a few (lro|>s at a time, into tile back part of the mouth or pharynx by means of an ordinary medicine- dropper or small glass piston syringe. When breast-milk is available, the iiKitlicr's or the nurse's breast slioidd gently be stroked witii the finger-tips until the milk flows freely, when, by means of a breast-piiiiip, 2 or .'5 drams of milk are withdrawn and placed in a warmed and clean rcceiUacle, from which the amount of food recjuired is immediately given to the infant. The s(!i;ond method is known as f/rrwf/yc. The infant is ])liiccd horizoiitallv on the imrse's lap, with head slightly raised. A No. 14 or KJ (I'reiich) sol't- nihhor urethral catheter, thoroughly sterilized, is first anointed with a little of the food to bo given. The end is introdiux'd into the j)iiai'ynx, and from there, as tho child swallows, it is gently i)assed on into the stomach. When thi! catheter has been introduced lo centimeters ((] inches) its tip has entered the stomach. From a small glass funnel or syringe inserted into the outer extremity of the tube the milk fresh from the breast or the artificial food warmed to a temperature of f>'")° F. (35° ('.) is allowed to pass slowly into the stomach. In wiihdrawing the tube it should be done with a rather ([uick motion, in order t(. prevent the milk from followiug it. liapid withdrawal of the catheter is facilitated by j)lacing the forefinger of the left hand upon the tongue and depressing it. If the presence of the tube causes no incon- venience, it may be left hi xltu over several feedings, being removed two or throe times a day for the purpose of cleaning it. After the child gains strength, and when its power to suck is sufficient, it may be given the breast several times a day, gavage and nursing being thus alternated until nutrition is well estiihlished. The carrying out of these several essentials in the proper care and nian- agcnient of the premature infant rc(]nires the most patient and careful atten- tion on the ])art of the nurse. The temperature of the incubator will reriuire 55 K- !. I 866 AMERICAN TKXT-IiOOK OF OBSTETRICS, ' \A dose attention to prevent too Ugh or too low degree of heat. The eh^aiili- ness of tlie child and of the appliances used at each feeding is also an iiiipoit- ant detail. The slightest neglect in any particular is apt to prove disasuoiis i,, our efforts. While this is especially true as regards the child born hetwci n the twenty-fourth and the thirtieth week, the child born later than this slioiiKl not therefore be in any way neglected. If the eight months' children wore treatetl, for a time at least, exactly as are those of seven months, more of tluin would be savetl. The following statistics show what has been accomplished by inciiljatlnn and gavage : Of infants born at the sixth month, 22 per cent, survived ; at the seventh month, 38 per cent. ; at the eighth month, 89 per cent. ; at oidit and one-half months, 1(5 per cent. The probability of rearing a prematurclv- born infant after the period for incubation and gavage has passed is largolv dependent upon the care exercised throughout the first year or two of life. Children born j)rematurely to parents in good cirv^umstances will very ofUii survive infancy, while the infants of the poor not infrequently succuuih to intercurrent disease. r^P ^\\e cloanli- an inn>(iit- lisa^ii'ims lu urn Uctwoi'n 1 this sliduKl liiklren varc iiore of tluiii VI. OBSTETRIC SURGERY. f;? 1 « !■■■ ! ?i t ll , J ;', »v incuUiitiiui survivotl ; at >nt. ; at c'\]ihi lircinatiiri'ly- sod is lar<i('ly ir two (if lift'. ill vovy (ifti'ii y succuinl) tti I. Instrumental Operations. General Requirements and Preparations for Operations. — Mo.st of the bad results following obstetrical operations are due i > the cari'lessness rather tliaii to the ignorance or incxpertness of the operator. Though most physi- cians feel that in the practice of medicine and surgery they must be pains- taking, methodical, and familinr with recent advances in knowledge, yet in ol)stetrical work they are apt to be careless and inditl'erent, trusting that nature will su])plement all deficiencies and somehow pull the patient safely through. Many who pride themselves upon their scientific precision as physicians or upon their exi)ertne.ss and rigidity of techni(iuo as stn-geons are nevertheless sloveidy and careless as obstetricians. This anomalous state of affaii-s may be ductotlie wide dift'usion of the erroneous idea that pregnancy is a physiological process wliose natural termination is laboi-, and that con.se(]uently no special care or precaution is necessary. ' INIoddlesome nudwifery is bad " is a half-truth which \\[\< done much harm, cramping scientific effort and serving ivs an I'vcr-ready excuse for the delays and procrastinations of incompetence and ignorance. Obstetricians can never do good, safe work until they learn to regard even/ ctinfinement as a surgical case with many pathological possibilities to be avoided or to be overcome, rather tiian as the natural termination of a physiological process. Oj>erative midwifery is a department of surgery governed by the liriiiciples and rules of surgery. Operative precision cannot be attained, nor can iiKirtality and morbidity be reduced to the utmost, unless practice is based upon broad surgical principles, and the same attention is paid to technique as in operations u\)o\\ other parts of the body. In the main, modern surgery owes its success to the observance of a rigid antis(>psis. Surgical cleanliness is imperative in even the smallest operations if the best results are to be obtained. Ill no department is this more important than in operative obstetrics, and in none does disaster follow carelessness and neglect more speedily and surely. It camiot therefore be too strongly impressed u|)()n all who practise the ol)- stctric art that <i rU/UJ technique Ik eKsentin/, and that success or faihire will ihpciid more upon surgical cleanliness than u|)on mere e.\j)er(iiess in operating. Septic niicro-organisnis do not normally exist in the uterus nor in the upper pai't of the vagina; tlicy are not formed iJenorn in the jtarturient canal. l)iit must lie introduced from without. Indeed, the micro-organisms wiiich do e.\ist in the vagina seem to lie ])art of nature's line of defence against invaders from willioiit. Tiie doctrine of aiitolnj'ecll'm as conimoidy expounded, if allowed to 8«7 5>i^ ">'^m:i. i 1 i it I! # 868 AMERICAN TEXT-BOOK OF OBSTETRICS. P% I, < \i\ influcneo our rules of prtuiticc, cau do uotliinj^ hut harm, aud therofore oaiiiint too sevorcly he eoudeniiied. Tlie man wlio hclievesthata patient ran goiiorati' in her own hody septie matters dc /(oro, aud eau therehy iufeet lierself notwiili- .stan(hng riyid autiseptie preeautions, will sooner or later relax those precau- tious, aud have ready to hand a salve for his eouseience when septieeiuia dors arise; but the one who makes it his working hypothesis that septieemia alwavs arises fnmi infection iutrodueed from without as the result of some failun; in techni(ine will be stinmlated to wateh his methods with ever-iucreasiug care, seeking for the weak points in his defeuee aud profiting by his errors and failures. It has well aud truly been said that the doctriue of autoiufeetiou is the gospel of desj)air aud tends to paralyze honest effort. In obstetrical as in all other operations it is of prime importaueeto sec tliat the field of operation and everything coming in contact therewitjj (hands, instruments, dressings, etc.) are thoroughly asei)tic, and are kept so througlioiit the operation and as nuich as possible during convalescence. This is ])erliaj)s harder to do in obstetrical than in general surgical work, on account of the ana- tomical arrangement of the ])arts and the difficulty and inconveniences under which operations must be performed. The external genitals and the vagina should receive special attention, being thoroughly scrubbed and washed with soap aud hot water and then douched with a liot solution of some reliable disin- fectant according to the circumstances of the case. Some use corrosive subli- mate (1 :1000, 1 :2000, 1 : 4000) ; others prefer creoliu, lysol, carbolic acid, permanganate of potash, etc. Good or bad results can be obtained with anv of these agents, as more depends upon the thoroughness of the cleansing than upon the choice of the autisc])tic. Plenty of hot boiled water is sufficient in most cases, Avith perhaj)s the addition of a little creoliu. Lubricants are unnec- essary and had better be avoided. Sponges are a fruitfid source of trouble ; a fairly good substitute can be niadc by sewing up rolls of absorbent cotton or of sterilized gauze of convenient size in a gauze covering ; they can be stcrili/ed just before operation and be do»stroyed afterward. Instruments are now made with metal handles, so arranged that tlicy can easily be taken to pieces and cleaned. Sterilized sutures and ligatures are also readily obtainable, and tiicre is no good reason why an obstcitrician nowadays should ever use instruments or dressings which are not siu'gically clean. Great <;are should betaken with the hands aud the nails, aud precise directions should be given to the nurse as to the cleansing of the vulva and the perineum aud the renewal of pads. These are all-important matters of detail, but they camiot here be discussed thor- oughly. Different operators have different methods, but all have the same aim — the maintenance of surgical cleanliness. The tendency seems to be toward simplification of method ; details may aud do change, but principles never. Passing' the Catheter. — This little operation may be required diiiini.'' pregnancy, labor, or the puerperal period. During }nr(/)i<nu'i/ two lactois co-operate in causing retention of urine: (1) Mechanical disturbance of tlio natural relations, and (2) loss of tone in the muscular fibres of the bladder. During Ittbor retention of urine from mechanical pressure is a common caiisL' 9 OBSTErniC SURGERY. 8G9 fore ciiniiiii ;an gonenUi' elf notwiili- jose imciui- ticemiii dots ieniiii iilwnys le fill In IT ill reasinji; <"ii'''i is errors ami toinfoc'tiun is HOC to sec tliat Dwith (haiiils, so tliroiiii'liinit Ills is ])erli;ii>s mt of the aiia- enienees iiiuler und the vagina (I washed with ,e reliable di>iii- LHirrosive siihli- [, earbolie a('i<l, tallied with any cleansing than is sufficient in •ants are unnee- •c of trouble ; a •bent cotton or •an be sterili/e«l s are now maile 11 to pieces ami liable, and tlu-re c instruments or taken with the the nurse as to )f iiads. 'rii<'>»' discussed tlioi- A-e the same aim ;ins to be toward lieiples never, required dmin.ir l>i(V/ two liiciors iturbanee of tin' of the bladder. a common ci>iise of delay in the second stage, and emptying the distended bladder often removes the so-called " uterine inertia" and allows labor to j)rocee(l. During \\\c inicrpcrlinn retenti<jn fretiuently occurs from the sudden removal of intra- abdominal pressure. Tiie uterus is smaller and the abdominal walls are laxer than before; the bladder, suddenly deprived of its wonted support from l)efore and behind, is apt to distend and to be unable to empty itself. C/ioice of Lttifnonrid. — A soft-rubber male catheter (Xo. 8, 10, or 12 I'jiglish) is most suitable. Ha.d instruments of metal or of glass and tlu; gum-elastic catheter with stylet are usually more readily rendered aseptic, but i((|uire very gentle manipulaticm. Potiition of P((tic)if. — The dorsal position, with limbs drawn up and crcrtcff so that the vestibule may be put upon the stretch, is pieferable, because it brings the meatus within easy reach. The lateral position presents no special ailvantages and greatly imjiedes manipulation. Method. — The meatus is exposed and thoroughly cleansed with a pledget (it cotton and an antiseptic solution. Two fingers of one hand are used to separate the labia, and after locating the meatus the catheter, chemically clean and lubricated with an antiseptic lubricant, is held in the other hand and ]);\ssed visually into the meatus to avoid carrying into the uretiira any infective material that may be near the urethral orifice. During labor it may be difficult to get the catheter through the urethra into the bladder if the ])resenting ])art is wedged low down in the pelvis. Tiie following maneuvres will generallv suffice to overcome the difficultv : First: place two fingers of one hand upon the presenting part, and lift it up out of the pelvis as far as possible while the catheter is guided into the hladder with the other hand. It maybe necessary to hold the presenting part away until the bladder is em])ty. Second: should the first nianeuvre tail, place the patient in the knee-chest ])osition ; the uterus and the presenting part will gravitate away from the pelvis, allowing the catheter to slip easily into the bladder. The latter method seldom fails unless the presenting part is too firmly wedged to be displaced. In the puerperal })eriod considerable diliiciilty may be encountered during the first few days, esjiecially in primipariB. Kdeina or laceration of the parts may so distort the natural relations that the meatus may be drawn over to one side or even down under the anterior vaginal iiorder. It is sometimes necessary to expose the vestibule before the dis|)laced iiuatus can be found. When the catheter has been pass*. I, one should make sine that the bladder is completely emptied by pressing upon the liypogastrium wliile the urine is flowing. The instrument must be perfectly clean ; preferably a new one should be used fiir each case. If needed from day to ilay, the cath- eter should be cleansed tlnn'oughly immediately after usciand be kept in a 2 per cent, solution of carbolic acid ; before being used again it should be rinsed and wiblicd with hot water to remove all traces of the acid, or an irritating ure- thritis or cystitis may be set uj). It is important to have the vestibule freed t'nmi all discharges iiefore the catheter is passed ; to do this properly the labia ^liuiild be well separated, the vestibule exposed, and a vulvar ihjuche be given. I % 870 AMERICAN TEXT-BOOK OF OBSTETRICS. The Douche. — Tliore arc three kinds of doudie, the vulvar, the vaf/iva'. and the uterine. The first two are usually entrusted to the nurse ; the la-i should be given by the physician. Vulvar Douche. — As the vulvar cavity extends to the vaginal entrance. ,i vulvar douche should clean all that ])ortion of the genital tract which lies ante- rior to the vagina. To do this properly the patient should be in the dor.sil position, with the limbs everted and tli.- labia separated with two fingers; tli.- vulvar cavity can then easily be fiiislicd out with an ordinary vulcanite or ghws nozzle (straight or rose; Fig. 44!)) nr by j)ouring water from a pitcher or :i bottle, or it can be washed clean with jute or gauze pads, which can tiieii he destroyed. Unless ]iropo"lv instructed, nurses are very apt to wash over tlie outtidc of the vulva only, iistcad of cleansing the whole vulvar cavity. Vaginal Douche. — The vaginal douche may be given warm or hot, a cold douche being rarely rccpiired ; it may be ])lain or medicated, the latter bcintx required only in special cases. The patient should be in the dorsal positidii. If a large vaginal douche is required, she should be placed across the bed with the hips well over the edge, the thighs everted, and the feet resting upon a cliair. A Kelly pad or a rubber sheet should be so arranged as to carry the Fir.. 419.— Curvert intra-utoriiu' nozzlo. :i:^ l''ii;. l')0.— Iiitm-utoriiu' nozzk'. IjciiiK iilmost striiit-'lit innl biiroly oiitoriiiR tlii' cervix, is iiimlilc lullnsli nut tliL' iitLTiuo cuvily. water into a sufficiently large receptacle below. A vaginal douche during lalMir or the puerperium should be given in large (juantity, the object being to coiiviy a volume of water with but little force, cleansing the parts by the aminiii! of fluid rather than by the force with which it is introduced. Nozzles are iiiinlc of glass, of metal, or of vulcanite; they are straight or curved, with upeiiiii^- :it the point or at the sides in the form of pinholes or of longitudinal eyes ui-lll-. Glass nozzles are good, l)ut tiiey are fragile and nuist be handled witii «:in ; II i • Hi (UiHTETniV NURdER Y 871 (luriiii: liilii'f hiui^ to roiivfv \\v amiHinl nl' »1\ npCuillL!- lit iiictiil is such a good conductor of heat tliat a very hot douche through a metal nozzle can hardly he home ; vulcanite is the he.st, hut it is apt to lose its .shape wlien hoiled. The openings should l)e in the form of slits rather than pinholes, Fiii. l")!.— Intra-utcrinc iiozzlo imssed ititn lower ulcrinc Kctrniciit, llio utiTiiu' ciivily not t)cinK sutisfuc- torily flushed out; tlio iieriiu'iil body is strongly ilopressud to uluviUu the tip of tlie tube. and on the sides of the nozzle, never on the point. In giving a vaginal douclie tlic practical point i.-' to make sure of a sutticient outflow. The Huid should flow out as rapidly as it flows in, otherwise there will he hallooning and dis- tintion of the vaginal canal. Two fingers should he introduced into the I'hi, I.'i2.— Anterior Up drawn down witli volsoUii, nnd rurvc<l nozzle passed up to tlio funilus: whole uterine cavity beiiij; IIusIhmI fnini above <luwinvard. vu!j;ina and be .separated like a glove-stretclier ; the nozzle is passed hetwecii llie fingers, and a good outflow is thus maintained. Where the parts are I'ooinv the same result mav he obtained bv i»ressinir the nozzle firmlv ajjrainst f a ■ • I '■ t i \ 872 AJ/EiiicAX Tj'LXT-jiooK OF onsTirrRics. l( Bvt I \i ^ one side of tlio vii<>iii;i. Double eatlieters are uiineces.suy ; they are exi)ensiv( hard to keep clean, and do not <^ive suilieient flow for obstetrie work niilc.- tiiey are of extra lartre size. When the donelie is finished the vagina sIkhiM be einjUied of tlnid. If corrosive sublimate or other poisonous antiseptic Ims been employed, a pint or two of plain hot water slioidd be run throu<>'ii i., wash away or to dilute any fluid that may have remained in tiie va>i;iiia tliii- diminishing the risk of abs(»rption. Vtcrhw Douche. — The position of the patient and the general arrangeinenls for the uterine douche should be the same as those for the vaginal douche. A large-sized inflexible nozzle of glass or of vulcanite with a i)elvie curve should he selected. The delivery-tube should be of large ealibrc; in order to <;ive a full-sized stream ; the small tubes attached to the ordinary douche apparatii-; of the shops are useless for obstetric work. Objection is sometimes taken to the large-sized uterine nozzle, but, as a general rule, a uterus that ww^U douching easily admits the passage of a good-sized nozzle (Figs. 450-452). In the puerperal period the uterine douche is employed to flush out the uterine cavity and to remove del)ris, shreds, clots, and discharges. This removal can be effected thoroughly and satisfactorily oidy by discharging a large <|uantitv of fluid at the fundus without force and by flushing the uterine cavitv from above downward; the nozzle nuist therefore be carried up to the fundus. Xo diftieulty will be found in passing the nozzle if the anterior lip of the cervix is seized with a jiair of blunt bid let- forceps and drawn gently downward, so as to straighten the canal and to bring its axis more in line with the vagina. Care should be taken that tube and nozzle contain no air and that the vagiiiii be washed out before the nozzle is passed into the uterus. The fundus should be supported by the hand while the douche is being given, and a good outflow should be secured to j)revent distention of the uterine cavity. Slight traction upon the anterior lip will generally sufHce to keep the cervix open and to allow the fluid to flow freely away. If sublimate has been employed, some plain hot water should be used as in the vaginal douche. When the nozzle is witlulrawn the uterus should be made to expel any fluid that may remain before the bullet- forceps is removed. The chief dangers of the uterine douche are tliat fluid or air may be forced into the Fallopian tubes and thence into the peritoneal cavity ; or that clots may be dislodged from the placental site, causing hemorrhage or permitting the eitrance of fluid or air into the sinuses; or that poisoning may result from the f.bsorption of some of the anti«eptic. Ciiill and rise of temperature often occur a few hours after a uterine douche, especially in nervous or debilitated ])atieuts. These unpleasant syn»pt.)ms may be avoided or be minimized (!) by giving a stimulant a few minutes before the douche; (2) by having the iMJcc- tion-fluid hot; (3) by raj)idity and gentleness; and (4) by so covering the patient that she is not exposed to chill while the douche is being given. Curettage. — This operation is indicated (I) in cases of incomplete abortion when portions of the ovum or placenta are retaincnl that cannot be removed by means of the finger or the ovum forceps, and (2) in the pucrperiam wlieii OliHTETRlC SVllUKR Y. 873 septic syinptoius have appeared which are prohahly attributable to the deeora- nosition of pieces ot" phieeiita or ineiubrane.s in the uterine cavity. In cases of incoiu})lete abortion before the end of the tiiird mouth it is ocneraily possible t(» remove the ovum completely by means of the Hnger. The vaj:;ina havin<:; been thoroughly douched and the operator's hands disin- llctedjthe patient is placed in the dorsal jmsition and anesthetized. The fundus is then depressed as far as possible, so that a finger may be passeil up to expl«;re tlie uterus thoroughly and remove any portions of the ovum which may still be adiierent. Occasionally the greater part of the hand must be introduced into the vagina to enable the finger to reach the fundus. If the finger is found to be iiisuflicient, the hand should be withdrawn, and the anterior lip seized with a vnlsolla or a strong bullet-forcej)S to steady the uterus. Schultze's ovum forceps (Fig. 453) may be introduced first and an attemj)t made to remove the retained (D=- 'liSfSiJ (T I'Ui. l.");i.— Scliultzu's ovum forci'ps. 1"'.(;.1M.— Blunt curcttp. fragments. If this instrument fails also, a blunt curette (Fig. 454) shoidd be passed into the uterus and gently manipulated until all adherent pieces are (lotached. It is important that the fundus be kept well depressed and the uterus steadied by the volsella while curetting is being done. Fn the i)Hci'pcrinm, if portions of placenta or membranes remain attached to tiic uterine wall, a douche will be insutticient to remove them, and they will not come away until uterine contraction has separated them entirely from their attachments. If septic symj)toms have appeared, it would be dangerous to wait for their slow natural separation, and the blunt curette may be employed to remove them immediately. The instrument should be long and iiiHexible, tiie beak being bent at an angle with the shaft. The patient having been placed in the dorsal position, the anterior lip is seized with a volsella and drawn well down in order to straighten the uterus and open the cervical canal. The curette is then introduced and nuule to explore the whole uterine cavitv carefully. The scraping should be done very lightly, no force being used, as iK Fui. ■15.'i.— DoK'ris's i^coiivillun. Fl(i. 4.'iri.— MdclilU'd Ocduvilltin. the uterine walls are thin and softened, and there is always danger of perfor- ation uidess the utmost gentleness is used. The greatest ditticulty is experi- I'lued when the retained piece of placenta is situated at the fundus or in one of the eornua. After the uterus has been curetted, a hot intra-nterinc douche sliould be given and an iodoform bougie passed uj) to the fundus. Some (mcrators prefer packing a strip of iodoform gauze into the uterine cavity and allowing the end t(» protrude through the cervix, in t)rder to promote eontrac- JH « ' I 874 AMKliWAN TKXT-nOOK OF 0:'.STi:TI{H'S. *Sii ^ m^ \*A tion and socuro free drainago. AVIion no portion of the phuienta lias been retained, hnt the canse of septic infection is dccfidnal dCbris or siireds of mem- brane, the brush (ecouvl/lon of Doleris, Figs. 455, 456) is more et!"eetive than the curette and is much safer. Having been soaived in very hot wat(!r to soften the bristles, it is passed into the uterine cavity and gently rotated until it reacliis the fundus. A few turns are usually suificient to free the uterine walls tVom ddbris. The brush is then withdrawn, a hot intra-uteritie douciie administered and an iodoform bougie or strip of gauze introiluce<l as after curettin<r. The writer has modified the brush somewhat to enable it to reach the cornua in dif- ficult cases. The t)perations of curetting and brushing are sometimes of irrcMt service, but are always attended with risk. They should be employed only in selected cases, and shouhl be practised with the utmost gentleness. Neither cu- rette nor brush should ever be used until the uterus has been steadied and its walls jHit on the stretch by means of the volsella. When the uterus is curetted or brushed, the operation should be done so thoroughly that it may not re(|iiirc to be repeated. If the septic symptoms continue, some practitioners are in tlie habit of curetting again and again, in the vain hope of thereby removing the focus of infection. Such jiractice cannot be too severely condemned, since it is rarely necessary to curette or brush more than once or twice. Ft has been urged as an objection to these operations that the brush and curette denude the uterine walls and open up fresh aveinies for infection. Experience proves that such objections are groundless if the operator is careful of his technique. The Tampon. — The tampon may be aj)plied to the vulva, the vagina, the cervical canal, or the uterine cavity. The vulrnr tampon is used in eases of labial thrombus where rupture has taken place and there is contimious oozing or free hemorrhage. The clots are turned out of the ruptured sai; 'uid the cavity is tightly packed with strips of iodoform gauze. Occasionally it may be necessary to pack the vagina also, in order to secure sufficient comj)ressi()ii to make the tampon etfective. The raglnal tampon is useful in cases of inev- itable abortion in the early months of pregnancy, when the (cervix is not suf- ficientlv dilated to allow the finger to be passed into the uterin(.' cavity in order to remove the ovum. When properly applied in such cases the vaginal tani|)(>ii checks hemorrhage, stimulates the uterus to more active contraction, and allows time for the patient to rally from the ette(!ts of hemorrhage befont other meas- ures are employed. The tampon is sometimes used to induce lai)or by stim- ulating uterine action : the infraccn-lcal tani])on is then employed, reinibrced by the vaginal tampon. J>ut in i)lacenta |)rievia the tampon is of tlie greatest value; the cervical canal and the vagina are packed lirndy enough to elieck hemorrhage and to |)revent the escape of blood from the vulva. The tampon acts directly and indirectly: directly by dilating the cervix, distending the vaginal vault, and making ilirect compression ; indirectly by exciting tlie uterus to vitrorous contraction. The tam|)on is used also in hvdatidifoini moles as soon as the diagnosis is certain and hemorrhage has begini. It i- occasionally of service in the treatment of post-partum hemorrhage, when the uterine muscle is weak and inert and cannot be stimulated to contract by other OBSTETIt IC S I '/ifJE/t 1 '. 875 i;ioaiis. Ill cases of rigid cervix or i)r(»l()iigo(l first stage in primipariu it is romotimes employed as a dilator; it is daiiued that l)y its use lal)or is short- ened, the mother is spared mueh pain, and the child's lite is placed in less i('oj)ardy. Materials for Tampon. — Various materials liave l)een used for tampons, .'^uch as sponges, tents (sponge and tupelo), halls or pledgets of cotton wrung (lilt of an antiseptic solution, strips of linen or cotton or sterilized gauze, either plain, borated, carholated, sublimated, or iodoformed, (Miarpie is us(;d exten- >ively in France. A favorite tampon in (Jermany and in France is a rul)ber l)ag (col peury liter) introduced Haccid and subsecpieiitly dilated with air or with water. When used as vaginal tampons these rubber dilators cannot Ik; so lirinly api)lied and <lo not make such even, steady pressure as the oid-l'ashioned liimpon. They are more useful as cervical dilators in cases of placenta pnevia. (iauze, charpie, and absorbent cotton are safer than sponges. Vaxjlual Tampon. — Absorbent cotton is s(»aked in carbolized water, the excess of fluid being squeezed out, and fifty or sixty l)alls or jdedgets are pre- pared, each being about the siz<! of a walnut. Some obstetricians use these ]»l('dgets separately ; others attach them to a string or a .strong thread at inter- vals of 6 or 8 inches, as in a kite-tail. Astringents are unnecessary, li)r tlicy do not come in contact with the bleeding surfiice and they only serve ti) irritate the vaginal mucous membrane; a weak solution of carbolic acid is better. Tire pledgets having been prepared, the patient is placed in the Sims pdsition, the perineum is retracted with a Sims speculum, and the cotton l)alls arc carried up with long dressing-forceps and packed closely around the vaginal portion of the cervix, then over the os, then from above downward into the va- gina until it is sufficiently well filled (Fig. 457). It is seldom necessary to ])ack the whole vagina, altiiough in some cases this must be done. A T-bandage is then applied to keep the tampon in xUn. When carefully packed about tiie cervix and filling out completely the dilatable upper portion of the va- <;iiia, the tampon is a perfect safeguard iinaiiist hemorrhage. The tampon mav i<"'suiy in tiic i .wor pdrti.m ..r nw v.i«iMii; inmrd ' , . ,. i 1 /• ,' ' '""1 T-lmii(liini' lire MpplkMl; ciise of |ilu(.'iiitii 1)0 left undisturbed tor twenty-tour ,,r;uviii witi. uiMihit..i irrvix. Iiiiurs, and is then removed piece by piece frnni without inward, the vagina is thoroughly douched out, the bladder and rectum are emptied, and another tampon is intnuhu'ed if necessary. A third tampon is seldom required. Too freipient tamjK)niiig irritates the vagina, causes more or less odor, and exposes the patient to tiie risk of septic infection. Aitcr twenty-four hours' tamponing many operators ])refcr to use carefully prepared sponge or tupelo tents, but, as a rule, tents are not to be recommended. Kk;. I'i7— Tain pdiii lie tlio viisriii'i witli i>U'(l,m'ts (if cottdii tinlitly packed ariniiid the crivix, iiiiirt' m 1:1 ■A- 'I I 87G AMEIiWAN TKXT-nOOK OF OJiSTKTIilCS W: T:/; The Sims speculum is not always availal)le, and it may ho (Uspeiised with. The patient is tiieii phieed in the dorsal position with legs and thighs Hexed. Thr labia iiaving been separated with two fingers, tiie pledgets of cotton are carried lip to the vaginal vaidt and firndy packed about the cervix. Tiie ilrsi lulls may be smeared over with an (.intment containing iodoform, boric acid, (,r carbolic acid. ( )ne hiyer after another is thus introduced until half the vagina is well tilled. Afany obstetricians prefer strips of absorbent cotton instead of balls or pledgets, because they arc more easily removed ; others use strips o|' sterilized gauze, either plain or medicated (Fig. 458). The strips should l)e 25 or Fig. 458.— Tamponing the vagina with strips of gauze or t'otton. 30 centimeters (10 or 12 inches) long and 5 or 7.5 centimeters (2 or 3 inches) wide; they should be smeared on one side with ointment, and be packed about the cervix in the same way as the pledgets. French obstetricians useoiiitiuents and cerates in large quantities when applying the vaginal tampon. Charpen- tier says that a pound or moi'e of chai-pie may be re(piiivd to seal the vagina hermetically; he prefers a borated cerate. Auvard, who uses cerates, says that sometimes as much as 500 grams (16 ounces) may be recjuired; he lays great stress upon the abundant use of cerate. In applying the vaginal tampon some obstetricians begin by packing the cervix first, and then the anterior and jios- terior cul-de-sac, while others reverse this order. At all events, the occlusion of the uterus and the vagina must be hermetic, otherwise the tampon will be ]>ainfid as well as ineffectual ; it is therefore necessary in all cases to take great pains in packing the cul-de-sac gently and thoroughly, but not foiribly. (mt:U differences of opinion seem to exist as to the length of time the tampon may be left in situ. From one hour to thirty-six hours are the limits that have been suggested. hdra-uterine Tampon. — The intra-uterine tampon was introduced in l.S<S7 by Diihrssen. Plain antiseptic gauze is the best material ; it attaches itself to the uterine walls, soaks up and drains away fluid, and swells when moistened without becoming liai-d or inicomfortable. It is used in strips 45 centinie(( is (18 inches) long and from 2.5 to 7.5 centimeters (1 to 3 inches) broad. When well applied it can be retained for forty-eight hours without danger or iiicoii- OBSTETRIC SURGEIt Y. 877 pi!1 inches) iilxml itinciits arpon- vatriiiii iay« that 's great on Honu' nd pos- 'hisitni will 1)0 vo L-Tcat (J real on may Kit liavo in 18.S7 itself to loistened ti meters When ir ineoii- veiiicnce. In oases ol" post-iKirtnm hemorrliajre the (jnantity which can he siuiletl into tho litems is very great. Half ti (U)zen sterilized gauze handages 7.5 or 10 centimeters (3 or 4 inches) wide are not too much. 'J'lie intra- uterine tampon is useful in hemorrhage at full term or after abortion, or where there is sejttic matter in the uterus after labor or abortion, whether curetting has been (Kme or not ; it is useful also when the uterus contracts imperiectly or irregularly after labor or abortion. In subinvolution it stimulates uterine contraction, relievos the turgid veins, and secures good drainage ; in such cases it is gonerally ])receded by irrigation and curetting. Method of App/ieation, — The bladiler and the rectum having been emptied and the vulva and the vagina having been thoroughly cleansed, the anterior and posterior lij)s of tiie cervix are drawn down by means of two volselhe. 11" the hemorrhage has occurred just after delivery and the hand can be passed into the uterus, the volselhe are unnecessary. The uterine cavity having been cleared of clots and debris, a strij) of gauze is carried up to the fundus and packed in until the free space about the fundus is completely filled. The firm- ness of packing is determined by the cireumstaiices of the (!ase; allowance should be made for the swelling of the gauze wlien soaked with secretions. When the uterine cavity has been sufficiently filled tho volselhe are removed, tlic vagina is lightly ])acked, and a firm abdominal bandage is applied. The tampon may be left in phice for one, two, throe, or even four days, according to circumstances, or it may be removed and renewed from day to day. Tam- poning has been kept up in a myomatous uterus for a week. Tho state of the bladder and the rectum must carefully be watched while tho tampon is in place. There are no contra-indications to the intra-utorino tampon if it is modified as to quantity, firmness, and length of application according to circumstances. It is easily removed by simple traction. Episiotomy. — Tho term cpmotomy is applied to the operation of incising the genitals during delivery to jM'event their laceration, substituting a clean cut of definite size in a place where it ciin do no liarm for a ragged tear of indefinite size in a place whore it may cause immediate danger and subsequent injury. This name was given tho operation by ^lichaelis (17i)i)), who incised the median raphe of tho perineum to prevent extensive laceration, but it is now apj>lied to any incision of the external genitals for a similar jmrpose. Episiotomy has fallen into comparative disuse in England, America, and Franco, but is still common in Germany and Austria. The indications are — threatening central riij)turo of the perineum ; great narrowness of the external genitals; excessive rigidity of the soft parts, especially fnmi the presence of cicatricial tissue; faulty presentation ; and undue size of the child's head. Opinions vary as to tho site, number, and size of tho incisions, but each case must bo treated according to the indications present. French obstetricians prefer the oblifpie incision (nvom- niended by Tarnier) which passes to one or the other side of the anus. Clian- troiiil recommends that where rupture into tho rectum is threatened a median incision bo made along tho raphe and then be carried obliquely off on both .sides of the rectum, the incision taking the shape of an inverted Y. German 878 AMEIUVAX ThWf.JiOOK OF OliSTETlilCS. V\ \: obstctricimis in-d'cr iiu-isioiis diivotod ol)li(iiicly toward tlio posterior ooruinijsHnro. Jt is claiiuotl that an incision of 1 i'('iitiriu'tcM-('| inch) incrtusfs the circuinCtn'iuc (»f the vulvar orifice 2 centinietorH(\» inch). Tiie incision should 1h; made dnriiK' a pain with a pair of straight, hhuit-poiuted scissors. WincUel and S lniUzc advise waiting until the epidermis at tlie frenulum begins to tear. In America most authorities depend more upon care and skill in delivering the head than upon incisions for the prevention of perineal laceration. Hut when the ruiiture of the j)erincum threatens to involve the rectum, as in ditlicult forceps cases uv where rapid delivery is necessary, an oblique incision passing well to one sidi; (»f the anus will often save the rectum and Icavi; a wound which can iiiorccasih' and satisfactorily be repaired. Moreover, it is not so liable to l)e contaminated with the lochiii, and primary union generally results. Tiie technique of epis- iotomy has been described and illustrated on page .'{7.'i. Premature Induction of Labor. — The course of gestation may be arrested artificially at any period in the interests of either mother or child. If it is arrested before the child is viable, the operation is called the "induction of abortion ; " if after the child is viable, it is called the '' induction of prematine labor." The date of fetal viability is therefore the dividing-line between these two operations. Ind i cation. s for the Induction of Abortion. — When the further eontiiuianco of gestation would seriously endanger the mother's life, it is juslifiable to induce abortion in the interests of the niothi-r. In uncontrollable vomiting with pro- gressive emaciation, where all other treatment has failed, abortion is indicated. In grave heart, lung, and kidney troubles, pernicious anemia, severe chorea, advancing jaundice, etc., prompt arrest of gestation may be the oidy means of saving the mother's life. Whenever there is such mechanical obstruction in the genital tract that the birth of a viable child is impossible, abortion may be induced. Excessive contraction or deformity of the pelvis, tumors mechani- cally blocking the pelvis, extensive cicatricial contraction of the vagina or the cervix, and advanced carcinoma of the uterus or the vagina are the commonest forms of such mechanical obstruction. Indication/ifor f/ie Induction of Premature Labor. — When the continuance of gestation to full term would expose iiiotlier ,)r child to serious risks which might be diminished or avoided by the an .^t of gestation, the induction of pre- mature labor is indicated. No absolute rulen can be formulated, but each case nuist be judged upon its own merits. The success which has attended modern Cesarean section and symphysiotomy has limited the range for this operation. If the mother's life is not imperilled, it is better to allow the child to attain its full development, and to deliver by section or by symi)hysiotomy than to bring into the world an immature child whose chances of living and thriving are fic- quently less. Peh-ic deformity which would jircvent the birth of a living i'liii<l at full term, but which would allow the safe delivery of a premature viable cliiiti, used to be considered one of the main indications for the induction of j)rcmatiiii' labor. A conjugate of 6.75 to 7 centimeters (2'^ inches) in the simple flat pelvis and of 7.5 to 8 centimeters (3 to 3y\ inches) in the generally-contracted pelvis oiiSTirriiK • s( naKii v. H7y i luv tlio lowest limits iisiiallv set. Hut hv svinplivsiotoiuv u I'lill-toriii child can jrciiorally ho (Iclivcrccl through a ju'lvis as small or even smaller with prohahly li il(< more risk to the mother. In tlccidiii;; upon the operative measures to |i adopted in cax's of moderate pelvic coMtraetioii it ismdyjust to remend)er tl ' claims of the iiiduetiou of pr«inature lahor and the good results it has vl' Ided in the past. In certain f^rave diseases which threaten the mother's Jili' this o|H'ration will alwnys hold its place. In ji/iKriila ftnrria, when a severe homorrha}:;e has taken placo laltor should he indiicetl in the inlere>ts of hoth mother and child. In crldinjiKld many authorities helievc that the siifest treatment is the induction of lahor; others, howev<r, strnn<jjly advocate tlir expectant plan. In chorea, advanced hciirt and Inn;; troubles, general (dcma, jaundice, etc., tile operation is sometimes imperative. When there is a (lead fetus //( iitero injuriously atlectin^- the mother's health, or where the iiiiitlier is likely to die hefore lahor sets in, there can he no donht as to the advisability of the operation. Time to Operate. — The best time to .select for operation is from two hundred and forty to two hundred and tifty days front the cessation of the last menstrual |M riod. It is better to operate too early than too late. Hchroeder generally operated in the thirty-sixth, rarely before the thirty-fourth, week. I'rof/nosin. — The progiK.. s tor the mollier is generally good, but should ;il\vays be guarded. JJesides the increased risk of septic infection, the state of the mother's health may materially atfei-t the progin.,sls. If there has been serious orgaidc disease, the chances of recovery will be lessened. For the I'hild, the more inunature it is, the worse is the prognosis; between the thirty-second and the thirty-sixth week its teinirc of life is feeble and it will re(|uire the ifrcatest care. The use of the incid)ator and artificial feeding greatly improve the chances of rearing very feeble infants (see j). 8(i2). Metlioih of Operation. — A great many methods have been employed for the iiuliiction of labor. Some are elHcient, but more or less dangerous ; others are safe, but less ef!i(!ient. Some are prompt, and are most usefid when speedy results are required ; others are slow, and are applicable oidy when time is not of importance. It is obvit)Us, therefore, that no one method is applicable to all cases. 1. Paneturimi the Membranes (\\\w\\\\ n^ l^eheeVx }[ethod). — A sound, .'unll, or other pointed instrument is passed through t'.ie os uteri and is made to riip- tiii the presenting bag of mendmuus. The liquor anniii drains away and uterine action is set up. This method is safe if the rules of antisepsis are observed, and is most useful when it is desired to relieve uterine tension ; but it is slow, and labor is apt to be tedious and painftd on account of the early loss of the waters. 2. Intrnduetion of an Elastic Bniir/ie into the Uterus (known as Kr<nise\s Miihinl). — After a vaginal douche has been given two lingers are passed up to the external os, and if possible through the cervix to the internal os ; a well- oiled solid bougie (Xo. 10 or 12) is passed aK)ng the Hngers and is guided by tlicm into the uterine cavity between the membranes and the muscular wall (H 880 i^ •Hi AJflJRJCAX Ti:XT-2iOOK OF OliSmTlUVS. (Fi«;. 459). It is tlioii ojontly rotated and made to work its wav sovoral iiidios ni)\vard toward tlio f.mdiis. Tlio hij-hur it can bo made to go, tho more certain aiul rapid s. \\\ bo tiie onset of labor. A light vaginal tampon of iodoform gaiize 1.S then applied to kooj)tlie bougie from slipping out and to prevent thoontraneo of air or septio matters into the uterino eavity. U active labor-pains hove not begun ill twenty-four hours, the tampon and the bougie are removed, a thorou-di Fio. 459.— Bougie passed through tho curvix nml liotwocn the incml)rnnos niul tho utoriiio wiill, ami rotainod Iiy a light vaginal tiiniiKm. ?, vaginal douche is given, and another bougie is introduced on tho opposite side of the uterus. Ustially one introduction t)f a bougie suffices to induce labor, though sometimes two or throe, or even more, nitty bo roqiiirod ; oxcoption:illv the method may fail altogether, and other measures will have to bo emplovtHl. Krauso's method is the safest and best for ordinary purposes when a speodv result is not required, and it is the one in most coinnion use. 3. Tampnuhuj thcVitgina. — A vaginal tamjion of gauze or of cotton pledgets, or a rubber bag (colponryntor, Fig. 460) ptissed up to the cervix and dilated with air or water, is sometimes a useful auxiliary in the induction of labor, but is too slow, uncertain, and painful to be relied upon alone. It is of great ser- vice in placentii pnevia and in some cases of accidental hemorrhage. It is useful also to strongtlien labor-pains which are growing weak or to apply counter-pressure to a presenting bag of monibranes which it is desirable to keep unruptured. The method of applying a tampon has already been described. 4. Dilatation of the Ccvvlr. — AVhen it is required to empty the uterus :is Kid. Itili.— ('iil|ioiirynlor. rapidly as possi ble, it mav bo necessarv to dilate the cervix artiticiallv. Fo r a description of this method see ]>age 882. There is more or le.ss risk atteiuiin forcible dilatation, and it should not be tittempted luile.^s the case is urgent. 5. Intm-utcrlnc Injection (known as Cohni'x McthotJ). — A ,><peeial nozzl (' or an elastic catheter is passed between tho membranes and the uterino wall, as in OBSTETlilV Sr lid Eli Y. 881 il inclios 13 certain entrance liino not tliorouii'h ino Willi, liiul positc side luce labor, roptionally employed. I a speedy In pledijets, Ind dilated |es a iisefnl labor, but int'ul to be iii'eat ser- 1(1 in some \o;e. It IS abor-])ains !• to apply llesirable to •eady been I uterus as llv. For a |< attending:; uri^ent. |l noz/le or wallas in Krause's niethod ; water or some oflier fluid is injected tlirouj^h the nozzle until tension is complained of. The injected fluid separates the membranes I'roiu their uterine attachments and stimulates contraction. The nearer to the fundus the fluid is conveyed, and the larger the area of detachment, the more certain and active will be the contraction. This method is eftieient but danj^erous ; several fatal cases have been reported from shock and from entrance of air into il 13 uterine veins. 6. Va(/inal IrHf/at ion (known as 7v7/r/,s(7<'« Method). — A stream of hot water (100° to 120° F.) is directed against the cervix for ten or iifteen minutes at a time every two or three hours until labor-pains set in. Some obstetricians use cold water, while others follow the hot douche immediately with a cold douche tor the purpose of obtainiuo; a more stimidating effect. This metho<l is tedious, painfid, and uncertain, and it involves risk of congestion and metritis. A iiot (louche se(!ms occasionally to augment the action of other measures, but the cold douche is apt to do harm, and is not to be recommended for general use, 7. Elcctriciti/. — The mild faradic current is said to be sometimes very effec- tive. The negative pole is applied to the cervix in the posterior vaginal cul- de-sac, while the j)ositive pole is |)laccd over the sacrinn or the lund)ar vertebra\ This method has not come into general use, although it has recently attracted some attention ; it is worthy of trial. 8. AKpirofioii of the llfentu per Vaf/iunm, — When ordinary means fail and the case is very i)ressing, the uterus may be punctured and the liquor amnii aspirated. Two fingers are passed into the vagina and the most prominent por- tion of the corpus uteri is located. The aspirator-needle is then passed along the fingers and made to enter the uterine wall at right angles. After the liquor anniii has been aspirated the needle is withdrawn and uterine contraction closes the puncture. 9. lujcvtion of Gli/cerin (known as Pchcr'x Method.) — A special nozzle or a flexible catheter is passed through the os internr.Mi as in the Krause method, and half an ounc- of pure asepti' glvierin is s'owly injected between the membranes and the uterine wall. Some operator, then apply a tampon to the cervix to prevent the escape of the glycerin. I'elzer first used 100 t'libic centimeters (3.} ounces) of glycerin ; he now prefers a smaller (jtiantity (;)0 to 50 cubic centimet rs) and rejieats the injection if the first is unsiic- eesstul. He explains tin action of glycerin as an exciter <-f uterine con- traction in three ways: (1) By mechanical separation oi' the membranes; (2) by a direct irritant efl'ect on the uterine nnicous men.brane, as in like manner recital glycerin injections set up muscular contracilons which persist as tenesmus after the bowel has been emptied coin})let( ly ; and (.">) by the allinity of glycerin for \,ater, the licpior amnii being drawn tluv-.iigh the Muinbranes, causing more or less collapse. 1' ' cr does not use glycerin in eclampsia or in placenta pnevia uide^s llu attachment is lateral and the iiijeetion can be made without injuring the plaii'r'.ia. Some operators claim ('(|iially good results from tamponing he "crviv wiili pledgets of absorbent cotton soaked i.'i glycerin. Pfannenstiel hold that I'clzer's method is 56 ^^^' 882 AMERICAN TEXT- ROOK OF ORSTETRICS. dangerous, because several cases have been reported in wliich glycerin produced nephritis. The method is still on trial ; it has been warndy advocated by some obstetricians and severely criticised by others. The data are not vet sufficient to warrant a positive conclusion. Personally the writer has exjic- rienced most difficulty in securing the retention of the glycerin long enough to produce any decided effect. As the operation of induction of abortion or of premature labor always involves more or less risk, it is advisable to obtain the advice and support of a colleague in consultation. Moreover, there often crop uj) certain moral and religious questions which the physician should not attempt to settle, but should leave to the decision of the family and its religious advisers. There have been employed for the induction of labor many other methods which do not merit serious considei'ation here. Artificial Dilatation of the Os Uteri. — Labor may be delayed by the rigidity of the cervix or the external os, and it may be found necessary to dilate artificially in order to overconie the obstruction. Similar measures mav be required when the condition of mother or child compels immediate deliverv and the cervix is not sufficiently dilated to permit the use of forceps or other instruments. The dilators most com- nioidy used for this jjurpose are either hard or soft. The hard dilators are made of metal or of vulcanite ; the soft dilators are various patterns of rubber bags 'which are introduced into the cervix collapsed and are then distended with air or witli water. In Germany Hegar's dila- o ^ Fi(i. 4t>l.— IIoKnr's liilntors. Fio. 'KVJ.— Actiuil calibre of Ili'K'ur's diliitors, Nos. 8 uiul 14, showing tliu miiount of ililiiliitloii produced. tors are much used (Fig. ^Gl). They are made of vulcanite, of polished steel, or of aluminum, and graduated from No. 1 to No. 44 or upward (Fig. 462). The smaller sizes can be passed through the cervix as easily as an ordinary uterine sound ; the larger produce sufficient dilatation to permit the application of force|)s or the introduction of one of the larger rubber bags.* The patient is placed across the bed in the dorsal position. with limbs everted and feet supported on a couple of chairs. The vagiiiii is thort)Ughly douched out, the anterior and posterior lips of the cervix :iiv steadied with volselhe, and the fundus is pressed well down and sunported by an assistant. The dilators, having been made aseptic and v/ell o'.l'd, arc passed in, one after another, oeginning with the smaller niJiMjers. It is nfteii * The circumference of No. 44 is 14 cciitinieters (about 5/ ini'lu'^J. Jl oducod itetl by not yet i expo- euough always )ort of a n-al and it should ei'e have I do not d by the pessary to ;ures n<av e delivorv s or othei' ir's (li\atiirs. (if ililiiliiti""! i)t' polislit'd |or upward as easily llatation to the larjier \\ position, 'he vajriiiii cervix :irf support CI 1 ll ;hi"d. :nv It is nlti'll m OBSTETRIC SURGER V. 883 possible to dilate the cervix sufficiently in half an hour or an hour, especially if the patient has been anesthetized. A speculum is seldom required. In Fio. 163.— Six-branched dilator. France a six-branched metal dilator (Fig. 463) or Tarnier's uterine dilator (Fig. 464) is preferred.* The latter instrument consists of two blades which Fi(i. 464.— Tarnii'r's uterine dilator. are introduced like forceps-blades, locked, and then kept separated by means of a rubber ring slipped over the end of the handles. The elastic pressure of the rubber gradually overcomes the resistance of the cervix, while the presence of the instrument stimulates uterine contraction in a reflex manner. »«*M«imniWi Fio. 465.— Barnes's bag. Fiii. inc.— McLean's model of H. sbaR. The siofl-rubber dilators are of various kinds. Barnes's fiddle-shaped bags ;Fig. 4<.?5), which are made in three sizes, are introduced by means of a sound. Fiu. 467.— Cbampetier do Ribes's \n\^: A, inlluted ; H, folded for iiitroiliiction into the uterus. McLean's modification (Fig. 466) is folded up as small as possible and pas.<ed ui the rervix in the grasp of a ])air of uterine forceps. When once fairly in place the bag is gradually inflated with air or with water until the required tlilatatiou is secured. Tarnier's dilator (Fig. 468), consisting of a rubber * Honnaire pivos a full deMoription of this instruincnt, its mode of application, its action, and its efli^cts in the Archiven </<■ Tncoloyie rl ik (h/iierolngii', 181)1, pp. 778, 881. f f.fl " « 884 AMERICAN TEXT-BOOK OF OBSTETRICS. T tube terniinatiug at one end in a dilatable ball, is introduced by means of a special sound. When properly placed the sound is withdrawn and water is pumped into the tube by means of a syringe fitting into the mouth-piece. The best of the soft dilators is that of Champetier de Ribes (Fig. 4G7). The bag is made of silk covered with rubber, and when distended it forms an inverted cone 8 centimeters (;5| inches) in diameter at its base. Tiic silk prevents bursting of the bag — a se- rious objection to the other soft dilators. The bag, folded as small as ix)ssible, well oiled, and grasped between the blades of an ajiplicator (Fig, 467, b), is slowly pushed through the cervix until half of it has passed within the internal OS. The applicator is then relaxed, but is not removed until the bau has been pumped half fuii of warm water to ensure its retention. The applicator is then withdrawn, and the batr is slowly pumjied full and left in situ. It acts as an artificial bag of membi-aues and produces safe and easy dilatation. Uterine action may further be stimu- lated by making traction upon the bag during a pain. The bag also prevents injurious pressure of the presenting part upon flu; matei-nal passages. Before the bag can be introduced the os must be dilated sufficiently to allow one finger to pass easily. It may be necessary to dilate to this extent with the finger or with Hegar's dilators. A similar dilatation may be required when Barnes's bags or other soft dilators are used. It is not essential for the membranes to be ru])tured before the bag is introduced, though it is generally safer and better if they have been naturally or artilicially ruptured. Champetier de Ribes's bag is a more powerful dilator than that of Barnes or Tarnier, aiitl is also less liable to be displaced. Besides its use in placenta pnevia and in the artificial induction of labor it has been found of great value in the treatment of a(.'ci(lental hemorrhage, i)rolapse of the funis, shoulder presentation with pr()laj)se of an arm, and too early rupture of the membranes in slightly cdM- tracted ])elves. The objections urged against it are that it may dis])hu'e the presenting ])art or rupture the lower uterine segment if it is nmeh thinned out ; but if care is taken that the bag be not too suddenly or too forcibly dis- tended, such accidents should not occur. The Forceps. — So far back as the time of Hippocrates it was reconi- mended in certain difficult cases of labor to seize the child's head with the liands and pull it down. This procedure was practically inijwssible until the Fig. 468. -Tarnier's uterine dilator in situ : the Img is round in shape, but is couipresseij by tlie iutra-uterine tension. OBSTETRIC SURGERY 885 1 T ■ aus of a water is th-pieco. g. 467). •ed witli it lonns tevrt (oj se. The ig — a se- : dilators, possible, ween the 167, r), is rs'ix until c internal I relaxed, e bag lias irm water applicator le bag is 'n situ. It uenibranes dilatation, be stinui- on the bag o prevents s. lleiore one tinger lie finger or n Barnes's neinbranes \- safer and nipetier <le |nier, and is and in the treatment tation with ightly eon- lisplaee the c'h thiniud [oreibly di^- kvas reconi- Id with the lo until the Fio. 469.— Forceps of Davis. Km. 470,— Forceps of Simpson. Fio. 471.— Forceps of Barnes. ra Fig. 472.— Forceps of Sawyer. Fi(i. 47S.— Forceps of White. Ficj. 47J.— Forceps of Hodge. Fig. 47.">.— Forceps of Dubois. Fig. 47t).— Forceps of Wallace. II Ml \i 836 AMERICAN TEXT-BOOK OF OBSTETRICS. Fig. 477.— Forceps of I'ajot. Fig. 478.— Forceps of Xuugele. Fig. 479.-Forceps of Elliott. 'L Flo. 480.— Forceps of Lazariewich (straight). Il^i •\ I i- Fio. 481.— Axis-traction forceps of Tarnier (to siiow tlie details the hand is represented in an im- proper position for trac- tion ; below is one of the traction-rods). Fio. 482.~Lusk'8 modification of the Tarnier forceps (the trac- tion-rods are shown ''■ce from the catches that hold th mi durinp; ap- plication of the blades and ready for attachment of the tractor). OBHTETRW S UR QER Y. 887 I ii Fig. 483.— Axis-traction forceps of Simpson. gelo. lott. Fig. 484.— Axis-traction forceps of llreus (the rofls having the right- iiiigled bend are against the shiiiik when application is made). azariewieh Fig. 485.— Axis-traction forceps of Poullet (tapes nin through eyes in blades and through ring on traction shunk, and fastened to a cross-bar). Axis-traction Tarnier <to etails the hand ited in an iiu- ition for trac- is one of the ds). Fig. 486.— Axis-traction forceps modified by Jewett (after Milne- Murray's specifications, with details of lock). modificftticiii 2eps (the trac- <".ee from the >m during ap- des and ready le tractor). T T 888 AMERICAN TEXT-BOOK OF OBSTETRICS. invention of the lbr(;ei)s supplied tlie obstetrieian with an instrument capahlc! of being applied to the liead while still in the parturient euual, and of exerting an amount of tractile force greater than that of the unaided hand. Although the use of forceps in obstetrics was mentioned by Aviceniia (980-H);J0) and subse- quently by other writers, it was not until the middle of the seventeenth century that the modern fon-eps was invented. The gradual development and jjerfecting of the instrument from the time of the Chamberlens to the present dav make an interesting and instructive chapter in the history of medicine. Spnci; docs not permit a consideration of the historical side of the subject, nor a descrip- tion of the numerous mo<lels which have been constructed, with their relative merits and demerits; it must suffice to point out the essential points of a good forceps and to indicate those models which are in most common use. No forceps is perfect or is equally adapted to all cases, and if a physician provides himself with only one pair, he should be careful to select a moilel which will be gener- ally useful, even though it may be inferior for certain special cases. More- over, he must use his forceps intelligently, knowing its limitations as well as its advantages, if he would minimize the risk of disappointment and failure. The obstetric forceps consists essentially of two arms or branches, curved on the side so as to grasp the fetal head, articulated to maintain their hold, and provided with handles to facilitate traction. All forceps have this cephalic curve. The blades are usually fenestrated, to make them lighter and to give a better grip of the head with less compression. The wider the fenestration the firmer the grasp. In the; Davis forceps (Fig. -169) great care has been taken to adapt the cephalic curvi' accurately to the contour of the head, and this cui-ve has been adopted by Wallace (Fig. 476), Sawyer (Fig. 472), and others in the construction of the instruments which bear their name. Most modern forceps have a second curve (pelvic), to accommodate the instrument to the siiape of the j)elvigenital canal and to enable it to grasp the head firndy when situated at or just below the brim of the pelvis. Such instruments are sometimes called "double-curved" forceps. The pelvic curve is usually greater in French than in English and American instruments. Those possessing a marked pelvic curve are more suitable for high operations; those with moderate curve are more suit- able for the low and medium operations, as they are less likely to interfere with natural rotation. When the branches cross each other like scissors, they articulate at the jui "on of blade and handle; when they are parallel, as in the Asselini forceps, they articulate at the extremity of the handles. In some varie- ties the blade is joined to the handle by a shaidv, which gives solMity to the instrument and diminishes the elastic spring of the blades. The articula- tion is in the form either of the open English lock (Fig. 487) or of the more complicated French mortise and tenon, tightened by means of a screw to j)i'e- vent the blades from disarticulating (Fig. 487). In some forceps there is a fixed tenon on one branch and a mortise on the other, but no screw to lix the joint. For general use the English lock is preferable. The handles may iu' quite plain, or be serrated, grooved, or roughened, to give a better hold. Sf)iiie e I capalile ■rtinj; ail ougli tlio 1(1 subsc- 1 century erfoctiiig ay make )a(!0 does descrip- • rolativo )t" a good so forceps s himscll" he gcnor- !. More- s well as failure, curved on hold, and s cephalic 1 to give a tration the m taken to [this curve lers in the rn forceps lape of the ated at or ines called •ench than vie curve more suit- ■rfere with ate at the e Asselini me varie- Bol'dity to articulii- the more c\v to pi-e- therc is a to Hx the lies may he Id. Some »^ OJiSTETRW SmOERY. 880 Fio. 4«7.-English (A) nud French (B) locks. have a ring in tiie shank (IJarnes's, Fig. 471), or projecting shoulders (Simp- son's, Fig. 470) to facilitate traction. Forceps, whetlier single-eurvetl or double- i iirved, are either long or f^hort. The short forceps is usually from 22.r) to 2>) centimeters (9 to 10 inches) in length, the long forceps from 32.6 to 40 centi- meters (13 to 16 inches) ; Tarnier's axis-traction torceps is about 45 centimeters (18 inches) long. The short forcejis is now very little used ; it is a relatively feeble ii trument, adapted only for tlie low operation, and has no spe(;ial advantages over the longer instrument, wliich is equally fit- ted for high, low, and medium operations. Saw- yer's is the best model of the short forceps. Jn recent years much attention has been paid to oxis-fradion — that is, traction in the axis of the parturient canal. Whenever traction is not in the right direction, a certain amount of the tractile force is wasted against tiie pelvic walls, and the maternal soft parts are apt to be injured. The fetal head, too, is subjected to more compression, since a greater amount of tractile i'orce is re(piire<l to etfect delivery. The best axis-traction forceps is that of Tarnier (Fig. 481), either the French model or Lusk's modification (Fig. 482). The Breus forceps, so much used in Germany, is lighter and less clumsy, hut not so powerful as that of Tarnier. Simpson added axis-traction rods to the ordinary Simpson forceps (Fig. 483), and tractoi-s have been contrivetl for most of the well-known long double-curved instruments. Stevenson fits a blunt-hook tractor to the lock of the ordinary forceps and thus makes axis-traction. Poulet aeeomplishes the same result by means of cords passed through holes drilled in tiie cephalic portions of the blades (Fig. 48.")). The axis-traction forceps is use- ful in the high operation, but is unnecessary and cumbrous in the low opera- tion ; the higher the head the more useful will this kind of forceps be found. A good forceps should be made of well-temi)ered steel ; the blades should be well polished and nickel-plated, and heavy enough to be firm without too much spring. The cephalic portion should be comparatively light and the shanks strong, the edges of the blades and the fenestne being rounded and smooth. The fenestra? should be of uKKlerate width (from IJ to 1>, inches); the tips of tiie blades should be from 1.3 to 2.5 centimeters (h to 1 inch) apart when closed, the greatest distance b(!t\veen the blades in the cejihalic portion being from 0.3 to 7.5 centimeters (2| to 3 inches). The blades should lock easily ; the handles should be of metal, smooth, and provided with a convenient shoul- der for traction. Wooden handles, complicated locks, and compression-screws should be avoided, and the instrument should be so constructed that it can easily and thoroughly be rendered aseptic. In England the fiivorite forceps is that of Simpson or of Barnes, or the Simpson-liarnes, which has the Barnes hlade and the Simpson handle. Jn America the Simpson (Fig. 470), Barnes (Fig. 471), Hodge (Fig. 474), Wallace (Fig. 47(5), White (Fig. 473), and Sawyer forceps are extensively used. In France some modification of the orig- '^ I h 890 AMERICAN TEXT-BOOK OF OBNTETBIVS. inal Lcvrot is used, such as the Dubois (Fijr. 470), l>.,j„t (Fig. 477), or Stoltz forceps; for axis-traction the Tariiier forceps (Fig. 481) is the favorite, thoiigii many prefer the simpler Poulet (Fig. 48r)). In Germany the Nacgele (Fig. 478) or liraun's mo<lification of the Simpson forceps seems to l)e in coimuonest use; for axis-traction the Brens (Fig. 484) and the Simpson (Fig. 48;}) models are preferred to that of Tarnier. Generally speaking, those obstetricians \vi»o follow the English method, and apply the forcej>s to the sides of the pelvis re- gardless of the position of the fetal head, use the Simpson or the Jiarnes for- ee[)S or some moditicatiou of them ; while those who follow liandelocciue and use the Continental method, applying the forcei)s to the sides of tlu; child's head regardless of its position in the pelvis, prefer the Continental model of forceps, which is usually a modifieatit)n of that of Levret. Action of the Forceps. — The obstetric forceps may act in four diflfbrent ways: (1 ) As a tractor, (2) as a comprcasor, (.'}) as a lever, and (4) as a rotator. 1. Tractor. — Traction supplements a deficient via-a-tergo by sufficient rw-(/- fronte to effect delivery, or ivplacies it altogether if the driving power of the uterus has become exhausted. The amount of fon* applied is under the con- trol of the operator; it may be much or little, continuous or intermittent, according to the necessities of the case. During traction there is always a cer- tain amount of compression and leverage, and usually more or less rotation. The forceps, tlierefore, cannot be used as a tractor only, but becomes a lever, a compressor, or a rotator of greater or lesser power according to the amount and direction of tractile fon^e employed. To be a good tractor the forceps must have a good grasp of the head, and the blades must not slip or spring apart when traction is made. To effect delivery with a minimum of force, traction must be made in the axis of the parturient canal. 2. Compressor. — In normal labor the head is elongated and moulded as it descends by the resistiuice of the pelvis and the soft parts. During forceps delivery a similar compression and moulding take ])lace. While the head is being pulled thrt)Ugh the resistant canal it dilates the passages as it advances and at the same time is compressed by them. When traction is a|)plied com- pression begins ; when traction is stopped compression ceases. The amount of compression is dire(!tly proportional to the amount of tractile Ibrce employed. As undue compression imperils the child's life, it is obvious that too much tractile force is dangerous for the child and should therefore be avoided. Long-continued comjH'ession is more apt to be injurious than intermittent compression, and a child may safely bear a greater amount of compression applied intermittently than if it is applied continuously. It is evident, therefore, that in the interests of the child traction should be gentle and intermittent, not forcible and contin- uous. Compression also may be made by the direct action of the blades. When the handles are long, as in the French forceps, the head can be compressed powerfully by forcibly pressing the handles together, since the leverage is good ; but when the handles are short, as in the English instruments, there is little leverage, and consequently only feeble compression. Some forceps are iittal with a screw by which the blades can be brought together so forcibly as to ex- OBSTETRIC SVRGKIi Y. 891 )r Stoltz , tlu)U}:;li iniuoiH'st i) iiuuli'ls iaiis wlio pelvis ro- inu's I'or- »c(iiu' and 10 cliild's iihkIi!! of ent ways : ;ieut r'lx-ii- t'or of the r tlu! COM- terniitteiit, vays a cer- s rotation. ■i u lover, a mount and rcops must >rinn; apart w, traction iionldod as njj; forceps ;he head is t advances died coni- he anionnt eniployetl. iioh tractile continued sion, and a ermittently bo interests iind contin- les. When leoni pressed kge is ifood : ■e is little are fittcnl V as to ex- ler I'rt powerful compression upon the head. Such contrivances are daufferous, and ^liould be used only in exceptional (uses. The forceps is chiefly and primarily I tractor, not a cephalotribe. It is usually stated that the head may be com- pressed from .6 to 1.3 centimeters {\ to \ inch) without danger; however, this lannot be taken as an invariable rule, since a great deal depends uj)on the degree of ossifieatiou and mouldability of the head, as well as upon the rapidity and continuousncss of the compression. 3. Lever. — The usefulness or the harndulness of the lever action depends upon what constitutes the fulcrum. If the instrument be swayed violently from side to side, pivoting first upon one side of the pelvis and then upon the other, delivery may be ettected rapidly, but the maternal soft parts will surely be bruised between the forceps-blades and the pelvis; but if the fortiops be used as a double lever, lus recommended by Barnes, each branch being made to act alternately as a fulcrum for the other, a gentle oscillating movement of the licad will be produced, and less tractile force will be re(pnred than if a straight pull be employed. A box or a barrel may more easily and safely be nn)ved along a narrow passage by tilting or canting it from side to side : so, too, the ll'tal head may be drawn through the narrow curved parturient canal more easily and safely by a gentle to-and-l"ro lever movement than by a straight, steady pull. It is important to remember that this pendulum movement must not be used alone, but always while traction is being made; it is nieant to sup- plement traction, not to replace it. Some o|M;rators use the forceps as a lever of tlio first or third order. I'ajot frecjuently adopted this plan ; Dr. A. H. Smith of Philadelphia for many years taught and practised a sinular method, using one hand as a fulcrum at the lock. Considerable strength and dexterity are i'('(|nired to use the forceps in this way, and there is always danger of the blades pivoting uj)on tho under surface of the symphysis ov the arch and injuring the soft parts. 4. Rotator. — If there be used a good model which has not too great a pel- vic curve, and if traction be made properly, the head should rotate in tho nor- mal way as it descends. If the handles bo hold too firndy, the head is apt to he dragged straight through without rotation ; but if traction be made upon the shoulder or the ring of the instrument at the level of the lock, the handles lu'ing left comparatively free -uid not tightly grasped by the hand. 1. forceps will seldom interfere with t'io natural mechanism of rotation. In 'i.. one case tiio forceps determines t'",e way in which the head shall descend ; in the other case the head descends according to the natural mechanism and carries the forceps along with it. Some operators use the forceps to rotate the head arti- ficially for the purpose of correcting faulty positions. Such a practice is dan- gerous, and should not be attempted by any one who is not sure of his diagnosis, IHissessed of wide exjxM'ience, and expert in obstetric; manipulation. It is ^f( iierally safer to allow the head to rotate naturally as it descends ; but if arti- ficial rotation is to be done, tho straight forceps should be used in preference to the double-curved instrument (see p. \i^(S). Indications. — The forceps may be applied to the presenting head, tho after- ii * r. I rili; fv 892 AAf/:/i/(A\ Ti:.\r-iiOftK in- tuisri/nncs. r 1 1 . V-:i H-. forniiijr hriul, or \\\i\ hrnrli. Ff lh»- JikuI Ih |m'H«'iitinj;, it wlioiild I in fli<- [xlvJM, \\ shoiild U; <»(' iif»rriiiil finriiK-Hrt and |»ro|Hirtl(tn;it parfiiricnt fjinal, and tlifrr; must Iw tn. nicrlianifid olrHtiidc t<. dd H' '•n^.'ai'fi *' 111 MIZi- f(i the tatin^ tlic iH<; of jjn-at fiirff to ov<noni<' it. 'I'lic nu-rnl I very in:<'«s-i- »rancs ^tlionld Ik- riin- tiir«;d and tlic oh should U- dilat«'<l or dilatal)I<-. Tin- o|MTation is indicated fl) In liiif^friiif; lalxtr when tlif natural effort s arc iinalilf to i \W\ oelivrv CI) wl icn Hpccdy <lcli very is ini|K!rativ«' in the interest of the mother as IP hemorrhage, eonviilsion-, exiiaiisf ion, advanced cardiac or |nilmoiiarv disea->e etc. ; (.'{) when s|M-ed\- delivery is indicated in the inteiof *,f the rrhild, as in impendini; death of the mf»ther or threafeiiinj; asphyxia of th<! child. Thr <}i,f:inHini. — Kver .since tlie days of Smellie aiifl Ii<fvret thftre has Ikch a keen controversy respecfiiifr the he«t metlio<l of applyinir the forceps. Kniellic formulated the rule that the hiades should always Ix- applied to the .sides of the child's head, sr> that it may he ^'ra-ped in the hipaiirtal diameter, l/vrrt adopted Smellie'- rule. Saxtorph »if I)emriarl< f 1 7 10-IM()(»(, a pupil r>f .Sme||i,. criticised tliis metliod, anti adv(K»ited the appli»-atioii of the l)la<les Xo the .>^i(|es of the pelvis, rej^ardless of the pr)sitioii of the child's head. Ffe arj^ued that the iH'lvic «'urve was added to accommo«lale the forceps to the natural curve of til'- pelvis, and that its maximum advantage is ol)t:iinai)le onlv when the two curves exactly coinr-ide. ;Viy diverf^en<'e hetween them is accompanied hy lo«-, of advantai^e from the (wlvic curv(!. flis tear'hini.f had many follr)werH until l>au<l'loc(pie's powerful advfK'acy of the old .Smellie method re-estaijlislied i a-' the rule of practice on the (-'ontinent. fii Kiii^land, llamshotham, Simpson, aiKJ r»arue- have done rniir-h to aholi-h (he use of short forceps; a- tln-e instriirncnt- have <li^appeare<l Smellie's nietlifKl has ^'one too, and Sax- torttli pli s rule IS now (generally adopt<'d It IS very curious that. aithoii(.'|i ajiplication of the hiades to the -ides of the head ori(.'iuated in Kiiirhiiid, it liiis heeti replnccd in that country liy the old ("ontiiieutal m<tliod of appJirnnriM to the .-ides of the pelvis; wliile on flic Continent the old Saxtorph method lia- heen ahandoiied for the r)rifriiial Smellie rnetho<l of applicsition to the side- of the head. .At the pivsent day, therefr)re, we find two di-tiiict metlirxls in u-e. oiif! adopted l>y the Kii^di-h, the other hy the (,'oiitiiieiital school. The Kiiirli-li appiv the hiades to the sides of thr* pelvi-i, reirardle— of the liea<l ; ( 'ontiiieutal ol).-tetricians apply them to the sides of the head, re^Mnlle-s of the pelvis. The Knirlish method is simjiler, ea.-ier, and less likely to injure tlicr maternal pa.s.saj.'es ; tli(! Continental method is more complicated and diflicult, hut le-- likelv to injure the child's head. On the whole, it is.saflirand hetfer for heL'in- ner- to Ii irii and pract; 'c the l'iii<,dish method ; when they hecoine rnon; ex|xri- enced and expert thev mav sometimes find the (Vintinental method prefeniile. The f: "orceps ofwration is divided into the hiffh, tl le rruflliiin, and the operation. Ft is called /ilf/fi when the head is at fir in the hrim, i)iit h,'i- im/ vet de.sceiided into the excavation ; i/irtlliini, when the head has passed tli'- hrim and entered the excavation, hut has not yet comedown upon the pelvic f|f)or; loir, when the head is pre^sinj^ upon the floor and pres«'iitiii(.' at theoiitl'f. When we say that tli(; h<ad is at or in, hut not through, the, hrim, we mean thai irrnr-* UllSTETIlK ' SIKdl'Ji >'. «5)r} ic rnat< riiMl its wifict pliiiD' ftlif liipiirit'tiil) i■^ iit or in liif |il:iii)' iif, luit \\n^ imt v«'t. (mHscd fliroii^li, til*' iiriiii. 'i'lic lii;.'li)'r tlic IiokI the mon- tlifli'iilt iiiul (liiii^croiH tlx' iIMTiitioii. 'I'Ik; low (i|MTiitioii is ijcin'rjilly cnsy iiiid Hafi- lor hotli iMutlitr iui'l 'liilfl ; tlif fiiifliiiiii i-i li;inl<r, lull not ii-iially fldiii^croiis \u citlur; \\\i- \\'\]r\\ u|i( ration i-. (lilliiiilt and ilan^troii-, ami ■^lioiild Ix' att('rM|iti'd unlv in rxccn- tional ciiM-ri. Tlu! tMidciicy of modern practice is to limit v<rv mM<'li tlw field of ilie Iii(_r|i o|Miaiioii. I'inard inwi^tH very stroni^ly tlial l"ore(|M should not lie nsed to r.venome osseous resistance, wlietlier at the hrim or at the outlet. Version and synipliy-iolonty are then ■^at'er alternativf's. '['he method of ipplyint^ forceps in the low and medium o|«"rations is practicallv the -ame, itrid will he deMril)ed fnvt. I'nxitloii. — In Kn^land it is customary to confine in the left lateral position; cin tin- (-'ontinent and in America th(t dorsal position is i^erirra I ly preferred. In the latter position the l)la<les are more easily applied ; in the forfner extraction is easier and safer. A very j^riod plan i^ to comhine thr- advantat^rs of hnth positions liy applying the hiades in the dr)r.«al |)osition and then tinning the patient into the left lateral position for delivery. flinrriil I'lC/KirnH'iiix. — IJefore hc^imiini^ th«' operation the l)la<lder and the rectum >honld always he r-rnptied, the va(.'ina sho Id he donched thoroii^rhlv with a hot antiseptic solution, and the vidva should can-fully he washed and -eruhhed. '{'he opirator's han«l.s, the in-truments, and cverythinij; which may conic in r'r)ntact with the parturient canal shouM, of coin>e, he made a-eplic. Luhricants are umi(!ces,suy if the hands and the instruments are dipped in a ' icolin solution ; soap is pr<'feral)le to oil or va-<liu il creolin is not at hand. It is well to provide jilenty of hoiled water, hoth hot and cold, and to jilace within C'asv reach u l)a>iu of warm wat<'r for rinsing the hands, and another of creolin for u-e duritiy; the (tpcration, as well as jute or ahsorlient cotton to cleanse til"' vidva, perineum, and amis. 'I'he hed should he protected with a clean iiiackinlosh -hect, and a siiilaMc receptacle should he arran^'cd to catcii tlut (li-char<res. .Anesthesia should always he iiscd unless specially contra-iiidicaled, for it not on I v saves the patient much |)ain, hut also makes the operation casifsr iiiid diminishes the risk of injury to the |)arturient canal ; if po-T^il)|e, the maii- iii.'r'mr'nt of the anesthetic should he entrusted to a com|)ctent assistant. Ofurdfi'iii III till' l)(iix(il /'iixiflfiii. — The patient is placed acro-s the hed, with the hr'ad supporte<l on a pillow, the hips well over the cd^rc of the hed, llie tiiij^hs evert«:d, ami the feet rc-tiu(f on a cf)Uple of chairs. Some operators prefl^T placinj; the patir-nt in the lithotomy position, the knee-, hein<,' ^uppf)rtc<l and steadied hv a couple of assistants. The operator sits in front of the patient, hetween the everted thitrh-. The lower Made of the forceps is pjissid first into thr' left side of the |)elvis, then the upper hiaile is passed into the ri<:ht side; when i)rr)|K'rly adjii-ted, the hiades are locked and extraction is hcjrun. To introduce a forceps-hladc properly hoth hand- are ii-ed, one to pa-s the liladr-, the other to ^Miidc it up to and around thr- head, 'i'lic /i,in ,■ hlade is passr-d hy the /(ft hand into the /r/f side of the jiclvis, while the finjrers of the ri^dit hand f.'iiide it internally ; the '//>/>o' hlade is pas-ed hy the rif//il hand into the ri;//if. • 894 AMl'JIilVAjy TKXT-llOOK OF OBSTETRIVS. side of the pelvis, while the fiiifrers of the left hand guide it internally. To make sure of the proper blade, it is always well, before introduciufr the blades, to loek them and hold them with the pelvie curve looking upward, and then ^/ I''i(i. ISK — Mftliixl 111' livlitly KiiispiiiK mill placing tliu Idwit hliuU' for iippliciitioii ; the iirriiw .sliuws the lire liiUowi'il hy the Imiiilk' us the liliiilc passes upwanl. seleet the lower blade. The lower i»lade, i)eak upward, is held lightly in tlie left hand, with the knuckles up, the tlunnb U|)on the flat of the handle, and \''"* ■"•V x \ ^"^ ■ ^ ■ dab Flo. 489.— BcKinnini; application nf llic si'cdikI or upper blade. Tin- liamlle fullnws the ilireitimi nf tin iirriiw to reaeh tlie pii.sitloii shown faintly near the lirst blade in plaee. four fingers upon the outer ])ortion, as shown in Figure 488. \o force is needed to pass the blade ; it is slipped along the lingers of the internal IimihI, and is guided by them around the convexity of the head; the handle is tlicii •ow ssliows tlu' OBSTETRIC sums E It Y. 895 >\vopt downward along; the internal surface of the mother's left thif^h, and the blade passes easily into [wsition between the head and the left lateral wall of the ])elvis. Then the upper blade, held in the rifjjht hand in sinnlar fashion, Is passed alonj? the finp;crs of the left hand, well u|) around the head-globe, and I lie handle is swept downward along the mother's right tliigh into its proper position in the right side of the pelvis ( Fig. 489). If the pelvic curve of the in- >trument corresjurnds witii that of the jx-lvis, the handles should be horizontal, looking one to (he right thigh and the other to the left. The handles are then depressed, and by gentle manipulations are maneuvred into Io(;king without the exercise of any force. Care should always he taken not to include? hair or the labia in the bite of the lock. When the blades h)ck easily, it is usuallv (unsidered that the case is suitable for the forceps operation. The proper , Axis of Met \ and of traction \ with head at irim. Kkj. liKl.— Axis (if tnirtion in tlic liitili (ipiTiiliiiii corrcBpoiMUnK with tlic nxis nf llio iiilrl. Iiinctinn 'if till' tnictiiin, lis tlu' fiiri'liuiid cschiil'S, Is iifiirly at ri^'lit iiiihIl'S to i\\v liniK iixis (if llic iiiiitliii's lioily. Thr iirniw fullciwN the course tiikoii liy the end of the ImiKlle. ninuagement of the internal hand greatly facilitates the introduction of the liladcs ; in fact, much of the difficulty experienced by bcgiiuicrs in introducing the blades is '';i.is(kI by failure to use the internal hand properly. To guide tli(( lower blade into position, two fingers of the right hand should be ])asscd along the left lateral wall of the vagina into the cervix and be ptishcd up as high as possible U])on the left side (tf the presenting head-globe; then, with the liiiger-tips ])ivoting U|)on the head, the bacik of the Hugcrs and the hand should !)(■ made to press the cervix, vagina, and vulva as fin as ))ossible toward the left. Tlic forceps-l)lade can then casilv be slipped along the palmar aspect of the fiii'_n'rs wt^ll uj) ov«'r the convexity, when(!e it glich's aromid the head without 1 m i :. ;i 896 AMERICAN TEXT- BO OK OF OBSTETRICS. , 'Sli difficulty and with little or no expenditure of force. The commonest error is the failure to pass the fingers of the internal hand far enough and to press the cervix and vagina sufficiently to the left. In passing the upper blade (Fig. 489) the fingers of the left hand are passed into the cervix in a similar man- ner, and the lateral walls are pressetl as far as possible toward the right. In Fig. 491.— Low forceps application; side view of tlio application of the second blade: 1, blade started; II., blade in jiosition and forceps locked. the low operation, if the head has emerged from the uterus and the cervix has retracted, the introduction of the blades is much easier, as the cervix need no longer be considered (Fig. 491). After the blades have been locked slight traction should be made, to det(>r- mine whether the head is firmly seized by the forceps, and whether any portion Fii;. Iit2.— Horizontal traction on a head whieli is beRiniiint,' to distend the pelvic floor, the (iccipiil lieiiit; under the pubic iircli. of the cervix or membranes has been included in its grasp. Extraction is tlicn effected by pulling steadily or with a .slight ijcndulum movement in the axis of the pelvi(! canal. Some authorities utterly condemn the ])endulum niovc- ment, and insist that the straight pull is always .safer (Fig. 492). In the high operation the handles must be pressed back against the perineum as iar as !f i bliulB started ; OlhSTETIiW SUIiaEE Y. 897 possible (Fig. 490), to make the line of traction correspond with the axis of the brim ; as the head descends the traction becomes horizontal (J^\^. 492), and is finally directed npward (Fig. 493) as the head distends the perineum and emerges from the vulva. In the medium and low operations the line of traction is not so far backward. If the pains are strong, traction should be made during a pain and intermitted during the interval ; but if the pains are feeble or absent, traction should be made for a minute or two and then be stopped, so as to avoid the dangers of too forcible compression of the fetal head and too rapid dilatation of the parturient canal. To(» speedy delivery endangers the child's life and exjxises the mother to the risks of laceration and hemorriiage. In the high and medium ojx'rations it is a good jdan to keep the left index finger upon the pre- senting part during traction (Fig. 494), to determine whether traction is being iiKule in the right direction and whether the head is descending and rotating properly or is being too forcibly com]>ressed. If the head rotates as it (Icscends, the fbrce|>s will rotate along with it, and the handles will turn fron» l''i(i. 4'.il?.— I'pwiinl Inictidii wluii tlu' occiiait has pussL'd tlie pubic urcli and tliu polvic Hour is on tilt' stri'lcli. w ' p . . ,l (iccipul licing Fic. ■ISM.— I'iniitT tli'tcrniininn diri'ftion of tniction niui amount of rotation and descent. the horizontal position into the ol)li(|Ue or the antero-posterior ; the blades ."^liould be unlocked and readjusted before the antero-posterior diameter is ri;«' !ied, or injurious pressure may be made upon the vestibule and urethra 67 m mn V 898 AMERICAN TKXT-BOOK OF OBSTETItJVS. ill front or the periiuMiiii and rcftiim heliind. Soniotinios the blades require to be readjusted several times before delivery is eoiiipleted. i^lion/d flic hiadex he removed hefore (he head is completelif driieeredj' Opinions are divided on this point. Those who favor non-removal elaiin that the foreeps gives the operator greater control over the head as it comes through the vulva, and enables him t(» Hex or extend it at pleasure, or hold it back if a viohiiit pain drives it down too suddenly upon an insufficiently dilated perineum. Those who favor the removal of the blades claim that thereby a certain amount of room is gained, and the vulva does not need to be so much distended to permit the passage of the head ; moreover, the head can more safely be piloted beneath the pubic arch by the hand than by the forceps. Upon the whole, better results arc obtainable if the blades Ix; removed when the head has descended sufficiently to bring the «'liin to the tip of the coccyx. They should be re- moved slowly during an interval between the pains, and in the reverse direc- tion from that in which they were introduced. In forceps operations, when the head descends in the transverse diameter and does not rotate forward, the blades should always be removed as soon as the head reaches the muscular pelvic floor. Non-rotation is apt to occur in flat or funnel-shaped ])elves, or when the fetal head is large and the occiput wide. Ill such cases the head may become impacted in the pelvic outlet, whence it cannot be dislodged by the natural efforts, and the child may perish, or the maternal passages may slough from pressure if the application of forceps be too long delayed. Before resorting to forceps, however, the patient should be anesthetized and an attempt made to rotate the head by means of two fingers passed up behind the ear which lies close to the .symphysis, as recom- mended by Tarnicr. This maiKUivre will probably fail in cases of contracted pelvis. Care having been taken to promote flexion, the forceps-blades should be apj)lied to the sides of the j)elvis and traction made until the head reatlics the muscular floor, when they should be removed. The head can then he rotated by means of two Angers placed on the posterior fontanelle, the f()relK'ad being jinvscd backward by two fingers of the other hand. If the head he dragged through the outlet in the transverse diameter, extensive laceration will certainly take j)lace. Some operators prefer the oblique application of the forcej)s ; others attempt to rotate the hetid by means of the forceps. Tiie latter ])ractice is dangerous and should ho. avoided if possible. T/ie High Openifiou. — Opinions are divided as to the indications for the high operation. Some operators claim that in certain emergencies the forceps mav be used even if the head is not yet engaged in the brim; others hold ihe operation to be unjustifiable until tlie head is well engagctl ; while others, again, insist that the largest diameter of the head shall have passed the lnim before fi)rcei)s can safely be applied. There can be very little question of ihe great danger to both mother and child if the head is nt)t well engaged in ihc brim; under such circnmstances version is safer and better. But when tiie liead is well engaged and there is no (lisproj)ortion between it and the pelvis, iiiid the OS is fairly dilated or dilatable, there need bo no serious risk to the moll id' Xhf OBSTETRIC SURGER V. 899 or tlic ohild. The chief (lim<>;ci' to the child is from comprossioii duriii«; the proh)ii<fc>d and somctinu's forcible traction which may be required to overcome the resistance of the maternal soft parts. The ilanger to the mother is from laceration and brnisin<>; of the lower uterine seijjment, the cervix, and the vaj^ina duriiifi; extraction. However opinions may ditfer as to the proper way of apply- ing the blades in the medium and low operations, there can be no doubt that in high operations it is best to apply them to the sides of the pelvis without regard to the position of the child's head. As the head usually engages in the brim either in the transverse or the oblique diameter, it will be grasped by the forceps antero-posteriorly or obliquely. If antero-postcriorly, one blade will ! V ri f 18 Fi(i. ■!',•■).— Dinjinim slKuvinn tlio ri^tit iii'.il wmii}; mttluids of puUini; mi tlio Imndlc-lnir, nr.il that the line ol traction is dirertly in tlu' axis iif tlio inlot (nmcli nuidiiicd liDni Kibi'inont). he over the forehead ;uid the otiier over the occiput ; if ol)li(|UeIy, one will be (tver a parietal protuberance and the other over the opposite coronal sutiu'e. During traction the forceps is liable to slip ami to wound the soft [)arts unless tlie handles are well compressed ; or the Hexion of tiie head may be imptiired and extraction be made more difficult. It is of tiie utmost importance that trac- tion should be made in the axis of tlie pelvis to minimize the amount of traction torco employed. The axis-traction forceps has been devised for this purpose. W\\\\ the ordinary forceps more or less force is wasted against the symphysis, witii the residt that the maternal tissues are bruised and the fetal head is need- lessly (compressed. A glance ;;t Figure 41)5 will show the advantiige of axis- tvaction at the brim and tli(> impossibility of securing it with the ordinary t'oiccps. Another great ctmse of tlifficulty and dangi'r in the high operation i.s % |s. f\ n 901 AMERWAN TEXT-BOOK OF OBSTETIUCS. the .'mperft'ct ililatiition of the os and the resistance offered by the cervix. If the operator attempts to overcome this by sheer force, he will most probablv need to use an amount of traction that will prove dangerous to mother and ciiild. It is better to overcome cervical resistanc-e by artificial dilatation before the forceps is applied than by main force afterward. If there is no time for artificial dilatation, the cervix should be incised ; accouchevient force is now rarely justifiable. IJy the use of axis-traction forceps and artificial dilatation of the cervix the high-forceps operation may be shorn of its (;hief dangers. Extraction should not be hurried, but jdenty of time should be allowed for the moulding of the head and the dilatation of the soft parts. The axis-traction forceps offers no advantages at the pelvic outlet, while it takes up more room ; nuiiiy oj)crators remove it when the head comes tlown upon the perineum, and complete the delivery with a lighter and less bulky instrument. In (kcipUo-poHtvnor PonitioiiK. — When the occiput is directed posteriorly, the case should be left to nature so long as possible, in the hope that forward rotation may take place. Some authorities rcconunend in such cases the; use of forceps to turn the occiput forcibly to the front. Such a maneuvrc rarely succeeds ; it is capable, moreover, of seriously injuring the child by rotating the head upon the trunk more than it is safe to do. liut if the natural efforts fail, or there is need for speedy delivery, the forceps may be applied and simpler traction be made. Natural rotation may still take place, but if it does not the head may safely bo delivered in the occipito-posterior position. The blades Kill, lilfi.— Forceps extriictidii in jHTsisti'iit orri)!- Fig. 4il7.— Over-distontioii (if the piTiiiciiiii itii-piistcrior iMisitiiiii : .\, iiiitiiil liiii' of Inu'tion ; H, In piTsistunt occipitopo.storior cluliverii's; tin' (linclioii in wliicli Ibnupsliiindlcs are lifted; (', di- nosi' rests under the pubie arch, rcction of force|>s, after occiput has esca])e(l, In order to deliver the face. are applied as in the ordinary low operation, and they adapt themselves usuallv to the sides of the child's head, since the long diameter is nearly or (piite in the antero-posterior diameter of the jH'lvis. In using traction the natural nieeli- anisin of delivery in this position should be borne in mind and the forceps he u.sed merely to tiid nature. The head becomes arrested in the pelvis because it has undergone extension; therefore, as IJarnes a])tly puts it, the essential tliiiio- to do is to get the occi|)ut down — that is, to restore Hex ion. Traction is made downward or hori/ontally until the forehead emerges siil- ficiently for the root of the nose to pivot beneath the pubic arch (Figs. liKi. 497); the handles are then raised in order to roll the occiput out over tlie I i onsTKTiiic smn/:/! v 901 ])orinouni, and tliov arc tlicn finally doprosscd ti) deliver tlie face and tlie chin bencatli tlu' piibes. If u])\vard traction is made too soon, the blades will be apt to slip off. Extraction should not be hurried, but plenty of time should be allowed for the inouldinjjf of the head and the dilatation of the perineum. The bulky (>'.'eiput distends the jierineum more than does the foi-ehead in oceipito-anterior deliveries (Fig. 4t)7) ; hence more time should be given the ])erineum to stretch, and special precautions should be taken against rupture. With proper care and attention forceps delivery in occipito-posterior ]>ositions sliould not be much more diilieult or dangerous than in ordinary low • )l)erations (see also p. 453). In Brow and Face PreHrntafiouti. — Brow presentations usually flex into vertex or extend into face presentations as the head descends into the ])elvis. Forceps should not be applied early in face presentations, but amj)le time should be allowed for the natural mechanism of forward rotation of the chin. When the face is presenting at the brim, vei-sion is preferable to forceps, if manipula- tion has failed to convert the face presentation into one of the vertex. When the face is descending transversely, forceps slioidd not he used, for traction woukl be (hmgerous from pressiu'e on the neck and thorax. When the chin is pointing posteriorly the forceps is contra-indicated ; but if the chin has r(»tated anteriorly and the natural efforts are insnflicient to complete delivery, the for- ceps may be used with advantage. The blades should be ap|)Iicd as nearly as ])ossil)le to the sides of the child's head, and far enough i)aek to give a good grasp of the occiput (Fig. 49(S). Traction is made downward until the chin has been brought fairly under the pubic arch ; it is then directed gradually forward, and finally ni)ward, as the forehead and oceipjit sweep out over the ]>eri- neum. J)elivery should be slow after ])i voting takes place, because the perineum becjomes enormously distended and is ai)t to tear deeplv. Fi.i.4ns,-F,.rco,.s oxtmotio., in a fa,..- i-nsmta- ' _ ' • tion : tlif ('lull lias imsscil tlu' arcli, iiml a|i|iiars at 8onie operators use the forceps to tiu' vulva, wiiiiu tiio luco is stiiidi.sioiuiing the poivic correct faulty jiositlons and to rotate "'""^' the chin forcibly to the front. Occa- sionally such manipulations may succeed, but they are always fraught with danger. If an early diagnosis is made by external palpation, there is lu good reason why a face presentation should not be conveited in'o a vertex one by external manipulation if the patient be deeply anesthetized ; l)Ul if rectification is impossible, version is usually easy, and is far preferable to a forceps operation. If labor has gone on for some time, and the head is too low down for rectifi- cation or version, the claims of symphysiotomy should be considered. In such ii case, if the symphysis be divided the faulty position can be rectified and the lu'ad be <lelivered with less traction, and therefore less comi)ression, while the i 1 : i I fi M ii': M 902 AMJ'JhWiA.y Ti:XT-JiO()K OF OliSTETIUCS. i;i i -ft •! niatcriial soft parts ai'o less cxjioscd to sorious l)nii>ihg and laceration. Kxternal palpation, external ••;rtiii('ation of I'aulty positions, and tiie modern symphysiotomy have jjjreatly altered the old ideas respecting forceps operations anil have vastly improved the resnlts (see also p. 402). In Jhrcch I'rexeiitafioiix. — In certain dilticult hreccli presentations, vhcn it is impossible to brinu; down a foot, the forceps sometimes succeeds. When the lind)s jM'e exten«led and the feet are on a level witii tlie shoulders {^nindc f/cs /*r,s'sc.s) the forceps proves particularly serviceable. Tarnier's axis-traction forceps sxives a better hold than the ordinary forceps and is less liable to slip, since it enables traction to be made more certainly in the pelvic axis. The blades shoidd be ap- plied over the tro- chanteric or bisiliac diameter, in order that the pelvis may be trrasped as nearly as possible trans- versely (Fiji". "JT.s, p. 47!>). If api)lic(l otherwise, tli(> blades are apt to slip, cans- ins;^ injury to the fetal abdomen and n'cni- tals. Traction should always be made »;en- tly and in the pelvic axis; the pendulum movement is to be avoided, Care should j also be taken not to " compress the blades Fu!. 499.— Forceps cxtractionof the iif[or-<M)inlii); lioiitl: tho arrows show ^^^^ forciblv for fear till' (liroctioii of tructidU. _• ' of fracturinu; the iliac bones. The forceps, properly applied, will injure the child far less than the Hllet or the blunt-hook (sec also p, 478). To the Aftcr-comuKj llvdd. — In breech cases, when there is difficulty in deliverinj^ the head (piickly enou<>;h to save the child's life, the forceps is some- times of j!;reat use as a dcniicr rcusorf. In such cases it is a (piestion whether the Iiead can be delivered soon enough to prevent thcchihl from aspliyxiatin'j, not whether it mi«>ht not possibly be delivered after a time by some oilier means. When ordinary measures have failed and the clnld's life is in im- minent danifer, tlu' forceps should be tried. The old ride is to apply the blades alont; the child's abdomen; if the occiput is to the I'ront, the child'-; body is lifted u|) over the pubes and the blades are applied to the head iVoiii beneath (Fig. 49!)) ; if the face is to the front, the child's Innly is carrie.l biiek (UiSTKTIilV SC'h'C.h'h' V 903 iH'iiuiiluin ovor tlie porinciim aiul the bliuUs arc .'ipplicil iVdiu above. Traction is iiiado ill tho direction tliat will secure speediest delivcrv. It will sonietiiues Ik" luiind more convenient to reverse tlie ride anil to apply the blades aloM"- llic child's back, especially if the perineum is very lon«>; and riuid. The bi'st plan is to apply the blades wherever there is most room. The application of for- ceps to the al'ter-comin<«: head is the only means of savini;- the child when tho cervix has retracted about the necU antl resists all cHbrts to deliver bv trac- tion upon the body. To the iSctrird Jlcad. — When deca))itation has been performed, it is some- times ditticult to deliver tlii' head. If an assistant brinn's the head down over tho brim and holds it tirndy there, the operator can <!;cnerally pass his hand into tho uterus and tinido the blaiJes over tho head until they jjrasp it securelv. Care must be taken that no spicules ol' bone protrude to lacerate the parturient canal durinu; extraction. Applicidion of Forceps in the Lcft-httcrnl Position {Vav^W'Ax Method). — Tho patient is placed across the bed, lying on her lel't side, with both knees drawn \^ fiAHt. ' tfrt'tv liii. rilK).— Apiiliciitiim 111' till' Idfci'iis in tlic Ifft liitcral iMisition: tlu' iirmws show tlic imirsi' takun tiy t'llcll llllKil'. iipand the hips brought well over tho right edge of the bed. Hoth blades are jKissed with th(! right iiand, while tho left guides them around the head. Two liiigersof tho left hand are passed along the posterior wall of the vagina (Fig. /JOO), tlii'ongh the cervix to tho presenting part, and are pushed up as lin- as possible. \\ ith the finger-tips j)ivoting upon the head-gloi)e, the backs of the fingers and ilie hack of tho hand {)rcss back the cervix, the posterior vaginal wall, and the perineum as far as the coccyx will permit. The lower blade, held in the right hand with the beak d<»wnward and the cephalic curve directed forward, is- %f L- 't I' i ,'4 I 904 AMEIiKWX TEXT- HOOK OF OliSTh'T/ilCS. passed liorizoiitally aloiiij tlu- jjuidinj; fiiifrcrs of the left IiuikI until its tip is directi'd over the ("oiivcxity of tlu; lu'ad-j^lolM'. Tlu' iiandlc is then raised and carried baekward aloDt; the mother's right thigii, wiiicili luovemeiit causes the j)<)int of the hlade to travel around the »)i^/fr surface of tlie iK'ad-glohe. Finallv tlie handle is carried backward and downward until the shaidv falls behind the operator's left wrist, which keeps the blade from shifting during the ])assage of the second blade. An assistant is not rcfpiired to hold the first blade, as in tiie dorsal operation. The upper blade, held in the right hand in precisely tlie same way as in tlu; dorsal operation, is then passed hori/ontally along the guid- ing fingers of the left hand, above i]w shank of the firM bladi^, until the finger- tips direct it over the convexity. The handle is then lowered and carried backward along tiie mother's left thigh ; this movement causes the blade to travel around the lijtpcr surface of the head-globe until it lies in the rigiit ilium. The left hand is then withdrawn from the vagina, and a handle is seized in each hand. The handle of the first blade is made to retrace its course a little until it lies directly over the secon<l blade ; with a little nianeuvrinf the blades can easily be locke<l if the case is suitable for the forceps operation. When the blades are locked oni^ handle should look vertically upward, the other vertically downward. When extraction is about to begin the iiandles are car- ried well back against the j)erineum in order to make traction approximatelv in the axis of the brim. As the head descends the handles are carried more and more forward. The introduction of the blades is somewhat more com- jdicated than in the dorsal jwsition, but in extraction the lateral position has the great advantage of enabling the operator to estimate more accurately the line of traction, and to modify it more easily as circumstances may retpiire. During extraction in the dorsal ])osition the handles describe a vertical arc from below upward ; in the lateral position they describe a horizontal arc from left to right. The amount of tractile force can better be graded, and the line of traction can more easily be kept in the pelvic axis, when the operator is pulling around the horizontal arc of the lateral jiosition than when pulling at a disad- vantage around the vertical arc of the dorsal position. As the tendency is generally to j)ull too much and too soon to the front, and as modern beds are low and the patient's jielvis is usually on a lower level than the arms of the operator, the dorsal position is apt to increase the tendency to pull too niiieli to the front. A certain amount of force is (!onse(piently wasted against the front wall of the ])elvis, and more force is required to effect delivery than it' the pull had been in the ])r()j)er direction ; moreover, the perineum is more fully in view throughout the operation, and can more easily be safeguarded, than in the dorsal position. In private ])ractice the lateral position is ofteii more convenient, since a skilled assistant is not required. On the contrary, the dorsal position permits the use of pressure on the fundus to supplement the operator's tractile force, and there is less loss of power from want of coinci- dence of the uterine and pelvic axes. Each method has its advantages as wdl as its disadvantages; in some cases it may be more convenient to use one, and r?' r' OliSTF/ntlV SUUUEIt Y 905 s lip IS ■*ih1 and iscrt the Kiiiully liiiil tlu; as ill tlie isoly tilt' \w ^uid- ii! tiii^t'i'- l carrittl bladt' to ;lio ri^ilit landU; is its course mcuvriiii? operation. , the other >s niH! car- •oximately ■riod more nore com- ,>sition has irately the ;iy require, al arc from .• from left |of traction is pnUinij!; at a disad- Itendency is •n beds ar(> Inns of tiie 1 too mncli aijainst tlie lory tlian it' uiu is more afe;j;nardi'd, on is ofteii 10 contrary, plement the of coinci- [iijes as well ,se one, ami ill some the other method, or even occasionally to change from one to the other dnrinjjj the (ionrse of the operation. Symphysiotomy {a^j/n/'ijat^, symphysis, ro/trj, a cuttiiiff) is an operation for division (»f the piihic symphysis. Its oljject in obstetrics is the enlarge- mont of the pelvic cavity to facilitate delivery in narrow pelves. Ilixtorif. — The first symphysiotomy of which we have any knowledj^e was performed in 1644 by Jean Claude de la Conrvcc, a Frciicli ])hysician jiractis- ing ill Warsaw, Poland. This operation was performed after the death of the mother for tiie purpose of saving the child. A similar post-mortem section was performed in 17()G by Joseph Jaccpies Piciurk ot IIiiii<fary. To Jean Rene Siganlt of Angers, France, belongs the credit of originating the opera- tion as applied to the living subject. The idea seems to have lieeii snggestccl to him, however, by a work of Severin Pineaud, first published in 1")98. While still a student of mediciin, Siganlt had several times practised tiie operation of symphysiotomy on the bodies of women who died in labor, and in 1768 lie read a memoir upon the subject before the Royal Academy of Surgery at Paris, jiroposing the divisicm of the pubic joint as a substitute for Cesarian section. His proposal for a time met with little tiivor, since his first experi- ments, which were performed on bodies that had become rigid from l)eiiig too long dead, faileil to show an amount of separation s ifficient to effect any material gain ill the pelvic diameters. The first operation on tlie living woman was per- formed Oct. 1, 1777, by Siganlt, with the assistance of Prof. Alphonse Leroy, who had liecomc interested in the subject, and in common with Siganlt had studied tiie operation on the cadaver. Tlie woman's recovery was tedious and complicated with a urinary fistula, yet both mother and child survived. At this time CV-sarean section was almost uniformly fatal, and the new operation, which seemed destined to replace it, was received with enthusiasm. In the next decade thirty-five symphysiotomies were done in various jiarts of Europe. Imperfect knowledge of pelvimetry and of the proper limits of the operation led to its frequent misapplication ; the technique, too, was faulty. Urethral and vesical injuries, sepsis of the pelvic organs, caries of the bones, and non- nnioii of the joint wen^ frequent results of the operation, and it soon began to lose favor. Symphysiotomy was bitterly denounced by Baudelocqiie and certiiin other obstetric authorities of the time, and in 1858 it had fallen into general disrepute. During tiie period between 1777 and 1866 there were, according to Harris, one hundred symphysiotomies, with a maternal mortality of 31 per cent, and a fetal mortality of 65 per cent. From 1818 to 1801 symphysiotomy was almost exclnsivcly confined to Xaples. Though it at no time wholly died out, it was practically obsolete from 1858 to 1866. In the latter year it was taken up by Prof. Ottavio Morisani of Xajiles, who first operated in January, 1866, saving both mother and child. Fncouragcd by this success, he became deeply interested in the cause of symjihysiotomy, and to his labors in its behalf w(! are indebted for its general re-adoption. Largely as the rosf.lt of Ids ctforts the technique was improved and tlie mortality greatly reduced. The first fifty Neapolitan operations done by Morisani and his fol- • I? i|: 'i I ii' I •'I i fv V h: 906 AMl'UUCAA TI'LXT-IiOOK O/' OliSTF/rniCS. hi 1 1 H.' lowoM saved SO per cent, of the motluTs, and later, when the operation eaiue to be jjerfornied nnch-r modern antiseptic nietiiods, tiie mortality wa.s still further diminished. The residts were frnpiently pid)lished, yet for a (piarter of a contnry the sneeessfnl work that was heiii},' done in Naples attracted little or n() attention outside of Italy. Tntil 1H!>2 the operation was almost imi- versally condemned or was ij>iiored by obstetric writers in other parts of the world. That year was a memorabh! one in the history of symphysiotoiiiv. In .January, 1H!)2, it a^'ain secured a footin<jj in Paris. At that date Spinolli, a jmpil of ISIorisani, ])ublished in the AnnalcH de (I'l/urmloi/ic a memoir with a detailed account of twenty-four c-ases. JSIoreover, Pinard, the editor of the journal, had seen the oju'ration demonstrated upon the cadaver by Spinelli. Jle at once became an earnest champion of symphysit>tomy, and recommended it in a paper upon the subject before he had performed it. He lirst operated in February, 18i)'2, and in little more than a year nineteen symphysi- otonues wore performed by himself and his assistants, savinjf nineteen women and sixteen children. Within a lew months after the pid)lication of his lh*t successes the operation had spread to the rest of the Continent and over both hemispheres. In the United States, Dr. Robert P. Harris of IMiiladelphia had lonir upheld the cause of symphysiotomy, and had repeatedly brouj;ht the subject to the attention of the Entflisli-speakin<f ])rofession. In September, 1892, lie presented a paper to the American (}ynecoloj>;ical Society entitled "The Kemarkable llesults of AntisejUic Symphysiotomy." ' From this tinu^ dated the introduction of symphysiotomy into America. On the 30tli of Septend)er, 1892, the operation was performed by the writer, and three days later by Prof Barton V. Hirst of Philadelphia. Other operations followid in rapid succession in various parts of the country. /iV.s»Ms of Si/mplii/fiiotoiiij/. — In 210 symphysiotomies performed since 188(), when the operation began to be done under Listerian precautions, there were, aceordinj; to Neusjebauer,'- 27 maternal deaths, a mortality of 12.85 per cent. Of the children 20.2 per cent, were lost, includinjij those that died shortly after birth. Under favorable conditions, however, and at the hands of skilled operators, the death-rate has been almost nil. Pinard lost but one mother in his first 20 operations, and Zweifel none in his first 2.'} — one death in 43 e i -. In the first 72 operations in the United States the maternal deal ijii was 14 per cent, and the infantile mortality was 26 per cent. liu residts cannot be taken as fairly representing the capabilities of symphy ^my. The operations were done by a large nnnd)er of operators of varying i. gree- (' skill and for the most part of little or no experience in syniphysiotoujy. In many cases the conditions were unfavorable for ])ubic section, and most of the deaths were due to causes wholly independent of the method of delivery. In Italy, at the hands of Morisani and his followers, in 55 modern sytii- ])hysiotonues .3.5 per cent, of the mothers and 5.5 per cent, of the children ' American G'ynecolni/intl Tranxnrlionit, \\>]. xvii. ' Ueber de Rekubililalioii der Schamfutjenlrennuiiij mler Sympliyseolomii; etc., 18'J3. 1 1? oHsTi'/rniv sviidKii v. 907 i-»l little DSt uiii- 4 of tllf siotoiny. |tinoHi, 11 ir witli a »r (»r tlic Spiiit'lli. iniiu'iitltil openitcd lympliysi- I'li Nvoincn )f his lii-t aiul over had h>ii<!; till' subji't't r, 1892, li(> tied "The this tinio u> 30th of three (Uiys js Ibllowcd siiiee lH8(i, here were, ;,") per ecnt. wx\ shttrtly llrf of skilled le mother in in 43 « - -. v'.w was i-.-sults my. T'l'' liotoiny. 1 " most of the ilivery. Iiodern syiii- Ithe chiltlreii I is'.t;?. were lost. I'iiiard of I'aris in his first "JO operations had lint one maternal death. 'V\w total mnnher (»f eases in the Handeloeiine elinie (l8l>2-!>4) was I!) ; I'onr women and live children died. Zwi'il'el of Leipsie operated 23 linios, savin*; ail the mothers and all lint two of the ehildren. It wonl ! seem iliat ill properly sileeted eases and with skilled oix-rators the death-rate for the women shonld not, at the most, excreed three or fonr in a hnndred. In the proptirtion of mothers saved the record of symphysiotomy compares lavoralily with that of Cesarean section. In 79 Cesarean operations performed ill the United States since the adoption of the Siintier method, ii'). 19 per cent, of the mothers and 12.()9 per cent, of the children w(!re lost. Zweili'l's results in 23 symphysiotomies with no maternal deaths and Morisani's .'jo eases with a loss of .').") per cent, of tlu! mothers have not lieen equalle<l l»y Cesarean see- tioii. In the best Cesarean record, which is that of Leipsic, three women were lust in 54 operat ions — a mortality of 5.5 per cent. Tin? proportion of children lost nn<ler symphysiotomy has j^reatly exceeded that of the (-esarean operation. In |)rematnre artificial labor under approved modern methods the maternal (Icatli-rate should not be more than 2 or 3 per cent., but the mortality for the cliildren is very <i;reat. Two-thirds of the children |)erish, if we inchide those who di(! within a few days or weeks after birth. In the early history of symphysiotomy suppuration of the symphysis and oi' the saero-iliae joints, caries of the pubic bones, and non-union were not inlVecpient results of the operation ; but they were for the most j)art faults of the crude sur<<;ery of that period, rather than of the operation itself. In several recent cases some mobility of the jiubie bones has been noted when the women betjan to walk, but rarely more than is occasionally observed after diflicult forceps deliv- eries and even after spontaneous births. The woman's jiowers of locomotion are not necessarily crippled by slijxlit looseness of the joint. Fronimel, however, recently reported a case in which a se(piestruni of bone an inch in length came away, and there was persistent iailure of union with inability to walk alter three months. As a ride, under a rigid asejisis, and with complete im- nuibilization of the pelvis during convalescence, the restoration of the sym- jiliysis in women not previously infected has been complete. Vesical and urethral injuries have been reported in several instances. They are liable to occur not only from the knife, but also from pinching tiie urethra and bladder hctween the bones when the latter are brought together. These accidents, Morisani declares, are faults of the operator, and should be prevented. Troublesome hemorrhage frequently happens, either from the incision or from lacerations. It is especially liable to be encountered on division of the subpubic ligament, owing to the vascularity of the structures about the lower id of the symjihysis. Tiacerations of the corpus cavernosum of the clitoris, with more or less bleeding, not infreipiently occurs. TIemorrliage, however, is controllable by use of ])ressure and the hemostatic suture. Pack- iiiu the wound and the vagina with iodoform gau/e generally suffices. The vauii particularly the anterior wall, is exposed to laceration during the extraeiion of the child. In septic conditions of the passages the latter i R! Ife'i i li' !'t 008 AMERICAN TEXT-BOOK OF OBSTETlilCS. 1. 1' ' I I injuries may assume no little importance by openinj; avenues t\»r the possiUIo infection of the symphysis. To what extent these eoniplieations may be pre- vented future experience must decide. Anatomical Liinifadons. — The piiu of s])ace attainable in syniphyKiotoniv is mainly deterniined by the mobility of the sacro-iliac joints {V\^. 501). Experiments on the cadaver by Wcliie and numerous other observers show that in non-puerperal pelves the ante- rior sacro-iliac ligaments rupture :it different degrees of pubic separation, ranging from about 4 to 9 centimeters (H to t\h indies), the results varying with the age and the j)hysical condition of the subject. In pelves from puei- peral women a se|)aration of 8, or even 9, centimeters is possible without injury to the sacro-iliac articulations. In two operations by Caruso an intcrpiibic .1(11.— si|iiinii ion or till' sacroiiiiic joint on spacc of 8.5 Centimeters [IVl ini-hes) in opening tho,,ui,ic«ym„i,>MMKarai,ouf,. ,,,,^ .j,,^| ,, (rutimetcrs (^f inches) in the other was obtained with no bad results; 6.5 centimeters (2^ inches) may be regarded as an entirely safe limit of pubic sepai .tion. With an interpubie Flc. 502.— Led innominate bono: o, li, n.xis at the illo-sacral joini upon wliicli llii' lionc rotates \slaii iliv pnliic I'Ud is alxluctcil (WcliU'). opening of 6 centimeters (2^ inches), the ((onjugala vera gains 1.2 centinieicrs (J inch), the transverse 1.9 centimeters {-^ inch), and the oblitpie diameti is i!,") OBSTETim ' SVRGl'Ui Y 909 3 possiUlo y be pi't>- ilccido. ■The p»ii» ivsiotoiuy ■ mobility ^\^. 501). by AVi'lllO vers show ? the anti - rupture tit separation, eentinieters Its varyint; \\ comlititiM from p>uM- [ 8, or even thont injury ns. In two interpubii^ i'^ ini'hos) in i inches) in inclies) nmy \n interpuhie ■ V.itlUOS wlirll \\W 2 centiinrtt'i'- |iliana'tfr> -•■ eentinieters (1 inch). With a separation of 7 eentinieters (2| inches), which is nossiblc under gentU^ pressure without hiceration of the sacro-iliac ligaments, the gain in the conjugata vera is 1.5 centimeters (5 inch). Ki<i. MH. — Siicrum ; n h, n h. nxps on \vlii<h the iiitKimiimtt' l)oiu's hini;e. Owinp to the wadRC-slinpo of IIk' siicniin, tliiy run I'miii iiliovi' dnwinviird mid inward (Woldc). Wehle' caUed attention to the fact that wiien the pul)ie bones are sejtarated the sacro-iliac joints rotate upon an oblicpie line running from above down- ward and from without inward, and that in conscfpienee the ends of the pubic iiones move downward as well as outward when tlic joint is opened (Figs. 502- I'h,, ."1(11.— Moist iinpiinitioii of iK'lvis iiI'iicIumI liy siuTUiii lo a post ; left iiiiioniinali' lioiii' iinniohili/.cd ; rif,'lit lioiK' alidnctcd. Sliows dou iiuard iiiovciiu'iit of piiliis on .1 1 id act ion iWi'ldci. r)llS). A separation <>f .3 centimeters (1 1 inches) cau,<cs a descent of 2 eenti- nieters (i^ incii), wiiicii is still I'urthcr increased by the downward pressure of till' Ic'tal head during delivery. This dcsceiil I' tlic pnhic Ixincs ailds matc- ' Arlifilcii (tii.i <lfr KihiitiHcldii l''riiiiriiUiiiiL in Dnsdfii, Iliunl i., lfi',11!. I?, m • w ftt ',:■ t 910 AMERICAN TEXT-BOOK OF OnSTIVritlVS. rially to the amount of pelvic space gained (Figs. 504, 505, 507). All the Fir;. "lO'i.— The eflt'ot of di'scciit of tliu imliic Ihhu's mi the fjiiin in K'iif.'tli i)f sacropiiljio (liniiictcr. I!y mere si'piinitioii of bonus, tliu K'li" in fonjuKiUii vera would be .S.S'; with udilod ulloet of (k'sccnt it is y,S"' (Wehlu). lines running from the promontory to the anterior half of the linea ilio-peotinea are elongated more than by mere separation of the pubic bones. But this is Klii. 506.— DliiKrani of iii'lvi<' brim, slinwintr friiiii in simcc on oiii'iiint,' imbic joint : P X, coiijnt-'nti' joint cIosimI ; I' S', coiijUHuti.' joint open (i ciii. (Wchlr). not all. As the bones recede from each other the juiterior parietal bos projects nearly a centimeter into the pul)ic interspace. The increase in the coiijii^alt' OBSTETRIC SUllUER Y Dll All the (liiimctiT. Hy )f (k'scL'Ut it is lio-peotiiioii But this is (•iiiij"i-'"''' J"'"' hos pmjirts diameter by opening the pnbio joint to the extent of 6.5 centimeters (2^ inches) amounts, tlierefore, in effect, to about 2 centimeters (^ inch). IncUcatioiis. — In general, symphysiotomy is applicable in obstructed labor in which the delivery of a living, viable child may be rendered po.ssible by a Via. M'. — Diftjjram of jielvic lirim, slinuiiin f^iiiii n( space on sopiinition of syiii))liysis. I'lihir joint ilosi'd, ivflvic cavity admits a fplicrc NJ mm. in iliamL'tcr; joint opened (J cm., the cavity admits u spliero ;is mm. in diameter (after Faralienf ). moderate expansion of the pelvis, fn the simph; flattened pelvis the limits of the operation may be computed from tlie data ali'oady considered. The l)iparietal diameter of the average fetal head is 9.5 centimeters (3| inches). It is reduced by compression during the birth to about 9 centimeters (3J inches). >*l nun. I'lii. "lOH.— Diasram of pelvic lirini, showing txiuu of space on sepanition of sympliysis. I'Mliic joint cIiisimI, tlie pelvic cavity admits a sjihere (iO mm. in dianu ter ; joint opened li em., the excavation admits II spliere M mm. in diameter (alier Iwiriibenf I. Alter full separation of the .symphysis the ])arietal l)os jtrojeots into tiie inter- pubic space, and this in effect shortens the biparietal diameter to the extent of nearly a centimeter more. A conjugate of H centimeters (31 inches) will there- line be retjiiired for the pas.sage of the head. Since a pubic separation of (5 centimeters (2|- inche.<) affords a gain >>!' 1.2 centimeters (^ inch) in the antero- m i »;„ .!} r<. 912 AMERICAN TEXT-BOOK OF OBSTETRICS. '\i posterior diameter, delivery under .symphysiotomy may be done in simple flat pelves with a conjugate not below 6.8 centimeters (2f inches). Clinically, liowever, at least in America, 7 centimeters (2| inches) is generally adopted as the minimum conjugate for pubic section. At its upper limit the field of synii)hysiotomy begins where that of forceps and version ends. The latter operations become dangerous to mother anil child in contractions below 9 centimeters (3^ inches), conjugata vera. Xot only is the maternal and the fetal mortality greatly increased imder prolonged and difficult extraction by forceps or version, but mental and physical infirm- ities, resulting from intracranial injuries, are also common in the children wlm survive. With a nornud heac', then, the field of symphysiotomy in simple antero-posterii>r contraction lies between 7 and 9 centimeters (2f and 3^ inches), conjugata vera. In generally-contracted pelves the operation mav usually be j)erforined with advantage with a conjugate between 8.2 and 10 centimeters (,3-^ and 4 inclies). The limitations of symphysiotomy, however, cannot yet be regarded as absolutely settled. Views dift'er according to the varying success of difi'erent operators. More extended experience will be required to determine fnlly the jdace which the operation shall finally hold in obstetric surgery. It is evident that the safe choice of procedure nuist depend upon an accurate estimate of the reiatis'e size of the head and the pelvis, and this is possible oidy for the exjiert well trained in pelvimetry and the methods of measuring the fetal head. The capacity of the jielvis to receive the head shotdd be judged not only by direct measurements, but also by trying whether the head can be crowded into the excavation or can be made to engage bv careful traction with the forceps. Symphysiotomy has been proposed fin* delivery in impacted and irreducible mento-posterior face cases and in occipito-posterior positions with imjjaction. In such emergencies and in irreducible brow presentations, provided all other conditions are favorable for both mother and child, pul)ic section would seem particularly apjdicable, since the small extent of pubic separation required would entail a minimum risk to the mother. The symphysis has been opened to facilitate delivery by embryotomy on the dead child in absolute (jontraction of the pelvis. The combination of symi)hysiotomy anil premature labor seems to the writer of doid)tfid utility. The object is to extend the limits of the former procedure into the higher grades of contraction, i)Ut the combined risks of both operations can scarcely oH'cr any advantage over Cesarian section, especially for the child, Synipliys- iotomy is obviously contra-indicated in aid<ylosis of the sacro-iliac joints, and theretbre in the Robert and the Xaegele pelvis. 3f('tlio(l of ()j)cr(it!on. — The instruments and materials required in syni- ])hvsiotomy are a common scalpel, a slightly curved, narrow-bladcd, inobe- pointcd bistoury, the Galbiati knil'e or the modified Galbiati knife of Harris, curved needles, needle-fitrceps, catgut and silk sutures, a few heniostatic force])s, a metallic catheter, and a yard or two of iodoibrm gauze. Tlircc r * > ii obstetrh ' sunaEn y. 913 iplo flat inically, jptccl as ^ forceps hor aiul ra. Not roloiijfi'tl .1 infirni- Iron who n siiiiplc \ and 3^ lion may ,2 and 10 iiardcd as f ditt'crent nine fully ;ery. [ upon an and this is nethods of p the head ig wlu'tlicr onsiano I'y irroduoiUlo impaction, -d all other Ition wtudd separation [ryotoniy on bination of ^tful utility, the hiu,her lean searecly Symphys- |e joints, and red in syni- le.d, probi'- I'o of Harris, hemostatic ku/o. Thivc tr assistants are needed — one to j^ive the anesthetic, two to hold the knees and render sueh other assistance as tlie operator may require. The ])roper time lor operation is at the close of the first .stage of labor. In emer<i;eney the dilatation of the cervix when already well advanced may be completed by the hand or by the use of Barnes' bags. In certain cases advantage may be gained by dividing the symphysis before fidl dilatation in order to jiromote the expan- sion of the cervix by permitting the head to sink into the excavation. Jm- mediately before tlio operation examination should be made for the ausculta- tory evidence of fetal life by listening over the abdomen. liefore finally deciding upon symphysiotomy the mobility of the sacro-iliac jf)ints should be te.sted by strongly flexing and extending the thighs and by rotating the knees out- ward. The ])atient is anesthetized and ])laced upon a firm table with her knees drawn up and held apart. The pubes should be shaved and tne abdominal walls shotdd be cleansed and disinfected as for celiotomy, 'i'ln^ vulva and the vagina should be rendered as nearly aseptic as jiossible, since the pubic wound is ex])osed to infection throngh vaginal lacerations. The location of the symphysis is then determined by searching for the depression at its upper margin. The slight motion produced by raising and lowering the legs helps in linding the joint. It must be remembere<l that an exact central |)osition of the sym])hysis is exceptional in deformed pelves. The depth of the joint is to be noted and the surfaces are to be examined carefully. An assistant then intro- duces a straight metallic catheter for the purpose of holding the nn^thra and th<> vesical neck backward and to the right side during the division of the joint : this at the same time serves to keep the bladder empty. Either a short or a long ])riraarv incision may be adopted. In the former method, which is that pursued by Morisani, a vertical incision of from 2 to 3 centimeters (f to 1^ inches) in length is made in the abdominal wall, terminating below at a point 1 centimeter {t inch) above the upper end of the symphysis. In the latter, or open method, the incision is made from 8 to 10 centimeters (3i to 4 inches) in length, extending well above the symphysis and terminating below at the root of the clitoris or turning to one side of it. The principal gain in the short incision is the lessened danger of hemorrhage and of subsequent infection from the lochial discharge. The long incision, however, has the advantage that it enables the operator to .see what he is doing at each step. The former is generally to be preferred. The incision may be prolonged and the joint exposed when foinid necessary for the control of hemorrhage or in consequence of other complications. INTorisani separates the attachments of the recti by cutting sideways suf- ficiently for the introduction of the finger. This practi<'e otlers no a<lvantage :ind unnecessarily Aveakens the abdominal wall. The better practice is to make the o])ening in the aponeurosis between the recti longitudinally, extend- ing down to the joint and large enough to admit the linger. The retropubic stiiictures are separated by the index finger, which is introduced into the Wiund, carried down behind the symj>hysis, and hooked under the inferior ligament. Upon this finger as a guiile the probe-pointed bistoury is passed 68 ft 914 AMERICAN TJ'LXT-nOOK OF OnSTF/miCS. If down bchiiul the joint to the lower edge of the subpubic ligament. The joint .structures are then divided, cutting from behind forward and from below upward until the bones are feU to give way. If tht; sickk;-shaped knife of Galbiati or of Harris is used, it is hooked under the sul)[)ubie ligament and drawn upward and forward through the joint. During the incision the urethra is held backward away from the pubic arcli and to the right l)y means of the metallic catheter in the hands of an assistant. Instead of tlie finger a Hays director may be passed behind the joint to guide the knife. The writer found no difficulty in passing the probe-pointed bistoury sal'ely along the posterior surface of the symphysis, guided by a finger of tlie left iiand in the vagina. If this method is attempted, the bistoury point should be made to hug the joint closely all the way. It may happen that the introduction of an ordinary bistoury behind the symphysis may be found difficult or impossi- ble, owing to a petululous abdomen. Tiie joint can tlien be cut mainly from above downward. Pinard and otiiers prefer to incise the symphysis from before backward. In this method of incision the retropubic structures should "be protected by a tamjion of iodoform gauze or by a lead plate phiced behind the symphysis. The plan of cutting from before backward and above down- ward has been advocated, for the reason that the symphysis is wider at the upper than at the lower margin, and is wider anteriorly than posteriorlv. There is usually little difficulty, however, in engaging the knife in any aspect of the joint. In rare cases, owing to the sinuous shape of the symphysis or to ossification of the joint, it has been found necessary to replace the knife witii a chain-saw or a finger-saw. Rarely the head may be crowded so firndv into the excavation that it may be necessary to push it up before the symjilivsis can safely be divided. As the joint is cut through, the bones usually fall apart .spontaneously to the distance of .'i or 4 centimeters {\\ to \^ inches). The wound is protected with a fold of iodoform or of sublimate gauze diu'ing the delivery. If hemorrhage occurs, it should be controlled by packing with iodoform gauze or by hemostatic suture. An important improvement in the technique of symphysiotomy has recently been proposed by Dr. J\I. I^. Harris of Chicago.' After dividing the sym- physis he detaches the std)pubic ligament (whi(rh has been left uncut) and the deep perineal fascia fn)m the pubic arch, using for the purpose a blinit-poiMttil bistoury under guidance of the finger and hugging the bone closely on cacli side. The pubes are allowed to separate gradually, and the detachment of the fascia from the bones is continued until its fibres are no longer felt to be ten^c. The separation of the symphysis will then have been carried as far as can he done without injury to the sacro-iliac joints. The object of this step i^ at once apparent. The deep perineal fascia, by reason of its attachment to the ischio-pubic rami, is so much stretclied tran>- ver.sely, when the joint is opened to any great extent, that in the usual nietliitil of operating it is often ruptured. This fascia is perforated by the vagina, tlic urethra, and the dor.sal vein of the clitoris. It surrounds a part of the cor- ' Am. Journal uj Obsletrics, Dec, 1S94. OBSTETRIC sLiiai:ii r. (115 It. The iiu Ih'Iow kiiiti' of nout and ision the l)V moans D fin>j;or a ^'he writer along the luul in the i made to hictiou of ^v impossi- ainly from hysis from iires should iced behind bove down- ,vider at the rly. There spect of tlie ihysis or to i knife with ) firmly into mphysis ean \\ fall apart liches). The ! during the lacking witli has recently hig the sym- licut) and the l)lnnt-pointe(l l)sely on eaeli Ihment of the It to be tense. far as ean be pal fascia, by Jetehed traii>- lusnal u\e'.lii'(l le vagina, tln' It of the .nr- pora cavernosa of the clitoris, aiul it contains between its layers the cavernous < bodies about the vagina and urethra and the plexus of veins around the vesical neck. Laceration of the tiiscia takes place in the direction of least resistance, which is usually through the line of perforation. The urethra and the clitoris are fre(|uently torn. The vagina, which is always a .septic tract, is .sometimes invaded by the tear. The venous plexuses and the cavernous bodies involved ilk the injury, and in a region that is much increa.sed in vascularity during pregnancy, are often the source of alarming hemorrhage. The bleeding, which is mainly or wholly venous, is sometimes extremely diflicidt t(t control, the veins being held open by the .stretched fibres of the torn fascia, and it has even ended fatally. All these injuries, too, greatly increase the risk of sepsis. Afost (tf the dangers and complications of .symphysiotomy are prevented by preserv- ing intact the deep perineal fasciia. While dividing the joint and separating the ftiscia the lateral halves of the pelvis nuist firmly be supported. Otherwise they may prematurely be forced apart, and the fa.seia be torn, .should the fetal head be suddenly driven down by a violent uterine contraction. In all ca.ses the joint is to be oi)ened to the I'nllest extent permissible, in order to prevent ])ossible rupture of the fascia from imexpected spreading of the bones during delivery. To detach the fii.scia from its subpubic attachment in the manner described, the primary incision must be free, extending from a little ab .e the .symphysis nearly down to the clitoris. Increasing experience is unfavorable to the osseous suture. (lood union is obtained without it, while wiring the bones may lead to caries and persi.stent fistula. After the joint has been opened the patient may be permitted to deliver her- self, a.ssLsted, if necessary, by expressio fetus. As a rule, it is better to termi- nate the labor at onco by forceps or by version. The woman is thus spared the danger of long-continued anesthesia and of prolonged exposure of the operation wound. In general, the choice between forceps and version should he decided in accordance with the commonly accepted rule of version before and forceps after engagement of the head. In breech presentation the delivery will not differ from the usual method of breech extraction. During the delivery the lateral halves of the pelvis .should be supported by an assistant to prevent too wide separation of the pubic bones, care being taken to prevent undue strain upon the anterior .soft parts during the extraction of the child. Some writers have advised a ])erincal incision when neec.s.sary to avert laceration of the soft structiu'cs that bridge the pubic intcr- spacic. The same end would perhaps be accomplished better by the usual lateral opisiotomy incisions. The placenta should be delivered before the joint is clo.sed. Afler delivery tne ends of the sundered bones are brought together by pressure on the trochanters. As the lateral halves of the pelvis are approx- imated, the retropubic structures are pressed gently backward to prevent injury to the bladder or the urethra by pinching between the bones. I icopohl sutures the cartilages with silk; Zwcifel unites the joint surfaces Mi 910 AMEIilVAX TEXr-nOOK OF OBHTETlilCS. ¥ .V by tlnw hiiriotl siitnros of catgut or of silkworm pit. Silver wire irritates, and is open to tho ohjoction that it may intcHbro with a subsequont operatimi. Most operators wholly reject the bone suture as unnecessary. Immobilization of the joint after operation, however, by means of the usual bandajre is Iron- blcsome and difficult, and in certain instances persistent looseness of the sym- physis has remained. The womid in tiie soft parts is closed with silk sutiurs. It is advisable to include th(! fibrous structures on the anterior surface of the joint in the sutures which close tlu; wound of the soft parts. Aftcr-fredfmcnt. — Absolute immobili/ation of the pelvis during convales- cence is essential to immediate and fii-m union of tho joint. Many operators have trusted to a strong muslin binder, simple or starched or ])ainted with water-glass. A canvas belt provided with straps and buckles for tighteninii makes a satisfactory dressing. The "Itroad part of an Ksmareh bandage h:is boon used. An excellent ])lan, which has been adopted by several American operators, consists in the use of adhesive straps of rubber plaster, sui)j)Iemeiit(d with the muslin binder. Three broad strips of plaster are carried across the abdomen from one wing of the pelvis to the other above the wound. Tiic muslin binder is pinned tightly over the plaster strajis. The adhesive strap- are ])articularly usefid as a partial support to tho pelvis while the muslin bandage, which frequently becomes soiled, is being changed. (larrigues suggests the use of Martin's roller-bandage of solid rubber. One opei-ator has used a wire cuirass to keej) the bones together. Guoniot proposes an apjiaratus which he calls an " iliac compressor," consisting of lateral ])lat(s well padded, compression being applied by means of anterior and posterior straps. Pinard and others have made use of a special bed with appliances for retention of the bones and for suspending the ])atient. Vaginal and vulvar lacerations should be closed by suture. The bladder and the urethra should bo examined for possible injuries. An ounce or two of boric acid and iodoform (1 : 8) may be loft in the vagina to keep the dis- charges sweet, and a large absorbent pad may be placed over the vulva. The patient is i)Ut in bed on her back, with the knees lightly tied together and the limbs outstretched. This position best favors the coaptation of the sun- dered bones, and should therefore be maintained until reunion of the joint is established. For evacuation of the bowels or the bladder the patient may lie lifted upon the bed-pan, the nurse seizing tho hips over the trochanters. The use of the catheter is frequently necessary for the first few days, but it sliould be avoided if possible. The dressing of tho pubic wound may remain undis- turbed for a week unless it becomes soiled by the lochial discharges. A con- .stant object of solicitude is the pelvic bandage. It should be examined scveriil times daily, and be tightened as often as the least slackness is noted. It is exposed to soiling with urine and focal discharges, and it is only by the utimi-t vigilance that proper cleanliness can be maintained. The simple nmslin binder must be replaced frequently with a fresh one. While it is being elianircd the lateral halves of tho pelvis should be supported firmly by an assistant. If a water-glass or a plaster dressing be used, the parts of the bandage liable ti to lie OBSTETIilC SI RCiFJt Y 'J17 iiTitatos. :)|)oriiti(iii. (bilizatiipii fc is lv()\i- tho syiu- k sutiins. 'ace of tlif convnlcs- ,' ()])orators inti'd with tijihtoniiiu, I Aiucriciiu pplcincntcd II across tlir omul. Till' osive straps tlio nmsliii (laiTijiiics )ne (>i)orat(if pr()j)os(>s an atcral plates ml postcrini' h appliaiK'is The bladder ounce or two ■cp the dis- ulva. Tl.e (liTcthor and of tlio sun- of the joint itieiit may he [inters. TIh' nit it shonlil •emain nn<li>- es. A eon- nincd sevend noted. It i> )y the iitniii-t imple nin-hn )oing ohaiiiifd assistant. H loe liable tn hr soiled may bo protected by a folded towel or a napkin properly placed under the buttocks and fre(piently changed. The bowels should be kept open as in other cases. The pelvic bandage is to be worn from four to si,\ weeks. The patient may usually leave her l)ed at the expiration of three weeks, and leave her room by the end of a month. Cesarean section is the operation of removing the fcti-s from the mother by opening the abdomen and iiicisiug the uterus. Amor^- t areicnts it was done immediately after the death of the nutther; but not m > ' r.. rburteenth or the fifteenth eentiny is there any record of the operation being ])erformed upon a living mother. The maternal mortality was so great that the operation was condennied by Ambroise Pare, ISIain'icjeau, and others, and for a long time was practically abandoned. The cause of death was usually hemorrhage or sepsis. The uterine wound was not closed, U'cause it was thought that the alternate contractions and relaxations of the uterus would make the stitches tear out. The uterine wound was left gaping, and eventually closed by adhesive inflam- mation to the abdonnnal wall. The cicatrix which was formed varied greatly in depth and strength, was extremely liable to subse(pietit rupture, and occa- sionally perndtted henna to take place. The use of the uterine suture was advocated and practiscnl in the beginning of the present century; nevertheless, the mortality remained high until Porro (187G) supplemented the ordinaiy sec- tion by amjmtatiug the uterus and including the stump in the abdonnnal siitiu'e. r>ut the greatest advance was made in 1882 by Sanger of Leipsii', who ))rojK)scd the complete closin"(! of the uterine wound by nudtiple sutiu'cs ; to him is in great measure due the credit of ])erfecting the modern operation. Its success is maiidy attributable to three causes : (1) A strict antiseptic technicpie ; (2) com- plete closure of the uterine wound by nudtiple sutures ; and (3) the deliberate selection of the operation before the beginning of labor, and its performance before the patient's strength has been exhausted or her i)assages infected by repeated exandnations and fruitless attempts to (kdiver by forceps or by ver- sion. Since the introduction of the Sanger operation craiuotomy upon the liv- ing child has been wellnigh abandoned in France, and even the nuitilating Porro operation has been restricted within very narrow limits. Indications. — Cesarean section may be porforined in the interest of the mother or of the child when safe delivery by version or by forceps is impossible. If the mother is moribund and the child is still alive, its life will depend upon a speedy delivery ; with the mother's consent the operation may k' performed to save the child. But the cases of real diiKctilty arc those in which the delivery (if a living child is impossible in any other way than by Cesarean section, yet the mother might be delivered with comi)arative safety by perforiidng a crani- iitoniy. Is it permissible to destroy the child in order to save the mother? lias she the right to refuse Cesarean section and to demand craniotomy in her (iwn interest, or to insist upon whatever operation will give her the best chance of recoverv, regardless of h(>r child? Has th(> obstetrician the right to weigh one life a<rainst another, and decide to take the one bv craiuotomy or to jeopard- ize the other bv Cesarean section? These are serious questions, with import- tt f^^ it' ' 918 AMKRIVAN TEXT-BOOK OF OBSTETRICS. m ^ ^ ant moral and rdi-riuiis lu'urinjrs, wliioli tlio physician shoultl not be called npi.ii to decide. He should fortily himself by consultiiifj; with a rmi/nVt; and then, having laid the medical aspects of the case plainly b( ore the patient and lier friends, should leave the ultimate decision to them. Undoubtedly his first duty is to his patient, but he is not called upon to over-persuade her or to override lu'r wishes. After a serious accident a surgeon may recommend the ami>utatinii of a lind) as the oidy means of saving life, and may even feel compeUed t(. retire from the case if his advice is not taken ; but he has neither the moral nor the legal right to amputate the limb against the will of his patient. The indications for Cesarean section are generally classed as aholnlc and ndative. Absolute. Jitdimtiotis, — The indication is absolute when it is impossible to extract the fetus, either living, dead, or mutilated, through the natural i)assage. This maybe the case in extreme pelvic contraction from arrested development, rickets, or osteomalacia, or where the i)assage is blocked by tumors of the pelvis (osseous) or of the uterus and the soft i)arts (cantinoma, fibroma, etc.). 'J'he modern symphysiotomy has narrowed the limits of Cesarean section somewhat, so that the indication is not now considered absolute uidess the conjugate is (i centimeters (2.^ inches) or under, the child being well-developed and at full time. Some authorities do not consider even 6 centimeters {'If^ inches) as an absolute indication if the ciiild is small and th(! head is mouldable. After it has been decided to deliver through an abdominal incision, it nuist still bo determined whether it is better to remove the uterus by the Porro ope- ration, or, by performing the Siinger o])erati()n, to subject the patient to the risk of a possible subsecpient ]iregnancy. In some cases the diftieulty may be over- come by ligaturing the Fallopian tubes or removing the appendages before^ closing the abdominal wound. Jn doubtful or debatable cases individual eir- (jumstances must decide, but, in general, it may be said that tiie Porro opera- ti(m is clearly indicated in preference to the Sanger — (1) if the uterus is infected, the chances of the motiier's recovery being much increased by re- moval of the infected organ ; (2) if there is ])artial or total obstruction of the parturient canal by tumors; (.3) if there is carcinoma of the uterus, espeeiallv of the cervix ; (4) in osteomalacia; (5) if complete inertia of the uterus occuis dui'ing the course of the operation. Rchdive In<Jic(tti(m)i. — The relative indications are difficult to formulate, and must generally be determined by the individual ])eculiaritics of the case. A <legree of pelvic contraction or oi)struction less than is requisite to constitute ;m absolute indication, but yet sufficient to make the safe delivery of a living and viable child by the natural passages doubtful, maybe considered a relative indi- cation. A conjugate of 6 to 8 centimeters (from 2J to 3J- inches) and tunidis of the pelvis or of the soft parts causing moderate obstruction are the ediii- raonest relative indications. The alternative operations arc symphysiotomy, forceps, version, and craniotomy (see p. 54.'}). Time fo Opcnitc. — TJiere is still a difTerence of opinion as to the best time to operate. Some operators wait until labor has fairly begun, in order to secure 1^ OJhS'. J . Til IV .SLliUERV. DID U'll upon iiul then, and her first duty ()V(M'li(l(! nputatioii IJK'llcd til ;he moral s patient. wUik: and )Ortsil)lo ti) id passa>;c'. /cl()j)n>ont, ' the pelvis itc). Tlu; somewhat, jut^ate is () it full time, an absolute ion, it nnist ■ Porro opt- ; to the risk lay be over- asres before ividual eir- "■orro opcra- e uterus is ased by re- etion of the s, ospeeially tcrus oeeurs rmulate, ami the ease. A constitute an la livinti' and l-elative iudi- aud tuiiiiivs Ire the eoiii- physiotoniy. lie best time ller to seeui'c 1: frop (lraiiin<j;e tiiroujjli the dihited cervix and to diininish the risks of lieinor- i!"i<re ; others operati; four or five days before tiie expected date of labor. 'I'iie latter method is preferable, because the patient can be prepared as carefully as for any other celiotomy, and the operation can bo done deliberately, with all the advanta<^es of a good light, trained assistants, etc. Those who wait for tlio onset of labor may have to oj)erate hurriedly or at night, without proper prep- aration or skilled assistance ; moreover, the membranes may rupture before the ojieration, which is always a disadvantage. (Vsarean section is an elective ope- ration whose success depends in great measure upon its being performed under the conditions most favorable to recovery ; it seems, therefore, more ])rudent for the operator to determine for himself the time, ])laee, and conditions of the ojieration than to trust to the uncertainties of a(!cident or of chance. The objections commonly urged against oj)eratiiig before labor are (1) that hemorrhage may take place on account of imperfect uterine contraction, and ("2) that .sepsis may occur from retention of the lochia, the undilated (cervical canal not permitting free drainage. Experience shows that the first objection is unfounded, because the uterus does contract promptly and well after being incised and emptied. The second objection can easily be overcome by dilating the cervix from above and passing a drainage-tube or a strip of gauze into the vagina. That these objections are theoretical rather than ju-aetical seems to be proved by the results of tlu^ early o]>erati()n in the riiitcd States, where in sixteen operations fourteen mothers and all the children were saved. General Preparation. — If possible, the patient should be prepared as care- fully as for any other celiotomy, special attention being paid to the state of the bladder and the bowels, disinfection of the vagina, and scrubbing and cleansing of the abilonien. The operation slioidd be performed under an anesthetic. Some operators prefer chloroform to ether, as anesthesia is more r'']);'l!y ])vv.- duced and the child is less likely to be asphyxiated. The instruments recpiired are scalpels, strong scissors, hemostatic forceps, needles and a needle-liold(>r, sutures, a hypodermatic syringe with a supply of ergotin and ether, an irri- gator, a piece of elastic cord or tubing, and occasionally a sliarj* curette and a tliermo-cautery. There should be provided also a plentiful supply of aseptic towels, sponges, gauze, and boiled water both hot and cold. The best needle for the uterine suture is half-curved, round-bodied, and without a cutting edge. Three assistants are required — one to give the anesthetic, another to take charge of the fundus and the uterine incision, and a third to tighten the rubber band around the lower uterine segment. The Abdominal Incision. — Operators differ as to the best method of ileliver- iiig the child. Some make a long abdominal incision and turn out the uterus before they open It and extract the child. Others make a much shorter in- cision, open the uterus, and extract the child before they turn the uterus out of tile abdominal cavity. In the first method time is saved and fluids are easily prevented from entering the abdomen, but the disadvantages are serious. A very long incision is required — usually from a point 4 centimeters (1 \ inches) • i ■/. I 820 AMHIilCAX TKXT-nooK OF OliSTiyrii l(\S. 'I IP' I. ii; f' •• : 3'^^ ;.' *- ) al)()vc the symphysis piil.is to one about 6 wiitinictcrs {'I'l iiiclics) alxtvf [W iiiul)ili('iis ; ail ciioriiioiis cicatrix remains, wliicli wcaUciis the liiica alba ami leads sometimes to lieniia, necessitating' snl»se(|neiit operation. In tlio seccunl method the incision need seldom hv. more than 15 centimeters (0 inches) in len;ith, exten<linj«; from a point 4 centimeters (1,^ inches) above the svinphvsis to a point 4 centimeters (l.V inches) below tlu; nmbilicns. This ii\eision is usually sullicient for the introduction of the hand and the ('xtraetion of the child. (Jreater care is needed to keep tlnitls out of the abdomen, but th(> tinal results are better and the abdominal walls are less liable to be weakened. Whichever method is selected, a small incision should be made in the linea alba, and when the peritoneal cavity has been opened a finj^er is introdiu'cd as a j:;uide and the incision is cnlarf^cd upward and downward by means of a stronn' pair of s(;issors. There will be less bleeding than if the whole incision is made with a knife. When the loiij; incision is employed, half a dozen lonj; wire sutures are passed throu<ih the upper portion of the wound and left to be ti<;litened after- ward. The uterus is then pushed up into the incision anil the abdominal walls are pressed back over it. As it emerifcs, the first assistant covers it with towels wruujjj out of hot water and supports it until a lar<re Hat spon}j;o or a gauze pad, also wrung out of hot water, has been adjusted behind it, and the wire sutures are tightened. The rubber band is then passed around the lower uterine seg- ment below the presenting part, and the ends are given to the second assistant. The anterior surface of the uterus is then incised in the niidtlle line without reference to the situation of the placenta. It is unnecessary to spend time detaching the placenta and pushing it to one side when it is in the wav, as reeinnmended by some operators. 77(f utcnnc invlxlnn should be about 10 to 12|- centimeters (4 to .'j inches) in length. An opening is made, just abose the lower uterine segment, large enough to admit one finger, and I'te incision is enlarged upward by means of a pair of scissors. The child is then seized by the extremity lying ne: 'est the incision, whether it be the head, the breech, or the foot, and is extracted as quickly as possible. The cord is quickly tied and cut, the elastic ligatiu'c is tightened, the placenta and the membranes are carefully peeled off and removed, and the uterine cavity is thoroughly irrigated with hot water or a hot antiseptic solution, such as corrosive sublimate (1 : 5000). Some operators dry the uterine cavity and dust it freely with iodoform just before closing the uterine wound ; others eontiinie irrigation with hot water while the sutures are being introduced and tied. After the uterine wound has been closed the elastic cord is relaxed and any oozing is checked with a hot sponge. The uterus, which has been kept well comi)ressed by the first assistant, is cleansed and returned into the abdomen. The pelvic cavity is irrigated and sponged dry, the toilet of tlio peritoneum is made, and the abdominal wound is sutured as in an ordinary celiotomy. The usual antiseptic dressings are applied, and a hypodermatic injec- tion of ergotin is given to prevent hemorrhage. The ])atient is put to bed, hot- water bottles are applied to the limbs, no food is given lor twelve hotus. and iMiVr llu> [0 SCt'Ulltl iiclics) ill vmpliysis iicisioii i-i oil of the t tho filial .vtakciK'tl, tlie" liiii'a •odiii'cd as leans of a lie incision (Utiircs arc ciiod aftcr- iiiinal wails tvitli toWL'ls ;^aii/e iKul, virc suturt'S itcrino sog- \(\ assistant. line without sjiciul tiin(> the way, as 5 inches) in ;iiient, larj!;o means of a lie; u'st the xtraeted as l; lijrature is itl removed. |ot antiseptic the uterine ■iiie wound ; \r iiitrodneetl •d is relaxed •h has hceii ■lied into tlic [toilet of tiie an ordinary Irmatic iiijec- to hed, iiiit- |e hours, and oiisTiyrim ' srna i:i{ v. 921 the howcJH nre moved within tiie first twenty-four hours. Duriii'j; tlie first week the iioiirisiinieiit should he ii((iiid exclusively. The aluloininal sutures can generally he remove<l from the tenth to the tiiiirteenth dav, and in favor- able cases tlu! patient may he ahle to sit up hy the middle of the third week. If the uterus is incised hefore heiii;; turned out, the technicjue is somewhat ditVerent. The alxlominal incision is onlyahoiit lo i-entimeters ((» inches) loiij; ; the hand is passed into the ahdoiuiual cavity and swept around to ascertain the preseiH'c and situation of any adhesions. The elastic loop, held hetween the ll>re and middle lin^fcrs, is passed over the fiiiuliis and adjusted alioiit the lower uterine segment ; the ends are then given to the second assistant, who makes upward traction on them, therehy preventing hemorrhage and holding the uterus steadily against the pnhes. While the uterine iiicisioii is being made the first assistant keeps the uterus firmly against the abdominal incision, and while the child is being extracted he promotes uterine contraction, makes steady pressure on the abdominal walls from above downward and it)rward, and gradually presses the uterus out through the abdominal incision. Wire sutures are not refpiired in the upper part of the wound to keep the intestines from protruding. The subsecjueiit ste|)s of the operation are tin- same as in the method previously described. Some ()perat(»rs make the operation comparatively bloodless by tightening the elastic ligature before the uterus is inciseil, and not relaxing it until the uterine wouiul is closed; others do iu)t tighten it until after the delivery of the child, [f the ligature is drawn too tight or is kept applied too long, there is danger of jiaralyzing the uterine muscle and producing suhse(|iient inertia and hemorrhage. To overcome this ditlicidty Siiiiger proposes the use of an anti- septic towel folded to form a band. Other operators use no band at all, but direct the second assistant to grasp the lower uterine segment before the uterus is incised, and to compress it Hrinly with his hands until the child has been delivered and the wound has been sutured. Hemorrhage into the abdominal cavity sometimes occurs subsequently from uterine inertia or faulty suturing. If slight, it may be cheeked by an ice-bag over the uterus and a hypodermatic injection of ergotin ; if abundant, the abdomen must be reopened, the clots turned out, and the bleeding point secured. Before the uterine wound is finally closed some operators dilate the cervix from above and pack a strip of iodo- form gau/e 7.5 centiiiieters (3 inches) wide and 91.5 centimeters (3 feet) long into tifc uterine cavity, passing the end through the cervix into the vagina, to provide free drainage and to guard against intra-uterine hemorrhage by stimu- lating contraction. This practice is unnecessary in most cases unless the uterine iiuisele is flabby and weak and does not contract well. The rtcrinc Siifitir. — Silver wire, silk, and catgut sutures are emidoyed, but, on the whole, silk or well-jirepared catgut seems to he preferable. Most operators use two sets of interrupted sutures — a deep layer to ajiproximate the divitled muscular coats, and a su])erficial layer to close the peritoneum. The deep sutures of \o. 2 silk pass from 3 to millimeters (J- to \ inch) from the border of the incision diagonallv down through the muscular tissue to, but do I ! ^-l t'i f^ I ! i i I I 922 AMERICAN TEXT-BOOK OE OJiSTETJUCS. not iudiulo, the deciclual lininsr (Figs. 509, alO). Thoy are about | inch apart, and arc eijrlit to twelve in number, according to the Icngtli A' the wound. As soon as they are all introduced the uterine cavitv is irrigated with a hot sub- l"i(i. .WJ.— Till' deep s\itiiro i>lii('0(i us a running Vu;. .Mo.— Tlio rumiiiii; stitches nl' tlio do'ii sii stitcli; it ini'ludi's lu'ritdiiciil and inusciilar coats, t\iri' cut tn I'onii iiiti'i-niiilcd sutures (lucidilicd but not decidual lining ^lnodilied from tiraiidinl. Iioui (iraudin). limate solution, the sutures arc tied securely, and the ends are cut short. The sujierficial sutures of catgut or of Xo. 4 silk arc then put in to bring the peri- toneal borders into close apj)osition (Figs, oil, 512). The Ijcnibert suture is generally employed for this purpose, though it is claimed that ctpially good restdts may be obtained by simply approximating the cut edges. ()iit> super- ficial suture is introdiu'cd over each deep one, and another midway between, Penforical Suture Pepifo7ieiwi j^^^_^^j^^ ^luscularWali ,^ Pccidna j^piscle^uiure //{/9c/p\fi//iire Km. "dl.— Ilianniins (d' llie peritoneal and nmscle-sutnros: A, before lliey are <ira\V" tinlit and ti<'d (niodilied from Krits(dil: It, the two slitehcs after tyiiif;. The miiscle-sutnre is buried and the upper suture folds the |M'ritoneum tonetlier. mtdving th(! number of su|»erli('ial sutures doid)le that of the deep ones. When they are ail tied the knots of the deep sutures are completely buried and the opposing siirlaccs of peritoneum are in dose apposition (Fig. All, w). The action iuid reltit ions of these two layers of sutiirt's tu'c slio" it in I'Mgure ")) I. Dudley' of New York recently adopted a contimioiis (atgiit suture of three hiyers, which h(> claims to be superior to the ordinary interrupted silk suture in two lavers. The tirst row, which begins tit th(> inner (>dge of the upper angle of the wound, includes the dtH'idua and the inner muscular coats, ll is ' American Journal iif OlmtrtrifK, .lati., 1S1I5, [i. l(i. OBSTtyriiir sritoER v. 923 , II n 1^1^ ^'> 7-^ r ' \ 1 h apart, ul. As lot sub- till' cU'cpsu L'.s ^Illll^li^n■ll ort. Tlio ; tlu' poi'i- : siitiuT is lally ii'ood )iic supor- bi'tween, Mil ^lil mill liiil il tlio Ul'pi'l' .. Whrll ,h1 ami tlic p.). Tl..' loiirc -'til. siitiirc nl iipt('<l >ill< llic upper •ats. It is Fic. filj.— Two pirituiuiU sutmcs aro Iuto shown, oiu' lyini; level, iiml tl\>' otluT iis it is in proccs.s oC lyintj; luiu'iilli tlic liittcr .siitiiri' is seen the knot of the tied niuselesiiture I'lnindin). contiuuc'd to the lower augle of the wouiul, and when tii^htened closes oft' the uterine cavity. Without cutting or tying tiie catgut, tiie second row is car- ried back to the upper angle, including the rest ot" tiie nniscular tissue and si- nuses, care being taken to pass the needle through the cut ends ot" any sinuses visible. Wiien this row is tightened about three-fourths of the depth of the uterine tissues has been clo,sely approx- imated. Without cutting or tying the catgut, the third row, in' an over-and- ^^ over stitch, eompletelv buries the two i lower layers and brings the peritoneal surliices together; the catgut is linally tied at tiie lower angle of the incision. The advantages claimed fortius metliud are — (1) that it brings the whole depth of the uterine wound into closer apposi- tion, shortens the wound considenibly, and prevents the danger of leakage be- tween the sutures and the formation of blood-clots between the woiind-etlges ; (2) that the suture is eomjiletely buried from beginning to enil e\cc])t where it c'telies the jieritoneum ; (."}) that there is no rolling in of the cut surfaces tuid no eversiou of the lips of the wound, and catgut is not more liable to be septic or to become septic than silk. It is urged against catgut tliat it is lial)Ie to stretch and to permit gaping of the wound, and that the knots are apt to untie; this may occur in the case of interrupted, but not with cnntiniioiis, sutures ; moreover, the abdominal siu'face of the uterine wound is covered with lynipii in a few hours, mm' i;.e peritoneal cavity is .sife .<o far as the wound is con- cerned. In eig'ni o'' nine days tiie catgut is absorbed and the wound is per- fectly uiiitct' : but when silk is used the suture btvomes encysted, and some lime ("lapses befo'c it can be disintegrated and removed. Dudley claims that with liis method there is le.ss lial)ility of adhesion taking place between the uterus and the abdominal walls, and there is no danger of cntliiig down upon an encysted suture in a subsecpient operation. lie performs tlie whole o|)era- tion, from the (ii'st incision in the abdominal wall to its final closure, under constant irrigation with hot water or with hot snbliniiite sol :*ion. IWairnn Section iiiiDifdidtcli/ affcr flic Pcatli n/' llic Mnfhcr or irlicn She /.s- MnvUmntL — When the inolher's life is extinct there is no spe-ial teehiii(|Ue. as the main point is to extract the fetus as (jiiickly as po.-sible. The operation is most likely to succeed if death has been sudden: ii" it has lu'cn slow or gradual, the child is usually as|)liyxiated beyond hope of restoration ix'llnv the mother's life is extinct. If she is living, but in ciicnnis, \\\c operation must be done deliberately and with due regard to her safety, fiir one catinot be certain that she must inevital)lv sticcumb. i: >! f • I \ •aI 924 AMElilCAN TEXT-BOOK OF OBSTETRICS. M I ) % J'orro Operation. — The procccliire in tliis is pivt-isoly the same as in tlie yiliiger operation until the uterus has been turned out of the abdominal cavity. Tlie elastic ligature is then {)assetl around the lower uterine segment and is tied loosely, and a large piece of thin rubber sheeting, a thermo-cautery, and a Koeberle ecraseur are prepared for use. A small opening is maile in the rubber sheet, to permit it to be ])assc'd over the fundus and carried down to the elastic band. It serves to prevent fluids from the uterus entering the ab- dominal cavity. The elastic ligature is then tightened, the uterus is incised, tlie child is delivered, the placenta is detached and removed, and the uterus and appendages are cut away just above the rubber sheeting. If the child has been extracted before the uterus is turned out of the abdomen, the ligature will have already been tightened, so that it remains only to slip the rubber sheet over the uterus as soon as it emerges through the abdominal incision, and amputate with- out delay. Many operators adopt Miiller's method of applying the clastic lig- ature before incising the uterus. Fehling passes an additional ligatiu'e beneath the (irst as a precautionary measure. After the uterus is removed the stump is carefully disiniocted and cauterized ; it is then treated extraperitoneally, or the entire stump and cervix are removed and the abdominal wound is closed. The extraperitoneal method is more rapid, and is generally preferred if the patient is very weak or is sutfcring from shock. The loop of the ecraseiu" is made to encircle the stump just beneath the rubber ligature, and is tightened until the tissues are blanched. Care nuist betaken not to enclose the bladder-wall in the looj) of the t'craseur. The rubber band is then removed, the stiunp is trimmed and cauterized, and is ti'ansfixed above the win; loop with two strong steel yi'ms passed transversely across the abdominal wound. The peritoneum is stitched aroinid the stump with a continuous catgut suture, the abdominal cavitv is cleansed and dried, and the ab(h)niinal incision is sutiu'cd. An iodoform dress- ing is ap[)lied, and left undisturbed for several days indess hemorrhage occurs or the temperatiu'c begins to rise. If the stumj) is moist, the dressings will soon become soaked with discharges; they nuist be removed and the stump thoroughly disinfected, any sloughy pieces being clipped ott' with scissors, and fresh dressings applied. If there is any bleeding from the stump during tlie first three or four days, the bleeding point should be found and ligatured. The stump sloughs away in from ten to fifteen days, leaving a large granulating surftice which is sometimes slow to heal. To hasten this process various expe- dients are employed. Sutiigin scrapes and pares the surface of the stump to produce a raw surface, and cl(»ses the borders with ligatinrs, introducing a small tent of iodoform gauz(! into the lower angle of the wound for drainage. Otiicis dilate the cervix and pass a strip of gauze from above through the cervix into the vagina. The intraperitoneal method is theoretically preferable, but so far its residts are not ideal. The technicpie varies according fo the circum- stances of the case, but the main line of proccduri' is to free the bladder from its attaciunents to the lower ut(>rine segment after the uterus has been removed and the stump has been disinfected, secure the broad ligament on each side with strong silk ligatures, tie the uterine arteries, divide the vaginal atladi- OBSTE riilC 8 ( Ve (lEli 1 '. 925 I in the cavity. ; tiiul is :^ry, uiid 3 iu the lIowu to tlie ab- ■is(,'(l, tlie >rus and has boon vill luivo over the ate witli- lastic liif- e bouoatli ! stump is Iv, or the tsod. Tlu; ic patioiit 5 made to until tlio ^•all in tlio s trinnnod stool piiis s stitoiiod cavity is )rm dross- itjo ocours •;injj;s will :ho stmiii) issors, and lurino; tlio (U-od. The ■anulatiiiir [ons oxpo- stnmp to Intra small Othois K'vvix into bnt so cirouni- Lldor iVoni \\ roiniivcd oaoh side al attaoli- f m meuts of the cervix, and remove the stump. Any bleedinj; points are then tied, the ends of the litfaturos being kit lonj;, so that thoy may be passed down through the vajrinal opening. Strips of iodoform gau/o arc firmly ])aoUod in the upper part of the vagina, and tlie peritoneal cavity is closed otf bv stitch- ing the peritoneal covering of the bladder to the peritoneal layer of the cul-de- sac with a contimious catgut suture. TIk; abdominal cavity is thou ciirefnllv cleansed and (h"ied and the abdonnnal woiuid is sutui'cd. The objuet of this method is to close the ])eritoneal cavity com[)lotoly, turn the raw surface down- ward toward the vagina, and obviate the necessity of draining from above. Unless the operator is export in abdonunal work, it will be safer and easier for him to choose the extraperitoneal method. If the uterus has been intictod, it is well to close the abdominal wound as nuich as possible beibre be»riiuiin<r to work with the pedicle, in order to avoid in looting the ])oritoneal cavitv. Laparo-elytrotomy. — This operation was devised by Thomas to avoid the risks of opeinng the abdonun and wounding the uterus ; but since the perfect- ing of the kSiinger and Porro operations has reduced these dangers to a mini- mum the necessity for laparo-elytrotomy can scarcely be said to exist. The method of procedure is to incise the abdominal walls in the line of Ponpart's ligament, lift the poritouenm, dissect down to the vagina, an<l tear it through transversely, so that the cervix may be reached and the child be delivered through the passage thus made. This oi)eration has been done thirteen times, seven of tin mothers being saved. 7Vor/)(o.s/.s' of Ccn(nr<tn .sVc/Zoji. — The mortality in ]>re-antiseptic days ranged from 30 to 50 jier cent. It has been reduced to about 10 per cent, by doing the operation early, and not as a <lcniicr rri^soii, and by ])ractising a scrupu- lously aseptic techni((ue. In private practice the jiDgnosis for the mother depends very nuich upon the urgency of the case and the jxtssibility of secur- ing favorable conditions f()r the operation. It is far more difHcnlt to carry ont a pro])or techni(pie in private than in hospital practice. The prognosis for the child is good ; from 90 to 95 percent. of the children have been saved. Since the mother should not run nnich more risk from Cosaroan section than from craniotomy, while the child is almost certainly saved in the one ca<e and delib- erately destroyed iu the other, there can bo very little (piestion at the ])r(\soiit ilav as to the choice of operation. In fact, craniotomy upon the living child is justifiable oidy under exceptional circumstances. It must be admitted, how- over, that the results of the Cesarean section in Amori<'a have so far boon disa))pointing, the mortality from the op(!ration being nmch higher than in Kurope. It should not bo so, and we cannot expect that Cesarean section will replace craniotomy until oiu" results liav<' been oiinsidorably improved. In the l*orro operation i!ie maternal mortality ranges higher, owing to the more serious condition of the mother boi'ore «tperation. Notwithsianding the unfavorable circumstances usuaUv jircsent, the mortality has boon reduced to about 25 per cent. In Italy the mortality is about 10 per cent., as the Porro ojieration is performed in cases whore the Siing(M' operation would bo proil'ri'od elsewhere. IJreisky performeil 11 opi.-rations, and Leopold 7, without a death. • ife . •( \ } "? : ( ■'? 926 AMEIilCAX TEXT-BOOK OF OBSTETIUVS. I-' '' i '^ J i' f\. I ( n ,0 '-iii "■f Craniotomy and Embryotomy. — These arc the terms a{)plie(l to all de- structive operations by which the volume of the fetus is reduced in order to permit delivery per vUiti nataraloi. Althoujrh in a literal sense all such opera- tions might be included under Kujbryotomy, yet general usage has sanctioned a more restricted application of the term. CnnwAomi) is used to denote mutila- tion of the fetal head ; einhri/utonii/, nuitilation of the fetal truni:. AVhen a destructive operation has to be performed, the choice of method is determined by the nature of the ])rcscntation. Since the head presents in the great ma- jority of cases, craniotomy is most fre(piently done, while embryotomy is com- paratively rare. Whatever may be the circumstances of the case, that operation should be chosen which is likely to expose tin; mother to the least risk. The operative procedures included under the general terms craniotomy aiul embryotomy may conveniently be classified as follows : 1. Upon the /lead: (a) Perforati(m ; (6) Cranioclasis ; (c) Cej)halotripsy ; {d) Basiotripsy. 2. Upon the «ec/;; Decapitation. ;i. Upon the trunk: Evisceration or eventration. Indications. — It is of primary imjjortance to determine whether the fetus is living or dead. If dead, its bulk should be reduced whenever there is suffi- cient disproportion to make delivery difficult or dangerous. It is far better to mutilate a dead fetus in oriler that the mother may be delivered easily and safely than to subject her to the risks of a tedious and difficult forceps opera- tion. Esthetic considerations and regard for appearances should not be allowed to weigh against the mother's safety. lint when the child is alive tliecjuestion becomes entirely different. Undoubtedly, in recent years syn.physiotomv, Cesarean section, and the iniluction of j)rematin'e labor have <;reatly narrowed the field of the destructive operations, but are we quite jireprred to admit that craniotomy upon the living child is never justifiable? Pinard and his follow- ers boldly take this ground, so do a few operiff.rs who have had exceptionally good results from Cesarean sedion ; but most obstetricians feel that the results of the conservative operations do not yet warrant such a sweeping assertion. Until it has been established that the maternal mortality after the conservative operations is not greater than that after embryotomy, it would be rash to say that mutilation of the living child is never justifi:ii)le. In the minor forms of dystocia the choice of operation will probably lie betw<>en craniotomy and syiu- phvsiotomv or the induction of j)remature labor ; in tli'" major forms, between craniot(unv and Cesarean section. The maternal mortality after basiotripsy in the Paris lios|>itaIs is practically ni/ when (lon(> in selected cases i.nd under favorable cireumstanciN. Leopold and olliers have had almost as good rc-iilts from Cesarean section under similar conditions. iJiit in private practice, when flic skill an<l exiiericnce of I lie operator are not iisrally so great, when lliciv is lack of skilled assistance and the surroundinii-. are unfiivorable, the result- fix: all (Ic- n'clor to 1 opora- ioiicd a mutila- ^Vliei\ a erminod cat uui- ■ is com- ipL'ratiun Diuy ami le fetus is ; is siiffi- " l)('tt(M' to ^'asily ami >ps ()]tL'ra- allowed le question vsiot(tiuy, narrowed dmit tiuit is t'ollow- ptionally iho results Assertion, isers'ativo sh to say lornis ot" and syiH- , Ix'tweeu itripsy in nd under (d re-uits t ice, when n tlierc is liic results OBSTETIUV SURGEJt Y. 927 after either operation will be less favorable. When Cesarean seetion is per- ibnned as an eleetive operation, the mortality should not be greater than 10 per eent. ; but wiien done as a dernier rcNtiort, after ineffectual attempts to de- liver by forceps or by version, tlie risk to the mother becomes very great indeed. Craniotomy in suitable cases, done deliberately and without force, should be little more dangerous than a forceps operation, but when done after repeated forcilde attempts to deliver with forceps, especially if the disproportion between the fetus and the maternal passages is great, it becomes one of the gravest and most difficidt obstetrical (operations. Embryotomy on the living child involves such serious responsibility that it would rarely be chosen as an elective opera- tion. Practically, therefore, elective embryotomy is seldom pitted against elec- tive Cesiu'can section. When the operation is one of election. Cesarean section is generally the choice ; when it is a <Ier)iier re^fsorf, embryotomy is usually safer for the mother. The whole ([uestion turns upon an early and exact diag- nosis. If the patient has been examined carefully before the onset of labor to determine ai)proximatcly the relative size of the fetus and the maternal pas- sages, there should be very little difficulty in deciding upon the best course to pursue. Rut if labor has been allowed to drag along, and the disproportion has been diagnosed only after rept'atcd failures to deliver by fori'cps t)r by ver- sion, the case assumes a different asjiect, and the chances of safe delivery by any means are impaired. Such case-< emphasize the necessity of making a careful examination of the pelvis in all pregnant women whose appearance or history suggests the possibility of defoi-mity or disproi)ortion. There is really no good reason why an amount of dispro[)ortion calling for Cesarean section or end)ryotomy should in)t be made out long before the onset of labor. But very often the physician does not see his patient until labor is well advanced, and then the case may call for prompt action, even though the surroundings are unfavorable and skilled assistance camiot be procured. Under such circum- stances, if the disproportion is slight or moderate, a craniotomy could probably be done with far less risk to the mother than a symphysiotoniy or a (*esarean section ; but if the disproportion is extreme, craniotomy becomes a very diffi- cult and dangerous operation, and Cesarean section will give the mother a better chance even if the operator is inexpert. It is ev'dent, therefore, that no posi- tive rules can be laid down, for, even in the mother's interest, sometimes one operation may be preferable and sometimes another. At all events, it is ])re- niature as yet to say that mutilation of the living child is never justifiable. Under any circumstances th(> physician should not assume the fidl responsi- bility in such cases, but should leave the ultimate decision to the patient and her friends, after having Iai<l the fact- fairly lieforr rhem. The ordiuarv indications for embryotomy may be gn^nu'd as follows: (1) Deformity of the pelvis, where fonrps or version is either impossible or is dangerous for tlie mother. (2) Disproportion between the parturicMit canal and the fetus that cannot safely be overcome by a conservative opcniiion. (I]) Tumor- — utiTiuc. ovarian, malignant, or osseous. >: f I « 928 AMERICA X TEXT-BOOK OF OJiSTETIilCS. (:':' iV-', Fio. 51IJ.— Perforator of Pmellic Fi(i. 'jU.— IVrforiitor (jt sim|ps<ni. Flo. M').— Perforator of NncRele Fi(,. >>IO.-rerforator of I'iniii-ii. !)' > Ai Fiii. r)17.— Perforator (jf Harnos > I I i Fig. .'jUs.— Trepliiiie of lirauii (straight anil eiuvetli OBSTETRIC SURG EH Y. 929 !,. I Kro. 519.— Craniotomy forceps of Meigs. Fiii. MO.— Craniodnst of Barnes. .: ; I \" 1 I. Fig. 521.— Cranioclast of Simpson. Fi(i. 522.— Cephalotribe of Braun. Fici. .'■)23.— Cephnlotribe of Lusk. * I I'lQ. .524.— Ccphalotribf of Ilicks. 59 §n|f^ 980 AMERICAN TEXT-BOOK OE OJiSTETIifCK I'h I i; i I !^ (4) Monstrosities, such as hydrocephalus. (5) Impaction of the presenting part, as in locked twins or in some face nic- entations, especially it' there are swelling and inflammation of the vagina av of the cervix resulting from long impaction. (G) P]clampsia and other canses which demand innnediate delivery, if it can- not safely be accomplished in any other way. It' the liquor amnii has lo.ig Ihcii drained away, the uterus sometimes becomes tetanically contracted about tlii^ fetus, and rupture is imminent ; in such cases forceps, version, and Cesarean section are dangerous, and embryotomy aflbrds the best chance for the motluir. The child will probably have perished long before the question of embryotoinv comes up for consideration. Inntruinciifs. — Space does not permit a description of the numerous innciii- ous instruments which have been devised for the mutilation and extraction of the fetus. As the prime object of these operations is to reduce the bulk of tin; fetus, the first step is generally to perforate the presenting part and evacuate its contents, and then to apply a powerfid instrument to compress it, so that it mav safely be extracted through the narroweil passages. When the fetus caimot be so compressed, its bulk must be reduced by breaking it up and removing it piece by piece. Perforation is done by means of a i)erforator; compression is made by a cei)halotribe, a cranioelast, or a basiotribe ; connninutiou of the vault of the skull by a pair of small craniotomy force])s; decapitation by a blunt hook or an embryotome. So far as possible, end)ryotomy instruments should be made of metal and be so constructed that they can easily be rendered aseptic. Pevforatorn. — Three types of perforators are in use — the scissors, the ti'c- phine, and the heavy, spear-shaped perforator of the basiotribe. The scissors perforator may be sti'aight or curved on the flat ; on the whole, the straight form is the safer and answers the purpose very well. The original model of Smellie (Fig. 51.']) is still in use, but Sinipson's (Fig. 514), Barnes's (Fig. 517), or Pinard's modification (Fig. 516) is preferable. Oldham's and Xaegele's (Fig. 515) are more jiowerful instruments, but have no special advantages. Tlie Germans prefer the trephine, claiming that the brain-sid)stance can more easily be broken up, the skull being perforated through a bone, and not through a suture or a fontanelle. The models most commonly used are Brau.n's (Fig. 518) and Martin's, either straight or curved. They are harder to manipulate, and an assistant is required. The spear-shaped perforator of the basiotribe is not withdrawn like the other perforators, but is pushed through the brain- substance and imbedded in the base of the skull to steady the head while crushing is being done. The craniodast is a powerful prehensile craniotomy forceps, one blade of which is passed into the cranial cavity through the o])ening made by the perfo- rator, while the other grasps the head outside. When the blades arc forcibly pressed together by means of a strong compressing screw at the end of tlii^ handle, a firm grip of the head is obtained, and extraction is easy unless the passages are very small. The small blade which is ])assed into the skull is solid and is grooved on its convex surface, with the tenou of the lock on tlir OBHTETRIC Sir lid Kit Y, 931 aco prt if it can- O.lg hci'll bout tlic Cesarean L^ motlicr. Dryntoinv IS injrciii- rac'tioii of iilk of the /aouate its lat it may lunot l)eso n^ it niece jn is iiuule e vault of blunt h()ol< should he !(! aseptic. rs, the tre- 'hc scissors he straiirht 1 uioilel of (Fi^'. 517), ele's (y\'£- liTfs. The noro easily throutrh a u'.u'ri (Fit;'. lanipulate, hasiotrilx' the hrain- lead while blade of |- the perfo- re foreil)ly hid of the I unless the lie skull is Lclv on the liandle ; the larj^er blade, whieh grasps the outside, is fenestrated and is grooved on its inner coneave aspeet. A moderate pelvic curve is generally given to the instrument to facilitate introduction and extraction. The tiivorite models are those of Barnes, Simpson, and liraun (Figs. 520, o21). The cranioclast is es.sentially a tractor, and is sufficient in most cases of craniotomy, uidess it is found necessary to crush the base of the sUuU. The advantages claimed for it are — (l)that it is not apt to tear away when scalp and bone are seized together; (2) that it seldom slips when once a firm hold is obtained ; (li) that the head can be .seized in any diameter witiiout fear of slipping ; and (4) that when the parietal bones have been reuioved tiie base of the skull can be .so seized as to bring it through a j)clvis with a conjugate of only 4.^ centimeters (If inches) and a transverse of 7i centimeters (3 inches) (Harnes). ('cphdlotribe, — This instrument was invented by liaudelocque to supersede th(! perforator. It is essentially a })owerful compressing forceps (Figs. 522- 524), made to crush the head before extracting it. Tiie blades are applied outside the head, like tho.se of the ordinary I'orceps ; the instrument therefore differs essentially from the cranioclast, which has one blade inside and the other outside the skull, and is not essentially a crusher, but is simply an extractor. The cephalotribe is more bulky, takes up more room in the pelvis, docs not inoniM) Fig. 525.— Tarnior's basiotribe. Via. r>'2ii.— TaniiiTs luisicitribi.' (so|iiirati' parts). grasp the head so .seeui-ely, and is more liable to slip than the cranioclast. The cephalotribe is therefore less u.seful in ordinary cases, and is nowadays very little n.sed. The Hicks model (Fig. 524) is preferred in P^ngland, while liUsk's instrument (Fig. 52.'5) is the flivorltc in America. Rimotribe. — Tarnicr's basiotribe is tlic most perfect instrument for crani- otomy yet invented, being at oiu'c a pertbrator, a cranioclast, and a cephalo- 9 !■« 932 AMJJh'K'A.X TEXT-JiOOK OF OBSTKTIUCS. Mi;r»|l! tril)e, iuid is capable of bciiijjf used in pelves ineasiirin<i; no more than from I to G centimeters (l.\ to 2';| inelies) in tiio eoiiin-rate diameter. The eranioeiast seizes well, bnt crushes poorly ; the ccjpiialotrihe crushes well, but sei/.es |)oorIy ; the basiotribc <'ombines the <^ood points of both, for it both seizes and erushes well. The basiotribe is composed of a perforator, two blades of un- equal lenj2;th, and a powerfid compressinjr screw (Fij;. 525), The central piece, or perforator, consists of a straij^lit bar of metal, terminatinj^ at one end in a fenestrated, spear-pointed tip, and at the other end in a small cross-bar, throu<rh which the compression-screw works (Fig. 526). About halfway down the handle is a tenon upon which the shorter blade articulates. The shorter blade 'i wi rc \ Fi<i. r)27.— Tiiniier's bnsiotriltc Kk;. .")2H.— The first l)liiilo of in motion ; the i)L'rt'iiriit()r liciii^' ill tliu Ijiisiotrilie has criislu'cl tlic place, tts is also the liret blailu. Dccijiut, and thu succinil l>laiii' is applii'd. ,UkUU,VUX) Fl(i. .V«J.— Tlio second liladc of tin' iHisiotriljL' has onisluMl ilir siniipiit. carries a tenon upon which the lonjier blade articulates, and a small hook to fasten it to the perforator after the first crushing has been done. At the ciki of the handle is a pivot to which the compressing screw is attached. The longer blade, about 42.5 centimeters (17 inches) in length, articulates with tlir shorter blade, and has a groove at the end of the handle to receive tiie coin- pressing screw. When closed the instrument measures from side to side 4 centimeters (IJ inches), from before backward 4 J centimeters (1| inches), ami weighs a little less than 1000 grams (21 pounds). Bar and Tarnier have iv- cently modified the original instrument so that it can more easily be used in face presentations. The blades of this modified instrument are made a iitilr longer and of equal length, and are so arranged that cither the right or tlir left blade can be introduced at will after the perforator. ff: 'IV OliS TK Tli I( ' ,S' 1 7>' (1 /■: /,• ) ' 933 tVom I lioclast , seizes zcs aiul of nu- ll pit't'e, >iul in a tlin»n«rh )\vn tli(( or hlacic iiiuuuuuu^ SI'CdIlll lllllll'' las i:rus\u''i tin' lill hook to At tlu' ciiu Lhe.1. Th" Ics with till' jc the ooiii- |i> to sidi' ^ t'h(s\ iintl T iuive n'- bo nscd ill luloii lit til' n<!; ht or tl 1^ Ifook and Crotclirf. — Tliis instrnincnt cons -its ol'a sliy-htlv curved metal bar terniinatiiif!; at one end in a blunt iiook and at tlic other end in a sharp crotehet- tip (Kif?. 530). The iiook is used tt» pull down tlie neck ; the crotchet is some- times caught into the orbit or the Ibr- "^ Viii. lliKik mill (Tiitclu't. amen ma;j;num, after perforation, and employed as an extractor, or it may be '"•^^ used to break up the brain after j)ertb- ration. The blunt hook may occasion- ally be serviceabh; in extractin*:; thi' after-eomiiij'' head lbllo\viiii>- ])erl'oration. It is passed through the openintr made by tlu; perforator, and is hooked over th(! base of the skull. Sometimes it may be emjtloycd with advaiita<j,(! in the delivery of the trunk in dillicult eases, if hooked under the posterior shoulder, Tlie hook and crotchet is less used than Ibrmcrly, but is nevertheless very helpful if better instruments are not at hand. It should be handled wilh care, t(>r it is very apt to slip and injure the maternal scjft parts. Siiudl ('r<nuoto)nif-J'orc('p.^. — It becomes necicssary sometimes to break down the cranial vault after perforation and to remove the bones piecemeal. For this purpose a modified bone-foree|)s is used. The best model is TavUir's moditication of ^Icij^s's instrument (Fig. 51 it). JhTajiitdtin;/ Hook. — In neglected transverse iiresentatioiis decapitation is sometimes the readiest and safest means of etlecting delivery. IJraun's hook is extensively used for this purjiose in (jermany. This instrument consists of a .steel rotl fitted with a strong handle at one end and a short hook tipped with Fiii. 031.— Briuin's hook. Kl(i. 'u','!.' Detail of honks, olil ninl iiupidvi'd forms. a rounded button at the other, 'i'he hook forms an acute angle with the shaft of the instrument, the distance between the button and shaft being 2 centime- ters (I inch, Fig. 532). Zweifel of Leipsie recently modified this instriiiiieiit^ as shown in Figure 531. Kmhryoiomoi. — Several ingenious but eomi)licated instruments have been invented for use in desperate cases. They are ex|)ensive, easily get out of order, are .«eldom available when wanted, are dillicult to :>pply, and are apt to injure the maternal .soft parts. However useful they may sometimes prove in large hospitals, they are practically out of the reach of general practitioners. The best is Taiv ier's embrvotome, which combines the blunt hook with a cut- ting in.struinen .so guarded that nothing but the part grasped by the hook can be cut when *(ie knife-blade is released from the guard. Operation. — In no other obstetric ojieratiou is strict attention to antisepsis more important than in craniotomy, since the maternal soft parts are .so liable to be wounded by the in.struments or by spicules of bone from the mutilated licad, and most of the sub.secpicnt ill ctlects arc directly traceable to .sej)ti(! infection. m rf i. fi .^.^Oc- IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I |50 ~^^ ^ 1^ |2.2 :!f li£ i2.0 II iiiiim l.25||,.4 ,.6 ^ 6" ► ^ ..'^'^^ Photographic Sciences Corporation 33 ^EST MAIN STREET WEBSVk:ic,K .' MSSO (716)S72-4S03 W7) l/.x I 6^ 934 AMERfCAN TEXT- HOOK OF OBSTETRICS. Ctanioiomy of the PreHvulinf) Ilmd.—Mmv the bladder has been emptied and the vulva and vagina dij^infected, the patient should be placed on a table in the doreal position as tor the forceps operation, an anesthetic administiuod, and the head steadied in the pelvis by pressure from above. Full dilatation of the cervix is advisable, but is not essential. Two fingers of the left hand are passed up through the (icrvix to the presenting part, and held firmly against it as a guide. Throughout the operation these fingers should guide the instru- ments and guard the maternal soft parts from injury. The perforator, held in the right hand, is psissed along the guide-fingers to a suture or a fontanelle if possil)le. The point should be I<ej)t at right angles to the presenting part, to prevent slipping, and the part selected for perforation should be nearer the sym- physis than the promontory (Fig. r);J3). Then, with steady pressure (»r a careful V\i,. MH.— Perforation of the licftd botjim : tlu' rinlit Imiid is tiriispiiin tlio tmiicllt's of tlic iiislniiMciit. TliL' lips sliouUl not l>i' scpiiriitcd until iifliT tliey Imvo outoroil the foiitaiu'lle. boring movement, the point is made tocnter the cranial cavity, and the perforator is pushed home as far as the shoulder-guard will permit. The opening is enlarged by compressing the handles so tis to separate the blades. The instrinnent is then closed and witlulrawn slightly to jierinit its being introduced again at rigiit angles to the first incision. The blades arv tigtiin separated, then finally closed and withdrawn. By this means a crucial incision is made, through which a metal noz/le or crotchet can be introduced to break up the brain-substance. The remaining steps of the operation will be more cleanly if a syringe is attached to the nozzle and the broken-down brain-matter is washed out with sterilized water. When the fetal skull is completely emptied of brain-matter, it can more easily be com])ressed and extracted than if it is only slightly or partially emptied. If a suture or a fontanelle cannot easily be reached,a gniMJ perforator with a sharp point can readily be pushed through the substance <il' any cranial bone. In face presentations tlu' perforator should be passcnl tliroiioli tiie orbit or one of tiie frontal bones if possible, or, failing in that, through the roof of the mouth, behind the nasal fossa;. When the bonv landmarks are J; oiiSTF/rniv sriiOEii v. 936 unrecognizable, j)erforation may he made wherever most convenient, hut should then be carried very deep. Cramotomif of the Aftev-cnming lleorl. — T\m is always a difficult oi)eration, since the trunk interferes with the neccssarv manipulations. Moreover, tlu; trephine can mrely be used, the scissors perforator is apt to slij), the thin cranial vaidt is out of reach, and only the thicker, denser ])ortions of the >kull are accessible. It is usually recommended to perforate throntih a lateral fontanelle or at the articulation of the occiput and atlas. The ixKly (tf the fetus may require to be drawn upward or downward, to the right or to the left, to bring the desired point within reach of the guide- fingers. Practically, the operator must generally be content to ])erforate at any point behind the ear that he can reach, without troubling to find a fontanelle or a sutiur. If the occiput is behind the pubes, the operator passes tluve or four finy;ers under the sym- physis to the occipito-atlantal articulation, while assistiUits steady the head in the pelvis and draw the bcnly downward and backward. The perforator, guarded by the fingeix, is inserted between the occiput and the atlas, and a crucial incision is made. A fertile brain-substance has been broken u\) and washed away the head can usually be delivered without ditticulty ; occasionally, however, the cranioclast is required. When jierforation of the occiput inider the symphysis is difficult or dangerous, the body may be drawn upward and the perforator intnMluced through the mouth or the orbit. If theoccijHit is poste- rior, the IxkIv is raised until the perforator can be pushed into the occiput posteriorly. If the head lies transveively in tin; pelvis and cannot be rotated into the antero-posterior diameter, tlu? body may be drawn upward or down- ward and the side of the head be jwrforated near the car. Strassmann of Ber- lin recently proposed perforating between the chin and the neck (Fig. S-'U), Kin. .".34.— rrnnlotomy on tin- afliT-coiniiig lieail ; one method of [HTforf ting. passing the instrument through the base of the tongue until its point is felt by the fingers in the mouth, then pushing it through the posterior nares into the firamen magnum, when the blades are separated and the base is broken up. r m 4 I 936 AMKRICAX TEXT-BOOK OF OBSTETRICS. m 471 A nozzle is pass-ed through tlie opening, and the cranial contents are broken up and removed. After iKjrfomtion and excerebration some openitors allow lalM)r to terminate by the natural efforts, while others deliver by means of forcejts, cranioclast, cephalotribe, or veraion. In most (Sises there is nothing to Imj gained by wait- ing, and it is generally safer and better to deliver without any unnecessary delay. With the strong French forceps, which is a powerful compressor, it is some- times possible to deliver the perforated head ; but the ordinary forceps is too feel)l(> an instrument, and is apt to slip unless the disproportion is very slight. When no other extractor is available, forceps delivery can be made less difficult bv washing away the brain-substance completely and removing jM)rtions of the cranial bon&s with short craniotomy forceps. Care should always be taken to protect the passjiges from injury by sharp spicules of bone during extraction. The forceps proves more ust^ful in the delivery of the |)erforated after-coming head ; there is then far less risk of slij)ping or of wounding the soft parts. Notwithstanding the warm commendatit)ns of Tarnier, Taylor, and others, version after craniotomy must be regardetl as a dangerous operation in most cases. When labor is protracted the uterus tends to retract about the body of the child and the lower uterine segiucnt becomes distendetl. Attempts to tin-ii under such circumstances, especially if any spicules of bone protrude from tiie opening in the skull, must expose the mother to serious risks. Crauiocta.si'i. — The cranioclast is a tractor, not a comminutor, and the ope- ration of cranioclasis consists in getting a firm hold of the mutilatal head witii the cranioclast and delivering it through the narrowed passages, not in crushing or breaking up the cranial bones. Tiie solid blade, held in the right hand, is guided through the opening made by the perforator and is pushed well down to the base of the skull. The fenestrated blade is then applied to the otitside of the skull, <lireetly opposite the blade which is inside; the blades are locked, and the compression-screw is tightened mitil the head is firndy grasped between them. The blades will be less liable to slip if tiie outer one is applied to the face rather than to the occiput. Before locking, the handles should not be iicid horizontally, but should be depressed, so as to make sure of including the cliiri in tiie bite. Before beginning to extract, the cranioclast should be so turned as to bring the longest diameter of the head into the transverse diameter of the pelvis. During extraction the left hand should be kept in the vagina to guard the perforation and to protect the maternal soft parts from being injured by projecting edges of bone. The line of traction should be in the axis of the pelvis, the same as in the forceps operation. Tf any pieces of bone ])r()tnid(>, they should carefully be removed before traction is continued. In difliciill cases it may be net^cssary to strip back the scalp and remove the parietal bones by means of small craniotomy forceps ; the blades of the cranioclast can tluii be so adjusted as to get a good grasp of the frontal bones and the lace, and extraction will be easy. Occasionally it will be found easier to introduce the fenestrated bhule first and to adjust it carefully before passing the solid blade OBSTETltIV SriiGEU W 937 the upo- 1(1 with UHliiiiii mml, is 1 down outsido lockctl, M'tWCH'll oil to tlio Im' 1i(>1«1 the tliiii turned us er of tlio to ifuard ijurcd l)y Lis of tlic protn\d<', ditticnlt tal Uoiits can tlu'ii i'ticf, aiid (dui'c tli<' |)lid blade 1;^ J V into the cranial cavity. In most cases the bmly comes tlironi^li easily after the head has been extracted. If the body is so larjre that it cannot be delivered with a moderate amount of traction, it should be perforated U^twoen the clavicle and tlie scapula, and the cranioclast so adjusted that the fenestrated blade is applicnl over the back. Tiie cases are extremely rare in which delivery cannot be aceomplishwl by perforation and cranioclasis. Cephdlotripsi/. — Occasionally the fetal head is too large or too nuich ossifiotl to be delivered safely with the cranioclast, anil it becomes necessary to crush it in order to reihice its bulk. CeplialofiijMy is the name given to this crushing and extraction of the fetal head. When the operation was first pro- posed, it was iioped that it wovdil supersede perforation ; but this hope has not been realizwl, and at the present day, whin the head is presenting, it is almost invariably perforated before being crushed. The cephalotribe in general use is a powerful forceps with slight cephalic curve, fitted with a strong com- pression-screw at the end of the handles. The blades are intriKluced like those of the forceps, and when the head has fiiirly been grasped the compression- screw is slowly tightened. The opening made by the perforator should care- fully be watchiil for pieces of extruiling bone while compression is being made, and the maternal passages should be protected during extraction. When the cephalotribe gets a good grasp of the head, it crushes satisfactorily ; but the difficulty is to get and keep a good hold, for the head is apt to slip away when the compression-screw is tigiitened. As Piuard remarks, it is one thing to seize the head with the blatles of the cephalotribe, but i|uite another to hold it while being crusheil. Cephalotripsy is indicated when the pelvic con- traction is only moderate or slight ; but when the contraction is extreme the instrument takes up too much room and the tractile force re(juired to effect delivery is dangerous for the mother. When the conjugate of the brim meas- ures less than 7 centimeters (2| inches), the (>j)eration becomes difficult ; when less than 6.3 centimeters (2^ inches), it is highly dangerous. In difficidt breech cases, when the aflor-coming head cannot be delivered by manipulati<m or by forceps on account of slight pelvic contraction, its bulk may be reduced sufficiently by cephahttripsy even without ])orforation. Or if per- foration has been done and the forceps does not hold, or if it is found neces- sary to reduce the bulk by crushing the base of the skull, the cephalotribe will be useful. Or if the body has been delivered and the head, which is free in the uterine cavity, cannot be seized and delivered with forceps, it is sometimes necessary to steady the head in the pelvis, fix it by means of a crotchet j)assed into the cranial cavity, and then apply the cephalotribe to crush the skull before it can be extracted. In all such eases the maternal tissues should be carefully guarded against injury. At the present day ce|)halotripsy is seldom done; when craniotomy is in- dicated and the pelvic contraction is only moderate or slight, perforation and cranioclasis usually suffice; when the pelvic contraction is extreme, basiotripsy or Cesarean section is preferable. Bmiotrijjxy. — Basiotripsy is an improved cephalotripsy that in France has i: 1 Ml 938 AMERICAN TEXT-BOOK OF OBSTETRICS. ill ' If:; completely taken the place of* the latter operation whenever plvic oontrnc- tion is nKMlerate or extreme. The steps of the oiK'ration are jwrforatioii, the small crushin}^, the j^reat crushing, and, fins.lly, extraction. The jM-rforator, held in the right hand, is guided along tiie fingers of thr left hand to the point selected for i)erforatioii ; kept at right angles to the skull, it is then thrust through the cranial bone and pushe<l along until its point is imbechUHl in the base. The short blade, which corresponds with the left or lower blade of the forceps, is introduced like the forceps-blade, and is articulated with the tenon on the handle of the perforator. The compression-screw is then adju8t(>d and tightened until the short blade is force<l close to the ]>erforator ; tiie hook is closed down, which sectu'ely fastens the short blade to the j)erforator. Tliis ])roce(hire is the small crushing. The compression-screw is remove<l, and tiic long blade is applied like the right or upper blade of the forceps and articu- lated witii the tenon on the handle of the short blade. Tjie compression-screw is again applied, and slowly tightened until the long bhuu^ is brought close to the perforator. This operation is the great crushing. If the instrument has been properly applie<l, the vault and base of the skull will have been crushed and flattened by the o|'oration to a little less than 2 inches, and extraction is comparatively easy. Tarnier and his followers set 4 centimeters (1^ inches) of the conjugate as the lowest limit for basiotripsy. Below this limit the mother is exposed to risks as great as from (Vsareau se<'tion, but above 6 cen- tinieters (2f inches) tlie maternal mortality is pra( tically nil. Pinard operatecl fifteen times consecutively without a death, the conjugate in one case njeasiu ing only 6 centimeters ("1^ inches). This optn-ation was done forty-nine timis without a death in the practice of Pinard and his coUeagJies, and in all the cases the puerperiui'i was normal. Decapitation and EriHceration. — These operations are indicated (1) in neg- lected transverse presentations with impaction, where version is dangerous or impossible and the head cannot be brought down far enough for craniotomy ; (2) whcMi a monster or some ])athologieal enlargement of the fetal struetin-es renders delivery oiierwise impossible. Decapitation is indicated when the neck of the fetus !S within reach and a hook can be passed over it ; eviscera- tion is indicat(Hl in all other cases. These operations are always difficult and dangerous. The <ri; aeti'»n of the fetus interferes with manipulation, while the uterine tissues are thinned and liable to be injured or be ruptured l)y the hands or instruments. For (Iccnpitation Braun's hook (Fig. S^H) is the simplest and most efficient in- strument ; it is less liable to injure the mother than the more complicated contriv- ances. Before operating the bladder should be euiptied and the parts thoroughly disinfected. An arm is then brought <lown and a tape is attached to it, so that an assistant may make traction when required. The whole hand is then passed into the vagina, palm upward, with the ihiunb close to the symphysis and four fingers in the hollow of the sacrum, until the neck is clasped between the thiuiil> and the middle finger. If the head is lying toward the mother's lef> side, \ho left hand is introduced into the vagina ; if the head points to the mother's right ii;^ F'VU onsTKTnic suita i:ii v. 9.'{9 timos all the ill no<i- •ous or otoniv ; •iK'turcs WW tlic •ult mill n, while uml 1>V '11 passt'tl and four 10 thumh side, ll»> pr'rt rii^ht side, tlio right hand is introdiu'cd. The hook, wiih its concavitv pointing away from the head toward tin Ix dy, is grasj)e<l in tiio other hand, palm down- ward, is passetl along the thumb of the inside hand, and is giiidwl over the ehihrs neck until the tip touehes the operator's middle finger. During the passage of the hook it should lie all the time beneath the thumb and the fingers, v/hich should not be separated. The neek is put on the stretch by pull- ing the handle of the hook firmly downward (Fig. 535) while an assist- ant draws down the arm by means of the tape. While strong traction is being made the handle is quickly raise<l as far as possible, and twisted forcibly /ro/u head toward breech, turn- ing the palm of the hand upward. Three or four twists (Figs. 536, 537) are generally suflicient to sever the head from the body. Throughout the opera- tion the insi<lo hand must protect th(( maternal tissues from injury. Twisting should never be done unless the hook is clasped between the thumb and the finger of th(> guiding hand. As soon as the neck is divided the head reredcs, and the body is casilv delivered bv pulling upon the prolapsed arm ; the head is subsequently extracted with for- Fui. ■>;!.■).— Dornpitntiiiti with r.nniir.-- Imok. Flo. 636.— Braiin's hook seizliit; the ciTViPHl vitU-- Km. M?.— Urmm'H lionk rntntcd in the niiimsiti' ili- bra> ami rotiUed. ri'ctioii: tlii' spina! cnlmmi tjivliiK «ii.v. ceps or the ceplialotribe. During the extraction of trunk and head the mater- nal j)assages should be guarded against injury from the ragged ends of the 940 AMERICAN TEXT- HOOK OF OBSTETItlCS. several vertebrte. If Brauii's Ijook ih not available, a strong cord may ho carrietl arounil tiie neek by means of a gum-elastie catheter, and the soft parts Ik; sawn through by pulling upon the ends of the cord ; or a long, bliuit- pointetl scissors may be used to snip through the tissues, always taking care to guard the points. EpiscemUon may be accomplishetl byojK'ning either the thorax or thealxlo- men with blunt-pointed scissors, and breaking up the internal organs and remov- ing them by means of a volsella ; or the scissors-perforator may be carried up to the most accessible portion of the trunk, and an opening l)e made througli wiiich a crotchet or a metal nozzle can be intro<luced to break up the internal organs. The operation is very tedious, and great care must be taken not to itijure the uterus or the passages. After any pieces of loose bone have been removcil the blunt hook may be introduced, and an attempt may be made to extract the trunk by pulling it down and bending it upon itself. If this maneuvre fails, nothing remains but to dismember the fetus and deliver it piece by piece. Chain-saws and enjbryotomes of more or less complicated pattern have been devised for use in difficult cases ; but they are seldom avail- able when wanted, are difficult to apply, and are apt seriously to injure the maternal passages. Symphysiotomy has been odvise<l in these difficult cases, to give more room for manipulation and extraction. Pinard, however, protests strongly against the use of symphysiotomy for the delivery of a dead or muti- lated fetus, maintaining that the mother's chances of recovery are thereb} much impaired. Cases are occasionally met with where the ordinary methods of decapitation and evisceration are not feasible. Spencer' of University College, London, has recently drawn attention to two such classes of cases: (1) When it is impossible to deliver the body after the head has been extracte<l, on account of unusual size of the l)ody or of pathological conditions in the serous cavities or the viscera ; (2) when the back of the fetus presents, rendering decapitation impossible. In the first class, when traction fails to deliver, he suggests snip- ])ing through the clavicles (clcidotomy) and introdu(!ing a blunt hook into the axilla to bring down the arms, or decapitating and then passing the hand over the thorax and opening the abdomen. Care must be taken to seize the neck with a volsella before decapitating, to prevent the trunk from receding out of reach after the head is remove<l. In the second class he suggests snip- ping through the spinal column with a pair of scissors, seizing the trunk with a craiiioclast, and so drawing it down that it can be snipped through. The two halves of the body can then readily be delivered. After-treaiment. — After the mutilated fetus has been delivered and the pla- centa has come away, a hot antiseptic uterine douche should be given, and the parturient canal examined for traumatisms, which should be repairetl imme- diately. During the puerperium the chief danger is sepsis, and the treat- ment should be regulated accordingly. Prof/nosis. — The prognosis of embryotomy depends in great measure upon the degree of disproportion present, the condition of the patient, the stage of ' British Medical Journal, April 13, 1895, p. 808. I- oiiSTiyntic sriidKit v. U41 lalK»r, tlie nature of previous attempts to deliver, tlie amount of injury done to the maternal tissues, und, above all, upon the presenee or absence of sepsis. When the disproportion is not extreme, and the operation is done early, before the patient has beeome exhausted by a pr()tra(!ted labor or by futile attempts to deliver, when the maternal soft parts have not lu-en bruise<l and lacerated, and when all the manipulations have been done with strict antiseptic jH'ccautions, the mortality shotdd be very low. Craniotomy may be a verv easy or a very ditTieult operation, according to the degree of disproportion and the stage of labor at which it is done. Other things being equal, embryotomy is more dan- gerous than <'raniotomy. In private practice there are many difticidtics and dis- advantages to overcome, which are not encounteretl in well-arranged maternities ; consecpiently the mortality may reasonably be expecttKl to be higher; but, unfor- tunately, it is far higher than it ought to be, owing in great measure to the want of early and exact diagnosis, and to the )>revailing tendency on the part oi' the general practitioner to postpone operation until forceps and version have repeat- e<lly been trial and have failed. The brilliant results in Paris of basiotripsy show the possibilities of the operation when done early in suitable eases. There can l)e very little doubt that early oj^ration and strict antisepsis would minim- ize the chief immediate dangers, rupture and sepsis, as well as the risks of subsequent pressure-complications, such as tistuln;. But we can scarcely look for much improvement in our results initil the profession as a whole comes to have clearer ideas respecting the limitations as well as the indications of the destructive operations, and is more generally possessed of a sensitive " antiseptic conscience." s snip- k with . Tl le l»e land til imme- le treat- Ire upon )f Itage n. Manual Operations. Varieties and jMethods of Version. Version is a manual operation, designed to bring about a ])artial or a com- plete change in the relation (»f the long axis of the child to the long axis of the mother, whereby a longitudinal is substituted for a transverse presentation, or one end of the child is substituted for the other. The object attained is the exchange of a less favorable presentation which nature cannot deliver, such as a shotilder, for a presentation that is favorable for expulsion, such as a head, a breech, or a footling ; or, in such an emergency as placenta ])ra?via or a con- tracted pelvis, a change of the presenting part from head to foot in order to secure speed or ease in delivery. Omitting the study of the infrequent cases in which nature can compass version, and which have been considered under the heati of Mechanism of Labor (p. 489), we find three varieties of version : (A) cephalic, (B) pelvic, and (C) podalic, and three methods oi' version: (1) external, (2) bipolar, and (3) internal. Varieties. — Cephalic version causes the head to present ; pelvic version, the breech ; and jiodalic version, one or both feet. Choice of Variety. — For cephalic version an easy case, an ample pelvis, and %rl I 2H 942 AMERICAN TEXT-BOOK OF OJiSTtyriilCH. labor not under way are the ordinary conditiotis ; pelvic version is an oeca- sional early prei)aratit>n for labor with placenta praevia ; while potlalic version is our chief reliance in urgent or difficult cases. Methods. — External version is accomplished by manipulation through the abtlominal wall. Bipolar versi* n is ett'ecteil by passing two fingers througli the cervix and tossing along the successively presenting parts of the child until the leg can be seized, while the exterind hand docs its part through the abdominal wall. For internal version one hand is pushed freely into the uterine cavity to grasp the foot or the knee, on which traction is made while the other hand assists from without. Choice of Method. — In a typical case we should attempt the correction of tlie presentation by the three methods in the order named. The indications for each method will be given in its proper section, but they may be sum- marixed here : 1. The exteniul method is not often employed, because its success depends on a c>onibination of conditions that is seldom found. It is the simplest and safest procethire, and will be more often required as early I'ecognition of the position of the child by abdominal palpation becomes more common. It demands the presence of the liquor amnii, or at least a relaxed uterus and abdominal wall, with free mobility of the child, and is usually available only beiore labor or early in its course. 2. The bipolar methoil has the advantage over the internal method in that " it can be performed at the commencement of labor, long before the os is com- pletely dilated, and that it obviates the necessity of introducing the whole hand into the uterus, which is not without danger to the parturient and the child." But it is not always easy or feasible. 3. The internal method is the obstetrician's chief reliance, especially in urgent or difficult cases, but it is many times an operation of no little moment. Indications for the Operation : A. Indications for Cephalic Version. — Breech presentation calls for cephalic version when all conditions are favor- able — such as a sufficiently roomy pelvis — and when it can readily be accom- plished by the external method before labor by a practised hand. Under such circumstances shoulder cases will also be amenable to this variety of turning. B. Indications for Pelvic Version. — As this maneuvre is rarely employed, its consideration may be brief. It is only undertaken by the method of external version, as by other methods we bring down one or both feet. It is indicated for placenta prsevia and for a slightly-contracted pelvis before labor or early in labor. C. Indications for Podalic Version. — Stated in the order of their import- ance, the conditions under which version should be chosen are : 1. In transverse presentations, which are chiefly shoulder cases. This indi- cation is the most frequent, and includes all except small or macerated fetuses, and the few instances in which cephalic version is preferred. 2. In normal pelves and head presentations, when the life of the child or UliSTETIiJl • SI RUKIt Y i)43 that of the mother is threutt'iied, if the heail cannot be inihieed to enj^age and tlie cervix i.s not dilateil «o that forceps can be applied. This indica- tion inchides phicenta prievia, exwpt in the sinipk'r marginal variety with the head K)w in tiie pelvis, and scant bleeding. It also covers cases of pro- lapse of the cord not otherwise manageable. In certain instances with pro- lapse of one or more extremities, and chicHy when the foot presents, podalic version is our resource, as also in the most troublesome face or brow presenta- tions with the head at the inlet, when the posture of the head cannot be recti- fied manually, and particularly in i)osterior positions. Lastly, in certain other emergencies, should the case call for rapid extraction, we employ version, as in eclampsia and in accidental hemorrhage. 3. In contracted jwlves. Version is called for in flat pelves where the true conjugate is not below 8 centimeters (31 inches), where there is a relative dis- proportion between passage and passenger c(]uivalent to the above-nanied con- traction, when; the head does not engage and changes its |)ositi()n frequently above the brim, or where previous breech deliveries have been more favor- able than vertex presentations, and also " in obli(piely-contractcd pelves and unsuccessful or unfavorable engagement of the head with the occiput over the contracted side." Contra-indications to Version. — Rigid and permanent contraction of the wall of the uterus, especially in dry labors; high position of the retraction- ring (5 to 7.5 centimeters — 2 to 3 inches — above the symphysis — Winckcl) ; engagement of the head ; impaction of the presenting part which would recjuire dangerous pressure to dislodge, — all contra-indicate version. Dangrers of Version. — Rupture of the uterus, shock, increased risk of sep- sis, hemorrhage, and laceration are the hazards for the mother. In external and bipolar version these dangers are usually insignificant, because we I'arely use nnich force in these procedures, but in internal version there is risk of uterine rupture. It is for this class of eases that we urge the necessity of firm gen- tleness and the avoidance of t)peration in the presence of pronounced tension or thinning of the uterine wall. There is, of course, no obstetric operation more likely than version to infect the mother if the operator does not carry out aseptic measures, except, perhaps, that of Cesarean section. The danger of laceration and of shock is proportionate to the rapidity with which the child is turned and extracted, aiid to the lack of skill of the operator. To the child the dangers are fracture of the femur or the humerus, together with the usual risks of breech labors. Cephalic Version. — "As head presentation is the tyi^e of natural labor, it follows," says Barnes, " that to obtain a head presentation is the great end to be contemplated by art, but practically head-turning is little known. De- livery by the feet is almost universally practised when the substitution of a i'avorable for an unfavorable presentation has to bo accomplished. AVhy is this? The answer rests chiefly upon the undoubted fact that in the great majority of instances, at the time when the mal-prosentation conies before us, tiu'uing by the feet is the only moileof turning which is practicable." It may ! \ < fill 944 AMHIilCAN TKXT-nOOK OF OliSrKTlUrS. also Ik' iiotod that lai-k of certainty coiuH'i'niiit; presentation and |)Osition, due to detective traininj^ in abdominal palpation, leaves the patient withont help until the time has passed for the milder manipidation. Omditiomfor ('f/Jtolir Wrfiion. — For a favoral)l(! outcome hv this method, labor should not yet be under way, or should not be so far advanced that there is any marked tension of the uterine walls. The liquor aninii should he present, and the alMlominal walls neither tense, tender, nor thickly padded with fat. Amoufij transverse conditions we prefer an obliquity that is nuxl- erate, with the shoulder not yet driven down into the jH'lvis. To convert a breech into a vertex presentation, not only nuist these favoring circumstances Ih^ present, but the operator should also Im endowed with skill in version and experience in abdominal palpation, so that his maneuvre shall not be arrested halfway and a breech ca.se be converted into a transvei-so presentation. The ailcantaf/es of cephalic version are evident, and in the ])resenee of a sufficiently capacious pelvis should induce skilled oj)erators t<> undertake this measure. Tlw (Imtdvautaf/ex consist in the limited scope of the procedun>an(l the experien(!e recpiired. Strps nf the Oprnitiou. — Cejihalic version is practically c*>nfined to the external and bipolar methods, uid the steps are the same as in these metho<ls, which are described on another paj^c, excejrt that the fetus is to be moved in the opposite direction from that describe*! under jwdalic version. If the oper- ator prefers to do version with the woman lyinj; on her side, she should be on the same side as that on which the head i> found. Supposing the case to be one in M'hich the head is in the left iliac fossa, and the fundus, with the breecii, is to the right of the mother's s})inal column, the woman is to be placed on her left side. In this j)osture the fundus of the uterus, loaded with tlu; breech and being movable, will tend to fall toward the dependent side. 1. External Version. — This method, the simplest and safest of the three methods of turin'ng, will become more comm<mly employed as the general practitioner adopts the habit of a thorough examination by abdominal palpa- tion a month before labor for each pregmuu ..oman under his care. When- ever possible, it should be attempted before the other methods are begun. As Fritsch well says: "Even to-day, when the danger from sepsis is small, a successful external version means the achievement of large results through little means." ImUcatiouH for Externnl Version, — The indications, in general, are the same as those that aj)ply to all versions, the special contHfioun required being the ])resence of the liquor anniii or its recent loss, leaving a relaxed and insensi- tive uterus with free mobility of the child. External vereion shoidd be un- dertaken oidy when it can l)e performed without violence; this period, as a rule, is before labor is actually established, or at any rate before rupture of the mend)ranes. It may be performed with advantage for a high transverse position of the second child in twin labors. Contrn-hnUcations. — External version cannot be effected when there is m macerated fetus, or in case of twins, or where the presenting part has sunk and I tho same 1)01111;; the insoiisi- \i\ he uii- 1, as a (•KM ro liptii Iraiisvorso hioro is a ojis Ti<: TR ic s I wf a ku y. Mh <leop ill tlio pelvis, or wiicrc tiio uinuiotii^ fluid is sinall in (|iiaiitity ; uoitlier is it practicable, as a rule, where an excess of fluid (;aiises marked tension of the uterine wall, as in such cases the fetus cann<u lie retained in its new posi- tion. It is seldom adapted to cases where a rapid termination of tli(( delivery is iiulispensalile. Malformations of the uterus and tumors are rare contra- indications. There is no (lanf/er connected with this operation. Its manifest advantages are that neither sepsis nor shocU can result from its use. The Ixjst time for npemtion is at the end of prefjiiancy, just before the onset of labor, because, later, uterine contractions impede the nianeuvre. Earlier, as at the seventh month, one sees transverse presentations in the multipara that rectify themselves, but version may be undertaken early, or, indeed, at any time during the first stage when the conditions above mentioned exist. If begun during labor, the manipulations should nu !>e persisted in so long that the uterine wall takes on firm and persistent coi, traction — a condition which renders the other methods very ditfieult. Preparation for External Version. — The bla''' r and the rei .urn should lie emptied, and the woman placed in the horizontal dorsal decubitus, the head and sh ^'Vl'rs moderately elevated, and the lower limbs .slij;htly flexed with the knees apart. Anesthesia is not rtquired unless the patient is extremely '.nsitive. Hteps of the Operation. — The hands are applied to the bare alHlomen and the diagnosis is carefully confirmed. A hand is then placed on each end of the fetal ovoid. In transverse cases the liead is lifted toward the fun- dus and the breech is driven down toward the inlet by a succession of moderate impulses which are checked as soon as a nterine con- traction is produced, while what- ever gain has been made is care- fully held until the uterine wall amiin relaxes. A method that has merit is the following: The opera- tor seizes the opposite ends of the fetus with the palms of his hands (iicing each other, the fingers of Diie hand opposite the wrist of the other, the hands lying parallel. The power is exertv' by simple flexion of the fingers moving in unison, and although the position of the hands may .seem forced, they will be found to work easily (Fig. 538). Alternating pushes, first ou the liead and then on the breech, most readily dislodge and turn the child. These strokes are made in rapid succession upon the two extremities, one hand giving a movement of ascent and the other a movement 60 Fio, '-38.— External version : arrows show the directioii in which the ends of tlie fetus should move. . ! • liii m i-i 4 II 946 AMERICAN TEXT-BOOK OF OBSTETRICS. of descent. CVplialic vei-sion should first be tried in transverse presentations wherever the pelvis i; sufficiently large and it is not likely that hasty extrac- tion will be required, or the tampon action of the leg will become necessarv as in placenta prujvia. If it is attempted to replace a breech by a vertex presentation, the first step of the <»peratit)n consists in lifting the breech into one iliac fossa while at the same time the head is driven to one side. As in all other methods, the end of the child to be brought down is made to ft)ll()w the shortest possil)lc arc that will bring al)out the desired result. This will be accomplisheil by pushing the head in the direction of the occiput and the breedi in the direc- tion of the feet. Patient and repeated atiempts should be made, but tiie woman should not suffer pain, though she nuiy be subjected to some dis- comfort. Wiien the turning is effected, a vaginal examination is to be made to make sure that the tlesired fetal pole has been brought to the inlet. JidentioH after Version. — JIaving succeeded in altering the presentation, it will be found that the causes which produced the tbrmer presentation will tend to reproduce it; therefore we either bandage the abilomen to retain what we have gained, or, if labor is under way, we make sure that the presenting part becomes well engaged. The bandage may be one of two kinds — either an impromptu afliiir of flannel or of unbleached muslin, like the ordinary binder, to which a longitmlinal pad on each side is carefully fitted and fas- tened, or one of the abdominal bandages to be found in any large instrument- store, reinforced, if ne<!essary, by lateral splints or padding. Pinard's bandage^ has long inflatable pads on the sides and straps under the thighs. If labor is under way and the new presenting part do(>s not engage well, the ])atiei'.t mav remain on her back, watched by the ol)stetrician or the mu'se, or on that side from which the presenting part was dislodged, with a firm pillow under the uterus to prevent undue sinking. In certain cases it is advisable to rupture the membranes to make sure that the child remains in the desired position. 2. Bipolar Version. — liKlicdtiovK. — The foregoing general rules apply also to the bij)()lar method of version. The special conditions necessary are that the liquor amnii be wholly present or so recently present that the child is still movable in a liur degree, and that the cervix admit two fingei-s, while the vagina must tolerate the preseiuie of the rest of the hand if necessary. " It is one of the natural (umsecpiences of a s'oulder prcsentaiion that the cervix- is but rarely found dilated enough for turning and delivery until after, per- haps long after, the indication for turning has clearly been present. The shoulder does not dilate the cervix \vell." The admntar/cs of the bipolar method over the internal method are that there is less danger of infecting the uterine cavity in its deej)er parts, and that it permits the operation to be done when the dilatation of the cervix is but slight. Its disadmntagvH are that the finger-tips have but a limited con- trol over the parts of the child that successiyely come within reach, and the niethod is therefore usually restricted by its limitations to those transverse cases in which one has not far to reach or far to turn in order to brin<^'. the OBSTETRIC SURGERY. 947 ations xtviu;- :essiu'y le fii'st I while lis, the )ossihle heel by B Uirec- but the nie ilis- ue intitle [ution, it ion will [lin what i-ertontinii s — either oriliiuiry aiul ia>- ■^tnunent- s hanclajie f labor is lent iiniy that side \iinler the ) rupture lositioii. ipply also y are that lihl is still while the lary. " It he eervix after, per- ent. 'Hie |m1 are that I parts, aii.l ie eervix is Inited eoii- |h, anil tlie transverse brini', tlie child's knee into tlie cervix ; nevertheless this resource should always l)e kept in mind. The preferred time of operation is early in the dilatation stage when the cervix is passable for two fingers. Preparation for lllpolar Version. — Anesthesia is not necessary nor usual, but it should be a preliminary procedure with an excessively sensitive or rest- less patient. The parturient lies on her back across the bed, with her hips near the edge, and her feet on the edge of the bed or supported by assistants or on chairs. Working short-handed, one nuiy pass a rolleil sheet under the patient's neck and tie the ends about the knees, to keep them flexed. The forceps is wraj)peil in a towel and boiled, t(» be at hand in case arrest of the after-coming head should suddenly demand it lltr a dillicult extraction. AVith the forceps, scissors, episiotomy knife, needles, needle-holder, catch-forceps for quick seizure of the cord, douche-bag and tube, tape;, and silk or silkworm gut are sterilized by heat. The douche-bag is filled. Towels, steamed, fresh- laundered, or wrung out of solution, gauze, iodoform or zinc-oxide gauze for tampon, basins, and solutions are ready for use. The diagnosis is coufn'med ; the hands of the operator are rendered sterile, the vulvar hair is clipped close, and the vulva and its vicinity, th(! lower abdomen, the Imier sides of the thighs, and the vagina and cervix are lathered and douched. Steps of the Operation. — The fingers of the hand that correspond in name with the side of tlie mother to which the presenting part is to be pushed — the left hand if the shoulder is to be pushed to the left — are sli|)ped through the cervix into the uterus, the remainder of the hand being inserted into the vagina only when the presenting part is at such distance as not otherwise to be reached. The outer hand grasps that end of the child which is to be brought into the cervix. A simj)le and efficient way to keep this hand liom contamination is to wrap it in a sterile towel or to lay-across the abdomen of the mother a towel wrung out of a warm disinfectant solution. Let us suppose that we have a vertex presentation, the occiput to the left and front, to be changed to a breech presentation. The head nuist be sent in the direction in which the occiput points — in tiiis case to the left. AVe now begin "the simultaneous action on the two ends of the fetal ovoid, the fingers of the internal hand pressing the head-gU>be across the pelvic brim and lifting it upward toward the left iliac fossa ; the hand outside ])ressing the breech across to the right and downward toward the right ilium (Figs. 0,39, 540). The movements by which this is eiVected are a combination of continuous pressure and gentle taps with the finger-tips on the head, and a series of half-sliding, half-pushing impulses with the curved hand on the breech " (Barnes). As tiie head is lifted out of the brim on to the shelf of the iliac fossa and is passed on, the shoulder nun-es along into its ])laee. Then the chest, elbow, or knee com<>s witliin reach, but further away and at times almost too high for touching. When the arms and legs are completely flexed the knees of the child are found about the h"ight of its navel or against its chest. Meanwhile the outer hand crow«ls the breech well downward to bring the M ! \f I i !ii hi 948 AMERICAN TEXT-BOOK OP OBSTETRICS. or if knee within the grasp of the fingers passed into the uterus, and the nurse assistant is requested to lift the liead upward. As soon as a knee comes within reach it should be seized. When a choice can be made, the lower or near knee should be chosen in a dorso-anterior position of the child (Fig. 543), and the remote knee in a dorso-posterior position ; that is to say, the lower of the two in the case we are considering. Often one cannot choose, but breaks through the membranes (if they are intact) and gets down either leg or both legs without ado, as the finger-touches cannot determine the mat- ter so readily as does the full hand-grasp of internal version. [A full con- sideration as to the choice of foot is found on page 950.] Still applying power to the ends of the fetal ovoid, the version is completed by drawing the leg down into the vagina to secure the engagement of the breech. If tlie arm is prolapsed, Braxton Hicks advises that it be flexed and pushed up over the anterior surface of the thorax, first noosing a fillet about the wrist. In ap- plying the above method to a transverse presentation (Figs. 540, 541) the steps we have described are undertaken so far as they apply — that is, one begins by tossing along whichever part first comes within reach of the inner fingers. Moreover, while we have described po- dalic version because it is the more common, cephalic version can be ac- complished by the same procedure. 3. Internal Version. — By this method, which is the most effective and the most commonly employed, as well as the most dangerous, the hand is passed into the uterus deeply enough to seize one or both feet and to bring them through the cervix. The indications are those already described on page 942, and the same may be said of the contra-indications, with emphasis on the fact that the reasons there given apply with their fullest vigor to this method, which in neglected cases may constitute a difficult and hazardous operation. The conditions necessary for the performance of internal j)odalic version — and podalic version is practically the only variety undertaken by this method — are rather numerous : 1. The mother must not be in gravest danger, for in such case v(>rsi()ii cannot save her. The child is likely to be so weak as certainly to die diirinir the process of turning and extraction ; and the fetal life could only be saved by Cesarean section immediately following the mother's death. 2. The pelvis nmst be sufficiently ample to allow free passage of the hand, Fi(i. r)39.— The first stei of bipolar pmlnlic version: two lingers witliiii tlie cervix lift tlu' hoiid toward tlio iliac fossa, while the breech is crowded over toward the other ilium. li OBSTETRIC SURGERY. 949 rse or 1 monies w ver or W y, the hoose, 1 either 1 e niat- § 1 con- 1 power the h% arm is N> |)liir pcM\ii\io :vix lift llH' he brocih is jribed on lempliasis lor to this imzardoiis .-ersioii — knethwl — \v, version lie (hiriiV-!! bo saved Ithe haiul, so tliat the fetal part can be grasped securely and the living fetus extracted. For the live child a true conjugate of not less than 8 centimeters (3J inches) will be desirable with a fetus of ordinary dimensions. 3. The cervix should be completely dilated, or in a nuiltipara almost com- pletely dilated, and at the least be freely dilatable and easily passable for the hand without injury ; for if rapid (jxtraction is necessary the cervix nuist permit ready passage of the head, and to secure this it should be large enough to allow the closed fist to j)ass. A note must always be made in passing of the size and dilatability of the orifice, for there is no more annoying obstruc- tion than to find the after-coming head firmly retained by a jwiwerful india- rubber-like band applied about the neck.* Where the dilation is not complete version is not forbidden, for we resort to it in oases of placenta praevia in Fio. MO.— Bipolar version : the shoulder ami arm are pushed along; the breech is pushed down- ward. Fio. ."i-ll.— Bipolar version: the knee is almost within reach, tlie head is pressed upward. order to plug the bleeding canal by the thigh or the breech and wait for dila- tation, and we are not deterred by the case wherein the elastic tube fits the head snugly, because incisions will permit us to extract rapidly if this become imperative. 4. The uterus must not be tetanica'.ly contracted about the child, for under such conditions there is imminent danger of rujiture; therefore the ob.stet- rician tries to ascertain whether there is a transveive ridge, the retraction-ring, between the symphysis and navel, and how high up it has been drawn. 5. The child should not be crowded too deeply into the pelvis, but should *The circumferenpe of tlie oone-shapcil Imnd is from 'JO to 24 centimeters (M to !t.\ inchesl, that of the dosed list from 25 to 28 centimeters (10 to 11 inches), while that of the flexed head is from 80 to 33 centimeters (12 to 13) inches), so thiit the closed list should imss loosely to ensure rapid extraction of the after-coming head. 1 1 it . i 950 AMERICAN TEXl-BOOK OF OBSTETRICS. be siifficlontly movable to allow the preseiitinj; part to be pushed back. Neitiier must the fetus be too large. If premature (before tweuty-uiglit weeks) and dead, and macerated, no ^'enr flint ^^jTiJ^^SM^ operation is likely to be needed. Most favorable will be the case wherein the child is relatively small, the uterus lax, the cervix open, the membranes intact, and the mother insensitive. Dangers of Internal Vermon. — The dangers, as has been said, are ruptir'e of the uterus from the employment of undue force, and sepsis caused by uncleanlincss, together with laceration, hemorrhage, and shock. The adrantages of this method are the complete control of the fetus and its evolutions which it affords. Choice oj Foot. — Before proceeding to operate, we must have a clear idea of Fig. ril'-'.— Dorso-antorior position: tlii' hand is passed diroctly across tlie cliild to soizt' tlie near foot. Fi(i. .m;).— Tractiiin iin tlic near Ic^ is niadi- ill- aRiinally ai'Hiss tlu- niotluT's pelvis to pull tlio child's breech into the inlet. Fl(i. rill.— Traction made directly downwiinl leaves the lireech seateil on the iliac fossa ami reiinires nseless force. the mechanism we desire to institute, and we shall diverge from oui- practical study to consider confiicting theories and teachings, since there is much diflcr- ^m OBSrETRIC SCRGERV. 951 Idownwiinl I'llSSH iiiwl hractu'iu ence of opinion as to the most advisable, expoditious, and successful method. The question at issue is whether to seize one or both feet, the near or the re- mote foot, or the remote foot in certain casi's and the near foot in certain other cases. We state, theoretically, the most advisable method, but we do not pre- tend to make hard-and-fast rules. In practice we often do — not what w(^ would, but what we may. We may summarize the discussion by sr.ying that traction on either foot will rightly effect the version, but that it is preferable to bring down the remote foot in dorso-posterior positions of the child, and the near foot in dorso-anterior positions. The simplest metluxl is to seize either foot indifferently. Some operators (Nagel, Grandin, Fritsch) endorse this practice. In the most difficult cases where the pressure of quick-recurring uterine contractions or the emergency during a hemorrhage is such that one is happy to be able to reach either lower extremity ; or in case only out; vaw be found ; or with an operator who has not been thoroughlv trained bv manikin teaching or who is without sufficient ex- perience and possesses cloudy ideas of position and meclianisni, — tiiis course is a sensible one to advise. Traction on either leg will l)ring about version. It is merely a question which leg will most efficiently produce the desired Vm. Ma— Till' hrccch oiitiTS tin." lu'lvis with triic- tiiiii ill till' rijilit I'.iri'ilidii. Kiii Vlfi.— Ni'W sfizurt' nil tlu' tliiuli; tlic li'BOii wliicli tructidii is iiiii till' ju'lvis. lie li.'ilit.' Ilif iiiitcTiiir Iff,' ill |1 ( lilVer- result; therefore, for the novice let us say if he is unable to get both. that either loot should be seized "(r i 952 AMERTVAN TEXT-BOOK OF OliSTKTRICS. The near foot nhrays is chosen by certain operators (Winckel, Lusk, Remote i /Jearfoot Fig. 547.— Dorso-antcrior position; suizurc of tlie Fkj. .MS.— Tlio rcmoti' fipot drawn in a ilia^^onul rrmotr fdcit. direction tliroiiuli tlii' inotluT's i)t'lvi.'*. Schroeder, (lalabiu), except with a freely movable child, because it i,s .simpler i Is Fig. 54U.— TIk' uiipiT Imttock i.s movin^r down, ird Fi(i. .'i.V).— Tlio l)r(U'o)i i-ntors tlio pelvis, tlic Ice and tlio lower shonlder rif' i;;. on which traction is made lieint; the i)()sterior lej; in the pelvi.s. aud less difficult, and l)ecau.se " only a revolution (Figs. 542-546) about the m OBSTETRIC SURGERY. 953 cliild's sagittal axis occurs, to which is added later one about its long axis, when the hip which has been brought down engages under tiie symphysis." In pulling on the upper foot "a revolution (Figs. 547-552) about the long axis, and then one about the sagittal axis, and finally a short revolution about the long axis of the chii<l occur, and a disastrous lifting of the arms is pro- duced." This objection to tract'on on the remote leg has force in dorso- auterior cases only. The remote foot always is sought by certain teachers (Simpson, Kristellar, Barnes). "The proper knee to seize is that which is farthest. We have, for example, a right dorso-anterior position (Fig. 547) ; the right arm and shoulder are dowumost, and these jjarts have to be lifted out of the brim. How can this be done ? Clearly, by pulling down the opposite knee, which, representing the opposite pole, must cause the shoulder to rise, the movements running parallel in opposite directions like the two ends of a rope around a pulley " (Fig. 549). " If only the foot of the same side as the presenting arm is seized, the effect is to increase the wedge and the impaction." In Figure 543 it will be seen that traction on the leg is like pulling on the stalk of a T, of which the horizontal bar is represented by the body. Moreover, in trans- verse cases the breech is usually further from the median bno than the head, and the near leg may pull in the long axis of the child at a disadvantage. The inadvisability and the bad mechanics of traction on the posterior leg, as compared with traction on the anterior leg, are well shown in Figure 560, (a-c). It needs but a glance to see that the pull in the direction of the '^^, Fig. 551.— The Ior on which Inu'lion is iiuide hi:s pp.ssed ovor from tlie left to tlu' rinht .siilo of the mother's pelvis. Km. 552.— Tlie Iok which was posterior in Fifjiire 551) is now unterior. arrow of Figure 560, a is at an angle which in no way coincides with the 'I ill 1 i 1' ^ 1 'i 1 954 AMERICAN TEXT-BOOK OF OBSTETRICS. axis of the inlet of the pelvis, whereas the pull indicated by the arrow in Figure 560, c, is at a much more favorable angle. Figure 560, n, shows rota- tion under way. Nagel demonstrated elinically that the leg swings the long way round the mother's pelvis. The Near Foot in Dorm-nnterior PosUiom — The Remote Foot in Dorm-poste- rioi' Positions. — In dorso-anterior positions the near leg should generally be brought down. A strong argument in favor of this method may be drawn If Fi(i. ."i3. — Porso-postiTidr iHisiticiii : tlii' hand Fio. rw^l.— The fodt is dniwii down; assistiincu by is passed in dm-ctly to seize the remote foot, the means of tlie hands without is sliown. mother in the d irsal posture (see Fig. 562). from these two facts — first, that in pulling the breech through the brim after turning, it is of great advantage to make traction on the leg which will come at once to the front behind the .symphysi.s, and .secondly, by this means the fetus never lo.ses its dorso-anterior position. But in bringing down the upper foot the child's face is turned to the front, requiring a subsetiuent rotation of the trunk to bring about a dorso-anterior condition, which is rcfjuired at a further stage of the extraction in order readily to deliver the shoulders and head. This will best bo demon.strated by consulting the two series of fig- ures (Figs. 547-551) illustrating the stages oi' the procedures here .set in order. It will be .seen that one evolution is simple and that the other is com- plicated ; that in one case the rotation of the body on its long axis is entirely avoided ; and that a very im[)()rtant consideration argues for the simpler pro- cedure — namely, that the chances of throwing the arms above the head are materially lessened by the method of traction on the near foot. When there is firm contraction of the uterus it is rightly objected that pulling on the near foot will more tightly wedge the parts, and that it will be necessary to push the head higher up in the iliac Ibs.sa in order to loosen the obstruction, iJiit ;4i m \ ' oBsrjyritw surgku y. 955 in the presence of . such relaxation as would justify version the simpler method is advisable. In dorso-posterior transverse positions the remote leg should be brought down. Here the back of the child is at the rear, and traction on the upper leg after the change in the long axis has been ett'ected will bring about an anterior position of the dorsum of the child. To secure this condition promptly, the upper leg is the one to seize, as shown by our graphic argu- Kio, riri'i.— Traotidii is iiiaiU' iliiiKoiiHlly iicniss till' iiKJtliiT's pi'lvis to ilislod^f till' liri'ech ; tho li'(f brought down is now thu iiuturior Itx. Kio. nrifi.— The chiUl slips fartlior down. inents (Figs. 55.'i-55G). As one i)ulls on the remote foot the body rolls over, the uj)per buttock follows over a <'oui*se toward the front and becomes lower than its fellow, while the spine is strongly curved. Imagining tlie tetal trunk to be a flat block of wood, the traction on the upper or sacral corner of the block forces the diagonal, or opposite, corner — the impacted shoulder — to rise. -.1 S!n(/le Foot. — The advantage of bringing down one foot instead of both feet is that the second leg applied along the fetal trunk ensures a larger mass (made up of the breech and the flexed thigh) by wliieli the cervix will be wedged more fully open for the benefit of the larger after-coming siioidders and head, than will be the case where this wedge is decomposed and l»oth legs are brought down, leaving a dilating mass of the cal'bre only of the child's hips. The circumference of the hips, with both legs down, is somewhat over 25 centimeters (10 inches), while that of the breech, witii one leg up, is 28 to ;iO centimeters (11 to 12 inches). ■Ifc ^ 906 A Mi: It I( AX TKXT-nOOK OF OBSTETRICS. fi' Both Fid. — Wlioii the cervix is widely dilated, when tiie most nipid ox- traetion is called for, or when the uterus is not well relaxed, both feet may he brougjjt down. The middle finger is passed between the child's ankles when seizing both feet, and the other fingers surround the ankles. U seizure of the foot is diftieult or if straightening of the leg is impeded, the leg may Ixj brought down l)y making pressure in the popliteal space, thus flexing the thigh alongside the trunk toward the back and side of the child and giving more space in which to pull down the foot (Fig. 561). In some cases the finger may be hooked over the knee, and the knee drawn downward in a jj Fio. G'>7.— Oorso-postcrior position : tiR' rear Icr has lioeii brought down. Kio. 55S.— The child's l)recch enters the pelvic cavity. flexed condition, extensijm of the foot being effected farther down in the birth- canal, but usually this method is troublesome. In all the above difficulties the outer hand supplements the work of the imier hand, pushing or feeding the desired ])art within reach of the fingers working in the uterus. Choice of Hand. — Xo stress is laid on the choice of hand, because the feet of the child usually lie within equally ea.sy reach of either baud, near the center of the uterus. The hand that is most readily u.sed depends somewhat on the position in which the ])atient is to be delivered. In general oneclioosos that hand which, in a given case, will most conveniently pass in to the leg to be brought down, in such a way that the .sensitive surface of the fingers will be turned toward the jiart to be examined and grasped — the palm toward the child's abdomen. Thus in the case shown in Figure 542, the patient - m onsTETjiii • suiidEii y 957 1 birth- ol" tho tiugcrs luse the liiear i\w Iniewhat ! chooses lie lofi; to tors will toward patioiit I: ill the dorsal posture with tlie fetal alKloiuen to the rear and the feet to the mother's left, the lelt iiaiul works more easily into the deep hollow behind the ehild. In dorso-posterior positions, or in cases <tf peiidnlons alKlonien, there is often diflienlty in passing the hand into the cavern above the syni- jihysis because of the troublesome backward bend at the wrist-joint (Fig. 553). In such coiulitions the latero-prone posture is of value, in combination with the expedient of passing the hand along the lower lateral wall of tlm uterus, the patient lying on that side on which the child's teet are situated (Fig. 562). PreparatioHH for the Operation. — Internal version may be undertaken in an emergency with no assistant except a nurse, but oik; works at a great dis- advantage, and would prefer to have one medical man as anestheti/er, and a second to assist, besides the nurse, who will have enough to do in carrying out directions that may be given her. Whenever possible the operation should be performed on a table. A large ene- ma should always be given. The cath- eter should be used if sitting on the chamber and the application of hot cloths to the vulva fail to induce an evacuation of the bladder. To prevent undue soiling of the bo<1, the floor, or the operator's person — for this is one of the bloody operations — some ample receptacle, such as a pail, dish-pan, or child's bath-tub, should be jilaced on the floor, and to guide the fluids into the vessel a Kelly pad, or a waterproof, or table cover, or some Fio. r,r,9.-The ihUd-s trunk is fully within newspapers under sheets should be the pelvis, but further rcitution is neeossary to spread beneath the hips. Over these bring the U'K to the front* . ,, , and next to the jiatient a sterile towel or one wrung out of an antiseptic solution should be laid. The operator pro- tects his clothing with a rubber apron or by a sheet tied under the arms. A well-equipped instrument-table will contain a large basin of hot water for the scrubbing or to resuscitate the child, a basin of antiseptic solution in which the uterine douche-tube, connected v ith a filled douche-bag, may con- veniently lie ; green soap and brushes ; gauze or towels to be used as sponges and in seizing the child ; a bandage or strip of gauze ; a fillet ; scissors ; silk or silkworm gut for tying the cord ; an episiotomy knifli' for the cervix or vulva, and forceps for the after-coming head. The assistant who administers the ether is at hand with restoratives, a hypodermic syringe, and ergot. * I am indebted to tlie beautiful work of I'arabeuf and Varnier for the suggestions from which many of the illustrations to tills article were made. For all of my cuts jihotogniphs of the pelvis and fetus were taken and painted over (Kobert L. Dickinson). J 4:H i, I 958 AM /:/,'/( 'AN Ti:XT-UO()K OF OJiSTF/ntTCS. AuvHthvHin is ic(|uin'(l lor all sensitive patients in most of tlic diffieiilt one- rations and wiienever complete relaxation of the alulominal and uterine walls is essential, Weeause tlie walls of the cavity l>e<'onie ten^e as the hand pushes in, and may take on a more or less eontinuons form of eontraetioii. Xantosis is nsnnlly desirahle to relieve the pain of the operation and t(» prevent striijrjrlin); on the part of the patient. It is to bo omitted where siieh favoralde conditions as the open vulva of tiie multipara, a fully dilated cervix, and Hahhyand insen- Klci. .".til.— Tci hriii); dnwii ii font when It l.« iitraliist tlic lilcc llu' klicc liMiy 111' li"ii| l.y |ilcssiin' ill llic |io|ilitciil spncc iiiiiHliUccI I'niiii I'liriilicul' mihI Viir- iiior). Flo. 560.— A, trnt'tion iin the ptistcriiir leg: ilie IdWiT urrdw slidw.s tlu' iixis of tlu' inlet, tlii' arrows to the rlulit, the axis of traction: the Imttoek is cauKlit on tlie tiriiii. H, coiitinueil traetion is ro- taliiiK tlie le^; to the iMwilion of ('. r, traction on anterior leu: the arrows show that the pull is nearly in the a.\is of the brim (moUilied froiu I'arabeuf and Varnior). Ftu. .WJ.— Iiorso-posterior position: the liaml passes easily aloni; the side wall of the uterus to seize the feet. sitive uterine and abdominal walls are present, or when serious heart disea.><e forbids its use. It may be discontinued as soon as turning is accomplished. Ether produces less complete relaxation than chloroform. In no obstetric operation is thorough antisepsis more urgently demanded. The operator's sleeves are rolled up nearly to the shoulder and ]>inne»l, a rubber apron or a sheet is fastened about him, and his hands and forearms are thor- oiiSTF/ntw smann y. 9r)9 ?*" ouf^hly scnihlKil. Tlicii tlio liuir is <>Ii|)|>e<l, aiul the vulva, tlio itisido (»t' the thighs, uikI tlie alHlotniiial wall ari> latlicriKl with ^aii/o, soap, and hot water. S('riihl)iii}r should 1>»' done with a brush after auestliesia is unch-r way. This cU'aiisin^' i.-. eminently desirable, because (xrasional eontaet with the skin-siir- f'aee is hardly avoi<lable. In eases of haste or in an einerjieney there uiav onlv 1m' tinieenoii^rh t(t send) ofV the vidva and to wrap the out«'r nianipidatin^ hand in a clean towel. The desirability of keeping; that hand aseptic is evident from the fre(|uent necessity for a change of hands by which the outer becomes the inner hand at a time when valuable minutes would be lost in <'leanin^ a con- taminated outer hand. Next, the vagina is well lathered with a wad of jjan/eand jrreen soap, everv fold being stretehe<l and scrubbed. The douche is then given. If time and material serve, each leg should be ndled in a separate sheet and the covering secured with safety-pins. In our hospital work the patient wears a pair of combination stocking-drawers tied about the waist. The shcet-sling (I'^ig. 56.'$) is employed when working short-handed. A clean towel, or one wrung out of an antis r'tic, on a chair or table, holds the instruments, which have been wrapped in another towel, and which have been boiling ten mimitcs while the j)atient was being shaved and anesthetized. J'oNfiiir of the Patient: Ihrml Poatuve. — Usually the patient is laid with buttocks close to tiie lower end of the tabic- or across the bed, her thighs flexed and supported by assistants or, in cases in which the operator works very short-handed, by the sheet-sling (Fig. 5G.'}). The shoulders may be low; a Kellii imd Fio. rifiS.— The shet't-sling : a sheet caught by diasonally opposite eorners aiirl roUed is passed under the neek and flexeil knees. To keep tlie legs well apart the knees should he widely sepnrnted holbre the feet are allowed to drop into this position. pillow under the hips covered with water-shedding material will lift the pelvis advantageously, and a light blanket protects the body frohi chilling. This po.sturc is mo.st commonly em])loyed, because it is the only one that allows free play to the outer liand ; the chances of infecting the outer hand are les.sened ; if working alone, one can better direct the anesthetic and watch the breathing ; 960 AMERICAN TEXT-BOOK OF OBSTETRICS. and extraction can bo completed in th- position in which version has been ac- complished. The accompanying illustrations (Figs. 564-5G6) show that with i! Fic. .Vil.— Dorsal posture with tliiRlis flat on the bed : the heavy black line iiuhcates the conjugate of tlic brim and its relation to the horizon. i Fio. 565.— Dorsal posture with moderate flexion of the thighs when the feet rest on the edge of the table. m Sit Fia. Ofifi.— Dorsal posture with strong flexion of the thighs against the abdomen; most ready access to the fun<lus. well-flexed thighs the operation will be easiest. Wl.i-n extracting the after- coming head, or whenever additional space in the conjugate diamcier of the '■'*% , i in ac- ; with the aftcr- a>r of thi OBSTETRIC SUIIGER Y 961 brim is demarKled — 6 to 9 millinu'tcrs {\ t(» f inch) — the thighs may bo cx- tentled to their utmost over the edge ot'tlie tabic or bed. This is the Wah'hev posture (Fig. 567). It will be seen that the axis of traction at the inlet in this posture must be almost directly downward. Latero-prone Posture, — If tiie patient is placed on her side, as is advisable *'''-~^'\.^ Via. 5G7.— Walohcr posture : the ('(injugate of the brim is a hlnek line, nnd the amount of space gained is a (lotted eontinuation of this line. in dorso-posterior positions, it should be on the side ttn which lies that end of the fetus which it is desired to bring down ; that is, when the breech is to the right the mother should be placed on the right side. By this method the operator stands behind or in front of the patient in such a way that he faces in the same direction as the child. The ne- cessity for the operator to assume these positions is somewhat less im[)erati ,'0 if he proceeds by slipping his iiand beneath the child along the lateral aspect of the uterus, since he can then easily pass his hand in either direction (Fig. 5G8). This method is particidarly availal)lc in dorso-posterittr ])()sitions and in cases of pendulous abdomen, liccauso in tlicse one can reach into tlie bay-wiudow-likc uterine cavity above the i)ubes to sci/e the feet without that distressing backward heud caused by tiie over-extension of the wrist-joint ahout the symphysis that is recpiired in operating in the tlorsal jMisition (Fig. 5.5;J). The right hand would uatin-ally 61 Kiel, fiiw.— '.nteriil jiiisliire for version; the hand is liassed aloMf; the side wall of tlie lilenis to the feet. Het- ter ad«|ited to dorso-posterlor positions. I :' [1. S' - ^ f^-t'i m IHIiH 962 AMEltlVAN TEXT-BOOK OF OBSTETRICS. beomploved with the ])ati(Mit on hor right side, and vice versd. liUter, when the feet have been drawn well down into tiie vagina, the patient may be turned over on the bark to facilitate tlu; !^-^»cx external manipulations necessary to complete the turning. Kncc-clhow Posture. — This atti- tude should be chosen in difficult cases when the presenting parts are sniijrlv fitted into the inlet. It oc- casionally yields brilliant results, rendering version possil)le when tiie fetus could not be dislodged in any other ])osture of the mother (Fig. 569). One of the disadvantages of tiiis posture is that unless the mother be sup|)orted anesthesia is not avail- able. The writer has been able to m-DiiiKrani of kuot-wiMiw |,..sii.ro f.,r iii- \^^^\^\ p.,tit'nts ill tliis position bv swinging a sheet between the backs '^'^^i^CT*,^^ Tlif liiwur |iiiil of tlu' IioIIdw i>1' the tcniiil \ uterus is lifted out of the pelvis. of chairs placed on eitlier side of the bed, directing the patient to bend herself double over this hammock, and ope- rating over the foot of the bed near whicli she knelt. Trenthhnbiuy Posfiire. — Tiiis posture is available for anesthesia, for which Via. .'iTil— Iiiiiirovisi'il 'fifuileleiiliurf! appnriitiis fur externiil version by ineiiiis of ii clmir laid on its fiu'c on tlu' lii'il. I'lir internal version a chair without runes is useil, the lesjs of the patient liein^ tied lo the hind Ick's of the chair. 'I'liis is availalile in Cesureau section. the knce-ciie.'^t attitude; is almost out of the (pie.stion. The necessary incliiud ))lane is easily improvised by turning a chair on its face, as shown in Figure 570. If internal version is to be ilouc in this attitude, a chair without rungs I i: OBSTETlilC SinaERY. 963 must he used, tlio buttocks must He against the hack edge of the chuir- seat, and the thighs be tied to the baek legs to allow working space be- tween the thighs. As a general rule, it is wise for the operator to use that position with which he is most familiar. The squatting position in its most extreme form, when the thighs ure strongly applied to the sides of the abdomen, is said to have some effect in diminishing the transverse diameter and increasing the longitudinal diameter of the uterus, and might be tried before other measures. Examination. — Whenever external examination has left any doubt as to the exact position of the child, the fingers, or even the whole hand, passed into the uterus will yield the desired information. Diu'iug this search the rate of pulsation of the cord may cautiously be determined and a low Im- plantaticm of the placenta be recognized. l^U'ps of the Operation. — Tiie stcj)s of the operation are four in number : (1) The introduction of the hand ; (2) recognition and seizure of one or both feet ; (3) turning of the child ; (4) extraction of the child. After completing the preparations just described and having confirmed the diagnosis of position, the obstetrician determines which hand to use and which foot to seize, and whether to ))ass the hand along the back or front or along- side of the fetus. He nooses a fillet on the child's wrist if the arm is in the cervix, and he proceeds with the first step of the operation, which is the — Introduction of the Hand. — The sterile hand is anointed on its external sur- face with vaselin, mdess a lubricating antisej)tie solution is used, such as 1 per cent, ereolin or lysol ; the tips of the fingers and thumb of one hand are so placed together as to form a cone ; the vulva is drawn wide open with the fin- gers of the other hand, the op M-ating hand being slowly |)ressed through the vulva by a rotary motion. To pass the hand in front of the fetus the elbow should be brought down low, even if it is necessary to kneel to do so. To pass the hand in behind the child, the fingers should be slipped up to one side of the promontory, which may seem to jut further forward than normal be- (uuse it can be so plainly felt. The operator should ])ush steadily but gently through the cervix, and having jwssed that opening sliuuld fiatten out the hand and "slowly slip it along without violence, without hesitation, steadily upward to the fundus, interrupting its ju'ogrcss only if a contraction commences, and ([uietly awaiting its passing away before further advance." If the membranes are inirnpturcti, it is advisaltle to break through them a sliort distance within the cervix, unless jHilsating Ioop«; of curd arc detected. In the latter ease a new and more circuitous path toward the foot may be chosen before rupture. One is loath to let part of the waters drain away, with the possibility of bringing the cord down, but when the hand is passed deep Ixtween the membrane and the uterine wall, it is ditticidt or impossible to determine quickly what part one seizes through distended mend)ranes. Work- ing within the amniotic sat- leaves an important natm-al covering on the uter- ine wall and protects the titerus against contact and infection. I \ ■}! ■ if- ■ ■ f ri Hi-.. . t'ii* I I 1:V ^ •■m\ 964 AMERICAN TEXT-BOOK OF OBSTETRICS. m The oporator'.s fiDgors aro held together to prevent the cord from slipping in between them. The hand may keep to the side of the child's body (Fig. 562), particnlarly in oblique cases, to avoid the cord, as the latter is easily compressed if the hand is passed roughly across the child's belly. Compres- sion of the cord is avoided Avhenever possible; if unavoidable, the remainder of the operation is hastjued. "From the time one conuuences to penetrate into the uterus, happy to Ix; able to push aside the engaging part, always watciiing to employ a force that is moderate, but continued and real — the other hand, free to act without, is applied over the fundus to slide the breech downward and to bring it to meet the hand within. Without this support the upward pressure of the inner hand might rupture the uterus or tear it from the vagina " (Farabeu^' and Varnier.) When the hand has been intro- duced along the child as far as tlie navel the knees will be encountered. The feet are usually found near ♦^he fundus, ajjplied to the child's breech. In a few instances the feet of the v^hild are against its face, or its knees are witiiin easy reach of the entering hand ; under such conditions the fingei*s need make but a short excursion inio the uterine cavity. In most cases, however, one nuist push on frankly and fearlessly to the fundus, and need not hesitate to .slip the arm into the vulva up to the elbow, in order that the finger-tips may reach well beyond the fetus (Fig. 542), and readily curved backward to secure a firm hold on the feet ; " lacking this there is no easy going. One wauders vaguely below the level of the feet, hesitating. Deep in the uterus, on the contrary, one readily seizes the feet, and from that moment is master of the situation" (Didx»is; see Figs. 547, 562). The early mistake of students and practitioners on the manikin, and of internes in the wards, according to the; writer's experience, is to waste time in half-hearted and fruitless attemjjts to seize parts of the infant out of reach. Seizure of the Foot. — At this stage the operator should pause to examine the largt! number of limbs that seem to be crossed in front of the child, in order to distinguish the hand from the foot, and, if desired, between the near and the remote foot. The foot is readily recognized by the large knob of the heel. The flexed knee points toward the head, the flexed elbow toward the breech. Nothing need hurry one except the numbing of the operator's hand under })ressure. It is embarrassing to ])ull down an arm. If but one foot is found, it should be seized ; if both feet can be had and the cervix is wide, both may be brought down. The foot is to be seized between the bent index and the middle finger, one over the projecting heel, the other over the arch (Fig. 541>), itv, indeed, in any possible manner (Fig. 554). Tarnhu/. — The operator now draws the leg downward to the sacral hollow and across the patient's body in the direi'tion of the child's head (Fig. 5")4). If the breech is to enter the pelvis on tlic! mother's left side (Fig. 54.")), lie should pull across to the right, while at the same time the extei'iial hand is pushing the head up toward the fundus with considerable vigor (Fig. 545). The assistant's hand may well be em|)loyed, meanwhile, in pressing the breech downward. After the toot has been drawn well downward and ver- f I? OBSrETIilC SURGERY. 965 H ■) I.I (Fig. easily iipres- aiiulor iietratc always il— the breech support tear it w intro- 1. The 1. In a e within led make ever, one esitate to -tii)S may ti) secnve B wauders u^, on the pter of the idents anil ng to tlu! ttenii>ts to ;amine the in order yar and the the heel, [he breeeh. and under l)t is found, I both may Ilex and the l(Fig. 541»), sion cannot yet be effected, before attempting to grasp the other foot one should secure the first foot with a fillet passed by means of a catcli-fijreeps (Fig. 571) up over the wrist of that hand of the operator which holds the foot, and fastened about the ankle. Failing still, the inner hand lets go the foot; the outer liand, steadying the breech and pushing downward, slips alonj^ to the shoulder and head and ])ushes up between the pains, returning to pull wpon the leg. Or, better, a fillet made fast to the foot is seized by the outer hand, which draws the foot down through the vulva, while the inner hand is pushed deej) in to lift up the shoulder and head, the assistant mean- while helping as he may externally ; but all the precautions wo have men- tioned should carefully be observed to avoid injury to the uterine wall. If, in any of these procedures, an arm slips down or a hand is brought down by niistake, a noose is made fast to the wrist in order to prevent the extension of this arm and its elevation above the head during extraction. In some cases when the child is in the transverse position the humerus may be used as a lever to siiove the shoul- der up and along. The hand inva- Fio.57i.-A-:.oii-forceps seizes the loop oi band- riably becouics uumb in a short time, age to Blip it up ovor tlie iiulile. , i j. i and must be changed for tiie otiier hand. The operation is complete when the child's breech is engaged in the pelvic inlet. To bring the feet through the vagina and out of the vulva, one will have to resort to seizure with a towel, or to the noose about the ankle, the slippery skin of which not affording a good hold to tlie tired hand. Immediate Extradlon verum Dvlaij. — Having completed the version, one carefully examines the fetal heart and considers the mother's general (!ondi- tion, to decide whether the child shall be delivered at once or whether its expulsion shall be left to nature. In any condition threatening grave danger, such as excessive loss of blood from placenta jMWvia, threatened rupture of the uterus, slow or very rapid fetal heart (near 100 or close to 200), immediate ex- traction is advisable. When the cervix is not sufficiently dilated, when mother and child are in good condition, and when there are no indications for imme- diate extraction, the patient may be allowed to pass out of anesthesia, and the uterus may be expected to expel its contents with its ordinary jtromplness, Extrnction. — In the section on breech delivery (p. 470) will be found a full description of the different methods of extracting the child when once the child's breech has been brought within the cervix. After a troublesome vereiou, and in any case where much traction on the breech has been required, k \<^; -*-^"- '"^^m^^ w^ %i,\t. • ' ■ ■ ), 966 AMKIiJVAN TEXT-JiOOK OF OliSTETJilCS. {j.i ^'4 [III 1 I; (■. it the arms are likely to be fbuiul in the most difficult position to extract- namely, above llie bead. The frozen section (Fijjj. 572) of a patient who died with a rnptnred uterus shows the distin-bed relations of the arms. In the ordinary method of extraction the trunk is carried sharply to one side, the jjosterior shoulder is brought as nearly as possible into the sacral hol- Kk;. r)7'_'.— Kni/cn section of a piiticnt who died of rupture of tlie uterus (Zweifel) : tlie nnterior lep is piivlly delivered, llie Inink lills tlie pelvic cavity snugly, and tlio arms and head are located in the elon- gated \iterus liiKli in the motlicr's alidonieu. low, and the hands are slipped along the back of this posterior shoulder until the operator's finger-tip can reach up near the elbow to swing the iirm across the chest c*' the child. This manipulation, as will be seen in Figure 578, is etfective when the elbow can be brought below the inlet, and, as a rule, only then. It is the procedure usually ad- visect in text-books. The writer suc- ceeded in unlocking some very diffi- cult cases by the method advised by Barnes. He swings the rear shoulder well backward, pas.ses that hand whose i'Ki. 57:' —The usual method (d swiiiKint; an ex- tenclcd arm across llie child's chest to extract it. rRi. .'iT I.— Rotation of the trunk lo lirinsoue shoul der to\var<l the sacrum. palm most conveniently lies against the child's back, forward under the ])iil(ic arch into tlit; vulvti, along the child's back and shoulder, Ibllowiiig down tiic liumerus as near to the el!)ow as jjossiblc (Fig. 575). I*rc.-Jsmv with the finger- tips now swings the elbow across the face in front of the promontory and toward OBSTETRIC SURd KR Y 907 the upper chest of tlie cliild. The writer slips in the otlier Imnd ah)ng tlie child's abdomen to extract the arm. The hands are tlien applied flatly against the sides of the tniid< and the body is rotated in order to bring the other Fio. o"5.— The littiul passed in under the jmhie iirch aloiiM; ttie arm swoops the elbow aeross the child's fiiee (not on the same scale as the preceding). shoulder toward the promontory (Fig. 574). This maneuvre is repeated on the remaining arm, the operator using the other hand ; but usually a deadloek is caused by the jamming of the elbow of the child between its tlice and the h; ^ % Flu. .W).— To enable the elliow to pass over the promontory the face must get out of the way. The left hand of the oiierator therefore rotates the licail to free the elhciW. promontory. This difliculty may be overcome by firm j)re.ssur(' with the inner fingers at the same time that the outer htind seizes the occiput (Fig. HTG), shoving the latter in the opposite direction from that in which the inner fin- gers are pushing. This manipulation causes rotation of the head and an ex- 968 AMF.IUCAX TEXT HOOK OF onsTETIUVS. Ifi t r! ciirsion of tlic fidvlioiid in tlic (lirccfidii in wliicli the (■ll)(>\v is attetiiptiiiji' to move; bosidi's, there is an iipprecial)!*- (liniiniition of tlie resistance to tlie flexiiis; of the arm. Siiould tliis nuinenvre fail, the child nnist he rotated throii<;h threi'-(niar- ters of a circle, so that the arm shall he left hehiiul, as it were, as the body is swept around, thus hrinuinjr the arm across the chest. A deep reach will secnrc the elhow. One must ex|)ect, in this procedure, to have the child run considerable risk, on account of the dangerous torsion to which the necU is subjected if the head does not freely follow the body-rotation. It is claimed that an additional leniith of true conjugate can be obtained by the Wulchor posture, whereby the thighs are drawn as far backward as possible, the patient lying on the edge of the table or the l)e(l (Fig. 5(j7). Xff/lccfcd or IiiijKictcfl ()i,srs. — Considerable judgment will be rcipiired in determining how far we dare proceeil, and much tact nmst be exercised in our mani])ulations, in cases where the uterus has fitted itseli' firmly about the child. A uterine wall in apparently tonic spasm will sometimes relax. 'I'he knee- diest posture or anesthesia to the surgical degree with the patient in the lateral or the Trendelenburg posture is necessaiy to secure the utmost relaxation. The feet of the child are drawn <lown while its head is pushed uj) by one (»1" the methods previously described. In case of iiiilnre, or in tiiosc cases whert; im|)aetion of a dead <'liild with |)ermanent contraction of the uterus renders further attempts dangerous to the mother's Hie, embryotomy is in order. De- capitation is the easie-it procedure. Symphysiotomy or Cesarean section mav bo considered where the pelvis is narrow and the child is living. in. Celiotomy for Sepsis in the Child-bearing Period. Since the first jHM'fornianee by Tait of abdominal section for purulent i)eri- tonitis there has been an extremely important develo])ment, especially in the last decade, in the scope of pelvic and abdominal surgery for septic iuHamma- tions during the child-bearing period. Regarded at first as a ])rocedure analogous to opening an abscess anywhere on the body, the whole abdominal cavity being looked upon as an abscess- eavity and the abdominal walls as its ca|>side, abdominal section for ])uer|)eral sepsis has become a generic term of wide sigit";'canee, including hystenH-tomy, salpingo-oophorectomy, evacuation of abscesses in the peritoneal cavity and in the pelvic coiuieetivc tissue, removal of gangrenous or infected neoplasms of or in the neighborhood of the parturient tract, and ex|)loratory incisions. I)i<}i('(ifio)i.s for Ah(Joinhi<il Sccdoti in flic Traifinciif of Piirrjicni/ .Syw/.v. — It is more convenient to deal gencrically with tlu." indications for abdominal section in the course of puerperal sepsis, for the operation is usually decided upon in practice without reference to what may be retpiired after the abdomen i- opened, the ])rudent and experienced obstetrician holding himself in readiness to perform any of the ])elvic or abdominal operations detailed above that may be found necessary when the abdominal cavity is exposed to view and to touch. In order properly to decide the extremely important and anxious (juestioii J < Kl.loToMY. l'i.\Ti; l!>. lo- to 1) the (juiir- i)(ly is li will (I run ii'C'k is )taiii»'<l anl as 51)7). lirctl ill I ill oiii" ,0 chiltl. (' kiu'c- (" lateral axatioii. ; i)\w of L>s wlifrc < rt'iulcrs 1(M-. 1>»'- tion iiiav )D. lout iii'ri- |ly ill till' iiHuiiiina- [inywlioiv alisccss- Duorju'ral Mvctoiiiy. Ity and i" llasnis i>t" Ions. |l)(loiiiinal Iv (kridi'il Ixlonu'ii is dint'ss to Itliat may to toiu'li. S (UU'StifMl ■v^., ! • ! S I niiSTKTlilC SI 11(1 Kll Y. 960 for or against celiotomy in tiie conrso of pnorporal soptic fcvor, tlio nio«lical attendant must Im; familiar with the (litU'tvnt forms of sepsis after labor, and should know whioh of them arc most, whieh are least, ameiial>le to surj^ieal treatment. In u general way it may be stated that the opisration is demanded most frequently for localized suppurative ])eritonitis ; it may be indicated, and often is, for diffuse suppurative peritonitis; for suppurative salpingitis and ovaritis; for suppurative metritis, if the inflammation extends outward toward the peritoneal investment of the womb or into the connective tissue of the broad ligament ; for abscesses in the pelvic coinieetlve tissue; for infected abdominal or pelvic tumors. On the contrary, abdominal section is contra-indicated or is not recpiired in simple sapremia ; in septic endometritis of all forms — diph- theritic,* ulcerative, suj)purativc ; in dissecting metritis, sloughing intra-uterine myomata, or in suppurative metritis with the abscess pointing into the uterine cavity; in phlebitis, lymphangitis, and in direct infection of the blood-current. One is most likely to perform an unnecessary operation in diphtheritic endo- metritis (PI. 49). The writer has thus erred several times. By the time that symptoms justify surgical intervention in this condition it is always too late. It is extremely difficult to lay down correct rules for the guidance of a physician in any situation involving so much responsibility, and of necessity so dependent u]>on many circiunstances, as that seeming to recjuire a very serit)us surgical operation in the midst of an adynamic fever with, very likely, pro- found depression, rapid pulse, high temperature — in short, with everything a surgeon least desires in the face of a major operation. First and foremost, then, the attendant should avoid the operative treat- ment of puerperal sepsis if ])ossible, and should not seek an excuse for siu'gi- cal intervention merely in the cardinal symptoms of septic; infection — high temperature, rapid i)ulse, and general depression. He sho\dd demand some tangible evidence of those forms of sepsis that are amenable to surgical treat- ment. But the physician of to-day, while reluctant to operate upon a jjatient under the least favorable circumstances and on his guard against unnecessary or harmful surgery, must be prepared in the event of certain symptoms or complications to o|)erate with the least possible delay. Thus, on the very first appearance of symptoms that will justif\' the diag- nosis of diffuse suppurative peritonitis, the abdonien must be opened without a moment's more delay than is necessary for an aseptic operation. Even with the utmost promptness the operation will almost always be too late, for the inflammation extends so rapidly and at first insidiously that by the time a diagnosis is possible the progress of the disease cannot be stayed. The writer must admit, however, contrary to his former belief and declaration, that an occasional success is possible by timely surgical interference.t * By diphtheritic enifometritis is meant a dirty, grayisli- or greenish-brown exudate on the endometrium, containing mixed micro organisms, and not necessarily tlie Klebs-Loeiilet bacillus (see PI. 4i)). t Hirst: "A diffuse, imlimited snpimrative peritonitis in a child-hearing woman cured by abdominal section;" Medical iVeuvs, 18i)4. A unique case, in the writer's experience. 1 B 1 ' »? h ^H : i- m r B.- Hci<;K!! ^Mt'l'F' Iflfl || ii ill II 970 AJ/hJilCAA- TKXT-IIOOK OF OUSTET/trCS. Af-aiii, ill tli(> prcsonro of exudate, ailliesioiis, or Miiuatural oiilargcmunt of any pelvic .stnietiire, sii|)piiratiou may l)e suspected if the piiysieal sijrns do not inijmn-e and if the temperature, pnlse, and jrenoral condition indicate a con- tinuance of septic inflai'imation. Jt is hardly necessary to state tiiat if pus forms it nuist he reached and evacuated irrespective of its situation. Just how long to wait, however, is a (piestion re(|uiring experience, good judgment, and a special study of each in<lividual ease for its correct answer. Knormous pelvic and aiidominal exudates may disappear ; adhesions may melt away ; enlarged and inflamed tul)es, ovaries, and uterus may resume tiieir proper size, functions, and condition on the subsidence of the inflammation ; hut in these favorable cases distinct signs of im|)roveinent manifest themselves in a few days, and the course of the disease is comparatively short. A mere protraction of septic symptoms is in itself suspicious, <(loii(/ irith /ocaf .tu/HK o/ hiflammaCiou. Without the latter, the same general symptoms, sometimes last- ing for mouths, mean phlebitis and infection of the blood-current. In this form of sepsis an operation can do no good and may do the greatest harm. In infected tiunors in and near the genital tract the indication for operation should be plain and the decision easy. The presence of the tumor should of course be known. On the first sign of inflammation in it, or in the event of an elevated temperature for which there is no good explanation, the tumor should be removed. Early operations in these eases have fnrni-ihed the best results, delayed operations the reverse."^' In cystic tinnors the likelihood of twisted pedicle should be remembered, and in every case of childbirth com- plicated by a new growth the woman should be watched with extraordinary care to detect the first indication of trouble. An exploratory abdoirdnal incision should be made, as a rule, only when it is desired to determine if a pelvic mass, [)resumably containing pus, is situated within or without the peritoneal cavity, and if the abscess had better be evacu- ated through the abdominal cavity or extra-peritoneally. The writer, in the early period of experimentation with abdominal section for puerperal sepsis, made exploratory incisions in obscure cases without any local symptoms of iuHammation in the jK'lvis or the abdomen, iMtl he has seen a number of such operations in the hands of others. None «»i" (lie-c operations yielded informa- tion of value, nor did they benefit the pati Mit-. Consequently, he adheres to the general rule not to o])en the abdomen of a puerpera for sepsis unless there are physical signs of iuHamnuition in the abdomen or the j)elvis. Following these general statements in regard to abdominal section for puerperal se])sis, it is ijow more convenient to describe in detail the different kinds of operations recpiired for the various forms of intra-abdominal septic inflammations. Alxloiniudl Section for Iiifraperitoiiral Almu'xKcs and DIJf'nse Si(j)j)ur(ttirr Pa'itonilifi. — The situation and extent of localized suppuration within the * The most desperate cases, however, need not l)e despaired of. Tlie writer successfully removed a gangrenous ovarian cyst from a pncrpcra who was so weak that compli'tc anesthesia was not attcnpted. 'I'lie hitu I)r. (ioudcll had dfclincd tlie operation as necessarily fatal. Iliii, ... ._,|j. Ill;:, oitsTiyriiK ' SI ltd Eli y. 971 uIhIdiiuiiuI cavity vary j^rcatly. Tlic writer lias seen a quarter of the al)- iloiuiiial eavity tilled with pus, the iiiij^e alxscess-eavity beiiij; thoroughly walled otr by dense exudate froiu the rest of the abdonuiial eavity. A smaller eol- leetiou of |)us about the oriliee of the tube is not uneoiuiuou. in one eas(> two or three abscesses the size of an orauj^e were found in coils of iiitcstino (juite far removed from one another and without apparent connection with the genital tract. In three cases abscesses were found between the fundus uteri and ad- joining structures — the abdominal wall near the uiubilieus in one, the caput coli in the second, and the sigmoid flexure in the third. In these cases infce- ti<»n had travelled through a sharply-delincd area of uterine wall and had ap- j)cared in the same limits on its peritoneal investment. Exudate and adhesions immediately walled off the infected area, with the result of an encapsulated abscess between the uterine wall and the structure nearest to it at the time of inHammation. The treatment of these abscesses consists in their thorough evacuation, the cleansing of i\\v eavity, and drainage. The cleansing may be effected by Hushing with hot sterilized water, if the rest of the abdominal cavity can be guarded from contamination. In some cases the writer has avoided irii- gation and in its place has thoroughly dried the cavities with gauze with good results. For drainage, as a rule, iodoform gauze will usiudly be found best. In certain cases of ab. esses near the abdominal walls a rubber tube answers better than the gauze, and in deep-seated abscesses on the base and the back of broad ligaments vaginal drainage by means of gauze or rubber tube is nnich to be preferred. If the work during the operation is well doiM', there n)ay be little or no subsequent discharge, and douching of the abscess-cavities during convalescence is uncalled for. Occasionally, however, if the absecss-eavity is very large and well isolated, daily douching with sterile lu)t water is an advan- tage. In diffuse sujipurative peritonitis the remote chance of success depends greatly upon the earliest possible operation, though there are many vindeut cases in which nothing could stop the spread of the inHammation and the deadly effect of septic absorption. This is not the plac(: to discuss the symptoms of diffuse suppurative \tm- tonitis, but one fact should be insisted upon from the operator's point of view. It is usually supposed that true diffuse suppurative peritonitis appears early after delivery; it nuiy, however, develop at any time. The writer has seen it as late as four weeks after eontinement. The woman, who had been up and about for some time, lifted an older child down a tew steps. The effort siiutezcd a few drops of pus out of one of the tubes. The abdomen was opened within twenty hours, but to no purpose. The teehni(pie of the operatiou is simple: A small incision is made, and the finger is ra])idly swei)t about the ])elvis and abdomen to determine the condition of the organs ; then the irrigating tube is passed into the eavity at the lowest angle of the wound and is swe|>t about in all directions, while the return-How is ]irovided fi)r by two fingers of the left liand distending the sides of the wound, which l)y the fingers and the irri- gating tube IS kept gaping as though by a trivalve speculum. (lauze drainage into the [touch of Douglas and the Hiud<s is provided for, and \- '^H 972 AJfKIUCAN TEXT-JiOOK OF OliSTr/riiTCS. the wound i.s loft open, or, at most, drawn togotlior bv a stitch or two. Rapidity of ojKM-ation and tlie sniaUost po.«sil)le quantity of anesthetic arc o:-'ential to success. Salphufo-odphoroeeimii for Puerperal Sepsis. — An acute pyosalpinx in the puerperiiun is •.cry rare. Jt is uncommon for acute septic infection after hibor to travel by the tubes ahine. Intection usually occurs in the uterine muscle, the veins, the lymphatics, or the connective tissue of the pelvis. When the track of the septic inflammation is confined to the nuicous mendirane of the genital trai-t, the pelvic peritoneum, in a case serious enough to tlcmand opera- tion during puerperal convalescence, bectmies infected, inflamed, and suppura- tion quickly follows, st) that the operation is usually performed for an intra- peritoneal pelvic abscess. The tube may be found somewhat swollen, inflamed, and containing a few drops of pus, and its removal is recjuired ; but the pyo- salpinx is a subordinate feature in the pelvic iuHanimatiou. It is the more subacute case, not usually re(|uiring operation in the conventional period of the ]>uerperimn, that results later in a typical uncomplicated pus-tube. Ovarian abscess is more common than pyosalpinx. The writer has seen the infection travel to the ovary, both by the tube and by the connective tissue or lymphatics of the broad ligament. In the latter case the whole ovary may be infiltrated with a thin sero-pus of a particularly virulent character, and, unfor- tunately, in excising the ovary the exposure of the infected pelvic connective tissue in the stump almost surely leads to infection of the peritoneal cavity and to a diffuse suppurative peritonitis. The commonest indication for salpingo-oophorectomy is furnished by a ]ius- tube antedating conception. The strain of labor excites a fresh outbreak of inHanimation or leads to its spread, and the ])ersistence of septic symptoms with the physical signs of pelvic inflammation justifies operative interference. In one exceedingly instructive case under the writer's charge an operation was i)er- formed on a presumptive diagnosis of old pus-tubes, the diagnosis being bated mainly upon the patient's history and the existence of serious septic sym[)toms, with tenderness on abdominal palpation over the region of the tube and ovary. The uterus was nnich too high in the abdominal cavity to permit of a satis- factory pelvic examination of the uterine appendages. On opening the abdo- men a j)yosali)inx was found. The patient recovered. There is nothing peculiar in the technique of these operations. Theydiflfer in no respect from similar operations upon non-puerperal patients. The ques- tion of removing the uterus along with the tubes will, however, arise rather more fre(]uently than in the non-puerperal wo;nan, on account of the infection of the endometrium or of persistent metrorrhagia. jri/s(ererfo)iiij for Puerperal Sepsis. — The latest development in celiotomy for ])uerperal sepsis is the removal of all the pelvic organs and structures that can be removed when the septic inflammation or supjmratiou involves tlu> uterine nuisdes and the broad ligaments. Every ])liysician who has seen many cases of puerperal infection during operations or j)os(-)uorte)ii is aware that there are some in which the nierc renu)val of infected tubes and ovaries or the evae- If' onSTETliR ' <S7 lid Eli Y 973 a pns- ?ak of IS with I n one as por- l)abC(l inptoms, ovary. a satis- 10 abilo- loy diffi'i' ho (Hios- rather in foot ion .'liotoniy ^ires that Lives the Ion many nt thoro the evao- uation of" polvio abscesses cannot bo ox|)octo(l to save the patient. Thoro wonid be left behind areas of infected and infiltrated broad ligaments that wonhl snroly conununicate infection to the ])eritoneal cavity, or there wonid remain foci of suppnration or infection in the ntorino body tliat mnst surely spread to tlie peritoneum or must result in septic metastases. The oidy luipe for the patient in such cases lies in the entire removal of all infected areas, leaving behind in the pelvis a healthy, non-infbctod stump. To otfoct this result the Fl(i. r)77.— nysteri'Ctomy for puruloiit siilpiiifjitis (Uirst). excision of the uterus, the broad ligaments, the tubes, and the ovaries is re- quii'cd. In addition to these oases there arc others in which, if the tubes and ovaries must be excised, the uterus might be removed with advantage, on account of an infected endometrium or of persistent metrorrhagia. Figure 577 is an example of such a case. The young woman from whom the speci- men was removed had a double pyosalpinx following a criminal abortion. For seven weeks she had been bleeding persistently anil at intervals had a foul- Fui. ,'i78.-Siirri"'iitivo (H'llutitis (if liniiid lifinmcnt; l'ys*'Ti'r|i my (IlirstV smelling dischaigo. Although tiie body of tiie won o was healthy and the endometrium was alon inflamed and inlictcd. it was oDviously wis* r to remove at once al! source of the trouble ratlior tha ■ m v.-ise the tubes and ovaries and then to treat s(>parately at some trouble ai'd \\. \ an organ that iiad lu'comc on- tirelv superlluous. Tlio rosidt jiistitiod the pnx -.'dure. Th(>re may also be such widespread sup|)uration and disintc'rration '••' 'Iw broad ligaments, along with tubal iuHammatioii, that the compietc rcinuv..! 'f all tiie infected area is more m % !#? i .# 974 A^fI^n^ICAN text-book of oustetrics. Ml'- ■• easily accomplished, cspocially as regards the control of hemorrhage, by a hys- terectomy. Figure 578 represents such a ease. In this woman a pyi)salpinx antedated conception. Labor excited fresh inflammation. The infection spread from the tube downward through the connective tissue of the broad ligament, resulting in a partial destruction of it, in a thick infiltration at its base, an;] in Fig. f)"!!.— Suppurativi' imd iilpcriUive iiU'tritis, snlpingitis; liystcrertomy (Uirst). an abscess between its layers, closely hugging the whole of one side of the uterine body. It was obviously impossible to remove ihe infected area here without removing the womb as well. The operation, though inidertaken under the most discouraging circumstances, was successful. There can be no doubt as to the necessity of hysterectomy in such a case as that represented in Figure o79. There were abscesses in the uterine wall directly under the peritoneal envelope about to break into the peritoneal cavity ; one, indeed, did rupture during the operation. There was a septic ulceration at the Fio. .wn.— Supiniralivc ovaritis (rear view). placenta site so nearly ])erforating the uterine wall that by a light touch dur- ing the op(M'ation the forefinger passed into the uterine cavity. Tliere was also a ])y()salpinx in this case that, judging by the iiistory, antedated or was coinci- dent with impregnation. The operation saved the patient. IndicatUmii for the Operafion. — The indications for hysterectomy during puerperal sepsis are furnished by the condition of the pelvic organs when tlicy are exposed to sight and touch after the abdomen is opened. The three cases described above are the types calling for hysterectomy. It is not often possible to determine upon hysterectomy before the abdomen is opened, but if .-houid be remembered that in any alxloii.'nal section for pnerj)era'i sepsis 'ly^lerei-toii y may be necessary. The careful obstetric surgeon therefore shoi.Id h> provi': d OJiSTETlilC SURFER Y. 975 loll V with the implements required for amputation of the womb in every abdominal scetion for puerperal rtepsi?^, and be prepared to remove the womb for anv one of the three indieations described above, but content with the least radical measure that promises his patient safety. The operation that is (piickest done and shocks the patient least is most successful, provided, of course, that it i.'' adequate. lh;hni(]Ke of the Operation. — There are two points in which the technique of hyfterecitoniy for puerperal sepsis may differ from the technicjue of the ope- ration performed iov other conditions. One of these points is the necessitv often of doing pan-hysterectomy ; th.' other is the necessity often of tying the ligatures in a broad ligament much thickened by inflammatory exudate. The writer's preference is strongly for amputation of the wond), leaving as little cervix as possible, and this he always does unless an examination of the cervix by a speculum shows septic ulceration or exudate upon it or in its canal. The reasons for this preference for amputation of the womb over pan-hyster- ectomy are that the former can be done more quickly, there is not the same anxiety about the cleanliness of the vagina, and the suture material is more certainly guarded from infection afterward. The thickened broad ligaments are often a source of serious embarrassment in placing and tying the ligatures around the uterine arteries. The writer had this difficulty to contend with in the majority of the operations he has ])er- fornied. In two instances the inflammatory exudate within and below the ligature broke down into pus, but in both cases an incision in the posterior vaginal vault evacuated the i)us and secured an immediate disappearance of somewhat alarming symptoms. In one case it was neces.sary to do this as late as four weeks after the hysterectos.iy. Exploratcrif Abdominal Sccfion for Paerpcral Scpxis. — ^ :> the writer's opin- ion, an exploratory incision should be nuule oidy in cases ; f suspected extra- ji" itoneal pelvic abscess, to confirm one's suspicion, to be certain that none of tlie pelvic organs, especially the tubes, are diseased, and to determine the best sitii.ation for the incision that shall evacuate the abscess-cavity without contaiu- inating the peritoneal cavity. This rule of practice would exclude exploratory a 'il Hiinal section in those cases in which there are no physical signs of pelvic inriammation, but in which there is evident septic infection of a nature ilillicult to determine. As stated previously, the writer resorted to this |)ractice formerly, and has seen others do so, but never with benefit to the patients. There are possible exceptions to the rule, however, as in the case described on page 972, of suspected pyosalpinx without physical signs, owing to the high position of the recently emptied wond) and of its appendages. Figure 5(S1, drawn from life, represents a typical case reipiiring exploratory abdiiminal section. The woman had a miscarriage some weeks before the writer's first visit to her. She had lost over thirty pounds in weight, was bed- ridden, had night-sweats, high fl-ver, profound prostration, and exacerliations of ])ain in the pelvis. On examination the usual symptoms of extra-perito- neal pelvic exudate and suppuration were found on the right side. When the m i' 1 f/ 97G AMJ'JRJCAN TEXT-BOOK OF OBSTETRICS. mi ^ abdomen was opened it was found that all the pelvic organs and the pelvic peritoneum were perfectly healthy. There was a large collection of pus be- tween the layers of the right broad ligament, giving to this structure a dome- shape. The tube and ovary running over the top of the distended broad lign- ment were perfectly healthy and without a trace of adhesion or inflammation of any kind. With the abdomen oi)eiied it was easy to locate the level of the anterior dupliciation of the peritoneum. A mark was made on the skin an inch below this point, the abdominal wound was closed, an incision was made l'"i(;. 5.S1.— KxpUiriitory nlxldininiil soctUni : iiu'isii)ii in uroin for extrii-piTitoiioiil al)Si'oss (Uirsl). in the groin, as shown in the drawing, and the pus washed out by douching. SiiHious tracts of suppuration were found by the finger running up the psoas muscle and down into the Hoor of the jielvis. Two drainage-tubes were in- serted, one upward into the psoas muscle, the other (Unvnward into the pelvis. In the course of this woman's convilesconcc it was found advisable to make a counter-opening in the right lateral fornix of the vagina and to pass a drain- age-tube through from the opening in the groin to the vagina. This estab- lished perfect drainage, and the patient made a good recovery. Cases like this of true extra-peritoneal pelvic abscess due to puerperal in- fection and without intra-peritoneal inflammation are rare. There are some gynecologists who deny their existence, but the writer has had two cases under his charge in which the diagnosis was established by abdominal section. lI'Bli iWic bc- imc- ligiv iition f the in an made f INDEX. [The construction of this Index Is based on tlio almost exclusive use of the ikuiii as the enteh-word, with uinple cross-references, und with the introduction of the topical lorin of arraUKinieiit of spccitie subjects; that is, a dash ( — ) indicates that topics thus marked are all included under the precediuK general head. The black-letter type is used to denote the section-heads of the work.) 'fl ( v i lllirsl). [ouclung. Ithe psoas wore in- |c pelvis. 1) make a i\ drain- Itis estal)- [•peral in- liire some ses inulef Abdomen, distention of, tym- panitic, Hiniuluting presnancy, diag- nosis, 17.'i enlargement of, due to mor- bid conditions, 172, 17.} hydatid of, suppurating, lOi) incisions of, in (Jesarean sec- tion.s, 019, \m of pregnancy, clianges in size and sluipe, 106 coloration of, KiO enlargemeiit of, lG(i fetal movements, 100 palpation of. (See Palpaiiou.) pendulous, ptithological con- dition, ;{")0 Abdominal section. (See Crliot- Abnormalities of fetal appen- dages, labor com- plicated bv, i'uO of force-s of labor, ■li)3-4!)7 of milk-secretion, 708-771 of presentation and position, 386 of the female pelvis, 510 Abortion, 2-Ji( after-management of, '272 causes of, 'j.xciting, 200, 201 maternal, 200 paternal, 200 predisposing, 2(i0 curettage after, 873 defined 2r)!», 318 diagii ..< of, 2()4 diseases causing, 200, 201 due to libroids, 18t), 187 duration of, 203 embryonic, 2o'.) etiology of, 200 e.xpulsion of uterine con- tents, 2(i4 fetal, -IV.) causes of, 261 fre<iueiu'y of, 25!) from eiKlonielritis, ISO, UK) from retroversion of uterus, 101 63 Abortion from salpingites, 190 from puerperal scarlatina, 244 " habitual," 256, 260 treatment, 207 hemorrhage and i)ain in, 263 history, clinical, 202 incomplete, 204 curettage in, 873 treatment, 272 induced bv ovarian cysts, 558 induction of, 878 indications for, 878 " mis.sed," 272 occurrence of, time, 20O ovular, 259 pathology of, 2()1 i prognosis and sequela", 265 j surgical operations influ- i encing, 201 .symptoms of, prodromal, 263 threatening, diagnosis, 265 treatment of, 267 treatment of, 2t)6 propliyla.xis, 266 actual" of, 208 "tubal," 281 Abscess due to puerperal in- fection, 707 intraperitoneal, abdominal section for, 975, 070 mammary, cold or chronic, 700 congenital, 840 milk-nodes following, 700 parenchymatous, 702 syniploms, 702 treatment, 703 l>rogiiosis, 700 subciitaneouH, 704 of the nipple, 751 ovarian, puerperal, 072 peritoni'al, oi tlie new-born, 858 submanmuiry, 7(i5 treatment, 705 vaginal, trealnu'nt, 725, 7'-'f! Abscesses, intraperitoneal, celi- otomy for, 071 Abscesses, intraperitoneal, treatment of, 971 mammary, puerperal, 762 of the areola, 765 treattueul, 700 pelvic, indicating celiotomv, 000 ".Vcanthopelys" pelvis, 530 Accidents and surgical opera- tions during preg- nancy, 248-252 to the umbilical cord, 573 Accouchement force, 590 Acepbalia, 304 Acini, glandular, mammarv, 0»), 07 Adenitis, treatment, 725 Adhesions and biuids, amni- otic. 25;> After-birth. (.<ee I'/dmitn.) Al'ter-coniing head, e.xtrnciion of, 355 After-pains, treatment of, (!58 Agalactia, 771 treatment, 772 Air-embolistu in the uterine veins, death from, S(l,", Albumin in the urine of preg- nancy, 157 of the e('latii]iti(', 027 .Ubmnimiria in iuulti|)le preg- iiaiu'ics, 5()0 in toxemia of pregnancy, 208 in tiie ei'hiiMptic, treatment, o;!4 of pregnancy, 198, 233 causes, 157 fre(|ueiu'v, iS3 prevalence of, 157, 158 treatment, 150, 233 puerperal, 7S0 etiology, 780 prognosis, 780 .Ucoliol, use III', in inertia uteri, 40i; in lactation, 708, 769 in pui'rperal infection, 728 117 r I: I' ^-.i & i \% V i \ U7H Allilllt'.l-!, Ilic, H\ A iri(i/,iii, 71*1 A "K'lK.rilicii in cxIra-iiU'riiK' firi'ifimiuy, 2H t (MVcllif !li, I'll Adiiifiiii '>t llif- <•( |;ii(i(ili( , <;2'< A riiMii, li<|ii'>r, Ml A KifiP'iip, (lie, ><'.', (|i-'.(iij«'H <>( tin-, ^■"i.'! (Ir'>(i»iy (iC (he, ^"MJ A iiiiii'itiiis, 2''i.". A rnfiullii' 'if niiiriirMH, I'lH ,\tri[.ii»iiti<in, iiilrii iilcriiK', •",'»'» lit )pr<yii!iiit iitf'ii-i, 2 (■< <>r iitcrim III [iiiir|)cr!il ^cp Aniili/<"(i!i in Ifili'n, indiiciKC '.f, ■:>,2 ::<;:, AiiiHiir<!i, li'hil, ;!*i!i AiintdKiy 111 the Icliis, 101 U)i; Anatomy of the f;nnera- tive orf(anH : (ic|v;m, 17 -U) (irti(iihi(ii.im uf, IZ '■ fjimifc fit, 2(», .",0 — niii'"l.''H 'if (tic true, 2''i 2'-» — jiflvic tliKir, "trrii ,\<\' it, :;o :;<; fciiinlc (/ciKrrfitivc 'ir«aii-<, — rfinn.H v«!ii';ri<, .'{7 — Iniiifi, :;?, .'IH (•jitiirm, .'!H — V»'><tililll»', •"■'< — iirinsiry niciilim, tli(;, 'iH - Iivnicn, till', -l!) — iirctlirii. 10 — I.lii'lil.r, 11 — ureter, II /.#^ \n<iiii;ili<M in iiit^^'cr'vtii, >^^^»iliill'iii ' tii'lwi'''ri llie li't:i 7'W Wiii^ ^J* ^I'yy • li'ii'l (iii'l llii":|iiiiii ,-i llif fiirccM ',1 \»\,ufr\%'. Vf* "// I'lliifiin, 'tO<i 'it llic, iiijiplct (iii'l iir<MiN,^F u#'lvi( , iji^.;''i 7 I". 'if tlic (iliii ciihi wliin in (ir;rviii, ■">'<7 (l<lvi<-, ••t|llllit;i( ill (liiHMifiia- li'in, \'.\',) 'liiii;n<i^i-< »if, 'iM) '^filiniiKritfiK- t«(,[irci<nun(7, re 1)1 X III inn '>f, A/iiijilii iit int' l;ili'if, 'ilO ri(|itiiri' 'if, ';|0, ''ill llif Ircfilnicnt, >'i tl Anli(iyMri(M in trcHliiicnl <if A-i'itc^ i ';iii(ili' .ilini.^ (ircn- [icritiiTiiii-i, 72'<,72'l A ii(iH»'|wis, inlliicn'*' 'it, 'in niiirliility '.f (iiicr- ficriil iniiTti'iii, 'I'J-". in ini'lwilcry, "Oh 7 10 in 'iiicr.'ili'in of iiilcrn;il vr Mi'in, '.••"iH ill |iriviil>^ |ii!i' til c, 7 17 7i!» in HiirKi'i'il 'i(i<'r.'ili'in^, HI'M iin(i'irt!iri( (• 'if, hCu, H'W ill till' iwc 'if iti'' '■(illi»'l«'r, ;!'17 'itislclric, ."ill, '.'A'l A nti-i»'|iti'x, clicniicjil, 'il'!, ''A 1, HfiK iHc (it, nn the new ti'irn, K'iO AniiH, iiliHcnc*' 'it, in IIm' nt-v*- li'irii. H'i7 v!ii/iniirR, "i"iO .ililiiliic iif the new li<irii, ><.",0 A [i'i|ili"< V 'il tli(T new li'irri, '^2'Z [ildccniiil, 'iVl H'Slllts. 2"l''l •(vtii|it'inH (iri'l trc;itiii»'nt, ■i-,l\ A [i|ifn'liit;<'<<, niiri' iilfir, lO'l ciiii'liil, If'iiil, :!02 iiiiii'v ,l-U trcjitincnt 'if. 'il.'il f»'t;il, ."iO',t <iiiiTiliitiiiK prfKnaiiiy, 'liai^ ii'ixii!, 172 Ai'(>-!i< in the |i(iii|icriniii, in iiir«i''il 'i(iiT;iti'inM, H'X As|iliyni(i, <x(r;i nOrinc, 'li;i^ ri'i<(iH, '<lfi i'ti(il(ij/y 'if, HI") l/r.'i'lc 'if, li'iw t'l 'I'lcr mini'. Hi") [i!itli'il'ii;y, HI'i |ir'is/ii'Mi«, Kl") ^viiijil'irn^, H|.") IroitriK'iit, 'if, Hid 'if tlr.il t'lii'lc, K Ml 'if ^cf'in'l (.Tii'lc, H\7 intrsi liter iiif, ii!itli'il'it;i' fil cliJini^''.!, Hll (lidKU'wi-! 'if, H|/» cti'il'iiry of, Hll [Ir'lJ<n'lHi^, XI. "i ^vrnIll''ln■l, H|4 treiitnicul 'if, H|."i 'if fill' ncw-ti'irn, '\ I ',', rlj|.isili(!ifi'in, Hi I — Vdi^lllll, ' iitcriw. 1 fctiil, iitiii'iriiiJililici ifi hiti'ir Atiiirnli'iii 'if tlic ntcriK in tin- (•'iiri(ili' iilc'l liy, .770 in'lii'li'iii 'if (ire A [iliMi'li' i'i"! in |ir''tri>!in'v, 2:;'! nuiliiri' liili'ii, '•'.I .(.(I'll < VI rinif'iriiii-i, I I <i A If (■(•i;i«l<, ''lilt." niliil, A rii'ir VI -iil'Tiw, lii^anicnl'! 'if 'il \r'li< -iivi'liictM 'ir i' >ill>i|ii;ii tllllC.*, I'l -nv!iric«, .77 I.I', V.I dorli' , 1011 ll't;ll 10/ niftiiiiKirjili'iHi^ 'if, I0!( '(iii.i<'i! (iii'l trcdlnicnl, H.;., Atli.li;!, 7 1--. Atonv'if the iiterii«, p'lst piir- tiini htiii'irrlini^e i-!(('r;il, 'livcl'i[iiiit'i .1 'ii, '.<i; - jifir'iviiriiirri, '12 - V('Hs<.|s jiri'l ii'TVft, '1^ M IC t'l, 001 till If iniiiniiiic 0. ro Ar''il!i. IfretKt, !ilw<'"*M-i 'if, Atrc-iii'i iini in tlif ncwii'irii flctcrnnniili'iii 'il fl'1.7 itl. W An'Tnifi 'if |iict?n;iri''y, 2.1 > cil'ir !in'l (•linriK'''', '>'» tniirnriiiirv, of (irci^niiricy of tlic fcrvin, .'il? trfsilini'iit. 2 iii('r)i<T.il, I H.7 ^ii'kliiii.^ in. I.Vl, ;<12 if till Artcrifv, (ft!!!. 107 A iicn' <'|ili!iliis, .'lOl A ni-tllK'.ii.'i, "IwKIri'', •!*12 iinf.<llnli' H in, 'li'ii'c ' livji'ii^intn no in.l.ili'iil, ;i;i, I 10 .fvic tl'i'ir. '10 F' v;n(iiiii I, l-'i If iirftlirii III tli«' iKW liorii, 'It'tiriiiiii;! fi'iii 'if, 'I'l.'i V!i'/iii:il, 'ilwtrn' lini.' hili'ir .■,.v» A iH' iillJiti'iii, Jili'I'iiiiiniil, 'I I Hi' A rlfnliM, iiinliili'dl, H.w fl'iS|.i llV 110 !i'liiiihlMtr;iti'in of, ;i<i: in 'i)i»T,iti'iTi of irit«TfiHl ver- sion, '.t."iH A iiesljieti's, .'l*I"i .'I'l.'i in hilior, eflerl of. .'!'12 "I'L'i Arikvl'i^is 'if ilf pelvi'' jointt, A rierv, fiini'i oviiriiiii, 'I'l iliir, o: Aiil'i infi'' lion, rl'iet.rine ol, |iiifin'iniiry, ernlKitiw nii' llironitKi^iK of, ^ii'l fnl If If y 'if. Hii: |iii(T[ier(il fever, 'I'l'.^ flen 'lentil Ir'iin, H02 .A iito irnntfiiti'iri in (ni-l |i:ii .itrii' li'iii if lir'ii/ii'ivm iiiift 'tiiii.'n'M|.i Ho:i Aiioiiidlii iii[(eiill!il 'I. tr''iitnienl 'il HO.'l vel'i|iliient of tli»' uterine, '1.'! iilerni, .i1 Anlirilis, HVfniit'irrix, 70' III lil' liili'ili, 7'IH lre;iliiieii t of, liiiii iieiri'irrlidi^' , 00^1 A XI- trd'ti'iii, HHfl in llie liiirli 'i(ieriiliori, MlU in llie low 'i(ier(itifiii, H!|i, HllH t %' iMn:x. |.rt«;- riK ill itii' <if pn- I,.,., ■'•'■I 1, -^W ,1, <•<■'> ,,..<! |.iii ,liii,t tlilil-"' iicw-li'irii, Kltl'lll '>', t|,<' iifw IctiriMiii^i nil-' l;il>"' rilliiil,''l»t' ,(t.iin<' '•'. .,1, -<'■'■', Lriii.rrliHK'' liiti'iii lriili"<>> I'.Ai fi.r.i ■<, li'lniHiu. 21''. (liictcriii, fTyii(i»'lii>(, ill llir ni-w-l,'.rii, «;W, H:!5) . ill liri^iiil. Ill I Ik. 771 ill loxf^iiiiii, 'iiiimil ri'liiii'iii (.1, •;(».",, -JO t in llic «""il"l Iriict, l'»'! ill III)! (iiii'i (XTiil liri^iiMt, iMddcit of cnl.niii'*!, 7. ".7, 7".K iriviiHioii of, ciiimiiit; «ori' iii|i|ili!4, 7 tH iiiiKral.ioii iif, from iiiiiMtiiiiI to fftiil circiilfilion, l.'l',) of |iMiT(ii'r!il infcclioii, 'W.t tyjilioi'l, ill |irc!fii!iii''V, '^42 I'.jiir, ol«l<lric. C'liiiliiiii'llt. of, .'i'll Jl!IJ(-t, lilirllCM'H, !!«■ o(, ill (Ii latfilioii of iw, ■<■<;! in iiKTiKi iiN'ri, 4'('» I'.iilloii lor till' iii'lii'lioii of prt'iiiiiiiirf! liilxir, I'.iilloHciiiciil, I';*'. ' iJiiii'lii^c, liri'd-il , *i'il jK'lvif, sifter iiyiiipli v-iioloiiiy, J)l»; ()ii<T(i<'rnl, llie, 7 I 'J I'lHiiHi, jiiiiiiiotic, ilcforiiiitii's lUti: to, 2!»!l r.ii«iolril.f, !l.".l 'liiriiifr''!, !»:'.!, W.'.i I'.fitiotrifwy, 'Iii7 I'lilli, cold, ill IrfjiliiM'iit i}{ |iiTiloiiiii^, 7v!5l I'.atlii III; (luring; pn'KiDiiiiy, HI of the new liorii, *>*'i."> " I'.altli'ilore |.lii(«'nl(i," 'J.'.K l!i''l, [irciKi rill ion of, lor jiilior, I'.f'j n/,rci [)iii'r|i(';"(il, 7ll7 Ir'sihiifiil of, 7'!'! I'.f'lly, iieii'liiloiit, in ol«lri|( l<!'l Ifilior, 'I'i'l r.cllv liJiri'l of till' new Icirii, (JllC, fitl7 iJi'ldi'rV di-t»'imc, .'Wm r.ili- of till' iu'wlioni infiiiil, HMI r.iiid'T, iilidoiiiiiiiil, .'Wl lirciKl , Miir(iliv, 'I'll, I'i'i in iirr<"tt of liii liilioii, 7 '17 in lirc'iil illN<■«■^»^, 7'i!> in iiifiitilit, 7''il in Iri'fitiiKMit of Mori' nip j.lcs, 71!» I'.irtli iiiiirkH, 'i\'.\ I'.irlli of inffinf, liyifi*'"''' '''"■»' I. Iter, KV I'.irtli-t, iiniltipli', coiiipliciitiiiK liilwir, 'Vi7 pliyiiolo(;y of, 112 H'» ' ('iliifk-ili'M'im*'," Hl'i lllfiddcr, iliH«'(i'«'H of, coinpli- (iitiiiK prfr«n(inry, H»7 r.lnd'li'r.ilinlfndi'l, linni Idling ^ pr>i/n!in< y, diiiKno -=M, 1 7;; di-liirlmii' i'« of llii', limclion III, niter liilior, l-^'i due to prfj/niiniy, I'l'J f.-tdl, 121 over di^t<■ntion of, in llie piierpiriiini, ''i'<') Ktnii Inri' of tlic, II l!li;itoinircK, 77 I'.liwlii'ii, 77 " r.lfcd, r-i," *<.",(), <',\ I'.lindiifi ill pnyniui'v, Hi!i in llic piifrperinni, 7'l'> I'.IoihI, di-wiri;iini/,iilion of, in tooiniii o) \<Tiv, niiii'v, 2'i:;, 'I'll in pr<'i;iifin(v, londition of, loj coiiditioimol, iil.iioriiiiil, 2.".". Ift.'il ;ii:d nijiltrniil, inter ' liiiiiKe of -;nli i^liiiiieii, le«ln, l.'.'l fir' iiidlion of. I,",*; II') iiiiKr^ilion of Idk leriii irorn iiiiileriiiil to, I .;;i of llie new liorii infiiiil, •^'itl lr!in-;lo-;ioii of, Irfiit iiiil:il, .'u.'i I'pIomI ( li!in(/ei! of prei/n;in'v, IM lilood 'jot, uterine (iiiHins; piierperni liemor rlmi^e, 7 l'» " !!lr>Ml i^lsind^of I'linder," I'll r.lo'><l-iiiipplv in prej/iiiincv, IM I'llood tiiinor. (erelir.il, fif llie. iiew-liorn. '<21 eoinplic'ilini/ Ifi'ior 'Wl '')•■•'! li'iiod ve»-!eli. exlrii eintiry oiiif, |(i:; fell I, I Id 112 iiiiiiniiiJirv, 'l!) of rividnelM, 'tl oviiriiin. Ii!! |iel vie floor, '!■"> phirenliil, K',!, (I'l iiinliilieiil, (I,'! iiretliril, 11 uterine, i|:'. diirint; the pnerperiiiiii, >;:,'■'. Iiypertrojiliv of, I I'l vsiiriniil. I'l I'lliiiil liook. lite of. in lireei h hil>or, 17'i I'.odv, fetjil, the, lO'l delivery of. '.'-^ee /></m./i/) eipiil-iion of. 'He.e I'ir/i'il ■tiiiii.) rjipid e^tr.'ietion of, in lireerh l.ilH.r, 17!t I'.one'i, di^'iiae« of, iiitrii nte rine, .",'17 of llie new-liorii infiiiil. HI I iiijnrieM to, K2I, ^I'l VVoriniiin (onipliintini^ In Itor, o'l'i {>7!> Monifie, iKe of, for iiidnetirm of preiiiiiliire hilior, '<7:i I'.owelM, eviii niilioii of, diirin« preKiiiiiiey, H.'l in the new liorn, Ho'i, H.-,(; in llie pniT •riiiin, 'i'iO injuries to, of n new liorn, oUlriietioii of,eoiii;eiiit(il,M."»7 •JVMplOIIK, •','il lre;itliieiit, HUl l!r;iin,dHe!it<'itol, r omplii n\\uu, iiiiior, 'ii;; feldl, ilevelopineiit ol. I J.") I2'< injiirie'i lo, of llie new l/orii, iiiiilloriiijiliontof, i/)iii/eni|,il, :;'ii of tlie ei Ijiifiplie, (',.';() I'.riiin-vesii ' .;, fcidl d,. olop- ine, '1.',, ',l<; priin.'iry, I2'> " I'.rfixtoii llieki' <^\i'{\ of prej/- njiiir'v," I'iV f'.rejKt |p!ini|,i|/e, <;M piierperfil, 7 I'l iJreiiit hinder, iiifirnniarv, 7."i.", .Vltirpliv, »;(;|,7.V2 C.re.'itt milk, mioiMjilieii in «e- ' relioii ol, 7'JH 77.'t iolo«triiiii eorpMse|ei( rif. H.,'t dryiiii; 11)1 of. !r( .(riient, 'i'i2 evaeiKition of, in iiumtili.i, 7'iO eTniiiiiKilion, mi' ro^icopicdl, 77(1 '|ii!iiilily (iiid 'jiiiilitv, 'I'll tnlKtitiiteii f'lr. 'I'W '171 '.Mee Mill:, l,i<iifl , IlreiiHl piim(i. 7">l ill firre-il '.f Ifielntion, 7'17 ill miHlilit, 7'!') Itreii-ilt, (ilwee««et 'if llie, 7'12 iiii'iiiKiliei 'if, 71") 7 I'l dj-senie^ of, 7'il diiriMi!' 1(11 tJili'iii, 'I'll fi-!|iil(e 'if piier|i<'r!il, 7I1'1 liy|iertr'ipiiy of, 'llie I'l prej^ niilifi'. lo2, I'll inlhimni'ili'in 'if, piKrperal, 7. 'i'l m!i-s;u'e of tlie, 7-'i'l 'if new li'irn iiiffint. H27 ^trii' tiire 'if. 'l''i iNpp'irt and e'liiipresii'in 'if, 7 ".2 liree' h lali'ir 'Hee l.nlnir. , (ireseiilali'iim 'Ht't'. I'n^rn- liiliiifin. J lirei/m!!, the, I'l". IJriiii, Itow preieritali'piit at, till!, iiiiinai'emeMl. of, 1(17 fii'e pre^eIltali'ln^^ at. the, in- terference, iipera- tiv«', 1'i.'! iiiniin(((!iiient, of, 1'J2 ■f vi I :;i 980 INDEX. Brim, tumors in the, producing fdce presentutions, 459 Brow, anterior, position of the, niunugenient of, 4()G-4«8 posterior, positions of the, 4()7 manngenient of, 468 presentations. (See Preaenla- lions. ) " Brown caries," 234 Brush, uterine, 874 Buhl's disease, 843 anatomy of, pathological, 843 diagnosis, prognosis, and treatment, 844 etiology, 843 symptoms, 844 Bulbi vestibiili, 38 Calcification, fetal, 283, 313 Canal, cerviral, anatomy of, 147 relation of, to formation of uterine sac, 147, 148 shortening of, during pregnancy, 103 genital, tumors of, com|)li- cating labor, 5ot) neural, 80 parUirient, anatomy of, 388 infrapelvic portion of, 397 maternal structures of. complicating labor, 546 obstruction to labor by the structures of the, 546 pelvic portion of, 390 shape and position, 397, 398 suprapelvic portion of, 389 "Canal of Nuck," 53 Canal is artiouhiris, 107 Cancer. (See Cftrci'iioDKi.) complicating pregnancy, 241, 744 of uterus, 187 extirpation in, 248 of the rectum complicating labor, 561 Caput succedaneum, 818 ■' "gnosis, 819 I logy, 819 in Justo-minor pelvis, 516 prognosis, 819 treatment, 819 Carcinoma of cervix, 187 complicating labor, 556 prognosis, 187, 188 of the uterus, 187 in the puerperium, 744 prognosis, 188 Cardiac di.seii.ses complicating labor, 642 pregnancy, 237 (Sec Heart.) Caries of pelvic bones, 531 Carunculiu mvrtiformes, 40, 551' Catalepsy during pregnancy, 217 Catarrh, septic gastro-intesti- !uil, of the new- born, 850 Catheter, antisepsis in use of, 347 passing the, 868, 869 choice of instrument, 869 method of, 869 position of patient in, 869 use of, in retcniion of urine, 660, 868, 869 Catheterization following labor, 716 in cystitis, 788, 789 in the puerperium, 660 "Caul," the, 570 , Cavity, pelvic, anatomy of, 19 Cecum, 116 Celiotomy for puerperal sep- sis, 968-970 contra-indications to, in treatment of puer- peral sepsis, 968 for difluse suppurative peri- tonitis, 970 for intraperitoneal abscesses, 970 I indications for, in treatment ! of puerperal sepsis, 970 Cell-division of ovum, stages, 77 or segmentation, 76, 77 Cells, Kauber's, 78 sexual, fertilization of, 74, 75, 76 Cellulitis, 695 diagnosis, 700 I prognosis, 700 j symptoms, 699 treatment, 725 Cellulitis, difiiise, of the limbs, 707 suppurative, of broad liga- ment, hvsterectomy for, 973 Celom, S2 formation of, 79 Cephalbeniatoma, 819 complications, 821 diagnosis, 820 etiology, 820 ireciuency, 820 patb(ilo),'y, 822 process of repair, 821 prognosis, 822 .symptoms, .S20 treatment, 822 Cephalic presentations. (See PrefiviiUitiunii.) Cephalopiigus, 305 Cephalotribe, 931 Cephalotripsv, indications for, 937 " Cervical plug," 163 Cervix, 47 atresia of, treatment, 547 carcinoma of, 187 complicating labor, 556 cavity of, 48 cicatricial contraction of, treatment, 547 closure and contracticm of, obstructing labor, 547 dilatation of, artificial, in induction of labor, 880 for internal version, 949 diseased, treatment of, dur- ing pregnancy. 181 displacement of, com)), ica- ting labor, 556 during the piierperiiuu, 652 epithelioma of the, 188 fibroids of, complicating la- bor, 557 hypertrophy of, in preg- nancy, 146 lacerations of, (514 causes and symptoms, 615 treatment, 616 rigid, intracervical tampon as a dilator in, 875 treatment of, 548 tamponing the, 874 uteri, changes in, during pregnancy, 163 softening and enlarging of, 163 virgin, 148 Cesarean section, 917 for ovarian cysts, 559 history of, 917 immediately after the death of the mother, 923 incision, abdominiil, 919, 921 uterine, 920 indications for, 917 absolute, 918 relative, 918 in cancer of the cervix, 188 of the uterus, 187 in eclampsia, 636 in epithelioma of the cer- vix, 189 in rupture of the uterus, 613 in sudden death in labor, 645 mortality from, 925 operation of, 919 I'orro, 924 Siinger, 917 prognosis of, 925 preparation for, gene- ral, 919 time to operate, 918 Children, generative orgau.s of fenuile, coii;reuit;il defe<is of, .">(I3 Chill, post-partum, 649 t I mw INDEX. 981 Chloasma iileriniini, 175 Clilui-iil, list' ol', ill ecluiiipsia, Cholera during' pretjiiancy, 245 treatment, 245, 240 Chorda dorsalis, SI Chorea during pregnancy, 214 etiology, 214 syniptoniM, 215 tKatnient, 217 hysterical, 215 diagnosis, 210 prognosis, 2! '• Chorion, the, S5 diseases of the, 254 frondosuni, H() lueve, 8<) Circidation, allantoic, 103 fetal, i:W-14() and maternal, interchange of siihstances in, 138, 13!) development of, 103 of the new-horn infant, 809 placental, 138 fetal changes in, 110 vitelline, 103, 130, 138 Circnlatory system, develop- ment of, 103 Cleanliness, surgical, import- ance of, 807, 868 Cleft, vaginal, 44 Cleidotoniy, <.t39 Clitoris, structure of, 3S fetal, development, 124, 125 Cloaca, 115 Clothing during pregnancy, 181 Club-foot, 304 Coils of umbilical cord, 93, 258 Coitus, date of parturition based on, 177, 178 during pregnancy, 181 influencing abortion, 207 midtiple conceptions, 144 puerperal infection due to, 092 Cold, exposure to, puerperal fever due to, 778 Cold pack in treating perito- nitis, 729 Colic in the new-born, 854 symptoms and treatment, 855 Colostrum, 153, 102, 054 Colostrum-corpuscles, 09, 153 in l,reast-milk, 774, 775 Colpeurynter as a cervical di- lator, 875 in induction of premature labor, 880 Compress, Priessnitz, 724 Conception, occurrence of, time of, 170, 177 Conceptions, midtiple, coitus influencing, 144 frequency of, 142 occurrence of, factors in the, 143 physiology of, 142-145 Conduct of normal labor, 341. (See Labor, nuniutl.) Confinement, preparations for, 3(il — thn ap|iliances, ;>01 —the beil, 300 — tiie lying-in room, 359 — the nurse, 359 — the patient, 301 Conjugate, diagonal, measure- ment, 503-505 pelvic, 359 diameter of, in Cesarean section, 918 diameter of fminel-shaped pelvis, 518 of generally contracted non-rachitic pelvis, 510 of jnsto-minor pelvis, 515 rachitic pelvis, 525, 520 external, measurement of, 501, •)02 pelvic, 358 in simple flat pelves, meas- urements of, 510, 511 spondylolisthetic, 530 (See Pclrinu'tr;,:) Constipati(m of the new-born, 850 laxatives for, 801 treatment of, 850 acute, puerperal fever due to, 780 Constriction-ring, closure of, about the neck in breech labor, 484 Contraction, intra-uterine tam- pon stinudating, 877 Contraction-ring, 147 of Schroeder, 583 Contractions, uterine, after ex- pidsion, 440 after labor, 377, '>^~S causing rupture of uterus, Oil, 012 danger of abortion from, 184 deficient action of, 493- 497 during pregnancy, 318, 319 in post-partuni hemor- rhages, 003-005 intermittent, method of, detecting, 107 in the puerperium, 051 ])romote(l by nursing, 001 Convalescence, management of, in the puerpe- rium, 003 Convulsions of eclampsia, 020 uremic, without eclampsia, 19S Cord, anatomical and physio- logical considera- tions of, 827 anomalies of the, 258 93 (,'ord, blood-vessels of, 93 coils of the, 258, 570 etiology, 570 ron)plicating labor, 571 dimensions of, at birth dressing of, 827, 828 fungus of, 833 healing of, slight disturb- ance in, 832 hemorrhage of, before sepa- ration, 828 hernia' of, 833 knots of the, 258 fetal death from, 311 ligation of, 375, 829, 830 Dubois' method, 832 malformations of, ,304 management of the, 374 prolapse of, 573 diagnosis, 574 etiology, 573 treatment, 575 reposition of, instrumental, 575 postural, 570 resisting jiower of, 579 rupture of the, and its ves- sels, 579 treatment, 581 shortness of the, accidental or natural, 577 diagnosis, 578 treatment, 579 stenosis of the, 259 structure, 93, 94 torsions of, 93, 259 traction on the, causing inversion of the uterus, 018, 019 in placental expulsion, 378 Cord, spinal, development of, 129 Cords, entanglement of, in twin labor, 5(iH Corona radiata, 00 Corpuscles, colostrum, 09 genital, 38 Corpus luteum, (Jl of menstruation, 61 of pregnancy, 01 Cortex, ovarian, 59 Corti, organ of, 133 Cotyledons, placental, 90 Couveuse, S03 Coxalgia, 540 Cranioclasis, 936 Cranioclast, 930 Craniotabes, 821 Craniotomy, 920 941 indications for, 92() Uistruments for. 930 — basiotribc, 931 — cephalotribe, 931 — cranioclast, 930 — craniotomy forceps, 933 — dcca])itation hook, 933 — hook and crochet, 933 — perforators, 930 i I' -I ■I ,1- If' 982 Craniotomy of tlie after-com- in>? head, !»;{') of tin- prc'weiiliii)? lifad, 934 operation, the, !)83 — l)asiotrip»y, 937 — cephaloti-ip.sy, 937 — eranioclasiM, 93(5 Cranium, fetal, KCi premature fissilieation of, eomplicalinjf labor, ")(;3. (See Ilidd.) Cretinism, rongenital, 309, 310 fetal. 310 Cup, oj)tii;, 131 Curettiige, H7'2-874 after aliortion, 873 indieatiouH for, 872 in suhinvolulion, 730, 737 post-purtum, (i(l3 te(lini(|ue of, 873, 874 Curette, blunt, 873 wire, use of, in obstetric cases, 7 '22 "Curve of Carus," 389 Curves, sacral, '2.') Cycle, nienstriinl, stages of, 72 Cystitis conii)litating preg- nancv, treatment, 197 due to infection from use of the catheter, 347 of pregnancy, treatment, 199 puerperal, 78() diagnosis, 787 etiology, 78(i prognosis, 788 treatment, 788 Cystocolpocele, 5()0 Cysts of the nunith, congenital, 303 ovarian. li'O complicating labor, 558 treatment of, 191 " DAUfillTKR-CKLLS," 77 Deaf-nuitism, congenital, 309 Death in labor. (144 in the i)uerperium from en- trance of air into the uterine sinuse.s, 803 of fetus in utero, 310 of mother, Cesarean section after, 923 sudden, during pregnancv, 212 in the jjuerperium, causes, 801, 802 from embolism and thrombosis of the ])ulmonary arterv, 802 Decapitation, fetal, 938 indications for, and the operation, 938-940 with Uraun's hook, 938, 939 Decapitation hook, Hraun's, 933, 938 Zweifel's, 933 INDEX. Decidua, hypertrophied, caus- ing uterine hemor- rhage, 740 removal of, in subinvolu- tion, 737 hypertrophy of the, 189 of ectopic gestation, 284 retained, curettage for, 873 Decidua rellexa, 80 sorotina, 8t> vera, 80 of pregnancy, 319 Decidua', anatomy and physi- ology, 8(1 Deformities, congenital, 299 of special regions and or- gans, 302 fetal, 299 causes of, 253 pelvic, 498 complicating labor: — coxalgic, 540 — Hat pelvis, simple, 510 — generally- contracted, flat, non-rachitic pelvis, 510 — justo-major pelvis, 521 ' — justo-minor pelvis, •■14 — kvphoscoliotic pel- ■ vis, 540 — kyphotic pelvis, 537 — narrow, f u n n e 1 - shaped pelvis, 517 — obli(|iicly - contracted [lelvis, 518 — osteomalacic pelvis, 520 — rachitic ])elvis, 522 — .scoliotic pelvis, 539 -split pelvis, 522 — spondvlolisthetic pel- vis,'532 — transversely - c o n- tracted pelvis, 521 Deseneration, calcareous pla- cental, 255 fatty, placental, 25() Delivery by basiotripsy, 937 by cephalotripsy, 937 by Cesarean st-iion, 923 indications, 917, 918 operation of, 919 preparation for, gen- eral, 919 time to operate, 918, 919 by cranioehisis. 930 by craniotomy, 920 by embryotomy, 920 by fetal decapitation, 938 by fetal evisceration, 938 by laparo-elytrotomy, 925 bv the I'orro operation, 924 by version, 941-908 forceps, compression in, 890 indications for, 891,892 in labor complicated by cardiac diseases, 042 ' Deliverv, forceps, leverage in, ! 891 of the after-coming litad, after craniotomv, 930 operation of, the, 892 rotation in, 891 traction in, 890 in high operation, 898 delined, 892 in bree(h |ire.sentati<iiis, 902 in brow and face pres- entations, 901 in dorsal and lateral positions, 904 in dorso-anterior ]iositi(inB, internal version in, 954 in dorso-posterior jxisitioiis, internal vrrsion in, 954 in hospitals, niiinngement, 710,717 in labor bv svmphvsiotomv, 905-917 in left-lateral position, 903 in occipito-posterior po- sitions, 900 obstructed by vaginal and vulvar timiors, 550 of the after-coming head, 902 of the severed head, 903 in low operation, dcliued, 892 in the dorsal position, 893 jiosition for, 8!)3 traction in, 89ti-89S in mcdiinn operation, de- lined. 892 in rupture of the uterus, 013 instriunental, after rupture of the svmplivsis, 040 choice of operative proce- dures, 92(i, 927 in sudden death in labor, 044 management of, in labor oljstriictcd by con- tracted i)elvi's, 543 precipitate, causes of, 497 Delivery-room in hospitals, 711 (See LyiiHj-hi room.) Descent, normal mechanism of, in dry labors, 4.'11 in vertex preseiilatioiis, 431 of head, normal rotation in. 512 Diabetes during pregnancv. 218 pathology, prognosis, ami "treatment, 220 rp TNDKX. f>H:j Diagnosis of pregnancy : of till' (liii'iition <>r jirej?- iiiiiK'v, ITti of the prolongation of preg- nancy, 17H of symptoms and signs: — nausea and vomiting, 15!) — ntenstrnal suppres- sion, KiO — mamma rv changes, Itil — functional disturl)- ances r)f the blad- der, Wl — intrapclvic signs, W,\ — abdominal changes, l(i(> — ballottcmcnt, Ititi — intermittent contrac- tions, l(i7 — quickening and fetal movements, lt)7 — uterine soiiUle, KW — fetal heart-sounds, 108 fetal contour, 170 — classilication of the phenomena of utero gestation, 170 — mental and emotional phenomena, 170 — relative value of symptomsand signs in point of diaguo sis, 171 — of the life or the death of the fetus, 17.") Diagnosis of presentation and position, 85()-;ir),s Diagnosis of the mechan- ism of labor. (See Ijtbiir, (lidtjiiDnis. ) Diagnosis of the puerperal state, »)•')«) "Diameter of Haudeloccjue," 501 Diametert! of fetal head, 403 lenj;ths of, 404 relative value of, com- pared with diame- ters of the pelvis, 404 of the pelvis. (See Priri.i.) Diaphragm, pelvic, 27 JUarrhea in the newborn, Soo treatment, 8.')() Diet in pregnancy, 180 in the prophylaxis of eclampsia, (ilU Dietary, infant, in constipa- tion, 8.')7 in nephritis, 7;i2 in peritonitis, 728 in the puerperium, 059 of the nui-sing woman, 769 Digestion, changes in, due to pregnancy, 155 Dilatation, cervical, I'or inter- nal version, 019 of the OS uteri, artilicial, SS2 in breech presentations, 471 mechanism of, after rupture of meml)rane^:, 427 normal, 424 with De Kibes' dilator, 884 with origiuallv seaniv wa- ters, 429 with Tarnier's dilator, 884 with undue elasticity of membranes, 4:>0 Dilator, uterine, Itarnes' lid- die-bag, SSo Harnes' fioft-rubher, 883, 884 Champetierde Kibes', 884 McLean's, 883 six-hranched, 883 Tarnier's, 883 Dilators, uterine, llegar's, 882 instrumental, varieties of, 882 Diphthei'ia, congenital, 851 puerperal, 781 Discus proligerus, (iO, 71 Diseases, eruptive, of fetus in utcro, 290 infectious, of the fetus in utero, 295 intra-uteriue, of the bones, 307 of the nervo'.is system, 309 of the skin, I'onnective tissue, and serous me., brane, 309 maternal, dvstocia, due to, 023 medical and surgical, inci- dent to the birth of the child. Mo of the breasts, 751 of the fetus in utero, 295 of the nervous system, 790 of the nipples, 747 of the nou-sexual organs, 778 of the sexual organs, 083 of the urinary organs, 785 puerperal, iiUercurrent, 780 septic, folhiwiug abortion, 205, 200 Disinfectants in treatment of jiuerperal infec- , ion, 708-710 Disinfecti(m by the obstetri- cian, personal, 344 hospital, 712-714 —of the doct(U's and nurses, 71. '5 — of the instruments, 714 — of the materials, 714 — of the mu'se, .")45 —of the patient, 345, 340, 713 — of the ward, 713 practical rules for, 343 Disinfection, vaginal, 720 (See Diiiirlii- Mu\ Irrii/itlioii.) I)isk, interpubic, 23 iiivertebral, 25 Dislocations, congenital, 301 i)isorders of vision in the eclamptic, 025, 029 Dosage of the new-born, 8t)0 — alteratives 801 — antacids, 8(il — antil'ernieiits, 801 — antipyretics, SOI —antispasmodics, 801 — digestives, SOI — diuretics, SOI — hemostatics, 802 — laxatives, SOI — nerve-sedatives, 801 — nutrients, 800 — siiundants, 801 —tonics. 800 Douche, the, 870 uterine, operation, 872 vaginal, in the induction of premature labor, 881 method of giving, S7() Douches, uterine, dangers of, 872 vaginal, utility of, 340 Drainage in i)reast-abscess, 704 Dressing, aiuiseptic, following labor, 7 It) of vulva after labor, 383 Drugs, ingestion of, in suck- ling, 770 " Div labor," 570 "Duct, (iiirtner's," 02 lactiferous or galactophor- ous, 1)7 Ducts of Cuvier, 107, 112 .Miillerian. 120, 121 Wolfhan, 11S-123 Ductus arteri<isus, 137 venosus, 112, 130 Dystocia : 1. Dystocia due to anomalies in the forces of la- bor, 493-573 deficient power of the uterine muscle ; in- • I ■; uteri, 493 deforiiiii'.t... of the pelvis, ■kis — classification of anom- alies in the female pelvis, 499 — diagnosis of pelvic deforiiiities: pel- vimetry, 5(l0 — freiiiicncy of deformed pelves, 4118 description of the several varieties of abnor- malities in the fe- male pelvis, 510 excessive [lower in the exi)iilsive forces of labor, 497 ti m :'■ B '*Ah h ft ^ m I 1* ; 1 i;' 984 DyHtociii line to ankvloNU and reliixatioii of the pelvic j()iiit«, .").'{1 — anoiiialius <liit> to (Mm- I'asi'H of till- Hiibjii- (•out skoU'loii, .VIO — carit'H anil ni'crosis of pl'lvic l)OIU'H, '(.'il — '-oxal^Mc pi'lvis, r)4() — frac'tiUL's of the pel- vis, M] — general Iv-coiitracteil, Hat, iion-racliitie pelvis, r)l() — jiisto-iiiajor pelvis, .VJl — jiisto-iiiinor pelvis, 514 — kyphoHfoliotii- pel- vis, .")4() — kyphotie pelvis, 't'M — lordosis, 540 — liixutioii of the fem- ora, 541 — narrow, funnel- shaped jiel vis: fetal or iindevelo|)ed pelvis, 517 — oliiicpiely - eontiiicted pelvis from imper- fect development of tlie ala on one side uf the saernni, 158 — osteomalacic i)eivis, 5-_»() — rachitic pelvis, 522 — scoliotic pelvis, 5;{!) — simi)lc Hilt pelvis, 510 — split pelvis, 522 — spondv loii!>thetic pel- vis,"5;52 — transversely-contract- ed i)elvis, the result of imperfect devel- opment of hoth sacral alic, 521 — tumors of the pelvis, 5:{(» management of labor ob- structed by the commonest forms of contracted pel- vis, 543 obstruction to labor on the jiart of the sotl maternal structures of tlic parturient canal, 54()-5(ll — clo ure and contra'o- Jon of the cervix, 547 — closure and contrac- tion of the vaffina or vulva, 549 — eonjrcnital anomalies of development in the uterus, 54t) — displacements of the uterus, 552 INDEX. Dystocia due to tinnors of the genital canal, 55t> —tumors i)f neiKhhor- iuK organs, 55s olwtruction lo labor on the part of the fetus, 5(il — labor complicated liy abnornmlities in the fetal append- ages, 570 — overgrowth of the fetus, 5(11 II. Dystocia due to acci<lents and diseases, 5715 accidents to the umbilical cord, 57;! 5M2 — coils or circulars of the cord, 57(i — natural or accidental shortness of the cord, 577 — prolapse of tiie cord, 57:5 — rupture of the cord and its vessels, 579 dvstt)ciii due to hemor- rhage, 581-1)23 — accidental hemor- rhage, 5i)() — hemorrhage after the birth of the child, (iOO — injuries to the infra- vaginal portion of the uterus, (114 — Inversion of the uterus, (iK) — lacerations and rup- tures of the uterus, (ilO — placenta pnevia, 581 dystocia due to disease of the nu>ther, 023- ()44 —diseases of the brain, t)43 — diseases of the heart, (i42 — displaced kidney, 039 — eclampsia, (123 — eventration, ()39 — hemorrhages, 1538 —hernia, ()3S — hyperemesis, <i37 — labor in pneumonia, (!44 — paraplegia, 043 — relaxation and rup- ture of the pelvic articulations, 040 — shock, 044 — sudden death in la- bor; delivery of the child, 044 — tumors of the rectum, 039 Eai{, fetal, development of, 132 Eclampsia, 023 Kclampsia, attacks of, dura- tion. 027 frwiuency, 020 causes, esHential, 032 exciting, ti32 predisposing, ti30 convulsions, uremic, with- out, 198 diagnosis, 029 etiology, 030 fre(|Uency, 023 in twin labors, 509 Induction of preuuiture labor in, 879 induence of, upon the uterus and the fetus, 027 occurrence of, periods and time, 024 phenomena of, 025 prognosis, (i29 post-mortem appearances, 030 svmptoms of, premonitory, 025 terminations of, 028 treatment, 034 medicinal, ()35, 636 prophylactic, ()34 Kcouvilion of Dol^ris, 874 Ectoderm, 77 Eczema of the nipple, 751 Edema of the vulva, 550 Electricity in the induction of premature labor, 881 Elephantiasis of the labia, 19'^ Embolism of the pulmonary arterv, death from, 802 " puerperal, 790 ceiebral, 790,791 Embryo, development of, 74 fetal stage of, 94 initial stages of. 80, 94 position and flexion, 95-100 Embrvos, double formation oi; 305 Embryotomes, 933 Embryotomy, 920-941 alter tnatinent of, 940 indications for, 927 instruments for, 933 operations of, 938-941 —decapitation, 938-940 —evisceration, 938, 940 prognosis, 939, 940 symphysiotomy in, 912 Emotion, puerperal, fever due to, 778 Emotions,- nuiternal, of preg- nancy, 182 aflectlng the (|nality of breast-milk, 770 Encephalitis, treatment, 732 Encephalocele of the new- born, 819 Endocarditis, symptoms, 706 treatment, 731 Endometritis, 094 causing abortion, 261 w 7 i\in:x. {W5 EndDiiiolritiN, dcindtml, etiol- ogy, 'i'V) tn'utiiionl, '2.')") (liplitherilic, coiitra-inilicat- ing fi'liotiiiny, iltJlt diiriiiK pri't^nancy, I Hit Huptif, (iS"), (IHd I'oiitrii - indicating celiut- DMiy, 'Jll'J syniploinsand protjnoHis, 009 treatnienl of, 190, 721 Enteritis, Ircalnient, I'M Enteroct'li', vaginal, ti;t!) coriiplicalin^r labor, ')'>9 Entodurni, 77 " Kpideniics'' of ])iierperul fever, (i9U, (191 EpiderniiH, infani, exfoliation of, H2ti lOpilepsy Hinmlating ecluinp- sia, ('.•29 Episiotoiny, 373 defined, 877 ineiHions, site, number, and wize, H77, 878 | indieations for, 877 | K(ii»taxis, fi38 I Kpitlielionia of the cervix, 188 Epo<"ii)lioron, ()2 E(|uino-varus, 304 I Ergot, use of, diirin/? labor, 016 following lalior, 71(1, 717 in labor coinplicaii'd by eariliac <lir-easeH, 043 in endometritis and me- tritis, 724 in inertia uteri, 49fi in proniotini; uterine con- tractions, 378 in subinvolution, (i(i2, 738 lacerations of the cervix from, (!ir> rupture of llie uterus from, ()12 Erosion of the nipple, 747 £rn|)tion, niiliarv, puerperal, 707 Eruptions, skin, puerperal, treatment, 732 of fetus in utero, 29(! Erysipelas complicating!; prejj- nancv, treatment, 242, 243 fetal, 297, 309 of the new-born, 838 of pregnancy compli,iated by mechanical in- juries, 2")1 puerperal, 781 Erythema, puerperal, 707 Evacuation, alvine, of the in- fant, 8.')-), 8ot> Evacuations, alvine, during pregnancy, man- agement of, 183 of the puerperium, G60 Eventration, ()39 Evisceration (fetal i, 938 after-treatment, 940 Evisceration, in<lications for, 938 operation. 940 Examination, abdominal, diag- nostic signs by, 41 1 for position, 422 obstetrical, 349 vaginal, diagnosis by, 41 1 for position, 423 (See l\tlfxitiii)i.\ Exanthemata of fetus in utero, 29(i puerperal, 780 Excavation, pelvic, anutomv, 394 Exencephalus, 304 l*'xercise in pregnancy, 180 Exfoliation of the infant epi- dermis, 82(1 Expulsion, mechanism of, in second stage of labor, 437 spontaneous, of (4iild, after sudden death in lalior, ti4() Extraction, breech, Harnes's method, 9(iti immediate, versus delay, after version, 9(15 in tiie dorsal postuf 9o9 in tlie Unee-elbow ijosture, 9(i2 in the latero-prone posture, 9(il in tiie Trendelenburg pos- ture, 9(12 of head and mums, diflicidt, by version, '.KJ.j, 966 operation of, after internal version, 9()5 Extra-uterine pregiuincy. (See Prtiniuirtj. ) Extremities, malformations of, congenital, 304 prolapsed, 492 Eves, fetal, development of, 130, 132 Face defokmitiks, congeni- tal, 302 Face, fetal, 402 deveioixnent, 100, 101 injuries to, of the new-born, 824 Face presentation. (See Pren- flllillioil.t. I Fallopian tubes, oO atlections of, during preg- nancy, 249 removal of, in puerperal sepsis, 973 Faradism in the puerperium, ()()2 Faradization of the stomach in [iregnancy, 183 F.-iscia, pelvic, 29 anal or ischio-rectal, 30 obturator. 21! recto-vesical, 29, 30 l''eces »if the new-born infani, 810 (See Miriiiiiiiiii.) 1'' ceding, artificial, of the new- born, 0(18, H(i(> breast, of (he ni-w-born, N">9, 8(1(1 intervals in, of the new- born, (167, 671 I'Y'eling or touch, sense of, in the new-born in- fant, 812 Femora, luxation of (dystocia), 041 Ferments, felal digestive, or- ganic and inor- ganic constituents of, 141, 142 I'erlilization of the ovule, 74 of ovum, period of, 76 h'etal movements. (See /■'fhin.) l''etation, double, determina- tion of, 3.J7 I'Vtus, the, 401-407 anasarca of, .">()9 arteries of the, 107 body of, 4('ii brain of, devxdopment, 12o- 128 calcification of, 313 operation after, in extra- uterine iiregnancy, 29.-) calcified, retention of, 313 circulation of, the, 13(1 coils and knots aroinid, 2o8 contour of, in diagnosis of pregnancy, 170 craniotomy upon, 926-9.38 cretinism of, 310 death of, in utero, 310 causes resulting from the amiexes, 31 1 from external vio- lence, 312 from faidty develop- ment, ■">! 1 from liie father, 310 from the mollier, ;!1() from maternal eciacipsia, 628 pre - natal, post - mortem clianges in, 312 decapitation of, in dcliverv, 938 deformities of. facial, 302, 402 special regions and or- gans of, 302 delivery of, operative pro- cedures, choice of, 926,927 (See Dflirery.) descent of, in vertex presen- tations, 431 normal mechanism of, in dry labors, 431 of head, normal rotation in, r)12 (See Head, fetal.) M 1. !ii>ii 1^ ..■■'I k: I 986 INDEX. \\ * Fetus, development of, excess- ive, 305 of external form, charac- teritstio periods of, 94-101 stages (if, 04 diflerentiatioii of the sexes in the, 122, 123 digestive tract of, 140 development of, 112 dise.use of, Bidder's, 308 M tiller's, 300 Schmidt's, 308 diseases and death of the, coniplicating labor, 5(!4, 505 dorsal plane and small parts, location of, 350 ears of, lirst appearance and development, 132, 133 erysipfr-.s, infection of, in titero, 243, 297 evisceration of, in delivery, 938 head of, aiiatoniy, 402 articulations between the, anil the spinal col- umn, 400 diameter of, relative valtie of the, as compared witii the (liuneter of the pelvis, 404 dimensions, 403 heart-sounds, detection of, 1(38 hydrocephalus of, 310 ill extra-iiterine pregnancy, 282 influep 'e of diabe'es upon the, 219,220 of eclampsia upon, 027 intra-uterine iVactiiics of, 300 amputation, 300 in tubal extra-uterine preg- nancy, 280 in utero, absorption of, 312 attitude of 3.S5 death of, 310-312 resulting from faulty de- velopment, 31 1 i'rom extenud vio- lence, 312 from the annexes, 311 from the father, 310 from the mother, 310 diseases of, 295-317 eruptive, 290 "habitual death." 311 life or death of the, diag- nosis, 175, 170 post-mortem changes of, 312 lengths of the, at different periods of gesta- tion, 103 life or deiiili of, diagnosis, 175 Fetus, lithopedion, retention of, in utero, 313 luxations of, congenital, 301 maceration of, 312 operation after, in extra- uterine pregnancy, 295 malformations of, causes, 253, 254 or marking, through ma- ternal impressions, 213 measles of, in utero, 243 membranes of the, compli- cating labor, 570 movements of the, 167 abdominal signs of, 1G6 influence of, on presenta- tion, 421 location of, 350 period, 101 procedure for detection of, 108 supposed, lOH mummitication of, 313 operation after, in extra- uterine pregnancv, 295 nervous system of develop- ment, 125 nutrition and growth, 136 organs of special sense of, development, 129 overgrowth of, complicating labor, 501 diagnosis, 503 pemphigus of, 309 peritonitis of, 309 physiology of the, 130-142 (See Infant.) pneumonia of, congenital, syphilitic, 298 position ol', classification, on I defined, 3S0 in vertex presentation, diagiKisis, 422 etiology, 422 prognosis, 423 pre-natal functions of, 140- 142 secretion of urine, 140 presentation of defined, 385 diagnosis, 407 etiology, 418 inlhience of gravitv on, 418 prognosis, 416 presentations of, classifica- tion, 380 conditions influencing, 421 (See I'lr^riildlions.) putrefaction of, 313 rachitic, 307 respiratory and metabolic changes, 139 tract of development, 118 saponification of 313 scarlatina afleciing, in utero, 243 Fetus, scarlatina and measles of, in utero, 296 sex of, recognition of, 123 "spontaneous evolution of," mechanism, 488, 489 strangulation of, 300 struma of, 309 syphilis of, in utero, 297 tuberculosis of, in utero, 297 tumors of, complicating la- bor, 504 congenital, 301,309 typhoid infection of, in utero, 242 vaccination of, protection by, 244 variola of, in utero, 297 veins of the, 110 version, in delivery, 943- 968 Fetus and uterus, adaptation, between 420 "Fetus papyraceiis," 144, 313 Fetuses, attached, 302 double, 305 twin, intervals in births of, 144 membranes of, 143 placenta' of, l43 Fever, milk, puerperal, 655 puerperal. (See Infection.) scarlet, puerperal. 780 typhoid, complicating preg- nancy, 241, 242 Fever-cot, Kibbee, 729 Fibroid, uterine, simulating f)regnancy, 173 Fibroids in pregnancy, surgi- cal operations for, 248 puerperal, hemorrhage due to, 743 uterine, 185 treatment, 186 Fibromata complicating labor, 557 prognosis, 558 Fillet, use of in breech labor, 477 Fimbria' of the oviducts, 50 Fissures of the nipple, 747, 749 Fistula, vesico-vaginal, in pregnancy, 193 Fistnlie, mammarv, puerperal, 706 Flexion, mainteuHiice of in posterior positions of the head, 453 management of, at the pas- sage of the excava- tion in posterior j)ositions, 453 mechanism of, 432 in anterior presentations of the brow, 408 in posterior presentations of the face, 412 due |iuil, in I'.ili |iiL'i'\it'i'al, of, in Ipositiiins la, 4'):'. the [iiis- ; exi'iiva- jKistt'i'ior |4r);{ jationsnl' I4(i8 liiticmsdl' ivi Flexion, operative, at the su- perior strait in pos- terior positions of tiie vertex, 4")() re-estabiishnient of, in pos- terior positions of tlie liead, •»•").'> Flexion of uterus, oirlusion of locliial How, 741 Floor, pelvic, 30 blood-vessels of, 3.") injuries to, 30i) nerves i)f, 3(5 veins of, 3(1 Fluid, anniiotic, 84 Fluid-pressure, intra-uterine, 433 influence of, on dilatation, 424-427 Fa?tus sanguinolentus, 312 Folds, genital, 123 Follicles, ovarian, number of, ()0, (il Fontanelle, anterior, 403 lateral, 403, ii. occipital, posterior, 403 Fontanelles of fetal head, 402 Food for the new-born, 859, 860 morbid longings for, in preg- nancy, KiO selection of, in pregnancy, 180 Footling presentation. (8ee I'lfHriittdidH.''.) Foramen ovale, 107 Forceps (obstetric), 884-017 action of, 8',I0 articulations of, S8S as a compressor, 890 as a lever, 891 as a rotator, 891 as a tractor, 890 axis-traction, 889 catch-, use of, in internal version, 9C5 craniotomy, 930 compressing, 931 Micks', 931 Lusk's, 931 small, Meigs', 933 "doubie-curved," 888 forms of, SS8 indications for use, 801,892 operation of the applii'ation of, divisious, 802 ovum, Schnllze's. 873 removal of, iluring opera- tion, 898 rotation f in deliverv of head, 897 selection of, S88 proper model in, 889 traction of, in low opera- tion, 89(1-808 use of, after rupture of the symiihysis, (i40 in inertia uteri, 49") injuries to the new-born from, 82o INDEX. Forceps, injuries in labor com- plicated by cardiac diseases, 042 varieties of, 880-887 Forceps, application of. dan- gers of, 899 in face presentations at the brim, 4(14, 4(1') in high arrest in breech labor, 477 in high ojieration, indica- tions for, 898 in breech presentations, 902 in brow a'ld face pres- entations, 901 in left-lateral position, 903 in occipito- posterior po- sitions, 900 to the after-comir.fr heiid, 480, 902 to the severed head, 903 in low arrest in breech labor, 478 in low operation, in dorsal l)osition, 893 position for, 893 preparation for, 893 in matuuil rotation of pos- terior positions of vertex, 451 methods of, 892 of rever.sed, in flexion, 454 (See IhUvi'ni, fi)icrp^.) Forceps of Uarnes, 889 of Davis, 888 of Dubois, 890 of Hodge, 889 of I'ajot, 890 of Sawyer, 888 of Simpson, 889 of Simpson-I'arnes, 889 of Wallace, 888, 889 of White, 889 Forceps, axis-traction, of liarnes, 880, 890 of Lusk, 8S9 of Naegele, 890 of I'oulet, 889, 890 of Simpson, 889, 890 of Stevenson, 889 of 'rarnier, 889, 890 Fore-gut, 1 13 Formations, fetal, double, 305 Fossa navicularis, .37 ovarii, 59 Fo.ssu', ischio-rectal, 35 Foin'chette, anatomy, 37 l'"ractures, intra-uterine, 300 pelvic, 5,31 Freiuim I'litoridis, 38 Fundus of uterus, 47 I-'ungus, umbilical, 833 <!ait, changes in, of preg- nancy, 15() ( iaiactocele, 7(17 (ialaclorrhea, 772 symptoms and treatment, 77 J 987 Gangrene of the navel, 837 of the vulva, 551 or vagina, treatment, 721 " lliirtner'b duct," 02 ( lavage, 8()5 (ieneration, organs of, fcnuile, anatoinv, 17, 30- 70 changes in, during preg- nancy, 150 external, anaiomy, 3C intermediate, anatomy, 1 internal, anatomy, 45 physiology of, 70-73 Genitalia, the, .30 (ienitals, female, external, during pregnancy, changes in, 150 Gestation, contractions, uter- ine, during, 318 ectopic, 273 diagnosis, 520-528 simulated by retroverted uterus. 195 extra-uterine, tnbo-titcrine, or interstitial, 281 tidjal, 280 injuries as allecting, 249, 250 length of fetus at dilil'rent periods, 10.'! medication favoring, 184 menstruation during, 72 mvomata in, influence of, 18(1, 187 prolonged, 178, 179 sm-gical operations as aflect- ing, 251 (See I'l-fijiKiiicii.) Gestation-sac, extra- peritoneal evacuation of, in extra-uterine preg- nancy, 294 rupture of, in extra-uterine pregnancy, treat- ment, 293 (ilands, alimentarv, j)re-natal, 140, 141 mammary, care of, during pregnant'v, 181 changes in, due to preg- nancy, 151 congestion anil engorge- ment of, 751 faidty development, 773 inllamniaiiou <if, 75(1 7(12 in the uew-liorn, 840 of infaiUs, 827 structure of, (15 su|i|)uraliou of, 702 7(18 of liartholiii, 38 of lirunner, fetal, lit of .Montgomery. (Ill, 153 salivarv, of the new-born infant, 800 sexual, development of, 121, 122 .iterine, 49 vaginal, 45 (ilans clitoridis, 38 •■'!< u ir ik r 1 1' i; ki I ■1 i'. It \ ! i S ( !:f 988 INDEX. Glycerin, injection of, in the induction of pre- mature labor, 8H7 Glycosuria of the nuerperiuni, 650 Goitre during pregnancy, 21^5 Gonorrhea of pregnancy, 23!) (Jraafian follicles. 59, CO, 71 (iroove, genital, 123, 124 j)riinitive, 78 Growth of new-born infant, 807 Hairs, fetal, development of, 101 Hand and a foot presentation. (See PreKenlntionii.) introduction of, in operation of internal version, !)()4 Hare-lip, congenital, 302 origin, 98 treatment, 302 Head and a hand, pres'jntation of. (See Pnvcnidliniis.) and arms, extraction of, dif- ficult, in breech presentations, 480, 484, 487 rapid, in breech labor, 480 high arrest, in breech labor, 482 Head, fetal, 402 arrest of, at the inferior strait, in breech presentations, 487 due lo contraction of the pelvis, 487 from e x t e n s i o n, in breech labor, 486 articulations between the, and the spinal col- umn, 40<i at fifth month, 101 compression of the pro- montory on the, in contracted pelvis, 52(i configin-ation of, after moulding in face hibor, 4(iO craniotomy of after- coming, 935 of the presenting, 934 upon the, 92(1-938 (leiivery of, arrested at the superior strait, 484 forceps, of after-coming, ill high operation, !)(t2 compression in, 890, 891 depressions on, in engage- ment wiili the pro- miintorv. 51.'! descent of, in jiisto-minor pelvis, 51 ti Head, descent of, in obliquely- contmcted pelvis, 520 rotation of, in, 512 (See Descent.) development of, 95-101 diameters of, relative value of, as com- pared with diame- ters of the pelvis, 404 dimensions of, 403 entrance of, into the pel- vis in posterior positions, 442 expulsion of, regulation of, 370-373 _ obstetric position in, 371, 372 large, com()licating labor, 563 management of the pas- sage of, in poste- rior positions of the excavation, 453 manual rotation and the application of for- ceps in posterior positions of vertex, 451 moulding of, in brow pres- entations, 466 operative delivery of a high arrest of, in posterior positions of vertex, 451 flexion, in posterior po- sitions, 450 overlapi)iug of cranial bones of, in engage- ment at the supe- rior strait in a rachitic pelvis, 527 passage of the excavation of, in right-poste- rior positions of vertex presenta- tions, 444 of the superior strait of, in posterior jiosi- tions, 450 restitution of. in expul- sion, 439 in occipito-posterior po- sition, 448 rotation of, in ilescent, 512 forceps, of, 891. 898 in face presentations,460 in poorly Hexed right- anterior positions, in vertex i)resenta- tioiis, 445 in unllexed right-poste- rior positions, in vertex presenta- tions, 446 in weil-llcxcd right- posterior jiositions. In vertex presenta- lioUN 144 Head, shape of, irregular, 433 sutures and fontanel le.s, 402 unequal lengths of the ends of, in descent, 432 Head, hind, fetal, undue length of, in face presenta- tions, 458 Head of the new-born, injuries to, 824 Hearing, sense of, in the new- born infant, 812 Heart, diseases of, complicat- ing labor, 642 pregnanev, 237 fetal, 104 conversion of, from the sin'-'" to a double. It enibryon: >age, 95 preponderance of size, 101 pulsations of, 169 hypertrophy of, in preg- nancy, 154 in puerperal infection, 688 malformation of, congenital, 304 of the new-born infant, 809 Heart-.sounds, fetal, 168 diagnosis of presentation by, 410 during labor, 365 in breech labor, 475 in extra-uterine preg- nancy, 286 Heart-tones, fetal, location of, 354 Hegar's sign of pregnancy, 164 Hematoma complicating labor, 680 etiologv and symptoms, 680 treatment, 682 of the sterno-inastoid, 824 of the vulva, 191 Hematomata obstructing la- bor, 549 Hematuria complicating preg- nanev, ti-eatment, 197 ■ puerperal, 790 Hemicepbaiia, 304 Hemorrhage, aci idental, 596 concealed, coiiiplicatiiig pregnancy, 2(10 diagnosis, 201 mortality, 200, 201 prognosis, 202 symptoms, 200, 201 treatment, 201 etiology, 597 prognosis, 599 symptoms, 598 treatment. 599 cerelmil, 818 822 during pregnancy, 212 puerperal, 790 congenital, from the female genital organs, 853 ' I I INDEX. 989 Heiuorrhuge, gastrointestinal, diagnusis, 854 prognosis, 854 symptoms, 854 treatment, 854 dystocia due to, 581 from intrapelvic tumors, treatment, (582 from lacerated cervix, treat- ment, GIG from the uterus during preg- nancy, 238 in Cesarean section, preven- tion of, 920, 921 in extra-uterine pregnancy, 285 in placenta prajvia, 589-592 in symphysiotomy, 907, 915 in syphilitic infants, 299 in the new-born, diathesis of, 852 treatment, 85S intra-ulerine, 877 treatment, (itW by bandage and tampon, GOG by bimanual compres- sion, G05 by compression of ab- dominal aorta, GOG by uterine injections, G04 of abortion, 2G3, 2()4 of pregnancy, caujes, 590 post-partum, GOO etiology, GOl prognosis, G02 symptoms, G02 tampon in, intracervical, 874 puerperal, causes of, 739-745 diagnosis and treatment, 740 due to fibroids, 743 from maligiutnt disease, 744 from jielvic congestion, 744 from relaxation of the uterus, 743 from secondary bleeding, 744 from separation or disin- tegration of tliroin- bi in the sinuses at the placental site, 742 umbilical, 828 diagnosis, 8;{2 etiology, 830 from ruptured cord, 580, 581 symptoms and signs, S.'il therapeutics of, 8:i2 Hemoptysis complicating pregnancy, 2;)S Hemorrhages in labor, (i;!S in the pucrpcriiuii, 738 Hemorrhoids, puerperal, 785 Hepatitis, symptoms, 706 treatment, 731 Hermaphroditism, 125 Hernia, cerebral, congenital, 304, 821 complicating labor, G38 inguinal, congenital, 303 and umbilical, of the new- born, 858 of the uterus complicating lab(U', 552, 553 umbilical-cord, anatouiy, 833 clinical appearance, 834 diagnosis, 834 operation for, 83;>, 834 ])rognosis, 834 treatment, 834 vaginal, complicating labor, 559 HerniiT funiculi unibilicalis, 833 Herpes of pregnancy, 211, 212 Hilum folllculi, 71 Hind-gut, 114 Hips, fetal, relation of the, in the mechanism of labor, 40G Hook and crotchet, 933 decapitating, 933 Hospitals, puerperal infection in, prevention of, 710 I f vdatid, stalked, of Morgagni, G3 suppurating, of the abdo- men, 199 Hydatids of Morgagni, 123 Ilydraumion, 311 death of fetus from, 311 determination of, 35() I Iy<lrencephalocele, 819 Hydrocele, congenital, 303 Hydrocephalus complicating labor, 505 diagnosis, 5G5 treatnicut, 5GG fetal, 309, 310 Ilydrometra sinnilating preg- nancy, diagnosis, 17;'. ■ Hydrorrhcea gravidarum, 255 llydrothorax, fet;.l, 309 Hygiene and thera])eutics of infant soon after birth, 859 Hygiene of pregnancy : —bathing, ISI — clotliinu', 181 —diet, 18(t — exercise, 180 —rest, 181 — sexual interc()urse, 181 Hymen during llie puerpe- fiuiti, 052 rupture of the, 39, 40 structure of tlu', 39 uiu'uptured, 549 variations in shape of, 39 Hyomaudibular clelt, 9S Hyperemesis, G37 etiology, G37 treatment, G38 Hyperlactation, 777 treatment, 778 Hypertrophy, decidual, 189 causing uterine hemor- rhage, 740 of i)lood-vessels, 14G of breasts, 152, IGl of cervix, 140 of heart, 154 of liver, 155 of nipple, 153 of spleen, 155 of uterus, 14ti, 185 nuicous membrane of, 145 of vagina, 150 Hysterectomy for puerperal sepsis, 972 for uterine fibroids, 18G, 187 indications lor the opera- tion, 974 in uterine cancer, 187 technicjue of the operation, 975 Hysteria of pregnancy, 221 IiK-HAo in mastitis, 701 in treatment of peritonitis, i 72G, 729 ! Icterus of the new-born, 82G symptomaticus, 843 Idiocy, congenital, 309, 310 ' syphilitic, 310 Impressions, maternal, 305 inlluence of, 213 I op|)()sing theories, 300,307 I results of, 182 i Incision, abdominal, in Cesar- I can section, 919,921 uterine, in Cesarean section, 920 I Incisions, symphysiotomy, 913 Incubators, infant, 8(53, 8ti4 Induction of aliortiou, .s78 of labor. |irematin-e, 878 cousiderations involved, 882 electricity in, 8SI indications for, S78 operation, methods of, 879-881 Cohen's, 880 Kiwisch's, 881 KruseV, S79 I'elzer's, 88 1 Scheel's, 879 prognosis, 879 time to operate, 879 Inertia uteri, I'.tli diajniosis, 494 etiology, 493 trealuieni, 495 Infant, cloth lug of the. 11(10, GG7 early life of, deviations from some of the ]>alh(>- logical |iriicesses which characlerize the, 82(1 :iiiii III 11 ■r ^* I :i f\ !. ' i i ^^1 .-.Hi 990 INDEX. Infant, feedinjj of the, arti- lioial, t)(;8 ingestion of drugs bv, tliroiigli the breast- milk, 770 new-born, apoplexy of, 822 aspliyxia of, 818 extra-uterine, SI") intra-iiterine, 81-1 atelectasis of, 8-J2 body -growth of, 807 bones of, 81 1 Buhl's disease of, 843 eare of the, ti(14 hygienic, iinniediatelv after birth, 8.')!) catarrh, se[)tic gastro-in- testinal, 8.')0 chest growth of, 808 circulatory system of, 809 colic in, 8')4 consiiiiation in, SoG laxatives for, 8(il diarrhea in, 8").") diathesis, hemorrliagic, of, 8o2 digestive system of, 809 diphtheria of, 8ol disejises of, general and iinelassilied, 80I infectious, 8.'!.") of the navel of, 827 fat of, 811 feeding of, 850, SdO growth of head, etc., 80S hemorrhage from the fe- male genital or- gans, 8'>;! gastro-intestinal in the, 853 hernia of, inguinal and umbilical. 8.'!3, S.>S icterus sy nipt omaticiis, 843 Inl'ection of the digestive and respiratory tracts of, 80O etiology, 80") frequency, 8.')") pathology, 83(1 sym])toms, 830 intestinal obstruction in, 8.-,7 la grippe of, 840 length of, 808 lymphatic system of, 811 mastitis in, 840 melcna of, 84o nnisdes of, 811 nniscidar action in. 812 navel wound of, disturb- ance in, 832 nervous system of, 811 nursing of, Otil ophthalmia of, 847 parotitis of, 840 [latliolo^y of, 813 I See I'dthiiliKiii.) pemphigus of. 845 lieritoncal abscess of, 858 peritonitis of, 840 Infant, new-born, phlegmasia of, 840 physiology of, 807 (See PlijiKiology.) respiration of, 80S rhinitis of, 851 sclerema of, 851 septicemia of, 687 skin of, 810 special senses of, 812 stomatitis aphthosaof, 850 syphilis of, 840 temperature of, 81 1 tetaiuis of, 841 therapeulii's of, 800 thrusli of, 850 traumatic injuries of, 823 tuberculosis of, 847 mnbilical hemorrhage, 828, 82i) iH'inary organs ol", dis- turbances of, .S58 urinary system of, 810 weight ol', 807 conditions inlluencing the, 808 increa.se in size and, 808 AVinckel's disease of, 844 wound-int'ection of, 830- 838 niM'sing of the, 0(')7 preiiuiture, delined, 802 bo(ly-temperatureof,main- tenance of, 802 nourishment of, 885 jirevention of exhaustion, 804 vitality of, instances of. 407 weaning of, 707, 773-775, 777 wet-nuising of the, (iOS Infants, premature, 802-805 care of, 8t;2-805 nourishmeiU of, methods of administering, 805 stimulants for, 8()l syphilitic, 208 heuiorrhage of, 200 liere<litarv, treatment of, 8(n Infection, gonorrluval, in preg- nancv, treatment, 230 ' in the new-born, 835 from wounds, 830-838 of the digestive tract in the new-born, 850 of the respiratory trad of the new-born, 850 puerperal, 083 contagion of, GS9 (liHerent forms of, 085 due to acute constipation, 780 due to causes other than puerperal infec- tion, 778 due to diseased conditions, 780 Infection, puerperal, due to emotion, 778 due to exposure to cold, 778 entrance of the poisons of, 091 epidemics of, 090, 091 etiology, 087 mortality, 093 nervous disturbances in, 700 non-infectious, 778 of the bladder, 787 of the limbs, 707 of the urinary tract, 780, 787 j)athology of, 094 prevention of, antiseptic precautions, 712- 714 in hospitals, 710 in private practice, 717 putrefaction causing, 090 skin diseases due to, 707 sources of the poison, 089 symptoms, diagnosis, and prognosis, 098 su]tpuration causing, 089 time of, 093 treatment, 708 curative, 719 zvmotic (li.sea.ses causing, 091 septic, celiotomy for, 908 following Cesarean sec- tion in uterine can- cer, 187 in syphilis of pregnancy, 240 small-j)ox, in pregnancy, 244 syphilitic, t)f jiregnancy, diagnosis an<i prog- nosis, 240 treatment, 240, 241 tetamis, in pregnancy, 241! typhoid, of pregnancy, 241 Infundibulo-pelvic ligament, 52 Infundibidm)) of the oviduct, 50 Injection, inlra-uterine. 715 in endometritis :md metri- tis, 723 in the induction of labor, 880 intravenous, of normal salt- solution, 009 vagiiud, during pregnancy, 181, 182 Injuries, mechanical, <liMing pregiiiincy, 249 nerve, following liibor, 791 perineal, prevention of, 30!>, 374 to the external genital organs following lalxir, 072 to the intravaginal jiortion of the uterus, 014 J: Injuries to the perineum fol- lowinjjf labor, (iT.'l to tlie viigina following labor, (178 to the vulva following labor, (572 traumatic, of the new-born, 823 Inlet, pelvic, anatomy of, 18 axis of, 20 dimensions of, 18 measurement of, oOl— ')09 oblique diameters of, meas- urement, oO!t transverse diameter, meas- urement, 507, 508 Insanity of eclampsia, C28 of labor, 71*7 of lactation, 798 of pregnancv, 797 puerperal, 794-SOl classification of types, 798 diagnosis, 799 etiology, 794 pathology, 797 prognosis, 799 symptoms, 797 treatment, 799 Inspection, abdomin;d, diag- nosis by, 407. (See Palpation. ) Instrument-table, e<iuipment of, in internal ver- sion, 957 " Internal os of Hraunc," 583 Intestines, malformation of, i congenital, 303 of the new-born infant, 810 anatomical pecidiarities of, 856 obstruction of, in the new- born, 857 Intussusce|>tion in the new- born, 857, S58 Inversion of puerperal uterus, 742 of the uterus, (U6 diagnosis, t)19 etiology, 018 freiiucncy, 617 post-mortem, (')46 prognosis, 021 symptoms, ()19 treatment, 621 varieties, 617 with prolapse, 619 Involution in the jjuerperiimi, 652 tardy, 197, 662, 734 Irrigation in breast-abscess, 763 vaginal, in the induction of prenuitnre labor. 881 in treatment of vaginal liiceratiims, 679 utility of, 346 Ischiopagns, 305 Isthnuis of the oviduct, 56 Isthmus uteri, 46 INDEX. Jaundick during pregnancv, 232 treatment of, 232 "Jelly of Wharton," 94 Joints, pelvic, ankylosis of, 531 relaxation of, 532 KiUN'KV, displaced, complica- ting labor, 639 of the new-born infant, 810 "Kidnev of i)regnancv," 197, 198 Kidnevs din-ing pregnancv, 197 fetal, development of, 118- 121 in toxemia of pregnancv, 205 of the eclamptic, 630 Kiesteiii, 163 Knee-and-elbow i)resentations, diagnosis, by vag- inal examination, 416. (See J'resi-n- talioii.i.) Knots of the cord, 258 Koumijs in stomach disorder of pregnancy, 183 Kyphoscoliosis, 540 Kyphosis, 537 Labia, elephantiasis of, 192 fetal, devclopmeMt of, 125 Labia majora, anatomy ol', 37 minora, 37 Labor, mechanism of: auatomv of the pelvis in, 388 — infra|)elvic portion, 397 — pelvic portioti, 390 — sujirapelvic portion, 389 of the male and female pelvis, ditli'rences between, 398 of the parturient canal, 397 classification of, 386 of |iosition, 387 of presentations, 386 -natural and uimat- ural, 386 — normal and abnor- mal, 386 diagnosis, 407 bv abdominal inspection, 107 by auscultation, 410 by examination, sinnmary of diagnostic signs fiirnislied by, 411 by jialpation, 407 bv vauiiial examination, 411 of presentation, frequency of each. 4Ui summary of signs of each presentation, 414 991 Labor, mechanism of, in breech presentation, 415 I — brow presentation, 415 — face ))resentation, 415 I — head or a foot presen- tation, 415 — knee and the elbow l)resentation, 416 — transverse presenta- tions, 41(1 fetus, the, 401 attituile of, 385 bodv of, 406 head of, 402 arti<'iilations between the, and the spinal column, 406 diameters of, relative value, compared with diameters of the i)elvis, 404 dimensions of, 403 position of, (lelined, 3.S(; presentation of, defined, 385 presentations, 417-492 brow, diagnosis, 466 etiology, 4il6 freiiuency, 166 management of, at the brim, 467 mechanism of, 466 prognosis, 466 face, diagnosis, 4."9 etiology of, 458 frc(|U(n('y, 458 nuuiiigcment of, 462 mech;misni of, 460 of posterior, M. D. P., 162 prognosis, 459 footling, mechanism and manngement, 487 pelvic, diiignosis, 470 eiioloiry, 470 fre(inency, 470 management of, 474 meciianisin of, 470 prognosis, 470 transverse, diagnosis, 488 etiology, 487 fre(iuency of, 487 management ot', 489 mei hanisni of, 488 prognosis of. 488 vertex, 417, 458 — posterior positions of, 442 — the first stage, 417 — the second stage, 430 —the third stage, 440 prognosis of, 416 Labor, normal : anesthetics in, 'M'2 administration of, 363 choice of, 3(13 antisepsis in, 341 abdominal binder in, the, 384 J'ls ill II j .'i •J t ,» ! ; t 992 ixnh\y. n- ' It J Labor (ni)rm!il), breech, nor- Diiil luana^enient of, -l".') eathiter in, imssin^ of tlie, 808 clasiiiticatioii of, ;?S() coiuliii't of, ;> 11-K84 in hospitals, 71(1-717 and jirivale |)raetiec compared, 717, 718 antiseptic, in hospitals, 714-717 in private })ractice, 718, 71S) contractions, uterine, after, I>77, lii 8 defined, ;U8 delivery of the head, maii- aijenient, ;}70-;{73 of the trunk, ;>7I descent of feltis in, second stage ol', ■i'M detachnicnl and expidsit)n after, 440 diaj!;nosis liv abdominal ans- >'uliation, 410 l>alpatioii, 407 dilatation in, niechanisni of, 4'J4, 8>-' disinfection in, rules, !M.'> expulsion of fetal shoulders, I 4;!'.» ! examination, abdominal, | during, 8(1") diagnostic signs fur- nished by, 411 vaginal, 80(5 fretpiency of. o(i9 techiii(iue of. 41 1 forces acting in, i'S-i injuries to the external geni- tal organs, follow- ing, ()72 to pelvic floor, during, l)i'evenlion of, liC'J ligation of cord after, 875 management of, 84S of patient after, ()57-G71 of the cord, 874 of the lirst stage, 807 of the .second stage, 808 of the third stage, 87() relation of the fetal hips in the, 400 of the fetal shoulders in the, 400 of the fetal trunk in the, 4(10 obstetric position in, 808 onset of cau.ses, :!18 over-distention of uterus causing, 8'JO phenomena of, 80r> Labor, physiology of, 818- 888 clinical course of the, 888- 840 — beginning lubor, sigiis of, 883 Labor (physiology of \ change in the pelvic floor, 887 — duration of labor, 840 delinitions of, .818 phenomena of", 8'21-8.'i8 — action of abdominal nnisclcs, 1)28 — action of the vagina, 8'J4 — bag of waters, 880 — changes in the body of the uterus, 82".t" — changes in the cervix, .824 — changes in the lower uterine segment, .827 — character of the li(i- nor anniii, 822 — formation of caput succedancuni, 888 — uterine contractions, 821 lireniature, detined, 2.")",), 818 |)resentations, contact be- tween breech and fundus in vertex, 4.88 vertex, diagnosis of posi- tion in, 422 by vaginal examina- tion, 414 etiology of position, 422 flexion in second stage of lalior in. 4,82 force of gravity in, 482 l're(picncy of, 4l7 influence of gravilv, 418,421 infra-uterine fluid-pres- sure in, 4i>8 irregular shape of fetal skull in, 4.")8 mechanism of descent in, 481 of left anterior posi- tions, 440 of right posterior po- sitions, 442 prognosis, 41() of position, 428 rotation in, 48"), 488 une(iual lengths oi the ends of the head in, 482 prognosis of, 800 repair of lacerations after, 870 method of, 880 restitution of fetal hea<l. 480 retraction of uterus, 488 rotation of fetal shoulders in, 48!) rupture of membranes in, 8()8 third stage of, miuiagement, 442 mechanism of, 4 10 toilet of patient after, 882 vulva, dressing of, after, 888 Labor, pathology of: deliverv in, bv basiotripsy, ■ 087 by cejihalotrip.sy, 087 by Cesarean section, 028 " indications, 017, 018 the operation ot', 010 preparation for, gen- eral, 910 time to operate. 018, 010 (See ( V.s(ii'C((» fccliiiii.) by cranioclasis, OliC) by craitiotomy, 020 by end)ryotomy, 020 by fetal "decapitation. 0.88 by fetal evisceration, 088 by biparo-elylrotomy, 02") bv svmjthvsiotomv, Oor)- 017" by version, 041-008 in dor.so-anterior posi- tions, Ool in dorso-posterior posi- tions, 054 bv the I'orro operation, 024 of the after-coming heiid, after craniotomy, 085 of the presenting head after craniotomv, 084 forcep.s, compression in, 800 high operation, 808 008 indications for, 801,802 low operation, 808, 890- 808 operation, tlie, 892 traction in, 890 chorea in, inlhience of, 210 complications during, 800 death in, sudden, 044 diseases, infectious, compli- cating, 088 784 of the brain complicating, (i48 of tlu^ lu'art complicating, (i42 displaced kidnev complicat- ing, 080 eclampsia in, occurrence of, 021 ele|ihanliasis compliciiting, 102 eventration (tomplieating, 080 forces of, anomalies in the, 408 deficient power in the, 408 expulsive power of, exces- sive, 497 hematoma complicating, 080 heinorrhiige in, accidental, 500 hemorrhages in, 0."iS hernia complicating, 088 induction of premature, 878 i I IT Lulior ^|iallii>li>v'.vl, iniliiclinn li of iiri'iiiMliirc, !is)ii- ration of till- iilt'i'iis l'<ir, SSI iiiili(-a<i(iii> I'lir, S7S j in I'danipsia, (i.'lT I in placcnla pru'via, "tiMi in |Milvliyiiraniniiis, '2')',\ irrlKalion ol' llic vMKiiiii lor, HSO ()|H>rnliiin, nu>tli<iils ol', S7<» j prognosis, ST'.t Hnffjical opiTalions lor, H7S lainponin^r I he va^'iiiii lor, sso tinio to operate, ST'.I infeelion, Heptie, lollowinfj, ()H7 flSlt injuries |o llie inl'ra-vaKinal po r t i on ol' (lie nteruH in. till )i|(> in inanaKeiiient ol' I'aee pre.s- entalions at llie liriin. 111;! insanity ol', 7'.i7 intrapelvie liiinors eoinpli- eatintc, (ISO CSli | inversion of the uterus in, (ill) i;-j:t j JiiHlo-niiuor pt^ivis in, inllu- ence of, ol") kypliolie pelvis in, inllu- enee ol", .");!',» Iiieeratioii anil rupture of tile uterus in, (illl iniinaKCiueut of, olistrueted Ity llie eoliiiuoiiesi foiiiis of eonlraeled pelvis, r)|;t of tlie eoi'il, patlio|ouii'<i| eoiKJilioiis ill the. ilioeliaiiisni of, with lioulile iMonsli'i's, otilt, "((I I in posterior positions of vertex, iiislruiiu'iit- al operations, lot, 4.').-, "iniHScd," -72 narrow, funnel shapeil pel- vis, iiiliueiice of, 517 neural and spinal alleeiions following-, 7111 treatiiieiit, 7'.t I (thli(|iiely-eoiitra('ted pelvis, inlliieiiee of, ^'Jd oitHtrili'tion to, hy almoriiial- ili(>s ill the fetal appeiida;;es, "i7() hy anus vayiiialis, ."lod hy ('(lils of the cord, .'"i7il hy closure and eoiilrailiou of cervix, ol7 of the vauiiia or vulva, 'il!) by (^(iiitrenital anomalies of the uterus, "illi 6» iihor ( paiholo^'y 1, olistriielion ! to, hy narrowness of vavrina and viil- | va, .Vil I hy displacement of cer vix, .■>.">( i of uterus. •'<:>'! hy edema of vulva, o")(i hy faulty posilioiis of the uterus, 'ilid hy felal enlerocele, ."ill I hv ,u;aii^;rene of the vulva, .-..-.1 hy lieinatomata, >'• I'.l hy lualpreseiilatioiis. ."i(l(» hy multiple hirtlis, .'ili7 hy pl.icenla piievia. oSI liv prolapse of cord, ")7.'f ")7() of uterus, !'f'i'.'> ■")■")•"• hy rij^iility of tissues of the pa r t 11 r i e n I canal, ofd, o.'i'J hy sacculation of the uterus, o"i;', hy shortness of cord, o77 hy tilliiol's of the Kcliiliil canal, r).")!! liy vaginal atresia, o'ld and vulvar tuiiKU's, .'(rid cicatrices, 5 I'.t enlerocele. ■>■>'.) hy llie soft maternal slriic- (ili'cH of (he partu- rient canal. ■'> Hi symphysiotomy in, !l| I osleiinialacic pelvis, inlhl- eiice of, rrJit paraplegia coinplicatiiiLr. (i l.'t pneumonia coinpliiatiiiK, i;ii positions, ohstetric, in. '.to'.t !l(i:t post-part nm hemorrha^'c, (iOd, (idl preinallire. (See liiihiilioii.) pri'wentations in hreccli. ar rest of an aim lie- liiiid the occiput in, IS I I arrest of the head at the inferior strait ill, ■|S7 arrest of the head at ihe superior strait in, IHI j arrest of head at the | superior strait, use of I'orceps in. |s('i arrt;st of head clue to conlractioii ol the pelvis in, ■IS7 arrest from extension of the head in. tsi; arrest, hiLdi,ol llieMiiiis anil head in, (s-J arrest, low, of aiiris and head, methods of , delivery, ISd I !I!KJ Iiilhor (pallioloi:y ^. presenlii- tioiis in hicci h, closure of a coii- striciion rin^ ahouf the liei'k in. IS I dillicull extraction of head and arms in, ISI diagnosis of, hy va;iiniil examination, 115 operative tri'iitmenl. 17(1. 177 pro^iiosi'. of, 1 17 rapid extiaclion in hi^h arrest, l7o in low arrest, 'ITH hrow. Kid diii>?nosis hy vai^iiial ex- amiuatiiin. 115 pronnosif., 117 eompound. complicalin^, .")(>(1, ."i(l7 etiolourv of, lis face, (lianiiosiH. hy vaginal exaiiiinalion, 115 mana^i'ment of, IdO niechanism of, |5S pmmiosi.s, III) foollini;. mechanism, ■\X7 hand and loMt,diauiioHis hy vaginal examina- tion, ll.'^i head and a hand, I'.l'J inlluence of gravity, I IK of fetal movements, 121 knee and clhovv, diagnosis hy vaf^inal exainin- aiinii, III) pelvic, I7d transverse, diiij^'iuisis hy vaginal examina- tion, IK) manajiemeiit, IS'.I mechanism. IS7, |S,S prof;noHis. 1 17 relative lici|ueiicy of four posilioiis, '1 17 vertex. iiialiai;cmeiil nf. in posterior positions, I lit (See I'liKiiitiiliniiK. I relaxation and riiptun' of pelvic articulations colllplil'alill^^ (i Id rachitic pelvis in, inllii ciice ot', 5'J('( sliocU compiicatiiiir, '• I I simple Hat pelvis in. inlhi encc of, 51 I spondylnlislhclic prdvis in, inlluence of, olid treatment, 51)7 tumors of the rectum coih plicalini.;, ():!!( twill, mecliaiiism of, 5(1K, 5mi varieties of. delilied, ;>|H diagnosis, l'i'e(pieiicy, and proLtliosis ol the several, Id7 vomiting' in, ^'<M illl I ^1 ; ■ \-'t 994 lyDEX. LaburpiiinH in extrauterine preKiiancv, '285 Labors, dry, oontra-iiidicatinp version, 04;) normal nieclianisin of de- scent in, 4;>1 Lacerations, cervical, ;{79, (il4 repair of, 37il pelvic- t'oor, after-eare of,382 prevention of, 8()1> repair of, liTi) types of, ;{71t, 381 perineal, l)7;>-()78 after-treatment of, ("7 repair of, method, 379, 380 vaginal, ('i78-(180 and vulva, suturing of, 720 vulvar, (17"J, 720 Lactation, t)54-(l(ll anomalies in, 7()8-773 arrest of, 707 i'leanliness of nipple during, 748 mammary glands during, changes in, 08 insanity of, 7',I8 jjcriod of, normal, 0")4-777 ' prolongation of, 777 La grippe, congenital, 84it diagnosis and treatment, 849 Lanugo, fetal, appearance and disapj)earanee. lOl, 102 Lajiaro-elytrotoiny, 925 Laparotomy in local peritoni- "tis, 730 in rupture of the uterus, 014 ^A'g, extraction of, in breech labor, 477 phlebitis of the, 097 symptoms, 703 Leukemia in pregnancy, 230 treatment, 237 Ligauient, ovarian, -VJ pelvic sacro-coccygeal, an- terior, 25 |)osterior, 25 sacro-iliae, anterior, 24 posterior, 25 sacro-sciatic, anterior, 20 posterior, 20 pubic, anterior, 23 inferior, 24 posterior, 23 su|)erior, 23 Ligaments, broad, removal of, sepsis ill puerperal 973 pelvic, 22-26 relaxation of, in preg- nancy, 202 recto-uterine, 54 round, 52 uterine, 51 anterior, 52 utero-sacral, 54 Ligature of the umbilical cord, 375, 829-832. (See Cord.) Limb8, fetal, first appearance and development, 95-101 injuries to, of the new-born. 824 puerjienil infection of, 707 Linea' albicantes, 150, 175 " Lipoid (Icgcneration," 312 Liquor amnii, 138 follicidi, 171 Lithopedion, 283, 313 Liver, fetal. 118. 141 atrophy of, acute yellow, during pregnancv, 232 hypertrophy of, due to preg- nancy, 155 of the new-l)l^ru infant, 810 ' of the eclamptic, 030 Lochia alba, 054 micro-orgiiuisins in the, ()54 ' puerperal, 054 rubra or eruenta, ti54 serosa, 054 Lordosis, 540 Lungs of the eclamjitic, 030 I Lutein, 01 i Luxation of the femora, 541 j Luxations, congenital, 301. Lymphangitis, 095 and i)hlebitis, ditlerentiation of, 705 diagnosis, 701 symptoms, 700 treatment, 720 Lymphatics, mammary, ()9 of internal organs of gene- ration, 04 of the new-born infant, 811 vaginal, 45 living-in, regulation of the. ti04 Lying-in room, 307 j pivpanition of, 3.")9 ' ventilation of, ()59 Maceration, fetal, 273, 283, i 284, 312 Malaria, puerperal, 782 diagnosis, 782 treatment, 782 Malformations, congenital, 299 of the brain, 304 of the circnlatorv appa- ratus, ,304 ' of the cord, .304 of the extremities, 304 j of the generative organs of female chil(iren, ' 303 ; of the stomach, 303 fetal, complicating labor, 503 Malpighian bodies, 119-123 : Malpresentations complicating j labor, 5f)0 Mamma', the, 05 abscesses of the, 702 blood-ves-sels of, 09 changes in, due to preg- nancy, 152, 102 Mammr olianges in, during the puerperium, (554, 055 nerves of, 70 position of, variations in, 70 supernnmerary. 70 Mammillaplasty, 748 Management of the puer- perium, 057-071. (See I'licrjxriiim.) Mania complicating preg- nancy, 222 of pregnancy, 159 diagnosis and prognosis, 222 treatment, 222 (See fiL^iuilli/,) Ma.ssage, breast, 001, 750, 755 in agalactia, 772 in arrest of lactation, 707 in mastitis, 70(t, 7til technique of. 755 Mastitis, congenital, 840 prognoses, 841 .symptoms, 840 treatment, 841 infant, prognosis and treat- ment, 827 liuerperal, etiology and pa- thology, 750 frequency, 750 symi)toms of, 759 treatment, curative, 700 l)ro))hyl;ictic, 759 varieties of, 750 Maturation, 74 Measles complicating preg- nancv, 243 fetal. 290 prognosis, 297 Measurements, jielvic, exter- nal. 358 internal, 358 Meatus uriuarius, 38. 40 Mechanism of breech presen- tations, abnormal. 472 normal, 470 of face presentations, 458, 4t;o of labor, tirst stage, 423-430 second stage, 430 third stage, 440 of transverse presentations. 488 of twin labor, 508, 509 of right posterior positions in vertex preseni:i- tions, 442 Mechanism of lahor, 384- 492. (See Ltthor, iiiechaiiixm iif.) Meconium at term, 102 chemical composition of, 142 tirst traces of, period and characteristics, HH of the new-born, 810, 855 source of, 141 r \ ini. ,70 uer- t)71. 1)11.') nosis, a, 755 m, 7()7 1 ,a treat- ve, 7G0 ii« preSJ- k- exU'i- 40 iilmormnU lOUS, 458. ;t.,423-4o0 ) jsentauoiis, 5l>9 |v jHisitioU!- Ix iireseiu;i- Jlbor, 384- [See Iaiooi; m of.) liliim of, 1 '•- Iperioa nn. 810, 855 Mediillii, ovariiin, 59, 60 ^[^'lt'lm iiei>imti)riiiii, 845, 853 Meinbruna ^niiiiilosM, tlO, 71 Menibraiie, vitulliiie, of ovum, 71 Membranes, fetal, 88 complieatiiiK labor. 570 in twin pre^'naiicy. 143 elastieity of, undue, dilata- tion of OH witli, 430 of uterine cavity, 378 rupture of bag of, in labor, 3t>8 in the induction of pre- mature labor, 879 dilatation of os after, 127 Meningiti.s during pregnancv, 213 treatment, 732 Meningocele, congenital, 304, 819 Meningo-myelocele, 304 Menstruation, 72 corpus luteum of, (SI cycle of, stages of, 72 during pregnancv, presence of, Kil suppression of, ItiO, 1(51 return of, suckling after, 77(1 Mesoderm, 79 Metritis, forms of, (194 symptoms and prognosis, (599 treatment of, 721 Metritis, dissecting, treatment, 725 suppurative, indicating celi- otomy, 909 and ulcerative, hysterec- tomy for, 974 Microcei)lialia, 305 Microma/ia, 74(5 Micro-organisms in Iniman milk, 757, 774 in the genital tract, 193 of puerperal infection, 084, 087, (592, 093 of the navel cord, 839 of the urinary organs, 787 transmission of, to fetus, 835 Microthelia. 745 Mid-gut, 114 Milk, breast, analyses of, 770 bacteria in, 774 changes in, qualitative, 771 drugs in, ingested by the infant in suckling, 770 drying uj) of, 707 ingestion of, infant, 850 quality of, abnormalities ' in, 7(58 diet influencing, 708, 709 emotional excitement influencing, 770 qiiantity of, abnormalities in, 771 supply and (piality of, 061, 771, 772 INDEX. Milk, condensed, in infant ' feeding, (570 cow's, composition of, (i(>9 pasteuri/.atioii of, (i71 transmission of tuber- culosis in, S47 I hinnan, composition of, (i.')5, 6(19 ■ micro-organisms of, 757, 774 I Milk-ducts, devt'lopment of, (58 Milk-glands, accessory, (Ki Milk-mixture, fornuda, 070 Kotcli-Meig'.s, 069 Milk-nodes, 766 Milk-ridge.s, 70 | Milk-secretion, anomalies in, 708 i due to pelvic diseases, 1(12 inlluence of malaria on, 782 in the new-born. 827 of pregnancy, 162 puerperal. (155 variations in, 771 Milk-sinuses of mamma, 68 Milk-stasis causing mastitis, 757 Milk-supply, delicient, 771 excessive, 772 variations in, 771 Miscarriage defined, 259,318 Mole, "blood," 262 cvstic. 254 '•flesh." 262 vesicular, 254 jiathology, 254 symptomatology, 254 synonyms, 254 treatmenf, 255 "Mole pregninicy," 312 Moles, hairy and pigmented, congenital, 3(19 hydatidiform, iutracervical tampon, 874 "tubal," -JStl Monstrosities (double forma- tions), 305 complicating labor, 563 Mons veneris, anatomy of, '.V! Morbidity, pueriieral. rciiuc- tion of, by vaginal disinfection, 346 "Morning sickness," (See Morphia, hypodermatic injec- tions of, danger of", in pregnancy, 212 use of, in eclampsia. 636 Mortality, fetal, due to syphil- itic infection, 24(J, 299 from accidental hemorrhage, 599 from Cesarean section, 925 from eclampsia, 623, (128, (129, 6:{(), 636, 637 from inversion of the uterus, 621 from labor, complicated by brain diseases, 643 995 Mortalitv from placenta prte- via, 591 from puerperal erysipelas, 781 infVcti(m, 341, 693,781 reduction of, by anti- seiisis, 709 from radical treatment of uterine fibroids, 186, 187 from retrovei-sion of uterus, 195 from rupture of (iclvic artic- idations, 641 of uterus, 61;} from sudden death in labor, 644 from svmphvsiotomv, 905- !H)7" from the I'orro operation, 925 from velamcntous insertion of the cord, 580 in breech presentations, 470 in labor complicated by rigidity of tissues of the parturient canal, 552 from ovariiin ('ysts, 558, 559 infant, 860 of concealed accidental hemorrhage in ])rcgnancy, 20O of delivery comiilicated by pelvic tumors, 53() in kyphotic pelvis. 5159 in obli(iuelv - contracted pdvei, 520 in osteomal icic pelves, 529 of face presentations, 459 of ovariotomy for cysts. 191 of [iregnaucy from mitral stenosis, 237, 2.'>8 of tetanus neonatorum. 841 of twin lrd)ors, 570 puerperal, iviluction of, anti- septic, 341 by vaginal disinfec- tion, 346, .■147 septic, 341 " Morula," 77 Mouth during pregnani'y. ab- normal conditions of, 234 treatment, 234 Movements, fetal. I See Feins.) Mucosa, cervical, 49 of ovi<lu('ts, 56 uterine, 49 vaginal, 45 Miilier's disease of fetus, 309 Multiple pregnancy. (See Pmjnani']!.') Munmiification, fetal, 273, 283, 313 Muscle, coccygeus, 28 levator ani. 27 hypertrophy of, 28 obturator internus, 26 S 1 I < K 99(5 INDEX. Muscle, pyrirorniiH, 2fi uterine, (lelicieiit puwer of, ill liiliiir, lit;} Miisiles of the new-born, 811 pelvic, 'ifi ueriniei builHi-ciivernosns, Wl i((L'lii()-<'iivi'ni()suH, \V1 milH-rlii'ial t runs versus, If;? uterine, -l!i eliiinj,'es in, din'in^ I'l'^'K^ nancy, 14"), lin during' the puerperiuni, (l.')H contnietious of, inlluenee of, in (lilutation, 425, 427 (See rui-ii.i.) Myoniiitii of tiie uterus, 1S5 intra-iiterine, contra-indi- cating celiotomy, iKill Myomectomy in pregnancy for tihroids, list), 187, 248 Myxoma of the placenta, 2")4 JsAlsEA and vomiting of pregnancy, l"),"), l.')!», 222 " causes, 22o diagnosis, 228 pathological anatomy, 225 plvalism complicating, 2;;i sym{)toms, 224, 225 treiumcnt of, IS.S medicinal. 229 rational, 227, 228 Navel, arteritis of, 837 diseases of, 827 dnssing of. 827, 828 gangrene of, >^'-M symptoms, >*88 treatment, 8.S8 phlebitis of, S87 woinidsof, healing of. slight disturbance in, 882 Neck, injuries to the. of the uew-borii, 824 Necrosis of pelvic bones, 51)1 Needles, suturing, 380 Nephritis following toxemia of pregnancy, 208 of pregnancy, 197, ]'.I8 prognosis, 191' puerperal, symptoms, 70t) treatment, 781 Neuritis, nndti[)le, complicat- ing pregmuicy, 218 septic, puerperal, 792, 798 Nerve-injuries following labor, 791 of the new-born, 825 Nerves, mammary, 70 of oviducts, 57 pelvic-lloor, 8G urethral, 41 uterine, (15 vaginal, 45 Nervous disturbances in puer- peral infection, tlS8, 7()G system, diseases of, h) the pnerperinm, 790 intrauterine, 809 oftlienew-l)orn infant, 81 1 NeiU'algia of ])regnancv, 208 facial, of pr.'gnancv, 209, 210 trealnieut, 209, 210 : pelvic, 209, 210 i New-bom infant, care of, ()(i4-(i71 i nin'sing of the, (i()7, S(iO by syphilitic mothers, 775 conditions interfering with. 778 intervals in, 708 syphilitic inoculation in, 840 transmission of tubercu- losis in, 847 New-bom infant, pathol- ogy of. (See I'dlli- iiIdijII. ) New-bom infant, physi- ology of, 807-818 —bones, the, 811 — digestive svstem, 809 —fat, the. 81'! — growth, 807 — lymphatic system, 811 — liiuscles, the, 811 — nniscidar action, 812 — nervous system, 81 1 — respiration, 808 —skin, the, 810 — s])ecial senses, 812 — speech, 818 — temperature, the, 81 1 — lu'iuary system. 810 trainnatic injuries of, 828 weights ot', variations in, 108 Nipple, abscess of the, 751 eczema of the, 751 hypertrophy of, due to j)reg- nancy, 158 muscular tissue of, 07 of pregnancy, 101 structure of, t)5 Nipples, anomalies ol'. 745 develoi)meut of, faulty, 74i'> diseases of, 747 during lactation, trealnieut of, tiOl pregnancy, care of, 184 in mastitis, 700 sore, 747 and iissin-ed, treatment of, 184 etiology of, 747 symptoms, 748 treatment. 748, 749 Nipple-shield, 749 Notochord, 81 Nourishment for premature infants, methods of administering, 8ti5 Nozzle, douche, uterine, selec- tion of, 870-872 Niiilens, segmentation, 70 Nurse, the. auti.septic precau- tions ot, 845 Nursing of the new-born, ()()7, 800 by sy|ihilitic mothers, 775 conditions interfering with, 778 i'ltervals in, 708 syphilitic inoculation in, 840 transmission of tuberculosis in. 847 wet-, of the new-born, 068 Nutrition, changes in, due to pregnancy, 155 Nymiilne, 87 Hottentot, .87 OuKsiTY, simidating |ireg- naucy, 178 Obstetric surgery. (See Sitn/rri/.} Obstetrician, the, antiseptic precautiouB of, 844 Occlusion, intestinal, from retroverted uterus, 195 Ointment for sore nipples, formula, 749 iodoform, I'ormula for, 720 Oligohydraimiios, 258, 254 Omphalitis, 887 prognosis and treatment, 887 Omphalorrhagia, 828, 830 Oiiphoritis, 095, (i99 complicating pregnancy, 190 Operations, surgical, 807 during j)regnaucv, 251, 252 general reciuirements and preparations for, 807 (See .S'h/y/cc//, (il»!li'lrii-.\ Ophthalmia neomUorum. 847 etiology, 847 pathological anatomy. 848 prognosis, symptoms, and treatment, 848 "Organ of Uoseumiiller," 02 Organs, digestive, in the puer- periuni. O'll generative, congenital, de- fects of. in female (4iildreu, .")08 hemorrliage from, 85:, female, anatomy ol'. (Sec AiKiliniii/.) external, 80 intermediate, 42 int(>rnal, 45 pelvic nerves of, 04. Oi physiology of. 70 7 (Sco 2.-M, Lriun. 1^-1" Jatoiny. S4S liiloins, iiiitl In. SIS liilkT," t>-^ li the l>iit-'i- lenital, <1«.- in t'l'iiiaU' Itl-DlU, S.>.' Iv Ol". 1!^«->C •12 l-s of, (>4. t!"> .r, :*• Oiniiiis, gi'iuTiitivi', iV'tal, ox- U'l-iiiil, 12". pi'riod (if ilistiiu'tion, 101, 121 ill till! |)iu;i'|)i!riiiiii, (i'>l iion-sexuiil, liisuasus of, in tin* puerpuriiiiii, 77S pi'lvic, IlOSt-pMI'tlllll OXIIIIii- iiiitioii (if, ()(!•'> si'xiiiil, (lise:i»c's of, (iSli nriimrv, disi^iises of the, 7Sr> disorders of, in preRniui- cv, ll»(J trc'iilniiMit, lost distiirliMiiiTS of, ill liie iiew-liorn, S."(«i ()s, dilaliitioii of, iirtillciul, SS2 in breech prcscntulions, 471 ineeiiiiniiiin of, uftor ni|i- tiire of nieiiibnines, 427 noniiiil of, 424 witii originally scanty waters, 42',i with inidiie ehisticity of nieinhranes, 1I!0 Os externum, anatomy, 48 iiiterniiin, 48, 148 uteri, 47 dihitalioii of, artificial, 8X2 Ossilicalion, epiphyseal, first fetal, 102 " Osteogenesis imperfecta," 308 Ostium alxloriiinale, !Hi iiiteninm, ')(» Outlet, pelvic, IS diameter of, antero-pos- terior measure- ment of, SIO transverse measure- ment, oOl) dimensions of the plane of, 1!) Ova, alecithal, 77 iiolohlastic, 77 lilieration of, time of, 71 number of, in ovaries of voungfemaleohild, 70 Ovaries, blood-ve8.sel8 of, ()3 dimensions of, o7 removal of, in puerperal sep- sis, !)7;} structure, 5i) tumors of, cystic, congenital, •.m Ovariotoniv during gestation, 'I'.ll, 24!>, .V)8 Ovaritis, suppurative, hyster- ectomy for, !t74 Ovary, diseases of, cumpli- catiiig pregnancy, 11)0 tumor of, in pregnancy, 24S, •>4'.) Over distention of iiie bladder. /.y/H'jx. Over-distention of the uterus, causing labor, IVJO rupture of uterus from, (111 Oviducts, "i(i blood-vessels of, r)7 nerves' of, '')7 structure of, rifj Ovisacs, number of, tiO Oviilie Nabotiii, 19 ( )vulatioii, 70 ill multiple (^inceptions. 111 Ovum, cell-division of, stages, 77 diseases of tlie, 2">2 form and structure, 71 fusion of speriiiato/o(">n and, 75 impregnation of, period of, 177 nintiiratioii of, 74 polar bodies of, 74 st.!ges of development, 94 villi of, 78 Oxygen, source of, in jilacental eirculiition, 139,140 I'ai.atI';, clel't, congenital, ori- gin, 9S " Palpation, .•ibdomiual, deter- mining involution of uterus 'ly, V.5(i diagnosis by, 407 diagnostic signs furnished by, 411 during labor, 3(!") pregnancy, IS;} for examination of the cephalic promi- nence, o'j^ of the lower fetal pole, :{.")2 of the upper fetal pole, ;5:)4 imj)ortance of, for the diagnosis of fetal piesentation and position, :5")() lociiting anterior shoulder in vertex presenta- tions, by, ;5")U dorsal plane and small parts by, 3")0 pathological condition.s deterinineilbv, 3")G, 3o7 in placenta previa, oOO of fel;d presentation and position, .'?"iO Pam])inifi)nn plexus, (14 Pancreas, fetal, 1 IS chemical substances in, 141 of tile new-born infant. 810 Paradidymis, 12;> Paralysis, congenital, S22 olistctrical, of the new iiorn, ,S2.") diagnosis, 82(J prognosis, 82(i treatment, S2t) !)97 Paralysisof prcgtmncy,79(),7!i| puerperal, tit:!, til 1, 791 794 Parametritis, (199 Paraplegia complicating labor, (i4;{ Paroiiiihoron, (i2, 123 Parotitis, congenital, 840 I'arovai'ium, (12 Parturition, rule for determin- ing date of ex- peeled, 17(i Pathology of the new-born infant, 8i;! 8(i7 1. Medical and surgical dis- eases incident to the hirlh of the child, Si 3 823 — apoplexy, 822 — asphyxia, 813 —atelectasis, 822 intra-iiterine, 814 extra-uterine, 8l"i — caput sueceiianeum, 818 — cephal hematoma, S19 2. Traumatii; injuries of the iie\v-l)orn, S23 — injuries to the brain and pe r i p li e r a I nerves: obstetrical paralysis, 82-") — injuries to the scalp, face, neck, limbs, trunk, and bowels, 824 — injuries to the .skull and other Ixmes, 82') 3. Deviations from some of the [ihysioiogical processes which characterize the early lite of the in- fanti 82(1 — diseases of the navel, 827 — exfoliation of tlie epi- dermis, 8:iG — mastitis, S27 anatomical and physiolog- ical ciinsiil(M'ations and dressing the navel, 827 omphalorrhagia, 828 — hemorrhage from the umliilical vessels, S-J9 slight disturbances in hcalini; of navel wounds, 832 — umliilical fungus, S33 umhilical-coi'd Iiernia',833 4. Infections diseases of the new-born, S;?.") — wound-in led ion, 8.''(! int'ection through the umbilicus; diseases of the umbilical vessels, 830, 837 { ; :■ I! i 1 I ^p 998 IND/'LV. '1 h ri tri! ■ 1 •ill !•' m tmi \l^ i 1 II ■' 1 '#1 'B ' ■ ^ '9 1 w 1 "«-Vt u M- Jilr Fiitholofty of the new-born iii- I'iiiit (iiili'i'tion I : — urifrilisuiiil phlfhitw, 8H7 — gaii^Tt'iieol'tlie imvel, KM — oiiiplialitiH, H,'{7 iiiffciidii of otiier wouiuIh, 8;{8 — Hiihl's (lisoiise, 843 — fr_vsi|K'l!i.H, 8;{8 — iftiTiiN Nvriiptoiuuti- ciis, 8i;{ — la f,'ri[)|ii', 811) — mastitis, 840 — nielt'iia iifonatoniin, 84") — opiitlialinia nuonalo- rum, 847 —parotitis, 840 — pt'iiipliiniis, 84") — pi-ritonitis, 840 — piik'giiiiisia, 840 — sypiiilis, 84(; — tetanus iiuotiatoruin, 841 — tiiliercnldsis, 847 — Wiiickiil's disc'iise, 844 infection of the diges- tive and respira- tory trat'ls, SoO — diphtheria, 8')1 — rhinitis, 851 — thrnsh, 80O — stomatitis aphthosa, 8.-)0 5. General and inielassilied diseases, 80 1 — eolie and diarrhea, 8r)4 — constipation, HhCt — disinrliances (>f the urinary orjj;ans, 8.'p8 — gastro-inteslinal hem- orriiaj^e, X'>'-\ — hemorrhage from the female K<^'nital or- gans, 8.");i — hemorrhagic diathe- sis, 8.")'2 — inguinal and mnhili- cal hernia, 858 — intestinal obstruction, 857 — peritoneal abscess, 858 — phimosis, 858 — sclerema neonatorinn, 851 (5. Hygiene and tlierapentics soon after birth, 85!) hygiene, 85!t —food, 85!) therapeutics and dosage, 8ti0 external remedies : — antiseptics, 8()0 — astringents, 8(30 Pathology of the new-born iii- fantltheriipeuticHi : — couuter-irritaiitN, siiO —heat and cold, 8ti0 internal remeclies: — alteratives, 8(il — antipyretics, Stil — antispasmodics, 8(11 — digestives, etc., 801 — diuretics, 8(>1 — hemoslalics, H&2 — laxatives, Mil — nerve-sedatives, 8tll — iniiricnts and tonics, 8(iO — timidants, 8()1 7. I'remuture iiifants, 8G'J Pathology of pregnancy. (See Priijnniicij, ah- imniKil.) of the puerperium. (See I'litrpiiimn, fmlhd- '>!/!/ "/■ I Patient, tiie, antisepsis of, 345, :M() Pellicle, kiestein, lot! Pelves, deformed, fre(|uency of, 4i»8 indications for svmphvsi- otomy ill,!)! I, iil'2 in breech presentations, 470 Pelvic floor, injuries to the, l)revenlion of, 3t)(t. (See /V/c/.x.) ])ri'sentations, diagnosis of, by palpation, 409. (See IWnfiildliiiii.t.) Pelvimeters, tvpes of, ;i(il, 500-509 Pelvimetry, 500-509 I'elvis, anatomy of, 17-3(;, 388 anomalies of, due to diseases of the suhjacent skeleton, 540 antero-posterior section of, diflerenees between the male and fe- male, 3!li) articulations of, 22 changes in, due to preg- nancy, 150 relaxation and ruptiu'eof, t>40 bones of, diseases of the, 531 cavity of, 19 measurement of, 509 conjugate of, for internal version, 948 contracted, arrest of lie;id due to, in breech presentations, 487 management of labor ob- structed by the commonest forms of, 543 coxalgic, 540 diameter, conjugate, in Ce- sarean section, 918 I'elvis, <liaineter, plane of least, 18, 19 diameters of, relative value of.as compared with the (liamelers (if the fetal head, 4U4 measurements of, 20 external, 35K of inlet, 501, 507-509 of outlet, 509, 510 vaginal, 358 deformities of, producing face presentations, 459 excavation of, anatomy, 394 expansion, plane of greatest, l.s, 19 false, anatomv of, 389 delincd, 18' fascia' of, 29 female, abnormalities in, varieties of, 510 anomalies of, classifica- tion, 499 diagnosis, 500 characteristics of, 21 dimensions of, 21 felal or inideveloped, 517 tiat, simple, 510 characteristics, 510 etiology, 510 diagnosis, 51 1 inlluence on labor, 51 1 generally-contracted, non- rachitic, 51() characteristics, 510 diagnosis, 510 etiology, 510 rachitic, characteristics, 522 floor of the, .30 blood-vessels of, 35 nerves of, 30 prevention of injuries to, 3t)9 veins of, 3() form of, influences of race on, 22 fractures of, 531 inlet of, diameter of, antero- posterior, 501 diameters of, obli(pie, 509 transverse, 507, 508 justo-major, 521 diagnosis, 521 justo-minor, characteri.- diagnosis, •«■.- etiology, 515 influence (m lali' : of, ' ' > kyphoscoliotic, 540 kyphotic, 537 characteristics, 537 diagnosis, 539 frequency, 539 influence on labor of, 539 male and female, anatomi- cal ditlercnces be- tween, 398 Naegele, 518 I T INDEX. 909 of ItlllU with ( of .404 r)09 ilions, y, :w4 I'utcst, I'S in, issilii'ti- 21 ,517 ■)10 r, nil tell, non- 10 .•s, 510 iteristiw, J5 liiries to, (it' nice |f, aiitero- 501 Ihine, 50'.! ")0H I 87 I)!- O i; 5;5u iiiiiitoini- be- ■omes Pelvis, narrow, funncl-shnpeil, r,l7 diuKiioHin of, olT iiilluciicii on liilior of, -)17 olili(|iit'ly coiitriictt'fl, olS clmrin'liTiHtics, ")I8 (liii^'niMiH, '>IU elioloifv, MM inlliionco on labor of, pro)?nosis, ^'JO trc:itincnt. o'JO (mti'oinalacic, ^'iO (lintfiioHis, ')2H infliieiicf on lalior of, o'J'.l ontli'i of, diameter, antero- poHlerior, oiO IransviTHe, 50SI posilion of, 'JO " lisendo-oHteoinalaoiu," 5'22, 524 rachitic, 522 eliaracteristirs, 522 diiiKnosiM, 521 jjenerallv e(|Maliv -con- tracted, 521' influence on labor of, 520 Robert. 521 scoliotic, 5.'1'J split, 522 sponilylolisthctic, 5,'12 cbaracleristicH, 5152 diiiKuosis, 5115 eiiolojry, 5.'14 iiilliienee on labor of, 5150 strait of iIk!. inferior, anato- my, ;!H2 superior, anatomy, lillO transversely -contracted, 521 treatment, 521 true, anatomy of, 390 delined, IM dimensions of, 21 nnisdcs of, 20 lumors of, 5,'iO " I'elvis plana," of Deventer, 51(» I'elvis spinosa, 5,'{() I'empbiijus, fetal, HOi) neonatorum, 845 etiolofiy, H45 treatment, 840 I'enis, lelal, development of, 124 lVptt)ne in toxemia of prej;- naney, absence of, 205 PeptoiuM'ia in pregnancy, 2.'13 of the puerperium, ()50 Perforator, scissors, Harnes's t»;{0 Naegele's, VM) Pinard's, WM) Simpson's, 930 Smel lie's, IHIO Perforators, types of, 928, 930 Pericarditis, (i9(> symptoms, 703 treatment, 731 Perimastitis, coiiKeidtal, 841 " I'erineal shelf," 32 Perineum (I'cmale), structin-e of, 31-35 injuries to the, following; ' labor, 073 causes of, 074 sympionis ot', ti75 treatiiienl of, 070 Peritoneum, pelvic, changes in, 149, 150 Peritonitis, cougenital, 840 ttyniptoms and treatment, 840 during pregnancv, 200 fetal, 3(19 in retroversion of uterus, 194 puerperal, 095 prognosis, 702, 703 symptoms, 701 treatment, 720 ver.iion in, 200 Pessary, use of, in retroversion of uterus, 194 Plinntoin, pregnancy, 2."il Phenomena, mental and emo- tional, due to preg- nancy, 170 of utero-gestation, classiliea- tion, 170 Phimosis in the new-born, 858 treatment of, 859 Phlebitis, 090 treatment, 733 mnbilical, 837 uterine, diagnosis, 705 symptoms. 704 treatment. 733, 734 Phlegmasia alba dolens, 097 symptoms, 703 treatment, 733 congenital. 840 Piiysician, visits of, in the puerperium, 057 Physiology of the female generative or- gans, 70-74 of labor. (See Liilinr.) of the new-bom. iSee Xi'ir-lxini liij'iiiil.) of pregnancy, 74-159 of the puerperium. (See I'lti'riuriiim. ) Pliysometra, 273 siimdatiug pregnancy, 17.3 PiginentatioTi, skin, in i)reg- nancy, 150 Placenta, anatomy and physi- ology, 80 anomalies of the, 257 when j)ra'via, 5.s7 aj)oplexy of the, 250 attachment of, in extrM- uterine pregnancv, 283 at term, size and shape, 90 blood-vessels of, 8!», 90 calcareous dcgeneratiiai of, 255 Placenta, detachnipnt and ex- pulsion of, 440 diseases of tbe. 255 expression of, 715 ('redi'''s, 377, 378 fatty degeneration of, 250 fetul, in extra-uterine preg- nancy, 280 implantations of the, in pra'via, 584 location of, by palpation, 35(i maternal attachment ol', in tidial pregnancv, 281 myxoma of the, 254 retention of, complicating labor, 571, 572 cnreftage I'or, 873 of portions of, causing hemorrhage, 7.'>9 separation of, premature, causes, 590-598 structure of, 90 syphilis of, 257 tumors of the, 257 villi of, 90 " I'lacenta mend)ranacea," 258 I'lacenta |)ra'via, 581 causes of, 587 fre(piency, 580 induction of premature labor in, .s7it, sso intracervical tampon in, 874 prognosis, 591 symptoms and diagnosis, 589 treatment, 592 varieties of, 584 Placenta', fetal, twin, 143 Placentitis, 255 Pleurisy, puerperal, 090 symptoms and prognoses, 703 treatment of, 730 Pneumonia complicating la- bor, ()44 during pregnancy, 244 progniisis, 245 treatmeni, 245 fetal, sypliililic, 298 puerperal, 781 svmptoms and ])rognoHis, 703 treatment of, 73(1 Poisons, toxemic, of pregnan- cy, 20:! Polydramnios, 253 Polygalactia, 772 Polvhvdranuiios, pathology of, 253 symptomatology, 253 treatment, 253 Polymazia, 740 Polvpi complicating labor, 558 Polythelia, 740 Position, fetal, abbreviations used to designate, 387 classification, 387 y S ! 1000 INDEX. Position, fetal, defined, 386 diii^nosis of, by imlpution, 409 in vertex presentations, 422 etiology of, in vertex pres- entations, 422 prognosis of, in vertex presentations, 423 Position, obstetrie, for ajjplying forceps in ilie low operation, .S!)3 Positions, left-anterior, me- elianisni of, in ver- tex presentations, 44!t right-posterior, niechanisni of, in vertex pres- entations, 442 posterior, delivery in per- sistently, 457 labor in, management of, 449 relative frequency of, in brow presentations, 4G(i in face preseiitations,4r)S Post-mortem changes of fetus in iitero, 312 I'ostiire and bearing of the jjregnant woman, 202 for operation of internal version, !)oi)-9()3 " Poucli of Douglas," o4 Pouch, vesico-uteriiie, o2 Pouches, pharyngeal, 113 Pregnancies, twin, frequcncv of, 142 proportii)!! of sexes in, 143 Pregnancy (abnormal) : accidents during, 24.S acute aflections during, 239 atleclions of the i''allopian tubes in, 249 all>iuninuria in, 233 appendicitis in, 2.'S3 a.sciles complicating, 231 blood during, abnormal con- ditions of, 23") cancer coniplicatiuu:, 241 ••ariliacdi'^ease complicating, 237 i'atalepsy (hiring, 217 cereljral thrombosis and hemorrhage dur- ing, 212 "cervical," 2(>2 I'holcr.i complicating, 24") chorea diu'iug, 214 <lealh (luriui;, sudden, 212 (liabcti's complicating, 218 <liscascs <'omplicating, 185 ilisorders of, general, 19(1 erysipelas complicating, 212 eruptive disoases in, inllii- ence of, on the fetus, 290 Pregnancy (abnormal) : extra-uterine, 273 classitication of, 278 conditions simulating, 174 diagnosis, 173, 28(3 mistakes in, 174 etiology, 277 extraperitoneal evacua- tion of gestation- sac, 294 after-treatment of, 295 rupture of gestation-sac, 285 tinnors simulating, 287 operation in, 291 after mununitication, etc., of the fetus, 295 after rupture of gesta- tion-.sac, 292 pre|>aration for, 289 symptoms, 284 treatment, 288 tubal, 280 intraperitoneal rup- ture, treatment, 288 tubo-uterine, 281 rupture of gestation-sac in, 281 the fetus, 282 fil)roids complicating, 185 gastric nicer complicating, 232 general accidents and in- juries during, 249 goitre during, 235 gonorrhea of, 239 hemorrhage, concealed acci- dental, 200 from uterus during, 238 hemoptysis comiilicating, ■ 238 herpes of, 211 hysteria during, 221 measles iiompiicaling, 243 insanity of, 797 interruption of, in cardiac diseases, 042 in eclampsia, (135 jaimdice complicating, 232 nuuiia complicating, 222 meningitis during, 213 molar, 254, 312 ]ieptonuria in, 233 jieritonitis during, 200 placi'Uta [jra'via of, 581 plin-al, predisposing to eclampsia, (131 pneumonia during. 244 pi'uriius, idiopatliic, compli- cating, 220 salivation of, 2I(( scarlatina complicating, 243 spleen in, hvpertropliv of, 155 ■ surgical operations during, 218. (See Snnji'nj.) sy])hilis during, 210 tet!inii.> complicating, 24(1 tct.iuy complicating, 24(1 Pregnancy (abnormal) ; toxc'nia of, 202 transmission of infections to the fetus in, 29(1 tumoi-s complicating, 248, 249 tyi)hoid complicating, 241 variola complicating, 244 (>See I'rej/iianci/, pathology of.) Pregnancy (normal) : abdominal changes due to, KIO walls, changes in. due to pregnancy, 151 blood, condition of, 154 breasts of, hypertrophy of, 152 cervix in, livpertrophy of, 14(5" circulatory system, changes in, thie to, 153 corpus luteum of, 01 decidua vera of, 319 diagnosis of, 157-179. 183, 184 diflerential, 171 duration of, 170-178 evidences of, positive, 171 presumptive, 171 probable, 171 female external genitals during, changes in, 150 heart hyj)ertrophy in, 154 llegar's, sign of, 104 hygiene of, 180 innervation of the uterus in, 320 kidneys during, 197 length of fetus at various periods of, 103 liver of, hypertrophy of, 155 nuunmarv changes during, "101 glands of, changes in, 151 nuuiagcment of, 180-183 dietetic, 180 medicinal, 183 (See MniHii/nne)!!.) maternal organisms in, gen- eral changes in, 153 local changes in, 115 mental I'ondition duritig,IS2 menstruation during, 72 moi'bid conditions simulat- ing, diliereiitiation of, 172, 173 mouth and teeth, duriui;, abnormal condi- tions ol', 233 nniltiple, determination of, by abdominal (lai- pation, 357 diagnosis, 171 physiology, M2-145 nausea and vomiting of, 155, 159. 222 treatment, 183 T f INDEX. 1001 I're{);n!incy (normal) : nervous system in, changes in, loy disorders of, 208 neuralgia of, 20S nipples of, livpertrophv of, 153" pelvic articulations during, changes in, 150 phantom ( pseudo-cyesis), 231 physiology of, 74-159 presence of chorionic villi, evi(leni:e of, 80 prior, diagnosis of, 175 prognosis of, complicated by tumors, 252 prolongation of, 178 res|iiratory changes in, 155 signs and symptoms: — abdominal changes, lt)t) — ballottement, lOO — clahsilication of, 170, 171 — disturbances of the bladder, functional, 1(;2 — evidence of prior, 175 — evidences of extra- uterine pregnancy, 173, 174 — evidences of mulli- |ile, 174 — fetal contour, 170 — fetal heart-sounds, 108 ^intermittent contrac- tions, 1()7 — intrapel vie signs, 103 — uuimmarv changes, Kil — menstrual suppres- sion, lliO — mental and emotional piienomena, 170 — morbid conditions simulating, '72, 173 — muisca and vondiing, l.V,* — ((uickening and fetal movements, l{i7 — relative value of, in {loint of diagnosis, 171 — uterine K'^nJHe, l(iS skin, gait, and osseous ele- ments, chauges in, 15(; suckling in, 77() termination of, by nipple- iiivagination, 748 chief factors in, 318 twin, dctcrmiiiaticin of, by alidomiiial palpa- tion, 357 umbilical changes due to, 151 urinary changes in, 15i) Pregnancy (normal) : uterine i-avitv din'ing, shape ^ of, 420, 421 uterus in, changed position of, 1(!5 changes in the, 145 conditions, pathological, during, 185 vagina during, changes in, 150 Pregnancy, pathology of, 185-1% 1. Uterus during, patho- logical condition of, 185 — bacteria in the genital tract, 193 — diseased coiulition of the ovary, compli- cating,' pregnancy, 190 — diseased conditions of the vagina, 193 — disorders of the vulva, 191 I — displacements of the ' pregnant uterus, 193 ! — end<mietritis during pregnancy, 189 ! — epithelioma of the cer- vix, 188 • — hvpertropliv of the de- cidua, "189 - mvomata of the uterus, 185 — salpingitis during preg- nancy, 190 — spontaneous rupture of uterus, 189 2. General disorders of, 196- 239 — abnormal conditions of the blood, 235 --abnormal conditions of the mouth and teeth, 234 — acute vellow atrophv of the liver, 232 — albiuniiniria of preg- nancy, 233 — a|>peiulicitis of preg- nancy, 233 — ascites of [jregnaucv, 231 — cardiac diseases compli- cating pregnancy, 237 — catalepsy during preg- nancy, 217 — cerebral thrombosis and hcMioirhageiliU'ing prcuTiaiu'v, 212 — cliDiva (luring preg- niuicy, 214 — comcaicd accidental lu'iniirrhage, 21)0 ~dial)cti's 'iiriiig [ircg- na'icy, 219 preg- preg- preg- Pregnancy (pathology of) : — exophthalmic and sim- j)le goitre, 235 —gastric ulcers of preg- nancy, 232 — hemoptysis compli- cating ])regtuuicv, 23S — hemorrhage from the lUerusdiM'ing preg- luuicy, 238 — herpes of pregnancy, 211 — hysteria during nancy, 221 — kidneys during nancy, 197 — mania during nancy, 222 — maternal impressions (luring pregnane V, 213 — meningitis during preg- nancy, 213 — nausea and vomiting during pregiuuicv, 222 — neuralgia of jjregiiancv, 208 — peptonuria of preg- iiaiu'y, 233 — peritoiutis during preg- nancy, 2(10 — l>osture and bearing of the pregnant wo- iu;m, 202 — l)riM'itus,i(liopatliic,(iur- iug pregiumcy, 220 — pseudo-cyesis of ju'eg- naiicy, 231 — relaxation of the pelvic ligamcTits, 202 — salivation of pregnane v, 210 — spinal irritation com])li- caling labor anil pregnancy, 213 — suppurating hydatid of the abdomen, 199 — sudden death diu'ing pregnaiu'v, 212 — toxemia of preirnaiicv, 202 3. Acute infectious during, 239 -247 — cancer, 211 — cholera, 245 — erysipelas, 212 — gonorrhea, 239 — measles, 24;') -— pnciuiiouia, 244 — scarlatina, 243 • — svphililic infection, ' 240 — tetanus, 24t) — tetany, 2ll> - tvpliiiid inlci'tiim, 241 —variola, 214 4. Accidents and surgical opcratioiis,2 18-252 ^1 r- u I If;. ft ^.\ ll f! I! % ■vS I 1002 INDEX. Pregnancy (pathology of) : — accidents and in- juries, 249 — aflections of the Kallopiun tubes, 241> — amputation of tiie uterus, 248 — niyoniectoniy and myotomy, 248 — tumors of the ovarv, 248 5. Diseases of the ovum, 2o2-2oit of the amnion, 2oo — adhesions and bands, 253 —polyhydramnios, 253 of tiie chorion, 254 — myxoma and vesicu- lar mole, 254 — oligohydramnios, 254 decidual endometritis, 255 of the placenta, 255 — anomalies of tiie pla- centa, 257 — apoplexy, 250 — calcareous degenera- tion, 255 — fattv degeneration, 2r)() — placentitis, 255 — syphilis, 257 — tumors, 257 anomalies of the cord, 258 --coils, 258 —knots, 258 — stenosis, 25S) — torsions, 25St 6. Abortion, 251)273 — clinical history, 2(52 — diagnosis, 2ti4 — definition, 25'.* — etiology, 2()0 — fre(jucncy of, 25'.t — missed abortion and missed labor, 272 — fiatliology, 21)1 — ])rodi'omal svmptoms, 2ti:J — prognosis and seque- lip, ~ — time 2(i0 — treatment, 2()(! 7. Kxtra-iilcrinc, 27:5-295 — diagnosis, 2S(i — etiology, 277 — ex tra-peritonetil evac- uation of gcstation- siic, 294 —fetus, the, 282 — history, 273 — operation after mum- milication, calcifi- cation, etc. of fetus, 295 — preparatioii for ope- ration, 289 — symptoms, 284 205 of occurrence, Pregnancy (pathology of): — symptoms of rupture, 285 -treatment, 288 — treatment after rup- ture, 292 — treatment at the time of rupture, 288 — treatment before rup- ture, 288 — tubal pregnancy, 280 — tubo-uterine or inter- stitial gestation,281 8. Diseases of fetus in utero, 295-299 infectious: eruptive, 295, 29() — erysipelas, 297 —measles, 29(5 —scarlatina, 290 — syphilis, 297 — tubercidosis, 297 — variola, 297 deformities and malfor- mations, 299- — amniotic l)ands, 299 — congenital defects of the generative or- gans in female children, 308 — congenital luxations, 301 — congenital tumors,301 ^leformities of the lace, 302 ^leformitics of special regions ;md organs of the body, 302 — double formations, 305 —excessive develop- ment, 3t'"> — intra-uteri.ie frac- tures, 300 — mall'orniations of the bniin and cord, 304 — mall'ormatioiis of the circulatory ap[iar- atiis, 304 ■ — malformations of the extremities, 304 — midtbrmations of the stoniach, 303 materuiil iriipressions, 305 intra-uterine diseases of bones, 307 — Hidiler's disense, 308 —fetal rachitis, 307 — Miilier's disease, 309 —Schmidt's (liscase,308 intni-uterine diseases of the siuii, etc., 309 — anasarca, 309 — |)einphigiis, 309 — peritonitis, 309 —tumors, 309 struma, 309 intra-uteriiic disea.scs of the nervous system, 309 Pregnancy (pathology of) : — cretinism, 310 — hydnx'ephalus, 310 — syphilitic idiocy, 310 sudden death of the fetus, 320 post-mortem changes, 812 — calcification, 318 - maceration, 313 -mummification, 313 — putrefaction, 3i;> — saponification, 318 — suppuration, 313 Prepntium clitoridis, 38 Presentation and position, di- agnosis, 350 during labor, 3(i5 abdominal palpation, im- portance of, for diagnosis of, 350 cephalic. (See Virtrr.) classification of, 380 diagnosis of, by palpation, 408 differential, bv palpation, 409 defined, 885 etiology of, 418 fetal moveinents, influence of", on, 421 frequency of each, 41(), 421 infitience of gravity, 418, 421 natur:il, 380 normal, 880 relative freciuency of four ])ositions, 417 summarv of signs of each, '414 vertex, changed to a breech by version, o[)cr!i- tion, 947 condilionsinlluencing, 421 contact between breech and fundus, 438 descent of fetus in .second stage of labor, 4."1 determination of, during labor, 800 diagnosis of, by palpation, 408 bv vaginal examination, 414 ditierential, by palpa- tion, 409 of position, 422 freiiiiency of, 417, 421 gravity in, force of, 432 infhamce of, 4 IS, 421 intra-uterine fluid-pi'cs- sures in, 433 irregular shape of fetal skull in, 433 locating anterior shoulder in, 353 management of labor, pos- terior positions, 1 19 mechanism of hibor, iu second stage of, 4.'!0 Ti, \f Presentation, vertex, mechan- ism of Ict't-iinterior (msitioHK, 44'.> of rifjlit-posterior posi- tions, 442 position in, diagnosis, 422 etiology, 422 positions, 387 prognosis of, 41G of fMisition, 423 rotation in, 435 mechanism of, 438 nnccjual lengtlis of the ends of tlie liead in, 432 Presentations (al)nornial), 386 breech, a]i|>lication of for- ceps in the high operation, 902 arrest of tlie liead at tiie inferior strait in, 487 _ at tlie superior strait in, 484 I forceps in, 48(5 ' due to contraction of the pelvis, 487 j from extension, 48() | closure of extension-ring ; about the neck in, > 484 diagnosis, 470 I by palpation, 40!' ' by vaginal examination, : 41.") j short cord in, 578 | diiiicult extraction of head j and arms in, 484 etiology of, 470 \ fre(|uency of, 470 i nuiiiagenient of, 474 mechanism of, 470 prognosis of, 417, 470 brow, application of the for- ceps in the high operation, t)01 diagnosis, 4(11) bv vaginal examination, 415 etiology of, 4fiG fre(iuency, 4(i(j management of, 4()7 after entrance into the pelvis, 4i)!) mechanism of, 4tit) moulding of fetal head in, 4titi prognosis, 417, 4('p(i treatment, operative, 4(19 face, application of the I'or- cei)s in the high oi)eration, 901 at the brim, operative in- terference in, 4(13, 4(14 diagnosis of, 459 by vaginal examination, 415 etiology of, 458 frequency, 458 INDEX. Presentations, face, low, chin | anterior, manage- ! ment of, 4(14 , chin posterior, manage- I meat, 4(15 j mat agement of, 4(i2 i mechanism of, 458 of posterior, M. O. P., ' 4(12 ! of M. L. A., 1(10 ' moulding of fetal bea<l in ! delivery of, 4(il ^ normal labor in manage- ! ment of, 4(13 ■ obliquity or abnormality | producing, 458 j operative treatment, 4(54, 4(15 pelvic deformities pro- ducing, 459 prognosis, 41(1, 459 tight adaptation in the posterior positions producing, 459 tumors in the brim pro- ducing, 459 undue length of the hind- head producing, 458 footling, mechanism of, 487 hand or a foot, diagnosis, by vaginal examina- tion, 415 in twin labors, 5(17-570 of a hand and a foot, -M)2 of the head and a hand, 492 j)rognosis, 492 treatment, 492 of the knee and elbow, diag- nosis, by vaginal examination, 410 ])elvic. (See Jirarli.) transverse, 487 diagnosis, 488 by palpation, 409 by vayinal examination, 4U1 etiology of, 487 fre(|uency of, 487 management of, 489 mechanism of, 4>.8 neglected, treatment of, 492 prognosis. 417, 488 version in, 48>l internal podalic', 190 inmatural, 3S(1 Pronucleus, female, 75 male, 7t) Prophylaxis nf labor in poste- rior positiimsiif the vertex, 149 Provertebric. SI Pruritus of the vulva, 191 treatment. 192 idiopathic, cmiiplicating prcLTiiancv, 'J'JO treatment. 2211. 221 Pseudencephalus, .'!(i| 1003 Pseiido-cyesis, 231 simulating pregnancy, 173 F'tomaVnes in toxenda of preg- nancy, 204 Pubic section. (See Si/mplnjiii- (itomy. ) Piidendimi, 37 Puerjieriiim, the, (149 80(1 celiotomy for sepsis in the, "9(18-970 curettage in, 873 indications for, 872,873 chill of, post partiim, (149 condition of the parturient tract in, (151 contractions in, uterine, (151 death in, rapid or sudden, 801 80(1 diagnosis of, (15(1 digestive organs during, (iol embolism in, 790 hemorrhage in, 738 cerebral, in, 790 insanity of, 798 involution during, 052 lactation din-ing, (154 lochia of the, (154 loss of weigiit during, (150 passing the catheter (luring, (1(10, 8(18, 8(19 pulse during, (149 secretions and excretions of, (150 sepsis in tlie, celiotomy for. 908-970. (See [,i- fiction.) temperature during, (149, C50 uterine muscularis during, (153 uterus during, (151 changes in, (152 contractions of, (151 Fuerperium, management of, (157 (171 — after-pains, (158 — asepsis, (158 - diet, 059 — evacuation of the bowels. (1(10 — lactation, (1(11 — physician's visits, (157 — posture. (157 - regidatioii, (1(13 - rest, (157 — retention of urine. (159 — special directions, (1(53 — tiirdy involution, 0112 ^nse of the catheter, (160 — veutilation, ()V,» care of the new-born infant. (1(14 ^biithiiig, tH15 — clothing, (Itid —feeding, artificial, 668 — nursing, (107 — wet-nursing, (168 ■J I t ;:': 1004 INDEX. m I Puerperium, pathology of, 072 injuries to the external geni- tal organs Ibllow- ing labor, 672- — Iieinatonia, — injuries to tlie peri- neum, (173 - injuries to the vagina, (178 — injuries to the vulva, '()72 diseases of the sexual organs, ()83 puerperal infection, ()83 etiology, ()87 mortality, 093 pathology. 094 ac'utest septioemia, <)97 — eellulitis, OOr) -encloiiielritis, 094 — lymphangitis, 095 — ui'.'tritis, 094 — oiiphorilis, 095 - peritonitis, 095 — phlebitis, 090 — pleurisy and pericar- ditis,' t!9() — salpingitis, 09o — vulvitis and vagini- tis, 094 symptoms, diagnosis, and prognosis, (i98-708 — absi'ess and ditl'use cellulitis of the limbs, 707 — actitest septicemia, 70S — arthritis, 707 —cellulitis, 099 — endocarditis, 706 — endometritis and me- tritis, 099 — hepatitis, 706 — lymphangitis, 700 — nephritis, 70() — nervous disturbances, 700 — pericarditis, 703 —peritonitis, 701 — phleliiiis, uterine, 704 — phlegmasia alba do- leiis, 70;{ —pleurisy, 703 — ]ineumonia. 701! — salpingitis and oopho- ritis, 099 — skin diseases, 707 — splenitis, 7(l(i — vidvilis and vagini- tis, 09S treatment. 7(IS 1. prevention of puer- peral infection in iiosjiitals, 710 disinl'cction, 71 "J — antiseptic conduct of labor, 7 1 4 Puerperium, pathology of: — disinfection of the doctors and luirses, 7i:{ — disinfection of the in- struments, 714 — disinfection of the materials, 714 — disinfection of the patient, 713 2. prevention of puer- peral infection in l)rivate practice, 717 3. curative treatment of puerperal infec- tion, 719-734 --acutest septicemia, 734 — arthritis, 732 — cellulitis and adeni- tis, 725 — encephalitis and men- ingitis, 732 — endocarditis and peri- carditis. 731 — endometritis and me- tritis, 721 — enteritis, 731 — hepatitis, 731 — nei hritis, 731 — peritonitis, 720 — |)hlebitis, 733 —pleurisy, 730 — pneumonia, 730 — skin, 732 2. subinvolution, 734 3. hemorrhages in puer- perium, 738 — fibroids, 743 — hemorrhage from malignant disease, 744 — pelviccongestion, 744 — rela.xation of the ute- rus, 743 — secoiularv bleeding, 744 ■ — separation or disin- tegration ol' throm- bi in the sinuses at the placental site, V42 — uterine displace- ments, 741 4. anomalies of the nip- ples and breasts, 745 — amazin, 74(5 — athelia, 745 — mii'romazia, 740 — microtheiia. 745 — polymazia, 740 — polythelia, 74ti 5. diseases of the nipples, 747 — abscess of the nipple, 751 — eczema, 751 — sore nipples, 747 Puerperium, pathology of: 0. diseases of the breasts, 751 — abscesses of the areola, 765 — cold or chronic ab- scess, 706 — congestion and en- gorgement of the mammary glands, 751 — fistula- of the hreasts, 766 — galactocele, 767 — mastitis, 756 — milk-nodes, 706 — parenchymatous ab- scess, 702 — subcutaneous abscess, 704 — submammary abscess, 7(i5 7. arrest of lactation, 707 8. anomalies in the milk- secretion, 768 abnormalities in qual- ity, 768 abnormalities in (|uan- tity, 771 — agalactia, 771 — conditions interfering with weaning, 777 — galactorrhea, 772 - hyperlactation, 777 — polygalactia, 772 diseases of the non-se.x- ual organs, 778 fever due to causes other than puer- peral infection, 778 — from acute constipa- tion, 780 — from emotion, 778 — from e.xpostu'etocold. 778 intercurrent disea.ses, 780 — diphtheria, 781 — erysipelas, 781 —exanthemata, 780 — hemorrhoids, 785 —malaria, 782 — pneiunonia, 781 — puerperal anemia, 785 — rheuiniitism, 781 disea.ics of the urinary organs, 785 — albiuninuria, 789 — cvstitis and pvelitis, ' 780 — functional disturb- ances, 785 — hematuria, 790 diseases of the nervous system, 790-801 - acute tympanitis. Sd! — cerebral hemonhaLie and embolism in the puerperium, 790 78 causes pntT- t ion, 778 diseases, "^ — ! ■ 11 781 u'liiiaJS.') 7S1 ; urinary i! 78'.l vy elilis. ilistiirl)- '.10 nervous k)0-80l jmitis, Sdl }inorrliani' lisni in leriierium. Piu'rperiuni, pathology of: — insanity in the ciiiid- bearinjf wotnan, 794-801 — neural and spinal afiections following lalior, 7!)1 rapid or sudden deatii in tlie puerperiutn, 801 — einliolisin and ihroin- hosis of the pul- monary artery, 802 — entrance of air into the uterine sinuses, 80S Puerperium, physiology of, ()4'.)-6o(J — blood-vessels of the uterus, ()5;{ — digestive organs, (i51 — genital organs: par- turient tract, 0-")l — involution, ()52 — lactation, <io4 — lochia, (l')4 — loss of weight, (>")0 — post-partuni chill, (149 — pulse, t)49 — reconstruction of the uterine mucosa, tir)4 — secretions and excre- tions, (ioO — uterine contractions, (iol — uterine niuscularis, — uterus, (552 Pulse of the new-born infant, 809 puerperal, t)49 Purpura luLMuorrhagica, 236 Putrefaction, fetal, 81;? Pyelitis, 78(i "treatment of, 788 Pyemia, t)97 Pyopagus, T)!):? Pyosalpinx, acute, puerperal, variety of, 972 Qi'ADHiil'iJ-ns, mode of origin of, 144 (Quickening, period of, lt)7 time of parturition deti'r- inincd by, 17.S. (See Fffi(.i,in(iri nil iil.idf, ) (juinin in treatment of puer- peral malaria, 782- 78") use of, in inertia uteri, 496 Kaciiitis, fetal, 307 "Rauber's cells," 78 Kectocele, otiO Rectum, conditions of, compli- cating labor, (i.S9, 5(50, oOl malformation of, in the new- born, diagnosis, 857 treatment, 857, 858 INDEX. Rectum, operations n])on, in pregnancy, 251 Remedies for the new-born, external, StiO internal, 861 Rejjosiiion of prolapsed cord, 575. 576 "Rei)tilian heart," 304 Respiration, changes in, due to pregnancy, 155 of new-born infant, 808 artiiicial, niethoils of, 816, 817 measures for induction of, 664, ti65 Rest in jiregnancy, 181 Retroflexion causing abortion, 261 Retroversion of gravid uterus, 193 Rheumatism. i)uerperal, 781 Rhinitis in the new-born, 851 Ridges, genital, 121, 123 Ring, contraction. (See Von- tniclioii.) Mailer's, 148 of Band), 583 Rotation in brow ])resenta- tions, 461). 4()7 in descent of the head, 512 in inei'iuuiism of face i)res- enfations, 460-465 in seccmd stage of labor, 435 manual, and application of forceps, in poste- rior positions of vertex, 451 Kug.c, vaginal, 43 Rupture of the uteriLs, 610 causes, 61 1 frequency of, 612 from cancer, 187, 188 from lil)roids, 1S6 prognosis, (113 spontaneous, 189 symiitoms, 612 treatment, 613 Ruptures of the perineum fol- lowing labor, t!73- 1)78 Saliva of the new-born in- fant, S()9 pre natal, ply.ilin in, 141 Salivation of pregnancy, 16((, 210 treatment, 210, 211 Salpingitis. ti!t5, (199 during pregnancy, 190 hysterectomy foi-, i)7l!, 974 purulent, hvsterectoinv for, 973 suppurative, indicating celi- otomy, 9(1!) Sal|iiugo-o(")phoreclomy tnr puerperal sepsis, 972 iudicutions for (jperation, 972 lOOf) Salt-solution, 609 transfusion of, in post-par- tum hemorrhage, 609 Saponification, fetal, 313 Sapremia contra-indicating celiotomy, 969 etiology of, (i85 Scalp, injuries to, of the new- born, 824 tumors of, in the new-born, ■S 18-822 Scarlatina complicating preg- nancy, 243 fetal, 296 prognosis, 297 Scarlet fever, puerperal, 780 prognosis and treatment, 7.S1. (See Feirr.) Schmidt's disease, 308 Schuitze's method of artiiicial resi)iration,817,818 Sclereniii neonatorum, 851 diagnosis and prognosis, 852 etiology, 851 pathological anatomy, 851 .symptoms, 851 treatment, 852 .Scoliosis, 539 Secretions and excretions, puerperal, 650 pre-natal gastric, 141 intestinal, 141 salivary, 141 lu'inary, 140 Secundines, retained, hemor- rhage from, 739. (See I'ldccnta.) .Segment, jielvic, anterior, 31 jxtsterior, 31 Segmentation of ovum, 7(i Scgmeiitalion-nucleiis, 7(! Sepsis, causing puerperal in- sanity, 796 of the new-born, 835 causing umbilical hemor- rhage, 831 pnerjieral, 341, 342, 346, 347 from svphilitic iul'ection, 240 abdominal section lor tlie treatment of 9liS exploratory abdominal section ill, 975 hysterectomy for, 972 techuii(ue of operation, 975 indications for, 974 for oiicratiou. 968, 9()9 sal|)ingo-odphorec t o ni y for, (172 mortality of, 341 ,*^cpta of tlu' cervical canal, 548, 549 of the vagiiui, 549 Septicemia in the new-born, 687 etiology of, 685 acut-st, 697 1006 INDEX. Septicemia, aciitost, symptoms, 708 trentmi'iit, T,\\ Sliei't-sliiij,', !»;")<) Shock, coinpliciitii)g lal)or,(J44 Shoulder jiresentation, podalic versi(m in, 490. (See J'ri'xciiUitiiiiin.] Slioiilders, fetal, exi)idsion of, 489 relation of the, in tiie median ism of la- bor, 40(i rotation of, nn expulsion, 489 Sifjhf, sense of, in the new- liorn infant, 812 Sinus venosiis, 105 Sinuses, uterine, entrance of air into,death from, 808 etiolofiy, Xin s.vnijjtonis, 804 treatment, 804 thrombosis of, 090, (!97 Skin, diseases of, intrauterine, 809 puerju'ral, 707 eruptions, jjuerperal, treat- ment, 782 of the new-born infant, 810 pigmentation of, in preg- nancy. ]")(1 Skin-protectives for the new- born, 800 Skull, injuries to, of the new- born, 825 Small-i)ox, fetal, 297 infection of, in pregnancv, 244 Smell, sense of, in the new- born infant, 812 Somatopleurc, 80, 82 Somites, Si Soutlle, funic or umbilical, 170 uterine or placental, 108, 411 "Space of Ketzius," 80 Speech, development of, in the new-born infant, 818 Spermatozoiin, fusion of ovum and, 75 Spina bifida, 804 Splanchnopleure, 80, 82 Spleen, hypertrophy of, due to pregnancy, 155 Splenitis, symptoms, 70(') Spondylolisthesis, 582-587 Spongiosum, 87 " Spontaneous amputation," 800 Stenosis, mitral, complicating pregnancy, 287, 288 of the cord, 259 Sterility, 18t) Slerili/ation by boiling, 843 by chemicals, 848 by dry heat, 848 Sterilization by steaming, 343 Stomach, malformations of congenital, 808,809 Stomatitis aphtliosa, 850 etiology and treatment, 850, 851 Stomato<la'um, 1 18 Strait, inferior, 18,19,392-394 didijrences between the male and female, 400 superior, 18, 19 arrest of head at the, the application of for- ceps, 486 in breech presentationB, 484 diameter of the antero- posterior, measure- ment, 501 diflt'rences between the male and female, 899 operative treatment at, in posterior jiosilions of the vertex, 450 shape and dimensions, 890-892 transverse diameter of, measurement, 507 Strangulation, fetal, 800 Stratum compacta, 87 Streak, jirimitive, 78, 79 '"Striic gravidarum," 151, ()5t) Stroma, ovarian, 00 Struma, fetal, 809 Subinvolution, 197, 784-738 Suckling after return of men- struation, 770 conditions interfering with, 778 diseases interfering with, 778 ingestion of drugs in breast- milk in, 776 in pregnancy, 776 in puer]ieral anemia, 775 Supcrt'e<'undation, 144 i Snperfetation, 144 Superimpregnation, 144 | "Super-rotation," 489 Sup[iositorv, iodoform, formula ■for, 722 '. Suppuration, fetal, 318 j Surgery, obstetric (instm-! mental), 807-941 operations, 807 — Cesarean section, 917 — craniotomy, 92(i — curettage, 872 — dilatation of the os, 882 — douche, the, 870 ; — embryotomy, 926 — episiotomy, 877 — forceps, the, 884 — passing the catheter, 808 — premature induction of labor, 878 I Surgery, obstetric (instru- mental) : — symphysiotomy, 905 — tampon, the, 874 general recpiircments and preparations for, 867 Surgery, obstetric (manual ), 941 operations, 941 version, 941 — contra- indications for, 948 — dangers of, 948 — indications for, 942 —methods of, 942 — varieties ol', 941 bipolar, 940 cei>lialic, 94."> external, 944 internal, 948 preparations for, 957. (See ViTKion.) Suture, amniotic, 88 coronal, 402 frontal, 402 lambdoidal, 402 sagittal, 402 uterine, in ( 'esarean section, 921 Suture materials, 880 Sutures of fetal head, 402 Suturing alter svmjjhvsiotomv, 915," 916 " in Cesarean section, 921- Svmphysiototuy, 905-917 contra-indications for, 912 history of, 905 incisions for, 918, 914 indications for, 911 limitations of, anatomical, 909 operation of, after-treatment, 910 Harris. 914 instruments required for, 912 method of, 912 Morisaui, 918 results of, 900 Symphysis, injuries to, from svmpliysi o t o m y. 907 separation of, amount of, bv svmphvsiotomv, 9()8,"914 Symphysis jmbis, articulation. Syndactylism, 304 Svphilis causing abortion, 200, 2()t; congenital, 84(i causing imibilical hemor- rhage, 881 etiology, 840 treatment, 840, 861 fetal, 297 diagnosis, 29S hereditary, 298, 299 sasm 957. to, fro'" lot II my, ii\inl ol', ysiotoiny, liculiilii'"' Hum, '2t><>, III hemor- 1 299 Syphilid, fetal, mode of trans- miHsion, 297-299 inateriiHl,siickliii|^ in, 775 of pregnancy, 240 of tlie placenta, 2o7 Sypliilis lia>rnorrlia)iica, 299 Syrinf<e.s, disinfection of, 717 Syrinf^o-niyelocele, ;W4 Taiiios, lactka, 777 Table, instrument, ecjiiipnient of, for internal ver- sion, 9-)7 obstetric, equipnieiit of, for the lyin{?-in room, 3t)0 Talipes varus, .'{0-1 Tampon, the, 874-877 intracervical, 874 intrauterine, 87(5 application of, method, 877 utility of, 877 materials for, 87o vaginal, 874, 875 vulvar, 874 Tampon in actual abortion, 2fi8-271 in threatening abortion, 268 Tainjionage, indications for, 874 in endometritis and metri- tis, 723 in intra-uterine hemorrhage, (iOll in placenta pricvia, 592, 593, (iOti, ti07, (108 in po.st-partum hemorrhage, 874 of uterus, techni(|ue, 877 of vagina, technicpie, 875, 87G Taste, sense of, in the new- born infant, 812 Teeth, during pn-gniuicy, al)- nornial conditions of, 234 Temperature in eclampsia, (527 reduction of, in peritonitis, 729 of the new-born infant, 811 puerperal, 049, ()50 Testicles, fetal, descent, 101 Tetanus and tetany, diagnosis, difterential, 247 in pregnancy, 24() Tetanus neonatorum, 841 diagnosis and prognosis, 842 etiology, 841 Tetany during pregnancy, 246 treatment, 247 Theca folliciili, 60 Therapeutics of the new-born, 860 — antiseptics, S()0 — astringents, 860 — counter-irritants, 860 — heat and cold, 860 — protectives, 860 I urinary, I INDEX. TiKiracopagus, 305, 563 Thrombosis anii hemorrhage, cerebral, during pregnancy, 212 of the pulmonarv artery, death from, 802 Thrush, congenital, 850 diagnosis and treatment, 8.50 Tongue-tie, congenital, 303 treatment, 303 Tonics for debility following childliirth, 663 heart, in the puerperium, 724 Toothache of pregnancy, 160, 209 Torsions of the cord, 259 Toxemia of eclampsia, 628, 632 of pregnancy, 202, 785 diagnosis, 207 treatment, 207 Toxins of pregnancy, 203 Tract, parturient, condition of, in the puerperiiun, 651 disorders of, in pregnancy, treat- ment, 199 in the pucriieritnn, 785 (See Vamd.) Traction, axis-, in the low oiieration, 89()-S98 in the high operation, 899- 904 Transfusion in post-partum hemorrhage, 609 Transverse presentations, de- fineil, 386 (See Pri'si;iUalii>ii!<.) Trendelenburg apparatus, im- provised, 962 Trephine, JJraun's, 9.30 Triplets, modeof origin of, 144 Trisnuis of the new-born, 842 Trimcus arteriosus, 106, 136 Trunk, fetal, relation of the, in the mechanism of labor, 407 injuries to, of the new-born, 824 (See Bod I/, ft'litl.) Tubercle, genital, 123, 124 Tuberculosis causing abortion, 260 congenital, 847 diagiu)sis and treatment, 847 fetal, 297 Tubes, Fallopian, anatomy, .5() during pregnancy, atli'c- tions of, 249 removal of, in juicrperal sepsis, 973 Tumor, blood-, complicating labor, 680-68;? Tumors, abdominal, congeni- tal, 301 indicating celiotomy, 969 congenital, 301, 302, 309 1007 Tumoi-s, cystic, 302 indicating celiotomy, 970 ol' the ovaries, 303 fetal, .309 complicating labor, 564 fibroid, com])licating labor, 558 in i)regnan(;y, surgical operations for, 248 uterine, hemorrhage from, 743 genital, infected, indicating celiotomy, 970 head-, of the new-born, 818- 822 in the brim, producing face presentations, 459 of the genital canal compli- cating labor, .556- 560 of the rectum complicating labor, 639 of the vagina and vtdva ob- structing labor, 5.50 ovarian, 190, 191 in prcgnanc;y, sinndating diagnosis, 173 pelvic, .530 indicating celiotomy, 969 treatment, 530 'placental, 257 .111(1 decidual, 740 p:)lvpoi(l,complicating labor, 558 sacral, congenital, 301 simulating extra-uterine pregnancy, 287 Tunic, vaginal, fibrous, 45 Tunica lilirosa, 71 Twins complicating labor, 567 formation of, 305 growth and development at birth, disi)arity in, Ml homologous. 143, 305 nioile of origin of, 143 Tvinpaiutes, (luerperal, acute, 801 Tympanites uteri, 273 Typhoid fever cumplieatiiig pregnancy, 241, 242 diagncjsis and treatment, 242 ¥ 248 pregnancy. Ulcer, gastric, complicating pregnancy, 232 Umbilicus, changes in, due to pregnancy, 151 hemorrhage from, 828-832 hernia of, 858 infection of the new-born through the, 836 (See ('(inl.) I 'rea in toxemia of pregnancy, 204 [Uremia of eclampsia, t)27 Ureter, female, siruclurc, 41 Urethra, blood-vessels of, 41 r. f lid I, ii I 1008 JNDl'LV. ; ^t- Urutlira, nerves of, 41 sirui'tiire of, 40 Irination, (liilieult, in the I)iiei']ieriuiii, treat- ment, (iiVJ, titiO I'rine, blood in the, after hibor, 7 '.10 fetal, |)re-natal secretion of, 140 incontinence of, puerjieral, 78;"), 7H() treatment, 781) of pregnancy, albumin in, changes in, loO examination of, 183 peptone in, 'IWi of the eclamptic, (j27, 633 retention of, in the puer- periuni, (i'j'J secretion and execretion of pnerperal, (i.JO toxicity of, in pregnancv, 208, 20o uric acid in the, of the new- born, 858 Utero-gestation, first period, 170 second period, 171 third period, 171 phenomena of, classification, 170 L'terns, the, 4o aspiration of, in the induc- tion of premature labor, 881 blood-vessels of, 03 during the puerperiutu, 6o3 cancer of the, 187, 241 in pregnancy, 241, 244 in the puerperiem, 744 obstructing labor, "jSO, o61 changed position of, in preg- nancy, 1(1") changes in, during the puer- periuin, C)")2 condition of, for internal version, 949 contraction of, after labor, _ 377, 378 contractions of, during gesta- tion, 318 influence of muscular, in dilatation, 425, 427 puerperal, (551 development of, congenital, anomalies of, 540 displacement of, anterior, complicating labor, 552 conditions following, 197 lateral, complicating la- bor, 553 puerperal, causes, 742 hemorrhage from, 741 douche of, (>|)eration, 872 during pregnancy, ))atho- logieal conditions ' of, 185 1 Uterus, entrance of air into, ileatli from, 803 excision of, in puerperal sep- sis, 973 extirpation of, for cancer,248 in carcinoma, 187, 188 fibroids of, complicating labor, 557 complicating the puerpe- rium, 743 hysiereclomy for, 180, 187 flexion of, occlusion of lochial (low bv, 741 hemorrhage from, during pregnancy, 238 puerperal, causes, 738-740 hernia of the, ct)niplicating labor, 552, 553 hypertropiiy of, during ges- tation, 145, 185 incarceration of pregnant, treatment, 195 incision of, in Cesarean sec- tion, 920 influence of eclampsia upon, 027 infravaginal portion of the, injuries to, (114 innervation of the, during pregnancy, 320 intermittent contractions of, during pregnancy, 107 introduction of an elastic bougie for induc- tion of premature labor, 879 inversion of the, 010 post-mortem, 046 puerperal, 742 involution of, tardy, 602 lacerations and rupture of, 010 ligaments of, 51 lymphangitis of, treatment, 720 muscle of the, influence of, in dilatation, 425-427 muscles of the, deficient power of, in labor, 493 nuiscnlar coats of, 49-51 mydmatii of, 185 nerves of, 03 normal position of", after labor, 741 obli(juity or abnormality of, l)ro(lucing a face l)resentation, 458 over-distention of, causative of labor, 320 position of, normal, 54 pregnant, amputation of, 2-18 changes in, 145 in form, 140 in position, 149 displ.iceirents of, 193 retro ver:ii)n of, 193 Uterus, pregnant, retroversion of", complications, 195 simulating, ectopic ges- tation, 193-190 prolapse of, following peri- neal lacerations, 075, 076 in inversion, 019 partial, with hypertrophic elongation of cer- vix, 553 puerperal, relaxation of, hemorrhage from, 743 phlebitis of the, 090, 704 treatment of, 734 putrescence of, treatment, 725 retraction of, in second stage of labor, 438 retn)version of, mortality, 195 frequency, 194 rupture of, from fibroids, 186 spontaneous, 189 version in, 013 sacculation of the, compli- cating labor, 553 shape of cavity, during pregnancy, 420, 421 structiu'e of, 49 subinvolution of, 734 diagnosis, 735 etiology, 734 treatment, 736 taniponage of, technique, /877 tamponing the, partum rhage, 600, 007, 608 veins of, air-embolism the, 803 virgin,. cavity of, 46, 48 Uterus and fetus, adaptation between, 420 Urine, retention of, passing the catheter for, 868, 869 Vaccination during preg- nancy, 244 maternal, protection to fetus in utero by, 297 Vagina, atresia of, obstructing labor, 550 axis of tiie, 43 blood-vessels of, 45 changes in, during preg- nancy, 150 cicatrices in, obstructing la- bor, 5 19 diseases of, complicating {jregnancy, 1 93 douche of, operation of, 870 injuries to, following labor, 078 causes of, 678, 679 treatment of, 679 in post- hemor- 592. 593, of ' r^DEX. Vagina, irrigation of, in ,i„. "iiliiction ,,(■ ,„.^,. ."mture labor, «.si Ivmi'liaii.s oi; .|.-, ""'•'■"»"e.s« oi; ..oMKcMH.al, ^■«mi)licatin.r|,,l,or, nerves of, 4.j '"• vulva, closure and oon- ti'iiction of.ojisinict- ' inff Jailor, rA\) P">ritnsof,,|„riny,.re,M,aM. ey, 220 stnietnre of, ^2 «an),,oninKtl.e,forin,Iuoti„n J^'J,pn'niature labor, '" '''"^;"^ I'nevia, m, U'clini,ji,e of, 87-,, 87« 't'^'l'ni'li.e of ,|i^.i(,,| ,.^^,,^^_ * a^'inisinns, o.",] Vaginitis, (i!)4, ,;(|.s ,;,,,, treatment oi; 7->() Variola .•on.pli,,,,!,,^, ...-e., ,. . nancv, 244 " Mai, 297 >.w'tis, the, 454 »»""is, allantoic III fetal, 110 "lanirii.irv, (i!) ovarian, (i;; ' " l>elvie-(lo,ir, .S(j nmliilioai, \r,i uterine, (l;{ air-en.holi„„ i„, .j^.^,, ironi, .so;; var,..ose,eo,„j,|i,,„i, ,,,, in/la/nniation of, 7;j4 vitelln.e, 110, 111 ' \ enie advehentes, 111 '■■•iva, III, 112 revehentes, 111 Neoeseetion in pregnancy, 1,-,;! '" "-e^fj^U of eclampsia, Ventilation!', ,|,e lvi„o..i„ .. . room, (jr.o " " \ernix caseosa, 101 \er.s,on after craniotomv,,Ian- , . , Ser oi; iJSC, ' '|'|>'>lar, !)4(i, 947 i'liiications for, 94C> pi-eparation foi>, 947 ;^"■l'■softheoperati,.n,947 I'nie to operate, 947 eepiialic, 942-944 eondiiii.ns for, 944 '•'>ntra-in.iicati<ins for 94;! indications for, 94-' «te|'soi; the o,,erati„i,. 1,44 ! v t'>'fa-in,licatio;,sf,„.9. ! U^ <lanf,'ers of, 94;{ ' ^ external, 944, 94.", I'oiilra-indieations fur, 944 04 100i» Version, external, in.Iicaiio„s - villi . f..r, 9/4 .\.'" • I'laecntal, 90 I'i'eparaiinn tor 94", .\"^''.''i'< "'" ovum, 71 '^.'•■I'^'-fiheopeWuiou 04-, ^ ','""" "Jr in la l,„r, (;;J7 . "II"' I'Miperate, 94.-, '' )" "''l:'ii'"iMreatmenl 7'!'> ;,';.'7'""i'itiMreatmen,72; "' I'lvunancy, |.-,.-,, i.-,,, \,.,:P ii'eaiinenl, I,s;{ ' """ '" ■■ !'•■'. aiiaioiuv of, ;{7 '"" « "i; ilurinir 'nv. nancv, nn ' "^ "uche ol, operation, ,S70 ' •^■''■^inj,' of, after labor, ;i,s;! t'dema (if, r),-,() • •' "•i'l'ation^.,,; i„ ,„.,„,i,,,^^ ganu,,,,,n. „f, treatment r.ol '".'"■^■■- 10, following. 1Mb,',. , fiealinent, fi72 'yniphanjritis of treatmeut, "'"■'■""•'itvs'T of, cono„„i,,,| <:'j'ii|''i«atin- labor' l"''"'i'ii« of'.lurin. pregnan- cy, 220 '" "'iH'rinr position of ,i„, I'nnv, 4().S "• ''"'i' I'l-esentations at the I'l'ini, 4(i4 '" 'i''«l^'''ted or impaeted eases, 9(i,S !;;rui.lnre of the uterus, (i|;i '" "ansverse presentations, internal. 94S '■lioice of hand. 9,-)(j 1 •■ondiUoiis for, 94,s j dangers of, 9-,() 1 feet in, both, 9,-,(j ! ioot 111, choice „/; 9r,o "*^"r, in dorso-anterior positions, (),J4 '••-''I'ote, in dorso-poMe- . '"lor positions, 9")4 sin^'le, 'j.-,r, "iL" operation, preoara- , '>'• --*' 'ions lor, 9:17 ' V i'"-'''"" "' "''V^74 operation „f : : ^ 'iivilis, (194 — L'xamiiiati(m, 9(i;{ —extraction, ()(;.-, i'uiikdiale, versus delay, <)().-, W . , , , , -iiitmduclion of the '''■*'' ■■i''''oniii,al, chaiiL'ev liand, 90,'j ''"" 'ii'iKnosis and prognosis. (;.)9 **.vniptoms, (lii.s '■■"•'» 'rt'alMieut, 720 posture of the patient 9o9-9(i;} ' <Ior.siil, 959 knee-elbow, 9(i2 latero-prone, 901 ,'j'_|Uattiii<.-, 9lia iiendelenbuiy,9(;-> Walcher, 901 — «'izureofthefoot,9(i4 — i^teps of I|n._ <„j;; — turniiiu', 904 prepar.ition for .- —anesthesia, 9oS , — antisejisis, 9o,S ""'"•""";-, ''"• oi'eration, j methods of, choice of 94-) Pt'lvic, indications for 1)4") -■'■^'"". podaiic, indi;ui^-,s .. V :i'r"";r'".-'^-* lor, 912 ,, • "', '""■ I 'a«eia 1. 29 ,'!( fur, 912 varieties(,f choice of, 941 \ ertex presentations deli„ed .WO. (.See P,r.,i>'. ,, . f'ltionK.) ^t'sical calculus of pre^nancv , . -'00. .-(01 ^r;:;!'''f,^''";"'"'- ovarian. 71 •esses l,|oo,|.. |Seey>V,„./.) ""'''"'"■^'1. 'liseasesoi; ,s;!7^ lieiiiorrhaye from, ,S2,S , . trealineni of, s;!() t;>;t'l'ide. ihc, sinu.turcof ;!s ""' '■horionic, 7S, ,s.-, ,s,; 91 ' ' ileKcner.illou ,,f, hv.ialidi- lorm, 2.">1 due to pre.u-naiicv, Jol • ' uterine, aiiatoiuv, V) I ,/'i«i'ial. auatoinV, 4;!-45 I VVash, lead-aud-opium. fo... ■ ,,- , luul.'i, 720 , »» aters. escnn. ..r . i \'l '^ ".'. <omplete, •lilalation of ,« •,(■. ler, 429 ; I'''r'ial. dilatation of os afier, 427 «-'nly, dilatation of OS uith ,.- . .original 429 It eaniiig, ^77 iirri;sl of lact.-.tion after, 707 '" iii'i'ieurrent .iiseases of the mother, 77;!- \y "'"' \U't-nurse, .selection of the, 0(18 „ ,V. 1."'" 'anes," 2;{4 \\- 11... ' '•••sciai. :j<i ; "imkels disease. 844 84-5 »»olflian bodies, 02, ll's-I').- '•I'fl, llS-12;! ^Voinan, child-bearing, insa,,. 'l.v in, 794 pregnant, posture and bear- 'ii.y: of, 202 •'^urgical operations on, ■>.-,! 'olerance of, to meclian- 'eal injuries, 249- ^\'oun.Ls afli^ctlng normal yes- tat ion, 2-I9-2.J2 XiiMioi-Adis, oO;! >^o.vA n:u.i( U..V of ovum, 71 m i;i ff m m^ ■ ' ' ■' 1 - i'l 1 1 i.;. if!;. 1 :;lj J ■ ■ ■ PUBLISHED BY W. g. gauRdet^, 925 Walnut gbeet, sP^iladelpl^ia. ;n JJR. SAUNDERS, In presenting to the profession thefol- hls 1:: V' °' ''"'""="'°-' "^-^ to state that the 2 m^dlo^r: t :*'" *'"'" ""^"^ °' the confidence of and bv '""'-"""^^^ "^ "^« high standard of authorsWp Ld IZl. ^'"-"^""^ - ^—P"- PaPe. printing The works indicated in the Index (see next page) with mnally through travelling solicitors, but they can be oh tamed ^,..., fro,„ the office of publication (charges of sll me"t Prepa.d, by remitting the quoted prices. Ll *.!> All the other books advertised in this catalogue are commonly for sale by i,o,s.Ue.s in all parts of the Uni ed S. es, bnt any book will be sent by the publisher to any address (post-paid) on receipt of the price herein given f !■ 1 ,-i CONTENTS. Aiintomy. lliiyiirs, Miiimnl (>r Aimldiiiy Niincri'ilf, Aiiiiliiniy and .Ma'riiial nf l)lNi<«etiou, , Muiiurvdu, IJutviitiulH ol' Aiiutoiiiy, m Ba«'t4>rioloiry. Hall, K•<Mllltilll^^ of HarU'il(ili>t!y l''rollilii»:liJiiii, LalHiiatciiy (iiiiilc Mcl'mlanil, Tuxt-KiHik ol' rathiiK»iiiu llucterla, . Ikttnny. Uustiii, Lalwralory KxitcInos In llutuny, .... t'lifiiilNtr.v uimI PhyHlcM. Brockway, KssiMitlals 111' riivMics, Wolir, Ivsst'nlial.s 1)1' Clinnisiiy 4'hll<lr<>n. *An Anu^iiiMin Tixl-Hdiik of l)lsi'aM's of Cliililron, . (iiillilh, Cari'dt' 111!' Italiy Towt'll, KsHi'iiliah 111' DiNca-tOH of Childrun, . . . , Clliiifiil <'linrlN. etc. Keen, Onrral ion lllank, l.aln^, 'lrni|iirainn' Clnii'l TliiJums, Dulaclialili' Dii'i l.isis, dr., ■lillKIIONiM. Culu'n and KshniT, ICsNi'iilials iif l)iat;n>iNis, . . . Mcliiiinilil, Siii^'iial liia);ni>sis anil Trt'alnn'nl, . . •Viurordt mill .stuai'l, .Mciliral I'iaKiiiisi.'t l>irti<tniiri«>N. •KcalinRand llninlllon, Now I'mnnnniinK Dictlon- aiv 111' Mi'ilicine Mdi'loh, Xnrse's |)i(lii(nai'v 111" Mi'dkal TiTius, . . Saniulers' I'ui'kot Medical Lexicon, Kitr. Ciluasun, Ks.HunUals or Disoasos 111' Kur, KI<><*trlFity. Stewart and Lawran<'c, 1'ls.suntial.s of Medical Elec- tricity, .... Kiiilir,v4>IOK.V- Helaler, a 'IVxt-Hook of KnilirynloKy Eye, NoMe. iiiitl Throat. ♦DcSclnvi'inil/., Diseases of Kvi' .Tarksnn anil (llca.siin, Kssentfalsof Dlsea-ses of Kye, Niwe, and Tliiiial Kyle, Manual of Diseases of Nose and Throat, . . < Ji>n i t<t-u r 1 iiiiry . Hvde, Sv|iliilis and llu' Viiii'ival Diseases Miirliii.'lvsseiilials of .Minor .><nrgury, Handaging, and Venereal Di.seast's, tJ.VIK'CMlOir.V. *Aii .Vnierican 'i'ext-liook iif (iyio'iiilogy, f'ra^'in, i;sseiitials of (iynei'iilogy, tiarri^nes. DiseiKis of Women, Jjong, .Syllalins of (iyneeology, Ui'e IiiHiiriiiire. Kealinn. How to Examine for Life Insnrance, . . Miiterin n«'«U<-n iintl TlicrnppiiticN. *An .\nierii an IVxI-liook of .Vpplied 'I'lierapentics, Ccnia, Notes on tin' Newer Hi'nn'ilies <irilfiii, .Manual of .Materia .Meiliea iind Tlieraiien lies, 5Iorris, Kssenlials of Materia Meiliea, etc., . . . Sannders' I'oekel .Meilieal I'ornnilury, Stevens, Mainnd of Tlierapenties, Tliorntoii, Dosc-liook and I'reMriplioii-Writiiig, •Wurreu, iHirgieal I'athology and 'I'lierapentics, . 2U 17 27 It 2!» t'J 27 '23 ■J" IB '.'0 'ill 2ri •2!) 8 9 2S 28 28 21) 7 2.'> 12 12 2r, 6 24 ir> 17 20 .SO 1,H 12 2:i 20 '20 14 10 Me«iicnl Jnrlnprndenee. paor (liapniun. Medical .Inrisprndenie and roxieiiliigy, 14 Si>niple, lutsuntials of Legal .Meilii'iin', ell'., , , , . 2.1 Me<ll<>liie. •An Ainerlean Text-Hook of I'rael lee 't l.oekwiiiHl, .Manual of I'rai'llie of .Medieliie, . . 12 Morris, Kssentiuls of I'rai'liee of .Miilieine, , . . . 21 •Saninlera' Ainerlcun Vear-lliHik of .Medlelne and Surgery, ;t2 .Stevens, Manual of I'ructlee of Medicine, 17 NervoiiN IllMoiiNeN nnil InNiinll.T. Ifnrr, Mainial of Kervons DNeases 12 Shaw, Essentials of Nervons Diseases uiid Iiisunlty, 27 .'WiirMliiir. All Anieriian Text-llook of Nnrsinu .10 tirillith, (are of the lialiy 2!t Uuiuptoii, Nursing: its 'I'rini'lples and I'ladice, . 1.5 ObMtetrleN. •An American Text-Hook of Olisletrics, :io Ashton, l';ssentials of Olislelries, 'ill Dorland. .Mannal of Olistetrles |:| .lewetl, Outlines of (llistelriis is Norris, Syllahns of Uhsletrieal l.ei'lnres 18 Orthti|tn'ili«'N. Wilson, rrevunling and t'orreeiing Del'nrnillies, . 15 l>Htliol»iry. Sem)ile, Ksscniinlsof I'athology ami .Minhlil .\nat- omy, . . . 23 *S<<nn, I'atholo^v and Surgical Treatment of Tninors, 2it Stengel, Mami;il of I'allioliigy 12 •\\'urreii, Surgical I'athology and Tlierapenlies, . . lu Phnriiiiie.v. Say re. Essentials of Pharmacy, 26 I*h,TNlolOK,V< ♦An Anieriian Text-Hook of I'hysiology .10 Hare, I'^sseiitials of I'liysioloyy, '22 Itayniond, .Manual of I'liysiidogy, l;{ Mkiii. Slelwagon, E.ssentials of Diseases of I he Skin, . . . 24 Nil rue ry. An .\iiierican Text-Hook of Surgery ;i Heck, Surgical .Asepsis 12 Dal osta, .Maiuial of Surgery, l:i Keen, 0|)eralioii HIank. .' l.'i McDonald, Snrgleal Diagnosis and 'Ifiatment, . . '2!) .Martin, I'Xscntials of Surgery '22 Martin, Essentials of Minor Surgery, etc ^'i •Saunders' American Year-Hook of .Medicine and Surgery .'(2 •Sciin, I'allioliigy and Surgical Trealmeiil of Tiiiuors, '29 .Senn, .Svllalius of Surgery 17 •■Warren, Surgical Pathology and Therapeutics, . . 10 Wilson, Oithopicdic Surgery, 1.5 I'riiie. Wolir, Es.seiitials of ICxamination of I'riiie, . . . '-'(! MiNcellHiieoiiN. •Gross, .\utiiliiograpl\y of, 9 Saunders' New .Mil Series of .Maniial.s 11-12 Saunders' (Question (onipends 21 Thomas, Detaehalile Diet Lists, etc., '29 Practical, Exhaustive, Authoritative. PAOW It ■Hi 4 Vi •Jl 112 17 SAUNDERS' NEW AID SERIES OF MANUALS. ''■■ FDR 12 27 :io 15 ;m 2;» i:i i« 18 lllllt- iii>r», 15 23 2» 12 lU 26 30 22 l:l 21 111" and Imuns, :i 12 l;i ir. 2'.t 22 2'i 32 29 17 10 15 9 .11-12 21 29 STUDENTS AND PRACTITIONERS. Mr. Saindkrs is pleased to announce that he has ready his NEW AID SSRIES OF MANUALS for Students and Practitioners. As publisher of the Standard Series of Question Compenus, and through inti- mate relations with leading members of the medical profession, Mr. Saunders has been enabled to study progressively the essential desiderata in practical "self- helps" for students and physicians. This study has manifested that, while the published "Question Compends" earn the highest appreciation of students, whom they serve in reviewing their studies preparatory to examination, there is special need of thoroughly reliable handbooks on the leading branches of Medicine and Surgery, each subject being compactly and authoritatively written, and exhaustive in detail, without the intro- duction of cases and foreign subject-matter which so largely expand ordinary text- books. The Saunders Aid Series will not merely be condensations from present literature, but will be ably written by well-known authors and practitioners, most of them being teachers in representative American Colleges. This nerv series, therefore, will form an admirable col- lection of advanced lectures, which will be invaluable aids to students in reading and in comprehending the contents of " recommended " works. Each Manual will further be distinguished by the beauty of the new type ; by the qjality of the paper and printing ; by the copious use of illustrations ; by the attractive binding in cloth; and by the extremely low price at which they will be sold. II i^ I r ■ ..'ii li !f Saunders' New Aid Series of Manuals. VOLUMES HOW BEADY, i /i PHYSIOLOGY, by Joseph Howard Raymond, A. M., M. D., Professor of Physi- ology and Hygiene and Lecturer on Gynecology in tlie Long Island College Hos- pital ; Director of Physiology in the Hoagland Laboratory ; formerly Lecturer on Physiology and Hygiene in the Brooklyn Normal School for Physical Education ; Ex-Vice-Presidentof the American Public Health Association; Ex-Health Clommis- sioner, City of Brooklyn, etc. Illustrated. $1.25 net. SURGERY, General and Oporative, by John Chalmers DaCosta, M. D., Demon- strator of Surgery, JefTersir. Medical College, Philadelphia; Chief Assistant Sur- geon, .Jefferson Medical College Hospital ; Surgical Registrar, Philadelphia Hospital, etc. 188 illustrations and 13 plates. (Double number.) $2.50 net DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING, by E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Price, cloth, $1.25 net. SURGICAL ASEPSIS, by Carl Bkck, M. D., Surgeon to St. Mark's Hospital and to the New York German Poliklinik, etc. Illustrated. Price, cloth, $1.25 net. MEDICAL JURISPRUDENCE, by Henry C. Chapman, M. D., Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia; Member of the College of Physicians of Philadelphia, of the Acade- my of Natural Sciences, of the American Philosophical Society, and of the Zoologi- cal Society of Philadelphia. $1.25 net. SYPHILIS AND THE VENEREAL DISEASES, by James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases in Rush Medical College, Chicago. Profusely Illustrated. (Double number.) ¥2.50 net. PRACTICE OK MEDICINE, by George Roe Lockwood, M. D., Professor of Practice of the Woman's Medical College and of the New York Infirmary; Instruc- tor of Physical Diagnosis of the Medical Department of Columbia College; Attend- ing Physician to the Colored Hospital: Pathologist to the French Hospital; Member of the New York Academy of Medicine, of the Pathological Society, of the Clinical Society, etc Illustrated. (Double number.) $2.50 net VOL UMES IN PRE PAR A TION FOR EARL Y PUBLIC A TION, MANUAL OF OBSTETRICS, by W. A. Newman Dorland, M. D., Demon- strator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispen- sary, Pennsylv.ania Hospital ; Member of Philadelphia Obstetrical Society, etc. Profusely illustrated. MATERIA MEDICA, by Henry A. Griffin, A. B., M.D., Assistant Physician to the Roosevelt Hospital, Out-jiatient Department, New York City. NOSE AND THROAT, by D. Braoen Kyle, M.D., Chief Laryngologist of the St. A^riies Hospital, Philadelphia; Hiicteriologist of the Orthopii'dic Hospital and Infirmary for Nervous Diseases; Instructor in Clinical Microscoi)y and Assistant Demonstrator of Pathology in the .lefferson Medical College etc. NERVOUS DISEASES, by Chaulk'* W. Burr, M. D., (liiii.al Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the OrthopaHlic Hospital and Infirmary for Nervous Diseases; \'isiting Physician to the St. .loseph Hospital, etc. MANUAL OF ANATOMY, by rnviNO S. ITaynes, M. D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the University of the City of New York, etc. MANUAL OF PATHOLOGY, by Alfred Stenoel, M. D., Instructor in Clinical Medicine, Medical Department University of Pennsylvania, etc. *** Tlicre will 1k' jiiilili.slu'd in tlie .saini' sfrics, at dose intervals, carefully-prepared works on the subjeeth of Chiklren, (Jyneetilogy, Hygiene, etc., by prominent speeinlists. lii' CA TALOGUE OF MEDICAL WORKS. »3 A MANUAL OF PHYSIOLOGY. By Joseph H. Raymond, A. M., M. D., Professor of Physiology and Hygiene, and Lecturer on Gynecology in the Long Island College Hos- pital ; Director of Physiology in the Hoagland Laboratory ; formerly Lecturer on Physiology and Hygiene in the Brooklyn Normal School for Physical Education ; Ex- Vice-President of the American Public Health Association ; Ex- Health Commissioner City of Brooklyn, etc. Illustrated. Price, Cloth, $1.25 net. A work for the student and practitioner, rep- resenting in a concise form the ex'.^ting state of Phybioiogy and its methods of inve^-ii ;ation, based upon Comparative and Patho- logical Anatomy, Clinical Medicine, Physics, and Chemistry, as well as upoi? experimental research. specimen Illustration. to A MANUAL OF SURGERY, General and Operative. By John Chalmkks DaCosta, M. 1)., Demonstrator of Surgery, Jefferson Medical College, Philadelphia ; Chief Assist- ant Surgeon, Jefferson Medical College Hos- pital ; Surgical Registrar, Philadelphia Hos- pital, etc. One very handsome volume of over 700 pages, with a large number of illus- trations. (Double number.) Price, Cloth, 52.50 net. \ new manual of the Princijiles and Practice of Surgery, intended to meet the demands of students and working practitioners for a medium-sized work which will f-ni'^otb- all the newer methods of pro- cedure det ;i_i! ■^•^ the larger textbooks. The work has been written in a concise, practical manner, and especial attention has been given o ih^ most recent methods of treatment. Illustrations are freely used to elucidai.'i the te.xt. specimen Illustration. I'dic leph of of .•ill ks oa A MANUAL OF OBSTETRICS. By W. A. Newman Dori.and, M. D., Demonstrator of Obstetrics, University of Pennsylvania; Chief of (gyneco- logical Dispensary, Pennsylvania Hosjjital ; Member of Philadelphia Obstet- rical Society, etc. Profusely illustrated. (In pre])aiati()n.) This work, whit h is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for the stutlent and of value to the prac- titioner as a (onveiiient handbook of reference. .Mthough concisely written, nothing of importance is omitted that will give a clear and succinct knowledge of the subject as it stands to-day. Illustrations are freely used throughout the text. \ 14 IV. B. SAUNDERS' ILLUSTRATED DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Med- ical College, Philadelphia. Price, Cloth, $1.25 net. But little attention is generally given, in \vorks on Materia Medica and Thera- peutics, to the methods of combining remedies in the form of prescriptions, and this manual has been written especially for students in the hope that it may serve to give a thorough and comprehensive knowledge of the subject. The work, which is based upon the last (1890) edition of the Pharinacof^a-ia, fully covers the subjects of Weights and Measures, Prescriptions (form of writing, general directions to pharmacist, grammatical construction, etc.), Dosage, Incom- patibles. Poisons, etc. MEDICAI.JURISPRUDENCE AND TOXICOLOGY. By Hknrv C. Chap- man, M. D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- delphia ; Member of the College of Phy- sicians of Philadelphia, of the Academy of Natural Sciences of Philadelphia, of the American Philosophical Society, and of the Zoological Society of Philadel- phia. 232 pages, with 36 illustrations, some of which are in colors. Price, $1.25 net. specimen Illustration. For many years there has been a demand from members of the medical and legal professions for a medium-sized work on this most important branch of medi- cine. The nece.ssarily proscribed limits of the work permit only the consideration of those parts of this extensive subject which the experience of the author as coroner's physician of the city of Philadelphia for a period of six years leads him to regard as the most material for practical purposes. Particular attention is drawn to the illustrations, many being produced in colors, thus conveying to the layman a far clearer idea of the more intricate cases. " The salient ])oints are clearly delined, and ascertained facts are laid down with a clearness that is une(|uivocal.'' — St. Louis .Mciiical aud Surgical Journal. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Lan(;i)()N Froi iiiN'fiH am, M. I). \'., .Vssistant in ISactL'riology antl N'eterinarv Science, Sheffield Scientific School, Vale University. Illustrated. Pri(o, C'loth, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as sim])ly and concisely as possible. The book is especially intended for use in laboratory work. CATALOGUE OF MEDICAL WORKS. NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Oraduate of the New York Training School for Nurses attached to Bellevue Hospital ; Superintendent of Nurses, and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superin- tendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 pages, jjrofusely illustrated. Price, Cloth, $2.00 net. This entirely new work on the important subject of nursing is at once compre- hensive and systematic. It is written in a clear, accurate, and readable style, suit- able alike to the student and the lay reader. Such a work has long been a deside- ratum with thost.' intrusted with the management of hos])itals and the instruction of nurses in training schools. It is also of especial value to the graduated nurse who desires to accjuire a practical working knowledge of the care of the sick and the hygiene of the sick-room. METHODS OF PREVENTING AND CORRECTING DEFORM- ITIES OF THE BONES AND JOINTS : A Handbook of Prac- tical Orthopedic Surgery. By H. Augustus Wilson, M. D., Professor of General and Orthopedic Surgery, Philadelphia Polyclinic ; Clinical Pro- fessor of Orthopedic Surgery, Jefferson Medical College, Philadelphia, etc. (In preparation.) The aim of the author is to provide a book of moderate size, containing com- prehensive details that will enable general ])ractitioners to understand thoroughly the mechanical features of the many forms of congenital and accpiired deformities of th(> bones and joints. The mechanical functions that are impaired will be considered first as to pre- vention as of primary importance, and following this will be described the methods of correction that have been proved practical by the author. Operative procedures will be considered from a mechanical as well as a surgical standpoint. Prominence will be given to the mechanical recpiirements for braces and artificial limbs, etc., with description of the methods for constructing the simplest forms, whether made of plaster of Paris, felt. Leather, paper, steel, or other materials, together with the methods of readjustment to suit the changes occurring during the progress of the case. A very large number of original illustrations will be used. AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Kf.en, M. D., LL.l)., Professor of Principles of Surgery in the Jefferson Medical College, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. A convenient blank (suitable for all operations), giving com])lete instructions regarding necessary jjreparation of patient, etc., with a full list of dressings and medicines to be employed. At the back of pad is a list of instruments used — viz. general instruments, etc., retpiired for all operations ; and special instruments for surgery of the i)rain and spine, mouth and throat, abdomen, rectum, male and female genito-urinary organs, the bones, etc. The whole forming a neat ])ail, arranged for hanging on the wall of a surgeon's office or in the hos[)ital o[)erating-room. i6 W. B. SAUNDERS' ILLUSTRATED 1 1 " i DISEASES OF WOMEN. By Henry J. Garrigues, A. M., M. D., Pro- fessor of Obstetrics in the New York Post-(iraduate Medical School and Hos- pital ; Gynaecologist to St. Mark's Hospital, and to the German Dispensary, etc., New York City. In one very handsome octavo volume of about 700 pages, illustrated by numerous wood-cuts and colored plates. Prices : Cloth, JI4.00 net; Sheep, ;S!5.oo net. specimen Illustration, A PRACTICAL work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough knowle jge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chapters on Operations and on Treatment are thoroughly modern, and are based uuon the large hospital and private jjractice of the author. The text is elucidated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying e»i/>ryo/(>x\\' and the anatomy of the female goiitalia, besides exemi)li tying, whenever needed, morbid conditions, instrimients, apparatus, and operations. EXCERPT OF CONTENTS. I)evelo|)inent of the Female (Jeiiitals. — Anatomy of the Female Pelvic Orp;ans. — I'liysiology. — Puberty. — Menstruation and Ovulation. — Copulation. — Fecundation. — The Climacteric. — F'tiolofjy in (ieneral. — FAaminations in Ciener.al, — Treatment in Ciencr;;! — Abnormal Men.struation and Nle- trorrluvia. — Leucorrhea. — Diseases of the Vulva. — Diseases of the Perineum. — Diseases of the X'agina. — Di.sea.ses of the Uterus. — Diseases of the F"allo|>ian Tubes. — Diseases of the Ovaries. — Diseases of the Pelvis. — Sterility. The reception accorded to this work has been most flattering. In the short period Avhich has elapsed since its issue, it has been adopted and recommended as a text-book by more than 60 of the Medical Schools and Universities of the United States and Canada. " One of the be.st text-l)ooks for students and nractitioners which has been [)ubli.shed in the F'.n^lish language ; it is condensed, clear, and coniprehen.sive. The i.rofound learning and gre.it clinical experience of the distinguished author lind expre.s.sion in this book in a nio.st attractive and instructive form. Voinig |)riiclitioners, to whom experienced consultants may not be available, will find in this book invalualile counsel and help." TiiAi). A. Hkamy, M.D, I,I,.I)., Professor of Clinical Gynecoloi^w Midital Colli'i:;e of Ohio ; Gyiiicoloffist to the Good Samaritan and lo the Cincinnati Hospitals. CATALOGUE OF MEDICAL WORKS. 17 ESSENTIALS OF ANATOMY AND MANUAL OF PRACTICAL DISSECTION, containing "Hints on Dissection." By Charles H. Nancrkde, M. L)., Professor of Surgery and Clinical Surgery in the Uni- versity of Michigan, Ann Arbor j Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, §2.00 net. No pains nor expense have been spared to make this work the most exhaustive yet concise Student's Manual of Anatomy and Dissection ever published, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an -Xijpendix added containing 60 illustrations rej)resenting the structure of the entire human skeleton, the whole being ba.sed on the eleventh edition of (iray's Anatomy. A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. I)., Instructor of Physical Diagnosis in the University of Pennsyl- vania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations. Post 8vo, 502 pages. Illustrated. Price, $2.50. Contributions to the science of medicine have poured in so rai)idly during the last (juarter of a century that it is well-nigh impossible for the student, with the limited time at his disjjosal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teach- ing, the author has been enableil. by classification, to group allied symptoms, and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the practice of medicine. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with The American Text-book of Surgery. By Nicholas Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This, the latest work of its eminent author, himself one of the contributors to the " .-Vmerican Text-book of Surgery," will i)rove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome or supplement to the larger work. A SYLLABUS OF GYNECOLOGY, arranged in conformity with The American Text-Book of Gynecology. By J. W. I.om;, M. D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Price, Cloth (interleaved), Si. 00 net. Hased u|)(i>i the teacliitiR mul mitlni<ts laid cii.wii in ilie lar^'t-r work, tills will not only lie luse- ful as a supplcnuMUary voUimc. bin to those who do not already possess the Textlkiok it will also have an independent valne as an aid to the practitioner in trynecolot^ical work, and to the stndent as a Riiide in the lecture room, as the subject is presented lu a manner at once systematic, clear, succinct, and practical. i8 IV. B. SAUNDERS' ILLUSTRATED SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. J5y Richard C. Norkis, A. M., M. D., Demonstrator of Obstetrics in the University of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, $2.00 net. "This work is so far sui)erior to others on the same .subject that we take pleasure in calling attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. 'I'hc author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially jjloased with the ])ortion devoted to the practical duties of the accoucheur, care of the child, etc. 'I'hc paragraphs on antiseptics are admirable ; there is no doubtful tone in the directions given. No details are regarded as unimportant ; no minor matters omittetl. W c \enture to say that even the old practitioner will find uselul hints in this direction which he cannot afford to despise." — Alciiical Record. OUTLINES OF OBSTETRICS: A Syllabus of Lectures Delivered at Long Island College Hospital. By Ch.^ri.i.s Jkwktt, A. M., M. ]),, Prolessor of Obstetrics and Pediatrics in the College, and Obstetrician to the Hospital. Edited by H.ar(ili) F. Jkwett, M. D. Post 8vo, 264 pages. Price, $2.00. This book treats only of the general facts and principles of obstetrics : these are stated in concise terms and in a systematic and natural order of seciuence, theoretical discussion being as far as possible avoided ; the subject is thus i)re- sented in a form most easily grasped and remembered by the student. Si)ecial attention has been devoted to practical (luestions of diagnosis and treatment, and in general {particular jjrominence is given to facts whicli tiie student most needs to know. The condensed form of statement and the orderly arrangement of topics adajjt it to the wants of the busy practitioner as a means of refreshing his know- ledge of the subject and as a handy manual for daily reference. NOTES ON THE NEWER REMEDIES: their Therapeutic Appli- cations and Modes of Administration. By David Cerna, M.D., Ph.D., Demonstrator of and Lecturer on Experimental Therapeutics in the Lhiiver- sity of Pennsylvania. Post 8vo, 253 pages. Price, $1.25. :. .^ J SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. The work takes up in atphal)etical order all the newer remedies, giving their physical properties, solubility, therapeutic ai)plications, administration, aiKi chem- ical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that, if each compound is to be thor- oughly studied, investigations must l)e carried tar enough to determine the prac- tical imi)ortance of the new agents. " K.spocially valuable becau.sc of its conipletoncs.s, it.s accuracy, it.s systematic consideration of the properties and therajiy of many remedies of which doctors generally know l)ut little, e.\])ressed in a brief yet terse manner." — Chicago Clinical Revinu. CA TALOGUE OF MEDICAL WORKS. »9 LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in tiie Philadelphia College of Pharmacy. With over 75 plates. Price, Cloth, $2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to tho.se used in medicine. Illustrations have freely been used to elucidate the te.xt, and a comjjlete inde.x to facilitate refer- ence has been added. The folding charts which supplement the subjects will be found useful in con- nection with the study of the text. Trailing Arbutus (Epigea repens). Sfccimen Illustration. SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. KE.vriNG, M. D., Editor of "Cyclopaedia of Diseases of Children," etc.; Author of the "New Pronouncing Dictionary of Medicine," and Henry Hamilton, Author of "A New Translation of Virgil's .Kneid into English Verse;" Co-Author of a "New Pronouncing Dictionary of Medicine." A new and revised edition. 32mo, 2S2 ])ages. Prices: Cloth, 75 cents; Leather Tucks, ^^i.oo. This new and comprehensive work of rcfercnie is the outcome of a demand for a more modern hand-book of its class than those at present on the market, which, dating as they do from 1X55 to i<S,S4, arc of but trifling use to the student by their not containing the hundreds of new words now used in current literature, espe- cially those relating to lOlectricity and Bacteriology. "Remarkably accurate in tenninology, accentualiou, ami delinition."— /o/r;;/^/ of Aineriatn Medical Asscnittioii. " Uriof, yet complete .... it contains the very latest nomenclature in even the newest depart- ments of medicine."— .)/c(//Wj/ Keconi. MO W. B. SAUNDERS' ILLUSTRATED SAUNDERS* POCKET MEDICAL FORMULARY. Hv William M. PowKLL, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1750 Formulas, selected from several hundred of the best-known authorities. Forming a handsome and convenient pocket companion of nearly 300 printed pages, with blank leaves for additions; with an Appendix containing Fosological Table, FormuUt and Doses for Hypodermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Dis- eases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Third edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, $1.75 net. " This liule l)ook, tliat can be convenitMitly carried in the ])ocket, contains an immense amount of material. It is very useful, and as the name of tlie autiior of each jirescription is given is unusually reliable." — A'aii York lejical Rnord. MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By .\. A. Stevens, A. M., M. D., Instructor of i'hysical Diagnosis in the Uni- versity of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 435 pages. Price, CMoth, ;f!2.25. This wholly new volume, which is based on the 1.S90 edition of the Pharma- copa'ia, comprehends the following sections: Physiological Action of Drugs; Drugs; Remedial Measures other than Drugs: Ap|)lied Therapeutics; Incom- patibility in Prescriptions; 'i'able of Doses; Index of Drugs; and Index of Dis- eases ; the treatment being elucidated by more than two hundred formulae. HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Ke.vi'ini;, M. D., Fellow of the College of Physicians and Surgeons of Phila- delphia ; Vice-President of the American P;ediatric Society ; P^x- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large }>hototype illustrations, and a plate prepared by Dr. McClellan from special dissections ; also, numerous cuts to elucidate the text. Price, in Cloth, $2.00 net. " This is bv far the most useful book which has yet ajjpeared on insurance examination, a sub- ject of growing interest and importance. Not the lea.st valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, tht-v Ibrm the latest instructions obtainable. If for these alone the book should lie at the right hand of every physician interested in this special branch of medical science." — The Medical Neivs, Philadelphia. TEMPERATURE CHART. Prepared by I). I". L.mne, M. D. Size 8 ■ 13^2 inches:. Price, jjer pad of 25 charts, 50 cents. A convenienlli' arranged chart for recording Temperature, with columns for daily aniounls of Urinary and l-'ecal Kxcretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, CHEAPEST, AND BEST ILLUSTRATED SERIES OP COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature WITH Students and Practitioners in every City of the United States and Canada. THE REASON ^VHY They are the advance guard of "Student's Helps "—that no HKLP; they are the leaders in tlieir special line, -veil and aitthoyitati-'ely •i<rittcn hv able men, 'c/w, as teac/iers in the large col- leges, know exactly what is luanteil !>y a stiiilent pre[>ariug for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, ()ui/-masters, and Assistants, most of them have become Pro- fessors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable tyjie, on tine paper. The entire .series, numliering twenty-three subjects, has been kept thoroughly revised and enlarged when necessary, many of tliem bein;j; in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizi.es, Manuals. .Vids, etc. in the market, none of them approach the " Blue Series of (,)uestion C'ompends ;" and the claim is made for the following points of excellence : 1. Professional distinction and rejiutation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and (luality of |)aper and binding. * Any of these Compends will be mailed on receipt of price. 21 aa ly. n. S.l(\V/)/;/?S' ILLUSTRATED % i ESSENTIALS OF PHYSIOLOGY. |{y M. A. Hakk, M. I)., I'rofessor of I'licnipLnitic s and Materia Mcdiia in the Jdlcrson Medical College of Philadelphia; Physician to St. Agnes' Hospital and to the Medical Dispensary of the Children's Hos- pital; Laureate of the Royal Academy of Medicine in lielgiiun, of the Medical Society of London, etc. I'hird edition, revised and enlarged by the addition of a series of hand- some plate illustrations taken from the cele- brated " bones Nervorum Capitis" of .Vr- nold. Crown .Svo, 2_:;o i)ages, numerous illustrations. Price, Cloth, Sioo net ; inter- leaved for notes, 51.2^^ net. S/>t-chnrn Jlluslyiiti^m. ;uuh(ii- lias lUiiie lii.s work thoroiii'lilv ami well. Spt\ itih-il Utu\tratioH. " .Vii exccf<linj,'ly u.stful litllc CdiiipciKl. 'I The plates of tliL- cranial iicrvis from .Vnuild an- .siipcrl)." — Ji'iirnal of Amcricun .^fediiul Asm eta t ion. 2. ESSENTIALS OF SURGERY, containing also. Venereal l~)iseases, Surg- ical Landmarks, Minor and ()])erative Surgery, and a Complete Description, together with full Illustrations, of the Lland- kerchief and Roller liandage. l>y IOdwakk M.VKTiN, A. M., .\L ])., Clinical Professor of (ienito-Urinary Diseases, Instructor in Operative Surgery, and Lecturer on Minor Surgery, Uni- versity of Pennsylvania; Surgeon to tiie Howard Hosj)ital ; .Assist.Tnt Surgeon to the University Hospital, etc. Fifth edition. Crown .Svo, 334 pages, profusely illustratcil. Considerably enlargetl by an Appendix contain- ing full directions and jirescriptions for the preparation of the various mate- rials used in Antiseptic Surgery ; also, several hundred recipes covering the medical treatment of surgical affections. I'rice, Cloth, $1.00 j interleaved for notes, $1.25. "Written to a.ssist the student, it will he of undoubted value to the ))raetitioiier, containing; as it does tile essence of suri^ical work." — A'ii,iA<;/ M(i/i<(!/ <iihf Sinxi<<i/ Joiiriia/. 3. ESSENTIALS OF ANATOMY, including the Anatomy of the Viscera. Hy Chaklks J5. Xaxckkui;, AL D., Professor of Surgery and of Clinical Surgery in the University of Michigan, .Ann .Arbor ; Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon to the Jefferson Medical College, etc. Fifth edition. Crown iSvo, 380 pages, icSo illustrations. Fnlarged by an .Xjipendix, containing over sixty illus- trations of the Osteology of the Human Body. The whole based upon the last (eleventh) edition of Cray's Anatomy. Price, Cloth, Si. 00 ; interleaved for notes, $1.25. " Truly such a book as no student can afford to be without." — American Pvactilioner and A'e-vi. " The questions have been wisely selected, and the answers accurately and concisely given." — University Medical Mai^azinc. . <r CArALOGUE OF MEDICAL WORKS. n 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC, containing also, (Jufstions on Mcilical I'liysics, C'hcniical I'liysiology, Analytic al l'ro( esses, Irinalysis, and Toxicology. 15y Lawkknh', WoMK, M. !)., Demonstrator of Chemistry, Jefferson Medical College; Visiting Physician to the derman Hospital of Philadelphia ; Member of Philadelphia College of Pharmacy, etc. Fourth and revi.scd edition, with an Appendix, Crown Svo, 21 j pages. i'rice, Cloth, ;j!i.oo; interleaved for notes, ;>;i.23. " 'I'lu! .scope of tliis work is c(;rl:iiiily i'i|iuil to tliat of the IksI course of lectures on Medica! Chcniistrv." — Pluii in,utiiti,ol J-.id. 5. ESSENTIALS OF OBSTETRICS. My W. Iv\STKKi.v .XsiiToN', M. I)., Profcssor of ( lyn- aicology in the Medico-Chinirgical College of Philadeli)hia ; Obstetrician to the Philadelphia Hospi al. Third edition, thoroughly revised and enlarged, Crown .Svo, 244 pages, 75 illus- trations. Price, Cloth, ;^i.oo; interleaved for notes, j;i.25. " An excellent little volume conlaiiiinf; correct and practical knowledge. \v\ admirable compiiid, and the he.st eonden.salion we have .seen." — Soiif/nrn Pi cufi/ioiirr. "Of extreme value to .students, and an excellent little hook to freshen u|) the memory of the practitioner." — C/iiajf;;o Medical Tillies. Spt'ci)iirn Illustration. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY, liy C. !•;. Akm.vnij Si'.Mi'i.K, P). A., M. H. Can- tab. L. S. A., M. R. C. P. Pond., Physician to the Northeastern Hospital for C'hildren, Hackney; I'rofessjr of N'ocal and Aural Physiology, and ivxaminer in Acoustics at Trinity College, l^ondon, etc. Crown Svo, 174 pages, illustrated, (sixth thousand). Price, Cloth, ;>i.oo ; interleaved for notes, $1.25. "A valuable little volume — truly a iiinlliim in par-v." — Cinciiiimti Medicci/ A'cius. S/>t citiu-n lihtsti'iitioti. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION-WRITING. By Hknuv Morris, M. I)., I-ate Demonstrator, Jefferson Medical College; Fellow College of Physicians, Philadelphia; Co-Editor Biddle's Materia Medica; Visiting Physician to St. Joseph's Hospital, etc. Fourth edition. Crown Svo, 250 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. '■ ^Jne of the best compends in this -series. Conci.se, pithy, and clear, well suited to the pur- pose .ir which it is ])repared." — Medial! and Surgical Reporter. " The subjects are treated in such a unique and attractive manner that they cannot fail to impress the mind and instruct in a lasting manne.." — Buffalo Medical and Surgical Journal. IMAGE EVALUATION TEST TARGET (MT-3) %' /aV ^^- ''^' 1.0 I.I 11-25 i 1.4 U;|28 |2.5 ■^ iii2 |2.2 M 1.6 Photographic Sciences Corporation 23 WI'SV MAIN STRfST WHSriR.N.Y. 145*0 (716) a.'2-4!aM >'^' .. .. 24 IV. B. SAUNDERS' ILLUSTRATED 8, 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D., Author of "Essentials of Materia Medica," etc., with an Appendix on the Clinical and Microscopical Examination of Urine, by Law- rence Wolff, M. D., Author of "Essentials of Medical Chemistry," etc. Colored (Vogel) urine scale and numerous fine illustrations. Third edi- tion, enlarged by some three hundred essential formulae, selected from the writings of the most eminent authorities of the medical profession. Collected and arranged by William M. Powell, M. D., author of "Essentials of Diseases of Children." Crown 8vo, 460 pages. Price, Cloth, $2.00. " The teacliing is sound, the presentation graphic, matter as full as might be desired, and the style attractive." — American Practitioner and News. " A lirst-class jiractice of medicine iwiled down, and giving the real essentials in as few words as is consistent with a tiiorough understanding of the subject.'' — Medical Brief. 10. ESSENTIALS OF GYN^ffiCOL- OGY. By Edwin B. Cragin, M. D., Attending Gynecologist, Roosevelt Hos- pital, Out-Patients' Department ; Assistant Surgeon, New York Cancer Hospital, etc. Fourth edition, revised. Crown 8vo, 198 pages, 62 fine illustrations. Price, Cloth, lli.oo ; interleaved for notes, $1.25. V " This is a most excellent addition to this scries of question compends The style is concise, and at the same time the sentences are well rounded. This renders the book far more easy to read than most compends, and adds distinctly to its value." — Medical and Surg- ical Reporter. IX. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwa(;on, M. D., Clinical Lecturer on Dermatology in the Jefferson Med- ical College, Philadelphia; Physician to the Skin Service of the Northern Dispensary ; Dermatologist to Phila- delphia Hospital ; Physician to Skin Department of the Howard Hospital ; Clinical Professor of Dermatology in the Woman's Medical College, Phila- delphia, etc. Third edition. Crown 8vo, 270 pages, 86 illustrations, many of which are original. Price, Cloth, $1.00 net; interleaved, $1.25 net. " An immen.se amount of literature has been gone over and judiciously cf ndensed by the writer's skill and experience." — Medical Record. " The book admirably answers the purpose for which it is written. The experience of the reviewer has taught him that just such a book is needed." — Neru York Medical Journal. Specimen Illustration. Specimen Illu-tration. CATALOGUE OF MEDIO :L WORKS. 25 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DIS- EASES. By EuwARD Martin, A. M., M. D., Author of " Essentials of Surgery," etc. Second edi- tion. Crown 8vo, thoroughly revised and enlarged, 78 illustrations. Price, Cloth, ^i.oo; interleaved for notes, $1.25. "Characterized by the same literary excellence that has distin- guished |)revious numbers of this series of compends." — American Practitioner and A'nus. " The best condensation of the subjects of which it treats yet placed before the profession." — Medical News, Philadelphia. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M. D., Author of "Essentials of Pathology and Morbid Anatomy." Crown 8vo, 212 pages, 130 illustrations. Price, Cloth, ;^i.oo; inter- leaved for notes, 1(1.25. " The leading ponits, the essentials of this too much neglected por- tion of medical science, are here summed up systematically and clearly." — Southern Practitioner. I\> ->, .S/>('< /■;«£'« ///us/ration. w^^^^SS^ i If^^^^IB^ s ll^^g m Sfecimen Illustration. 14. ESSENTIALS OF REFRACTION AND DISEASES OF THE EYE. By Edward Jackson, A. M., M. D., Professor of Disea.ses of the Eye in the Philadelphia Polyclinic and College for (Graduates in Medicine ; Member of the American Ophthalmological Society ; Fellow of the College of Physicians of Philadelphia ; Fellow of the American Academy of Medi- cine, etc. ; and ESSENTIALS OF DISEASES OF THE NOSE AND THROAT. By E. Baldwin Gleason, M. D., Surgeon in charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia ; formerly Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylvania, and Assistant in the Nose and Throat Department of the Union Dispensary, etc. Two volumes in one. Second edition. Crown 8vo, 294 pages, 124 illustrations. Price, Cloth, lii.oo; interleaved for notes, $1.25. '%57>wrffTTT# specimen Illustrations. " .\ valuable Ixiok to the beginner in these branches, to the student, to the busy practitioner, and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers know what a student most needs" — JVe^v York Medical Reco d. 26 ty. B. SAUNDERS' ILLUSTRATED 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women, at Atlantic City, N. J. ; late Physician to the Clinic for the Dis- eases of Children in the Hospital of the University of Pennsylvania and St. Clement's Hospital ; Instructor in Physical Diagnosis in the Medical Depart- ment of the University of Pennsylvania. Crown 8vo, 216 pages. Price, Cloth, jjSi.oo; interleaved for notes, $1.25. " This work is gotten up in the clear and attractive style that characterizes the Saunilers' Series. It contains in appropriate form the jjist of ail liie l)est worlis in the department to wliich it relates." — American Practitioner and Niius. " The book contains a series of ini|)ortant <|ucstions and answers, which the student will lind of great utility in the examination of children." — Annals of Gynacology. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrenck Wolff, M. D., Author of " P>ssentials of Medical Chemistry," etc. Colored (Vogel) urine scale and numerous illustrations. Crown 8vo. Price, Cloth, 75 cents. " A little work of decided value." — University Medical Magazine. " A goo<l manual for students, well written, and an- swers, categorically, many questions beginners are sure to ask." — Afedical Renn-d. " The questions have been well chosen, and the an- swers are clear and brief. The book cannot fail to Ix; use- ful to students." — Medical and Siiri;ical Reporter. 17. ESSENTIALS OF DIAGNOSIS. By Solomon SoLis-CoHKN, M. D., Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic, and Augustus A. Eshner, M. D., Instructor in Clinical Medi- cine, Jefferson Medical College, Philadelphia. Crown 8vo, 382 pages, 55 illustrations, some of which are col- ored, and a frontispiece. Price, ;?i.5o net. " A good book for the student, properly written from their standpoint, and confines itself well to its text." — Medical Record. " Concise in the treatment of the sulyect, terse in expression of fact. . . . The work is reliable, and represents the acce|)ted views of clinicians of to-day." — American Journal of Medical Sciences. " The subjects are explained in a few well-selected words, and the required ground has been v*v thoroughly gone over." — International Afedical Magazine. Specimen Illustration. \ 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre, M. D., Professor of Pharmacy and Materia Medica in the University of Kansas. Second edition, revised and enlarged. Crown 8vo, 200 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. "Covers a great deal of ground in small compass. The matter is well digested and arranged. The research questions are a valuable feature of the Ixwk." — Albany Medical Annals. "The best quiz on Pharmacy we have yet examined." — National Drug Register. " The veterpn pharmacist can peruse it with pleasure, because it emphasizes his grasp upon knowledge already gleaned." — Western Drug Record. f ym I I'll ^""•«p^«OTHpppitq CA TALOGUE OF MEDICAL WORKS. n r\ Specimtn Itluitrution. 20. ESSENTIALS OF BACTERIOLOGY: A Concise and Systematic Introduction to the Study of Micro-organisms. \\y M. V. Bali,, M. D., Assistant in Microscopy, Niagara University, Buffalo, N. Y. ; late Resi- dent Physician, (ierman Hospital, Philadelphia, etc. Second edition revised. Crown 8vo, 200 pages, 81 illustrations, some in colors, and 5 plates. Price, Cloth, $1.00; interleaved for notes, $1.25. " The amount of material conden.se(l in this hule Ixink is so great, and so accurate are the furmuKv and methods, tliat it will l)e foun<l useful as a lalxjm'ory hand-book." — Medical Ne%vs. " Hacteriology is the keynote of future medicine, and every |)hysician who expects succe.ss must familiarize himself vith a knowledge of germ-life — the agents of disea.se. 'I'liis little hook, with its beautiful illustratinns, will give the students, in brief, the results of years of study and research unaided." — Pacific Record of Medicine and Surgery. 21. ESSENTIALS OF NERVOUS DIS- EASES AND INSANITY, their Symp- toms and Treatment. By John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hos- pital Medical School ; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital ; formerly Medical Superin- tendent King's County Insane Asylum. Second edition. Crown 8vo, 186 pages, 48 original illustrations, mostly selected from the .Vuthor's private practice. Price, Cloth, $1.00; inter- leaved for notes, $1.25. "Clearly and intelligently written." — Boston Medical and Siiri^ical Journal. " A valuable addition to this .series of eomi)end.s, and one that cannot fail to be appreciated by all physicians and students." — Medical Brief. " Dr. Shaw's Primer is excellent. The engravings are well executed and very interesting." — Times and Register. 22. ESSENTIALS OF PHYSICS. By Fred. J. Brockwav, M. D., Assistant Demonstrator of Anat- omy in the College of Physicians and Surgeons, New York. Crown 8vo, 320 pages, 155 fine illustrations. Price, Cloth, $1.00 net ; interleaved for notes, $1.25 net. "The publi.sher has again shown himself as fortunate in his edi- tor as he ever has l)een in the attractive .style and make-up of bis compends." — American Practitioner and Xe^vs. " Contains all that one need know of the subject, is well written, and is copiously illustrated." — Medical Record. " The author has dealt with the subject in a manner that will make the theme not only com- paratively easy, but also of interest." — Medical News. V- •" Sf'iJntin Illustration. Specimen Ittuslralhn. — »KIif^T 28 CATALOGUE OF MEDICAL WORKS. i 23. ESSENTIALS OF MEDICAL ELECTRICITY. By D. D. Stew- art, M. D., Demonstrator of Diseases of the Nervous System, and Chief of the Neurological Clinic in the Jefferson Medical College ; Physician to St. Mary's Hospital, and to St. Christopher's Hospital for Children, etc., and E. S. Lawrv^-nce, ]V^D., Chief of the Electrical Clinic, and Assistant Demonstrator of Diseases of the Nervous System in the Jefferson Medical '••'^College, etc. Crown 8vo, 148 pages, 65 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25.. •| Clearly written, and affords a safe guide to the beginner in this subject."— J/f</;Va/ and Surgical Journal . " The subject is presented in a lucid and jileasing manner." — Medical Record. " A little work on an imiiortant subject, which will prove of great value to medical students and trained nurses who wish to study the scientific as well as the practical points of electricity.'- - The Hospital, London, England. " The selection and arrangement of material are done in a skilful manner. It gives, in a condensed form, the princiijles and science of electricity and their application in the practice of medicine." — Annals of Surgery. t jl^H % U- :■ -^BV I.; \ ■' 'ii^vli 1 : ' B '9^Kn ! ■■ •■gKS ', k specimen iltustialion. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, S. B., M. D., Clinical Professor of Otology, Med- ico-Chirurgical College, Philadelphia; Sur- geon in Charge of the Nose, Throat, and Ear Department of the Northern Dispen- sary of Philadelphia ; formerly Assistant in the No.se and Throat Dispensary of the Hospital of the University of Pennsylvania, and Assistant in the Nose and Throat De- partment of the Union Dispensary. 89 illustrations. Price, Cloth, $1.00; inter- leaved for notes, ^1.25. This latest addition to the Saunders Compend Series accurately represents the modern aspect of otological science. While small in compass, it is logically and capably written ; it comprises upward of 150 pages, with 89 illustrations, mostly from original sources. NURSE'S DICTIONARY of Medical Terms and Nursing Treat- ment, containing Descriptions of the Principal Medical and Nursing Terms and Abbreviations ; of the Instruments, Drugs, Disea.ses, Accidents, 'I'reat- ments. Physiological Names, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. Compiled for the use of nurses. B^ HoNNOR Morten, Author of "How to Become a Nurse," "Sketches ot Hospitiii Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. This lit'ile volume is intended merely as a small reference-book which can be consulted ut the bedside or in the ward. It gives sufficient explanation to the nurse to en;;ble her to comprehend a case until she has leisure to look up larger and fuller works on the subject. By D. D. Stew- em, and Chief of Physician to St. "hildren, etc., and ic, and Assistant Jefferson Medical ce, Cloth, iiSi.oo; )ject." — Medical and H-ord. to medical students ints of electricity."- - nner. It gives, in a )n in the practice of — R '*■.. illustialion. ipably written ; it original sources. lursing Treat- d Nursing Terms Occidents, Treat- etc. encountered of nurses. B\l " "Sketches ot Dk which can be planation to the look up larger ;>^